Cruel blows

Can medical technology save boxers from brain death?

Published April 30, 1999 4:00PM (EDT)

Muhammad Ali came to the Russell Senate Office Building last week to lend
his presence to a federal bill that already bears his name -- the Muhammad
Ali Boxing Reform Act, which is intended to curtail the brazen corruption
in the boxing industry. While a friend testified on his behalf, Ali sat
stolidly at the witness table, noble and glorious and mute, like one of the
stone heads on Mount Rushmore.

In fact, Ali's brain has become the fleshy equivalent of stone. He suffers
from parkinsonism -- brain cells turned to scar tissue as a result of the
many cruel blows landed on his head. And while the senators were not
primarily concerned with Ali's brain -- the subject at hand was the rip-off of
boxers and their fans by Don King and his ilk -- the boxer's funereal
presence was an inescapable reminder of the brute facts of the sport. You
had to wonder which was more disturbing -- watching a fixed fight or one in
which a man gets beaten half to death.

Ali, the icon, unable to speak for himself, was lavished with the sort of
praise he seldom got from politicians back in the days when his
rhetoric -- "No Viet Cong ever called me nigger" -- was as mighty a weapon as his fists. Would it be paternalistic to say that authorities should have
stopped Ali's career before it became virtual suicide, that more should be
done to protect a boxer's most vulnerable organ -- his brain?

A new crop of zealous boxing reformers, including John McCain, the Arizona Republican senator and presidential hopeful (who boxed in the Navy), and Eliot Spitzer, the attorney general of New York, have been asking just such questions as they move to clamp state and federal controls on a sport they say is deeply corrupt. In 1996, Congress passed the first federal boxing law -- a boxing safety act that created a computerized I.D. system so fighters suspended after a knockout in one state could not fight under an alias in another. But the law didn't specify the type of medical examinations boxers should get, and regulations vary enormously. In some states, boxing commissions will accept a cursory physical by any M.D. In others, such as New York, each boxer must undergo a CAT scan -- at the state's expense -- every year and after each knockout. "We saved a few lives," says neurologist Barry Jordan, who instituted the changes as medical director of the New York State Athletic Commission from 1987-95.

The New York physical also includes an hour-long neurological exam and an
EEG, which measures brain waves. A task force of attorneys general headed by Spitzer now wants to go further, with uniform medical standards around the country. The group's model regulations recommend that boxers in high-risk categories -- those over 40, with 15 or more losses, three consecutive KO losses or a career of more than 350 rounds -- be suspended until they receive an MRI exam, which shows more anatomical detail than the CAT scan, as well as an EEG and a detailed neurological exam. Meanwhile, Sen. Daniel P. Moynihan, D-N.Y., has introduced an amendment to the 1996 law that would require CAT scans semiannually for every boxer.

Boxing traditionalists will squawk at such regulations, but the boxers'
brains are worth it. Over the past 80 years, about 700 fighters have died
in the ring. Every generation has a sickening example -- Benny Paret,
pummeled into a coma by Emile Griffith in a 1962 grudge bout (during the
weigh-in, Paret called Griffith a maricsn, or fag); Duk Koo-Kim, killed by Ray
"Boom-Boom" Mancini in 1982; Jimmy Doyle by Sugar Ray Robinson in 1947.
When a gloved fist strikes a head, the brain and skull accelerate at
different speeds. The brain, sitting in a pool of fluid that acts as a
hydraulic buffer, lags behind, and the resulting pressures tear veins and
rip membranes. While a kinked brainstem might cause nothing more than a
concussion, severe bleeding between the brain and the skull can be fatal.

Overall, ring mortality has declined in the past two decades; for all participants, in fact, the rate of death is lower in boxing than in
sports such as ice hockey and skiing. What makes
boxing uniquely brutal for anyone who fights long enough, though, is the
near inevitability of brain damage. "It is impossible to prevent chronic
brain injury in a sport that strives to inflict multiple blows to the
head," Dr. Mario Mendez wrote succinctly in a 1995 article in the
International Journal of Psychiatry in Medicine. Head blows accelerate the
aging process by killing brain cells, inducing disease processes similar to
Parkinson's, Alzheimer's and other syndromes. Neurologists use the language
of impact mechanics to explain how, when the head is knocked sideways, the
brain swirls in the skull, its layers shearing and sliding off one another,
tearing vital nerve fibers. Mendez's study, a review of several decades of
boxing injury studies, estimated that 50 to 60 percent of all boxers suffer
some brain damage.

And for most boxers, there seems to be little incentive to quit while
they're ahead -- or still have one. Nearly every former heavyweight champion has made a comeback. There's no weight limit to keep heavyweights away from the ring, and the money is too good to
renounce. The price is ending up punch-drunk, slug-nutty, slap-happy -- pick
your phrase; dementia pugilistica is the clinical term. A partial list of
champions and top contenders who died in gray oblivion: Jerry Quarry, Sugar Ray Robinson, Zora Foley. Wilfred Benitez is brain-damaged. Jimmy Bivins was recently discovered, starving and demented, in an attic in Cleveland. Floyd Patterson, the champ who emerged from the
streets of Bedford-Stuyvesant to become one of New York's best-loved
citizens, had to resign as state athletic commissioner last year when he
revealed at a hearing that he could scarcely remember his wife's name. And
it could well be that the rages of Mike Tyson are partly the product of
organic brain damage. "Tyson can't fight anymore -- that's why he went into
ear biting," says Dr. Allan J. Ryan, who co-founded the field of sports
medicine in 1945 and has watched thousands of fights with a clinical eye.
"He's virtually helpless in the ring, and if he continues to fight
someone's going to kill him."

In the 1980s, the British and American medical associations, as well as the
American Academy of Neurology, called for a ban on professional boxing.
It's not going to happen. But the good news is that boxing is becoming
somewhat safer -- referees generally intervene earlier to stop fights. The
bad news is that many boxers aren't that happy about it -- especially when
they lose the bout. Some die-hard fighters would still rather die hard.
Consider the April 24 WBC middleweight title bout between Hacine Cherifi of
France and Keith Holmes of Washington. In the seventh round, Cherifi
received 28 unanswered blows, including several powerful crosses to the
head that left him staggering at the ropes with his gloves down until the
referee jumped in and called a TKO. Did Cherifi thank the referee for
preserving his brain? Of course not. He tried to argue his way into more
punishment, screaming that he'd been robbed: "I'm not knocked out, I'm
still fighting!"

A boxer like Cherifi, who can take many blows before succumbing, is said to
have "heart." And heart, in the words of neurologist Norman Relkin of the New York Presbyterian Weill Medical Center, "tends to correlate with chronic traumatic encephalopathy." Quarry, who died at 53 on Jan. 9 in a childlike state after many years of being dressed by others, was the emblematic big-hearted fighter. He would take round after round of pounding by the likes of Ali and Joe Frazier, but stayed on his feet to lose decisions or late-round KOs. It made him a popular fighter -- "a Quarry never quits," was the family motto; Quarry's boxing brothers Mike
and Bob are also severely brain-damaged.

The truth is that while scientific knowledge of the damage boxing causes
has become more and more precise, there is little consensus yet on what to
do about it. Consider this example: Neurologists examining the brains of
deceased fighters with dementia pugilistica frequently observe an unusual
feature called a cavum septum pellucidum -- a rupture of the thin membrane, the septum pellucidum, that separates the fluid-filled ventricle in the middle of the brain. Scans of active boxers have detected this feature far more frequently than would be expected in the general population. Nobody knows for sure whether the membrane has any function (a role in the limbic system, which controls emotional impulses like rage, has been
hypothesized). But even if the condition is meaningless in itself, it is
probably a marker for brain damage. "The inference," says Relkin, the neurologist, "is that if
there's been enough force delivered to the cranial cavity to create the
cavum, there's been enough force to cause diffuse axonal injury" -- widespread death of brain cells.

Yet when Relkin finds a cavum in the brain of a boxer referred to him by
the New York Athletic Commission, he does not automatically recommend that the boxer be suspended. There are both medical and political reasons for this. On the medical side, there isn't enough scientific data available to
know whether the condition is dangerous, or even that a particular membrane was damaged by boxing -- although the abnormality is believed to occur naturally in only about 1 percent of the population. Relkin wouldn't let his own kid box with a cavum septi pellucidi -- "I wouldn't let my son box at all," he adds. But boxers are a caste apart. "This is their
livelihood," he says. In Relkin's experience, "Even if they've been made
aware of the risks, it has almost no influence on their decision to fight.
This is an occupational hazard they are more than willing to accept."

More sophisticated exams will turn up more abnormalities -- but they aren't
failsafe, and the cost rises as a factor of the level of detail. A cavum
will turn up in a CAT scan, which may cost about $300. White matter damage
appears in MRI scans, but they cost four times as much. Many changes won't
turn up on either scan, or in a neurological exam: the theory of dementia
pugilistica is that brain-cell death during a boxer's career isn't
sufficient to cause obvious symptoms until later in life, when, as
additional neurons die in the natural aging process, a critical mass of
neuronal death leads to dementia. PET scans and other tools that measure
blood flow and chemical changes in the brain might show such changes
earlier on, but these scans are experimental at present.

Genetics may help. In a 1997 study published in the Journal of the American
Medical Association, Jordan and Relkin found that boxers who have a gene
variant called apoE4 -- a genotype originally linked to early-onset
Alzheimer's disease -- were far more likely to develop severe brain disease,
regardless of how many punches they took. Someday, prospective boxers
could be screened for apoE4 -- about 25 percent of the population has one
copy of the gene -- and kept out of the ring if they have it. But all these
tests -- CAT scans, MRIs, genetic screens -- could end up being prohibitively
expensive. "Who's going to pay for that?" asks Rob Lynch, the executive
director of the California Athletic Commission. "Boxers won't pay for it."

The obvious answer is to have the moneybag promoters and TV networks shell out for the exams. It's the height of paternalism to think that just
because boxers come from poor backgrounds, they are happy to make a living getting slowly battered to death. Some younger boxers clearly are not.
That, at least, is the impression given by Mark "Too Sharp" Johnson, whom
I found shadowboxing to the go-go rhythms of D.C.'s own Rare Essence at
Finley's, a legendary boxing gym in northeast Washington. When I
interviewed him last week, Johnson, who is 27, was already the IBF
flyweight champ and, with a 36-1 record, ranked by Ring magazine as the
world's fifth-best fighter. (He went on to whip Ratanchai Vorapin of
Thailand on Saturday to gain the junior bantamweight title). Johnson
already owns a barber shop and a hair salon, and he planned to use the
$85,000 purse from the Vorapin fight to start an ice cream parlor. If he
gets clobbered in the ring, Johnson says, he wants to be able to leave the
sport gracefully. And he strongly supports tough medical exams -- of himself
and his foes. "This isn't a sport like basketball or golf where your
health doesn't have to be up to par," he says. "A lot of fighters who been
knocked out are still fighting that shouldn't be fighting. There ought to be stiffer rules -- look at Muhammad Ali. I want to leave the profession in good health. I have kids I want to take care of."

By Arthur Allen

Arthur Allen writes on health, science and other issues for Salon and Kaiser Health News. He lives in Washington.

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