Sir,
It is with interest that I recently read the case of hanging from an indigenous rocking cradle reported by Saha et al.[1] I would like to point out, however, some language issues that have implications on mechanisms of death and pathophysiological concepts.
Firstly, strangulation should not be used as a synonym for hanging. Strangulation is defined as asphyxia by closure of the blood vessels and/ or air passages of the neck as a result of external pressure on the neck.[2] It is subdivided into three main categories: hanging, ligature strangulation and manual strangulation. The distinction between these three entities is attributed to the cause of the external pressure on the neck — either a constricting band tightened by the gravitational weight of the body or part of the body (hanging); a constricting band tightened by a force other than the body weight (ligature strangulation); or an external pressure by hands, forearms or other limbs (manual strangulation). Strangulation being an imprecise term, the usage of term hanging would have been preferable in the case presented by Saha et al.
Secondly, two types of hanging are recognized — hanging with complete free suspension of the body (complete hanging); and hanging with incomplete suspension, with part of the body supporting the victim's weight (incomplete or partial hanging).[3] Saha et al. describe their case as being that of a partial hanging; whereas in the Figure 3 of their paper, the feet of the child are in free suspension above the ground.
Thirdly and most importantly, hanging with a fall from height is not a typical form of hanging and is not a subtype of strangulation. [2] Indeed, hangings after jumping or being pushed from height (including judicial hanging) are very different in nature from typical hangings. Death in these cases is related to fracture-dislocation of the upper cervical vertebrae rather than by asphyxia. This confusion explains the following comments in the report by Saha et al.: “Spinal cord injuries are uncommon in pediatric strangulation.” In fact, spinal cord injuries are virtually nonexistent in hanging and strangulation, whereas they are the most commonly encountered lesions in hanging with a fall from height.
When the term hanging is used appropriately, with the exclusion of fall from height, only three possible mechanisms of death have been proposed — closure of the blood vessels of the neck; compression of the air passages; and vagal inhibition by pressure on the baroreceptors in the carotid sinus and the carotid body.[3,4] Recent studies of filmed hangings by the Working Group on Human Asphyxia have clearly demonstrated that, in all cases deep rhythmic abdominal respiratory movements were not only visualized but were also audible.[3,5] These studies challenge the theory of airway obstruction. Furthermore, the analysis of the witnessed agonal sequence is more in favor of the hypothesis of death being caused by compression of the blood vessels than by vagal inhibition.
These comments do not undermine the interest in the case presented by Saha et al. It is just a reminder that language does matter, and that different terms connote different mechanisms of death and pathophysiological concepts.
REFERENCES
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