ABDOMEN 275 A young Mahomedan male died after receiving a kick from a horse. On post- mortem examination on the 21st February 1926, fourteen hours after death, there was no external injury, but the left ninth rib was fractured, the fractured ends projecting inwards. The spleen, which was normal, was lacerated and divided almost into two parts across the middle of its outer surface with triradiate tears on its inner surface. The left kidney was also lacerated in two places on its outer surface. An enlarged spleen becomes softened and brittle. Hence it is liable to rupture from a fall or from violence of a very slight degree. In such cases the abdominal wall may not show any external mark of injury. During a period of eight years, I met with thirty-six cases of rupture of the spleen as a result of falls and blows. Of these cases six showed marks of bruising on the abdominal wall over the splenic region and in one the left ninth and tenth ribs were fractured. Rupture usually takes place in its .concave or inner surf ace, and causes death rapidly from haemorrhage owing to its great vascu- larity. There may be frequently more than one rupture from a single blow, and its substance may rupture leaving the thickened capsule intact. In such a case death may be delayed for some days, as the capsule limits the rupture or prevents excessive bleeding, and the small quantity of blood, which has already effused under the capsule forms into a clot, and presses on the rupture and prevents further bleeding. But with sudden muscular exertion or excitement, the clot is disturbed, further bleeding occurs and death takes place immediately. Thus, an old punkha cooly in the Agra Fort, who had his spleen ruptured by a kick on the left side of the abdomen, appeared to be all right for three days, and died on the fourth day, when he went to his village in a jolting ekka. Crawford48 records a case in which a Mahomedan boy, aged fifteen years, survived for seventeen days after the spleen and left kidney were ruptured, and three bones of the skull were fractured. Chevers49 mentions the case of a soldier, who died oa the eighteenth day after receiving a blow which ruptured the enlarged spleen. Rupture of an enlarged spleen from very slight violence is a common occurrence in districts where malaria and kala-azar are prevailing, and every medical jurist is familiar with such cases. Sometimes, the enlargement is so great that its length is more than fourteen inches and its breadth more than eight inches, while the weight is often more than four pounds. Of all the enlarged spleens that were seen ruptured in the Agra District between 1909 and 1910 (the years of a high malarial inci- dence) the smallest spleen measured 6" X 5" X 2" and weighed nine ounces; while the largest measured 13" X7"X2J" Fig. 129.óRuptured spleen. and weighed four pounds and eight ounces. An enlarged spleen may sometimes rupture spontaneously from the contraction of the abdominal muscles during the act of sneezing, coughing, vomiting, or straining, and some cases of this nature have been recorded (see cases below). Rare cases have also been reported in which it is claimed that a perfectly healthy normal spleen has ruptured spontaneously. It is difficult to believe that a normal spleen can rupture suddenly without apparent cause. It is, however, possible that occasionally, in certain individuals and at certain phases, a healthy normal spleen may rupture from minimal trauma. If the capsule is intact in such a case, the symptoms may be delayed for hours or days, and when eventually the patient collapses 48. Ind. Med. Gaz^ June 1902, p. 219. 49. Med. Juris., Ed. m, p. 461.