he bladder by a
horse falling on its rider. In this case there was but little
extravasation of urine, as the vesical aperture was closed by omentum
and bowel. Assmuth reports two cases of rupture of the bladder from
muscular action. Morris cites the history of a case in which the
bladder was twice ruptured: the first time by an injury, and the second
time by the giving way of the cicatrix. The patient was a man of
thirty-six who received a blow in the abdomen during a fight in a
public house on June 6, 1879. At the hospital his condition was
diagnosed and treated expectantly, but he recovered perfectly and left
the hospital July 10, 1879. He was readmitted on August 4, 1886, over
seven years later, with symptoms of rupture of the bladder, and died on
the 6th. The postmortem showed a cicatrix of the bladder which had
given way and caused the patient's death.

Rupture of the bladder is only likely to happen when the organ is
distended, as when empty it sinks behind the pubic arch and is thus
protected from external injury. The rupture usually occurs on the
posterior wall, involving the peritoneal coat and allowing
extravasation of urine into the peritoneal cavity, a condition that is
almost inevitably fatal unless an operation is performed. Bartels
collected the data of 98 such cases, only four recovering. When the
rent is confined to the anterior wall of the bladder the urine escapes
into the pelvic tissues, and the prognosis is much more favorable.
Bartels collected 54 such cases, 12 terminating favorably. When
celiotomy is performed for ruptured bladder, in a manner suggested by
the elder Gross, the mortality is much less. Ashhurst collected the
reports of 28 cases thus treated, ten of which recovered--a mortality
of 64.2 per cent. Ashhurst remarks that he has seen an extraperitoneal
rupture of the anterior wall of the bladder caused by improper use of
instruments, in the case of retention of urine due to the presence of a
tight urethral stricture.

There are a few cases on record in which the bladder has been ruptured
by distention from the accumulation of urine, but the accident is a
rare one, the urethra generally giving way first. Coats reports two
cases of uncomplicated rupture of the bladder. In neither case was a
history of injury obtainable. The first patient was a maniac; the
second had been intoxicated previous to his admission to the hospital,
with symptoms of acute peritonitis. The diagnosis was not ma