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Letter to the Editor |
Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, e-mail: fhall{at}bidmc.harvard.edu
Editor:
I very much enjoyed the article by Lee et al on musculoskeletal colloquialisms in the July–August 2004 issue of RadioGraphics (1), and offer a few additional comments and observations on a few of the terms defined by the authors.
Colloquial is defined as informal, slang, or conversational, and certainly hip fracture is one of the more common and inappropriate colloquialisms used in musculoskeletal medicine (2,3). Of course, hips, knees, and other joints do not fracture. The term still regularly appears in manuscripts, and as a reviewer, I generally take a dim view of these documents.
Lee et al (1) state that "a hangman fracture consists of bilateral fractures through the lamina or pedicles of the axis (C2)." The more appropriate term is "hangee" fracture, because it is not the hangman who is injured. If medieval hangmen had suffered this fate every time they performed their duties, that entire profession would have been rapidly decimated, with presumed difficulty in recruiting a new workforce.
Lee et al (1) describe the gamekeeper thumb, named for a characteristic injury to the ulnar collateral ligament of the thumb during the twisting or snapping of necks of rabbits and other small game. Medieval gamekeepers were the keepers of the hounds on large estates. In preparation for hunts, they trained and exercised these dogs by dragging meat, tied to a rope behind a horse, through the fields and forests. Since there was no refrigeration, meat was preserved by salting and in smokehouses. Atlantic herring, which turn brownish red when smoked, were a favorite among gamekeepers for the dog training exercises because of the meat’s particularly pungent odor. This history illustrates the derivation of another radiologic and general colloquialism, the red herring or false trail.
References
Department of Radiology, University of Arizona College of Medicine, 1501 North Campbell Avenue, PO Box 245067, Tucson, AZ 85724–5067, e-mail: tbh{at}3towers.com
We appreciate Dr Hall’s kind remarks about our article on fracture colloquialisms and his comments concerning appropriate fracture terminology (1). We are afraid we are guilty of using the term hip fracture in our writings and daily practice. Although we agree the term is out of step with our description of fractures in other joints, we believe its use by radiologists and other physicians is too ingrained for it to disappear in favor of more appropriate terms.
Dr Hall suggests replacing the term hangman fracture with "hangee fracture," because it is not the hangman who is injured. His suggestion is reasonable, but as with the term hip fracture, we feel its use is too ingrained to be easily changed. Moreover, the term may be appropriate as used. The hangman had an important mission to fulfill from the point of view of both society and the hangee. If the hangman was sloppy, uninformed, or intentionally malicious or sadistic, he could arrange for a particularly long, suffering death for the prisoner by asphyxiation rather than a rapid neurologic death by injury to the brain or spinal cord (2,3). It is his handiwork that is being celebrated by this colloquial term. A detailed history of judicial hanging is summarized by Schneider and colleagues in 1965 (4). It is interesting to note that judicial hanging was long the official mode of execution of the common felon in the British Isles, whereas death by decapitation remained the prerogative of individuals of royal or noble blood (4).
In a succinct one-page article in 1913, Wood-Jones described "the ideal lesion produced by judicial hanging" (3). To quote from this article: "Men were at one time hanged by the neck until they were dead-ie, strangled; and at that time as many old prints depict the knot was suboccipital. With the introduction of the "drop" in 1813, this knot was found unsuitable and a subaural knot was used. I imagine that these series of lesions will show clearly what many have advocated for years, that the submental knot should now supercede the subaural knot in our English judicial hangings." The suboccipital knot produced death by asphyxiation, and the subaural knot produced death by asphyxiation or fracture of the base of the skull, either of which would cause a very bad death (3).
Wood-Jones advocated the submental knot because it led to a fracture dislocation of the axis from the C3 vertebra. According to Wood-Jones, ". . . the posterior arch of the axis is snapped clean off and remains fixed to the third vertebra, while the atlas, the Odontoid process, and the anterior arch of the axis remain fixed to skull." He surmised that instantaneous death was produced by the abrupt severance of the high spinal cord.
Schneider and colleagues first introduced the term hangman fracture into the modern medical lexicon in 1965 when they described eight patients who sustained bilateral fractures through the neural arch of the axis, with or without dislocation of the body of the axis from that of the third cervical vertebra (4). According to these authors, "This type of fracture-dislocation occurs in modern judicial hanging and in some instances of traffic accidents" (4). They did comment that permanent neurologic deficit rarely occurs with these injuries from automobile accidents. They did not comment on why victims of hanging died rapidly from such injuries, whereas victims of automobile accidents often escape long-term serious sequelae. Most likely, the forces involved in judicial hanging are much greater than those sustained by many motor vehicle accident victims, and the spinal disruption between C2 and C3 caused by judicial hanging is considerably greater.
From these considerations, we see that the role of the hangman was more involved than is first apparent, and that the issue of how one dies by judicial hanging is complex. As far as we know, judicial hanging is no longer used in North America or Europe, but the term hangman fracture remains, and the term may be appropriate because of the role of the hangman in determining the type and quality of the prisoner’s death.
We also enjoyed Dr Hall’s elucidation of the term red herring. Although we have nothing to add to his interesting information, we have obtained permission from the Journal of Bone and Joint Surgery (British) to illustrate the "gamekeeper thumb" with the original figures from the 1955 article by Campbell (Fig) (5). According to Campbell, "[injury to the ulnar collateral ligament of the metacarpal phalangeal joint of the thumb] . . . is so common among gamekeepers as to constitute an occupational characteristic . . . there are other occupations [and sports] in which a similar strain constantly applied to the inner side of the thumb could cause a comparable ligamentous laxity . . . however, the condition is so characteristic that a recent patient who denied being a gamekeeper later admitted an extensive interest in the poaching of rabbits (5)."
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