POST-TRAUMATIC PSYCHOSIS IN ROMEO UND JULIA AUF DEM DORFE

BY HAWRY TUCKER, JR.

ONE of the climaxcs in Gottfried Keller’s Romeo trnd Julia aufdem Do$ is Marti’s loss of mental competence subsequent to head injury-the blow inflicted by Sali, the son of his bitter enemy Manz. This incident results in the auction of Marti’s remaining property and his admission into a facility for the care of the mentally ill; most importantly, Sali’s act and its con- sequence motivate Vrenchen’s conviction that ‘dies wiirde immer ein schlechter Grundstein unserer Ehe sein . . .’.I

Keller’s description of the trauma and its immediate result possesses no more detail than suits his purpose: upon finding Sali and Vrenchen together, Marti becomes uncontrollably furious, scizes and stnkes his daughter, then starts to take her away for further mistreatment. Sali snatches up a stone and stnkes Marti on the head, causing him to stagger briefly, then to collapse unconscious. Marti returns in the early morning of the next day to at least partial awareness of his surroundings, though with amnesia as to his identity. On the following day, he is unable to walk, and is ‘ohne Bewusstsein’, indicating a clouded sensorium, a state which lasts for almost six weeks, during which time his altered mental condition becomes apparent: ‘. . . er machte nichts als Dummheiten, lachte und stoberte um das Haus herum, setzte sich in die Sonne und streckte die Zunge heraus oder hielt lange Reden in die Bohnen hinein.’* When Vrenchen takes her father to the institution, his odd behaviour attracts attention; at the place, he dances solus, sings, and is delighted at this change of environment. His amnesia has now become anterograde as well, since he believes that his wife is still living, who had died four years earlier.

It is obvious that Marti’s personality has radically changed: once imbued with hatred toward Manz and Sali, he now has no recollection of them; once stubborn, he now tractably allows himself to be placed into custody; once highly irascible, his mood is now pathologically jovial; once acquisitive, he now takes no thought of possessions, this in marked contrast to his previously litigious tem~erament.~ Keller manifestly intends the reader to assume that these morbid alterations of personality collectively resulted from the head trauma which Marti sustained, nor has h s post hoc ergo proper hoc presentation been questioned. But the reader asks himself in the light of our knowledge of mental illness: does Keller offer a credible picture of Marti’s loss of his reasoning faculties; what is the most likely psychopathology in this ‘case’? These questions seem all the niore justified since ‘the lay public probably tends to overemphasize head injuries as a cause of niental dis- order~’ .~ D

248 PSYCHOSIS I N ‘ R O M E O U N D J U L I A A U F D E M D O R F E ’

Although it has been acknowledged that ‘the relation between head injury and mental disease is a highly controversial ~ubject’,~ two associated factors have received particular emphasis : psychologically, the pe of personality subjected to head trauma, together with the nature 07 his interpersonal relationships; physically, his age, the kind and severity of injury, general state of health, and circunistances surrounding the trauma. Regarding the first factor, it has been stated categorically that ‘in mental conditions precise knowledge of the mental status of the patient prior to the injury is essential in order to determine the exact effect of a particular trauma’.6 With regard to the physical factor, age seem of special significance; younger patients appear to recover more spontaneously than those in later years: ‘Age is probably an important predisposing factor for mental sequelae to head trauma . . . the more serious after-effects with deterioration [in our series] are in the older age group^.'^ In Marti’s ‘case’, we are interested first, in establishing his mental status prior to head injury; second, in defining his psychological and physical state immediate to the trauma, as nearly as these factors can be ascertained; and third, the nature of this trauma. Answers to these questions should lead to answers to the primary questions we posed.

Mam’s pre-traumatic personality exhibits two phases. In the first, he is congenial with Manz, owner of the field neighbouring his own; as Keller’s introductory description shows, both are simply farmers engaged in the peaceful cultivation of their respective fields. Marti is here physically and psychologically functional. The second phase appears with the question of ownership of the middle tract of land, particularly of the triangle to which both men lay claim, and causing prolonged and ruinous litigation. While Manz moves to Seldwyla, Marti remains at home; his wife dies, and he has only Vrenchcn. His hostility towards Manz now assumes a dimension which can only be termed pathological, the culmination of which is the encounter on the bridge. Keller makes plain thc leading features of Marti’s ‘second’ personality (which, of course, has its roots in the ‘first’) : rigidity of thinking, contentiousness, hostility amountin to monomania, obduracy, irascibility,

to this picture the loss of the wife, and the steadily worsening economic situation in which Marti finds himself, the reader cannot escape the con- clusion that t h ~ s man is able neither to handle his impulses constructively, nor to exercise enough control over his affairs so as to avert financial ruin. These features suggest a pre-psychotic condition, possibly with paranoid involvement; certainly it can be affirmed that Marti s conative behaviour is not in his own best interests, and that he is therefore ill. In terms of depth psychology, we might say that he has regressed to the pre-phallic stage, mobilizing infantile anger and fear toward Manz, whom he takes to be the aggressor attempting to seize what is rightfully Marti’s. It is as if Marti

and strong resentment in the face o B what he believes to be injustice. Adding

P S Y C H O S I S IN ‘ R O M E O UND J U L I A A U F DEM D O R F E ’ 249

identhes with the triangle of land, cathecting it almost literally in terms of life or death: the loss of the land means the loss of his own life, the tearing asunder ofa symbiotic relationship. We can also note a possible manifestation of Freud’s death-instinct : perhaps Marti really doesn’t want to go on plough- ing, but to join his wife in the grave.

We know that Marti is about forty years old, near to middle age. Keller mentions no diseases or injuries prior to the head trauma, but does let us know that Marti is known to consume alcohol; when the news of his mis- fortune spreads, the townspeople assume that he fell while intoxicated. His physical condition can only be supposed; at least, he is strong enough to aim a challenging blow at the much younger Sali, and to have drawn furrows manually. Since he is highly enraged when struck, his respiration is likely to have been rapid, and his blood pressure elevated. Psychologically, he is poised toward fight rather than flight, and hence incapable of logical thinking. His aggressive gesture toward Sali unmistakably bears a homicidal stamp; and toward his daughter, his actions are punitive in intent. Marti’s physical and psychological condition at the moment he suffers head trauma, then, is such as might well predispose him toward a poor mental prognosis.

Keller tells of this injury in one concentrated sentence: ‘Ohne sich zu besinnen, raffte er einen Stein auf und schlug mit demselben den Alten gegen den Kopf, halb in Angst urn Vrenchen und halb im Jahzorn.’8 We know, then, the object causing the trauma, its approximate size and weight, and also something about the force with which it was applied: strong enough to bring about unconsciousness, yet not so strong as to cause death. This blow illustrates the ‘first mechanism’ of brain trauma: ‘. . . a traumatizing object of various size, shape and consistency, being delivered with a variable degree of force, strikes the quiescent head.’9 After being struck, Marti totters for a moment, then falls senseless. No blood appears; the respiration is shallow; and the pulse, presumably, weak.

As to the nature of Marti’s injury, it seems clear that this is cerebral con- cussion, with or without fracture; the lack of bleeding indicates that the wound was of the ‘closed’ type. The presence or absence of fracture is not at issue, since mental illness subsequent to head trauma may occur in either case, according to Bowman and Blau on ‘primary traumatic psychosis’: ‘The mental scquelae may arise after slight or severe types of head injury. A skull fracture is not always present even in the most severe cases. The traumatic psychoses may also occur when the major lesion is apparently outside the brain proper as in subdural and epidural hemorrhages.”O In the same paper, these physicians refer (p. 369) to F. Kalberlah’s term ‘Com- motionpsychose’, under which rubric Marti’s mental illness may temporarily be subsumed. We find, further, that ‘a subdural hematoma is a common accompaniment of head injury’; that in the chronic form of this pathological

2SO P S Y C H O S I S I N ‘ R O M E O U N D J U L I A A U F D E M D O R F E ’

entity, patients ‘. . . may be quite ill from the beginning, tending to improve for several weeks’ [Marti is in bed for almost six weeks]; that ‘it is almost always traumatic in origin’ and that fights may precede it; that skull fracture may or may not acconipany it; and that personality disorders may follow upon this lesion.” One patient in follow-up studies by Gurdjian and Webster was committed to a mental hospital, and ‘the hcad injury was thought to bc of importance in the resulting mental abnormality’ (p. 167), seemingly a parallel to Kcller’s Marti, whose injury may have either initiated, or exacerbated, a subdural hematoma. His post-concussional state does not con- form to the picture of epidural hematoma, with its rather prompt return to clarity of thinking. Further, ‘a hcad injury may usher in, or cxpcdite the course of, a chronic brain disease, especially ccrcbral artcriosclcrosis.’12 There is no direct evidence that Marti suffered some form of pre-traumatic intra- cranial pathology, although his behaviour may well hint at this.

Marti is describcd as ‘moving’ on the morning after injury, but as being unable to walk for nearly six weeks, after which tinic he moves about freely.13 This appears to indicate locomotor dysfunction with spontaneous remission; in fact, the reader’s impression is that Marti makes a practically complete physical recovery aside from h s brain syndrome, which includes both rctro- and antcrograde amnesia. His euphoric mood state remains apparently constant, resembling schizophrenic reactions of the hebephrenic and schizo-affcctivc types. Wc may note here that Keller’s Novelle appeared not quite twenty years after Esquirol’s and Pritchard’s pioneering studies of head trauma as an etiological factor in niental illness, and that Keller himself had personal acquaintancc with certain forms of psych~pathology.’~

The authorities we havc adduced in studying Marti’s ‘case’ have provided an answer to the first of our initial queries: is he a clinically credible character? The answer is affirmative, especially given the adverse features of the man’s pre-traumatic personality; his excessive drinking;15 his declining social and economic position; his wife’s death; his age; and his physical and psycho- logical condition at the time of trauma, as nearly as these factors can be estimated. Indeed, considering that Marti is suffering inordinate stresses, caused by impcnding frnancial ruin ; sexual deprivation ; morbid brooding upon what hc considers to be a morc crucial deprivation, the loss of what he deems his r i g h h l property; and his monomanic antagonism toward Manz, onc may surmise that such an individual in actuality might well pass into a psychotic state even minus the precipitating agent of ccrcbral trauma. That this trauma takes place makes Marti’s resulting mental condition all the morc understandable, giving evidence of Keller’s accurate observation of the world about him.16

It now remains to define the naturc of Marti’s illness. Returning to ‘primary traumatic psychosis’, and to Bowman and Blau’s reference to

PSYCHOSIS I N ‘ROMEO U N D J U L I A AUF DEM D O R F E ’ 25 I

Cornrnotionpsychose, we can state that Marti’s disorder is not functional, but organic. His psychosis may be described as a chronic brain disorder associated with trauma, quite likely with subdural lesion. It is of interest also to note that this condition represents the attainment of a goal, albeit by a pathological route,which Marti had sought before he became ill: an anxiety- free state, to be attained by the concession of the disputed land. His post- traumatic picture gives evidence of this secondary gain, fieedom from anxiety, mediated by a symptomatology resembling that of the schizophrenic in his breaking with reality.17

NOTES

Gotdried Keller, Simfliche Werk (Munich, 1954). Vol. I. 653. Ibid., p. 651. See Otto Fenichel, The P s y c b d y t i c Thcory ojNeurosu (New York, 19 s), p. 434. ’ Karl M. Bowman and Abram Blau, ‘Psychotic States Following Head and Brain Injury in Adults

and Children’, in Injuries offhe Brain rmd Spiital Cord aid Their Coverings, ed. Samuel Brock, 4th ed. (New York. I*),

Bowman and Bk;?;. cit. F, Bowman and Blau, p. 361. ‘A study of the previous personality pattern is essential for an appreciation

of the post-traumatic personality changes’ (Sir Charla Symonds, ‘Concussion and Contusion of the Brain and Their Sequelae’, in Brock, op. cit., p. 87); *. . . I have frequently read as a comment on a case that the patient is suffering from a psychoneurotic reaction to his head injury, when a more correct interpretation would have been that because of his head injury the patient’s personality is now such that he develops a psychoneurosis’ (M. Kremer, ‘Post-Traumatic Personahty Change’, in Proc. R. S. M . , Vol. XXXVII (1944), 564. quoted by Symonds. op. cif., pp. 87-8); ‘Was he a stable or a neurotic person- ality? . . . Has his life been one of domestic felicity and economic security?’ (Samuel Brock. ‘General Considerations in Injuries of the Brain and Spinal Cord and Their Coverings’, in Brock, op. cit., p. 14; see also this editor’s note on page 404).

Bowman and Blau, p. 366. Keller, p. 649. C. B. Courville, ‘General Aspects of Pathology of Craniocerebral Injury’, in Brock, op. cit., p. 23.

lo Op. cit., p. 366. E. S. Gurdjian and J. E. Webster, ‘Traumatic Intracranial Hemorrhage’, in Brock, op. cit., pp. 149,

160, 162, 162-3, 164, 167. lz American Psychiatric Association, Diafnosfic and Stafisfical Manual , Afenfal Disorders (Washington.

I952), P. 20. l3 Marti may be in what Sir Charles Symonds calls ‘traumatic delirium’ in the severe degree of injury.

which ‘. . . may continue for days or weeks, and the same is true of the subsequent stages of confusion and amnestic-automatism’, op. lit., pp. 78 f., 83. Scc also Bowman and Blau, op. [if . , p. 369.

I‘ E. Esquirol. Des maladies mm*lles (Paris, 1837), J. C. Pritchard, A Treatise on Insanity and Other Disorders A$ectiizx the M i n d (Philadelphia, 1837). Keller’s art teacher lost his reason, as did his sweetheart in youth, Johanna Kapp.

l5 Of the rimary traumatic psychoses, Bowman and Blau say that ‘the most common combination is that of alcotolism with head trauma’, op. cit. , p. 368. l6 ‘Indeed, it is a commonplace of psychiatric wisdom to say that the causes for a particular person’s

psychosis are always multiple, in the sense that any one etiologicil factor would not initiate or maintain a psychotic reaction if other factors did not combine to induce or to permit such a reaction’ (John C. Whitehorn, ‘Psychodynamic Approach to the Study of Psychoses’, in Dynamic Psychiatry, ed. Franz Alexander ef al. (Chicago, 1952), p. 265. For this reference, and for checking the scientific aspects of this paper, my cordial thanks go to Wilmer C. Bets, M.D. I7 See Fenichel, op. cif . , p. 439 f. For the relationship of head trauma to the manic-depressive syndrome,

schizophrenia, and paranoia, see Bowman and Blau, o p cit., p. 403. and I. S. Wechler. ‘The Relationship of Brain Injury to Other Organic Diseases of the Brain’, in Brock, op. cit., p. 451.