Department of Neurology, University Hospital, Lausanne, Switzerland
The nature and the neurological consequences of the shell wound to the head of the famous French poet Guillaume Apollinaire, on March 17, 1916, during World War I, remains unclear. However, his contemporaries and biographers have been unanimous in stating that this event affected a major shift in his life. His personality and behavior changed dramatically, and his affective relationships were deeply modified, the most significant example being his rapid disinterest for his fiancée Madeleine, to whom he had written passionate letters nearly every day before the trauma. The study of Apollinaire's letters, scarce medical reports, available memories from friends, and Apollinaire's helmet allow one to better understand the type of brain lesion he had and why neurobehavioral dysfunction developed. While an 'intracranial abscess' had been emphasized initially, clinical manifestations, free interval, no infectious problems, and quick resolution of hemiparesis and seizures after a burr hole was performed strongly suggest a chronic subdural hematoma in the right temporal region. Irritability, susceptibility, emotional intolerance, affect flattening, anxiety, and personality change fit perfectly with the diagnosis of right temporal lobe dysfunction involving the lateral-basal area. Sparing of the mesial-temporal, parietal, and frontal regions explains the absence of significant memory, cognitive, and executive impairment, without disturbing his creative skills as a poet and art writer. This cognitive-affective dissociation secondary to isolated right temporal post-traumatic lesion allows one to delineate the 'deep sorrow' of Apollinaire during the two and a half years before he died of Spanish influenza in 1918.
Copyright © 2005 S. Karger AG, Basel
Guillaume Apollinaire (Wilhelm Apollinaris de Kostrowitsky, 1880-1918), one of the greatest French poets of all time, was wounded in the head during World War I, after which his personality and behavior changed dramatically, until his premature death from Spanish influenza 2 years later. While the nature and the neurological consequences of the wound remain partially unknown, Apollinaire's contemporaries have been unanimous in stating that this event was a major shift in his life. In particular, his affective relationships were deeply modified, the most significant example being his rapid disinterest for his fiancée Madeleine Pagès, to whom he had written passionate letters nearly every day before the head trauma. The study of Apollinaire's own letters, scarce medical reports, available memories from friends, and his preserved helmet allow to better understand which type of brain lesion he had and why neuro-behavioral changes developed [Bogousslavsky, 2003].
At age 36, Apollinaire already was a well-established writer and art chronicles journalist, who had been one of the first to defend cubism, as an admirer and friend of Picasso, Derain, Braque, and others. Shortly after the outbreak of war, Apollinaire, who was of Russian nationality through his mother's side, joined the French army as a voluntary soldier in December, 1914. Initially, he had been drafted into the artillery, but he was moved to the infantry, as he wanted to be involved in the front line of battle. He was promoted to the rank of under-lieutenant in November 1915 and, on March 14 1916, he received the documents informing him that his application to get his French nationality had been accepted. On the same day, he wrote a long letter to the famous poet Max Jacob and another one to his fiancée Madeleine, which looked somewhat premonitory: 'I give you anything I own in case I die, this is my will'. On March 17, in the trench 'au bois des buttes' in the Champagne countryside, while reading the literary magazine Le Mercure de France, he was shot in the head during a bout of enemy fire, while wearing his helmet. He did not lose consciousness, as he stated later to André Billy: 'I thought I had not been hit, when all of a sudden I started to bleed'. Indeed, the wound initially seemed of little gravity, as he wrote the following day to Madeleine: 'I was wounded in the head yesterday by a shell which penetrated my helmet. In fact, the helmet saved my life. I am well taken care of, and apparently this will not be severe'.
I have been able to trace Apollinaire's helmet which hung at a hook for over 70 years in his apartment, 202, boulevard Saint-Germain in Paris, preserved as everything else by his young widow after he died in November, 1918. Together with part of Apollinaire's library, the helmet was subsequently acquired by the Bibliothèque Historique de la Ville de Paris, where I could examine and study it (fig. 1). There is a triangular (2 X 1.2 X 1.2 cm) hole just above the right
Fig. 1. Apollinaire's helmet (Bogousslavsky, 2003).
temporal region, the shape of which suggests an anterior to posterior, downward, trajectory of the shell. This is confirmed by the hole in the leather piece covering the inside of the helmet: this hole, which is smaller than the first one (1 cm), is located 2.2 cm behind the perforated metal. Moreover, examination of the leather bandage (worn by Apollinaire when recovering), which has also been preserved, shows that the center of the protecting pad is located 3.3 cm away from the point of entry into the helmet, backwards and downwards. These data allow one to reconstruct the potential point of impact on a standard skull and brain (fig. 2) [Bogousslavsky, 2003].
Three days after the wound, Apollinaire was transferred to Château-Thierry, and subsequently to the Val-de-Grâce in Paris. We are lucky that the doctor who took care of him knew more about neurology than the usual army physician, since she was the wife of the renowned neurologist Jean Nageotte, who had worked with Babinski and Dejerine. Herself a pediatrician, she left the best available description of Apollinaire's developing brain dysfunction. Her notes already mention the absence of any initial neurological event, with 'no brain accident, loss of consciousness, vomiting, visual or auditory disturbance, gait or speech disorder' until the last days of March, when Apollinaire developed headaches, fatigue, and dizziness. She also emphasized his 'neglected' aspect at that time. During the first days of May, while recovering at the Italian Hospital,
Fig. 2. Skull (a, b) and brain (c) impact of the shell, reconstructed (Bogousslavsky, 2003).
Apollinaire developed increasing dizziness and had a sudden loss of consciousness in the street, suggesting a seizure, which was followed by a fluctuating hemiparesis mainly involving the left arm. Apollinaire was trepanated on May 9 by Dr. Baudet at the Villa Molière, which was affiliated to the Val-de-Grâce. An 'intracranial abscess' was reported, but no medical documents are available.
Retrospectively, it seems highly unlikely that Apollinaire had an intracranial abscess. The fluctuating clinical course, with a 6-week free interval followed by a complete resolution of the neurological manifestations (hemiparesis, seizures) after surgery, with no major infectious features, as well as uncomplicated survival without antibiotherapy, are much more compatible with a subdural hematoma over the right convexity. This is also suggested by the trivial-looking initial trauma, during which the helmet and skull seem to have absorbed most of the kinetic energy of the projectile, with only a superficial, non deeply penetrating, wound. A last clue for a subdural hematoma is the report by the attending nurse of an immediate improvement of the hemiparesis during the operation: 'As soon as the skull was opened... the fingers of the paretic hand started to move slightly, which was followed by some movement in the leg'.
While the hemiparesis completely resolved, the personality and behavioral changes shown by Apollinaire persisted, which suggests a permanent damage to the lateral-temporal part of the right temporal lobe, due either to compression sequelae or to associated contusional damage.
Apollinaire's Affective and Emotional Disorders
In contrast with his own initial minimalization of the head wound, the first observable consequence was Apollinaire's new, dramatic, intolerance to emotional stimuli. This was particularly obvious in his correspondence with his fiancée Madeleine. While his previous letters, which he signed 'Gui', had been passionate, he changed to report mainly casual facts and ordered her 'not to irritate him' in either writing to him or coming to see him: 'Do not come, it would give me too much emotion. Do not write sad letters to me either, it terrifies me'; or: 'I am not anymore what I was in any matter, and would I listen to myself, I would become a priest'. 'I have become very emotional'. 'Do not send anybody, because visits from people I do not know frighten me'. 'It gives me too much emotion when I do not know'. This emotional dysregulation also appeared in letters to other persons, such as his war godmother: 'I am still very nervous, excessively irritable, and it seems that it will take more than one year for me to recover from this major trauma, which nearly killed me'.
Apollinaire's behavior also changed dramatically, the most spectacular modification probably being his rapid disinterest in his fiancée Madeleine, to whom he completely stopped writing within 4 months, without having seen her again after he was wounded (he had last seen her in Oran, Algeria, early January, 1916, i.e. 3 months before being wounded, and never saw her again). He interrupted any contact with her without any clear explanation to anybody, displaying an indifference, which was a great shock to many of Apollinaire's friends, who did not recognize his personality and behavior from before the trauma. There are several anecdotes, which emphasize Apollinaire's changes in emotional behavior and affective reactions: he was reported as having become irritable, susceptible, anxious (fig. 3), and with unpredictable emotional bursts, which contrasted with a loss of his sense of humor. Some degree of emotional flattening had also been noted rather early after the trauma, such as his striking absence of emotional manifestation when the doctors and nurses, themselves
quite moved by the circumstances, came to his room to proceed with the trepanation on May 9, 1916.
Since Apollinaire died from Spanish flu less than 3 years after he was wounded, definitive conclusions on long-term changes in his behavior remain speculative. While he never mentioned Madeleine again, shortly before his death he married Jacqueline, an acquaintance who had taken care of him on several occasions. However, this relationship was characterized by its quietness, with none of the passionate features which had been so prominent with Madeleine, as well as with his previous girlfriends.
Emotional-Cognitive Dissociation with Spared Creativity
While brain parenchymal dysfunction was initially reflected by hemipare-sis and seizures, no significant loss in cognitive and executive abilities was ever noted by Apollinaire's contemporaries. In the very same letters to Madeleine in which he was urging her not to provide him with any emotional stimulation, he was able to make a very detailed list of personal items, which he wanted her to send him back. Actually, his memory and cognition were never reported to be altered. He also quickly went back to literary writing, both for poetry and art commentaries. He even introduced events of his head trauma in manuscripts, such as 'The Poet Assassinated' or 'Calligrammes' [Apollinaire, 1977, 1991, 1993]. He referred to a 'deep sorrow', and a 'secret unhappiness' with which he acknowledged he now had to cope and he could not control. Overall, while his lyrism did not decline, his general tone became darker, more defiant, and nostalgic, referring to 'something lost'. These elements underline a marked dissociation between Apollinaire's emotional-behavioral changes and the absence of impaired cognition and executive functions, including creativity. They also emphasize emotional dysregulation and modified (if not decreased) emotion-to-cognition coupling, rather than just a simple loss or flattening of emotional life.
Apollinaire's Right Temporal Syndrome
Apollinaire's emotional changes, including irritability, anxiety, defiance, intolerance to emotional stimuli, and sadness without true depression, fit very well with the rarely reported syndrome of lateral temporal dysfunction in the nondominant hemisphere. Indeed, right lateral temporal lobe lesions have been associated with such changes, in connexion with modification of personality, and affective behavior [Annoni et al. 2001; Bakchine 2001; Bogousslavsky, 1991; Bogousslavsky and Cummings, 2001]. This is in sharp contrast with mesial temporal damage, which is associated with memory impairment, and visual field defects and agnosia, due to involvement of the hippocampal and parahippocam-pal-fusiform gyri. In Apollinaire's case, the observed emotional and behavioral changes, together with spared cognitive and executive function, point to a limited lesion in the lateral part of the right temporal lobe, located immediately under the impact on the skull (fig. 2), together with full integrity of the mesial temporal, frontal, occipital parietal regions. This would be compatible with either direct concussion or compression sequelae from the subdural hematoma. A very similar, although non-traumatic, case was that of George Gershwin, who had undergone prolonged psychotherapy sessions for personality and emotional changes, while he shortly died thereafter, from a right temporal malignant glioma [Bogousslavsky, 2003; Ruiz and Montañés, p. 172-178].
It is interesting to emphasize that in the case of Apollinaire as well, the organic brain causality of his modified emotional behavior was not recognized by scholars, who paradoxically preferred to underscore a psychological shock associated with war experience, despite the head trauma [Apollinaire, 1977, 1991, 1993]. Given the purely emotional - behavioral nature of the clinical manifestations associated with right lateral temporal damage, it is likely that part of the rarity of this syndrome is due to its lack of recognition, and mis-attribution to psychodynamic factors without organic cerebral dysfunction.
The lost love of Gui and Madeleine may be one of the best and purest historical examples of a dissociated emotional-cognitive/executive impairment from a focal brain lesion. The 'Poet Assassinated' indeed also was the 'Lover Assassinated'.
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Department of Neurology, University Hospital CHUV, BH-10
CH-1011 Lausanne (Switzerland)
Tel. +41 21 314 1220, Fax +41 21 314 1231, E-Mail [email protected]
Bogousslavsky J, Boiler F (eds): Neurological Disorders in Famous Artists. Front Neurol Neurosci. Basel, Karger, 2005, vol 19, pp 9-16
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