REACTION. — As soon as reaction oc curs in these cases another danger threatens the patient, that of hemor rhage, which the state of collapse has so far prevented to a degree, unless an extensive injury have caused overwhelm ing exsanguination. In this event, how ever, the patient's recovery from the preliminary shock would hardly have taken place. Hence the necessity of closely watching the sufferer.
After a severe abdominal injury the patient passes through a stage of col lapse, through a stage when the diag nosis remains uncertain, through a period when the signs of hremorrhage show themselves, and through a period of slow complications. Van Verts (Arch. Gen. de Med., Jan., '97).
Cases of prolonged collapse sometimes turn out to be trivial, while a short period of it may be the prelude to the most grave complications. The former cases are, unfortunately, rare, and pro found shock of any duration should be looked upon with suspicion. This is especially the case when a second period of shock is passed through—the "relaps ing collapse" of Bryant—indicative of a secondary hemorrhage or the giving way or separation of some damaged tissues.
That cases, clearly showing by their history and the active symptoms a grave injury, should be submitted to surgical measures as early as possible will hardly be gainsaid in the light of our present knowledge. An equally positive conclu sion, based on every means of diagnosis available, will alone warrant the asser tion that no serious injury is present; but if, on the other hand, doubt exists, abdominal section will alone insure the patient adequate protection. If nothing be found, no harm will have been done if precepts governing aseptic surgery have been Ancely followed • if a rent in u in the liver, an intestinal tear or rupture, a serious be discovered and adequately dealt with, the patient will have received the benefit of all our art's resources.
Hyperzesthesia of abdomen after injury is indication for operation. An increase
in respirations to twenty-eight or thirty per minute makes indication absolute. Cold extremities also significant. Le Dentu (Le Progres Med., Oct. 27, '97).
In abdominal injuries when there is pain without cessation and nausea, it is best to operate. J. B. Murphy (Jour. Amer. Med. Assoc., July 9, '95).
The seat of rupture being located, the nature of the injury will deter mine the procedure to follow, linear enterorrhaphy being indicated iu longi tudinal ruptures, and circular enteror rhaphy in complete ruptures, a Murphy button being employed. These proced ures are now generally preferred to an artificial anus. It is sometimes impos sible to adequately adjust the edges of the \round, owing to the condition of the margin, and an omental graft must be used to cover the contused area so as to avoid a secondary perforation.
Considerable extravasation of feeces, blood, and other liquid or semiliquid ma terial may have occurred into the peri toneal cavity. All chances for further contamination of the intestinal tract having thus been removed by closure of the rupture, the peritoneal cavity should be carefully cleansed by flushing with warm, sterilized water, a soft aseptic sponge being employed to gently mop all the surfaces that may, in any way, have come in contact with the infectious fluids. The cavity is then closed and free drainage insured.
Satisfactory results are obtained even in eases in which very great injury and ample opportunity for infection of all wounds have markedly compromised the issue.
Case in a young man who, some time previously, had been severely wounded in the abdomen by a wagon-pole. The intestines were much contused and very dirty. In some places the serous and muscular coats were torn through. The intestines and peritoneal cavity were carefully cleansed with a solution of iodine terchloride (1 to 1000) and the wounds united. The patient recovered without fever. Langenbuch (Deutsche med. Woch., Apr. 28, '92).