Perforation

PERFORATION (from Latin perforare—pierce, bore), perforation, a full breach in the integrity of the wall of a hollow or tubular organ, as a result of which a communication is established between the cavity of the organ and the surrounding medium. The causes of P. can be very diverse. Sometimes the destruction of the wall of one of these organs occurs upon the introduction of a foreign body into it, and such introduction may proceed from outside into the organ (for example, upon gunshot or stab injury) or from inside to the outside (for instance, in the digestive tract upon the entry of a fish or beef bone into it; in the uterus upon careless curettage with a sharp spoon). In other cases, P. occurs as a result of the destruction of the organ wall by a necrotic, inflammatory, or other ulcerative process. Perforation can also be led to by a neoplasm that destroys the wall of the organ. Finally, P. can be the consequence of the rupture of the organ wall, which has gradually thinned from increasing distension. Of various organs, perforation is most often observed along the digestive tract: in the esophagus upon injury by a swallowed bone or upon destruction of its wall by a cancerous neoplasm; in the stomach—upon a penetrating round ulcer through its wall and upon cancers of it; in the intestine—upon the penetration through its wall of typhoid, tuberculous, or dysenteric ulcerative processes, as well as upon neoplasms of it; in the vermiform appendix—upon the decay of the wall in gangrenous appendicitis. Perforation of the uterus is instrumental, i.e., caused by a surgical instrument (curette during curettage, perforator during perforation of the fetal head) or occurs as a result of a purulent inflammatory process or the growth of a neoplasm. In the Fallopian tubes, P. occurs from their distension in ectopic pregnancy and in purulent salpingitis, but here one usually speaks of rupture (ruptura) of the tube, just as in the case of a breach in the integrity of the uterine wall during difficult labor (rupture of the uterus); in the same way, a breach in the integrity of the heart wall or aneurysm (for example, of the aorta) is more often designated as rupture of the heart, aneurysm (ruptura cordis, ruptura aneurysmae), than perforation of the aneurysm. Perforation of the heart valve in ulcerative endocarditis, of the pulmonary pleura, for example, upon rupture of a cavity or abscess of the lung, and of the gallbladder upon stones in it are also included among perforations. The essential phenomenon in each P. consists in the entry of the contents of the perforated hollow organ into the surrounding medium. Therefore, the consequences of P. can be diverse depending on the character of this content in the sense of its significance for the whole organism or in the sense of its local action, as well as depending on which organ is perforated and where the perforation occurred. In particular, perforation of the aorta usually has as a consequence rapid death as a result of large internal or external hemorrhage; perforation of the pulmonary pleura gives the entry of air into the pleural cavity and the formation of pneumothorax (see.) with compression of the lung. Very often the effusion of the contents of a hollow organ is the cause of inflammation of that area into which this content has effused; such inflammation can be aseptic (for example, upon the entry of sterile bile from a perforated gallbladder into the abdominal cavity), but more often has a septic character; this includes, for example, purulent pleuritis upon perforation into the pleural cavity of a cancer of the esophagus or a lung abscess, purulent peritonitis upon perforation of the stomach, intestine, or uterus. These inflammations, which are consequences of P., are conventionally called perforative (for example, perforative peritonitis, pleuritis), and the process causing P. is designated as perforative (for example, perforative appendicitis). Another consequence of P. may consist in the formation of a fistulous communication between the perforated organ and another hollow organ into which the perforation occurred; for example, a biliary-enteric fistula upon perforation of the gallbladder into the intestine, a uterorectal or uterovesical fistula upon perforation of the uterus into the rectum or bladder. Speaking of the consequences of P., one must bear in mind that not every P. is accompanied by one of the above-mentioned consequences; in those cases where perforation was preceded by the development of connective tissue adhesions, these adhesions may even in the case of a full perforation not allow the contents of the perforated organ to effuse into the neighboring tissue (so-called covered perforation). Close to P. stands the concept of penetration; this term denotes the penetration through the wall of the body cavity or hollow organ by various foreign bodies as well as by various pathological processes; the adjective penetrating is used to characterize such penetrating processes: for example, penetrating chest wound, penetrating ulcer of the stomach or intestine. Penetration and penetrating processes often lead to perforation.