The posterior median furrow (PMF) literally means “back middle groove.” This vertical depression is most visible in thoracic and lumbar regions of the back. It tends to be shallow in thecervicalregion, diminishes over the sacrum and is continuous with the glutealcleft (Aye, the sweet cheeks! <G>).
PMF is most visible in those with robust para-spinal (erector spinae) muscles. These muscles flank the vertebral column; the more developed the muscles, the deeper the PMF.
PMF is useful during physical exam because the vertebral spines can be palpated and counted in the groove. Specific vertebral spines mark levels for anesthesia delivery, location of abdominal organs, and vascular anatomy. For example, C3 marks the level of the hyoid bone (wink, wink to book readers).
More Fun Facts: English is replete with idioms about the back. These are a few of the many:
Back away
Back me up
Back and forth
Back to square one
Back in the day
Back to the drawing board
Back down from
Back the wrong horse
Back to back
Back in circulation
Read about Jamie’s posterior median furrow in Outlander book. Yes, Herself describes it! 👏🏻👏🏻👏🏻
Compassionate Claire notes the groove as she describes Jamie’s badly damaged back:
He sat patiently, not moving as I circled behind him and inspected his back…I was appalled…The scars covered his entire back from shoulders to waist. While many had faded to little more than thin white lines, the worst formed thick silver wedges, cutting across the smooth muscles. I thought with some regret that it must have been quite a beautiful back at one time. His skin was fair and fresh, and the lines of bone and muscle were still solid and graceful, the shoulders flat and square-set and the backbone a smooth, straight groove cut deep between the rounded columns of muscle that rose on either side of it…I tried not to imagine the muscular arms raised…ropes cutting into wrists, the coppery head pressed hard against the post in agony…Involuntarily, I reached out, as though I might heal him with a touch and erase the marks with my fingers. He sighed deeply, but didn’t move as I traced the deep scars, one by one, as though to show him the extent of the damage he couldn’t see.
Och! See Jamie’s PMF in Outlander, episode 105, Rent, after Uncle Dougal rends Jamie’s sark to expose BJR’s handiwork! 😱 Back off, Dougal!
Greetings anatomy students! Hanging is a ghastly topic, but it has a substantial presence in Outlander and is pertinent to anatomy. So, here we go!
The Oxford Dictionary defines hanging as “specifically to put to death by suspension by the neck.” But, in the past, hanging also meant death by crucifixion or impalement!
An interesting fact…. The appropriate terminology is the person was hanged, not the person was hung.
Outlander’s first traditional hanging appeared in episode 115, Wentworth Prison; crusty Taran MacQuarrie of the Watch and Jamie Fraser face their ends with stirring gallows’ humor: Jamie is afraid “My wife will never forgive me for getting myself foolishly hung!” Hanged, Jamie…. the word is hanged!
But, Taran aways knew he was fated to die at the end of a rope – his name is read next.
Jamie’s turn! Scribe, Liam McCallum, recorded Jamie as guilty of “a very extraordinary and abominable crime and most atrocious injury against us!” Snort!
Jamie struggles, but is subdued and resigns himself to this ignoble fate. Such an unworthy end for Laird Broch Tuarach!
Then one of Lucifer’s avenging angels swoops in to spare Jamie for a different fate! But, this outcome awaits another lesson.
No further traditional hangings, until season four. Episode 401, America the Beautiful, starts off with a bang… Well, with a hangman’s noose, truth be told.
In a drunken state, Gavin Hayes lay with a marrit woman (psst…Jamie warned him!). When the outraged hubby came at him with a pitchfork, Gavin kicked him down the stairs and now, the hangman’s noose awaits. He should have listened to Mac Dubh! (In Drums of Autumn book, Gavin was guilty of stealing six pounds, ten shillings).
Hayes asks Jamie for two favors:
#1. Whisky!
Herself described in Drums of Autumn:
“It was what he asked of me,” he said. “And the best I could manage for him.”
“Brandy or whisky?” asked Fergus, evaluating Hayes’ appearance with a practiced eye.
“The man’s a Scot, wee Fergus.” Jamie’s voice was as calm as his face, but I heard the small note of strain in it. “Whisky’s what he wanted.”
“A wise choice. With luck, he won’t even notice when they hang him,” Fergus muttered
#2. May his last sight be the face of a friend.
Again, from Drums of Autumn:
If Hayes was still sober enough to see anything, the last thing he saw on earth would be the face of a friend.
He could see; Hayes glared to and fro as they lifted him into the cart, twisting his neck, desperately looking.
“Gabhainn! A charaid!” Jamie shouted suddenly. Hayes’ eyes found him at once, and he ceased struggling.
Jamie musters a wan smile for his auld friend and fellow Ardsmuir prisoner.
Drums of Autumn quote continues:
The captain of the guard stood poised, saber raised.
Suddenly, the condemned man drew himself up straight. Eyes on Jamie, he opened his mouth, as though to speak.
The saber flashed in the morning sun, and the drums stopped, with a final thunk! I looked at Jamie; he was white to the lips, eyes fixed wide. From the corner of my eye, I could see the twitching rope, and the faint, reflexive jerk of the dangling sack of clothes. A sharp stink of urine and feces struck…
The rope drops. Hayes death appears mercifully quick! Again from Drums of Autumn:
The hangman had known his business; there had been no undignified struggle, no staring eyes, no protruding tongue; Gavin’s small round head tilted sharply to the side, neck grotesquely stretched but cleanly broken.
OK, but, what about non-traditional hangings? Any of these in Outlander. But, of course!
Two Jacobite traitors hang from crossed stakes courtesy of Red Coats in Outlander episode 105, Rent. Dougal and his party find the dead men with “T” for traitor carved into their flesh.Although we don’t know how they died one can reasonably consider this a variation of a crucifixion hanging.
And, finally! In ep 402, Do No Harm, Jocasta’s slave, Rufus, dangles from a hook thrust under his ribs. This type of hanging is known as impalement.
From Drums of Autumn:
From everything I could sense and feel, I thought that the curve of the hook had gone upward through the liver. Likely the right kidney was damaged, and the jejunum or gallbladder might be nicked—but none of those would kill him immediately.
So, one may reasonably conclude that Outlander has dutifully presented both traditional and non-traditional hangings!
So, what does hanging have to do with human anatomy? Quite a lot actually, because hanging destroys normal anatomy. Let’s see how.
Understanding traumatic events from hanging requires a bit of neck anatomy.So….
Neck Anatomy: The neck is complex because it contains a mess of structures. These include:
pharynx for food and air passage
larynx for air passage and vocalization
trachea for air passage
esophagus for food passage
common carotid arteries supply blood to head
jugular veins drain blood from head
cervical vertebrae for support
hyoid bone for speech, swallowing, tongue movements
cervical spinal nerves, for neck and upper limb innervation
muscles for movement of head, neck, scapula and clavicle
Hangings typically traumatize one or more of these neck structures:
cervical vertebrae
hyoid bone
carotid arteries
jugular veins
trachea and larynx
Cervical Vertebrae: The neck contains seven cervical vertebrae numbered from skull downward as C1-C7 (Image A). C1 is also known as the atlas; C2 is the axis.
Cervical vertebrae are smaller and more delicate than thoracic and lumbar vertebrae; this is especially true of C1 and C2. Collectively, all seven cervical vertebrae form the cervical skeleton and are bound together by strong ligaments.
Vector illustration of cervical vertebrae. Medical scheme with close-up skull and isolated C1 atlas, C2 axis, C3, C4, C5, C6 and C7 vertebra. Diagram of Intervertebral disc and anterior tubercle.
Image A
Hyoid Bone: The hyoid bone and cervical vertebrae are the only bones in the neck . The U-shaped hyoid (Image B, red) is unusual because it is the only bone of the body that does NOT articulate with other bones. Rather, it is suspended in the neck via muscles and ligaments connecting to neighboring bones and cartilages. More detail on hyoid and cervical vertebrae in Anatomy Lesson #12, Claire’s Neck – The Ivory tower.
Try This: You can palpate your own hyoid bone. Hold chin parallel to floor. Place thumb and forefinger of one hand on either side of your larynx (voice box). Move fingers upward until just under mandible. Squeeze gently, then swallow. You will feel a thin hard structure on each side, the R and L arms of the hyoid.
And, for book readers, Diana wrote about the hyoid bone in Written in My Own Heart’s Blood.
Image B
Common Carotid Arteries: The neck has a R and a L common carotid artery; each is a primary or secondary branch of the aorta arch (Image C).Common carotids straddle trachea and larynx (Image C -blue/green structures) before splitting into internal and external carotid arteries which supply blood to neck and head.
Image C
Jugular Veins: The neck has two jugular veins on each side; external and internal jugulars. These drain blood from head and neck structures toward the heart Image D).
Image D
Trachea and Larynx: All of larynx plus upper trachea lie in the neck. Both are conduits for air to reach the lungs during inhalation and to leave the lungs during exhalation. In addition, the larynx produces vocalizations. Trachea and larynx provide the only normal route by which air can move to and from the lungs. Of course, a tracheotomy is an exception, but it is also not normal. (Psst…No S5 spoilers frombook readers, please!)
Image E shows trachea and larynx. Tracheal wall is stiff due to cartilage plates. The complex larynx consists of nine cartilages of various shapes and sizes. Learn more about the larynx in Anatomy Lesson #42, “The Voice – No, not that One!”
Image E
Now, for some info about hanging.
Hanging: One might think hanging is a rather simple act, but it is not. There are many types of hanging although death is typically from either strangulation or neck fracture. Here are three common types of hanging.
*Short Drop: A condemned person is placed on a stool, ladder, cart, horse, etc. with noose around the neck. The object is removed leaving the person dangling from the rope. Although the person is unconscious within 15 seconds, death usually takes 10-20 minutes as the noose tightens causing slow strangulation.
*Standard Drop: A condemned person drops 4-6 feet (1.2-1.8m). This is considered more “humane” than short drop because it typically fractures the neck which traumatizes spinal cord and causes immediate unconsciousness and rapid brain death.
*Long Drop: Drop varies. Height and weight of the condemned were used to calculate the drop needed to fracture the neck, preferably at C2, the axis. This is known as a hangman’s fracture.
Yes, I know! Horrifying to think about, but charts were developed to augment a swift death, the preferred outcome.
Submental Knot: Submental means “under the chin.” Careful placement of the eye or knot of the noose under the chin jerks the head backward, contributing to neck fracture. Side and back knots tend to strangle rather than fracture the neck.
Back to Outlander: So, with knowledge about vulnerable neck structures and types of hangings plus their effect on anatomy, let’s review Outlander hangings.
What about Taran from ep 115, Wentworth Prison? Taran was pushed off a not-very-tall scaffold – so in effect a short drop. Sadly, it didn’t break his neck and the Watchman kicked and struggled at the end of the noose! A member of the execution squad pulled down on his legs to break his neck, an act that was often required to end the misery. Of course, Jamie and other condemned prisoners witnessed this horror!
And, then there’s Hayes. Although his end was swift in Drums of Autumn book, not so in the episode. He did experience either a standard or long drop but afterward, his face is red and bloated and his eyes bloodshot. These findings are more consistent with strangulation than neck fracture, meaning his jugular veins were obstructed leading to death by brain edema and ischemia, wherein:
Bleeding in conjunctiva overlying whites of eyeball (subconjunctival hemorrhage)
So the FX were very good but not well-matched for this type of hanging.
Just so we know, if the deeper lying common carotid arteries are occluded by strangulation, the face appears pale or white.
And, sphincters do relax spontaneously so urine and feces are evacuated. Thankfully, these weren’t part of the FX scheme! 😱
And poor Rufus! Impalement by hook is a very old punishment occurring in Babylonia! Later, it was used in 18th-century Ottoman-controlled Bosnia and by Dutch overlords in Suriname (South America) who impaled troublesome slaves under the ribs.
An 18th century observer recorded that an impaled person could hang as long as three days before expiring. The primary source of pain was extreme thirst.Thankfully, this type of hanging has been pretty much abandoned.
As for the hyoid bone…. It fractures in about a quarter of hangings but is not the cause of death. Forensic scientists look for a fractured hyoid in suspected homicides because about 50% of hyoids fracture with manual choking.
Fracturing the hyoid bone depends on applied force, age of victim, nature of instrument (ligature vs. hands) so even if the bone is not fractured, a murder is still possible (Image F –red arrow).
Image F
Today, we can be grateful that many countries have abandoned hanging as a means of punishment. An excellent film is available on this topic: Pierrepoint: The Last Hangman. Bonus! Tobias Menzies plays Lieutenant Llewelyn!
In Jamie’s time, hanging was an ignoble death. Why, we might ask? Here is one reasonable thought:
“The sword connoted an honourable way of dying, and an honourable return to the earth, but the rope left the body hanging between heaven and earth and was therefore an unseemly death.”
