Some of the concluding remarks in the foregoing pages will have suggested that the use of gum infusion may be considered of more value in treating pure shock than in treating hæmorrhage. For this reason, apart from other diagnostic considerations, it may be of importance to be able to distinguish clinically between shock and hæmorrhage. Attention has already been drawn to the fact that the symptoms and appearance seen in a patient suffering from severe shock very closely resemble those seen in hæmorrhage. It may, in fact, be impossible to say from purely clinical evidence whether a patient is suffering from shock, or hæmorrhage, or both. A case which recently came under my own observation well illustrates this point. A very stout, elderly man had fallen down a lift-shaft and was brought into St. Bartholomew’s Hospital soon after the accident. He appeared to have fallen on his feet, and the lower ends of both tibiæ had been driven through the inner sides of his soles, but there were no other signs of injury. His general condition on arrival at hospital was fairly good, but all the usual measures were taken to minimize shock. An hour or two later he had passed into a condition of extreme collapse, and exhibited all the symptoms which have already been described. Not much hæmorrhage had taken place from the wounds in his feet, and the question arose as to whether his present condition was due to internal hæmorrhage from visceral injury, or whether it was due chiefly to shock. His abdomen contained so much fat that no evidence could be obtained from an examination of it, and it was in fact impossible to arrive at any conclusion. There could, however, be no question of performing any operation, and the patient made no response to other treatment. At the autopsy it was found that there were fractures of the ribs, spinal column, and symphysis pubis in addition to the injuries to the legs. There was very little hæmorrhage in connexion with any of the fractures, and it appeared that death was to be attributed almost entirely to shock. This was perhaps a somewhat unusual case, in which no help could be derived from an examination of the patient, but similar difficulties will sometimes be met.