Two boxers died in July 2019. One was Maxim Dadashev. He was 28 years old. He had a wife and a young child. The other was Hugo Santillan. He was 23 years old. Dadashev collapsed after the 11th round of his fight. Santillan finished his fight then collapsed, as the decision was being announced.
In October 2019, Patrick Day, a middleweight, was knocked out in the 10th round. He never regained consciousness. He died four days later. All three fighters, Dadashev, Santillan, and Day, were rushed to hospitals. All three had surgery. All three had bleeding inside their skulls and in their brains. All three got some of the best medical care 21st-century doctors had to offer. The best medical care could not save them. When large blood vessels in the brain rupture during a fight, it is almost impossible to save the person's life. The few who are saved from death are left with serious neurological disabilities.
One study found 339 boxing deaths from 1950 to 2007. That is roughly six deaths per year.
After Dadashev died, commentators felt obliged to offer expert opinions. One said that no one forces boxers to fight. He said that fighters know the risks -- they know that death is a risk. But do they really know the risks? Do they really know how they die? Do they really know how boxing damages the brain? I don't think so. Certainly, the expert commentators don't seem to know. Even some doctors don't seem to know.
In 2019, I was watching an MMA fight. A fighter was evaluated by the ring doctor. The doctor asked this fighter to raise his arms by his side. He told the fighter to hold them there while he pushed down. The fighter was able to hold his arms against the doctor, pushing down on his arms. So the doctor said he could keep fighting. Shortly thereafter, he lost.
What that doctor did, having the fighters raise his arms, made no sense. The issue was not the fighter's arms. Rather, the issue was his neurological condition. There is a great deal of medical ignorance and medical misinformation associated with boxing.
In my youth, I took up boxing. I was raised by a single mother and exposed to domestic violence. Such experiences can drive a boy to fight.
I hung out in boxing gyms. One such gym was on Louisiana Street in Houston. It was run by an ex-boxer named Shifty Dandio. When I was 16, he told me that he could make me a champion -- for a price. I had a few boxing matches in the gym. In one, I fought a fellow who had just gotten out of the army. They said he was the middleweight champion in the army. He knocked me down three times in a three-round fight.
After that, I decided that studying harder in school might be a better option. Genetically speaking, I was more a natural nerd than a natural fighter. Expressing my nerd genes propelled me into medical school. But I never lost interest in boxing. It is a sport that can get a hold of a person and not let go. However, my medical training prompted me to view it from the medical angle. It prompted me to study the medical history of boxing.
I discovered an interesting history. In 1928, Dr. Harrison Martland studied the brains of "punch-drunk" fighters. He found serious damage in those brains. He found signs of previous small hemorrhages. He found that scar tissue had replaced brain tissue. It is like what happens to the faces of fighters. That is, their faces get cut, and scar tissue gets laid down. The same thing happens in the brain. Scar tissue gets laid down in the brain, and it interferes with normal brain function. This scar tissue causes the punch-drunk syndrome, which is characterized by slowed thinking, by word-finding problems, by a slow shuffling or unsteady gait, by tremor and, in its worst stages, severe dementia.
Martland also pointed out that some boxers develop Parkinson's disease as a result of boxing. This is what happened to Muhammad Ali. Some have said this can't be proven, that maybe Ali had a genetic form of Parkinson's disease. That explanation seems highly unlikely. Parkinson's disease is caused by damage to an area in the brain called the substantia nigra. It is characterized by tremor, stiffness, difficulty walking, and difficulty talking. Muhammad Ali exhibited these symptoms.
In 1980, when Muhammad Ali was scheduled to fight Larry Holmes, he was already showing signs of Parkinson's disease. The Nevada Athletic Boxing Commission was aware of his neurological deterioration. They required that he be evaluated by a neurologist to be cleared to fight. Ali went to a doctor at the Mayo Clinic. This doctor found evidence of neurological deterioration in Muhammad Ali. In his medical notes, he documented the abnormal neurological signs he found in Ali. Nevertheless, he cleared Ali to fight Holmes.
Some doctors involved in the fight game may not have the interests of the fighters as a top priority. Larry Holmes severely beat Muhammad Ali. It was sad to watch. I was a medical student at that time. I had learned enough by then that I could clearly see the signs of Parkinson's in Ali. This brings up another aspect of the fight game. It assumed that fights are fair. It is assumed that fighters are evenly matched. But that is almost never the case. Someone always has an advantage. When Larry Holmes fought Muhammad Ali, he had a clear advantage. Ali was neurologically impaired.
In 1984, at the age of 42, Ali was officially diagnosed with Parkinson's disease. This disease advanced rapidly in Ali. In 1996 when Ali carried the Olympic torch in Atlanta, he was severely affected by Parkinson's disease.
That his disease advanced so severely, even though he was no longer boxing, indicates that the damage to the brain that is done by repeated blows may not stop once the blows stop. We don't know why the punch-drunk syndrome seems to advance rapidly in some but not in others. It probably reflects the extent of the damage caused by the blows. Parkinson's disease that afflicted Muhammad Ali came from multiple blows. These blows likely damaged his substantia nigra. That his thinking seemed preserved is evidence that other parts of his brain held up better to the blows.
How the punch-drunk syndrome manifests in any particular boxer depends on which areas of his brain sustain the damage. As I mentioned before, it is analogous to what happens to the face. Some fighters cut easily over the eyes and develop scar tissue there. Others develop cauliflower ears. Others develop both. A few avoid serious damage to their faces.
It is the nature of the human body that people have different weak points and different strong points. In many fighters, their large blood vessels are strong points. But in some, they are not strong enough. The weak points for Dadashev, Santillan, and Day were their large blood vessels. When blows to the head caused these to rip open, there was major bleeding. This major bleeding killed them. But when Patrick Day went down, it looked like a typical knockout. His opponent, Charles Conwell, was applauded.
A knockout is the ultimate goal in a boxing match. It is exhilarating. Once when I was boxing, my opponent threw a left jab that missed. I came over his left with a right cross. It landed square on his jaw. He went straight down and did not get up for a couple of minutes. I was proud of myself. It was my first and only knockout. At that time, I had no idea about the physiology of a knockout. I didn't know how the brain worked. I didn't know how boxing affected the brain. I was just a teenager who ran with guys who liked to fight. So I fought.
A knockout is a severe concussion. In football, efforts are made to prevent concussions, and when a football player has a concussion, he is often taken out of the game and not allowed to play for a week or more. But in the sport of boxing, a concussion is the goal. The boxer who causes the most concussions in his opponent wins the fight.
Concussions occur when the brain bounces inside the skull with such force that abnormal electrical circuits are activated. This can result in abnormal electrical signals being sent to the sleep/wake center in the brain. This sleep/wake center in the brain is called the reticular activating system (RAS). If an abnormal electrical signal from a punch shuts down the reticular activating system, then the person becomes unconscious. It is a knockout.
The abnormal signals from a severe blow, as they travel to shut down the RAS, can affect other neurological circuits. They can abnormally activate muscle circuits. Hence, when some boxers are knocked out, you will see their arms and legs stiffen and extend, and you will see their eyes deviate. This pattern of abnormal muscle activation is seen with generalized seizures. Hence a knock-out from boxing can cause the brain to have a type of seizure.
Another area in the brain that can be affected by a severe blow to the head is the balance center, which is part of the inner ear called the vestibular apparatus. This vestibular apparatus sits in the brain just beyond where the nerves to the ear enter. It consists of three tubes that contain fluid. These fluid-filled tubes are similar to the fluid-filled tube that is used for a level sold in a hardware store. When a severe blow disrupts the fluid in the vestibular apparatus, it will make the fighter dizzy. He will lose his balance and stumble around the ring.
The goal of boxing is to produce neurological damage. It is hypocritical that we condemn concussions in football but applaud them in boxing. It takes a lot of dedication and a strong work ethic to become a professional fighter. It requires courage. There are admirable features to the sport. However, it would be naïve not to see that the sport is also driven by anger and by what might be called a dominance ethic. A dominance ethic holds that to dominate another person is to be superior. It is an ethic that can lead to conflicts, including domestic violence and wars. It is an ethic that contributed to a culture that embraced slavery in the U.S.
Cus D'Amato, the boxing trainer who adopted Mike Tyson and made him a world champion, said that boxers are motivated by fear. He may have been right about that. When a 5-year-old boy runs up against a grown man, when he tries to fight back, when he sees his mother get hurt, when he runs out of the house and onto the street, a deep fear gets down inside of him. For the rest of his life, fighting may help him deal with that fear.
The psychological forces that make people want to hurt others often have deep, pathological roots. The fight game is pathological, physically and mentally. Dadashev, Santillan, and Day died because of the pathological nature of that sport. Perhaps it is time for society to evolve beyond applauding a sport that is dedicated to hurting people.
W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. Graham received an NIH fellowship at The Salk Institute for oncogene research in 1985. He was professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.