According to a study published in JAMA in 2017, Chronic Traumatic Encephalopathy (CTE) was found in 99% of deceased NFL players’ brains donated for scientific research. CTE and the NFL have become inextricably linked in recent years, to the point where many may see CTE as primarily an NFL issue.

CTE, however, is not limited to the NFL, or even just sports. While the NFL does provide the setting for head injuries and repetitive head traumas, participants in other sports and other professions such as military service also provide settings for potential head traumas. In fact, with over 300,000 soldiers returning home with brain injuries since 9/11, the potential devastation from CTE among the military is alarming.

Studies and research of the disease began in the 1920s with boxers and was followed by the landmark 1949 work by British neurologist Macdonald Critchley entitled Punch-drunk syndromes: the chronic traumatic encephalopathy of boxers.

The disease was long thought as being limited to the boxing profession until the defining work in the early 2000’s of Nigerian neuropathologist Bennet Omalu in his study that began with football player Mike Webster.

In an interesting twist to the CTE story, forensic psychiatrist, Andrew Farah, chief of psychiatry at the University of North Carolina Healthcare System, makes the case that Ernest Hemingway, suffered from CTE which led to his accelerated decline and suicide.

In his book, Hemingway’s Brain, Dr. Farah, uses available biographical, medical, and historical information to argue that the long-accepted diagnoses of depression, bipolar disorder and alcoholism did not add up to explaining Hemingway’s relatively rapid decline, further accelerated by electro-shock therapy, which had the catastrophic result (for Hemingway and his eagerness to keep writing) of memory loss. Dr. Farah does not assert medical mismanagement of Ernest Hemingway, but rather explains a lack of understanding of CTE at the time.

Ernest Hemingway certainly had more than his fair share of head traumas. He was severely wounded in World War I by a mortar blast, was injured in Paris in 1928 by a falling skylight that hit his head, suffered numerous head injuries on his boat, the Pilar, suffered numerous concussions in actions during World War II, suffered head trauma in a car accident in Cuba and was injured twice in multiple plane crashes while on safari in Africa in 1954.

In the later crash, Hemingway used his head as a battering ram to smash the door open to escape the burning wreckage, after which friends began to note evidence of his cognitive decline. It should also be noted he enjoyed boxing which certainly could have led even more concussions.

Hemingway’s symptoms also fit in with the CTE profile; difficulty thinking, depression, impulsive behavior, aggression, substance abuse and suicidal thoughts and behaviors. While CTE can only be determined in a postmortem autopsy (no longer an option for Hemingway), Dr. Andrew Farah certainly makes a convincing case, and his book makes for a fascinating read.