Neurological speech deficits as plot devices in novels

Stroke is a leading cause of death worldwide and a common cause of disability in adults in developed countries. ¹ Most strokes are not fatal and, in contrast to coronary artery disease and cancer, the major burden of stroke is chronic disability rather than death. ² It is unsurprising, therefore, that characters with stroke appear frequently in literature, although sometimes the diagnosis is wrong. In George Eliot's Silas Marner, for example, the title character is thought to suffer ‘strokes’ whereas the diagnosis is probably narcolepsy. There are a number of common themes in literary descriptions of people with stroke; first, the stroke is often brought on by high emotion or shock, but before the days of adequate treatment of hypertension, cerebral haemorrhage is likely to have been more common. Second, they frequently result in complete or partial loss of speech, which prevents the protagonist from imparting vital information or exposing villains. Third, they are often treated with bleeding if there is a doctor handy. Notable examples of this treatment are Billy Bones in Robert Louis Stevenson's Treasure Island, Squire Dornell in Thomas Hardy's short story The First Countess of Wessex and Prince Bolkonsky in Tolstoy's War and Peace. In the first two cases the treatment is apparently effective (although Bones dies a little while later of a second massive stroke when he receives the pirates ‘black spot’), although in reality the hypotension induced by bleeding would be dangerous and likely to extend the stroke if it was a cerebral infarct.

DECLARATIONS

Competing interests

None declared

Funding

The authors have no competing financial or non-financial interests that may be relevant to the submitted work

Ethical approval

None declared

Guarantor

Professor Richard Sainsbury

Contributorship

RS Richard Sainsbury identified the novels and wrote the discussion. Christine Wyles and Gina Tillard both provided expert Speech Language Therapy advice and contributions to the discussion.

Stroke related speech deficits can be used by authors to influence a novel's plot. We discuss several prominent examples using well-known novels where this occurs.

The Cases

Case 1

Madame Raquin in Therese Raquin by Emile Zola (1867)

Madame Raquin is the selfish, well-meaning but overbearing aunt who raises her orphaned niece, Therese, in Zola's novel that bears her name. As Therese grows up, her aunt manipulates her into marriage with her sickly and overbearing son, Camille. Therese starts a torrid love affair with Camille's friend Laurent, and the pair murder Camille by drowning him in the Seine. On hearing of her son's apparent accidental death, Madame Raquin suffers her first stroke which results in progressive weakness. Indeed Zola's description would be more in keeping with a progressive neurological disorder such as motor neuron disease. Some time later she suffers a second stroke that causes aphasia. We are told:

… she stopped in the middle of a sentence, gasping, feeling as if she were being strangled. She tried to shout for help but could only utter raucous sounds. Her tongue had turned to stone. Her hands and feet had stiffened. She was struck dumb and motionless … Then they realised that there was nothing left facing them but a body, a body half alive who could see and hear them but could not speak (TR, 199).

Relations between Therese and Laurent had already begun to sour and the stress of looking after the old woman exacerbates this. In the course of an argument in front of Madame Raquin they reveal her son's murder, forgetting that she can still hear while she cannot speak. She decides to attempt to reveal the pair's guilty secret to her two erstwhile dominoes partners, Michaud, a police superintendent and Grivet, a chief clerk for the railways, who still visit the house to play dominoes in front of her. With a superhuman effort she takes a pen intending to write, ‘Therese et Laurent ont tue Camille (Therese and Laurent killed Camille)’ but her strength runs out at ‘Therese and Camille ont t…’. Frustrated by the delay Grivet claims to know her meaning, ‘It is quite clear… she wanted to say Therese and Laurent have been very good to me’, Michaud concurs saying, ‘Madame Raquin desired to show due appreciation of the loving care her children are lavishing upon her. It does honour to the whole family’. Not only is the opportunity for Therese and Laurent's exposure lost, but the false impression of their dedicated care is reinforced.

Case 2

Mrs Clennam in Little Dorrit by Charles Dickens (1856)

Arthur Clennam is the chief male protagonist in this novel which concludes with his marrying Little Dorrit after whom the book is titled. Mrs Clennam is a strict, bitter, unloving woman and it later transpires that she is not Arthur's biological mother. Arthur was the result of his father's premarital affair As much as she tries to suppress this information, it becomes known to the villain Rigaud who blackmails her. Mrs Clennam has a stroke as she witnesses the collapse of her house, which kills Rigaud in the process:

There Mrs Clennam dropped upon the stones; and she never from that hour moved as much as a finger again, or had the power to speak one word. For upwards of three years she reclined in her wheeled chair, looking attentively at those about her, and appearing to understand what they said; but, the rigid silence she had held so long was evermore enforced upon her, and, except that she could move her eyes and faintly express a negative or affirmative with her head, she lived and died a statue. (LD 827).

She appears to be in a ‘locked-in syndrome’ ³ and others ⁴ have noted that authors appear to have a particular fascination with this relatively rare condition. The result of her severely disabled state is that any possibility of reconcilliation with Arthur and enjoyment of his changed circumstances is irretrievably lost.

Case 3

Sir Leicester Dedlock in Bleak House by Charles Dickens (1853)

Sir Leicester Dedlock is a crusty baronet and unthinking conservative, married to a restless wife who is 20 years his junior. Unbeknown to him, she had a lover before their marriage. Esther Summerson, the main female protagonist in the novel, was the result of this relationship. When the truth of her past is discovered by the shrewd manipulative solicitor, Tulkinghorn, and her French maid Hortense, Lady Dedlock flees her home. On hearing of his wife's past, and flight, Sir Leicester suffers a devastating stroke:

He fell down, this morning, a handsome stately gentleman, somewhat infirm, but of a fine prescence, and with a well-filled face. He lies upon the bed, an aged man with sunken cheeks, the decrepit shadow of himself … he had so long been thoroughly persuaded of the weight and import to mankind of any word he said that his words really had come to sound as if there were something in them. But now he can only whisper, and what he whispers sounds like what it is - mere jumble and jargon.

After vainly trying to make himself understood in speech, he makes signs for a pencil. So inexpressively that they cannot at first understand him; it is his old housekeeper who makes out what he wants and brings in a slate…. After pausing for some time, he slowly scrawls upon it in a hand that is not his, ‘Chesney Wold?’ (BH,691)

Shortly afterwards he lapses into a period of unconsciousness which was preceded by moaning (an extension of the stroke or epilepsy?). On waking he is still unable to speak but can write a few words on his slate. His housekeeper translates the letter ‘B’ as his wanting to speak to Inspector Bucket, and when the latter arrives he writes ‘Full forgiveness. Find…’ Bucket goes in search of Lady Dedlock but she is dead before the pardon can be given. Interestingly Sir Leicester later recovers the power of speech on the receipt of good news.

Case 4

Mr Tulliver in The Mill on the Floss by George Eliot (1860)

Mr Tulliver, the owner of the mill, has a bitter rancorous relationship with the solicitor, Wakem. Tulliver is ruined by losing a court case with another mill operator represented by Wakem. His financial situation is compounded because he had acted as a guarantor to Riley, who dies of a stroke, leaving Tulliver unable to recover the money. On losing the case, Tulliver also has a stroke while riding home:

Mr Tulliver's own wagoner found him lying by the roadside, with an open letter near him … he had become conscious, and after vague, vacant looks around him, had muttered something about ‘a letter’ (MP, 198).

His only words are ‘a letter’ and ‘the little wench’ (his favourite Maggie):

He repeated the words impatiently from time to time, appearing entirely unconscious of everything except this one importunate want, and giving no sign of knowing his wife or anyone else… (MF,199)

By the time a family council is held to plan their future, Tulliver has regained some purposeful speech. He does not attend the meeting, however. ‘How's the poor man upstairs?’ asks Mrs Glegg, his sister in law. Tulliver's family exclude him partly through concern that the stress will harm him but mainly through the supposition that because of his stroke, his contribution is meaningless. Tulliver dies prematurely a few years later.

Case 5

Prince Nikolai Bolkonsky in War and Peace by Leo Tolstoy (1865-1868)

The autocratic Prince Bolkonsky suffers a stroke as the French army closes on his estate:

The doctor, who was fetched that same night, bled him and announced that the prince had had a stroke paralysing his right side…. His mind had gone; he lay like a twisted corpse. He muttered without cease, twitching his eyebrows and lips, and it was impossible to tell whether he was aware of his surroundings or not… her (Princess Maria's) presence always intensified his agitation and confirmed her supposition that he wanted to tell her something (WP, 847-8).

Before his death a few days later, he is able to regain speech for a very brief period during which he is able to ask her forgiveness for his overbearing treatment of her with the words, ‘Thank you … daughter dear … for all the, for all… forgive … thank you … forgive … thank you’, and the tears trickled from his eyes. Apart form the words ‘Russia is lost’ (incorrect as it happens) those are his last words until he dies the following day.

Discussion

Each of the protagonists in the novels discussed suffers a stroke at a time of high emotion resulting in significant disability including severely impaired speech. In each case their stroke and impaired communication has a crucial influence on the novel's plot.

The most severely disabled is Mrs Clennam who has no speech or limb movement. Given her unpleasant manipulative premorbid personality, we could speculate that she might be electing not to communicate but she does appear to comprehend. Her description seems to be consistent with the so-called Locked-in syndrome. ³ In reality the complete syndrome is rare but seems to affect literary characters more frequently. Williams discusses this syndrome in relation to Monsieur Noistier de Villeforte in Alexandre Dumas’ The Count of Monte Cristo. ⁴ Locked-in syndrome results from haemorrhage or infarction of the ventral pons and is characterized by total immobility except for vertical eye movements and blinking combined with preserved consciousness; the result of transection of all the corticospinal and corticobulbar pathways with sparing of the reticulo activating system arousal system. Dumas describes this eloquently as ‘when the soul is trapped in a body that can no longer obey its commands’. ⁴ A most vivid autobiographical account of living with this syndrome was provided by Jean-Dominique Bauby former editor of Elle magazine in the book The Butterfly and The Diving Bell, which he dictated to a secretary by blinking his eyelids, and which was published only a short time before his death.

The case of Madame Raquin provides a number of salutary lessons. Her speech deficit not only means that she is unable to expose her son's killers, but people also assume that she cannot comprehend. The most significant consequence of this allusion is that Therese and Laurent reveal the murder to her in an argument. Her former dominoes partners continue to play in front of her with the intention of comforting her, but no-one attempts to see if she can still play Given her effort to write the message exposing the miscreants it is highly possible that she could still play dominoes, but no-one attempts to find out. Most important of all, her friends, frustrated by her slowness, attempt to second guess her communication attempts with the result that they take the wrong meaning entirely. We have all been guilty of trying to finish the sentence for someone with a speech deficit and this must be very frustrating to the person concerned, even if it does not have the severe consequences of this case.

Sir Leicester Dedlock and Edward Tulliver both show improvement in their speech with time, quite remarkably so in the case of the former. Sir Leicester Dedlock manifests features of delirium, then short-lived coma before recovering enough to mumble the single phrase ‘Chesney Wold’ — the name of a house he owns. Later he is able to write letters or single words on a slate with sufficient accuracy for his housekeeper to interpret them. Despite the shock of his wife's earlier affair, he is able to convey his feelings of forgiveness, but because of his disability he entrusts the task of telling her to another, who is thwarted by her dying before the pardon can be delivered. His reduced intelligibility suggests a dysarthria in addition to aphasia. His non-fluent effortful speech is consistent with Broca's aphasia. A person with Broca's aphasia often has ‘telegraphic’ or agrammatical speech with enough content words for communication partners to interpret the utterance. ⁵ Writing abilities typically parallel verbal expression. ⁵ Sir Leicester is also unusual in that he later recovers the power of speech on the receipt of good news. His speech is still described as ‘in a thick crowd of sounds, but still intelligibly enough to be understood’ (BH 718). The rapid recovery does not fit with the typical course of recovery from such a severe communication disorder It would be unusual unless the patient had a conversion disorder. This seems unlikely in Dedlock's case, given the documented delirium and coma at the time of the stroke. We must conclude therefore that Dedlock's speech problems represent some artistic licence on Dicken's part in order to fulfil the requirements of the plot.

Edward Tulliver's speech problem leaves people thinking that he is initially cognitively impaired, a not uncommon mistake. The doctor contributes to this by saying ‘his memory's gone a long way back’ (ME 208). His sister-in-law refers to ‘the water on his brain’ (ME 208) and states, ‘It's much if he ever gets up again: and if he does, he'll be most childish’ (ME 208). This leads to his exclusion from the family council even though it is probable that he could express his views by gesture. Months later his speech has improved sufficiently for him to get his son Tom to swear a continuation of his lifetime feud with Lawyer Wakem. While this is happening, his daughter and wife are entreating him not to excite himself, presumably worried about a further stroke. George Eliot is therefore able to use both Tulliver's loss of speech and its recovery to significantly influence the plot.

Prince Bolkonsky unlike the other protagonists discussed in this paper, dies very shortly after his stroke. Initially restless and delirious, he is able to articulate a few short words and phrases. These are enough to ask her forgiveness and ask the whereabouts of his son in the army. He does well to apologise to his daughter whom he has treated harshly but dies convinced that the French will successfully conquer Russia. He is thus able to partly reconcile his affairs, which might not have happened but for the stroke.

Neurological speech deficits have profound effects for each of the characters we have considered. Not only is their communication affected, but also the way other people treat them. People with expressive dysphasia are often treated as if they have comprehension or cognitive deficits, even though these are by no means a universal accompaniments. Authors can therefore be guilty of perpetuating myths about stroke, but literary descriptions of stroke can also provide salutary lessons to carers and health professionals. None of the authors in the novels we have discussed had speech language therapy or medical training and so cannot be expected to give perfectly accurate descriptions of the deficits involved. Indeed it can be argued that each has provided a striking example of the devastating nature of neurological speech defects. Our primary interest in this paper has been the use of neurological speech defects to influence plot, but we also note that the authors were all renowned for their astute social commentary, so we can infer that their representation of people with stroke reflects how they were viewed by society.