206: The Fraser Family Recipe for Faking Smallpox

Episode 206:  Best Laid Schemes…

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Need to feign illness with smallpox?  Want to impress your friends, alarm the local harbormasters, and make a bonny prince squirm?  The Frasers have you covered!

The Fraser Family Recipe for Faux Smallpox

Ingredients:

  • Essence of Rosemary
  • Bitter Cascara
  • Mash of Nettles
  • Rose Madder

Method:

  1. Drink a concoction of essence of rosemary and bitter cascara to cause flushing and realistic ill appearance
  2. Apply mash of nettles over the area of skin where the characteristic rash of smallpox is desired
  3. Drink a small vial or rose madder to mimic blood in the urine
  4. Prepare to be quarantined!
a family that schemes together
A family that schemes together…

 

Essence of Rosemary

In Dragonfly in Amber, rosemary was used to cause redness or flushing of the skin to mimic the fever of smallpox.  Rosemary is thought to increase blood flow, though topical application rather than ingestion of rosemary may produce more redness.  Other uses of rosemary include the treatment of stomach upset and flatulence, gout, cough, headache and high blood pressure.  If its mechanism for treating elevated blood pressure is via dilation of the blood vessels, such dilation of the small capillaries may explain a mechanism for flushing and redness to mimic how one might look while febrile.

I handed him the second bottle, this one of green glass filled with a purplish-black liquor. “This is concentrated essence of rosemary leaves. This one acts faster. Drink about one-quarter of the bottle half an hour before you mean to show yourself; you should start flushing within half an hour. It wears off quickly, so you’ll need to take more when you can manage inconspicuously.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Bitter Cascara

Cascara seems to be a popular choice with Claire and Master Raymond!  Hopefully he keeps it well stocked in the apothecary!  In Dragonfly in Amber, the use of cascara had been discussed but decided to be too harsh.

The plan took several days of discussion and research to refine, but was at last settled.  Cascara to cause flux had been rejected as being too debilitating in action.  However, I’d found some good substitutes in one of the herbals Master Raymond had lent me.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

However, the cramping and abdominal pain will make for a realistic picture of an ill patient and as we see, Jamie had immediate symptoms just as Claire did when she drank cascara-laced wine.

 

Nettles

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Stinging nettle / source

There is a reason that the medical term for hives, urticaria, comes from the Latin urtica, the word for nettle!  Also known as Utica dioica, the nettle plant is native to Europe, Asia, northern Africa and western North America.  It grows to a height of 3-7 ft tall and has stinging hairs (trichomes) along its leaves and stems which, when touched, transform into needles that can inject several chemicals including histamine, formic acid and leukotrienes.  This causes a painful stinging sensation to the victim and a characteristic rash with red itchy wheals and itchy white bumps.

His fair skin had flushed dark red within minutes, and then settle juice raised immediate blisters that could easily be mistaken for those of pox by a ship’s doctor or a panicked captain.

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

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Rash from stinging nettle / source

 

Rose Madder

The root of the madder plant has been used throughout history as a source for red dye.  Medicinally, it has been used for preventing and disintegrating kidney stones.  When taken orally, it causes red colored urine, saliva, perspiration and breast milk.

Rubia_tinctorum_-_Köhler–s_Medizinal-Pflanzen-123
Rubia tinctorum with its red colored root / source

A rare and severe form of smallpox, hemorrhagic smallpox, or the “bloody pox”, causes active bleeding in the gastrointestinal tract as well as blood in the urine.  The appearance of blood in the urine would be particularly alarming for those familiar with smallpox!

And should any doubt remain, the madder-stained urine gave an absolutely perfect illusion of a man pissing blood as the smallpox attacked his kidneys.

“Christ!” Jamie had exclaimed, startled despite himself at the first demonstration of the herb’s efficacy.
“Oh, jolly good!” I said, peering over his shoulder at the white porcelain chamber pot and its crimson contents. “That’s better than I expected.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 23

 

Jolly good work, indeed, Frasers! And well executed by wee Fergus!

 

Questions, comments, concerns, or suggestions for future Outlander medicine topics?  I’d love to hear from you!  Leave a comment here or find me on twitter @SassenachDoctor.

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204: The Bonesetter

204: La Dame Blanche

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STARZ

The image in the title sequence of a nail hammered into a leg has made many fans squeamish and curious for 3 episodes now.  Tonight we finally meet the poor owner of that leg.

title sequence nail
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In classic Claire style, despite of the dinner plans for the evening in which the “who’s who” of Jacobite France will be hosted at Chateau Fraser, Claire rushes to L’Hopital to help following news of an explosion at the armory. She assists Monsieur Forez in treating a man with a significant injury to his leg – an open fracture to the tibia is shown.

open tibia fx
STARZ

It seems that despite his primary job as executioner, Monsieur Forez is an empathetic healer who has employed a technique to minimize the pain of reducing an open leg fracture.

As we’ve seen already in Outlander, with Jamie’s dislocated shoulder and the leg amputation in the tavern, anesthestic options of the day were mostly limited to whisky, laudanum and a strong stick to bite. Monsieur Forez, however, presents an additional option.

He reached into his capacious pocket one more, this time coming out with a small brass pin, some three inches in length, with a wide, flat head. One bony, thick-jointed hand tenderly explored the inside of the patient’s thigh near the groin, following the thin blue line of a large vein beneath the skin. The groping fingers hesitated, paused, palpated in a small circle, then settled on a point. Digging a sharp forefinger into the skin as though to mark his place, Monsieur Forez brought the point of the brass pin to bear in the same place. Another quick reach into the pocket of marvels produced a small brass hammer, with which he drove the pin straight into the leg with one blow.

The leg twitched violently, then seemed to relax into limpness.

From Dragonfly in Amber by Diana Gabaldon, Chapter 14.

Monsieur Forez has performed what may be considered the 18th century version of a nerve block! He has injured the femoral nerve, causing the (hopefully) temporary interference of transmission of signal along that nerve.

Nerve blocks are widely used today, and probably the most familiar is at the dentist’s office when a portion of the mouth is temporarily numbed and part of the face paralyzed by the injection of local anesthetics (lidocaine, bupivacaine, etc.) to block the nerve to that respective area. Other common applications of nerve blocks:  repair of lacerations, spinal anesthesia for surgeries, nerve blocks in the upper and lower extremities for surgery, nerve blocks to help control chronic pain.

In Dragonfly in Amber, Claire’s patient has a fracture of the femur in the thigh as well as the tibia in the lower leg.  She describes a block of the femoral nerve – piercing the femoral nerve in the front of the upper thigh near the groin.  This block primarily was for the femur fracture – it provided anesthesia to the front of the leg where the bone protruded from the thigh and additionally, made the reduction of the fracture (or realignment of the bones by Monsieur Forez) easier by temporarily paralyzing the strong muscles of the thigh that would be forcefully contracting in response to the trauma, allowing him to more easily maneuver the bones into anatomical position.

The image below shows the areas of the leg numbed by the femoral nerve block.  All of the colored areas of the front of the leg as shown below are numbed:

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Source:  NYSORA.com

Claire’s patient in Dragonfly in Amber suffered different injuries from our patient in the Starz adaptation:

The leg, though, was something else;  an impressive double compound fracture, involving both the mid-femur and the tibia.  Sharp bone fragments protruded through the skin of both thigh and shin, and the lacerated flesh was blue with traumatic bruising over most of the upper aspect of the leg.

From Dragonfly in Amber by Diana Gabaldon, Chapter 14.

Instead, in episode 204, Claire and Monsieur Forez are dealing with only a lower leg fracture – an open fracture of the tibia and possibly the fibula as well.  Monsieur Forez performs a nerve block just below the knee on the medial (inner) side of the lower leg.  It would appear he has performed a saphenous nerve block with a below the knee approach.  This would result in numbing of the lower leg on the medial (inner) side.

Same image, but with this saphenous nerve block, only the blue-gray colored area on the lower leg labeled saphenous n. would be numb:

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Source:  NYSORA.com
lower leg wound wide
STARZ

 

The nerve block made a lot of sense in the book for dealing with a femur fracture as it provided anesthesia to the front of the leg in the area of the thigh with broken bone protruding.  Additionally, paralysis of the strong thigh muscles helped facilitate the reduction (realignment) of the fractured bone.  For the lower leg fracture in the show, the nerve block performed to just the lower leg may have provided some pain relief but wouldn’t have been quite the game changer of the femoral block in a femur fracture.

 

Some other medical musings on this episode:

thigh bite again
This scene suggests that Jamie has obtained these bite marks just prior to returning home to her.  While I appreciate a good look at Jamie’s thighs as much as the next girl, I’m wondering about the timing of these bites.  The yellowish discoloration around the bite suggests they are at least a few days old.  Perhaps he has numerous bites, in varying stages of healing.  Further examination of those thighs must be in order…/ STARZ

 

monkey bite
As it turns out, “brunette whores” are not the only Parisians with a biting fetish this week.  Bonny Prince Charlie should be careful – monkey bites can transmit herpes and rabies! / STARZ

 

claire doesnt feel so good
Claire accepts a glass of wine from a servant at Versailles, takes a drink and immediately doubles over in pain.  As we learned from Mater Raymond in episode 203, cascara is a good “faux” poison, causing severe symptoms that later resolve spontaneously without lasting effects.  In therapeutic doses for the treatment of constipation, cascara acts in 6-8 hours.  Now, Claire has received a dose larger than normal in order to produce these severe symptoms, but still the symptoms would not have come on instantaneously.  Perhaps she was dosed in an earlier glass of wine that day and now it is beginning to take effect. /  STARZ

 

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Yes, Mary.  PLEASE go wash your hands.  Hangman’s grease.  (shudder) / STARZ

 

203 (part deux): A Useful Deception

Murtagh has found diversion and finally something to like about Paris.

happy murtagh
Happy, happy Murtagh! / STARZ

Murtagh’s new situation benefits many, as no doubt Claire is grateful for any excuse to occupy herself with a visit to Master Raymond once more, this time in search of a contraceptive for Suzette.

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STARZ

Master Raymond notes the irony in Claire seeking a contraceptive for her maid rather than the other way around, and suggests Mugwort.

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Mugwort / source

A member of the daisy family, Mugwort is said to derive its name from its use in flavoring beer and other beverages one might drink from a mug. Others theorize its name originates from moughte (a moth or maggot) as it was also used as an insect repellent. Medicinally, it has been used for gastrointestinal problems like colic, diarrhea and constipation. It has historically been used to stimulate women’s menstrual cycle and was used in the past to induce abortions.

As Claire browses the store, she is very alarmed as she pulls from the shelf a jar labeled “Aconitum napellus” or Monkshood.

poison bottle with text
Aconitum napellus / STARZ

Monkshood is a strong, fast-acting poison that affects the heart and nervous system, causing nausea, vomiting, dizziness, muscle spasms, hypothermia, paralysis of the respiratory muscles and heart rhythm disorders. It is so toxic that poisoning has occurred following picking leaves of the plant without wearing gloves. It has been used as arrow poison, including for hunting whales among the indigenous people of Alaska.

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Monkshood / source

Master Raymond assures Claire he does not actually dispense Monkshood to his customers, but often provides them with bitter cascara when they are seeking to poison a foe.

Bitter in taste, the aged, dried bark of cascara stimulates the large intestine and has a laxative effect.  In larger doses it causes severe diarrhea, a well as abdominal discomfort and cramping.  It was available over the counter in the US as a treatment for constipation until it was banned in 2002 over safety concerns.

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Cascara / source

Master Raymond sells this to unknowing customers as a “fake” poison – while long term use can lead to electrolyte abnormalities due to continued fluid loss by diarrhea, short term use will result in diarrhea and abdominal pain, but this will only be temporary.

“Yes, that’s right, cascara.  The rival will fall sick tomorrow, suffer visibly in order to satisfy the Vicomtesse’s desire for revenge and convince her that her purchase was a good one, and then she will recover, with no permanent harm done, and the Vicomtesse will attribute the recovery to the intervention of the priest or a counter spell done by a sorcerer employed by the victim.”

From Dragonfly in Amber by Diana Gabaldon, Chapter 8.

Useful occupations and deceptions, indeed, wise Master Raymond!

Hmm, if the parritch doesn’t do the trick, Master Raymond may have another customer for that bitter cascara!

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