Claire Meets a Hernia

Hello, Outlander friends!

Long time no see!  Well, about that…with finding myself as patient and mother to a patient and a few knee surgeries between us in the past few months, Outlander and its associated fun has taken a back seat.  While we aren’t fully done with the knee sagas at my house, I’m glad to be finding mental energy and time to “play” again in this medicine of Outlander world!  Many thanks to my dear friend A Dram of Outlander for again inviting me to join in on the fun of another #ADOO read-along, this time for Drums of Autumn!

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Drums of Autumn Read-along with A Dram of Outlander

As the title of Chapter 6 would suggest, in this week’s read-along of Drums of Autumn, we do indeed meet a hernia, one belonging to the unabashedly immodest Mr Myers!

“Damnedest thing, though;  all of a sudden this great big swelling come up just along behind of my balls.  Purely inconvenient, as you may imagine, though it don’t hurt me none to speak of, save on horseback.  Might be you could take a peep and tell me what I best do for it, hm?”

“Big purple thing,” he explained to me, fumbling his loosened thong.  “Almost as big as one o’ my balls.  You don’t think it might could be as I’ve decided sudden-like to grow an extry, do you?”
“Well, no,” I said, biting my lip.  “I really doubt it.”  He moved very slowly, but had almost got the knot in his thong undone;  people in the street were beginning to pause, staring.
“Please don’t trouble yourself,” I said.  “I do believe I know what that is – it’s an inguinal hernia.”
The wide hazel eyes got wider.
“It is?”  He seemed impressed, and not at all displeased by the news.
“I’d have to look – somewhere indoors, that is,” I added hastily “-to be sure, but it sounds like it.  It’s quite easy to repair surgically, but …”  I hesitated, looking up at the Colossus.  “I really couldn’t – I mean, you’d need to be asleep.  Unconscious,” I amplified.  “I’d have to cut you, and sew you up again, you see.  Perhaps a truss – a brace – might be better, though.”

From Drums of Autumn by Diana Gabaldon, chapter 6.

 

hernia her·ni·a (hûr’nē-ə)
n. pl. her·ni·as
The protrusion of an organ or other bodily structure through the wall that normally contains it.

A hernia occurs when the contents of a space bulges through a weak spot in the wall that should normally hold it in, for example, loops of intestine bulging through a weakness in the abdominal wall. These may occur anywhere the wall is weakened, either by normal anatomy, or by prior injury to the wall, whether from trauma or previous surgery and look like a bulge under the skin.

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Source:  Creative Commons

In this case, the unforgettable Mr John Quincy Myers is suffering from an inguinal hernia, in which some of the contents of the abdomen bulge though a weak spot in the abdominal wall in the inguinal region.

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Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014“. WikiJournal of Medicine 1

Inguinal hernias are quite common, with a prevalence of 5-10% in the US.  Worldwide, 20 million groin hernias are repaired each year!  Risk factors that may increase the chance of developing an inguinal hernia include being male, older in age, Caucasian, having a chronic cough or chronic constipation (things which increase the pressure in the abdomen), having a family history of hernias, history of previous hernia or hernia repair, or premature birth.

Aside from causing discomfort, with symptoms including groin pain with exertion (such as lifting or coughing), heaviness, and aching, hernias can develop significant complications.  The loops of intestine within a hernia can sometimes become trapped within the hernia and no longer be able to be reduced, or pushed back into the abdominal cavity.  This can result in a bowel obstruction.  Additionally, when loops of bowel are trapped within the hernia and cannot be reduced, the blood supply to the bowel can be squeezed off, resulting in rapid tissue death.  While the risk of these complications is low, these situations require urgent surgery.

How are inguinal hernias treated?  Generally, most are repaired electively, either via laparoscopic or open surgery, each method having particular indications, depending on the location of the hernia and the patient’s history.

Inguinal hernia repair would of course be routine for Claire, but the question of course, is what to do about anesthesia (or the lack thereof in the 18th century)?  Hmm, let’s stay tuned!  In the meantime, Claire has suggested Mr Meyers try a truss, or brace, to help with his symptoms, and in fact, these are still used today. The truss is a supportive undergarment/belt that exerts pressure on the area of the hernia to prevent it from bulging out. While elective surgical repair is generally the preferred treatment for hernias, some find a truss to help reduce sytpoms while they await surgery.

What about that mention of the morbid sore throat?

“Old Hector caught the morbid sore throat, up and died late last winter.  Don’t figure they get much mail, wherever he is now.”

Morbid indeed!  The term “morbid sore throat” was quite formidable and refers to what we now know to be diphtheria.  Read all about it in this post (Old Hector isn’t the first Outlander character we’ve learned to die of it!)!

Hope to see you at this Wednesday’s #ADoO twitter chat where @dramofoutlander and friends delve into all things Outlander, morbid, herniated, and all!

 

 

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307: Back in the Saddle

It didn’t take long at all for Claire to rediscover the need for her medical skills in 18th century Edinburgh and she started off her new medical practice with a doozy!  I’m glad to finally learn about the patient we’ve seen for 7 episodes now int he season three credits.  I’ve been dying to know who the poor soul was who needed Claire’s trephination skills and today we learned the fate of the victim.

trephination
Property of STARZ

While the procedure Claire performed on her patient appears quite crude, it is actually one of the oldest medical procedures still used in practice today!

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Trephination tools, 1802.  Source: Creative Commons

The injury to his head resulting from his fall onto the stone hearth has caused the exciseman to develop an epidural hematoma.  This is a condition in which a strong blow to the head results in damage to an artery surrounding the brain, leading to the rapid accumulation of blood between the outer protective membrane (dura) of the brain and the skull.  Being quite solid, the skull is not going to bend or swell to accommodate this rapidly accumulating blood, so instead, the brunt of this expanding mass of blood is placed on the brain, compressing delicate brain tissues and increasing pressure to devastating effect.  In response to an epidural hematoma and the resulting compression of the brain, a patient characteristically experiences weakness or paralysis on the opposite side of the body.  Swelling of the brain then causes compression of other parts of the brain, including the third cranial nerve, resulting in dilation of the pupil of the eye on the same side of the head as the injury.

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CT showing an epidural hematoma – note the lens shaped white hemorrhage.    Source: Wikipedia Commons

After hearing the sickening clunk of the exciseman’s skull on the hearth and allowing a moment for the shock of her attack to wane, Claire jumps into action.  It isn’t exactly clear how she so quickly landed on the diagnosis of epidural hematoma.  Classically (though of course not always), a patient with an epidural hematoma will initially have loss of consciousness, then awaken and experience a “lucid interval” before losing consciousness again as the hematoma grows and exerts its effects.  We didn’t see this play out in the episode.  Claire seems to make the diagnosis while he is still unconscious after the initial blow.  In modern times, these are diagnosed on CT scan or are suspected in a patient with a head injury along with a lucid interval and/or characteristic changes in the pupils.  Claire checks the patient’s pupils and states there is still time.  Does this mean the pupils are normal?  If they are normal, what are the clues she is using to deduce that he has an epidural hematoma?  If the pupils are not normal and the left pupil is ominously dilated, there isn’t much time to waste.  Hmm…

To relieve this pressure, a hole must be drilled into the skull to allow evacuation of the blood and relieve the excess pressure within the cranium.  When time allows, a neurosurgeon performs a craniotomy in the operating room.  However, this is quite time sensitive as the hematoma rapidly expands, causing significant injury to the brain.  In austere environments or in situations when transport to an operating room will take more time than the patient has, a burr hole is made to rapidly decrease the pressure.  While this is now done with a specialized hand-held drill rather than a hand crank trephine, the procedure is pretty much as Claire demonstrated.

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Property of STARZ

As Claire readies for surgery and examines her patient’s pupils once more, she finds the left pupil is dilated, pressure is increasing, and she must move now.  She deftly drills a burr hole in the skull to allow the pressure to be relieved and to evacuate the blood.  However, despite her efforts, the exciseman has died of his injury.  Even today, epidural hematomas have a mortality rate ranging from less than 5% to as high as 41%, depending on the patient’s age, the size of the hematoma, the effect of the pressure on the brain, and timing of surgical intervention.  Claire gave the exciseman the best chance he could have had for survival in the 18th century and did what she knew to be morally right thing to do.

A Little Help from the Apothecary

Claire requested laudanum, ground yarrow root, and tormentil from the apothecary. Laudanum, for obvious reasons (though that apothecary seems to stock an amazing formula that works instantaneously!  That patient was OUT quickly!).  Yarrow root and tormentil have hemostatic properties to help stop bleeding, which also make good sense in this situation and my guess is they are for topical application to the wounds.

Herbal medicine was certainly not covered in any depth, if at all, in Claire’s medical education.  I always wonder whether she spent time on her own in Boston over the years learning about herbal remedies, storing those tidbits for possible future (past?!) reference?

I’m sure seeing Claire perform trephination on the exciseman wasn’t everyone’s cuppa tea, but my guess is that if you are reading this, you enjoy this stuff too.  Getting excited for the loa loa, plague ships, and hernias yet to come!   How about you?  What Voyager medical scenes are you hoping make it to the screen?

 

 

 

 

304: Murphy’s Sign

Well, this doctor was the patient this week for a wee bit of knee surgery and recovering nicely (but where is Claire and her medicinal whisky when I need her?).  I’m squeezing in a quick post about episode 304 just before the next episode is available on streaming in about a half hour!

What was this pressing surgery that Joe called Claire about?

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Harry Greenbaum has abdominal pain, a positive Murphy’s sign, and calcifications on his x-ray.  Hmmm.  What’s going on?

What is Murphy’s sign? 

Murphy’s sign is a test performed during physical exam of the abdomen that may indicate the presence of inflammation of the gall bladder.  The examiner palpates the abdomen just under the rib cage on the right side as the patient inspires.  During inspiration, the abdominal contents (including the gallbladder) move downward because the lungs are expanding.  If the patient halts inspiration due to pain while the area is palpated, this is considered a positive Murphy’s sign.  See below the location of the gallbladder in the right upper part of the abdomen just under the ribcage:

 

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Image Source: Wikimedia Commons

What about those calcifications?

Could they be gall stones?  The could, though most gall stones are made up of cholesterol and are not visible on x-ray.  In fact, only 15-20% of gallstones are visible on x-ray.  Today, these are most commonly diagnosed on ultrasound.

The calcifications on Harry’s x-ray could also be a porcelain gall bladder, or a condition when the gall bladder wall becomes calcified due to chronic inflammation, generally associated with gall stones and occasionally associated with cancer of the gall bladder.  This type of calcification is easily seen on x-ray.

Either way, it is time for Harry’s gall bladder to be removed.  Because Joe made it a point to call Claire in Scotland to discuss this, my guess is that Harry is a long time patient of Claire’s and Joe wanted to give her the chance to perform the surgery herself if she would be back in time.  Cholecystectomy, or surgical removal of the gall bladder, is a routine surgery and certainly not anything Joe would need Claire to return for, if there were not other circumstances surrounding this case.

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Whew!  Done with a few minutes to spare!  On to episode 305 as this patient continues to enjoy a little bit of downtime recovering from surgery herself!

Cheers!

Outlander images property of STARZ

 

303: Hello, Old Friend

I’ll admit I’ve been on team #SaveMurtagh since season two and as soon as the music changed in the prison cell and the bearded face of everyone’s favorite BFF appeared, I was grinning ear to ear!

murtagh

That’s right.  Murtagh is back!

Murtagh Fitzgibbons Fraser seems to have nearly as many lives as Jamie.  He has survived more battles than anyone cares to count and despite abysmal conditions at Ardsmuir, he is still hanging on.  It does seem, though, he could use a little bit of help.

We learn that Murtagh has been struggling in the 9 years since Culloden, suffering frequently from La Grippe as well as festering wounds (from rat bites no less!).

What does this all mean?

La Grippe

La Grippe  

La Grippe is a name for influenza, meaning “to seize suddenly,” likely a reference to violent shaking chills accompanying the fevers of an influenza infection.  The term Influenza comes from the Medieval Latin “influentia,” from the belief that epidemics of this illness were due unfavorable astrological influences.

With influenza season now starting to revisit the northern hemisphere, we often hear the tips and tricks to try to avoid the flu.  In addition to an annual influenza vaccine, we are advised to: avoid close contact, wash your hand frequently, avoid touching your eyes, nose, and mouth, get enough sleep, eat a healthy diet, avoid crowds.  Hmm, that definitely doesn’t bode well for these men living in the squalid, tight quarters of Ardsmuir prison!

And what do these men have to treat influenza?  A diet of thin barley brose and the occasional rat?  The odds are stacked against them.  Jamie is on the right track with his requests for blankets and improved food rations.

Did you miss the Outlander Science Club post and podcast all about La Grippe during the Voyager read along?  Check it out here!

murtagh wounds

What about those festering wounds?  Jamie seems to think greens are the answer.  He is right!

Murtagh (and likely most of the men on the Ardsmuir diet) are suffering from scurvy.  Scurvy is the result of a deficiency in vitamin C, which is required in the production of collagen in the body and plays a significant role in immune function.  Without adequate intake of vitamin C, these men will begin to experience fatigue, malaise, inflammation and bleeding of the gums, bruising, joint pain, and poor wound healing.  Thanks to his education from Claire, Jamie recognizes that Murtagh’s rat bite wounds are not healing and surmises this is due to a lack of greens in his diet.  Watercress to the rescue!

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Always the keen negotiator, Jamie has convinced Major Grey to provide Murtagh with needed medical help.  I’ll admit I was waiting to see that doctor come in and bleed Murtagh dry in typical 18th century fashion, but it turns out that with help from this doctor and vitamin C rich foods from Jamie, Murtagh is back on his way to health…just in time for a long voyage to the colonies.

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See you soon, friend?

 

All images property of STARZ

302: Phantom Pains

Ian. Rupert. Now, Fergus.

All may now find themselves suffering from phantom pains.

“My leg, it’s not there as anyone can plainly see.  And yet, it pains me terrible sometimes.  Even wakes me up at night.” – Ian Murray

Phantom Limb Pain:  a phenomenon characterized by the experience of pain, discomfort, or other sensation in the area of a missing limb or other body part.

In fact, one does not have to lose a limb to suffer from Phantom Limb Pain.  It also can occur with the loss of other body parts: eyes, tongue, nose, even breast.

The concept of phantom limb pain is not new.  First described by the 16th Century French Military Surgeon Ambrose Pare, the term was first coined during the American Civil War by surgeon Silas Weir Mitchell.  Up to 80% of patients who undergo amputation experience phantom limb pain with a range of symptoms including burning, shooting pain, “pins and needles,” twisting, crushing, electric shock feelings, itching, and vibration.

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Why does Phantom Limb Pain occur?

In brief?  The medical community don’t know exactly.  There are a number of working theories.

One mechanism thought to be responsible for these symptoms is due to the direct trauma of the nerves themselves during amputation. The severed nerves grow and form groups of nerve cells called neuromas which then generate impulses that travel back to the central nervous system and are interpreted as pain.

Another theory suggests that the part of the brain cortex that normally receives input from that body area finds itself no longer receiving input.  The cortex reorganizes and neighboring areas take over that part of the cortex.  Because of this, pain impulses from areas of the body near the amputated limb are now interpreted as pain in the missing limb itself.

Or perhaps the symptoms are due to the lack of input.  Deprivation of the normal perception of that limb causes abnormal signals to be transmitted which are interpreted as pain.

Whatever the exact mechanism (and there are likely more than one coming into play), unfortunately phantom limb pain remains a problem difficult to treat.

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Treatment of Phantom Limb Pain

When possible, controlling pain prior to amputation can help.  Phantom limb pain occurs more frequently in those who had significant pain in that area prior to amputation.

Medications including acetaminophen, NSAIDs, opioid medications (these are thought to diminish the cortical reorganization which is one of the potential mechanisms PLP develops), antidepressants, and anticonvulsants.

TENS (Transcutaneous Electrical Nerve Stimulation) has been found to be helpful for some.

Mirror Therapy is an interesting adjunct in treatment.  Some theorize that the symptoms of Phantom Limb Pain are in part due to the absence of visual feedback about the limb to the brain.  When a patient watches the reflection of their intact limb moving, the brain interprets it as the phantom limb moving, resolving the mismatch between the visual and sensory inputs about the limb.

Fortunately, the prevalence of phantom limb pain tends to decrease over time following the amputation.

What about broken hearts?

“Feeling a pain in a part of ye that’s lost. And thats just a hand. Claire was yer heart.” – Ian Murray

The pain of love lost.  So similar.  Jamie and Claire both feeling less than whole, the pain still raw, and a constant reminder of what they have lost.

If only there was an effective treatment for that…

 

All images property of STARZ

 

 

 

301: “Where’d she get the red hair?”

A sweet moment for a new family.  Claire and Frank are finally connecting, joyful over the birth of Brianna.

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“Where’d she get the red hair?”

Buzzkill.

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The nurse has no malicious intent.  Instead, she likely understands the Mendelian inheritance of red hair.  A child born with red hair carries two copies of the recessive gene for red hair – one from the mother and one from the father.  She of course then assumes that Claire or Frank likely has a redheaded family member they can recall in their line.

Of course, there is much more to the inheritance of hair color, including details of blonde, various browns, and black hair, but for today, lets focus on red.

We now know that the specific gene responsible for red hair is called melanocortin 1 receptor (or MC1R).  Red hair is a recessive trait.  Recalling back to genetics class, this means that for a person to be born with red hair, they must inherit a red hair gene from their mother and one from their father.  If only one red hair gene is inherited, the child will have brown hair and simply be a carrier of the red hair gene.

Could Frank and Claire have a biological child with red hair?  YES!

Setting aside the question of whether Frank Randall is indeed fertile to begin with (we will have to revisit that too!), here is an example showing how Claire and Frank might have a biological child with red hair. R indicates the dominant gene for brown hair and r indicates the recessive gene for red hair.  If each of them is a brown haired person who carries the red hair gene, they will have a 25% chance of their child being a redhead:

Claire and Frank

Indeed, Frank and Claire could have a redheaded biological child, though it would have been much more likely for Jamie and Claire.  Assuming that Claire carries the gene for red hair (and we know she does since we’ve seen Brianna!), each child of Jamie and Claire will have a 50% chance of having red hair.

Claire and Jamie

Frank and Claire had better get used to answering the question of the red hair.  No doubt this is only the first of hundreds of times they will be asked.

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While on the topic of red heads, here are some fun facts:

  • Only 1-2% of the human population has red hair.
  • About 13% of the population of Scotland has red hair, the highest concentration in the world.
  • Redheads are more sensitive to pain!  They require significantly more anesthetic to block pain.  This is thought to be due to the fact that the MC1R gene responsible for red hair also codes for a receptor that is related to a family of receptors involved in pain perception.
  • They are also more sensitive to cold tempeteratures
  • Redheads have a higher risk of skin cancer, specifically melanoma.
  • Redheads are more likely to be left handed than people with other hair colors!
  • Redheads tend not to go grey.  Their hair pigment lightens to blonde and white and avoids grey.
  • People with red hair actually have fewer strands of hair than those with other colors.   However, their red hair is thicker so it appears just as full.

 

So glad to be back in the world of Outlander!  Life has been pretty crazy and this is always a welcome diversion!  What did you think of the Season Three premiere?  I’ve been avoiding previews and teasers so I knew very little going in and loved it.  So excited for what is to come!

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All Outlander images property of Starz

The Morbid Sore Throat

It has been a while, Outlander friends!  How are we all holding up?  What have you been watching and reading?  Any great recommendations?  We’ve got some time to fill between now and September…

In the meantime, for those who haven’t seen the season 3 teaser (or just want to watch again!):

A few months ago at a meet up with local Outlander fans, a lovely new friend commented that she’d read more than once of something called the morbid sore throat in the Outlander books and wondered what the heck it was.  Strep throat?  Abscess in the throat? Something else?  With a name like morbid sore throat, it has got to be something pretty terrible!

References to the morbid sore throat are scattered throughout the Outlander books, including this excerpt from Dragonfly in Amber.  Here, Claire learns the fate of the man against whom Jamie once dueled over his sweetheart Annalise de Marillac:

“A duel?  With whom?” I asked, glancing around warily for any male attachments to the China doll who might feel inclined to follow up an old quarrel.

“Och, he isna here,” Jamie said, catching and correctly interpreting my glance. “He’s dead.”

“You killed him?”  Agitated, I spoke rather louder than intended.  As a few nearby heads turned curiously in our direction, Jamie took me by the elbow and steered me hastily toward the nearest French doors.

“Mind your voice, Sassenach,” he said, mildly enough.  “No, I didna kill him.  Wanted to,” he added ruefully, “but didn’t.  He died two years ago, of the morbid sore throat.  Jared told me.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 11

In episode 202, this is changed to smallpox, which does tie in nicely with the smallpox epidemic at the docks in episode 201 and a later with Claire’s concoction to mimic the symptoms of smallpox in episode 206.

Analisse Husband Duel
A duel?  Do explain, Jamie! Source: STARZ

“The Scourge of Childhood”

The morbid sore throat, known now to us as diphtheria, was morbid indeed.  Without modern treatment, half of those infected with diphtheria died, with the young and old particularly hit hard.  Even now, with modern medicine, the fatality rate is 5-10%, but approaches 30% for those younger than 5 years or older than 40!

Much More than the Common Cold!

Transmitted through respiratory droplets from coughing or sneezing, or from touching a contaminated object, infection with diphtheria begins innocently enough.  Initially, a person infected with diphtheria may experience symptoms of a typical cold – sore throat, fever, runny nose, body aches, cough, etc. However, within 2-3 days, it becomes clear this is no run of the mill cold. The diphtheria bacteria starts wreaking havoc by producing a toxin that acts by both suffocating and poisoning its victim.

The toxin begins to destroy the healthy tissues of the throat and upper respiratory tract.  This dead tissue forms a  thick grey substance called a pseudomembrane that adheres very tightly to the tissues and spreads over the lining of the nose, throat, tonsils, and even over the trachea, blocking the airway and suffocating the victim.

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Greyish-white pseudomembrane of diphtieria infection.  Source

And as though that wasn’t enough, the toxin also spreads throughout the body causing damage in the heart and kidney as well as paralysis!

Prior to the era of antibiotics and vaccinations, diphtheria was one of the most dreaded of diseases, with frequent wide-spread outbreaks.  Treatment options were few.  Some attempts at intubation and tracheostomy were made to prevent suffocation from airway obstruction. No doubt many herbal and medicinal remedies were attempted, like this one from 18th Century New England.  Devastating epidemics took countless lives, including as many as a third of all children under 10 in some New England towns from 1735-40.  As recently as the 1920s, the US saw over 200,000 cases and over 15,000 deaths per year.

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Desperate attempts to cure diphtheria before the advent of antibiotics and vaccines.  This “Wizard Oil” remedy promises to cure a dozen ailments, including diphtheria. He looks skeptical…  Source: Library of Congress/Public Domain

The start of widespread use of the vaccine in the 1940s led to a rapid drop in diphtheria cases.  The CDC has had only 5 cases reported in the US in the past 10 years.  However, it is still reported globally, with the WHO reporting 4,530 cases in 2015.  Adults should receive the tetanus and diphtheria booster shot every ten years to remain protected!

vintage-diphtheria-poster
Library of Congress / Public Domain

Morbid sore throat is just one of many old wonderfully descriptive names for medical problems.  Ague.  Apoplexy.  Dropsy.  Quinsy.  I’ve started a small glossary of them here and I’m sure there will be plenty more to add as we all read and re-read the big books!

Thank you to Gina for the question about the morbid sore throat!  What archaic medical terms have you come across that you’d like to learn more about? Leave a comment here or find me on Twitter or Facebook if you have a suggestion for a post.

Stay strong, Outlander friends!  September is coming!

Header image: STARZ