The Concussion Crisis

by Linda Carroll

  Promptly turning his attention to the ring, he started by seeking out fight promoters because he knew they had a knack for judging the physical and mental fitness of boxers. One promoter provided a list of twenty-three former fighters he considered punch-drunk. Of those, Martland was able to locate ten and personally examine five.

  What he found in those examinations, coupled with descriptions of other fighters’ symptoms gleaned from boxing aficionados, informed his definition of the condition. The early symptoms, he observed, often manifested themselves in an unsteady or unbalanced gait and sometimes in slowed movement and periods of slight mental confusion. As the condition progressed, movements slowed further, hands developed tremors, legs dragged, heads nodded involuntarily, and speech became halting. In severe cases, symptoms included vertigo, a staggering gait, a marked dragging of one or both legs, and the blank facial expression often seen in Parkinson’s patients. Sometimes, dementia and mental deterioration became disabling enough to require commitment to an asylum, as was the case with four of the ten punch-drunk fighters Martland had tracked down.

  “The occurrence of the symptoms in almost fifty percent of fighters who develop this condition in mild or severe form, if they keep at the game long enough, seems to be good evidence that some special brain injury due to their occupation exists,” Martland declared in his presentation, hammering home his considered opinion that “in punch drunk there is a very definite brain injury due to single or repeated blows on the head or jaw.”

  That was hardly a fashionable opinion during the Jazz Age, when boxing’s popularity soared to unprecedented heights with each furious flurry of Dempsey’s fists. In challenging the status quo, Martland found himself faced with skepticism from all corners. That included one noted sportswriter who, Martland scoffed, “recently stated that punch drunk was greatly exaggerated and that he had consulted eminent neurologists who had assured him that such a condition did not exist.”

  To show its existence to the eminent pathologists seated before him, Martland presented “one case of advanced parkinsonian syndrome due to punch drunk,” that of an ex-fighter he identified only by the initials N.E. A sturdy lightweight who began fighting professionally at age sixteen, Nathan Ehrlich was forced to retire at twenty-three because of a tremor in his left hand and an unsteadiness in his legs. Though he seldom drank, he was often wrongly accused of being intoxicated, thanks to the tremor and unsteadiness that plagued him the last year of his career after a knockout punch had rendered him unconscious for an hour. As the symptoms gradually worsened following his retirement, Ehrlich sought treatment in numerous clinics where doctors told him that the condition had nothing to do with the fifty-three pro bouts he’d fought. He was just thirty-eight years old when Martland examined him and observed that his gait was staggering and propulsive, his speech stammering and hesitant, his facial expression masklike.

  Such case histories enabled Martland to deduce what factors might put certain boxers at greater risk. “Punch drunk most often affects fighters of the slugging type, who are usually poor boxers and who take considerable head punishment, seeking only to land a knockout blow,” he reported. “It is also common in second-rate fighters used for training purposes, who may be knocked down several times a day. Frequently it takes a fighter from one to two hours to recover from a severe blow to the head or jaw.”

  Martland, who had built his national reputation as a crusading forensic pathologist by alerting the public to the lethal effects of radioactive poisons on factory workers, submitted his groundbreaking “Punch Drunk” paper to the Journal of the American Medical Association in an effort to reach the widest possible audience. It was a clarion call as clear as the ring bell. “The condition can no longer be ignored by the medical profession or the public,” he wrote. “It is the duty of our profession to establish the existence or nonexistence of punch drunk by preparing accurate statistical data as to its incidence, careful neurologic examinations of fighters thought to be punch drunk, and careful histologic examinations of brains of those who have died with symptoms simulating the parkinsonian syndrome.”

  Martland concluded his paper by quoting Gene Tunney, the cerebral champion who had shocked the world by wrenching the heavyweight crown from Dempsey two years earlier. Shattering all the stereotypes, Tunney famously read Shakespeare between sparring sessions in which he mastered a scientific style designed to turn boxing matches into chess matches. His clear-cut 1926 decision over Dempsey, who’d ruthlessly ruled the heavyweight division for seven years as The Manassa Mauler, was hailed as a triumph of brains over brawn and brawling. In a sparring session for their ballyhooed 1927 rematch, Tunney was dazed by an accidental head butt and then rocked by a hard right to the jaw, dispatching him into a bout of amnesia so profound that he didn’t even know who he was for forty-eight hours. The episode wasn’t enough to keep him from retaining his title with another decision over Dempsey, but it did scare Tunney into resolving to retire. “From that incident was born my desire to quit the ring forever, the first opportunity that presented itself,” Tunney would explain, providing the quote with which Martland chose to close his paper. “But most of all I wanted to leave the game that had threatened my sanity before I met with an accident in a real fight with six-ounce gloves that would permanently hurt my brain.”

  By the time Martland’s landmark paper had been published in October 1928, Tunney was already two months into retirement, having abdicated his throne in the prime of his career. Tunney may have been smart enough to get out by the age of thirty, but few others appreciated the danger to their brains. It was easy for most fighters, trainers, managers, promoters, and even ringside doctors to discount Martland’s message. They were willing to admit that the occasional fighter did indeed become punchy, but they continued to insist that boxing was not the cause. Furthermore, no one—not even the pathologist Martland—had shown them that there was actual brain damage involved. But what Martland had indisputably accomplished, by coining the medical term “punch drunk” as a condition that would soon find its way into diagnostic manuals as well as popular dictionaries, was to open the floodgates for a wave of future research into the phenomenon.

  Gradually, what he had observed in a handful of ex-boxers would be extended through increasingly larger population studies. Researchers expanded the narrow list of symptoms Martland had found in his physical exams to a much broader one that emphasized cognitive deficits. And they replaced the “punch drunk” label he’d co-opted from boxing aficionados with terms they deemed more clinical and less insulting. The term “dementia pugilistica” was coined in 1937 by a U.S. Navy surgeon, Dr. J. A. Millspaugh. Two decades later, an eminent British neurologist, Dr. Macdonald Critchley, introduced the phrase “chronic progressive traumatic encephalopathy of boxers.”

  For a 1957 study published in the British Medical Journal, Critchley examined sixty-nine boxers with chronic neurological disease and determined that most were suffering from the condition. He observed a spate of mental symptoms: dementia, memory loss, slowed thinking and speech, mood swings, irritability, violent behavior. He found that mental and physical symptoms insidiously developed an average of sixteen years after the beginning of a boxer’s career and that they progressed inexorably and irreversibly. He found the condition more common among professionals than amateurs, among sluggers than “scientific boxers,” among those who were “slow on their feet rather than nimble,” among those who were “notorious as being able to ‘take it,’ ” and among those who were knocked out more often or, just as importantly, “knocked out on their feet.” Though his research had proved beyond a doubt that the condition existed, it still gave no inkling as to how prevalent the problem was.

  That question festered another five years before reaching a boiling point in the British House of Lords during a heated debate over a 1962 bill that sought to ban boxing throughout the commonwealth. Thirty-four years to the day after Martland’s “Punch Drunk” presentation, Lord Walter Russell Brain—Brita
in’s most eminent and fortuitously named neurologist—stood in the ornate Palace of Westminster and urged his peers to commission a scientific inquiry to determine the scope of the problem. Led by Lord Brain, who had authored the standard textbook on neurology, the Royal College of Physicians resolved to tackle the issue by appointing an enthusiastic research scholar named Anthony Herber Roberts to conduct a large-scale survey of prizefighters and the long-term effects of their perilous profession.

  For the most comprehensive study ever undertaken on the subject, Roberts randomly selected 224 men from among the 16,781 who had been licensed to fight professionally by the British Boxing Board of Control for at least three years between 1929 and 1955. His neurological examinations of the former boxers were detailed and thorough, including EEGs and neuropsychological tests. Thirty-seven of them—17 percent—had clear evidence of dementia pugilistica as manifested in varying combinations of slurring, drooling, tremor, vertigo, unsteady gait, memory loss, disorientation, slowed thinking. In thirteen of those cases, the cognitive and physical symptoms were already permanently disabling. In addition to the thirty-seven cases attributable directly to boxing, another eleven ex-fighters evidenced brain damage that could have been explained by causes outside the ring. Whether the condition was directly caused by head blows or merely exacerbated by them, that brought the overall prevalence of clear brain damage in the population studied to 22 percent, with an unspecified number of others showing “disturbed neurological function.”

  All told, Roberts’s prevalence data established the condition as a true epidemic. Perhaps even more telling, all but 2 percent of the study volunteers interviewed by Roberts reported seeing fellow fighters they described as “punchy” or “puddled.” And they estimated that up to half of ex-boxers were clearly symptomatic, generally from “too much punishment about the head for too long.”

  From his data, Roberts was able to tease out a host of risk factors that explained such cause and effect: length of career, number of bouts, number of losses, fight frequency, sparring exposure, number of knockouts suffered, poor performance, poor skills, age at retirement. He found the correlation between brain damage and boxing exposure to be striking. Half of the ex-fighters over fifty who had boxed at least ten years showed signs of brain damage, as did half of those who had fought at least 150 bouts. The longer a boxer’s career, the likelier he was to have symptoms that were more conspicuous.

  When the report was presented in 1969, the Royal College of Physicians was impressed enough to publish it in book form. The 132-page book—titled Brain Damage in Boxing: A Study of the Prevalence of Traumatic Encephalopathy among Ex-Professional Boxers—concluded that “the accumulated sum total of these lesions, each perhaps of negligible importance in terms of function, may eventually produce a clinical syndrome bearing some resemblance to those in which there has been one severe traumatic episode causing diffuse destruction of cerebral axons.” But even while linking the pathology of those two conditions, Roberts was careful to acknowledge that “there has been no specific pathological evidence to confirm the assumption that boxing is causally related to the clinical syndrome described.”

  Dr. Nick Corsellis read Roberts’s book with intense interest. A respected neuropathologist, Corsellis had been collecting the brains of former boxers in his London lab for over a decade. To study the pathological effects of head blows on the brain, he focused on fifteen men who had boxed in their youth, twelve of them professionally, eight of them national or world champions in their weight classes. All fifteen had died of natural causes. Piecing together case histories from their friends and families, Corsellis determined that all fifteen had developed the classic symptoms of dementia pugilistica. The autopsies revealed striking abnormalities and cerebral atrophy in fourteen of the fifteen brains—changes that would become widely accepted as the hallmark pathology of dementia pugilistica.

  Corsellis and his colleagues documented damage in a variety of brain regions. The septum, a vertical membrane separating the left and right sides of the brain, was ripped, and in some cases only shreds remained. The cerebellum, a structure located toward the back of the brain that controls movement, was scarred and atrophied, explaining such punch-drunk symptoms as staggering, spasticity, and tremor. The substantia nigra, a deep brain structure associated with Parkinson’s when damaged, had been so decimated that the injury could be seen with the naked eye. Even more intriguing were the tangles of protein scattered in the hippocampus and other brain regions—the same kinds of tangles found in Alzheimer’s patients.

  The 1973 publication of those findings in the journal Psychological Medicine would have a profound impact, proving once and for all the existence of documentable brain damage, fueling debate on the medical ethics of boxing, and leading to safety reforms in the most controversial of sports. While noting that medical controls had probably improved since the era when his study subjects would fight upwards of a thousand career bouts as well as take on all comers in fairground boxing booths and tents, Corsellis warned, “There is still the danger that, at an unpredictable moment and for an unknown reason, one or more blows will leave their mark. The destruction of cerebral tissue will have then begun, and although this will usually be slight enough in the early stage to be undetectable, it may build up, if the boxing continues, until it becomes clinically evident. At this point, however, it could already be too late.”

  • • •

  Millions of people, many more than had ever seen Slapsie Maxie Rosenbloom box professionally, found themselves rolling in the aisles of movie theaters across America as they watched him spoof the stereotype of the punch-drunk fighter on the silver screen. Rosenbloom was still light-heavyweight champion of the world in 1933 when he launched his second career—as a character actor playing the punchy pugilist in B-movie comedies. It may have been his penchant for cuffing opponents with open-fisted slaps that had inspired Damon Runyon to dub him Slapsie Maxie, but the nickname took on a whole new meaning once Rosenbloom discovered he could make people laugh in the gym by parodying the slaphappy figure fight fans knew so well.

  Once Rosenbloom took his punch-drunk act to Hollywood, his Runyonesque pugs became as familiar to movie audiences as he had been to real-life fight crowds through his 289 professional bouts. With his splayed nose and cauliflower ear, he was easy to typecast as the punch-drunk pugilist. He certainly had all the symptoms down pat, from the slurred “dese,” “dems,” and “does” of his heavy New York accent to the tipsy, lurching gait of a fighter walking on his heels. He honed his portrayal of them at his Hollywood nightclub, Slapsie Maxie’s, stumbling onto the stage, rocking back and forth on his heels, and slurring his punchlines.

  After a while, as the symptoms he portrayed grew more pronounced, people began to suspect that it wasn’t just an act. In a case of life imitating art, Rosenbloom ironically became the punchy character he’d played onscreen throughout the ’40s. His speech thickened, he would repeat tales from his colorful past without realizing he’d just told them, and he stopped recognizing his friends. He lived out his final years destitute and demented, committed to a sanitarium in his sixties, his doctor attributing his decline to too many head blows from too many fights.

  By the time Rosenbloom died, three years after Corsellis’s study was published, the punch-drunk punchline was no longer a joking matter. A new tool that enabled doctors to peer inside the skulls of living patients—the CAT scanner—revealed clear cerebral atrophy even in asymptomatic boxers. In fact, by the early ’80s, studies were finding brain damage in the majority of professional boxers scanned and correlating the degree of damage to the number of bouts fought.

  The damage evident on those scans was as clear as the symptoms exhibited by two of history’s most celebrated champions, Joe Louis and Sugar Ray Robinson. The two friends had captivated America like no other sports heroes in the middle of the twentieth century: Joe Louis reigning as the world heavyweight champ for an unheard-of twelve straight years, Sugar Ray Robinson earnin
g the title of “the greatest pound-for-pound boxer of all time” with his dominance of the middleweight and welterweight divisions. Both retired as champions at the top of their game only to fall victim to the prizefighter’s curse, returning to fight on long past their primes and fading away with ignominious career-ending defeats. Ultimately, both would suffer mightily from the cruel blows of the sport they had ennobled. Given Louis’s role as a Las Vegas casino greeter, it was easy for fans to trace his descent from the Brown Bomber they had long cheered into the forlorn, punchy, paranoid, demented shell he would become by his death at sixty-six in 1981. In contrast, Robinson’s parallel descent into the shadowy darkness of dementia would be much more private, if no less heartrending.

  Once the world’s most flamboyant celebrity both in and out of the ring, Robinson gradually withdrew from public view after retiring for good at age forty-five in 1965 after 202 professional fights. In 1984, he was finally diagnosed with Alzheimer’s, joining Rita Hayworth as the most famous victims of a disease the American public was just becoming aware of. He would watch live fights featuring current superstars like his namesake Sugar Ray Leonard on TV and exclaim, “I beat that guy!” When Gene Fullmer visited him, Robinson failed to recognize the middleweight he’d battled through four memorable title fights. Alzheimer’s had erased his memories of not only his greatest triumphs but also his closest friends.

  When Sugar Ray Robinson died at sixty-seven in 1989, his brain and body ravaged by Alzheimer’s and diabetes, there were many who implicated boxing as a cause of death. Head trauma had long been associated with Alzheimer’s. Studies showed that people who had sustained head injuries were more likely than others to develop the disease. When head injuries resulted in a loss of consciousness, the risk for Alzheimer’s rose by 50 percent. Of all nongenetic risk factors, brain injury was found to be the strongest.