Eric Lis

In writing Insults & Injuries, we tried hard to find diseases that were relevant in one of three ways: that were either common in players' day-to-day lives, and therefore interesting; that would have been particularly common in a medieval or renaissance setting; or that had the potential to make particularly good plot hooks. Of those, the "plot hook" diseases got the least attention, because they're the ones at the risk of being most overused, thereby lessening their impact. We all like to incorporate neat story ideas into our games, but if a disease has an incidence of one case per million people in the real world, players who see it pop up in three or four sequential campaigns get irritated. There are plenty of diseases which make ideal plot hooks which got left out of the book because they were either too rare or too esoteric, and therefore seemed like it wouldn't be worth including them. They're neat, though, so here's one of them.

Locked-in syndrome is a rare condition wherein an individual is trapped inside of their own body, paralyzed. The origin of the name is obvious: the individual is locked in their body, unable to move, express their wishes, or escape from pain. Classically, the disease is caused by an injury to the brainstem, usually a haemorrhagic stroke, which leaves the entire body paralyzed except for the eyes. If the individual survives the stroke, which is by no means guaranteed, they may still be able to communicate via their eyes, but their condition can be easily mistaken for a coma. When the condition is recognized, their medical care takes two forms. First, in the short term, they often require help to breathe, and in modern hospitals these individuals often end up on respirators either due to the stroke itself, or soon afterwards, when they develop pneumonias and other lung infections due to an impaired ability to clear their airways. In the longer term, there's often a good potential for rehabilitation, and over the course of years some survivors do regain the use of facial muscles and upper limbs. Less classic forms of locked-in syndrome can also be caused by progressive neuromuscular diseases, like amyotrophic lateral sclerosis or polio, and there are particular causes that start in childhood. In these cases, the prognosis may be quite a bit poorer as rehab is much less likely and the disease tends to only get worse with time.

When I call the syndrome a rare disease, that's not a value judgment, but rather an objective fact. In medicine, a "rare disease" is variously defined as a disease which affects less than between 1 in 1500 to 1 in 2500 people, depending what guidelines you read, and locked-in syndrome is thought to afflict less than one person in a million (once numbers fall that low, our ability to estimate the prevalence much more accurately becomes poor). In my career, I've seen the disorder once, and I'm personally acquainted with a second case. So, not something one sees every day outside of a specialized neurological ward, and not something that should necessarily be seen terribly often in a game.

A fantasy setting does introduce some interesting wrinkles into the idea of locked-in syndrome, however. For one thing, a fantasy setting introduces a variety of ways for locked-in syndrome to be a good deal more common. Personally, I've always thought that the Hold Person spell is a lot more frightening than most people give it credit for. Granted, it may last for only seconds to minutes, but a lot can happen in seconds to minutes, and if the spell's victim doesn't know that it's temporary, I would have to imagine that it's a horrific experience. The fact that it's such a low level spell means that there are potentially any number of minimally-magical thugs capable of using it to terrifying effect, and it's always puzzled me  that no storyteller I've played with has used this spell to its full emotional potential. Now imagine that a character does know that the spell is temporary, but they're afflicted with an extended version. Can you imagine their fear as they tick off the third minute mark in their head and they still haven't regained motor control? Now consider what happens if the spell was made persistent. Now, permanent. The cure may be a simple second-level spell, but if the nearest cleric is a day's walk away, or if the other characters think the victim is already dead, it becomes the stuff of nightmares.

The real storytelling utility of locked-in syndrome is how it can work as a plot hook. Locked-in syndrome is most likely to happen to people who live otherwise healthy lives into their fifth or sixth decades, which in a medieval world suggests that locked-in syndrome would be one of those diseases that primarily strikes the rich and powerful. The thing about rich and powerful people is that they often have the means and the will to try to change their situation, and when powerful people become desperate, stories happen around them. The biggest stumbling block here for the storyteller is finding a way to keep the action from ending too suddenly. Obviously, for dramatic purposes, curing the locked-in syndrome would have to be more complicated than finding a fourth-level cleric to cast Remove Paralysis. Perhaps a stroke, leading to death of brain tissue, requires unusually powerful magic to fix, or perhaps the syndrome was caused by a ninth-level spell and similarly powerful intervention is needed to remove it. A paralyzed psion might only be more dangerous than before, while a mage might be willing to go to extraordinary lengths to regain the power of speech. Locked-in syndrome is a disorder which probably never afflicts a PC but can shape an entire campaign if it afflicts the right NPC.

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on August 18, 2013. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system