Railway Spine/Erichsen’s Disease

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Definition and description[edit]

This was a 19th century diagnosis which as a label has long gone out of favour. It was a largely a type of post-traumatic back pain which was more severe and longer lasting than would have been expected based on the injury. Some of the patients developed debilitating chronic pain and exhaustion. It is almost certainly a variant of what in the early 1900s was called neurasthenia and of what we now call post-traumatic fibromyalgia.

Railway spine became a hot topic amongst doctors at the time. It was, for example, intensely debated in the late 19th century at the meetings of the Imperial Society of Physicians in Vienna, 1886.

Railway spine as an antiquated form of post-traumatic fibromyalgia[edit]

In all probability, railway spine is a form of what we now called "post-traumatic fibromyalgia". It is also likely that many of the patients, who in bygone days were diagnosed with railway spine, also had some elements of post-traumatic chronic fatigues syndrome, PTSD (and perhaps even some post-traumatic migraine.)

The precipitating events: train accidents in the late 1800s[edit]

The 1860ies, the era of Erichsen, was a time of frequent rail travel in Europe and North America. Injuries were more common. The railway cars tended to be flimsy and offered limited protection. Cases of very serious injury and death occurred. All in all, at the time, rail travel was more frightening than it is now.

Staplehurst rail crash.jpeg
Engraving illustrating the Staplehurst rail crash which appeared in the Illustrated London News, 1865.
Public domain image found in Wikimedia Commons.
Note the dramatic horrific nature of the crash depicted here. Images such as this were emblazoned in the minds of Londoners during this period and may have had a psychological effect on them. This image, and others like it that were drawn of similar accidents conveyed the psychologically charged idea of massive damage. Perhaps, they influenced the same kinds of patients described in Page's book on railway spine. Onlookers drawn by the artist seem captivated by the scene. Nowadays, when onlookers drive by a car crash and slow down the traffic, they are called "rubberneckers". These are examples of the part played by catastrophes in capturing and firmly gripping human of people. This relates to evaluative psychology i.e. to the psychology of good and evil. There is something about horror which is gripping to the mind. Perhaps this evolved originally because it offered survival value.

Railroad Disaster at Meadow Brook, Rhode Island.jpeg
Scene of the Railroad Disaster at Meadow Brook, Rhode Island, 1873.
Public domain image found in Wikimedia Commons
This is a wood engraving from a sketch by Theodore R. Davis, published in Harper's Weekly, May 10, 1873 several weeks after the disaster which occurred on April 19, 1873.

Disaster on railway.jpeg
Disaster on the Railway between Versailles and Bellevue, 8th May 1842, A.Provost.
Public domain image found in Wikimedia Commons.
Fifty five people were killed in this incident including the French "explorateur" Jules Dumont d'Urville.

Erichsen's views in 1866[edit]

The phenomenon of railway spine was reviewed in depth by one of the leading London surgeons of his day, John E. Erichsen. In 1866 he wrote a book called On Railway and Other Injuries of the Nervous System. The book became widely known and debated over an extended period. (On Railway and Other Injuries of the Nervous System. Erichsen, John Eric, Published by Henry C. Lea, Philadelphia, 1867 available in its entirety online at: http://archive.org/details/onrailwayandoth00ericgoog and in full text mode at: https://archive.org/stream/onrailwayandoth00ericgoog/onrailwayandoth00ericgoog_djvu.txt.)

He "developed the influential hypotheses that psychological symptoms after railway accidents were caused by a concussion of the spine followed by ‘molecular changes’ in the spinal cord (‘railway spine syndrome’).” ([Post-traumatic Stress Disorder: history of a politically unwanted diagnosis].[Article in German] Löwe B1,Henningsen P,Herzog W Psychother Psychosom Med Psychol.2006 Mar-Apr;56(3-4):182-7.)

By 1866 it was already commonplace for doctors to be involved in medico-legal cases involving railway accidents.

The following quotation indicates that Erichsen considered the problems that patients experience to be the results of railway accidents and to involve a multi-factorial combination of physical forces (such as momentum of the body and the sudden arrest of body motion), along with psychological factors which he called referred to as perturbations of the mind.

Erichsen wrote: “…in no ordinary accident can the shock be so great as in those that occur on Railways. The rapidity of the movement, the momentum of the person injured, the suddenness of its arrest, the helplessness of the sufferers, and the natural perturbation of mind that must disturb the bravest, are all circumstances that of a necessity greatly increase the severity of the resulting injury to the nervous system, and that justly cause these cases to be considered as somewhat exceptional from ordinary accidents. This has actually led some surgeons to designate that peculiar affection of the spine that is met with in these cases as the 'Railway Spine’.” (Page 9.)

Here is a portion of Erichsen's introductory remarks with italics added after the fact for emphasis:

"Gentlemen: It has justly been said by one of the greatest Boasters of the Art of Surgery that this or any other country has ever produced” Robert Liston” that no injury of the head is too trivial to be despised. The observation, true as it is with regard to the head, applies with even greater force to the spine; for if the brain is liable to secondary diseases in the one case, the spinal cord is at least equally, and probably more so, in the other.

My object in these Lectures will be to direct your attention to certain injuries and diseases of the spine arising from accidents, often of a trivial character” from shocks to the body generally, rather than from blows upon the back itself” and to endeavour to trace the train of progressive symptoms and ill effects that often follow such injuries..

These concussions of the spine and of the spinal cord not infrequently occur in the ordinary accidents of civil life, but from none more frequently or with greater severity than in those which are sustained by passengers who have been subjected to the violent shock of a railway collision; and it is to this particular class of injuries that I am especially desirous of directing your attention.

For not only have they, in consequence of the extension of railway traffic, become of late years of very frequent occurrence, but, from the absence often of evidence of outward and direct physical injury the obscurity of their early symptoms, their very insidious character, the slowly progressive development of the secondary organic lesions, and functional disarrangements entailed by them, and the very uncertain nature of the ultimate issue of the case, they constitute a class of injuries that often tax the diagnostic skill of the surgeon to the very utmost. In his endeavours not only to unravel the complicated series of phenomena that they present, but also in

the necessity that not infrequently ensues of separating that which is real from those symptoms which are the consequences of the exaggerated importance that the patient attaches to his injuries,

much practical skill and judgment are required.

The secondary effects of slight primary injuries to the nervous system do not appear, as yet, to have received that amount of concentrated attention on the part of surgeons that their frequency and their importance demands; and this is the more extraordinary, not only on account of the intrinsic interest attending their phenomena, but also from their having become of late years a most important branch of medico-legal investigation. There is no class of cases in which medical men are now so frequently called into the witness box to give evidence in courts of law, as in the determination of the many intricate questions that often arise, in actions for damages against railway companies for injuries alleged to have been sustained by passengers in collisions on their lines; and there is no class of cases in which more discrepancy of surgical opinion is elicited than in those now under consideration."

John eric erichsen.jpeg
Sir John Eric Erichsen (1818-1896).
Public domain image

For a review of Erichsen's ideas about railway spine see Harrington, who wrote a modern review article on railway spine. (The railway accident: trains, trauma and technological crisis in nineteenth-century Britain. Ralph Harrington available online at: http://www.esocialsciences.org/Download/repecDownload.aspx?fname=Document169200700.6935694.pdf&fcategory=Articles&AId=1181&fref=repec. For a bibliographic listing see: https://ideas.repec.org/p/ess/wpaper/id1181.html. This article appeared in a book entitled Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870-1930, by Mark S Micale and Paul Frederick Lerner; Cambridge University Press, Cambridge, 2001. It is also partially visible online at Google Books at: https://books.google.ca/books?id=GOdu8X99oAYC&printsec=frontcover#v=onepage&q&f=false.)

Herbert Page on the psychology of the traumatization process in railway spine[edit]

Page's background as an insurance doctor[edit]

Prior to writing his 1883 book on railway spine, Herbert Page had served for nine years as a surgeon to the London and North Western Railway Company where he amassed considerable clinical experience about railway spine based on assessing large numbers of these accident patients.

1883 was near the height of the railway spine era. The title of his first book was Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects, (Page, Herbert William, Published by J. & A. Churchill, London 1883 available online at: https://archive.org/stream/injuriesofspines00page/injuriesofspines00page_djvu.txt.

He wrote a second book in 1891 entitled "Railway Injuries:With Special Reference to Those of the Back and Nervous System, in Their Medico-legal and Clinical Aspects" (Griffin, available from Internet Archive at: https://archive.org/details/railwayinjuries00pagegoog and in full text mode at: https://archive.org/stream/railwayinjuries00pagegoog/railwayinjuries00pagegoog_djvu.txt.

Page's comments on sudden trauma in railway spine[edit]

Page wrote: "The suddenness of the accident, which comes without warning....the utter helplessness of the traveller, the loud noise, the hopeless confusion and the cries of those who are injured....are surely adequate to produce a profound impression upon the nervous system."(Page 163, Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects, Herbert Page, 1885 available from Google Books in preview mode at: https://books.google.ca/books?id=cvlj2l1o-pkC&printsec=frontcover#v=onepage&q&f=false

Common features of railway spine according to Page[edit]

In his 1885 book (Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects), Page described many of the common features of railway spine. This appeared in his chapter entitled "Shock to the Nervous System".

Here is a lengthy, insightful key quotation that demonstrates significant powers of observation and psychological insight on his part. After the quote, an analysis is provided. Italics have been added for emphasis.

Page stated: "The fact, however, must never be lost sight of, that there are few cases of nervous shock after railway collision in which some bodily injury has not likewise been sustained. The mode of accident, as scores of cases abundantly testify, has an unquestionable tendency to cause injury of the vertebral column, an injury which in the great majority of cases is a simple sprain of the spinal muscles and spinal ligaments, with the inevitable consequence of severe vertebral pain. Sprains are, moreover, not unlikely to have been received in other parts of the body, even when the patient was perfectly conscious at the time that he had no blow, and not a mark is subsequently to be seen. Hence it comes to pass that from the inherent nature of the bodily injuries themselves, pain in various parts of the body”in the trunk and in the arms and legs”is very liable to come on some time after the accident, to be severe in character, deep-seated in position and, from the absence of all bruising, seemingly most obscure. Psychical elements again arise to aggravate the patient's condition. His mental balance has already been upset by the shock of the collision, and it is disturbed still further by the onset, the character, and the obscurity of the pains which supervene. And it is obvious that this result is most likely to happen in those cases where the appearance of the pains has been delayed, as is not uncommon, for two or three days. They renew the alarm of the sufferer, whose attention is thereby more closely directed to them, and their import becomes gravely aggravated in his mind. These pains, moreover, are prone to increase in severity during the first few days and to last for a long time, and their very duration tends to maintain the exaggerated estimate which has been formed of them by the patient himself. Nor does familiarity with them lessen his alarm, for the original psychical disturbance has laid the sure foundation for an altogether erroneous estimate of the sensations which he feels. And thus we find that before very long the mind of the patient, unhinged by the shock, and directed to the pains and other abnormal sensations of his body, tends as it were to run riot with the symptoms which he feels. Dwelling constantly on his bodily sensations, he is on the look-out for any new sensation that may arise, and is alive to and makes discovery of sensations which to the healthy have no existence at all. Is it possible, we would ask, that a large number of the abnormal sensations of which patients so frequently complain while the mental balance and tone are thus perturbed, can be due in any measure to a conscious perception of the perennial sensations of organic life? The ‘hysterical’ condition —”we use the word for want of a better and without a shadow of reproach—the hysterical condition is essentially one in which there is loss of control and enfeeblement of the power of the will, and amidst the various ways in which these may show themselves, there is loss of the habitual power to suppress and keep in due subjection the sensations which are doubtless associated with the various functions of the organic life of the individual."(Pages 174-175 Injuries of the Spine and Spinal Cord without Apparent Mechanical Lesion: Nervous shock, and their surgical and medico-legal aspects. Herbert W. Page, Published by J.& A. Churchill, London, 1883 and available online at: http://ia600505.us.archive.org/5/items/injuriesofspines1883page/injuriesofspines1883page.pdf.)

We will now analyze a number of the important details from the above quotation:

He is describing what in modern times is referred to as "post-traumatic fibromyalgia". Both railway spine and post-traumatic fibromyalgia may occur after relatively minor injuries. Both generally affect the mental balance of the patient.

Page states that the patient's mind begins to focus on the pains. He provides an insightful account of what could be called "pain-focused thinking". This is the type of thinking which generally accompanies what is known in the modern literature as "pain-focused behaviour".

A key lesson that we can take from his account is that it is important for the doctor to monitor the patient starting as soon as possible after accidents and to follow not only their physical injuries but also their psychological status in order to be on the lookout for early warning signs of post-traumatic fibromyalgia. Perhaps this will improve the chances of preventing great and needless misery provided that successful timely interventions are made to break up pain-focused thinking patterns before they can take hold.

This highlights the need for doctors caring for the injured, including family doctors, emergency doctors, pediatricians and orthopedic surgeons to have a high index of suspicion for the problem of post-traumatic fibromyalgia and to actively screen for it during the immediate aftermath of an injury.

Page poignantly states that the accident "runs riot". While this is not a precise term, it is nonetheless very helpful because it draws attention to the idea that there is a complex chain reaction which is damaging in nature.

Page also highlights the tendency for railway spine to occur after injuries to the vertebral column. [There is some support for this position in modern medical literature in that studies show that neck injuries are a risk factor for fibromyalgia.] He also speaks of a typical consequence of "severe vertebral pain".

Page uses the word "obscure" and he makes some fascinating comments on how the obscurity of the symptoms exacerbates the situation. It seems he is trying to say that the fear of the unknown nature of the injury is psychologically destabilizing to some patients. This is a very reasonable position. Notable are his comments saying that the "mind of the patient" becomes "unhinged by the shock, and directed to the pains and other abnormal sensations of his body". Here it is clear that he is saying that pain becomes essentially a special topic for mental preoccupation. He notes that the patient is: "Dwelling constantly on his bodily sensations, he is on the look-out for any new sensation that may arise, and is alive to and makes discovery of sensations which to the healthy have no existence at all."

Clearly, Page is drawing are attention to a large shift in the patient's attention towards pain after the trauma. Even more importantly, he is saying that the patient is in a state of what might now be called "hypervigilance to somatosensations". Being "on the lookout" is a form of vigilant evaluative processing about danger to the person. In lay terms we could call it "looking for trouble". (On theoretical grounds, if such a pattern were to be discovered in modern day accident victims, it would be reasonable to try to treat it. Ideally, all interventions should be evidence based. However while awaiting solid proof that a treatment works, it is reasonable for clinicians to offer advice if there are strong theoretical grounds.) Perhaps one day we will have greater clarity about the neurobiological basis of this hypervigilance. For now what doctors can do is try to identify it early, then bring it to the attention to the patient and finally try to motivate the patient to catch themselves when they are doing it and restrain themselves from over-engaging in it.

Page's description is a masterpiece of clinical observation and psychological insight. With our modern utter preoccupation with controlled clinical trials we have lost the clinical art of taking the patient's history in the kind of rich detail that is found in the type of account and analysis done by Page found in this passage.

Till this day, most of the neural processes that underlie his clinical observations have yet to be fully worked out. For example, little is known about the breakdown in neural processing that occurs in what Page called the "loss of the power of will". But it is fair to say that severe pain-focused patients seen regularly in modern pain clinics sometime become slaves to the pain and as Page says the dwell on it.

Page's explanation and description of how some patients become captivated by their pains is very instructive. If this phenomenon were to be studied further it could lead to preventive treatments offered to recently traumatize patients before they slip further into the depths of post-traumatic fibromyalgia and PTSD. In a personal communication, Dr. Harvey Moldofsky, a seasoned psychiatrist and fibromyalgia specialist recommended a more organized and proactive approach to this problem. Instead of waiting for trauma patients to develop fibromyalgia after an accident they should all be screened after accidents early on for warning signs and early signs of fibromyalgia or PTSD, and then place id an early prevention program at the first sign of trouble.

With the current sorry state of affairs as of 2016, it is still commonplace for patients to receive the diagnosis of post-traumatic fibromyalgia several years after it commenced.

Harrington wrote a modern review article on railway spine. (The railway accident: trains, trauma and technological crisis in nineteenth-century Britain. Ralph Harrington available online at: https://ideas.repec.org/p/ess/wpaper/id1181.html or at: http://www.esocialsciences.org/Download/repecDownload.aspx?fname=Document169200700.6935694.pdf&fcategory=Articles&AId=1181&fref=repec. This appeared in a book entitled Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870-1930, by Mark S Micale and Paul Frederick Lerner; Cambridge University Press, Cambridge, 2001.)

Here is what Harrington had to say about Page: "In a lecture from 1885, Page sketched a model of traumatic nervous disruption in which hysterical symptoms develop when the shock and terror of the railway accident abruptly drains the nervous system of the force it requires to retain control over the organic functions of the body. Railway accidents, he explains, provide “… the requisite conditions for inducing profound exhaustion of the nervous system or traumatic neurasthenia…Railway collisions…provide the conditions for inducing severe effects upon the nervous system and they do so because the circumstances of most railway accidents are such as to produce a very profound mental impression upon many persons subjected to them... the determining cause of the nervous condition which underlies the neurasthenia is very largely fright and alarm." (Clinical Papers on Surgical Subjects, Herbert W. Page,London: Cassell, 1897, available in full online at: https://wellcomelibrary.org/item/b21519778#?c=0&m=0&s=0&cv=0&z=-0.9683%2C0%2C2.9365%2C1.6098. See especially the first two chapters.)

Hysteria associated with railway spine in the time of Page[edit]

Another interesting feature of Page's writings is that there was more talk about hysteria in relation to railway spine. Hysteria was more common in the 19th century, but the author has seen a number of cases of combined fibromyalgia and hysteria in his fibromyalgia cases. No doubt there has been an influence of culture and possibly education in the incidence of hysteria. Perhaps people now try to appear more rational and they know there is something irrational about hysteria. For further information see: https://encyclopediaoftouchbodysenseandpain.com/Post-traumatic_Hysteria

Charcot also promoted the importance of hysteria in railway spine.

It is now known that hysteria is one of the many fibromyalgia comorbidities. It is also well-known that hysteria can follow a trauma. (This was, for example, documented in traumatized soldiers in WWI.)

Charcot's comments on railway spine[edit]

(See especially pages 97-101. https://archive.org/details/43730450R.nlm.nih.gov and in full text mode at: https://archive.org/stream/43730450R.nlm.nih.gov/43730450R_djvu.txt.)

He believed that many cases were essentially post-traumatic hysteria. He discussed what he called the "Role of traumatism in the development of this affection; railway spine."

He said: "They have recognized, along with Page, who has also interested himself in this question in England, that many of those nervous accidents designated under the name of railway spine, and which, in his opinion, might better be called railway brain, are in reality, whether appearing in man or in woman, simply hysterical manifestations. It is easy, then, to understand the interest which such a question has to the practical mind of our confreres of the United States. The victims of railroad accidents quite naturally claim damages of the companies. The case goes into court; thousands of dollars are at stake.

Now, I repeat, often it is hysteria which is at the bottom of all these nervous lesions. Those neuropathic states, so grave and so tenacious, which present themselves as the sequel of " collisions " of that kind, and which render their victims unable to work or pursue any regular occupation for months and for even years, are often only hysteria, nothing but hysteria. Male hysteria is then worthy of being studied and known by the medico-legalist, for he is often called upon to give his opinion, in matters concerning which great pecuniary interests are at stake, before a tribunal which would be likely to be influenced (and this circumstance renders his task the more difficult) by the disfavor which is still attached to the word hysteria on account of prejudices profoundly rooted."(Clinical lectures on certain diseases of the nervous system, by Charcot, J. M. (Jean Martin), 1825-1893; Hurd, E. P. (Edward Payson), 1838-1899, translator, Pages 98-99. https://archive.org/details/43730450R.nlm.nih.gov and in full text mode at: https://archive.org/stream/43730450R.nlm.nih.gov/43730450R_djvu.txt.)

He further commented: "You see how delicate in such cases is the mission of the medical jurist, and it is this medico-legal side of the question which seems among our American confreres to have awakened a new interest in the study of hysterical neuroses heretofore a little neglected." (Page 100)

Range of injuries[edit]

Based on common sense, it seems logical to assume that in train wrecks there were bound to be a wide range of physical injuries and a wide range of levels of emotional shock. Without doubt, all but those with the slightest physical trauma would have had changes at a molecular level in their tissues. However, the main questions at the time of Erichsen, and the ones we see in modern times are these: Why do some patients become more disabled than expected? And: Why are their some patients who by their own admissions were not severely struck, yet they go on after the injury to become chronic pain and fatigue patients?

Physical injury of the spinal cord and spinal tissues in railway accidents[edit]

Oppenheim realized that there could be serious damage to the spinal cord in some patients that were injured in a rail accident. For example, he wrote: "We are, however, justified in considering concussion of the spinal cord at this point. A fall on the back, a blow or push against it, concussion of the whole body, e.g. in a railway accident, may have many severe results. It is certain that haemorrhages may occur in the cord and meninges without any external injury or solution of continuity of the spinal column. Severe lesions and even rupture of the cord are said to have been observed under these conditions." (Page 395) He also acknowledged that in rare cases, a blow to the spine could cause myelitis.

He even stated: "It cannot be denied that a railway accident which does not cause severe external injury may yet give rise to myelitis, due to a simple blow on the back. Gowers describes one such case in the latest edition of his text-book, and the investigations and cases of Schmaus, Westphal, Spiller, Bikeles, Jolly, Hartmann, Fickler, etc., show that myelitis may arise in this way, but such a result is exceedingly rare..."

The debate over mental vs. physical causes in traumatic brain injury and traumatic spine injury[edit]

This debate is now well over a hundred years old. It is based on a common clinical problem: The patient has been injured and they develop some symptoms for which an organic cause is unclear. The question is this: Is there a hidden organic cause such as tiny bleeds into the nervous system or tiny tears of brain or spinal nerve tissue? Or is there an indirect cause such as the effects of psychological factors and poor sleep?

Too often so-called experts weigh in on this. Some are driven by theories. Patients often jump to the conclusion that the problem must be physical because it started after the accident. They may have what is as "gain" or the may be entirely legitimate. (See: https://encyclopediaoftouchbodysenseandpain.com/Gain)

The assessment of such patients requires a very detailed approach. Organically minded doctors often find such patients frustrating. They can be quick to brand them as functional. Psychiatrists may recognize psychological factors but may neglect to examine the patient properly. It is not unusual for both groups to omit the all-important 18 tender point test. This often makes it clear the patient is over-reactive and tender and that they have a disorder of their pain system, in which case it is wrong to brand them as simply psychiatric or organic. For example symptoms like exaggerated withdrawal reflexes or frowning to even relatively low levels of pressure applied to a tender point defied traditional classification as they are neither purely physical or purely psychological.

Oppenheim's theory of neurotic cases of railway spine[edit]

Introduction and relevant publications[edit]

In 1889, one of Germany's leading neurologists, Hermann Oppenheim published a treatise on what he referred to as "traumatic neurosis". His use of the term had a different meaning than the modern psychoanalytic meaning. (See: Die traumatischen Neurosen nach den in der Nervenklinik der Charit© in den letzten 5 Jahren gesammelten Beobachtungen. published by Hirschwald, 1889 and available in full online at: https://archive.org/details/dietraumatische00oppegoog. The english translation of the title is "The Traumatic Neuroses."This manuscript is 145 pages. As of 2019, not English translation was found for this important work on the internet.)

Hermann Oppenheim, 1858-1919.
Public domain image found in Wikimedia Commons.

Oppenheim also published a major textbook on neurology entitled Textbook of Nervous Diseases for Physicians and Students. (H. Oppenheim, fifth enlarged translation by Alexander Bruce, Otto Schulze & Company, Edinburgh, 1911 available in full online at: https://archive.org/details/b21981590 and in full text at: https://archive.org/stream/b21981590/b21981590_djvu.txt.)

Oppenheim described himself as a follower of Page.

While the term "traumatic neurosis" is often ascribed to Freud, it may have been coined by Oppenheim.

Oppenheim's insights are very relevant today because they shed light on car and other accidents. They could be useful to the legal profession in understanding personal injury cases.

Oppenheim's concept of traumatic neurosis in railway spine[edit]

In Textbook of Nervous Diseases for Physicians and Students, he makes a number of mentions of his term "traumatic neurosis". He stated: "In the great majority of cases shown to me as ascending neuritis, I have found that there was not a neuritis, but a traumatic neurosis or hysteria; there were only two or three in which a true ascending neuritis seemed to exist, as one case in which a musculo spiral paralysis followed a slight wound of the finger, which the patient had treated with urine, and where influenza had also previously been present."

With respect to the role of trauma in railway accidents Oppenheim stated: "Trauma is undoubtedly an important factor. Injuries to the head and concussion, especially if associated with mental excitement, as in a railway accident, frequently cause neurasthenia, but the traumatic form tends to be combined with symptoms of other neuroses. Neurasthenia also often develops after surgical operations." [Page 1113.]

[Author's comment: Neurasthenia was a very popular diagnosis at that time. The word has gone out of fashion but it can be thought of as the spectrum of what we now call chronic fatigue syndrome and fibromyalgia.]

Here are Oppenheim's comments on pain in post-traumatic neuroses:"Pain in the affected part is usually the first complaint and is the chief subjective trouble during the whole course of the disease. In the neuroses which follow a railway accident, the pain is usually situated in the back, the sacral, or occipital regions. It gives rise to constraint in the active movements, as the patient endeavours to fix the painful parts and to avoid or, as far as possible, restrict the movements which would disturb them."

Facial expression.png
Facial expression in traumatic neurosis.
Public domain image by Oppenheim, Sourced from https://archive.org/details/b21981590/page/1164.

Oppenheim's observation of the gradual onset of symptoms[edit]

He wrote: "In many cases the symptoms of a nervous disease develop gradually and insidiously after the injuries described; it was formerly thought that they must be due to a chronic meningomyelitis, and the spinal site of the disease seemed to be so certain that the nervous affections arising after a railway accident were summarised under the name ‘railway spine.’ It cannot be denied that a railway accident which does not cause severe external injury may yet give rise to myelitis, due to a simple blow on the back. Gowers describes one such case in the latest edition of his text-book, and the investigations and cases of Schmaus, Westphal, Spiller, Bikeles, Jolly, Hartmann, Fickler, etc., show that myelitis may arise in this way, but such a result is exceedingly rare, and the affections of the nervous system occurring after such accidents should for the most part be regarded as neuroses (see chapter on Traumatic Neuroses).(Page 396) [Italics added for emphasis.] (Textbook of nervous diseases for physicians and students. H. Oppenheim, fifth enlarged translation by Alexander Bruce, Otto Schulze & Company, Edinburgh, 1911 available in full online at: https://archive.org/details/b21981590 and in full text at: https://archive.org/stream/b21981590/b21981590_djvu.txt.) For his chapter on the traumatic neuroses see page 1062.)

His claim that the symptoms come on "gradually and insidiously" is a common finding in modern clinical medical practice in cases of pain after accidents. This temporal pattern has always called for an explanation, especially in cases of severe symptoms coming on after relatively minor physical trauma such as a low speed car accident. In the experience of the author of The Encyclopedia, this mystery can often be explained by what I refer to as the "fibromyalgia vortex". (See entry fibromyalgia vortex effect, The)

Oppenheim's thoughts on the role of mental shock[edit]

Here is one of his key quotes: “Mental shock — fear and excitement — plays an important part in the etiology of this morbid condition; indeed, it is the sole cause of the trouble in some instances. Accidents in which a physical trauma is associated with a mental shock, as in a railway accident, are specially liable to produce this neurosis. These have indeed been the main source of our knowledge of traumatic neuroses. But any injury, even although it involve merely some peripheral part of the body (hand, foot, etc.), may result in this condition. In such cases, however, the injury has usually been accompanied by severe concussion of the affected part or by some great mental shock. Thus, I have occasionally seen severe neuroses follow a heavy fall or blow on the finger-tips or prolonged crushing of the fingers. Some of the paralytic conditions following a stroke of lightning (kerauno-neurosis) should be regarded as traumatic neurosis. In such cases symptoms of the functional neurosis are often associated with signs of an organic nervous lesion ; I have recently noted this in one particularly severe case. Traumatic neuroses have been often observed of late after an electrical shock (contact with electrical currents, falling of the conducting wires of electric railways, etc.)…"

The foregoing observations, which agree with those of Jessen (Jf. m. W., 1902), Panas, and others, and specially the careful work of Jellinek and Battelis, indicate clearly that the danger to life and damage to the nervous system depends not merely upon the tension, but also upon the duration, nature, and site of the stimulus, and the condition or power of resistance of the skin at the point at which the current enters the body, the intensity of the current, etc. Although such cases are often merely the result of the sound (Eulenburg) or the fright, the electric shock may sometime be the actual cause.

Oppenheim's thoughts on post-surgical cases[edit]

Neuroses may also develop after surgical operations. I have observed them specially after operations on the ear, but also after perityphlitis and ovariotomy, and it is difficult under such circumstances to determine how far the symptoms are due to the pre-existing disease, the absence of an organ, etc….” [Page 1163, italics added.]

Oppenheim's thoughts on the role of pain[edit]

He commented on the prominent role of pain in these patients:

"Pain in the affected part is usually the first complaint and is the chief subjective trouble during the whole course of the disease. In the neuroses which follow a railway accident, the pain is usually situated in the back, the sacral, or occipital regions. It gives rise to constraint in the active movements, as the patient endeavours to fix the painful parts and to avoid or, as far as possible, restrict the movements which would disturb them.

The pain is accompanied by other symptoms which are specially marked if the mechanical concussion has directly affected the brain (injury to the head, railway accidents), or if the accident has been associated with intense mental excitement. These phenomena are specially of a mental nature; hypochondriacal-melancholic depression develops, and is often manifested by the facial expression and outward bearing (Fig. 411). The patient gives way to gloomy thoughts about his misfortune, his illness, and his "hopeless" position. He is at the same time abnormally excitable and sensitive, weeps on the slightest occasion, and is effeminate in his demeanour. He very often complains of anxiety, restlessness, and dread, and has sometimes attacks of intense fear, less often of hallucinatory delirium." (Page 1164)

[Author's comment: This is sounding much like post-traumatic fibromyalgia.]

Oppenheim's thoughts on the effect on cognition and the problems of constant introspection and preoccupation[edit]

He goes on to say: "In most cases there is no real impairment of the intelligence, but the memory often becomes weak. The constant introspection and preoccupation with his own condition lessens the patient's interest in the outer world, and this may give rise to apathy which simulates mental weakness." (Page 1164)

Author's comment: Nowadays, the pain literature speaks of "pain-focused behavriour".

Author's comments on the problem of uncertain micro-injury still causes a cloud of uncertainty and difficulties in adjudicating insurance cases[edit]

Page noted a century ago that: "The incidents of every railway collision are quite sufficient----even no bodily injury is inflicted –to produce a various serious effect upon the mind, and to be the means of bringing about a state of collapse from fright and from fright only." (Page 36, Railway Injuries: With Special Reference to Those of the Back and Nervous System, in Their Medico-legal and Clinical Aspects, W. Wood, 1892, available from Google Books in preview mode at: https://books.google.ca/books?id=P5MjAQAAMAAJ&printsec=frontcover#v=onepage&q&f=false.

As in the 1800s when it was popular to diagnose railway spine, we still have the problem of recognition of possible microinjuries especially int medium impact situations.

Post-traumatic fibromyalgia can occur after minor accidents. This seems counterintuitive to many. The fact that the accident may have been minor in terms of speed and physical damage is frequently used to try to discredit the patient and to argue that little if any compensation is deserved. Some patients may feel that they are being taken advantage of and they may "retaliate" by exaggerating their descriptions of their pain. Other may be catastrophizers and genuinely believe or worry that they injury is severe.

Based on the author's experience, one common situation is that a patient had some or many risk factors for fibromyalgia prior to their injury, but they only developed fibromyalgia after a motor vehicle or other accident.

Another common situation is that the patient had a minor case of fibromyalgia or a manageable case before an accident; but after the accident there is a major deterioration. Insurers may argue that they should not have to absorb the full financial accountability in these scenarios.

The issue as to why a minor accident could lead, in some cases to a major disability, may turn on the predispositions of their nervous system and their prior experience. In my experience, a minor accident that was not too horrific emotionally, might induce illness in a person who is quite predisposed.

Having worked with many motor vehicle accident victims who developed post-traumatic fibromyalgia, my impression as to what drives the deterioration of many patients is what I call the "fibromyalgia vortex". For details see the entry under this heading in this encyclopedia. Essentially it is a chain reaction triggered by the accident of reverberating pain, poor sleep and worry which can sprawl to become a behemoth.

Conceptual folly in the analysis of railway spine by of physicians in the late 1800s[edit]

Erichsen probably overlooked an aspect of the problem which should have been obvious, which is the prominence of fatigue and sleep problems after traumatic injuries. It is hard to imagine that this was not prevalent in his railway cases. We now know that severe fibromyalgia patients and severe chronic fatigue patients are terrible sleepers. If one includes the numerous possible symptoms of sleep deprivation and the many disorders of sleep that can worsen or occur after trauma, then they could have dozens of sleep-related complaints.

The battles over financial compensation[edit]

During the railway spine era, some patients applied for compensation from the railway companies. They in turn often tried to fight off the claims by arguing that the patients were fakes. They hired physicians to investigate such claims who tended to side with the railways. Little has changed and the same types of insurance battles are routine today, but instead of being focused on trains, they are now focused on motor vehicle accidents.

It was not easy then, nor is it now to be objective in dealing with accident cases involving insurance claims. Personality issues can cloud judgment. Vested interest and bias on both sides can also cloud judgment. Ignorance of the neuroscience and psychology of pain by all involved including judges and further contributes to false beliefs.

As in politics there are "hawks" and "doves". The hawks are biased in favour of a tendency to believe that patients are often "fakes" who are exaggerating their symptoms for money or sympathy. The doves are biased in favour of people who appear to be victims. The hawks think of themselves as trying to ensure people don't take advantage of the system. The doves worry that the evil corporations might abuse their position of strength. Typical shenanigans on the insurance company side are to deny the existence of anything for which there is not hard proof. Given that for most patients the main issue is pain and given that to date there is no affordable front-line objective test for pain that does not rely on the patient's description of their own pain intensity, they can be at disadvantage. Currently, brain imaging is moving quickly in the direction of objective tests for pain. Once such tests are validated, we can expect to see a shift in the debate.

Modern day cases of railway spine[edit]

A study by Buskila et al. (2009) looked at the "prevalence of fibromyalgia in survivors of a major train crash in southern Israel, three years after the event". Their main findings were:"Fifteen percent of survivors participating in the study met ACR criteria for the classification of fibromyalgia." This is much higher than average national rates. They also noted that: "Significantly lower rates of physical and emotional functioning were found among survivors with fibromyalgia compared with those not meeting the classification criteria. Survivors with fibromyalgia rated significantly higher on scales of somatisation, obsessive-compulsive ideation, interpersonal sensitivity, depression, anger, anger and hostility, phobic and general anxiety, paranoid ideation and psychoticism. Survivors with fibromyalgia also rated significantly higher on scales of post-traumatic symptoms including intrusion, avoidance and arousal. These individuals also rated significantly higher on the Peritraumatic Dissociative Experiences Questionnaire (PDE-Q) and the Dissociative Experiences Scale (Hebrew version) (DES-H)."

There are critics today that do not believe in post-traumatic fibromyalgia. This study should go a long way towards demonstrating the legitimacy of such a diagnosis.

The authors concluded as follows: "Fibromyalgia was found to be highly prevalent, three years after a major train crash, among individuals exposed to the combination of physical injury and extreme stress." (A painful train of events: increased prevalence of fibromyalgia in survivors of a major train crash. Buskila D1, Ablin JN, Ben-Zion I,Muntanu D, Shalev A, Sarzi-Puttini P, Cohen H. Clin Exp Rheumatol. 2009 Sep-Oct;27(5 Suppl 56):S79-85.)

Further information[edit]

The Derailment of Railway Spine: A Timely Lesson for Post-Traumatic Fibromyalgia Syndrome Milton L Cohen John L Quintner, Pain Reviews 1996; 3:181-202 available in full online at: http://www.pain-education.com/the-derailment-of-railway-spine.html

Trains, Brains, and Sprains: Railway Spine and the Origins of Psychoneuroses, Caplan, Eric Michael, Bulletin of the History of Medicine, 69:3 (1995:Fall) p.387 available in full online at: https://www.academia.edu/9227908/Trains_Brains_and_Sprains

Railway spine revisited: traumatic neurosis or neurotrauma? Keller T. J Hist Med Allied Sci. 1995 Oct;50(4):507-24, Extract of first page visible at: http://jhmas.oxfordjournals.org/content/50/4/507.extract

The "railway spine" diagnosis and Victorian responses to PTSD. Harrington R. J Psychosom Res. 1996 Jan;40(1):11-4.

Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870-1930, Mark S. Micale, Paul Lerner, Cambridge University Press, Sep 4, 2001. This is available from Google books in preview mode at: https://books.google.ca/books/about/Traumatic_Pasts.html?id=GOdu8X99oAYC&redir_esc=y. For a partial description see: http://www.cambridge.org/us/academic/subjects/history/history-medicine/traumatic-pasts-history-psychiatry-and-trauma-modern-age-18701930?format=PB.)

Railway spine, posttraumatic fibromyalgia, and junk science in the courtroom (ca. 1975). Wallace DJ. J Clin Rheumatol. 2004 Oct;10(5):284.

The lessons of railway spine. Ferrari R. Med Sci Monit. 2002 Feb;8(2):LE1-2 available online at: http://www.medscimonit.com/download/index/idArt/420886.

The Railway Accident: Trains, Trauma and Technological Crisis in Nineteenth Century Britain, Ralph Harrington. This may be an online only publication which is available in full at: https://ideas.repec.org/p/ess/wpaper/id1181.html.

Railway Traumas, blog posted on July 15, 2012 by Paul Rennie, available online at: http://bagdcontext.myblog.arts.ac.uk/2012/07/15/railway-traumas/.

The fight for 'traumatic neurosis', 1889-1916: Hermann Oppenheim and his opponents in Berlin. Holdorff B. Hist Psychiatry. 2011 Dec;22(88 Pt 4):465-76.