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Fun Fact: Consumption

Anatomy Def: Consumption is a progressive wasting away of the body, particularly from pulmonary tuberculosis.

Outlander Def: Sad demise of Mary Hawkins true love, Alexander Randall; age 30 – brother of Captain Black Jack Randall!

History: Back in the 1700s, the disease now recognized as tuberculosis was identified by the odd term, consumption. It was named consumption because the disease literally consumed the sufferer; health was ravaged, tissues lost (weight loss), and the patient wasted away.  This disease was so widespread and feared that it was depicted in many novels, operas, and paintings, such as “The Sick Child,” (1885-86) by Edvard Munch.

Types: The word consumption now has several meanings but all refer to the using of resources:

    • Conspicuous = consumerism (😉, 😉)
    • Economic = use of goods and services by households
    • Sociological = resource use at the national level
    • Tuberculosis =  TB!

Pandemic: We may think  that COVID-19 is the only current pandemic, but this is not so. Humanity suffers from another, much older pandemic: tuberculosis. Yep, tuberculosis is a global disease, found in every country in the world!  It is also the leading cause of infectious deaths worldwide. The WHO estimates that about 1.8 billion people are infected with TB, almost 1/4 of the world’s population! And, TB has been a scourge for thousands of years as signs of tuberculosis have been found in Egyptian mummies dating to 3000-2400 BCE.  

What’s in a Name? OK, consumption is now called tuberculosis. So, what does this word mean? Tuberculosis is Latin for tuberculum (tubercle) + -osis (condition). Ergo, tuberculosis is the condition of having tubercles. 

TB produces tubercles (rounded) growths in tissues, especially the lungs. This a bit gross, but over time, the centers of such nodules undergo cell death, a term known as caseous necrosis because to the naked eye, the areas resemble white creamy cheese! 🤢

Lung x-rays of advanced pulmonary TB typically show large “holes” surrounded by a white border (see arrow in image below). These are clusters of tubercles (white rim) with caseous necrosis in the center (the hole). 

Cause: TB occurs if the body is successfully invaded by a bacterium known as Mycobacterium tuberculosis (M.tb). But, M.tb isn’t the only culprit as four other species of Mycobacterium also cause TB, including one which survives in un-pasteurized milk! Moo…🐄

Body Distribution: Without question, TB is a ghastly disease that can attack any tissue of the body. Pulmonary TB harbors in the lungs; extra-pulmonary TB invades other body parts, including heart, lymph nodes, bone and joints, pancreas, gastrointestinal tract, and brain/spinal cord, to name a few.  Although about 90% of TB settles in the lungs, some poor victims suffer both pulmonary and extra-pulmonary disease! 😲

TB Symptoms:

    • Chest pain
    • Poor appetite
    • Night sweats
    • Weakness
    • Fever
    • Gastrointestinal symptoms
    • Coughing spells
    • Clubbing of the nails

As if this isn’t enough, TB may become dormant in a patient only to return with a vengeance causing prolonged cough with mucus and, eventually, blood if the tubercles erode through pulmonary blood vessels. 😳

Spread: TB is a disease to be feared and respected! When people with active pulmonary TB cough, sneeze, speak, yell, sing, or spit, they expel tiny infectious aerosol droplets. A single sneeze may release up to 40,000 such droplets, each one capable of transmitting disease. Especially horrifying, inhaling fewer than 10 M.tb particles is sufficient to infect a new host! 😲

There are other risk factors besides proximity. Here are a few:

What about Claire? Do I worry about Claire’s contact with Alex? Not so much because her contact with him was minimal. Mary, most assuredly, would be at risk for contracting TB  since she spent much time with Alex in his final weeks and carried his unborn child.

Treatment: Today, a number of drugs are used to treat active TB, including isoniazid, ethambutol, and rifampin.  Alarmingly, there is also growing resistance of M.tb to treatment regimens – more than a half million drug-resistant cases of TB were identified  in 2020.

In Outlander, episode 212, The Hail Mary, Claire cannot cure Alex, but she does offer palliative therapy using thorn-apple smoke as she did with Ned Gowan in Outlander, episode 105, Rent. (Note: Ned suffered from asthma, not TB). During prolonged coughing, airways undergo spasm making it difficult for the sufferer to breathe.

Thorn-apple smoke allayed the cough by relaxing the airways (bronchi) and quieting the patient.  Surprisingly, thorn-apple is considered a better cough-remedy than opium, but must be used with extreme caution, as it is a strong narcotic poison! ☠️

Read about Alex’s consumption (and congestive heart failure) in Diana’s second big book, Dragonfly in Amber (chapter 39): 

The man who lay on the mattress had thrown off the quilts, over-heated by the effort of coughing, I assumed. He was quite red in the face, and the force of his coughing shook the bed frame, sturdy as it was. 

…The coughing gradually eased, and Alexander Randall’s flushed countenance faded to a pasty white. His lips were slightly blue, and his chest labored as he fought to recover his breath. 

I glanced around the room, but didn’t see anything suitable to my purpose. I opened my medical kit and drew out a stiff sheet of parchment. It was a trifle frayed at the edges, but would still serve. I sat down on the edge of the bed, smiling as reassuringly at Alexander as I could manage.

“It was … kind of you … to come,” he said, struggling not to cough between words. 

“You’ll be better in a moment,” I said. “Don’t talk, and don’t fight the cough. I’ll need to hear it.” 

His shirt was unfastened already; I spread it apart to expose a shockingly sunken chest. It was nearly visible from abdomen to clavicle. He had always been thin, but the last year’s illness had left him emaciated. 

I rolled the parchment into a tube and placed one end against his chest, my ear against the other. It was a crude stethoscope, but amazingly effective. 

I listened at various spots, instructing him to breathe deeply. I didn’t need to tell him to cough, poor boy.

…What is it?” His dark hair was disordered by the coughing; trying to restrain the feelings it roused in me, I smoothed it for him. I didn’t want to tell him, but he clearly knew already. 

“You have got catarrh. You also have tuberculosis—consumption.” 

“And?” 

“And congestive heart failure,” I said, meeting his eyes straight on. “Ah. I thought … something of the kind. It flutters in my chest sometimes … like a very small bird.” He laid a hand lightly over his heart. 

I couldn’t bear the look of his chest, heaving under its impossible burden, and I gently closed his shirt and fastened the tie at the neck. One long, white hand grasped mine.

“How long?” he said. His tone was light, almost unconcerned, displaying no more than a mild curiosity. 

“I don’t know,” I said. “That’s the truth. I don’t know.” 

“But not long,” he said, with certainty. 

“No. Not long. Months perhaps, but almost surely less than a year.” 

“Can you … stop the coughing?” I reached for my kit. “Yes. I can help it, at least. And the heart palpitations; I can make you a digitalin extract that will help.” I found the small packet of dried foxglove leaves; it would take a little time to brew them.”

BTW, Alex’s congestive heart failure could be the result of extra-pulmonary TB or some other unidentified cause.

See Alex slow demise and decline played to perfection by actor, Laurence Dobiesz, in Outlander episode 212, The Hail Mary.  Puir lad! 😢

The deeply grateful,

Outlander Anatomist

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Photo Credits: Sony/Starz; www.aerzteblatt.de; www.infectioncontroltoday.com; www.munchmuseet.no; www.wikipedia.com

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Fun Fact: Anatomical Snuff Box

 

Anatomy Def: A triangular hollow on the back of hand, at the base of thumb 

Outlander Def: Up-to-snuff divot of Jamie’s hand – holds Claire’s kisses! 💋

Students, before we delve into our mini-lesson, it is worthwhile to consider the word snuff, which enjoys many meanings – some old, some new:

    • charred part of a candle wick
    • umbrage or offense
    • huff (chiefly Scottish)
    • extinguish 
    • execute or kill
    • a type of film
    • forcible inhalation
    • sniff
    • powdered tobacco

The last definition refers to a smokeless tobacco made of pulverized tobacco leaves. In the late 15th century, members of Christopher Columbus’s crew observed indigenous peoples of the Lesser Antilles inhaling ground tobacco. Labeled snuff, the practice of sniffing the snuff-stuff took hold in Europe in the 1500s. 👃🏻

Warning: Similar to other tobacco products, snuff contains nicotine and numerous carcinogens. Snuffing is also addictive and associated with increased risk for certain cancers. 🚫

Now, onward and upward with our Fun Fact!

Learn about the awesome hand and its components in Anatomy Lesson #22: Jamie’s Hand – Symbol of Sacrifice and Anatomy Lesson #23: Harming Hands – Helping Hands – Healing Hands, both lengthy and detailed lessons. Why? Because, the hand is one of the most elegant and detailed regions of human anatomy, and the anatomical snuff box (ASB) is a fascinating bit of its story. 

Found on the back of the hand, at the base of the thumb, the ASB was used to snort snuff, hence its name! A pinch of the stuff was placed into the divot and then brought to one nostril and forcibly inhaled. Ditto on the other side. Reportedly, it gave the inhaler an instant and significant nicotine ‘hit’.

The ASB has a range of appearances. In some people, the divot is deep and obvious (below image); in others, it is less noticeable. Either way, the divot is most evident with the thumb extended (as in hitchhiking). 

ASB is formed by three tendons of the back of the hand, extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus, as shown on this image from Grey’s Anatomy:

Why is the ASB important, other than for snuffing? Because, two crucial structures are associated with it: 

    • radial artery
    • scaphoid bone

The all-important radial artery passes through the floor of the ASB, where its pulse can be detected; it is a major contributor to blood circulation of the hand. Its loss compromises roughly half of the hand’s the blood supply.

The scaphoid bone (Latin, meaning boat-shaped), a bone of the wrist helps form the base of the ASB. This oddly-shaped, small bone confers mobility but not stability, to the wrist. 

A person who “falls onto an outstretched hand” experiences a FOOSH, wherein the heel of the hand is forcefully driven into a surface by the body weight. Thus, the scaphoid bone is at high risk for fracture. 

Below, the L x-ray shows a broken scaphoid (green arrow); the R x-ray shows a screw securing the fragments. Scaphoid fracture is common and is a leading cause of medico-legal challenges.

x-ray by Hellerhoff 

Try This #1: Want to see your own ASB? Lay your non-dominant hand on a flat surface, palm down. Fully extend your thumb. You should see two tendinous ridges on the back of your hand. The tendon nearest your little finger is extensor pollicis longus, the other will be both extensor pollicis brevis and abductor pollicis longus. 

Try This #2: You may be able to feel the pulse of your radial artery by placing the tip of the middle finger into the ASB and pressing toward the thumb tip. Can you feel it? Do not use your index finger to test the radial pulse as the index finger has its own pulse which may fool you.

Try This #3: You may also palpate the mound of scaphoid bone by pressing the same finger into the ASB but toward the wrist. This is the wee bone often injured by a FOOSH.

Hopefully, you now understand the history and importance of the Anatomic Snuff Box!

Read about Jamie’s ablutions in preparation for war in Diana’s fifth big book, The Fiery Cross:

I had done it often enough to recognize this particular ritual when I saw it. Jamie was not merely washing; he was cleansing himself, using the cold water not only as solvent but as mortification. He was preparing himself for something, and the notion made a small, cold trickle run down my own spine, chilly as the spring water.

Sure enough, after the third bucketful, he set it down and shook himself, droplets flying from the wet ends of his hair into the dry grass like a spatter of rain.

He took his dirk from its discarded sheath, and with no hesitation, drew the edge across the fingers of his right hand. I could see the thin dark line across his fingertips, and bit my lips. He waited a moment for the blood to well up, then shook his hand with a sudden hard flick of the wrist, so that droplets of blood flew from his fingers and struck the standing stone at the head of the pool.

See Jamie’s anatomical snuff box as he conjures up his uncle, War Chief, Dougal MacKenzie! Visibility of his ASB indicates the tension in his hand as he prepares for battle in episode 507, The Ballad of Roger Mac!

Anatomy, Anatomy, everywhere,

So exciting when we share! 🤗

 

The deeply grateful,

Outlander Anatomist

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Photo Credits: Sony/Starz; Grey’s Anatomy; www.assh.org; www.oceanortho.com; www.teachmeanatomy.info; www.wikipedia.org;

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Fun Fact: Necrosis

 

Anatomy Def: Necrosis means tissue death, as caused by disease, injury, or loss of blood supply.

Outlander Def: Jamie’s dreadful, blackening wound courtesy of a fang-bang! 🐍

Doubtless, Jamie’s horrific thigh wound in Outlander, episode 509, Monsters and Heroes, caused each of us to cringe! 😣

Learn about necrosis in Anatomy Lesson #37: Outlander Owies – Mars and Scars!

Depending on the species of snake, venoms cause predictable signs and symptoms. Within minutes to hours after the bite, Jamie exhibits most of the following:

    • Puncture marks at the wound ✔︎
    • Redness, swelling, bruising, bleeding, or blistering around the bite ✔︎
    • Severe pain and tenderness at the site of the bite ✔︎
    • Increased salivation and sweating ✔︎
    • Labored breathing (in extreme cases, breathing may stop altogether) ✔︎
    • Rapid heart rate, weak pulse, low blood pressure ✔︎
    • Numbness or tingling around face and/or limbs ✔︎
    • Disturbed vision (?)
    • Nausea, vomiting, or diarrhea (?)
    • Metallic, mint or rubber taste in mouth (?)
    • Muscle twitches (?)

Back at the surgery, Claire quickly ascertains that Jamie’s wound is infected!

What might be the source(s) of the infection? Here are some ideas:

    • Bacteria from the snake’s fangs and saliva
    • Bacteria from Roger’s knife
    • Bacteria in Roger’s saliva, as he drains Jamie like a vampire (Sorry, Bree)
    • Dirty bandage
    • Forest floor
    • All the above? 😲

As recorded in The Fiery Cross (TFC),  Claire determines that Jamie’s infected wound shows signs of septicemia, broadly known as blood poisoning.

The foot and ankle on the injured side were still warm and pink—or rather, red. That was a good sign, insofar as it meant the deeper circulation was intact. The problem was to improve circulation near the wound, enough to prevent a massive die-off and sloughing of tissue. The red streaks bothered me very much indeed, though; they could be only part of the hemorrhagic process, but it was more likely that they were the early signs of septicemia—blood poisoning.

Claire must halt the infection quickly because sepsis is life-threatening! Using the serpent’s fangs she injects Jamie with home-brewed penicillin to kill the blood-borne organisms.

Add insult to injury: the wound  also exhibits necrosis! Claire evaluates the red-black tissue at the bite-site (see above image) –  this tissue is dead. 

What causes necrosis? Most likely, loss of blood supply. Necrotic tissue must be removed to avoid loss of muscle mass, gangrene, and possible amputation! 🦵Removing  the dead tissue is a process known as debridement.  

Alrightie, then. How might Claire debride the wound to remove dead tissue but spare the living? Surgical removal is always an an option but difficult to perform with the precision required. If she accidentally leaves necrotic tissue, it can still turn gangrenous. If she accidentally removes living tissue along with the dead, it further compromises Jamie’s thigh tissues. Hum…. 🤔

Well, here’s an idea….. 💡 How about someone rustles up some fly maggots, blow-fly maggots to be precise – Bree (in TFC) or Josiah (in ep 510)??? 

So, into the wound go the maggots and its suppertime! 😋 As gross as it seems, not only will maggots clean Jamie’s wound of necrotic tissue while sparing the living,  his wound will heal faster. Truth! 

“Nothing but a mouth and a gut,” declares Claire (TFC)!

So, where did Claire get the idea of using maggots in Jamie’s wound? From her medical training, of course.

Maggot therapy is the introduction of live maggots into human or animal wounds to remove necrotic tissue but spare the living. (Psst….Just so you know, in today’s medicine, maggots are disinfected before use.) 🤫

Understand, maggot therapy is not new. Aboriginals of Australia and Mayan tribes in Central America frequently used fly larva to clean wounds. Clearly, these folks were observant of the world around them! 👀

When did Western medicine start to employ maggots? In the 1500s, some field surgeons (e.g. Ambroise Paré) observed that wounds infested with maggots healed faster but failed to credit the wee beasties as healers. The first documented therapeutic use of maggots in the US is credited to Confederate medical officer, Dr. J.F. Zacharias, who reported during the American Civil War that:

“Maggots … in a single day would clean a wound much better than any agents we had at our command … I am sure I saved many lives by their use.

Today, some modern hospitals employ medical maggots (Maggots, LLC? 😜) to solve otherwise vexing cases that do not respond to traditional therapies.

One last note – do we believe that a poisonous snake bit Jamie? Nope.

I love Jamie’s (Diana’s) succinct and accurate comparison of venom vs. poison; from Diana’s fourth book, Drums of Autumn:

“Venemous,” Jamie corrected him. “If it bites you and makes ye sick, it’s venomous; if you bite it and it makes ye sick, it’s poisonous.”

Read about Jamie’s horrific snake bite injury and Claire’s therapy in Diana’s fifth book, The Fiery Cross.

“It looks nastier than it is,” I said reassuringly, hearing Marsali’s unguarded gasp at the sight. That was true, but the reality was nasty enough. The slash marks were crusted black at the edges, but still gaped. Instead of the sealing and granulation of normal healing, they were beginning to erode, the exposed tissues oozing pus. The flesh around the wounds was hugely swollen, black and mottled with sinister reddish streaks. I bit my lip, frowning as I considered the situation. I didn’t know what kind of snake had bitten him—not that it made much difference, with no antivenin for treatment—but it had plainly had a powerful hemolytic toxin. Tiny blood vessels had ruptured and bled all over his body—internally, as well as externally—

See Jamie receive maggot therapy for his necrotic wound in Outlander, episode 509, Monsters and Heroes.

Thank you, Claire!

Be well, Jamie! 🙏🏻

The deeply grateful,

Outlander Anatomist

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Photo and Video Credits: Sony/Starz