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

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A Voyager Read-Along with a side of Outlander Science Club — A Dram of Outlander

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The White Plague

What is tuberculosis?

Also known as “phthisis” or “consumption” (due to the wasting away of the infected individual) and “the white plague”  (describing the pallor of the skin of those infected), tuberculosis was responsible for more deaths in industrialized countries in the 19th and early 20th century than any other cause.  In the early 19th century, in fact, 25% of deaths in England were due to tuberculosis.

Tuberculosis is caused by the organism Mycobacterium tuberculosis. A person with active tuberculosis sneezes, coughs, speaks or spits, emitting numerous tiny droplets containing the bacteria (a sneeze can release up to 40,000 droplets!).  Transmission occurs when one or more of these bacteria-containing droplets are inhaled.

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Public Health Poster c. 1920s / source

Once in the lungs, the M. tuberculosis bacteria invades and replicates within cells. This leads to a response in which the body creates an organized aggregate of immune cells, called a granuloma, around this infected cell in order to contain the bacteria and concentrate an immune response to the area.

After initial infection with M. tuberculosis, about 10% will develop TB pneumonia with infection spreading from the site of initial infection. The remaining 90% of people will remain asymptomatic and noninfectious, with the bacteria remaining dormant in the granuloma.  In most individuals, the infection remains in this prolonged suppressed state called “latency”.

However, in about 10% of infected individuals with latent disease, active tuberculosis will eventually develop, either due to a continuous process within a year or so of infection, or years later after a period of dormancy.  Symptoms of fever, chills, night sweats, fatigue and loss of appetite develop along with chest pain, wheezing, persistent cough with sputum and the coughing up of blood (hemoptysis).  As cells die within these areas of infection, a cheese-like proteinaceous mass of dead cells accumulates in cavities within the lung tissue.

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Chest X-ray of a patient with advanced tuberculosis.  White arrowheads indicate areas of infection.  The formation of a cavity is marked by black arrows. source

What is scrofula? 

Back at L’Hopital, after finding Claire of impressive skill and knowledge as a healer, asked her to help tend the wounds of a boy with scrofula.

Scrofula
Child with scrofula, 1893 / source

Scrofula is a term used to describe the enlarged lymph nodes of the neck caused by infection with tuberculosis outside of the lungs, in this case in the area of the tonsils and adenoids.  While tuberculosis primarily affects the lungs, in 15-25% of active infections, it spreads outside of the lungs and can occur anywhere in the body.  Most commonly involved areas include the central nervous system (TB meningitis), lymphatic system (scrofula), genitourinary system, bones and joints (termed Pott’s disease when it is present in the spine).

Treatment of Tuberculosis

Tuberculosis has plagued humans for thousands of years.  Evidence of tuberculosis infection has been found in Egyptian mummies, ancient China and India and in the writings of Hippocrates. A variety of treatments were applied prior to the era of antibiotics.

In ancient Greece, patients were treated with healthy food, milk, and exercise.  Some recommended eating wolf livers or elephant urine.  Bloodletting was common.  Later, TB sufferers were treated with various treatments with equally varied results such as carbolic acid, gold, arsenic, and cod liver oil.

For many years it was believed that disease could be cured by a king’s touch and this became a common approach for the treatment of scrofula.  This became so common that scrofula became known as “mal du roi” or “King’s Evil.”

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Healing by the “King’s Touch” / source

The Sanatoria Era

The 1880s brought the sanatoria movement or the “rest cure”, an attempt to cure TB and prevent its spread by moving patients in to quite environments, isolated from normal life, with freely circulating pure air.  Surgical treatments became more common in the sanitariums, based on the theory that the part of the lung with TB needed to “rest” in order to heal.  Surgeons would collapse the affected lung by way of various methods, to allow the lung to rest and heal.  This would include causing a pneumothorax, perfuming plumbage (inserting air, oil, wax, etc., into the chest cavity to collapse all or part of the lung), removing ribs to collapse a lung, severing the phrenic nerve to paralyze half of the diaphragm to reduce the functioning of the affected lung.

Vaccination

Vaccination against TB became available and widely used beginning in the 1940s and 50s in the form of the BCG vaccine (bacilli Calmette-Guerin, named for the two researchers who developed it in the 1920s and 1930s).  The BCG vaccine does offer protection against TB meningitis and disseminated TB in children, but does not prevent primary infection or prevent reactivation of latent TB infection.  While it does prevent some severe forms of TB in children, its impact is limited.

Antibiotics

1946 marked the development of the antibiotic streptomycin, the first effective treatment for tuberculosis.  The development of isoniazid would follow in the 1950s.  Antibiotic treatment of TB was so effective that almost all of the sanatoriums closed permanently in the 1960s.  Rates of TB infection dropped steadily until the 1980s, when they again started to rise.  This has been attributed to the rise in HIV infection (patients with HIV have a much higher rate of developing active disease from a latent infection) and the emergence of multi-drug resistant TB.

Because of drug resistance in TB, today the typical initial regimen for treating TB is four medications taken for 6 -9 months. TB can be cured when the regimen is followed but such a regimen leads to issues with compliance, perpetuating the problem.  If a patient fails to complete the treatment or if the infecting bacteria is already immune to one of these antibiotics, some of the germs will survive, adapt and grow stronger, passing on drug-resistant traits as the bacteria reproduce.  Thus, it is vital to eradicate the infection in its entirety with the first course of treatment.

Extensively drug resistant TB (XDR-TB) has recently emerged, complicating treatment further.  This is a rare type of drug resistant TB that is resistant to the two most potent TB drugs in addition to at least 2 other agents used in the treatment of TB. This is, of course, much more difficult to treat and cure has shown to be possible only in about 30-50% of patient with XDR-TB.

The Global Threat

TB remains a significant global health threat, particularly in developing countries. In 2014 alone, 9.6 million people developed TB infection and 1.5 million died from it.  95% of TB deaths occur in developing countries where it is among the top 5 causes of death for women aged 15-44.  Challenges remain in developing fast-acting diagnostic TB tests that can also determine whether resistance is present (currently it can take 6-16 weeks to determine the resistance pattern of an infection), development of a more effective vaccine, and work to increase the reporting and treatment of TB.  The stigma of tuberculosis remains a problem, leading to delay in seeking treatment and lower treatment compliance, allowing further spread of the disease.

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Prevalence of TB per 100,000 people in 2004. / source

CDC Information about Tuberculosis

WHO Information about Tuberculosis

My Conversation with The Sassenach Doctor — A Dram of Outlander

I had a most delightful and informative conversation with my new friend and sisterly science geek, Karen Daugherty, the emergency physician behind the insightful site, Sassenach Doctor. A many year book series fan and a TV series fan, Karen began writing about the medicine of Outlander during a hiatus prior to the Season 2 launch of […]

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