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The Ten Rights of Medicalized Fiction (Part 4): The Right Disease.

The Right Disease: Physical and Mental Illness.

Abnormal appearance (See Richard III and The Hunchback of Notre Dame) or psychopathological behavior sets fictional characters apart. Messing with a character’s physical or mental health can mess up a novel or screenplay, unless the writer finds out how to do it.

For most physical ailments, this will entail investing in a second-hand pathophysiology textbook. Look for lists of symptoms, and drawings or photographs of people showing the noticeable signs of an illness.

In Margaret Mitchell’s Gone With the Wind, Scarlett O’Hara’s father Gerald is a good example. I’m convinced that Mrs. Mitchell was personally acquainted with someone who had Cushing’s Syndrome, because when she describes Gerald O’Hara’s appearance and his behavior, those descriptions are of a person with that adrenal gland disorder.

Psychological problems can accompany visible physical disorders (the chronically high cortisol level in Cushing’s Syndrome provokes labile emotions), or they can be hidden, and only manifest themselves in aberrant behavior. The four most important characters in Irish Firebrands each have different mental health issues, so when I was writing that novel I thoroughly reviewed my psych nursing textbook, and also invested in a hefty 2-volume work about manic-depressive (“bipolar”) disorder.

My current work-in-progress, The Passions of Patriots, deals with “shell shock” (or “neurasthenia,” as it was delicately described when it occurred in officers), now known as Post-Traumatic Stress Disorder (PTSD). Authors Robert Graves and Siegfried Sassoon, First World War veterans, both suffered from it (Graves admits it, but Sassoon denies it, although the evidence is there). The writer of the Downton Abbey screenplays passed up a good opportunity for increased drama by neglecting to effectively explore the combined physical and psychological effects of PTSD, in portraying a main character who returned wounded from the war.

Not all fictional characters need to suffer something seriously wrong between their ears, but even apparently well-adjusted people are going to have spells of ineffective individual coping. Because novels are all about change and what it does to people, your fiction will be much more plausible to readers if you consult reliable resources in the mental health field during your writing research.

The Biggest Medicalized Mistake in Fiction: Pregnancy.

Make sure you’re not writing about health conditions from the perspective of popular belief. Pregnancy and childbirth fall into this category, resulting in an enormous amount of book and screen writing that is horrifically wrong, because pregnancy is not a disease.

Reproduction is a normal physiological state, and not particularly high-risk. This flies in the face of generalizations about the past, in which it’s commonly believed that all women were highly likely to die because of childbearing. The truth is that if pregnancy and childbirth were such dangerous states, human beings would not have survived as a species. Many women did die in times past, but most pregnancy-related deaths are due to malnutrition, infection, or hemorrhage, which are unlikely to arise spontaneously in normal, healthy women who are carrying normal, healthy pregnancies. (More about pregnancy as a cause of death will appear in the future post The Right Demise.)

 

Pregnancy loss has been a popular way to add drama to fiction, but in reality, most spontaneous abortions (“miscarriage”) occur before women know they are pregnant. Some women have a problem with their immune systems which prevents successful pregnancy (another topic dealt with in my novel Irish Firebrands), but most failed conceptions have chromosomal or other abnormalities which are incompatible with life, and generally result in fetal demise during the first three to five months of pregnancy. (Anencephaly – an incomplete development of the brain which can prevent a fetus from initiating labor – is an exception, so in anencephalic pregnancies labor is induced.)

Injury to the woman is a favorite method of ending a fictional pregnancy, usually by having her fall down. Unfortunately for writers, this is pure mythology: if a healthy woman conceives a healthy fetus, that baby is going to stick around, because a fetus in utero is too well protected by the woman’s skeleton and musculature, and by the shock-absorbing effects of the surrounding amniotic fluid, for a blow to the abdomen caused by a fall to make a pregnancy fail. For example, Scarlett O’Hara’s tumble down a staircase with a resultant pregnancy loss in Gone With the Wind has done a great deal of damage to a lot of desperate women, who throw themselves down stairs in an effort to end unwanted pregnancies: they break plenty of bones, but come out of it just as pregnant as they were to begin with.

This is where the writer of the Downton Abbey screenplays made a big mistake that cost a great deal in suspension of disbelief, as well as lost opportunities for plot development. The whole premise of the first two seasons had to do with the entailment of the estate in favor of a male heir. Rather than having the middle-aged wife of the incumbent lord of the manor lose an unexpected pregnancy at 4½ months along due to the popular myth of a fall, it would have provided much more suspense to have her give birth to a live male infant; and then to discover that he had Down Syndrome (a chromosomal defect that can afflict children conceived by older couples), which during the time period covered in the screenplay likely would have resulted in death during infancy or childhood.

In the same vein, a bumpy ride in a buggy does not bring on labor: witness the numerous pregnant women who have been involved in modern automobile accidents – even sustaining injuries so severe that they were reduced to persistent vegetative states – but whose pregnancies were unaffected by the trauma, and when they reached term even the unconscious women delivered normal, healthy infants. Therefore, if a pregnancy spontaneously terminates after a traumatic event, there was probably something wrong with the fetus that was incompatible with life, so the loss was a coincidence.

The inability to pass a term fetus through the pelvic outlet is another hot topic in fiction. Obstructed delivery may have become somewhat more frequent after the Industrial Revolution, due to rampant childhood malnutrition among the poor: young girls who didn’t have enough calcium in their diets, nor enough vitamin D from sunlight exposure because they worked all day in factories (meaning their skin never received 10 minutes of direct sunlight daily while they were actively growing), were at risk of developing skeletal abnormalities (rickets), which sometimes involved the shape of the pelvis.

Nevertheless, the notion that a woman will “need” obstetrical forceps for delivery because her pelvic outlet thought to be “too narrow” for a baby to pass through is fundamentally flawed: a forceps is a large, sturdy instrument which occupies a considerable amount of pelvic real estate, in addition to the size of a baby’s head, so if there’s enough space for a forceps and a baby to simultaneously occupy the outlet of the pelvis, there’s plenty of room there for the baby to come out by itself. This is especially true of any woman who has a “proven pelvis” (meaning that she has already delivered at least one term baby vaginally). To see the size of two common models of modern obstetrical forceps and learn how this tool is used, watch this video:

(Or visit this URL, or its sponsoring website.)

In any event, pregnancy hormones have a softening effect on cartilage, which becomes stretchy enough to permit the joints of the pelvis to expand generously for the passage of a baby. This is why only five or fewer out of every one hundred pregnant women (≤5%) genuinely require a caesarian section because of a stubbornly malpositioned fetus. When women are physically active during pregnancy, and during labor are unmedicated and freely move about (using the postures of hands-and-knees and squatting), almost all babies move into the head-first position for birth (whether facing backwards or forwards makes no difference, except for how the contractions feel: both are vaginally deliverable). Unmedicated laboring women also can feel when and how to push, and can on their own push out their babies.

Finally, consider whether it’s really necessary to throw into the works of your story the monkey wrench of a pregnancy after a one-off sexual encounter, because the monthly window of opportunity for conception is small: only a couple of days before and after ovulation.

If you do decide to include pregnancy among your medicalized fiction plot twists, study an anatomy and physiology textbook, a maternity nursing textbook, and consult an expert, such as an independent Certified Childbirth Educator, when it comes time to birth your fictional baby.

From “Prenatal Assessment of Gestational Age – Case Presentation” courtesy of Nawras AlHalabi at LinkedIn SlideShare.

 

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