Hemingway’s Chronic Traumatic Encephalopathy

September 26, 2017

In Dr. Andrew Farah’s new biography of Ernest Hemingway, Hemingway’s Brain, he details the neuropsychiatric demise of a great literary mind.

An Interview With Andrew Farah, MD, Author of Hemingway’s Brain

In Dr. Andrew Farah’s new biography of Ernest Hemingway, Hemingway’s Brain, he details the neuropsychiatric demise of a great literary mind. Dr. Farah argues that Hemingway suffered from chronic traumatic encephalopathy (CTE) as the result of numerous severe concussions during his life, and this ultimate dementia was complicated by alcoholism as well as untreated diabetes and hypertension, possibly contributing a vascular component. He believes this condition not only informed Hemingway’s day-to-day life, interactions, and relationships, but the later literary works as well.

Ms. Smith: Dr. Farah, your book is a wonderful contribution, not only to Hemingway scholarship but to medicine in general. What interested you in Hemingway’s mental demise?

Dr. Farah: Shortly out of residency, I met with a Hemingway biographer. He had seen some of my research on ECT, and he wanted to know why Hemingway declined and committed suicide after receiving ECT, rather than improving. He had read that 90% of patients who receive ECT achieved the cure they were hoping for. I mentioned that in my experience, the patients who deteriorate after ECT generally have some undiagnosed organic brain disease, and the ECT is a biological stressor that serves to unmask that disease.

He wanted to know what that disease could have been for Hemingway, so I began reading this author’s biography of Hemingway and all the other biographies I could find-all the memoirs, letters, and so forth. I had been a fan of Hemingway’s fictional work for a long time. I made a couple of trips to the Hemingway Collection and archives at the John F. Kennedy Library in Boston and was able to put the pieces together.

Ms. Smith: Your thesis centers on the numerous concussions Hemingway suffered, starting in World War I, correct?

Dr. Farah: Yes, you are referencing Hemingway’s first major concussion. During World War I, while in Italy, a 5-gallon Austrian mortar exploded fairly close to him. The report of the Department of Military Affairs indicates that it exploded just 3 feet from him, so his first major head injury was a blast-type concussion. His best friend at the time, and fellow reporter and ambulance driver, Ted Brumback, wrote to Hemingway’s father from Milan that “an enormous trench mortar bomb lit within a few feet of Ernest.” It killed a soldier standing between him and the blast, blew the legs off another, and blew Hemingway several feet and covered him in earth. He was so blood-soaked from the dead soldier he attempted to carry once he roused himself that a Florentine priest administered last rites to Hemingway at the dressing station nearby.

That first major concussion was followed by an accident in Paris in 1928, after he had been out drinking with friends and came home late. Rather than pulling the cord for the commode, he accidentally grabbed the cord that was attached to a cracked skylight, which caused the skylight to fall on the left frontal area of his head, resulting in another major concussion and a famous scar.

More accidents followed. There was a fall from the flybridge of his fishing boat while off the coast of Cuba, then a serious car accident in London during the blitz. His head hit the windshield, and he required 57 stitches in the frontal area. There were 3 more concussions during World War II. A German antitank round blew him off a motorbike while he and Robert Capa were on an ill-advised adventure. He struck his head on a boulder as he landed. That incident involved a blast injury as well as blunt trauma. There was another motor vehicle accident in Cuba with his fourth wife and, finally, he and his fourth wife survived 2 plane crashes in Africa during the 1954 safari. The second crash prompted his friends to comment on his cognitive decline.

You can see the pattern here: multiple concussive injuries, in fact both blast-type and direct blows. It is also noteworthy that Hemingway boxed as a young man, feeling it a testament to his manhood, and he played football in high school as well. Certainly, the football equipment in 1915 and 1916 was not particularly protective.

Ms. Smith: You emphasize the 2 blast-type injuries in your book. Were they crucial to the diagnosis?

Dr. Farah: Yes, we are aware that CTE can occur after just 1 blast-type injury; Hemingway suffered 2 such injuries. Even without the numerous other blunt-trauma concussions, we might be having the same discussion.

Ms. Smith: How did these concussions affect Hemingway’s work?

Dr. Farah: The symptoms of post-concussion syndrome were clearly described by Hemingway in various letters after different injuries, particularly after the fall on his fishing boat, and after the World War II concussions, and certainly after the plane crashes. Hemingway had no difficulty describing the symptoms, such as persistent headaches, irritability, sensory changes, and double vision, which were typical for post-concussion syndrome. In his letters, he directly attributed them to his concussions. After the back-to-back plane crashes, he wrote in a letter from Kenya: “This is a funny thing. Maybe-concussion is very strange-and I have been studying it: double vision; hearing comes and goes . . . .”

My argument is that the cumulative effect resulted in the progression to CTE, accelerated by alcoholism, and possibly by a vascular component, as we have an individual who was generally overweight after 1940. Moreover, he did not treat the diabetes that was eventually diagnosed at the Mayo Clinic years later, and he was probably prediabetic for a long time. His blood pressure would have fluctuated pretty dramatically as well. Those who study his work can see that the posthumously published later novels don’t demonstrate the skills that the masterpieces do.

I spent an entire chapter on A Moveable Feast because this is the last of Hemingway’s works and was certainly written during the time of his demise. At this point, CTE and mixed dementia were evident, and the final book is very different than the original manuscript that he left, which had been heavily edited by his wife and his editor at Scribner’s.

Ms. Smith: I have always been told that Hemingway suffered from a bipolar disorder. Then I read that he possibly had hemochromatosis, and finally that the ECT itself caused the suicide. Can you clarify?

Dr. Farah: Yes, we have all heard that Hemingway was bipolar, but he never had a true manic episode. Certainly, he was prone to depression when he felt he could not work because of injuries in his early life and mental difficulties later in life. But again, true manic symptoms were simply not there. Certainly, there was mood volatility and irritability, but these are easily explained by heavy drinking. His youngest son did indeed have a severe bipolar condition complicated by alcoholism, as well as gender identity issues, and he received even more ECT treatments than Hemingway did.

The idea of hemochromatosis is certainly intriguing. It was first introduced in 1990, but this was an easy enough diagnosis to make and to test for in 1960 and 1961. So when Hemingway was at the Mayo Clinic, an iron level would have easily revealed whether he had hemochromatosis. I was fortunate to interview a retired physician who followed Hemingway’s case at the Mayo Clinic and who had many opportunities to chat with him. He recalled Hemingway’s internist considering a liver biopsy, but in the presence of a normal serum iron level, the chances were too slim for that risk.

Many biographers have blamed ECT for ruining Hemingway’s mind-in Hemingway’s own words, “a brilliant cure” that lost the patient. The short-term memory deficits that he believed were permanently erasing his memory, and thus accentuating his decline, propelled him toward suicide. The piece of truth to that is that ECT was the biological stressor on a brain compromised by CTE as well as a probable component of vascular dementia, and a component of alcoholic dementia. ECT was a stressor that this compromised brain could not handle-not on a molecular level and not on a psychological level.

Ms. Smith: The chapter “Modern Times” describes Hemingway’s treatment today. Neuroprotection is a focus of research for you. What advice would you give clinicians who see patients who are vulnerable after traumatic brain injuries and who are now at risk for CTE and dementia?

Dr. Farah: Neuroprotection is key. Much like the military’s post-concussion protocol, vitamins such as Enlyte are designed to lower homocysteine in the CNS, as are high doses of N-acetylcysteine as an antioxidant and a good omega-3 supplement.

Ms. Smith: What is the appeal of Hemingway? Why is there still so much attention to this author?

Dr. Farah: Many consider Hemingway to be the greatest American author, or at least in the same league with Whitman, Melville, Eliot, Twain, Nabokov, and so forth. We are attracted to the work, and his biography is fascinating. As we consider the major events of the 20th century-World War I, the Lost Generation in Paris, the Spanish Civil War (which is now more correctly referred to as “the Spanish Holocaust”), World War II, and the Cuban revolution-Hemingway is a figure in each of these, sometimes a major figure.

There are many different facets of his life that appeal to so many. For example, I found his case fascinating from a medical standpoint. He was a truly great icon with a tragic end. His suicide is perhaps the most famous in American history, competing with those of Marilyn Monroe and Robin Williams.

Ms. Smith: Could you speak to the genetics of suicide? You spend a great deal of time in the book discussing Hemingway’s father’s suicide.

Dr. Farah: There is a photo in the book from when Ernest Hemingway was just a little boy. I note in the caption that everyone in the photograph committed suicide except one sister and his mother. His father shot himself with the Colt pistol that his own father had carried in the Civil War. His brother committed suicide, and 2 of his sisters committed suicide. Hemingway also wrote of his grandfather Hall, the grandfather on his mother’s side, and his attempted suicide. He understood himself to be the descendant of suicidal men on both sides of his family. His first wife’s father also committed suicide. It’s no wonder that Hemingway predicted his own suicide, and practiced and rehearsed his suicide as a morbid form of entertainment for friends in Cuba. He’d place the butt of his Mannlicher shotgun on the floor, the barrel in his mouth, and click the trigger with his big toe, and then grin at his guests.

He wrote to his second mother-in-law, very pleased that their bloodline was now in his family to breed the suicidal streak out of his children. Suicide was on his mind even as a young man. And research shows that the impulse toward self-destruction, as a genetic risk, can be passed on independent of mental illness.

Ms. Smith: Has the book stirred any controversy? You are on record as a Shakespeare denier. Are the Hemingway faithful angry at you as well?

Dr. Farah: The reviews have been very complimentary so far, knock on wood. I am on record as believing that Shakespeare, the greatest of writers, was Edward de Vere, the 17th Earl of Oxford, who used a pen name. I believe millions have accepted a fictional story of the Stratford man rather than the true story of who wrote the plays and sonnets. The same is true for Hemingway: millions accept that he was bipolar, and I hope to set the medical record straight.

One individual wrote to me that Hemingway’s behavior during the 1954 safari-when he “went native,” shaved his head, dyed his clothes like a local, and went around hunting with a spear-all argue for a manic episode. I see his point, but the context is that we have a man with a history of several severe head injuries who was drinking heavily on that safari, and who even fell out of a moving Land Rover at one point-a man with narcissistic traits and early dementia. So the behaviors can be explained without a different diagnosis. I think we have it correct now.

Hemingway’s Brain is available in all formats, published by the University of South Carolina Press, April 2017.

Disclosures:

Ms. Smith is UNC-Regional Neuropsychiatry Research Fellow, University of North Carolina, Greensboro.

Dr. Farah is Chief of Psychiatry, High Point Division of the University of North Carolina. He maintains inpatient, consultation, and forensic practices, and spent 17 years researching the neuropsychiatric demise of Ernest Hemingway. His forthcoming book, Diagnosing Ezra, is a similar study of the writer Ezra Pound.