Posted by Outlander Anatomy | Anatomy Lessons

In Voyager, one of the Outlander books, Herself writes about a character named Dr. Joe Abernathy. As he examines some human bones, he softly sings to himself:

“Oh, de headbone connected to de…neckbone…de neckbone connected to de…backbone…Now hear…de word…of de Lawd!”

This spiritual song, composed by African-American author and songwriter James Weldon Johnson (1871–1938), provides a fitting introduction for today’s Anatomy Lesson #12: The Neck.

NOTE: there is a SPOILER ALERT after Photo G. Keep an eye out for it.

We need a model for our lesson on the neck and can ye think of a better one than bonny Claire? Here’s Claire drinking celebratory bubbly at the end of World War II; her ivory, blood-smeared neck rises from her torso as a long column of muscle, bone and sinew (Starz episode 101, Sassenach).

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The neck lies between base of skull and top of sternum. In Photo A, the chin is angled toward the right acromion (Anatomy Lesson #2) and the pliable neck is lengthened on the left and shortened on the right. The anatomical word for neck is cervix (Latin meaning neck) referring to neck region of the body or neck of the uterus. For simplicity, I will divide the neck into posterior and anterior compartments.

The posterior neck compartment contains cervical vertebrae with overlying muscles. The anterior neck compartment contains respiratory and gastrointestinal viscera (organs), important blood vessels, a bone and numerous muscles.

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Photo A

The posterior neck is supported by the cervical spine (cervical is the adjective form of cervix). You may recall that Anatomy Lesson #10 covered thoracic, lumbar, sacral and coccygeal regions of the spine but not much about the cervical vertebrae; these extend from base of skull to first thoracic (T1) vertebra and include C1 through C7 (Photo B – cervical spine viewed from right side). Only vertebrae C2-T1 appear in Photo B; their anterior cylindrical bodies are directed to your right and their posterior unpaired spinous processes point left. The spinous processes form midline knobs just under the skin covering the back of the neck. The cervical curvature, convex anteriorly and concave posteriorly, allows for a springy and flexible neck that adjusts head position to greatest advantage for sight and hearing.

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Photo B

Viewed in situ (Latin for in position), several strong ligaments bind cervical vertebrae to one other and the skull base (Photo C – right side). The unpaired ligamentum nuchae extends from skull base to C7 spine anchoring the cervical vertebrae and providing partial origin for the trapezius muscles (Anatomy Lesson #3).

In the neck, ligamentum nuchae covers the spinous processes and is aligned with the median furrow, a midline vertical groove running the length of the back (Anatomy Lesson #10). Known as the paddywhack in sheep and cattle, ligamentum nuchae helps support head weight in four-legged animals. Dried paddywhack is sold as dog treats as suggested by the 19th century Welsh children’s song This Old Man:

“With a knick-knack paddywhack, give the dog a bone…”

The long, prominent spinous process of C7 receives a special name, the vertebra prominens because in most people it is most prominent. Palpate your own C7 spine: drop the chin toward your chest and feel the big bony knob of vertebra prominens at the neck base. Interestingly, in about a third of people the spine of C6 or T1 is most prominent. Intervertebral (IV) discs separate vertebrae C2-C7.

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Photo C

Next is Claire’s very visible vertebra prominens (red arrow) as she cries after  teasing Jamie about kissing LungHair. She was jealous of their intimacy and she misses her hubby (Starz ep 103, The
Way Out
). Now the spines of C6 and T1 are also prominent in this image because Claire’s neck is very long and slender like a swan.

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Vertebrae C3-C7 (Photo D) are similar to thoracic vertebrae (Anatomy Lesson #10) except they are smaller and typically have paired transverse foramina (holes) for passage of blood vessels carrying blood to and from the brain. The bodies are also smaller and less round. Spinous processes project posteriorly and most are bifid – forked – just like Claire’s life line! Understand that the spinal cord passes through the vertebral foramina (pl.).

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Photo D

C1, also known as the atlas, articulates with skull above and C2 vertebra below. So named because it supports the head (Atlas of Greek mythology held up the celestial spheres), C1 anatomy is unique. Photo E shows the atlas as viewed from above. It is an odd vertebra because it has no body! Rather, it bears a small articular facet for the dens (see below) on its anterior bony arch and a small posterior tubercle but no spinous process. Two peanut-shaped depressions (superior articular surfaces) articulate with two matching bulges (occipital condyles) on the base of the skull.

Try this: Nod your head up and down (as in “yes”). This sets up a rocking motion between the atlas and occipital condyles at the paired atlanto-occipital joints. No IV disc intervenes between C1 and occipital condyles base as it would interfere with this motion.

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Photo E

C2 or the axis is also an oddly-shaped vertebra (Photo F) that articulates above with C1 and below with C3 vertebrae. A bifid spinous process projects posteriorly. It has an elongated body topped by the tooth-shaped dens (odontoid process). You may wonder why C2 has a dens and C1 has no body (some biologists hold that the dens was once the body of C1 but became part of C2 during evolution). Well the answer is the dens is held against the articular facet of C1 by a very strong ligament (what else?).

Try this: Move your head from side-to-side (as in “no”) and understand that the dens acts as a pivot point around which C1, carrying the head with it, rotates at the atlanto-axial joint. Again no IV disc intervenes between C1 and C2 as it would interfere with head rotation.

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Photo F

I understand if you canna perform some maneuvers, but try this: stick a clean finger in your mouth
and push it all the way to the back of your throat (stop if you start to gag…); the dens lies deep to your finger. For this reason, radiographs of the dens are taken with an open mouth. Photo G (red arrow) is an x-ray of a normal dens; it projects upward like a large tooth (hence the alternative name, odontoid process). You can perhaps see the lower teeth embedded in the mandible?

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Photo G

The history of hanging is pretty gruesome but is important to mention here. With the standard or long drop type of hanging, the condemned is suddenly dropped from a specified height. Weight of the plunging body plus a properly prepared and placed noose breaks the neck – usually meaning the dens snaps off C2 and is driven upward into the brainstem causing instantaneous death.

SPOILER ALERT: If you haven’t read The Fiery Cross, the 5th book of the Outlander series, mayhap you should skip the next two paragraphs and Photo H. But, I hope you have read the entire series (more than once!) as they are very wonderful! Anyway, in the book Herself records:

“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.”

The quote refers to the hanging of a character after sliding from the back of a horse. This type of hanging, known as short drop, results in a slow and agonizing death by strangulation because the
body weight didn’t drop far enough to break the neck! Had this character been hanged either by standard or by long drop method, the dens would likely have snapped from the body of C2 as shown in Photo H (red arrow). NOTE: I don’t have access to the medical history of the patient shown in Photo H, so his/her fate is unknown. However, there are several types of dens fractures and treatment is possible.

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Photo H

Viewed from the back, the cervical spine is overlaid wi’ three layers of muscles: superficial, intermediate and deep. The paired trapezii (Anatomy Lesson #2, Anatomy Lesson #3 & Anatomy Lesson #10) form the most superficial layer (Photo I – left side). If ye recall, these muscles move the scapulae and clavicles and consequently the glenohumeral joint.

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Photo I

Sans the trapezius muscles, two pairs of intermediate neck muscles are revealed: splenius capitis and semispinalis capitis. Both reach from spine to base of skull (Photo J – left side); they help laterally flex (bend head to one side), rotate (turn head to one side) and/or extend (backward arching) the neck.

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Photo J

Remove the intermediate layer of neck muscles and four pairs o’ deep muscles are exposed
(Photo K – right side). These muscles attach to C1, C2 and/or the skull; they also help laterally flex, rotate and extend the neck. Don’t fash about their names; too much info for this lesson!

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Photo K

Now, an important question: why is Claire’s lovely neck as long as it is? It isn’t because she has more than seven cervical vertebrae – that would be rare! Two reasons account for her unusually elegant and swan-like neck as seen here in Starz episode 104, The Gathering.

First, the bodies of C2 – C7 vertebrae are slightly taller. Just a little addition to the length of the bodies of these six vertebrae and it increases one’s overall neck length!

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Take for example, the neck of an adult giraffe (Photo L) which reaches 2 m (6.5’) in length yet it also has only seven cervical vertebrae. The neck length is achieved because each vertebral body can exceed 25.4 cm (10”) in height. Now, please don’t fret, I’m not implying that graceful Claire’s neck is like a giraffe’s! I use this extreme example only to make the point.

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Photo L

The second reason for Claire’s long neck is because her trapezius muscles are very feminine allowing for a definitive angle between their slope and the column of her neck. This gives a looong profile to her ivory tower. Here she weeps as a sick BJR relates the horrific account of Jamie’s scourging (red arrows – Starz episode 106, The Garrison Commander). Beautiful photography as we even see the reflection of a tear fallen on her left breast.

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Now, compare and contrast Claire’s trapezii with Jamie’s which are very well-developed! His amazing trapezii slope downward from head and cervical spine to clavicles and scapulae (Anatomy Lesson #2) filling in the aforementioned angles. This widens the neck and effectively causes it to look shorter but no less appealing. Make sense?

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Now, movin’ on to the anterior neck, it provides passage for pharynx (back of the throat), larynx (voice box), trachea (wind pipe) and esophagus (tube to stomach), viscera that will be left for a later anatomy lesson. We will, however, consider two superficial structures of the anterior neck. First, do you recall the paired platysmas in Anatomy Lesson #11? Each is a thin, flat subcutaneous muscle that pulls down the lower lip (green arrow) and webs the neck skin (red arrows). Here’s Claire with platysmas contracted as she tells Jamie that she had a wee bit too much of Colum’s rhenish (Starz episode 103, The Way Out). Och, he thinks she has had waaay too much! She must have because she is trying to match-make between Jamie and LungHair. What was she thinking?

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The second superficial structure of the anterior neck lies deep to each platysma; it is the external jugular vein. Each vein collects blood from its side of the face and empties it into a large vein at
the base of the neck (Photo M – black arrow).

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Photo M

Claire’s right external jugular vein (red arrow) shows vey well in this scene where she verbally spars with dirty Dougal (Starz episode 102, Castle Leoch)! She’s clearly pissed and for good reason – Dougal has her watched day and night by those hooligans, Rupert and Angus, thinking she’s an English spy! There are other scenes where this vein is apparent in both Claire and Jamie. Hope you watch for it!

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Next, an important pair of muscles provides contour to the anterior neck. To understand their function, we must first learn about their bony attachments. The adult sternum (breastbone) is divided into three parts; the top part is the manubrium (Latin meaning handle).The other two parts will be left for a later lesson. At the top of the manubrium is a divot known as the jugular notch or suprasternal notch (Photo N). The clavicles (Anatomy Lesson #2 & Anatomy Lesson #3) articulate with the manubrium at paired sternoclavicular joints (black arrow – right joint only).

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Photo N

The next image clearly shows Claire’s jugular notch (red arrow) as she watches a tense exchange
between Colum and the wee tailor (Starz episode 103, The Way Out) who unfortunately misjudges the length of a man’s standard frock coat!

Try this: Place fingers at the top of your sternum and feel the bony indent; this is your own jugular notch.

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The paired sternocleidomastoids (SCM) are the large muscles that provide anterior neck contour (Photo O – right side). Each SCM has two heads: the sternal head takes origin from the manubrium and the clavicular head from the clavicle. The heads merge into one belly that inserts on the mastoid process, part of the occipital bone (Anatomy Lesson #11).

Try this: Place your fingers in the jugular notch – drag chin towards your chest and feel a stout tendon on each side – the sternal head of each SCM!

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Photo O

Although his collar is a bit in the way, you can clearly see the sternal heads of both SCMs in BJR’s neck (Starz episode 106, The Garrison Commander) as he bellows at corporal milk sop to “kick her!” Nice guy, eh? Wouldna want ta meet him in a dark alley. Hey, wait, we did meet him in a dark alley in Starz episode 108, Both Sides Now…or that was his 6th times great grandfather? Tcha, not much difference between the two, at least in that episode!

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The clavicular head of each SCM is thicker and wider than the sternal head creating a mound easily viewed in this image of Claire getting liquored up by Colum (Starz episode 102, Castle Leoch). Yep, a
servant has just delivered a jug of his rhenish! Do ye also see the sternal heads of each SCM?

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Now, see Claire below in her bonny ribbon with both SCM tendons tensed? She is sooo pleased and relieved by Jamie’s clever handling of his scheming uncles at the Gathering (Starz episode 104); he
is her patient after all!

Now, do you see anything unusual about her SCMs? Well, turns out that Claire has three SCM heads on each side of her neck rather than the usual two. Here’s the explanation: in some people, the clavicular head may split into two or even three tendons. In Claire’s case, the inner pair of tendons (red arrow – her right side) belongs to the sternal heads of her SCMs; the next pair (green arrow – her right side) belongs to her first set of clavicular heads. The wide tendon (aqua arrow – her left side) belongs to her second set of clavicular heads.

This variation doesn’t alter function – it is just an less common presentation that immediately caught my eye. You can see it in many scenes especially when she lifts her clavicles as in taking a deep inspiration of air. The tendons look very bonny on her ivory tower enclosed like it is by a pert and lovely ribbon (as always, kudos to Terry and team for the gorgeous costuming!). No one wears a neck ribbon quite like Claire! It is the best except, mayhap, when Jamie is taking one off? Snort! Check out your own SCMs for their tendon patterns.

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The SCM performs three movements for us (other neck muscles assist with these movements). First, both sternal heads contract to arch the neck and depress (lower) the chin. Here you see Claire (Starz episode 102, Castle Leoch) contracting both sternal heads as Colum grills her about the proper pronunciation of Beauchamp and her distant famly from Compiègne, France.

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The second function of SCM is turning the chin to look over one shoulder. This occurs when the clavicular head of only one side contracts. Again, we see Claire smile at Colum at the supper table afore he starts her grilling (Starz episode 102, Castle Leoch). Now, her left SCM muscle tendons are clearly visible because they are stretched. But, in fact, it is her right SCM that contracts to move her chin toward her right shoulder. Try it yourself! You might also re-watch this entire scene to appreciate the array of gracious neck movements performed by our braw heroine!

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The third movement occurs when both clavicular and sternal heads of one SCM contract to pull
the same ear toward the shoulder. Here is Jamie (Starz episode 102, Castle Leoch) having his gunshot wound cleaned. How many times have we seen guys perform this neck movement? It seems a universal guy thing, but, I didn’t ken it was done in 1743 by 23 y. o. Scottish virgin! Yup, that’s both heads of his left SCM in action.

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Next, the anterior neck compartment contains an unpaired bone (Photo P – viewed from above). The U-shaped Hyoid bone is Greek meaning shaped like the letter upsilon, the 20th letter of the Greek alphabet. In adults it measures roughly 2” (5 cm) side-to-side and front-to-back with a body and two cornua (Latin meaning horn). Unlike the other 205 human bones, the hyoid doesn’t articulate with any other bone!

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Photo P

The hyoid bone sits in a mostly horizontal orientation about a finger’s breadth below the bottom of the mandible (Anatomy Lesson #11) and at the level of C3 vertebra (photo Q). The hyoid is suspended in the neck by two strong ligaments attached to our styloid processes, a pair of gothic-looking bony spikes. Aye, our skulls really do have these wicked-looking projections!

OK. Let’s stop for a funny story: once a student asked me to examine his plastic skull model for accuracy. It looked fine until I turned it over and noticed it had no styloid processes! I voiced the observation and he responded that he had broken them off because he thought them to be leftovers from the modelling process! We got a good belly laugh over that one!

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Photo Q

Try this: Feel your own hyoid bone. Open thumb and index finger into a curved U and slip the opening over the front of your neck just below your jaw bone. Gently tighten your digits a wee bit and then cough or swallow. You should feel a hard bar move up and down on each side. This is the hyoid bone. If you push gently with your index finger your thumb feels the hyoid more easily on the contralateral (opposite) side. The hyoid is tucked so deeply under the mandible that it is rarely fractured except with compression during manual strangulation. Ugh!

Note: The hyoid bone appears in Diana’s 8th book Written in my Own Heart’s Blood but I will save that context for a later post. NO spoiler here!

A whopping nine pair of muscles attach to the hyoid. The thyroid cartilage (part of larynx) also hangs from it by a fibrous membrane. These muscles help control the tongue, floor of mouth, pharynx and larynx such that the hyoid plays important roles in breathing, speech, swallowing, chewing and coughing (Photo R). Some muscles lift the hyoid forward or backward, others pull it down and forward or backward. Then there are combinations of movements between the muscles making for complex changes to throat, esophagus and airway. The arrows in Photo R indicate the directions the named muscle pull.

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Photo R

I won’t cover all nine pair of muscles attaching to the hyoid (only eight are listed in Photo R) because it is too much info. But, I will comment on the paired omohyoids. Each omohyoid (Photo S – right muscle) has two bellies: an inferior belly arises from the scapula and ends at an intermediate tendon near the clavicle (Photo S – black arrow) and a superior belly arises from the intermediate tendon and inserts on the hyoid. Although not shown in the image, the intermediate tendon is bound to the clavicle by fibrous tissue. As each omohyoid contracts, it pulls the hyoid bone downward and backward.

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Photo S

The omohyoid is rarely seen because it lies deeply. However, I saw this muscle in action during Starz episode 101, Sassenach. Now, I bet you watched this scene more than once but I encourage you to do it again. Here, Jamie has just chased Claire down (YES!). She spits “NO” ta his question: does she want him to pick her up and throw her over his shoulder (YES! erm…NO!). He says: “Well, then, I suppose that means yer comin’ wi’ me!” (oh YES, I mean NO!). Whew, gettin’ a wee bit dizzy here!

Now see the location of the red arrow on Jamie’s neck? Go back and watch this episode as he speaks the line about comin’ with him while keeping an eye peeled at the area indicated. Ye will see a bump rise and fall a couple of times. This is Jamie’s right omohyoid muscle contracting to depress his hyoid bone as he speaks. When I saw it, I nearly fell out of my chair! OMG it is bloody awesome! (Anatomists are a bit weird and easily entertained, ye ken?)

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“Oh, de headbone connected to de…neckbone…

Let’s end this lesson with a final view of Claire’s magnificent ivory tower (not to mention Angus cleaning out a lug in the background)! Aye, she looks marvelous!

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Before I close, I’d like to add a wee personal note at the request of a reader: I write my blog anonymously not because I have anything to hide but because I prefer to focus on Diana’s splendid books, the fabulous Starz Outlander series and fascinating human anatomy! I am a woman and a traditional one at that. If my blog encourages anyone, regardless of gender, to pursue an interest in science then I feel I have done my job. Namaste!

The deeply grateful,

Outlander Anatomist

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photo creds: Starz, Netter’s Atlas of Human
Anatomy, 4th ed., Clinically Oriented Anatomy,
5th ed., Hollingshead’s Textbook of
Anatomy, 5th ed., www.radiopedia.org www.wikipedia.orgwww.commons.wikimedia.orgwww.medical-dictionary.thefreedictionary.com