Hemingway's Brain

by Andrew Farah

  A night in the open was punctuated by attempts at jokes and the fear that a nearby elephant herd might get curious about the intruders. They had crashlanded essentially in the herd’s living room, and Mary woke Ernest during the night to stop his snoring, which was a strange attraction for a few of the elephants.24 By sheer luck, the next morning a boat that had been chartered by a British surgeon from Kampala appeared (interestingly, it had previously been chartered by John Huston while he was filming The African Queen). The captain, an East Indian, actually charged the stranded group to climb aboard. The exact figure was one hundred shillings apiece, so high as to be nothing short of extortion. He dropped them near Butiaba, on the eastern shore of Lake Albert, where they were met at the dock by a policeman and the bush pilot who had been searching for them throughout the day in his twelve-seater, twinengine de Havilland Rapide.

  The pilot of the third doomed aircraft was Reginald Cartwright. The next day, his plane was gassed up and waiting at the Butiaba airport, where the runway was described as nothing more than a badly plowed field—rocky, furrowed, and bumpy—at best, a dangerous excuse for an airstrip. The trip would not take them to Entebbe as planned but would end in mere seconds, in a crash more violent and more fiery than the previous one. The plane bumped along for a while and lifted off only for a few seconds before it slammed down in explosive chaos. The cabin filled with smoke, and there were flames visible outside the windows. The starboard engine was on fire, and Mary found the door jammed shut. Cartwright, Mary, and Marsh all escaped after the pilot kicked out the front windshield, but Hemingway was too large for this exit, and his movement was limited by the pain from his shoulder injury the day before. He very unwisely chose to batter open the jammed door with his head, no doubt sustaining another major head injury. Staggering onto the port-side wing, he made his escape, but he sustained fractures of two vertebral disks and a dislocation of his right shoulder. There were first-degree burns on his head, face and arms, and, whether from the force of the impact, from his using his head as a battering ram, or both, his skull was now fractured. Cerebrospinal fluid drained from his left ear, and by the next day he reported the recurrence of his double vision, hearing that “came in and out like a radio in a thunderstorm,” frequent vomiting, loss of vision in his left eye, and even complete loss of hearing on the left (fortunately, these last two symptoms were fairly short lived).

  Mary and Ernest then endured what he called “the longest ride of his life,” fifty miles to Masindi.25 Though woozy, his head pounding, he told the press, “My luck, she is still good.” He must have truly believed that, because he and Roy Marsh climbed aboard a small Cessna 170 to head for Nairobi, while Mary and Patrick (who had flown out to meet them) took a commercial airliner.26

  In the 1950s, physicians had yet to define “postconcussive syndrome” (PCS), although it was well known that head injuries could result in a variety of neurological and psychiatric symptoms. To complicate matters, the symptoms can be variable and intermittent over time. The older a patient is, in general, the less resilient his or her brain is, the more severe the symptoms, and the longer they persist. Typical cases involve irritability and mood swings, memory and concentration deficits, noise and possibly light sensitivity, headaches, dizziness, fatigue, tinnitus (ringing in ears), insomnia, and impaired judgment. Hemingway had, at various times after this fifth concussion, all of the above.

  When a commercial airliner spotted the wreckage of the first crash, the pilots radioed back that there were no survivors. Obituaries for Hemingway sprang up, and, once out of Africa, he read them late into the night with an intense fascination. Though it was a cliché, he was well aware of his reputation for romancing death in his life and work, and this time, in Africa, as in Italy and France, he had once again survived when the odds were against him. Perhaps this explains why he couldn’t put the obituaries down. And after all, it was his best friend who wrote in Ulysses, “Read your own obituary notice; they say you live longer. Gives you second wind. New lease of life.”

  By contrast, twenty-one years earlier, when Scribner’s mailed him galley proofs of Death in the Afternoon, with the tag “Hemingway’s Death” across each page, he became so furious that he immediately fired off a telegram to his editor: “DID IT SEEM VERY FUNNY TO SLUG EVERY GALLEY HEMINGWAY’S DEATH OR WAS THAT WHAT YOU WANTED?”27 He even wrote a follow-up letter to Perkins: “You know I am superstitious and it is a hell of a damn dirty business to stare at that a thousand times even to haveing it (in this last filthy batch) written in with red and purple ink. If I would have passed out would have said your goddamned lot put the curse on me.”28

  His reaction was certainly out of proportion, as the perceived offense was essentially a function of his imagination, not an editor’s attempt at dark humor. Yet he was so sensitive and superstitious that he found red and purple ink part of the jinx, and he was unable to even spell out the words “If I had died,” writing only “If I would have passed out.”

  Though the plane crashes and the “greatly exaggerated” reports of his death are treated metaphorically by scholars, the second one in particular involved significant traumatic brain injury. This was his most severe concussive incident to date, partly because of his age, partly because of the multiplying effects of cumulative damage. None of his other accidents had taken such a toll, and friends agreed that after the crashes Hemingway was never the same man. He was just fifty-five, but his downhill slide was accelerating. And Hemingway had no difficulty in diagnosing his condition at the time. After the back-to-back plane crashes of January 22 and 23, he wrote in a letter from Kenya on February 2, 1954, “This is a funny thing. Maybe—concussion is very strange—and I have been studying it: Double vision; hearing comes and goes, your capacity for scenting (smelling something) can become acute beyond belief.”29

  It has been known since the 1920s that boxers suffer from a cognitive decline as they age. This condition was originally termed “dementia pugilistica” and was the result of repeated head blows of subconcussive force, as the fictional Ad Francis would describe and further demonstrate. This form of dementia is usually associated with ataxia (balance and gait difficulties), speech problems, tremors, and of course, a cognitive decline similar to that seen in Alzheimer’s. In the 1956 film The Harder They Fall, a colleague tries to dissuade the Humphrey Bogart character, a sportswriter, from joining a group of corrupt fight promoters by showing him a film of a boxer with these exact symptoms. Of course, not all boxers develop the syndrome, but it has been a well-known possibility almost as long as there has been professional boxing.

  The brain is suspended in a fluid-filled sac, and thus rapid acceleration-deceleration trauma will cause the brain to slam against the skull. The temporal lobes are particularly susceptible, as they sit above the rough structures of the petrous sections of the temporal bones. Temporal lobes are critical for retaining visual memories, understanding and processing sensory inputs, storing new memories, and interpreting past memories and moment-to-moment emotional responses. From an anatomical standpoint, it is clear why so many head trauma patients have memory deficits and emotional dyscontrol once their temporal lobes have been battered against bone.

  Side-to-side and rotational movements are thought to be more harmful than front-to-back movement. The damage found on pathological examination reads exactly the same as a list of the various mechanisms known to cause dementia: damage to the blood-brain barrier and the release of neurotoxins (chemicals damaging to the brain cells), damage to the vessels that supply blood to the brain cells, disruption of the brain cell membranes so that calcium flows into cells (the accumulation of calcium inside cells is part of the mechanism of cell death in dementia), atrophy (or shrinkage) of brain structures, inflammation, and the release of cytokines (chemical messengers that attach to specific sites on the surface of brain cells and direct events inside those cells). In addition, a phenomenon known as “apoptosis” can also occur. Apoptosis is a form of DNA damage that acts as a time bomb
, literally reprogramming the DNA of brain cells for premature death. In the laboratory setting, these traumainduced mechanisms for accelerated cell death continue to unfold and affect DNA for up to a year after the initial injury has occurred.

  One posttraumatic symptom that is commonly present is the persistent headache that Hemingway complained of during his World War II exploits. But brain cells have no pain receptors; the blood vessels that supply them do. So a persistent headache is the sign of vascular constriction, much like a migraine. This vascular constriction also compromises blood flow and can further impair memory and processing. After a trauma, the brain vessels often overreact, and their continual constriction can be easily seen on scans. The patient will simply say the headache never goes away and worsens with barometric changes or during flights (or in any setting in which air pressure changes). If the temporal vessels are constricted, the patient will lose memory and may even be accused of malingering, because long-term memories are absent even though shortterm memory holds up well.

  Hemingway famously exaggerated his traumas, particularly his first concussion and other World War I wounds. In one of his reports from the Spanish Civil War he wrote, “In the war that I had known, men often lied about the manner of their wounding. Not at first; but later. I’d lied a little myself in my time.”30 But lies were not necessary—the simple facts were damaging enough. The mortar explosion in 1918 had created vulnerability on a molecular and chemical scale, and when repeated concussions took place, his brain cells were more compromised with each successive blow—their demise was accelerated, and the areas of the brain affected were ever more diffuse. In Hemingway’s case, these blows were adding more and more bricks to a load that was ever weighing down the life itself. By his mid-fifties, he had become a version of Ad Francis (and, with a tragic self-awareness, confessed as much to his associate Hotchner).

  He had all the hallmark symptoms of postconcussive syndrome after his London car wreck and after his Africa plane crashes, but PCS can resolve. Every brain is different, every head injury unique, and we don’t know why some of our patients recover fairly well or even completely and others have symptoms for years. Few patterns of recovery emerge, except that patients who suffer concussions at an older age and those with very severe traumas are more likely to have deficits for a lifetime. And individuals who suffer multiple concussions as Ad Francis and his creator suffered can progress from postconcussive symptoms to a form of progressive brain degeneration. However, the new terminology that replaced “dementia pugilistica” is “chronic traumatic encephalopathy,” or CTE.

  CTE is can result from concussive injuries like those Hemingway experienced but also from multiple “subthreshold” brain traumas, that is, numerous blows each of which is not so forceful as to result in a concussion but does damage nonetheless. After the Hemingway stand-in, Jake Barnes, is knocked out in a Spanish café by the boxer Cohn in The Sun Also Rises, Barnes describes how “everything looked new and changed.… It was all different. I felt as I felt once coming home from an out-of-town football game.… It was all strange … my feet seemed to be a long way off, and everything seemed to come from a long way off, and I could hear my feet walking a great distance away. I had been kicked in the head early in the game.”31 Whether Hemingway really had such an experience in high school or borrowed it as was his gift, making it convincingly his own (such as the 1917 retreat at Caporetto), he was no stranger to the bizarre sensory changes that can accompany a head injury.

  The National Football League’s August 2013 settlement in which the league paid $765 million to former players with head injuries, as well as several other high-profile cases, has made this form of dementia a widely discussed topic in the media and in popular culture. Hall of Famer Mike Webster’s CTE was highlighted in the 2013 Frontline episode “League of Denial: The NFL’s Concussion Crisis” and the major motion picture Concussion, released in 2015. Webster was the center who anchored an offensive line that protected Terry Bradshaw for nine years. After hiking the ball, he usually slammed his forehead into the nearest defensive lineman trying to run through him. Tony Dorsett, the 1976 Heisman Trophy winner and Hall of Fame running back, spent twelve seasons in the NFL. Early in 2015, in tears, he discussed his symptoms. He gets lost when driving, and his daughters are afraid of his anger outbursts. And recently the family of Hall of Famer Frank Gifford revealed in November 2015 that he too had suffered from CTE, in hopes that this posthumous disclosure will further advance player safety.

  Sadly, Hemingway’s case is a textbook example. His own words describe the symptoms of postconcussive syndrome. The injuries from early blows resolved, but, with additional assaults, his brain developed CTE. This syndrome can develop years, even decades, after the traumas themselves. At autopsy, doctors find that the brain has atrophied and shows neurofibrillary tangles as well as deposits of tau protein and Beta-amyloid, just as seen in Alzheimer’s patients. But CTE is not the complete picture, just one of the largest pieces in the puzzle of Hemingway’s illness. His brain cells suffered other, diverse forms of injury as well. Those additional insults on the cellular level, in addition to the repeated nature of his concussions and their cumulative damage, all propelled the pathology from PSC to CTE and, eventually, to a permanent dementia.

  Chapter 3

  Giant Killer

  Hemingway famously described a life without alcohol as driving a race car without motor oil, and he lived his adult life determined to run a well-oiled race. Though numerous drinks have been named after him, probably only a few deserve the moniker. In Cuba, the Florida became famous for serving a Papa Doble, which consists of two and a half jiggers of Bacardi rum (white, not dark), the juice of two limes and half of a grapefruit, and six drops of Maraschino liqueur, all poured in a blender with ice chips and “whirled vigorously and served foaming in large goblets.”1 Still, a purist may point to Islands in the Stream, in which Thomas Hudson drinks gin mixed with lime and coconut juices (though the exact ratios were never clarified), with dashes of Angostura bitters. The fact that so many drinks around the globe in any number of oak-lined bars as well as numerous dives are named after him is a testament to the twofisted drinking Hemingway—a part of the legend he seemed all too eager to live up to.

  There is no shortage of drinking references in memoirs and biographies about Hemingway and, of course, plenty of references to his drunkenness—the flask in the pocket, the skin of wine on road trips, and the resultant volatility and arguments with spouses and others are noted throughout multiple biographies. Perhaps the most tragic and embarrassing alcohol-related incident occurred after a V2 rocket hit the neighborhood where Hemingway and other correspondents were staying in London during the Blitz; he was either too hung over or still too drunk to get up from breakfast and help his colleagues with the rescue efforts. Alcoholism, simply put, is the reason the term “bipolar disorder” does not apply in this detailed look at Hemingway’s mental illness: the fact is that all of his affective (mood) instability and “bipolar” symptoms can be fully explained by the illness of alcoholism. What biographers have termed “bipolar” or “manic-depressive” disorder would more accurately be termed “alcohol-induced mood disorder.” On paper, the symptoms of alcoholism—mood swings, volatility, depression, erratic sleep and insomnia, self-destructiveness, and even psychosis—are also hallmarks of bipolar illness. Contrary to popular myth, Hemingway never had a manic episode, and his name should be erased from every list of “famous bipolar patients.”

  Bipolar illness affects 1 percent of the population, and, as the name suggests, the abnormal mood states can be depressed or manic, thus representing two polar extremes. Of course the individual’s mood state can be normal, or “euthymic,” but long-term studies indicate that bipolar patients spend the majority of their lives in the depressed state. This is certainly risky, as the lifetime chance of suicide in the bipolar population is 15 percent, and opinion is now divided as to whether antidepressants are helpful and safe for bipolars. A patient m
ay even present in a mixed state of mania and depression, such as being hyperactive and speaking rapidly but also crying and stating that she is depressed and perhaps even suicidal.

  There are plenty of artists and writers who have suffered from this illness. Robert Lowell was a contemporary of Hemingway whose struggles with bipolar illness are well documented. His manic states were marked by hyperreligiosity and delusions (“I suspected I was the reincarnation of the Holy Ghost.”), bizarre behaviors (standing in the street with outstretched arms to “stop the traffic”), and pressured speech—which even resulted in his arrest at one point. He termed the condition “pathological enthusiasm.”2 When a young Flannery O’Connor saw him in New York, as she was on his list to be canonized into sainthood, the naïve Flannery didn’t understand the illness. She described herself as too inexperienced to recognize that he was mad; she just thought that was the way poets acted.3

  Hemingway’s behavior never reached a threshold of pathology that would qualify him for a diagnosis of bipolar illness, but his youngest son had documented manic episodes and, as discussed, suffered greatly. Still, no other first-degree relatives were ever in a manic phase as far as we know. Though some excellent biographies have been written with the underlying premise that Hemingway was “on a manic high” for discrete periods and “in a bipolar depression” at some other times, the premise is false. His stretches of productivity are best explained by the enthusiasm that success brings and as the result of a genius taking advantage of the visiting muse, knowing she may leave without warning at any instant. He felt exhausted when he had completed a major work, and the subsequent lulls caused him to ruminate about never completing another. Once he began writing again, a natural enthusiasm followed from realizing that his two worst demons—that he could not write and that he had nothing to say—were being exorcised. There is nothing pathological in these cycles; if there is, all artists are pathological to some degree.