...See, all the bruins are in a sort of cup, and after you get hit a few times it shakes them out of that cup. When they give you smelling salts it pulls them buck into the cup. It's when the brains get shook up and run together that you get punch-drunk.
...I don't want to be one of them old [retired] fighters with a Hat nose saying 'duh-duh-duh' before a fight.
—MUHAMMAD ALI, announcing his withdrawal from boxing on Dec. 12, 1981
If a boxer ever went as batty as Nijinsky, all the wowsers in the world would be screaming "punch-drunk." Well, who hit Nijinsky? And why isn't there a campaign against ballet?
—A.J. LIEBLING, "The Sweet Science"
The death of Korean boxer Duk Koo Kim last fall aroused yet another cry for the reform or abolition of prizefighting in the U.S. Haifa dozen times over the past 50 years a fatality has prompted a like reaction—in editorials or in Congressional hearings—but the result has been nil. Certainly reform is needed, but no amount of it will eliminate death in the ring. As long as there's boxing, there will be fatalities. Boxers die from acute brain trauma, caused either by a blow (or blows) to the head or, sometimes, a heavy fall to the canvas. The brain is like so much jelly suspended in a bucket, and when you strike the bucket sharply, the brain inside accelerates, twists and bumps around. In a knockout, which is technically a concussion, the force of a punch, transmitted to the brainstem, causes the fighter to lose consciousness. A KO is considered an acute injury, but it's relatively mild compared to what happens if the jarred brain ruptures the blood vessels that surround it. Then a hematoma (a massive buildup of blood) occurs in the narrow space between the rigid skull and the soft brain. As it expands, the hematoma simply squeezes the brain to death. There has been no dispute about that for 50 years.
April 11, 1983
But no one can predict when a punch will cause a knockout or a killing hematoma, and the wearing of protective headgear is no guarantee against serious injury or death. Some of the more recent boxing deaths occurred despite the use of headgear. The only way to prevent fatalities is to ban blows to the head—or ban boxing altogether. On these drastic alternatives the reform movement founders.
Another type of boxing injury has received less public attention. It's chronic brain damage, and here there's the possibility of real reform. Chronic brain damage occurs when a fighter is hit in the head thousands of times during the course of a career. Boxers' encephalopathy is the scientific term; the colloquial expression is punch-drunk. The volume of research on this condition hasn't added up to much over the years, yet, ironically, each time a prominent boxer dies in the ring from an acute injury, a physiological event bearing little relation to chronic brain damage, the impetus for discussion of and research into this more widespread and insidious problem is increased. The widely noted editorials denouncing boxing that appeared in the Journal of the American Medical Association last January weren't merely inspired by the death of Willie Classen in 1979 or of Kim so much as by several new studies, based on new medical techniques, that shed hard scientific light on the punch-drunk syndrome.
After the JAMA editorials and the reports of new studies appeared, Muhammad Ali was interviewed on national TV. He was seated in front of a fireplace at his home in Los Angeles. He did not speak particularly clearly and he seemed distant and grim. Asked whether he might have suffered brain damage from his 61 fights and 21 years in the ring, he replied softly, "It's possible." To many observers, the interview seemed to substantiate rumors within boxing that the 41-year-old Ali, who has been slurring his words more noticeably and acting depressed of late, was indeed becoming punch-drunk.
In a subsequent telephone interview (box, page 67) Ali declined a request by SPORTS ILLUSTRATED that he undergo neurological testing to set the record straight. He said he'd been tested before his last two fights, in 1980 and 1981, and had been found normal. (But an investigation by SI, detailed below, shows that those test results are open to a quite different interpretation.) Ali asked why he, a black champion, was being singled out and whether SI was planning to "check the brains" of white fighters who'd taken a lot of punches. Among others, he cited Jerry Quarry.
A few weeks ago heavyweights Quarry and Randall (Tex) Cobb and a bantamweight named Mark Pacheco were brought together by SI for neurological examinations at Quarry's rural training camp north of Los Angeles. Quarry, 37, retired in 1977 after 63 professional fights. Beaten by Ali in 1970 and '72, he was the last white heavyweight to make a serious championship bid until Gerry Cooney challenged Larry Holmes last year. But Quarry wants to come out of retirement; he has reportedly agreed to fight again in June. Cobb, 28, has a record of 20-3. Last year he earned a measure of fame when, courageous but incompetent, he lost to Holmes in a WBC title bout. He took such a bad drubbing that a dismayed Howard Cosell, who announced the fight for ABC-TV, declared he'd never broadcast a professional boxing match again. Pacheco, 23, isn't a celebrated fighter. With a record of 11-11-1, he's one of those unsung battlers who hit and get hit on undercards in cities like Portland, Ore. and Sacramento. But Pacheco has become a minor notable because of two defeats. He was TKO'd in Portland in May 1982 and denied a license, on medical grounds, to fight in Oregon again for 45 days. But he had a bout 43 days later in New York, and he was again TKO'd. In the current round of Congressional hearings on boxing, which began after Kim's death and the JAMA editorials and reports, the Pacheco case has been cited as evidence of the sport's inadequate medical supervision.
All three men signed releases waiving their rights to medical privacy, and Quarry and Cobb were confident that nothing would be found amiss. The three were examined by Dr. Ira Casson of New York, a board-certified neurologist at Long Island Jewish Medical Center who was acting as a consultant to SPORTS ILLUSTRATED. Admittedly, this trio doesn't constitute a scientific sample. But recent research published by Casson and others indicates that the degree of a boxer's brain impairment can, as a rule, be related to the number of bouts he has fought. This indeed proved to be the case with two of our subjects, as will be shown. But none of the three are at this point in their lives punch-drunk.
In May 1928, Dr. Harrison Martland, a New Jersey pathologist, delivered a landmark paper at the New York Academy of Medicine. Using punch-drunk as a formal term for the first time, Martland said that its early signs were well recognized by the fans and promoters. They also referred to these boxers, he said, as "goofy," "cuckoo," "slug nutty" and "cutting paper dolls."
"Punch drunk most often affects boxers of the slugging type, who are usually poor boxers and who take considerable head punishment, seeking only to land a knockout blow," Martland reported. "It is also common in second-rate fighters used for training purposes, who may be knocked down several times a day." Early symptoms, he said, usually appeared in the extremities, for example, as a slight unsteadiness in gait, and in some cases periods of slight mental confusion occurred. In more advanced cases, there was a general slowing down in muscular movement, "a peculiar mental attitude characterized by hesitancy in speech, tremors of the hands and nodding movements of the head." In severe cases, symptoms included a peculiar tilting of the head, a staggering gait, "the facial characteristics of the Parkinson's syndrome," backward swaying of the body, tremors and "marked mental deterioration" that sometimes required commitment to an asylum. Martland estimated that almost 50% of veteran professional boxers had the condition in either severe or mild forms.
Martland said, "I am of the opinion that in punch drunk there is a very definite brain injury due to a single or repeated blows on the head or jaw which cause multiple concussion hemorrhages in the deeper portions of the cerebrum." About this pathology he was wrong, because he had no scientific data and could only speculate on the basis of his study of people who had died from random head injuries. He admitted that his theory couldn't then be proved, yet he felt compelled to report it because "the condition can no longer be ignored by the medical profession or the public." Accordingly, he called it "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."
Martland ended his paper by quoting Gene Tunney on his retirement after his second heavyweight championship fight with Jack Dempsey the year before. While training for the fight, Tunney had been hit hard by a sparring partner and suffered amnesia. Tunney said later that he didn't know who he was for 48 hours and that it was not until the seventh round of the Dempsey fight that he felt entirely normal. Martland quoted Tunney as concluding, "From that incident was born my desire to quit the ring forever, the first opportunity that presented itself.... 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 injure my brain."
Though it made further study of the punch-drunk condition respectable among medical researchers, Martland's technical paper did little to alter the perception of the condition in the public mind, the sport or the press. Most promoters, writers and ringside physicians continued to discount it. Yes, they agreed, there was such a thing as a boxer becoming punchy, and it probably happened to more than a few, but it could not be accurately diagnosed and therefore was not a matter of serious concern.
Besides, it was not unusual for boxers, especially aging former fighters, to drink too much, to take pills, to eat poorly and generally not to take care of themselves. Some were said to have contracted syphilis, which in advanced cases can attack the brain. In any case, most people in the fight business attributed punch-drunk symptoms solely to causes unrelated to boxing. To do otherwise was to launch an attack on the sweet science. As for the boxers themselves, the ones who seemed punch-drunk denied it; the others didn't care to talk about it. One fighter, Slapsie Maxie Rosenbloom, had it both ways: He made a career in show business spoofing the punch-drunk myth (box, page 56).
For 50 years after Martland, the best medical research on the punch-drunk syndrome was done in England, which has a rich prizefighting tradition. In the heyday of the sport early in this century, novice boxers and fading pros used to fight in booths at fairs, taking on all comers in unsupervised bouts and receiving all kinds of punishment for little money. There were a great many organized fights as well. Thirty-year careers in the ring were not uncommon.
In 1957 an eminent neurologist named MacDonald Critchley reported in the British Medical Journal that he had examined 69 cases of chronic neurological disease in boxers and that "many of these—perhaps the great majority—should be looked upon as examples of punch-drunkenness, either early or well established." Like Martland, he found the symptoms more common among professionals than amateurs, in sluggers than in more stylish boxers and "in the second-rate or third-rate performers than in the intelligent scientific exponent with a championship title." He also concluded that "the sum total of contests is important, as well as the number of occasions upon which the boxers have been rendered unconscious."
Focusing on 21 patients, Critchley found that on the average punch-drunkenness developed 16 years after a boxer began his career. "Of great interest, pathological as well as practical, is the fact that this traumatic encephalopathy is a progressive condition," he wrote. "Once established, it not only does not permit reversibility, but it ordinarily advances steadily. This is the case even though the boxer has retired from the ring and repeated cranial traumas are at an end." Critchley went on to note that a victim usually showed little insight into his deteriorating condition even though his speech and thought became progressively slower and his memory lapsed. "There may be mood-swings, intense irritability, and sometimes truculence leading to uninhibited violent behavior. Simple fatuous cheerfulness is, however, the commonest prevailing mood, though sometimes there is depression with a paranoid colouring."
In 1959 an editorial in the British medical journal The Lancet concluded, "The medical case against boxing is now so strong that we have a clear duty to fight for its total abolition." But in the U.S. medical opinion was divided, and appeals for the banning of the sport were considered ill-founded and fanatical. A study released by Drs. Harry A. Kaplan and Jefferson Browder in 1954 had taken the steam out of the reform movement. The researchers had given 1,043 boxers electroencephalograms (EEGs), a test that records patterns of electrical activity in the surface aspects of the brain. Kaplan and Browder could find nothing wrong in the EEGs of boxers. Sluggers who were hit often tested no worse than skillful fighters, although those with lower ring ratings tended to have "disorganized" EEGs more frequently. The study noted that derogatory remarks about punch-drunk boxers were prevalent, but that this was only "popular theory." Martland, they said, had no documentary evidence such as theirs. The punch-drunk probably would have suffered the same fate had he never boxed at all. Kaplan said that he had served as a ringside physician for three years and that his slow-motion films showed that most blows in the ring missed their mark. Not surprisingly, defenders of boxing still cite this study, though subsequent research has proved that the EEG doesn't reliably measure the type of brain damage that would result in punch-drunkenness.
The consensus of American medical opinion in the late '50s, at the time of The Lancet editorial, could be summed up in the words of Dr. Ira McCown, medical director of the New York Athletic Commission, who wrote in a research paper in 1959 that the notion of punch-drunk was a "medical cliché with which to label any boxer whose performance and behavior in or out of the ring is unsatisfactory or abnormal."
A series of conspicuous fight deaths in the early '60s brought renewed medical attention to boxing. In the spring of 1960 Charlie Mohr, a middleweight from the University of Wisconsin, died of a hematoma he suffered while defending his NCAA championship in Madison, Wis. Mohr was wearing headgear. An overhand right to his padded left temple literally propelled his brain against the other side of his skull, where the fatal damage occurred. His death led to the banning of boxing as an intercollegiate sport, but the controversy over the circumstances continues. The editor of Ring magazine claimed earlier this year that Mohr had gone into the ring with an aneurysm, a cerebral blood vessel waiting to burst. But this charge is hotly disputed by the neurosurgeon who operated on Mohr, and he was the only man to examine Mohr's brain.
In 1962 the professional boxing world was shocked by the death of Benny (Kid) Paret in a welterweight title bout with Emile Griffith. Paret had been knocked out twice in the previous year—demonstrating, in the view of some observers, a serious inability to defend himself. That wasn't a big consideration; Paret was known for being able to absorb punishment. Significantly, he had taken a pre-fight EEG and had been found normal.
Davey Moore, a former flyweight champ, was killed in a Los Angeles bout in 1963. Moore, too, had taken and passed an EEG, but he apparently lied to the California authorities about other health problems. It was clear that the medical supervision of boxing was superficial and, thanks to disparate standards among state commissions, gravely inconsistent. Some boxers were fighting in different states under different names; commissions had little knowledge of medical histories. But the very lack of data and the paucity of long-term research dissuaded most doctors from pressing for reform. Boxing, after all, was a popular and powerful industry.
A 1962 JAMA report asked for upgraded safety standards and more thorough medical exams in boxing. It also called for experimentation with "less padding in the gloves so that the threat of damage to the hands will inhibit the power of blows." At the time, eight-ounce gloves were in general use, as they are today. Compared with the six-ounce gloves used early in this century, they reduced hand injuries and facial cuts, but they allowed boxers to punch each other harder in the head.
Meanwhile, in Britain, research on the punch-drunk syndrome continued. A book-length study completed by Dr. A.H. Roberts in 1969 established the condition as a statistical reality. Roberts examined 224 men randomly selected from among 16,781 who had registered as pro fighters. All were retired. Seventeen percent had hard evidence of brain damage, in the form of drooling, slurring, unsteady gait and/or memory loss. An unspecified number of others showed "disturbed neurological function." Roberts' statistics also indicated that the longer a boxer's career had been, the more likely he was to have conspicuous punch-drunk symptoms.
In the same year a psychiatrist named John Johnson reported on the psychological problems of former fighters in the British Journal of Psychiatry. Johnson found that 16 of the 17 subjects he examined were suffering from one or more of the following clinical conditions: chronic amnesia, morbid jealousy, undue rage reactions or outright psychosis. Using air encephalography, a technique that produces an X ray after air is injected into the brain, Johnson also found a pattern of cerebral atrophy in 10 of the 17. It had long been known that brain tissue doesn't regenerate, that damaged brain cells are lost forever. More than half the men in the sample, in other words, were missing brain tissue. Johnson was interested in the charge that punch-drunk fighters had drinking problems. Alcoholism, like senility, can cause loss of brain cells and evoke psychological disturbances similar to the ones he studied, but Johnson maintained that the patterns of damage in his air encephalograms of boxers were never seen in alcoholics.
In 1973 came the most important study to date, when the brains of punch-drunk fighters were examined in physical detail. Dr. J.A.N. Corsellis, a neuropathologist, and his colleagues in England performed autopsies on the brains of 15 former fighters who had died of natural causes. Friends and family members had provided accounts of the boxers' conditions in later life, from which Corsellis had determined that they had been punch-drunk. The autopsies revealed a striking pattern of cerebral atrophy in 14 of the 15. Though the researchers said that medical controls in boxing had probably improved since their fighters were active, they 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...."
The abnormalities and atrophy Corsellis found were located deep in the middle of the brain, around the septum pellucidum (illustrations, pages 62-63), and also in the cerebellum, the outer section close to the back of the head. The cerebellar structures regulate muscular coordination and balance. A person with damage here may slur his speech or may appear to stagger—"walk on his heels," in ring parlance. The deep midline regions help regulate short-term memory. Forgetfulness may occur if a person has lost tissue here. The conspicuous hallmarks of this damage are abnormally enlarged ventricles, the ventricles being the brain vessels filled with spinal fluid. They expand to fill the space left by the tissue atrophying around them. A more critical finding is a cavum septum pellucidum—literally, a cave in the septum. The jarring from cumulative punches may eventually cause the septum to pull apart, leaving a tunnel-like hole two to eight millimeters wide between the ventricles.
In the 1970s came the introduction of the tool that has revolutionized the medical literature on boxing. This is the CAT scan (computerized axial tomography), a highly advanced form of X ray. With it, abnormalities in the brain can now be observed as they develop and before they result in symptoms. Within the past year three independent studies utilizing CAT scans have come to similar conclusions about chronic brain impairment among boxers.
The first was published in February 1982, in the British Journal of Neurology, Neurosurgery and Psychiatry. In this study Casson and other specialists performed detailed neurological examinations, EEGs and CAT scans on nine professional boxers in New York shortly after they'd been knocked out in a bout and on a 10th boxer who had been stopped on a TKO. The 10 boxers, who came from all weight divisions, were from 20 to 31 years old. CAT scans showed that five of the boxers had cerebral atrophy. "We were surprised by [these] findings [in] active boxers," Casson and colleagues reported. Three fighters who had become champions all showed signs of brain damage. A fourth boxer, who was top-ranked, had a normal scan, but he was the only boxer in the series with an organic mental syndrome—memory loss and confusion. Further analysis revealed that the number of bouts was probably of critical importance. Of the five fighters with 20 or more fights, four had cerebral atrophy; of the five fighters with fewer than 12 fights, only one did. The CAT scan of one fighter, whom Casson characterized as a "slugger," showed a cavum septum pellucidum, and he'd had more fights than any of the others. "Since none of the boxers had been knocked out more than two times in their careers," the researchers concluded, "a cumulative effect of multiple subconcussive head blows is the most likely culprit."
Last November in The Lancet, Dr. M. Kaste and a team of physicians at the University of Helsinki reported on 14 boxers (six professionals and eight amateurs) who had been Finnish, Scandinavian or European champions. Using EEGs and CAT scans, the physicians found brain injury in four of six professionals and in four of eight amateurs.
Finally, in the controversial JAMA issue of last January, Dr. Ronald J. Ross, a Cleveland radiologist, and colleagues published a paper that agreed with the key finding of Casson and Kaste: the more bouts, the worse the CAT scan. Their study involved 40 boxers, only two of them still active. Thirty-eight had CAT scans, and 24 had a complete neurological examination. "The number of bouts fought was significantly related to the presence or absence of ventricular enlargement," wrote the researchers. Moreover, "Patients with abnormal findings on CAT examination did have more frequent neurological symptoms and abnormal neurological findings."
In the same issue with the Ross study was a report by a scientific council formed by the AMA to summarize what was known about brain injuries and deaths in boxing. (Although the report cited the literature on chronic injuries, the council was formed primarily as a reaction to Classen's death. Classen, a middleweight, had been knocked out twice in the eight months before his fatal fight, proving that little had changed in the medical regulation of boxing since Paret's death 17 years before. Kim's death occurred as the council was completing its work.) The council did not recommend a ban on boxing, although two passionate editorials in the front of the journal did so. Instead the council called for a national registry of boxers' records and medical histories, more training for ring personnel and standardized safety regulations among state and local commissions. Responding to the JAMA initiative, Congress has once more held hearings and proposed legislation to create a federal boxing commission.
Casson, meanwhile, says that he has now seen examples of cavum septum pellucidum on the CAT scans of eight pro boxers. It's disquieting that five of the eight are former world champions and two others were top-ranked. Champion fighters stay on their feet in the ring; they can take a punch. The question is, how much will they have to pay for that durability later in life?
Ali has a cavum septum pellucidum, SPORTS ILLUSTRATED has learned. The abnormality shows up clearly on his CAT scan, along with other indicators of damage or atrophy, such as an enlarged third ventricle. The scan was performed at New York University Medical Center in July 1981, five months before Alt's final fight, with Trevor Berbick. In the radiologist's written report, these two findings are noted, but the conclusion is that the scan is "negative," meaning normal. It's a question of interpretation. In reviewing CAT scans of the general population, neuroradiologists occasionally see a cavum or a widened third ventricle. This atrophy is more often characteristic of older people. But most neuroradiologists aren't familiar with the scans of boxers. They don't know that the atrophy like that found on Ali's scan shows up in 50% of boxers with more than 20 bouts—a percentage far higher than in the general population, and that, by other criteria, these same boxers often show evidence of brain impairment. The cavum abnormality is found four times as frequently in boxers as in non-boxers.
As far back as 1976, Dr. Ferdie Pacheco, a general practitioner who has known Ali since 1962, warned him that he should retire from the ring to avoid brain and kidney damage. In 1977, Pacheco quit working Ali's corner. "If you spent 20 years in boxing and an equal amount of time in medicine, you could see brain injury coming up," Pacheco says. "He took some mammoth beatings. There were the fights with Frazier, Foreman and Norton, to say nothing of all the sparring with Larry Holmes and Michael Dokes. Holmes and Dokes were not ordinary sparring partners. They're now heavyweight champions of the world. A moron could add up the picture of impending brain damage, and I urged him to quit because I didn't think it would be wonderful to have the most joyful, talented guy in the world stumbling around and mumbling to himself. But he was the one who wanted to stay on stage. The only role he knew was being champion. I'd just as soon have been wrong."
At the time of his first warnings, Pacheco was unheeded—understandably, perhaps, because he had no data, no hard proof. But in April of 1980, after Ali announced that he was returning to the ring after a 10-month "retirement" to fight Holmes, his father, Cassius Clay Sr., publicly expressed concern. "I thought he wasn't walking good," he said. "I thought maybe his hip was bothering him. I wasn't sure of his speech, either, but the way I look at it, that boy has been fighting since he was 12 years old. A man can only stand so many licks to the head."
Ali went to the Mayo Clinic in July of that year for a series of tests. The Mayo report, attesting that he was normal, reassured Nevada authorities that he was fit to fight Holmes in October. But after his poor showing—Holmes was awarded a TKO when Ali didn't come out for the Nth round—Ali consulted Dr. Dennis Cope, a specialist in endocrinology at the UCLA Medical Center. Ali revealed that he'd been taking excessive amounts of medication for a thyroid condition while training for the Holmes bout. One of the drug's effects had been to help Ali lose weight, but it also left him drained for the fight. However, Cope's report released in December 1981 declared Ali's thyroid gland normal. Cope also wrote that a neurological examination, which included an EEG and a CAT scan, had found no abnormalities except for a partial or complete loss of smell. The report stated, "The patient tended to talk softly and to almost mumble his speech at times; but when he was questioned about this, he was able to speak appropriately without any evidence of a speech disorder. He was evaluated by a neurosurgeon and neurologist who felt that his speech pattern was not pathologic." The report concluded, "The patient's health status is excellent and there is no evidence from a health standpoint that he should be limited whatsoever in his activities."
Two weeks later Ali visited England. Interviewed on BBC radio, he slurred his speech, and when he recited a poem on how he would beat Holmes in a rematch, listeners found most of it incomprehensible. The BBC canceled the broadcast of a taped interview for another program because Ali's speech was too slurred to be understood. A BBC spokesman said, "It was very sad that so much of what history's most celebrated fighter said was unintelligible." When a London reporter asked him if he could possibly be punch-drunk, Ali replied, "I have heard about people being punch-drunk, but I do not feel drunk." He added, "When you get as great as me, people always look for some type of downfall."
The series of tests that Ali underwent at the NYU Medical Center in the summer of 1981 was supervised by Dr. Harry Demopoulos, a professor of pathology. Ali had met Demopoulos through Clint Eastwood, the actor, and Demopoulos says, "He [Ali] came here to NYU because he was contemplating going back into the ring, or at least trying to get in shape, to think about it. I don't think any of us encouraged him to go back into the ring. We did encourage him to get back into shape, though. Because he had gotten fat, eating crap, laying around the house. We didn't think that was good for him. So we sort of convinced him that he ought to go through a full battery of tests to see if he could go back into training."
The tests included an EEG, a neurological exam and a CAT scan. Then, before the Berbick fight, Demopoulos was quoted as saying that the Mayo Clinic, UCLA and NYU tests, which involved 30 doctors, all showed "absolutely no evidence that Muhammad had sustained any injury to any vital organ.... His blood tests indicate he has the vessels of a young man." He attributed the slurring to "a psychosocial response" and added, "If the slurring were due to permanent damage, it would be there all the time."
Last February, Casson and SI reporters visited Demopoulos at NYU to review Ali's CAT scan. "They read this as normal?" Casson asked, referring to the NYU neuroradiologists who had approved the report. Demopoulos assented. "I wouldn't have read this as normal," said Casson, looking closely at the sequence of X-rays. "I don't see how you can say in a 39-year-old man that these ventricles aren't too big. His third ventricle's big. His lateral ventricles are big. He has a cavum septum pellucidum." Demopoulos stood by the NYU specialists' negative findings.
In the course of the discussion that followed, Casson made the point that many boxers with enlarged ventricles and a cavum have neurological problems. He said that given what Ali's CAT scan showed, additional testing—particularly exams that identify shortcomings in memory—might have been in order. Such testing was not done at NYU. Demopoulos said that Ali probably would not agree to these tests now because "he's depressed" and because "everybody is telling him there's something dreadfully wrong with him, that, in essence, 'You're no good anymore.' "
Casson asked, "What do you base this diagnosis of depression on if a psychiatrist hasn't examined him? Does he have any of the vegetative symptoms of depression? Loss of appetite, changing sleep patterns?"
Demopoulos: "He has changes in sleeping patterns. But I'll tell you what tips you off that it's not an organic problem. The man perks up sometimes under favorable circumstances, and he's just like the Ali of old."
Casson: "Well, that doesn't mean it's not organic. I've seen many patients, especially the early dementias, who one day seem fine, the next day seem terrible, the next day seem fine.... Do you think slurring of speech is from depression?"
Demopoulos: "I think in his case, yes. You have to see the man. You have to meet him, you have to know him, and you have to talk to him."
The testing methods employed by contemporary researchers such as Casson, Ross and Kaste have centered on CAT scans, neurological exams and neuropsychological testing. A formal neurological exam consists of a battery of tests measuring muscle tone and strength, reflexes, coordination and balance (the subject is asked to walk and then hop in a straight line), eye movement, heart and lung function and basic cognitive exercises. In the cognitive tests, the subject is asked to spell some simple words backward or to name the year and day of the week. Casson stresses that in the case of Ali one cannot make a judgment on the basis of the scan alone; one must also test Ali neurologically. All's previous neurological results have all been reported as normal, although SPORTS ILLUSTRATED has learned that one of those exams nevertheless revealed a mild organic mental syndrome, i.e., failure to perform normally on the cognitive tests.
In their unpublished, ongoing research, Casson and his colleague, Dr. Ozzie Siegel, chief psychologist at the Queens Hospital Center in New York, have introduced a third test to their study of boxers, the neuropsychological battery. These are standardized probes of perception and short-term memory. The subject is asked to recall the details of a paragraph that is read to him. He also uses a pencil to connect dots and to draw simple geometric designs, once from memory and once with the design in front of him. His performance is timed as well as analyzed. To a layman, how somebody draws a squiggle may not seem like a sophisticated test of brain damage. But Siegel points out that this battery had been used for years to measure damage in victims of head injuries, from such things as car crashes or falls, and it had been found reliable. When neuropsychological tests are given to boxers, say Casson and Siegel, the results tend to correlate with the findings of the CAT scans and, to a lesser extent, the neurological exams.
Which brings us back to SI's tests of Quarry, Cobb and Pacheco, who is not related to Ali's former doctor. All three men had CAT scans. At Quarry's camp, all three were given neurological exams by Casson and underwent neuropsychological tests, administered by Casson and evaluated by Siegel, who wasn't present. The CAT scans were reviewed and the results confirmed by specialists other than Casson—Ross and the two radiologists who collaborated on his JAMA paper, and Dr. John Bentson of UCLA, where Quarry and Pacheco underwent their scans. Ross and his colleagues did not know the subjects' identities.
First, Cobb. His neurological exam was normal. His CAT scan (left) was normal. His neuropsychological results were also normal. In other words, Cobb shows no evidence of brain damage. Is this surprising, considering the beating he took from Holmes and given that he fits the "slugger" mold? The key fact about Cobb is that he has had only 23 professional bouts, most of them victories by knockout, and no amateur fights at all. (He had been trained in karate.) It can be concluded that the cumulative effects of his short career in the ring have not made a mark—not yet, maybe never.
Next, Pacheco. His neurological exam was normal. But his CAT scan showed a cavum septum pellucidum and a mildly enlarged third ventricle. He performed badly on the neuropsychological tests, says Siegel, who guessed—accurately—that his scan would reveal some damage. But Pacheco is only 23, five years younger than Cobb. "I'll bet this guy had a lot of fights," Siegel had predicted to Casson.
Pacheco says he has been boxing since he was four. He estimates that he has had "over a couple hundred" amateur bouts. In his 11 losses as a pro, he has sometimes been hurt, particularly in the back-to-back TKOs in Portland and New York, and since then in a defeat in California in which the ref stopped the fight in the first round. "The way his record was going," says Dr. Jack Battaglia, who lifted Pacheco's licence after the Portland loss, "he didn't need a CAT scan, he should have just been stopped."
Pacheco himself is disgusted with his career in boxing and won't continue it. "It's not worth it," he says. "The officials are getting worse. I can't give it 100 percent anymore. I'm just tired of it. So I might as well get out before I get hurt." Upon hearing the results of SI's tests, Pacheco reconfirmed his decision to retire.
Finally, Quarry. Like the others', his neurological exam was normal. But his CAT scan was slightly worse than Pacheco's—it showed a cavum, enlarged lateral and third ventricles and a suggestion of cortical atrophy. And his neuropsychological results were poor. Says Casson: "He did poorly on the test of visual motor perception. He did poorly on that test of connecting the dots. The only one he did well on was the digit symbol test. The psychologist and I are not saying that Quarry is punch-drunk where he can't walk straight, that kind of thing. What we're saying is that he has problems with certain cognitive functions—short-term memory and perceptual motor ability."
Quarry had his first formal fight at the age of five, a junior Golden Gloves event. At 16, he had had 105 amateur bouts. His amateur record was 170-13-54, and his pro record 51-8-4. One of his early losses occurred 10 days after he broke an ankle. His trainer, Harold Taber, went to Quarry's father, who was then the boy's co-manager, and told him that Jerry couldn't fight because his ankle was broken. "He's got to fight," Quarry's father said. "We've got to have the money." Before the fight, father and trainer took Quarry to "a Mexican witch doctor," says Taber, "who put fire on his ankle and everything, but they still stuck him in there."
Quarry says, "I fought a lot of fights I shouldn't have fought—one with a broken hand, one with hepatitis and another one with a broken back. I was 22 years old. I was so naive and young I didn't have the intelligence. If I had the intelligence I have now, there's no way in hell I would have gotten in the ring like that. I figured I had some people behind me, especially my father being my co-manager, that they would have pulled me out. But no, they needed the money, so they sent me to the wolves. 'Prostitute him'—that's exactly what they did."
As Quarry says these words, he doesn't sound bitter, and he doesn't sound punchy. A thoughtful, animated man, he is mindful of the need for medical reform in boxing, yet personally philosophical, not bothered by the threat of brain damage. "You step into the ring," he says, "and you know there's a chance of getting knocked out, of getting hurt, but you figure your abilities are good enough that you can handle yourself appropriately." But he hopes that federal legislation will result in uniform medical standards and that these in turn will protect fighters from ruthless managers. "The manager is the one putting a fighter back into the ring one week after he's been knocked out," he says. "But if they have strict enforcement of physicals, then the manager won't have a damn thing to do with it." Quarry's scenario for himself, which apparently wasn't altered by learning the results of the tests, is to get in shape and, if all goes well, mount a challenge for the cruiser-weight title.
Although Casson was troubled by the prospect of Quarry's return to the ring—he urged Quarry against it—he emphasizes that his research has not convinced him that boxing should be banned. Casson describes himself as a sports fan; he will watch a fight on TV. "No matter what anybody says, boxing will continue," he says. But he thinks that young boxers could reduce their chances of injury by passing up unnecessary bouts at the lower levels and fighting only to advance their careers. "Even bums hit you in the head," he observes.
But to become a champion, wouldn't a boxer have to withstand a sufficient number of punches, 20 or 30 fights' worth, to affect his CAT scan, even if those punches didn't result in neurological or punch-drunk symptoms? Just when his work was beginning to pay off, would a doctor tell him he should stop? A real dilemma, Casson concedes. Still, he says, "A boxer ought to know what he's getting into if he wants to go on and be a champion. He should know what he may be sacrificing. A doctor has to tell the boxer if he thinks the fighter should stop, but in the end it's not really a medical decision. Society has to decide what we're going to do about boxing."
Just how bad is the brain damage that shows up on CAT scans and neuropsychological tests? For Quarry and Pacheco and perhaps Ali, it's not bad, not a disability. Minor memory failures aren't crippling. But aging certainly compounds whatever deterioration may exist, as all the research shows.
Physicians who disagree with the implications of Casson's work and that of researchers like Ross point out that there are no prospective studies; that is, studies that track a younger boxer with alleged abnormalities over a period of 10 or 20 years.
"I think we're jumping the gun," says Dr. Edwin Campbell, medical director for pro boxing in New York. Campbell helped enlist the fighters for Casson's studies and was a co-author, but says, "We just haven't done enough work yet. And we don't know how boxers compare with athletes in other sports, like football, who get frequent concussions."
Casson and Ross are the first to admit that more detailed, long-term work should be done. "But let's start now," Casson says, "before another generation of fighters comes through." Though Ross's work received considerable publicity, three months later he's frustrated by the lack of follow-up concern. "The big people in boxing haven't commented," he says. "Who's going to pay for these longer studies? What's being done? I'm afraid everything's going to die down."
The new legislation being discussed in Congress would create a commission to institute national standards among state commissions for all pro fights. There would be rigorous physical screenings and a "passport" for each boxer that would certify his medical history from past bouts. But CAT scans and full neurological exams before and after fights aren't practical—nor, at $300 apiece, cost-efficient, given what the average boxer earns. Casson and Siegel suggest that their neuropsychological tests, which are easy and cheap to administer, might serve as a first screen for possible brain damage. They have developed an "impairment index." If a fighter scores abnormally on at least half their tests, they have found, his CAT scan and/or EEG will also show abnormalities. Of course, no legislation is a substitute for vigilance and care within boxing itself. Dr. Battaglia of Oregon points to the ringside physicians. "If you've got problems on a CAT scan, you're too darn late," he says. "You've got to pick up the signs in these kids way before then. If I see a kid taking three licks now to put one in, as far as I'm concerned school's out—then you do the scan."
Will there be real reform? Cobb's reaction to the brain injury controversy may give a clue, even though he might be described as a boxing anarchist. "Dammit, I'm a grown man," he says heatedly. "If a man doesn't want to fight, then lay down, sucker. I'm not going to have someone run my life for me. If you get a federal commission involved, all you're going to have is a bunch of political appointees. A lot of flurry, a lot of fluff, all show and no go.
"I'm a whore who sells his blood instead of his ass. But that comes with the sport."
This illustration compares a boxer's brain that has been severely damaged with a normal one. In each case the bruin is sectioned as at right. The red mass of blood at upper left is a hematoma, which usually causes death. The signs of chronic injury are indicated by color coding: Enlarged ventricles (the three green pockets) show cerebral atrophy, as do the deep spaces I orange) on the brain's surface. The pink cavity at center is a cavum septum pellucidum.
From lop to bottom are CAT scans of Cobb, Pacheco and Quarry. The illustration beneath them shows where this X-ray "slice" was taken, Yellow circles were added to point out the septum pellucidum, a membrane between the ventricles. Cobb's normal septum is the light vertical line between the dark curving ventricles. But on the scans of Pacheco and Quarry there's a double line with a dark band in between, showing the septum is divided to form a cavum septum pellucidum.
In their neuropsychological exam, Quarry, Cobb and Pacheco each took a test of visual motor perception, which measures ability to reproduce simple designs like those in the top row. Cobb's figures were normal. Errors by Pacheco and Quarry, even subtle tilting or overlapping, show brain injury.