The hidden face of boxing

The AMHE Newsletter (# 254) has debated in one article the complications of brain injury in professional soccer and American football players. Recently a world super featherweight boxing champion-contender to the world title, lost his life in a championship fight after being knocked down in the 10th round. This was the third death of the kind recorded in the last two months in the world of professional boxing. This professional athlete who lost his life was one of the AMHE’s son. Patrick Day was 27.

Professional boxers have been known forever to be victims of repeated blows to the head. In the antiquity, a sport called “Pankration” was practiced in a combination of what we call now Boxing and Wrestling with the addition of biting and gouging eyes and/or any weaponless form of attack with feet and fists as weapons. Arrachion of Phigalia won an Olympic title in this discipline in 564 BCE, after dislocating a toe of his opponent prior to be himself a victim of a sudden death. He was crowned winner even though he was dead.

Simon Byrne also called “the Emerald Gem” fought a Scottish champion Alexander McKay in June 1930.and knocked him down in the 47th round of a bare-knuckle fight with a punch to the throat. McKay died the same day. Three years later Simon Byrne fought James Burke for the championship in England on May 30 1833 during a match which lasted 3 hours and six minutes. Both boxers were exhausted, collapsed in the 99th round and could not get up. Byne won the fight but died three days later.

Tom Molineaux, a former slave fought in England and retired in 1815 to turn himself to drinking alcohol and died in poverty at age 34. Many articles from the United Kingdom and Australia. have discussed the lifetime of a professional boxer in the ring, dropping from 19 years to five years because of fear of Traumatic Brain Injuries. The training activities looked at less interactions with sparring partners to avoid repeated injuries to the brain, an increase in monitoring by a medical team, with frequent neuroimaging assessment for early detection of traumatic brain injuries. This routine has alerted the team to encourage the fighter’s longevity in the ring and to minimize brain injuries.

What in the past was called a “punch drunk syndrome” is now termed “Chronic traumatic brain injury” (CTBI)!!! A constellation of Neurological symptoms affecting the pyramidal, cerebellar and extrapyramidal domains become predictable. Cognitive impairment is seen in the late stages as well as neuropsychiatric and behavioral symptoms. Amateur boxers showed the same signs at a lower incidence than the professional spite of their protective headgear and shorter bouts.

There were 266 documented deaths during the era (1740-1889) before gloves were introduced in the rings. Between 1809 and 2019, it was found that 1876 boxers have died as a result of blows to the head. Statistics were reported by Manuel Velazquez after one of his friend, a retired boxer (Pete “Kid Indian” Nebo) was confined to a mental institution following multiple blows to the head and judged incompetent. His compilation of events was later updated after his death by Joseph Smith.

Death in the ring never stopped. A 49–year-old Italian (Christian Daghio) became a fatality in November 2018, in a World Boxing Council title fight in Thailand when he was knocked down twice in the 12th round of the match. Taken to the hospital, he was pronounced dead two days after. It is now a pattern in boxing, when an American boxer, of Haitian descent, Patrick Day was knocked down as well in the 4th, 7th and 10th rounds during a championship fight in Chicago and carried out on a stretcher with a head injury. He never recovered from a coma and died two days later. Two more fighters in the earlier months have succumbed from blows to the head following their Knock-down.

In the past, amateur boxers were found to have a longer career in spite of many unsupervised bouts each day, without any medical supervision. They fought with 6 oz. gloves and the ring official showed less willingness to stop bouts when a boxer was overmatched. There was also no mandatory exclusion after a knockout or a head injury. It appears that the period of the great depression in the 1930’s was responsible for the longer involvement of boxers in the ring because of financial gains. More, many professional boxers at retirement chose to become professional sparring partners or tent/boot boxer with their documented neurological problems.

There is currently a false perception that professional boxing is decreasing in popularity around the world especially not in the United Kingdom, Australia or the United States. The prevalence of Chronic brain injury may be difficult to determine but if one has expected to find in professional boxing, a “dying art”, recent statistics have proven the inverse. The sport enjoys a popularity everywhere.  A significant risk reduction in terms of exposure to head injury was observed overtime, but unfortunately, challenged by the three recent championship fights which resulted in the death of a boxer following knockdown blows to the head.

Boxing exposure, as a surrogate for repetitive concussive head trauma is a risk factor for Chronic Traumatic Brain Injury. Mandatory computerized cognitive screening, magnetic resonance scans, Apo E genotyping are now required in the United Kingdom and Australia to be performed each three years to allow a boxer to continue fighting. Neuro-diagnostic methods to assess the frequency of Chronic Traumatic Brain Injury are non-existent. It is difficult to understand why such sport is still permitted by the authorities in charge of the regulations. It is true that the boxers practicing this art is also aware of the risk of injury.

In the past, many boxers had a rough life. They were gang members or served time in prison. They fought with different kind of gloves without any medical supervision. Knockdown on knockdown, these fighters will stand up and continue to fight. Boxing was their way of life.

One remembers certainly, decades ago, the long boxing fight between Espana and Lira, for the World Boxing Association in a fight for the Lightweight title. Ernesto Espana threw an uppercut which snap his opponent’s head upward in a gush of blood over the right eye, stopping Johnny Lira in nine rounds. Lira suffered a broken jaw.  Howard Cosell did not understand that he was witnessing a fight who took the “life” of Johnny Lira. The ring doctor stopped the fight and Espana won by a technical knock-out.

Cosell is now dead and Johnny Lira suffered from paranoia, forgetting things and drinking profusely. His speech become slurred and he used sign-languages he picked up while training young deaf boxers. The boxing community in Chicago rallies around and held fundraisers to pay for his medical bills. He died penniless like many others.

In 1982, Barry Mc Guigan fought Young Ali and Ali went to a coma to never recovered. In the late 2015, Hamzah Aljahmi died in Ohio following his professional debut.  In 2016, Mike Towell a Scottish boxer died after a match in Glascow. Nick Blackwell an English boxer was forced to retire after a head injury sustained during a fight. The boxers who haven’t died in the ring, have healed their bloodied noses or their split lips. The old “Punch Drunk” is now better called Chronic Traumatic Encephalopathy (CTE).

In April 2013, a Zambian-born boxer, Michael (Hitman) Norgrove felt dizzy during his sixth professional fight which was stopped by the referee. He died in the hospital following the fight. A Mexican boxer, Frankie, “the little soldier “was knocked out and carried out on a stretcher in March 2012, but returned to fight in October 2013. He was again knocked down to the canvas in Cabo San Lucas. He died days after.

An Australian fighter Davey Browne Jr fought Carlo Magali from Philippines in a 12 rounds super-featherweight fight in Sydney, but unfortunately took a crashing blow to the head which knocked him down. He was transported to the hospital and died four days later from a brain injury. Scott Westgarth in February 2018 was knocked down in the last round of a fight but got up and was declared winner on points. He later collapsed and died shortly in the hospital. The list of fatality goes and goes on.

A Russian fighter Magomed Abdusalamov was badly beaten by a Cuban Mike Perez in November 2013 heavyweight fight at Madison Square Garden but because he was still standing the referee allowed the fight to continue. The ring physician cleared the boxer for any neurological damage. Abdusalamov was found in a coma after the fight at a Hospital and never re-gained the ability to speak or to walk. In 2017, the State of New York agreed to pay the boxer 22 million. A writer wrote a plea to ban boxing.

In a basement in Chicago, a gym’s owner, Glenn Leonard, 6 foot-tall, gave up his boxing carrier to work as a trainer and rarely gets into the ring to spar and when asked why he quitted fighting, he responded that he suffered from headaches. Other boxers may present with a history of paranoia or with violent behavior and mood swings. Some have terrorized members of their families with violence to a point that they used the extreme act of suicide to put an end to their life.

We have demonstrated in a previous AMHE Newsletter (#254) what science believes happen in the early stages of CTE where people with a history of concussion and repeated blows to the head like in NFL players present with memory loss, slowness of movement because the brain is affected. You would expect many boxers to come forward with symptoms. Unfortunately, they appear to be in denial and refused to talk about the blows to the head responsible for some of their symptoms. Most boxers in such condition are amateurs and they have little support.

A movie in 2015 in which Will Smith played the significant role of a professional Football player with Chronic Traumatic Brain Injury, has bought to light the consequences of repeated blows to the head. After viewing it, people had the tendency in believing that this condition was strictly seen in professional Football players, victims of the disease. In fact, the first known description of an athlete with Chronic Traumatic Brain Injury was reported in boxers by a New-Jersey physician, Harrison Martland MD, in an article called “Punch drunk” in 1928. A second physician JA Millspaugh MD, named the condition “dementia pugilistica” but now the term Chronic Traumatic Encephalopathy is coined (CTE).

We will never know how many boxers can be affected by this disease. The accumulation of blows to the brain have led to the release of the “Tau protein”, also found in the Alzheimer’s disease. It spreads to the brain, eroding its function and showing as dark-brown discoloration. Another AMHE Newsletter (# 262) has also addressed the problem of Alzheimer’s as well and we will refer you to it for review.

If we need to look for boxers with early or late symptoms of paranoia, memory loss and confusion, we will need to search for young or old boxers living in deprived communities. A marine veteran of the name of Paul Pender, in his 50’s, who fought Sugar Ray Robinson and became World champion twice but 20 years after the end of his career, he felt depressed and irritable and was unable to hold on any job. He was diagnosed with Alzheimer’s disease because of confusion and memory loss. When he died, an autopsy confirmed the disease.

Symptoms can be insidious or begin many years later after the boxer stops fighting. Memory, judgement and organization skills can be affected. Boxers will show mood change. apathy, rage, aggression and loss of self-control. They can also develop tremors, slowness in movement, a limited facial expression which appear to be a trademark of a symptomatic boxer not seen in the professional football player suffering from Chronic Traumatic Brain Injury. It is not sure why some boxers develop the disease and others do not.

Boxers die but not as often as they used to. Safety regulations, medical supervisions, fewer round and shorter careers have not change the rhythm in which fighters are dying. 230 boxers died in the 1920’s while 103 has the same outcome in the 2000’s. If there are rules aimed at protecting the health and the safety of the boxers, they are not working properly. By example if a boxer is knocked out, he should not be able to engage in contact for at least 60 days. Those rules are not followed properly especially in the deprived areas.

On October 12, a young boxer Patrick Day, 27-years-old, ranked among the 10 best boxers in the world by the WBA and the IBA gained the right to fight Charles Cromwell in a World Championship bout for the super welterweight crown. He fought well but was knocked down on the 4th and the 7th round and finally in the 10th round, he sustained a fury of blows to the head which sent him to the canvas. I knew he was hurt and my heart was pounding. The fight was over. He was transported in emergency at a hospital in Chicago via ambulance and underwent a surgical drainage of a massive brain hemorrhage. Patrick never woke up from his coma. He was declared “brain dead” 48 hours after.

Patrick Day, a NY-Golden Glove winner, Alternate on the US Olympic boxing team, World rated super welterweight contender, WBC continental America Champion in 2017, IBF International Champion 2019, was rated in the top 10 boxers. in association: the WBA and the IBA. He knew that Boxing was a sport at risk but he chose to perform this art. He has a dream of becoming World Champion. He left us pursuing this goal. Rest in peace son! May God have Mercy on your soul.

This paper is dedicated to Patrick, this son of the AMHE and to all the boxers who, like him, came so close to reach their dream in becoming World Champions.

Maxime Coles MD


1-    Critchley E. Nervous disorders in boxers. Medical Annual 1937:318-320.

2-    Martland HS. Punch drunk. JAMA 1928(19):1103-1107.

3-    Chronic Traumatic Brain injury associated with boxing. Semin Neurol 2000L20):179-185.

4-    Haglund Y, Eriksson e. Does amateur boxing lead to Chronic brain damage? A review of some recent investigations. Am J Sports Med 1993L21):97-109.

5-    Casson IR, Siegel O, Sham R Et al. Brain damage in modern boxers. JAMA 1984L251):2663-2667

6-    Joseph E Syinth: “Death under the Spotlight: The Manuel Velazquez Boxing Fatality Collection”. Journal of Combative Sport, October 2011.

7-    Brophy III Robert H: “Deaths in the Pan-Hellenic Games: Arrachion and Cruegas”. American Journal of Philology. Autumn 1978.

8-    “It’s time for New-York to Give up the fight and Ban boxing”. Filip Doaln, New York Daily, News. November 30, 2013.

9-    “The general Medical Guidelines for WBF Championship Contests” Dr. Adam Balogh, World Boxing Federation.

Return to homepage