Hemingway's Brain

by Andrew Farah

  So why did the treatments continue? Why continue to administer a treatment to Hemingway that was failing? One reason is simply the unpredictable course of ECT: often, a patient requires more than the standard number of treatments to recover. Some patients need the recommended amount of antidepressant medication, and some need three times as much, and only that individual experiment determines the answer for that patient. For the majority of patients, administering more treatments proves to be the correct course of action. Those who administer ECT are well aware of cases that responded only after the eighteenth or nineteenth treatment rather than the usual four to eight sessions. Some researchers argue that response is a function of “cumulative seizure time,” that is, keeping track of the length of seizures during the treatments until a threshold is reached that leads to a cure.

  And Hemingway’s case was challenging to his doctors in another way. Treating celebrities requires that physicians be mindful of appropriate boundaries, that they not allow their medical judgment to be compromised by this distraction or by narcissistic demands. Hemingway was treated not exactly treated like a celebrity but rather as a friend. He dined with Dr. Butt and family on several occasions, and he even shared Christmas Eve dinner with them. The patient also went target shooting with Dr. Butt and his son in an old quarry, shattering wine bottles and clay pigeons (an impressive twenty-seven in a row). Hemingway elaborated in a letter to his editor that he “dined last night with my Dr [at his] house” and they shared French wines—Muscadet, Haut-Brion, and Sancerre—“so things are perking up.”4 His physician was not only one of the best clinicians of his day; he was also a wine expert, and at Christmas time he was known for gifting cases. He allowed Hemingway two glasses of wine per night while hospitalized. We can only speculate about the conversations between doctor and patient that led to that decision, but he may have concluded that it was unrealistic to expect Ernest to agree to detox, go to AA meetings, and never drink again. Perhaps he didn’t see the alcoholism as a problem at all. Either way, he couldn’t let his patient go into alcohol withdrawal. And when Ernest reported that his libido had improved, Mary was summoned for a forced rendezvous. His doctors obviously understood the importance of his libido to his sense of self, but, not surprisingly, the night was less successful than hoped. The hospital ward was no substitute for the Paris Ritz.

  His primary psychiatrist, Dr. Howard Rome, maintained strict confidentiality after Hemingway’s death and for the rest of his life would indicate his code of silence by placing his index finger to his lips when asked by anyone to comment on his famous case. During Hemingway’s treatment, he was well aware of his patient’s delusions and tried to dispel his fears of FBI surveillance by meeting with the nearest agent. According to a memo dated January 13, 1961, in the FBI file from the Minneapolis agent to the Director:

  ERNEST HEMINGWAY, the author, has been a patient at the Mayo Clinic, Rochester, Minnesota, and is presumably at St. Mary’s in that city. He has been at the Clinic for several weeks, and is described as a problem. He is seriously ill, both physically and mentally, and at one time the doctors were considering giving him electro-shock therapy treatments.

  [At the request of Dr. Rome, psychiatrist of the] Mayo Clinic, advised to eliminate publicity and contacts by newsmen, the clinic had suggested that Mr. HEMINGWAY register under the alias GEORGE SEVIER. [Dr. Rome] stated that Mr. HEMINGWAY is now worried about his registering under an assumed name, and is concerned about an FBI investigation. [Rome] stated that inasmuch as this worry was interfering with is treatments of Mr. HEMINGWAY, he desired authorization to tell HEMINGWAY that the FBI was not concerned with his registering under an assumed name. [Dr. Rome] was advised that there was no such objection.5

  Dr. Rome has been universally criticized for his efforts in this vein, and he did indeed unwittingly contribute to Hemingway’s FBI file. But the file’s entry prior to this memo was photocopy of a newspaper article from 1958, titled “Hemingway’s Suit,” describing his legal attempt to block Esquire from “republishing some of his old stories about the Spanish Civil War”—a trivial entry, and not at all the focus of his delusions. In retrospect, Dr. Rome’s gesture was compassionate. He understood that his investigation into the matter and his medical authority might reassure his tormented patient, and he sought the FBI’s approval. He was confronting delusion with reality. But his patient was so deep in the world of unrealistic rumination that the very name he was using as an alias was somehow a source of crime and FBI concern. When Dr. Rome’s reassurances fell on deaf and delusional ears, it was all up to the ECT.

  After his second round, thought to be ten treatments, which was the usual schedule, he was at least aware of how he needed to present himself in order to obtain a discharge, even if still paranoid, depressed, and harboring a self-destructive desire. Hemingway was deceiving his doctors for a speedy release and would prove to still be delusional at the time, thinking one of the interns was really an FBI agent sent to the ward just to spy on him. He had played the game, learning what was expected of him for a hospital discharge and acting the part perfectly when he was really in no shape for release. Mary described him as sitting in his psychiatrist’s office “grinning like a Cheshire cat,” awaiting his dismissal, all the while knowing he had conned the doctors, knowing it would be disastrous, and feeling helpless.6

  Mary had been in the same situation only six months before—on Christmas Eve 1960, when she sat weeping in her hotel room as her husband was being treated the first time at Mayo. She pulled herself together long enough to write in her journal that Ernest seemed “almost as disturbed, disjointed mentally as he was when we came here.… He no longer insists that an FBI agent is hidden in the bathroom with a tape recorder.… He still says … that he feels terrible … mumbles about breaking the immigration law (he has some unspoken guilt about Val). He is convinced that the Ketchum house will be seized for non-payment or something … still feels penniless … still waits for the FBI to pick him up.” Despite the severity of his illness and Mary’s distress, the pathological ballet between them was still intact. He was delusional and harboring “unspoken guilt about Val,” and six days later, the first of the New Year’s resolutions Mary penned in her journal was “I will not worry or fret or brood about other women in love with Papa.”7

  And just before his last discharge, she must have been as much distressed as incredulous. He was better only at acting the part of a recovered patient. He made the trip home uneventfully but never settled into his previous routine. He visited Fritz Saviers as he had hoped to, and Fritz did survive the bout of endocarditis. Later that night he dined on rare New York strip at the “Christy” restaurant with Mary as they sat in his favorite corner booth. They drank Châteauneuf du Pape. Once home, he and Mary sang verses from a favorite Italian song, “Tutti mi chiamano bionda” (“Everybody calls me blonde”) as they readied for bed, and Ernest joined in on the refrain of “porto i capelli neri” (“I wear my hair black.”).8 She noticed nothing unusual when she got out of bed at 6 A.M. for a glass of water.

  That morning, July 2, 1961, Ernest woke just before sunrise and put on his slippers, then his red bathrobe, dubbed the “Emperor’s robe,” that Mary had sewn for him years ago in Italy. He had suffered from insomnia for most of his adult life, and that night was no different. He was still tormented by the fear of surveillance and by imagined financial woes and often had the typical insomnia of one who indulges in too much alcohol—sleepiness at the start of the night and restlessness thereafter. However, during this night, as he drifted in and out of sleep not deep enough for dreams, his mind did settle into a place of strange clarity and resolve. He considered his wife that morning, but only to the extent of not waking her as he quietly walked past her bedroom and headed downstairs.

  He then went directly to the windowsill in the kitchen where he knew he would find the keys he needed. He then made his way to a storeroom in the basement where his guns were locked up to prevent exactly what was to happen in about
thirty seconds. His favorite shotgun was a 12-gauge Boss model purchased at Abercrombie and Fitch. He loaded the shells, snapped the barrels in place, and headed back upstairs and into the foyer. All of his vulnerabilities coalesced in one final instant.

  It was less than forty-eight hours since he had arrived home after his release from the Mayo Clinic and his second round of ECT. Mary woke again, this time to what she surmised was Ernest slamming his dresser drawers shut.

  The shotgun Hemingway used to end his life was retrieved by his friend Chuck Atkinson, who took it to a local welding shop owned by Elvin Brooks. Chuck had already busted the stock off, out of frustration and anger, and Brooks cut the gun into three pieces. They were so concerned about souvenir hunters that the pieces were buried in a secret location that Brooks’s son believes will never be discovered because of subsequent construction in the area.9 Only the trigger remains above ground. Some writers have reported that Hemingway placed the gun to his forehead and pressed down on the trigger, but what little forensic evidence we have from those first at the scene indicates that he placed the gun barrel to the roof of his mouth, as he had rehearsed years before in Cuba.

  Of course, once a patient has fully decided to take his own life, the doctor becomes the enemy. The paradigm shifts, and the patient is no longer working with the doctor for a cure but works solely to defeat our efforts. Dr. Rome was not incompetent; he was simply treating someone who did not want treatment. Four months after he learned the fate of his most famous patient, he wrote to Mary: “I think I can appreciate what this has meant to you; the whole ghastly, horrible realization of its finality. And all of the endless echoes of why, why, why, why. And the totally unsatisfying answers. This kind of a violent end for a man who we knew to possess the essence of gentleness is an unacceptable paradox. It seems to me that these are some of the reasons why the ceaseless effort to make sense of things which seem not to fit. In my judgment he had recovered sufficiently from his depression to warrant the recommendation I made that he leave the hospital. You accepted this in good faith. I was wrong about the risk and the loss is irreparable for you and me and many others.” His final wish for Mary was that “these answers to your questions help you find composure in your head if not your heart.”10

  In the days that followed Hemingway’s death, Mary would indeed display composure of the head and hide what pain her heart may have felt. And though suicides may be predictable, this does not mean they are preventable. As much as a suicide can be predicted, Hemingway’s was more predictable than most. Yet, before this publication, he had never received a fully accurate diagnosis.

  Chapter 9

  Working Man

  As Hemingway’s brain demented over his last decade, at what appeared to be an exponential rate toward the end, the very act of creative writing became a struggle. His lifelong therapy became instead a primary source of depression because of the loss of his capacities and the subsequent fear that he could no longer make a living. As discussed, his difficulty with memory and his mental decline were accentuated by the stress of ECT itself, and, Hemingway believed, to an irreversible degree. The physiological stress of the treatments was too much for his compromised brain cells, pushing his cognitive abilities into an inexorable decline, all the while an acute self-awareness fueled his torment. After his second discharge from Mayo, there would be no recovery, and Hemingway knew it. He believed his memory had been “tampered with,” much as he sensed after his plane crashes, when it was a challenge just to remember and then to write about the Africa safari he had just taken. Given enough weeks, his memory would have recovered to some extent, but never fully.

  It is often challenging to accurately diagnose dementia in patients with very high IQs or in those who display great talents. Any mental illness that occurs in such an individual is bound to be atypical in presentation as is evident from Friedrich Nietzsche’s last decade of institutionalization, psychosis, and even mutism. However, in some cases of dementia, artistic ability may be preserved despite the deterioration of pathways for memory, processing, and cognition. Hemingway’s own mother could still play the piano despite her dementia late in life. Learned musical skills, like other learned behavior, rely on the pathways of the basal ganglia, which control movements long committed to the physical memory. Her piano skills did not emanate from higher cortical structures that were deteriorating above the basal ganglia. An example of artistic ability and, arguably, creative enhancement in the face of progressive dementia is that of Hemingway’s contemporary, Willem de Kooning.

  De Kooning, born in a working-class district of North Rotterdam in 1904, is considered one of the greatest artists of the twentieth century. Because his clinical course was so similar to Hemingway’s and because he too produced brilliant art until his death, it is worth discussing his mental decline in detail.

  De Kooning began his career as an expert draftsman, but once he immigrated to America, his ultrarealistic approach began to evolve into a unique style of abstract expressionism. By the 1950s he and Jackson Pollock were in a league of their own. He called Jackson “The leader … the painting cowboy … the first to get recognition.”1 Their very names remain synonymous with the Abstract Expressionist movement they had popularized. But, for de Kooning as for Pollock, alcoholism took its toll, although not through a deadly car crash like the one that took Pollock’s life at the age of forty-four, along with the life of one of his two passengers. Rather, de Kooning’s drinking would contribute to the insidious and premature death of brain cells. At times his alcoholism was incapacitating and life-threatening. Though he did go through detox and even attended AA meetings, he would never stay clean for long. To complicate matters, as in Hemingway’s case, prescription sedatives mixed with alcohol would cause further impairment. His biographers noted: “The sound of an ambulance wailing down Woodbine Drive [his street] to collect him became almost routine.”2

  De Kooning’s dementia was also caused by multiple factors or had a “mixed etiology.” Alcohol was one component, but at one point de Kooning was diagnosed with vascular dementia (at the time termed to “multiinfarct dementia”) from a series of small strokes (common in smokers like de Kooning). In addition, his doctor suspected Alzheimer’s as well (as the majority of patients with vascular dementia also have Alzheimer’s findings at autopsy).3 His clinical picture of dementia was very similar to Hemingway’s, with two exceptions: de Kooning’s vascular component would have been greater because of his smoking, and Hemingway had accumulated further damage and symptoms from his numerous concussions.

  And de Kooning would also develop paranoia. During a trip abroad (to the Stedelijk Museum in Amsterdam) in the early 1980s, he feared he’d be deported upon returning to the United States.4 Though at first he was indeed an illegal immigrant, he was now unaware that he had long been a U.S. citizen. By 1984 he failed to recognize those familiar to him and spoke very little. An existence of confusion was punctuated by brief moments and at times even extended periods of lucidity when he could carry on a conversation. He suffered from long stretches of mutism, his days and nights were scrambled (indicating a circadian rhythm disruption), and hallucinations developed and worsened. Eventually he required full-time attendants. Still, through the 1980s, his art flourished. In fact, the only time he was in complete control and seemed free of his impairments and disruptive symptoms was when he was at the easel. His production as measured by the sheer number of completed canvases during this period was the greatest of his life. With a term reminiscent of Andy Warhol’s career, de Kooning was described as “a factory,” completing fifty-four paintings in 1983 and fifty-one in 1984; in 1985, his most productive year ever, he completed sixty-three paintings.5

  Historically, de Kooning had great difficulty finishing a picture. Somehow, his dementia erased this ill-defined anxiety, and he no longer agonized for days over his works—they flowed. Only during those periods early in the decade when he simply could not work due to injury or illness did his idle mind revert to its dete
riorated state—the familiar and therapeutic “action painting” was not there to temporarily crowd out his confusion, agitation, and psychosis.

  The late works are sparse, the canvases are more blank than painted, and nearly all of them were composed with just primary colors. When his wife and assistants placed colors other than red, yellow, and blue at his disposal, he ignored their efforts and remained in complete control of his palette. The late works are ethereal and pleasing, and, like Hemingway’s work, their simplicity is deceptive. They are, however, somewhat uneven in quality, which is fully understandable given that patients with dementia usually have highly variable days. But overall they are more than competent. Even at the time of production, the canvases were deservedly very expensive, bringing $300,000 to $350,000 each, and today they sell for millions in galleries and at auction.

  For de Kooning, the complex motor actions of painting, the brush that moves by instinct and feel, was at this point (probably as always) guided by a subconscious drive. The technical skill and his understandings of color and composition had long been second nature to him. De Kooning’s art could flow from him as long as he could hold the brush. And, with regard to content, those who understand Abstract Expressionism know it’s useless and inappropriate to analyze the works in terms of “what they mean” or “what they look like.”

  But Hemingway’s critics would give him no such pass on his “meaning.” And his skills would not be enhanced as his illness progressed: his art required a poet’s attention to every word, an intact memory, and processing power—the very cortical activities that were in a state of decline over his last decade. The very tools he needed to write with were defective. But, like an abstract painter, Hemingway understood the subconscious underpinnings of his work. He deliberately did not reflect on what he was writing between stints with the notebook or at the typewriter: “That way my subconscious would be working on it and at the same time I would be listening to other people and noticing everything.”6 And when his art flowed for him, the story would write itself. Toward the end of his life, his psyche still held mythical and spiritual allusion and great insights, yet at some point they had become unexpressible and were trapped forever.