What Happens When A Boxer Is Beaten To Death, And How We Can Stop it After Jermichael Finley's recent spinal cord injury, a sportswriting friend of mine shook his head and referred to football as “America's sickness.” As severe as it was, though, Finley's injury wasn't nearly the worst a professional athlete suffered last weekend. On Saturday night, 26-year-old junior featherweight Francisco "Franky" Leal was knocked out by Raul Hirales in the eighth round of a fight in Cabo San Lucas, Mexico and never regained consciousness. He was pronounced dead three days later. If football is America's sickness, what then do we call boxing?

Chronic neurologic impairment has long been recognized as a sequelae of boxing. (CTE—much in the news in recent years due to its association with football—was once known as punch drunkenness, or dementia pugilistica.) This is unsurprising when we learn that being hit by a professional boxer is like being struck by a 13-pound bowling ball swung at 20 mph. After a series of blows to the head, a fighter will often appear glassy-eyed, with observers saying, “The lights are on, but nobody’s home.” Generally, the fighter looks this way because he has just sustained a cerebral concussion, which is marked by a sudden impairment of consciousness, paralysis of certain reflexes, and loss of memory.

We haven’t sorted out just what's happening yet, and some of the details remain controversial, but scientists have discovered that during a traumatic brain injury—the kind boxers routinely experience—cerebral blood flow is diminished and the concentrations of ions like potassium and calcium that live inside and outside of the neurons are disrupted. In addition, neurotransmitters like glutamate are released in excessive amounts. These things cause the brain's neurons to begin to fire excessively. That’s a problem.

Researchers have examined the brain waves of recently concussed animals and determined that their brains resemble that of an animal suffering an epileptic seizure. This comes as a bit of a surprise, because the brain waves (measured by an electroencephalogram) show hyperactivity, which implies that when a fighter is glassy-eyed and unable to answer the referee's questions appropriately, his neurons might actually be overactive, not underactive.

But a hyperactive brain is not the only problem. When the head is hit at high speed, shearing movements within the skull can cause micro-hemorrhages of the blood vessels within the brain tissue. If the shearing force is large enough, or if the head is it hard enough, a large bleed can occur. This becomes a medical emergency because the skull is fixed, enclosed space. As blood accumulates, usually in the form of a subdural hematoma, it can squish the brain and potentially compromise critical neural functions like breathing; death becomes imminent.

Boxers dying isn't exactly rare—there have been a substantial number of fatalities in the sport at both amateur and professional levels due to brain injuries sustained in the ring. The number of such fatalities has decreased a bit in recent years owing to measures taken by authorities to decrease the physical hazards in the ring and to better monitoring of boxers by referees and ringside physicians. Many of these changes occurred after the death of a South Korean boxer you may never have heard of.

On November 13th, 1982, lightweight Duk Koo Kim challenged Ray Mancini, the reigning world lightweight champion, at Caesar Palace in Las Vegas. In the 14th round, Mancini was declared the winner by technical knockout. Moments later, Kim lost consciousness and was taken to a nearby hospital, where he was found to have severe brain swelling and a subdural hematoma. Kim was rushed to the operating room to remove the blood inside his skull, but died four days later.

Kim’s death shook the boxing world. The World Boxing Council conferred with medical advisors, determined that most severe injuries came in rounds 13 through 15, and decided to reduce the number of rounds in championship fights down to 12. (The International Boxing Federation and the World Boxing Organization eventually followed their lead.) Clearly this change was a move in the right direction. Was it enough?

What Makes Boxing So Dangerous?

Generally, it’s easy to see why football and boxing get lumped together as high-risk sports, but it’s important to understand that boxing is much worse. The reason often has to do with the angle of impact rather than the force behind it.

Boxers endure a high prevalence of glancing blows to the head, which results in rotational acceleration. This is different from the biomechanics involved in football, where the impact is more commonly directed at the center of the body, causing something called translational acceleration. The glancing blows in boxing create a rapid rotation of the skull, which carries a higher risk of severe head injury than linear movements, theoretically by creating greater tension on the bridging vessels and brain tissue. It may be counterintuitive, but it probably explains why we’ve actually seen more boxing deaths in the lower weight classes. It’s not the force of impact; it’s the angle. (The man who landed the lethal blow on Saturday night weighed just 123 pounds.)

Knowing this, it’s not hard to argue that boxing simply cannot be made safe. The Journal of the American Medical Association famously declared in an editorial that boxing should be banned in civilized countries. Some have called for sports physicians to make a public statement by ending their professional relationship with boxing.

Others among my colleagues, though, think this sort of high-mindedness is misguided, that boxing is here to stay and that it would be a mistake for doctors to cut ties with the sport. Rather, they argue, we should make the sport safer by insisting on a ringside neurologist, post-concussion assessments, and mandatory neurophysiological assessments for all professional fighters.

Either way, while the NFL is coming in for the closest scrutiny in the head trauma debate, boxing should certainly be under the microscope as well. Football players at least have a union; boxers have the likes of Bob Arum.

Some say the NFL will cease to exist as we know it once a player dies on the field, but boxers are dying in the ring. What are we actually going to do about it? The Wikipedia page of deaths due to injuries sustained in boxing is a sobering reminder of the dangers of the sport, and it doesn’t begin to approach the actual number of boxing-related deaths. How many more need to be added to the list before we do away with this ridiculous sport? Football may be America’s sickness; boxing is one of our tragedies.



Matt McCarthy is board-certified in internal medicine. You can follow him on Twitter here.

Image by Jim Cooke