A man was lying in the middle of the room, in a circle drawn on the ground with a piece of plaster from the wall, almost naked, his clothes having fallen into tatters. He was drawing very precise geometrical lines in the circle and appeared as absorbed in solving his problem as Archimedes when he was killed by one of Marcellus’ soldiers… ‘I am Abbé Faria, born in Rome, twenty years secretary to Cardinal Rospigliosi. I was arrested early in 1811, I’m not quite sure why, and since then I have demanded my freedom…The Count of Monte Cristo by Alexandre Dumas
1. Review the portrayal of illness and disease within The Count of Monte Cristo
2. Examine the portrayal of Abbé Faria and the clues Dumas offers regarding his underlying medical diagnosis
3. Explore some of the advances in medical knowledge at the time and how they may have influenced Dumas in writing the novel
Continuing the thread of medicine within the pages of The Count of Monte Cristo by Alexandre Dumas, this post will examine one of the key characters within the story. Once again, spoilers are inevitable.
The health of Abbé Faria has long been a puzzle and the focus of speculation for some medical authors. Encountered in the prison of Château d’If, he is first introduced as an entertaining imbecile, deluded about his wealth and status:
Abbé Faria had gone mad in prison and was condemned, by his very madness, to perpetual confinement… As a certified madman, above all as an entertaining madman, the old prisoner enjoyed certain privileges, among them that of having bread that was a little whiter than the rest and a small jar of wine on Sundays.The Count of Monte Cristo by Alexandre Dumas
Faria (as we come to learn) is far from being unintelligent. Yet, there is an impact of solitary confinement on health and wellbeing. Perhaps the prison guards in The Count of Monte Cristo were accustomed to the fantasies and hallucinations that prisoners in such situations sometimes experience. Feelings of anger, hatred, bitterness, boredom, stress, depression have are reported. However, it is primarily the physical health of Faria that Dumas places in the spotlight.
Physically, Faria is described as short in stature with white hair, a long black beard and a furrowed face aged at least 65 years, although his agility suggests he could be younger.
Although the real Abbé Faria has little resemblance to the one Dumas describes, it is interesting to consider the parallel history of him being sent to the The Château d’If in 1797 as punishment for his part in the French Revolution. After being released, he eventually died of a stroke in 1819.
However, Dumas’ fictional Faria is different. Working with Dantès on their escape, this is what suddenly happens:
Dantès was just fixing this when he suddenly heard a cry of distress from Abbé Faria, who had stayed in the young man’s cell sharpening a peg which was to hold the rope ladder. Dantès hurried back and found the abbé standing in the middle of the room, pale-faced, his forehead bathed in sweat and his fists clenched.
‘Oh, my God!’ Dantès cried. ‘What is it? What is wrong?’
‘Quickly,’ the abbé said. ‘Listen to what I say.’
Dantès looked at Faria’s livid features, his eyes ringed with blue, his white lips and his hair, which was standing on end. In terror, he let the chisel fall from his hand.
‘But what is the matter?’ he cried. ‘I am finished,’ the abbé said. ‘Listen to me. I am about to have a terrible, perhaps fatal seizure; I can feel that it is coming. I suffered the same in the year before my imprisonment…The Count of Monte Cristo by Alexandre Dumas
What are the differential diagnoses?
Faria immediately asks for his medication, described as a red liquid in a little flask. We’ll come back to what this mysterious red liquid may have been in a future post. For now, the differential diagnoses are numerous. Instinctively, a form of epilepsy comes to mind as one of the most likely causes for Faria’s symptoms, but syncope and cardiac arrhythmias are also important and common causes.
Dumas’ Faria reports the prodromal phase of a seizure. Preictal symptoms can vary considerably but one review reports the most frequent symptoms were “funny feeling” (10.4%), confusion (9.0%), anxiety (8.6%), and irritability (7.7%). Such symptoms can develop minutes to days before seizure onset. About a third of patients with epilepsy report prodromal sensations more than 30 minutes before a seizure .
Further clues are gained by examining what happens next:
‘This is what will happen: I shall fall into a cataleptic fit. I may perhaps remain motionless and not make a sound. But I might also froth at the mouth, stiffen, cry out… When you see me motionless, cold and, as it were, dead – and only at that moment, you understand – force my teeth apart with the knife and pour eight to ten drops of the liquid into my mouth. In that case, I may perhaps revive.’
‘Perhaps?’ Dantès exclaimed, pitifully.
‘Help me! Help!’ the abbé cried. ‘I am … I am dy …’
The seizure was so sudden and so violent that the unhappy man could not even finish the word. A cloud, rapid and dark as a storm at sea, passed over his brow. His eyes dilated, his lips twisted and his cheeks became purple. He thrashed, foamed, roared. But, as he had been instructed, Dantès stifled the cries beneath the blanket. The fit lasted two hours. Then, totally inert, pale and cold as marble, bent like a reed broken underfoot, he fell, stiffened in one final convulsion and paled to a livid white.
Edmond waited for this semblance of death to invade the whole body and chill it to the very heart. Then he took the knife, put the blade between the man’s teeth, prised the jaws apart with infinite care, measured ten drops of the red liquid one after the other and waited.The Count of Monte Cristo by Alexandre Dumas
What is catalepsy?
In the original translation, Dumas uses the word catalepsie, so we can be reasonably assured nothing too much has been lost in translation. The etymology of the word catalepsy is from the Greek katalēpsis (a seizing) or katalambanein (to hold down) and can be defined as a state of prolonged rigid posture and is often associated with loss of consciousness and sensation. Sometimes it is even considered synonymous with catatonia. Indeed, when it comes to considering the Victorian-era use, the more modern informal or lay use and the medical or psychiatric applications of these words is where ambiguity can occur. Moreover, there is additional confusion with the similar sounding word and term cataplexy from the Greek kataplēxis (amazement) and plēssein (strike) which again has various interpretations but is sometimes defined as a sudden episode of muscle weakness triggered by emotional factors, most often in the context of positive emotions (such as laughter) and is associated with narcolepsy.
It’s unclear exactly which meaning Dumas was referring to in The Count of Monte Cristo, however it is worthwhile noting that he also uses the words apoplexy and apoplectic elsewhere in the text. At the risk of being side-tracked slightly, now is perhaps also the moment to consider what apoplexy means.
What is apoplexy?
Apoplexy can be defined in a few different ways, such as a extreme anger, a stroke, a haemorrhage into an organ cavity or tissue, a sudden (usually marked) loss of bodily function due to rupture or occlusion of a blood vessel, a sudden fit of paralysis and dizziness or unconsciousness or incapacity that appears usually moments before death. It is an umbrella term that has become increasingly obsolete in medicine as science as advanced and is almost now exclusively used metaphorically. The etymology is with considering, seeing as it derives from the Old French apoplexie, Late Latin apoplexia, or Greek apoplektos (disabled by a stroke, struck dumb). It’s probably worth noting here that the term stroke itself originates from the term, by the stroke of God’s hand which again refers to the sudden striking down or paralysis that today we sometime synonymise with cerebrovascular accident (CVA) or brain attack. Indeed, the term stroke has inherited the history of apoplexy.
Williams considers the concepts of apoplexy at the time The Count of Monte Cristo was written and puts forward the intriguing proposition that Dumas was influenced by Abercrombie’s 1828 work Pathological and Practical Researches on Diseases of the Brain and the Spinal Cord which divides apoplexy into a number of different subdivisions eventually concluding that Faria may have succumbed to primary apoplexy with serious effusion.
However, Dumas didn’t use the term apoplexy (or apoplexie) when describing Faria’s illness, he instead used catalepsy (or catalepsie). What makes this point particularly notable is that elsewhere in the text, Dumas does indeed use the term apoplexy to describe the illness of other characters in the novel… but importantly never when referring to Faria. This suggests that perhaps Dumas drew some distinction between catalepsy and apoplexy that we need to acknowledge and factor into our understanding of Faria. Conversely, maybe Dumas used them synonymously and his varying use of the term was purely coincidental.
The story continues:
An hour passed without the old man making the slightest movement. Dantès feared that he might have waited too long and sat, clasping his head in both hands, looking at him. Finally, a slight colour appeared on the old man’s lips; the look returned to his eyes, which had remained open, but blank, throughout; he uttered a faint sigh and moved slightly.
‘Saved! He is saved!’ Dantès cried.
The sick man still could not speak…
The abbé had regained consciousness, but was still stretched on his bed, motionless and exhausted…
The abbé shook his head: ‘Last time the fit lasted half an hour, and after it I felt hungry and got up by myself. Today, I cannot move my right leg or my right arm. My head is muddled, which proves there is some effusion on the brain. The third time, I shall either remain entirely paralysed, or I shall die at once.’…
…The blow that has just struck me has condemned me to prison for ever…‘This arm is paralysed, not for a day, but for ever. Lift it yourself, feel its weight.’
The young man raised the arm, which fell back, inert. He sighed.The Count of Monte Cristo by Alexandre Dumas
How has your differential diagnosis changed?
Faria seems postictal and some patients with epilepsy report intense hunger after a seizure. However, he is left with a permanent hemiparesis: this the second attack and he predicts the third will kill him. This doesn’t sound like a typical grand-mal seizure anymore.
This succession of episodes culminating with a final and fatal recurrence sounds reminiscent of transient ischaemic attacks (TIA) culminating in a stroke. The risk of stroke following a TIA is somewhere in the order of 10-20% within 90 days, with the 50% of the risk within the first 48 hours. Of note, the risk of cardiovascular disease is higher in those experiencing social isolation and like our fiction Faria trying to escape his prison, the real Abbé Faria did indeed die of a stroke which may have inspired Dumas. A further influence may have been that Dumas’ own mother experienced a “a shock of apoplexy” around 1829 and developed a hemiparesis eventually dying in 1838 following another attack.
One striking coincidence with Faria’s temporal description of his illness is the story that Napoléon dreaded the prospect of apoplexy and asked his physician Corvisart, who we discussed in a previous post for more information about the condition. Corvisart, who was the first professor of medicine at The Charité Hospital where Dumas gained medical experience under Thibaut, is reported to have outlined his rule of three to Napoléon:
Apoplexy is always dangerous; but it is always preceded by certain symptoms. Nature seldom strikes a blow without giving warning: A first attack, which is often slight, is a summons without costs; a second, a summons with costs; but a third is an execution on the person.Of the Causes, Nature, and Treatment of Palsy and Apoplexy
The notion that the third stroke kills can still be found in the cultural consciousness. But again, the term apoplexy makes an appearance. Perhaps we get a further understanding of the ambiguous and multifaceted word when we consider Copland’s 1850 text Of the Causes, Nature, and Treatment of Palsy and Apoplexy. It includes a list of symptoms preceding an apoplectic attack that we now recognise as typical features of a classic TIA such as incoherent talking (dysphasia), dimness of vision (amaurosis, presumably fugax/fleeting) and paralytic affections, chiefly of the face (facial droop). However, Copland mixes in a vast array of other spurious symptoms which could easily represent numerous other conditions modern medicine now recognises.
But didn’t Faria experience a seizure before the onset of his hemiparesis? From a modern perspective, seizures are not often a typical TIA feature, although not impossible in a small minority of patients. In the English text Faria is said to experience a violent seizure, although in the French it is perhaps better translated as the arrival or return of a pathological phenomenon, which leaves the medical reader with a wider scope of differentials.
Copland reports that the most severe form of this apoplectic attack is known by the French as apoplexie foudroyante. Dumas indeed uses this term elsewhere in his novel, but doesn’t include it in his description of the condition suffered by Faria. Helpfully (or not), he uses some of the other characters in the story to explain the difference between apoplexy and stroke. The English translation essentially equates it ‘more or less’ to a stroke. whereas the French version conveys that cerebral congestion is almost the same thing as a stroke.
‘A stroke, apparently, or an apoplexy. It’s the same thing, isn’t it?’
‘More or less.’
‘Apoplexy?’ said Beauchamp. ‘Now that’s hard to believe. I too saw Madame de Saint-Méran a couple of times: she was petite, slightly built and much more of a nervous than a sanguine temperament. It’s very rare for grief to produce apoplexy in a person of Madame de Saint-Méran’s constitution.’The Count of Monte Cristo by Alexandre Dumas
D’une congestion cérébrale, à ce qu’il paraît, ou d’une apoplexie foudroyante. N’est-ce pas la même chose?
Mais à peu près.
D’apoplexie? dit Beauchamp, c’est difficile à croire. Mme de Saint-Méran, que j’ai vue aussi une fois ou deux dans ma vie, était petite, grêle de formes et d’une constitution bien plus nerveuse que sanguine; elles sont rares les apoplexies produites par le chagrin sur un corps d’une constitution pareille à celui de Mme de Saint-Méran.Le Comte de Monte-Cristo par Alexandre Dumas
With such ambiguity, it is difficult to be certain what Dumas means when he uses either the term catalepsy or apoplexy, and whether there is any overlap or not.
So in terms of diagnosing Faria, what we’re left with at the moment is that he experiences some sort of episodic but progressive condition that has a preictal prodrome and leaves no obvious residual symptoms after the first event, with the second event occurring many months afterwards leaving a permanent hemiparesis. Thankfully, Dumas does give us more tantalising clues to the origin of Faria’s condition:
‘You are convinced now, Edmond, aren’t you? Believe me, I know what I am saying: since the first attack of this sickness, I have thought about it constantly. I was expecting this, because it is a hereditary illness; my father died on the third attack and so did my grandfather. The doctor who made up this potion for me, who is none other than the celebrated Cabanis, predicted the same fate for me.’The Count of Monte Cristo by Alexandre Dumas
What hereditary condition could Faria have?
Our limited knowledge Faria’s family tree suggests an autosomal dominant condition, although of course a multitude of polygenic conditions and pure bad luck in terms of explaining heritability cannot be excluded. As we have mentioned, Williams supports the diagnosis being related to recurrent cerebral haemorrhage (as Faria mentions an effusion on the brain) and suggests the autosomal dominant differentials of Osler-Rendu-Weber syndrome (hereditary hemorrhagic telangiectasia) and Sturge-Weber syndrome although Faria’s description doesn’t match the typical clinical appearance of either. Goodwin adds another differential of cerebral amyloid angiopathy.
Interestingly, the French physician Rendu (of of Osler-Rendu-Weber syndrome fame) was born in 1844, the year The Count of Monte Cristo was completed. The prevalence of HHT is also much higher in the Haut-Jura region of France due to a probable founder effect. Whether this was known to Dumas or not is unknown.
Dumas also mentions the French physiologist and philosopher Cabanis (1757 – 1808) who is also recognised as an unsung pioneer of the neurosciences. He died due to an apoplectic condition, having one attack, recovering and then developing crescendo episodes culminating in his death a year later. This sounds remarkably familiar to what happens to Faria. Cabanis had a post-mortem that revealed left ventricular hypertrophy (described as being nearly three times its natural size) and is noted to have had what sounds like an interventricular haemorrhage. Could this have have represented an aneurysmal subarachnoid haemorrhage or perhaps a hypertensive-related cerebral bleed?
Perhaps Dumas incorporated the idea of crescendo temporarily into Faria’s history to add drama to the narrative. We have already considered the possibility of TIAs but the suggestion of haemorragic pathology rather than ischaemic goes against this.
Perhaps Dumas had become aware of a number of important medical texts released a few years prior to the publication of The Count of Monte Cristo. Rayer was a French physician who published Traité des maladies des reins between 1837 and 1841, only a few years before the completion of The Count of Monte Cristo. Within the three volumes, Rayer describes cystic degeneration of the kidneys. In addition, the French anatomist and pathologist Cruveilhier also describes cystic changes in his two volume Anatomie pathologique du corps humain published between 1829-1842, also published relatively close to but before Dumas’ novel. Autosomal dominant polycystic kidney disease (ADPKD) meets the heritability criteria of Faria’s disease and is associated with hypertension, another of the possible co-morbidities in his fictional case.
Maybe as a nod to Cabanis, Dumas wanted to include a part-presentation of subarachnoid haemorrhage (SAH) in the story as well as highlighting its familial tendency seeing as it is associated with berry aneurysms as part of polycystic kidney disease. Seizures and some of the focal neurological deficits expressed by Faria can occur with SAH, but a sentinel bleed usually progresses to SAH within two weeks, which goes against Faria’s more protracted history and most importantly, Faria doesn’t complain of a headache.
As Faria predicted, he soon experiences his third and final episode:
One night Edmond woke up with a start, thinking he had heard a cry…
In the vague, shimmering light of the lamp (which has already been mentioned), Edmond could see the old man: pale, still standing, clinging to his wooden bedpost. His face was already contorted by those fearful symptoms that Edmond now recognized, which had so terrified him when he saw them for the first time…
‘I am starting to feel cold and can feel the blood rushing to my head. The awful shivering that makes my teeth chatter and seems to unhinge my bones has begun to spread through my body. In five minutes the seizure will strike me, and in a quarter of an hour I shall be nothing but a corpse.’…
A violent trembling interrupted his words. Dantès looked up and saw the eyes becoming bloodshot: it was as though a wave of blood had flowed up from the chest to the forehead…
The fit was terrible. All that remained on the bed of pain in place of the intelligent being that had lain there a moment before were twisted limbs, swollen eyes, bloody froth and a motionless corpse.The Count of Monte Cristo by Alexandre Dumas
What are your final thoughts on Faria’s diagnosis?
The further prodrome and bloody foam around the mouth again point toward a grand mal seizure. But once more, there may be some bias in the translation, the English version describing it as a seizure whereas the French reports a ‘terrible crisis’/’la crise fut terrible’. Indeed, in the French version, the original seizure is in fact described as ‘a terrible evil’/’un mal terrible’ and the chapter where Faria dies is translated in English as ‘The Third Seizure’, whereas the French is titled ‘Le Troisième Accès’, perhaps better translated as bout or outburst.
Translation pedantry aside, even if Faria has an underlying epileptiform condition, why does it present now, only in Faria’s late age? Why only three episodes, each progressively more severe with initially no residual symptoms, then a hemiparesis and then finally full paralysis/death? Dantès does give Faria one more (but large) dose of the mysterious red medicine, which only produces a short lived but violent tremor. Faria is dead.
Although it is possible that Faria’s illness represents a single condition, I’m inclined to wonder whether it is instead a compendium of various illness that Dumas may have encountered or become aware of and stitched together to create an engrossing character. Medical knowledge was fast advancing at the time, with new and interesting ways of understating disease, fascinating even the non-medically educated. Perhaps Dumas just cherry-picked the bits of clinical medicine that worked most effectively for his dramatic story, Faria is a fictional character after all and Dumas not a physician.
Interestingly, seemingly like his mother, Dumas himself died as the result of what was described as a paralytic seizure in 1870.
What are your thoughts on Faria’s condition? Do you have a differential to add? Please share your thoughts in the comments section below.
The case of Abbé Faria is a fascinating foray into cerebrovascular diagnosis that has puzzled interested physicians since the publication of The Count of Monte Cristo. Nuances in translation can have an impact on how doctors formulate a clinical diagnosis. Moreover, subtle changes and ambiguities in the cultural understanding of previous medical and lay terms over time make the task of retrospective medicine particularly challenging for physicians accustomed to modern medical thinking.
From Apoplexy to Brain Attack, a Historical Perspective on Stroke to Date
Apoplexy, cerebrovascular disease, and stroke: Historical evolution of terms and definitions
Cerebrovascular disease in The Count of Monte Cristo (comment)
Clinical medicine in revolution: 1 – new elements in the old regimen
Faria’s disease, a fictional character in search of a diagnosis