by Andrew Farah
Alcohol was not the only chemical Hemingway’s body and brain were dealing with during the 1940s and 1950s. He took a variety of medications and supplements, including high doses of vitamin A, which he thought would help his eyesight, thiamine (vitamin B1), and vitamin E because he believed it would improve his libido. He used the potent sedative Seconal, a barbiturate, to sleep and took Reserpine for hypertension; this medication is known to cause depression by preventing the transport of serotonin, dopamine, and norepinephrine to cells. At times he was prescribed Ritalin (methylphenidate) for low energy when he complained to his doctors that after he had lunch he was sleepy and unable to write. He was also prescribed testosterone at one point.20 These latter two therapies are still in common use and were probably good ideas. Indeed, many patients today are prescribed testosterone when this hormone is found to be depleted, especially if the patient has mild depression or libido changes. And Ritalin has also been commonly used as a part of the therapy mix for older depressed individuals. But the potential benefits were likely drowned by the whiskey, wine, and Papa Dobles.
Hemingway’s personal physician for the last years of his life went on record in a rare interview with William Smallwood (coauthor of The Idaho Hemingway). He was asked his opinion about the discrepancy between the Hemingway of the biographies—“a liar, braggart, back-stabber” and an “immodest philanderer”—and the Hemingway everybody knew in Idaho—“a kind, humble, generous, sensitive, playful, mischievous, loyal, polite gentleman.” Dr. George Saviers believed that the difference was alcohol. In the summer of 1959, he had joined Hemingway in Spain to attend Hemingway’s sixtieth birthday party, an elaborate affair arranged with great effort by Mary. According to Smallwood’s notes (retold by Tillie Arnold), Dr. Saviers “told how Papa was drinking around the clock in Pamplona and how his personality was so different than what we had seen. He said that he was loud, that he pontificated as an expert on everything, and that he told stories about himself that were obvious lies. George was especially disgusted with how Papa had treated Mary when she broke her toe at a picnic on the Irati River. He said that Papa was downright cruel to Mary and he did not know how Mary put up with it.”
Dr. Saviers also referenced some long rambling passages from Green Hills of Africa and elaborated on the influence of alcohol on Hemingway’s writing, his correspondence, and even his tendency toward paranoia. But the doctor ultimately believed that it was an oversimplification to divide the life or the work into the “drunk or sober” Hemingway: “Hemingway,” he concluded, “was a complex man.”21
Dr. Saviers’s point about complexity is accurate, as alcohol was not the only answer to Smallwood’s question about the contradictions in how Hemingway was seen by people in different settings. The friends that Hemingway had and made during his last years in Idaho saw a man who was humble, polite, sensitive, and even mischievous (implying childlike), because he was regressed. With illness, particularly a dementia when one is aware of one’s limitations, comes a childlike regression that was evident in his every interaction in the community.
Of course, Hemingway did not have a monopoly on alcoholism among his fellow writers. Scott Fitzgerald’s addiction did not destroy his talent, as Hemingway thought, so much as ruin his production. The novelist and poet Malcolm Lowry (who was ten years younger than Hemingway) began drinking by age fourteen. He was amazingly productive despite a short, volatile life of near continual drinking. James Dickey’s alcoholism was well known and also socially disruptive. When asked by an intern during a hospital admission for detox how much he drank, Dickey responded, “As much as I damn well please.”
And William Faulkner, the contemporary whose stature is most commonly equated with Hemingway’s, also met the criteria for a diagnosis of alcoholism. Yet, by contrast, Faulkner’s alcoholism would best be described as binge-type—not like Hemingway’s functional steady intake. Faulkner would completely incapacitate himself at random intervals and require hospital detoxification. Saviers’s assessment that alcohol compromised Hemingway’s craft is debatable. In works such as Green Hills of Africa, Hemingway, in his free-form writing and his pontificating, sounds roughly the same, drunk or sober. (Yet his more disinhibited, abusive, and rambling letters make it clear that many of these letters were written while he was experiencing some level of impairment.) Some biographers insist that Faulkner always worked sober, though the basic observation that his fiction is rambling and his train of thought often difficult (or impossible) to follow argues against this.
And, like Hemingway, Faulkner was compromised not only by alcoholism but also by repeated head trauma that would also play a critical role in his demise. On December 29, 1961, the horse he was riding stepped in a hole, throwing him. Nearly all falls from horses are awkward and can result in the head striking the ground. Faulkner’s postconcussive symptoms included amnesia and headache, and this was in fact the worst in a series of falls. He would be dead in seven months.22
Both alcoholism and traumas were referenced by The New Yorker’s brief mention of Hemingway’s much-anticipated 1926 novel. After first elegantly summarizing the author’s effortless mystique and magnetism, the review continues: “‘The Sun Also Rises’ … is a new novel by that already almost legendary figure in the Parisian group of young, American authors. This is a story of exquisite simplicity built on the sensational theme of a love affair between an American who has been sexually incapacitated during the war, and a credible and living counterpart of the jejune Iris March. The author of ‘Torrents of Spring,’ who has only to publish to be read by a certain circle of the intelligentsia, and not even to publish to be discussed, has written wittily and with a smooth deliberateness astonishingly effective in numerous passages of nervous staccato. An unconscious sense of security in the author carries the reader from episode to episode with mounting curiosity and no fatigue.”23
The review ends: “Related in the first person with a fierce flippancy rarely seen in the sober and surely never in the casually drunk, the book is the verbal expression of anguish not wholly of mind nor of body, unless it is of an alcoholic mind in a tragically maimed body.” Perhaps no other review was ever more prescient and applicable to the “already almost legendary figure,” even if accidentally so.
Chapter 4
Dementia, Disinhibition, and Delusion
Hard living takes its toll. The concussions, alcohol, hypertension, and prediabetes all contributed to the changes in Hemingway’s brain. As his sixth decade progressed, Hemingway’s volatility worsened; he grew more and more paranoid and became irretrievably depressed. And by the time he presented with psychiatric symptoms so severe as to warrant hospitalization, his brain had been dementing for years, and, sadly, the damage was irreversible. Yet the severe bout of depression that led to his two Mayo Clinic admissions was not his primary illness; rather, it was a manifestation of the larger process of brain dementia—as were his delusions and his cognitive decline. The illness of dementia, seen with the benefit of hindsight, clarifies much of the biography of his last decade—including not only the character of his professional writing but his eventual inability to write. It also explains the escalation of his abusive behavior and the internal torment of paranoia.
Dementia, in the medical sense, is a general term—like pneumonia or cancer—a disease that may have one of many different causes or, as in Hemingway’s case, multiple comingled causes that overwhelm the body’s defenses. Dementia is further diagnosed as a specific type on the basis of its underlying etiology. Alzheimer’s disease, named after its discoverer, Dr. Aloysius Alzheimer (who first examined his dementia patient in 1901), was one of the first categories of dementia described in the medical literature. But strokes can also cause dementia. The illness can result from a single large stroke or from an accumulation of smaller ones. This syndrome is termed “vascular dementia” and is second to Alzheimer’s in prevalence. These patients often decline in a “step-wise” fashion; that is, their confusion worsens and their functioning declin
es suddenly—seemingly overnight, in response to a medical stressor, such as a fall, or an infection. Parkinson’s disease may also involve a progressive dementia as well. And, of course, chronic alcoholism is a common cause.
A particularly disabling form of dementia that is often rapidly progressive is frontotemporal dementia, also termed “Pick’s disease” after its discoverer (who described the condition in 1892). Frontotemporal dementia patients are often younger than the average dementia patient, sometimes in their late forties or early fifties. Because frontal lobes of the brain govern our morals and inhibitions, this form involves personality changes, and often inappropriate behaviors and speech are prominent. And a newer category, termed “Lewy body dementia” (which is named for the describer of the specific protein deposits seen in the brain tissue under the microscope), has appeared in the past two decades. Lewy body patients report vivid hallucinations, very detailed delusions, and symptoms of Parkinson’s disease—often atypical and asymmetrical, such as a tremor affecting only one hand, not both. Curiously, when Lewy body patients are given medication to treat their hallucinations, their symptoms often become much worse. Thus, one way of telling early on if the dementia is of the Lewy body type is by observing that antipsychotics worsen the patient’s psychosis.
Another newer category of dementia is associated with HIV infection, which also involves its own form of dementia, characterized by apathy, sluggishness, slowed and dysarthric speech (poor articulation due to neurological damage), clumsiness, and cognitive difficulties (for example, memory and concentration impairment). Finally, patients may present with any mixture of these types; for example, the alcoholic may develop Alzheimer’s or suffer from an accumulation of small stokes that also contribute to dementia. A recent study showed that, at autopsy, 77 percent of patients with vascular dementia had enough pathological evidence to diagnose Alzheimer’s as well. And as our ability to discern the various types of dementias continues to improve, we are discovering that combined dementias are the rule, not the exception (or at least the various types share many of the same mechanism of brain cell demise and death and thus many of the same pathological findings).
To be diagnosed with dementia, a patient must have memory deficits as well as impairment in one or more other cognitive domains, such as planning, organizing, mental processing, or abstraction. Other areas that may be affected include language, an inability to recognize and name objects (“agnosia”), and motor skills, or “apraxia.” A thorough neurological exam and various motor tests, such as to assess finger and hand coordination, are performed in patients suspected of having any form of dementia. We always examine the patient in detail, looking (and hoping) for any sign that the dementia may be reversible, such as dementia caused by a thyroid condition or a vitamin B-12 deficiency, which can cause difficulties with concentration and memory. But, unfortunately, these reversible cases are rare.
A PET scan (or Positron Emission Tomography study) is the best way to definitively diagnose dementia. This test involves injecting radioactive glucose into the venous system and then measuring exactly where in the brain the glucose is being utilized. Thus, it’s a real-time look at which brain cells are working and using energy and which ones are not. A PET scan is different from tests to measure blood flow; certainly one needs blood flow to the neurons to see metabolism, but even when there is adequate flow, metabolism can still be impaired. The brain cells in patients with dementia are simply not functioning properly; even if the cells are alive, they cannot uptake and utilize glucose normally, and over time they die sooner than they should.
By simply writing a basic medical history of Ernest Hemingway, one is listing all the known risk factors associated with developing a dementia: repeated severe head injuries and concussions, alcoholism, hypertension (especially if untreated or poorly managed), and prediabetes. His weight during the last decade of his life is associated with elevated glucose levels, even if he was never formally treated for diabetes. Neuropathy and vascular injury associated with diabetes can occur in patients months or years before their glucose levels rise to a threshold that qualifies for the diagnosis (much like his father’s condition).
One of the curious aspects of dementia is that patients who have never experienced psychosis can begin suffering from delusions and hallucinations as the brain is progressively affected. As mentioned, Lewy body dementia patients often have very vivid hallucinations and elaborate, well-organized, or “systematized” delusions (when patients explain them in detail, they may involve great complexity). Hemingway’s delusions are well documented during his last years in Ketchum, Idaho. He feared he would be arrested for hunting on private land despite repeated explanations (including from the land’s owner) that it was perfectly fine. And one evening, in 1959, simply noticing lights burning after business hours in Ketchum’s First Security Bank triggered his paranoia. Lloyd and Tillie Arnold had just picked up the Hemingways and were heading back to their home for a roast beef dinner. A snowstorm was moving in that night, and, with chains on the tires, Lloyd’s car crawled through town, past the ski shop, and then the bank. Ernest nudged Lloyd hard. “They’re checking our accounts in there,” he said, in all seriousness.
Tillie believed it was just the cleaning women, and Mary insisted that she and Ernest weren’t active enough clients at that particular bank to have any records to check, but Ernest had no doubt. He had suspected as much for some time; now he “was sure.” He believed “they were trying to catch us … they wanted to get something on us.” “They” was the FBI. At the Arnolds’ home, Ernest kept looking through the large living room window, staring down on the dim light at the bank in the distance. Lloyd made drinks and tried his best to reassure Ernest. The bank manager was putting in overtime, likely protecting Ernest’s assets. “Yeah,” he responded, “but you don’t know how the big outfits work, absolutely none of it [money] your own anymore, no matter how hard you try to play straight with ’em … you can’t win, they won’t let you.” His friends now realized how seriously ill he was and feared that the Hemingway they had known for years was gone forever. Tillie went to bed that night crying.1
Another telling delusion involved his young Italian muse, Adriana Ivancich. She was a month short of nineteen when she met Hemingway when both were on a hunting trip in northern Italy in 1948. Adriana conveyed an elegant presence, but she was not as beautiful as Hemingway perceived her to be. The fact that she had descended from Italian nobility impressed him very much, and he was no doubt smitten with her the instant his hunting party found her standing in the rain by the side of the road. She was waiting for their mutual host (and friend of her brother), Count Carlo Kechler, to pick her up in the large Buick that was chauffeuring Hemingway around Europe. He was impressed during the ride by what he described as her “quick mind.” She refused a drink from his flask of whiskey, and as the conversation progressed, she apologized for not having read any of his books. Hemingway explained that she could learn “nothing good” from them, but Adriana disagreed, saying that there is “something good” in everything.
The next day was damp and dreary as well, and the shooting was equally disappointing. After the men had finished their partridge hunt, they gathered to drink and warm up in the hunting preserve’s home. In the kitchen, Ernest found Adriana rain-soaked and thoroughly worn out from her less than successful day with the rifle. He chatted sympathetically with her in front of the large fireplace, broke his plastic comb in half to share with her, and was more than charming—he was conversant, warm, and very kind. The self-possessed young woman combing out her long dark hair in the firelight knew nothing of Ernest’s hair fetish. Of course he made plans to see her again, inviting her to his favorite Venetian watering hole, Harry’s Bar.2
Adriana was hazel eyed and thin and had a narrow pale face that “went shadowy under the cheekbones.”3 By their next meeting, a luncheon, he was calling her “daughter.” In letters he also addressed her as “Daughter,” and he signed them “Mister Papa,” bu
t the words between are tender and imply more than a paternal affection:
First, daughter, I think you write beautifully in Italian and I understand it. The style is clean and good and you never get florid (flowery) unless you are angry. I never mind when you are angry because I think when I was twenty I was angry nearly all the time. Also I remember that when we have a chance to see each other neither one is very angry very long.…
I am lonesome for you and do not want to say these things to anyone else.…
Am prejudiced about you because I am in love with you. But in any situation, under any circumstances where it was my happiness or your happiness I would always want your happiness to win and would withdraw mine from the race.…
I love you very much. Mister Papa4
He professed his love many more times, in many other letters: “I cannot do anything but love you”; “I will love you always in my heart and in my heart I cannot do anything about it.” He even wrote (the day after Valentine’s Day, 1954) that perhaps Mary would understand that what had happened to him when the two met at the crossroads in Latisana “was just something that struck him like lightening.” When Adriana heard the false reports of his death in Africa, she wept for the entire day, her heart “heavy like a stone.” When he wrote to her after having survived the crashes, he claimed he had never loved her so much as “in the hour of his death.”5
In his letters he also addressed her at times as “Adriana Hemingway,” while he was “Ernest Ivancich.” This private experiment with gender and identity exchanges had played out in some of his short stories and would also figure prominently in his (unfinished) manuscript, The Garden of Eden. As Hemingway’s last decade progressed and his mind and its associations loosened, Adriana and the idea of Adriana would play multiple roles.