by Andrew Farah
When a parent’s worst nightmare had come true and no words could really change things, Scott had found words that could at least help. He had lived Zelda’s psychosis with her, and he had emerged, at least temporarily, from his depression and alcoholism with wisdom and empathy. Yet, for Hemingway, the stigmas of psychosis and depression were not only a barrier to treatment; they actually served to preclude what few approaches might have been helpful. The demise of friends, the psychology of denial, and the dementia itself, which served to impair his judgment—all conspired within his mind. Depression was obvious, his dementia was unsuspected, but psychosis, his detachment from reality, was the white elephant in the room, and another diagnosis would have to serve as an excuse for hospital care—anything but “crazy.”
Chapter 7
Mayo
Hemingway’s physician in Idaho was fifteen years his junior and humbly described himself as “just a country doctor.” Though it was obvious to everyone that his patient needed immediate help, Dr. Saviers felt the condition was “so far out of my field that I cannot even diagnosis it.”1 Saviers was underestimating himself. Though he had no local behavioral health facility or even a psychiatrist to consult, like many country doctors he displayed wisdom and compassion in dealing with his patient, and even if he did not have the psychiatric vocabulary necessary for a diagnosis, he could still describe Hemingway’s symptoms: Ernest was anxious, depressed, obsessed with delusional fears; his moods were erratic, and his personality had changed. Routine conversations revealed a decline in his cognitive skills, and Saviers also came to believe that his writing had deteriorated to standards well below his abilities and stature. Surely the doctor had seen other patients who suffered dementias and displayed many of the same symptoms. But it is also true that he and Ernest were close, and it must have been distracting and painful to watch his friend decline.
Alfred Hotchner was another close friend, as well as business partner, sometime editor, frequent travel partner, and sometime errand boy. He had met Hemingway in the spring of 1948, over Papa Dobles at the Floridita, and was instantly trusted; in fact, he was always a confidant, even during Hemingway’s most extreme periods of paranoia. Hotchner described Hemingway’s clinical picture to a respected New York psychiatrist, who recommended the Menninger Clinic in Kansas, but he and Mary understood that an admission to a facility known solely for psychiatric care had to be rejected—there was the issue of publicity, but, besides that, Hemingway would never agree to it.2 When he did agree to enter Rochester’s Mayo Clinic in November 1960, he was told and believed that it was to address only his elevated blood pressure (which had risen to 220/125). It is hard to be critical of this action; like many patients with psychosis, Hemingway needed treatment but refused it. He also needed privacy to recover, but his celebrity status would make this a challenge anywhere. At every turn, it seems that Mary was doing the best that she could.
Fifty years before Ernest’s admission, his father had walked into that same clinic for a refresher course and sent a postcard to his then eleven-year-old son: “It will be only a few years before you and Papa will be visiting clinics together.”3 Standing in the same wards five decades earlier, Dr. Ed Hemingway was dreaming of his handsome little boy’s future medical career.
It is widely thought that Hemingway’s alias while hospitalized, “George Saviers,” was assigned to protect his identity, and even his psychiatrist at Mayo believed the alias was given at the clinic’s directive. However, the admissions process was so tedious that it agitated Hemingway. Dr. Saviers, who had accompanied him en route on Larry Johnson’s single-engine Piper to Rochester, noted how restless Hemingway was becoming. They had come too far and too close to lose the patient now over paperwork, so Saviers filled out the paperwork in his own name simply to expedite matters.
On his fourth hospital day, Ernest sat in his room and wrote a letter “TO WHOM IT MAY CONCERN, My wife Mary at no time believed or considered that I had ever committed any illegal act of any kind. She had no guilty knowledge of any of my finances nor relations with anyone and was assured by Dr. George Saviers that I was suffering from high blood pressure of a dangerous kind and degree and that she was being booked [at the Kahler Hotel, Rochester] under his name to avoid being bothered by the press. She knew nothing of any misdeeds nor illegal acts and had only the sketchiest outline of my finances and only helped me in preparing my [tax] returns on material I furnished her.… She was never an accomplice nor in any sense a fugitive and only followed the advice of a doctor and friend [Saviers] that she trusted.”4
So entrenched was his paranoia that despite the extensive medical evaluations and the writing duties that awaited him at home, his focus was solely on exonerating his wife, Mary, whom he believed would “take the rap” with him for the numerous fictional crimes that continued to torment him. His addition that she had “no guilty knowledge of any of my finances nor relations with anyone” indicate he still had fears of being charged with “indecent liberty.”
The internist who cared for Hemingway, Dr. Hugh Butt, ran a series of tests and diagnosed him with mild diabetes. As his weight fluctuated, his blood glucose had likely been at various times prediabetic or diabetic over the previous decade, but this was his first official diagnosis of the condition. Dr. Butt was able to palpate the left lobe of his enlarged liver. Though most associate alcoholism with the development of cirrhosis, actually fewer than 15 percent of alcoholics will develop this complication. More common is a “fatty” and enlarged liver. Over time, scar tissue may accumulate and lead to cirrhosis, and the liver will shrink in size. Hemingway could have developed cirrhosis to a minor extent, but at this stage it was a “fatty liver” from alcohol intake (and also from being overweight) that caused the enlargement.
His internist was also concerned over blood pressure readings as high as 220/150, but he advised it was likely that anxiety was pushing Hemingway’s pressure to these dangerous levels. The doctor wisely discontinued his reserpine, a possible contributor to depression. Reserpine was a widely prescribed antihypertensive agent at the time, but up to 20 percent of patients reported depression as a side effect. The drug acts in the brain to lower stores of serotonin and norepinephrine, chemicals needed in adequate supply to maintain a normal mood state. The patients at highest risk were those who already had a history of depression prior to reserpine therapy, such as Hemingway.
It has been theorized that Hemingway was suffering from a specific metabolic disorder, hemochromatosis, that accounted for all of his symptoms, physical and psychiatric. It has further been suggested that he inherited it from his father, a fellow sufferer.5 This illness is essentially a disease of iron storage; iron itself is deposited in the liver and various other tissues, leading to a numerous clinical signs and symptoms: liver enlargement, excessive skin pigmentation, diabetes, possibly even heart failure, and, of course, depression. Dr. Butt did suspect this as a possibility but advised against a liver biopsy. Though a tissue sample proves or disproves the diagnosis of hemochromatosis definitively, liver biopsies, particularly in 1960, carried a risk of hemorrhage, possibly a fatal risk and one that outweighed curiosity. In addition, a simple serum iron measurement would suffice. Cecil’s Textbook of Medicine, the standard reference in 1959 and 1960, elaborated that “An elevated serum iron and saturation of the iron-binding capacity of the serum are the most useful special laboratory findings.”6
The standard battery of laboratory work at Mayo while Hemingway was there would have included an iron level. Symptoms of hemochromatosis look like those of any number of psychiatric and medical illnesses, and it was briefly considered at Mayo because it was indeed a convenient “fit” for the patient’s cluster of symptoms. But it was easily rejected either because a serum iron test was normal or because he lacked many of the hallmark clinical findings and because his clinical picture so obviously suggested something else.
The “something else” was dementia with associated depression and psychosis. However, in the eyes of h
is doctors, Hemingway was experiencing severe depression with psychotic features. And antidepressants were available at the time, as the first antidepressant, imipramine, was introduced in 1957, and in 1961 amitriptyline would also become widely used. There were antipsychotic medications as well; chlorpromazine was available by 1955. But there was as yet very little clinical experience with these agents, and their use was not yet standard therapy. Furthermore, the side effects associated with their use would have been problematic—a patient treated with early antidepressants (termed “tricyclics” because of their three-ringed chemical structures) and early antipsychotics might experience sedation, short-term memory problems, dry mouth, blurry vision, constipation, a drop in blood pressure, and sexual side effects, such as a decrease in libido or an inability to perform in the bedroom. Any degree of memory trouble would most likely have further distressed Hemingway, already aware of his cognitive limitations and ongoing decline. Like many depressed patients, he already lacked a libido, and he had struggled with intermittent bouts of impotence from at least his forties. Further difficulties would no doubt have led to more depression. There are many patients who take these medications alone or in combination without significant side effects, and some have no side effects at all, but more senior patients and those with organic brain disease, like Hemingway’s CTE, are at higher risk for all of the side effects, particularly for memory and concentration difficulties.
The main error in Hemingway’s case was not the failure to use newly synthesized antidepressants and antipsychotics but the failure to accurately diagnosis his condition. Perhaps it was his celebrity status that clouded the clinical judgment of his doctors, or perhaps it was his extensive worldly knowledge and genius that made the diagnosis of dementia unthinkable—but his brain was dementing, and series of routine memory tests, though they would not have fully proved his diagnosis, would at least have gotten the clinicians into the right ballpark. Yes, he was visibly depressed, he was tormented by various paranoid delusions, and he was indeed suicidal, but these were all symptoms of an overarching illness—“dementia, mixed etiology.”
The standard treatment of a patient understood to have a severe psychotic depression in 1960 was electroconvulsive therapy. In fact, it is still a standard therapy today. Perhaps his clinicians were not oblivious to his symptoms of dementia but assumed that his cognitive issues—memory deficits, disinhibition, paranoia, and personality changes—were all secondary to the depression. In fact, many patients with depression have memory difficulties and look as if they have dementia. The term “pseudodementia” has entered the medical literature and it is defined as just that—symptoms of dementia that are due to depression, not Alzheimer’s or some other type of dementia. But patients with pseudo-dementia often display apathy and don’t even attempt to answer memory and concentration tasks. They often just say “I don’t know” when asked elements of mental status exams, and they appear as if it is too much of an effort to even cooperate with a medical evaluation. By contrast, a patient with dementia will usually try but simply not perform well on the exams and tasks. Given their assumptions, it is understandable, then, that Hemingway’s doctors expected a recovery in all of the domains affected by his illness after his course of shock therapy, the fail-safe cure for depression (usually at a 90 percent cure rate in the 1950s and 1960s).
Thus, he was administered ECT, each treatment consisting of an electrical impulse applied at his temples, causing a generalized seizure. The treatments were most likely given on a Monday-Wednesday-Friday schedule. The most current textbook of the day (1960) described “Electric Shock Treatment of Psychiatric Therapy” as follows: “The usual treatment involves the administration of 100 to 160 volts of alternating current to the patient, between bitemporal electrodes, for a period of 0.1 to 0.6 of a second. Within five seconds, the patient has a convulsive seizure—unresponsiveness and sudden generalized tonus, succeeded by forty seconds of clonus—which is followed by thirty to ninety minutes of confusion and amnesia. Several preparatory measures are customary: a position of mild dorsal hyperextension, gentle restriction of movement and a rubber mouth gag between the teeth; inhalation of 90 per cent oxygen before and after treatment is sometimes used. Muscular relaxants, such as succinylcholine, and appropriate anesthetics will lessen the danger of injury.… Depressive reactions in middle or late life and manic depressive reactions remain the primary indications for ECT. Ninety percent of these reactions can be interrupted with six to ten treatments, administered two to three times per week.”7
Hemingway is believed to have received fifteen such treatments, after which he was noticeably different but not cured. He was deemed safe for release on January 22, 1961, and once again climbed into Johnson’s plane for the trip home to Ketchum. Things did seem much better at first, though he was more silent and not up for company, canceling his usual parties around the Friday-night fights on TV. He tried to work but found himself mostly just shuffling papers. He and Mary began walking up to four miles a day for exercise, and he ordered more than thirty new books from the Scribner’s Bookstore, including Shirer’s The Rise and Fall of the Third Reich and a new biography of Ezra Pound by Charles Norman. At this point in his life, Hemingway would find himself listed in the indexes of books on other literary giants, and few know this odd sensation of realizing one’s immortality, of course, another way of realizing one’s mortality. If he thumbed to page 257 of the Ezra Pound biography, he’d find a lovely passage about his youth, which must have stirred some enthusiasm for the sketchbook of his Paris years: “Hemingway was often to be found in the pavillion in the courtyard. ‘A big young man with intent eyes and a toothbrush mustache was there when I arrived,’ wrote Malcolm Cowley, ‘and Pound introduced him as Ernest Hemingway; I said that I had heard about him. Hemingway gave a slow Mid-western grin. He was then working for the International News Service, but there were rumors that he had stories in manuscript and that Pound had spoken of them as being something new in American literature. He didn’t talk about the stories that afternoon; he listened as if with his eyes while Pound discussed the literary world. Very soon he rose, made a date with Pound for tennis the following day and went out the door, walking on the balls of his feet like a boxer.”8
Back home, a pattern settled in—he always woke before Mary, made breakfast, and went to his study to work on the Paris sketches and the bullfighting book, but nothing was progressing. He struggled with titles for the Paris book and wrote a list of options that were uncharacteristically terrible, such as It Is Different in the Ring, The Part Nobody Knows, To Hope and Write Well, Good Nails Are Made of Iron, To Bite on the Nail, and The Early Eye and the Ear.9 He was fully aware of his difficulties, writing to his editor “am … also working on title. This is very difficult. (Have my usual long list—something wrong with all of them but am working toward it—Paris has been used so often it blights anything.) … All the truth and magic in but we need a better title than The Paris Stories.” He even lists his additional stressors as “Cuba situation—lack of library to work from—etc.”
He further asked Harry Brague, his last editor at Scribner’s, to send him the King James Bible and the Oxford Book of English Verse, his longtime favorite sources for titles. He also volunteered that “Drs fixed my allowed alcohol intake as 1 liter of claret a day.” And when discussing his writing: “This is all being done under difficulty but it is being done.”10
It was no doubt a further setback when on April 15 he heard the news of the Bay of Pigs fiasco. The CIA had hoped to spark a Cuban uprising by training a small force to storm the island (the Bay of Pigs, or Bahía de Cochinos, is roughly one hundred miles southeast of the Finca). Despite the small number of CIA-trained Cuban exiles who landed, it still took Castro’s forces three days to put down the attempt. Hemingway was already worried he would never see his Cuba home, his paintings, or his boat again, and now he must have been sure of it. His “African Journal” and two other manuscripts that would one day surface as posthumously publi
shed works were sitting in a Cuban bank vault and were also presumed lost.
Three days after the Bay of Pigs, he wrote to Charles Scribner Jr., stating that the Paris sketches should not be published: there was no ending, and the manuscript was cruel and unfair to Pauline, to Hadley, and—in a spark of honesty—to Scott Fitzgerald. There would be libel suits (though Fitzgerald had been twenty-one years in the grave), and if it had to be published, it would be labeled as fiction, and Scribner’s would bear the burden of the legal action that was sure to follow.11
During the three months between admissions, he grew more and more abusive to Mary, driven to berating her because of his paranoia, which never really responded to the ECT. She had “neglected him” while he was in hospital, she was spending too much money, “not helping him find someplace safe from taxes,” and she was even guilty of enjoying TV while they were in “so much danger.” After trees had fallen across the Big Wood River behind their home, Ernest made the peculiar militaristic comment that their “defenses had been breached.” Mary was clearly frayed, and it didn’t help that she suffered a scalp laceration after a fall down the stairs in early April.
On April 21, a Friday morning, she came downstairs and found Ernest holding a shotgun and two shells, as well as a suicide note he planned to leave for her. Mary patiently talked to him, about his “courage, his bravery, faith and love,” anything to stall for time. Dr. Saviers would be there, she hoped he was already on the way—Ernest was due for his routine blood pressure check, which was usually part of an extended morning visit by the doctor. It was a tense hour that required all she had emotionally, but Mary succeeded. Papa was alive. Saviers quickly grasped the situation and talked Ernest into a Sun Valley hospital stay, where he received sedatives. It was clear that he needed another psychiatric stay, but rough weather made the flight to Rochester impossible. A general hospital admission in Sun Valley would simply have to do to keep him safe for the time being. After sedatives and bed-rest there, he seemed better by April 24 and even convinced Saviers that the chores were mounting at home and he needed to tend to them. Mary simply needed him back there. But, taking no chances, Saviers sent a nurse, Joan Higgon, as well as Hemingway’s friend Don Anderson, along at discharge just to be on the safe side.
