by Andrew Farah
Once in the driveway, Hemingway rushed into his home and went straight to the living room. Don wisely followed him and found Ernest shoving shells into his shotgun; he even managed to close the breech. Anderson was able grab his large friend from behind, pinning his arms against his body, and somehow found the gun’s opening lever with his thumb. Joan quickly removed the shells. They were then able to then get Ernest back into the car and speed off to another hospital admission. By the next day a flight was possible as there was a break in the bad weather, and once again he boarded Johnson’s plane. Saviers was joined by Anderson for this trip. While the plane refueled in Rapid City, it has been reported that Ernest left the plane to “stretch his legs” but was soon rummaging through cars and the tool chests in the airport hangars “looking for a gun” and that he even attempted to walk into the whirling propeller of another plane. When he was about thirty feet away and heading toward the props, he was saved when the alert pilot sensed what was happening and quickly cut the engine.12
Though the propeller story has been repeated as fact in each significant biography, Dr. Saviers, who was at his side the entire trip, disputed it: according to Tillie Arnold, “He said he and Papa were standing together, just watching the airplane like any spectator would do, and that he had no sense that Papa was ready to run into either of the rotating blades.”13 With or without this episode, Hemingway was still suicidal and needed treatment. And once again he received the wrong type.
His second and final stay at Mayo lasted two months, April 25 through June 26. While there, he learned that George Savier’s nine-year-old son had been diagnosed with viral endocarditis and was also hospitalized. Hemingway was still receiving his shock treatments, but he managed to send a letter to the doctor, one of the last pieces of writing he ever penned:
TO FREDERICK G. SAVIERS, Rochester, 15 June 1961
Dear Fritz:
I was terribly sorry to hear this morning in a note from your father that you were laid up in Denver for a few days more and speed off this note to tell you how much I hope you’ll be feeling better.
It has been very hot and muggy here in Rochester but the last two days it has turned cool and lovely with the nights wonderful for sleeping. The country is beautiful around here and I’ve had a chance to see some wonderful country along the Mississippi where they used to drive the logs in the old lumbering days and the trails where the pioneers came north. Saw some good bass jump in the river. I never knew anything about the upper Mississippi before and it is really a very beautiful country and there are plenty of pheasants and ducks in the fall.
But not as many as in Idaho and I hope we’ll both be back there shortly and can joke about our hospital experiences together.
Best always to you, old timer from your good friend who misses you very much.
(Mister) Papa
Best to all the family. Am feeling fine and very cheerful about things in general and hope to see you all soon.”14
Though Fritz survived this bout of endocarditis, he died six years later, in 1967.
Chapter 8
The Body Electric
Michael Reynolds’s classic biography of Hemingway uses the same Whitman reference as the title of this chapter for his chapter describing Hemingway’s courses of electroshock therapy. The body is indeed an electric system, including the brain. The very tissue of the brain is a system of chemically charged networks, capable of sending and receiving impulses that in turn release chemical messengers to attach to specific receptors and signal other messengers and reactions inside the cells. But that’s just the tip of the iceberg. Our brain cells construct an infinitely complex and interwoven network, with influences as direct as our senses and as vague as a stray and random memory. We can hear the music of a symphony and visualize infinite imagery in our minds.
The realization of these facts transcends the cold science of membrane and neurotransmitter. The capacity for abstracting Whitman’s “I sing the body electric” to the title of an electric-based medical therapy for another great writer, all the while wondering whether a reference is necessary or whether “fair use” guidelines apply, fits into no single brain pathway but an unchartable array of instantaneous activity. The more we know, the less we know. But what is clear enough is that the mind’s infinitely complex design and activity argue for our transcendental nature.
When electrical abnormalities occur in the brain, they may take the clinical form of seizures. These electrical discharges disrupt the delicate balance of electrical charges across membranes and cause a group of neurons to begin firing off in a nonstop manner. They can be either localized to certain parts of the brain or generalized, spreading to many areas. The exact bodily manifestation of the seizure depends on where in the brain the abnormal flooding of electrical impulse begins and whether and where the impulses spread. Temporal lobe seizures involve mood and behavior symptoms (even mimicking bipolar illness in some patients), while generalized or “grand mal” seizures involve a tonic phase (stiffness) followed by a clonic (shaking) period that involves numerous muscle groups. Patients may or may not lose consciousness, and they may even have various neurological symptoms that last for hours or days after the seizure has ended. These transient symptoms may be as severe as amnesia or paralysis or as minor as numbness or tingling. Yet “controlled” seizures, those we induce, can be therapeutic and even curative for certain conditions.
Electroconvulsive therapy, or ECT, developed like many medical therapies, out of sheer observation: it was noted that schizophrenics who also suffered from epilepsy were much less likely to be psychotic or depressed than those who were seizure free. This, along with the pathological finding that schizophrenics had fewer glia cells, cells that support and supply neurons, while epileptic brains had an abundance of them, argued for seizure induction as a form of therapy. The Hungarian physician Ladislas Meduna was using chemicals to induce seizures by 1934 (first camphor-in-oil injected into muscle, then Metrazol intravenously), and he reported a series of successes in treating schizophrenics. His first patient was catatonic, a condition that was often fatal at the time, but Meduna brought the patient out of the frozen state with his new seizure therapy. After his first publication, in 1935, he was visited by doctors from Europe and the United States who sought to learn about his advances, but he was repeatedly annoyed by the cost of having to entertain them at his home (but he still shared his ideas).
The problems associated with seizures are obvious—bone fractures (2 percent), dislocated joints (17 percent), and compression fractures of the spine (a staggering 50 percent rate) were all observed early on with these chemically induced seizures, but by 1940 injections of muscle relaxants prior to the treatments had eliminated most of these orthopedic problems. In 1938, two Italian physicians introduced electricity as the means of seizure induction, which proved far superior and more predictable than chemical induction. A version of this procedure has lasted and has continually evolved over subsequent decades.
There are several theories as to why ECT should work for depression or psychosis, but none are conclusive. In fact, much of the evidence for what ECT accomplishes on the molecular level is contradictory and counterintuitive when we compare it to what we know about other therapies for depression and, in particular, how antidepressants work. Early theories were more true to our Freudian past than to our neurotransmitter future, postulating that administering ECT was in reality a form of punishment, which then freed the patient of guilt—a guilt that was the root cause of the depression. ECT was thus a psychotherapeutic cure. But the theory presupposes that all sufferers are truly guilty in some way or at least perceive themselves, consciously or unconsciously, as deserving punishment. Studies of “sham ECT,” in which all of the procedures of ECT are applied, including IV sedation, except the electrical impulse and seizure itself, do not benefit patients in any way.
The images and understanding most people have of the ECT procedure is highly negative, no doubt the result of a conflation of Holl
ywood depictions and organized efforts to publicly discredit the treatment. Most readers will recall the scene from One Flew over the Cuckoo’s Nest in which Jack Nicholson’s character is administered ECT as a punitive measure. When he emerges after a lobotomy, it is unclear to most viewers that this was a completely separate procedure, and many assume that the ECT created the zombie-like and permanent changes. (Lobotomy is a surgical procedure that disconnects the frontal lobe pathways from the rest of the brain. Though administered exclusively to psychiatric patients, it was developed by a Portuguese neurologist, and in the United States it was actively promoted by a neurologist, not a psychiatrist. The psychiatric community was instrumental in ending its use, which, thanks to these efforts, was minimal by the time the book One Flew over the Cuckoo’s Nest was published, in 1962.)
In the film A Beautiful Mind, the main character undergoes insulin coma therapy but is also shown as having a seizure shortly after his insulin infusion. Seizures did occur in roughly 20 percent of patients receiving insulin coma, but viewers of the scene may be confused as to which therapy John Nash (played by Russell Crowe) received. These are difficult images to see and recall, yet the procedure of ECT in Hemingway’s day had been refined to the approximate version that remains in use today. It was humanely administered and was lifesaving for many patients, such as those who were catatonic or psychotically depressed.
In 1960 and 1961, Hemingway’s ECT treatment involved his leaving his private room in a hospital gown and being taken to a special procedure suite, where he lay on a gurney. He was probably quite frightened, fearing it was all an FBI plot of some sort and likely forcing a joke or two to counter his anxieties. An intravenous line was started in his arm, and amobarbital flowed into his veins. Within a few seconds he was asleep. A blood pressure cuff tightened around one ankle, and another intravenous infusion of succinylcholine paralyzed his muscles. The rubber bite-guard was placed in his mouth, and a conductive gel was rubbed in circles over his temples. A rubber strap was placed around his head, holding two metal electrodes, one over each temple, in place. The ECT machine was set at a high enough current level to induce a seizure. Though Hemingway was paralyzed, direct current through the temporal muscles would cause his jaw to clinch but the bite-guard prevented any injury.
Men require more electricity than women for a successful treatment, because of the thickness of the male skull, which acts as a resistor to the electric impulse. In both sexes, the skull is a very effective barrier—only about 5 percent of the electricity administered actually enters the brain; most of the current arcs from one electrode to another, so that 95 percent of the electrical impulse arches over the head, not through the brain. In fact, the amount of electricity needed for effective therapy is surprisingly minimal—enough to light a 60-watt bulb for merely one second. Hemingway likely received fifteen treatments during his first Mayo admission and ten more during his second.
Later, it was discovered that sending the electrical impulse through just the right side of the brain (or the left side in the patients who are lefthanded) resulted in less confusion and fewer memory complaints than the bilateral approach. The unilateral technique spares the language center from the electrical stress (since most people are right-handed, their language center is on the left side of the brain). Yet one-sided or “right unilateral ECT” is ineffective in up to two-thirds of patients, and these patients eventually require a transition to the bilateral type if they hope to be cured. Not until 1963 would the “bilateral versus unilateral” debate begin. Hemingway received the standard bilateral/bitemporal ECT, the only form at the time and the one that would prove to be more reliably effective in the future. The seizure was timed and monitored by the shaking of his foot, as the blood pressure cuff had prevented the muscle relaxant (succinylcholine) from reaching this part of his body.
When he woke, forty-five minutes later, his mouth was dry and his vision was blurry. His head felt clouded. He wanted to get up, he wanted to speak, but his body wouldn’t do what his brain wanted it to. It was like trying to rouse himself from the dirt in Italy all those years ago—his head felt heavy, his body was numb and not moving, the noise came in waves—these were the minutes he would never remember, when he experienced the world as a blur, the drunken disconnect between mind and everything else, the mind adrift and helpless, much the way his creation, Frederic Henry, described what happened after an explosive blast: “there was a flash … as when a blast-furnace is swung open, and a roar that started white and went red and on and on in a rushing wind. I tried to breathe but my breath would not come and I felt myself rush bodily out of myself.”1
Hemingway was “postictal,” the medical term for the state of amnesia and confusion after a seizure. It gradually clears, but for Hemingway it would clear more slowly and never fully. ECT has been universally blamed for erasing Hemingway’s memory and thus ruining his craft. ECT’s seizure induction does not erase memory, but it does temporarily disrupt the circuitry that allows the storage and retrieval of memories. Patients do not recall the events directly before or after the treatment, but objective memory testing usually shows improvement after ECT as the patient is no longer depressed or psychotic. But Hemingway was suffering from a dementia. His neuronal pathways, the bridges of connection in his mind, were rickety and collapsing, and the ECT was the storm that covered them with flood waters. ECT did not erase his long-term memory, but the procedure itself was a biological stress that his brain could not handle, and that stress accelerated his dementia’s progression—as a result not of the mechanism of ECT but rather of the stress on his vulnerable system. (A hospitalization for a hip replacement would have yielded similar cognitive results.)
Once the first round of procedures was complete, Hemingway himself asked “Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient.” To Hotchner he would elaborate: “I called the local authorities to turn myself in but they didn’t know about the rap.”2 This indicates that his paranoid delusions remained intact despite the intense treatments and is also an indication that his delusions were driven not by depression but by the process of dementia (as depressive delusions resolve with ECT, even with comorbid dementia). And one of his greatest fears was the loss of his ability to work and provide, particularly since he was overly concerned, indeed, delusional, about his financial situation. Just as Zelda’s psychosis had put Scott “out of business,” his doctors had done the same for him.
At this time he was struggling to complete and even to title A Moveable Feast. And the ECT was so problematic precisely because of his undiagnosed and underlying illness. At that time, his doctors expected that the ECT would cure depression and the associated delusions, particularly since ECT is most effective in the most severe cases. It is also the treatment of choice for catatonia, when the patient is mute and literally frozen, unable to speak or move. ECT is life-saving in such cases. The common statistic in 1960 was that ECT yielded a “90 percent cure rate.” But Hemingway’s primary illness was dementia. He suffered not only more severe memory disruption with ECT but more postictal confusion, both serving to convince him he was “out of business.”
A review of the medical literature, including very recent studies, indicates that, on the whole, dementia patients can receive and benefit from ECT and that, despite their being at risk for more complications than other patients, the majority do achieve the desired cure of their depression. But these studies are generally done with Alzheimer’s patients. Hemingway’s dementia had multiple causes: alcoholism, vascular injury, and concussive or traumatic brain injury.
Hemingway’s mother suffered just such a stressful event in her seventy-ninth year that seemed to turn her mild dementia into a severe disability. The Hemingway scholar Bernice Kert described the sequence of events as follows:
A head injury sustained at Oak Pak Hospital when an attendant mishandled her wheelchair and caused it to tip over had
left Grace’s memory severely impaired, and then senile dementia set in. Sunny took her into her own house in Memphis for the last months that she lived. “It was heartbreaking,” recalled Sunny. “… She would hide from me like a child.…” When the family doctor tried to prompt Grace to recognize her daughter, she referred to Sunny as a lovely lady who was taking care of her. On the night that she was hospitalized for the last time, she sat at the piano and played several classical pieces with great gusto. A few weeks later she died in a Memphis hospital.3
Hemingway would have most likely been one of the 90 percent who responded well if his diagnosis had been only psychotic depression. His son Patrick received ECT in 1947 (unlike his father, he received no anesthesia or muscle relaxants before the electric shock was administered), and his son Gregory would receive many more treatments throughout his tormented life; in fact, Hemingway even wrote to Gregory asking him to agree to the treatments that had benefited Patrick so much, which he hoped would free Gregory of his intense suicidality. But Ernest’s brain at this point was not capable of receiving the treatments and recovering, only deteriorating. (When Faulkner received ECT for his depression, he did recover, but the treatment induced a postictal state of childlike regression for an unusually long period of time. Faulkner’s alcoholism was also well known, but his ECT was administered when he was slightly younger than Hemingway was when he received treatment; Faulkner was in the exact middle of his fiftieth decade, and though he had some risk factors for dementia, it never fully manifested.)
