Damage: The Untold Story of Brain Damage in Boxing by Tris Dixon (Hamilcar Publications) is an important book.

In 1928, a doctor named Dr. Harrison Martland wrote an essay titled “Punch Drunk” that was published in the Journal of the American Medical Association. People knew that fighters could be severely injured in fights or even die in the ring. But there were also fighters walking around who were derided as “cuckoo,” “goofy,” “cutting paper dolls,” or “slug nutty.” Martland called these fighters “punch drunk” and believed that roughly half of all boxers would fall victim to this condition if they fought long enough. He studied what was happening to men who were being hit in the head again and again in fights and in sparring. And he concluded, “I am of the opinion that in punch drunk there is a very definite brain injury due to single or repeated blows on the head or jaw which cause multiple concussion hemorrhages in the deeper portions of the cerebrum.”

As Dixon notes, “not only did ‘punch-drunk’ sound like a term of mockery, but the medical professionals who used it said that it happened to sparring partners, to journeymen, to fighters who were not that good. They said it did not happen to the better boxers. But they were wrong.” As Sammy Lewis, who owned a nightclub with former light-heavyweight champion Maxie Rosenbloom said as Rosenbloom’s cognitive abilities deteriorated, “If you take those punches, something’s got to give.”

Over time, the term “punch-drunk” was replaced by “dementia pugilistica” and eventually “chronic traumatic encephalopathy (CTE).” Its symptoms, depending on the sufferer, include slurred or garbled speech, unsteady gait, tremors, loss of analytical ability, memory loss, mood swings, irritability, confusion, depression, and erratic violent behavior.

By and large, the boxing establishment has ignored this issue. When a fighter dies or suffers a life-changing traumatic brain injury in the ring, it’s talked about for a while. But the story soon fades away. And little is written, said, or done to address the issue of longterm chronic brain damage.

As Showtime Boxing commentator Steve Farhood told Dixon, “The fighters suffering the effects that they have to live with for maybe thirty or forty years just don’t seem to generate the same amount of attention. Boxing does nothing to help them. I also think that the fact that we don’t discuss this issue more is emblematic of the fact that a lot of people in boxing, and perhaps boxing as a sport, tends to treat its fighters as disposable commodities. They are warriors as long as they can fight. And when they can no longer fight at that level, they’re useless to a lot of people.”

Many athletic commissions have failed to implement even the most basic standards with regard to protecting fighters against brain damage. Dr. Margaret Goodman has been in the forefront of those seeking to improve fighter safety in the United States. “Unfortunately for boxing’s sake,” Dixon writes, “her beliefs and values do not align with the sport’s power brokers or their economic goals.”

Goodman, for her part, states, ” No one wants to give up their piece of the pie, irrespective of what the repercussions are to the fighters. The politics involved in the sport is probably just as important as the actual head trauma the fighters are taking because people don’t want to step on other people’s toes. In most states, the person running the commission office has no real knowledge of boxing or MMA. They wouldn’t know if someone was hurt if you punched them in the head to show them what it was like.”

CTE progresses steadily long after a fighter has retired from the ring. It’s largely irreversible. Also, as Goodman points out, “The most difficult aspect of chronic brain injuries lies in the fact that by the time a fighter is showing symptoms, it’s too late.”

“Some fighters feel they have dodged the bullets and retired unscathed,” Dixon writes. “But only time will truly tell.” In that vein, he recounts attending an International Boxing Hall of Fame induction weekend in Canastota, New York.

“It was like a scrapyard of high-price vintage cars that had decayed over time,” Dixon recalls. “It was heartbreaking. And the Hall of Fame treats the fighters wonderfully well. It gives them more days in the sun when otherwise they would be forgotten. But it’s a fan’s guilty pleasure – posing for a picture with someone who is looking emptily into a camera, habitually holding up a shaking fist in a fighter’s pose, or watching them sign a scarcely legible scrawl. I’ve seen the decline of fighters I looked up to, some I idolized and some I’ve known. And I will keep seeing it. The next wave will be fighters I’ve watched and become friendly with. Then it will be fighters who I have covered from their debut. Then it will be fighters who weren’t born when I started writing about the sport. The brutal wheel will keep turning and fighters will keep getting spat out, broken and damaged. They will be asked to pose, staring vacantly into cameras, to sign autographs with pens they cannot control, using letters they can scarcely remember. This is not all, but it will be some, and more than a boxing man like me should care to admit.”

Former Ring Magazine editor Nigel Collins echoes that theme, saying, “I went up to Canastota one year with somebody who’d never been before but was a boxing fan. And he was mortified when he saw all of these broken-down people, that some of them could hardly speak. That was a real shock to him. People have asked me about becoming boxers and I say, ‘You’re going to get brain damage. It’s cut and dried.’”

The boxing media rarely acknowledged the problem of chronic brain damage in fighters until Muhammad Ali’s struggle became public. And as Dixon notes, “The old punch-drunk terminology was rarely used with Ali. Perhaps they thought it was too cruel a label for a man who had given so much and who had awed the world with his brutal elegance.”

But the same media has largely ignored the problem of CTE apart from Ali. And there are times when the cause of Ali’s condition isn’t honestly addressed.

Three decades ago, I was Ali’s authorized biographer. With his consent, I reviewed hundreds of pages of medical records and talked at length with his doctors. There was no doubt in my mind, or that of his primary physicians, that boxing was the main cause of his physical decline at that time.

Ali preferred to think that boxing was not the cause. I believe this was in part because of his vanity as a great boxer. Also, he didn’t want to think that boxing – which he loved – would cause a condition like his. Anytime someone talks about studies that show an outsized proportion of football players in the United States suffering from CTE, what they’re really saying is that football causes brain damage. What was Ali going to do? Get up and say, “I’m talking the way I am because I boxed too long. Boxing did this to me.” The next logical thing to say would then be, “Don’t box.” And Muhammad wasn’t prepared to say that.

Aaron Pryor, one of the greatest fighters ever, suffered from chronic brain damage after retiring from boxing. He died in 2016 at age 60. Having talked at length with Frankie Pryor (Aaron’s widow), Dixon writes, “Frankie wished Lonnie Ali, Muhammad’s wife, had publicly acknowledged the reason behind the icon’s demise. Frankie felt that their involvement would have shone a light on CTE far faster and would have helped countless more fighters understand and admit to what had happened to them. If boxing could shut down the best – The Greatest – where is the shame in that?”

Frankie Pryor emphasized that point to Dixon, saying, “The one fighter who had the notoriety and could have brought a lot of attention to this was Ali. And then they went off on the Parkinson’s thing. That pissed off a lot of people in boxing, that Ali’s family chose to say, ‘Oh, he has Parkinson’s, it has nothing to do with boxing.’ It has everything to do with boxing. I don’t think it was done maliciously. Maybe Lonnie didn’t fully understand the impact. But just to say, ‘It wasn’t boxing; it was Parkinson’s.’ No, it wasn’t.”

Further to that point, historian Mike Silver declares, “The false narrative with Ali has mostly been foisted [by] people who are ignorant of the problem and don’t understand it or they’re Ali lovers that don’t want to believe it. His own family, who are really trying to preserve his legacy in the most positive light, says that he suffered from Parkinson’s disease and would have got that if he was a bricklayer. That’s ridiculous. Now, would he have developed Parkinson’s on his own? Possibly. But you cannot tell me, no logical person would say that someone who has taken whatever it was he took – and he took some horrific beatings, especially to the head – that his brain is not going to be affected by that. He’s boxing’s poster-person for brain damage.”

Fighters like George Foreman, Bernard Hopkins, and Archie Moore – each of whom fought to an old age without apparent ill effects – are the exception to the rule. Looking at some of Ali’s better known opponents from what is often called “the golden age of heavyweight boxing,” Dixon cites the early deaths and cognitive/neurological problems suffered by Joe Frazier (dead at age 67), Floyd Patterson (71), Jimmy Ellis (74), Ernie Terrell (75), Jimmy Young (56), and Jerry Quarry (53). Quarry’s neuropsychologist said that his brain “looked like the inside of a grapefruit that has been dropped dozens of times.”

Dixon also recounts interviews he conducted with a wide range of fighters now suffering from CTE.

“I told my neurologist that sometimes I think about killing myself,” Freddie Roach confessed. “He asked me why, and I said, ‘It’s just f—– difficult sometimes dealing with this sh!t.’”

“Everybody’s concussions are different,” Micky Ward explained to Dixon. “Some people suffer from headaches. Some people suffer from depression. Some people get tired. Some people get angry. Some people want to hurt you. Some people want to hurt themselves.”

What are Ward’s symptoms?

“There are some things like my memory. Long term, I could tell you first-grade things I remember. I couldn’t tell you yesterday. If I don’t take my medicine, I get snappy, I get edgy. And I didn’t have that years ago. I don’t have the [slurred] speech, but I have the headaches, the aggravation, and all the crap. It is what it is. Boxing has been this way since day one and it’s going to stay that way. Watch. It’s sad.”

Dixon’s recreation of time spent with Leon Spinks is particularly poignant. Some of what Spinks said was coherent; some wasn’t. But one thing Leon said came through loud and clear: “All of the motherf—— were hard punchers.”

Dixon writes well, which is a good start for any book. He’s a meticulous researcher which further elevates his work. There are places where Damage is a bit too technical and dry. And there are too many case studies, some of which are close to a century old. But Dixon approaches his subject with sensitivity and he understands its gravitas. He explains medical concepts in a way that the average reader can understand. And the technical parts in Damage are important to informing ring doctors and other medical personnel associated with boxing about the issues involved.

Dixon also writes in self-revelatory fashion about his years as an amateur boxer.

“I wonder if I am damaged,” he acknowledges. “I’m forty. I can be moody. I can be emotional. I can get cranky. My temper can be short. I was an amateur for ten years. I only had a handful of fights. I was stopped, but never knocked down – not that that matters. There are four or five guys I could tell you I boxed more than a hundred rounds with. My defense was abysmal. I took some blows to the head that really hurt, and some of them I didn’t shake for several weeks. My memory catches me out at times. There could, of course, be many reasons behind it. But I remember once, after driving back from a fight in the West of England (stopped in the second or third round) that I drove clean over a roundabout and did not think anything of it. In fact, I thought I was being clever. That Saturday night, I had taken a left hand to the crown of my head when coming in underneath my taller opponent. I saw some patchy bright colors, felt my knees buckle, and the pain did not subside for a few days. It certainly was not helped when I was back in the gym sparring on Monday.”

Dixon also recounts a particularly harrowing sequence of events that occurred when he journeyed from England to the United States to hone his craft.

“One time when I was sparring with some of the pros in Kevin Rooney’s Catskill Boxing Club in upstate New York, I was clobbered harder than I can ever recall being hit. My legs bolted firmly to the mat like I was some kind of robot screwed in the floor. I was stricken, frozen solid like a block of ice, looking at the light hanging above the ring. A volley of punches came my way. I clumsily swiped back and the round passed. The next day, the other fighters and I did our roadwork. I had a splitting headache from the sparring. It was not the sort of migraine pain you get around your temples but toward the top and back of my head. It was like my brain was loose within my skull and, as we ran up the mountains and along the sweeping roads, it felt as though there was a rattle in my head. The next day we sparred again, and it was hard. With hindsight, I believe I was concussed. But when Rooney called me into the ring, what could I say? I could not take a battering in sparring one day and opt not to box the next. I would look like a wimp. What are you going to say? ‘My head hurts from boxing yesterday?’ Of course it hurts. It’s boxing. You get hit on the head. It’s the fight game. Heroic boxers have fought through infinitely worse. I said nothing and boxed, but my timing was off. I felt lethargic and flat. My head felt a great deal worse after the four rounds, too. That rattle did not completely leave through most of the summer. I continued to train in New York, Atlantic City, and other places. I was still getting hit all the time.”

“How many times does an ordinary person recall being banged on the head?” Dixon asks. “Maybe once when they stood up quickly somewhere there was a low ceiling, or when they fell off their bike while learning to ride, or perhaps even in a drunken punch-up. But fighters take blows to the head repeatedly, often several days a week. That is where the real danger lies.”

Can boxing be made safer?

Let’s start with the premise that we’re talking about a sport in which the objective is to cause brain damage (a concussion) to an opponent. There are no easy answers. Athletic commissions should be more vigilant in determining who is licensed to box. Ring doctors, referees, and cornermen should be better informed with regard to when to stop a fight. Uniform national medical standards, a worldwide data base, and better education for all parties would help.

More importantly, gyms should be better regulated and, in Dixon’s view, fighters should spar less.

“It’s not the fights,” Kelly Pavlik told Dixon. “Fights are the glamorous part that people see. The damage comes in three, four days a week sparring. Some of these guys are doing like three hundred rounds in camp. I can’t remember what I did, but it was minimum a hundred rounds in camp and sparring was full go. That’s where the damage comes.”

Micky Ward concurs, saying, “There’s no way they can stop concussions in boxing. The only thing you can do is probably minimize the sparring. What I believe – and I don’t know this for sure – is three minors [head injuries] is a major. Just getting stunned in the gym with a right hand or whatever, not hurt, just stunned, that’s a minor. I used to get those constantly. I don’t know how many of those I had. Full-blown, I had a whole bunch. But the minors are the ones that you don’t think hurt but they still do damage. Then you’re going back and sparring again and again.”

Wearing headgear while sparring might guard against cuts. But it doesn’t protect a fighter’s brain against concussions. To the contrary, it makes it easier to shake a fighter’s brain because headgear increases the hitting area. Anyone who doubts that assertion should ask themselves whether wearing helmets protects football players from CTE.

But when asked about fighters cutting down on sparring, Paulie Malignaggi answers, “That’s not going to happen. If you’re going to prepare yourself for a fight, you’re going to have to spar a lot of rounds. Otherwise you’re not going to be sharp. Fighters have to be fighters.”

Tris Dixon has made a major contribution to the health and safety of fighters. Now let’s see who’s paying attention. Damage should be required reading for ring doctors and high-ranking state athletic commission officials. If one of these people doesn’t read Damage, that person is doing less than should be done in the performance of his or her job. Fighters, managers, and trainers should read it too.

Sugar Ray Robinson, Joe Louis, and Muhammad Ali – the three greatest fighters of all time – all fought too long. And they all wound up in poor health with significant cognitive issues. There’s a message in that for anyone who’s paying attention.

Meanwhile, as Dixon states, ” It’s time to be open about it. It’s time to talk about it. It’s time boxing confronts its own worst problem, stops ignoring it, and steps up to address it at all levels. Boxers should be told what might be happening to their brains.”

Thomas Hauser’s email address is thomashauserwriter@gmail.com. His most recent book – Staredown: Another Year Inside Boxing – was published by the University of Arkansas Press. In 2004, the Boxing Writers Association of America honored Hauser with the Nat Fleischer Award for career excellence in boxing journalism. In 2019, he was selected for boxing’s highest honor – induction into the International Boxing Hall of Fame.