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264                                               MEDICAL JURISPRUDENCE


Injuries of the chest are mostly accidental, occasionally homicidal, and
rarely suicidal.

Traumatic Asphyxia.—This results from severe compression of the chest
and abdomen sufficient to prevent respiration for an appreciable length of
time, as when an individual is crushed in a dense crowd or under a heavy
object, or caught between the two buffers of a railway carriage. In such
cases the face and neck are deeply cyanosed, accompanied by ecchymoses
of the skin and conjunctivse. This discoloration is brought about by
mechanical overdistension of the smaller veins and capillaries with stasis
of deoxygenated blood. It extends to the root of the neck, and rarely
passes down beyond the level of the clavicles owing to the absence of com-
petent valves in the jugular and facial veins. The discoloration may
disappear in ten to fourteen days without passing through the colour
changes of a bruise, if it is not associated with severe injuries. Coullie 12
describes the case of an epileptic young man, who suffered from traumatic
asphyxia caused by the unyielding collar-band of his shirt compressing the
jugular veins, together with the partial asphyxia, high blood pressure, and
fixation of the chest caused by the epileptic fit.

Wall.—Contusions and abrasions of the chest wall may be caused by a
blunt weapon, fall or crush under a heavy weight as in vehicular accidents.
These may be accompanied by fractures of the ribs or sternum, or associated
with grave visceral injury. Even when not accompanied by such injuries
severe blows on the chest wall may produce concussion of the chest causing
considerable shock followed by death.

Simple contusions and abrasions of the chest wall may be followed by
pleurisy or pneumonia.

Wounds of the chest wall are not dangerous, unless the cavity is pene-
trated and a vital organ is injured. In non-penetrating wounds there may
be free haemorrhage from the divided mammary and thoracic arteries.

Ribs.—Fracture of the ribs results from direct violence, as by blows or
stabs, and from indirect violence as in compression of the chest or very
rarely from muscular contraction during violent coughing, sneezing, or
straining. When due to direct violence it is more dangerous, as the splinters
are driven inwards and are likely to injure the underlying pleura, lungs,
heart, large vessels, liver, or diaphragm, while in indirect violence fracture
occurs at the most convex parts of the ribs near their angles, and the frag-
ments are driven outwards. The ribs that are most frequently fractured are
the middle ones, viz. the fourth, fifth, sixth, seventh and eighth, as they are
most prominent and fixed at both ends. The upper ribs are not usually
fractured unless very great force is used, when the lesions of the viscerar
as a rule, occur. The lower ribs often escape on account of their great mobi-
lity. Owing to diminished elasticity and increased brittleness of bones in
old age, rickets, osteo-malacia, general paralysis of the insane and general
wasting diseases, fracture of the ribs is liable to occur easily from the
slightest violence.

Symmetrical^fractures of the ribs on both sides are often met with,
when a person sits on the chest and compresses it considerably by means
of the knees or elbows, by trampling under feet, or by means of two
bamboos, a -process known as "bans dola. They may also occur in accidents
as in a fall from a height, or when run over by a heavy bullock cart or
motor car or when caught between railway buffers. In such cases the ribs
are often fractured in front near the costal cartilages, where the compress-

12.   Brit. Med. Jbwr, Sep. 29, 1928, p. 569.