The French writers consider phlebitis and diffuse cellular inflammations to be the most common causes of death after lithotomy, and they atuibute both these fatal affections to an incision carried beyond the base of the prostate. They maintain that the cut surface of the gland is sufficiently tough and resisting to bear the urine with impunity, and that the lax cellular membrane around the neck of the bladder, and the veins in the same locality, speedily inflame when irritated by that secretion. In Paris the bilateral operation is therefore mostly practised, as it gives the largest incision prac ticable within the circumference of the prostate gland, at the same time that it protects the common ejaculatory ducts, the rectum, and the pudic artery from injury.
In these countries the lateral method is still generally preferred, whether it be that British surgeons usually find a section of one side of the prostate sufficient for the extraction of the calculus, or that a moderate division of the neck of the bladder in their hands seldom leads to the above described unfortunate results, particularly if a ready outlet for the urine be ensured by a free section of the superficial structures.
In the bilateral operation a double risk of wounding the irregular dorsal arteries of the penis must be incurred ; and should the blades of the lithotome, in consequence of a miscon ception of the width of the prostate gland or of the transverse measurement of the bony boundary of the perineum, be too widely di varicated, a twofold liability to venous hemor rhage and to injury of the rectum will be the result, and the pudic vessels on both sides will be endangered,—accidents which deniand due consideration from the practitioner in weighing the relative merits of these rival operations.
In dividing the prostate gland the knife is apt to slip from the groove of the staff by reason of the great toughness of the capsule, and to pass between the rectum and bladder, causing extreme mischief. When this pan of the operation is performed with the simple knife, the lithotomist guards against such an unpleasant accident by incising the membra nous portion of the urethra fredy before commences the third incision, and by depre ing the handle of the knife considerably as pushes its blade onvvards to the bladder; the former precaution he makes certain that t point of the knife is properly lodged in the groove of the staff, and by the latter that it follows the groove fairly into the bladder. Some excellent instruments have been devised to prevent the occurrence of so serious an acci dent, but to describe them here would be too wide a digression.
The lithotomist is liable to commit other mistakes still in the same stage of the lateral operation. His incisions may fall short of the bladder altogether, leaving the prostate insuffi ciently divided ; or he may, on the other hand, transfix the bladder by plunging his knife too deeply. The former error may lead to disap pointment in extracting the stone, and to severe injury of the neighbouring parts in the attempt to do so; it admits, however, of correction if discovered in time,,but the latter mistake must be irreparable. Occurrences such as these result from an imperfect knowledge of the depth of the perineum, and may be accounted for by the great variation in this respect which the region presents in different subjects. Du puytren and Velpeau found the distance from the neck of the bladder to the integument of the perineum to vary in different cases to the extent of two inches and upwards, the disparity depending chiefly on the degree of obesity of the individual.
The deep compartment of the anterior divi sion of the perineum has claims upon the attention of the practical surgeon independent of lithotomy. Matter sometimes forms within this space, and from the contiguity of the rectum on the one hand, and of the urinary organs on the other, such collections produce most distressing symptoms. The triangular ligament of the urethm prevents the abscess from gaining the surface directly, so that at length it either bursts into the rectum or makes its way gradually behind the base of the liga ment. The finger introduced into the gut affords satisfactory information as to the nature of such cases, and free incisions through the perineum are followed by the most rnarked relief.
Effusions of urine from accidental ruptures of the urethm occur less frequently behind the triangular ligament than in front of it, for in the former situation the canal is so thoroughly protected by its deep position that contusions inflicted upon the surface of the region but rarely affect it. False passages from the forci ble introduction of instruments take place in general anterior to the triangular ligament; but when the urethra gives way behind a stricture in consequence of violent expulsive efforts of the bladder, the urine sometimes escapes into the deep compartment of the perineum, and destructive consequences are sure to ensue unless counteracted by thnely treatment.