INJURIES OF THE PROSTATE.
Traumatism of the prOstate, aside from that incidental to surgical operations and manipulations, is exceptional. Contusions and lacer ation of the prostate due to direct force from falls or blows are espe cially rare on account of the situation of the organ, protected as it is by the pubic and ischiatic rami and the ischial tuberosities. The force of falls and blows upon the buttocks is usually broken by the prominent osseous parts. Blows upon the perineum are not likely to injure the prostate on account of the distance of the organ and the elasticity of the musculo-cellular cushion constituted by the tissues of the ano-perineal region and ischio-rectal fossa. Accidents have been known where the membraneous urethra has been torn completely across at the apex of the prostate, and yet that organ has escaped injury. This was long ago noted by Chopart. A crushing injury involving the prostate is almost necessarily fatal, excepting where the prostate is injured indirectly through the medium of fracture of the pelvic bones fragments of which wound the organ. In cases of exten sive crushing injury the traumatism of the prostate is comparatively a minor consideration. Incised, punctured, and lacerated wounds of the prostate from accidental injury are occasionally seen. Sharp bodies may be driven into the perineum, the patient perhaps falling astride them. Most of the accidental injuries are due to a fall upon some pointed object. Dugas cites a case in which the branch of a tree was driven into the perineum and the prostate wounded (Forge, " Traite de Chirurgie"). Velpeau reports a similar case in which a wooden stake was driven into the perineum. Brittle substances in troduced into the rectum have been known to penetrate the prostate.
Obviously such penetration might occur with great facility. Injury to the prostate by firearms is necessarily very rare. Ricord, however, reported a case in which a musket-ball penetrated the false pelvis, passed downward along the iliac fossa, entered the true pelvis, and penetrated the prostate. It was detected by a digital examination through the rectum and extracted by perineal section. Wounds of
the prostate inflicted in the performance of surgical operations of various kinds are frequent. It is necessarily wounded in all of the perineal operations of lithotomy with the exception of the simple median or Marian operation. It is often wounded in perineal ure throtomy, and is invariably wounded in the proper performance of perineal puncture for drainage of the bladder. Operative wounds of the prostate are not dangerous per se, unless the incision or lace ration, as in the case of extraction of too large a stone, extends beyond the bounds of the fascial investments of the prostate, thus involving the pelvic cellular tissue or peritoneum. The prostate is often in jured from its urethral aspect in the passage of the catheter or sound, or in the performance of that extremely hazardous operation, inter nal prostatotomy. These forms of prostatic trauma are exceedingly dangerous because of the exposure of the injured tissue to sepsis and the necessarily imperfect drainage. An additional element of danger is uncontrollable hemorrhage. These factors are done away with in perineal or suprapubic operative wounds of the prostate. Another danger is the formation of a false urinary passage. False passages traversing the prostate and beginning in the prostatic urethra, or at some point in the urethral walls at a greater or less distance anterior to the apex of the organ, are very frequently seen. Tnstances have been known in which a catheter or sound has been passed through the urethral walls at some point in front of the bulbo membranous region and made to traverse the tissues outside of the urethra, penetrating one or the other lobe of the prostate, thus reaching the bladder by a roundabout and most dangerous route.
Results of Injuryalready suggested, wounds from the inte rior are most likely to be followed by serious results, providing the injury be limited to the prostate itself. Lacerations and contusions are more dangerous than smooth incisions, excepting in respect to the danger of hemorrhage, which is obviously greater in clean in cised wounds, unless such wounds be external and open.