Virus image by Tomislav Jakupec from Pixabay, Image rotated by Mike

Whew, finished at last! Six hrs overdue, but it’s more than twice the usual length, so hopefully that can be forgiven!

Is it too easy to cure disease in RPGs? I analyzed that question from various angles last week and came to the conclusion that the answer was arguably ‘yes’ – and also arguably ‘no’ – but that the advantages of making ‘Cure Disease’ hard to do were too significant to ignore.

I also described a system of rating diseases on a 1-5 star scale, and that’s fairly relevant to this second part of the article, so I’ll quote an edited highlights:

I once played in a game in which the GM rated all diseases on a one-to-five scale. Double the rating and subtract one and you got the required spell level of a spell designed to deal with that specific illness. I’ve shamelessly appropriated the concept for my own use, expanding it in the process, as you will find out later in the article.

• Specific One Star Diseases are curable with a specific 1st-level spell. This healing will be available in most towns and villages.
• Specific Two Star Diseases are curable with a specific 3rd-level spell. A survival rate of one in three per character level gives distance to a cure of a day or two’s travel in a country with the population of medieval France.
• Specific Three Star Diseases are curable with a specific 5th-level spell. One in three survival gives a distance of 1-2 weeks to a cure in a country with the population of Medieval France.
• Specific Four Star Diseases are curable with a specific 7th-level spell. The 1-in-3 rate means there’s one place in the equivalent of Medieval Europe to find a cure.
• Specific Five Star Diseases are curable with a specific 9th-level spell. Finding such a cure will mean searching several Planes of existence.

For this system to work, “Heal” and “Mass Heal” need to be weakened significantly or eliminated completely. No decision has been made yet on the best alternative.

So that’s where we’re at.

Weakening “Heal”?

So what might weakening heal look like? Well, let’s start by putting another interpretive spin on that five-star ratings system:

• One Star = common diseases
• Two Stars = uncommon diseases
• Three Stars = severe diseases
• Four Stars = deadly diseases
• Five Stars = disastrous diseases

So, let’s try the following on for size:
“Heal can cure any common or uncommon disease. It can also heal severe disease from any one general category of diseases, but this capacity must be specified when the spell is taken at the start of the day and choice may be restricted by deity.”

So this one spell can replace a whole bunch of 1st-level spells and a whole bunch of 3rd-level spells, and a select (and possibly restricted) group of 5th-level spells. That seems reasonable for a 6th level spell.

Of course, for this to work, we need to specify some general categories of disease. But I actually view that as a side-benefit of some rules for simulating a disease.

Simulating A Disease

This is the heart of today’s subject, so far as I’m concerned; last week’s article described how important disease was (or should be) to most RPGs, but D&D in particular, this article is all about populating Pandora’s Box.

NPC Susceptibility

Who cares? NPCs will come down with things at the speed of plot. Want a plague? Here you go. Want disease to be holidaying in his summer palace? Not a problem.

Still want some rules? Okay:

Chance of catching (%) = (20 × stars) — 10 + (Age / 5), round down.

Specific Diseases may have modifiers to that chance. Some of these modifiers are age-specific because the diseases are known as ‘childhood diseases’ or ‘geriatric diseases’; the applicability of these modifiers is up to the GM.

Non-humans should have their ages converted to human physiological equivalents.

Is that better? Arguably, the last two paragraphs are the most important, in my opinion. At this point, something I used as the foundation of another article should also be brought to mind: If you have an X% chance of something happening, and 100 opportunities for that chance to manifest, you may as well say that in X cases out of that 100, it happens.

In this case, that means that if there’s a 1-star disease going around, the chance of under 5s catching it will be 10% unless there’s a specific modifier, rising by 1% for every 5 years of age:

     0-4: 10% of this age group will have it.
     5-9: 11% of this age group will have it.
     10-14: 12% of this age group will have it.
     15-19: 13% of this age group will have it.
     20-24: 14% of this age group will have it.
          …and so on, up to
     95-99: 29% of this age group will have it.
     100-104: 30% of this age group will have it.
          …and up from there.

Or you could take the average age of a community – let’s say 30 – and simply get a general “16% of the population are ill”.

For comparison, let’s look at a 4-star illness, no special modifiers:

Chance of catching (%) = (20×4) — 10 + (Age / 5), round down, i.e. 70% plus age modifier.

     0-4: 70% of this age group will have it.
     5-9: 71% of this age group will have it.
     10-14: 72% of this age group will have it.
     15-19: 73% of this age group will have it.
     20-24: 74% of this age group will have it.
          …and so on, up to
     95-99: 89% of this age group will have it.
     100-104: 90% of this age group will have it.
          …and up from there.

Average age method: 76% of the populace are sick.

PC Susceptibility

But this is where the rubber really meets the road. A PC encounters an NPC with the disease – what’s the PC’s chance of coming down with this dreaded lurgy? (Actually, for various technical reasons, the game mechanics that came to me actually work better as a resistance).

Base Resistance

Base resistance is 5 × CON minus Age.

For non-humans, convert their age to a physiological human equivalent if they are even susceptible to this particular illness.

Specific Disease Modifiers

Subtract 10 times the Star Rating of the disease.

Wounded Modifiers

     If the character has been wounded in the last week, add 5.
     If the character has been wounded in the last 24 hrs, add 10.
     If the character has been wounded in the last 6 hrs, add 15.
     If the character has been wounded in the last 3 hrs, add 20.
     If the character’s wounds were not healed within 30 minutes, add 10.

(These all represent the likelihood that the character’s immune system is fighting off an infection).

Age Modifiers

This represents modifiers from a specific disease toward a specific age group. For this purpose, age groups are

     Infants
     Children
     Young Adults
     Adults
     Senior Adults
     Elderly Citizens

Where a GM chooses to put his boundaries is up to him or her. I would probably use:

     Infants: 0-2 yrs
     Children: 2-13 yrs
     Young Adults: 13-20 yrs
     Adults: 20-40 yrs
     Senior Adults: 40-60 yrs
     Elderly Citizens: 60ys+

— but I would vary those numbers based on the genre of the campaign, using very different numbers in a Cyberpunk world, for example, simply because the state of the medical art would have extended both the human lifespan and the fitness of individuals at later ages. I might also toss in another category, “Teens”.

So, some rules:

• For every +5% in one age bracket, two others must have a -5% risk.
• If one age bracket has more than a +10% risk, it’s neighboring age brackets must have at least +5%.
• If one age bracket has more than a -10% risk, it’s neighboring age brackets must have at least -5% unless it has a +5% from the preceding rule and no other age modifier from this section.
• No age bracket can have more than a -80% risk and no age bracket can have more than a +60% risk.

That means that resistance based on age is broad-based, while susceptibility is narrow, and that there is at least a nod towards curve smoothing. It also places some hard limits on how big a modifier is permitted.

EG: Let’s create an Infants/Childhood Disease. We need to reserve the Young Adults category for the minimum +5% risk described above. That means that we have three age brackets to load up with resistance.

Let’s take all three to the maximum of -80%, for a total of -240%; but only half that much ‘comes across’, so -120%; and splitting that evenly between the two vulnerable age brackets gives the +60% maximum permitted.

But the rules given above state that the Young Adult category has to have either a +5 (from the childhood side) or a -5 (from the adult side), with ties broken in favor of the +5. The only place we can get it from are the two +60s, so one drops to +55.

The results:
     Infants +60%
     Children +55%
     Young Adults +5%
     Adults -80%
     Senior Adults -80%
     Elderly Citizens -80%

The power of these adjustments is really only appreciated when you factor in the standard age modifiers given earlier.

Note that these modifiers apply to both PCs and NPCs.

Other Modifiers

Finally, a catch-all category to cover things like climbing through sewers, rolling in mud, wrestling with plague-carrying Giant Rats, and whatever. The GM can add up to +30% additional resistance or -50% weakened resistance for other circumstances as he sees fit.

Total these up and you get any character’s resistance to any given disease. I recommend doing the base resistance calculations in advance, and doing the age modifiers when you specify a disease in-game.

A General Rule

Which brings me to a general rule that was strongly implied by last week’s post:

Diseases of more than 2 stars should never appear in a game by accident, or capriciously. “Realism” alone is not enough justification for their presence. ONLY use them when they will add significant impact to a story.

Disease Descriptions

So, each GM should describe the common diseases in their campaign for themselves. The first thing to think about is a standard format, so that’s the next thing. I’ll be adding additional rules as they become relevant to an entry within the standard format.

0. The Text Block

Obviously the place to start is with a text block because (at the very least) that will contain the name. So we may as well put all the other text here, too.

• Name – I would stick to common names except in a high-tech society. Note however that non-human cultures may well have their own names for illnesses to which they (or their domesticated creatures) are susceptible, which should also be listed here.
• Appearance / Symptoms – what does the disease do? Go for the most common first, and assume that every case will have all the symptoms; anything else is far too complicated for RPG usage.
• Effect – if you need to include a game mechanics effect, this is where it goes. That includes age modifiers.
• Game Impact – this is a concluding text block that deals with how the society in general views the disease. In most cases, this can be left blank.

After that, we get down to some statistics, that should be used as a guideline by the GM to the handling of the illness.

1. Incubation Period (0-5)

This is how long after your exposed that you get sick.

Suggested Values:
     0: 1 day
     1: 2 days
     2: d4+2 days
     3: d8+6 days
     4: d12+9 days
     5: 2d10+8 days or more

2. Infectiousness Period (1-6)

How long after you get sick are you dangerous to be around?

Suggested Values:
     1: 1 day or less
     2: 2 days
     3: d4+2 days
     4: d8+6 days
     5: d12+9 days
     6: d12+3 months or more

3. Infectiousness Risk (1-5)

If you encounter someone in the Infectiousness Period, how likely is it that you will pass the disease on?

Suggested Values:
     1: 10%
     2: 20%
     3: 30%
     4: 45%
     5: 55%

4. Lethality (0-5)

How likely is the illness to kill you?

Suggested Values:
     0: 5%
     1: 10%
     2: 15%
     3: 30%
     4: 60%
     5: 80%

These assume that you have to roll once to survive or die. If you want a daily or even an hourly check, they should be much lower.

How much lower? Well, that gets complicated.

Because you stop rolling to survive if you die, we first need to convert our number into a decimal, and then subtract it from one. From now on, let’s call that X.

Next, we need the Yth root of X. Let’s call that Z.

We then need to convert that back into a chance of dying by subtracting the result from 1, and then converting that back to a percentage.

If our initial number was 60%, and we wanted four checks for three days, that gives us a Y of 12 and an X of 0.4.

That gives a Z of 0.92648487247906914467417516897626 (my calculator is exuberant with the decimal places).

Subtract from 1 and then multiply by 100 and we get a death chance per roll of 7.3515127520930855325824831023735. I would use 7.35 as near enough, round down, and let the 0.35 remainders add up until they got to a whole percentage point.

     1st check:7.35 =7% and 0.35 carried forward.
     2nd check: 7.35 + 0.35 = 7.7 = 7% and 0.35 carried forward.
     3rd check: 7.35 + 0.7 = 8.05 = 8% and 0.05 carried forward.
     4th check: 7.35 + 0.05 = 7.4 = 7% and 0.4 carried forward.
     5th check: 7.35 + 0.4 = 7.75 = 7% and 0.75 carried forward.
     6th check: 7.35 + 0.75 = 8.1 = 8% and 0.1 carried forward.
     7th check: 7.35 + 0.1 = 7.45 = 7% and 0.45 carried forward.
     8th check: 7.35 + 0.45 = 7.8 = 7% and 0.8 carried forward.
     9th check: 7.35 + 0.8 = 8.15 = 8% and 0.15 carried forward.
     10th check: 7.35 + 0.15 = 7.5 = 7% and 0.5 carried forward.
     11th check: 7.35 + 0.5 = 7.85 = 7% and 0.85 carried forward.
     12th check: 7.35 + 0.85 = 8.2 = 8% and that’s the last check.

If you go to all the trouble, you can work out that this all comes to

     1 – 100 × [ ( 0.93 ^ 7 ) × ( 0.92 ^ 5 ) ] = 60.343% net chance of death.

My, but that’s a lot of palaver. You could save some of it by rounding to 0.3 or 0.4, I suppose, and it wouldn’t make a huge amount of difference but would be a lot easier to calculate.

A quick-and-dirty shortcut
But, in fact, I would use a highly inaccurate quick-and-dirty calculation: Square Root of (Original X minus Y) plus Y/100.

If the number of checks is too high, halve them.

     60-12=48. Square root of 48 is 6.9. Add 0.12 to get 7.02. Then ignore the 0.02. (If it had been 0.1 or something like that, I’d have tracked it).

Twelve checks at 7% gives 58.1% total risk. I’m not bothered by the missing 1.9%, are you?

Let’s do another one: Hourly checks, 1½ days, net exposure of 30%.

1½ × 24 = 36 checks. There isn’t enough room in 30% to subtract 36, so we halve the number of checks and make them two-hourly instead.

     30-18=12; Square root of 12 is 3.46; add 0.18 to get 3.64. Ignore the 0.04, use 3.6.

     1st Check: 3.6 = 3% and 0.6 carried forward.
     2nd Check: 3.6 + 0.6 = 4.2 = 4% and 0.2 carried forward.
     3rd Check: 3.6 + 0.2 = 3.8 = 3% and 0.8 carried forward.
     4th check: 3.6 + 0.8 = 4.4 = 4% and 0.4 carried forward.
     5th check: 3.6 + 0.4 = 4%.

With nothing carried forward, this then becomes a 3, 4, 3, 4, 4 pattern that repeats until we get to the required 18 checks:

     3 4 3 4 4 3 4 3 4 4 3 4 3 4 4 3 4 3

If you work backwards from those results, you get

     1 – 100 × [ ( 0.97 ^ 8 ) × ( 0.96 ^ 10) ] = 47.894% net chance of death.

That’s a fair bit higher than the target 30% – in fact, it’s past half-way to the next value of 60% – but so what? I said this was quick and dirty, not accurate.

5. Recovery Period (0-5)

Once you start to experience the symptoms, how long is it until you start to feel better? This is relative to the infectiousness period.

     0: +25% after the infectious period
     1: +3 days after the infectious period
     2: +1 day after the infectious period
     3: when the infectious period ends
     4: d4 days before the infectious period ends
     5: 1/2 way through the infectious period

Observe that the lower this is set, the less dangerous the disease is because you may be feeling better but can still spread the illness. It’s also possible with the right settings to pass completely through the recovery period before you become infectious!

6. Recovery Chance (0-5)

Some symptoms may be marked as persistent, indicating that there’s a risk that they will persist in the long term. It’s assumed that any symptom not so marked will pass when the infectious period passes.

This is the chance per month of recovering from those symptoms. As usual, the higher the rating, the worse the disease.

     0: 8% each month
     1: 6% each month
     2: 4% each month
     3: 2% each month
     4: 1% each month
     5: 0% each month

7. Disease Star Rating (1-5)

Last, but not least, the star rating, which sums up how bad this particular illness really is.

I suggest using actual stars if you can manage it: ★★★★★

This post is displayed using web-browser language (HTML, technically “HyperText Markup Language”) as is everything else that you will see on the web, so I did the ones above by typing &-star-f-semicolon five times. If you’re producing your disease reference using a word processor, look for a symbols library or font.

Creating a Disease

Okay, so now that we know what’s in a text block, let’s look at how to crunch those statistics.

The General Case

Multiply the star rating by 4.5, and round up. Divide the results amongst the 6 other categories.

If you do the math, that gives you the following:

     1-star: 5 disease construction points
     2-star: 9 disease construction points
     3-star: 14 disease construction points
     4-star: 18 disease construction points
     5-star: 23 disease construction points

This means that you can have diseases that are very infectious or very lethal or any other variation that best describes them (note that this is why some of the categories offer a ‘0’ rating and others don’t). The alternative would have complicated the “multiply by 4.5”.

Specific Strains

With the current concern over the rising spread of the Delta variant of Covid-19, the concept of specific strains is front-and-center for a lot of people. Most of the time, you can use the generic signature of a disease, but every case is just a little different.

1. Roll 1d8 per star and total the results.
2. Average the results with the general case build points, round up.
3. Subtract the general case build points.

The result is the over-or-under relative to the generic version of the disease. If you came up with 4 points under, for example (that’s a result of -4) then this specific strain is, overall, milder. So you start by allocating those -4 points to different categories. You can’t take any category below it’s minimum.

You can also take the opportunity to tweak the profile – once you’ve allocated the specific strain points, you can increase any single category by 1 step while reducing another by a step. Once only, note!

An example: a 4-star disease has 18 build points for it’s generic version. These have been allocated:

     Incubation Period (0-5): 3
     Infectiousness Period (1-6): 4
     Infectiousness Risk (1-5): 3
     Lethality (0-5): 1
     Recovery Period (0-5): 2
     Recovery Chance (0-5): 5

Rolling 4d8 gives me a total of 20. Average with 18 to get 19. So this specific variant is one point nastier than the base.

I’m going to add the extra point to the Recovery Period. I’m also going to use my one-time-per-specific-variant deal to take one point off Infectiousness Period and further increase the Recovery Period. So this specific variant looks like this:

     Incubation Period (0-5): 3
     Infectiousness Period (1-6): 3
     Infectiousness Risk (1-5): 3
     Lethality (0-5): 1
     Recovery Period (0-5): 4
     Recovery Chance (0-5): 5

So you can’t infect others for quite as long, but the symptoms will stay with you for longer. This is actually a milder but more persistent strain.

Other Species

Generic Profiles for humans are fine, but don’t expect the illness to progress in the same way for Elves or Dwarves or anyone else that’s susceptible. Add 1d6 to the build points per star and subtract 1d6 to the build points per star.

Here’s the trick: it’s up to the GM to decide which dice are added and which subtracted. This lets him deliberately tune the disease to the plot, one way or the other, or simply let it be a random input.

Specific Diseases Considered

I was never going to have time to do full stat blocks for a whole bunch of diseases, and that wasn’t the point anyway – why provide the mechanics for a GM to make his own decisions and then usurp that authority?

What I have done is list every disease that I could think of off the top of my head (excluding Covid and Bird-Flu and the other new kids on the block). I am sure that this list is not exhaustive!

Some of these will be the result of metabolic failures, others will be caused by infectious agents or other harmful substances. I deliberately haven’t listed symptoms, like indigestion, as diseases in their own right.

As a general thing, these have been loosely grouped into families, not in any scientific way, and with one or two curve-balls thrown in. As a general rule, I’ve tried to go from low-star to high-star members within each family, and the final member is always a generic category – which feeds back in to the modifications to Heal that I proposed earlier.

For example, at one point, the list runs

8. Influenza
9. Scarlet Fever
10. Yellow Fever
11. Black Death
12. The Fevers

but “Malaria” (which arguably should be in this family) has actually been put into a group with “Bites and Venom” as it’s head. Why? Because direct infection from another person is unlikely in that case but assumed to be possible in the list above.

I’ve tried to jot down a few words to serve as the basis of a text block for each disease, but my primary goal was to indicate how many stars I thought it should have, and why.

1. Cold ★

Colds are actually multiple similar illnesses caused by completely different viruses. That’s why it’s so hard to come up with a cure. They also mutate extremely quickly. In effect, you would need five or ore different vaccines to be developed every year. Not that they aren’t searching for a magic bullet!

Almost all colds cause your nose to run. This gets onto hands and from there onto other surfaces and then gets picked up by someone else. I’ve seen unverified suggestions that they can survive for months on a surface. So they are easily spread and hard to kill. The phlegm can cause sore throats, laryngitis, upset stomachs, sinus headaches, watery eyes, and will usually irritate at least part of the nose. The virus will usually cause some difficulty in breathing due to phlegm in the lungs. The cold can cause either a dry cough or a wet cough (the latter being an attempt by the body to ‘cough up’ phlegm. Muscle and joint aches are also possible.

Treatments are usually aimed at controlling symptoms and have become far more effective over the last 25 years or so. This is still a fertile area for home remedies.

2. Heatstroke ★★

Not a disease that you can catch from someone else, this comes from dehydration and being out in the sun too much. Had it once, don’t care to repeat the experience. Symptoms include delirium, dizziness, blurred vision, and headache. Sometimes you can be susceptible. for no apparent reason even if you usually aren’t. There have been suggestions that other illnesses that can lead to dehydration such as influenza can make you more susceptible. Treatment is simple: get into the shade and drink plenty of fluids until you feel better.

Heatstroke can kill in severe cases or when treatment isn’t available. In even a semi-dangerous environment, though, making mistakes of judgment is probably the leading cause of fatalities. “Look at the nice kitty with such long and sharp teeth, let me just get my toothpaste, it’s here in my pack somewhere….”

3. Cold Sores ★

Cold sores are a little more serious than Acne, which I decided not to list. They are an infection on the lips, that are spread by lip-to-lip contact. If touched, it’s possible to transfer the agent (Virus? bacteria, I think?) to other parts of the body, where the consequences can be more serious. They like moist environments so this is especially true of open wounds. They seem to be more common in colder weather, hence the name, but that might be an old wives tale.

4. Ulcers ★★

Ulcers are sores, often in the lining of the stomach. They cause pain, under certain conditions – certain foods can trigger them. They are associated with stress and worry. If not treated, they can bleed, and this can eventually be fatal. But the pain and malnutrition that result from avoiding the pain are more likely to do a sufferer in.

5. Measles ★★

Measles used to kill children regularly. Then we developed a vaccine. Since the rise of the Antivax movement, measles deaths are again rising. Measles are characterized by a rash on the skin and may be accompanied with a fever. Thankfully, most people can only catch them once.

6. Leprosy ★★★

Leprosy is relatively noninfectious but disfiguring and can last for a long time. It’s a bit like a measles that won’t go away and that leaves severe scarring in survivors. It can kill, but this is relatively rare.

7. The Poxes ★★★★

A catch-all for other types of diseases that cause a rash. The most notorious member of the family is smallpox. These are generally assumed to be fairly lethal and fairly infectious.

8. Influenza ★★

People die of influenza every year, despite it being little more than an irritant in most cases. This is one of the most common diseases that people should encounter. It generally produces weakness and a lack of energy. The body’s attempts to make itself as unhospitable an environment as possible produce a fever, and that fever can get out of hand in severe cases, causing death. There are often no outward signs that someone has the flu, and that’s a major component of its infectiousness and risk profile.

There are four major strains of flu, and the flu vaccine is good for two of them. Immunity lasts 1-3 years. Each year, the most common / most dangerous varieties currently in circulation are identified and used to create the specific vaccine combination for that year. This suppresses the strains against which it is targeted, creating an open meal-ticket for the ones that are not the following year. So a flu shot one year will provide very limited protection the following year. Because the virus mutates fairly readily, the vaccines have to be custom-built every year, and there is only time and money enough to get two done, combined, and distributed.

There were early attempts to downplay Covid-19 as no worse than the flu. I prefer to think that Covid-19 shows just how bad the flu can get. Reference the epidemic of 1918.

9. Scarlet Fever ★★★

I know the name, and believe that it can cause infertility. I know very little about it beyond that.

10. Yellow Fever ★★★★

Yellow Fever is spread by mosquitoes but that wasn’t known for a long time. This accounts for this being a disease restricted to tropical climates. The building of the Panama Canal was fraught because of Yellow Fever. It’s more commonly fatal than any of the fevers listed thus far. I am not sure whether or not surviving it creates immunity or for how long it lasts.

11. Black Death ★★★★★

Elder statesman and patriarch of the Fever family. Highly dangerous. It was believed that you can catch it from another human, but I’m not sure that’s been scientifically verified; what is known is that it can be carried by the fleas that infest vermin and small animals, and be transmitted to humans by a bite. Quite often, when such animals die, the fleas jump off in search of a new host. They bite and make themselves at home, and pass on the disease as their housewarming party. The Black Death is rare but deadly; the last major outbreak is believed to have killed off one sixth of the population of Europe. Has the Black Death ever run rampant through Asia or Africa? I don’t know.

12. The Fevers ★★★★★

As a general rule, individual fevers can be survivable if you can keep the Fever symptom controlled. There are environments in which that’s tough, and there are some members of the fever family that are worse than others, so the general rule can only go so far.

13. Cancers ★★

I tend to think of Cancer as a disease that only really starts when we started using medicine to extend and improve human life. I now know that to be only partially true. Most cancers start off posing minimal direct threat of death but they can and will spread to other organs. Each time one does, add another star. They kill by interfering with key biological processes within the organ affected, which eventually shuts down (effectively) as more and more of it becomes cancerous, and by the accumulated systemic strain of coping with these messed up processes. Some cancers are more common than others, and there are a host of environmental triggers that were poorly recognized at first.

What truth there is in the above statement is enough to show that in a society in which Heal is the ‘routine’ treatment for serious illness, Cancer would escalate as a cause of death, because the effect would be the same as what we have achieved with technology – people live longer, and remain in better health for longer, until some systemic breakdown takes place.

Treatments tend to be invasive, the goal being to destroy or excise ALL the defective tissue. If surgery isn’t a thing in your society, you will be in big trouble. If it is available, you will still be in trouble.

The star rating is based on the relative availability of appropriate magical treatment using Heal. In a nutshell, under the proposed modifications to that spell, find one early enough and Heal will cure it. Once overt symptoms start showing up (usually when it grows to a three-star disease), it’s almost too late for Heal to be effective; the window would be very narrow, because it’s now on the verge of becoming a 4-star disease against which Heal isn’t enough – a Miracle might do the job, though.

Some people can survive for quite a long time with Cancer. Others seem to be taken within weeks or months. There are a huge number of variables and variations and no-one can predict the course of an individual case, only identify what has happened after the fact – though general predictions are usually safe if enough margin is allowed.

14. Blisters ★

I don’t know anyone who’s never had a blister. Repeated rubbing on the skin can cause them. Touching something too hot can cause them. Either way, some of the skin cells break down and release their contents into a bubble that causes the skin to swell. This is a nutrient-rich soup that can easily become infected. Avoiding that is as simple as preventing the blister from bursting; in just a day or two, the fluid will get absorbed back into the body and the swelling will subside as new skin begins to grow over the injury.

Even if a blister does become infected, it takes bad luck and neglect for it to become life-threatening. It’s a greater risk for the limb in question to become necrotic, i.e. start to die; in extreme cases, this secondary infection can pose a risk of death, but the limb is usually amputated before that can happen. Even that is an unlikely outcome, though.

15. Boils ★★

Boils are big, nasty sores, often (always?) full of pus, which are dead white blood cells, which are caused by an attempt to fight off an invading organism. Lance and clean the boil, and prevent a fresh infection from taking hold, and they can be quite survivable – but that prescription is often not available in a more primitive society. They can be quite sensitive, and there always seems to be some routine activity that triggers pain, whether that be sitting, or riding, or whatever.

It’s pretty rare for someone to catch boils from another sufferer; I have the impression that the causative agent is routinely present on human skin but rarely manages to find a way into a more vulnerable location. If correct, that would raise the “pretty rare” to “almost impossible”.

If the infection spreads to the body, it can cause a fever and more serious problems that are potentially fatal.

16. Chilblains ★

Damage to the blood vessels in the extremities (usually the feet) causing blood to leak, creating sensitivity, redness, swelling, and possible blisters. They most commonly occur when susceptible. individuals (especially women and children) are exposed to cold and humidity. Treatment is preventative, involving the wearing of gloves and warm footwear.

17. Scurvy ★★★

This is a Vitamin C deficiency, a fact that has been forgotten and rediscovered numerous times through history. Early symptoms of deficiency include weakness, feeling tired and sore arms and legs. Without treatment, decreased red blood cells, gum disease, changes to hair, and bleeding from the skin may occur. As scurvy worsens there can be poor wound healing, personality changes, and finally death from infection or bleeding. It takes at least a month of little to no vitamin C in the diet before symptoms occur. It was a limiting factor in long-distance sea travel, often killing large numbers of people; in the age of Sail, it was routinely assumed that half of the crew would be lost to the disease on any major trip.

The condition goes away with the reintroduction of Vitamin C into the diet.

18. Malnutrition ★★★

Malnutrition is the family name for a range of illnesses that result from a diet that is inadequate in one or more essential nutrients. The resulting conditions can be very complicated and difficult to diagnose. Malnutrition can kill quickly, especially in children, but is more frequently a slow and tortuous death. The good news is that this gives time to correct the problem..The treatment is simple – a good diet with the essential food groups represented. For most of history, though, that has been easier to say than come by.

19. Diabetes ★

Diabetes comes in two varieties, Type-I and Type-II, but they both mean that the body doesn’t process blood sugar properly. Type-I starts at birth and needs the blood sugar to be regulated with insulin; prior to the discovery of this medication, it could easily result in comas and death. Type-II results later in life and is more easily regulated. By itself, Type-II is rarely fatal, but the list of potential complications can seem never-ending, including loss of peripheral vision, amputation of limbs due to necrosis, slowed healing, and increased risk of heart failure.

20. Tonsillitis ★★

The tonsils are the body’s first line of defense against ingested or inhaled pathogens, but for a long time were considered to be of secondary importance as a protection. Because of this function, they can become inflamed or enlarged, and it was common practice from 50BC until the 1970s to surgically remove them when this happened in case they blocked the airway. It is still the second most-commonly performed outpatient surgery in the US for children. In somewhere between 1 in 2360 and 1 in 56000 cases, patients can die from complications, but the procedure is one of the safest surgical interventions. There is a level of controversy about the efficacy of the treatment in modern times; in essence, it is removing a bodily organ because it is doing its job. Medications to mitigate the swelling are now the preferred first-resort treatment of many surgeons.

21. Appendicitis ★★★★

The appendix used to be considered a vestigial organ that performed no useful function in the body, but that view has been challenged by modern research, which suggests that it may be a reservoir of useful gut bacteria, assists in the proper removal of waste material from the digestive system, and plays a role in training the immune system to recognize and respond to pathogens entering the body through the digestive system. Because these contributions to health were not recognized (and still are unconfirmed), it was routine practice to remove the appendix when Appendicitis occurred. Approximately 7.5% of people have appendicitis at some point in their lives.

This is inflammation of the appendix caused by an infection. It normally presents initially as poorly localized gut pain and may induce mild fevers, nausea, vomiting, digestive upsets of various kinds, decreased appetite, and abdominal bleeding. As the inflammation grows worse, the pain & sensitivity localizes on the right hand side of the stomach area and especially in McBurney’s point – however, it should be noted that 40% of cases do not experience typical symptoms. It used to be (relatively) routine to remove the appendix when it became inflamed because if it burst, it could and frequently did induce peritonitis (inflammation / infection of the abdominal wall), followed by shock, and, if untreated, death.

Studies in 2013 found that the Appendix had been lost to human anatomy and to have re-evolved at least six times, and possibly as many as 38 times. 32 separate evolutionary modifications to the organ have been identified genetically. Since the body has had ample opportunity to abandon a vestigial leftover, and it keeps coming back, the only explanation was that the organ had an unappreciated function or benefit to the overall organism. A more recent study produced different numbers but reconfirmed the fundamental principle. As a result, there has been significant effort expended in trying to find a non-surgical treatment for non-critical cases using intravenous antibiotics, with some success.

22. Peritonitis ★★★★★

I mentioned this illness above. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications can include shock and acute respiratory distress syndrome. Causes include perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, stomach ulcer, cirrhosis, or a ruptured appendix. Without treatment death may occur within 48 hours.

Without modern medicine, there is very little that can be done. Even now, if treatment is not sought promptly, it may be too late to prevent death. As a result, desperate measures may be undertaken with little hope of success in less advanced cultures.

23. Infections ★★★★★

The infection family sounds fairly mild and moderate at first glance – but that’s a perspective distorted by modern medicine. During the civil war, less than 200 years ago, any sort of cut or nick could become infected with lethal consequences. There were so many presenting with such wounds (or more serious ones) that physicians had little choice but to amputate such limbs on first suspicion of infection. If they didn’t proceed quickly enough, they might remove a foot only to have to re-amputate below the knee, then above the knee, then at the thigh – with increased risk to the patient at each step of the process. That’s how bad infections can be.

24. Malaria ★★★

I tossed up between making Malaria a three or four-star disease, and even now I’m not sure I made the right call. Like Yellow Fever, malaria is a tropical disease carried by mosquitoes. Symptoms that typically include fever, tiredness, vomiting, and headaches. In severe cases, it can cause yellow skin, seizures, coma, or death. Symptoms usually begin ten to fifteen days after being bitten by an infected mosquito. If not properly treated, people may have recurrences of the disease months later – and no treatment was known until 1640, and even then, it would have been incredibly rare in Europe (the bark of a tree from South America). In those who have recently survived an infection, reinfection usually causes milder symptoms. This partial resistance disappears over months to years if the person has no continuing exposure to malaria.

References to the unique periodic fevers of malaria are found throughout history. Hippocrates described periodic fevers, and the Roman, Columella, associated the disease with insects from swamps. Malaria may have contributed to the decline of the Roman Empire; it was so pervasive in Rome that it was known as the “Roman fever”.

25. Frostbite ★

Frostbite is a skin injury that occurs when exposed to extreme low temperatures, causing the freezing of the skin or other tissues, most commonly affecting the fingers, toes, nose, ears, cheeks and chin areas. The initial symptom is typically numbness. This may be followed by clumsiness with a white or bluish color to the skin. Swelling or blistering may occur following treatment. Frostbite is rarely directly fatal; instead, the dead tissue necrotizes and becomes infected when warmed, and it is this secondary infection that can kill. The treatments most commonly depicted in media involve rapid warming of potentially affected tissues, and/or rubbing of same; in reality, both are contra-indicated. A gentle warming is more common. In a world without antibiotics, this may not be an option. Fortunately, such a process accompanied by a low-level healing is probably enough.

Things become more serious if untreated. There are estimates that 40% of mountaineers experience frostbite every year; fortunately, they routinely utilize protective garments and the resulting injuries are slight.

Frostbite, like burns, is classified into four different grades, called degrees. First degree frostbite is superficial surface skin damage that is usually not permanent. Early on, the primary symptom is loss of feeling in the skin. In the affected areas, the skin is numb, and possibly swollen, with a reddened border. In the weeks after the injury, the skin’s surface may slough off, leaving pinkish scar tissue.

Second degree frostbite causes the skin to develop blisters quickly, and the skin’s surface hardens. In the weeks after injury, this hardened, blistered skin dries, blackens, and peels. Lasting cold sensitivity and numbness can develop.

Third degree frostbite occurs when the layers of tissue below the skin freeze. Symptoms include blood blisters and “blue-gray discoloration of the skin”. In the weeks afterwards, pain persists and a blackened crust (eschar) develops. There can be long-term ulceration (skin cracking and subdermal infection) and damage to bone structures.

Fourth degree is the most serious. Structures below the skin like muscles, tendon, and bone become frozen, and cell membranes can rupture from the cold, effectively killing the affected parts of the body. Early symptoms include a colorless appearance of the skin, a hard texture, and painless rewarming – the latter is a key warning sign. Later, the skin becomes black and mummified. The amount of permanent damage can a one month or more to determine. Autoamputation can occur after two months. If secondary infection occurs, it can kill before that takes place, so forcible amputation of digits or whole limbs may be necessary. Frostbite can be said to “creep” from the digits up the limbs, a progressively worsening condition.

Add one star for each degree of frostbite after the first, and one more if two or more limbs are affected at the same time.

26. Bites & Venom ★★★★★

Frostbite, is – of course – the Bite Of Winter. The cold is often pictured as a beast stalking the poor and infirm. Frostbite injuries often look like some savage animal has chewed away part of the affected digit or limb, especially in third and fourth degree cases. So it seems natural that in a less advanced society, Frostbite will be considered part of the family of Bites and Venoms.

It’s a fact that most media amplifies the dangers of the latter, in particular in terms of the speed with which they can kill something the size of a human. Where minutes are the common depiction, the reality can be hours or even days. Much depends on the quantity of venom delivered; the most dangerous creatures have sufficient reservoirs to inflict multiple bites, each potentially lethal in time. Other creatures have but one shot at a lethal outcome and are then relatively safe until more is excreted into the sacs which store the compounds.

Creature attitude is another significant factor. Some creatures will bite/sting you if they feel they must in order to protect themselves, but they would prefer to simply be elsewhere; others are naturally fearful of anything the size of a human, and – if not directly threatened – will usually put on a show and then depart. They will attack if cornered or startled, however. And then there are some creatures that are just plain ornery, as they might have said in the wild west. The Australian Brown snake is one such, at least by reputation – but at least they won’t chase after you if they try and bite. Cobras and the Australian Black Snake are more of the fearful kind, less prone to attack, but the Black is bad-tempered and will chase after you if it misses the first time or try to back away. Rattlesnakes seem to be somewhere in between – capable of lashing out if really threatened, but if they aren’t sure, they seem to have to work themselves up to it.

I will never forget the M*A*S*H episode in which a patient presents with a mystery malady that none of the medics can solve – until they postulate that a snake bit him in his sleeping back and then wriggled out, satisfied with its’ days work. Examination of the patient didn’t find the bite marks due to his other injuries, and of course, he was comatose and couldn’t answer questions. Heck, if there’s one thing that regular blood tests and flu vaccinations have taught me, it’s that if the tooth is sharp enough and small enough, you might not even feel the bite – if asleep.

Of course, venoms and poisons have a great variety of effects to consider. In addition to the neurotoxins, you have venoms that inhibit breathing, venoms that cause fevers, venoms that cause necrosis, and no doubt many more besides. Get creative!

27. Arthritis ★

Arthritis isn’t something that you can catch from someone else. It’s an inflammation of the joints, often accompanied by swelling. It can be extremely uncomfortable, and there’s no know cure, but it’s not lethal.

28. Gout ★

Gout is a type of Arthritis caused by consistently elevated levels of Uric Acid in the blood, and characterized by recurrent attacks of a red, tender, hot, and swollen joint. Pain typically comes on rapidly, reaching maximum intensity in less than 12 hours. The joint at the base of the big toe is affected in about half of cases. It can cause Kidney Stones or even more severe forms of Kidney Damage. At high levels, uric acid crystallizes and the crystals deposit in joints, tendons, and surrounding tissues, resulting in an attack of gout. Those who regularly drink beer or sugar-sweetened beverages, or who eat foods that are high in purines such as liver, shellfish, or anchovies, or are overweight, are most susceptible. to Gout. Perhaps the most famous sufferer was Henry VIII. Because of their rich diets, royalty was far more prone to suffering from gout than common folk, and for that reason, it was nicknamed “The Disease Of Kings”. Many attacks seem to take place at night.

While there are modern treatments, there was nothing effective against Gout for most of human history. While agonizing during an attack, and potentially mentally unbalancing over time, it is not directly fatal.

29. Lost Limbs ★

A lost limb whose stump has been properly cared for poses no direct threat to the health of the victim. What danger exists is the result of secondary infection. It should be noted that poorly-fitted prosthetics can cause blistering and infection in the same way that a shoe of the wrong size can do, opening the door to such infections. Improper cleaning of stumps can also provide a vector for infection.

30. Lost Organs ★ or ★★★ or ★★★★★

Lost organs are a lot more serious, especially in a world in which chemical / physical replacements aren’t possible. For one thing, the victim loses the function of the organ, and that alone can be fatal. For another, infection can easily result. At the low end, we have tonsillectomies and appendectomies, the loss of an eye or an ear, and the amputations of fingers and toes; in the middle, we have kidney damage and lung loss (they get downgraded in severity to this level because we have two of them) and the amputation of limbs; and the surgical repair of more critical organs; and at the extreme end, we have critical organs whose functioning is essential to the perpetuation of life. Livers, Hearts, Brains, and so on. Lose one of those, and you’re in trouble.

But in a world with magic, there may be other ways to sustain life. Losses in the first group are one-star; losses in the second are three stars; losses in the third, or the loss of both organs from the second (both kidneys, both lungs) are five-star events.

31. Allergies ★ to ★★★★

A family with no lesser members. There are literally thousands of things that you can be allergic to, and some people think that everyone has at least one of them (whether they know it or not, and however mild it may be). Once aniphylaxis is understood, and epipens invented, allergies are only lethal some of the time, even if they are of the more acute varieties. I have a serious allergy. Both my brothers have allergies, one mild and one more severe. Allergies are common.

Before the technology existed to treat allergic reactions, the risks entailed in accidental discovery were far higher. It could be honestly said that if an allergy didn’t kill you in childhood, you were reasonably safe from them – provided that you avoided the things you had survived in that early period of life. The ratings above presume, however, that you failed to do so – chowing down on clam chowder when you shouldn’t.

“What doesn’t kill you tells you what to avoid in future,” my brother once said.

32. Toothache ★

It’s fairly rare for a toothache to be fatal. Nevertheless, you can spark quite an intense debate by asking two GMs if a Healing Potion can repair damaged teeth or simply inhibit further decay for a time. I know at least one PC who used to gargle a CLW potion daily on the off-chance that it helped.

As is not unusual, the real dangers to life stem from secondary infections.

33. Headaches ★

There are lots of possible causes of headaches when you get down to specifics, but in the general sense, they are all about blood flow within the brain. It’s always struck me as a little strange that you can have headaches and yet the brain has no pain sensors, a fact exploited routinely during neurosurgery. To me, that suggests that there is at least this one case in which “it’s all in your head” might have a more literal, and accurate interpretation – that your brain receives news flashes of something wrong in the surrounding tissues and ‘interprets’ these as pain within the head.

Depending on the cause, headaches can be lethal, but that usually marks the headache as a symptom, not an event in its own right. Unfortunately, there’s no way to tell the two apart; all you know is that your head hurts. The usual response (absent some obvious potential cause) is therefore to provide some form of painkiller and see if the problem goes away on its own; if it doesn’t, people start looking for an underlying cause.

This entry refers to those specific cases in which time will do away with the headache. It may recur if it’s the result of a head wound, and there is some evidence that PTSD (or whatever the modern terminology is) can cause recurring headaches even without a past physical trauma.

34. Migraines ★★★

Migraines aren’t just intense headaches; those are the most ubiquitous symptom, that’s all. Typically, episodes affect one side of the head, are pulsating in nature, and last from a few hours to three days. Other symptoms can include nausea, vomiting, and sensitivity to light, sound, or smell. The pain is generally made worse by physical activity, although regular exercise may have prophylactic effects. Up to one-third of people affected experience ‘aura’ – typically a short period of visual disturbance that signals that the headache will soon occur Occasionally, aura can occur with little or no headache following, but not everyone has this symptom.

The causes are still not understood; the more research is done, the more complex the phenomenon seems to become, and it’s near certain that there are dozens of possible causes all being lumped together under a single umbrella term. It is known that cranial nerves and blood flow are involved, and that some medications are effective in some cases. Hormones are thought involved in some cases, as are stress and hormonal stress response.

Treatment usually consists of trialing one chemical after another until one is found that ‘clicks’. I first developed them at the age of 19 or 20, and went through 13 different medications until finding one that relieved the pain. During an episode, the pain would frequently bring me to tears and I was close to screaming on a number of occasions. Picture someone hitting your head with a hammer in the same spot over and over again, as hard as they could, while someone else kept stabbing at your forehead repeatedly, for 12-14 hours at a time – that’s what it felt like! Over time, I became aware of a sort of ‘tension’ in my head that preceded an episode, and learned that promptly taking the medication would in my case prevent the episode sometimes. At first, this happened perhaps one time in three; over time, that rose to nine times in ten. This year marks fifteen or sixteen years since my last episode – and a good thing, too, because that medication is no longer on the market; instead, it’s been bundled with caffeine to form what is supposedly a ‘more effective’ formulation, but one that exacerbated a sense of drunkenness on the few occasions when I had to use it. (One side benefit: a number of doctors and specialists have noted a high pain threshold. I put that down to having experienced migraines in my past).

Migraines aren’t usually lethal, but they have been known to drive victims to suicide. They can have a significant negative effect on employment and career prospects, which can contribute to depressed states of mind. The worst thing is that it can be physically painful to hear any noise louder than a whisper – making it extremely difficult for some people to seek help while at their lowest ebb. They can talk plenty when it no longer matters, though.

35. Epilepsy ★★★★★

Still in the general category of ‘things wrong with your head’, we come to Epilepsy – a group of neurological disorders characterized by recurrent seizures, episodes that can vary from brief and nearly undetectable periods to long periods of vigorous shaking and jerking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly (broken bones for example) or through causing accidents. In epilepsy, seizures have a tendency to recur and have no immediate recognizable underlying cause. It is known that brain injuries (including strokes) can sometimes cause the condition in someone who did not previously experience it. Seizures are controllable with medication in about 70% of cases. Not all cases of epilepsy are lifelong, and many people improve to the point that treatment is no longer needed.

The oldest medical records show that epilepsy has been affecting people at least since the beginning of recorded history. Throughout ancient history, the disease was thought to be a spiritual condition. In most cultures, persons with epilepsy have been stigmatized, shunned, or even imprisoned. As late as in the second half of the 20th century, in Tanzania and other parts of Africa epilepsy was associated with possession by evil spirits, witchcraft, or poisoning and was believed by many to be contagious. Before 1971 in the United Kingdom, epilepsy was considered grounds for the annulment of marriage. The stigma results in some people with epilepsy denying that they have ever had seizures.

People with epilepsy are at an increased risk of death. This increase is between 1.6 and 4.1 fold greater than that of the general population, and most pronounced in the elderly. Mortality is often related to the underlying cause of the seizures, status epilepticus, suicide, trauma, or Sudden Unexpected Death in EPilepsy (SUDEP) syndrome – the latter being a fancy label for a “we don’t know” from the medical community. It gets applied in cases of sudden, unexpected, non-traumatic, and non-drowning death of a person with epilepsy, without a toxicological or anatomical cause of death that can be detected during a postmortem examination. In other words, we’ve ruled out everything that we can think of.

36. Dementia ★★★

Another disease for which I struggled to allocate a correct star rating. Dementia is a cognitive disorder in which progressive impairments to memory, thinking, and behavior, occur. These negatively impact a person’s ability to function and carry out everyday activities. Aside from memory impairment and a disruption in thought patterns, the most common symptoms include emotional problems, difficulties with language, and decreased motivation. It’s common to think of Dementia as “profound confusion interspersed with moments of lucidity”. This is not an entirely accurate clinical picture but it’s good enough for game purposes. Many of the problems that arise with dementia patients relate to uncertainty as to the level of impairment from day-to-day, moment-to-moment. Someone can be completely clear and lucid one day, and enveloped in a mental fog the next; that fog can lift for seconds, minutes, or hours, seemingly at random. As such, it is very hard to consider any decision taken to have been made in a lucid state; there is an inherent tendency to treat the individual as though they were at their worst all the time, even when knowing better. Dementia is considered primarily a disease of the elderly.

Alzheimer’s and Parkinson’s are now considered to be subtypes of Dementia.

There is no cure, and – in science – little prospect of one, at least in the near future. The condition can be managed somewhat and progression slowed, and that’s about it.

Dementia can be fatal when a sufferer forgets that they need to eat, and so does not, or other extreme manifestations of the illness.

39. Muscle Strains & Tears ★

A strain is an acute or chronic soft tissue injury that occurs to a muscle, tendon, or both. The equivalent injury to a ligament is a sprain. The muscle or tendon overstretches and partially tears under more physical stress than it can withstand, often from a sudden increase in duration, intensity, or frequency of an activity. Strains most commonly occur in the foot, leg, or back.

Muscle strains are generally not directly fatal and are temporary in nature. However, they can cause a permanent weakness that allows repeated and progressive injury to the muscle or tendon. Typically, once a muscle strain occurs, it is more likely that the muscle in question will experience a future strain with less provocation and greater severity. It is possible to minimize this progression but it usually takes considerably longer and substantially greater effort than simply recovering to the prior state of fitness. It has been shown that ‘warming up’ (i.e. an intermediate level of activity in preparation for exertion) greatly diminishes the risk of a muscle strain.

40. Back Strain ★

Back strain is the injury occurring to muscles or tendons in which those tendons and muscles that support the spine are twisted or pulled. Chronic back strain occurs because of the sustained trauma and wearing out of the back muscles. Acute back strain can occur following a single instance of over stressing of back muscles, as in lifting a heavy object. Chronic back strain is more common than the acute type.

Spinal problems involving trapped nerves can force the back muscles to attempt to provide the entirety of the support normally deriving from the spine; this effectively results in a chronic back strain with the potential for acute manifestations. It is as though the back is taken to the limits of its capacity by the normal everyday tasks involved, making it more susceptible. to acute strains when called upon to perform some additional task. It is normal for such injuries to be only somewhat predictable, and to be chaotic in the mathematical sense, i.e. sensitive to very small changes in input conditions that make the impact of any given task unpredictable. Over time, sufferers tend to learn the warning signs that they are approaching their limits and find ways to avoid exceeding them. The longer that they can go without triggering an acute episode, the greater their capacity for short-term bursts of activity as core strength grows in excess of the daily requirements. Life is thus a balancing act of managing the potential for Acute injuries while performing the necessary tasks for daily life.

Back strains are not directly fatal, though they can leave sufferers crippled, slow-moving, and unable to exert themselves.

41. Cardiac Problems ★★★★★

The ultimate muscular problem lies in the ultimate muscle, the heart. Anything that goes wrong with this organ is potentially fatal. There are a wide range of possible injuries and failures possible – everything from heart valve failures to cross-chamber leaks to blocked arteries to muscle strains after extreme exertion to electrical or rhythmic problems. Small problems have a tendency to progressively become larger and more life-threatening; for example, a stroke may disrupt the electrical signals that regulate the heartbeat, causing part of the muscle to die, permanently reducing the heart’s capacity to pump blood and leaving it more susceptible. to blockages that it could previously have endured (probably with discomfort).

42. Blindness ★

I’ve talked elsewhere about the loss of eyes, so this refers to the situation where the eyes are present but just don’t work properly any more. Astigmatism, Cataracts, Retinal damage, Optic Nerve damage, or even damage to the brain can be responsible. There is a technical difference between legally blind and completely sightless that may be relevant in some circumstances. Blindness is not usually directly fatal, though the cause of the blindness may be lethal. Death is more commonly the result of some form of increased helplessness because of the blindness, though the human capacity to cope with this disability (especially with the support of a trained seeing-eye dog and modern technology) is remarkable.

43. Deafness ★

Pretty much as per Blindness; we’re talking about a different sense, is all.

44. Polio ★★★★

This was an afterthought, and probably should not have been so. Polio is an infectious disease caused by the polio-virus. In about 0.5 percent of cases, it moves from the gut to affect the central nervous system and there is muscle weakness resulting in a flaccid paralysis. This can occur over a few hours to a few days. The weakness most often involves the legs, but may less commonly involve the muscles of the head, neck and diaphragm. Many people fully recover. In those with muscle weakness, about 2 to 5 percent of children and 15 to 30 percent of adults die. Up to 70 percent of those infected have no symptoms. Another 25 percent of people have minor symptoms such as fever and a sore throat, and up to 5 percent have headache, neck stiffness and pains in the arms and legs. These people are usually back to normal within one or two weeks. Years after recovery, post-polio syndrome may occur, with a slow development of muscle weakness similar to that which the person had during the initial infection.

Those who are infected may spread the disease for up to six weeks even if no symptoms are present. In cases of spinal polio, if the affected nerve cells are completely destroyed, paralysis will be permanent; cells that are not destroyed, but lose function temporarily, may recover within four to six weeks after onset. Half the patients with spinal polio recover fully; one-quarter recover with mild disability, and the remaining quarter are left with severe disability. Spinal Polio is rarely fatal.

Without respiratory support, consequences of poliomyelitis with respiratory involvement include suffocation or pneumonia from aspiration of secretions. Overall, 5 to 10 percent of patients with paralytic polio die due to the paralysis of muscles used for breathing, up to 30 per cent in the case of adults.

45. Taboo Diseases ★★★★★

I looked hard for a nice euphemism to describe these diseases! Most of them are controllable or curable using modern antibiotics, though resistant strains are an increasing global concern. Probably the worst of the Taboo Diseases is Syphilis, which can literally rot the brain of sufferers. In any pre-20th century environment, most of these STDs can kill.

Of concern is the fact that some of these diseases can be spread by means other than promiscuity, even though this is relatively rare. Even abstinence is not a complete protection.

In most cases, it will be inappropriate to designate specific Healing spells for this type of disease; they are better left as a disease family, even though most members of that family have nothing other than the common means of transmission in common.

Disgustingly Healthy vs the Cough And Wheeze

The end at last! I started by asking the question, “Is healing too accessible in D&D” (and in other RPGs). The answer is clearly a “Yes, some of the time, and in some campaigns”. If you have good reason to want everyone in your campaign to be a Captain America knockoff, then widespread Healing is probably your best shot at achieving that. But be sure you can live without all the things that you are giving up.

If the words “Grim” or “Gritty” or “Realistic” are to be commonplace in the way you think about your environments, even if you don’t choose those terms all the time so as to avoid overuse, then the answer is a yes. Prepare your list of diseases. Add some more of your own creation. Add some that only affect Elves or Dwarves or whatever. Add a few that started off that way but have now jumped species. Think about the social impacts of the diseases in your campaign, and the economic consequences of both the diseases and whatever level of healing ubiquity you consider appropriate.

There is nothing wrong with either choice. Blind choices, on the other hand, are problematic at worst and sources of vulnerability at best. So think carefully about the Disgustingly Healthy, the Cough, and the Wheeze.

985… 986…

I’m still looking for ideas on how to commemorate my 1000th post at Campaign Mastery. Fourteen to go!