There seems to be a deep, even innate, need on the part of many young men to actually, or vicariously, strike out at other people to cause pain and injury while striving to dominate.

In 1996, I wrote an editorial entitled “Blunt Force Violence in America” describing “a modern continuum from street fights to barroom brawls to domestic child, spousal, and elder abuse, to ultimate fighting to extreme fighting, to toughman fighting, to professional boxing, and to amateur boxing: shades of gray or shades of red.”

I then called ultimate fighting “a revolting event, utterly without redeeming social value.”

But that was back in its extreme “early days” when the promoters hyped that there were no rules; that there may be no referee, no rounds, no holds barred, promoted as almost literally a fight to the death. Many of you may recall the JAMA position taken in 1983 and thereafter that “Boxing Should be Banned in Civilized Countries.”

It was an easy jump also to harshly criticize this newer extreme activity.

The stated objections to boxing include that it has the principal purpose of winning by harming the opponent physically or mentally as quickly and completely as possible. The best way to win is to knock the opponent out, deliberately producing a cerebral concussion.

We now know that concussions as well as acute intracranial bleeds from venous tears can seriously damage the brain. But we have also learned that repeated sub-concussive blows that induce rapid head acceleration and deceleration tear brain fibers and small blood vessels.

Over time this results in chronic traumatic encephalopathy leading to functional dementia in an unacceptably high proportion of boxers. Impaired vision secondary to traumatic retinal detachment is another major recognized hazard of boxing.

Worldwide support from the AMA and many medical associations did not eliminate boxing but did sharply decrease its “respectability,” the number of boxers, boxing matches, and rounds per fight. It improved medical supervision before, during, and after boxing matches.

Since 1996, in order to make more money by growing extreme or ultimate fighting, the promoters have instituted many rules from mixed martial arts — octagonal cages, weight classes, partial gloves, timed rounds, referees, no head butts, no biting, eye gouging, rabbit punches, small joint manipulation, fish-hooking, or groin shots. Fighters can surrender and the fight physician and fighter’s corner can stop the fight. Winning is by knockout, TKO, surrender, or by judges’ votes.

With all these new rules and relentless reality promotion, watered down “Ultimate Fighting” as mixed martial arts is now flourishing.

What should a physician make of this? Obviously, all kinds of injuries are possible, many such injuries being deliberately produced to win and to sell tickets and pay-per-views. The more blood the better.

Here’s the skinny. Revolting though the activity may be, especially the abhorrent piling on and beating up the downed opponent, the injuries recognized to be common so far in ultimate fighting are mostly external and can heal.

Those in traditional boxing are often internal, in the brain and eyes, and often cannot ever heal.

Thus, based upon current but incomplete knowledge, I judge both boxing and ultimate fighting to be evil, but ultimate fighting seems the lesser evil.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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