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A CONTRIBUTION TO THE STATISTICS
OP
RTJPTUEE
OF THE
URINARY  BLADDER;
WITH
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w
A TABLE OF SEVENTY-EIGHT CASES.
          BY

   STEPHEN SMITH, M. D.

ASSISTANT SURGEON TO BELLEVUE HOSPITAL, NEW-YORK,
[REPRINTED FROM THE NEW-YORK JOURNAL OE MEDICINE.]
^ftj'o
         NEW-YOBK:
JOHN F. TROW, PRINTER, 49 ANN-STREET.
            1851. 
 
STATISTICS
RUPTURE  OF THE URINARY BLADDER.
 The case of rupture of the urinary bladder, published  in the
last No. of this Journal, occurring to parties known to me per-
sonally, I was led to make a collection, as far as in my power,
of the reported cases of this  lesion, at first only with reference
to the  legal settlement of that case, but subsequently, to  ap-
pend them to it  in a tabular form when  published.  Beside
their incompleteness at  the issuing of the March No. of the
Journal, I was convinced upon reflection,  that their separate
publication, with such  conclusions as they necessarily enforce,
would  be the most useful disposition I could make of them.
   The importance of  this collection is  seen in the various
views  of writers upon this subject, and the conflicting  and
often contradictory testimony of medical witnesses in the suits
at law  which these accidents frequently involve.  This arises
in great part from the limited  experience of every, even  the
most extensive practitioner, of cases of such rarity;  and  the
difficulty of examining a sufficient number  to  come to safe
general conclusions without extraordinary painstaking.   The
history of no disease is complete without the record of a suffi-
cient number of cases to establish every class  of symptoms,
which  variety of constitution or  circumstance  may develop;
and hence the importance and necessity of a collection of well
authenticated cases of every disease ; especially if that disease 
4             Smith on Rupture of the Bladder.
 is of frequent, but not common occurrence; and still more if it
 involves  the practitioner in the expression of a medico-legal
 opinion.
    For the sake of comprehensiveness, and to facilitate refer-
 ence, I have arranged them in the form of tables;  by which
 many cases otherwise deserving a full record are necessarily
 much abbreviated ; but where cases thus lose in their individ-
 ual  interest, their collective importance  far more than com-
 pensates for this mutilation.  To those who have undertaken
 a similar  task I need  but hint at the pe%lexity under which I
 have labored in finding cases imperfectly reported; and to this
 circumstance I must refer the apparent deficiency in many
 cases;  all will be found, however, to have some points suffi-
 ciently important to make them valuable in a collection where
 we wish to obtain only the aggregate.
    It is not presumed that these  tables  comprise all the pub-
 lished cases of this  accident,  but only  as many as limited
 opportunities to consult the volumes and periodicals  of a large
 medical library would admit of collecting.   Reference  was
 had  to cases in foreign  journals quite  impossible to obtain ;
 and  others to catalogues* of pathological museums placed still
 further beyond the ordinary means  of consultation.
    The literature of this affection is very imperfect, consisting
 principally of briefly reported  cases, with  a few  comments
 upon them by their writers.  Dr. Cusack published,  in  the 2d
 volume of the  Dublin Hospital  Reports, the  histories of two
 cases, and  added  some  valuable  remarks.  Nothing further
 appeared  but  occasional cases until the publication of Dr.
 Harrison's paper  in  the Dub. Jour.  Med. Sci. volume IX,
 1836; who is indeed the only  author  who  has made it the
 subject of extended and critical remark.   Subsequent authori-
 ties have  justly referred  to his article, as containing the most
 complete exposition of the symptoms, diagnosis, and  treatment
 of this  lesion;  for in  these  particulars he has left but little to
 be added,  except what future cases  have revealed.   The larg-
est number of cases reported at one  time, were by Mr. Hewitt;
published  in the Lond. Med. Gaz.  April 26th, 1850.  In this

  * See Descriptive Catalogue of the Path. Specimens contained in the Museum
of the Royal Coll. of Surg, of Eng., vol. iv., p. 74. 
               Smith on Rupture of the Bladder.             b

 country but few cases have  been reported, although they are
 of not infrequent occurrence in our hospitals.
     The following  remarks will  be founded entirely upon the
 results of these tables ; and the inferences drawn in reference
 to symptoms, diagnosis, prognosis, treatment, &c, will be sus-
 tained  by reference to the  conclusions  under  these  several
 heads.

                       Sex and Age.
     The frequency of this lesion in  the adult male as compared
 with the female  is attributed by Dr. Harrison to  the greater
 size of the female  pelvis, the cavity of which  is not so exten-
 sively occupied by the bladder when this is full of urine.  Nor,
 says he, does the bladder incline so much  backwards as in the
 male; on the contrary it inclines more forwards, and enlarges
 more in the  transverse direction, while the uterus and its late-
 ral broad folds may assist  to  break the shock of any external
 violence, applied to the hypogastric region, and so prevent the
 direct concussion of the bladder against the sacral promontory.
 It would seem from a remark of  this author, that no cases of
 this accident in the female from external  violence had come
 under his observation or notice, previous to the publication of
 this article;  and hence this explanation loses much of  its sig-
 nificancy  in the fact that such cases have  occurred under
 similar circumstances as in the  male.  Although the relation
 of the bladder to the pelvis and uterus in  the female tends  to
 diminish  the chances of severe injury to the former,  that it
 proves an exemption from this accident these tables  abundantly
 disprove.  Attaching to this  opinion a relative importance, a
 more satisfactory explanation may be found in the difference
 of habits, mode of life, &c, of the two classes.
    In the large majority of instances the subjects  of this injury
 have been intoxicated and engaged in pot-house brawls, the
 first  circumstance  predisposing them to a distended bladder.
 and  the latter to unresisted,  direct, external violence;  others
 have fallen under carts,  from heights, and  upon  hard bodies,
 and under each class of causes rendered themselves the subjects
of direct injury.  The female, though often the subject of abuse
and violence, is far less disposed to  confirmed habits of intern- 
6             Smith on Rupture of the, Bladder.

perance ; and infinitely less to the exciting causes of this acci-
dent, blows, falls, &c.; from the fact that her duties  lie within
doors, where  even her fits of intoxication may pass off without
the liability to external injuries.  But direct violence applied
to the distended bladder of the female must, as shown by these
tables, result  in rupture of that viscus, with all the attendant
consequences.  This explanation is further shown to be the
correct  one,  in  the fact that no cases of this  accident are
recorded,  where  the  subject was  above 60  years of age;
because at  this period  persons  may be considered  as having
retired from the active duties of life.
   The frequency of this injury in trie adult  male over the
boy is attributable to the circumstance that the latter seldom
allow the bladder to become  inordinately distended; but when
distended and relaxed, it is exposed as in the female and adult
male to rupture on the application of a direct blow.
   The period of life at which this lesion is most liable to occur
is between  the ages of 30 and 40; this period comprising about
one-third of the cases  given in these tables.   The next most
frequent, being between the ages of 20 and 30.   Taking the
number included between the  ages of 20 and 40, and adding
to this  the adults of whom   the precise age is not  given, but
which  most  probably come  within this period, and we have
more  than three-fourths of  all  the  cases that occur.   This
period occupies the most active part of man's life—when he
is  especially  exposed  both  by confirmed habits and active
occupation to the  predisposing and  exciting  causes of  this
accident.   The extreme infrequency of this lesion under 20
years of age, and its non-occurrence above  60,  can  only be
thus explained.

                        Condition.
  The state of the  bladder,  most subject  to this accident, is
that of distension.  In  more  than half of the cases in which its
condition is given, at the time of the injury, it was distended ;
and adding to these the number of cases  of which the only
note is, that the persons were intoxicated ; and in which the
strong probability is, that the bladder was  distended;  and we
have a vast majority in the distended state.  In this condition, 
1851.]         Smith on Rupture of the Bladder.             7

the bladder approximates the solid viscera ; having for its sub-
stance a fluid, but incompressible material, and for its capsule,
a tightly drawn and overstretched membrane, scarcely capable
of containing its gradually increasing contents, when quiescent;
and much less so when agitated by a direct blow or general
concussion.  The bladder empty, and contracted down within
the pelvis, can only be injured by such a degree of violence as
shall separate the symphysis pubis, or crush the pelvic bones.

                          Causes.

    The causes of rupture  are direct  or indirect violence, con-
cussion, or internal causes.  In the  majority of cases,  direct
violence has been the cause;  in several cases, concussion, as a
fall from a height,  has  resulted in rupture of this organ ; the
fluid contents, in these  circumstances, remaining a solid re-
sisting body, only sufficiently  disturbed by the general agita-
tion to  give a sudden and  fatal determination to some part of
the bladder.  Civiale* remarks, that  when this accident results
from a  blow, fall, concussion, or any direct violence impinging
upon the  bladder, when full of urine ; the rupture depends upon
the impulsion given to the liquid by the sudden force  commu-
nicated.   The internal  causes are strictures, resulting in over
distention, ulceration, and consequent rupture, or violent strain-
ing to overcome the impediment to the escape of urine; pres-
sure of the child's head upon the urethra,  during a protracted
second  stage of labor, giving rise to fatal distention from an ac-
cumulation of urine, or finally, retroversio uteri, in which the
mal-position of  the  uterus had the same mechanical effect in
causing retention as the  child's head  during labor.  Three
cases of rupture, from violent  efforts to evacuate the bladder
when retention  was  caused by stricture, are given  in these
tables;  the first, case  8,  rupturing  into  the  cellular tissue ;
the second, case 2, into the cavity of  the peritoneum; and the
third, case 29, being only a partial rupture. A case of this kind
is given by Mr.  Brodie, (Dis. Urin. Org.)  but is too imperfect
for  our  use.  The case of partial rupture, by Mr. Keal, though
reported and referred to as authentic, and as such entitled to

  * Maladies des Organes Genito  Urinares, par M. Citiale.  Paris, 1812.  Vol.
ii.  p. 261. 
 8            Smith on Rupture of the Bladder.

 a place in these tables, admits of some doubts as to its correct-
 ness.  Rupture in the parturient female, of which four cases are
 given, depended in two upon a long protracted second stage ; in
 one the labor was easy, in one not given.   In a fifth, the cause
 of rupture was, pressure of the retroverted uterus in a pregnant
 woman upon the urethra, causing fatal retention.

                        Symptoms.
    The symptoms of rupture  of the  bladder may be  severe,
 slight, or absent.   When severe, they consist  of collapse, in-
 tense pain in hypogastric region, a great desire but incapacity
 to expel urine,  rapid feeble pulse, hot skin, thirst, and in the
 progress of the case, all the symptoms of peritonitis ensue, as
 tension, great  tenderness of  the  abdomen,  vomiting, &c.  ;
 power to  void urine may be experienced, or desire but inabi-
 lity to urinate may remain a very aggravating  symptom to the
 last; and when, finally, dissolution approaches, all  the most
 prominent symptoms subside, and the sufferer dies in possession
 of his reason.  In the great majority of cases, severe symptoms
 continue from the first; those of rupture into the  peritoneal
 cavity pursuing the course of  acute peritonitis, those into the
 cellular tissue of urinary infiltration ; or the symptoms may at
 first be slight, even when the seat of rupture is in the posterior
 wall of the bladder, not preventing sleep, or even the usual oc-
 cupation of the patient; but these are sooner or later followed
 by all the most aggravating symptoms of acute peritonitis, and
 death finally  supervenes as rapidly as in the most severe forms
 —or primary symptoms may be entirely absent, as in case 36,
 where the patient, after receiving the  injury, went to a convi
 vial party to  dine, and upon relating the occurrence to a  sur-
 geon, one  of the party, was for the first time informed of the
 nature of his accident, and died in 24 hours after.  In these
 cases, also, severe symptoms usually soon supervene, and death
 follows rapidly.   The desire to evacuate the bladder, generally
 a most harassing symptom, may not exist at  all; though  pre-
 sent immediately before the accident,  as seen in  cases 27, 34,
48, &c.  The power to  void urine  from the first is very rare,
but in many it is developed in the progress of the case.  Loco-
motion, though  generally absent, is not invariably so, as is seen 
Smith on Rupture of the Bladder.
9
in cases 30, 58, &c, in the former of which it was present in a
remarkable degree.   The constancy with which bloody urine
is drawn by the catheter, makes it a very important symptom
in regard to diagnosis ; still it is not always present, clear urine
being drawn  occasionally throughout the whole progress of the
case.

                        Diagnosis.

    The difficulty of diagnosis, in cases of rupture of the urinary
bladder, will  depend  much upon the seat of the lesion, the cha-
racter of the  accident, and the complications which may exist
from injuries of other parts.  In reference to diagnosis, Dr.
Harrison remarks, that, " In general, rupture of the bladder is
attended with such symptoms as to render the diagnosis tolera-
bly clear and certain ; in some instances the nature of the case
is almost manifest to the most superficial observer ;  in  others.
it is more obscure, and will require some close and careful ob-
servation to determine its existence; and in others again, it
may be altogether overlooked from the  pressing character of
some  other more urgent symptom.  As  rupture of the bladder
is the effect of only two species  of injury,  the  account of the
accident may afford much information;  thus every case on re-
cord has been the result, either of some force directly  applied
against the abdomen, such as a blow or  a fall upon some resist-
ing body, or of a fall from a  height causing a general  concus-
sion of the whole frame ; in this latter case, the injury is more
likely to be overlooked, particularly if the individual have suf-
fered  in any other and more obvious manner ; hence after such
accidents, the attention of the practitioner should be early di-
rected to the urinary discharge, and if there be any inability to
pass urine and a desire to do so, the catheter should be intro-
duced, from which, in all probability, some information will be
obtained.   When the rupture has been the effect of violence
directly applied to the hypogastric region, the symptoms are
more  obvious, and the real nature of the  injury can scarcely be
overlooked ; the patient is himself often aware of it, and states
that he knew that his bladder was full of urine at the  time of
the accident,  that he  felt it to burst within him ; together with
                                                     \ 
 10           Smith on Rupture of the Bladder.

 this account, the sensation of sinking sickness, pain in  the ab-
 domen, and peculiar feeling about the praecordia, are all indica-
 tive of the rupture of some viscus.  Should the patient, how-
 ever, have been intoxicated at the time of the accident (no un-
 likely circumstance), the surgeon will be deprived of this infor-
 mation, and must therefore rather depend on  the symptoms
 present: such as the desire to make water without the power
 to do so ;  the severe pain in the abdomen and perinaeum during
 these attempts;  the tense state of the abdomen ;  the general
 fulness, and the absence of any circumscribed tumor, as in re-
 tention of urine ; all these are important features, and charac-
 teristic of this serious injury; finally, the passing of the cathe-
 ter will throw considerable light upon the nature of the case,
 the introduction of this instrument into the bladder being at-
 tended with a peculiar resistance; also  the manner in which
 the urine flows through it,  not in a stream, but as if it merely
 filled and overflowed the instrument slowly ; at one time only
 a few drops passing, at another a considerable  quantity—this
 difference depending on some alterations in the  direction of
 the instrument, or in  the degree of pressure with which it is
 pushed against the bladder, whereby the edges of the rupture
 must be separated, and more  or  less of the  abdominal and
 pelvic  urine be discharged."
    Rupture on the anterior surface or about the neck is more
 generally  complicated  with severe injuries to  the  pelvis and
 other organs, which tends to render their true nature more
 obscure ; but the more prominent symptoms immediately per-
 taining to the bladder are usually present, with infiltration into
 the  cellular tissue and the  resulting  irritation,   sloughing,
 typhoid symptoms, &c.   " If immediately after any accident
 likely to injure  the bladder,  severe pain  follows in the hypo-
 gastric region,  with passage of blood or bloody urine by the
 catheter; if more than a very small quantity of blood is never
 voided at one time, nor drawn off by the catheter ;  if a pecu-
 liar sensation of pressure  against the point of the catheter be
 felt, and if these symptoms be  unaccompanied by  the severe
 prostration of strength and depression of pulse  which  always
follow  peritoneal perforation, rupture of the bladder external
 to the  peritoneum may fairly  be  inferred, and the treatment 
              Smith on Rupture of the Bladder:            11

founded  on the inference."*  In  some cases there may be a
mixture of both classes of symptoms, as in several of the cases
reported by Mr.  Hewitt, where the  peritoneum became  in-
volved and separated from the abdominal wall ; and as in case
8, by Sir E.  Home, where rupture occurred in the anterior
wall from stricture, and the urine infiltrated the cellular tissue
as high as the  umbilicus, where it ruptured the peritoneum and
entered the cavity of the abdomen.


                         Prognosis.

    Although recovery has taken place both  when the rupture
has been into the  peritoneum  and the cellular tissue, yet so
uniformly does it terminate  fatally that the prognosis  cannot
be otherwise than fatal.  Mr. Syme in his " Path, and Practice
of Surgery,"  remarks, that " if the rupture takes place above
or within the  reflexion of the peritoneum,  there cannot be  the
slightest  chance of  escape.  But if the rent is at the anterior
part,  so  as to discharge the contents of the bladder by a sud-
den gush into  the cellular  substance, and condense it  in such a
way that only the portion in contact with the urine  may be
deprived of life;  it appears that  the patient may be  saved by
timely incisions."   Facts, however, prove that rupture  may
take place into the peritoneal cavity, and the patient survive ;
such is case 54, by  Mr. Chaldecott, the diagnosis of which was
confirmed by  Aston Key; another was reported by Mr. Arnott
to the Medico-Chirurg. Soc. in 1843,  the particulars of which
I have not been able to  obtain  (Taylor's Med. Juris., Second
Am. Ed. p. 313);  a third is referred  to by Civiale  as having
been reported by him in Le Parallel.f  Dr. Blundell takes the
opposite  ground in his prognosis  of rupture.  " If," says he, " the
urine is  extravasated in front, I fear there is little to be done;
inflammation, sloughing, death,—these are successively the fate
of your unhappy patient.   If, however, instead of the anterior
rupture, there is a laceration of  the bladder behind, so that al]
the urine escape into the peritoneal sac, I conceive there is yet

   *Mr. Wells. London Medical Gazette, N. S., 'Vol. xxxvi. 1845.
   f Civiale Op. Cit. p. 260. 
12            Smith on  Rupture of the Bladder.
something  which might  perhaps  be  attempted."*   These
instances of recovery,  together with those in which nature
seems  to have made an effort to repair  the  lesion,  but  was
rendered abortive by  the  imprudences of the patient, as  in
cases 22, 32, &c, must encourage the practitioner to promptly
meet all the indications which may occur, and not despair of
a favorable termination.
   Of the  fatal cases the majority  die  within five days from
the receipt  of the injury; somewhat less than  \  between the
5th  and 10th  days, while  within  10  days,   more  than  \
prove fatal; those which survive  this latter period are rare ex-
ceptions, especially  when  the rupture  is into the peritoneal
cavity.
                       Pathology.
   The pathology of rupture of the bladder,  consists of the
morbid appearances in the  cavity of the abdomen, when rupture
takes place in this region ; of the  seat of rupture in the bladder
and the morbid appearances of this viscus ; and finally, of those
changes  which infiltration  of urine  and inflammation may
cause when rupture is into the cellular  tissue, and external to
the peritoneum.
   When urine is extravasated into the peritoneal cavity, we
have the exciting cause of acute  peritonitis,  and in the vast
majority of cases this  affection is  rapidly developed, and its
autopsical evidences are usually well marked.   Urine is gener-
ally found in the cavity of the peritoneum, but not invariably
when the rupture is in  the posterior wall of the bladder ; when
not found  the  patient  has usually  had  power to expel urine,
and  by this  means its  collection had been prevented.   The
signs of inflammation  are generally much more abundant in
the region  of the bladder, especially in the pelvic cul-de-sac,
where the urine tends to collect; and about the rent, consisting
of effusions of lymph and adhesions of the folds of the intestines
to each other  and to  the  bladder;  in some cases forming
pouches which circumscribe the  effused urine and prevent  its

   * Principles and Practice of Obstetric Medicine, by James Blundell, M.D.,
late Prof, of Obstetric Medicine, at Guy's Hospital, London.  Lee and Rogers'
edition, 1840,  p. 862. 
              Smith on Rupture of the Bladder.           13

further extravasations, and a thick coating of lymph upon the
pelvic peritoneum.   The marks of inflammation are frequently
though not universally slight in the upper part of the abdomen,
which the urine does not perhaps reach;  or at least where it
does not collect.  In some cases the peritoneum has been strip-
ped off from the abdominal walls as high  as the umbilicus,
depending upon the infiltration of urine into the cellular tissue
consequent upon a rupture external to  the peritoneum.  The
exceptions to this rule  are  where there are no signs of peri-
tonitis or inflammation within the peritoneal  cavity,  though
the rupture has been through the posterior wall of the bladder,
as  seen in case  57,  by Mr. Bower, where all the prominent
symptoms of peritonitis were present, but not a trace  of inflam-
mation after death.
    By far the most frequent seat of rupture is in  the posterior
wall, into the peritoneal  cavity, and  generally the result of
direct violence.   Rupture may, however, occur in the anterior
wall from direct blows upon the  bladder, and even in conse-
quence of voluntary efforts to overcome a stricture.  Dr. Har-
rison accounts for the posterior rupture of the bladder, by sup-
posing that when distended  it is compressed against the pro-
monotory of the  sacrum ; but  in very many cases the seat of
rupture is in  the superior fundus beyond the level of the pro-
jection of the sacrum, and not liable to be brought in contact
with it. Especially must this explanation fail to account for the
rupture in the posterior part of the superior fundus, when the only
cause is a general concussion, where the  patient  falls striking
upon his feet.  A more  satisfactory explanation would be that
the posterior is far the weaker portion of the bladder, when
this viscus is greatly distended, as  in  that condition its mus-
cular fibres are separated, and allow rupture to take place.
    Dr. Harrison thus decribes the appearances of the bladder  :
" The rent is generally obliquely transverse ;  the serous mem-
brane  is  cleft to the distance of an inch and a half  or two
inches ; the edges are clean  cut, and  the division in  this  coat
extends further, particularly upwards, than  that in  the other
tunics of  the bladder ; the internal or mucous coat  is  rugose,
and rather pale  or  slightly  reddened in parts,,and generally
free from any acute  inflammation; near the edges  of the 
14           Smith on Rupture of the Bladder.
opening  a slight submucous effusion exists, rendering them
somewhat pulpy and protuberant;  the muscular coat presents
no peculiar appearance, except at the lips of the wound; here
it appears jagged and irregular or torn, with slight ecchymosis
between the fibres.  In some cases the lips of the rupture have
been  found  partly agglutinated, so as  to prevent any further
communication between the bladder and the peritoneum."  Rup-
ture occurring in  the anterior wall or neck is very generally
accompanied by extensive  injuiies  to the pelvis, the cause
being some crushing force, as a cart-wheel, and the result being
laceration from the forcible separation of the symphyses or
fracture  of the  pelvic bones. There are cases in which rupture
has taken place in this situation from over-distention and even
direct violence.
   In the majority of instances the bladder itself, though the
seat of the injury, does not suffer materially from the surround-
ing inflammation, except its peritoneal coat; in some cases the
mucous  membrane  has  marks of intense inflammation,  with
effusion of lymph, while in the last two cases mentioned in these
tables, the most remarkable on record, the bladder  seems  to
have entirely disappeared.

                       Treatment.
   The treatment  of rupture of the bladder varies with the
seat  of the  lesion, whether  without or within  the peritoneal
cavity.   In the former case free  incisions, to give  exit to the
urine extravasated into the pelvic cellular tissue and such gene-
ral remedies as  the nature of the case indicates, is the course
of treatment which  is recommended and has  generally  been
pursued.   To be successful this treatment must be early adopt-
ed, otherwise  sloughing and all its  severe  consequences will
rapidly follow.   Dr. Walker of  Boston, case 50, in a case of
rupture external to the peritoneum, adopted a practice hitherto
untried, and which not only saved his patient but seems the
most  rational  yet  pursued.   This gentleman  performed the
lateral operation upon the bladder as for stone, and thus not
only secured the escape  of the infiltrated urine, but prevented
its further extravasation by affording it a ready outlet from the
bladder.   Convalescence in this case was rapid and complete, 
              Smith on Rupture of the Bladder.           15

although the accident to the bladder was complicated with ex-
tensive injuries to the pelvis.
    In regard to intra-peritoneal rupture, Dr. Harrison  thus
states the indications : first, to arrest peritonitis; secondly, to
abstract the effused fluid from the abdomen; and thirdly, to
guard against any further effusions by  disposing the vesical
wound to  heal.   In regard to the first of these indications he
advises " bleeding, local and  general; leeches to the perineum
and anal region, small and often repeated doses of calomel and
opium; the latter medicine I consider in this case peculiarly
applicable  ; the solid opium or the watery extract, in doses of
one grain or one and a half very often repeated, and a supposi-
tory of the same, together with bleeding, fomentations and the
warm bath, are  general  remedies, on  which I should place
most reliance."
    To  remove  the effused fluid from the cavity of the perito-
neum, the  operation of paracentesis has  been performed, but
invariably without success.   Dr. Harrison remarks very justly
of this operation : " The urine which is  effused, and which is
the source of all the  danger, is principally lodged  in the pelvic
cul de sac, and is more or less confined to that region, partly
from its depending  position, and  partly  from the  adhesions
which we  have reason to  expect under proper  and active treat-
ment may have  been formed between  the bladder and the
adjacent viscera, at the upper orifice of the pelvis.   Paracen-
tesis of the abdomen, as performed in the ordinary situations,
cannot possibly evacuate this region, nay, it may rather prove
injurious by inducing a more general effusion of the  fluid, and
of course irritation of the peritoneum by a partial removal of
the urine from this depending position."   To meet this second
indication  Dr.  H. proposes  the following  operation, which,
though it has never been performed, has received the sanction
of the highest authorities, viz., to  puncture this pelvic cul de
sac through the rectum.   The operation might be done with a
trocar, or a long curved bistoury, with a  sheath, and a cutting
edge only on its extremity.  The patient being in  the recum-
bent posture, with his knees drawn up and somewhat separated,
the finger of the left hand  might be passed up the rectum as far
as possible  and pressed against its fore-part.   The catheter in 
16           Smith on Rupture of the Bladder.
the bladder might also assist in guiding the finger to the cul de
sac behind  that organ.  The canula of a  long  curved trocar
might next  be passed along the finger, and, when its extremity
has been placed against the fore-part of the rectum, exactly in
the median line, the  stillette might then be pushed through it,
and the peritoneum opened.
   To guard against further effusions of urine into the perito-
neal  cavity, I  would propose the lateral operation upon  the
bladder as performed in the case of Dr. Walker, which would ef-
fectually drain  off this fluid as fast as secreted ; this the catheter
cannot do,  as the bladder is in the majority of  instances con-
tracted  to a small capacity.  This operation to  be successful
ought also to be performed as early as possible, to afford an im-
mediate channel for the escape of the accumulating fluid.
   Dr.  Blundell proposes an entirely new operation  in cases
of rupture into the peritoneal cavity, which is as inconsiderate
as the experiments which he instituted  to prove its practica-
bility are novel.   " Were a relation of mine,"  he remarks,  " in
this condition, I should recommend the making  of an  opening
above the symphysis pubis so as  to withdraw the urine ;  and
the thorough ablution of the abdominal cavity and its contents,
by means of the free injection of distilled water at ninety-eight
degrees (or more) of Farenheit's thermometer.   The operation
should  be  continued prudently,  no symptoms  forbidding, till
the water  comes away without manifesting the urinary char-
acteristics.  The peritoneum thoroughly washed, I would then
recommend that the ruptured part should be drawn up to the
abdominal  opening; and, the bladder being, at this  time, lax
and dilatable,  this might easily  be  done.  This accomplish-
ed, the  laceration might be closed with a1 ligature"; the parts of
the bladder lying forth beyond the ligature, being  carefully cut
away ;  and the bladder being then drawn  up, by means of the
ligature, to the abdominal opening internally, one of the ends
of the ligature might be cut away  and  the other might be
brought to lie  out at the wound;—to separate  and be with-
drawn afterwards as in tying up an artery."
   He  thus continues in reference  to his experiments,  which
are chiefly interesting as showing what a degree of irritation
the peritoneum may be subjected to, without exciting  a  fatal 
Smith on Rupture of the Bladder.            17
inflammation.   " To assist in clearing the ground a little, I
have already made some experiments upon  the rabbit;  and it
may be proper  to  give you the results.  Into the abdominal
cavity of four rabbits, I threw about two ounces of human
urine,  and left  it there for an hour;  after which I withdrew
the urine and washed the viscera thoroughly with tepid water
from the cistern.  Of these four rabbits, three  died with gen-
eral inflammation  of the peritoneum;  but the  fourth  lived.
It follows, therefore, that this animal—though prone to dis-
ease within  the peritoneum  and containing many and large
viscera—may, nevertheless,  escape  with  life,  even  though
these  viscera have been  bathed in urine for fifty  or sixty
minutes; — provided the cavity  be  then  washed out.   In
another set of experiments I tied up the fundus of the bladder
in the  rabbit;—afterwards cutting the fundus away, I  found
that in a few days the ligature separated ;—leaving the bladder
closed.  Some  of the rabbits  perished, some months  after-
wards, in  consequence of chronic disease;—not,  apparently,
the necessary, but the accidental effect of the experiments."

                 Medico-Legal Relations.
    The bearing which these tables have upon legal medicine
are not  unimportant, as this  accident  is becoming more and
more  frequently the subject of litigation.   The  medico-legal
questions which are generally raised in suits at law where this
subject is litigated are stated by Mr. Taylor to be  : Was the
rupture the result of wilful violence or of an accidental fall ?
or, did it proceed from spontaneous causes as from over-disten-
tion ?*  The settlement of these questions depends  very much
upon the nature  of the accident,  and the  previous history of
the patient;  little difficulty can arise except where  violence
and  accidental  injuries  occur in the  same case, making it
doubtful which has precedence.  Mr. Taylor thus  remarks in
reference to  cases where violence alone is used.  " If a man
were in good health prior to being struck,  if he  suddenly felt
intense pain, could not pass his urine afterwards, and died from

   * Medical Jurisprudence, by Alfred Taylor, F.R.S.  Second American
Edition  from the Third London Edition, with notes and  additions, by R. E.
Griffith,  M.D. &c.  Philadelphia :  1850. 
18           Smith on Rupture of the Bladder.
an attack of peritonitis in five or six days ; if, after death, the
bladder was found lacerated, but this organ and  the  urethra
were otherwise in a healthy condition, there can  be no doubt
that the blow was  the sole cause of  rupture and death.   In
such cases to attribute the rupture to spontaneous causes would
be equal to  denying  all kind of causation."   Where wilful
violence and accidental injuries occur in the  same case it may
be difficult or even impossible to determine which was the ac-
tual cause of the rupture.   In a case of this  kind, reported by
Mr. Syme ;  the deceased, after a quarrel in which blows were
exchanged, walked home, a distance of more than a mile; and
in crossing the threshold of his own door, fell forwards upon
his abdomen.  He began to complain of great pain, was unable
to exert himself; he died in two days,  and upon dissection  the
bladder was found  ruptured at its  fundus.   Under these  cir-
cumstances  it became  a question  whether  the rupture was
caused by the violence of his companions, or  by the accidental
fall at the door of his own house.  It was denied by two medi-
cal witnesses  that  a person suffering from  this injury could
walk the distance of a mile, and hence the accident must have
happened at the time of the fall upon his door-step.  This opi-
nion involved the question of the power of locomotion after
ruptures of the bladder; and although the fall was undoubtedly
the cause of rupture, we may assert with the utmost positive-
ness that the ability to walk a mile does not disprove the opin-
ion that the  injury was caused by the violence  he received
from  his  companions.  In such  cases the  previous  history
of the patient, the  nature  of the  accident,  and a careful dis-
crimination  of symptoms, must guide in  the formation of an
opinion.
   In regard to spontaneous rupture it is exceedingly rare, the
great majority being the result of violence ;  but it may occur,
first, when straining to overcome a stricture, or, second, from
long distention or ulceration.  " The causes of spontaneous
rupture are easily recognizable by  ascertaining  the previous
condition of the deceased, or examining  the  bladder and
urethra after death."— Taylor.  But so infrequent is this cause
compared with external violence, that it rarely need  occur in
forming an opinion. 
              Smith on Rupture of the Bladder.             19

   Other circumstances of a medico-legal  importance which
these tables establish are; firstly, rupture may occur from an
accidental fall, the person striking upon his feet; secondly, when
rupture is produced by a blow where there is  rarely the slightest
apparent injury to the skin;  thirdly, the patient may have the
power immediately after  the accident  to empty  the bladder
voluntarily; while, in very many cases, this capacity to uri-
nate is developed in the progress of the case; fourthly, in re-
gard to the question of survivance  for a given period, no rule
can be given; for, although the majority of cases prove fatal
within five  days, persons may actually survive the severest
forms of this injury.
   Rupture of the bladder during  parturition from pressure of
the child's head upon the distended  organ  has, according to
Taylor, fixed a charge of malapraxis on the medical attendant.
In these cases he is expected to know the probability of such
an accident, and to guard against it, if  necessary, by the fre-
quent use of the catheter. 
20
Smith on Rupture of the Bladder.
Sex.	Age. 30	Cause.	Primary Symptoms.	Progress and Treatment,
M. 1.		Fell 15 feet.	Insensible; soon began to complain of pain in abdomen and about epigastrium.	Abdomen became swollen ; symp-toms increased in severity ; voided a few drops of urine at each attempt; paracentesis abdominis performed, but blood only flowed through trocar.
M. 2.	23		Severe pain in abdo-men, vomiting, in-ability to void urine.	Abdomen swelled ; catheter was in-troduced into bladder and remedies administered without relief; belly became more tympanitic, and other symptoms increased in severity.
M. 3.	Ad.	Fell upon the ground, striking hy-pogastrium.	Abdomen enlarged, inability to urinate.	Symptoms increased in severity.
F. 4.	38	Parturition.	Slept well night after delivery.	2nd day complained of pain in hy-pogastrium, thirst, desire to pass water, could discharge but 2 or 3 oz. 3d day, urine passed stillicidium. 4th day, abdomen more painful and distended; respiration quick and labored ; pain and dyspnoea increas-ed when incumbent. 5th, worse, introduced catheter with difficulty, and drew six oz. of dark colored urine ; gradually failed. Treatment, venesection, &c.
F. 5.	40	Retroversio uteri.	Suffered retention 7 days, felt something burst within her ; re-lief to her previous symptoms followed.	Catheter removed ; no urine ; failed rapidly.
M.	28	Retention.		
6. M. 7.	Ad.	Fell, strik-ing his belly on a hard body.	Fainted; in a few hours had urgent de-sire but inability to urinate ; severe pain in abdomen, vomiting, &c.	On following day drew off 6 oz. urine, no relief; warm bath, in which he passed large quantity of water; symptoms increased in se-verity.
 
Smith  on Rupture of the Bladder.
21
Result.	Post Mortem appearances of Viscera.	Post Mortem appearances of Bladder.	Condition.	Authorities.
Lived	Abdomen contained	Opening in posterior	Bladder dis-	BONETUS.
42	a large quantity of	part sufficient to ad-	tended.	Sepul. Anal., Lib.
hours.	blood; right kidney inflamed; lumbar and iliac regions ecchy-mosed.	mit a hen's egg.		3,sec. 24. Obs. 12.
Died.	Urine effused into	Rupture in fundus ad-		PlERUS.
	cavity of abdomen.	mitting two fingers.		Hist. Anatomico-Medica, par Lieu-taud, Lib. Fri-
	■•^			mas. Sec. xii., art. vi. Obs. 1279.
Died.	Effusion of urine into	Rupture at posterior	Intoxicated.	Platerus.
	cavity of abdomen.	part.	Bladder dis-tended.	Vide last author-ity.
Death	14 pints of urine in	Ruptured at superior	Parturient,	Mr. Hay.
on the	cavity of abdomen;	part so as to admit a	bladder dis-	Med. Obs. d-Inq.
8th	intestines not in-	finger; edges ragged	tended.	Vol. iv.
day.	flamed ; appearance of viscera healthy ; uterus contracted and healthy.	and blackish; rest healthy.		
Death	9 or 10 pints of urine	Rupture at fundus	Pregnant;	Mr. Lynn.
on 2d	in cavity of abdomen.	sufficient to admit	bladder dis-	Med. Obs. & Inq.
day.		finger; edges of aper-ture gangrenous.	tended.	Vol. iv.
Died.		Circular hole of an	Bladder dis-	Mr. Johnstone,
		inch and a half in ex-	tended.	Mem. of the Med.
		tent in left side of		Soc. of London,
		bladder ; edges		1773. Vol. iii, p.
		smooth, without ap-		543.
		pearance of lacera-		
		tion ; this opening led		0^" Mr. Harrison
		into a cavity in pel-		considers this a case of hemia of the lin-
		vis, which contained		ing membrane, not
		urine.		rapture.
Lived	Peritoneum inflamed;	Very large opening		C. Montague.
5 days.	intestines distended with flatus.	in upper fundus.		Med. Commun. London, 1790. Vol. vii., p. 284.
N. S.—VOL. VI. NO. III.           24 
22
Smith on Rupture of the  Bladder.
e x	Age.	Cause.	Primary Symptoms.	Progress and Treatment.
M.	44	Stricture.	Felt a rush from up-	On 2d day, still slept much; passed
			per part and severe	no water. 3d day, symptoms in-
			pain in region of blad-	creased in severity. No passage of
			der ; desire to urinate	water; punctured bladder through
8.			before urgent; now	rectum, 3 oz. of urine ran off, no re-
			absent; passed no	lief.
			water, abdomen en-	
			larged, painful and	
			tender, slept much,	
			pulse 140, feeble;	
			thirst, tongue dry and	
			brown.	
M.	26	Fell upon a	Felt as if his heart	Constant desire to urinate; abdo-
		bench.	had burst; pain at umbilicus — intense when erect; face pale	men tense; pulse 126; catheter drew but little water. On 2d day, by changing its direction, drew 3
9.			and anxious.	pints. 3d day, punctured abdomen above pubis ; large quantity of clear urine escaped; temporary relief; complained of seminal emissions; delirious on 8th day.
M.	30	Fell 20 feet,	Complained only of	When placed in bed made ineffec-
		striking on	the bruise and pain	tual efforts to urinate ; catheter drew
		his feet.	about his loins and	off 2 oz. urine. 2d day, abdomen
10.			back; peculiar sensa-tions about heart.	became tense and painful, symptoms of peritonitis increased.
M.	Ad.	Straining at stool.	Felt something burst in abdomen; all the	Symptoms continued.
11.			symptoms of rupture of the bladder follow-ed. Inability to urinate,	
M.	Ad.	Coach		Tobacco enema given, which pros-
		wheel pas-	no swelling of abdo-	trated excessively. On the 4th day
		sed over	men, catheter drew	h*d symptoms of peritonitis ; slight
12.		belly.	off 8 oz. of urine, passed water volun-tarily in warm bath.	tension of abdomen ; no pain except on pressure.
M.	Ad.	Horse fell	Symptoms as last	Severe symptoms continued.
13.		upon him.	case.	
M.	35	Fall forward	Collapse; severe pain	Abdomen swollen, excessively ten-
		several feet,	in abdomen.	der ; a little bloody urine drawn by
14.		striking on abdomen.		catheter. No reaction.
F.	20	Retention.	Symptoms of intesti-nal inflammation; in-	Pulse small and contracted ; urine passed often in small quantity;
15.			ability to urinate.	thirst.
 
Smith  on  Rupture of the Bladder.
23
Result.
Lived
3 days.
Lived
Lived
8 days.
Death
on  2d
day.


Death
on  5th
day.
Death.
Death
on  2d
day.
Death.
Post Mortem appearances
      of Viscera.
Large   quantity  of
urine  in  abdomen;
intestines    covered
with       coagulable
lymph and adherent;
urine  infiltrated  cel-
lular tissue as high as
umbilicus,  where   it
ruptured  peritoneum
and entered cavity of
abdomen.

Slight marks of inflam-
mation in epigastric
region;   intense  in
hypogastric, especially
at seat of puncture ;
intestines  glued  to-
gether ;   peritoneum
coated  with  lymph;
pint of urine in pelvis
under  the  adhesions
of bladder to adjacent
viscera.
Peritoneum exhibited
usual effects of  active
peritonitis; intestines
adherent;   consider-
able  urine in  cavity
of abdomen.
Large   quantity  of
urine  in cavity  of ab-
domen; signs of  se-
vere  inflammation of
peritoneum.
Slight    effusion  of
urine into cavity  of
abdomen; peritoneum
inflamed.
10  or 12  pounds of
serous fluid in cavity
of abdomen; marks of
inflammation on intes-
tines.
Post Mortem appearances
      of Bladder.
Ruptured  at anterior
part of fundus, size of
goose quill in mucous,
an inch in dameter in
muscular tissue.
Contracted      and
empty ;  rupture   an
inch in  extent,  ob-
lique, posteriorly and
to right side.
Contracted ;  rupture
in posterior part near-
ly transverse ; mucous
coat protruding  and
vascular.

Rupture through pos-
terior part of superior
fundus.
Aperture at  superior
and posterior part of
fundus,  jagged  and
sloughy;     mucous
membrane inflamed.

Same appearance  as
last case.
Rupture  near fundus
sufficient   to  admit
three  fingers.
Rupture       nearly
throughout the whole
extent;  tissues much
reduced in thickness.
Condition.
Bladder dis-
tended from
stricture.
Bladder dis-
tended.
Had evacu-
ated bladder
some   time
previously.
Suffering re-
tention from
stricture.
Suffered
from  stric-
ture.
Bladder dis-
tended.
Bladder dis-
tended.
Authorities.
  Sir E. Home,
Tract.  Obs.  on
Treatment      of
Strictures.    Vol.
vii., p. 239.  Lon-
don, 1803.
   Dr. Cttsack.
Dublin   Hospital
Reports.    1818.
Vol. vii., p. 312.
   Dr. Cusack.
Dublin   Hospital
Reports.     1818.
Vol. vii., p. 312.
P,
  -M«7=SC03G¥.  J''  f*~
London Med. Be-
pos.   Vol.  xvii.
  Mr. Ewbank.
Bell on  Diseases
of   Urethra,  p.
404.     London,
1822.

   Mr. Bell.
Vide  last author-
ity; p. 437.

   Dr.  Mott.
Preparation in Dr.
M's      museum.
Comm.   by   Dr.
Van Buren.

    Dr.  Fix.
Phil.   Med.  and
Surg. Jour.  Vol.
d 
24
Smith on Rupture of the Bladder.
Sex.	Age.	Cause.	Primary Symptoms.	Progress and Treatment.
M.	Ad.	Blow from	Severe pain set in;	All the symptoms of peritonitis fol-
		knee over	inability to pass water.	lowed; catheter removed only
16.		pubis.		bloody fluid.
M.	35	Horse fell	Tenderness of abdo-	Drew off one pint of bloody urine ;
		on him.	men ; vomiting; pulse	great tenderness of abdomen; ten-
17.			very feeble; pain in left hip.	sion ; vomiting, &c.
M.	27	Fell upon	Severe pain in hypo-	Mind grew dull, but rational; ina-
		smooth	gastrium; swelling	bility to urinate ; catheter not pass-
18.		ground.	and tension of belly.	ed, treated with antiphlogistics.
■M.	Ad.	Fall upon a	Complained of excru-	On 2d day, catheter removed half a
		bed-post.	ciating pain in abdo-	pint of urine; had a voluntary dis-
19.			men ; desire but in-ability to void urine.	charge of water afterwards.
M.	21	Caught un-	Extreme pain in hy-	2d day, inability to urinate ; cathe-
		der a falling	pogastrium ; " felt	ter drew bloody urine ; faeces mixed
		bank of	something give way	with blood; scrotum cedematous ;
		earth.	in his belly;" face	symptoms more severe ; pulse 124.
20.			anxious ; pulse quick; lips livid.	3d day, less suffering, but symptoms more unfavorable. 4th, sinking. Treatment, antiphlogistics.
M.	Ad.	Kick on ab-	Acute pain at pit of	Passed no water for three days after
		domen.	stomach, sense of in-	accident; abdomen became swollen
21.			ternal heat.	and painful, catheter not passed,
M.	30	Kick on hy-	Felt instantaneous and	Treatment; leeches to abdomen,
		pogastrium.	severe pain in abdo-men ; catheter re-moved turbid urine when directed toward	rigid diet, &c.; severe symptoms gradually subsided, with marked im-provement in every respect. On 6th day, imprudent in diet, return of
22.			anterior superior por-tion; entered an in-definite extent, and more urine was eva-cuated.	severe symptoms.
M.	30	Kick on lower part of abdo-men.	Collapse; intense pain	Blood flowed from urethra. Treat-
23.			in hypogastrium; ab-domen tense and pain-ful.	ment, antiphlogistics; improved; was imprudent in diet.
 
Smith on Rupture of the Bladder.
25
Result.	Post Mortem appearances	Post Mortem appearances	Condition.	Authorities.
	of Viscera.	of Bladder.		
Death	Cavity of abdomen	Rupture in superior		M. Cloquet.
on 9th	filled with urine;	fundus.		North Am. Med.
day.	signs of severe inflam-mation.			and Surg. Jour. Vol. v.
Death	Abdomen contused;	Empty; contracted;	Intoxicated.	Lond. Med. and
on 3d	symphysis pubis sepa-	rupture in fundus,		Phy. Jour. Sept.,
day.	rated ; intestines in-flamed ; ilium quite black.	transverse 4 inches.		1828.
Death	Abdomen distended;	Rupture on superior	Intoxicated;	Dr. Dewar.
on 5th	9 or 10 lbs. of bloody	and anterior surface,	bladder dis-	Ed. Med. and
day.	fluid escaped from its	three and a half	tended.	Surg. Jour. Vol.
	cavity; no odor of	inches in length.		xxxi.
	urine; 3 lbs. of coa-			
	gulated blood among			
	bowels.			
Death	Signs of severe perito-	Rupture at fundus;	Intoxicated;	Dr. Bush.
on 4th	nitis.	firmly contracted.	bladder dis-	West. Jour. Med.
day.			tended.	and Phys. Sci. Vol. iv.
Death	Soft parts about hypo-	Empty; ruptured at	In good	Mr. Gamack.
on 4th	gastrium contused;	fundus and at neck,	health.	Medico - Chirurg.
day.	scrotum and penis much distended; in-testines distended with flatus; slight blush of inflammation; other viscera healthy.	close to prostate.		Rev. Vol. xiii.
Death	Ecchymosed and livid	Round hole with	Intoxicated.	M. Boyer.
on 5th	spots in different parts	sphacelated edges in		Malad. Chirur.
day.	of abdominal parie-tes; scrotum and penis black, involving only skin, 15 pints yellow fluid, not urinous, in cavity of abdomen.	upper fundus.		Tom. ix., p. 61. 1831.
Death	Inflammation in hypo-	Rupture two inches	Intoxicated.	M. Duptjytren.
on 7 th	gastric region ; adhe-	in extent, in posterior		Archives Gene-
day.	sions between the ab-dominal walls and bladder; the latter and adjacent viscera all agglutinated, form-ing an organized pouch, which circum-scribed the urine, and prevented further effu-sion.	wall.		ral. June, 1834.
Lived	Effusion of urine and	Bladder contracted ;		M. Duptjytren.
17	pus in pelvis ; inflam-	two ruptures on an-		Amer. Jour. Med.
days.	mation in this region; no signs of general peritonitis.	terior surface; blad-der and intestines ad-herent.		Sci. Vol. xii.
 
26
Smith mi Rupture of the Bladder.
Sex.	Age. 50	Cause.	Primary Symptoms.	Progress and Treatment.
M.		Fell under a	Collapse.	Severe abdominal pain, face anxious,
24.		car.		pulse very feeble, delirious.
M.	35	Kick on lower part of belly.		
25.				
M.	Ad.	Kick on lower part	Was shocked; rallied to fight but felt sick;	Symptoms of peritonitis nsued.
26.		of belly.	attempted to urinate but could not; walk-ed 200 yards.	
F.	26	Fall on edge	Syncope; intense pain	Catheter drew but little urine ; symp-
		of a tub.	in abdomen; inability	toms of peritonitis set in ; antiphlo-
27.			to urinate.	gistics used, but without relief.
M.	35	Fall upon a	Intense pain in belly ;	Severe symptoms continued unre-
		bench.	inability to urinate;	lieved.
28.			catheter drew bloody urine.	
M.	22	Straining to	" Felt something	Tenderness of abdomen ; sense of
		evacuate	crack in abdomen,"	distention ; no circumscribed tumor
29.		bladder.	followed by a chill; relief to his former symptoms.	in hypogastrium ; catheter drew two quarts bloody urine ; catheter con-stantly used. Treatment, active antiphlogistic.
M.	26	Blow on ab-	Symptoms slight ;	2d day, had hot skin, quick pulse,
		domen.	abdomen not tense ; slept soundly first	thirst, inability to pass water. Ca-theter drew a pint of clear urine ;
30.			night.	bled, purged, &c, but no relief. 3d day, excessive vomiting, tympanitis, constant desire to urinate ; catheter never drew but an oz. of water at a time.
M.	28	Horse fell	Shocked; inability to	2d day, great pain in abdomen;
		upon him.	urinate; blood only flowed by catheter.	pulse 120, great desire to urinate. Catheter drew only blood, at night
31.				passed water voluntarily, less pain. 3d day, suffering slight, passed water, great prostration, features pinched.
 
Smith on Rupture of the Bladder.
27
Result.	Post Mortem appearances	Post Mortem appearances	Condition.	Authorities.
	of Viscera.	of Bladder.		
Lived	Extensive injuries to	Bladder ruptured in		Dr. Kirkbride.
3 hours	other parts.	posterior part.		Amer. Jour. Med. Sci. Vol. xvi.
Death	No external marks of	Vertical rupture at		Annales d'Hy-
on 7th	injury; sanguineous	superior and posterior		giene et de Medi-
day.	fluid in abdomen;	part,2 inches in length,		cine. Legall. No.
	having an ammonia-	involving all the tis-		29. Jan., 1836.
	cal odor ; adhesions	sues only at lower		
	of viscera.	part; mucous mem-brane inflamed at neck.		
Death	No external marks of	Rupture at superior	Intoxicated.	Land. Med. Gaz.
on 5th	injury.	and posterior part.	Bladder dis-	April 9, 1836.
day.			tended.	
Death	Marks of severe in-	Small aperture at		Mr. Syme.
on 6th	flammation in perito-	fundus of bladder.		Ed. Med. and
day.	neum.			Surg. Jour. Vol. ii. Oct., 1S36.
Lived		Rupture into perito-	Intoxicated.	J. F. South.
36		neal cavity.	Bladder dis-	St. Thos. Hosp'l
hours.			tended.	Reports. Vol. i. 1836.
Reco-			Retention	Mr. Keal.
vered.			from injury.	Lond. Med. Gaz. 1836-37.
Lived	Intestines filled with	Rent in superior and	Intoxicated.	Mr. Ellis.
15	flatus, peritoneum	posterior part suffi-	Retention	London Lancet.
days.	but slightly vascular,	cient to admit the	from stric-	Vol. xvii. N. S.
	with several patches	little finger.	ture.	
	of lymph; 2 or 3			
	gallons of pale urin-			
	ous fluid in abdomen.			
Lived	Quart of reddish fluid	Rupture in posterior	Intoxicated.	Mr. Ellis.
3 days.	in cavity of abdomen,	and superior part of	Bladder dis-	London Lancet.
	having a urinous odor.	fundus, through which the catheter intro-duced into urethra, readily passed into cavity of abdomen.	tended.	Vol. xvii. N. S.
 
28
Smith  on  Rupture of the Bladder.
Sex.
Age.
M.
32.
35
Cause.
Antagonist
fell   across
lower  part
of belly.
 M.



33.






M.


34.
27
Kick     on
lower  part
of belly.
2£   Cart  wheel
     passed  over
     lower   part
     of belly.
36
35.




M.

36.



M.

37.
Ad.
Ad.
Parturition.
Fell,  strik-
ing the ab-
domen
against    a
stair.

Fell upon a
door step.
Primary Symptoms.
Felt excessive pain in
hypogastrium ;   sick
and  weak;   rallied
and   walked  home
alone; tried  to uri-
nate but could not.
Syncope ;     intense
pain in belly; inabil-
ity to urinate ; thirst;
pain  extending  from
hypogastrium and in-
creasing in  severity;
unable  to remain in
one posture but for  a
short  time.
Collapse ;
urine voluntarily;  no
blood ; lower part of
belly bruised and ten-
der;   perineum dis-
tended with fluid.

Twelve  hours  after
labor attacked  with
severe pain in lower
part  of abdomen, ex-
tending down thighs.
The sense of fulness
of bladder ceased and
he walked to a friend's
house to dinner.


Complained of great
pain.
Progress and Treatment.
Had a restless night, but slept some,
made ineffectual efforts to urinate,
took breakfast on 2d day and walked
three miles  for a surgeon ,  catheter
drew six  oz. urine ;  walked home
again, passed one or two oz. urine.
3d  day, rose and  began his usual
labor;  at noon felt so sick that he
walked  again to town three  miles
for  medical relief.   4th  day, still
kept  about,  but  symptoms  in-
creased  in severity, gradually sank.
Drew  quart  of bloody urine  with
some   difficulty,  vomiting,  pulse
quick and  hard, intense abdominal
pain.   Ord,  venesection, leeches  to
abdomen, opium,  &c. ; symptoms
continued with  increasing severity
until near his dissolution, when they
abated;  continued to  draw  small
quantities of bloody urine.
2d day, pain slight; passed water ;
features natural, cheerful, pulse 120;
perineum   fluctuating;  symptoms
mild until 4th day, when  erysipelas
appeared on lower part of abdomen.


2d  day, high  fever,  thirst,  rapid
pulse,  abdomen tense and tender,
inability to pass water, countenance
anxious, restless ; catheter drew no-
thing  from  bladder.   Treatment,
that for peritonitis.
Severe symptoms continued. 
Smith  on  Rupture of the Bladder.
29
Post Mortem appearances
      of Viscera.
Viscera  of  epigastric
and umbilical regions
healthy; small intes-
tines  distended with
flatus,  and  adherent
at some points by soft
fibrin ;  no fluid ; ca-
vity of pelvis separ-
ated from that ot ab-
domen  by agglutina-
tion of lower intestines
with    bladder,  and
abundant effusion  of
lymph ; quart of color-
less urine  in  pelvis,
containing shreds  of
lymph.

Intestines   distended
with flatus; vascular,
slightly     adherent;
bloody urine in lum-
bar region, with flakes
of lymph;  marks  of
severe  inflammation
about pelvis; perito-
neum   coated  with
lymph.

No trace of inflamma-
tion in  cavity of ab-
domen or pelvis; ossa
pubis fractured  and
separated.


Slight marks of inflam-
mation  of peritoneum
and intestines; uterus
contracted, signs of in-
flammation around it;
cellular  tissue  of ab-
domen  and thighs in-
filtrated with urine
and sloughy.
Post Mortem appearances
      of Bladder.
Oblique fissure in pos-
terior part of bladder
an inch and a half in
length; interior show-
ing no signs of inflam-
mation.
Bladder   not  much
contracted;     trans-
verse rent  an  inch
and a half in length,
on posterior  part of
fundus,  through   all
its tissues, but  most
extensive  in  perito-
neum ;  interior  not
at all inflamed.

Vertical rent  in  an-
terior wall-;  interior
acutely inflamed.
Fundus  of  bladder
ruptured,  and  urine
effused into cavity of
abdomen.
Bladder ruptured two
or three inches.
Condition.
Intoxicated.
Intoxicated.
Good health
in    labor,
which   was
easy.
Bladder dis-
tended.
Authorities.
 Dr. Harrison.
Dub. Jour.  Med.
Sci.   Vol. xi.
  Dr. Harrison.
Ibid.
  Dr. Harrison.
Ibid.
Mr. Bedingfield.
London  Lancet.
June, 1837.   '
Taylor's     Med.
Juris.  See Am.
Ed., p. 287.
   Mr.  Syme.
Taylor's    Med.
Juris.   See Am.
Ed., p.  284. 
30                   Smith on Rupture of the  Bladder.
  Sex.


  M.


  38.



  M.


 39.


  M.


 40.




 F.


  1.


 F.


 42.




 M.


 43.



 M.


 44.

 M.

45.
Age.
35
38
31
Cause.
Primary Symptoms.
Ad.
36
27
42
32
53
Carriage fell
on him.
Stricture.
Kick     on
lower  part
of abdomen.
Parturition.
Parturition.
Hurried   respiration;
pulse  quick;  vomit-
ing ; no  urine flowed
from catheter ; blood
on   the   end  when
withdrawn; pulse 140.

Had retention 3 days
while at sea ; sudden-
ly seized with severe
pain in region of blad-
der ;   followed   by
great prostration.
Walked  one fourth of
a mile in a stooping
posture and  in great
pain ;  chills ;  desire,
but inability to  pass
water;   pulse  rapid
and feeble.

Collapse  near close of
labor.
" Felt something give
way"  near close of
labor,   followed   by
sudden   pain   about
umbilicus;   pains  of
labor  ceased;  pulse
6mall;  tongue  dry.
Was  fallen  Slight pain in hypo-
upon  in  a  gastrium ;  not to pre-
fight.         vent sleep.
Cart  wheel
passed over
abdomen.
Fall   of  a
rock.
Fall on edge
of a tub.
No complaint of pain;
noisy from drink ; un-
able  to pass water.
Severe pain in abdo-
men;  desire but in-
ability  to  urinate;
pulseless.

Syncope ;  vomiting;
tympanitis ;  counte-
nance anxious.
Progress and Treatment.
Symptoms continued  to increase in
severity;  leeches  were  applied  to
abdomen  and  opium administered,
but without relief.
Sloughs of cellular tissue separated
from rectum, so that the hand could
be  passed  up  to sacrum.   Urine
passed in a stream from rectum, ca-
theter left in bladder.

Drew off 12  oz. bloody urine.   On
3d  day passed water in a  stream,
and  continued to  do so until day
before death ; vomiting, tympanitis.
Stimulants administered; revived.
Extracted child with forceps; abdo-
men swelled and became  painful,
pulse quick ;  tympanitis, sinking.
Symptoms of peritonitis, inability to
pass water, intense pain in abdomen,
which became tense  and  tender;
was treated with  tonics and stimu-
lants.  On 4th day drew off 52  oz.
of brownish fluid but no blood.

2d day, great tenderness over blad-
der, tympanitis, incessant vomiting,
pulse  140 ; mind clear; bloody urine
passed by catheter ; cal. and opium
freely exhibited.
Catheter removed only blood from
bladder;   scrotum  distended with
blood.
Blood flowed from catheter. 
Smith  on  Rupture of the Bladder.
31
Result.
Death
on  4th
day.
Recov-
ered.
Death
on  5th
day.
Death
in   2
hours.
Death
on  3d
day.
Death
  .  4th
Death
on  3d
day.


Lived
12
hours.
Death
on  5th
day.
Post Mortem appearances
      of Viscera.
Fluid in abdomen not
having   a   urinous
odor ; universal  peri-
tontis, most intense in
region of the bladder.
No external marks of
injury; fluid in abdo-
men not  urinous; no
sign of peritonitis.
Urine   effused  ' into
cavity of abdomen.
Marks of inflammation
in cavity of abdomen ;
uterus    contracted,
having a tubercle on
its   anterior surface,
corresponding   with
rent in bladder.

Three pints of bloody
fluid in cavity of ab-
domen ;  viscera  ag-
glutinated by recently
effused lymph.
Post Mortem appearances
      of Bladder.
Bladder   contracted
and  ruptured  on  its
posterior aspect.
No external marks of  Firmly    contracted
Rent  in superior and
posterior part one and
a half inches, valvu-
lar.
Extensively lacerated.
Rupture   in  fundus,
size of the finger.
Rupture  at  superior
and   posterior   part,
rent one and a quar-
ter inches  in length,
taking  an  oblique
course.
Condition.
injury ;  4 pints unco-
agulated   blood   in
cavity of peritoneum.

Separation of symphi-
sis    pubis;   thigh
bone dislocated   into
ischiatic notch.

Signs of peritonitis.
and torn at itssupero-
posterior portion
Rupture at fundus.
Very large transverse
rent in superior  and
posterior part.
Bladder^dis-
tended.
Bladder dis-
tended.
Intoxicated.
In childbed,
primipara.
In childbed,
primipara.
Intoxicated.
Bladder dis-
tended.
Intoxicated.
Authorities.
 Mr. Lawrence.
Lond. Med. Gaz.
Vol.xxiii.
   Dr. Ward.
New- York  Lan-
cet.      Vol. I.,
1842.
   Mr.  Hiley.
London  Lancet.
May 14,1842.
Mr. Ramsbotham,
Pract.  Obs.  in
Midwifery,   2d.
Ed., p. 146. 1842.
Mr. Ramsbotham.
Ibid.
   Mr.  Scott.
London  Lancet.
Vol.2.  1843-44.
  Mr. Oldfield.
London  Lancet.
Vol. 2.   1843-44.
    Mr. Syme.
Lond. and   Ed.
Month. Jour. Med.
Sci.  June, 1843.

  R. W. Smith.
Dub. Hosp.   Re-
ports.  1844. 
32
Smith  on  Rupture of the Bladder.
Sex,
Age.
F.

47.


F.
48.

M.

49.


M.
50.
M.
38
Cause.
42
23
30
Cart  wheel
passed over
body.
Run over by
a cart.

Cart  wheel
passed over
pelvis.
Injured   by
rail cars.
Fall   from
hammock
upon a stool
51.
M.
24
52.
Fall   from
hammock
across chain
cable,   in-
juring loins.
Primary Symptoms.
Collapse ;    intense
pain in hypogastrium.
Severe pain, suffering
intense.

Pain  about  hypogas-
trium ; catheter drew
bloody urine.
Collapse;  no  power
or desire  to  urinate ;
tumor in  right iliac
region,  and  fracture
of  pelvic  bones de-
tected ;    tenderness ;
vomiting ;   catheter
removed 6 oz. urine,
with  relief;   rupture
of  anterior  wall  of
bladder  diagnosed.

Severe  pain   above
pubes ;  great  desire
but inability to  urin-
ate ;    catheter  re-
moved 2 oz. of bloody
urine  ;  pulse  quick
and small.
Progress and Treatment.
Severe symptoms fol-
lowed  immediately ;
circumscribed    hard
tumor,  like   gravid
uterus, felt in  hypo-
gastrium ;  tender  on
pressure;   pint   of
bloody  urine  drawn
by catheter.
Reaction incomplete.
Bloody urine drawn by catheter.
Severe pain over abdomen, respira-
tion difficult, distention over bladder,
passed no water, blood  only  flowed
from catheter.

Lateral operation performed on blad-
der, with subsidence  of tumor and
tenderness;  improvement followed,
and rapid convalescence.
2d day, 6 oz. pure blood passed by
catheter, vomiting, increase of pain
and tenderness, urgent desire to void
urine and passed half pint  voluntar-
ily;  features  anxious,  thighs  and
thorax flexed, circumscribed hard-
ness felt above  pubes where there
was most pain.
2d day, had extreme  pain and ten-
derness over  bladder;  relieved by
bleeding and purging  ; passed small
quantities of urine voluntarily ; re-
turn of severe symptoms on 5th day,
tumor  above pubes still felt, painful
and tender ; pain  gradually extend-
ed over whole abdomen. 
Smith  on  Rupture of the Bladder.
33
Result.
Death
in   17
hours.
Death
on  2d
day.
Death
on  2d
day.
Reco-
vered.
Death
on  6th
day.
Death
on  9th
day.
Post Mortem appearances
      of Viscera.
Fracture  of   pelvis,
separation of symphi-
sis pubis.
Spleen ruptured;  pel-
vic bones fractured.

But few signs of peri-
tonitis.
 No  external injury;
 tissues beneath super-
 ficial fasciae of abdo-
 men of a dark color ;
 softened;   gangren-
 ous ; exuding on pres-
 sure  bloody  serum,
 having   a   urinous
 odor;  cellular tissue
 around   bladder   in
 same condition; peri-
 toneum entire ;"marks
 of intense inflamma-
 tion ;  intestines  ad-
 herent   by  recently
 effused  fibrin.

 Hemorrhage in both
 kidneys;   intestines
 adherent and united
 to abdominal walls by
recently       effused
lymph; bloody serum,
not urinous, distend-
ed cavities formed by
these      adhesions;
other  viscera healthy.
Post Mortem appearances
     of Bladder.
Rupture  of  superior
and  anterior portion
involving peritoneum.
Bladder  ruptured in
three places.

Contracted ;    large
rent in posterior wall.
 Peritoneum   pushed
 upwards from its re-
 flection from anterior
 surface  of  rectum ;
 posterior and superior
 surfaces   of bladder
 forming  a  large  ca-
 vity filled with  urine
 and coagulated blood,
 at  bottom of  which
 was bladder, contract-
 ed, with  a rent one
 and a half  inches in
 length   in   anterior
 wall, edges  red and
 hard.

 Much enlarged; pos-
 tero-inferior  surface
 gangrenous   in  ap-
pearance ; perforation
inch in length anter-
iorly on right side be-
low reflection of peri-
toneum ;     mucous
membrane   intensely
inflamed; urinary in-
filtration of cellular
tissue of pelvic cavity.
Condition.
Intoxicated.
Authorities.
Intoxicated.
Bladder dis-
tended.
Intoxicated.
Intoxicated.
  Mr. Coofeb.
Guy's  Hasp. Re-
ports.     Vol. 2.
1844.

  Mr. Cooper.
Ibid.

  Mr. Cooper.
Ibid.
  Dr. Walker.
Med. Comm.   of
Mass. Med Soc,
Art. iv.,  case  6,
of vol. vii.   1845,
   Mr. Wells.
London     Med.
Gaz.  Vol. xxxvi.
N. S. Aug., 1845.
  Mr.
op. cit.
Wells. 
34                   Smith on Rupture  of the Bladder.
Sex.	Age.	Cause.	Primary Symptoms.
M.	35	Blow on	Inability to urinate ;
		lower part	passed some blood
53.		of belly.	from urethra ; pain on moving catheter; drew bloody urine.
M.	50	Ran against	Great pain over ab-
		a post in the	domen ; collapse ; de-
		dark.	sire and ineffectual
54.			efforts to urinate; rapid, feeble pulse ; walked 100 yards after the injury.
M.	Ad.	Kick in hy-	Symptoms of perito-
		pogastrium.	nitis.
55.			
M.	36	Run over by	Walked 3 miles ; be-
		cab.	gan to have severe pain in hypogastrium
56.			3 hours after acci-dent ; vomiting ; pas-sed a little water; chills; pulse 120.
M.	29	Fell upon	Intense pain, but
		corner of	with assistance walk-
		table.	ed home ; but little desire and inability
57.			to urinate ; anxious countenance; pulse quick and small; re-spiration ; labored.
M.	Ad.	Fallen upon	Intense pain in belly ;
		in a fight.	ineffectual efforts to urinate ; abdomen
58.			tender.
M.	32	Cart wheel	Pain in perineum and
		passed over	above pubes; desire,
		left groin	but inability to pass
59.		and thigh.	urine.
Progress and Treatment.
2d day, passed water  with tolerable
freedom, pain  in  left  groin  and
across abdomen.  3d day, pain  and
tenderness  increased;  pulse  116.
4th day,  abdomen not as  tender,
sinking.

Drew  bloody urine 18  hours after
accident;  afterwards  urine  always
clear.  Treatment, as for peritonitis;
on 6th day, strained to  pass water,
felt something give way, symptoms
of peritonitis  ensued,  but  was suc-
cessfully treated.
2d day ; efforts to pass water, but
little escaped ; severe pain at um-
bilicus and perineum, thirst; cathe-
ter removed 10 oz.  of  high-colored
urine; pressure of finger in  rectum
increased  its flow.   3d day, much
worse, sinking.

2d  day,  drew  2 oz. by  catheter;
symptoms worse ; decubitus  dorsal;
knees drawn up ; never  got but 2 or
3 oz. of urine at once, passed an oz.
voluntarily.   3d day, worse ; con-
tinued to sink.
Drew 3  pints of reddish urine 10
hours after  injury,  healthy urine
afterwards.
On 3d day, symptoms continued se-
vere ; countenance anxious, respira-
tion rapid ; pulse 113, feeble ; bloody
urine  flowed from catheter ; cellular
tissue of thigh, scrotum and perineum
swollen. 4th day, free incision made
in perineum, without relief;  urine
continued to flow from  wound, but
patient finally became exhausted by
the sloughing. 
Smith  on  Rupture of the Bladder.
35
 Result.


Death
on  4th
day.
Reco-
vered.
Lived
55
hours.
Death
on  3d
day.
Death
on  6th
day.
Lived
3 days.
Death
on  8th
day.
Post Mortem appearances
      of Viscera.
Dark fluid  in  abdo-
men, not urinous ;  no
trace of inflammation
of peritoneum; pelvis
sound.
Urine    extravasated
into the cellular tissue
of  scrotum ;  perito-
neum not  lacerated,
but  extensively  in-
flamed.

No marks  of  disease
in upper part  of ab-
domen ; much lymph
effused on pelvic peri-
toneum ; pint of dark
urine in pelvis.
Not the slightest trace
of  inflammation  in
cavity  of  abdomen;
viscera all healthy.
Intestines   adherent
by  recently  effused
lymph.
Effusion of blood be-
neath  pelvic  fascia;
extensive  fracture of
pelvic bones.
Post Mortem appearances
      of Bladder.
Rupture three-fourths
of an inch on inferior
and left surface.
Rupture   near   the
neck,  half-inch   in
length.
Bladder  small  and
contracted;     rent
oblique, an inch and
a half  long  at pos-
terior   and  inferior
part; mucous  mem-
brane healthy.

Rent  at superior and
posterior part one and
a half inches.
Contracted;    large
rent in fundus, around
which     intestines
formed a  cul  de  sac
by  their   adhesions,
limiting  the effusion
of urine.
Rupture  through  left
side of neck,  admit-
ting  three  fingers;
opening   into  large
abscess extending up
between  bladder  and
Condition.
Intoxicated.
Bladder dis-
tended.
Intoxicated.
Intoxicated.
Authorities.
   B. Cooper.
Lond. Med. Gaz.
Aug. 27,1845.
Mr. Chaldecott.
Prov.  Jour,  and
Dub. Med. Press.
Vol. 3.
Mr. Steavenson.
Taylor's    Med.
Juris.  See  Am.
Ed., p. 245.
   Mr. Hird.
London  Lancet.
Oct. 26,1846.
   Mr. Bower.
London  Lancet.
Dec,1846.
 Mr. Hamilton.
Dub. Quar.  Jour-
Vol. ii., No.  5.
  Dr. Watson.
Mon. Jour. Med.,
Sci.   Dec, 1848. 
36
Smith on Rupture of the  Bladder.
Sex.
Age.
 M.

 60.



 M.




 61.





 M.



62.




M.


63.



M.


64.



M.


65.
M.

66.
27
17
22
Ad.
18
40
Cause.
30
Caught in a
steam   en-
gine, receiv-
ing a severe
blow on the
back.
Fell against
a  spar  in
attempting
to  leap a
fence.
Fell  12 feet
striking  on
his feet.
Blow on ab-
domen.
Caught  be-
tween  rail-
Stone   fell
upon  lower
part of belly
Caught  be-
tween cars.
Primary Symptoms.
Collapse ; desire and
ineffectual  efforts  to
urinate ; bloody urine
drawn  by catheter;
pulse quick and feeble.

Intense pain; feeling
as if bowels protrud-
ed; walked a few steps
with support.
Progress and Treatment.
No  symptoms  first
day.
Collapse.
Collapsed; ineffectual
efforts to urinate.
Pain  slight;
and   faeces
from injury.
Severe  symptoms continued unre-
lieved.
Abdomen  became  distended;  fea
tures pinched ; 4 oz. urine drawn off
by catheter, which was  left in blad-
der ;   on 4th day  oedema of back
and  lower limbs, fluctuation below
umbilicus ; punctured  and gave exit
to urine with relief;  nothing from
catheter; on 7th, cellular substance
sloughed, and  a rent in  posterior
part  of bladder could be felt through
the opening.   Patient rapidly con-
valesced.
On 2d day walked  to hospital; se-
vere  pain in abdomen, which was
tense and tender; ineffectual efforts
to vomit, and defecate];  face anx-
ious, pulse  feeble and quick ;  symp-
toms of peritonitis increased ; 2 oz.
bloody urine drawn off on 2d day ;
passed  water  voluntarily at stool;
active antiphlogistics.

Two quarts of urine  drawn off 17
hours after the accident.
Pain in hypogastrium  and tender-
ness in abdomen.   2d  day, dis-
charged urine 2 feet from meatus ;
antiphlogistics.
Abdomen tympanitic ; some tender-
ness over bladder;  reaction in two
hours; pint  of bloody urine drawn
off;  pressure made  over bladder in-
creased the  flow ;  clot  of blood in
the catheter  ; instrument passed in
the whole length, vomiting of green
matter, breathing thoracic 
Smith on Rupture of the  Bladder.
37
Result.	Post Mortem appearances of Viscera.	Post Mortem appearances of Bladder.	Condition.	Authorities.
Death	Small quantity of	Transverse rupture	Good health	Dr. Watson.
on 2d	urine in cavity of ab-	at fundus, admitting		Ibid.
day.	domen ; blood effused into pelvis; injuries of pelvic bones and articulations.	three fingers.		
Reco-			Good health	Mr. Syme.
vered.				Ed. Med. $■ Sur. Jour. 1848.
Lived	No external injury ;	Rent three-fourths of	Bladder dis-	Mr. Stapleton..
6 days.	fluid in abdomen ;	an inch in posterior	tended.	Dub- Quar. Jour,
	slight adhesions of in-	and upper part.	Intoxicated.	No. 16. Feb.
	testines ; peritoneum			1850.
	coated with thick			
	layer of lymph ; pint			
	of turbid fluid in			
	cavity of pelvis, hav-			
	ing an arnmoniacal			
	odor,			
Death	2 or 3 oz. of urine	Firmly contracted ;	Bladder dis-	Mr. Solly*
on 1st	and lymph in cavity	vertical rent an inch	tended.	Lond. Med. Gaz.
day.	of peritoneum ; some congestion of and fibrinous effusion on viscera ; no other signs of peritonitis.	in length at posterior part.		April 26, 1850.
Lived	Serum in cavity of	Contracted to one-	Bladder dis-	Dr. Lente.
2 days.	abdomen ; no odor of	third its natural size;	tended.	New- York Jour.
	urine; no sign of	rupture at fundus, ad-		Med. Vol. iv.,
	peritonitis.	mitting the thumb; separation of symphy-sis pubis.		N. S., 1850.
Death	No external marks of	Contracted and lacer-	Bladder dis-	Dr. Vreeland
on 2d	injury; fluid and pus	ated at its superior	tended.	New- York Jour.
day.	in abdominal cavity.	part.		Med. N. S., Vol. iv.
Lived	Large abscess in both	Contracted ; mucous	Bladder	Dr. Peaslee.
42	iliac regions; frac- membrane congested		emptied one	Am. Jour. Med.
days.	ture of pelvic bones, and covered with pus j		and a half	Sci. N. S., Vol.
	j	rent at neck.	hours before	xix.
 
38                  Smith on  Rupture of the  Bladder.
Age.
35
Ad.
50
12
40
38
32
Cause.
Husband
knelt  upon
abdomen.
Man jump-
ed upon ab-
domen
while lying
on back.
Iron railing
fell on lower
part  of ab-
domen.
Wheel   of
carriage
passed over
lower  part
of abdomen.
Primary Symptoms.
Collapse  from which
he never rallied.
Was  sensible  of  a
severe   internal  in-
jury.
Great pain and  ten-
sion  over lower part
of abdomen ; inability
to pass  water;  ca-
theter  removed  pint
of bloody urine.
Inability   to    pass
water;  swelling and
redness of lower part
of   belly,   scrotum,
groins and thighs.
Progress and Treatment,
Large  quantity  of  bloody  urine
drawn  by  catheter,  which  passed
without difficulty.
Most intense suffering.
Improved  under treatment ;  three
fluctuating  tumors appeared, one on
misial  line, others in  illiac regions.
On   12th  day, opened  the   left,
which  discharged foetid  pus   and
urine.
Tympanitis;  tension  of  abdomen ;
small quantity of bloody urine passed
by catheter ; delirium, low fever.
Bloody urine drawn off by catheter.
Bloody urine drawn  off; pain and
tension  of the belly came on ; ty-
phoid symptoms set in rapidly. 
Smith  on  Rupture  of the  Bladder.
39
Lived
2 days.
Lived
24
hours.
Lived
23
days.
Lived
6 days.
Death
on  1st
day.
Lived
5 days.
Death
on  4th
day.
Post Mortem appearances
      of Viscera.
No marks of inflam-
mation  in peritoneal
cavity;      extensive
fracture  of   pelvis;
other viscera healthy.
Cellular tissue in hy-
pogastric   and  iliac
regions      sloughy ;
peritoneum   in   this
part  " stripped  off"
as high as umbilicus.
Pelvis     extensively
fractured ;      small
quantity  of blood in
cavity of peritoneum.
Extensive  injury  of
pelvis;   effusion   of
blood into sub-perito-
neal cellular tissue.
Pelvis  severely frac-
tured ; cellular tissue
of  pelvis,   hypogas
trium,  illiac  regions,
upper  part of  both
thighs  and  right side
of  scrotum, sloughy
and  infiltrated  with
urine and pus.
Extensive  laceration
of  symphysis  pubis;
cellular  tissue  infil-
trated  with  sanious
fluid.
Post Mortem appearances
      of Bladder.
Rupture  at apex two
inches in length and
one  and a  half in
breadth ; contracted,
and  containing  clots
of discolored blood.
Two   ruptures,  one
half an inch in length
into  peritoneal  sac,
the other two inches
in length into cellular
tissue of pelvis.
Rupture  in  fore  part
an  inch in length by
half  an   inch   in
breadth,  leading  into
a       circumscribed
cavity in  cellular tis-
sue ; firmly  contract-
ed ;  mucous,  mem-
brane of a dark color,
with spots of  lymph.
Two ruptures  on fore
part,  size of a large
bougie ;   urine  infil-
trated  into  cellular
tissue of pelvis, scro-
tum and thighs, caus-
ing sloughs.
Laceration   on  left
side of  bladder, one
inch in length by half
an   inch  in  width,
leading   into cellular
tissues.
The  two   anterior
thirds of  the neck of
the bladder  separated
from prostatic portion
of the urethra;  marks
ofsevere inflammation
of bladder, its mucous
membrane being  of a
dark color.
Rupture  size  of  a
goose-quill  on  right
side,  leading  into a
circumscribed cavity,
formed  in cellular tis-
sue   by  effusion  of
lymph; mucous mem-
brane inflamed,  hav-
ing patches of lymph.
Authorities.
  Mr. Hawkins.
  O3  This  and
the  nine following
cases were report-
ed by Mr.  Hewitt
to the Lun. Path.
Snc.  Vide Lond.
Med. Gaz  April,
26, 1850.
  Mr. Hawkins.
Mr. Tatum.
Mr. Cutler.
Mr. Hawkins.
Mr. Keate.
Mr. Keate. 
40
Smith  on Rupture of the  Bladder.
Age.
M.


 4.
32
Piece    of
timber  fell
upon    his
back.
 M.



 75.




 M.

 76.



Boy.



77.




M.





78
46
34
29
Primary Symptoms.
Kick   from
horse    in
lower  part
of belly.
Fall from  a
great height
Was   trod
upon.
Blow   from
knee   over
lower  part
of abdomen.
Swelling of scrotum,
perineum  and  lower
part of abdomen ; no
urine from catheter.
Rigors; intense  pain
in abdomen.
Was not  considered
seriously injured until
24 hours after.
Collapse ;    intense
pain and  tenderness
of  abdomen ;  great
desire but  inability to
urinate; bloody urine
passed by  catheter;
thirst.
Progress and Treatment,
Free incisions into urethra and  in-
flamed  parts  through  which  urine
escaped ;  cellular tissue sloughed ;
typhoid symptoms ensued.
Urine mixed with  blood  passed by
catheter.
Abdomen became tympanitic ; ten-
derness extreme; countenance anxi-
ous ; passed water and fasces after
taking oil;  vomiting  grumous mat-
ter ;  pulse 106 ; symptoms increased
in severity.   Treatment, antiphlo-
gistic.
2d  day. drew  off a pint of clear
urine ; blood followed on withdraw-
al of instrument ; all symptoms as
at first.   3d day, passed catheter 9
inches,  removing   2 quarts  clear
urine ; on the 4th passed water by
bearing down  forcibly  and  taking
full  inspiration; symptoms more un-
favorable ; vomiting of stercoraceous
matter  came  on, desire to urinate
constant and  unrelieved, rolling of
bowels detected  through abdominal
walls, urine  high colored and offen-
sive ; gradually failed, sufferings un-
abated.   Treatment, actively  anti-
phlogistic. 
Smith  on  Rupture of the Bladder.
41
Result.
Lived
4 days.
Death
on  3d
day.
Death
on  1st
day.
Lived
4 days.
Death
on  7th
day.
Post Mortem appearances
      of Viscera.
Extensive fracture  of
pelvis;  slight  marks
of inflammation on pe-
ritoneum, which  was
stripped off nearly as
high   as  umbilicus,
between  bladder  and
pubes, a  large  cavity
containing     blood,
urine and pus.

Extensive infiltration
of  blood  and  urine
into cellular  tissue;
peritoneum   stripped
off from wall of abdo-
men as high as um-
bilicus.
Separation  of sym-
physis pubis ; fracture
of pelvis.
Three gallons of fluid
in abdomen ; pus in
pelvic  cavity; other
organs healthy.
No external marks of
injury ; but little fluid
in cavity of abdomen :
no urinous odor ; pe-
ritoneum    healthy ;
bowels distended with
flatus; lemon-colored
pulpy  substance   in
appearance  softened
membrane or cellular
tissue in cavity of pel-
vis ;  an  intussuscep-
tion in the ileum just
above  the  ileo-ccecal
valve; marks  of in-
flammation  at  this
point.
Post Mortem appearances
      of Bladder.
Rupture  in fore-part
behind     symphysis
pubis, size  of end  of
little finger.
Rupture  in fore part,
just  below  reflexion
of peritoneum.
Ruptured immediate-
ly behind pubes.
No  appearance   of
bladder.
Condition.
Bladder dis-
tended.
Authorities.
Mr.  Hawkins.
Mr.  Hawkins.
No  part  of bladder
found, except neck, to
which adhered shreds
of softened membrane,
in which a blood ves-
sel  was  observed  ;
ureters terminating in
the  pulpy  mass  in
pelvic cavity.
Intoxicated.
Bladder dis-
tended.
Mr. Hawkins.
 Dr. Pendleton.
Charleston  Med.
Jour.   Vol . v.
 Dr.  Kneeland.
New- York  Jour.
Med.     March,
1851. 
42
Smith on Rupture  of the Bladder.
    The following is an analytical summary of the  seventy-
eight cases of rupture  of the  urinary bladder reported  in the
foregoing  table:—

    Sex.—Males 67 ; females 11; making about 6 of the former to 1
of the latter.
    Age.— Under 10, 3;  10 to 20, 3 ;  20 to 30,19 ;  30 to 40, 26; 40
to 50, 7 ; 50 to 60, 4 ; above 60, none ;  adults 16, age not  given.
    Condition.—Bladder distended, 30 ; of which 10 were  intoxicat-
ed ;  5, from stricture; intoxicated, condition not given, 14 ;  par-
turition, 4 ; in good health, 4 ; doubtful, 2 ; no note of 24.
    Causes.—Direct violence, 48; concussion,  15 ; internal  causes, 9;
of which 4 were parturition, 4 results of structure, 1 retroversio uteri;
no note of 6.
    Primary Symptoms.—Severe, 59;  of which 43 were ruptured
into the peritoneal cavity; 2, not involving peritoneum;  10,  into cellu-
lar  tissue;  3, not given.  Slight, 9 ;  of which  7, were into peritoneal
cavity; 2, into cellular  tissue.   No  symptoms, 3 ;  2, into peritoneal
cavity; 1,  indefinite.  No note of 7.  Inability  to  urinate,  28; of
which 22 were into peritoneal cavity; 1, not  involving peritoneum ;
5, into cellular tissue.   Power  to void  urine, 3; 2, into the perito-
neal cavity; 1, not involving peritoneum.  Power  of locomotion, 7 ;
all through the peritoneum.   Felt a sensation as of the bladder burst-
ing, 7.
    Progress of Cases.—Severe symptoms continued in 48 ; of which
39 ruptured into the peritoneal cavity; 7,  into cellular  tissue; 2,
peritoneum not involved.  Severe symptoms set in in 10 ; in 1, three
hours after accident; 6, two days ;  2, four days ; 1, three  days—all
ruptured into  peritoneum except last.  In 1,  power to  urinate con-
tinued, the rupture being into cavity of abdomen.  In 14,  it came
on ; in 12 of these, on 2d day ;  9, being into  peritoneum ;  2, not in-
volving peritoneum ; 1, into cellular tissue ; in 1, on third day; in 1, on
fourth day.  Locomotion continued in 2, both ruptured into perito-
neum.   Bloody  urine  drawn in 25 ; clear  in 4.   Symptoms  were
mild in 2, both ruptured into cellular tissue.
    Result.—Died, 73.   Within 5 days, 39;  26 being ruptures  into
the peritoneum ; 9, into the cellular tissue;  3, not given.   Between
5 and  10 days, 22 ; 17, into peritoneal cavity; 3, into cellular tissue ;
2, not  involving  peritoneum.  Between  10 and 15 days, 2; both into
cellular tissue.  Between 15  and 20 days, 3 ; 1, into the peritoneal
cavity ; 2,  into cellular  tissue.  Above 20 days, 2;  both into cellular
tissue; of which 1  lived 42 days. 
Smith  on Rupture of the Bladder.              43
    Recovered, 5 ; 3, into  cellular  tissue; 1, into peritoneal cavity •
 1, partial.
    Post-mortem appearances of Viscera.—External marks of injury
 in 2, both ruptured  into peritoneal  cavity.   No external marks  of
 injury in 8 ;  7, ruptured into cavity of peritoneum ;  1, not involving
 peritoneum.   Fracture and injury of pelvis in 15 ;  11, ruptured into
 cellular tissue ;  3, into peritoneum ;  1, not given.   Marks of inflam-
 mation in abdomen,  in 34 ;  27, being into peritoneal cavity ; 5, into
 cellular tissue;  2, not involving peritoneum.   No marks of inflam-
 mation in cavity of  abdomen, 7 ; 4,  being ruptured into cellular tis-
 sue ;  3, into cavity of abdomen.
    Post-mortem appearances of Bladder.—-Rupture into  cavity  of
 peritoneum, 50;  39,  the result of direct violence ; 6, concussion or
 indirect violence; 4, from  parturition; 2, stricture; 1, retroversio
 uteri.  Rupture  in the anterior wall of the bladder, 9 ;  5,  being di-
 rect violence; 3,  concussion;  1, stricture.  Rupture at neck, 6-  5
 direct violence ;   1, not given.   No bladder found, 2; bladder firmly
contracted in 17. 
1^.