Hemingway's Brain

by Andrew Farah

  Though he recalled its cost as 5,000 francs, documents reveal it was 3,500 francs, or $175 at 20 francs to the dollar, still a huge sum. He put 500 francs down with promise to pay the remainder by October. He scrounged and borrowed and ultimately used some of Hadley’s trust money to buy the painting, but it would prove to be their wisest investment.

  When the painting was included in an exhibition at the Art Institute of Chicago in 1934, the owners were listed as “Mr. and Mrs. Paul Scott Mowrer, Chicago,” as Hadley had remarried. But in January 1935 another show catalogue from the Pierre Matisse Gallery of Madison Avenue attributed The Farm to Ernest Hemingway’s collection. According to two sources, Ernest had promised to return the painting within five years. But by January 1940 it was still in his possession, even if not true ownership. It hung in the dining room of his Key West home and eventually in his Cuban home. Though Castro rolled into Havana in January 1959, The Farm was saved from his regime’s “appropriation” of the Hemingway property, as Ernest had lent it to New York’s Museum of Modern Art. It was the political savvy of the MOMA staff that secured it for the 1959 exhibition “Joan Miró” and thus returned Hadley’s painting to American soil (but still in Cuba were Hemingway’s paintings by Paul Klee, Andre Masson, and the cubists Juan Gris and Georges Braque).

  The Farm’s value today is enhanced by the legend, the famous provenance, and its unique place in the Miró oeuvre. Miró began the work at his family’s summer home in Mont-roig del Camp and then hauled the large canvas to Barcelona and on to Paris, where he completed it in his dilapidated, unheated, but tidy studio. He took it to several dealers, all of whom held it for a while and then requested he retrieve it. Picasso’s dealer even advised him to cut the canvas into eight smaller pieces and sell them separately. To repay the loans that he used to buy the work, Hemingway stooped to delivering produce part time, according to one of his Paris friends, Gerald Murphy. The painting’s value in the years just after his death, as determined by the settlement Jack Hemingway accepted from Mary to relinquish any claim on the painting, was $20,000.18 Mary eventually hung it in her New York apartment, and she donated the painting to the National Gallery of Art in Washington in 1987.

  The Cuba house was next on the agenda. Working with Kennedy’s State Department, Mary was allowed to return to Finca, where Castro himself came to call. The house would become a museum, and Hemingway’s beloved boat, the Pilar, was dry docked on the grounds. Two paintings could leave the island with her, as well as her jewelry, some twentyfive of his books, and his papers. She described the transaction as “handing over the house in exchange for those 40 pounds of precious papers.”19 However, according to Jeffrey Meyers’s biography, she burned “many papers she was certain Hemingway would not want anyone to publish or to see.”20 This was according to Ernest’s instructions and included “diarylike drafts of inferior fiction” and letters about Martha and illness in his family. (To some of us, this is akin to burning the Dead Sea Scrolls.) The remaining letters and manuscripts are now housed in the John F. Kennedy Presidential Library and Archives in Boston.

  She wrote to Walton on August 1, 1961, “On Papa’s typewriter” (using the stationery embossed with “Finca Vigia” at the top), “I doubt that Papa would be totally in favor of this arrangement for disposal of the Finca; but since we cannot haul this place out to sea and sink it, as I hope to do with Pilar, I think he would prefer this to any other arrangements we might make.” No doubt he would have preferred that his beloved fishing and “sub-hunting” boat be scuttled, but his long time first mate Gregorio Fuentes feared what Castro would do in retaliation. The boat is now on the Finca grounds.21

  The years Ernest and Mary shared were turbulent from the start. One cannot argue that she didn’t know what she was in for. When they were new lovers just getting to know each other at the Ritz in Paris during their World War II days, he had slapped her across the face after she scolded him for behaving “horribly” the night before. His friends were all “drunks and slobs” who “threw up all over her bathroom.”22 He was “a big bully … a woman hitter … a fly-blown ego.” After his scolding, Hemingway transformed overnight to the contrite but naughty little boy, asking forgiveness and another chance to be good to the angry and disappointed mother. They played their parts flawlessly that day and adopted these comfortable but pathological roles for the rest of their lives. His behavior was not contrite for long; he soon took a photo of Mary and her second husband, dropped it into the toilet of her Ritz bathroom, and fired six rounds into the bowl. He shattered the plumbing and was again banished.23

  Perhaps the allure of celebrity and financial security trumped any expectation of future verbal and physical abuse. One way of coping, of course, was to simply join in with Ernest. Mary Hemingway’s drinking has generally been reported as problematic only in the years following Ernest’s death; however, a waiter at their favorite Ketchum restaurant said, “I didn’t care for Mary that much. It seemed like all she did was sit there and drink one martini after another.… Often she would only take two or three bites of her food while she got plastered on martinis.”24

  But when they met during their Paris days, perhaps she really did fall deeply in love despite his brutish behavior, and perhaps that’s why she tried to protect his reputation by denying his suicide. Her sense of identity would always remain linked to Ernest—the header on her personal stationary would read “Mrs. Ernest Hemingway” for the rest of her life.

  Mary’s stoic denial would eventually fade to resignation. Below the olive-drab top of the Look magazine cover dated September 6, 1966, were the words “HEMINGWAY—His wife sets the record straight on her life with the great novelist.” The bottom half shows Julie Andrews on a sailboat, showing off her perfect legs and giving us a faint smile. Mary agreed to the interview with the renowned and accomplished Italian journalist Oriana Fallaci, perhaps because of their shared histories as war correspondents (Mary reported from Europe during World War II, while Fallaci fought in Italy with a resistance unit despite her youth and later reported from Vietnam and other conflicted places around the globe). Perhaps it was because of Oriana’s elegance and stature, or perhaps it was just time. Her second question to Mary was

  “You’ve just said something: ‘that he killed himself there [Ketchum].’ To my knowledge, it is the first time you’ve admitted Hemingway’s suicide. Until now, and against all evidence, you’ve always maintained his death was accidental.”

  “No, he shot himself. Shot himself. Just that. For a long time, I refused to admit it … it’s true. I’ve never discussed it with a psychiatrist, but I suppose it had something to do with self-defense.… I defended myself like that, by pretending it had been an accident. Admitting the truth would’ve snapped my nerves, split open my brain. But I soon realized it was stupid to go on pretending and believing it an accident.

  “Yes, if Ernest thought that was the right thing to do, I must accept it. Without thinking of how lonely he left me, without crying with the regret that I wasn’t able to stop him … we cannot judge the behavior of a sick and desperate man. In his condition, I too, would’ve ignored the sorrow I was about to inflict … would’ve ignored the idea of leaving him alone.… there is a kind of loneliness much worse than my present one: his. And writers are lonely persons, even when they love and are loved.”

  “You are very lonely, aren’t you, Miss Mary?”

  “Totally lonely … I never had any children of my own. How sad not to have been able to bring a miniature of Ernest into this world. I longed so much for a child, and so did he. In 1947, a year after we were married, I became pregnant. Ernest was so happy; he hoped it would be a girl. But the child was never born, we lost it during a trip to Wyoming. The greatest loss of my life, except the death of Ernest. Yes, I am all alone.”

  Mary concluded the interview by reiterating this state: alone with her loneliness.25

  Chapter 12

  Modern Times

  If Ernest Hemingway walked into a modern c
linic or hospital with his exact symptoms—anxiety, depression, and delusions, as well as an overall decline in his cognitive abilities—his evaluations and treatment would be very different from what he experienced in 1960 and 1961. One would hope for a vastly different outcome as well. This chapter is not a criticism of his care at Mayo; indeed, some of the measures taken deserve praise. Hemingway received state-of-the-art therapy while at Mayo, just for the wrong diagnosis. ECT would have been curative for a case of psychotic depression, not his mixed-etiology dementia with associated depressive and psychotic features.

  There are many options now for patients with dementias, and some are natural therapies, such as vitamins, ketones, and amino acid based. There are even new and promising strategies that may prevent dementias. I hope the reader will find this departure enlightening, but it is not a guide for their own therapy, as that is always reserved for you and your personal physician.

  Nothing in medical school prepares a doctor for the celebrity patient. Although there are plenty of opportunities to deal with demanding, difficult, or entitled patients, the real challenge for the doctor of the famous patient is not letting the person’s very presence become a distraction. It is best to be singularly focused on the medical issues at hand. By the reports we have, there is every indication that Hemingway was a model patient. A retired Florida physician who was a medical student when Hemingway was at Mayo during the second admission recalled in an interview that Hemingway was still recognizable as the man on dust jackets, but he was much less robust. Though he was famous and conveyed such a stature, he was humble and deferential and spoke little on the ward. He was respectful and cordial to the student and others but overall reserved.

  Dr. Rome had at least one luncheon with Hemingway and seemed more mindful of appropriate patient-physician boundaries than his internist, Dr. Butt, who shot skeet, dined, and drank with Hemingway. By today’s standards, such recreational, nonclinical contact is generally off limits for the psychiatrist.

  Hemingway’s privacy would of course be respected, and it is still common to admit patients under aliases. Reporting that he was admitted for hypertension was the method chosen to maintain confidentiality. His doctors were correct to order a battery of tests—routine blood work, including a thyroid screen, B12 and folate levels, iron level, and physical exams. Today we would also order neuropsychological testing, an MRI scan of brain, and a PET scan as well. In all likelihood, on the basis of his symptoms, his MRI report would read “moderate atrophy and small-vessel ischemic changes.” The atrophy would mean that there was some shrinkage of the brain, or a loss of brain volume. A small degree is normal with aging, but an exaggerated amount is common in dementia (and also in patients who are chronic drinkers). The small-vessel ischemic changes would be interpreted as small strokes over time, due to his long history of prediabetes and poorly controlled hypertension. None of these strokes by itself would result in major neurological findings, such as paralysis or weakness, but a diffuse collection of them would contribute to his dementia. This was the predominant component of de Kooning’s mixed-etiology dementia due to chronic smoking. But MRIs do not detect the changes associated with past concussions.

  The PET scan would measure overall metabolism of the brain. By infusing glucose tagged with a radioactive tracer and then scanning for where in the brain that radioactivity is seen, we can see which cells are taking in glucose (energy) and utilizing it and which ones are not. In general, the darker areas on the scan indicate an accumulation of dead or dying cells. In Alzheimer’s, some of the cells may be viable but unable to take in and utilize glucose, and these cells are essentially nonfunctional.

  On the basis of his clinical history and symptoms, we would expect Hemingway’s PET scan to demonstrate that all lobes of the brain were affected to some extent. If he had some component of Alzheimer’s dementia, the temporal and parietal lobes would show the least glucose utilization (areas for memory and processing). No doubt, his PET scan would have some abnormalities, but this test is the most challenging to predict because of his several concussions. PET scanning is fairly new technology, and what limited data we have from boxers and NFL players show that multiple areas are affected, frontal and cerebellar areas in particular (but again, this is very preliminary).1

  His neuropsychological testing would be somewhat difficult to predict as well with accuracy. This would involve some paper-and-pencil tests of memory and processing, and he would have to complete them in several sessions (just the hospital paperwork was a great source of anxiety). The testing is often confounded by the genius who outsmarts his own deficits to arrive at better-than-expected scores. Still, Hemingway would not be able to compensate for short-term memory deficits and might have difficulty with attentiveness and concentration. Some of these evaluations would also indicate his paranoia and depression, and, if a more extensive battery of testing was chosen, it might be possible to see whether reaction time and motor skills were compromised (although his bird-hunting skills seemed very much intact).

  Hemingway would still demonstrate a capacity for and no doubt a gift for abstract thinking, which improves over time and deteriorates much later in dementia. But this capacity is a double-edged sword, allowing for seeds of delusion to blossom and consume the creative, analytical genius.

  Of course, these “findings” are just conjecture, based on the diagnostic workups of hundreds of patients I have evaluated who fit Hemingway’s profile. Though any clinician may argue with these hypothetical scan predictions, there is no doubt of his diagnosis based on a retroactive comprehensive review of the forensic evidence.

  We would next discuss the results in detail, meeting with Ernest and Mary, to report exactly what illnesses we had found and to outline a full plan of treatment. I would explain that he suffered from a form of dementia, from multiple causes. And I would explain that his psychosis, the fears of excessive surveillance, the conviction that he had somehow broken the law, and so on, might be part of this overall illness. His delusions might have also been driven by his depression to some extent, as patients with severe depression can become psychotic, but his were more characteristic of those seen in dementia. It would be important to express that he likely did have an FBI file, as did many others who were involved in the Spanish Civil War or who had an extensive background on Cuban soil, but it would be important to distinguish between realistic insights and excessive and unrealistic worry. Also, depression had come and gone throughout his life; now it was severe and best categorized as a chronic, underlying illness, exacerbated by the dementia. Both diseases would require treatment. I would propose exactly what I do with every patient who has dementia, no matter how mild or severe: treat aggressively.

  First we would have to approach his drinking. All of the strategies planned would be defeated by continued alcoholism.

  Hemingway’s doctors allowed him wine while hospitalized and drank with him at dinner parties, but alcohol had taken too much of a toll to be allowed to continue to flow freely. Though Hemingway found life almost intolerable when not drinking, he would be reassured that at least we would not risk a withdrawal syndrome once he entered into treatment. For such cases, a detoxification regimen would be advised, but there is a subset of patients, albeit this is extremely rare, for whom we prescribe a daily amount of medication simply to keep them from abusing alcohol. Benzodiazepines, such as diazepam (Valium), are cross-tolerant with alcohol; that is, Valium provides the same (or a similar) level of anxiety relief as patients felt when drinking, prevent a withdrawal syndrome (in 90 percent of alcoholics) who make it their substitute, and do not further damage the liver and brain.

  Again, this approach is recommended only rarely, and it can be rightly criticized as substituting one addiction for another, but it would be one that would likely keep Hemingway engaged in treatment. His history was that of the patient who, when ordered into abstinence, eventually defies any such order or alcohol limit and continues to decline with further alcohol overuse.

&n
bsp; Psychotherapy would be critical, and though there would be no talking him out of his delusions at this point, we would encourage him to focus on his health, remind himself he is safe, and buy some time until other treatments could take hold. Until the medications begin to work, we simply deemphasize the paranoia until it can be confronted with success. Again, the “reality-based therapy” would be essential—he did have an FBI file, and he should have been the least surprised by that fact. The “crimes” for which he worried about being punished (sexual liberties with a minor, taxes on gambling winnings, Valerie’s immigration status—he even worried that a state trooper might arrest him for driving home with bottles of wine in his car) were nowhere in the file.

  Many antidepressants are available now, not just two, and their potential for side effects is much lower than that of their 1961 predecessors. The best options for our modern Hemingway would be escitalopram (Lexapro), vortioxetine (Trintellix), or desvenlafaxine (Pristiq)—because of their minimal risk of drug interactions and favorable side-effect profiles. Desvenlafaxine would be the least likely to affect his weight or love life adversely. Though many antidepressants are generic now, we try to use brand products whenever possible. One-third of antidepressant patients who are switched from brand to generic lose the response they had achieved on brand medication, and another third begin to experience new side effects they didn’t have on the official version. For two-thirds of our patients, a generic is a much less successful strategy.

  But the platform of his depression and dementia therapy would be a daily pill containing B vitamins and micronutrients. New data indicate that the root cause of depression is linked to low levels of B vitamins across the blood-brain barrier. B vitamins, particularly B9 (folate), B12 (cobalamin), and also B6 (pyridoxine), are necessary co-enzymes in the synthesis of serotonin and norepinephrine.2 For decades we were told that low levels of serotonin and norepinephrine (chemical messengers in the brain, or neurotransmitters) were the cause of depression, but it seems now they are just symptoms of depression. The root cause is an inability to synthesize enough of these messengers, particularly in the presence of stress. When B vitamins are low, then neurotransmitter production is low.