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
Essence of Rosemary
Mash of Nettles
Drink a concoction of essence of rosemary and bitter cascara to cause flushing and realistic ill appearance
Apply mash of nettles over the area of skin where the characteristic rash of smallpox is desired
Drink a small vial or rose madder to mimic blood in the urine
Prepare to be quarantined!
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
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.
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
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.
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.
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.
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.
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.
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:
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:
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.
Murtagh has found diversion and finally something to like about Paris.
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.
Master Raymond notes the irony in Claire seeking a contraceptive for her maid rather than the other way around, and suggests Mugwort.
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.
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.
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.
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!
What was ailing poor Arthur Duncan, who always seemed so uncomfortable?
Claire and Geillis are unceremoniously dropped into the thieves’ hole where they have a bit of time to bond as they await their fate. Claire confronts Geillis about Arthur’s death and Geilis admits that she did poison him with cyanide but only after trying for months to kill him with arsenic!
Indeed, Arthur appears ill every time we see him, suffering from various stomach ailments and discomfort. Even Claire was stumped as to what may have been causing his trouble.
The symptoms were rather puzzling; not like ulcer, I thought, nor cancer- not with that much flesh still on his bones- perhaps just chronic gastritis, as Geilie insisted.
From Outlander by Diana Gabaldon, Chapter 24
But now it is all so clear. Arthur has been suffering the effects of chronic arsenic poisoning all these months.
Arsenic is ubiquitous in the environment, found in ground water most commonly, and also a byproduct of mining and smelting metals. It has been used medicinally for over 2400 years in traditional Chinese medicine and also used to treat syphilis in the western world before the development of penicillin. In the Elizabethan era, women used a mixture of vinegar, chalk and arsenic which they applied to their faces in hopes of preventing aging and creasing of the skin. Arsenic is an ingredient in green pigments used to color most anything – wall paper, textiles, paint.
Arsenic has been a favored poison throughout history. Tasteless and odorless, it was an easy choice. It is particularly known to have been used by the Borgias in Italy and is also thought to have been responsible for the death of Napoleon Bonaparte. In the 19th century, arsenic was dubbed “inheritance powder” because it was suspected that many impatient heirs ensured or accelerated their inheritance by means of poisoning with arsenic.
The most toxic form, white arsenic, or arsenic trioxide, is of course what Geillis chose.
Arsenic poisoning is due to ingestion most often, but also occurs via absorption through the skin and by inhalation. Arsenic is readily taken up by the red blood cells and distributed throughout the body, and is particularly toxic to the gastrointestinal system, kidneys, bone marrow, skin and nervous system.
White arsenic binds to and interferes with numerous enzymes in the cells of the body, wrecking havoc on normal cell function.
Symptoms after acute poisoning develop in minutes to hours and generally begin in the gastrointestinal system causing nausea, vomiting, abdominal pain and severe watery diarrhea. It can cause a garlic odor on the breath and in the stool. Severe poisoning leads to abnormal heart rhythm, shock, acute respiratory distress and death.
What Arthur suffered, however, is chronic toxicity – long term exposure of lower levels of arsenic. The symptoms come on more slowly but still have significant consequences. Chronic exposure leads to abdominal pain, nausea and diarrhea as well, but also skin lesions, peripheral neuropathy (numbness and tingling, then intense burning pain to the hands and feet), cancer of the skin, bladder, lungs and liver, type 2 diabetes, and respiratory problems.
We’ve witnessed Arthur suffering with abdominal distress just about every time we’ve seen him. He’s been treated with peppermint by Geillis and fennel from Claire for his discomfort. These provide temporary relief but won’t cure him.
But alas, when that doesn’t do poor Arthur in, Geillis employs another technique and Arthur meets his end by cyanide poisoning.
Ah, Geillis, we wanted so much to like you, what with the fabulous red shoes and talk of BBQs…
By the light of the full moon and clearly in her element, Geillis Duncan reveals to Claire that she loves Dougal MacKenzie and is pregnant with his child. Maura MacKenzie, wife of the war chief has conveniently and suddenly died, leaving only Arthur Duncan in the way of these star-crossed lovers, or so it seems.
The Duke of Sandringham has arrived at Leoch to take counsel with the Laird and hopefully to be of some help to Jamie in securing a pardon from the murder charges he faces. A banquet is held in his honor and all associated with the clan enjoy the lavish feast.
The Laird of the MacKenzie offers a toast to his longtime friend and ally, His Grace, the Duke of Sandringham. Everyone drinks, the food is passed, and merriment ensues.
Arthur Duncan suddenly stands, coughing and apparently choking. His hands grasp at his throat and he collapses to the ground. Claire rushes to his side to help but quickly it becomes clear that he cannot be saved. She smells bitter almond and recognizes the scent as that of cyanide. Arthur Duncan has been poisoned.
Knowledge of the poison cyanide may date back as far as ancient Egypt, as “death by peach” has been translated from Egyptian hieroglyphics. In more modern history, cyanide was used by the Nazis in extermination camps and later ingested by the Nazi leaders themselves as they committed suicide as the Russian forces approached in 1945. The mass suicide of 912 cult members in Jonestown in 1978 was due to a cyanide-laced kool-aid type drink. Saddam Hussein included cynanide among the chemical weapons used against the Kurds in the 1980s. The still unsolved mystery of cyanide poisoning in Chicago in the 1980s in which random containers of the medication were spiked with cyanide led to the universal tamper resistant packaging we now have in over the counter medications.
Cyanide is simply a carbon atom bound to a nitrogen atom and is a very potent poison, found in many foods and manufactured items. It is found in the pits and seeds of bitter almond, cherry laurel, apricot, plum, pear, peach and apple as well as in cassava root, bamboo and soy. Some species of centipedes, millipedes, beetles, moths and butterflies synthesize and excrete cyanide for defensive purposes. When burned, wool, silk, polyurethane and plastics like cyanoacrylate (superglue) emit cynaide gas. It has even been used as an insecticide and to fumigate ships and buildings. The major source of cyanide poisoning now is smoke inhalation from residential or industrial fires in which cyanide is released as plastics and textiles burn.
Cyanide exposure can occur by inhalation, ingestion or even absorption through the skin. It then enters the blood stream and is distributed rapidly throughout the body. Cyanide irreversibly binds to and inactivates energy pathways in the cells, leaving them unable to absorb oxygen or produce energy, resulting in cell death. The cells are in effect suffocating, unable to use the plentiful oxygen available. The heart and brain are especially dependent on the body’s oxygen supply and the effects on these organs is particularly deleterious.
Within minutes, the victim of cyanide poisoning will begin to experience symptoms: Headache, anxiety and confusion will progress to seizure and coma. An initially elevated heart rate and blood pressure will progress to severely low heart rate and blood pressure, heart block and cardiac arrest. Pulmonary edema, or accumulation of fluid in the lungs will cause coughing of frothy sputum and progress to respiratory failure. Vomiting, kidney failure and liver failure occur. Death occurs in minutes, depending on the dose.
Antidotes for cyanide poisoning are available. Those patients who receive a dose of cyanide that is not immediately fatal and receive prompt medical care can be treated with medication that binds the cyanide in the blood an allows it to be eliminated via the urinary system. However, cyanide is so quickly acting that those who receive a fatal dose will almost always die before they can reach medical care and receive such an antidote.
This beautiful title card promises an episode about medicine!
The medicine bottle reads “ELIX: PECTOR: WED.” I found on the Smithsonian Institute website’s online collection a very similar bottle, labeled “ELIX PECTORAL WED” which dates from the 18th century and would have held Wedel’s Pectoral Elixir, made by Georg Wolfgang Wedel (1645-1721) for chest ailments. This medicine consisted of benzoic acid, ground irises, sugar, fennel oil and sulphur for the treatment of cough and congestion. I love the attention to detail both in this series of books and the show!
Claire spends time exploring the surgery and all of the tools and medicines Davey Beaton has left behind.
Among them are slaters which, it turns out, are live wood lice.
Apparently, in the past these have been thought to be medicinal and helpful for digestive ailments when swallowed whole. No, thank you!
Claire busies herself, caring for the residents of Leoch. Here, she fashions a splint for an injured wrist.
She is summoned to Colum’s chamber where he tells her that Davey Beaton used to massage him to ease his pain and make movement easier. He hopes Claire will do the same for him.
Indeed this is likely very helpful to Colum in easing his pain, stretch sore or atrophied muscles and reduce muscle spasms.
Claire later visits Geillis Duncan’s home to stock up on medicines she may need when the clan has gathered at Leoch, in particular white willow bark for whiskey headaches! Aspirin, even its earliest forms, has a long history with hangovers!
Claire witnesses a crowd surrounding the tanner’s lad who has been accused of stealing two bannocks. Geillis Duncan’s husband, Arthur, is the procurator fiscal for the district and must determine the boys fate.
Arthur Duncan seems to suffer perhaps from both indigestion or acid reflux as well as quite a bit of flatulence. He asks Geillis for peppermint to help. Peppermint has been used medicinally for over 10,000 years and is often used for digestive problems. It has anti-inflammatory and antispasmodic properties and also is a cholagogue (promotes discharge of bile from the biliary tract). We don’t yet know what ails Mr. Duncan (though readers of the book know we soon will), but the peppermint seems to do the trick for him and he leaves in better spirits, much to the benefit of the tanner’s lad who will get to keep his hand today. Instead, he will be sentenced to “one hour in the pillory and one ear nailed.”
The poor tanner’s lad. In addition to the risk of bacterial infection of his wound and obvious lasting deformity, this (hopefully rust free) nail through his ear puts him at risk for tetanus.
Tetanus is a life-threatening disease caused by the bacteria Clostridium tetani. The spores of this organism can survive in soil or on surfaces for years. Most cases follow an injury such as puncture wound, laceration or abrasion, particularly from a rusted nail or similar object. Infection occurs at the site of injury and an exotoxin produced by C. tetani, called tetanospasmin, spreads to the nervous system causing muscle rigidity, violent muscle contractions and instability of the autonomic nervous system. Difficulty swallowing, difficulty breathing, heart abnormalities and even sudden cardiac arrest can occur. Patients will suffer from stiffness and pain in the masseter muscles of the face responsible for chewing, resulting in lockjaw, the common name for tetanus. Symptoms begin in the face and progress downward.
Tetanus is almost completely avoidable with vaccination. Vaccination for tetanus began in the US in the 1940s, when there were approximately 580 cases of tetanus reported in the US and 472 deaths. Most recent data shows this has decreased significantly to 41 cases and 4 deaths in the 2000s.
Modern day treatment of tetanus includes administration of tetanus immune globulin to neutralize the tetanospasmin toxin, muscle relaxants, temporary induced coma if needed and medications to mitigate the effects of the autonomic nervous system dysfunction. Mortality of tetanus is around 10-20 percent. Of the cases reported in the US, about 90 percent had not received appropriate tetanus vaccination and indeed this disease primarily affects non-vaccinated and under-vaccinated people. Remember to get your tetanus booster every 10 years!
Throughout the course of this episode, Claire has been learning that the son of Colum’s chambermaid has died after visiting the Black Kirk. His friend, Tammas Baxter, who visited the kirk with him is possessed by the devil and near death.
Claire, of course, suspects otherwise.
She visits the boy and notes he has no fever and likely does not suffer from an infection. Rather, she notes that his heart rate is slow and his pupils are constricted to pinpoints and she suspects poisoning.
Jamie accompanies her to the Black Kirk where her fears are confirmed. Jamie explains that the boys who visit the kirk to prove their manhood often eat berries and wood garlic there. Wood garlic is an edible plant related to chives.
Except it isn’t wood garlic. It is lily of the valley.
Lily of the valley is a highly poisonous plant that contains cardiac glycosides. These chemicals act by inhibiting cellular function leading to dangerously elevated potassium levels, slowing of the heart rate and potentially fatal abnormal heart rhythms, as well as nausea, vomiting, diarrhea, abdominal pain and confusion.
Claire has identified the poison and now has to figure out a way to counteract the effect of the poison using the tools and medicine she has at her disposal in the 18th century.
The cardiac glycosides of lily of the valley are very closely related to the modern day medicine digoxin. Digoxin is used to treat patients with heart conditions like atrial fibrillation, where it controls ventricular rate and in heart failure in which it can increase contractility of the heart. If a child like this young boy presented today with cardiac glycoside poisoning, either from consuming plants like lily of the valley or oleander or from ingesting digoxin, digoxin-specific antibodies would be administered. These would bind to the cardiac glycosides circulating in his body and they would be excreted from his body via the kidneys.
However, this wouldn’t be on Claire’s radar as they were not developed until later in the 20th century.
She must figure out a way to counteract the effects of lily of the valley, in particular his slow heart rate, and our brilliant heroine recalls that another toxic plant, deadly nightshade or belladonna, contains atropine as an active component. She knows that atropine will act to increase the heart rate. Belladonna in this case will potentially act to counteract the slowed heart rate which can be fatal to our patient Tammas. The hope would be that she can mitigate the dangerous effects of the poison until the boy’s body has metabolized and excreted it.
This is risky business, though, as Claire points out. “…but if I was wrong about the dosage or the original poison, it will cause convulsions and kill the boy just as quickly.” Indeed belladonna is a poison in its own right. She has no way of knowing the quantity of active medication she is administering and she is taking a big gamble, but it appears the boy will die without her intervention and it is a risk that proves successful in the end.
She administers a concoction of belladonna to the boy and within minutes he is awake and talking and recovering. A miracle!
Claire hopes that this has garnered favor with the brothers MacKenzie and will persuade them to allow her to travel to Inverness. Jamie, however, informs her that Colum is taking credit for bringing Claire and her gift of healing to the MacKenzies and likely won’t want to see her leave any time soon.
Yet Claire is determined to get back to the stones and to frank. Or die trying. And we know our girl is stubborn, resourceful and not averse to big risks…
Resources: http://americanhistory.si.edu/collections/search/object/nmah_993857 Adams, C. (2014). Herbal Medicine: 100 Key Herbs With All Their Uses As Herbal Remedies for Health and Healing. CreateSpace. Fauci, AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL. (Eds.). (1998). Harrison’s Principles of Internal Medicine (14th ed.). New York, NY: McGraw-Hill. Roush, SW, Murphy TV and the Vaccine-Preventable Disease Table Working Group. Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States. JAMA. 2007;298(18)2155-2163. Tintinalli, JE, Kelen, GD, Stapczynski, JS. (2000). Emergency Medicine A Comprehensive Study Guide (5th ed.). New York, NY: McGraw-Hill.