The Concussion Crisis

by Linda Carroll

  Although Fahn hadn’t treated him since the 1984 evaluation, the neurologist tracked the inexorable worsening of Ali’s symptoms over the following two decades. The pattern led Fahn to believe that the Parkinson’s syndrome had progressed into full-blown Parkinson’s disease, the traumatic blows having kicked off an irreversible sequence of destruction in Ali’s brain.

  What made Ali’s case unusual among boxers was that the parkinsonian symptoms predominated to the apparent exclusion of dementia symptoms. Pugilistic parkinsonism, as first described in the medical literature by Harrison Martland back in 1928, is relatively rare. Dementia pugilistica is not. It could ravage whole weight classes—and whole families.

  • • •

  Jerry Quarry was not the only one of Jack Quarry’s sons to go into the risky family business. Jack, a onetime fighter of sorts with the letters H-A-R-D tattooed across the knuckles of his left hand and L-U-C-K across his right fist, schooled all four Quarry boys on boxing technique and toughness as a rite of passage. By the age of five, when they were required to step into the ring for real bouts against real opponents, they already had their father’s family motto tattooed into their brains: “There’s no quit in a Quarry.” The oldest, Jimmy, did manage to quit before he could turn pro and before boxing could do too much damage to his brain. Jerry and his two kid brothers weren’t so lucky.

  Mike, younger by six years, idolized Jerry but wanted desperately to emerge from his shadow, their sparring sessions degenerating into brawls in which both would fling off their headgear to see who could withstand the hardest punches. A jab-and-move stylist who lacked the punching power that made Jerry a top heavyweight contender, Mike ran off thirty-five straight wins to earn a shot at the world light-heavyweight championship. In that 1972 title fight, on the undercard of Jerry’s rematch with Ali, Mike was knocked out in the fourth round by a left hook so devastating that the champion, Bob Foster, was sure he’d killed his unconscious challenger. Mike would never be the same after that, but, like Jerry, he had too much heart and not enough quit in him.

  Five years later, Mike was taking a bloody beating when Jerry, working his corner, stopped the fight after the sixth round. In the locker room afterward, Jerry caressed Mike’s swollen face and declared, “I’ll never let him fight again, not if I can help it. He’s gonna quit. I will make him quit.” Then he turned to Mike and said firmly, “Say it.”

  Mike countered, “I’m gonna fight one more to go out a winner—”

  “Say it!” Jerry shot back, his voice rising.

  Mike nodded in resignation as Jerry leaned over and kissed him on the neck. But Mike didn’t say it, and he didn’t do it. He fought nine more times over the next five years, finally retiring after his eighty-second pro bout ended in a dismal loss. Within a few years, he was forgetful and disoriented, walking on his heels, losing his balance, punching holes in walls. He spent the next decade bouncing from job to job—construction worker, insurance salesman, hairdresser, landscaper’s assistant, church janitor—only to get fired over and over because he couldn’t remember what he was supposed to do. In time, his wife became his round-the-clock caregiver, feeding him, bathing him, sitting him down on the toilet while she showered so he wouldn’t wander off. Finally, she had no choice but to move him into a full-care facility, where he gradually lost the ability to walk and to talk.

  Mike Quarry’s descent into dementia pugilistica paralleled that of the famous big brother he echoed both in life and in death. Despite his own deteriorating condition, Jerry had the presence of mind late in his life to apologize to his little brother for hitting him so hard and so often. By the time Mike died at age fifty-five in 2006 from the same dementing disease that had killed Jerry seven years earlier, their brother Bobby, the youngest by twelve years, was battling pugilistic parkinsonism following a short, mediocre heavyweight career.

  If boxing was the family legacy, brain damage was the family curse. To be sure, the Quarry brothers had inherited a lot from their father: the toughness, the passion for the fight game, the motto that kept them from quitting before it was too late. But they also may have inherited something worse: genes that made them more susceptible than other boxers to punch-drunk syndrome.

  Dr. Barry Jordan didn’t need to see dementia pugilistica racing through families for him to wonder whether there was a genetic predisposition. All he had to do was glance up from his ringside seat at boxing matches everywhere from Madison Square Garden to small clubs in upstate New York.

  As chief medical officer for the New York State Athletic Commission since 1987, Jordan was the physician responsible for clearing all boxers to fight professionally anywhere in his jurisdiction. A neurologist at the Hospital for Special Surgery in Manhattan, he had gravitated to boxing only because he was interested in brain injuries and knew he would see a lot of them as a ringside doctor for fights featuring George Foreman, Mike Tyson, Sugar Ray Leonard, and numerous lesser lights. Even he was surprised when he became a fan of a sport that the American Academy of Neurology and the American Medical Association condemned and pushed to have banned. Believing that such a prohibition would send boxing underground and lead to more injuries and deaths in bootleg bouts, he resolved to make the sport safer through stricter regulations, closer medical supervision, and further scientific research.

  Through the years, Jordan observed many boxers with brain damage and, in his research, tried to figure out why some were more prone to dementia pugilistica. No single factor could completely explain why some became punch-drunk and others didn’t. He would see two boxers with identical exposure to the sport and wonder why one appeared healthy while the other was walking on his heels. He began to suspect there might be some sort of genetic predisposition. Then in the early ’90s, when scientists discovered a genetic mutation that predisposed people to typical late-onset Alzheimer’s, a bell went off in his head. Recalling earlier studies that showed head trauma raised the risk for the disease, he started thinking about his punch-drunk boxers. The dementia they suffered seemed very similar to Alzheimer’s, from the debilitating symptoms right down the plaques and tangles in their brains. Maybe, he thought, the boxers who developed dementia pugilistica possessed the recently discovered genetic mutation.

  To test his hypothesis, he recruited twenty-seven retired boxers and three active ones for a study he led with Dr. Norman Relkin, director of the Memory Disorders Program at Cornell Medical Center in Manhattan. The two neurologists and their colleagues conducted detailed examinations of the thirty boxers and found nineteen had symptoms of chronic traumatic encephalopathy. At the same time, DNA samples were analyzed to determine whether the boxers possessed the genetic mutation implicated in Alzheimer’s. The mutation, an allele of the apolipoprotein E gene dubbed apoE 4, was found to significantly increase the risk for Alzheimer’s in people who had at least one copy; the risk rose as much as tenfold in those who inherited copies of it from both parents. What was more, a subsequent study showed that people with the allele who had suffered a traumatic brain injury were five times more likely to develop Alzheimer’s compared to those who possessed the allele but no history of TBI.

  When Jordan and his colleagues analyzed the boxing data, they determined that fighters who had the mutation were far likelier to get dementia pugilistica and to get it more severely and at a younger age. Among the boxers showing obvious symptoms, 50 percent had at least one copy of the mutation, as compared to 11 percent of the others. All three of the boxers with severe symptoms had at least one copy. Boxers who had fought more than twelve pro bouts suffered worse symptoms if they possessed the allele.

  With its 1997 publication in the Journal of the American Medical Association, the study raised an ethical question that extended far beyond the confines of the ring. The hypothesis that apoE 4 conveys a genetic predisposition to chronic traumatic encephalopathy, the authors wrote, “potentially has extraordinary ramifications for the regulation of health and safety in boxing and other high-risk sports including American foo
tball, soccer, and ice hockey.”

  As it turned out, apoE 4 wasn’t a strong enough predictor for anyone to revoke even a boxing license. But Jordan, now director of the Brain Injury Program at Burke Rehabilitation Center, is still hunting for a better biomarker. Sitting in his cluttered office in White Plains, New York, surrounded by photos from his days as a ringside doctor, Jordan mulls over the conundrum presented by a disease you don’t see until it’s too late. By the time boxers develop symptoms of dementia pugilistica, he points out, “the horse is already out of the barn,” so you need to find a way to identify which ones are genetically at risk before they even start to fight. That at least would enable you to advise susceptible boxers on their risks, to follow them more closely with mandatory exams and scans, and to alert their doctors about the need for heightened vigilance.

  If scientists ever discover a biomarker that could predict with absolute certainty which athletes would develop trauma-induced dementia, it will create an ethical dilemma: Do officials have the right to stop them from participating in contact sports? Until medical science can offer a solution, everyone must continue grappling with the real dilemma that has predominated the century and a half since the Marquess of Queensberry rules reformed boxing into its modern era: How do you make the most brain-damaging sport safer?

  • • •

  Hours after retaining the world welterweight title with a left hook that knocked Jimmy Doyle into a coma from which he never awoke, Sugar Ray Robinson was summoned to the Cleveland morgue to testify at a coroner’s inquest.

  “Did you intend to get Doyle in trouble?” the coroner asked the champion.

  “Mister,” Robinson replied deliberately, “it’s my business to get him in trouble.”

  Thus did Robinson speak for all the boxers who have unintentionally killed or maimed men in a legally sanctioned sport where the goal is to injure an opponent’s brain by inflicting damaging blows to the head. Each high-profile ring death from acute brain trauma, like Doyle’s in 1947, would invariably spur a new round of calls for the abolition of a sport that killed an average of ten boxers a year. Sweden outlawed boxing in 1969 and Norway in 1981, but the United States did little to discourage it since the late teens when brief bans in some American locales succeeded only in driving fights underground into backrooms and onto barges.

  The medical community had a stronger case than politicians, on moral and ethical grounds. In 1984, the American Medical Association formally called for the elimination of both amateur and professional boxing. Dr. George Lundberg, editor of the Journal of the American Medical Association, had fired the first shot in the AMA’s crusade with a 1983 editorial demanding that boxing be banned, calling it an “obscenity [that is] less sport than is cockfighting” and “a throwback to uncivilized man [that] should not be sanctioned by any civilized society.”

  The AMA offered a smoking gun the following spring when its prestigious journal published a study that evaluated eighteen retired and active boxers with neurological exams, EEGs, CAT scans, and neuropsychological tests. Thirteen of the fifteen professional boxers in the study—a staggering 87 percent—showed definite evidence of brain damage on at least two of the four measures. Eight of the eighteen professionals and amateurs had abnormal CAT scans, including 75 percent of those with more than twenty pro bouts. All eighteen had abnormal neuropsych test results. “Existing medical controls and safety measures did not prevent chronic brain damage in this group of boxers,” Ira Casson, the neurologist who had recently found Jerry Quarry’s brain damage, and his co-authors concluded. “There is no reason to believe that future generations of boxers will be any more fortunate.”

  The AMA was hardly alone in its campaign against boxing. The World Medical Association started waging its own fight to ban what it called a “barbaric” sport, as did the national medical associations of Britain, Australia, Canada, and other countries. All cited the alarming incidence of not only acute brain injury from a knockout punch but also chronic brain damage from repeated head blows.

  Until the fall of 1984, the American Academy of Neurology held out hope that its seven thousand member neurologists could help find ways to make the sport safer. But its president, Dr. Nelson Richards, changed his mind after hearing Muhammad Ali give an unintelligible TV interview and then hearing colleague Stanley Fahn’s diagnosis of the ex-champion’s parkinsonism. With Richards joining the fight against “a so-called sport that defines itself by having one man try to destroy another,” his organization formally called for a ban, as did the American Neurological Association.

  Even if there were a ban, of course, the odds of ever stopping people from boxing are about as good as changing what fighting reflects in human nature. With no realistic hope of outlawing the sport or even banishing head blows from it, the medical community found at least one thing that boxing officials couldn’t fight them on: the need for safety reform. Unfortunately, the federal government’s attempt at reform, the Professional Boxing Safety Act of 1996, was like putting a Band-Aid on a bleeder, failing even to set up a national regulatory body to oversee the health and safety of fighters. That left licensing decisions up to the individual state commissions, many of which would clear boxers to fight based on the most cursory of physicals by any kind of doctor.

  New York proved an exception. During Jordan’s fifteen-year tenure as chief medical officer, the New York State Athletic Commission enacted the strictest medical code of any state in the nation: all boxers had to pass annual neurological exams, CAT scans, and EEGs before they could be licensed to fight professionally, with MRIs required every three years. Revoking licenses and denying applications in as many as 5 percent of cases, Jordan noted, “We saved a few lives.”

  It wasn’t just about saving lives, but also about preserving quality of life for the countless survivors like the protagonist in Simon and Garfunkel’s 1969 hit—“The Boxer”—who “squandered [his] resistance for a pocketful of mumbles.” The concern extended beyond the short-term effects of acute TBI to the long-term effects of chronic TBI. For every boxer who becomes symptomatic while still active, countless more develop deficits years after retirement. So insidious is the disease that brain damage inflicted during their glory days may not manifest itself until their golden years.

  That’s how it caught up with Floyd Patterson. The youngest world champion ever when he won the heavyweight crown at twenty-one in 1956, Patterson had gone on to distinguish himself in many ways throughout a twenty-year pro career. He was an anomaly—too slender, too insecure, too mild-mannered to survive without a killer punch and a killer instinct. He was the sensitive soul who, after becoming the first man ever to regain the heavyweight title, delayed his own celebration to cradle his knocked-out opponent in his arms before helping him off the canvas. He was the tortured soul who would pack a fake beard and mustache in his equipment bag as a disguise so he could slip out of arenas incognito should he suffer a humiliating defeat.

  Patterson found more and more use for the disguise after being separated from his senses and his crown with seven knockdowns in the third round of his 1959 title defense against Ingemar Johansson. Though Patterson avenged that knockout a year later by rendering Johansson unconscious for eight minutes to regain the title, the humiliating losses would come as furious and fast as the fists of Sonny Liston and Muhammad Ali. Liston needed just two minutes to knock out Patterson and take away the title in 1962, and just two minutes to embarrass him again in their 1963 rematch. Two years later, Patterson challenged Ali, who’d taken the title from Liston, in a grudge match fueled by the ugly barbs they had traded over which one would be the better role model for black America. Throughout their 1965 title bout, Ali taunted, teased, and toyed with Patterson, continually pummeling him to the point of collapse only to back off as if to deliberately extend the torture. The mortifying punishment went on for twelve rounds until the ref stopped it with the challenger out on his feet. Patterson fought for another eight years until a knockout loss in his 1973 rematch
with Ali convinced him to finally leave the ring at age thirty-seven.

  In retirement, Patterson was often asked about the most dubious of all his feats: being knocked down more than any other heavyweight champion. “Yes,” he’d reply with a proud smile, “but I also got up more than anyone.” Maybe he shouldn’t have. His weakness—the glass jaw that signaled his inability to take a punch—wouldn’t have been such a health liability if not for his determination to keep getting up only to absorb more punishment. Beyond all the knockdowns and knockouts, there were all the punches that the aging Patterson had absorbed over twenty-two rounds in two bouts against a young up-and-comer named Jerry Quarry, the first a draw and the second a loss by split decision. The impact of all the punches a boxer like Patterson took over the course of his career—from the hardest hooks to the softest jabs—could add up to more brain damage than the knockout blows.

  Patterson was maybe fifty when the cumulative effect of sixty-four professional bouts and countless sparring sessions caught up with him. In the mid-’80s, he began showing signs of dementia, often forgetting the names of people he’d known for years. Within a few years, it was clear that his affliction was more than mere forgetfulness. Even when he was appointed chairman of the New York State Athletic Commission in 1995, it was already an open secret among boxing insiders that he was no longer capable of handling a job whose duties were anything but demanding.