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.

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.

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!

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


201: Claire Fraser, Champion of Public Health

201: Through a Glass, Darkly


So what is Claire making all this fuss about at the docks?

At the harbor in La Havre, Claire finds a man carried off a ship on a stretcher appearing quite ill and with a very concerning rash. She follows the crowd into a warehouse where she is able to examine the ailing sailor a bit more, finding him covered with lesions and suffering from a high fever. It is smallpox, she declares.

claire with patient face pox

On hearing this, and with a large crowd watching on, the harbormaster does what he must and declares that the ship and its entire cargo must be destroyed. Unfortunately for the Frasers, the owner of this ship is the Comte Saint Germain, who does not take the news well nor does he seem the type of guy one would like to make an enemy of.

fierce comte

The ship and its cargo are burned in the harbor and completely destroyed.

ship burning in harbor

What’s the big deal? Certainly the harbormasters of Europe were not burning every ship that came into port carrying unwell sailors with fevers, coughs or gastrointestinal ailments.

Smallpox, though, is another animal.

Known as smallpox to differentiate it from  “the great pox” (syphilis), smallpox killed 400,000 people annually in 18th century Europe and was justifiably and greatly feared.

Smallpox is thought to have emerged in human populations around 10,000 BC. The earliest evidence of the pustular rash is seen on the mummified body of Pharaoh Ramses V of Egypt.


It is thought to have been responsible for killing a third of Japan’s population during an epidemic in 735-737. Smallpox was brought to the New World by Spanish and Portuguese conquistadors and was instrumental in the fall of the Aztec and Incan empires. Smallpox devastated Native American populations with a 90% mortality rate among native groups.

Smallpox is caused by the variola virus which is in the same family as cowpox, monkeypox and vaccinia viruses. It is highly contagious and transmitted between people, primarily by direct and fairly prolonged face-to-face contact (i.e. within 6 feet of each other for at least 3 hours or so).  This occurs via inhalation of airborne droplets from the mouth, nose or throat or an infected person. It can also be spread through direct contact with infected bodily fluids or contaminated objects like bedding or clothing.

Following exposure, a person will go through an incubation period of about 2 weeks during which they are not contagious. After about two weeks, the patient will begin to experience symptoms of a prodrome like fever to 101-104 F, malaise, body aches, headache and sometimes vomiting. Once the fever and prodrome symptoms begin, the patient is contagious. The most contagious stage occurs as the rash develops. Small red spots develop on the tongue and in the mouth which develop into sores that break open and spread large amounts of virus into the mouth and throat. A rash of red spots appears on the skin starting at the face and spreading out to the arms and legs and then hands and feet. The rash covers the body within 24 hours. Over the next few days, the spots become raised and then appear to be filled with pus, raised, round and firm to the touch, as though there is a small round object under the skin. These pustules scab over and by around day 20, the scabs fall off, leaving pitted scars. Once all of the scabs have fallen off, the patient is no longer contagious.

smallpox progression cdc
source:  CDC


Mortality for patients with small pox is around 30%, but higher for young children.

Those who survive can be left with permanent scars over large areas of the body, especially the face, blindness and limb deformities.

Smallpox lesions / source

The devastation of this disease led to the experimentation with the practice of inoculation as early as the 10th century.  This was an effort to immunize against smallpox whereby infectious material from a smallpox lesion was rubbed into a superficial skin scratch of a healthy person. This would often result in more mild smallpox infection than that naturally acquired and confer lifelong immunity. However, it was not without risk and sometimes caused severe smallpox infection and death.

A safer alternative was developed and popularized by Dr. Edward Jenner in England. In 1796, Jenner discovered that immunity to smallpox could be produced by inoculating a person with material from a cowpox lesion. Using infectious material from a lesion on the arm of young dairymaid Sarah Nelmes who had a mild case of cowpox, he inoculated 8 year old James Phipps on the arm. James developed mild fever and nine days alter he was completely recovered. To prove that this would confer immunity against smallpox, 2 months later, he inoculated James again, this time with smallpox virus. James developed no symptoms or disease.


Vaccination using Jenner’s approach was widely adopted and paved the way for worldwide use of the vaccine, ultimately leading to the global eradication of the disease.

The word vaccine actually originates from this process from vacca ‘cow’.

The smallpox vaccine is not administered by injection like other immunizations. For smallpox vaccination, a live virus preparation of infectious vaccinia virus is made – this virus is of the same family as smallpox and cowpox and confers the same immunity. A two-pronged needle is dipped into the vaccine solution and then used to prick the skin of the upper arm a number of times in a few seconds. A red and itchy bump arises at that location in 3-4 days and then develops into a fluid filled blister. The blister drains and during the second week a scab forms. In the third week, the scab fans off, leaving a small scar.

Two-pronged needle for smallpox vaccination / source

A very characteristic scar!

geillis small pox looking at camera
The mark of the devil? / STARZ

Smallpox was declared eradicated worldwide in 1980 and vaccination ceased, aside from use now for some military troops and for laboratory scientists who work with the virus.

So, was it worth it, Claire?

Smallpox was devastating in the 18th century and killed 400,000 Europeans a year.  Transmission occurs both but direct face-to-face contact AND with contaminated objects (bedding, clothing, the cargo of a ship!)   It would not have taken long for disease to spread in the conditions of the time. Claire is a healer and her instinct will be to protect these people from this terrible disease, though no doubt there will be a cost (cue haunting Comte Saint Germain theme from Bear McCreary!)

you will pay a price

Hurray for the end of Droughtlander!  Looking forward to many medical discussions to come as Claire the Healer finds her way in Paris!

Further Reading:

The Sickly Stuarts – the Medical Downfall of a Dynasty

CDC – Smallpox Information