Anatomy Lesson #42: “The Voice – No, not that One!”

Welcome anatomy students to another exciting session! Today’s Anatomy Lesson #42 is, The Larynx. Some folks think the larynx only generates “The Voice” (Christina, CeeLo, Blake and Adam, notwithstanding). While this is certainly true, it also serves two other critical functions. Stay tuned for the fascinating saga of laryngeal (adj.) anatomy.

As always, Starz images and Diana’s book quotes are sprinkled throughout to make our studies more endearing. A couple of book spoilers appear, meaning the quotes are from books that have not yet been filmed; these will be preceded by a red flag warning for those who prefer to skip!

First, the sad-bad news. I waited for Starz to depict Dougal’s Demise after a reader asked more than a year ago for a lesson on the voice! I waited patiently because Uncle D’s Death as described in Dragonfly in Amber book is a perfect lead-in for a larynx lesson. Then, horror of all horrors – Starz episode 213, Dragonfly in Amber – didn’t follow the book! Och!

BOOK QUOTE: Dragonfly in Amber describes Jamie’s and Dougal’s shocking Fight with Fate, involving a knife to the throat and a struggle with voice:

A shift, and a jerk, a sudden grunt of effort, one of pain. Dougal stepped back, staggering, face congested and pouring sweat, the hilt of the dagger socketed at the base of his throat… There was a terrible sound from Dougal, a sound of shock and stifled breath… The big body went limp, then spasmed, sliding out of Jamie’s grasp. Dougal lay crumpled on the floor, muscles jerking with involuntary contractions, struggling like a fish out of water. His head was pillowed on Jamie’s thigh. One heave brought his face into view. It was contorted, and dark red, eyes gone to slits. His mouth moved continuously, saying something, talking with great force—but without sound, save the bubbling rasp from his ruined throat.

Imagine my dismay as the Starz scene unfolds wherein Jamie + Claire stab Dougal in the chest – not in the neck!  What? To quote Rabbie Burns: “The best laid schemes o’ mice an’ men – gang aft a-gley.” Ah, well, tha sin mar sin!

ep 213 Dougal 01

Many a time, Jamie casts a wary eye at Dougal (Starz episode 101, Sassenach) and for good reason. Mayhap, the ruadh laddie kens that a battle to the death is the only way a male will prevail? One of these fellows must go!

ep 101 larynx

Now for the lesson: Let’s start at the beginning with how to pronounce the word, larynx.  Well, it is pronounced ler-inks, not lar-nix. Emma does a swell job, so check this out:

https://www.youtube.com/watch?v=4mX4-zer2e0

Commonly known as the voice box, the larynx is a splendid structure of startling complexity. A hollow tube with stiff walls, the adult larynx (Image A – orange) lies in the neck where it links pharynx or back of throat (Image A – green) with trachea or windpipe (Image A – trachea).

Just so you are aware, pharynx is pronounced fare-inks, not far-nix. One of my anatomy profs used to declare: “if you say lar-nix one more time, I will rip out your far-nix” (in those days, professors were minor gods)!

The human larynx serves three critical functions:

  • Maintains the airway so air enters and leaves the lungs during each breath cycle
  • Excludes food, drink and other unwanted stuff from entering trachea
  • Creates phonation – “the voice” and other sounds

We will learn how the larynx manages these important functions. But first, the anatomy!

Print

Image A

General Anatomy of Larynx:

A vertical, midline section through the larynx reveals its considerable length, extending from C3 (third cervical) vertebra (Image B – red arrow) through C6 vertebra (Image B – blue arrow). In case you forgot, back in February 2015, we learned about cervical vertebrae in Anatomy Lesson #12, “Claire’s Neck” or “The Ivory Tower.”

The adult larynx is supported by a rigid skeleton of cartilage, ligaments and membranes (Image B – cartilages named). Numerous intrinsic and extrinsic muscles move these cartilages.

Its hollow interior is lined with mucous membrane or wet mucosa (Anatomy Lesson #14 ,“Jamie and Claire” or “Anatomy of a Kiss”), meaning the surface is moist, a necessity because its living cells will die if allowed to desiccate.

The larynx is a dynamic structure that changes throughout life, from the newborn state through old age. It is also a secondary sex organ undergoing marked changes during puberty. Male and female larynges (pl.) respond differently to the internal hormonal milieu, a quality known as sexual dimorphism (Anatomy Lesson #39 “Dem Bones – the Human Skeleton”). We will return to these issues later in this lesson.

larynx-01-Figure0059

Image B

Laryngeal Skeleton:

The laryngeal (adj.) skeleton features nine cartilages: three large, unpaired and three small, paired. Only unpaired cartilages (epiglottis, thyroid and cricoid) are visible from a front (anterior) view (Image C). The rounded, curved tip of epiglottis peeks above the hyoid bone. The thyroid cartilage is shaped like a helmet visor; two broad plates (laminae) meet anteriorly at a pronounced angle, the laryngeal prominence (Image C – red arrow). The cricoid cartilage is a complete ring, thin in front but expanded in back.

larynx-02-Figure0073A

Image C

Laryngeal cartilages do not float, they are anchored by strong connective tissue elements (Image D). The thyroid cartilage hangs from the hyoid bone (Anatomy Lesson #12, “Claire’s Neck” or “The Ivory Tower”) via a tough thyrohyoid membrane. Cricoid and thyroid cartilages are united by the cricothyroid ligament and a cricotracheal ligament (Image D – red arrow) binds cricoid cartilage to trachea. Although not shown in Image D, ligaments also hold the epiglottis in a mostly vertical position. The trachea is not part of the larynx but its wall is also formed of cartilage rings (see below).

larynx-05-Figure0073A

Image D

WARNING! The first RED FLAG means a book spoiler quote is next! Skip, if need be.

redFlag

BOOK SPOILER: Larynx and hyoid bone appear in Diana’s 9th book, Written in My Own Heart’s Blood. An important character’s name is omitted to “protect the innocent!”

McEwan’s broad fingers were cold on his neck; he felt the icy touch delicate on his skin as it traced the line of the rope scar, then firmer as the healer prodded gently round his damaged larynx… McEwan fitted his hand snugly round _______ neck, just under the chin… “Do you know what a hyoid bone is?” “If I had to guess, it’s something in the throat.” “Why?” … “It’s just there,” the healer said, pressing with his thumb, high up under _______ chin. “And if it had been here”—he moved the thumb down an inch—“ you’d have been dead, sir. It’s a fragile wee bone. Easy to strangle someone by breaking it—with your thumbs or a rope.”

Question #1: Do any of the above structures appear as mounds at the skin surface? Hyoid bone, epiglottis and cricoid cartilages are not visible because these are embedded too deeply or are too small to create a skin mound. But, we often see a bulge that moves during swallowing, talking, singing, etc.; the bulge is created by the laryngeal prominence of the thyroid cartilage, commonly known as the Adam’s apple (Image E). Great tattoo, although most of it lies below the laryngeal prominence. Ha!

Try This: Place two fingers over your laryngeal prominence – don’t press hard as it causes discomfort. If you cannot find it, gently tilt head backwards and feel a firm mound under your fingers. Now, straighten the neck and feel the prominence lift as you prepare to swallow and fall as the act completes. Now cough or sing a few bars and see what happens. I hope you are surprised by its mobility. Remember, this is only a small part of the larynx; much more is happening that you cannot feel.

Try This: Next, tilt head back again and run fingers down the laryngeal prominence until you feel soft tissue; this is the cricothyroid ligament. Below it lies a thin hard line of cricoid cartilage. Below this is another bit of soft tissue, the cricotracheal ligament binding cricoid cartilage to first tracheal ring. From this point, the trachea continues down the throat and into the thorax (Anatomy Lesson #15 “Crouching Grants – Hidden Dagger”). Appreciate that the larynx is solidly built and well-anchored.

Clinical Correlation: If an “owner” desires a smaller laryngeal prominence, then chondrolaryngoplasty is available. The neck is entered via surgical incision and the prominence reduced by shaving. Erroneously called a tracheal shave (trachea isn’t involved), it usually leaves a modest scar.

Adam's apple

Image E

Time for a Jamie fix! Jamie’s laryngeal prominence is clearly visible (Starz episode 210, Prestonpans – red arrow) as, tilting his head back with immense pleasure, he relieves a full bladder! Hot-shot lad that he is, he attempts to win a bet by peeing into a pot without looking. Splish-splash! Odds?

BOOK QUOTE: Diana describes the delightful scene featuring Jamie’s Adam’s apple (Dragonfly in Amber):

Grinning at the success of his joke, he raised his kilt further, grasped his clearly visible weapon and took careful aim. He squinted his eyes, bent his knees slightly, and his fingers tightened their grip. Nothing happened. “It’s a misfire!” crowed one of the English. “His powder’s wet!… Jamie squinted dubiously at his equipment, bringing on a fresh riot of howls and catcalls. Then his face cleared. “Ha! My chamber’s empty, that’s all!” He snaked an arm toward the array of bottles on the wall, cocked an eyebrow at me, and when I nodded, took one down and upended it over his open mouth. The water splashed over his chin and onto his shirt, and his Adam’s apple bobbed theatrically as he drank. “Ahhh.”

ep-210-adams-apple

Back to Anatomy: The best way to see remaining laryngeal cartilages is flip the structure into a posterior view (Image F). The odd, leaf-like epiglottis is fully visible from this perspective; it’s curved superior surface peeking above the hyoid bone. Thyroid cartilage, visor-shaped, is incomplete, posteriorly. The cricoid cartilage expands in back, much like the dome of a signet (class) ring. Perched atop the cricoid are the important, paired arytenoid cartilages, each shaped like a three-sided pyramid. Atop each arytenoid is another small curved cartilage (corniculate) which we will ignore along with a couple of other tiny cartilages. Although difficult to visualize from this perspective, a lumen (channel) runs vertically through the center of the laryngeal cartilages; remember, this lumen is lined with mucous membrane.

Posteriorly, the tracheal rings are incomplete, but the C-shaped cartilages are united by strong connective tissue sheets. This brilliant engineering feat allows food blobs and globs to slide and glide down the esophagus (see Image B – esophagus behind trachea) without getting hung up on tracheal rings.

larynx 03 Figure0073B

Image F

One last structural component to consider are the paired vocal ligaments. A vertical section of the larynx, through the midline, reveals internal anatomy of the left side of larynx (Image G). Locate the left vocal ligament, a band of elastic tissue reaching from thyroid cartilage in front to arytenoid cartilage, in back. This arrangement is duplicated on the right side. More about the vocal ligaments below.

larynx 04 Figure0073E

Image G

Intrinsic Laryngeal Muscles: Intrinsic muscles arise and insert within the larynx itself. There are 6 (8 by some counts) pairs of intrinsics; thin, tiny muscles moving various laryngeal cartilages. I can bear witness that these are very difficult to dissect! One of a pair of intrinsic muscles is clearly visible from a side view (Image H – red arrows). Naming intrinsic muscles will bog us down. Suffice it to say, the one in Image H is the cricothyroid, so named because it arises from cricoid cartilage and inserts on thyroid cartilage. Get the idea? Grand!

Muscles-02-Figure0074B

Image H

Remaining intrinsic muscles are visible from a posterior view (Image I). These are strategically oriented to move the various laryngeal cartilages in specific ways and again, named by the cartilages they attach to or the function they perform.

Muscles 01 Figure0074A

Image I

The following is a short list of how intrinsic muscles act on various laryngeal cartilages.

  • Rock thyroid cartilage forward to lengthen vocal ligaments and deepen the voice (Image J – top)
  • Rotate arytenoid cartilages together to open airway and allow airflow (Image J – middle, left)
  • Rotate arytenoid cartilages apart to close airway and stop airflow (Image J – middle, right)
  • Narrow the airway to reduce airflow (Image J – lower, left)
  • Tense vocal cords to raise voice pitch (Image J – lower, right)

Ergo, these intricate adjustments, caused by muscle contraction, allow nuanced movements of laryngeal cartilages to manage airflow and to produce and modulate sound. And, these amazing, small muscles contract very rapidly with great capacity for prolonged work, as any singer can verify. Lastly, the lower right image shows muscle fibers stretched from thyroid to arytenoid cartilages; these tiny muscles lie inside the vocal folds (see below).

Muscles 05 larynxFigure0075

Image J

Extrinsic Laryngeal Muscles: Not only do intrinsic muscles move the larynx, eight pair of strap-like extrinsic muscles also effect laryngeal position. Extrinsic laryngeal muscles are so-named because they take origin from or insert into body parts outside the larynx. Located in the neck or beneath the mandible, extrinsic muscles connect mandible (Anatomy Lesson #26, “Jamie’s Chin – Manly Mentus”), sternum, scapula and skull to thyroid cartilage and hyoid bone. Read more about these muscles in Anatomy Lesson #12 “Claire’s Neck” or “The Ivory Tower.”

Image K identifies extrinsic laryngeal muscles but more importantly, shows upward or downward directional pulls (red arrows); four pair of extrinsic muscles depress (lower) and four pair elevate (lift) hyoid bone and thyroid cartilage. Further, the pulls are not strictly upwards or downwards. Rather, the upper four pair of muscles pull hyoid bone up and forward or up and backward; the lower four pair of muscles pull hyoid bone and thyroid cartilage down and forward or down and backward. The larynx, suspended from that wee hyoid bone, is mostly carried along for the ride!

Thus, these many muscles and their attachments allow for nuanced changes of laryngeal position during talking, laughing, screaming, singing, coughing, clicking, sneezing, snorting, swallowing, etc. Impressive!

muscles 03 Figure0025B

Image K

Thyroid Gland: Remove the extrinsic muscles and we see an important and intimate relationship between larynx and the highly vascular thyroid gland. The bilobed thyroid gland straddles the larynx, its lobes connected by an isthmus (bridge) of thyroid tissue overlying the second and third tracheal rings (Image L).

thyroid larynxFigure0070B

Image L

Vocal Folds: Next, let’s consider vocal folds. Vocal folds, commonly known as vocal cords, are paired folds of mucous membrane, each containing a vocal ligament (see Image G) and the tiny (vocalis) muscle (see image J, lower right).

Looking down the pharynx via laryngoscope (laryngoscopy), true vocal folds appear as pale thin bands (Image M). Below these, are epiglottis and tongue base. Above the folds are bumps created by mucosa overlying arytenoid cartilages. Vocal folds carry out the first and third critical functions listed below:

  • provide airway
  • exclude unwanted materials
  • generate sound

Let’s discuss each of these functions in greater detail.

Provide Airway: As muscles rotate arytenoids together, vocal folds open allowing air to flow through the lumen or glottis (Image M – left side). As other muscles rotate the arytenoids apart, the folds close and air flow slows or stops (Image M – right side). Psst: Just so you know, vocal cords lie horizontally in the neck; their vertical orientation in Image M is how they appear on a screen during laryngoscopy.

vocal folds

Image M

True vocal folds are so named to distinguish them from false folds. Find the false vocal folds in Image M. False vocal folds do not produce sound but do add resonance to the voice. Two exceptions are Tibetan Chant and Tuvan throat singing, both of these produce an undertone using small spaces (laryngeal ventricles) between true and false vocal folds (ventricles not visible in Image M).

If you find animals endlessly fascinating, get this: Male gorillas and some other primates, such as the gibbon shown in Image N, enlarge their necks by deliberately forcing air into their laryngeal ventricles. The ventricles of some primates are so large, they may extend into the thorax! In most humans, they are small.

ape ventricle 01

Image N

Remember the second crucial function of the larynx? It closes to exclude unwelcome materials. Yep, it discriminates!

Exclude Undesirables: The weird-looking epiglottis helps with the second laryngeal function, to exclude unwanted stuff from the larynx. Here is how it works: During swallowing, hyoid bone lifts and tongue depresses pushing the epiglottis downwards and backwards to cover the laryngeal inlet (Image O – black arrow). This helps prevent food, drink, spit, etc., from entering the larynx as only air is welcome (Image O – white arrow). The epiglottis also has a shape which encourages food and drink to flow around its sides and backwards into the esophagus where it belongs! Does it sometimes, fail? Well, sure, especially if we try to swallow and speak at the same time. In such instances, stuff gets into the larynx , eliciting a paroxysm of coughing! Expel the infidel!

Try this: Wait! Wait! If you have a sensitive gag reflex, don’t try this. Otherwise, do you want to feel the tip of your epiglottis? Here’s how: open mouth wide and relax tongue. Lay one (clean) index finger atop tongue. Slide it gently backward and downward along the tongue surface until you touch the rounded, thin tip of the epiglottis. Don’t gouge it with your fingernail and avoid touching soft palate, sides or back of throat as this initiates the gag reflex! Did you feel it? Good job to those who dared!

epiglottis

Image O

Generate Sounds: Last but not least, vocal folds produce sounds. During phonation, vocal folds open and close, change shape and vibrate. This brief video shows the fluid movements involved in this process – watch until the end, to see and hear the patient sing. The folds are a pale pink V in the still shot below.  The tracheal inlet is the dark hole In middle. Mounds near the top are arytenoid cartilages – these move dramatically during the film clip. The thin mobile curl at the bottom of the video is the tip of epiglottis. Oh, and the sticky material coating the vocal folds is mucus, a viscous fluid that lubricates and protects the folds. Hope you watch all of this fascinating footage!

Clinical Correlation: Please understand that if the larynx is blocked or narrowed by trauma, infection, birth defects, cancer, polyps, scar tissue, etc., the impediment must be removed or bypassed to restore the airway. Two sites commonly used for bypass are cricothyroid membrane and trachea. An opening through the cricothyroid membrane (see Image D) is a cricothyrotomy or cricothyroidotomy. An opening between tracheal rings, is a tracheotomy; if a breathing tube is inserted into the opening, then it is termed a tracheostomy (Image P).

Tracheotomy is not new as it was depicted on Egyptian artifacts dating as far back as 3600 BCE! Here’s an startling tidbit: Alexander the Great purportedly saved a soldier from suffocation by making an incision into the man’s trachea with the point of his sword! Gah! I don’t recall seeing Colin Farrel do that in Alexander.

Tracheostomy

Image P

Red flag and wee black dog are back. Must be another book spoiler! Best skip if you haven’t read ahead of Starz episodes!

redFlag

BOOK SPOILER: This quote is very pertinent to our lesson, from Herself’s fifth book, The Fiery Cross,  as it mentions structures and procedures covered in this lesson. Yay, Diana!

A cricothrotomy? Fast, and requiring no great skill, but difficult to keep open—and it might not be sufficient to relieve the obstruction.

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.

… 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.

Way to Hustle, Claire: Claire assiduously avoids cutting the thyroid gland isthmus, otherwise, blood would quickly flood the surgical field. She also likely pressed her knife through the soft connective tissue between 3rd and 4th tracheal rings. And, she performed a tracheostomy, inserting a pipe stem into the tracheal incision to serve as a breathing tube. Yay, Claire!

Newborn Larynx: At lesson start, I promised to consider age- and sex-related differences of the larynx. Here we go! The larynx is a tiny organ in the newborn which sits much higher in the neck (C2-C3 vertebrae) than in the adult (Image Q – infant left, adult right). The higher position of an infant larynx allows epiglottis and soft palate to touch during suckling (Image Q – left side). This important juxtaposition enables the infant, an obligate nose-breather, to simultaneously suckle and breathe. Otherwise, they would have to swallow, stop, take a breath, stop – repeat. Exhausting for such a tiny body!

Many a nursing mam knows that if her wee bairn bites down (ouch!), she can stop this by gently closing off its nostrils – the babe must let go to breathe!

It should be noted that although infant larynges are much smaller than those of adults, their vocal folds and higher lung pressure enable them to produce very audible howls,  yowls and growls!

Childhood Larynx: The larynx continues to grow throughout childhood in proportion to the remaining body with no significant differences between male and female larynges.

infant & adult larynx

Image Q

Adolescence: Then, puberty raises its provoking head, accompanied by some fascinating changes! Both sexes experience facial development, descent of the larynx in the neck, increased circumference of chest wall and greater lung capacity, all of which typically deepen and strengthen the voice. But, the larynx of a pubescent male is also exposed to a flood of androgens (mainly testosterone) which induces growth of laryngeal cartilages.

Adult Male Larynx: By 20 y.o., the average male larynx is about 40% taller and vocal folds about 60% longer than the female’s (Table A). Plates of the male thyroid cartilage meet at a 90º angle making the thyroid eminence more prominent than that of the 120º female angle (i.e., female angles are more open, so eminence is less pronounced). Male intrinsic muscles become larger and stronger and vocal folds thicker and longer leading to a drop of about one octave in voice pitch. These differences illustrate sexual dimorphism of the larynx; its responsiveness to hormones qualifying it as a secondary sex organ.

Adult Female Larynx: But, did you know that female vocal folds also respond to hormonal changes? Puberty causes the female voice to drop about 1/3 octave. But, female vocal folds also respond to hormone (progesterone and estrogens) fluctuations during each menstrual cycle becoming more edematous in the latter half which often lends the voice a breathy or husky quality. After menopause, the female voice becomes even lower due to increased circulating androgens.

After 20, the larynges of both sexes remain stable until about midlife when cartilages begin to ossify (bone replaces cartilage). Ossification is not usually a problem but one of my young readers (<20 y.o.) has ossified laryngeal cartilages and they are problematic for this person.

An astute student might ask, why would nature make the male voice deeper and stronger? Well, scientists have some suggestions about that: Perhaps, male voices have deepened over the course of evolution to signal dominance and/or to increase the speaker’s attractiveness. Studies do confirm that vocal frequencies correlate with a speaker’s hormonal status – which may or may not be attractive in a potential mate. Gals tend to like Jamie’s baritone voice. Mmphm!

Table A Mean Measurements of Male and Female Larynxes

MALES FEMALES
Height 44 mm 36 mm
Transverse diameter 43 mm 41 mm
Front-back diameter 36 mm 26 mm
Circumference 136 mm 112 mm

Sexual Dimorphism: Let’s turn to all things Outlander to witness sexual differences of the larynx. Here, in Outlander Starz episode 202, Not in Scotland Anymore, we see a near perfect example of the female Adam’s apple – or is it an Eve’s apple? Bwahahaha!

A small bump of the laryngeal prominence appears on Claire’s lovely ivory tower as she casts stink eye at stinky Duke! Love, love, love those earrings – perfect accessory for her swan-like neck!

ep-202-Adam's-apple

Compare and contrast Claire’s gentle laryngeal prominence with that of a typical male. Weil, now, perhaps not entirely typical, but certainly impressive! Jamie obligingly lifts his chin to reveal his prominent Adam’s apple (Starz episode 107, The Wedding). Lots of testosterone plus Claire help him have a vera fine time. Whinny and snort!

ep-107-Adam's-apple

The Voice: Let’s end this lesson with a brief discussion of The Voice…No, not the TV show! – just voice in general, the third important function of the vocal folds. Phonation is arguably less critical than maintaining the airway, but very important for communication and quality of life.

Roman physician Galen (130 – c. 200 CE) declared the larynx as the “first and supremely most important instrument of the voice.” Was he correct? Yes, because sounds are normally generated by vibrations of vocal folds and action of laryngeal muscles (side note: people lacking functional vocal folds can be taught esophageal speech and/or use of an electrolarynx). However, sound quality is nuanced by numerous other factors including:

  • Lung capacity
  • Extrinsic laryngeal muscles
  • Tongue movement
  • Lip action
  • Mouth anatomy
  • Pharynx, cheeks and soft palate changes
  • Paranasal sinus configuration

The cumulative effect of these factors grants to humans a voice that can be modulated to an amazing degree; never more evident than during singing. Consider the movements of lips, tongue, soft palate, etc. in this wonderful MRI of a man singing opera. The movements are astounding. Try to locate epiglottis and arytenoids. I hope you enjoy watching this internal byplay on the screen!

https://youtu.be/Q9eFqX4wvnw

Question #2: Readers have asked why our taped voices and spoken voices sound differently to our own ears? Answer: Taped voices are recorded via sound waves traveling through air before reaching our ears. The spoken voice creates vibrations transmitted to the inner ear (Anatomy Lesson # 25, “If a Tree Falls – The Ear”) mostly via bone and soft tissues, lending the voice a less tinny quality. Most folks seem to favor the spoken voice over the taped version. Make sense?

Final Outlander Fixes: Happily, Outlander gives us many treacherous throat and larynx scenes to consider!

Barely out of the chute, Claire is confronted with Captain of Dragoons’ blade at her neck (Starz episode 101, Sassenach). Good way to lose a Lovely Larynx! Fortunately for our nimble nurse, his threat is only virtual. The man’s got skills, ye ken?

ep 101 thoat slit 01

Puir not-a-wet-nurse Claire doesna get a break in episode 101. Next, Dougal jerks her around and tells her to stay with the rest of his troop of hairy-merry lads or he will obligingly slit her throat (Starz episode 101, Sassenach)! Lovely larynx at risk, again!

ep 101 throat slit 02

Remember the Sadist’s Shave? Captain Jack-Rat’s larynx is fully exposed to a vera sharp blade (Starz episode 106, The Garrison Commander). Too bad Corporal Milksop’s hand didna slip. Would have saved team Fraser a world of grief!

ep 106 larynx 01

Oops. Flip-flop and the tables are turned. Corporal Hawkins’ hand DID slip – now, he is under the blade, getting the absolute worst: a dry-neck shave (Starz episode 106, The Garrison Commander)! Vera unpleasant, especially at the hands of the foul fearsome fiend!

ep 106 larynx 02

BOOK QUOTE: Now, a few fabulous apropos lines about a dearly departed larynx from Dragonfly in Amber book:

Mary sneezed, and wiped her nose hastily with a fold of her plaid. She stared at Murtagh, eyes wide and baffled. I gazed down at the bulging saddle-bag, feeling a sudden deep chill that owed nothing to the weather outside. But it was Hugh Munro’s widow who sank to her knees, and with steady hands opened the bag and drew out the head of the Duke of Sandringham.

In Starz episode 211, Vengeance is Mine, Jamie, Claire and contrary-Mary witness Sandringham, forever separated from his smooth-speaking larynx. No more mocking jibes from this oily opportunist. Sure and true, Murtagh’s ax seeks its mark!

Diana, author of both Starz episode 211 and Dragonfly in Amber book, offers two different routes to the Duke’s Demise although the outcome is identical…. grand example of “the end justifies the means?”

The Duke, he lost his larynx,

Along with his pharynx.

The ax performed a hi-jinx.

Murtagh’s work is done!

(Let’s hear it for the Godfather!)

ep 211 Duke

Final voice Issue: According to 13 August 2016, New Scientist, and Buzz Feed, Appen, a voice recognition firm working for Google, a call for help has been posted on Reddit’s Edinburgh page for people with Scottish accents to submit recordings of themselves reading certain phrases to help train its software! Users with certain accents – particularly Scottish – have complained that voice recognition systems such as those used by Good Now and Apple’s Siri struggle to understand them. Here is a great comment to illustrate the dilemma.  Well, at least Siri got “street” right! Am I right?

sub-buzz-22604-1470315959-1

I hope you enjoyed learning about the incredible human larynx. Give a brief salute the next time you take a breath or utter a no-no word! Have a wonderful breath-taking day.

A deeply grateful,

Outlander Anatomist

Photo creds: Starz, Netter’s Atlas of Human Anatomy, 4th edition (Images B,C,D,F,G,H,I,J,K,L,M), Grey’s Anatomy, 39th edition (Table A data), www.flickr.com (Image E), www.kit10phish.wordpress.com (Image Q), www.scienceblogs.com (Image N) www.newhealthadvisor.com (Image O), www.quizlet.com (Image P), www.thisiscommonsense.com (red flag and dog), www.vocalclinic.org (Photo A), www.voicedoctorla.com (Image N), Buzzfeed

Anatomy Lesson #37: Outlander Owies Part 3 – “Mars and Scars”

Hello, anatomy students! Today’s Anatomy Lesson #37 covers the ginormous topic of mars and scars, better known as wound healing. A mess of wounds and scars appear in the Outlander books and the Starz series so let’s learn from this perfect anatomical smorgasbord.

You will recall from Anatomy Lesson #35: Outlander Owies! Part One and Anatomy Lesson #36: Outlander Owies! – Part Deux! that pathology is the study of abnormal anatomy. Well, it turns out that wound healing also belongs in the realm of pathology. Our lesson will examine healing of closed and open wounds.

Surprise! Jamie is our model because he has more mars and scars than anyone else of Outlander fame! Let’s also enjoy a drinking game because Jamie’s wounds inspire one to drink more than any others, I ken! Down a wee dram each time you read “Och! Jamie’s puir…”

Drams in hand? Let’s begin…

Blood: Because blood is essential for healing and scar formation, it requires a brief brief mini-lesson of its own. Blood is a connective tissue (yes, it is!) composed of fluid plasma, in which two classes of blood cells are suspended: red blood cells (RBCs or erythrocytes) and white blood cells (WBCs or leukocytes). Blood also contains cell fragments known as platelets (thrombocytes) along with many other suspended or dissolved substances.

RBCs arise in bone marrow as nucleated cells but lose their nuclei just before entering the blood stream. Image A shows a 3-D SEM (Scanning Electron micrograph, Anatomy Lesson #34) image of a blood vessel containing blood cells. Understand that the colors in Image A were computer generated. RBCs are flat, biconcave discs (red in Image A), whose shape and lack of a nucleus allots them maximum oxygen-carrying capacity; think of them as tiny flat bags filled with hemoglobin (Hgb). As RBCs pass through lung capillaries, oxygen binds to Hgb molecules, turning RBCs bright red. As RBCs reach capillaries of other body regions, Hgb molecules release their oxygen burden into the tissues and the RBCs turn a dark, deep red color. Such color changes are important in wound formation and healing.

WBCs are the round, gray fluffy balls in Image A. They arise in bone marrow but retain their nuclei. There are five classes and several subclasses of WBC. All WBCs serve various defensive functions; more about these later in the lesson.

Platelets, which do not appear in Image A, play a crucial role in blood clotting.

SEM blood KLS edited

Image A

That was a “quickie” blood lesson. Now, on to healing processes!

The outline for today’s Lesson is:

  • Healing Closed Wounds
    • Trauma
    • Contusion Development
    • Contusion Resolution
  • Healing Open Wounds
    • Trauma
    • Hemostasis
    • Inflammation
    • Proliferation
    • Remodeling
    • Scars

Healing Closed Wounds: Closed wounds are injuries wherein the skin remans unbroken. The contusion will serve as today’s example of a closed wound, although simple bone fractures are another. Anatomy Lesson #35 explained that a contusion is the medical term for a bruise. Bruises form in subcutaneous tissues (Anatomy Lesson #5: “Claire’s Skin” – “Ivory, Opal and White Velvet.”) where they are often visible through the skin, but they can also form in deep organs such as muscle. Symptoms may include a bump, a hard knot and tenderness. And, bruises do not blanch under pressure. A number of steps occur to form and heal a bruise including:

  •  trauma
  • contusion development
  • contusion resolution

Let’s look at each of these steps.

Trauma: Contusions are caused by blunt force trauma wherein the skin is not broken. Claire’s foot presents an formidable blunt force directed at Jamie’s face (Starz episode 109, The Reckoning)! Weil, now, she did warn him not to belt her. This lass is not going down without a stramash!

ep 109 Claire kick

Contusion Development: Contusions pass through an impressive array of colors during development and healing. The first color is redness which occurs because blunt trauma bursts local capillaries allowing oxygen-ladened RBCs (bright red) to spill into nearby tissues. Although time has passed since Claire’s kick, the skin overlying Jamie’s right bony orbit (Anatomy Lesson #30: Aye, Eye – The Eyes Part 2!) shows the redness typical of a fresh contusion (Starz episode 110, By the Pricking of My Thumbs). Or, mayhap he is just blushing because the Duke of Sandringham has a certain fondness for his hindquarters? <G> Och! Jamie’s puir right eyelid! Have a wee dram.

ep 110 Jamie eye

Redness is followed by purple and blue discoloration as Hgb molecules inside the spilled RBCs release their oxygen; the RBCs turn dark red-purple as do the tissues they occupy. Next image is a good example of purple/blue discoloration (Starz episode 116, To Ransom a Man’s Soul). Och! Jamie’s puir left shoulder! (And, another dram). A quote from Outlander book reminds us of the vicious swipe that produced such discoloration!

The spot on his left side where the mallet had struck was an ugly contused swelling…I bit my lip, feeling gingerly down the swell of his biceps. He had one of the worst bruises I had ever seen; a huge mottled splotch of purple-blue—but I was fairly sure the arm wasn’t broken.

ep 116 Jamie bruise

Next, a contusion exhibits the classic black and blue discoloration as spilled RBCs rupture and release their iron-containing Hgb into the soft tissues of the injured area. Och! Jamie’s puir left fingers; they argued with that damnable mallet and lost (Starz episode 116, To Ransom a Man’s soul)! Quick! Take another sip!

ep 116 Jamie hand 01

Contusion Resolution: Yay! It rhymes! Now, the contusion begins to heal assuming first, green and then, yellow hues. These color changes occur because cells known as macrophages (Greek makros meaning large + phagein meaning to eat) devour freed Hgb, Macrophages break the Hgb into the green compound, biliverdin, (Latin meaning green) which turns the tissues an icky green color. This is followed by yellow hues as the biliverdin is metabolized into the golden chemical, bilirubin. As macrophages clear the last of the debris from the bleed, the yellow fades and if the contusion isn’t too profound, normal coloration and function are restored.

Ergo, changes oin Hgb molecules form the basis for color changes of a healing contusion. A single bruise can simultaneously display all of the above colors because the amount of spilled blood varies in different areas and the stages of healing overlap. Here is a gut-wrenching example (Starz episode 106, The Garrison Commander)! Och! Jamie’s puir back! (Another swallow!) Gah! Skin near the lash marks is red, purple, blue, black, green, and yellow! Herself writes in Outlander book:

Dougal grimaced. “A pitiful sight, it was, too—still raw, no more than half-healed, wi’ the weals turned black and the rest yellow wi’ bruises. The thought of a whip comin’ down on that soreness was enough to make me blench, along wi’ most of those watching.”

Now that we understand the healing of a closed wound, let’s consider open wounds.

ep 106 Jamie wounds 01

Open Wound Healing: Open wounds entail skin breaks; abrasions, lacerations, and incisions (Anatomy Lesson #35) are good examples of open wounds. Such injuries undergo a cascade of events during wound healing.

Trauma: First, open wound healing requires trauma; finding good examples of open wounds in Outlander is a no-brainer – as they are pretty much everywhere! This is a fine one: Starz episode 110, By the Pricking of My Thumbs, shows the type of trauma-drama awaiting highlanders that mess with Jamie! The MacDonald lads hurl nasty insults and then attack Jamie. Thalla gu h-Iort – “to St Kilda with ye!” bellows Jamie. With a quick dirk-jerk, Jamie gifts one lad with an incision of his right hamstring tendons! Young MacDonald came to harm, E-I-E-I-Oooooh; that stings!

ep 110 MacDonald cut

Open wound healing: Following trauma, the body immediately springs into action and initiates the following four steps of open wound healing (Image B):

  • Hemostasis
  • Inflammation
  • Proliferation
  • Remodeling

Wake up, students! Let’s examine each of these four steps.

Основные RGB

Image B

Hemostasis: A fancy word for blood clot, hemostatsis comes from the Latin for blood + Greek for stop. Hemostasis is typically the first step in open wound healing. If trauma ruptures blood vessels, they bleed (duh!) and then undergo spasm to reduce bleeding. Next, platelets stick to the injured site forming a temporary platelet plug, followed by a complex, ten-step!!! cascade of events leading to blood clot formation. If all steps work normally, a clot stoppers each damaged blood vessel to halt blood loss. The dusky red plug of Jamie’s gunshot wound is a massive blood clot formed by the process of hemostasis (Starz episode 101, Sassenach). Och! Jamie’s puir right trapezius muscle! Slàinte!

And, just to keep us honest and abreast of Outlander time line, a common 17-century word for blood clot is grume!

ep 101 Gunshot wound

A blood clot with its seeping fluids usually hardens into a scab, the body’s version of a Band-Aid! This firm shell protects the wound from infection and desiccation (drying). Tissues under a scab are repairing so best to leave it alone. If you pull it off, the healing process will be prolonged. Jamie kens better than to tear that scab off his gunshot wound! Nurse Claire will skelp his arse if she catches him doing that (Starz episode 103, The Way Out) From Outlander book:

“That’s good,” I said, clearing my throat of some obstruction that seemed to have lodged there. “It is healing well; it’s scabbed over nicely, and there’s no drainage at all. Just keep it clean, and don’t use the arm more than you must for another two or three days.” I patted the undamaged shoulder, signifying dismissal.

ep 103 Jamie scab

Inflammation: Hemostasis is quickly followed by acute inflammation, a rapid but brief response that is not the same as infection, although both may occur simultaneously. Just so you know, the body also experiences chronic inflammation (e.g. RA), a prolonged response that lies beyond today’s lesson content. So, let’s investigate acute inflammation.

About 2,000 years ago, the Roman, Celsus, described four signs of acute inflammation (rubor, tumor, calor, dolor). The fifth sign (functio laesa), was described centuries later by Rudolf Virchow, father of modern pathology. The signs, in Latin followed by their English equivalents, are:

  • Rubor (redness)
  • Tumor (swelling)
  • Calor (heat)
  • Dolor (pain)
  • Functio laesa (loss of function)

Acute inflammation is the topic of a terse tête-à-tête between Mrs. Fitz and newly arrived Claire (Starz episode 102, Castle Leoch). Claire declares she doesn’t want Jamie’s gunshot wound to become infected. Oops, she means inflamed! Why did Claire change her words? Because, she kens that the terms infected/infection, meaning invasion by micro-organisms, will not be accepted for another 140 years or so! Herself enlightens us from Outlander book:

“But he’s hurt. He was shot yesterday and stabbed last night. I bandaged the wound for riding, but I didn’t have time to clean or dress it properly. I must care for it now, before it gets infected.” “Infected?” “Yes, that is, I mean, inflamed, you know, with pus and swelling and fever.” “Oh, aye, I know what ye mean. But do ye mean to say as ye know what to do for that? Are ye a charmer then? A Beaton?” “Something like that.”

Hee, hee – more like a WW II combat nurse. If only Mrs. F. knew!

ep 102 Fitz

The five signs of acute inflammation are caused by dramatic changes in small blood vessels, WBC distribution, and chemical mediators. These changes are very complex so suffice it to say that intact blood vessels near the injury become leaky such that plasma and some types of WBCs pour into the injured tissues. The increased blood flow causes redness. Leaked plasma causes swelling. Freed WBCs release chemical mediators that initiate a host of tissue changes including more redness, swelling, pain, and heat. These responses are designed to eliminate the cause of cell injury, to remove damaged cells, and to initiate tissue repair. Because the injured area hurts, it is hard to use, so it undergoes loss of function. Got it? Grand!

Back to the present (or past): here’s a great example of an injury that leads to acute inflammation. Just before Jamie’s dirk-jerk, he is stabbed by one the MacDonald lads during the big Mac-Attack (Starz episode 110, By the Pricking of My Thumbs). Och! Jamie’s puir left side! Time for another swallow!

image

 

Turning to Claire for a wee bit of TLC (she isna very accommodating) and suturing…well, at least he gets stitched <G>, we see signs of acute inflammation in Jamie’s wound (Starz episode 110, By the Pricking of My Thumbs)? See the redness? See the puffy, swollen wound margins? It hurts even before not-a-closed-mouth-woman, Claire, jabs him with her needle! And, the wound will feel warm to the touch. Och, Jamie’s puir inflamed incision wound! Getting dizzy yet?

Four of the five cardinal signs of acute inflammation accounted for! Where’s the fifth?

ep 110 stitching 01

Here’s the fifth sign of acute inflammation: Jamie grips his newly-stitched left side to protect and support it as Colum gives the Highlanders Holy Hell (Starz episode 110, By the Pricking of My Thumbs)! This is loss of function: the wound hurts too much to use and the pain is intended to stop the victim from using the wounded area while it heals. Och! Jamie’s puir left side! Another gulp! All five signs of acute inflammation present and accounted for! Now back to the steps of wound healing.

ep 110 Jamie disfunction 01

Proliferation: So, the wound has bled and is inflamed, what’s next? The wounded tissues undergo proliferation, a complex process (yes, another one) involving three parts: angiogenesis, fibroplasia, and re-epithelialization (Image C). Whew – more terms! What do these words mean?

Angiogenesis means that new blood vessels grow into the wounded site to supply the healing tissues with oxygen and nutrients and remove waste products (red arcs and loops in Image C).

Fibroplasia means that fibroblasts (connective tissue cells) make gobs of new collagen and other structural proteins to fill the gap left by an open wound. Although laid down in a haphazard fashion, the new collagen fibers provide a structural framework for the repairing tissues (represented by ellipsoid cells and brown and yellow stacks in Image C).

Re-epithelialization means that new epidermis (Anatomy Lesson #5: Claire’s Skin – Ivory, Opal and White Velvet and Anatomy Lesson #6: Claire’s Hair – Jamies Mane or Jesus H. Roosevelt Christ!) regrows to cover the gap caused by the wound (green bricks in Image C). This fascinating step requires old epidermal cells to divide and new epidermal cells to crawl over and cover the breach (blue bumps in Image C). Then, fibroblasts (acting like muscle cells), grip the wound edges and contract, pulling the rim inward and puckering it (not shown in Image C).

If the wound is minor, the three steps of proliferation occur rapidly and the wound closes with little trace. If the wound is deep and/or wide, then proliferation results in a scar (see below).

proliferation

Image C

Remodeling: Finally, we arrive at remodeling, the fourth step of wound healing! Here, the randomly-arranged proliferated collagen is replaced with new collagen fibers that add strength by orienting along stress lines. Near the end of remodeling, scars contract and become smaller and paler. Image D shows that remodeling takes between 21 days for a minor wound and up to 2+ years for significant injuries! NOTE: This graph skips bleeding as the first step in open wound healing.

phases of wound healingImage D

Necrosis:  Before we move to scars, please know this…..If some process interferes with establishment or maintenance  of normal blood flow following open wound injury, then injured tissues may undergo cell death, a process known as necrosis.

Scars or Cicatrix: We’ll end this lesson with a discussion about scars, the remnant of a healed wound. The Latin (medical) term for a scar is cicatrix or cicatrice, and has been around since the 17th century.  Scars (pl.) are known as cicatrices. With the exception of minor injuries, all wounds (e.g. accident, disease, surgery) result in some degree of scarring. We are familiar with scars of the skin but did you know that our internal organs also scar and the nature of such scars is often organ-specific (e.g. fibrosis of liver).

Let’s address some common wound and scar questions.

Why are wounds stitched? Nowadays, wounds are stitched, stapled, glued, and taped. These processes align and hold together the edges of a wound to minimize bleeding, exclude infectious organisms, and reduce scar size. First recorded in 3,000 B.C., suturing is the oldest of these procedures. Approximating the edges of a wound by any the above methods permits healing by first intention.

Claire’s careful needlework on Jamie’s smashed fingers approximates his lacerated skin and restores it’s continuity, thus promoting healing by first intention and minimizing scar formation (Starz episode 116, To Ransom A Man’s Soul). She also uses interrupted stitches so if one knot releases, the entire line of stitching does not unravel. Och! Jamie’s puir left fingers! Gulp! Gasp!

ep 116 stitching 01

Claire stitches Jamie up so many times, she might have welcomed help from this amazing little fellow!

What is the red, grainy “stuff” that fills gaping wounds? If the edges of a wound remain agape or the epidermis is gone (think floor burn), then the gap fills with granulation tissue; this red, grainy “stuff” is a combination of new blood vessels and new collagen. Known as healing by second intention, this type of healing is slower than healing by first intention and usually forms larger scars (Image E).

Granulation tissueImage E

Have you heard the term, “proud flesh” (caro luxurians)? Noooo, I dinna mean the Kardashians, snort! Proud flesh is an oldish term for excess granulation tissue. Image F shows proud flesh, an overgrowth of granulation tissue that developed from a small finger cut. Such overgrowths are atypical but the image is useful because it clearly shows the red blood vessels and grainy appearance of granulation tissue.

proud flesh

Image F

What is a scar? Scar tissue is remodeled collagen fibers that aligned in one direction for added strength. Unfortunately, scar tissue is not as functional as the tissue it replaces. For example, scar tissue of skin lacks hair follicles and sweat glands (Anatomy Lesson #6: Claire’s Hair – Jamies Mane or Jesus H. Roosevelt Christ!) and is less pliable than normal skin. Scars of heart muscle lead to loss of muscular power during cardiac contractions. Scars of liver are due to death of liver cells and formation of excess collagen – less tissue to preform the ten life-giving functions carried out by the liver. Then, there’s amazing bone that often heals without any structural or functional loss.

Why do scars turn white? Scars usually turn white within a year or two after injury. They do so after collagen remodeling and scar contraction is complete and the need for increased blood flow has diminished.

Why do some scars remain red or purple for a long time? Scars remain red or purple as long as WBCs of the area produce chemical messengers to promote increased blood flow. Thus, it may be months or even years before redness completely fades. A good example is the persistent redness of Jamie’s gunshot scar which is apparent months after the event. Oh, no! More sass from Claire who gives him a thorough Sassynach scolding for being a lousy laird (Starz episode 112, Lallybroch). Have ye ever seen a sweeter, more innocent face? Ha, ha! He enjoys a good tongue lashing now and then (hee hee!).

ep 112 Jamie scar 01

Here is a great … ah, erm, … I forgot what I was writing about! Gah! Oh, I remember! The scar from the sword swipe is white at the millpond even though Jamie’s earlier gunshot scar is red in the same episode (Starz episode 112, Lallybroch). Ahem, students!! The red arrow helps focus your attention on the white scar! Now this can occur because tissues in different regions of the skin may heal at different rates. More likely, it is because that bloody freezing burn contracted Jamie’s skin capillaries: reduced blood flow = paler skin! Och, Jamie’s puir left side! Are we woozy yet?

ep-112-Jamie-scar-02

Why are Jamie’s lash scars so prominent? Back skin is thick and when lacerate, it should be sutured or stapled; unfortunately, neither of these procedures were available to Himself at the time of injury. His deep, wide lash wounds filled with granulation tissue and healed by second intention so the resultant scars are wider and more significant. BTW, his lash scars are also shiny and raised, features of hypertrophic scars, an abnormal healing process due to overproduction of collagen. His lash scars were probably designed for dramatic effect, as Jamie’s skin is an unlikely candidate for hypertrophic scarring. Och! Jamie’s puir back! Glass refill STAT!

ep 116 Jamie back

Jamie appears over and over in this lesson because the lad has suffered more than his fair share of mars and scars. Who is to blame for most of these owies? Why, that dark, dastardly devil, BJR, of course. Claire is constantly cleaning up that SOB’s messes! Sadist that he is, Jack-Jerk finds his handwork compelling and erotic (Starz episode 116, To Ransom a Man’s Soul)! Writer Ira Steve Behr explains:

To me, the line that was truest to Black Jack’s character was when he ripped open Jamie’s shirt and said with wonder, “How does it feel to be alive and wear so much dead flesh?”

I go on record as stating, au contraire, repugnant, reptilian Randall! Scars are NOT dead flesh, they are living tissue, the end game of the body’s ability to heal wounds. Scars are molded by our own private first responders; tiny “robots” that dart into action on our behalves. Let us be grateful that our bodies possess such marvelous repair mechanisms!

ep 115 Jamie's dead flesh

Shakespeare once wrote, “There’s nothing good or bad, but thinking makes it so” (Hamlet; Act two, Scene two, p. 11). Apparently Will never met BJR – as some handiwork is just plain E-V-I-L!

If you have yet to witness this riveting compilation of Black Jack’s dark and dirty deeds, watch this admirable video – created by Julia LaBlanc and posted by E. Jamie via YouTube. Just keep in mind it grimly showcases the depths of BJR’s depravity.

https://m.youtube.com/watch?v=6GRAsvTFH4s

Closing with my own wee Ode to BJR:

BJ is a fiendish auld cur; a fiendish auld cur is he,

He called for his whip and he called for his brand,

To abuse our darling Jamie!

(Git yer foul tongue off him!)

Hope you are still standing after all those drams! As for me: Hic! Thud!

A deeply grateful,

Outlander Anatomist

Photo creds: Starz, www.bioloby-igcse.weebly.com (Image A – SEM of blood cells), www.medscape.org (Image C – proliferation), www.surpassinc.com (Image B – four steps of wound healing), www.en.wikipedia.org (Image F – proud flesh), www.woundeducators.com (Image D – phases of wound healing), www.wisegeek.com (Image E – granulation tissue)