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ABBOMEN                                                           279

crushed between the buffers of a railway carriage. They are also apt to be
injured when the body is violently flexed forwards at the lumbar region*
Kupture may prove rapidly fatal from collapse or haemorrhage, or more
slowly from peritonitis or suppuration caused by extravasation of urine.
Slight rupture may result in recovery.

E. W. Riches 54 reports the case of a man, aged 24 years, who lived for eleven
days after rupture of the right kidney sustained by him when a lorry knocked one of the
handles of his wheelbarrow violently into his sides. Fowler Ward54 cites even a case
of recovery from a ruptured kidney without an operation.

Bladder.—Rupture of the bladder may be produced generally at the
posterior and upper surface by blows, crushes or kicks on the hypogastrium,
especially when it is distended with urine. Sometimes, very slight violence
may rupture the bladder without any external sign of injury. Rupture may
also occur from a fall, from fracture of the pubic bone, or from a sharp
weapon penetrating through the vagina or rectum.

In June 1923, a woman, 25 years old, was run over by a tonga, and died in a few
hours. On examination there was no external mark of injury, but on opening the
abdomen an oblique transverse ecchympsis in an area of three inches by two inches
was seen in the substance of the muscle in the left iliac region. The pelvic cavity-
contained blood. The bladder was found lacerated to an extent of two inches in the
tipper surface and was covered on the inside with clotted blood.

On the llth November 1923, a woman was run over by a bullock cart and died
immediately. There was no external mark of injury to the abdominal wall, but there
was extravasation of blood in the muscles of the abdomen across its lower part above
the pubes with rupture of the bladder in its upper part and fracture of the pubic and
iliac bones.

Spontaneous rupture of the normal bladder is rare, almost impossible,
though it may occur in its base from over-distension when it is diseased or
ulcerated, or when there is an obstruction in the urethra from stricture,
enlarged prostate and tumour. Similarly, it is liable to rupture in females
during parturition, owing to the pressure of the child's head, if the bladder
is over-distended. Persons who are habituated to excessive indulgence in
alcohol or opium are apt to go about with a distended bladder owing to the
depressed effect on the nerve centres. In such a condition slight pressure
or an accidental fall on the lower part of the abdomen may be sufficient to
rupture the bladder.

The symptoms of rupture of the bladder are pain, tenderness in the
abdomen, rigidity of the abdominal muscles, inability to pass urine and the
presence of blood in the urine. In some cases the symptoms may be delayed
for eight hours or more. The patient may be able to walk for some time
after receiving the injury.

Death may occur suddenly from shock, but usually occurs in three to
seven days from peritonitis due to the extravasation of urine into the
peritoneal cavity, or from suppuration and sloughing due to urine being
extravasated into the cellular tissue if the bladder is ruptured at its extra-
peritoneal portion. Taylor5C cites a case in which death did not take place
until the fifteenth day.

Uterus.—The non-gravid uterus is not ordinarily injured unless involved
in the injuries of the pelvic organs, but the gravid uterus is likely to be
ruptured by a blow, kick, or trampling on the abdominal wall, or by the
passage of a sharp instrument per vaginam to procure abortion. Death may
result from hemorrhage, peritonitis, or septicaemia. The pregnant organ
may also be ruptured during injudicious obstetrical operations or by con-
tinued, tonic spasm during parturition, especially in obstructed labour.

54.   Proceedings of the Royal Society oj MecL, Feb. 1931, p. 470.

55.   Princ. and Pract. of Med. Juris., Vol. I, Ed. X, p. 384.