Traumatic perforation of the bowel

Abstract

In fiction, particularly in cinema fiction, we often see the victims of stabbing or gunshot wounds to the abdomen dying rapidly and often dramatically at the site of combat. All surgeons who have been involved in the treatment of traumatic perforations of the bowel know that this is far from the truth. Death is not the inevitable consequence of traumatic bowel perforation; it now occurs rarely and, if it does so, then only after days, weeks, or even months of a battle against infection. We also know that traumatic perforation of the bowel, even in elderly Presidents and Popes, eventually responds satisfactorily to surgical intervention. There will probably be few of us who have the worrying privilege of being on duty when Heads of State or Church are admitted with such a mishap, but in case we ever are we should be aware of current thinking lest the eyes of the world turn on us and find us unprepared. The management of such perforations has been subjected to pendulum swings of fashion almost as great as those of skirt length. Most of the major advances in the management of this once frequently fatal mishap have been the experience of war, which has provided thinking surgeons with an enormously concentrated experience. Sadly, in modem so-called ‘peacetime’ there are some parts of the world with such endemic violence from what is sometimes described as the local Knife and Gun Clubs that some hospitals have such a wealth of clinical material that even prospective randomized trials become possible. In 1979, following the presentation to the Annual Meeting of the American Surgical Association of one of the few prospective randomized studies performed on this subject (Stone and Fabian, 1979) the discussant was Dr Owen Wangensteen of Minneapolis (Wangensteen, 1979), already emeritus and steeped in surgical history. It was he who informed the audience that it was a Russian surgeon and affluent Princess, Vera Gedroitz, who was the first to operate successfully on a series of abdominal gunshot injuries in the Russo-Japanese war of 1904. Apparently her wealth enabled her to engage ambulances to send to the fighting front and evacuate the casualties rapidly to hospital. It is amazing that in those days any such patients survived. That they did was a tribute to the Princess’s surgical ability and clairvoyance in arranging early ambulance evacuation. Before the Second World War and the ready availability of antibiotics, the surgical textbooks apparently advocated primary closure more in hope than expectation. In Britain it has been customary to cite the writings of Major General (later Sir) Heneage Ogilvie who, observing a 53 per cent mortality in battle wounds associated with a perforated