• Did Chronic Traumatic Encephalopathy Contribute to Ernest Hemingway’s Death?

    In June 1961, I began as an undergraduate at the University of Kansas. My first assignment in American Literature was a paper on Ernest Hemingway’s A Farewell to Arms. I never thought that, within a month, the legendary author would place a double-barreled shotgun to his forehead and pull the trigger.

    Subsequent to his Pulitzer and Nobel prizes in the early 1950s, Hemingway’s literary reputation had diminished even as the public’s interest in the writer’s life remained high. Hemingway “look-alike” and “bad-Hemingway” writing contests were still being held annually. Fittingly, both were sponsored by his favorite bars.

    Multiple causes for his suicide have been proposed and all undoubtedly contributed to the depression, which characterized his later years. Certainly, there was a genetic predisposition for suicide, since five close relatives, including his physician-father, took their own lives. Physiologic side effects from his hemochromatosis or “bronze diabetes” have also been implicated, as well as the physical ravages of his chronic alcoholism.

    I would postulate yet another possible etiology, which I do not believe has been previously considered. Benjamin Omalu, MD, a forensic neuropathologist, first described chronic traumatic encephalopathy in 2005. He noted an abnormal accumulation of tau protein in the brains of two NFL football players who had committed suicide. Following the publication of Omalu’s book Concussion, many additional researchers have defined CTE as a progressive neuropathy related to multiple episodes of brain trauma.

    As yet, no definitive neuroimaging or hematologic test for CTE has been developed and the diagnosis can only be made with certainty by postmortem findings. Obviously, this was not possible in Hemingway’s case, so I can only draw an inference, based upon a history of multiple concussive injuries.

    Hemingway graduated from high school in 1916, where he competed in both football and boxing. No record exists of his athletic exploits but, in the era before padded headwear was used, head trauma would likely have occurred.

    He continued to box into adulthood, coercing guests into sparring in a ring he constructed in the backyard of his home in Cuba. Despite his physique, he seemed to lack defensive skills and was bloodied and floored frequently. Jack Dempsey once declined a sparring invitation, fearing that he would kill the famous writer. Hemingway sustained at least five documented concussions during adulthood.

    Significantly, each concussion predisposes the victim to develop future concussions. Two of Hemingway's occurred during World War II, causing him to be grounded from flying in RAF planes as a correspondent. One followed an auto accident in London and the other when he was blown from a motorcycle in Normandy and struck his head on a rock.

    A 1954 plane crash, while on safari in Africa, left him trapped in a burning airplane. Forced to use his head as a battering ram, he sustained a skull fracture with cerebrospinal fluid filling his ear canal. Finally, a slip on the deck of his fishing boat caused him to strike his head on the deck, resulting in his last recorded concussion.

    During his final years, the combined effects of his physical problems began to induce severe depression. He had difficulty concentrating and was increasingly bothered by headaches and both visual and auditory difficulties. When asked by Life magazine to compose a paragraph for President Kennedy’s inauguration issue, he found even that short task impossible.

    Eventually, paranoid tendencies emerged and he was treated with electroconvulsive treatments at the Mayo clinic in 1960 and again one week before his suicide. It was believed that ECT might be effective by inducing further traumatic damage to the brain.

    In summary, with his history of multiple head trauma, it seems reasonable to add the diagnosis of CTE to the other causes of the depression, which caused Hemingway’s suicide.