Hill recorded a case of sudden death in which numbers of minute extravasations and some clots existed in the muscles of the abdomen, chest, heart, and in the brain and viscera. Tillmanns says, further, that the lower extremities are more often injured than the upper, the lungs not uncommonly, and the abdominal viscera are occasionally injured.

The distinguished Leipzig surgeon quoted founds his conclusions largely upon the observations of Tardieu and Vipert: upon the Charenton accident in which 400 people were injured. Not unusually after a railroad injury there is great hemorrhage from a surface wound or a passing of blood into the cavities of the body. The immediate effect of the accident is modified by several factors.

Sex. More men are injured than women; this is not because men are more prone to injury than women, but because more men travel. Shock is less manifest in men than in women, but visceral injury is more common because men in middle life are more apt to have visceral disease than are women. Women suffer much from shock and frequently develop persistent and severe nervous symptoms. The liability to shock is greatly increased if at the time of the accident the victim was pregnant, was menstruating, or was lactating. Of course, an accident may be responsible for abortion or premature labor.

Age. Children are profoundly shocked if they suffer from great hemorrhage or severe pain, but otherwise they are not, because they do not have a keen appreciation of the nature of an accident, and the mental effect of the calamity is either absent or is slight and transitory. In children, especially in those predisposed by hereditary tendency, a nervous disease may result from the fright. The viscera of a child are rarely injured. This is because they are usually healthy, because the tissues are elastic and limit concussion, and because the bones are elastic and the joints mobile. Permanent disability is not so apt to ensue as in adults; in fact, the injury in a child is usually soon repaired. The aged suffer very much from shock, and are particularly liable to visceral injury and to sudden death.

Obesity. A fat man, because of his great weight, is apt to be seriously injured by falls, jars, oscillations, or concussions, and is liable especially to fracture or dislocation. Every fat man is not unhealthy, but many fat men are. An unhealthy fat man has flabby muscles and relaxed ligaments, and is thus peculiarly liable to sprains, strains, and dislocations. He suffers severely from shock, his viscera are unhealthy and are apt to be damaged, and after an injury his appetite fails at once, he loses strength rapidly, and wounds do not heal kindly.

Habits. A man who drinks liquor to excess is almost certain to do so after an injury, and even an ordinary regular drinker is apt to come to harm after an accident. Such subjects suffer from insomnia and nervousness. The appetite fails, the kidneys cease to perform their functions properly, and delirium tremens may arise even if the individual has not been an actual drunkard. If a fracture exists, the muscular tremors of delirium tremens can separate the ends of the bones and lead

to non-union, or faulty union if the patient is so fortunate as to escape death. A very slight injury may produce an extensive ecchymosis in a drunkard, and the same statement is true of a tea inebriate, an opium eater, a hemophiliac, or an individual who is anemic from any cause whatever.

Temperament.-People of choleric temperament stand shock well, but occasionally after a shock develop emotional derangement, hypochondriasis, or actual mental disease. Persons of a nervous temperament have weak muscles and are liable to strains and sprains. In them the immediate effects of shock are very severe, but the rally is rapid and thorough. After the shock they frequently suffer from hysteria, hypochondriasis, neurasthenias, neuralgia, insomnia, dyspepsia, and sometimes actual insanity. People of the lymphatic temperament suffer but little from shock unless the injury is complicated by hemorrhage. They are especially liable to complications produced by exposure to cold. They rarely have at the time any clear realization of the horror of the affair. Their after-impressions are cold and indistinct, and they do not dwell upon the catastrophe with the fearful fascination of the nervous or choleric. People of a sanguine temperament react readily from shock, but not very uncommonly develop maniacal excitement or hysteric delirium. They soon recover from the terror of the accident, and, as a rule, like to narrate incidents of it and tell of the part they played.

Race.-Negroes suffer considerably from fear and shock. Jews, especially Russian Jews, often become frantic with terror after an accident and develop many secondary nervous phenomena. It has been alleged that Chinamen when in a railroad accident as a rule remain placid, orderly, and quiet. The French suffer much from shock, but soon react. Irish, Germans, Englishmen, and Americans have no special racial peculiarities in regard to it.

SHOCK OR COLLAPSE.

Shock or collapse is a condition of depression of the vital powers which follows a physical injury or a powerful mental impression. It is not dependent upon loss of blood, although hemorrhage, if present, greatly adds to its intensity. The peripheral irritation of an injury or the central commotion of a mental impression, and in many cases both factors combined, weaken the heart. The cardiac weakness arises from irritation of the pneumogastric centers and from paralysis of the vasomotor nerves of the abdomen. The blood no longer circulates freely, but gathers in the abdominal viscera and the man may be said to "bleed to death in his own viscera." As a matter of fact, the correct mode of expression is to designate the causative impression as the shock, and the resultant condition as collapse, but it has been the usual custom to use the term shock to signify both the impression and the condition. which results. Some surgeons are in the habit of applying the term shock to a condition associated with physical injury, and the term

collapse to a condition arising from mental commotion. Shock is especially manifest in women, in children, in the aged, weak, and debilitated, in sufferers from chronic visceral disease or nervous maladies, in drunkards, in negroes, and in Russian Jews, and after injuries to the head, testicles, abdominal viscera, or joints.

That fear alone can produce profound collapse is certain. It causes pallor, tremor, goose-skin, dyspnea, weakness and slowness of the circulation, coldness of the extremities, subnormal temperature, involuntary evacuation of urine and feces, and excitement and delirium. It may cause death. That it can do so has been proved by the fact that men have died at the minute they were condemned to be hung. Lauder Brunton has recorded a remarkable case in which fright caused instant death. Haller has told of a man who, in stepping over a grave, thought he was seized by the foot, was greatly frightened, and died the same day.

Intense mental preoccupation opposes shock.

A shock can sober

the drunkard, establish a great number of maladies, and wake into activity hitherto unsuspected morbid tendencies. It varies in degree from the slightest and most transitory disturbances to the most profound impairment of the vital functions. It is highly important to remember that shock may produce a condition in which the memory fails properly to register events, and events which were immediately antecedent to the accident may pass from recollection. Such cases have been recorded by Carpenter and others, and amnesia of this character may be temporary or permanent. A man, after an accident, may sit up, walk around, and talk and yet have no subsequent memory of this period, just as a somnambulist has no memory of his movements or as the victim of epileptic automatism has no recollection of having done anything unusual. The account of the accident given by an individual who was profoundly shocked may even be believed by himself and yet be erroneous in the most essential particulars, and should never be accepted without substantial corroboration.

It is usual to divide shock into three forms-the torpid or apathetic form, the delayed or secondary form, and the erethistic or delirious form. The so-called erethistic or delirious shock is not shock at all. It may mean the delirium of hemorrhage; it is often a purely emotional delirium; when it happens a short time after the accident it may be due to septic infection. In this condition the pulse and respiration are irregular and the face is flushed.

The common form of shock is the torpid or apathetic. The face is pale, the features are sunken, the eyes are bright and staring, the skin is covered with a cold sweat, the pulse is very rapid and feeble and often intermittent, the breathing is irregular, shallow, and quiet, the muscles are relaxed, the sphincters as well as the voluntary muscles are relaxed, the pupils are equal and dilated, but react slowly to light. There is usually retention of urine and impaired sensibility. The patient is, as a rule, conscious, although apathetic, and answers sensibly, though in a very low voice when spoken to loudly or per

emptorily. In some cases there is temporary unconsciousness. Not unusually there are nausea and vomiting. The temperature is frequently as low as 95° F. A man in this condition may become unconscious and die in a short time. He may react and go about, although he feels shaken and weak for a considerable period and frequently has a blurred memory or complete amnesia as to the events of the accident and often of the events which immediately preceded and followed it. He may remain shocked for many hours, with occasional episodes of excitement, from which condition he subsequently recovers. He may recover completely from shock, or the condition may be responsible for the production of some grave collapse, or of the weakening of morbid tendencies into activity, or disclosing an organic disease which was not previously recognized as existing.

It is necessary to distinguish this form of shock from the constitutional condition which accompanies hemorrhage, from syncope, from concussion of the brain, from compression of the brain, and from alcoholic intoxication. In the collapse of hemorrhage the individual has fainting attacks from which he reacts. He is extremely restless, tossing himself from side to side, suffers from excessive thirst, has a pallor more deadly than the paleness of shock, and the blood shows a notable diminution of hemoglobin. In syncope the patient becomes suddenly unconscious, and from this condition he quickly recovers or in it he quickly dies. Concussion of the brain is considered by many to be a form of shock. As a matter of fact, it presents practically the same symptoms, but with a greater amount of involvement of the mental processes. The patient may be absolutely unconscious, or may be capable of being aroused for a moment by peremptory speaking. Compression of the brain is marked by coma, paralysis, loss of pupillary reflex, etc., and is hence not confused with shock. In drunkenness it is rare that there is complete unconsciousness. The patient can usually be aroused, his face is generally flushed, not pale, there is thickness in speech, the pulse is distinct, though possibly weak, and there are incoherence and incoördination.

The form of shock which is known as the insidious, secondary, or delayed form was described many years ago by Travers. The patient at first has slight symptoms of shock, but in the course of a few hours positive manifestations appear and the patient has episodes of delirious excitement and is apt to die.

Delirium Tremens.-If a hard drinker becomes the victim of an accident, he frequently develops delirium tremens. A drunkard is almost certain to, but a regular spirit drinker who is not a drunkard may also do so. This condition is especially common in drinkers injured in a railway accident.

Traumatic Delirium-Delirium Nervosum.-This condition is a state of afebrile delirious excitement which is occasionally observed in people after an accident. It comes on in from two to five days after an accident or operation, and lasts a day or two or even longer (Le Dentu).

It occasionally causes death. In most patients it is hysteric delirium, and in some it is acute maniacal delirium. Occasionally a case which begins as traumatic delirium after a time becomes a confusional insanity, a dementia, or a melancholia.

Injuries of the Back.-Injury of the back is often alleged as the basis of a claim for damages. Undoubtedly injuries of the back are frequently produced by railroad accidents, but as they are apt to be complicated by nervous symptoms, they constitute a great source of litigation, error, and fraud. These injuries may be produced by direct blows upon the back, violent oscillations of the body, propulsion forward or throwing backward, bending, thrusting, lifting, violent jars, or jumping from the train.

Such injuries are intraspinous, extraspinous, or a combination of both forms. Page tells us that 99 per cent. of cases are examples of extraspinous injury, and in very many cases the injury of ligaments and muscles is absolutely unassociated with injury of bones or nervous structure.

Strains and Sprains of the Back. The cervical region suffers most often, and the dorsal region least often, from strains and sprains, but in some cases two regions, or all the regions, are involved. Symptoms may arise promptly and be marked and positive, but in most cases they come on gradually and are at first trivial and uncertain. In fact, two or three days may pass before the symptoms are positive and disabling.

The symptoms are pain on deep pressure, on using the injured muscles, or moving the sprained articulations. Pain may radiate some distance, but does not follow a recognized nerve distribution when the nervous structures are not damaged. Points of tenderness frequently exist in the skin overlying the area of ligamentous or muscular damage. In severe injuries there is some local pain, even when the patient is quiet, but it is much intensified by motion. If pain on pressure is complained of, a simple maneuver will prove the pain to be real. Make firm pressure and this will cause rapid pulse and possible pallor and sweating (Mannkopf). The back is stiff and immobile, the muscles being in tonic spasm because of pain and inflammation in muscles, ligaments, or joints. If the patient bends to pick up something, he acts like a child with Pott's disease and bends the knees instead of the back. Unilateral rigidity may exist, and this cannot be simulated. Limitation of movement in the cervical region can be detected by asking the individual to turn his chin far over one shoulder and then far over the other shoulder. Then have him sit in a chair, look at the ceiling, and throw his head farther and farther back. Rigidity in the dorsal region is hard to make out. In the lumbar region rigidity can be detected by undressing the patient, placing him face down, and watching the lumbar curve while the leg or body is raised.

In severe cases swelling and discoloration are observed. In bad sprains the pain on movement is so severe that the individual dreads the very thought of motion, and his refusal to move may be mistaken for paralysis. In such a case the movements of the legs and arms are