RAILWAY SHOCKAND

ITS TREATMENTBY

F. X. DERCUM, M.D.,Instructor in Nervous Diseases, University of Pennsylvania; Neurologist to

Philadelphia Hospital.

Address Delivered before the Ninth Annual Meeting ofthe Lehigh Valley Medical Association,

August 16, 1889,

REPRINTED FROM THE THERAPEUTIC GAZETTE, OCTOBER is, iBBg.

DETROIT, MICH. :

GEORGE S. DAVIS, PUBLISHER.

1889.

RAILWAY SHOCKAND

ITS TREATMENT.

Mr. president and gentle-MEN ;—ln making a choice of sub-

ject I was guided mainly by the considerationthat an address before a body of medical menactively engaged in practice should be emi-nently practical in nature. Ere I have fin-ished I think that you will agree with methat the subject of railway shock is onefraught with many practical questions, someof which bear an intimate relation to theroutine of our daily lives, and which are im-portant not so much because of the frequencyof railway shock, but because of the valuablelessons which they teach. The theoreticalaspects of the subject I shall be obliged toconsider to some extent, but I propose doingso as briefly as the clear understanding of itwill permit.

To many, doubtless, on first seeing the an-nouncement of the title of this paper, “ Rail-way Shock,” the thought occurred that shockfrom railway injuries cannot differ in any es-

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sential point from shock produced by othercauses. You will find, however, that thecausation of railway shock is peculiar,—thatits causation is composite, and that, there-fore, the resulting condition presents specialfeatures. Certainly railway shock differs fromordinary traumatic shock, from surgical shock,and from purely emotional shock, and thereis abundant justification for the use of theterm.

Before proceeding, let us endeavor to ob-tain clear notions of shock itself. What isshock ? What is its pathology ?

Let us recall, to begin with, the classicalexperiment of Goltz. You will rememberthat he took a frog, placed him in an erect orvertical position, and then exposed the heartso that its pulsations could be readily studied.He then struck the abdomen a severe blow.Instantly the heart ceased beating, and onlyafter a while did it resume its pulsations.The latter, too, were much weaker than be-fore. Evidently the impression, the shock ofthe blow, had been transmitted to the nerve-centres, and thence, acting upon the heart,had caused it to become suddenly arrestedand also for a time much weakened. Physi-ologists, as you know, express this phenome-non as one of reflex inhibition ; but in what-ever terms we state it, the cardinal point forus to recognize is, that it is one of suddencardiac paresis.

The behavior of the heart, however, wasnot the only thing observed by Goltz. Henoticed in addition that the blood, which hadbut a moment before distended the heart andvena cava, was gravitating into the abdominal

3veins, leaving the heart and its vessels practi-cally empty. Evidently the same impressionthat had caused diastolic arrest of the hearthad here caused paralysis of the walls of theabdominal veins, or rather of the vaso-motorsystem of nerves that control them ; and weare now led to suspect that a general paraly-sis of the entire vascular apparatus is whatreally obtains in this form of shock. Indeed,among other things, this view receives ampleconfirmation from the elaborate sphygmo-graphic studies of the pulse made in cases ofshock by Furneaux Jordan,* the tension inthe arteries being invariably very low. Again,it is extremely probable that even the capil-laries are involved in this paralysis, for JohnHunterf observed in a lady, whom he wasbleeding, and who fainted during the opera-tion,—and fainting is a kind of shock,—thatthe blood flowing from the vein, “ instead ofbeing dark and venous, was of a bright scarletcolor, like that of arterial blood,” a phenome-non which could only obtain provided thecapillaries were much dilated.

Let us pause a moment and ponder uponthe generalization we have just reached. Themost salient feature of shock from a blowupon the abdomen is a general vascular paral-ysis. Evidently this means that the greatvaso-motor nerve-centres have been para-lyzed, and certainly it is in the highest degreeunphilosophical to suppose that the effect of

* Furneaux Jordan, “ Hastings Essay on Shock,Surgical Enquiries.” London, 1880.

f Cited by Lauder Brunton, “ Shock and Syncope,”P- *3-

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the blow is limited exclusively to these cen-tres, or to attempt to explain all of the symp-toms of shock by the mere vascular paralysis.It is known, indeed, as an absolute fact, thatstrong peripheral impressions will cause anabeyance of all the functions of the cord.S. Weir Mitchell has placed beyond all cavilthe facts of paralysis from peripheral irrita-tion,* and in dwelling upon the explanationof these strange phenomena, he quotes atlength the conclusions of Morehouse, Keen,and himself, from which I extract the follow-ing pregnant sentences :

“ Either the shockof a wound destroys directly the vital powerof a nerve-centre, or it causes paralysis of thevaso-motor nerves of the centre, with conse-quent congestions and alterations. But thereis no reason why, if shock be competent to de-stroy vitality in vaso-motor nerves or centres , itshould be incompetent so to affect the centres ofmotion or se?isation.”\ Again, in speaking ofvarious effects, quite common, the results ofgunshot wounds, he says,J “ These have beenmore or less vaguely treated of as shock,commotion, stupor, etc. The larger part ofthose who receive flesh wounds, involving noimportant organ, are but little affected at thetime, or may even be unconscious of havingbeen hit, and exhibit no well-marked imme-diate constitutional disturbance.

“In other cases, and particularly in wounds

* S. Weir Mitchell, “ Paralysis from Peripheral Irri-tation” [New York Medical fournal, 1866, vol. ii. pp.321 and 401).f Loc. cii., p. 353. Italics in the original.J Loc. cit., pp. 403 and 404.

5of graver nature, the patient instantly fallssenseless, and so remains during a few min-utes, or many hours, when he revives again,either completely, or to suffer from a con-tinued state of depression known as theshock, and marked by the usual features ofgreat weakness, feeble circulation, pallor, etc.

“ In other cases the last-named symptomscome on at once and without the interventionor accompaniment of unconsciousness.

“ These very interesting states of the systemmay be due, it seems to us, either to an arrestor enfeeblement of the heart’s action throughthe mediation of the medulla oblongata andthe pneumogastric nerves, or to a generalfunctional paralysis of the nerve-centres, bothspinal and cerebral, or, finally, to a combina-tion of both.”

Again, he says, “A severe injury, as a gun-shot wound of a limb or the neck, may pro-duce its effects of unconsciousness and lossof power, by greatly weakening, or for a timedestroying, with various degrees of complete-ness, the functions of all the nerve-centres andof their conducting cords.” A little fartheron occurs this significant paragraph :

“ Themajority of physicians will, no doubt, be dis-posed to attribute the chief share in the phe-nomena of shock, in its various forms, tothe indirect influence exerted upon andthrough the heart. There are, however, cer-tain facts which, duly considered, will, wethink, lead us to suppose that in many casesthe phenomena in question may be due to atemporary paralysis of the whole range ofnerve-centres, and that among these phenom-ena the cardiac feebleness may play a large

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part, and be itself induced by the state of theregulating nerve-centres of the great circula-tory organ.”

Mansell-Moullin, also, recognizes the gen-eral involvement of the nervous system, forhe tells us that “ shock is an example of reflexparalysis in the strictest and narrowest senseof the term,—a reflex inhibition, probably inthe majority of cases general, affecting all thefunctions of the nervous system, and not lim-ited to the heart and vessels only.”* Theword inhibition, however, mars this otherwiseexcellent definition. It implies that the vari-ous functions of the nervous system are sup-pressed or held in abeyance by some activeagency, whereas the condition is, doubtless,one of simple loss of function, the result ofviolent molecular jar. To use a well-worncomparison, it is a loss of function similar tothe loss of power in a magnet when the latterhas been struck a violent blow. Not that Idesire to give the impression that the nervoussystem must necessarily receive a violent me-chanical jar, but merely a sudden profoundand exhausting impression, whether the latterbe a blow upon the stomach, the crushing ofa limb, the wound of a nerve, or merely aviolent mental shock.

Further, Groeningenf points out in themost conclusive manner that the vascularphenomena alone are utterly incapable ofexplaining the symptoms of shock, and at-

* Mansell-Moullin on “ Shock” in “ InternationalEncyclopaedia of Surgery,” vol. i. p. 369, 1881.f Groeningen, “Ueber den Shock.” Wiesbaden,

1885.

7taches himself, with some minor reservations,to the theory of Leyden,* “ that a powerfulirritation, whether it impresses the cord di-rectly, or indirectly through the mediation ofa peripheral sensory nerve, provokes in it pow-erful (molecular) movements of the nerve-mass, and renders the same insensitive to thetransmission of less intense excitations.”Leyden includes in the resulting disturb-ances of function not only those of motilityand sensibility, but also the action on theheart, on the vaso-raotor nerves, and on therespiration. Groeningen, however, definesshock as “ a fatigue or exhaustion of thespinal cord and medulla oblongata caused by apowerful sudden impression (insult).”f Thisrestriction of the field of shock-action to thecord and medulla appears to us to be mostunphilosophical and entirely unwarranted.To what, for instance, is the paresis of the will,the general and profound mental anenergia,to be attributed if not to a participation bythe cerebrum ? Again, what becomes of thecases of shock due to mental influences alone,not to speak of shock (concussion) due toactual blows upon the head ? Is it becausethe cardiac and vascular phenomena, thetemperature phenomena, may be less markedin these latter instances, that they are to beexcluded ? If so, what becomes of the un-doubted cases of railway shock,—a form ofshock in which mental action plays so promi-nent a part ? Surely, if the cord and medullabe capable of undergoing a suspension of

* Cited by Groeningen, loc. cii., p. 45.f Loc. cit., p. 69.

8function, due to violent molecular move-ments, the same must be true of the brain;true alike whether we have gross concussionor simple sudden exhaustion due to mentalaction alone. The fact that the variousforms of cerebral shock—shock from emotion,shock from coarse vibratory jar, shock fromactual trauma—form such widely differentclinical pictures, cannot weigh against thetruth of this proposition. That shock, havingits point of departure, its focus of distribution,in the brain, should present special symptoms,must be expected on a priori grounds, and,further, that the symptoms should vary withthe character of the impression also followsof necessity. It would be equally impossibleto draw a distinction between the shock ofthe cord by a blow upon the abdomen or theconcussion of the cord due to the impact of abullet upon the vertebralcolumn. The symp-tomatology is different in large part, but theprinciple is intrinsically the same. (See Ley-den’s view.)

Thus far, then, we have every reason to re-gard the symptoms of shock as referable tothe nervous system as a whole. Further, weshould expect on a priori grounds that cer-tain symptoms, or groups of symptoms, shouldpredominate, according to the part of the bodyby which the injury is received, and this, ina general sense, we find to be the case.For example, in shock from a blow upon theabdomen, vascular phenomena predominate ;

in shock from a blow upon the lumbar cord,spinal symptoms predominate (although vas-cular symptoms are also present) ; and inshock from a blow upon the head, of course,

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brain symptoms predominate. That shock ofthe cord does occur is known to every experi-mental physiologist, while the cases of Erb,*of Hunt,f that of Jordan,J and one latelyplaced on record by myself,§ show that itactually occurs in man.

Again, while the symptoms of shock arethus modified, according to the part bywhich the injury has been received, we mustremember that it may be of all degrees ofintensity, and that, therefore, individual casesinjured in a similar manner may differ clin-ically. Further, the symptoms may be verymuch modified by the emotional state of thepatient at the time of the injury. This factand its importance we will presently realize.Again, as was pointed out by Jordan,(| ageis a modifying factor in shock. Children,other things equal, are less readily shockedthan the middle-aged or the old. Lastly, thetemperament of the individual, as has beenrecognized by all writers, exerts a powerfulinfluence in determining not only the symp-toms but also the occurrence of shock.

Let us now, in order that we may fullyunderstand the subject, carefully rehearsethe symptoms of simple severe shock. Letus take a case in which a powerful blow hasbeen received, and let us suppose that the

* Erb, “ Ziemssen’s Encyclopaedia,” American trans-lation, vol. xiii. p. 349 et seq.

f Hunt, “Pepper’s System,” vol, v. p. 913J Jordan, loc. cit., p. 39.$ Dercum, “Remarks on Spinal Injuries” (Thera-

peutic Gazette, May 15, 18S9).j| Jordan, loc. cit., p. 30.

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case has been observed very shortly after theoccurrence of the accident.

We have, to begin with, profound, muscu-lar weakness; secondly, a feeble, shallowrespiration ; thirdly, a feeble, slow, soft, al-most imperceptible pulse; fourthly, greatpallor of the surface ; fifthly, great coldnessof the surface ; sixthly, a cold, clammy sweat.Examination further discloses that the sensi-bilities, both general and special, are blunted ;

that the will is weakened, if not altogether inabeyance ; for the patient can only be stimu-lated to exert himself by repeated urging. Inshort, the whole picture is one typical of ex-treme depression.

I cannot do better, perhaps, in order tovividly recall this picture, than to cite theclassical description of a case by Fischer:*“ The patient, a strong and perfectly healthyyoung man, was struck in the abdomen bythe pole of a carriage drawn by runawayhorses. No serious injury was done to anyof the internal organs, at least we have notbeen able, after a careful examination, tofind any trace of one. Nevertheless, thegrave symptoms and the alarming look,which he still presents, made their appear-ance immediately after the accident. Helies, as we see, perfectly quiet, and pays noattention whatever to anything going onaround him. His countenance is sunk andpeculiarly elongated, his forehead is wrinkled,and his nostrils dilated. His weary, lustre-less eyes are deeply sunk in their sockets,half covered by his drooping eyelids and sur-

* Cited by Lauder Brunton, loc. cit., p. 3.

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rounded by broad dark rings. The pupilsare dilated and react slowly to light. Hestares, purposelessly and apathetically, straightbefore him. His skin, and such parts of themucous membranes as are visible, are pale asmarble, and his hands and lips have a bluishtinge. Large drops of sweat hang on his fore-head and eyebrows. His whole body feelscold to the hand, and a diminution of tem-perature is readily detected by the thermome-ter, which indicates a degree and a half in theaxilla and a degree Centigrade in the rectumbelow normal. Sensibility is much bluntedover the whole body, and only when a verypainful impression is made on the patientdoes he fretfully pull a wry face and make alanguid, defensive movement. He does notmove a single limb spontaneously ; but, afterbeing repeatedly and urgently requested, heshows that he can still execute limited andbrief movements with his extremities. If thelimbs are lifted and then let go, they imme-diately fall as if dead The pulse isalmost imperceptible, irregular, unequal, andvery rapid. The arteries are small and the ten-sion very low. While the patient was beingbrought to the hospital, the pulse becamequite imperceptible, and the cardiac soundsvery irregular and intermittent. The patientis perfectly conscious : he replies very slowlyand only when repeatedly and importunatelyquestioned, but his answers are quite to thepoint. . . . He gave the details of the acci-dent reluctantly and imperfectly, but in themain correctly. Only while he was beingbrought to the hospital did he refuse toanswer at all. His voice is hoarse and weak,

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but his articulation is good. . . . His sensesare perfectly acute. His respiration appearsto be irregular, and abnormally long, deep,and sighing inspirations alternate with verysuperficial ones, which are scarcely visible oraudible. While being brought to the hospitalhe vomited several times, and nausea andhiccough still remain. Any one who knewthe patient, or had seen him shortly beforethe accident, could hardly recognize him now.His appearance, cold skin, and hoarse voiceimmediately recall the appearance of a cholerapatient to the memory of the attentive ob-server ; the characteristic dejections arealone wanting to make the resemblance com-plete.”

In this graphic account you may noticethat the pulse is spoken of as very rapid,while in the summary of symptoms I firstgave it is mentioned as slow. That thepulse is probably always slow, as an immedi-ate result of the accident, is shown by theobservations of Jordan,* who, on making aspecial examination of the heart’s action inforty-seven cases of shock from variouscauses, found it to be invariably slow. Jor-dan interprets the rapid pulse as a pulse ofreaction. In this he is followed by mostwriters. By far the majority of cases ofshock which we see are cases in which re-action has already begun, and in them wefind, or are apt to find, a rapid pulse.

You will notice, also, that the senses,doubtless meaning the special senses, are

* Loc. cit., p. 45.

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spoken of as acute, while in our summarythey are spoken of as dulled. It is veryprobable that this occasional sharpening ofthe special senses is also a symptom of re-action. This brings us to the discussion ofthe so-called erethistic form of shock.

Long ago Travers* distinguished from theform of shock we have been considering an-other, which he termed prostration with ex-citement, and which later writers have termedthe erethistic form. Instead of lying abso-lutely quiet in the position in which they haveaccidentally fallen or been placed, the patientstoss about wildly, complain loudly, say thatthey cannot breathe, act as though sufferingthe greatest agony, and frequently expresstheir fear of impending death. They pay noattention to what is going on around them,being entirely taken up by their own suffer-ing. Sometimes they are actively delirious.Their muscles tremble, and the breathing israpid and short, now and then a deeper in-spiration occurring. The pulse is rapid andsoft. Instead of great pallor of the surface,the face is flushed, and the skin, instead ofbeing cold and clammy, is at first hot anddry. But see what happens. “As the ex-haustion increases the skin becomes coveredwith cold and clammy sweat, which is oftenvery profuse. The face becomes pale andthe expression haggard, the pulse innumer-ably rapid, irregular, fluttering; subsultuscomes on ; slight convulsions ; coma more or

* Travers, on “Constitutional Irritation.” London,1827.

14less profound ; and (it may be) death.”*Evidently, then, the so-called erethistic formis at times only a precursor of the ordinarytorpid form ; and, as Lauder Brunton pointsout, “ Patients recovering from the torpidform may come gradually to present thesymptoms of the erethistic form.”f Withoutdiscussing the matter further, I am inclinedto look upon the erethistic form as either apreliminary stage, or incomplete stage, ofsimple shock ; or it is to be regarded as astage of imperfect reaction from simple shock.I think with Groeningen, therefore, that thisso-called erethistic shock is not to be consid-ered as a separate form.

Having now formed a conception of shockin general, let us turn our attention to rail-road shock in particular. Jordan, in speak-ing of general shock, recognizes four causes

“ i. Those which act on the corporeal or-ganization.

“2. Those which act on the psychicalfunctions.

“3. Those which act on both the corporealand the psychical functions in equal or un-equal degrees.”

4. Cold.Without stopping to criticise the fourth

cause, which, it seems to us, really belongsto the first,—namely, causes “ which act onthe corporeal elements,”—let us see underwhat head the causes of railroad shock are tobe sought.

* Savory, on “Collapse” (Holmes’s “ System of Sur-gery,” vol. i. p. 378).

f Lor. cit., p. 6. X Loc. cit., p. 8.

15A moment’s reflection will convince us

that the causes of railway shock may befound under any of the first three of Jordan’sdivisions.

A railway accident may ensue in such away that the subject of it receives a vio-lent trauma, with instantaneous loss of con-sciousness, and the shock, then, is the re-sult purely of the corporeal impression.Secondly, it may occur in such a way thatthe subject receives no physical injury what-ever, but merely suffers from an intensepsychic impression. Thirdly, the subjectmay suffer from a combination of both thesecauses ; and this includes, indeed, the vastmajority of cases of railway shock. Jordantells us that “ the principal feature in railwayinjuries is the combination of the psychicaland corporeal elements in the causation ofshock, in such a manner that the former, orpsychical element, is always present in itsmost intense and violent form. The inci-dents of a railway accident contribute toform a combination of the most terrible cir-cumstances which it is possible for the mindto conceive. The vastness of the destructiveforces, the magnitude of the results, the im-minent danger to the lives of numbers ofhumanbeings, and the hopelessness of escapefrom the danger give rise to emotions whichin themselves are quite sufficient to produceshock, or even death itself. Syncope, or con-cussion of the brain, may destroy conscious-ness for a time, or possibly altogether ; but ifconsciousness return, depressing influencesstill operate, although less injuriously, but ona blunted nerve-power. All that the most

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powerful impression on the nervous systemcan effect is effected in a railway accident,and this quite irrespectively of the extent orimportance of the bodily injury. Indeed, ifthere be no bodily injury whatever, the shockmay, nevertheless, be intense, and be followedby ulterior results, the nature and mode oftermination of which it may be difficult toforesee. With the fullest extent of mentalshock, the extent of bodily injury may varygreatly, from an abrasion of the skin tothe crushing of the body into a shapelessmass.”*

We can fully understand, then, that sequelaeof the most persistent and distressing kindshould result from railway shock. The sud-den, excessive, exhausting discharge of ner-vous energy in the excitement, the fright, thehorror of the moment, must certainly resultin a general weakness more or less marked,more or less enduring. That such a condi-tion does result is a matter of daily clinicalexperience. It was fully recognized by Jor-dan, who termed it chronic shock or chronicasthenia, while later writers have termed ittraumatic neurasthenia.

If we add to this the fact that in railwayaccidents the trunk and head are particularlyliable to injury, that the body, as a whole, isapt to be “ thrown violently into contact withsurrounding objects,” and that brain or cordsymptoms are correspondingly present, we areat length in a position to appreciate what ismeant by “ railway shock and the subjectassumes still deeper significance when we are

* Loc. cit., p. 37.

17brought face to face with the fact that degen-erative processes, actual organic changes, mayoccur in the nervous centres themselves.

Recognizing, then, that railway shock ismade up of two elements,—physical andpsychic,—we can readily understand that inany given case the symptoms will vary ac-cording as the one cause or the other pre-dominates. As Page and other writers be-fore him have pointed out, shock from purelymechanical injury, such, for instance, as thecrushing of a limb, is relatively short, andnot, as a rule, followed by symptoms of gen-eral nervous disturbance, while shock frompurely psychic causes is usually very per-sistent. Page* says, “It is a seeminglyanomalous and most noteworthy fact that thecollapse which in these railway accidents ac-companies serious bodily injury, such as severelaceration of limb orfracture of bones, —alwaysexcepting the collapse from severe concus-sion of the brain, —is not followed, or is, in-deed, very rarely followed, by the train ofafter-symptoms indicative of general nervousshock. This is a fact of the greatest interestand importance, and one which will help tothrow light upon those symptoms of generalnervous shock which are so often seen afterthe slighter degrees of initial collapse.” Asan example of the persistence and the kinds

* Page, “Injuries to the Spine and Spinal Cord.”London, 1883, p. 15°- That this does not always holdgood is shown by two cases reported by Knapp, “Ner-vous Affections following Injury” (Boston Medical andSurgical Tournal, November 1 and 8, 1888; Cases XI.and XII.).

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of symptoms presented by cases in which thepsychic cause largely predominates, Pagecites* the case of a tall and powerful man,aged 46, who “ was in a very severe and de-structive collision. He received bruises overboth arms and legs, and also a blow upon theface, which abraded the skin over and frac-tured the bones of the nose. He was notstunned. He lay for several days after theaccident in a state of great nervous depres-sion, with feeble and rapid pulse, and inabil-ity to eat or sleep. He suffered at the sametime much distress from the fact that a friend,sitting beside him in the carriage, had beenkilled, and this seemed to prey constantlyon his mind. The bodily injuries progressedrapidly towards recovery, and in seventeendays after the accident he was able to bemoved home. Nine weeks after the accidenthe had fairly recovered from his injuries, andmade no complaint of bodily sufferings. Theordinary functions of the body were natural,but his mental condition showed extremeemotional disturbance. He complained thathe had suffered continuously from depressionof spirits, as if some great trouble were im-pending. He feels very upset at our visit,and begins to cry. . . . His voice is veryweak and indistinct, and occasionally, hesays, it is almost inaudible. He sleeps verybadly, waking frequently, and being con-stantly troubled by distressing dreams. Hispulse is weak, 104. , . . Words, in fact, failadequately to portray the distressing picturewhich this otherwise strong and healthy man

* Loc. dt., p. 151.

19presented.” Subsequently he underwent aslight and gradual improvement, but fouryears afterwards his medical attendant wrotethat “ his appearance was much altered, thathe looked older, haggard, and that he hadbecome very bald, that he was very de-pressed, sometimes had palpitation, loss ofsleep, bad dreams, very easily tired, had lostall his energy, and was easily upset.”

An interesting case of this form of shockwas recently studied by myself. A gentle-man, accompanied by his wife and child,started to spend a two weeks’ vacation at oneof the smaller resorts along the New Jerseycoast, and to reach which it was necessary tochange cars at a small way-station. Theparty alighted in safety on the platform ofthis station, which was raised a few feet abovethe level of the surrounding ground. It sohappened that attached to the rear of thetrain were several freight-cars filled with rail-road-ties, which laborers were unloading atvarious points along the road. During thestop made at this way-station a number ofties were likewise thrown off. One of them,however, had become so jammed into thebody of the pile that the laborers, during theshort time allowed, could not disengage it,and it was left jutting several feet beyondthe side of the car. The train being started,this tie swept the platform on which our pas-sengers had alighted, like a scythe. The hus-band, who was now at a little distance fromhis wife and child, was the first to perceivethe danger. He cried out to his wife to liedown, while he himself jumped for his life.His wife obeyed, but as she did so she saw

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her child, a little girl of 6, struck full in theabdomen and shockingly injured. She her-self escaped all physical injury, but becameat once uncontrollably excited and hysterical.She remained in this condition, with but littlechange, for three weeks, when, being threemonths pregnant, she miscarried. Subse-quent to this she gradually improved, butshe was evidently a very much changedwoman. A year after the accident she wasstill very neurasthenic. From having beenof a bright and cheerful disposition she be-came depressed and melancholic. Her color,too, was now habitually pale and of a verysallow tinge. She was exceedingly nervous,weak, and irritable, and utterly incapable ofmanaging her household. Her pulse wasweak and rapid, and her knee reflexes slug-gish. Her back was painful, and superficialtenderness was discovered over the lumbarregion. Her grip was decidedly tremulous.Regarding the miscarriage, it should bestated that though she had been a numberof times pregnant, no miscarriage had everoccurred before. She had always, though ofan admittedly nervous temperament, enjoyedgood health.

Various instances might be cited, if timepermitted, in which neurasthenia and hys-teria, more or less marked, and even actualinsanity, resulted from shock.

Page attempts to explain the marked dif-ference between the sequelae of shock fromgross mechanical injury and shock frompsychic causes by saying that in a case, forinstance, of a broken leg, the patient has adefinite injury on which his mind may dwell

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and the progress towards recovery of whichhe daily sees. Further, the enforced rest isbeneficial, and, the injury being definite,“ there is less likelihood of a dispute arisingas to compensation.” That these considera-tions are, however, not sufficient in them-selves to explain, on the one hand, the ab-sence or short duration of the symptoms ofnervous shock, or, on the other, their long-continued existence, is vaguely recognized byPage himself, for he even resorts to the re-markable expedient of blaming bromide ofpotassium for the protraction of the symp-toms !

It may be that in the present state of ourknowledge no perfectly satisfactory explana-tion can be given. However, may it not bethat in shock from severe bodily mutilation,the very depth and intensity of the processrenders the nervous system insensitive to thepsychic impressions, just as a nerve, otherthings equal, already exhausted by one stim-ulus, is insensitive to others ? Rememberthat a man whose limb or whose trunk iscrushed in a railway accident, is hurt, as arule, suddenly and unexpectedly,—i.e., beforehe has time to realize what is about to hap-pen, or has happened,—and that the very re-ception of his injury and the sudden on-coming of collapse makes the additionalpsychic shock impossible. Remember thepicture of extreme anenergy, both mental andphysical. Remember the torpor motor andsensory, and you will realize that here theadditional factor of emotion can play no role.Certainly this explanation is in harmony withthe facts. Why the sequelae of psychic shock

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should be so persistent does not concern us.It is simply the fact with which we have todeal.

Further, how serious and profound purelypsychic shock may be is illustrated by a caserelated by Lauder Brunton, and which is sointeresting that I may be pardoned forquoting it. “ Many years ago the janitor ofKing’s College, Aberdeen, had renderedhimself in some way obnoxious to thestudents, and they determined to punishhim. They accordingly procured a block andaxe, which they conveyed to a lonely place,and, having dressed themselves in black,some of them prepared to act as judges,and sent others of their company to bringhim before them. When he saw the prepara-tions which had been made he at first affectedto treat the whole thing as a joke, but wassolemnly assured by the students that theymeant it in real earnest. They proceeded totry him, found him guilty, and told him toprepare for immediate death, for they weregoing to behead him then and there. Thetrembling janitor looked all around, in thevain hope of seeing some indication thatnothing was really meant, but stern lookseverywhere met him, and one of thestudents proceeded to blindfold him. Thepoor man was made to kneel before theblock, the executioner’s axe was raised ; but,instead of the sharp edge, a wet towel wasbrought smartly down on the back of theculprit’s neck. This was all the studentsmeant to do, and, thinking that they had nowfrightened the janitor sufficiently, they undidthe bandage which covered his eyes. To

2 3their astonishment and horror, they foundthat he was dead.”* Surely no mechanicalshock ever killed more surely or moreswiftly.

Another interesting case is related byBaunis.f A farmer, accompanied by anumber of Arabs, had set out to kill apanther, which was making the farm inse-cure. Barely had he fired a shot before thepanther leaped upon him and seized him inhis claws. The bullets of the Arabs, how-ever, immediately despatched the animal, andthus liberated the farmer. The latter was re-moved to the lazaret. Baunis discoveredseveral scratches on the shoulder which mighthave been grasped by one of the animal’spaws. The scratches were entirely super-ficial and had hardly bled. However, thepatient was in a condition of deepest pros-tration. Face pale, skin cold. He was fullyconscious, but was suffering from the inde-scribable impress of the fright he had re-ceived. Baunis in vain made use of stimu-lants and of moral persuasion; the nextmorning the unfortunate man was dead. Atthe autopsy no traumata whatever of the ab-dominal or thoracic cavities, nor of the cen-tral organs, were found. The injury of theshoulder proved to be entirely superficial,and had not involved the joint.

PageJ cites two fatal cases the result ofrailway collision, and they are especially in-teresting from the fact that death was delayed

* Lauder Brunton, loc. cit., p. 8.f Cited by Groeningen, loc. cit., p. 137.J Loc. cit., p. 168.

24for several weeks. The first was that of “ aman 40 years of age, of exceedingly delicatephysique, who was in a collision at night.The accident was a slight one, and he wasthe only passenger injured. He was said, inthe official report, to be ‘violently shaken,’but he was able to go on home. The nextday he was delirious, and on the third day hewas still talking somewhat incoherently. Hecomplained of being much shaken and feel-ing seriously injured, but there was no evi-dence discoverable of bodily hurt. He im-proved for a time, and his condition was notthought to be serious. He never seemed,however, to make any marked progress, andfour weeks after the accident he became moreprostrate, and greater anxiety was felt abouthim. From this time he gradually got weakerand weaker, and died on the thirty-seventhday. No organic disease whatever was foundon post-mortem examination in any of theviscera.

The other case was that of “ an apparentlystrong and healthy girl, 19 years of age, ingood position in life, who was in a most seri-ous collision. She received no bodily injury,but on the night of the accident she wokescreaming that the engine was rushing intothe room. Her illness followed much thesame course, and she died in about five weeks,no structural disease whatever being foundafter death. The brain and spinal cord wereexamined in both instances.”

Again, some years ago, there was broughtto the nervous clinic of the University a childof 4 years, in which marked imbecility andpermanent loss of speech had followed a

2 5fright by a drunken man. Professor H. CWood is in the habit of relating to his class asimilar case, in which loss of speech and epi-lepsy followed a protracted ride in a railway-car, the child being the while in a perfectparoxysm of terror. Cases such as these arecertainly very significant as indicating actualorganic changes as the result of psychicshock.

Having now formed an idea of psychicshock and its possible role in railway acci-dents, let us turn our attention briefly to thephysical shock that may be received, and de-termine whether the latter is always the tran-sient affair that many writers would have usbelieve. In many cases it is impossible to sepa-rate the two elements of shock, and also toestimate such complicating factors as loss ofblood. However, in the instance of simpleand uncomplicated direct shock (concussion)of the cord, the symptoms can be readilystudied, and these cases we shall use as illus-tration.

That the cord is actually the subject ofshock I need hardly repeat. Despite its deepsituation and despite its elaborate protection,it is known to suffer severely from blowsupon the spinal column. That temporaryconcussion of the cord—i.e., transient arrestof function—can occur is indubitably provedby the cases of Hunt,* in one of which a bul-let had lodged against a vertebra, but withoutin any way injuring the spinal canal, and, inthe other, the cord had been shocked by afall upon the feet. In both cases the ensuing

* Loc cit .

26paraplegia was transient. The case reportedby Jordan* proves that shock to the cordmay in every way be as fatal as shock to thebrain. The case was that of a man who had“ discharged a pistol into his mouth and im-diately died. Examination of the bodyshowed that the bullet struck the body of thesecond cervical vertebra ; but, beyond slightlaceration of the tongue and of the upperpart of the larynx and pharynx, no injury wasdone ; no vertebra or any other bone wasbroken. The naked eye could detect nochange in the upper part of the cord or themembranes.”

Further, that shock to the cord is not alwaysa transient affair is shown by a case alreadyplaced on record by myself ;f and, secondly,that permanent changes in the cord occur asa result of spinal concussion is ably main-tained by Gowers,J who, in addition to casesin which hemorrhage into the membranes, orinto the substance of the cord, occurs, recog-nizes also those cases in which “ no lesion ofthe cord has been found, either with the nakedeye or the microscope, a few days after theinjury,” Further, he tells us, that “in otherinstances, in which the cord is examined someweeks or months after the accident, the signsof chronic myelitis are found, in scatteredfoci or more diffuse tracts, in the white col-umns or gray substance.” He cites the caseof a lady who was merely shaken in a railway

* Loc. dt.f Dercum, loc. cit.J Gowers, “Diseases of the Nervous System.” Phila-

delphia, 1888, pp. 435-437.

27

collision, who, in a few days developed para-plegia, and in six weeks was dead, and inwhom a post-mortem examination revealed“ indications of subacute myelitis, chiefly inthe white columns, varying in its extent indifferent regions, but in most parts consider-able in the pyramidal tracts.” Edes* alsorecords four cases of degeneration in thepostero-lateral columns of the cord, the resultof spinal concussion, and in one of these casesdetermined the actual existence of the lesionby an autopsy. Similar results were reachedby Dum6nil and Petil,f and Spitzkaj; alsostates that shock and injury are among thecausal factors of both posterior and dissemi-nated sclerosis. Other writers are also inharmony with these views.

While some of the cases of organic diseaseof the cord following blows upon theback aredue to intramedullary hemorrhage, and othersto small foci of inflammation, others stillappear to be due to a simple degenerativeprocess, just as though the vitality of varioustracts had been permanently affected by theconcussion.

We have considered thus far, though briefly,the elements that enter into railway shock, aswell as some of the sequelae. Let us nowturn our attention to treatment. What we

* Edes, Boston Medical and Surgical Journal, Sep-tember 21, 1882.

f Dumenil et Petil, “Commotion de la Moell,Epiniere” (.Archives de Neurologic, 1885, vol. ix. pp. 1,145. 3°7)-

J Spitzka, “Pepper’s System,” vol. v.

28

have thus far considered will now be foundto have more or less practical significance.

The treatment of railway shock, as well asof shock in general, naturally falls into twosubdivisions, — first, the treatment of thestage of shock itself; and, secondly, thetreatment of its sequelae. In the treatmentof the stage of shock itself two objects mustbe born in mind,—first, the averting of actualdeath and the production of a healthy re-action ; and, secondly, the averting, if possi-ble, of either functional or organic sequelae.

How, then, shall we treat a case of pro-found general shock ?

Let us remember that the symptoms ofshock are essentially paralytic in theirnature.Let us recall for a moment the feeble, almostimperceptible pulse, the feeble respiration,the cold, clammy surface, the extreme pallor,and the profound muscular weakness. Thefirst thing that occurs to us is the use of acardiac stimulant, and in all times alcoholhas been used for this purpose. Whiskey,and preferably whiskey to which hot waterhas been added, is to be given, if possible ;

but, it may be, either because the patient isvomiting, or by reason of the very depth ofthe shock itself, no decided effect is pro-duced. Ammonia, in its various prepara-tions, also suggests itself; but, for like reasons,its effects may be inappreciable or altogethertransient. A powerful remedy, however, wehave in digitalis. Lauder Brunton* suggestsits use in shock, basing his opinion upon thecase of Wilks, in which shock followed labor,

* Loc. at., p. 17.

2 9and in which recovery ensued on adminis-tering tincture of digitalis in dosesevery half-hour. That in digitalis we have amost valuable remedy there can be no doubt,and that in urgent cases it should be used inlarge doses, if at all, is equally true. It hasthe additional advantage of being readily ad-ministered subcutaneously, and, with propercare, can thus be given with great accuracy.Ten to twenty minims of the tincture, slightlydiluted, can be injected at short intervalsuntil some effect is noted upon the pulse.Further, atropine administered in the sameway, in small doses and not too frequentlyrepeated, may also be used to the same end,this drug being, as we know, a stimulant tothe circulation, and notably to the vaso-motorcentres.

However, we must remember that shockaffects the nervous system as a whole, thatnot one system of centres but all are affected,and that, therefore, some remedy, more gen-eral in its action, should be employed. Sucha remedy we have in strychnine. I have forsome time past regarded strychnine as one ofthe remedies of the utmost importance inshock. Mansell-Moullin* and Groeningenfboth recognize its value, especially the latter.Certainly, in profound shock—the shock thatthreatens to be fatal, shock that refuses toyield to other measures—strychnine shouldbe given subcutaneously, and, if necessary, inmassive doses. In extreme cases, I shouldnot hesitate to use it in doses of or even£, of a grain. On a priori grounds alone,

* Loc. cit., p. 373. f Loc. cit., p. 232.

30the remedy must be regarded as of the ut-most value, for by no other means can thenervous system be so profoundly impressed,so rapidly re-energized. It is strange, in-deed, that it has been not more frequentlyresorted to.

While these thoughts are passing throughour minds, we must not forget that our pa-tient is cold, cold even unto death, and thatartificial heat is one of the very first desid-erata, This heat can be supplied by cans orbottles of hot water, or other heated objects.The best of these means, however, meet theindications but imperfectly. The late Dr.Hunter, of Philadelphia, suggested the use ofhot baths, but even these threaten to exhaustthe almost dying patient by the unavoidablehandling. Recently, in a case of collapse,occurring in a child during the course of apleurisy, and in which the temperature fellto 96.5°, I caused an ordinary hospital water-bed to be filled with hot water, and, havingcovered it with several layers of flannelblankets, placed my patient upon it. Theresult was gratifying in the highest degree,the temperature of the body soon rising to alittle above normal.

Evidently this expedient meets every indi-cation. Not only have we a large amount ofheat applied to a very large surface of thebody ; but, what is very important, it is dryheat. Certainly, by no other means can thetemperature of the body be so readily influ-enced as by the /W-water-bed.

Further, there can be no doubt that sina-pisms to the epigastrium, and large enemata ofhot coffee, are also conducive to reaction.

3 1

The subcutaneous injection of ether is, like-wise, also beneficial, though, in the cases inwhich I have seen if used,—namely, collapseduring abdominal operations, —it seemed toact rather as local irritant, and thus stimu-lating the heart in a reflex way.*

We must remember, above all things, thatour patient must be kept in an absolutelyhorizontal position, with the head rather lowerthan the trunk, that he must not be movedabout or lifted unnecessarily, and that allmanipulations, except such as are absolutelynecessary to determine the condition of thecirculation, the respiration and the tempera-ture must be avoided. Very rarely, indeed,attempts at artificial respiration may be justi-fied, or friction of the limbs, the directionbeing always towards the . trunk, may be ad-missible. In the main, however, our patientwill be most benefited if let alone.

Regarding such measures as transfusion ofblood, the course pursued must depend on inhow great degree the symptoms are due toloss of blood alone ; but, at best, I considerthis means as of questionable utility. As re-gards the opposite expedient,—that of blood-letting,—it needs but to be mentioned to becondemned, notwithstanding the recommen-dation of Savory to open the external jugu-lar ! f

* There can be no doubt that in shock, as elsewhere,the inhalation of ether —i.e., its cautious and sparing ad-ministration—acts very much as does alcohol, namely,as a stimulant. This is, I believe, in harmony withthe experience of surgeons. Chloroform in shock is,of course, to be rigidly tabooed.

f Loc. cit., p. 383.

3 2

Of the various measures, then, at our com-mand for treating a case of shock, whiskeyand dry heat should first be employed ; sec-ondly, our case being at the outset verythreatening, a full dose of strychnine shouldbe given hypodermically,—say of a grain.Following this, digitalis and atropine may beused. Repetition must be guided by thedeepening of the collapse.

In shock with restlessness and excitement—that is, the so-called erethistic form—thereis a strong temptation to the use of sedatives.No one, however, fully cognizant of the truenature of this state, can shut his eyes to theirdanger. The bromides, for instance, in smalldoses, are inefficient; in large doses, depres-sant. Chloral, on the other hand, may giveus sleep, but it will be at the expense of stillfurther weakening the heart. How is it, youask, with opium? Travers, Savory, and Jor-dan each speak in favor of its use,—that is,with qualification. It is like a two-edgedsword ; it may in one instance quiet our pa-tient, produce a restful sleep, and in anothermay overpower his already weakened nerve-centres. If used at all, it should be used insmall doses, administered hypodermically,and repeated, if at all, with caution. On thewhole, I regard it as a remedy rather to beavoided than courted. Travers speaks favor-ably of hyoscyamine, as does also Savory, andcertainly this drug deserves a more extendedtrial.

I believe, however, that in the erethisticform of shock, in addition to the variousmeasures employed in simple shock, we haveno more valuable remedy than musk. Un-

33fortunately, it can only with difficulty be ob-tained, much of that dispensed in its namebeing practically inert. However, should theremedy be at our command, it should befreelyadministered, in doses say of 15 grains,and preferably by the rectum. Its action insoothing, quieting, and steadying the nervoussystem is undoubted. Should musk be in-accessible, valerian might be employed, inlarge doses, of course, in its stead, but withmuch less promise of success. Better still,hops, in the form of the fluid extract, adrachm or more, may be administered.

You are to remember, however, above allthings, that, as in the simple form of shock,needless interference with the patient is to beavoided, and that it is better to err in doingtoo little than attempting too much.

The individual judgment of the physicianmust always guide him in the selection ofhis remedies in any given case. Rest alonewill in some cases in due time be followedby reaction. In others, again, a dose ofwhiskey, or, possibly, whiskey to which asmall dose of morphine has been added, willgive the most gratifying results. In others,still, the depression may be so great thatthe prompt application of external heat, andthe various other powerful remedies alreadydetailed, may be required. No fixed rulecan be given ; the indications must be metas they arise.

Let us suppose, now, that the stage ofshock itself has been successfully combated.Let us suppose that our case has been oneof railway shock in which the psychic ele-ment has played a prominent part, or that

34it is one of those cases in which powerfulblows have been received upon the trunk orupon the back. We will remember at oncehow frequently psychic shock is attended bypersistent sequelae, not to speak of thosemore rare cases in which death itself fol-lows after a time. Further, we recall thefact that permanent spinal symptoms, actualorganic cord changes, may follow blows uponthe trunk. What, then, shall be done, whatmeasures shall we adopt, to meet these pos-sibilities ?

Evidently the state of rest must be pro-longed,—prolonged far beyond the apparentneeds of the patient’s condition. All thetime we should be on the alert for symp-toms indicative of chronicity, and by allmeans in our power combat them. Surelythe neurasthenia and the profound hysteriathat occasionally ensue upon shock demandrest, and the sooner it is given them thebetter ; and, in those cases in whicn shockof the cord is suspected,—in which, it maybe, organic changes have been set up,—ab-solute rest is likewise indispensable. Inother words, I believe that every case ofrailway shock, if at all severe, should atonce be submitted to a rest-cure based uponthe Weir Mitchell method. In such cases,whether mental or spinal, absolute rest, iso-lation from friends, forced feeding, massage,and electricity should be the order of the day.

Even with these precautions cases in whichthe sequelae are delayed would escape us ;

but “better late than never” should be ourmotto, and the rest-cure should be adoptedwhenever the sequelae are detected.

35The benefit of a careful watch over rail-

way cases can be no better illustrated thanthose in which subsequent vertebral diseaseleads to paraplegia, and in which interfer-ence at an early day may avert this unfortu-nate result. This field, however, does notbelong to to-day’s discussion, and I merelymention it because it is not improbable thatorganic cord-changes dependent upon shockmay be arrested, or at least delayed, byactive measures taken in time.

The further consideration of this importantsubject, which can hardly be condensed intoa brief address, and which I feel I have dealtwith but imperfectly, I leave now to your-selves.