Category: Fun Facts

Posted on

Fun Fact: Cricothyroidotomy

Anatomy Def: Cricothyroidotomy is an incision through the cricothyroid ligament. Wait!!! Whaaaat???

Outlander Def: Puir Roger gets a pipe stem stuck in his neck, not his mouth!

Learn more about the cricothyroid ligament in Anatomy Lesson #42, The Voice!

Here we go! What is the cricothyroid ligament?

Bear with me, here…. In order to understand, we must examine the anatomy of the larynx. This requires a longer Fun Fact than usual – more like a mini-anatomy lesson. 🤓

Larynx: The larynx is what people often call the voice box. Regardless of the name, it is an anatomical wonder formed of a whopping nine different cartilages squished into the upper neck! Together, these cartilages create a hollow conduit for air to pass from nose/mouth/pharynx to the trachea and thence into the lung airways.

We will investigate  two of these cartilages and the ligament that unites them.

    • Thyroid cartilage – shaped like a shield
    • Cricoid cartilage – shaped like a signet ring turned backward
    • Cricothyroid ligament – tissue connecting thyroid and cricoid cartilages

The below figure shows these structures from a frontal view 👇🏻. Notice that the trachea begins directly below the cricoid cartilage.

If the upper airway is obstructed, a temporary hole may be cut in the conduit allowing air into and out of the lungs. 

Bingo! A cricothyroidotomy is an incision in the cricothyroid ligament to reestablish airflow after an obstruction. Yay!

This procedure is also known as a cricothyrotomy. In Roger’s case, the obstruction is caused by swelling of tissues following a short-drop hanging and subsequent strangling 😱.

But, wait! Is there a correct spot to cut the neck? After all, it contains a host of crucial structures: 

    • Carotid arteries (supply blood to most of head)
    • Recurrent laryngeal nerves (cut these and the vocal cords are paralyzed)
    • Thyroid isthmus (bridge) between right and left lobes of thyroid gland (cutting causes major bleeding)

But, of course there is a correct spot! A skilled physician makes the cut using important anatomical landmarks! Let’s use Jamie’s neck to demonstrate👇🏻!

The red arrow points to Jamie’s Adam’s apple, anatomically known as the laryngeal prominence, a mound on the thyroid cartilage. A finger is placed on the laryngeal prominence (red arrow) and then moved downward until it enters a dip. The dip marks the location of cricothyroid ligament (white arrow); the cricoid cartilage lies below. A knife tip can be safely inserted in this dip but only in the midline to avoid injury to the above structures. 

Try This: Lay face up. Relax your throat. Locate your laryngeal prominence. Slowly move finger downwards until you feel a dip, the cricothyroid ligament. It won’t be far, roughly an inch or so. You will also feel a very firm structure below the dip, the cricoid cartilage. Oh! Well done, all!!!🥇

The episode did not show Claire locating the cricothyroid ligament, but obviously, she found it because Roger is still with us!

Claire makes the incision!

The incision will collapse unless it is held open. So, Claire temporarily inserts what appears to be a wooden peg into the cricothyroidotomy.  

But, a wooden peg doesn’t permit air flow, so a hollow tube is needed, STAT! Brilliant surgeon that she is, Claire commanders Mr. Caswell’s imported English pipe, ruthlessly breaking off the hollow stem!

Rinsing it with alcohol to disinfect……

And successfully inserting the cleaned stem into the cricothyroidotomy.

Voilà! Roger breathes through the tube thus bypassing swollen and mangled tissues of his upper airway.

Read about Roger’s throat surgery in Diana’s fabulous tome, The Fiery Cross.  In the book, Claire gives Roger a tracheotomy, not a circothyroidotomy.

A tracheotomy is a bit more perilous because it is done very near the thyroid isthmus, the landmarks are less sure, and the neck must be hyperextended –  not as good for a “hanged man!” 😳

I took a moment, hands on his neck, eyes closed, feeling for the faint throb of the artery, the slightly softer mass of the thyroid. I pressed upward; yes, it moved. I massaged the isthmus of the thyroid, pushing it out of the way, hard toward his head, and with my other hand, pressed the knife blade down into the fourth tracheal cartilage. 

…The cartilage here was U-shaped, the esophagus behind it soft and vulnerable; I must not stab too deeply. I felt the fibrous parting of skin and fascia, resistance, then the soft pop as the blade went in. There was a sudden loud gurgle, and a wet kind of whistling noise; the sound of air being sucked through blood. Roger’s chest moved. I felt it, and it was only then that I realized my eyes were still shut.

…He was breathing, though; she could hear the faint whistle of air through the tube in his throat. Claire had commandeered Mr. Caswell’s imported English pipe, ruthlessly breaking off the amber stem. Rinsed hastily with alcohol, it was still stained with tobacco tar, but seemed to be functioning well enough.

See Roger’s cricothyroidotomy scar in Outlander episode 508, Famous Last Words.

Roger-the-dodger, dodged an awful fate. Kudos to MIL! 👏🏻👏🏻👏🏻

Wow! Dr. Claire continues to impress! 😲

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo credits: Sony/Starz; www.thenakedvocalist.com

Posted on

Fun Fact: Petechiae

Anatomy Def: Petechiae are small round spots of blood in the skin.

Outlander Def: Telltale signs of the Roger’s distress as he slowly strangles to death!

Learn about petechiae (petechia) in Anatomy Lesson #65, Anatomy of a Hanging!

What are petechiae?  Petechiae are pinpoint, round spots signaling the leakage of blood from capillaries, the tiniest blood vessels of the skin’s dermis. These often appear in clusters and may look similar to a rash. 

More succinctly, petechiae are:  

  • Small hemorrhages (bleeding) in dermis of skin
  • 1-2 mm in diameter
  • Red, purple, brownish coloration
  • Usually feel flat (not raised)
  • Do not blanch (lose color) when pressed

What causes petechiae? Turns out there are lots of causes. Here are some general categories:

  • Strenuous coughing
  • Vomiting
  • Giving Birth
  • Lifting heavy weights
  • Infections/sepsis from bacteria, fungi, viruses
  • Reactions to some medications
  • Blood and immune disorders
  • Lack of vitamin C (scurvy)
  • Lack of Vitamin K ( needed for blood clotting)

Can petechiae appear elsewhere? Well, yes! Sometimes they appear on the linings of mouth or inner eyelids (palpebral conjunctiva)! The below image compares petechiae of the skin with those of the palpebral conjunctiva. 

What else causes petechiae? The answer circles us back to Outlander! 

Gah! Short drop hanging may cause petechiae. In this instance, the condemned sits astride a horse, stands on a barrel or some other support; the support is suddenly removed.

The ghastly short drop may be insufficient to snap the neck so the person slowly strangles to death. They struggle for breath, blood pressure rises in the head, and capillaries burst allowing small pockets of blood to accumulate in the skin and palpebral conjunctiva. Inhumane, for sooth! Roger!!! 😱 

Just so we ken, a long drop hanging (e.g. from a platform) usually snaps the neck resulting in a quick and more “humane” death (if the hangman knows his ”craft”). 

Read about Roger’s hanging and its horrific aftermath in Diana’s fifth large tome, The Fiery Cross: 

On a rise at the far end of the meadow stood a huge white oak, its spring leaves bright in the slanting sun. My horse moved suddenly, dodging past a group of men, and I saw them, three stick-figures, dangling broken in the tree’s deep shadow. The hammer struck one final blow, and my heart shattered like ice.

Too late.

It was a bad hanging. Without benefit of official troops, Tryon had had no one to hand with a hangman’s gruesome—and necessary—skills.

See petechiae of Roger’s facial skin (red arrows) in Outlander episode 508, Famous Last Words. Slow hanging is a ghastly way to die! 😭

Not-So-Fun Fact: Today, we can be grateful that many countries have abandoned hanging as a means of execution. If you are interested, an excellent film is available on this topic: Pierrepoint: The Last Hangman. Bonus! Tobias Menzies plays Lieutenant Llewelyn in this engrossing movie!

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo credit: Sony/Starz;  www.sciencedirect.com

Posted on

Fun Fact: Liver

Anatomy Def: Liver is a multi-functional, dense, blood-filled organ of the upper abdomen.

Outlander Def:  Murtagh’s likely cause of death! 😩

Not much fun…. this week, Outlander Fanmily was sucker-punched by the death of Jamie’s beloved Godfather. Wanna know what killed Murtagh (other than Hugh Findlay)? Read on!!!

Learn a lot about the liver in Anatomy Lesson #49, Our Liver – The Life Giver!

Fun Fact: A healthy liver performs more than 500 vital functions for the human body!  This clearly justifies its historic name: lifer.

The Roman anatomist and physician, Galen (200 A.D.), posited that the liver is our most important organ! Thus, springs its descriptor, “liver the life giver.” Understand, liver isn’t our most important organ but most assuredly it is essential for life. 👍🏻

Here are more interesting facts about the liver (consult image below 👇🏻):

    • Reddish-brown hue because it is saturated with blood
    • Right dome of liver abuts right dome of diaphragm
    • Sits high in abdomen, rising nearly to right nipple (in the lean 😜)
    • Right dome of liver and lower right lung overlap one other

The liver is saturated with blood because it receives 25% (1/4) of the entire cardiac output! Two vessels deliver blood to the liver and three drain it:

    • Portal vein – delivers nutrient-rich, deoxygenated blood from GI tract
    • Hepatic artery – delivers oxygenated blood via a branch of the aorta
    • Hepatic veins (3) – drain deoxygenated blood to inferior vena cava

So, what killed Murtagh? Sleuth hats on!

In episode 407 (see red arrow in first image), Hugh Findlay’s musket ball pierces Murtagh’s chest slightly below and to the left of his right nipple.  His wound appears roughly in the location of the green arrowhead in the above Netter image 👆🏻. In this location, the ball will pierce both liver and lung.

Now consider:

    • Blood seeping from his mortal wound is a deep red color, more consistent with liver blood than with bright red lung blood.
    • Flow of blood suggests the wound may have torn a hepatic vein.
    • Wheezing suggests that his right lung was also pierced and beginning to collapse (pneumothorax).

Ergo, our beloved Godfather exsanguinates from a horrific liver wound before Claire can treat either his blood loss or pneumothorax.

Read about one of Claire’s liver diagnoses at the gathering. Here, from The Fiery Cross:

I was a good ten feet from the stool where Murray plied his trade, but could see the man’s eyes, yellow as mustard even in the dim morning light.

“Liver disease,” I said to Brianna, taking no particular pains to lower my voice. “You can see the jaundice from here, can’t you?”

“Bilious humors,” MacLeod said loudly, snapping open his fleam. “An excess of the humors, clear as day.” Small, dark, and neat in his dress, Murray was not personally impressive, but he was opinionated.

“Cirrhosis due to drink, I daresay,” I said, coming closer and looking the patient over dispassionately.

“An impaction of the bile, owing to an imbalance of the phlegm!” Murray glowered at me, clearly thinking I intended to steal his thunder, if not his patient.

Claire is right, Dr. MacLeod. 🚫 excess humors! 🚫 fleam! 🚫 quackery!

See Murtagh’s mortal wound in Outlander episode 507, The Ballad of Roger Mac.  

RIP, Murtagh! 😭

The deeply grateful,

Outlander Anatomist

Follow me on:

Photo credit: Sony/Starz; https://www.netterimages.com