Tag: The Fiery Cross

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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

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

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Fun Fact: Conjunctiva

Anatomy Def: Conjunctiva is a clear membrane covering part of the eyeball and lining inside of eyelids.

Outlander Def: Roger’s bloodied and abused tissues as he gazes at the world through his burlap hood!!! 😥

Learn about the conjunctiva in Anatomy Lesson #30, Aye, Eye – The Eyes, Part 2. 

Conjunctiva is a clear, thin mucous (adj.) membrane of the eye. It is a mucous membrane because, indeed, it contains glands and cells which secrete mucus (n.). This sets it apart from serous membranes that do not secrete mucus.

The conjunctiva has two parts:

    • Bulbar conjunctiva: Covers front part of sclera (“white” of the eye)
    • Palpebral conjunctiva:  Lines inner surfaces of eyelids 

Is the conjunctiva useful? Oh, indeed it is!  👏🏻👏🏻👏🏻 It performs two important functions: 

      • Produces mucus and tears to help lubricate the surface of eye
      • Protect against microbes entering the eye which is vulnerable to the outer world

The conjunctiva contains many small blood vessels that are not especially noticeable unless stimulated to dilate. Dilation allows for increased tear and mucus release. What might cause such a response?

    • Allergens, such as pollen
    • Irritants, such as air pollution, makeup, cosmetics
    • infections
    • Contact lenses
    • Fatigue
    • Hypoxia (reduced oxygen supply)

But, Roger’s conjunctivae are bloody! Why??? This occurs because strangling increases pressure in the conjunctival blood vessels and they swell. The vessels then burst from straining for air and against the rope!

Slowly rewatch the color version of the hanging; you will see blood blooming during his conjunctival bleed. Or, more precisely, subconjunctival bleed, as blood collects between conjunctiva and sclera! 

The special effects are excellent, btw! In Rik’s recent Q and A, he explains he was fitted with special contact lenses and thought CGI was also added. I agree, as I see an increase in conjunctival blood during the footage.

Ergo: If Roger every gets his hands on William Buccleigh MacKenzie!!! 💪🏻💪🏻💪🏻

Fun Fact: Some people worry that a contact lens could wander towards the back of the eyeball and reach the brain. For several anatomical reasons, this doesn’t happen. One major reason is the conjunctiva folds on itself forming a closed pouch all the way around the eyeball. The figure explains 👇🏻.

The L panel shows the bulbar and palpebral conjunctiva from a frontal view.  Note: the bulbar conjunctiva stops at the edge (limbus) of the cornea. It does NOT cover the cornea!

The R panel shows a vertical section through the eyeball. The bulbar conjunctiva is shown as blue and the palpebral conjunctiva is red. A red arrow marks the pocket where the two layers meet. This blind pocket encircles the entire eyeball. Hence, a lost contact lens can only travel as far as the blind pocket. Want to know what to do about a “lost” contact lens? This is a pretty good website!

Try This: Gaze into a mirror.  Locate the clear membrane overlying your sclera. Can you see its tiny blood vessels? This is your bulbar conjunctiva. Gently pull down on the lower eyelid. See the glistening surface? This is your palpebral conjunctiva. Got it? Good job!

Herself explains Roger’s horrific ordeal in The Fiery Cross. Accurate details and explanations accompany her descriptions coupled with fantastic story-telling.  Read the books, folks! 🙏🏻

The others had strangled, slowly. The bodies were twisted, held by their bonds in the final postures of their struggle. One man—one body—was cut down as I rode up, and carried past me in the arms of his brother. There was not much to choose between their faces, each contorted, each darkened in its separate agony. They had used what rope was to hand; it was new, unstretched. Roger’s toes trailed in the dust; he had been taller than the rest. His hands had come free; he had managed to hook the fingers of one hand beneath the rope. The fingers were nearly black, all circulation cut off. I couldn’t look at his face at once. I looked at Brianna’s, instead; white and utterly still, each bone and tendon set like death.

See Roger’s bloody conjunctivae in Outlander, episode 508, Famous Last Words!  ❤️ Roger!

The deeply grateful,

Outlander Anatomist

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Photo credits: Sony/Starz; www.aafp.org

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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

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