In considering the question of hemorrhage from operative or ac cidental wounds about the prostate, it is well to remember that the region of the prostate is very vascular and rather difficult of access for the application of methods of lmmostasis. Retention of urine from congestive or inflammatory occlusion of the urethra, or from complete, or partial obliteration of the canal as a result of the trau matism, is likely to be the next point for consideration in prostatic injuries. Pyogenic infection and abscess, possibly followed by uri nary fistula, and septic cellulitis, are serious results which are likely to occur in extensive injuries, especially those in which drainage is imperfect. The septic cellulitis may be limited to the ano-perineal region and ischio-rectal fossa, or may extend over a large area of the subcutaneous and intermuscular planes of cellular tissue. In case the wound extends beyond the bounds of the prostate, septic pelvic cellulitis or general peritonitis may supervene, these latter conditions being intrinsically fatal. Constitutional manifestations of septic or pathogenic intoxication may supervene. It will be observed that, in a general way, the conditions produced by, and dangers of, prostatic injuries are essentially the same as in traumatism of the urethra and bladder.
is nothing characteristic in the symptomatol ogy of wounds of the prostate. In a general way, they are similar to those of deep urethral traumatisms. The principal symptom pro duced by the injury is urethrorrhagia, providing the wound of the prostate communicates with the urethra. If an open wound of the prostate exists and the urethra be injured, the hemorrhage occurs at the site of the. injury and also in the form of a urethral hemorrhage. Retention of urine has already been alluded to, and is an important factor in the symptomatology of prostatic traumatism. If the ex travasation of blood into the surrounding tissues be extensive, hmna toma may result, which may be felt by way of the rectum, around which viscus it may burrow for a considerable distance. The local and constitutional symptoms which speedily follow serious injuries of the prostate are by no means distinctive, but are precisely similar to those which follow urethral injuries producing urinary infiltration, cellulitis, or abscess.
Treatment.—Operative wounds from the exterior require no spe cial consideration. In both internal and external wounds which are not extensive, and in which a catheter can readily be passed, a full sized soft instrument should be introduced into the bladder and re tained from three days to a week or more according to the progress of the case. Great care is necessary to maintain urethral asepsis. If the hemorrhage be excessive and urinary extravasation exist, or if there be any reason to believe that the wound of the prostate is of a serious character, or in any case in which the catheter does not pass readily, a free perineal section should be made and the bladder drained by a large tube, the after-care of the case being based upon strict principles of antisepsis. In cases in which the perineum is ex tensively disorganized by the injury and it is a difficult matter to find the proximal end of the urethra, suprapubic cystotomy, retrograde exploration, and perineal incision should be combined. Through and through drainage should be instituted in such cases. In the author's opinion this procedure is far safer than a prolonged and necessarily haphazard search for the normal channel via the peri neum. Infiltration of urine demands free incisions in any and all situations in which intumescence of the tissues is suggestive of the presence of extravasated fluid. The incisions can hardly be too free or too numerous—with due respect to anatomical dangers. The same principles should be adopted in the management of urinary abscess and cellulitis. The early and free use of the knife in septic cases is the only hope of saving the life of the patient. The tendency to asthenia, incidental to the profoundly depressing influence upon the sympathetic nervous system produced by injuries of this region, and the great danger of toxemia, constitute a direct and positive indica tion for free and liberal supportive measures of a dietetic and stimu lating character.