(fnrn^U few Btl^anl Ctbrary 
 
RA 1121 ^i°^"*"""'™''S'«y Library 
 
 Railway in 
 
 uries.-with special reference 
 
 3 1924 017 513 353 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924017513353 
 
RAILWAY INJURIES: 
 
 WITH 
 
 Special Reference to those of \|be^ B^cl^^?; 
 and Nervous System 
 
 IN THp;iR 
 
 MEDICO-LEGAL AND CLINICAL ASPECTS. 
 
 HERBERT W. P^GE, M.A., 
 
 M.C. Cantab., F.rT.C.S. Eng. 
 
 Surgeon to St. Mary's Hospital, and Lecturer on Surgery at its Medical School ; 
 
 Consulting Surgeon to the Cumberland Infirmary : Examiner in 
 
 Surgery, University of Cambridge. 
 
 REPRINTED FROM WOOD'S MEDICAL AND SURGICAL MONOGRAPHS. 
 
 NEW YORK: 
 
 WILLIAM WOOD AND COMPANY. 
 
 1892. 
 
0713 
 
CONTENTS. 
 
 CHAPTER I. 
 
 PjSGE 
 
 Injuries of the Back, 5 
 
 CHAPTER II. 
 General Nervous Shock, . 33 
 
 CHAPTER III. 
 General Nervous Shock (Continued), ...... 58 
 
 CHAPTER IV. 
 The Fright Neuroses — Traumatic Hysteria, VO 
 
 CHAPTER V. 
 The Fright Neuroses (Continued), ' 85 
 
 CHAPTER VI. 
 On Treatment, 109 
 
 CHAPTER VII. 
 Malingering, 116 
 
 CHAPTER VIII. 
 The Medico-Legal Aspect of Railway Injuries, .... 189 
 
RAILWAY INJURIES. 
 
 CHAPTEE I. 
 
 INJURIES OF THE BACK. 
 
 The aim of this book is to give an account of the injuries 
 sustained in railway and similar accidents which become the 
 subject of medico-legal inquiry. In a book published in 1883, 
 "Injuries of the Spine and Spinal Cord and Nervous Shock" 
 (Churchill, 3d ed., 1885), the results of my experience up to 
 that time, together with the views I had been led to form of 
 the nature of railway injuries, were placed on record. While 
 this work is to a considerable extent founded upon the book 
 of 1883, and draws largely from it, the scheme is somewhat 
 different, for it is now no longer necessary to say wherein I 
 had come to differ, and that very widely, from the opinions 
 then prevailing as to the nature of these injuries. The task 
 of preparing the former book had not been undertaken, it is 
 right to say, without ample personal observation of the cases 
 and injuries described. I had indeed been seeing them fre- 
 quently during a period of nine years, and from the beginning 
 I had resolved that I would not write a line upon the subject 
 until after, at least, five years' experience. The four years 
 devoted to the preparation of that book afforded time for an 
 inquiry into the after-histories of a large number of injured 
 persons, and a table of cases formed no inconsiderable part of 
 it. It has been impossible again to undertake the extraordi- 
 nary and systematic labor which that inquiry involved, the 
 labor of travelling thousands of miles and the inconvenience of 
 frequent absence from London. The length of time which was 
 spent over the preparation of the former work has, moreover, 
 been fully justified, for although I have more to say in the 
 
6 • Railway Injuries. 
 
 present work than I said before, yet I have nothing to unsay 
 as being out of accord witli the later experience of eight addi- 
 tional years. And I have the further satisfaction of knowing 
 that the views which I then propounded have been practically 
 accepted by all who are familiar and have to do with injuries 
 of this class, both in this country and in America, as well as 
 in France, Germanj'^, and elsewhere. It is unnecessary, there- 
 fore, again to travel over the ground which was formerly oc- 
 cupied in dealing with concussion of the spinal cord and " con- 
 cussion of th e spine." The theory which attributed the nervous 
 symptoms after railway injury to meningo-myelitis of the 
 brain and spinal cord no longer meets with general acceptance 
 (" est definitivement abandonnee " is the expression of a French 
 writer. Dr. Dutil), and it is hardly likely to regain it in the 
 future, unless it has the support of more pathological and clin- 
 ical facts than were originally adduced in its favor. The con- 
 sequences of railway injury are happilj'' not so grave as that 
 theory demanded, but they are none the less deserving of at- 
 tention because of the serious, albeit usually transient, effects 
 which are wrought upon the nervous system by this form of 
 accident. 
 
 Renewed attempts have been made in recent j'ears to un- 
 ravel and explain the complex nature of collision injuries; and 
 by many writers in this country and abroad, by Thorburn, 
 Dreschfeld, Ross, and Collier here; by Weir Mitchell, Dana, 
 Hodges, Putnam, and others in America; by Charcot and 
 many of his disciples, by Guinon and Berthez, Moricourt, 
 Terrier, and Vibert in France; by Oppenheim, Striimpell, Bern- 
 hardt, and Westphal in Germany, and by a host of others, 
 fresh light has beeenshed upon the traumatic psycho-neuroses 
 and on the hysterical and neurasthenical conditions which are 
 prone to ensue from the profound mental disturbance, and the 
 shock to the whole nervous system, which a railway accident 
 causes. This practically was the view which I sought to up- 
 hold, that most of the strange nervous symptoms so commonly 
 seen after railway accidents were not due to physical injury 
 sustained by the spinal cord, but were the more or less imme- 
 diate concomitants of the profound mental emotion aroused 
 by the unquestionably special features and incidents of every 
 collision. And I endeavored to show how the accompaniment 
 of some form of injury to extra-spinal, muscular, and ligamen- 
 
Railway Injuries. 7 
 
 tous Structures was at the root of the entirely erroneous notion 
 that the nervous symptoms were due to lesion in that part of 
 the central nervous system which has its seat in the spinal 
 column. The further experience gained since I last wrote has 
 confirmed the opinions which I then expressed; and the ex- 
 tensive opportunities which I enjoyed of studying this class of 
 injuries during my seventeen years' tenure of the office of Sur- 
 geon to the London and North-Western Railway Company, 
 warrant me now in laying before the profession in a more 
 comprehensive manner what I have to say on the subject of 
 railway injuries. 
 
 The book makes no pretension to be a text-book of nervous 
 diseases. It is simply one chapter in their history; and if for 
 convenience' sake it is itself divided into chapters, it is as one 
 chapter on the subject of which it treats that it must be read. 
 The various parts of it are meant to hold together, and if the 
 statements made are not every one of them supported by the 
 published record of individual cases, none the less are they 
 founded on actual experience and observation. I have through- 
 out endeavored fairly and evenly to hold the balance, bearing 
 in mind that no work upon such a subject can be, as I am de- 
 sirous this should be, of use to others, unless it is conceived in 
 a judicial spirit, and is free from partiality and bias. 
 
 The object of this chapter is to give an account of the spi- 
 nal injuries which are so frequent in railway collisions. It is, 
 of course, true that injuries of all kinds and degrees are caused 
 by railway accidents, but they differ in no respect from those 
 which are seen after any and every form of violence. Nor 
 indeed do injuries of the back received in railway accidents 
 differ from injuries of the back received in many other ways, 
 but their frequency, and above all the character which they 
 impress on the features of many other forms of railway injury, 
 especially on those which will be dealt with in the succeeding 
 chapters, demand for them a place by themselves, and a sep- 
 arate chapter for their consideration. Their frequency is a 
 matter of no question. It has been attested by Riegler (" Ueber 
 die Folgen der Verletzungen auf Eisenbahnen, insbesondere 
 der Verletzungen des Riickenmarks," Berlin, 1879. Riegler 
 gives statistics which show that, since the passing of a law in 
 Germany for the compensation of persons injured on railways, 
 the number of injuries or complaints of injuries had enormouslj' 
 
8 Railway Injuries. 
 
 increased, and that, moreover, of thirty-six complaints after 
 injury no fewer than twenty-eight were of the back), by every 
 one, in fact, who has ever written on the subject of railway 
 injuries, while among my own cases more than 60 per cent 
 of the injured persons made some complaint at some time or 
 other of having been hurt in the back. The influence of such 
 injuries upon the more purely nervous effects of railway acci- 
 dents it will be one purpose of this book to teach, and those 
 who do more than merely skim its pages will find how true it 
 is, that the complexion of the other injuries to be described 
 may be at times afl'ected, or even changed, by them. 
 
 I will speak in the first place of the more common injuries 
 of the back received in collisions on railways or in other similar 
 accidents, and will refer afterward to those conditions or 
 symptoms, which indicate that there may have been injury to 
 one or other of the nerve elements of the spinal column. And 
 it may be well to premise that in none of the cases quoted was 
 there any reason to suspect the perfect bona fides of the in- 
 jured persons. The following is a very frequent occurrence. 
 A man has been in a collision; he was perfectly conscious at 
 the time that he met with no blow — knows, in fact, exactly 
 what occurred to him when the accident happened, and yet 
 he finds that within a few hours, occasionally much sooner, 
 he is seized with pain in his back. What has happened to 
 him ? Let us look at a case where the symptoms were simple 
 and unobscured by other injury. 
 
 Case I. — Simple IJumbar Sprain — Traumatic Lumbago. — 
 M. A., a strong and active man, was riding in a first-class car- 
 riage, when a slight collision took place. He was, at the mo- 
 ment, leaning forward reading, and was not even moved from 
 his seat. He felt a little' upset and shaken, and had some 
 brandy in consequence, but he was able in a few minutes to 
 set off and walk to his business. The next day he felt some 
 pain in the lumbo-sacral region, which on the following day 
 became acute, especially on movement, and on the third and 
 fourth days after confined him to the house. He was ordered 
 a belladonna plaster, ahd in a week he began to improve, 
 though having occasionally sharp pain. There was no local 
 tenderness, and it is evident from the history that the injury 
 in this case was a simple sprain of the muscles and ligaments 
 
Railway Injuries. g 
 
 about the lumbo-sacral region. It was, in fact, a " traumatic 
 lumbago." 
 
 In a slight collision like this it is very common to hear that 
 the passenger was thrown backward and forward in the car- 
 riage, and although this man had hardly been moved, the sud- 
 den arrest of the train is frequently themeans of jerking the 
 traveller from his seat, and perhaps landing him upon the floor. 
 Now it is that the physical structure of the spinal column ex- 
 poses it to this form of injury. Endowed with extreme mo- 
 bilitj'- in every direction, forward, backward, in rotation, and 
 from side to side, as provided by its many articulations and 
 by its thousand muscular and ligamentous attachments, it 
 nevertheless has to guard the spinal cord within its central 
 canal. To do this well, both conscious and unconscious effort 
 is made at the moment of the collision to hold the column rigid, 
 and as a result of the violence and of the sudden resistance 
 induced by "setting" of the muscles and ligaments, the liga- 
 ments and muscular attachments are strained, overstretched, 
 and, it may be, even ruptured in the dorso-lumbar or lumbo- 
 sacral regions of the column. The injury is precisely the same 
 as that which is met with every day, where a man complains 
 that while lifting a heavy weight he suddenly felt a severe and 
 acute pain, which almost prevented him from moving, in the 
 lower part of his back. You examine him and can find no ex- 
 ternal sign of injury, but he hesitates to stoop when you ask 
 him, he holds his back unnaturally stiff, he finds it difficult or 
 impossible to rise from his seat, and very likely there is some 
 local tenderness in the muscular mass on either side of the 
 lumbar vertebrae. We may meet with the same injury in 
 very different degrees of severity, and the pain may be felt at 
 an altogether different part of the spinal column. 
 
 Case II. — Cervico-dorsal Sprain. — A man aged forty-two 
 was in a train which ran (without time for warning) at fifty 
 miles an hour into a coal train standing on the line. He was 
 thrown suddenly forward, and instantly felt acute pain in the 
 cervico-dorsal region. The pain was never again acute, but a 
 weary aching was felt at the part for several weeks, both over 
 and on each side of the spine. There were no other indications 
 of injury, and the nausea and feeling of faintness experienced 
 at the moment of the accident soon passed away. Obviously 
 
10 Railway Injuries. 
 
 the injury in this case was of preciselj'- the same nature as the 
 traumatic lumbago already named. The spinal injury may, 
 however, be even more widespread. 
 
 Case III. — Sprain of the whole Vertebral Column. — A 
 rather smart collision caught a man, aged fifty-eight, sitting 
 upright in the carriage with his head slightly turned to one side. 
 He was thrown back, and his head was knoclied against the 
 partition, the brim of his hat fortunately saving him from a 
 severer blow. He felt shaken and sick, but did not vomit. With- 
 in a couple of hours of the accident he was seized with pain, and 
 tenderness was felt in the lower part of the back, especially 
 over the two lower dorsal and two upper lumbar vertebrae. 
 He was taken home and put to bed, where he lay for a month, 
 suffering at first from such severe pain throughout the whole 
 spine — cervical, dorsal, lumbar, and sacral regions — that he 
 was barely able to move. There was never anj!- acceleration 
 of pulse, elevation of temperature, or peripheral pain. At the 
 end of the month he began to improve, and was able to move 
 his arms and his head without pain, and occasionally to sit up 
 in bed. In a couple of months he was able to get up, and in 
 three months to move about so well as to do a little business. 
 He gradually recovered, and five years after the accident was 
 reported to be in good health, although he still felt an "un- 
 certainty " when travelling, and unless he carefully supported 
 himself was liable to have a return of pain in the lower part 
 of the back. 
 
 These cases afford good examples of the same kind of in- 
 jury, though affecting different parts of the spine. It is unu- 
 sual, however, to meet with cases such as these where there is 
 no other complication. "Nervous shock " in its varied mani- 
 festations is so common after railway collisions, and plays so 
 .prominent a part in all cases which become the subject of 
 medico-legal inquiry, whether they be real or feigned (in the 
 " Times " of Saturday, February 19th, 1881, a case was recorded 
 of an action against a railway company for injuries received 
 by a man in accidentally putting his leg through a hole where- 
 by he was thrown down and hurt his leg. The judge com- 
 mented strongly on the fact that the symptoms complained of 
 bore a strange resemblance to those heard of so frequently 
 after railway collisions. The symptoms, I think, in such cases 
 
Railway Injuries. il 
 
 ought properly to be termed "litigation symptoms/' as I shall 
 subsequently show), that we are almost sure to meet with the 
 symptoms of it in association with pains in the back, and with 
 points of tenderness along the vertebral spinous processes. It 
 is this frequent combination of the symptoms of general ner- 
 vous prostration, neurasthenia, or shock w^ith pains in the back, 
 such as these cases presented, which no doubt laid the foun- 
 dation of the erroneous views which were at one time preva- 
 lent as to the nature of the common injuries of the back re- 
 ceived in railway collisions. 
 
 A man has a general nervous shock, and at the same time 
 he is alarmed himself, and gives continued alarm to others by 
 the pain and tenderness, often very severe, which he suffers at 
 some part of the spinaL column, or of the structures lying con- 
 tiguous to it. In the first two cases recorded there can be no 
 question that simple muscular or ligamentous strain was the 
 sole cause of the pain; and the entire absence of any indication 
 of other injury shows that the cause of the pain, which ex- 
 tended throughout the whole spinal column, and made every 
 movement of trunk and limb almost intolerable, was exactly 
 the same in the third and more serious case. Cases like the 
 last are rarely met with in ordinary practice, but railway col- 
 lisions provide the conditions which determine the possibility 
 of such extensive strain of the vertebral column. Now one 
 part, now another, is sprained in the jerks and jolts which ac- 
 company most collision accidents, and the pain, more com- 
 monly situated in the lumbar region alone, may thereupon 
 affect other parts of the column. And very variable may be 
 this pain both in range of distribution and in character; and 
 variable also the time when it may begin. 
 
 Case 1Y.— Lumbar Sprain— Very Acute Pain.— A. young 
 man who was in a bad colUsion began three days afterward 
 to feel pain and stiffness across the loins, so that he moved 
 with difficulty, and felt easiest when flat upon his back. The 
 pain in his back gradually increased, and, to use his own 
 words, he thought all was over with him, and that he was 
 going to be paralyzed, for when he tried to stand up a sharp 
 pain seized him in the back like a knife cutting into him, and 
 shot downward and upward from the loins like an electric 
 shock, so that he dropped upon the floor. This state of things 
 lasted, for about three weeks, during which he lay almost help- 
 
12 Railway Injuries. 
 
 less, and had the greatest difficulty in defecation and micturi- 
 tion. There was at the same time considerable local tender- 
 ness, but never any outward sign of injury. This description 
 is almost characteristic of an attack of acute lumbago. 
 
 Stiffness, however, and local pain are not the only indica- 
 tions of spinal sprain. There is very often some degree of lo- 
 cal tenderness as well, felt on pressure over one or more spi- 
 nous processes, or occupying a wider area on each side of the 
 spine, and it is important to inquire whether this is evidence 
 of some graver injury than I have said is ordinarily signified 
 by the local pain. My own experience lends no support to this 
 supposition. Local tenderness is often found in cases of simple 
 sprain of the back from lifting heavy weights, and it would be 
 very strange if the same symptom were not found in those 
 cases, where the spinal sprain has been caused by the severe 
 wrenching and straining suffered in a railway collision. In 
 the worse cases the same conditions are in all probability pro- 
 duced as are to be found around an ankle or other joint which 
 has been sprained, but you cannot see the swelling about the 
 small joints of the vertebral column and about the muscular 
 and ligamentous attachments, simply because the structures 
 sprained are more deeply situated, and are much smaller in 
 size. A deep-seated discoloration, however, may be sometimes 
 seen, even where there has been no blow. Tenderness is thus 
 a more or less inevitable consequence of the injury, but is it 
 by itself a more dangerous symptom than the pain on move- 
 ment ? Let us ask if tenderness of the back is a prominent 
 sj'mptom in cases of spinal cord disease which we see in our 
 hospital wards. Is it not rather conspicuously absent, and is 
 not a diagnosis made by a totally different train of symptoms ? 
 Any one who has ever looked at a vertical section through the 
 centre of the spinal column, and has noted how far the spinal 
 cord is from the surface, how the spinous processes overlap 
 each other, and how thick is the mass of muscles on either 
 side, must have felt convinced that all ordinary pressure on 
 the column can have little or no effect upon the structures 
 within. Tenderness by itself is therefore not to be regarded 
 as an indication of grave injury to the contents of the spinal 
 column; it is a symptom, which, if of any value at all, ought 
 rather to reassure, as pointing to the kind of injury which we 
 are here considering. 
 
Railway Injuries. 13 
 
 But although local tenderness may be of small value as 
 evidence of Intraspinal lesion, its long- continuance at one spot 
 is very decidedly suggestive of some inflammatory affection 
 of one of the small spinal joints. " It may be deemed singular," 
 Mr. Shaw writes in Holmes' " System " (Holmes' " Sj'stem," 
 Vol. IV., 2d ed., p. 103), "that numerous as are the small joints 
 formed by the opposing surfaces of the oblique processes, in 
 the , posterior segment, disease is scarcely ever witnessed in 
 them." ' Yet we know that these joints may be very seriously 
 aflfected in rheumatoid arthritis, and that they do not escape 
 suppuration in pytemia. There is no inherent reason why one 
 or more of them should not occasionally be affected by a sim- 
 ple synovitis, such as is seen in other and larger joints as the 
 result of injury. Traumatic synovitis of a spinal joint is 
 doubtless extremely rare, but it may be occasionally the cause 
 of otherwise inexplicable tenderness and pain. 
 
 The three most prominent and distinctive signs of simple 
 sprain of the back commonly met with are stiffness, tenderness, 
 and pain, and we have seen that these may be present at any 
 part of the spinal column, or maj' even involve the whole of it. 
 This widely-distributed "lumbago" — if the term may be al- 
 lowed to indicate the aching and the pain on movement 
 throughout every part of the spinal column— may of itself 
 give rise to a form of pseudo-paralysis, which, if unrecognized, 
 may cause unwarranted alarm. The pain in all movements 
 may be so great, whether the movements be of the hmbs, of 
 the body, or of the head, that the patient is really afraid to 
 move at all. This well-grounded fear of moving may soon as- 
 sume the importance of an absolute inability to move, espe- 
 cially when the sprain has chiefly affected the lumbar and 
 lumbo-sacral regions. Ask any man who has had a severe 
 lumbago, whether from a sprain, from rheumatism, or from 
 cold, if he has not at the same time felt a strange sense of 
 difficulty in moving his legs. Brisk walking becomes impos- 
 sible; the effort needed to put one leg before the other must 
 be unnaturally great; fatigue comes early, and the patient 
 complains to you that his legs feel weak, and as if he could 
 hardly move them. The injury may frequently be diagnosed 
 by the peculiarity of the gait alone. 
 
 Micturition may at the same time be interfered with, from 
 lack of the natural support and help which the lumbar mus- 
 
14 Railway Injuries. 
 
 cles provide when this act is being performed. The patient, 
 perhaps, cannot completely empty his bladder, and there is a 
 certain amount of dribbling at the close of the act. It thus 
 appears to himself that his " water runs from him," and if, as 
 a consequence of slight retention, there be added some irrita- 
 bility of bladder, symptoms of somewhat ominous import seem 
 to be developed. Many men find it practically impossible to 
 empty their bladders when they are laid upon their backs, and 
 "residual urine," recognized as perhaps the most frequent 
 cause of cystitis, is very prone indeed to occur as the indirect 
 result of any injury which dooms a man to bed. And this 
 may arise quite independently of any retention due to shock, 
 to which reference will be found at p. 54. It is obvious, there- 
 fore, that sprains of the lower back provide the very combi- 
 nation of conditions likely to lead to this result, and every now 
 and then we find that trouble with the bladder may rise into 
 considerable promijience. Especially is this likely to happen 
 when the nervous system has been much upset by the shock 
 of the accident, and you may find a condition of " nervous blad- 
 der," in which the patient has a frequent desire to pass water, 
 with inability at the same time to perform the act perfectly, 
 and consequent slight dribbling at its close. Constipation also 
 arises from the same muscular incapacity, and becomes an 
 almost invariable feature in the case. Thus it is nothing more 
 nor less than natural for the friends to say that the patient 
 is " paralyzed," and paralj^zed from severe injury to the spine. 
 If you do not avoid these fallacies, and do not correctly inter- 
 pret this state of things, you will add greatly to the dread, 
 which after railway collisions is strangely real, that "paraly- 
 sis " is going to supervene. 
 
 This very natural fear of paralysis is still further increased 
 by the abnormal sensations incidental to the muscular and 
 ligamentous incapacity. There is a strange feeling of weak- 
 ness in the legs, ana the patient complains to you that he can- 
 not walk, or that his legs give way when he makes the at- 
 tempt to do so. Repeated observation, however, leaves no 
 doubt in my mind that these results are more dependent on 
 the fear of moving (this fear of moving was strangely shown 
 by a man who had received such injuries as have been de- 
 scribed, who was confined to bed in consequence, and who 
 needed three persons to help him out of bed every time he 
 
Railway Injuries. 15 
 
 wanted to pass water in the day-time. To himself it appeared 
 wholly unaccountable and extraordinary that whenever he 
 woke in the night he could jump naturally out of bed without 
 any help for the same purpose. It need hardly be said that 
 the case was perfectly genuine) than on any real inability to 
 move because of nerve lesion; and the personal knowledge of 
 many hundreds of cases, together with the absence of any rec- 
 ord of such a consequence in medical literature, enables me to 
 allege that there is no more cause to anticipate real paralysis 
 after a sprain of the back received in a railway collision, than 
 there is after the thousand and one different kinds of injury 
 which fall under the notice of the surgeon. 
 
 In the absence of other signs of injury for which, of 
 course, full search will be made, do not therefore let undue 
 weight be given to this pain and tenderness at one or more 
 points of the spinal column, or to the stiffness and pseudo- 
 palsy which accompany them. In cases of real damage to the 
 spinal cord or its membranes, both pain and tenderness may 
 help to localize the point at which mischief is going on, but 
 they do not indicate the mischief itself, nor are they in any 
 sense pathognomonic symptoms of spinal cord disease. In no 
 wise would I undervalue the real importance of these verte- 
 bral sprains. They may be exceedingly distressing to the pa- 
 tient; the pains may last for a very long time; there may even 
 be occasional reminders of pain for months or years under 
 suitable conditions; but it is right that we should attach no 
 more import to them than they deserve, and their existence 
 should not entail a needless dread of serious injury to the 
 structures within the spinal canal. 
 
 The long continuance of pain in the back is very naturally 
 the cause of alarm to the patient, and of doubts as to his ul- 
 timate recovery ; but if the pain be rightly estimated, and its 
 real value as a symptom of spinal disease be recognized, there 
 will be less reason for these fears. Look at it in connection 
 with maladies other than simple sprain. In spinal caries, for 
 example, we know that local pain at the site of disease is not 
 one of the most pronounced symptoms, and that it is of much 
 less value in diagnosis than pains at the periphery, instinctive 
 d^ead of leaving the recumbent posture, or an absence of 
 natural flexibility in the spinal column when the patient moves. 
 The pain, indeed, is indicative of nothing more serious than 
 
1 6 Railway Injuries. 
 
 muscular or ligamentous strain. In character, moreover, it 
 may be said to be almost typical of this form of injury. Ach- 
 ing, weary, and more or less constant both over and near the 
 spine, and in the muscular masses on either side of it, it is lia- 
 ble to be rendered acute by movement, so that the patient 
 dreads to move at all; or if he be able to go about, it is likely 
 to seize him suddenly and sharply, to make him cry out for 
 the moment, and to be followed by renewed aching of the 
 back. The spinal pains are, indeed, very like the pains which 
 may affect any contused or sprained joint, and there is pre- 
 cisely the same indication for treatment. Exercise — and not 
 fixation of the whole back in poroplastic jackets — is essentially 
 the best thing for relieving them, after adequate rest has been 
 given to recover from the immediate effects of the shock, and 
 to avoid what risk there may be from too early movement of 
 the bruised and strained parts. True, the effort necessary to 
 move for the first time may have to be very great, and the 
 pain on first getting out of bed or attempting to walk may be 
 so acute as to drive the patient back to bed again, yet if this 
 initial pain will be endured, and a little perseverance and de- 
 termination be exerted, it is pretty certain that the pain will 
 daily be lessened, and that greater freedom of movement will 
 be gained at the same time. In a sprained joint we know 
 that stiffness and pain go frequently jsaripassw together, and 
 the same associated phenomena in these injuries of the back 
 form an additional aid to the diagnosis that the spinal pains 
 are not of more serious import, than those due to muscular 
 and ligamentous strain elsewhere. They share this feature 
 likewise in common with them, that they have a tendency to 
 last obstinately for a long time; to recur after intervals of 
 comparative or entire ease; to be induced by changes in the 
 weather, or by any extra exertion ; and so, by their very na- 
 ture, they unduly alarm the patient, and encourage him in the 
 belief that his injuries have been greater than they really are, 
 and that the prospect of his recovery, without permanent 
 damage or disablement, is verj'^ remote indeed. It behooves 
 us not to share in his alarm, but rather to use every influence 
 to induce the patient to take those steps which alone can in- 
 sure his recovery — to leave his bed, to have change of air, if 
 need be, to improve his general health, and to allow of greater 
 opportunities of movement than were he to stay at home. Be 
 
Railway Injuries. 17 
 
 careful, however, before all things, not to overlook any symp- 
 tom which is a real indication of injury of the spinal mem- 
 branes or of disease of the spinal cord. 
 
 Not for this reason only is it desirable to make a correct 
 diagnosis as soon as possible, but also because there are few 
 things worse for a patient, whether man or woman, than for 
 the back to be constantly examined, and for pain and tender- 
 ness to be elicited over and over again at the injured parts. 
 Repeated examination is the very way to develop a state of 
 undue nervousness, and to bring about a hypersesthesia of the 
 surface which is often most distressing. Just as hypersesthesia 
 over a wide region of the skin of the hip may be seen in cases 
 of so-called hysterical coxalgia, so a widely-diffused sensitive- 
 ness of the skin of the back may arise in many cases of simple 
 sprain unassociated with other disease of the spinal column. 
 Its onset and development may occasionally be observed, and 
 its real origin be thus made manifest. 
 
 Case V. — Sprain of the Dorsal and Lumbar Vertebrce — 
 Great Surface Hypercesthesia. — A young man was slightly 
 shaken in a collision of no great severity, and in a few days 
 had pains about the vertebral column such as have been de- 
 scribed. He gradually recovered from the effects of the shake, 
 but the aching in the back continued, and the spine was there- 
 fore more especially examined, not much attention having been 
 paid to it hitherto. The examination revealed a point of ten- 
 derness on pressure over one of the dorsal vertebrae, at the 
 point in fact where the sprain had probably been most severe. 
 Within a day or two his back became so sensitive that he com- 
 plained of, and shrank from, the very lightest touch of the 
 finger on almost every part of it, whether over the spinal 
 column or over the muscles at the side. He was so sensitive 
 to touch that he endeavored to avoid being touched at all, 
 seemed even afraid to have his back looked at, and moved him- 
 self away with so much contortion, as in itself to afford evi- 
 dence of- the absence of any serious mischief about the verte- 
 bral column or its contents. The hyperesthesia was doubtless 
 perfectly genuine; but in addition to the mode of onset, observe 
 the inconsistencies of the hyperaesthesia itself. So great was 
 it, that had it been real and not imaginary, it must have been 
 unbearable for the man either to have rested against his 
 couch, or even to have borne the contact of his clothes. 
 
1 8 Railway Injuries. 
 
 This is the hypergesthesia so often found superadded to the 
 pain which is a real consequence of the vertebral sprain; and 
 yet too frequently the inconsistencies thereof are ignored, and 
 the hypersensitiveness is regarded as another, and more tell- 
 ing, symptom of some inflammatory condition of the mem- 
 branes of the spinal cord. It has little in common, however, 
 with the hypereesthesia or the " eccentric " pains which are a 
 result of irritation of the sensory nerve-roots, whether by 
 thickening of membranes or otherwise; and it is unlike the 
 zone, or girdle of hypersesthesia, which may feel to the patient 
 like a cord, or some other abnormal sensation at the periph- 
 ery. The hyperaesthesia is too wide-spread over one area, 
 and is at the same time too limited to the area which is the 
 chief seat of attention. It is, moreover, unlikely that real 
 irritation of the sensory nerve-roots should give rise to hypei-- 
 Eesthesia upon the back alone. It is rather the natural out- 
 come of that alarm, which, both in hospital patients and in 
 those more especially who have been in railway collisions, seems 
 to be inseparable from injuries to the spine or back; and al- 
 though undoubtedly a real condition to the patient hmself, it 
 is 3'^et unreal, and the product of his disordered imagination 
 alone. 
 
 It is hardly necessary to dwell upon the pain and local 
 tenderness of which there is no sign when the attention of the 
 patient is otherwise engaged and directed away from the 
 affected part. These may be of the same nature as the hy- 
 peraesthesia, though much more often they have no real exist- 
 ence, and are heard from those persons only who are pur- 
 posely exaggerating the effects of the injuries they have 
 received. Let it be remembered that a far more important 
 sign than variableness of the pain under examination, is the 
 very fact that the attention of the patient can be so easily 
 diverted from the affected part. Call to mind a case of severe 
 inflammation of the knee-joint, and ask whether it is not well- 
 nigh impossible to divert the patient's attention from his knee 
 when being examined, and whether he does not guard it with 
 all the more conscious care, because he is being asked ques- 
 tions wholly unconnected with the painful limb. The very 
 readiness with which the attention can be diverted from the 
 tender back is of greater diagnostic import than the spinal 
 tenderness or pain. 
 
Rcdhvay Injuries. 19 
 
 The hypergesthesia and tenderness just alluded to are of a 
 nature akin to the tenderness which is observed in the cases 
 of so-called "spinal irritation," a malady with which the 
 brothers Griffin dealt very fully in 1834, in their interesting 
 and well-known work, " On Functional Affections of the Spinal 
 Cord." They there point out (p. 301) how spinal tenderness 
 is a "common attendant on all hysterical complaints, on 
 numerous cases of functional disorder where the hysteric dis- 
 position is not so obvious, and in many nervous or neuralgic 
 affections." The tenderness might be both local and general 
 over the spine, and in their judgment it was enough to throw 
 doubt on any other symptom suggestive of intraspinal lesion 
 or inflammation. 
 
 Passing, then, from the pain, tenderness, stiffness, and hy- 
 pergesthesia which are the more immediate signs of that kind 
 of injury which the back most frequently receives in col- 
 lisions, I proceed in the next place to speak of other symptoms 
 or complaints which occasionally accompany them, and which 
 may be regarded as evidence of damage to structures other 
 than the bony, the ligamentous, and the muscular of the ver- 
 tebral column. 
 
 And in the consideration of them it is necessary to bear in 
 mind that however well the spine itself, and the muscles and 
 ligaments which bind its various parts together, may be 
 adapted for protecting the intraspinal structures from injury, 
 even at their own expense, it is simply a question of the de- 
 gree of the violence whether muscles and ligaments are alone 
 injured by forces which tend to overbend the spine. Up to a 
 certain point these soft structures may succeed in keeping safe 
 the parts within, even though they themselves may suffer in 
 the attempt; beyond that point their resistance is overcome, 
 and there may, as a consequence, be separation of parts 
 which it is their business to hold together. This is, of course, 
 much more likely to happen when the violence has fallen upon 
 one part, instead of being widely diffused, ftnd a not uncom- 
 mon way in which the cord may be locally damaged, is by 
 overbending of the spine. 
 
 The pseudo -paralysis of muscular incapacity has already 
 been described, but abnormal sensations of tingling and 
 numbness, or of " pins and needles " in some parts of the limbs, 
 are not very uncommon after severe collisions. (Abnormal 
 
20 Railway Injuries. 
 
 sensations described as " tingling " or " pins and needles " are, 
 although purely subjective, much more trustworthy terms 
 than "numbness," which the laity use with a signification 
 wholly different from that in common use among ourselves. 
 Dread of moving the limbs without causing pain, bodily weak- 
 ness and stiffness from confinement to bed, or the sensations 
 produced by general bruising of the limbs, may each and all 
 be described as " numbness," even when we find, and the pa- 
 tient admits, that there is no real anaesthesia nor true loss of 
 muscular or sensory power. Thus, for example, a man de- 
 scribed his leg as feeling " numb " alter having received a slight 
 blow on the side of the knee.) All such complaints ought 
 rightly to be regarded as worthy of attention and anxiety, es- 
 pecially if they last for any length of time after the accident, 
 or if it can be definitely asserted that the spine alone received 
 injury. It is rare, however, for the injuries received in severe 
 collisions to be limited to a single blow on one part of the 
 spinal column, and it is important to determine whether these 
 abnormal peripheral sensations are not really due to some 
 blow sustained by the limbs themselves, before deciding that 
 they are the manifestation of central damage. When this ob- 
 vious fallacy has been excluded, the remaining proportion of 
 cases in which these complaints are made is found to be very 
 small. 
 
 Case YI. — Severe General Vertebral Sprain — Sensations 
 of Numbness and Tingling.— Ei. H. D., aged thirty-five, re- 
 ceived in a severe collision " a blow," as he expressed it, " down 
 his whole back," and also on the back of his head from a fall- 
 ing carpet-bag. He did not consider himself much hurt, al- 
 though from the accouat of his appearance there must have 
 been a considerable degree of shock. He proceeded on his 
 journey, but three-quarters of an hour after the accident he 
 felt compelled to stop and go to bed at a neighboring inn. He 
 then began to suffer from severe pain in the head, and from 
 pain down the whole of the spine, but more especially about the 
 sacrum and the lower cervical region. There were no marks 
 of bruising. He also complained of "numbness and tingling" 
 in his limbs, with some difficulty in moving them. He suffered 
 for three days from extreme nervous prostration; dreaded the 
 least noise; spoke only in a whisper, and lay in a darkened 
 
Railway Injuries. 21 
 
 room. There was, however, no disturbance of pulse or tem- 
 perature, and he had been able to sleep without narcotic for a 
 few hours on the night after the accident. On the following 
 days his limbs felt more natural, and the tingling and sensa- 
 tion of numbness had very much lessened. In five days these 
 sensations had completely disappeared, but he still suffered 
 from much pain about the vertebral column, and movements 
 of the neck and trunk were painful to him. He was exces- 
 sively nervous, and much dreaded any examination of his 
 back. The pulse and temperature were throughout normal. 
 He continued steadily to improve, and in three weeks was able 
 to be moved. In three months he was going out daily, walk- 
 ing slowly about three miles a day, but complaining much — 
 especially under examination — of pain in and about his verte- 
 bral column, the movements of which were evidently stiff and 
 painful. He was still very nervous and felt generally weak, 
 but there was no impairment of motion or of sensation in his 
 limbs. He returned to work in about seven months. Five 
 years after the accident he was at work and in good health, 
 though often complaining of his back, " especially when lifting 
 heavy weights." 
 
 It is obvious both from the history at the time and from 
 the long-continued pain afterward, that there was here pre- 
 cisely the same kind of injury, as far as the spinal column was 
 affected, as in the two previous cases, but with the important 
 addition of some abnormal sensations in the limbs, coming on 
 synchronously with the pains, and disappearing after a few 
 days. These sensations were general, and were not confined 
 to any one limb or part of a limb; and although it is impossi- 
 ble to define their cause with certainty, there are good 
 grounds for believing them to be due to some effect produced 
 by strain or blow upon the nerve trunks proceeding from the 
 spinal column to the limbs. In severe collisions, where there 
 is a risk of the body being suddenly bent and strained in many 
 different directions, it is, indeed, highly probable that every 
 part of the spinal column is subjected to muscular and liga- 
 mentous strain, and it is not inconceivq,ble that the nerves 
 which permeate the column at both sides should be involved 
 in the same injury. 
 
 No one will dispute the wisdom of absolute rest in all such 
 
22 Railway Injuries. 
 
 cases, even though there is no warrant for thinking that the 
 symptoms will be followed by some less dubious indication of 
 central nerve lesion. In themselves they are rare, and found 
 only after the more serious accidents in which there is a risk 
 of extensive bruising and straining of the whole body. 
 Whether the result of definite structural lesion or no, the 
 symptoms of nerve disturbance leave no trace behind; in other 
 "words, recovery from the condition on which they depend is 
 complete: and although the precaution of absolute rest is im- 
 perative, there is no evidence so far to show that they are of 
 more serious import than is the sensation of tingling in the 
 ulnar distribution after a blow upon the elbow. 
 
 Their presence, however, does not militate against the 
 broad conclusion that the spinal cord is very securely pro- 
 tected from injury in its osseous canal, and that we shall prob- 
 ably find more definite symptoms when there has been un- 
 doubted lesion of the marrow itself. No matter what be the 
 organ or structure, the severity of a lesion may differ vastly 
 in degree, and it may perhaps be that these abnormal sensa- 
 tions are the symptoms of a disturbance which, in cases of 
 more obvious local injury, amounts to actual damage — dis- 
 coverable and giving rise to less transient symptoms — of -the 
 spinal cord or of the nerves proceeding from it. 
 
 The record, however, of a large number of injuries indispu- 
 tably proves that the cases are few and far between, in which 
 there has been unquestionable lesion either of central or more 
 peripheral parts of the nervous system. Lesions of the spinal 
 cord are met with only in a few isolated cases, and it is es- 
 sential that this fact should be duly recognized if a right esti- 
 mate is to be formed of the much larger class of cases, in 
 which the injury and symptoms are rather those of general 
 nervous shock, variable in degree, protracted in time, where it 
 may be held by some that there has been concussion of the 
 spinal cord, even though there has been no evidence of blow 
 upon, or of damage to, the structure of any one organ or part 
 of the body. 
 
 Case VII. — Severe Lnimbo-sacral Sprain — Probable Irv- 
 jury to Cords of Sacral Plexus.— S, Y., aged forty-eight, the 
 mother of several children, gave the following account of the 
 injuries she received m a severe collision which occurred at 
 
Railway Injuries. 23 
 
 night, and in which a great many persons were hurt. She had 
 no distinct remembrance of what happened to her, but after 
 she had been carried home and put to bed, marks of severe 
 bruising were found between the eyes, at the back of the head, 
 on the chest, and more extensively about the lumbar and 
 sacral regions of the vertebral column. Beyond the bruising 
 there were no physical signs of injury to the spine. She was 
 in bed for three months, suffering chiefly from pain in her 
 back, so bad at first that she could not move in bed. She also 
 had what she described as a " numbing pain down the left leg." 
 At the end of three months she was so much better as to be 
 able to get out, and shortly after to be moved to the seaside. 
 Ten months after the accident her chief complaints were of 
 pain in the back, especially on movement, and of a partial loss 
 both of motion and sensation in the left leg. She was then 
 using the leg as much as she could, though obliged to go about 
 with crutches. There was ^revJ slight wasting of the limb, all 
 the movements of which, it may be said, were sluggish and 
 defective in power. There was diminution of ordinary sensa- 
 tion, slight only, but yet undoubted. There was no dragging 
 of the limb in walking, the leg being rather held stiffly, and 
 conveying the impression of injury having been received about 
 the hip. There could, indeed, be no doubt that, in addition to 
 the paresis, there was injury to the muscular and ligamentous 
 structures about the hip and pelvis, injury which led to much 
 of the stiffness about the thigh, such as might have been 
 remedied by freer movement than the patient could give to it. 
 There was never any paralysis of bladder or bowel. From the 
 time when this patient was seen she steadily improved. Thir- 
 teen months after the accident she was able to abandon her 
 crutches, though the report of her then was that " sensation 
 is still very feeble in the injured leg, but there is still progress 
 made." Two years later, or three years after the accident, 
 this last report was sent by the surgeon under whose care she 
 had continuously been : " The case you saw two years ago has 
 resulted in a complete cure, and she is now able to walk about 
 almost as well as ever." 
 
 It must, I think, be regarded as very highly probable that 
 the impairment of motion and sensation in this case was due 
 to some injury to the nerve trunks, but it is impossible to say 
 
24 Railtjuay Injuries. 
 
 with certainty whether that injurj' was after the nerves had 
 formed the plexuses outside the vertebral column, or when 
 they still were individual cords in the cauda equina. If the 
 paresis was due to traumatic lesion of the nerve trunks within 
 the spinal canal, it is almost inconceivable that the effects 
 could have been confined to the nerves of one limb only, and 
 on this ground it seems more reasonable to conclude that the 
 injury to the nerve trunks was outside the vertebral column. 
 The length of , time, moreover, that elapsed before the recovery 
 of the patient, seems further to confirm this opinion, whether 
 the essential lesion was of the nerves themselves, or, as is 
 equally probable from the character of the blow, was hemor- 
 rhage lying around and pressing upon them. 
 
 Case VIII. — Lumho- sacral Sprain — Probable Injury to, 
 or Hemorrhage round, Pelvic Plexuses. — A strong and 
 healthy man, aged twenty-nine, was thrown down on the floor 
 of the carriage in a sharp collision, and knew that he had had 
 a severe blow over the right sacro-iliac region. He almost 
 directly afterward had sensations of pins and needles all over 
 him. These soon passed away, but he was in bed more or less 
 for four months, suffering from great pain in the lower part of 
 the back, and numbness and heaviness in his legs. For three 
 months his pulse was as slow as fifty-six. Eight months after 
 the accident he was still quite unable to attend to his work, 
 and suffered at times very much from pain in the back and 
 from weakness in the legs. This weakness more especially 
 involved the right leg, and although every required movement 
 could be performed, it was evidently done with difficulty, and 
 there was some impairment of common cutaneous sensation. 
 There was no wasting, and the reflexes were normal. His gait 
 was distinctly suggestive of lumbar stiffness, and there was 
 clearly in addition some defect in the innervation of his right 
 leg; and five years after the accident, although he was well 
 and at his work, there was still said to be pain abou t the sa- 
 crum and right hip, made worse by walking or long standing, 
 and the right leg was described as being not as large as the 
 other. This statement, however, there was no opportunity of 
 confirming by a medical examination, and it must remain a 
 matter of doubt whether any and what injury had been in- 
 curred by the pelvic plexuses. 
 
Railway Injuries. 25 
 
 It is never easy, in cases like these, to separate the symp- 
 toms which are due to interrupted or damaged nerve function 
 from those which depend on muscular, ligamentous, and osse- 
 ous bruise and strain. These last may be very severe, and 
 may ^ive rise to great mechanical impairment of motor power, 
 producing the pseudo-palsy to which easier reference has been 
 made; and only a very careful examination of the limb, and 
 of all the attendant symptoms, will enable one to decide that 
 there has or has not been injury to nerve structures. In the 
 _great majority of these cases of general lumbo-sacral strain, 
 they usually escape direct injury; but there is no question 
 that this form of traumatic lumbago, due to violent wrench of 
 all the ligamentous structures of the ilium, sacrum, and lower 
 spine, of all others is the most painful and the most incapaci- 
 tating, and the pain is very prone indeed to radiate widely 
 from the part where it has its original seat. It is by no means 
 uncommon, in cases of ordinary lumbago, for the pain to 
 spread to the lower abdomen, to the testes, and down the legs, 
 but there is no reason to think that the pain which radiates 
 in this way, whether in simple or in traumatic lumbago, is due 
 to any gross lesion in nervous structures. Help in diagnosis 
 will always be had by learning the character of the blow 
 which has been received in the collision, or the precise mode in 
 which injury has been inflicted upon the back. My own in- 
 quiries and experience leave no doubt in my mind that any 
 local lesion of nerve centres, or of nerve truks, has its origin in 
 injury at or close to the part, and that the general concussion 
 of the accident is inadequate to bring about so grave a result. 
 The cases already given exemplify this, but not ,so markedly 
 ^s the following. 
 
 Case IX. — L,ate Myelitis following Obscure, Spinal In- 
 jury. — T. L., aged twenty-nine, a thin, delicate man, was in a 
 very bad collision in which three persons were killed, and in 
 which a large number were injured. He could give no clear 
 account of the accident, saying he was dazed and could not 
 stand. He was confined to bed for about a fortnight, suffer-, 
 ing much from pain in his back and legs. He then improved 
 a little, and was able to go to a hydropathic establishment in 
 the country, where he stayed for two months. His back con- 
 tinued to trouble him very much (this is in his own words), 
 
26 Railway Injuries. 
 
 but otherwise he improved. Toward the close of these two 
 months the weakness which he had all along felt in his legs be- 
 came a much more definite loss of power, and in a week or ten 
 days he was quite unable to walk. Ten months after the ac- 
 cident there was no mistake as to his condition. Loss of 
 power to move, and almost entire loss of sensation in his legs, 
 paralysis of bowel, paralysis of bladder with alkaline urine, 
 bed sores, and reflex spasms of the lower limbs, undoubtedly 
 pointed to softening of the spinal cord. His pulse was fre- 
 quent, and his temperature above normal. He complained of 
 pain in the lower part of the back, but there was no marked 
 tenderness. He lingered for some months without improve- 
 ment, and then died. 
 
 It is unfortunate that no post-mortem examination was al- 
 lowed in this case, for it would have been in every way desira- 
 ble to have learned exactly the nature of the injury, if any, 
 which the vertebral column sustained, and how it came to 
 pass that the cord became affected. The precise train of 
 events can therefore be a matter of conjecture only. Two 
 months elapsed between the receipt of the injury and the on- 
 set of definite symptoms of inflammation and softening of the 
 spinal cord itself, and there is unfortunately no more accurate 
 record of what his condition really was during this period. 
 The mode in which he was injured, however, seems to render 
 it not improbable that there were symptoms which should 
 have made a fortnight's stay in bed altogether inadequate, and 
 so early a move to the country most unwise. For the accident 
 really happened in this way, as was learned from another per- 
 son who was with him at the time. The patient was thrown 
 on his face on the floor of the carriage, and a very " heavy 
 man then fell on the top of him, right in the middle of his^ 
 back." There was thus no doubtful history of a blow, of ob- 
 scure injury to a remote part, or of a general shake of the 
 whole body, but a clear account of an accident so happening, 
 that, without any visible signs of damage to the spine, there 
 may well have been some separation of vertebrae, or some un- 
 due bending of the column, which, damaging at the same 
 time the membranes of the cord, or causing slight intraspinal 
 hemorrhage, was the real starting-point of the mischief whick 
 supervened. 
 
Railway Injuries. 27 
 
 I would suggest the following' as a very probable sequence 
 of events : A small localized injury of the membranes, or hem- 
 orrhage, at the site of the injury to the vertebral column, fol- 
 lowed by a meningitis which was at first too limited in extent 
 to give rise to any precise symptoms, but which preceded, and, 
 having implicated the cord, was the cause of the myelitis which 
 had a fatal issue. If this bq the explanation, the meningitis 
 must have at first been exceedingly limited, because traumatic 
 meningitis does not usually follow an unobserved course. 
 Sometimes it is acute, spreads rapidly, gives rise to definite 
 symptoms, and has a fatal result. At other times a less vio- 
 lent inflammation leads to local thickening and adhesion about 
 the spinal roots, causing peripheral symptoms of impaired in- 
 nervation; or similar pathological changes may involve the 
 cord itself, and setting up degeneration therein, present very 
 definite indications of structural disease. But acute myelitis 
 at so long an interval after injury is most uncommon. Still 
 further doubt, however, surrounds this case, for at the time 
 when the symptoms of spinal softening were becoming marked, 
 the man had epididymitis. It is true that gonorrhoea was al- 
 together denied, and that the epididymitis may have been 
 caused by the frequent use of the catheter; but it is to be re- 
 membered that myelitis of the cord may be the result of 
 thrombosis of the pelvic and vesical veins, a direct consequence 
 of the same urethral infiammation which had produced epidi- 
 dymitis. It seems, therefore, within the range of possibility 
 that the myelitis and the fatal result were not due to the in- 
 jury at all. 
 
 I have seen no case of acute traumatic meningitis following 
 railway injury, nor any in which I could satisfy myself of the 
 presence of subacute or chronic meningitis as the basis of the 
 symptoms of general nervous shock which are frequently seen 
 after railway collision, and which will be described in a com- 
 ing chapter. I have often heard " subacute meningitis " put 
 forward as the cause of the localized pains in the back which 
 are common after sprains of the vertebral column, more es- 
 pecially when such pains have been associated with general 
 bodily weakness due to long confinement in bed or in the 
 house, and with the nervousness and emotional disturbance 
 which are inseparable from severe shock to the system. The 
 history and course of the cases, however, and the entire ab- 
 
2" Railway Injuries. 
 
 sence of the real symptoms to which meningitis gives rise, 
 have convinced me that no such serious mischief could exist. 
 For meningitis of the spinal membranes is a serious organic 
 lesion, and it is hard to believe that if subacute meningitis of 
 traumatic origin were, as common as some would seem to be- 
 lieve it to .be after collisions, we should not much more fre- 
 quently meet with cases of nteningitis running an acute 
 course, or with cases where there is likewise degeneration of 
 the spinal corA. 
 
 Injuries to the cervical spine are, for obvious reasons — its 
 lesser strength and its greater mobilitj^ — more likely to be 
 followed by local meningitis than are injuries to the lower 
 parts of the column; but wherever the lesion be, it should 
 never be forgotten how frequently syphilis has a share in keep- 
 ing up any chronic inflammation of the membranes of the 
 spinal cord. (See paper by Dr. Buzzard on "Cases of Syphi- 
 litic Paraplegia," " Lancet," Vol. I., 1879, p. 469. After detail- 
 ing a case of paraplegia, with strangely variegated symptoms, 
 cured by anti-syphilitic i-emedies, he writes: "With the clear 
 history of syphilis before us, we can well imagine that the 
 meningitis was gummatous, and that it probably involved 
 especially the internal surface o£ the dura mater (pachymenin- 
 gitis), but extended also to the contiguous soft membranes. 
 . . . Note, also, that there was no tenderness on percussing 
 the vertebral spines. The absence of this symptom is too often 
 regarded as being almost inconsistent with the existence of 
 serious lesion of the cord or its coverings. Nothing can well 
 be less founded in fact. If we put aside cases in which the 
 vertebral column itself is diseased, we shall find that the ex- 
 istence of very marked spinal tenderness points strongly in 
 the direction of a functional nervous affection of comparatively 
 little importance, and does not indicate a serious organic lesion 
 of the spinal cord.") In a case under my own observation not 
 long ago, the symptoms of a scattered meningitis — to wit, 
 slight wasting and partial loss of motion and sensation in the 
 legs — had been attributed to an injury to the spine; but as a 
 matter of fact there was a very distinct history of syphilis, 
 the symptoms had more than once been lessened and almost 
 removed by the administration of anti-syphilitic remedies, and 
 careful inquiry proved that the supposed injury was alto- 
 gether trivial. And although, from a medico-legal point of 
 
Railway Injuries. 29 
 
 vitw, the presence of a syphilitic taint does not debar the pa- 
 tient from compensation for injuries received, such taint must 
 of necessity be acknowledged if we are to form a correct esti- 
 mate of the probabilities of recovery in any particular case. 
 (" Inasmuch," says Dr. Ross [Diseases of the Nervous System, 
 2d ed.. Vol. I., p. 293], " as there is no severe org-^ic disease 
 affecting' the nervous system" in which the results of treatment 
 are so often satisfactory^, so there is no disease which deserv- 
 edly brings so much discredit upon the practitioner who over- 
 looks its presence.") 
 
 Happily there is no doubt of the exceeding rarity of spinal 
 meningitis as an immediate result of localized injury to the 
 vertebral column. The same remark applies with especial 
 force to the results of the injuries which have been considered 
 in the early part of this chapter; and I know of no case in 
 which meningeal inflammation has been caused by injury to 
 some part of the body remote from the spine. 
 
 While then the victims of railwaj' collision are not by any 
 means exempted from liability to suffer from any and every 
 form of lesion of the spinal cord and its membranous cover- 
 ings, accumulated experience leaves no longer any doubt that 
 these grave results are most uncommon, and that though the 
 back is especially prone to suffer injury in this form of acci- 
 dent, it is the extra-spinal structures which, in ninety-nine 
 cases out of a hundred, bear the brunt of the violence and suf- 
 fer from it. Such is the immediate consequence, but in every 
 medico-legal inquiry the future as well as the present has to 
 be considered. What is the prognosis; and what risk is 
 there after the receipt of some such obscure injury of the back 
 as we have been dealing with, there shall supervene, as a con- 
 sequence of the injury, the symptoms of degeneration of the 
 spinal cord ? No more vital question can be asked in treating 
 of railway injuries. It has from the first engaged my very 
 careful attention, and I have endeavored to learn of cases 
 where there has been degeneration of the spinal cord as a re- 
 mote consequence of spinal injury. My inquiries have either 
 been singularly unsuccessful — and they have been made by di- 
 rect oral and written communication with many professional 
 brethren in all parts of the country— or it must be admitted 
 that secondary and remote degeneration of the spinal cord, 
 in cases where there has been no distinctive evidence of injury, 
 
30 Railway Injuries. 
 
 is very rare indeed. Nor have I been able to discover any 
 grounds for thinking that the injured in railway collisions, 
 numbering many thousands since the first accident happened, 
 have afforded a larger proportion of those degenerative sys- 
 tem-diseases of the spinal cord, which in recent years have so 
 much engaged the attention of neurologists and pathologists, 
 than have those persons who have not been exposed to the 
 same influences. It is perfectly true that in some recorded 
 cases the onset of a system-disease has had no more obvious 
 cause than injury and there is nothing inherently improbable 
 in such a sequence of events; but cases of the kind are wholly 
 exceptional, and are too few in number to call for the intro- 
 duction of any account of them in a chapter devoted only to 
 the common and everyday forms of spinal injury as seen after 
 collision accidents. 
 
 A survey has thus far been taken of the common spinal 
 injuries of railway collisions, but there is nothing in all that 
 has been said to suggest that these injuries differ in any way 
 from spinal injuries received in other forms of accident. Their 
 frequency is, however, unquestionable; and this, as we have 
 seen, is due to the special nature of railway collisions, where- 
 \iy the back is very liable to be sprained. Given a case in 
 which a mere sprain of the back is the onlj^^ injury sustained, 
 there is not, and there ought not to be, much difficulty in 
 diagnosis ; but again, the nature of a railwa}'- collision deter- 
 mines a liability to other forms of health disturbance, which, 
 in company with a spinal sprain, may make the diagnosis far 
 from easy, and may be the source of needless alarm. Here 
 step in to perplex the clinical inquirer those so-called func- 
 tional, emotional, and hysterical disorders, which have yet to 
 be considered, which are really due to the fright and mental 
 shock incidental to railway accidents, but which have been too 
 often looked upon as the result of injury to the spinal mem- 
 branes or the spinal cord. Here also in very common associ- 
 ation are the symptoms due to severe general nervous shock, 
 which are seen even when there has been no evidence of injury 
 to any one organ of the body, or of a blow, having been in- 
 flicted on any single part. They may come on soon after the 
 accident, or be delayed for many hours; they are character- 
 ized by enfeebled function both of body and mind, and are not 
 
Railway Injuries. 31 
 
 uncommon in those who have received no bodily injury- what- 
 ever. As I shall have to point out, they are the continued 
 expression of severe nervous exhaustion. Picture a case of 
 this kind, and add to it sprain of the muscles and ligaments 
 of the vertebral column with the resultant pain on movement, 
 so obstinate in its duration, and the tenderness — sometimes 
 acute — on touch, and it is neither more nor less than natural 
 — though a natural mistake — that the whole condition should 
 be attributed to some alteration or morbid change of the spine 
 and spinal cord which have been concussed. 
 
 The jar or vibration of a collision must doubtless shake the 
 spinal cord as much as the brain and every other organ of the 
 body, but there is scant reason for an explanation of the symp- 
 toms of general nervous shock in degenerative changes of the 
 structures lying within the spinal canal, simply because the 
 patient has a painful, stiff, and tender back. However alarm- 
 ing such cases may be, the tendency' is toward perfect recov- 
 ery after a longer or a shorter time. And, inconsistent though 
 it may at first sight appear that anything apart from the in- 
 jury and the bodily condition itself should influence convales- 
 cence, it is none the less a fact, which daily experience con- 
 firms, that the period of recovery very frequently begins at 
 the moment when all mental anxiety and worry are at an end 
 as to the legal aspects of the case. The settlement of the 
 patient's claim for compensation has a potent influence in 
 bringing about convalescence, not necessarily because there 
 has been imposture or a lack of perfect genuineness in the 
 facts and features of the case, but because, as a very symptom 
 of the malady itself, there must have been an inability to bear 
 the strain of a medico-legal inquiry. The strain removed, the 
 anxiety lessened, there is nothing now in the way of a hopeful 
 effort being made to return to a more natural and healthful 
 mode of life, and each returning day of improved mental tone 
 forges one more link in the chain of progress toward recovery. 
 I am not referring here, be it remembered, to cases which are 
 not strictly genuine, and where there is grave reason for sus- 
 pecting the hona fides of the patient. Examples of this kind 
 are not uncommon, where the prospect of larger pecuniary 
 gain acts as a temptation to keep up the invalid state; but 
 we must be careful that the absence of objective signs of nerve 
 
32 Railway Injuries. 
 
 lesion does not lead us into the error of throwing doubt on 
 the integrity and veracity of those who are really suffering 
 from the symptoms of general nervous shock. There is a vast 
 difference, however, between the false and the true, and the 
 one can be distinguished from thfe other without much diffi- 
 culty. 
 
CHAPTER II. 
 
 GENERAL NERVOUS SHOCK. 
 
 Having thus far given an account of the injuries of the 
 back which are commonly met with after railway collisions, 
 my next duty is to turn to the cases vastly more numerous, 
 and even more important, to which I have already referred 
 under the name " general nervous shock." This term is applic- 
 able rather to the whole clinical circumstances of the case 
 than to any one symptom which may be presented by the in- 
 jured person. It is a phrase which, in its very lack of preci- 
 sion, appears suitable to describe the class of cases which we 
 must now consider; for we shall see that the course, historj', 
 and general symptoms indicate some functional or dynamic 
 disturbance of the nervous equilibrium or tone, rather than 
 structural damage to any organ of the body. 
 
 We are all familiar with the term " shock " as synonymous 
 with the collapse which accompanies all profound and sudden 
 injuries, whether inflicted upon the head or upon some other 
 part of the body. And this collapse or shock we are wont to 
 regard as the immediate expression of lowered, or annihilated, 
 function of the great nerve centres which preside over the 
 vascular system; paresis of the heart and of the peripheral 
 parts of the circulation being the essential factor in inducing 
 the pallor and coldness which affect the whole surface of the 
 body, and the mental enfeeblement which is due to impaired 
 flow of blood within the brain. 
 
 This, however, is not the place to enter into any lengthened 
 description of the nature of true shock or collapse. (Mr. 
 Savor j''s article in Holmes' System is known to every one, and 
 in Groeningen's "Ueber den Shock" will be found a full ac- 
 count of all the symptoms and of every theory upon it.) No 
 matter how the injury may have been inflicted, provided only 
 it has been sudden and severe, whether by railway accident 
 or by the more ordinary casualties of everyday life, shock or 
 
34 Railway Injuries. 
 
 collapse In greater or lesser degree is invariably recognized as 
 one of the features of the patient's general condition immedi- 
 ately after the injury has been received. The collapse may 
 be lasting and profound, or it may be slight and transient, but 
 in every case it is an immediate consequence of the injurj', 
 which, by its suddenness and severity, has induced the paresis 
 which primarily affects the great central organ of the circula- 
 tion. Nor need any description be given of the history and 
 symptoms of cases of shock or collapse, with which all are 
 doubtless familiar in hospital practice. There is, in fact, no 
 condition which is more obvious or more striking than that of 
 the seeming lifelessness, which is an indication that some 
 severe impression has been made by injury upon the nervous 
 system. 
 
 The term "lifelessness" is indeed an appropriate one to 
 give to the state of shock from injury in its more serious de- 
 grees. There is a lowering of the vitality of every organ and 
 function of the body, from mental activity and capacity to 
 that of the least important function in the animal economy. 
 And that which probably lies at the very foundation of many 
 of the symptoms of shock or collapse is temporary paresis of 
 the heart, and of the whole circulatory system. The slow, 
 feeble, or almost annihilated pulse, the pallor of the lips and 
 coldness of the extremities, the mental hebetude, the ansesthe-- 
 sia of the surface, the relaxation of the sphincters, the lessened 
 secretion of the urine, the impaired muscular action, each and 
 all are dependent in varying degrees on the paresis of the 
 heart and vascular system, and on the impression upon the 
 whole nervous system of which that is the first and most im- 
 mediate result. 
 
 The collapse may be so profound as to be a source of 
 greater danger to the patient than the bodily injury which he 
 has sustained. The issue may be rapidly fatal, although death 
 is the exceptional rather than the usual result of uncompli- 
 cated shock. The heart, under the appropriate treatment of 
 quietude and warmth — masterly inactivity — or if need be, of 
 stimulants — alcohol, strychnine, and digitalis— ^regains its nor- 
 mal power, and the functions are once more naturally per- 
 formed. The collapse is frequently succeeded by a period of 
 "reaction," in which the temperature and pulse are slightly 
 raised until the equilibrium of health has been established; 
 
Railway Injuries. 35 
 
 but whether there be reaction or no, the symptoms pass away, 
 and except as an indication for treatment, as a rule, they give 
 us little more concern. Patient and surgeon are far more in- 
 terested, after the subsidence of the initial collapse and its in- 
 cidental risks, in the successful issue of the needful operation, 
 or in the usefulness restored to the limb or organ which has 
 been damaged. If these results be satisfactory, the patient 
 leaves the hospital gratified at the recovery which he has 
 made, and thankful, perhaps, that his injuries were not more 
 severe. What has become of the collapse which on his admis- 
 sion into hospital was a striking feature in his case ? Has it 
 on after-symptoms, or has it, as we thought it had, completely 
 passed away ? Important questions these; but as a matter 
 of fact we know so little of the after-history of hospital pa- 
 tients, that from their cases we can draw but little help in 
 elucidation of the general nervous shock which is met with 
 after railway collisions, and whose after-symptoms may per- 
 haps be far more prominent than those which immediately 
 followed the injury. Our hospital patients, as we believe, re- 
 cover, and rarely or never do we hear of the symptoms, nor 
 do we meet with the class of cases to which I shall direct at- 
 tention now. 
 
 Surgeons are pretty well agreed that the collapse in cases 
 of accident brought into hospital is usually very profound 
 after the injuries— crush of limbs, for example— which railway 
 servants meet with at their work, and which often call for 
 operative interference. Compare two cases of like injury, the 
 one received by accident on a railway, and the other by being 
 knocked down and run over in the street, and there is great 
 probabihty that the manifestations of shock will be much 
 more marked in the former case than in the latter. The dif- 
 ference I believe is this, that in the one case there is an ele- 
 ment of great fear and alarm, which has perhaps been alto- 
 gether absent from the less formidable and less terrible mode 
 of accident. How largely fright may of itself conduce to the 
 condition recognized as shock is well shown by a case com- 
 municated to me by a surgeon of large experience, who, sum- 
 moned to .a railway station to see and conduct to the hospital 
 a railwayservant who had had his foot, as was supposed, run 
 over on the line, found him in a state of collapse, and in great- 
 est alarm as to the injury to his Umb. Upon examination it 
 
3^ Railway Injuries. 
 
 was discovered that the only damage was the dexterous re- 
 moval of the heel of his boot by the wheel of a passing engine. 
 And medical literature abounds with cases where the gravest 
 disturbances of function, and even death or the annihilation of 
 function, have been produced by fright and bj^ fright alone. 
 
 It is this element of fear, this great mental shock which in 
 railway collisions has so large a share — in manj' cases the 
 only share — in inducing immediate collapse, and in giving rise 
 to those after-symptoms which may be almost as serious as, 
 and are certainly far more troublesome than, those which we 
 meet with shortly after the accident has occurred. The rea- 
 sons for this are not far to seek. The incidents indeed of al- 
 most every railway collision are quite suflBcient — even if no 
 bodily injury is inflicted — to produce a very serious effect upon 
 the mind, and to be the means of bringing about a state of 
 collapse from fright, and from fright only. The suddenness 
 of the accident, which comes without warning, or with a 
 warning which only reveals the utter helplessness of the trav- 
 eller, the loud noise, the hopeless confusion, the cries of those 
 who are injured; these in themselves, and more especially if 
 they occur at night or in the dark, are surely adequate to 
 produce a profound impression upon the nervous system, and, 
 even if they caused no marked shock or collapse at the time, 
 to induce a series of nervous disturbances at no distant date. 
 "The principal feature in railway injuries," says Mr. Fur- 
 neaux Jordan, " is the combination of the psj'-chical and cor- 
 poreal elements in the causation of shock, in such a manner 
 that the former or psychical element is always present in its 
 most intense and violent form. The incidents of a railway ac- 
 cident contribute to form a combination of the most terrible 
 circumstances which it is possible for the mind to conceive. 
 The vastness of the destructive forces, the magnitude of the 
 results, the imminent danger to the lives of numbers of human 
 beings, and the hopelessness of escape from the danger, give 
 rise to emotions which in themselves are quite sufficient to 
 produce shock, or even death itself. . . . All that the most 
 powerful impression on the nervous system can effect, is effected 
 in a railway accident, and this quite irrespectively of the ex- 
 tent or importance of the bodily injury." ("Surgical En- 
 quiries," 2d edit., p. 37.) 
 
 In these purely psychical causes lies, I believe, the explana- 
 
Railway Injuries. 37 
 
 tion of the remarkable fact that after railway collisions the 
 symptoms of general nervous' shock are so common, and some- 
 time so severe, in those who have received no bodily injury, or 
 who have presented little sign of collapse at the time of the 
 accident, o'he collapse from severe bodily injury is coincident 
 with the injury itself, or with the immediate results of it, but 
 when the shock is produced by purely mental causes the 
 manifestations thereof may be both prolonged and delayed. 
 Warded off in the first place by the excitement of the scene, 
 the shock is gathering, in the very delay itself, new force from 
 the fact that the sources of alarm are continuous, that they 
 may recur for days, and for a time be all potent for evil in 
 the patient's mind. " In certain temperaments, wrought into 
 a. state of extreme excitement, a comparatively severe injury 
 may not be attended with that degree of shock which, under 
 other circumstances, would be seen. In those cases, however,' 
 shock is usually deferred, and not altogether averted; and it 
 may be all the more severe, seeing that reactionary mental 
 exhaustion, itself a kind of shock, is superadded to the effects 
 of bodily injury." (Furneaux Jordan, op. cit., p. 37.) 
 
 Due weight must, therefore, be given to alarm and pro- 
 found mental emotion as causes of the symptoms of general 
 nervous shock so frequently seen after railway collisions. Suf- 
 ficient importance, indeed, has not been attached to them, and 
 many errors in diagnosis have been made, because fright has 
 not been deemed of itself sufficient to bring about the train of 
 symptoms which will be described. On the one hand, we may 
 hear the condition regarded as evidence of serious and irre- 
 mediable pathological change in the chief centres of the 
 nervous system; and on the other hand, no clear history of 
 pronounced shock or collapse at the time of the injury being 
 forthcoming, the symptoms are deemed unreal, and the hona 
 fides of the patient is called in question. The mistakes are at 
 opposite ends, and I hardly know which is the worse for the 
 patient, who, really suffering and ill, lies in the condition in 
 which we find him because his whole nervous system has re- 
 ceived a shock, not so much from severe bodily injury which 
 shows itself in unmistakable signs, as from the impalpable 
 element of alarm, which has to be measured by the events of 
 the accident itself, and by the temperament of the individual 
 who has been affected thereby. 
 
38 Railway Injuries. 
 
 The indications of collapse at the time of accident are very- 
 variable. The profoundest grades are occasionally seen after 
 the worst accidents, where there has been in all probability 
 destruction of life and limb. In these circumstances it is no 
 marvel that we should meet with examples of most alarming 
 collapse, associated with definite structural injury, an injury 
 such as would be commonly marked by collapse, however and 
 wherever it had been received. The collapse, however, which 
 in these railway accidents accompanies serious bodily injury, 
 such as laceration of limb or fracture of bones— always except- 
 ing the collapse from severe concussion of the brain— is very 
 rarely followed by the train of after-symptoms indicative of 
 general nervous shock. This is a fact of great interest and 
 importance, which will help to throw light upon those symp- 
 toms of general nervous shock which are often seen after the 
 slighter degrees of initial collapse. 
 
 More numerous than the cases of profound immediate col- 
 lapse are those where the accident has been less severe in its 
 effects upon life and limb, and where the earliest signs of shock 
 have been comparatively slight. " I was thrown forward and 
 backward in the carriage; I felt myself shaken, but did not 
 think I had been much hurt; I got out of the carriage, and 
 was able to help some of the other passengers, and I came on 
 home by the next train." Such is perhaps the simple story of 
 the man who finds himself in a few hours, it may be only after 
 two or three days, compelled to take to his bed because he 
 feels so unnerved, and shaken, and ill. You make inquiry as 
 to the more immediate effects of the accident upon him, and 
 you perhaps learn that he felt shaken and was obliged to have 
 some brandy, that he felt sick and faint for a few moments, 
 or that he even vomited. He thought little of it, however, 
 and gave help to others. A few hours elapse, and he finds he 
 cannot sleep; he has aches and pains in various parts of the 
 body, most likely in the back; he feels as if he had been beaten 
 all over; he is thirsty, feverish, and ill; and, gathering fresh 
 alarm from the very fact that he thought he had happily 
 escaped all injury, he sends for his doctor, who sees that the 
 symptoms of nervous disturbance and prostration have al- 
 ready begun. The prominent symptoms, however, do not al- 
 ways arise so soon. Conscious that he has sustained no bodily 
 injury, the man continues at his work, and days go by before 
 
Railway Injuries. 39 
 
 it is brought home to him that he is not ready or active at his 
 business, that he is soon tired, and has to leave off and lie 
 down in the middle of the day. It is an increasing worry and 
 annoyance to him to write his letters, or to talk with people 
 on business affairs; the back of his head feels heavy, and his 
 appetite deserts him. Nevertheless he struggles on, each day 
 not feeling quite as well as on the day before, until at last 
 the necessity is forced upon him of completely abstaining from 
 his work. With varied modifications in detail, such stories as 
 these are often heard of the effects which an accident has had 
 on numbers of persons. It is clear, from what happened at 
 the time, and from the early symptoms of reaction afterward, 
 that there was undoubted shock immediately after, or within 
 a short time of, the accident. Its early manifestations were 
 slight, and were disregarded as little more than a feeling of 
 faintness or of being dazed, but it was enough to show that 
 the alarm of the accident produced an instantaneous or early 
 result, and to be the starting-point of that disturbance of the 
 nervous system which may assume an aggravated form, and 
 continue for a very long time. It will be one aim of this work 
 to explain how it is that the after-results of even very trifling 
 initial shock from railway accident are often more lasting 
 and serious, than are the later nervous symptoms of those in 
 whom the early collapse, with extensive bodily injury, was 
 originally more profound. 
 
 Lastly, at the other end of the scale are the cases where 
 there is no evidence whatever of injury or of collapse, no faint- 
 ness, nausea, or vomiting, no early reaction from an initial 
 stage of depression, but where the after-history very closely 
 simulates that of the more numerous cases which fall under 
 our care. These I shall consider by-and-by, for few are com- 
 moner than cases of spurious nervous shock. 
 
 Let me now illustrate the kinds of symptoms with which 
 we have to deal. 
 
 Case ^.—Severe General Nervous Shock— Prolonged 
 Symptoms— Physical Injuries Slight.— ^M ., aged forty -six, 
 a tall, somewhat powerful man, was in a very severe and de- 
 structive collision. He received bruises over both arms and 
 legs, and also a blow upon the face which abraded the skin 
 over, and fractured the bones of, his nose. He was not stunned. 
 
40 Railway Injuries. 
 
 He lay for several days after the accident in.a state of great 
 nervous depression, with feeble and rapid pulse, and inability 
 to eat or sleep. He suffered at the same time much distress 
 from the fact that a friend sitting beside him in the carriage 
 had been killed ; and this seemed to prey constantly upon his 
 mind. The bodily injuries proceeded rapidly toward recovery, 
 and in seventeen days after the accident he was able to be 
 moved home. Nine weeks after the accident he had fairly 
 well recovered from his local injuries, and made no complaint 
 of bodily sufferings. Examination at this date discovered no 
 structural disease, but he was evidently in a most feeble and 
 wretched state. The ordinary functions of the body were nat- 
 ural, but his mental condition showed extreme emotional dis- 
 turbance. He complained that he had suffered continuously 
 from depression of spirits, as if some great trouble were im- 
 pending. "He is easily upset and prone to cry. He says he 
 used to cry whenever he spoke to any one, but that now he 
 has rather more control. He has been out of doors for a few 
 yards, but was stopped by a sudden sensation as if his breath- 
 ing were very short. His voice is very weak and indistinct, 
 and occasionally he says it is almost inaudible. There is no 
 disease of the larynx or adjoining parts. He sleeps very 
 badly, waking frequently, and being constantly troubled by 
 distressing dreams. His pulse is weak, 104. He occupies him- 
 self by a little reading, and by occasionally going out, but he 
 feels so shaken and weak that he is unable to do anything 
 more. In many respects, however, he is improving. The 
 weight he lost is being regained. He can walk rather further, 
 is not so ready to cry, and his voice is stronger." He re^ 
 mained in much the same condition for several months, though 
 with undoubted tendency toward improvement. Fifteen 
 months after the accident, several months, that is, after his 
 claim had been settled, I learned that he was better, though 
 yet very far from right, and he was considered wholly unfit 
 for work. His history, given four years after the accident by 
 his medical attendant, is as follows : " In my opinion he will 
 never be anything like the same man again. His appearance 
 is much altered. He looks much older, haggard, and has be- 
 come very bald. His voice is very weak, almost gone at times. 
 For some time he went about in search of health, but improved 
 very slowly, if at all. Lately he has obtained two posts, the 
 
Railway Injuries. 41 
 
 work at which is of a very light nature. I just jotted down 
 the following symptoms as he mentioned them, and I feel sure 
 he would not wilfully'- exaggerate them. Very depressed 
 spirits, sometimes palpitation, loss of sleep, bad dreams, very 
 easily tired, can't walk more than two miles, then gets very 
 tired and quite loses his voice. Did nothing for two years 
 after the accident. Has lost all his energy. Sometimes has a 
 great dread of impending evil. He can travel by railway with- 
 out feeling nervous, but can't drive without feeling frightened 
 all the time. I may add that his heart sounds are rather 
 feeble, but not otherwise abnormal. Pulse 72. No special 
 spinal symptoms; no paralysis; no bladder symptoms; always 
 ^ets much upset if dining in company or if many people are 
 talking near him. I knew him well before the accident, and 
 he was a very energetic and very honorable man." Three 
 years later his symptoms were still subsiding. Since he be- 
 gan regular work he had continued more markedly to im- 
 j)rove. 
 
 It must be prettj^ obvious from his history, that this man's 
 prolonged illness was due in only small measure to the bodily 
 injuries which he received. From these injuries, indeed, he 
 had recovered, as soon as if they had been inflicted in any 
 other accident and in any other way. The cause of his illness 
 and of his altered condition, even after the lapse of several 
 years, was the mental shock, call it fright or what we may, 
 which the whole circumstances of the accident wrought upon 
 him. There is no reason, in such a case, to believe that the 
 condition is due to any gross pathological change, such as the 
 unaided eye might see upon the post-mortem table, and cer- 
 tainly there is not meningo-myelitis of the brain and spinal 
 cord. 
 
 Evidences of the immediate effects of fright alone are, of 
 course, not often obtainable. In the following case, however, 
 it was recorded in the official report of the accident that " a 
 man, name unknown, was so frightened, and trembled so bad, 
 that he had to be detained all night." 
 
 Case Hl.—Qeneral Nervous Shock— Great Fright.— B. 
 J., aged forty-four, a thick-set, somewhat robust-looking man, 
 was in a carriage which ran off the line when the train had 
 just left a station, and which, after jolting along off the rails 
 
42 Railway Injuries. 
 
 for a few yards, was turned over on its side. He says he was 
 far more shaken, " terribly shaken " was his phrase, by the 
 previous jolting than by the overthrowing' of the carriage; 
 and when he had got out, his condition was that mentioned in 
 the official report. On the following day he travelled home 
 alone, presenting on arrival so dazed an appearance that his 
 doctor was immediately sent for. Ten days afterward he was 
 suffering from muscular pains, increaised by movement, in 
 various parts of the body, and due, no doubt, either to bruis- 
 ing or straining when the carriage had been jolted and over- 
 turned. "He can hardly get any sleep, having before his 
 mind a constant fear of the railwaj' accident, and he becomes 
 occasionally ' light-headed ' at night. He is lying in bed with 
 his eyes closed and the blinds down, complaining that he 
 dreads the light. He gets very low-spirited, arid frets about 
 his business, the thought of which pains his head. He is much 
 alarmed at the pains which he suffers, says he is afraid to 
 move on account of them, and that he fears he has received 
 internal injury. The bowels are confined. His temperature 
 is 99° F., and his pulse is 102." Notwithstanding his expres- 
 sions of fear, he was able to sit up in bed without sign of suf- 
 fering, and in talking he moved his head naturally from side 
 to side. He very soon also seemed quite content to have the 
 blind drawn up, and gradually opened his eyes. There was 
 no evidence of his having received any bodily injury other 
 than muscular bruising and strain, and his condition was re- 
 garded by all who saw him as essentially one of general ner- 
 vous shock likely to pass away after a time. When seen again 
 at the end of two months, he had a somewhat worn and anx- 
 ious expression, but said he was better, his "nervousness" be- 
 ing not so great as it was. " He complains of being easily 
 upset and startled, and that the least excitement brings on a 
 sharp pain in the head. The muscular pains are better, that 
 which still troubles him most being a pain in the muscles of 
 the left side of the neck. He sleeps better, though he occa- 
 sionally has disturbed nights. He could walk two or three 
 miles pferhaps, but would be very fatigued. His pulse is 100." 
 He had evidently much improved, and it was advised that 
 after further change he should begin his work. Several weeks 
 more elapsed, and I then found him neither looking nor feeling' 
 as well as before. He was very nervous about himself, felt 
 
Railway Injuries. 43 
 
 unable to do his work, was depressed and melancholy, and 
 losing' heart from the thought that he would never get well. 
 He had been attending to his business for two or three hours 
 a day, and the anxieties of it were verj' distressing to him. 
 He was, moreover, very anxious to arrange his pecuniary 
 claim for compensation, as both he and his doctors felt that 
 that was now beginning to prey upon his mind. In bodily 
 health he seemed well. Eighteen months after his claim was 
 settled, I again had the opportunity of seeing him. He was 
 then in perfect bodily health, able to follow his occupation as 
 usual, and to endure as much physical exertion without fatigue 
 as before the accident. He could not, however, remain as 
 long at his desk without feeling worried, and his wife said 
 that he was more irritable than he used to be. In these re- 
 spects, nevertheless, he was admittedly improving, and he him- 
 self felt confident that before long he would be absolutely well. 
 Case XII. — Slight General Nervous Shock. — ^A case of 
 lesser severity is the following: M. F., aged forty-four, a man, 
 to use his own expression, of " excitable temperament," was in 
 a sharp collision which the whistling of the engine had warned 
 him was going to happen. He had thus been able to prepare 
 himself for the crash. He was conscious of having a blow on 
 the back of the neck. He did not, however, think that he had 
 been hurt, and was able at once to help the other passengers. 
 This work over, he walked a mile to catch a train at another 
 station, finished his journey, and completed the business which 
 had called him away from home. ' On the following day he 
 ■felt " queer," and sent for his doctor, who found him agitated 
 and depressed, unable to occupy himself, and complaining that 
 he felt shaken. His pulse was, however, natural, and his tem- 
 perature normal. He subsequently suffered from sleeplessness, 
 and he had pains in various parts of the spinal column, where 
 it was supposed he had been sprained or bruised. There was 
 never any evident disturbance of the organic functions, but for 
 some months he suffered from sleeplessness, from much depres- 
 sion of mind, from inability to occupy himself, and from a con- 
 stant sense of weariness in the small of the back. After 
 change of air he found himself better, and then complaining 
 that want of work was distressing to him, he attempted to 
 resume his business, but found that it made him worse, more 
 nervous and depressed, and more sleepless at niglit. Further 
 
44 Railway Injuries. 
 
 change of air, however, did him good, and in nine months he 
 arranged his claim. In twelve months he was again at his 
 ordinary work, having " entirely recovered " from his illness. 
 He continued at his business for some years afterward, and 
 then retired. 
 
 Case XIII. — Neurasthenia Induced by Fright — Previous 
 Ancemia. — A lady, aged twenty-four, was in a collision which 
 took place at night without the slightest warning. The^g- 
 gage fell all about the carriage, and her husband was thrown 
 against her, but she herself was neither moved from her seat 
 nor injured on any single part. As soon as she got out she 
 was much alarmed at seeing a carriage had been smashed to 
 pieces, and then she watched a man being rescued from the 
 debris in which he was buried. She went on her journey, and 
 the next day felt, to use her own words, as if she had passed 
 through something terrible, and from that time onward she 
 became sleepless, lost her appetite and strength, suffered from 
 pain in the back of her head and at several spots down her 
 spine, and was quite upset by any attempts at household work, 
 or by reading and writing. Thinking she had not been hurt, 
 her friends urged her to do as much as possible and not to 
 give way, but she steadily got worse rather than better, and 
 although not in the least hysterical, it was not until proper 
 treatment was begun that improvement set in. The case was 
 complicated by previous dysmenorrhcea and ansemia, both of 
 which were increased for a time by the accident. 
 
 These examples give a good idea of the history and class 
 of symptoms which cases of general nervous shock usually 
 present. They were all of them, I believe, free from the taint 
 of conscious exaggeration or imposture, but it must be abun- 
 dantly obvious how largely the reality of many of the symp- 
 toms, lacking all vestige of objective sign, depends upon the 
 veracity and good faith of the patients themselves. On this 
 account it is that the cases are so difficult to describe, and 
 that it is almost impossible to convey an adequate impression 
 of them to those who may have never seen them. I propose, 
 therefore, to bring together and to say something about each 
 of the various symptoms which are commonly met with, or of 
 which the patients complain, when suffering from "general 
 nervous shock." And here it may be well to premise that I 
 
Railway Injuries. 45 
 
 draw a broad distinction between the condition to which this 
 name is given and that in which genuine hysteria is a pro- 
 nounced symptom. General nervous shock is not hysteria. 
 It is frequently met with in those who show no hysterical dis- 
 turbance whatever, as likewise there may be much hysteria 
 without any symptoms of general nervous shock. 
 
 Nevertheless, while I see much to agree with, and that I 
 carfEot improve upon, in Mr. Thorburn's tentative classifica- 
 tion of the post-traumatic functional neuroses ("A Contribu- 
 tion to the Surgery of the Spinal Cord," p. 186. Griffin & Co. 
 1889)— 
 
 " 1. Acute effects. 
 
 " (a.) General nervous depression—' shock ' or ' collapse.' 
 
 " (6.) A more locahzed and defined disturbance of cerebral 
 (cortical) origin— ' acute hysteria' or 'hysterics.' 
 
 "2. Chronic after-effects. 
 
 " (a.) General nervous depression — ' neurasthenia.' 
 
 " (6.) A more localized and defined disturbance of cerebral 
 (cortical) origin — ' chronic hysteria ' " — 
 
 it is by no means uncommon in my experience for the two 
 states — hysteria and neurasthenia — to be associated together. 
 Both are originated by the same cause, but the symptoms due 
 to each can usually be determined. Should there be any tend- 
 dency to hysteria, the state of general nervous depression is 
 clearly one likely to develop and maintain the purely hysteri- 
 cal disorder, and it is frequently' obvious that the hysterical 
 disturbance protracts the symptoms which are really depend- 
 ent on the general nervous exhaustion. To cure the one is 
 very often the best and only means of removing the other. 
 
 Thorburn writes: "The sj^mptoms of neurasthenia arise 
 from a general defect in the nutrition and action of the nerv- 
 ous system. . . . The symptoms follow those of shock, and 
 are the expression of an exhausted nervous system. They are 
 generally transient, and will pass away under conditions and 
 a line of treatment which may be briefly described as ' tonic' " 
 (Op. cit., p. 185.) Neurasthenia — to use the word now com- 
 monly given to the aggregate of symptoms of an exhausted 
 nervous system — is, in my own experience, very much more 
 common than hysteria. It is characterized by some or all, in 
 varying proportion and degree, of the symptoms which I shall 
 now describe, placing them merely in the order of their fre- 
 
46 Railway Injuries. 
 
 quency, after a careful survey of many hundreds of cases per 
 sonally observed. 
 
 Sleeplessness. — The physiological value of sleep is unques- 
 tionable, whether we merely look on it as the time for rest, or 
 as an indication that no bodily or mental disturbance is there 
 to prevent it. Inability to sleep, wakefulness during the whole 
 or part of the night, is a sign of considerable import in esti- 
 mating the amount of injury and of shock which the nervous 
 system has sustained. It shows that something has happened 
 to break the most regular habit of life, and to interfere with 
 the healthy equilibrium and function, of the whole nervous 
 system. This continued sleeplessness may be a source of the 
 greatest possible distress to the patient. He goes to bed tired 
 and worn, and ready to fall asleep, but no sooner is his head 
 on the pillow than he is seized, as it were, with an unnatural 
 and dominant wakefulness which positively prevents him from 
 closing his eyes. Or he falls asleep, and soon wakes again, 
 and has to pass through a night of intense wretchedness, 
 nervous and alive to the slightest sound. The furniture creaks 
 or the mouse gnaws. Night after night this goes on, and he 
 tells you that if he could only sleep he is sure he would be 
 well. And what he saj's is very true, for not only has there 
 been no serious shock to the nervous system of the man who 
 can sleep comfortably and well after a railway accident, but 
 on the other hand also, the return of sleep, after it has been 
 long absent or disturbed, is a very certain sign that the ner- 
 vous system is regaining its equilibrium and tone. It must not 
 be forgotten, however, that sleeplessness may be due to other 
 causes than the original nervous shock, and that it may form 
 a prominent complaint in those cases where convalescence is 
 being prevented or retarded by circumstances of which I shall 
 speak at a future page. Its value is thus to some extent im- 
 paired as a diagnostic symptom of general nervous shock from 
 railway collision, unless it be at periods not remote from the 
 time of accident; and, furthermore, there is frequently no 
 means of knowing whether sleeplessness is undoubtedly pres- 
 ent, for the reality of its existence may have no other basis 
 than the uncorroborated statement of the patient himself. 
 
 Disturbances of the Circulation. — Disorders of the circu- 
 lation, whether of the heart itself or of more peripheral parts 
 of the circulatory system, play a no less important part in the 
 
Railway Injuries. 47 
 
 nervous derangement than inability to sleep, and are very 
 commonly to be met with in cases of general nervous shock. 
 It has been pointed out already that the shock originally 
 showed itself by some degree of cardiac paresis, by smallness, 
 feebleness, or slowness of the heart-beat. It is a natural con- 
 sequence, therefore, that in the more serious cases of nervous 
 shoclv, especially where continued mental terror and emotion 
 tend to perpetuate the nervous disturbance, derangements of 
 the circulation should be frequent and long-continued. The 
 patients complain of palpitation, and palpitation from alto- 
 gether trifling causes. The cardiac innervation may be so 
 disturbed as to induce great frequency of the pulse, which may 
 vary from 100 to 150; but far more commonly the palpitation 
 is occasional, and it is only from exciting causes that the 
 pulse-beat is increased. It is important to remember this in 
 the examination of patients, for if you count the pulse only at 
 the beginning, and omit to count it at the end of examination, 
 you may be led to believe that the cardiac disturbance is more 
 serious than in reality it is; and by the opposite error you 
 may fail to discover any cardiac disturbance at all. A per- 
 fectly steady pulse throughout the whole examination tells its 
 own tale. Nay, the rate, the character, and the excitability 
 of the pulse form an almost metrical indication of the amount . 
 of disturbance of the nervous balance, strength, and tone ; and 
 the pulse is often the only sign there is to guide us to a right 
 estimate of the patient's condition. It is important, however, 
 to learn as far as possible the character of the patient's circu- 
 lation before the accident, and the existence of any constitu- 
 tional states or diseases, of which gout is perhaps the most 
 common, which may give rise to functional cardiac disorder. 
 
 But while the state of the pulse may form the test of 
 what we may call the grosser circulatory disturbances, there 
 are yet other symptoms which are by no means uncommon. 
 The whole vaso-motor system maybe deranged; and when 
 you hear the patient complain of alternate sensabions of heat 
 and cold, or of flushing of the face and head, or when you find 
 that at one time his hands and feet are unnaturally warm, 
 and at another unnaturally cold, there are evidences of dis- 
 turbance in those peripheral parts of the circulatory system 
 which are not necessarily or immediately under the same ner- 
 vous influence or control as the heart itself. The functional 
 
48 Railway Injuries. 
 
 strength of the vaso-motor system has been weakened — it has 
 lost its nervous tone or healthy balance; and the loss is shown 
 by the symptoms which have been named, as well as by the 
 occasional presence of well-marked tache cerebrale. These 
 disorders will be referred to again, for they seem to me to 
 have some share in giving rise to the abnormal sensations of 
 which complaint is often made, and whose obscurity tends to 
 cast doubt upon the hona fides of the man who feels them, 
 and who can only describe them as they seem to him. With 
 returning health and nervous tone these various symptoms 
 disappear, although, as will be presently shown, they are lia- 
 ble to be maintained by those influences and circumstances 
 which tend to retard convalescence. 
 
 Headache. — Intimately connected with the foregoing symp- 
 toms is the complaint of headache, rarely amounting to actual 
 pain, unless indeed there has been concussion of the brain. 
 "Pain" is so relative a term, however, that it is difficult to 
 estimate it at its true value, depending so largely as it does 
 upon the idiosyncrasy of the individual. More common than 
 actual pain, or the sensation to which the word pain would be 
 applied, is a sense of weight or oppression. This feeling of 
 heaviness may be at any part of the head, but is most com- 
 mon at the back of it, over the whole occipital region. Occi- 
 pital oppression or pain is, indeed, the headache par excel- 
 lence of neurasthenia. It may be always present, or be 
 brought on by attempts at mental occupation — by reading, 
 talking, agitation, or want of quietude. Alcohol nearly al- 
 ways increases it. These sensations are doubtless to some 
 extent dependent on the irregularities of circulation which 
 have been named. The exciting causes of palpitation, or of 
 alternate sensations of heat and cold, may at the same time 
 indirectly give rise to morbid feelings of weight and heaviness 
 in the head. Hence, also, have origin the sensations of giddi- 
 ness and swimming in the head when the patient suddenly 
 rises from the recumbent posture, sensations not uncommonly 
 experienced by those who are first beginning to move about 
 after serious and weakening illness. These various abnormal 
 sensations are, moreover, largelj"^ due to the sleeplessness which 
 is so common, and which invariably shows itself in impaired 
 mental power, as long as the brain is deprived of natural rest. 
 Occupation of the mind very early induces brain fatigue, and 
 
Railway Injuries. 49 
 
 this fatigue is revealed to the patient by pain or oppression of 
 the head and by an indefinable sense of worry. And as long' 
 as the general prostration leads to lessened bodily activity, 
 derangements of digestion, constipation, and the like, tend in 
 a still further degree to make headache a not uncommon com- 
 plaint of those who are suffering from general nervous shock. 
 Bring about sleep and natural rest, improve the cardiac tone 
 by restoration of the general health and strength, and it will 
 be found that the headaches and the brain fatigue soon pass 
 away. 
 
 Nervousness. — Under this heading must be placed a vari- 
 ety of complaints and symptoms which are very indefinite in 
 character, and which often have no more substantial basis 
 than the statements of the patients themselves. But they 
 are the kinds of complaints which, in my judgment, display 
 the alliance between the state of general nervous depression 
 and true hysteria. Not that this association is always to be 
 found or is always obvious in cases of hj-steria, but that in 
 this particular series the one is very much dependent on the 
 other, owning a common cause, and possibly due to the same 
 underlying condition of the nervous system. Complaints of 
 being easily startled, of a sense of depression and melancholy, 
 of trembling under excitement, of a desire to be alone and to 
 avoid all noise, of hopelessness as to future prospects and the 
 possibility of recover^', of agitation in the presence of others, 
 of globus hystericus — these are often heard, and their nature 
 is sufficiently obvious; and beside them may be placed in the 
 same category sighing and panting, screaming at night, irri- 
 tabihty of temper, stuttering and stammering, feebleness of 
 voice, and the other hundred- and- one complaints and symp- 
 toms which may be taken as evidence of nervous prostration 
 and loss of tone, of the patient having been reduced to a more 
 or less emotional or hysterical state, wherein loss of control is 
 a prominent feature, whether it be as cause or effect, of the 
 strange condition in which the patient seems. 
 
 Disorders of Secretion occupy no small place in the clini- 
 cal picture of cases of general nervous shock. Excessive 
 sweating is one of the most common, and is an objective sign 
 of wrong somewhat less vague than the subjective symptoms 
 last referred to. It is an evidence of impaired nerve function, 
 and is a symptom, when it occurs without obvious exciting 
 
50 Railway Injuries. 
 
 cause, of general weakness and prostration, and of disordered 
 and weakened function of the nerves which control the action 
 of the sweat-glands. 
 
 Here also, in all probability, we should rightly include 
 those vaso-motor disturbances which, limited to special regions 
 or tracts, may also give rise to very obvious symptoms. Of 
 these polyuria is the most pronounced, and may be the start- 
 ing-point of much future trouble with the bladder, for the fre- 
 quency of micturition which it necessitates may continue as a 
 nervous affection long after the original cause for it has been 
 removed. Menorrhagia is also not uncommon, coming on 
 within a few hours of the accident, and wholly independent of 
 any normal menstrual period; and in several cases profuse 
 diarrhoea has begun almost immediately after a railway colli- 
 sion. These also must be regarded as kindred signs of vaso- 
 motor disturbance, dependent, in all probability, on some ex- 
 haustion or paresis of the vaso-motor centre — if there be but 
 one — in the upper part of the spinal cord, or of the vaso- 
 motor centres — if there be many — in different parts of the 
 cerebro-spinal system. How strange and inexplicable the 
 symptoms may sometimes be, was well shown by the case of 
 a woman who was terribl3' frightened by the thought that an 
 accident was going to happen to her child, and who was her- 
 self knocked down on the platform at a railway station. She 
 had had polyuria some years before, and it now came on again 
 soon after this accident. It lasted for several weeks, with 
 one exception of twenty-four hours, during which it was re- 
 placed by an enormous flow of milk from the breasts. She 
 was not at the time suckling. Cases such as this seem to 
 support experimental observation as to the presence of vaso- 
 motor centres in the cerebral hemispheres, and better to ex- 
 plain the intimate association of emotional and vaso-motor 
 disturbances than if the centres lay in the spinal cord alone. 
 
 Photophobia, Asthenopia, and Size of the Pupil. — In 
 some of the worst cases of general nervous shock we may oc- 
 casionally meet with a considerable degree of photophobia. 
 This is usually a transient symptom in the days soon after the 
 accident, and is merely an evidence of the severity of the shock 
 and of the need for absolute quiet. The patient finds a strong 
 light unbearable, just as he cannot bear any loud noise. Far 
 more common is the subsequent complaint of defect of vision, 
 
Railway Injuries. 51 
 
 even when there has been no damage to or near the eyeball. 
 " I can read for a short time, and then the lines all seem to 
 run tog-ether," the patient tells you; and he thus describes a 
 symptom, like those which have gone before, of prostrate 
 nerve force. The asthenopia is due in nearly all cases — whether 
 there has previously been ametropia or not — to loss of accom- 
 modative power, a result of the general weakness and depres- 
 sion which render any sustained effort difficult or impossible. 
 It is merely another sign of easily -induced fatigue; and in 
 those persons who have neither error of refraction nor pres- 
 byopia, the asthenopia will disappear — as the general muscu- 
 lar fatigue and the brain fatigue will disappear — ^with return- 
 ing health and strength. The asthenopia is precisely the 
 same as that which is a not uncommon symptom of hyperme- 
 tropia, and which may be felt for the first time after an ex- 
 hausting illness or during the weakness induced by prolonged 
 lactation. In vigorous health the accommodative power is 
 adequate to overcome refractive error and to prevent fatigue 
 of vision; reduce the strength, and asthenopia ensues as a di- 
 rect consequence of weakened power of accommodation. It 
 is very doubtful whether this power will ever be perfectly re- 
 stored to its original strength in those who have abnormal 
 refraction, or in whom presbyopia is either imminent or ad- 
 vanced. Thus you find it occasionally happen that persons, 
 who have suffered from the shock of a railway collision, must 
 in future years wear glasses to correct the refractive error of 
 which they had not been conscious before. It is in these cases 
 of induced asthenopia that muscse volitantes are so commonly 
 seen, and so often alarm the patient. They are of no path- 
 ological significance whatever, and as a matter of fact there 
 are singularly few persons to whom they are not at times ap- 
 parent. 
 
 The size of the pupil often affords valuable evidence of the 
 state of the nervous tone. A widely-dilated, sluggish pupil is 
 incompatible with a healthy tone of the nervous system, as, 
 conversely, a small pupil, which readily varies according to 
 the degree of light, is a rare accompaniment of exhausted 
 nervous strength. Whatever be the physiological explana- 
 tion of these facts, the size and activity of the pupil should 
 always be taken into account in endeavoring to estimate the 
 amount of general nervous prostration. 
 
52 Railway Injuries. 
 
 The Optic Discs. — At this point it may be weU to consider 
 whether, in addition to these various ocular phenomena, there 
 is a risk of any more definite pathological change arising in 
 the deeper structures of the eye. In my former work I en- 
 tered at some length into this question, and the conclusion, 
 drawn from my own observations and the records of published 
 cases, amounted practically to this, that there was no evidence 
 of pathological change being common in the cases of spinal 
 injury and general nervous shock, such as are seen after rail- 
 way collisions. I had often heard the retina described as con- 
 gested — whatever that expression might mean — but I felt sure 
 that too little account had been taken of the innumerable 
 varieties of shade and color presented by the normal fundus in 
 perfect health, and still more, I will now add, of the appear- 
 ances produced in healthy discs when refractive errors, hyper- 
 metropic astigmatism, and the like, had not been taken into 
 proper account in ophthalmoscopic examinations. I empha- 
 size these conclusions now, not alone because further experi- 
 ence supports them, but also because the matter has been 
 more recently and very fully investigated anew by Mr. Thor- 
 burn, to whose work the reader must refer. He is in substan- 
 tial agreement with what has been said here. Thus he writes : 
 " Slight spinal injuries are very common, but there is no evi- 
 dence that they tend to be followed by changes in the optic 
 disc. Such injuries are, however, in rare cases" (he himself 
 having met with two only in 400) " followed by chronic men- 
 ingitis or myelitis, and in the latter condition there is an a 
 priori probability that optic neuritis may supervene. Both 
 of these affections are, however, very rare, and with the excep- 
 tion of Dr. Clifford Allbutt's eight cases, in which we have not 
 the material for an accurate diagnosis, there is but one re- 
 corded instance of this conjunction" (op. cit., p. 178). Fur- 
 thermore, speaking of the traumatic neuroses, he says : " Here 
 changes of the optic disc are so rare that among the numer- 
 ous railway injuries which have come under my own observa- 
 tion, and which include many severe cases of traumatic neuro- 
 sis, I have seen but one doubtful case of lesion of the optic 
 disc." In no instance has he seen the functional eye symptoms 
 followed or accompanied by organic changes, although exam- 
 ination of a few recorded cases makes it " appear that there is 
 an a priori probability that the functional traumatic neuro- 
 
Railway Injuries. 53 
 
 ses may give rise to clianges in the optic discs." These 
 changes ai-e indicated by transient vascular disturbance. 
 
 The sufferer from spinal sprain and its frequent accom- 
 paniment, nervous prostration, has therefore small cause for 
 anxiety on this point; while at the sa,me time every care must 
 be taken that any pathological changes discovered are not the 
 result, to use Dr. Gower's words in writing of this very class 
 of cases, " of an affection of the mind of the observer, rather 
 than of the eye observed" ("Medical Ophthalmoscopy," 2d 
 ed., p. 169). 
 
 Loss of Memory. — Complaint of "loss of memory" is com- 
 mon, and yet the phrase is hardly an appropriate one to con- 
 vey an accurate description of that which the patients usually 
 mean by it. This so-called loss of memory is not an inability 
 to recall the events and incidents of pa&t life, but is rather an 
 incapacity for sustained thought, and for continued applica- 
 tion to the work which may be taken in hand. It is a lack of 
 tbe power of volitional attention, and is an indication of easily- 
 induced fatigue. It is not a symptom of serious import, nor 
 is it evidence of mischief in the brain. The nutrition of the 
 brain, as of the rest of the body, is for the time impaired, and 
 there is failure in the power of concentration and attention. 
 It is merely another phase of the general weakness, and of the 
 inability to apply himself to any settled occupation, which a 
 patient very naturally feels under the sense of weakness and 
 depression incidental to the nervous state in which he is. 
 That this is the true explanation is frequently shown by those 
 who make the most complaint. They can relate every inci- 
 dent of the accident, and of the events which followed it, and 
 they are perfectly accurate as to the dates of many occur- 
 rences in their lives both before and since, but they are unable 
 to apply themselves to work, or to collect their thoughts, or 
 even to engage in conversation. 
 
 Catamenial Derangements. — Menorrhagia has been al- 
 ready named as- a not uncommon and immediate consequence 
 of the nervous shock. Suppression of the catamenia, either at 
 the moment of the accident, or as a subsequent concomitant 
 of the general nervous prostration, is likewise not infrequent. 
 Who shall say what determines the one or the other ? The 
 catamenia may thus be suppressed for several months— in 
 fact, until the neurasthenical condition has passed away. At 
 
54 Railway Injuries. 
 
 any rate the return of the periodic flow is usually coincident 
 with a marked improvement in the general condition. As to 
 pregnancy, this may be pointed out as a remarkable fact, that 
 railway collisions rarely produce abortion or premature labor 
 — strong evidence that the concussion is not as violent as it is 
 often thought to be, for disturbance of the uterine contents is 
 one of the recognized causes of induced labor. But although 
 the fear of miscarriage need hardly be entertained, it is only 
 natural that the injured woman should feel more than ordi- 
 nary anxiety as to the coming labor. As a matter of fact, the 
 neurasthenia keeps this anxiety alive, while the anxiety in its 
 turn keeps up, or even in the circumstances develops, the neu- 
 rasthenia. SuflBce it that it is very unusual for any marked 
 improvement to be noted until after the confinement. Then 
 follows the natural result, from joy that a man is born into 
 the world. 
 
 The Qenito-urinary System. — Every one is, of course, 
 familiar with the risks of retention of urine in all cases of pro- 
 found shock, and this should never be lost sight of in the case 
 of persons injured in railway collisions. Unrelieved hyperdis- 
 tention of the bladder may be the cause of much subsequent 
 trouble from the ^tony thus induced. The general muscular 
 feebleness, which is a marked feature of the state of neuras- 
 thenia, may also in both sexes be a further reason why the 
 bladder is not completely emptied in micturition; and if, as 
 has already been remarked, to these causes be added an in- 
 ability to get out of bed, there is almost certain to be some 
 residual urine — the commonest and most generally ackrowl- 
 edged cause of cystitis. 
 
 As to sexual matters, this only need here be said, that, as 
 long as the neurasthenia lasts, there is not likely to be either 
 the desire or the will. Both will return in due time, but be- 
 fore that time neither should be gratified, for the smallest 
 degree of sexual exhaustion is sure to be most prejudicial to 
 recover3^ Conjugal isolation should be rigidly enforced as a 
 matter of treatment. 
 
 The Digestive System is ordinarily much deranged. The 
 nausea, and even the vomiting, which have accompanied the 
 early collapse, are both prone to continue, and the patient 
 acquires an absolute loathing for food. The bowels are cos- 
 tive from the confinement to bed or the house, and the tongue 
 
Railway Injuries. 55 
 
 becomes thickly furred. All this is obviously most hurtful to 
 the neurasthenical state, and it has a large share in produc- 
 ing the wasting and muscular flabiness which are soon de- 
 veloped. The wasting, however, is not due to this alone. The 
 general nutrition is interfered with because of the nervous de- 
 pression, whereby the proper and requisite nervous stimulus is 
 withdrawn from the digestive and nutritive processes. Ad- 
 mittedly this is theory only, but there can hardly be much 
 question that the health and vigor of the nervous system are 
 essential for the orderly working of every other function in 
 the body, and the action of the nervous system in connection 
 with the functions of nutrition and digestion is not more, nor 
 is it less, incomprehensible than is its action in connection 
 with the circulatory or reproductive systems. At any rate, 
 marked general wasting is often a striking phenomenon in 
 cases of neurasthenia, and impaired nutrition may frequently 
 be the cause of bad sleep. 
 
 Prognosis — Exceptions to the Usual Rule. — There have 
 thus been brought together a number of the symptoms and 
 complaints which make up the condition to which the term 
 " neurasthenia " is nowadays commonly applied. It is synon- 
 ymous with that of " general nervous shock," which has been 
 used so often in these pages; and though there are many ob- 
 jections to it, it is on the whole a convenient clinical phrase. 
 It has at any rate no underlying suggestion as to the pathol- 
 ogy of the condition which it is meant to indicate. Of the 
 pathology of the varied complex of symptoms which we call 
 neurasthenia nothing indeed is known. We say there is gen- 
 eral depression of nervous force, a dynamic, not a structural 
 change, resulting for a time in the manifestation of one or all 
 of the symptoms which have been named. For a time only: 
 because, however severe the symptoms may be, the prognosis 
 of these cases is usually favorable; and with appropriate 
 treatment, and the avoidance of all things likely to foster the 
 nervous depression, there will come a restoration of the ner- 
 vous strength and tone, and the evidences of its former depres- 
 sion will pass awaj'. 
 
 This is the ordinary rule, but the gravity of the condition 
 is attested by occasional, by happily very rare, instances, in 
 which the result is different. The history of nervous shock 
 would be incomplete were no mention made of the fact that 
 
56 Railway Injuries. 
 
 death sometimes ensues as a consequence of uncomplicated 
 nervous exliaustion. No case of this kind lias fallen under my 
 own observation, but the following- examples w^re communi- 
 cated to me by a surgeon of large experience in railway inju- 
 ries, the only cases, it may be said, which he had met with in a 
 period of more than thirty years. 
 
 Case XIV. — Severe Shock— Death from General Nervous 
 Prostration. — A man, forty years of age, of exceeding^ deli- 
 cate physique, was in a collision at night. The accident was 
 a slight one, and he was the only passenger injured. He was 
 said, in the official report, to be " violently shaken," but he 
 was able to go on home. The next day he was delirious, and 
 on the third day he was still talking somewhat incoherently. 
 He complained of being much shaken, and of feeling seriously 
 injured, but there was no evidence discoverable of bodily hurt. 
 He improved for a time, and his condition was not thought to 
 be serious. He never seemed, however, to make any marked 
 progress, and four weeks after the accident he became more 
 prostrate, and greater anxiety was felt about him. From 
 this time he gradually got weaker and weaker, and died on 
 the thirty- seventh day. No organic disease whatever was 
 found on post-mortem examination in any of the viscera. The 
 lungs were greatly congested, and the cavities of the heart 
 were distended with blood, as if death had occurred from fail- 
 ure of respiration and circulation. 
 
 The accident was regarded as the unquestionable cause of 
 the death. Though moderate in character, it no doubt exer- 
 cised a very unusual influence in depressing vital powers — 
 never vex^y strong naturally — and flnallj- induced such an 
 amount of nervous exhaustion as to terminate fatally, even 
 though there were no evidences before or after death of phy- 
 sical injury to any one part. 
 
 Case XV. — Severe Shock from Fright Ending Fatally. 
 — The other case was that of an apparently strong and healthy 
 girl, nineteen years of age, in good position in life, who was in 
 a most serious collision. She received no bodily injury, but 
 on the night of the accident she woke screaming that the 
 engine was rushing into the room. Her illness followed much 
 the same course, and she died in about five weeks, no struc- 
 
Railway Injuries. 57 
 
 tural disease whatever being- found after death. The brain 
 and spinal cord were examined in botli instances. 
 
 Cases such as these are happily most rare. They are not 
 peculiar to railway accidents, and similar examples of death 
 from mental shock, without anj' organic change discoverable, 
 are recorded in works on nervous diseases. 
 
 The Complex of Symptoms. — Taking a final view of the 
 symptoms and cases recorded, one can hardly fail to see how 
 indubitably all of them point to a state of lowered nervous 
 action or tone, and that there is a weakening and depression 
 of every function which is under nerve control. In other 
 words, the function of every organ and structure in the body 
 is affected. There is mental weakness and there is physical 
 weakness ; weakness of will, of attention and power of thought ; 
 weakness, or easily-induced fatigue, of the special senses which 
 minister, both consciously and unconsciously, to the processes . 
 of the mind ; feebleness of voluntary muscles and general lack 
 of muscular tone: and feebleness of the involuntary, as shown 
 by the character of the circulation both central and peripheral, 
 by want of tone in the bladder wall, and by feeble peristalsis 
 in the intestines; depression of the secretory apparatus indi- 
 cated by sweating and other vaso-motor disturbances; im- 
 paired digestion and nutrition, and loss of sexual vigor — each 
 and all bear witness to the nervous exhaustion and depression, 
 to the wide-spread weakness which results from the nervous 
 .shock, and is expressed in the convenient word "neurasthenia." 
 
CHAPTEE III. 
 
 GENERAL NERVOUS SHOCK— (Continued). 
 
 I SHALL now consider some of the causes which contribute 
 to prolong the symptoms which have been described in the 
 last chapter, and shall endeavor to show wherein there is an 
 alliance between the state of neurasthenia and the develop- 
 ment of conditions which are more distinctly of an hysterical 
 type. For although on paper it may be an easy thing, and 
 for purposes of clear understanding a useful thing, to separate 
 the different effects of railway collision into distinct classes, I 
 , yet entertain no doubt that neurasthenical and hysterical, or 
 so-called functional, disorders of the nervous system are closely 
 linked together, and are very often to be found side by side in 
 the clinical picture presented to us. Thej^ have a common ex- 
 citing cause, and both may begin at the moment of the acci- 
 dent, as those cases show in which an outburst of "acute 
 hysteria," to use Mr. Thorburn's phrase, has occurred imme- 
 diately. More commonly, however, the signs of hysteria are 
 developed at a later period, and are developed, I believe,, 
 through and by the intermediate agency of neurasthenia, 
 which, as it were, prepares the nervous system, or puts it into 
 a suitable state, for the origination of true hysterical disturb- 
 ance. The profound psychical shock of a railway collision may 
 there and then determine some grave hysterical disorder of 
 the emotions only, or of some more definite function, such as 
 that of common sensation; or it may do so only after there 
 has been sufficient time for the nervous system to reach that 
 condition of functional weakness in which hysterical disturb- 
 ances are prone to arise. Neurasthenia is that condition; 
 and a very common sequence of events is for hysterical dis- 
 turbances to be grafted on to the neurasthenical state — grafted 
 on to it, and thereafter growing with it. I mean no more 
 than this when I say that they are linked together, and al- 
 though I have sought to convey the impression of a close alli- 
 ance between the two conditions and their respective symp- 
 
Railway Injuries. 59 
 
 toms, I am yet in substantial agreement with Mr. Thorburn 
 in his opinion " that neurasthenia and hysteria are distinct, 
 and that, often as they are found in combination, neurasthenia 
 is common without liysteria, and hysteria is at least not un- 
 known without neurasthenic symptoms" (op. cit., p. 189). 
 
 Sex plays but a small part in the association, and although 
 in ordinary life women are more commonly emotional than 
 men, it is nevertheless true, that as the direct and indirect 
 outcome of the nervous shock of a railway coUision, men may 
 become no less emotional and hysterical than women. " The 
 frequency of hysteria in men is not fully recognized," Mr. 
 Furneaux Jordan wrote (op. cit., p. 27) some years ago; but 
 we all know now that a condition closely allied to, nay identi- 
 cal with, the hj'steria of women, is commonly developed in 
 men after the great psychical shock of a railway collision or 
 through the neurasthenia induced thereby. I shall waste no 
 words in academic discussion as to the use of the term " hys- 
 teria " as applied to men. When a better is invented it shall 
 be used, but in the mean time we have to consider the why and 
 the wherefore of the distressing condition to which a strong 
 and healthy man may be in time reduced — a condition in 
 which all control of the emotions is well-nigh gone; in which 
 he cannot sleep because he has before his mind an ever-present 
 sense of the accident ; starting at the least noise ; lying in bed 
 almost afraid to move; his heart palpitating whenever he is 
 spoken to; and unable to hear or say a word about his present 
 condition and his future prospects without bursting into tears. 
 
 The long continuance of such a condition forms an obvious 
 exception to the ordinarj' rule — to the rule, with which all are 
 familiar in everj^-day practice, that convalescence is soon en- 
 tered upon, and that the sj^rnptoms of the original shock be- 
 come gradually less severe, and in the course of a few weeks 
 or months glide almost imperceptibly into a state of health, so 
 that the man is able once more to resume his business, and to 
 engage in the pursuits of life. Convalescence, however, may 
 be unduly delayed after the shock of a railway collision, the 
 symptoms and their duration seeming to be out of all propor- 
 tion to the injury sustained; or, convalescence having once set 
 in, and the patient being almost well enough to resume his 
 work, the symptoms may recur in all their severity, and the 
 period of recovery be much delayed. What are the reasons 
 
6o Railway Injuries. 
 
 which conduce to this protraction of the illness, and which 
 conduce also in great measure to delay in convalescence, when 
 all the circumstances, the amount of injury, and the evidences 
 of initial shock, pointed in the direction of very early recovery ? 
 Comparatively little has been said hitherto of the bodily 
 injuries received, and it has been assumed throughout that 
 the causes originally at work to bring about the shock and its 
 after-consequences were essentially psychical. The fact, how- 
 ever, 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 we have already seen, has a tendency to cause injury of the 
 vertebral column, an injury which in the majority of cases is 
 a simple spram of the spinal muscles and spinal ligaments, 
 with severe vertebral pain as an inevitable consequence. 
 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. Psychi- 
 cal causes are again at work to aggravate the patient's con- 
 dition. 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 this result is most likely to occur in those 
 cases where the appearance of the pains has been delayed for 
 two or three days. They renew the alarm of the injured man, 
 his 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 psj'chi- 
 cal disturbance has laid the sure foundation for an altogether 
 erroneous estimate of the sensations which he feels. And 
 thus you find that before very long the mind of the patient. 
 
Railway Injuries. 6i 
 
 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 lookout for any new sensa- 
 tion that may arise, and is alive to and makes discovery of 
 sensations, which to the healthy have no existence at all. 
 Perhaps he even keeps a chart of his back or of his whole 
 body, and marks down from day to day the precise spots 
 where he has had some queer sensation, ache, or pain. 
 
 Is it possible that a large number of the abnormal sensa- 
 tions which are thus discovered, and of which patients so fre- 
 quently complain while the mental balance and tone are thus 
 perturbed, can be due in any measure to a conscious percep- 
 tion of the sensations of organic life ? The " hysterical " con- 
 dition is essentially one in which there is loss of control and 
 enfeeblement of the power of the will, and amid 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. In the process 
 of evolution toward a higher state of intellectual activity and 
 endowment, man has become more and more unconscious of 
 the sensations, which of necessity accompany the functional 
 activity of the various organs and structures of his body. 
 That the stomach, for example, the liver, the heart, the ovary, 
 the oesophagus, are, as are the organs of special sense, repre- 
 sented somewhere and somehow, though in less degree, in the 
 sensorium, is highly probable on a priori grounds, and is, 
 moreover, established by the experiments of morbid physio- 
 logical action, in originating those abnormal sensations, which 
 ma,y affect these and other parts by an aura at the commence- 
 ment of an epileptic discharge. And if in perfect health of 
 body and stability of mind these varied sensations play little 
 part in the sentient hfe of the individual, it is because the 
 intellectual development of man has enabled him to control 
 them, and to allow them neither lot nor share in the sentient 
 consciousness of active life. In the lower animal, whose brain 
 is hardly differentiated from the other parts of its nervous 
 system, or which has no brain at all, the organic sensations 
 doubtless have a more important part in the economy, and 
 probably in the enjoyment of life; but as we step higher and 
 
62 Raihvay Injuries. 
 
 higher in the scale of development, with increasing' size and 
 complexity of brain, the organic sensations have a propor- 
 tionately smaller representation in the centres of intellectual 
 activity. Let some sudden, profound psychical disturbance 
 arise, such as may be induced by the shock and terror of a 
 railvvaj' collision, forthwith the intellectual control is lessened, 
 while the organic sensations declare their being, and force 
 themselves into the conscious life of the individual. " If the 
 nervous system," writes Sully, "has been slowly built up, dur- 
 ing the course of human history, into its present complex 
 form, it follows that those nervous structures and connections 
 which have to do with the higher intellectual processes, or 
 which represent the larger and more general relations of our 
 experience, have been most recently evolved. Consequently, 
 they would be the least deeply organized, and so the least 
 stable; that is to say, the most liable to be thrown hors de 
 combat. 
 
 " This is what happens temporarily in the case of the sane, 
 when the mind is held fast by an illusion. And, in states of 
 insanity, we see the process of nervous dissolution beginning 
 with these same nervous structures, and so taking the reverse 
 order of the process of evolution. And thus, we may say that 
 throughout the mental life of the most sane of us, these higher 
 and more delicately-balanced structures are constantly in 
 danger of being reduced to the state of inefficiency, which in 
 its full manifestation is mental disease " (" Illusions," p. 132). 
 
 And thus it is, it seems to me, that when by the profound 
 shock of a railway collision the " higher intellectual processes" 
 are thrown hors de combat, these organic sensations, which, 
 as the same writer says, "constitute for the most part in 
 waking life an undiscriminated mass of obscure feeling, of 
 which we are only conscious as the mental tone of the hour," 
 and which form " ' as the vital sense ' an obscure background 
 for our clear discriminative consciousness, and onl3' come for- 
 ward into this region when very exceptional in character" 
 (ibid., pp. 148, 149), step out of their natural obscurity, and 
 become the foci of the uncontrolled and misdirected attention 
 of the mind. (The reader will find some interesting and phi- 
 losophical remarks on the subject in Dr. Mercier's able work, 
 " Sanity and Insanity," pp. 85-94, 1890.) 
 
 Not one of the abnormal sensations has any organic lesion 
 
Railway Injuries. 63 
 
 as its basis, but tliat there is some physical substratum seems 
 highly probable. Continued disorders of the circulation are 
 the most obvious after-signs of shock, and it is not at all un- 
 likely that many of the morbid sensations which form the 
 burden of the patient's complaints have a real, not an alto- 
 gether imaginary, basis in transient flushing, or in transient 
 angemia, of the affected part. Some such cause as this must 
 be at the root of many of the sensations which afflict per- 
 ipheral regions of the cutaneous surface, and not improbably 
 of those also which are felt in the central or in more vital 
 parts. 
 
 And as the mental state may be influenced and deluded by 
 the abnormal sensations, so in an even greater degree may 
 these be affected by the mind. The results of attention, of 
 anxious attention concentrated on a part, are seen in their 
 most aggravated forms. Pain and other morbid sensations 
 are thus made more acute and more oppressive; they'become 
 more dominant in the mind, and less under the control of the 
 already weakened will. Small Avonder that the patient, alive 
 to every new sensation which may arise, should tend to exag- 
 gerate its import, to describe it in terms which to the healthy 
 man seem almost absurd, and that exaggeration should be a 
 pronounced feature of the morbid state which is called hys- 
 teria, no niatter which be the sex afl"ected. 
 
 And out of this very exaggeration itself arises another 
 cause of prolongation of the illness. The exaggerated esti- 
 mate of the symptoms themselves leads to an erroneous esti- 
 mate of the present incapacity, and to an increasing belief in 
 the impossibility of future recovery and usefulness. Hence it 
 is only natural that differences of opinion should arise between 
 those who are entitled to receive compensation for the injuries 
 and for their prospective consequences, and those who have to 
 provide it, and who take a wholly unsentimental view of the 
 value of the patient's health and life. Months perhaps are 
 thus wasted in disputing about the claim; or, worse than this, 
 the man is drawn unwittingly into litigation, and is subjected 
 to the anxieties and worries which a lawsuit involves. What 
 surer means than this for aggravating his symptoms? Is 
 recovery possible under such an influence; is there not, indeed, 
 every hkelihood that the symptoms will get worse and worse, 
 or at best will undergo no change, and is it not more appro- 
 
64 Railway Injuries. 
 
 priate now to call them " litigation symptoms," than those of 
 general nervous shock ? 
 
 And herein also lies the explanation of the great majority 
 of those cases where improvement has advanced to such a 
 stage that return to work seems on all hands desirable, and 
 yet nevertheless when work is suggested or attempted im- 
 provement stops J and even in some instances the patient 
 seems from that very moment to fall back and to become 
 worse than he was before. For, as a matter of fact, it is very 
 rare to find the patients return to work while the question of 
 compensation, and the possible disputes attending it, remain 
 unsettled. Now and then you may meet with a patient, over 
 whose plans and resolves the time and matter of compensa- 
 tion have little influence, who returns to his business with 
 every benefit to himself at the moment when he has sufficiently 
 recovered to do so. Such instances, however, are the excep- 
 tions to the rule, and occur probably in those only whose 
 mental balance has never been very seriously upset, in whom 
 the symptoms of general nervous shock have not been severe, 
 or who have the good judgment not to allow these matters to 
 weigh upon their minds. The experience of hosts of cases es- 
 tablishes this fact, that patients will not, or cannot, make the 
 necessary effort to resume work so long as the settlement of 
 the pecuniary claim has been unefCected. And thus, in addi- 
 tion to the worries and anxieties of litigation and dispute, 
 there arises another very potent cause for continuance of 
 the symptoms, and for inducing a state of chronic invalidism, 
 which is far more dependent upon thri circumstances of the 
 moment than upon the original nervous shock received. This 
 cause is the wa,nt of occupation. Can anything be worse for 
 a man — is there anything more likely to lead to irritability 
 and fretfulness, to sleeplessness and loss of appetite, to ner- 
 vousness and anxiety about himself, to hopelessness as to the 
 future, to a lack of power to concentrate his attention upon 
 anything which he may have in hand — is there anything more 
 fitted to disturb the relation between the mens sana and the 
 corpus sanum than want of healthy occupation ? And when 
 this goes on for months and months, each month more weari- 
 some and more wasted than the one before, is it to be won- 
 dered at that the picture which these patients present is often 
 lamentable indeed ? Still more wretched is it likely to become 
 
Railway Injuries. 65 
 
 if, in addition to the want of occupation, tlie patient has re- 
 mained altogetlier in -doors, and has been deprived of the good 
 which healthy bodily exercise might have done him. 
 
 Make all the allowance that may honestly be made for the 
 special circumstances of terror attendant upon a railwaj' col- 
 lision — and I would n9t for a moment seek to lessen their real 
 influence — and compare the state of one waiting for compen- 
 sation, whom for the nonce we will call a railway patient, with 
 the state, as nearly similar as may be, of a hospital patient 
 who has had no compensation to look forward to, and who has 
 been compelled to resume his work as soon as he was able, 
 and then see how different is their lot, and how infinitely less 
 wretched is the one man than the other. The hospital patient 
 has long ago been well, while the railway patient has been 
 waiting, for months it may be, until compensation has been 
 paid him, verily believing that he could not return to work 
 and to a ng^tural and more healthful mode of life. " Settle 
 your claim aud get to work," is the best advice which can be 
 given a man in these circumstances. Get to work and you 
 will soon find you have the strength for it, and will forget the 
 gloomy prognostications of those who say that you never can 
 tell what may happen after a railway accident, and that you 
 ought to wait and see how things turn out. 
 
 Quite apart, however, from these various causes, the con- 
 dition, life, and habits of the patient before the accident have 
 no small share in determining the severity of his symptoms 
 and the rate of his recovery after it. It is evident that the 
 man who has been in feeble health, or who is in a state of con- 
 valescence from some recent illness, is likely to present the 
 sj'mptoms of neurasthenia in an extreme degree ; as also does 
 the man who, although in perfect health, has been living a life 
 of hard and constant work at the high pressure which every- 
 day competition entails. He has an extensive business, with 
 numbers of subordinates, and wide-spread interests in connec- 
 tion with it, which he must himself look after, and which he 
 cannot delegate to another. He has been in good health, but 
 this has been his life, and he has had no holiday for the past 
 five years. He is much terrified and slightly shaken in a col- 
 lision. He does not know he has been hurt, but not many 
 days go by before he is completely prostrated, unable to eat 
 or sleep, and feeling thoroughly ill. His business still compels 
 
66 Railway Injuries. 
 
 his own attention, and so perhaps weeks go by before his o^ 
 viously broken health and unfitness for work necessitate com- 
 plete rest. It is difficult to say how he could have acted other- 
 wise, but all the circumstances conduce to make his illness a 
 long- one, and to delay the period of convalescence and recov- 
 ery. For however good his health may have been to all ap- 
 pearances before the accident, his nervous system was in such 
 a state of tension that it was likely to give way unduly from 
 an adequate exciting cause. This is the ainvarnished story of 
 an actual case, and there are numbers like it. So, also, we 
 may find a nervous system ill prepared to bear the brunt of a 
 railway shock in those of intemperate habits — habits of in- 
 temperance not in matters only of food and drink, to which 
 the word is supposed commonly to apply, but habits of intem- 
 perance also in regard to the sexual desire. This is in my 
 judgment a far more powerful predisposing cause of the neu- 
 rasthenical state than errors in diet and alcoholic excess. At 
 any rate, such causes as these must be borne in mind if we 
 would seek for the reason why the symptoms are severe or 
 are being unduly prolonged. Treatment is little likely to be 
 of use unless they are recognized and put out of the way. 
 
 It is a striking fact that in cases where there has been 
 serious injury to limb, such as simple or compound fracture, 
 even if at the time of the accident the collapse was extreme, 
 it is most unusual to meet with the protracted after-symptoms, 
 which have been described as due to general nervous shock. 
 
 Case XVI. — Severe Bodily Injuries — Absence of Pro- 
 longed After-symptoms of Shock. — A man, aged forty-seven, 
 was in a very bad collision at night, and in addition to severe 
 bruises and burns about the face and body, he had a simple 
 fracture of one fibula, and a compound fracture of both bones 
 of the other leg just above the ankle. There was haturallj' 
 great collapse, but he rallied in the ordinary way and did well. 
 Six months after the accident his general health was good ; 
 he was well nourished, he had no nervous symptoms, his pulse 
 was quiet, and sleep and appetite were both excellent. Nor 
 were there any after-symptoms, for at the end of five years he 
 was reported as feeling no ill effects whatever from the acci- 
 dent, save a little pain and stiffness in the ankle when the 
 weather was cold. Never at any time were there neurastheni- 
 cal symptoms. 
 
Railway Injuries. 6"] 
 
 What is the reason that in a case such as this, and in 
 others lil?e it, there should be so marked an absence of the 
 after-symptoms of general nervous shock, when originally 
 the collapse was very severe ? In psychical conditions lies, I 
 believe, the explanation of this seeming anomaly. In the 
 very defihiteness of the injury there is something on which the 
 mind of the patient can dwell with a certain measure of satis- 
 faction, for, as far as he knows, the usual result after fracture 
 is perfect restoration of health and bodily usefulness. The 
 collapse subsides, and the patient finds himself with an injurj' 
 not more obscure, it may be, than that of a broken leg. He 
 knows that he has been doomed for a time to his bed, and that 
 as soon as he is allowed to be up he will begin to move about 
 again and to get well. The injury is definite and precise, its 
 symptoms are obvious from the moment it was received, it 
 lacks the seeming obscurity that is a feature of those symp- 
 toms which onlj'^ supervene after several hours or days, there 
 is probably less pain as time goes on, and all the circuni- 
 stances combine to induce a repose of mind, which is absent 
 from the commoner cases which have been considered. And 
 there is also the necessity of complete bodily repose from the 
 moment that the patient can be placed in bed. The enforced 
 rest is good both for body and mind. Confinement to bed at 
 an end, the patient is only too thankful that he is able to 
 move about again, and gradually begin to walk. Returning 
 strength goes hand in hand with returning possibility of ex- 
 ercise, and there is less excuse for staying in-doors because of 
 the fear that the after-consequences of some wholly obscure 
 injury may turn out very serious. There is, moreover, less 
 likelihood of dispute arising as to compensation, and the 
 money calculation becomes all the easier and the readier, be- 
 cause the nature and extent of the injury can be definitely ap- 
 praised. Thus the absence of the symptoms of continued ner- 
 vous shock in cases of bodily injury, where the amount of true 
 collapse may have been originally severe, throws light on the 
 sj^mptoms which the more ordinary cases present, and tends 
 to support the view that those symptoms are due to mental 
 causes rather than to the bodily injury or to any vibratory 
 jar sustained. 
 
 And how largely the continuance of the symptoms is due 
 to mental influences is shown, perhaps even more conclusively. 
 
68 Railway Injuries. 
 
 by the speedy recovery which often ensues, when the exciting' 
 causes of the symptoms are removed. It is all very well to 
 say, it is a diagnosis easy enough to make, that so-and-so, who 
 recovered as soon as his claim was settled, was shamming, 
 and that his symptoms were altogether untrue or wilfully 
 exaggerated; but this will hardly suffice in explanation of 
 the symptoms which have caused so much anxiety and trou- 
 ble, and have been so little amenable to treatment. Suspense 
 is at an end, and there is nothing any longer in the way of 
 his making the requisite and successful effort to resume his 
 work. " How long I have been ill, how little I improve, how 
 small seem the chances of my recovery," have been the up- 
 permost sentiments in his mind, and they speedily give way 
 to this one, which is wholly different and far more hopeful, 
 " How soon shall I be well ? " 
 
 It remains to be considered to what extent recovery is pos- 
 sible in these cases of nervous shock, and how far the patient 
 regains the mental and bodily vigor which he had before the 
 accident. Happily the record of cases known to me is con- 
 clusive upon this point, that recovery is usually complete, and 
 the patient is able to resume his occupation and to carry on 
 his business as well as he did before. There are, of course, 
 exceptions to the rule, exceptions which show that some alter- 
 ation has taken place in the bodily physique, and very possibly 
 in the mental vigor also. Thus you may hear that the man is 
 less able to bear prolonged fatigue, either bodily or mental; 
 that he is more susceptible to the influence of alcohol, more 
 irritable and easily excited; that he lacks that complete self- 
 control which he may formerly have had in his business rela- 
 tions with his fellow-men; that he is nervous when travelling, 
 is afraid to ride or drive, and has been compelled to give up 
 his hunting and shooting; that he is a more nervous man than 
 he was before, and more subject to headaches; and in the 
 severer cases, that his hair has turned gray, and he looks 
 prematurely aged. Some years have been added to his life, 
 and he is never quite what he was before. 
 
 And here very appropriately arises this important ques- 
 tion, How far does the course of the protracted illness, apart 
 from the nature of the original injury and shock, conduce to 
 imperfect recovery hereafter ? Remember that the symptoms 
 have been largely those of emotional disturbance, that loss of 
 
Railway Injuries. 6g 
 
 control and feebleness of will have been at the foundation of 
 many of them, and there can be little doubt that an uncon- 
 scious or wilful yielding to every sensation that, may arise, 
 the abandonment of the conscious self to the thraldom of the 
 morbid state, the enjoyment, so to speak, of the luxury, not 
 of woe exactly, but of gloomy forebodings and feelings and 
 fears, pave the way for the impossibility of regaining, even in 
 the best of circumstances, that complete mental stability and 
 continuous self-control, which are the happy appanage of per- 
 fect bodily and mental health. A vicious habit is being im- 
 pressed upon his nervous system, from which the sufferer will 
 find it difficult to rid himself. If he thus allows the various 
 influences conducive to the morbid state to have the mastery 
 over him for weeks and months, because he thinks it better to 
 " wait and see how things turn out," unable, or making no de- 
 termined effort, to resume his natural occupation and mode of 
 living until some wholly impossible compensation has been 
 received, depend upon it he will suffer in the future. Or worse 
 than this, if he keeps up the morbid state by wilful means, his 
 moral and his physical nature are subjected to a long spread- 
 out shock, from which it will be hard to rally. As he sows so 
 also shall he reap. 
 
CHAPTER IV. 
 
 THE FRIGHT NEUROSES— TRAUMATIC HYSTERIA. 
 
 I PROCEED, in the next place, to the consideration of a class 
 of cases to which the name " traumatic hysteria " is now very 
 commonly given. In my former work they were dealt with 
 as examples of so-called functional or neuromimetic disorder, 
 and although I shall still have to insist that that is their es- 
 sential nature, the term traumatic hysteria has come into 
 such general use in more recent years, that though I should 
 prefer to call them the " fright neuroses," I intend to adopt it 
 here. Objection has from time to time been made to the use 
 of the word "hysteria" because of its etymology, and still 
 greater have been the objections made to it when in company 
 with the word " traumatic." Nevertheless I doubt very much 
 whether it w^ill ever be possible to get rid of the word hys- 
 teria, or if we should gain much by doing so; and if it be ever 
 used to signify the nature of the symptoms presented by ner- 
 vous disturbance occurring in the male, there is, I venture to 
 think, no insuperable difB.cultj'^ in so using it without thinking 
 of the womb. Nor can any reasonable person doubt, after 
 perusal of the works of Charcot, Oppenheim, Striimpell, 
 Guinon, Thorburn, Dreschfeld, Weir Mitchell, and many others, 
 that hysterical disorders are prone to follow and to be the 
 result of injury. No better phrase for their description has, 
 as far as I know, been suggested than " traumatic hysteria," 
 and I suppose there is not a single neurologist of experience 
 or repute, who nowadays will be found to deny that the gravest 
 disturbance of nerve function, to which the term hysteria is 
 more or less applicable, may be met with in the male sex, and 
 be the result of injury. Examples will be given here in sup- 
 port of this contention, but if any one doubts the possibility of 
 hysteria in the male, let him turn to the authors who have 
 been named, and there he will find unquestionable instances 
 which will surely carry conviction to his mind. 
 
Railway Injuries. 71 
 
 Do not let it be thought, that in speaking of symptoms as 
 hysterical or functional, there is any desire to minimize their 
 importance and it maj' he their gravity. Far too often, it is 
 true, the symptoms of nervous disorder have been placed in 
 the category of hysteria, and been forthwith regarded as of 
 small concern; but it may be questioned whether the treat- 
 ment of a case has ever been found much easier because of the 
 diagnosis of hysteria, and it is tolerably certain that we are 
 not much nearer the correct understanding of its nature be- 
 cause it has been so described. That has never been my own 
 feeling with reference to the so-called functional disturbances 
 of the nervous systent, which are common after railway acci- 
 dents. It has always been my opinion that some material 
 and morbid change must underlie the nerve disorder, but it 
 seems to me most unlikely that such change can be of the 
 same nature as the coarse pathological lesions, which we are 
 wont to see in the post-mortem room, or which are shown us 
 by the microscope.- For all we know the change may be a 
 chemical one, and the nervous disturbance be altogether sec- 
 ondar3\ The course of the symptoms themselves, and their 
 rapid and often very sudden disappearance, form well-nigh 
 conclusive evidence that they cannot be due to gross patho- 
 logical lesion. Nevertheless, if, at the present day, we are un- 
 able to say what is the precise morbid change underlying the 
 so-called functional disorders of the nervous system, and must 
 acknowledge with Guinon that, as far as known pathological 
 lesion is concerned, they are disorders sine materia, we are 
 not debarred from their clinical study; nor is the hope denied 
 us that a close observation of the symptoms displayed may 
 lead in time to a knowledge of their pathology, whether the 
 change be in the affected parts of the nervous system them- 
 selves, or in their nutrition and blood- supply. 
 
 From the clinical point of view, then, we may take it as 
 an accepted fact, that fright is a common and powerful de- 
 termining cause of the onset of hysterical phenomena, and it 
 is that element in them which makes railway coUisions so 
 fertile in functional neuromimetic disorders. Apart, however, 
 from the immediate effects of fright, which is not always or in 
 all cases followed by injurious consequences, there are certain 
 predisposing conditions in the individual which have to be 
 considered. The constitution of the nervous system may be 
 
72 Railway Injuries. 
 
 itself at fault, either because of inherited instability, or as the 
 result of causes which have had injurious influence upon iti 
 Inherited weakness may show itself in what is called a ner- 
 vous temperament, such as may be obvious even to superficial 
 observation, or as may be brought to light only by illness or 
 disease. We all know how very variable are the effects of 
 illness upon the nervous system, and how often it happens 
 that those who are free from any trace of nervousness during 
 health reveal their nervous temperament when ill. And even 
 if the hereditary instability has never been manifested in 
 themselves, the family history may afford strong grounds for 
 suspecting it. (In his classical work on hysteria [" De I'Hys- 
 terie," p. 396] Briquet records that in only ten out of 396 
 women subject to hysterical disorders could he discover no 
 evidence of predisposition. Thorburn, Oppenheim, and others, 
 however, have had a somewhat different experience, and do 
 not regard hereditary predisposition as so common.) 
 
 Moreover, in addition to the hereditary predisposition, there 
 are predisposing causes incidental to the individual himself. 
 Recent illness and the consequent weakness, sexual excesses, 
 overwork of body or brain, alcoholic intemperance, the gouty 
 diathesis with its clironic mal-assimilation and impaired nutri- 
 tion, the existence of some definite nervous disease — all these 
 things and many others predispose a person to suffer from 
 the great mental shock which appertains to a railway collision, 
 and to almost every serious accident whether by land or sea. 
 For more detailed information on the manifold predisposing 
 causes of functional nervous disorders, the reader may turn 
 with advantage and profit to Georges Guinon's recent work, 
 " Les Agents provocateurs de I'Hysterie." He will there learn 
 that many of these disorders arise, not so much as the result 
 of an immediate cause, but from the state of the nervous sys- 
 tem being such, that an exciting cause is able to provoke it to 
 the manifestation of functional disorder. It is in. this way 
 that railway accidents very often lead in time to functional 
 hysterical disturbance, in that by them there is induced that 
 condition, which has been dealt with in previous chapters, and 
 to which the term neurasthenia has been applied. 
 
 It seems, therefore, an almost natural step to pass from 
 the consideration of general nervous shock to the considera- 
 tion of the cases of nervous mimicrj' and traumatic hysteria,. 
 
Railway Injuries. 7}, 
 
 "because the shock has been, in many instances, the means of 
 inducing' that very condition of the nervous system, which 
 predisposes to the manifestation, and underlies the origin, of 
 these functional nervous disorders. The cases which will be 
 quoted, moreover, show that in the worst instances there is 
 frequently some evidence of menlral disorder in the previous 
 history of the patient himself, or that he comes of a stock in 
 which mental or emotional disturbances and peculiarities, not 
 necessarily amounting to insanity, have been recognized as 
 prominent- in the family record. It has been impossible in 
 every case to obtain evidence of the kind, but, in the absence 
 of discoverable predisposing tendency, there is a sufficient 
 cause for the origin of the hj'^sterical disorder in the profound 
 nafve exhaustion, prostration, disturbance, or whatever we 
 may like to call it, which the moral and physical shock of 
 the accident and its varied consequences have had upon 
 the nervous sj-stem. We need not seek further tha.n this 
 for a cause of the functional disorders — the paralyses, the 
 spasms, and the convulsions — which are mimicries of grave 
 disease. 
 
 We may now consider in greater detail the different varie- 
 ties of hysteria which are the result of injury. In the first 
 place, and of infinitely less moment than those which have to 
 be spoken of presently, are the convulsive sobbings, cryings, 
 and laughter of acute hysteria, such as maj' come on immedi- 
 ately after or within a few hours of the accident. Every one 
 is familiar with these sorts of attacks, and I say they are of 
 comparatively small moment, because they are usually tran- 
 sient. They very probably give relief to nervous tension, and 
 are thus productive of good; and experience tells that they 
 are not followed by, or commonly associated with, those hys- 
 terical manifestations, which, copying the symptoms of real 
 disease, ai-e more determinedly fixed in, and are with greater 
 difficulty eradicated from, the disordered nervous centre. They 
 lack that fixity which is one of the most serious and trouble- 
 some among the characteristics of hysterical disorder of the 
 chronic, as distinguished from the acute, variety. The prog- 
 nosis is distinctly more favorable, and I shall say nothing 
 more about them than this, that they are to be met with in 
 both sexes in almost equal degree, and that it is of importance 
 to insure perfect quietude and to avoid all reference to the 
 
74 Railway Injuries. 
 
 exciting- cause of the hysterical seizure. Condoling friends 
 had better keep out of the way. 
 
 Passing, therefore, to the more chronic, rarer, and more 
 imitative forms of traumatic hysterical disorder, the multi- 
 plicity and variety of the symptoms, and the very nature of 
 hysteria itself, render it impossible to draw up any conipre^ 
 hensive classification. Suffice it that the symptoms very com- 
 monly consist of disorders of motion and sensation ; paralyses 
 or contractions of a limb; diminution or other impairment of 
 common and special sensation; convulsive epileptiform seiz- 
 ures; vaso-motor derangements; and more markedly psychi- 
 cal troubles. The varied symptoms are, I think, best studied 
 in the record of individual cases, but I propose in the first 
 place to say something as to the possible origin and nature «f 
 some, at any rate, of the symptoms which may be seen. In 
 my former work I expressed my " belief that the primary seat 
 of functional disturbance lies in the brain itself, and that, as 
 in the hypnotic state induced by a profound mental impres- 
 sion, there is a temporary arrest in the function of that part 
 of the sensorium which presides over and controls the move- 
 ments and sensations of the periphery." There can, I think, 
 be no question that the underlying cause of the neurotic symp- 
 toms, even of such as " functional paraplegia," is to be found 
 in the cerebral cortex. The disorder has had its beginning in 
 profound mental disturbance or shock, and the presentation 
 of the symptoms seems to direct one entirely awaj' from the 
 periphery of the nervous system in search for an explanation. 
 In paraplegia from organic disease, other than that of abso- 
 lute destruction of the cord, the loss of motor power and of 
 common sensation is rarely' absolute, and the patient, at any 
 rate, is only too anxious to show how much power of move- 
 ment he has. In functional paraplegia, on the contrary, the 
 paralysis is usuallj'- absolute, nor can any movement be elicited 
 at all. The thing at fault is obviously the power of initiating 
 movement. The mandate from the brain is in the one case 
 checked hy lesion in the cord^bej^ond which it makes its way 
 with difficulty. It makes it, however, and some movement is 
 the result. In the other case the mandate never leaves the 
 cerebral cortex at all — no impression reaches the limbs, and 
 thsre is no movement. When we come to consider individual 
 cases, we shall see the same sort of defective power of the 
 
Railway Injuries. ^^ 
 
 cerebral cortex in initiating movement in such a simple act as 
 that of putting out the tongue. Asked to put out his tongue, 
 the patient is wholly unable to do so. Vigorous effort is made 
 — the facial muscles and the muscles of the trunk and limbs 
 are called into play as if they could determine the result; and 
 the result is entirely abortive, or the tongue perhaps reaches 
 no further than the teeth or lips. But if such a patient be 
 carefully observed, it will be noticed that there is no impair- 
 ment whatever in the movements of the organ itself: speech 
 is unaffected, and if by any chance the automatic and involun- 
 tary act has to be performed of removing a particle of food 
 from the outside of the lip, out goes the tongue in a perfectly 
 natural w'ay. This was a striking phenomenon in one of the 
 cases to be presently recorded, in which there were symptoms 
 of functional neurosis, such as we may conceive could not pos- 
 sibly be feigned; and it is the presence and coexistence of 
 such other symptoms which enable us to establish it as toler- 
 ably certain that these defects in motor power are not fraudu- 
 lent, but are likewise due to a real inability on the part of the 
 patient to call his cerebral centres into the activity requisite 
 for the particular movements desired. It may be difficult or 
 impossible, mere conjecture, to say wherein the cerebral de- 
 fect lies, but there seems to be neither more nor less difficulty 
 in the case of sensory, than there is in the case of motor dis- 
 orders. Both are alike inexplicable; but if defect of the will 
 power of the higher cerebral centres be indicated by inability 
 to perform desired movements, is it altogether inconceivable 
 that the same cause is at work in the abolition of common 
 sensation and in impairment of the special senses? Auto- 
 matic movements continue unimpaired, purposive desired 
 movements are those alone which fail; and it has often oc- 
 curred to me when in the presence of a case of functional 
 anaesthesia, that the loss of sensation may be quite as much 
 a phenomenon of the moment, as is inability to put out the 
 tongue a phenomenon of the moment when that particular 
 and specific act has been desired. May not sometimes the 
 very examination of a hemiauEesthetic patient largely deter- 
 mine the hemianaesthesia, which forthwith disappears as soon 
 as the examination is at an end ? Common sensation, for all 
 we yet know, may be quite as much both voluntary and auto- 
 matic as is the power of ordinary movement; and although 
 
7^ Railway Injuries. 
 
 we talk about a patient not choosing to do this or that, the 
 psychical condition which determines his inability to put out 
 his tongue may equally determine his inability to feel, and the 
 loss of the one power may be as much, or as little, dependent 
 on the brain activity which we call Will, as is the loss of the 
 other. At any rate, both defects have a common exciting 
 cause, and that is the state resembling hypnosis which is in- 
 duced by fright. 
 
 We know how great is the part played by " suggestion " 
 when the patient is in the hypnotic condition, and how it may 
 lead to the manifestation of various motor and sensory dis- 
 turbances. The examination of a patient may, therefore, it 
 seems to me, sometimes provide the suggestion whereby anaes- 
 thesia results. Looked at in this light, suggestion and expect- 
 ancy are very much the same thing; and underlying each, 
 whether the same or different, is an abnormal, and, for the 
 time, unhealthy condition of the higher cerebral centres, 
 whereby a change is brought about in the ordinary relations 
 of mind and body. Let it be granted to the full that the 
 severe psychical disturbance of an accident, in which there 
 has been reason for fright, is responsible for all the evil conse- 
 quences which ensue, yet I have little doubt that the resultant 
 symptoms are not altogether independent of the method of 
 procedure which is adopted for discovery of the symptoms 
 present or expected. To take a specific instance. If it became 
 the custom to test forthwith the sensation of every person 
 who has been injured in a railway collision, we should pres- 
 entlj' find the opportunities of studying hemianaesthesia enor- 
 mously increased ; much as in the same sort of way, when it 
 was the custom to examine everbody's spine, injured or no, 
 complained of or no, spinal tenderness and surface hyperges- 
 thesia of the back were very much more common than they 
 are at the present time. This is no merely idle speculation. 
 Those who have had the opportunity of seeing large numbers 
 of cases of railway injury cannot help observing how much 
 there is of fashion in the symptoms which are seen, and a 
 word of warning is not, in my judgment, out of place to-day. 
 
 Students of the works of Charcot know how close in his 
 judgment is the alliance between many of the phenomena of 
 hysteria and those which may be purposely induced in the 
 hypnotic state. Recognizing the ease with which many con- 
 
Railway Injuries. yj 
 
 ditions, such as palsy or contracture of a limb, for example, 
 may be developed by oral suggestion during the hypnotic 
 sleep, he sees a close analogy between the origin of those phe- 
 nomena and the origin of many of the phenomena of traumatic 
 ■hysteria. In place, however, of oral suggestion, it is the in- 
 jury which suggests the special form of neurotic disorder, and 
 traumatic suggestion takes the place of oral suggestion in 
 hypnosis. But as oral suggestion is followed by the desired 
 result only when the higher regions of the cerebral cortex are 
 in the hypnotic state, so tratimatic suggestion has no influence 
 unless the centres are in a condition allied to that in which 
 they cart be put in hypnosis. The cirqumstances in which the 
 injury was sustained provide the requisite condition. Speak- 
 ing of railway collisions, he says that nervous troubles often 
 occui in such cases apart from any traumatic lesion, and sim- 
 ply as a result of the psycho-nervous commotion produced 
 by, yet frequently not appearing immediately after, the acci- 
 dent. It is the state induced by the psycho-nervous commo- 
 tion which renders traumatic suggestion possible. Turn to 
 one of his iliost typical cases of hystero-epilepsy (" Diseases of 
 the Nervous System," Vol. III., 1889, New Sydenham Soc, tr. 
 by Dr. Savill, p. 236 et seq.), where all the prolonged symp- 
 toms had had their beginning from a severe cut on the arm, 
 on the receipt of which the patient had fallen to the ground 
 with hemorrhage and fright. Was the wound, he asks, suffi- 
 cient to provoke the development of the nervous symptoms? 
 No, he answers; and he would have us bear in mind that 
 "along with the injury there is a factor which most probably 
 plays a much more important part in the genesis of these 
 symptoms than the wound itself. I allude to the fright ex- 
 perienced by the patient at the moment of the accident, which 
 was betrayed shortly afterward by a loss of consciousness, 
 followed by a sort of transitory paralysis of the lower extrem- 
 ities." The same nervous condition, which formed the psychi- 
 cal substratum of the hystero-epileptic phenomena in that 
 instance, exists in all probabiUty in those cases where some 
 trifling injury, in the neighborhood of a joint, for example, has 
 led to palsy, contracture, or angesthesia of a whole limb, or to 
 the physical signs and symptoms which imitate disease of a 
 joint. The injury was the cause of some abnormal sensation 
 which in a healthy nervous condition would have been totally 
 
/S Railway Injuries. 
 
 disregarded, but which to a nervous system, the victim of 
 psycho-nervous commotion, fright, or mental shocli, becomes 
 suggestive of serious wrohg. This, in other words, is " trau- 
 matic suggestion," and having expressed similar views in 1883. 
 I am now in full accord with Charcot when he says that in 
 railway collisions a "peculiar mental condition is often devel- 
 oped, which is intimately connected, in my judgment, with the 
 hypnotic state. In both of these conditions, in fact, the men- 
 tal spontaneity, the will, or the judgment, is more or less sup- 
 pressed or obscured, and suggestions become easy. And thus 
 the slightest traumatic action, for instance, directed to a 
 member may become the occasion of a paralysis," of a con- 
 tracture, or an arthralgia. It is in this way that one so often 
 sees after railway accidents cases of monoplegia, paraplegia, 
 or hemiplegia simulating organic lesions, although they are 
 no other than dynamic or psychical paralyses, very analogous, 
 to say the least, to hysterical paralyses." This condition, so 
 closely allied to the hj'pnotic state, may be developed by the 
 nervous shock, but I believe that it may be the result also of 
 the neurasthenia which the nervous shock has initiated. 
 
 It is in such cases that the term auto-suggestion is, I think, 
 more appropriate than traumatic suggestion to indicate the 
 origin of the nervous phenomena. Nevertheless, there is no 
 material difference between them. The thing essential for 
 suggestion to have any influence is the special psychic state, 
 induced immediately by nervous shock or through the inter- 
 mediate agency of the general nervous depression, which, for 
 the sake of brevity, we call "neurasthenia." And in many 
 other ways than in affections of the limbs and joints, auto- 
 suggestion has, in mj^ opinion, much to do with the origination 
 of symptoms which are clearly of the nature of hysteria. 
 That some form of local paralysis should be a very frequent 
 result of suggestion is not a matter of surprise, when we re- 
 member how very commonly local injuries, and local injuries 
 of no great severity, as has been previously pointed out, are 
 met with by the sufferers in railway collisions. The sense of 
 heaviness and numbness which follows a blow, more especially 
 if in the excitement of the moment the person has been uncon- 
 scious of having been struck on any one part, is very likely 
 indeed to suggest the notion of paralysis. It is astonishing 
 how often after a railway accident one hears the fear of pa- 
 
Railway Injuries. 79 
 
 ralysis expressed, and has to recognize how very real this fear 
 may be to the patient, and how difficult it is to eradicate it 
 from his mind. There is much truth in Mr. Thorburn's re- 
 mark (op. cit., p. 219) that " in the case of railwaj' accidents, 
 at any. rate, the general public of this country has been edu- 
 cated to expect ' concussion of the spine ' with paralysis, and 
 that, in the minds of the laity, the very mention of a railway 
 accident calls up the required idea." If the reader will recall 
 what has been said as to traumatic lumbago, and the symp- 
 toms which frequently accompany it, he will have no difElculty 
 in appreciating Mr. Thorburn's remark; nor will he find cause 
 for surprise that hysterical affections of the spine should be 
 common after railway collisions, having as their basis the 
 fascial and muscular injuries which have been described. 
 
 Touching on the subject of hypnotism, the same writer 
 sees an alliance to it in the unconsciousness of which patients 
 often speak, as having affected them at the time of the col- 
 lision. It is a familiar fact that a period of transient uncon- 
 sciousness, or a period, at any rate, in which there is no con- 
 scious impression of events, is by no means uncommon, even 
 when those who tell of it have had no blow upon the head, and 
 there has certainly not been concussion of the brain. I have 
 myself regarded this as a dazed condition, the result of fright, 
 and have never thought it strange that some persons should 
 have been wholly unable to give any account of what tran- 
 spired, or what they themselves did after a collision, when 
 one bears in mind how terrible may be the accompanying 
 events of a severe collision, and how vast and appalhng is the 
 contrast between everything before it and everything after. 
 Mr. Thorburn, however, goes further than this, and is inclined 
 to regard this state of daze as of the same nature as the 
 state of hypnotism, and thereby he finds an explanation of the 
 many strange and unremembered acts of persons thus af- 
 fected, and of the imaginative and altogether incredible stories 
 which they may tell of what befell them, but which they 
 themselves, nevertheless, implicitly believe. He records ex- 
 amples of this nature, to one of which I may refer here, be- 
 cause it is the history of a man known both to Mr. Thorburn 
 and myself, and because there was no question of compensa- 
 tion to throw doubts on his veracity. 
 
 "A gentleman while travelling with me," writes Mr. Thor- 
 X— 7 
 
8o Railway Injuries. 
 
 burn, " allowed the train in which he should have proceeded to 
 leave a side station without him. Seeing the train already 
 started, he ran after it, attempted to get on, and fell on the 
 line, sustaining fortunatelj' no serious injur}-. He afterward 
 described minutely how he had tried to get on to the third 
 carriage from the rear of the train, but failing, had fallen be- 
 hind it, and how the remaining coaches had then passed over 
 him. To this account he always adhered, although several 
 railway servants who saw the occurrence noticed that he 
 jumped at and missed the last carriage, and fell behind the 
 whole train, nothing passing over him." 
 
 Clearly in this instance there was the psychic state in 
 which auto-suggestion might have played a part in the devel- 
 opment of some symptom of traumatic hysteria had there 
 been any local injury to determine it. This is what happened 
 in the case of one of Charcot's patients, the history of which 
 is recorded in the appendix to his lectures. Omitting many 
 of the symptoms, it may be said that this was a case of para- 
 plegia following an injury, severe contusions to the thighs and 
 lower abdomen, which the man described as having been 
 caused by a heavy van passing completely over him. The 
 occurrence, as he believed it to have taken place, came before 
 him often in his dreams ;' but it was known, as a fact, that he 
 had not been injured in this way at all, but that he had been 
 violently knocked down on the footpath while he was drawing 
 his barrow. He lost consciousness immediately, remained 
 comatose for several hours, and afterward for two or three 
 days was in a state of intellectual torpor, in the condition suit- 
 able for the efficacy of suggestion. And the suggestion here 
 was made by the abnormal sensations in the limbs which 
 were the consequence of the local injury. The mental condi- 
 tibn which this man presented is precisely that which, in vary- 
 ing degrees of duration and severity, may be induced by the 
 profound psychical commotion of a railway collision. In it 
 the affected person may do things of which he has no subse- 
 quent recollection, he may be led to believe that things hap- 
 pened to himself which are altogether contrary to fact, and 
 any local injury may thereby be made the starting-point, 
 through suggestion, of some definite hysterical disorder. 
 
 The all-powerful influence of psychical commotion and 
 emotion is the very root and foundation also of the teaching 
 
Railway Injuries. 8t 
 
 of Oppenheim, in his short but most valuable work on the 
 traumatic neuroses ("Die traumatischen Neurosen," Berlin, 
 1889). The physical injurj^, he tells us, is only in part aswer- 
 able for the consequences which follow. "Die HauptroUe 
 spielt das psychische: der Schreck, die Gemiithserschtitte- 
 rung." His cases were mostly those of hospital patients, and 
 although they were regarded from a somewhat different point 
 of view, in that he looks on the symptoms of each case as in- 
 dicative of a more definite psycho-neurosis, yet this author is 
 in practical accord with what has been written in the last 
 chapter. It was there insisted that the psychical disturbance 
 was the reason why the pain of some trifling injury became so 
 magnified as to suggest all sorts of grave and enduring dis- 
 orders. The injury has, of course, as Oppenheim says, a di- 
 rect result; but as a rule this is of small and transient mo- 
 ment, unless the mental disturbance should alter its usual 
 character and impress on the bodily disorder the features of a 
 lasting disease. The influence of fright at the time of the ac- 
 cident is so great as to induce a long-continuing psychical dis- 
 turbance, and this it is which determines and governs the 
 phenomena of the traumatic neurosis. A very careful study 
 of his writings leads me to the conclusion that there is no 
 very great difference between the views of Oppenheim, and 
 those which have been advanced by myself. He lays greater 
 stress, perhaps, on the psychical element in the neuroses and 
 less on that of nerve prostration, but both, it must be remem- 
 bered, are neuroses of traumatic origin. 
 
 "Die HauptroUe spielt das psychische: der Schreck, die 
 Gemiithserschiitterung."— The whole sensorium, apparently, 
 may be thus affected, and may pass into a state of slumber, 
 as is shown by mental hebetude, by lessened volitional power, 
 by anesthesia and analgesia, and, on the other hand, also by 
 excessive activity of the lower automatic centres from lost or 
 torpid cerebral control. The abnormal condition is allied in 
 all probability to that of the hypnotic sleep, and it is, more- 
 over, akin to it in the readiness with which the symptoms may 
 pass away when the requisite stimulus has aroused the brain 
 from its -torpid state. The stimulus may be some profound 
 mental or bodily impression ; it may be exerted only by the 
 more tedious influence of re-education of the movements of the 
 affected part; but in either case the activity of the sensorium 
 
82 Railway Injuries. 
 
 is once more alert, and the cerebral control can be exercised in 
 its normal and healthy way. Not less mysterious than slum- 
 ber of the sensorium, whether it be of the whole or of a part, 
 is the fact that daily familiarity with the morbid process seems 
 to give the individual patient the voluntary and more facile 
 power of putting the affected region of the sensorium into the 
 state of torpor, or of voluntarily abandoning himself to the 
 easily-induced influence of the abnormal condition. Repeti- 
 tion and perpetuation of the morbid condition of the sensorium 
 make the symptoms easier of production than they were be- 
 fore. The man who has once been hypnotized can be more 
 readily hj'pnotized again, and thus it is that in course of time 
 the " medium " of the mesmerist or of the so-called spiritualist 
 can be reduced by the most trumpery and frivolous influences 
 to the hypnotic or cataleptic state, and so becomes the most 
 pitiable of mortal men. 
 
 It has been said already, in speaking of the sj'mptoms of 
 general nervous shock, that the man who voluntarily aban- 
 dons himself to the morbid state submits both his moral and 
 physical nature to a long spread-out shock from which he will 
 find it hard to rally, and the same remark may be here reiter- 
 ated with even greater force in connection with the functional 
 disorders which are results of the unnatural nervous state. 
 For there can be no doubt whatever that many neuromi- 
 metic conditions are more or less under the voluntary control 
 of the patient; and that, as may be seen in cases of convul- 
 sion, the mimetic seizures — in themselves typical in character 
 — may be brought on by the will of the patient himself. And 
 this can be done with greater ease as time goes on. Herein 
 lies the explanation of those happily-timed convulsions which 
 occur when it is most important that you should see them, 
 and should be impressed by their severe reality. The seizure 
 itself — qua seizure — is typical of its kind, and its phenomena 
 lie outside the conscious control of the individual. But within 
 his control has been the commencement of the seizure at the 
 precise moment when it began. Thus, in speaking of the ease 
 with which the hypnotic state may be induced in those who 
 have been often hypnotized, Heidenhain writes : " Many of the 
 gentlemen upon whom the above experiments have been made, 
 need only to sit down, close their eyes, and think intently — 
 other thoughts being excluded — that the hypnosis is coming 
 
Railway Injuries. 83 
 
 on, in order to, as it were, voluntarily submit themselves to 
 the charm " ("Animal Magnetism," p. 86). And, as of the 
 hypnotic state, so of other neuromimeses also, the patients 
 may voluntarily submit themselves to their exhibition, and 
 the manifestations thereof become in themselves not less real. 
 The existence of a certain amount of control is shown, more- 
 over, by the disappearance of the mimicries, when all cause 
 for their representation is removed. The matter of compen- 
 sation, as we have seen, exerts in many cases a very favorable 
 influence on the symptoms of general nervous shock. It does 
 so in these cases also, and examples are not few in which typi- 
 cal neuromimetic phenomena came to an end, shortly after 
 settlement of claim had secured for the patients complete re- 
 pose of mind, and had freed them from the necessity of any 
 longer allowing themselves to be their victims and exponents. 
 In speaking of the objections made t9 hypnotic experi- 
 ments, Heidenhain seeks to show that the repetition of them 
 does not appear to be fraught with danger or evil, but he 
 mentions cases where attacks of convulsions constantly ac- 
 companied every hypnotic experiment, and one patient who 
 suffered after every experiment from a certain degree of ner- 
 vous irritability which lasted twenty-four hours (op. cit., p. 
 102 et seq.). I have myself no doubt that the risk of perma- 
 nent damage to the stability of the nervous system and tone 
 must be very considerable in all persons who repeatedly sub- 
 mit themselves, whether voluntarily or involuntarily, to the 
 hypnotic state, even though it is not accompanied by convul- 
 sions or is not followed by " nervous irritability.'" The hyp- 
 notic state is not a natural, it is a morbid state; to repeat it 
 is to perpetuate it, and make it an abiding part of the organi- 
 zation of the individual. Not less does risk of permanent 
 damage to the stability of the nervous system lie in long con- 
 tinuance of any functional mimetic disorders. The longer 
 they exist the more prone are they to give rise to lasting ner- 
 vous disturbance, and to the phenomena which may be the 
 result; and even in cases where the neuromimeses pass away 
 under returning cerebral control, the risk is by no means small 
 that from some exciting cause the conditions may be very 
 readily reproduced. The lesson to be learned from this is ob- 
 vious, that the sooner any cause for the representation of the 
 phenomena is removed the better, and that the patients should 
 
84 Railway Injuries. 
 
 as far as possible be freed from the hurtful sympathy of 
 friends. There is little chance of improvement or cure as long 
 as the patient need not make the necessary effort to get well, 
 and as long as his friends, in ignorance of the real nature of 
 his malady, foster by misdirected sympathy and kindness 
 those very symptoms whose continuance is fraught with 
 danger to the stability of his nervous system. The question 
 of diagnosis is thus all-important, and once established it is 
 doing him a grievous wrong if his sufferings and symptoms 
 are to be made the occasion of litigation and prolonged dis- 
 pute. 
 
OHAPTEE Y. 
 
 THE FRIGHT l^BVROS^S— (Continued). 
 
 I SHALL now illustrate the foregoing remarks by the brief 
 record of several cases, the symptoms of which will suggest 
 various comments as we go on. I adopt this plan because the 
 multiplicity and variety of the so-called functional disorders 
 prevent any suitable classification of them, and because this is 
 not a text-book of nervous diseases. Information is at hand, 
 and must be sought elsewhere, as to the condition of the re- 
 flexes, for example, in the different diseases of the nervous 
 system, organic and hysterical, and only passing reference 
 will be made to these and other indications of nervous dis- 
 order. 
 
 Case XVIa. — Case of Functional Paraplegia — Bapid 
 Recovery after Settlement of Claim. — V. S., a widow, aged 
 thirty-eight> the strong and healthy mother of seven children, 
 was in a collision. There was no history of her having been 
 much hurt at the time> but within a few hours she began to 
 have a pain, or a sensation which she described as " opening 
 and shutting," in the small of her back. The next morning 
 she continued her journey of nearly 200 miles, and finding that in 
 a few days the pain in her back was a good deal worse, she 
 went to a hospital. She was an in-patient in the hospital for 
 six weeks, during the first three of which she was in bed, suf- 
 fering from pain and stiffness in the small of the back and 
 from general weakness. For three weeks she was up and 
 moving about the wards, and she then made a journey of 330 
 miles in order to take one of her children to school. This bus- 
 iness over, she then travelled home to the place where the 
 accident had originally happened. This was exactly two 
 months after the accident, and as soon as she got home she 
 at once took to her bed, suffering from great pain in the back, 
 from much hypersesthesia in the dorsal and lumbar regions, 
 
86 Railway Injuries. 
 
 and from general prostration. She remained almost entirely 
 in bed until about fifteen weeks after the collision, when it 
 was accidentally (" accidentally," because this is just what so 
 frequently happens in hysterical affections. " It is necessary 
 to bear in mind," Charcot says, " that hemianaesthesia is a 
 symptom which requires to be sought for, as M. Lasegue very 
 judiciously remarks. There are, in fact, many patients who 
 are quite surprised when its existence is revealed to them." — 
 Charcot, " Diseases of the Nervous System," New Syd. Soc, 
 1877, p. 350) discovered that she had lost all motion and sen- 
 sation in the legs. She had complete control over both bowel 
 and bladder, and there was neither wasting of the legs nor 
 bed-sores. The paralysis of motion and sensation seemed ab- 
 solute. The woman was at the same time exceedingly "hys- 
 terical," and complained fearfully of pain in the back and of 
 innumerable queer sensations in different parts of the body. 
 The opinion was given that this paraplegia was not dependent 
 upon organic disease; that it was not feigned; and that, al- 
 though there was every prospect of her recovery, it was quite 
 impossible to say how long she might suffer from the paraly- 
 sis, or how soon she might be well. She was attended through- 
 out this illness by a trustworthy nurse, and there was never 
 any suspicion that the woman was wilfully maintaining her 
 condition. No material change took place in her condition 
 up to six months after the accident, when her claim was set- 
 tled. Within a fortnight she left the house where she had 
 been stajnng, and in three months she was walking about 
 without assistance in perfect health. Further account of her 
 cannot be obtained. It is open, of course, to any one to re- 
 mark that this was a case of malingering. I do not take this 
 view, and I think it of greater interest to consider what were 
 the circumstancse conducive to the paraplegia, and what were 
 those which brought about her recovery. There can be no 
 doubt that the woman received a sprain of her vertebral col- 
 umn, and that she had some "shock;" but of greater moment 
 in the history of the case is the fact that the long and fa- 
 tiguing journeys, which she took within a short time of the 
 accident, must have been largely instrumental not only in 
 preventing complete recovery from the early prostration, but 
 even in increasing the general weakness from which she suf- 
 fered. After the first journey she was compelled to go to a 
 
Railway Injuries. 87 
 
 hospital, and after the second and longer journey she was so 
 much exhausted that she had at once to take to her bed. 
 
 In two other cases of paraplegia, occurring in young girls, 
 there was very much the same sort of history. One of them 
 was remarkable in this, that after the collision the girl lay in 
 a dazed, semi-unconscious state for a couple of hours, having 
 received no injury beyond a slight bruise on the middle of her 
 back by the fall of a box from the carriage rack. Movement 
 was painful, and she took to her bed, gradually losing there- 
 after the use of her legs. They became extremely cold, but 
 there was no other alteration in nutrition, and the reflexes 
 were quite normal. No improvement took place in this case 
 until the patient had been taken from home, placed in a hos- 
 pital, and there put under suitable treatment. It is probable 
 that the feebleness of circulation and coldness of the extremi- 
 ties often noted in these cases, together with the pain induced 
 in moving the legs, provide the " suggestion " to the sensorium 
 which results in loss of motion and sensation. And let it be 
 noted that the effect of the accident was to produce that con- 
 dition of daze to which reference has been already made, and 
 to which, in the etiology of such affections, considerable im- 
 portance must be attached. The legs of the other girl were 
 equally cold, and in addition to tlie paraplegia, she presented 
 this characteristic symptom, flexion of and inability to extend 
 the fingers when asked to do so, although in all automatic 
 movements there was no impairment or defect. 
 
 The way in which cases of this kind frequently recover 
 shows pretty conclusively that the morbid seat is in the 
 brain. A sudden impression which compels the automatic use 
 of the legs may in a moment arouse the torpid sensorium, or 
 a process of re-education, beginning at the very beginning, as 
 it were, may be needful to restore the lost movements of the 
 limbs by reawakening the brain to a full sense of its responsi- 
 bilities in the circle of the will. Cases like these may look Uke 
 fraud, bub I feel sure that Paget is right when he says that in 
 many of them the " fault is rather in weakness of the will 
 than in its perverse strength." The patient says, " as all such 
 patients do, 'I cannot;' it looks like 'I will not,' but it is 'I 
 cannot will'" ("Chnical Lectures and Essays," pp. 188, 189). 
 
 The cases of functional paraplegia which have been recorded 
 
88 Railway Injuries. 
 
 were very typical of their kind, but we shall do well to draw 
 remaining examples from patients of the sterner and, usually, 
 less hysterical sex. 
 
 Case XVII. — Case of Functional Motor Paraplegia- 
 Extreme Emotional Disturbance — Ultimate Recovery. — T. 
 B., aged forty-one, a man of gouty family, naturally very ex- 
 citable, and able, as he said, to hear a pin drop in the next 
 room, was in a very severe collision in which the carriage he 
 was in was smashed to pieces. He crawled out of the debris 
 as best he could and went on his journey, but in about half 
 an hour he began to have retching, pains in the abdomen, and 
 shivering. He therefore returned home. There were slight 
 bruises about the limbs, and one on the forehead ; and the next 
 day, when in bed, he complained of pain in the right side of 
 the abdomen and the lower part of the back, but at neither of 
 these places was there mark or tenderness. For the next few- 
 days he seemed very ill, had severe pain in the head, occa- 
 sional retching, and at night he wandered. For three days 
 his temperature was raised. He was in a highly nervous 
 state, and spoke frequently of a dread of lock-jaw and paraly- 
 sis. Three weeks after the accident he still complained of 
 severe pain about the sacral region, but there was no tender- 
 ness. He complained also of," numbness'" in his legs, a word 
 used by him to express not impaired sensation, but a difficulty 
 which he felt in moving them. There was no hyper- or an- 
 Eesthesia, but his walking, in which he helped himself by hold- 
 ing on to the furniture, was done with apparent fear and effort. 
 He could stand quite well with his eyes shut, and there was 
 no spasm of the muscles of the legs. His temperature and 
 pulse were normal, and the bodily functions were naturally 
 performed. His general condition improved, he was able to 
 eat and sleep better, and even to get out-of-doors in a chair. 
 He still suffered, however, from extraordinary emotional dis- 
 turbance, was very irascible, and frequently cried. He con- 
 tinued to dwell on the fear of paralysis, and steadily lost the 
 power of moving his legs. He made for himself an ingenious 
 contrivance whereby he was able to move about by the sup- 
 port of his arms, but his legs were hardly used at all in pro- 
 gression. Eight months after the accident he was quite un- 
 able to walk, and failed entirely to make any requested 
 
< Railway Injuries. ■ 89 
 
 movements of the legs or feet during examination. The 
 attempt to move his legs produced great mental agitation. 
 There was no paralysis of bowel or bladder, and sensation of 
 the legs was but very slightly, if at all, impaired. There was 
 no material wasting. The cremasteric reflex (this case was 
 seen before the value of patellar and other reflexes Avas known, 
 and the cremasteric alone was tested) was normal. There 
 was no rigidity or spasm, and no sign of bed-sore. 
 
 Nine months after the accident he had an attack of aphonia, 
 brought on suddenly by hearing of the death of a friend. The 
 aphonia lasted for three weeks, and then disappeared as sud- 
 denly as it began, when startled by one of his children rushing 
 into the room. He also suffered from frequent nausea and 
 retching, the least excitement, such as the visit of a friend, 
 almost certainly making him sick. It is indeed very difficult 
 to express in words how extreme was the emotional disturb- 
 ance in this patient. He had always been a man of highly 
 nervous temperament, likely, so it was said, to suffer severely 
 from the shock of a railway accident. 
 
 I satisfied myself that the paralysis was not dependent on 
 organic lesion, and eleven months after the accident reported 
 to the railway companj^ that the " cause of the paralysis seems 
 to lie rather in the directing power of the will than in lesion 
 discoverable of the brain or spinal cord." I had, moreover, no 
 doubt that the case was perfectly genuine, but felt that it was 
 impossible to say how long he might be ill, and that litigation 
 would be exceedingly detrimental to him. The man himself 
 was advised to make every effort to use his legs, and to re- 
 educate the movements of them by daily practice. Litigation 
 was avoided, and the claim, naturally and rightly a large one, 
 was amicably settled thirteen months after the accident. By 
 the kindness of his medical attendant I had frequent reports 
 of this man after his claim was settled. For long he did noth- 
 ing, and remained in a nervous hysterical state, and it was 
 not until fotir years after the accident, when he made a com- 
 plete change in his living and occupation, that he began to get 
 well. Seven years after the accident, in the course of the 
 year 1882, this was his own story, and it speaks better of his con- 
 dition, past and present, than any other words. He considers 
 that he was ill for between four and five years. He used the 
 appliances for walking for about two years, and then began 
 
90 Railway Injuries. 
 
 to use sticks. Two years and a half ago he took a public- 
 house in the country, and began to lead an out-door, active 
 life. When he first began this, he could not get up from his 
 chair alone, having either to be helped up, or to pull himself 
 up by getting hold of something in front of him. Suddenly 
 one day he got up without knowing it, and his son said to 
 him, " Why, father, look what you've done ! " " Good God ! " 
 he replied, " I have got up myself." From that day forth he 
 was able to get up without difficulty. He still has great fear 
 about his spine, and onlj^ a few weeks ago, when a friend 
 struck him in the back in joke, he was terribty alarmed, and 
 for two days could hardly walk. He can walk nine miles with- 
 out fatigue and ride all day, he has gained weight, and is 
 altogether stronger and better than he was before, regarding 
 his recovery as due to change of life and scene. In appear- 
 ance he was at this time the picture of health, and as far as 
 his legs were concerned there was not a sign or symptom of 
 anything whatever amiss with them, reflexes and nutrition 
 being perfectly normal. I saw him again in 1890 in perfect 
 health. (See a remarkable case recorded by Dr. Webber, 
 "Boston Medical and SurgicalJournal," Vol. X., p. 44, 1873— 
 " Recovery after four years' paralysis following railroad in- 
 jury.") 
 
 Case - XVIII. — Supposed Spinal Injury — Spasmodic 
 Twitching s of One Arm, efc.— S. B., aged thirty-three, was in 
 a railway collision at night, when a large number of persons 
 were more or less shaken and hurt. He himself was not in- 
 jured, as far as he knew, at any one place, and no marks of 
 external injury were at any time discoverable. He com- 
 plained, however, of being shaken, and looked pale and ill. He 
 took to his bed, and in a few days complained very much of 
 his back, and was in a continued state of alarm about his 
 " spine." Beyond appearing shaken and nervous about him- 
 self, he had no sign of structural injury to any one part of the 
 body. He remained in this negative condition for some weeks, 
 and then began to move about the house, and once or twice he 
 went out of doors. About this time there came on a peculiar 
 twitching in the left arm, which is thus recorded in the notes : 
 " To-day on my arrival he was lying dressed on his bed. I 
 asked him to go into the next room, a.nd he got up without- 
 apparent difficulty and did so. He sat down in an easy-chair^ 
 
Railway Injuries. 91 
 
 when his left arm and hand at once began to jerk with sharp 
 clonic spasms or twitchings, not unlike the movements of 
 chorea. The movement kept on when his arm was held, and 
 he said he could not control or arrest it. It was noticeable, 
 however, that it ceased entirely when he began to undress, 
 partially ceased when he engaged in conversation, and alto- 
 gether stopped when his attention was specially directed to / 
 some other part of his body. Coincident with this movement 
 of the arm was a continuous jerking of the head. There was 
 no wasting nor any sign of loss of power in the limbs." He 
 complained greatly of his back, and evinced tenderness on 
 touch at the mid-dorsal and upper sacral regions. The tem- 
 perature was normal, and all the bodily functions were natu- 
 rally performed. He continued in much the same condition 
 for nearly a year, a severe injury to the " spine " being made 
 the basis of a demand for large pecuniary compensation. 
 There was, however, neither history nor sign of lesion in any 
 central structure, and the whole condition was regarded as 
 one of neurotic disturbance, which might be verj' much con- 
 trolled if the patient would only choose to exert his will. This 
 view of the nature of the case received strong support from 
 his previous history. He had been in a railway collision 
 twelve years before. He then received no bodily injury, but 
 he was very nervous about himself, and four months after- 
 ward began to suffer from spasmodic wry-neck, which lasted 
 for four months, and which recurred again for a short time 
 after an interval of two years. 
 
 There was no reason in this case to attribute any want of 
 hona fides to the man in the presentation of his symptoms, 
 although the largeness of his claim and the sequel of his case 
 would rather tend to throw doubt upon its perfect genuine- 
 ness. When compensation was settled he very speedily lost 
 all the spasms and returned to work, and it was even said by 
 one who had taken a friendly interest in his case that he had 
 recovered with indecent haste. But his recovery, in my judg- 
 ment, was due rather to the fact that settlement of his claim 
 enabled him to make the requisite effort to do some work, and 
 that healthy occupation provided the means of diverting his 
 attention from himself and his ailments, so that the spasms 
 were unconsciously forgotten and forthwith disappeared. Five 
 
92 Railway Injuries. 
 
 years after the accident the report ran that he was in good 
 health, although he had been shaky and nervous for some con- 
 siderable time after his claim was settled. 
 
 Both these cases present examples of undoubted predis- 
 position to neurotic disturbance. It is impossible to say why 
 the disorders should have assumed the forms they did, but it 
 is interesting to note that in both of them there was a genu- 
 ine dread of spinal injury, and that in the second case the 
 wry-neck after the former accident, and the chorea-like move- 
 ments of the arm and head, after an interval of no less than 
 twelve years, were disturbances of the same kind. The cases, 
 moreover, show of how much importance it is to know some- 
 thing of the previous historj'^ of the patients, and their special 
 liabilities to disease, in order to arrive at a correct diagnosis. 
 
 Case XIX. — Shock to Nervous System — Hysterical Seiz- 
 ures Beginning in Syncope. — E. C, aged thirty-nine, an offi- 
 cer in the army, was in rather a severe collision at night. He 
 was awake at the time, and was thrown backward and for- 
 ward in the carriage. He had no knowledge of being hurt, 
 and helped the stoker, who was much injured. He then fin- 
 ished his journej', the "excitement," as he supposed, "keeping 
 him up." The next morning he felt very ill and vomited, and he 
 soon began to suffer from pain across the loins, queer sensa- 
 tions all over the body, nausea, giddiness, and want of sleep. 
 On the third day he took a long journey of several hundred 
 miles to be with some friends; and on the twelfth day after 
 the accident he suddenly fell and struck his nose against the 
 corner of a table. He soon became conscious and screamed 
 violently. To use his own words: "The fit came on about 
 three in the afternoon; I fell down and screamed, and then 
 began to cry and sob violently. During it I was unconscious, 
 although I knew that people were around me, and that I must 
 use all my efforts to restrain myself and to keep quiet. When 
 all was over, I did not know what had happened." He called 
 this fit an " hysterical attack," and the doctor who saw him 
 immediately afterward, and who found him more or less un- 
 conscious, thought that this was its nature. Six weeks after 
 the accident he complained of pain in the back, loss of memory, 
 inability to apply himself, occasional giddiness, nausea, and 
 want of sleep. He looked anxious and worn, and his doctor, 
 
Railway Injuries. 93 
 
 who had known him for some time, said that he was undoubt- 
 edly much changed in manner and appearance. He had lost 
 flesh, but all the bodily functions were natural. He described 
 the fit in the words which have been given, and said that he 
 had had two or three since, though not so violent as the first. 
 A fe'w minutes after this I had the opportunity of seeing him 
 in a fit. It had begun with screaming, and he was found ly- 
 ing on the sofa with his eyes closed, his face very pale, and a 
 small pulse. He took no notice o'f my entry into the room, 
 but occasionally sighed. Asked how he was, he opened his 
 eyes and looked wildly about. He was then very sick. After 
 vomiting he roused himself, asked how long I had been there, 
 and said he was better. Before leaving him he was appar- 
 ently asleep. Within the next two months he had three or 
 four attacks of the same kind, though of gradfually lessening 
 severity. His claim was settled six months after the accident. 
 Twelve months afterward he still suffered in a slight d'egree 
 from the effects of the injury, but it did not prevent him from 
 attending to his work. No later record than this can be ob- 
 tained, that six years after the accident he was still on active 
 duty. It has some bearing on the history that this patient 
 wrote repeated, and what might almost be called " hysterical," 
 letters about his condition and future prospects, and that he 
 made an enormous claim, thrice the amount which he ulti- 
 mately received, without resort to litigation. 
 
 Nothing is known of this patient's previous history, other 
 than that he had always enjoyed good health; and it is worth 
 asking, what was the origin of these hysterical seizures ? It 
 seems to me that in all probability they began with syncope, 
 which was a direct result of weakened cardiac power from the 
 nervous shock, and that they assumed the form they did from 
 the very fact that the accident had produced a profound im- 
 pression on the patient's mind. He was reduced to a condi- 
 tion in which he was ready to be alarmed, and when, after 
 the fainting, he became partially conscious upon the floor, he 
 screamed hysterically in very natural and increased fear. And 
 each subsequent fit began in the same way, by a sensation of 
 •syncope— not perhaps amounting to actual fainting— which 
 by the alarm it caused him at once determined the screaming 
 and sobbing which were characteristic signs of each attack. 
 
94 Railway Injuries. 
 
 With returning strength and cardiac tone the seizures lessened 
 in frequency and severity, until they came to an end. In 
 other words, the sensations induced by syncope provided a 
 suitable and adequate "suggestion" for the attacks from 
 which this man suffered. Just as a blow on the shoulder may 
 cause sensations which provide the suggestion for palsy of 
 motion or sensation in the affected arm, so in disturbances 
 which are apparently more purely psychical in character, 
 there is need of some suggestion which shall determine the 
 particular disorder manifested in any given case. 
 
 A like explanation seems to me to account for such a sj'rap- 
 tom as continued vomiting, the origin of which is otherwise 
 obscure, and which may be erroneously regarded as due to 
 some grave central or other disease. 
 
 Case XX. — Nervous Shock — Continued Vomiting.— A 
 healthy woman, aged twenty-nine, the mother of one child, 
 was in a very slight collision in shunting. She was thrown 
 suddenly forward, and a box fell from the rack and inflicted 
 a minute punctured vvround on the left frontal eminence. 
 Until she felt the blood trickling on her forehead she did not 
 know she had been hurt. An hour and a half after the acci- 
 dent, when she arrived at home, she vomited, and from that 
 time onward vomiting followed immediately upon each at- 
 tempt to take food. Never at any time was there the small- 
 est indication of injury about the stomach. Four days after 
 the accident she had an attack of acute hj'sterical laughter 
 and crying, and in the course of the next four weeks attacks 
 of a like character were repeated several times. She com- 
 plained of shooting pains in the neck and head, and of pain, 
 hypersesthesia, and tenderness over the dorsal region of the 
 spine. Nevertheless there was no spinal rigidity, nor any dif- 
 ficulty in moving her limbs. When I saw her a month after 
 the accident, no evidence of local injury was anywhere discov- 
 erable, but her pupils were sluggish and wide, the knee-jerks 
 were decidedly exaggerated, and there was well-marked 
 though not sustained ankle clonus, such as is frequently seen 
 in similar cases of so-called functional neurosis. The vomit- 
 ing was still going on, but without pain, and with a perfectly- 
 clean tongue. All this time she had been in bed, and had be- 
 come extremely weak. There was no rise of temperature. 
 
Railway Injuries. 95 
 
 A new line of treatment was now begun, the object of it being 
 to improve the nutrition, by often repeated small quantities 
 of milk or other light food; and if possible, by the smallness 
 of the amount taken at a time, to baulk the vomiting habit. 
 The lapse of another month saw a considerable improvement 
 in her nutrition, she was able to be up and out of doors, the 
 pupils were smaller, the knee-jerks were within the normal 
 range, and the ankle clonus had entirely disappeared. There 
 was not, however, any great improvement in the vomiting, 
 for an endeavor to take an ordinary meal immediately made 
 her sick. The reason for this was not far to seek. The pa- 
 tient had now become an object of special sympathy in the 
 village,"and her only return for the bounty of her neighbors, 
 both rich and poor, was to go on vomiting. One thing was 
 now essentially called for in order to bring about her recov- 
 ery, and that was isolation from her friends. Accordingly 
 she left home, was placed in the charge of a nurse, and treat- 
 ment suitable for her condition was forthwith begun. It 
 would be untrue to say that she never vomited again, because 
 in the course of the next three months she did vomit twice, 
 and twice only, in the old purposeless way; but this may be 
 said, that her convalescence began from this time, and that she 
 ultimately, within nine months of the accident, was quite well. 
 
 This case is, to my mind, a very instructive one. Almost 
 uninjured at the time of the accident, it is certain that there 
 must have been an amount of shock sufQcient to cause the 
 vomiting within an hour and a half, and the psychical effect 
 was indicated by an outbreak of acute hysteria on the fourth 
 day. The reality of the nervous disturbance was shown, 
 moreover, by the increase of the knee-jerks and by the ankle 
 clonus; and a vicious circle was quickly estabUshed— mal- 
 nutrition affecting the nervous centres alike of brain and cord, 
 whose condition in turn made the act of vomiting more easy 
 and more durable in the absence of some physical cause. 
 There never was any question as to the nature of the case, 
 and it seems to me that there can be as little doubt as to the 
 origin of that one symptom which was its especial feature. 
 The initial act of vomiting gave the suggestion for its contin- 
 uance to a sensorium profoundly affected by the circumstances 
 of the accident. And it is abundantly obvious how a recogni- 
 
96 Railway Injuries. 
 
 tion of this sequence of events was essential for the adoption 
 of the line of treatment which speedily ended in cure. Had 
 this patient stayed at home, and been treated on the supposi- 
 tion that she had some serious organic disease, the result 
 would surely have be. n different. I have now had under oc- 
 casional observation during the past eight years the case of a 
 young man whose symptoms were not unlike those of this 
 woman. He had been very severely shaken in a collision, and 
 there was much shock, out of all proportion to the physical 
 injuries sustained. Vomiting came on within twenty-four 
 hours, and has continued ever since in varying degrees. Re- 
 peated examinations have failed to discover any .organic cause 
 for it either in the stomach itself, the peritoneum, or- the ner- 
 vous centres, disease in one or other of which would in all 
 probability have shown itself in this length of time. By a 
 process of exclusion, therefore, the diagnosis points in the 
 direction of the last case, but neither his own medical attend- 
 ant nor I have been able to persuade him to submit to treat- 
 ment by isolation. His case is of value as an illustration of 
 the fact that settlement of claim does not always work for a 
 patient's recovery. (In Dr. Bristowe's " Diseases of the Ner- 
 vous System," p. 40, is an interesting lecture on "The Func- 
 tional Vomiting of Hysteria," in which he relates a case of vom- 
 iting which lasted between two and three years, and which 
 dated from a voyage made across the Atlantic. The author 
 doubts whether food ever reached the stomach, and whether 
 there was not some functional affection of the oesophagus.) 
 
 We may pass on now to say something of hemianaesthesia, 
 surelj' one of the most remarkable indications of cerebral dis- 
 order. The text-books of medicine and of nervous diseases 
 contain such full accounts of this strange condition, of its 
 many vagaries and its accompanying disorders of the special 
 senses, that there is no call to describe it here, and I shall 
 content myself with a few remarks upon particular cases, 
 choosing those of men for consideration. 
 
 Case XXI. — HemiancBstliesia and Hemiparesis, follow- 
 ing Hypnotic State from Fright. — A highly neurotic but 
 otherwise healthy man, aged forty-seven, was bruised in sev- 
 eral places, head, neck, and buttocks, by being thrown sud- 
 denly backward and forward in a railway collision of no great 
 
Railiuay Injuries, 97 
 
 severity. He instantly lost consciousness, and so remained 
 for two hours. On arrival at home his doctor was sent for 
 immediately, and found him suffering from left hepiiplegia in 
 addition to great emotional disturbance, crying and sobbing. 
 No examination was then made as to sensation, but two days 
 afterward he was found completely anaesthetic on the same 
 side, and all the corresponding special senses, hearing, taste, 
 sight, and smell, were likewise affected. There was also loss 
 of muscular sense, impairment of the sense of color, and spas- 
 modic deviation of the tongue. The knee-jerks were increased, 
 and there was slight ankle clonus. When I saw him three 
 months afterward the various symptoms were much dimin- 
 ished in degree, and there was no longer any deviation of the 
 tongue. Though able to walk and even get down-stairs, his 
 gait when under observation was singularly slow and labored 
 because of inability to use the left leg, the movements of which 
 were now made in one way and now in another, there being 
 nothing specially characteristic about them. The whole mus- 
 cular system was extremely flabby, but there was no wasting 
 of one part more than another. The man's aspect was sug- 
 gestive of great mental depression, but he acknowledged that 
 he was somewhat better than he had been. He has gone on 
 improving, but it is impossible yet to give a complete history. 
 The case is nevertheless worthy of note as it stands because 
 of the early onset of the symptoms, and from the fact of the 
 man having immediately passed into that state of daze or 
 unconsciousness which seems to be so important a factor in 
 their development. There is no reason to think that his un- 
 consciousness was the unconsciousness of true brain concus- 
 sion, for there was no local blow sufficient to determine a state 
 of coma of two hours' duration, and the condition was more 
 probably that which is due to fright alone. Why in this par- 
 ticular case the so-called functional disturbance should have 
 shown itself in hemiplegia and hemiansesthesia it is impossible 
 to say, just as no reason can yet be given for hemianajsthesia 
 being more common on the left side than on the right. The 
 loss of sensation was in all probability as early a phenomenon 
 as the loss of motor power, both ensuing upon the hypnotic 
 state which was an immediate effect of the accident. In an- 
 other case the hemianzesthesiawas detected on the day after 
 the accident. 
 
98 Railway Injuries. 
 
 Case XXII. — Hemiancesthesia, etc., etc. — A man, aged 
 forty-three, of neurotic temperanaent, was in a very trifling 
 collision, which jolted him, however, from his seat and depos- 
 ited him on the floor of the carriage. There he found himself, 
 and was subsequently unable to give any better or more ex- 
 plicit account of what happened to him. There was no evi- 
 dence, however, of his having been hurt bodily, and he went to 
 his business next day. He soon broke down completely, and 
 a doctor who was sent for found him in a semi-dazed condition, 
 and proceeded immediately to examine the state of cutaneous 
 sensation. It was absent on the whole right side, and was 
 accompanied, as in the last case, by some loss of power in the 
 right leg. There were also present in an extreme degree the 
 usual affection of the special senses, loss of muscular sense, 
 and spasm of the tongue. With it also were many neuras- 
 thenical symptoms, coldness of the limbs, especially of the 
 right leg, occipital headache, loss of sexual desire, and widely- 
 dilated pupils. Occasionally also he had hystero-epileptic 
 seizures. For many months there was little or no improve- 
 ment, and at the end of a year, during which he had led the 
 life of an invalid, and made no attempt to work, the hemian- 
 sesthesia still continued. His claim was finally settled, but 
 whether that put an end to the ansesthesia or not I am unable 
 to say. I think, however, it is highly probable, for it put an 
 end to the " suggestion " of it in frequent medical examina- 
 tions; and this is certain, that the man very soon resumed his 
 ordinary mode of life, and within nine months gave every in- 
 dication that his bodily health had been restored. 
 
 I do not for one moment wish to convey the impression 
 that this case was not a perfectly genuine one. -There was, of 
 course, no doubt as to the existence of the hemiauEesthesia and 
 the accompanying phenomena, but from beginning to end of 
 its long history it was an example of the injurious influence 
 which the matter of compensation, and dawdling about at 
 home, have in cases of the kind. Hemi- or any other distribu- 
 tion of anaesthesia is a valuable indication of the nature of 
 any given case. It is an expression of an abnormal cerebral 
 condition, and, whatever may have been its origin and excit- 
 ing cause, there cannot be anything much worse for a patient 
 than to have the symptom, if not revived, at any rate kept 
 
Railway Injuries. 99 
 
 alive, by repeated examinations, whicla are made either from 
 genuine interest in the case, or in preparation for an action at 
 law. I have pointed out on an earlier page how movements 
 which fail from failure of the will to make them may, never- 
 theless, be automatically performed. The conception of some- 
 thing of the same kind is much more difficult in the case of 
 sensory than it is in the case of motor power, but one could 
 hardly go as far as to say that it was impossible for common 
 sensation to be within the range and influence of what is 
 termed will. The receptivity of the sensorium for impressions 
 which reach it from the periphery may likewise be both vol- 
 untary and automatic; and the history of some cases inclines 
 me to think that a person may acquire the power of inducing 
 anaesthesia, much in the same waj' as by practice he may in- 
 duce the repetition of motor phenomena which are close imita- 
 tions of real disease. At all events I do not think that hemi- 
 anassthesia, real in itself though it be, can be regarded as 
 outside the category of those cases to which the following 
 quotation from Dr. Wilks is more or less applicable: "I do 
 not look on hysteria," he says, " as a fictitious disease or a 
 sham; the condition with all the phenomena is real enough; 
 at the same time the hysterical state is so often associated 
 with some moral obliquity that it is very difficult to say how 
 far a particular sj^mptom is feigned or exaggerated " (" Dis- 
 eases of the Nervous System," p. 55, 2d edition). He records 
 a case of gross imposture, in the history of which a pilgrimage 
 to Lourdes played a conspicuous part, hemiauEesthesia being 
 among the man's symptoms. 
 
 It would be wrong and most unjust to say or to suggest 
 that moral obliquity is an attribute of all persons who present 
 hysterical symptoms, yet, even where there is a condition such 
 as hemianaesthesia, the possibility of a certain amount of con- 
 scious influence over the chief symptom must be borne in mind. 
 
 Case XXIII.— ffemzawcesi^esm, etc.—Douhts of Perfect 
 Oenuineness.—A man, aged flfty-one, was in an altogether 
 trivial accident, in which, if he was injured at all, he sustained 
 a slight sprain of his posterior cervical muscles. He did not 
 know he had been hurt until the night after the accident, 
 when he woke with a start, and the next morning he felt shaky 
 and nervous, and was unable to write a letter. He took to 
 
loo Railway Injuries. 
 
 his bed, and after he had been there for a week he was exam- 
 ined by a surg-eon, who observed such inconsistencies in his 
 statements and symptoms as to lead him to regard the case 
 as not perfectly genuine. When I saw him myself a month 
 afterward there was left hemiansesthesia, and some weakness 
 in motor power also. There were spasms during examination 
 of the shoulder and neck muscles of the left side, and certain 
 movements, such as squeezing with the left hand and putting 
 out the tongue, he professed himself unable to perform, al- 
 though neither in his speech, nor in ordinary movements of 
 the limb automatically performed, was there any sign of pa- 
 ralysis. The special senses were also affected in the usual way. 
 After an interval of two months there was slight, but only 
 slight, improvement. How long this state of things lasted it 
 is impossible to say, because renewed requests that the man 
 might be seen by surgeons for the railway company were re- 
 fused on the ground that he was far too ill to allow of any 
 examination. An exorbitant claim was presented, and the 
 case went to trial. It was then conclusively proved that dur- 
 ing most of the time when he was too ill to be examined, and 
 was wholly unfit for anything except confinement to bed, he 
 was deceiving his own doctor, and was leading a life of very 
 considerable enjoyment — after dark. In fact he loved dark- 
 ness rather than light. No good purpose can be served by 
 giving in detail all the facts of this case — let them be recorded 
 by his own advisers, legal and medical; but this may be said 
 about it, that the accompanying exaggeration and imposture 
 were such as to throw very grave suspicion on the perfect 
 genuineness, not on the perfect reality, of the symptom hemi- 
 ansesthesia. And in endeavoring to come to a right conclusion 
 as to the value of this symptom in any given case there is an 
 error, I feel sure, to be avoided in looking upon hemianes- 
 thesia as a thing which stamps a case at once as genuine sim- 
 ply because we cannot say how it is induced. Experto crede. 
 
 The record of two cases will now be given where the hyp- 
 notic condition was even more marked than in any which 
 have preceded. In both the patients there was a history of 
 previous psychical disturbance, and there was insanity, more- 
 over, in their families. Both, I believe, were predisposed to 
 suffer from neurotic disorders should any adequate cause arise. 
 
Railway Injuries. loi 
 
 Case XXIV.— Hypnotic Catalepsy, etc.—B. A. B., aged 
 thirty-six, a strong and active man, wag in a railway collision 
 at night, in which a large number of persons were more or less 
 injured, though the accident was not severe. He complained 
 shortly afterward of having been shaken, and also that his 
 back had received a wrench, owing, he thought, to his sitting 
 sideways when the collision occurred. He had one or two 
 slight bruises on one arm, and a sprain of one wrist. For 
 the first few weeks after the accident there were no symp- 
 toms of constitutional disturbance or of serious injury, but the 
 man said that he could not hold himself upright or walk any 
 distance in consequence of the injury to his back, and the doc- 
 tors who saw him thought that he was to some extent exag- 
 gerating the effects of his injuries. About five weeks after 
 the accident he suddenly changed. He constantly repeated 
 that he was going mad, and that he was sure he was going to 
 be paralyzed. He began at the same time to take violent 
 exercise, walking several miles a day at great speed. This 
 was followed by great exhaustion, during which he was 
 " wandering and hysterical," and there ensued attacks which 
 were described by a medical man who saw him as " hysterical 
 mania." These continued for several days. The state which 
 followed next can only be described in the words recorded at 
 the time. " He is lying in bed on his right side with his knees 
 drawn up. There is not the slightest movement when he is 
 spoken to, or when he is touched through the bed-clothes. 
 There is a continuous quivering of the upper eyelids. Asked 
 to put out his tongue, there is no response, though when the 
 lips are pulled apart he seems to make some effort to open 
 the jaws and protrude the tip. By raising the lids the pupils 
 are seen to be equal in size, and they react normally to light. 
 The aspect of his face is that of complete repose and disregard, 
 but he is obviously not entirely unconscious. Pulse 56. His 
 arms and hands remain in any position in which they are 
 placed. The arms and legs are very much wasted, and the 
 whole body seems emaciated. The legs are at once drawn up 
 spasmodically on tickling the soles, and pinching the calves . 
 evidently causes pain, for he groans and much contorts his 
 face. On touching any part of the chest or abdomen rather 
 firmly with the fingers, the whole body, face, and arms are 
 spasmodically worked, the legs being frequently abducted and 
 
I02 Railway Injuries. 
 
 adducted. The abdominal muscles are almost as hard as a 
 board." He is said to have occasionally an " hysterical fit/' 
 consisting of spasms all over the bod^s beginning- with an ex- 
 pression of fright, and lasting about fifteen minutes. An ex- 
 perienced nurse attending him says they are not like epileptic 
 fits. He takes plentj^ of nourishment, milk and beef-tea, but 
 little or no alcohol. He passes water only once within twentj'- 
 four hours, sometimes groaning beforehand as if in sign to the 
 nurse. The bowels are never moved without enema. He lies 
 for hours absolutely motionless, and three weeks ago he never 
 moved a finger for a whole day, nor passed water once. A 
 serious feature in the case is the great wasting, food, although 
 taken in abundance, seeming to have small influence in main- 
 taining the bodily nutrition, and he looks as if he might sink 
 and die. This condition lasted for about six weeks, and then 
 under the influence apparently of larger doses of alcohol — the 
 increasing exhaustion and wasting having seemed imperatively 
 to call for it — he began to emerge from the state in which he 
 was, to move in bed, to open his eyes, to take more solid food, 
 and even to speak a little very feebly. He was soon able to 
 get up and go about, made flesh again rapidly, and took some 
 exercise. He was, however, very nervous and apprehensive, 
 and felt sure he should never get well. Seven months after 
 the accident he still complained of his back, and held himself 
 in a stooping posture. Questions were answered very slowly, 
 and any required act, such as that of putting out the tongue, 
 seemed to demand an unnatural effort. From this time he 
 continued to improve, and in eight months he was so far well 
 that it was thought riglit and prudent to allow him to arrange 
 his compensation. 
 
 It bears upon the case that the claim was by no means 
 large, and there was no reason at any time to believe that 
 the ir.atter of compensation was unduly affecting the patient's 
 mind. Of far greater importance is the fact that there was a 
 strong family history of insanity. His father and one uncle 
 were " queer," a brother had actually been in an asylum, and 
 his sister is very hysterical. His own account of the condition 
 in which he lay so long is, " that he knew all that -was going 
 on around him, that he remembered when the doctors came, 
 and knew always when there were more of them than usual, 
 
Railway Injuries. 103 
 
 but that he could not speak, and supposed that his brain 
 would not direct him to do so." The sequel of the case is sat- 
 isfactory, the following report of him being obtained two years 
 after his claim was settled, or thirty-three months after the 
 accident: "His recovery was gradual, but without any re- 
 lapses. He married six months after his claim was settled, 
 and has one son about two months old. He has had no ill- 
 nesses, is at present strong and stout, and is emigrating some 
 time this month." 
 
 It is impossible to conceive that the symptoms in a case 
 like this could have been in any way dependent upon injury to 
 the spine, and this much may be said of it, that, when this 
 strange condition supervened, all thought of injury to the 
 spine as a cause thereof passed from the minds of those who 
 were attending him. The man, indeed, himself had shown, 
 by the violent bodily exercise which ushered in the mental 
 disturbance, that there really was no sign of paralysis or even 
 weakness in the legs, and that the pain in the back was very 
 slight indeed. The condition was essentially one of profound 
 mental disturbance originated by shock, immediate fright, and 
 the fear of impending evil, in a man with a strong family 
 taint of insanity. The higher cerebral faculties seemed for the 
 time to be in that state of slumber which has been mentioned, 
 and his general condition was very like that described by 
 Heidenhain and others as occurring in the so-called mesmeric 
 or hypnotic state, and associated with cataleptic phenomena. 
 (Writing of the disturbances of the motor apparatus which 
 have been observed during hypnosis, he says : " More or less 
 extensive cataleptic rigor becomes established; the limbs thus 
 affected remain in any imaginable position they are placed 
 in. The will has, it is true, not wholly lost influence over 
 them, but it is exerted with very great difficulty. If, however, 
 with a great effort, the parts be set in activity, there often re- 
 sults, instead of simple, convulsive movements which spread 
 to other parts of the body."— Op. cit., p. 77.) 
 
 Case XXV. — Hypnotic Catalepsy — Delusions. — Almost 
 exactly parallel with the last case is that of a strong and 
 healthy man, aged thirty, who was in a collision, and who 
 presented the usual signs of having received a sprain of his 
 back and some general shock to his nervous system. He lay 
 
I04 Railway Injuries. 
 
 for long in much the same hypnotic state as the last patient, 
 alternating with fits of violence and passion. When he awoke 
 from this, he became the subject of a delusion that he was 
 being poisoned, and was accordingly removed to an asylum, 
 about ten months after the accident. He remained there six 
 weeks; and while an inmate he adopted a peculiar gait, which 
 lasted up to the time when his claim was settled, two years 
 after the accident, and which formed the ground of a very 
 serious view that he had received a permanent damage to his 
 spinal cord. His mode of walking was thus described when 
 he came out of the asylum : " He puts the weight of his body 
 on two sticks placed in advance of him, and draws each leg 
 alternately forward with the foot much everted. When about 
 to advance one leg he twists the other inward on the toes, so 
 that the latter points forward instead of outward. He keeps 
 the knees quite stiff. In this way he shuffles along with great 
 rapidity. As he stood with his back against the wall, he was 
 asked to lift up his knee, but he professed utter inability to 
 do so." Very careful examination was made at this time as 
 to the nutrition and state of the legs, and a report shortly 
 afterward ran thus : " The reflex irritability and f aradic exci- 
 tability of the muscles of the lower extremities are normal; 
 there is an entire absence of affection of the bladder or rectum, 
 or of any trophic change, such as muscular atrophy and bed- 
 sores. There is also an entire absence of muscular tension, 
 rigidity, contraction, or deformity in the lower limbs. Exam- 
 ination did not enable me to determine whether any affection 
 existed on the sensory side, as the patient absolutely refused 
 to answer any questions. On the whole, my opinion of the 
 case is that it is an example' of many I'ecorded instances, in 
 which a slight and unimportant injury develops various emo- 
 tional and hysterical symptoms." At a final visit made to 
 him before his claim was settled, he complained more than 
 ever of pain in his back, and called out loudly when touched 
 upon his clothes. While sitting in his chair he could move his 
 legs in any direction required of him, though much persuasion 
 was necessary to get him to move them at all. He suddenly 
 vomited without any precedent sign of nausea or retching. 
 Asked to walk across the room, he essayed to do so after 
 much persuasion, and walked in the manner already described. 
 There was no tremor of the legs during progression, and 
 
Railway Injuries. 105 
 
 nothing' like ankle-clonus or the gait which is seen when there 
 is secondary degeneration of the cord. Subsequently, on being 
 asked to go into the next room, he began to do so, but almost 
 immediately fell down flat on the floor, whence he was lifted 
 and carried away. A very large claim for compensation was 
 preferred, and was arranged two years after the accident, not, 
 however, without a resort to litigation. He shortly after- 
 ward left the house in which he had been living, and for some 
 "time it was not known where he was. Forty-two months, 
 however, after the accident, he was fortunately seen by one 
 of the medical men who had visited him during his long ill- 
 ness, and he found him in perfect bodily health and vigor, and 
 the father of another child. It should be stated, as having an 
 important bearing on the case, that the man's previous his- 
 tory was bad. He was always very irascible, and some years 
 previous to the accident he had been laid up with sunstroke. 
 There was also some doubtful history of insanity in his 
 lamily. 
 
 It will not be thought that this case has been mentioned 
 unnecessarily, when it is pointed out that pain in the back was 
 throughout a prominent symptom, and that it was considered 
 by some to be a case of severe injury to the spine. From, the 
 first moinent, indeed, treatment was specially directed to his 
 vertebral column, and a most careless examination of the 
 urine, which was found to be feebly alkaline after it had been 
 standing for some time, seemed to lend support to the diag- 
 nosis that there had been injury to the spinal cord. 
 
 It need cause no surprise that there were wide differences 
 of opinion as to the nature of this case. " Shamming," on the 
 one hand, to sclerosis of the lateral columns, preceded and 
 orig-inated by a meningitis, on the other, formed the two ex- 
 tremes. The truth lay between them, and that opinion proved 
 correct which held that it was essentially a case of functional 
 disturbance, and that as there was no special reason or symp- 
 tom to place any lesion in the spinal cord, the man would in 
 all probability get perfectly well. The previous history of the 
 patient showed that he was liable to serious psychical disturb- 
 ance, but it is only right to add that the motive in this case 
 for maintaining the neurotic state was exceedingly strong. 
 <;!ontrol might have been exercised, I beUeve, by this man far 
 
io6 Railway Injuries. 
 
 more easily than by the previous patient, and the representa- 
 tion of many of his symptoms was not very far from beings 
 wilful. Since this case was originally described, the man has 
 been in another accident, and in support of his claim for com- 
 pensation he again adopted the peculiar gait which has been 
 described. He carelessly forgot, however, to keep it up on all 
 occasions, and the early settlement of his claim was a direct 
 consequence. As to this particular symptom in the case no 
 more need therefore be said. Some parts of a case may be 
 genuine but not all, nor does a real psychical disturbance en-^ 
 able a man the better to resist the temptation to invent or 
 exaggerate symptoms in view of a pecuniary claim. 
 
 Glancing finally over the cases mentioned in this chapter, 
 the number of which might have been multiplied almost in- 
 definitely, it has to be noted that the physical severity of the 
 accident or the bodily injury has obviously but little to da 
 with the symptoms which supervene. Nothing is more cer- 
 tain than this, in searching for a cause of the symptoms, that 
 it is not in bodily injury that the cause is to be found. One 
 man may be hurt in one way, another in another, many are 
 not hurt at all, but the symptoms have all a common causO; 
 best and most comprehensively expressed in the one word-- 
 fright. And varied though the symptoms may be, they are 
 the manifestations of a fright neurosis. This also is the bur- 
 den of the teaching of Oppenheim in the work to which refer- 
 ence has been already made. In his experience, however, and 
 in his view psychical disturbance and change, amounting al- 
 most to insanity, have a more prominent place in the history 
 of his cases than has been my own experience, or is to be met 
 with in the description of cases in the English tongue. Thus, 
 in one place we find him speaking of anxiety growing into a 
 real pathological entity, and of the great majority of the- 
 cases falling into a distinct category of traumatic neuropsy- 
 choses. He is satisfied neither with "traumatic hysteria," 
 nor with " traumatic neurasthenia," as suitable terms to de- 
 scribe the cases which he has himself had under observation. 
 I do not, however, think that "neuropsychosis " is a term al- 
 together applicable to the majority of the cases seen in this 
 country, and I am inclined to believe that there are three 
 main types of functional nervous disorder following injury — 
 the hysterical, seen in France; the psychical, and more mark- 
 
Railway Inpiries. 107 
 
 edly hypochondriacal, seen in Germany; and the neurastheni- 
 cal, seen here. So much, however, depends on the way in which 
 cases of this kind are looked at, that it would be no surprise 
 to me were Oppenheim to see in a hundi-ed English cases typi- 
 cal examples of his own neuropsychoses; Charcot in a hundred 
 German a vast amount of hj'steria ; and an English observer 
 both in French and German cases many symptoms indicative 
 of neurasthenia. All are, I believe, describing the same thing, 
 and neurasthenia, it must be remembered, is itself a functional 
 nervous disorder through and by which many symptoms arise. 
 
 At any rate, if the cases described by Oppenheim are ex- 
 amples of the cases most frequently met with in Germany, the 
 type in that country differs, it seems to me, from the type in 
 this. Not that cases of psychical disorder are not met with 
 here, but that they are far less common than in that country. 
 In some of the cases in my own experience the symptoms have 
 been originated by something more than fright, and there has 
 been a clear history of concussion of the brain, while in others 
 the evidences of nerve prostration or general neurasthenia 
 have been especially prominent. Thorburn relates the case of 
 a woman with left hemiangesthesia (op. cit., p. 196) following 
 severe shock and bruises in the Hexthorpe collision, of whom 
 he writes : " Her mental condition was remarkable. She had 
 an intensely frightened ' scared ' look, like that of a wild ani- 
 mal. She paid little or no attention to her surroundings, and 
 it was with the greatest difficulty that she could be got to 
 answer even simple questions. She was quite incapable of 
 connected speech, but there were none of the emotional mani- 
 festations usually regarded as hysterical." A year later this 
 condition had passed away, although there was still some im- 
 pairment of sensation. Commenting on the case, he says that 
 beyond the hysterical hemianesthesia, there was for a time 
 a profound mental change also of hysterical origin. 
 
 The same writer describes a case of hj'sterical melancholia 
 with occasional suicidal impulses. The man, however, had 
 never attempted to follow them out, and when his claim was 
 settled he improved. In a case quite recently under my own 
 observation, in which there were symptoms of extreme neu- 
 rasthenia, the patient, a man aged thirty-three, suffered for 
 some weeks from the greatest mental depression, had visions 
 of horrible faces before him at night, and suicidal impulses 
 
io8 Railway Injuries. 
 
 wliich led him — himself — to take care that he was never left 
 alone. Thus protected, he never made any attempt on him- 
 self, and when his strength began to return, all thoughts of 
 self-destruction passed away; but so overpowering was the 
 sense and the remembrance of his mental depression that, 
 weeks afterward, he said he wished that he had really com- 
 mitted suicide. This man had been in a very severe collision, 
 and was bruised in many places, but it was not until three 
 hours after the accident, when he was far from the scene of it, 
 that he became unconscious. And on this there ensued the 
 symptoms of nerve prostration, together with slight hemian- 
 assthesia of transient duration, and the mental symptoms 
 which have been named. Six months after the accident, when 
 he was beginning more rapidly and decidedly to improve, he 
 still had an expression of the intensest anxiety, as if he had 
 passed through something very terrible. I do not propose to 
 dwell longer on this class of symptoms, because the type of 
 case to which they belong is certainly not common in this 
 country. The reader must therefore turn to Oppenheim's 
 work for information on the subject. 
 
 These symptoms of mental disorder seeni to me to empha- 
 size in a special manner the fact that most of the results of 
 railway' injury are essentially psychical in origin. Belief in 
 their reality is certainly not lessened by the fact that, in Opr 
 penheim's experience, many of the sufferers were not in a posi- 
 tion to claim compensation for the injuries they had sustained; 
 and at the same time it will not be questioned that the symp- 
 toms of mental disturbance may be readily increased and 
 kept alive by those very things which, in the case of other 
 symptoms, are so prone to work prejudicially and to retard 
 recovery. A very great deal depends also on the manner in 
 which the various complaints are regarded and observed, and 
 no one will deny that the creation and development of all 
 sorts of symptoms may be readily induced, when patients are 
 in this condition, by leading questions which suggest them to 
 their minds. 
 
CHAPTEE YI. 
 
 ON TREATMENT. 
 
 I PROPOSE in this chapter to make a few collective remarks 
 on the principles which should underlie the treatment or gen- 
 eral management of the various cases which have heen con- 
 sidered. It has heen pointed out that compensation very fre- 
 quently exerts an injurious influence on the clinical history of 
 railway injuries, and it may at once he said that were there 
 no question of compensation the treatment of them would be 
 decidedly easier than it is. An endeavor, however, must be 
 made as far as possible to keep this matter in the background, 
 and to discuss the subject of treatment on the assumption 
 that our patients are anxiously desirous to get well, and to 
 have the best that can be done for them in order to promote 
 recovery. 
 
 First of all, as to those spinal injuries, which we have seen, 
 in the great majority of cases, to consist of sprains of muscu- 
 lar and ligamentous structures. The two conditions which 
 have to be remedied are pain and stiffness, and care has of 
 course to be taken that no harm shall ensue from the treat- 
 ment adopted. Diagnosis is, therefore, all-important, and it 
 is essential, by a very careful examination, to make sure that 
 the injury is not of a more serious nature than usual, for the 
 line of treatment which is necessary for the removal of stiff- 
 ness would be that which above all others is objectionable in 
 the case of osseous or meningeal injury. 
 
 Rest and warmth are, in the early, stages, the two things 
 most conducive to relief from spinal pain ; rest by reclining in 
 bed, warmth hy the continuous application of hot fomenta- 
 tions or poultices. In every case, the question has to be con- 
 sidered, " How long ought a man to stay in bed ? " and the 
 answet" to it must very much depend upon the severitj' of the 
 injury, on the character of the pain, and the extent of the 
 
no ■ Railway Injuries. 
 
 spinal column which is involved. There are very few in- 
 stances, however, in which the patient should he longer than 
 three weeks in hed, and in many it is decidedly advantageous 
 that he should be up much sooner. For the longer he is at 
 rest upon his back — and the rest, be it remembered, is simply 
 to allow time for the complete resolution of the subcutaneous 
 injury sustained— the more likely is it that he will suffer from 
 spinal stiffness afterward. This is what we are wont to see in 
 the case of sprains in the neighborhood of the joints of the 
 limbs, and there is nothing in the case of spinal sprains to 
 exempt that part of the body from like consequences. The 
 man must be up and move about; and gentle gymnastic exer- 
 cise each day, such as he himself can make at home, will do 
 much to prevent the increase of spinal rigidity, and to remove 
 that which is already present. Here, however, comes in the 
 difficulty, that the pain which is sure to follow the first move- 
 ments made will be to his mind an unanswerable reason for 
 not moving any more. Compensation is likely to support 
 him in this resolve, and all attempts to get him to move about 
 are likely to be frustrated. The stiffness increases, and is 
 more incapacitating, and it becomes essential, perhaps, to 
 adopt some more definite and vigorous treatment. Massage, 
 it is well known, is of inestimable value in the treatment of 
 sprains and other injuries in the neighborhood of joints, and 
 recently the practice has been advocated of treating sprained 
 joints, and even fractures in the neighborhood of joints, by 
 immediate massage without a preliminary period of rest. The 
 same treatment is to be recommended for the stiffness of a 
 sprained spine, but it must be systematically carried out, care 
 being taken throughout that no undue strain be put upon the 
 system generally, should the bodily nutrition be below the 
 natural standard of health. Especially has this to be remem- 
 bered in those cases where the spinal pain, with its accom- 
 panying stiffness, is the result of weakness rather than of any 
 injury sustained. The weary aching of myalgia, which is 
 prone to arise in all cases of prostrating illness (and we have 
 seen how common is general bodily and mental prostration 
 after railway accident), is not to be remedied by the" vigorous 
 manipulations of the masseur, unless something be done at 
 the same time to improve and build up again the general 
 bodily nutrition. This method of treatment is usually more 
 
Railway Injuries. 1 1 1 
 
 satisfactory in its results than that of faradization of the 
 muscles on either side of the spinal column, although hoth in 
 this manner, and in the galvano-faradization recommended hy 
 De Watteville, there are powerful means for improving the 
 muscular nutrition, calling muscular fibres into action, and so 
 relieving the stiffness. What is wanted is to get some of the 
 muscular fibres which have been disused into action, and if by 
 any chance there has been adhesion of neighboring ligamen- 
 tous fibres because of the sprain, movement is imperatively 
 necessary to start the reparative process. Thus it is that 
 ironing the back with an iron as hot as can be borne is fre- 
 quently an admirable remedy in these cases. The warmth is 
 good in itself, the friction stimulates and restores the local 
 circulation both of capillaries and lymphatics, and the appli- 
 cation of great heat to the skin makes the patient shrink and 
 move, and so calls fibres into action over which he has no vol- 
 untary control. I am altogether opposed to the treatment 
 of these spinal sprains by the application of spinal jackets; 
 they merely postpone to another day the treatment which 
 will have to be carried out, and they moreover tend to in- 
 crease the rigidity, and make the ultimate treatment more 
 wearisome and difficult. Cumbrous in themselves, they do 
 little but harm. Nevertheless, it is certain that patients 
 sometimes find rehef when they begin to go about again from 
 wearing a belt, for it gives support to, and provides warmth 
 for, a part which has the sensation of weakness. Belief also 
 may be given sometimes by wearing a plaster over the loins, 
 belladonna or other; but as a matter of fact the best reUef of 
 all comes in time from daily exercise and leading the same life 
 as before. A neurotic, gouty, or rheumatic history and inher- 
 itance are prone to make all these cases troublesome, and any 
 special element of the kind should never be ignored in consid- 
 ering the question of treatment. 
 
 While, however, the vast majority of the cases with which 
 one has to do are either cases of simple sprain or myalgia 
 from a lowered condition of the general health, the compara- 
 tively few cases in which there is more serious injury out- 
 weigh all the rest in importance. If we are convinced, by the 
 abiding character of the pain or by the involvement of a nerve 
 trunk, that there is inflammation, perhaps with synovitis, of 
 a small spinal joint, or some local meningeal thickening, then 
 
112 Railway Injuries. 
 
 it is very obvious that a wholly different line of treatmeni; 
 must be adopted. Rest, local rest, must be rigidly enforced, 
 and such help in the absorption of inflammatory products as 
 is likely to be given by local counter-irritation must not be 
 neglected. Further, if there be any suspicion of syphilis, influ- 
 ence must be brought to bear on that element in the case by 
 those special remedies with which all are familiar. Above all 
 things, it is important that the patient be kept under careful 
 observation. 
 
 Passing now to the symptoms which frequently accom- 
 pany spinal sprain, but which are nevertheless independent of 
 it and are often found alone — those symptoms which are col- 
 lectively indicative of neurasthenia — the essential line of treat- 
 ment to be adopted is to keep up the bodily nutrition. A 
 word, however, may first of all be said about the medicinal 
 treatment of these cases, emphasizing at once and decisively 
 that there is no specific remedy. We all know how much of 
 fashion there is in medicine, and in the days when bromide of 
 potassium was administered for almost every form of nervous 
 disease it was the custom to flj- to bromide, under the impres- 
 sion that a sedative was essential to quiet the nerves. In the 
 early stages of severe mental shock, with its sleeplessness, 
 general nervousness, and agitation, it is certain that bromide 
 of potassium occasionally brings considerable relief; but al- 
 though every one can take a casual dose of bromide without 
 harm, the continued taking of it is likely to be most injurious. 
 And in my former work, as well as in a special clinical lecture 
 on the subject (" The Abuse of Bromide of Potassium," " Medi- 
 cal Times and Gazette," Vol. I., April 4th, 1885), I ventured to 
 point out how much, and how often, harm had been done in 
 the management of these cases by the administration of 
 bromide of potassium in frequent doses over long periods of 
 time. And it is absolutely true that the convalescence of 
 many patients has only begun when the bromide so adminis- 
 tered has been withheld. The symptoms of bromism, be it 
 remembered, are essentially those of general depression both 
 mental and bodily, irritability of temper, a continued feeling 
 of exhaustion and incapacity for any work, intellectual dul- 
 ness and loss of memory, a sense of utter feebleness, a tend- 
 engy to be despondent and to cry, and loss or impairment of 
 sexual desire. These, it will be recognized, are very much 
 
Railway Injuries. 113 
 
 the symptoms of general nervous exhaustion after railway 
 collisions ; and it is certain that the continued administration 
 of bromide of potassium is likely to do them harm, and seri- 
 ously prevent their removal. As Dr. Anstie pointed out many 
 years ago, it is only those who are in vigorous bodily health 
 who can bear its prolonged administration. It is the potas- 
 sium which is the injurious element in the salt, and if it be 
 merely desired to produce sleep and quiet let the bromide of 
 sodium or ammonium be given in preference. 
 
 One of the greatest and most frequent difBculties in these 
 cases is to procure sleep, and the whole round of the Pharma- 
 copcBia may be almost gone through without success. Of 
 opium compounds the bimeconate of morphia is often the least 
 injurious, and sulphonal and chloral, with or without bromide, 
 are sometimes useful. I have no faith, however, in any one 
 remedy, nor is any one infallible. The patient is often much 
 better without them, and if he sleeps much or little during 
 the day there need be less concern as to his not sleeping at 
 night, provided that at night he is not left alone to work him- 
 self into a state of nervousness, agitation, and fear. Alcohol 
 is of little or no use in these circumstances, and it may be said, 
 once tor all, that patients with the symptoms of general nerve 
 prostration can rarely bear it. In the majority of cases, how- 
 ever, it is not the want of sleep which is so harmful, but the 
 want of food. 
 
 It has already been pointed out how often disturbances of 
 digestion accompany the symptoms of general nervous ex- 
 haustion; they do something more than accompany, they are 
 in themselves important signs of the condition; and it is sim- 
 ply an inevitable part of the condition that the patient cannot 
 take ordinary food in the ordinary way. In a word, the notion 
 that he can subsist on his usual three meals should as soon as 
 possible be abandoned, for otherwise it is practically certain 
 that he will obtain an insufBciency of food. The consequence 
 is this, that the already exhausted nervous system is prone to 
 become more exhausted still from the want of proper nutri- 
 tion. The rapid wasting that is sometimes seen in these cases 
 is often quite as much due to the want of food, as to any direct 
 effect upon the nervous centres themselves. Easily- assimila- 
 ble food must therefore be given in small quantities at fre- 
 quent intervals, and neither at night nor by day should the 
 
114 Railway Injuries. 
 
 patient be long without it. Just as convalescence has fre- 
 quently set in when bromide of potassium has been withheld, 
 so also it is true that convalescence is frequently seen to begin 
 at the moment when special attention is directed to this mat- 
 ter of providing adequate nutrition and food. And what fol- 
 lows in its train ? An improved sense of bodily well-being 
 and a diminution of the myalgia from easily-induced muscular 
 fatigue, and, above all things, very often the return of some- 
 thing like natural sleep. Food is the thing to break through 
 the vicious circle which encompasses the patient. 
 
 There is yet that other class of cases in which the volun- 
 tary taking of food is difficult, and where there is perhaps a 
 more decidedlj^ hysterical element acting prejudicially on the 
 symptoms. The symptoms alone defy treatment; the patient, 
 if the expression may be used, has to be treated as a whole. 
 His surroundings are objectionable, and the sympathy of his 
 friends is misdirected and injurious. Removal from home is 
 almost an essential part of the treatment, and there are, per- 
 haps, few cases in which the Weir Mitchell treatment in its 
 entirety — isolation, massage, and excessive feeding — is so likely 
 to be followed by good results. Isolation frees him from that 
 sympathy which fosters and keeps alive the mental attitude 
 of the patient toward his own case, and the feeding, together 
 with the massage, provide the nutrition and the physiological 
 stimulus of exercise of which he is so sorely in need. It is 
 verj' often, of course, a matter of considerable difficulty to in- 
 duce patients to undergo this treamtent, for reasons which are 
 sufficiently obvious. Here I can do no more than say of how 
 much benefit it is likely to be, and how eminently true this is 
 of the cases Avhere there is some definite neuromimetic sign of 
 nervous derangement. Isolation will at any rate be an obstar 
 cle to frequent examination of the patient, a thing which is so 
 prone to keep alive the manifestation of any special nervous 
 symptom. 
 
 Be it further borne in mind that in all these cases of ner- 
 vous exhaustion rest is a very essential thing in their man- 
 agement, and it is a matter of supreme importance that at no 
 stage of the illness shall the symptoms be aggravated by the 
 exhaustion of overwork. If a man has his leg broken he is of. 
 necessity doomed to rest, but it is far otherwise with the man 
 who has not met with any physical injury such as to prevent 
 
Railway Injuries. 115 
 
 Mm from gomg to his wo.k the day after the accident. He 
 feels only a little shaken, but nevertheless it is eminently ad- 
 visable that such a man should for a time rest quietly at 
 home. I am sure that in very many cases the severity and 
 continuance of the symptoms have been due to want of rest at 
 first. The precaution of complete rest may wisely be adopted 
 in all cases of railway injurj', be the early symptoms never so 
 slight; and at a later stage it is equally certain that no per- 
 fect rest can be enjoj^ed, when a man is worrying about com- 
 pensation; just as the enjoyment and rest of a holiday are 
 assuredly destroyed, when a man has his letters sent after him 
 to plague and annoy him. 
 
CHAPTEE YII. 
 
 MALINGERING. 
 
 " Is the condition before us real or feigned ? " is a question 
 which we have sometimes to aslc ourselves in the routine of 
 practice. A correct answer to it is obviously of great moment 
 \o both doctor and patient; and I propose, therefore, to say- 
 something on the special kind of malingering which may be 
 met with after the injuries, or after no mjuries, received in 
 railway accidents. It may be well, however, in the first place, 
 to name some of the points which have to be borne in mind 
 in the endeavor to come to a right conclusion, that we may 
 decide whether the signs of disease before us be real or as- 
 sumed, or the complaints we hear be genuine or the outcome 
 of wilful exaggeration; whether, indeed, to adopt the classifi- 
 cation of Ogston, the disease be feigned, factitious, exagger- 
 ated, or aggravated. It is a common experience that most 
 feigned disorders have in them some basis of reality, or some 
 revival of the symptoms of a former lesion or injury used 
 again for purposes of deception. Familiarity with the phe- 
 nomena and history of disease can alone, therefore, enable a 
 man to pronounce with certainty as to the real nature of any 
 particular disorder, and to detect the mistakes into which 
 mahngerers so often fall. 
 
 An apt illustration may be taken from the attitude and 
 position of joints in real and assumed disease. By his loud 
 complaints a man may wish to suggest the presence of de- 
 structive mischief in a joint, but in all probability he will go 
 wrong in the attitude and position which he gives to his limb. 
 Or without pretending to be afflicted with actual joint disease, 
 a patient will sometimes affirm that a joint has become stiff, 
 and that it is impossible to move his arm or leg. It is un- 
 necessary to make any mention here of the recognized causes 
 of stiffness and anchylosis of joints; suiHce it that the entire 
 absence of them, both in the history of the case and in the 
 
Railway Injuries. wj 
 
 course of the disease, will reveal a flaw in the evidence suffi- 
 cient to raise suspicion. Suspicion grows into tolerable cer- 
 tainty if you are caxeful to observe the conduct of the person 
 under examination. 
 
 A man complained that he could riot work because of stiff- 
 ness in the right elbow and inability to straighten his arm. 
 He said he had fallen on his elbow a month before, but it was 
 clear from his answers to questions that the injury had not 
 been at all severe. Comparison of the two elbow-joints showed 
 an entire absence of physical signs, and there was no wasting 
 of the limb. Noticing, in examination, that attempts to flex or 
 extend his arm were forcibly resisted, he was told to look in 
 the opposite direction, questions were asked him unconnected 
 with his arm, and there was no diflBculty in bringing it at once 
 to natural and full extension. A turn of his head and eyes 
 toward the affected limb was immediately followed by active 
 flexion to the original degree. Complete flexion also could be 
 produced under like circumstances. Examination of both 
 arms simultaneously seemed to confuse him, for he called out 
 with pain when pressure was made on the sound limb. Such 
 inconsistencies as were met with here ought, at any rate, to 
 place us on our guard. A man based a large demand for 
 compenstion from a railway company on stiffness of his elbow 
 and inability to move his arm, the result of a collision. A 
 verdict incommensurate with his expectations having been 
 recorded, he threw up his arms and exclaimed, "My God! I'm 
 a ruined man." 
 
 Furthermore, an impostor may adopt devices to produce 
 conditions, which, in themselves alarming, are yet seen to be 
 without significance when every feature of the case is exam- 
 ined. A prisoner took to his bed complaining of great pain 
 and swelling of the abdomen. Although the belly was enor- 
 mously distended and tympanitic, there was no other sign of 
 illness about him, and there was an entire absence of any one 
 condition on which tympanites usually depends. After a few 
 days' observation, and having carefully weighed all the facts 
 of the case, the surgeon came to the conclusion that the man 
 purposely induced the distention by swallowing air. Loudly 
 enough for the prisoner to hear him, he accordingly remarked 
 to the warder, " When I come to-morrovs^ I shall bring an in- 
 strument to tap him." On the morrow the tympanites had 
 
ii8 Railway Injuries. 
 
 disappeared. (The same method of imposture is recorded by 
 Gavin [" Feigned and Factitious Diseases," p. 299], who writes : 
 " This affection, tympanites, has been so successfully feigned 
 as to deceive a board of French medical offlcers; but this in- 
 dividual possessed the extraordinary power of greatly distend- 
 ing his abdomen by swallowing air. He, however, obtained 
 an unqualified exemption from military service by presenting 
 himself in this state, with clothes made for the occasion.") 
 
 More common are the cases where patients assure you that 
 they are losing blood in large quantities from the bowel. 
 The causes of hemorrhage from the bowel are well known, 
 although an exact diagnosis may be sometimes diflftcult be- 
 cause of their very number and variety. The malingerer, 
 however, does not know that profuse hemorrhage — and it is 
 of profuse hemorrhage of which he invariably complains — 
 gives rise to well-defined symptoms due to loss of blood. Who 
 ever saw a patient losing blood, either in alarming quantities 
 or in small amounts spread over a long time, with a florid 
 lip, a tranquil pulse, a cool skin ? Should not the presence of 
 every indication of health warn us that we have to deal with 
 something altogether unusual ? Should we be doing rightly 
 if we paid little or no attention to the general condition of the 
 patient, and endeavored to estimate his case by simply hear- 
 ing the story he told us, without examining the blood which 
 he showed ? By neglect of such simple precautions an errone-' 
 ous diagnosis was made of a case where pints of blood, not the 
 man's own, were presented as having been passed per rectum; 
 and the same thing happened in another case where a man 
 showed, from the same supposed source, prodigious quantities 
 of " blood and corruption." Both were cases of imposition — 
 subsequently known and proved — after railway accidents; and 
 yet in both of them the fraud was successful. Surely when 
 conditions such as these occur alone, when there is neither 
 discoverable cause, nor the usual, inevitable result, one ought 
 to be able to say of them at once, " Impossible, untrue ! " 
 
 In the same category it is not amiss to refer to dilatation 
 of pupil induced by the use of atropine, a point of some im- 
 portance, because it has been shown in a previous chapter that 
 a wide sluggish pupil is a valuable sign of loss of nerve tone. 
 " The access to atropine or belladonna," writes Mr. Hutchin- 
 son, "on the part of the public is now so easy that we cannot 
 
Raihvay Injuries. 119 
 
 be surprised that we encounter mydriasis as the result of an 
 accidental and perhaps unknown use of this agent, or of its 
 use with intention to deceive. It is the first question which 
 will occur to a surgeon on seeing a dilated pupil, ' Has atro- 
 pine been used ? ' and he must be on his guard in cases of 
 hasty denial. . . . Not infrequently the ophthalmic surgeon 
 has to encounter cases of intentional deception. These occur 
 usually in young women of emotional tendencies. ... A 
 highly-cultivated young lady consulted me for ' pemphigus.' 
 She had blebs all over the left half of her body. But these 
 blebs were, some of them, not round but oblong, in a style 
 which no skin disease ever- assumes, and very obviously the 
 result of the application of a brush. She was liable also, I 
 was told, to attacks of dilatation of the pupils and loss of abil- 
 ity to read. These attacks usually lasted a week. This case 
 is only an example of what has frequently come under my 
 notice. Although it is possible to use atropine in such a weak 
 solution that the ciliary muscle is not affected, yet in most of 
 these cases a more complete effect is obtained, and the loss of 
 power to read is produced in addition to mydriasis. If the 
 latter be present alone, and if it persist for long, the suspicion 
 of deception may be put aside." (" On the Symptom-signifi- 
 cance of Different States of the Pupil," " Brain," Vol. I., p. 463.) 
 In all cases where the use of atropine is suspected, it is essen- 
 tial to examine the patient frequently, and carefully look for 
 some concomitant and confirmatory symptom of nerve dis- 
 turbance. The pupils, moreover, it need hardly be said, must 
 be examined both in light and shade; and it should be borne 
 in mind that, where there is inequality of the two pupils, the 
 dilated pupil need not necessarily be the one affected. The 
 pupil which is the smaller of the two may, for example, be 
 unable to dilate, and be the one really at fault, because of 
 sympathetic paralysis— a condition of things by no means un- 
 known after organic injury to the lower cervical spine. The 
 question might here arise whether eserine had been used, but 
 I am not aware that eserine can induce the other signs of 
 sympathetic paralysis— shrinkage of the globe, and contrac- 
 tion of the palpebral fissure. 
 
 Let it not, moreover, be forgotten that any kind of old in- 
 jury, deformity, or want of perfect symmetry may provide 
 the malingerer with the opportunity for the practice of im- 
 
I20 Railway Injuries. 
 
 posture. Hydroceles, varioceles, and herniae; fatty tumors, 
 sloughing gummata, and sebaceous cysts; distended bursee, 
 and anchylosed joints from long-past disease, are some of the 
 conditions, which, in my own experience, have been attempted 
 to be palmed off as the result of railway shock. No man who 
 knows his business can be taken in by such things as these. 
 Great care, however, must be alwaj's exercised in the exam- 
 ination and estimation of abnormal conditions which may be 
 presented, that no injustice may be done a man in coming to 
 a hasty conclusion'that he is malingering. 
 
 It is singular, for example, how ignorant some persons 
 seem to be of the existence of deformities, or states of body, 
 which must have been endured for a long time. 
 
 Case XXVI. — Case of Old Lateral Curvature of the 
 Spine — Condition Unknown to the Patient. — A man, seventj' 
 years of age, came to St. Mary's Hospital, complaining of pain 
 over the right side of the thorax. When he had been stripped, 
 it was found that he had lateral curvature of the spine to an 
 extreme degree. He said that this condition was of quite re- 
 cent date, and that he had only noticed it since he felt the 
 pain. Judged by itself alone his story was enough to cause 
 alarm; but, both from the ossification of his costal cartilages, 
 and from the fact that there had been no alteration in his 
 stature, it was clear that the spinal curvature was of old 
 standing, in all probability nearly as old as the man himself. 
 Had it been an acute change at this time of life, and had the 
 pain which brought him to the hospital been due to the curva- 
 ture, or been a symptom of some serious malady which lay 
 behind it, a simple liniment and a tonic would hardly have 
 restored him in a short time to his usual state of health. 
 
 So also the absence of perfect symmetry between the two 
 halves of the body, some trifling difference in the facial lines, 
 or slight excess in size of one limb over the other, and of one 
 half of the spinal muscles over the other half, may be regarded, 
 when taken by themselves, as evidence of very grave disease. 
 
 Case XXVII. — Paralysis from Pressure on Musculo-spi- 
 ral Nerve — Accompanying Facial Asymmetry. — ^A laborer, 
 aged forty-two, came to the hospital on June 13th, saying 
 
Railway Injuries. 121 
 
 that on waking from his usual nap after dinner the previous 
 afternoon, he found his right arm and hand " numb," his An- 
 gers and thumb flexed, and his wrist dropped. This paralysis 
 of the extensor muscles was partial only, and was accompanied 
 by some tenderness above the elbow on the inner side of the 
 arm, and by a small anaesthetic area over the ball of the 
 thumb. As usual, recovery was slow, and, although he was 
 then able to work, he had not regained full use of his wrist 
 and hand when he was seen six weeks afterward. Interesting 
 though this part of the case may be, the special point about 
 it was the fact that the left side of the man's face was almost 
 entirely wanting in facial lines, while their presence on the 
 right side gave him the appearance of having left facial pa- 
 ralysis. To the palsy of the arm there thus appeared to be 
 added paralysis of one side of the face, and the combination 
 might have suggested grave disease, had not a careful inquiry 
 into every circumstance of the case led to the diagnosis that 
 this asymmetry was peculiar to the individual. And this 
 opinion was subsequently confirmed by the patient himself. 
 Yet how easily, under the besetting temptations of railway 
 injury, might a hastily-expressed conclusion as to the patho- 
 logical origin of such a state have given an unscrupulous 
 patient the opportunities of using his natural peculiarity for 
 purposes of deception and fraud. We meet with such condi- 
 tions every day, and it is of supreme importance to recognize 
 and rightly estimate them, not onlj' that we may allay the 
 anxiety of the patient who honestly believes his old complaint 
 is new, but also that we may nip the means of deception in 
 their very bud, and not ourselves unwittingly befriend the im- 
 posture. 
 
 I shall not attempt to enter in any detail into the feignings 
 of paralysis and kindred nerve diseases. The same principles 
 must guide us, and we shall And them very seldom fail. The 
 artifice may be clever and well devised; it may be long sus- 
 tained and free from variation; but it is very difficult, and 
 therefore rare, for the malingerer to simulate a real disease 
 with accuracy. He exaggerates; that which he could not do 
 he does; he will not do that which he could do if his state 
 were real; and you find that his symptoms are such as you 
 have never seen or known resulting from any affection of the 
 
122 Railway Injuries. 
 
 brain, the spinal cord, or the nervous system generally. Sub- 
 jective symptoms largely predominate, and you observe that 
 such objective symptoms as he has are mostly those over 
 which he can exercise his will. He cannot make his eyehd 
 droop; his tongue does not always deviate, nor is the angle of 
 his mouth always drawn; he knows not how to paralyze his 
 bladder; there are no bed-sores; he does not waste; his palsied 
 limb resists examination; his flits occur at convenient moments 
 when he cannot harm himself, or when he can be under the 
 observation of those who do not know their import or their 
 signs; in his coma he is not unconscious; and added to all he 
 has the aspect of health, nor is any vital function deranged. 
 (" In peripheral paralysis of the facial the expression of the 
 face is very striking, for, owing to the loss of muscular ten- 
 sion on one side, it falls, while the opposite side is drawn up. 
 This distortion is much increased in smiling or talking, or 
 whenever the influence of the will is exerted on the muscles " 
 [Wilks, op. cit., p. 439]. But in laughing or talking the impos- 
 tor moves, he cannot help moving, the paralyzed side, and the 
 asymmetrj'- becomes less instead of more obvious. I have a 
 case in mind.) 
 
 The so-called functional, hysterical, and neuromimetic dis- 
 orders have many symptoms which often look like imposture, 
 but I believe that the sufferers who present them are prone to 
 deceive themselves more than other people. That the mani- 
 festations of hysteria are not necessarily feigned, or due to 
 expectant attention, is indeed shown by the fact that they 
 may be found even in young children, who have what may be 
 called the requisite hysterical neurosis. 8ome remarkable 
 cases of " hysterical analgesia in children " recorded by Dr. 
 Barlow ("British Medical Journal," Vol. II., p. 892, 1881) 
 show conclusively that a symptom of hysteria, which in the 
 adult may lead to the suspicion of imposture, may be -seen in 
 children so young that the very idea of feigning is out of the 
 question. As I have already pointed out, the one common 
 characteristic of all these cases lies in a strange perversion 
 and abeyance of volitional power or will, whereby each action, 
 word, and thought seem to run riot, as it were, for want of 
 due control. Largely unreal and independent of structural 
 change, the symptoms admit of easy exaggeration and repre- 
 sentation whenever the uncontrolled whim of the moment al- 
 
Railway Injuries. 123 
 
 lows; but having- grown, step by step, out of slighter condi- 
 tions which there was neither the wish nor the determination 
 to subdue, they seem in their very nature to exclude deliberate 
 imposture. Practically, too, the kind of treatment these dis- 
 orders require is very different from that which suffices to 
 cure ailments altogether feigned. Be the condition, however, 
 what it may, to the patients themselves it is very real: the 
 pain, the stiffness, the palsy, are as great to them as they are 
 described, or as full of evil consequences as it is imagined and 
 believed. The symptoms may be of little moment in them- 
 selves, but it is wrong to look upon them as altogether feigned. 
 
 The cases already given in illustration of some of the points 
 and principles, which it behooves us to bear in mind, have been 
 designedly drawn from ordinary hospital work; and they are 
 of value in showing that no special practice is required to 
 teach important lessons bearing upon the subject, and that 
 these can be learned from cases which are met with everj' day. 
 
 As I have already said in speaking of the after-history of 
 nervous shock, so now in turning to the more special topic of 
 malingering after railway accidents, it must be acknowledged 
 that ordinary hospital patients provide little opportunity for 
 gaining familiarity with the kind of malingering with which 
 we have now to deal. This, however, has to be noted, that, 
 whatever may be said of every other form of malingering, 
 there is no obscurity or doubt in the case of railway injuries 
 as to the motive which may induce a man to exaggerate or to 
 assume symptoms of disease. It may be summed up in the 
 one word " compensation," to which the law of the land en- 
 titles him, whether for damage to his person or loss in his 
 business consequent on the negligence of the public company 
 which had engaged to carry him. Has his injury been great; 
 has he lost a limb, or been otherwise maimed; or has his life 
 been then, or in the future, imperilled; it is almost needless to 
 remark that, while no money can adequately compensate him, 
 the amount to be paid him must of necessity be large. When, 
 however, the injury is trivial and passing, when there is neither 
 structural damage nor prospect of lasting enfeeblement of 
 body or mind, it is evident that the amount of money sufficient 
 to compensate him ought to be very small. And herein, in 
 the endeavor to gain large compensation for small injuries, 
 the malino-erer finds reason and excuse for practising decep- 
 
124 Railway Injuries. 
 
 tion m order to magnify his claim. The motive is one re- 
 quiring great moral courage to resist. Many a man, whose 
 character hitherto has known no stain, has yielded to the 
 temptation, and has thereby lowered himself in general es- 
 teem. It is not the language of sentiment but of sober fact, 
 when it is said that whole households are sometimes made 
 miserable by the devices to which it is needful to resort, in 
 order to obtain the desired end. Hopes are conceived of future 
 gain, thoughts are centred on the one aim in view, and there 
 is but a sorry consolation when the day of reckoning has 
 come. So powerful indeed is the motive that you find persons 
 taking to their beds, abstaining from food, shutting them- 
 selves up, neglecting their business, and making themselves 
 weak in body and wretched in mind. While, however, this 
 has to be written of those who wilfully malinger, it would be 
 doing many an injustice if we did not recognize that prospec- 
 tive compensation may exert a. retarding influence on the 
 process of recovery quite apart from any deliberate imposture. 
 Entitled as he is to compensation, it is only natural and right 
 for a man to feel anxiety, both in his own interests and in the 
 interests of his family, that compensation should be adequate 
 and fair, and a nervous, yet really honest, dread may be en- 
 gendered lest some mistake be made in the settlement of a 
 rightful claim. The injurious influence of any such nervous- 
 ness and suspense is sufficiently obvious, and it may some- 
 times be a matter of no small difficulty to determine whether 
 the protraction and aggravation of a man's illness are really 
 due to one cause or the other — to wilful imposture taking the 
 form of not choosing to recover, or to the unconscious weight 
 round his neck which arises from apprehension as to compen- 
 sation. I have never known any difficulty, however, in mak- 
 ing the honest sufferer understand how and why the settle- 
 ment of his claim for compensation will, more readily than 
 drugs or change of air, promote his recovery and work only 
 for his good. Some may think that there need not be much 
 regard for the feelings of an impostor. 
 
 Curiously alike are the means of deception adopted in dif- 
 ferent cases, and it is extraordinary how persons in the hum- 
 bler walks of life possess a knowledge of the kinds of injury, 
 which are popularly deemed inevitable in a collision. Provin- 
 cial journals are to some extent responsible for this, for in 
 
Railway Injuries. 125 
 
 them are often to be found in considerable detail the history 
 and symptoms of those who, by litigation or otherwise, have 
 received compensation from railway or tramway companies. 
 And if a man has in this way learned that large compensation 
 was awarded for injuries apparently like his own, it is a great 
 temptation to him to adopt courses which seem to him poten- 
 tial of future gain. A publican well up in years made an 
 exorbitant claim for trifling injuries. His enlarged prostate 
 gave rise to the usual symptoms, but when it was pointed out 
 to him that this was the real cause of his urinary trouble, he 
 replied, " No, it is mj' spinal cord to which all my symptoms, 
 are due." "Drag your leg, you fool; don't you see the doctor 
 coming ? " called out by a workman to his fellow, who had 
 been in an accident, and heard by the doctor as he was then 
 crossing the yard to see him, was but the audible expression 
 of many a like lesson, which may be learned with ease in the 
 solitude of a sick-room. And as the views of the nature of 
 railway mjuries have changed, so also has there been a nota- 
 ble change in the methods of imposture. Ten years ago the 
 malingerer could not walk, or he dragged his leg because of 
 some obscure injury to the spine; nowadays he presents an 
 admirable picture of nerve prostration, for his nervous sj^stem 
 has had a severe shock, the consequences of which are readily 
 induced by abstinence from food. This is unquestionably a 
 far better way of malingering than the endeavor to simulate 
 some spinal disease, for the fraud in that case can be soon 
 found out ; but in the case of wilful starvation it is only a 
 question of time when your waistcoat will hang flabbily about 
 you, and you can measure at any automatic, and thoroughly 
 trustworthy', machine the number of stones you have lost in 
 weight. It caused no surprise at all that a man, who had 
 been going about on crutches for months, should have led off 
 the dance at a ball which he gave to his rejoicing friends at 
 the close of litigation; but I have heard expressions of genuine 
 amazement at the speed with which the human form divine 
 has sometimes put on flesh. 
 
 And yet it is unusual, in my experience, to meet with cases 
 where it would be possible to say with certainty that no in- 
 jury has been received at all. The pain of some trifling bruise 
 or strain is exaggerated and unduly prolonged, and thence 
 are developed other conditions and complaints, in whose very 
 
126 Railway Injuries. 
 
 obscurity lie the ready means of untruthfulness and deception. 
 The still wide-spread, yet erroneous, impression, that the effects 
 of a railway collision are likely to he remote, does much to 
 foster a sense of uncertainty and alarm, and to give the ma- 
 lingerer scope for the course which he intends to pursue. And 
 so it comes to pass that it is after the most trivial accidents, 
 or in cases where no definite injury has been sustained upon 
 which to base a claim, that we hear niost often of the obscure, 
 subjective, and intangible symptoms and complaints, which 
 are supposed to indicate some serious damage to the nervous 
 system, and to forbid all prospect of future recovery. Is it 
 not a strange anomaly, something altogether extraordinary, 
 that it is only the slightest injui-ies which are followed by 
 these purely s'ubjective symptoms, whose very obscurity gives 
 rise to alarm ? Is not some light, however, thrown upon them 
 by the facts of accumulated experience, that these symptoms 
 vanish and the complaints are no more heard when the motive 
 for their existence is at an end ? Have we not strong grounds 
 for doubting their genuineness and reality ? Are we right in 
 ignoring the absence of early symptoms and signs of injury 
 or shock, and in assuming that a condition is alarming, or a 
 prognosis grave, simply from assurances of the patients them- 
 selves ? And yet this is what is seen far too often in dealing 
 with cases of alleged injury after railway accidents. Little 
 regard is paid to the early condition and to the actual state of 
 the patient, and undue attention is given to ceaseless com- 
 plaints of hidden symptoms, whose real existence you should 
 be all the more cautious in acknowledging, being as they are 
 without objective signs, and traceable to no injury met with 
 in the beginning. Time runs on, the complaints become louder 
 and more continuous; and forensic eloquence, it may be, is 
 left to tell a harrowing tale of the frightful collision, and of a 
 nervous system shattered and beyond repair. 
 
 I trust that I am not myself lapsing into the " region of 
 nisi prius." These are facts, however, and it would be well 
 if they were more widely known. That cases of severe and 
 unquestionable injury should usually go on to recovery, or to 
 such restoration as the nature of the injury will allow; and, 
 on the other hand, that cases of slight injury, from which re- 
 covery without complication or sequelae is, in other circum- 
 stances, the rule, should after railway collision be followed by 
 
Railway Injuries. 127 
 
 innumerable and protracted subjective symptoms on which 
 not a finger can be laid, are facts to arrest attention and to 
 call for explanation. And the simplest explanation is the 
 best. In the one set of cases there is an obvious basis of com- 
 pensation for the definite injuries received; virhile in the other 
 there is little or none, and there arise exaggeration and un- 
 reality, and subjective symptoms to make the specious founda- 
 tion of a claim. But enough, perhaps, directly and indirectly, 
 as to the motive for malingering. It is notorious, and it has 
 an all-powerful influence over the course and symptoms of 
 railway injuries. 
 
 Let us now learn from definite examples something of the 
 ways of malingerers. 
 
 Case XXVIIL— ,S'^^■grAi Sprain and Nervous Shock- 
 Protracted Symptoms from Wilful Starvation.— A travel- 
 ling agent, aged fifty-eight, received, in a trifling collision, a 
 blow over the right iliac crest. He complained to a fellow- 
 passenger at the time, so he said, of being hurt, and of feeling 
 rather faint. There was never any mark of bruising, and his 
 niedical attendant— a hospital surgeon well able to judge — 
 thought his injury altogether trivial. The patient, however, 
 abstained from his work; nor did he resume it until eleven 
 months had passed away. During this time he complained of 
 pain about the right hip, which compelled him to use a stick 
 and made him walk lame; of pain in the head; of inability to 
 sleep; of poor appetite and nausea; of constipation; of such 
 general weakness as to prevent him from walking a mile, and 
 that only now and then ; of impaired vision, so that he could 
 only read the largest type; of loss of memory; and of incapac- 
 itj' to apply his mind to anything, so that neither physically 
 nor mentally did he feel himself flt for any occupation. He 
 frequently stayed in bed for the whole day, and rarely got up 
 before twelve; for days together he never went out-of-doors, 
 and he took the very smallest quantity of food. Thus he 
 gradually acquired a worn and anxious aspect, and looked 
 pale, thin, and ill. 'So known means of examination were able 
 to discover any sign whatever of injury or disease; and al- 
 though he twice undertook journeys of some two hundred 
 miles to be seen by a well-known oculist, could I ever, with 
 the ophthalmoscope, find a trace of disease in his eyes, or any 
 
128 Railway Injuries. 
 
 cause for his loss of vision. No remedies adopted seemed to 
 have the slightest effect upon him. Liniments did not soothe 
 his pam, soporifics did not make him sleep, and tonics im- 
 proved neither his appetite nor his strength. On only one oc- 
 casion did he give a clue to the absence of perfect genuineness 
 and reality in his case. To the surgeon who had several 
 times examined him by request of the railway company, the 
 patient one da-y remarked as he left the house, " You've got a 
 cobweb on your hat, perhaps you'd like to brush it off." He 
 was known to be at this time, and he had been formerly, in 
 pecuniary difficulties. He made a very large claim. This 
 was ultimately settled, and he forthwith went into the coun- 
 try for change of air. He returned home in a fortnight look- 
 ing and saying that he was in every respect perfectly well. 
 He resumed his work at once, and continued it for many years 
 after the accident. Could recovery in this case have taken 
 place in so short a time had the symptoms and complaints not 
 been purposely induced, maintained, or fabricated ? Is it not 
 as well-nigh certain as can be that had not the prospect of 
 compensation held out the temptation to this man to make 
 the very worst of his injury, with, the hope of pecuniary profit 
 to himself, he would have been laid up for not more than two 
 or three days ? And yet he was an invalid for eleven months 
 — a wretched picture, indeed, of induced malaise; but a malin- 
 gerer nevertheless, purposely maintaining his condition in 
 order to increase his claim. 
 
 Case XXIX. — Physical Injuries — Nervous Shock — Early 
 Recovery. — Two cases out of the same accident, those of a 
 father and son, may be compared. The father, a man in a 
 small way of business, aged fifty-eight, was seen in bed at an 
 hotel in a provincial town the morning after a bad collision. 
 He was unable to give any account of the accident, having 
 been stunned by a blow which had closed both his eyes. He 
 had also a broken rib, and was much bruised elsewhere. He 
 had had about two hours' sleep in the night, had rallied, and 
 felt better. A week later he was still mending, and although 
 he was pulled down by rather severe epistaxis, he was able in 
 twenty-four days to be moved home. There he continued to 
 go on well. In six months his claim Was arranged without 
 trouble for a. reasonable sum, and when I saw him three 
 months afterward he looked and said he was perfectly weU. 
 
Railway Injuries. 129 
 
 Case XXX.— Slight Injuries— Prolonged Complaints- 
 No Evidence of Ill-health.— The son, a strong and powerful 
 man, aged twenty-four, a messenger by occupation, was not 
 stunned, and was able to help his father to the hotel. When 
 seen on the following day he said he had had a good night, 
 but that he felt rather shaken. He had a slight bruise on the 
 right knee, and a simple fracture of the third metacarpal bone 
 of the left hand. A week later, to my astonishment, I found 
 him still in bed, but neither in aspect, temperature, nor pulse 
 was there anything abnormal, and he had been able to eat 
 and enjoy, from the very morning after the accident, three 
 meat meals a day. He was ordered up, and he would have 
 been sent home immediately had not the illness of his father 
 obliged him to stay. When he got home he at once, by the 
 aid of a litigious lawyer, took steps to make an exorbitant 
 claim against the railway company. Two months after his 
 return home he had not yet resumed his work. The reasons 
 assigned for this were that he had giddiness and pain in the 
 . head, that his memory was bad and his sleep disturbed by 
 dreams of the accident, that he was very weak and incapable 
 of work, and that he could not trust himself to apply himself 
 to anything. His knee and hand were still in bandages, the 
 arm being carried in a sling. I failed to discover any sign 
 whatever of ill-health about him. Thus he continued to com- 
 plain and to live in idleness until ten months had flown, when 
 a jury awarded him a sum in reasonable compensation, or 
 about one-fourth of that which he had demanded. He was 
 then to every appearance and test in perfect health, though 
 still complaining as before. 
 
 Case XXXI.— Slight Shock— Prolonged Complaints — 
 Absence of all Symptoms. — A man, aged forty-two, strong 
 and healthy, was in two slight collisions. In the first there 
 was no evidence or history of his having received any blow or 
 injury. He stated, however, that the day after the accident he 
 felt weak, ached all over, and had pains in the loins and legs 
 as if he had a cold. No amendment took place, nor had he 
 indeed been free from suffering up to the time when I saw him 
 eight months afterward. He then complained of weakness 
 and fatigue, of bad sleep and loss of memory, and of such 
 great nervousness that the whistle of an engine or the sound 
 of a train threw him into a state of excitement. His manner 
 
130 Railway Injuries. 
 
 was whining, and he made several attempts to cry. His med- 
 ical attendant had never found any evidence of illness beyond 
 the statements made to him by the man himself. Neither in 
 his general aspect, nor in the action of any one of his organs, 
 could any sign of ill-health be discovered. He abstained from 
 work for fifteen months, and at once resumed it on the settle- 
 ment of his claim, then grown in size through length of alleged 
 suffering and loss. Two years went by, and he was fortunate 
 enough to be in a second collision in which he received a trifling 
 bruise on one leg. He at once abstained from work, placed 
 himself under medical care, made precisely the same com- 
 plaints as before, and presented as little evidence of ill-health. 
 Again there were months of idleness, and again on the settle- 
 ment of claim immediate recovery, and return to work. 
 
 Further examples of this particular kind of malingering 
 are hardly necessary, although many might have been given, 
 which, with insignificant variations, have followed the same 
 course. They are often styled cases of " shock to the nervous . 
 system." Their chief characteristic is the obscurity, the in- 
 tangibility, and entire subjectivity of all the symptoms and 
 complaints which disappear at a particular moment. They 
 are not rarely accompanied by some manifest disturbance of 
 health, whi(;h is induced by the mode of life to which the indi- 
 vidual restricts himself. Can want of proper occupation and 
 exercise act otherwise than harmfully even to a healthy man ? 
 Sleep becomes unsound, the bowels are sluggish, appetite fails, 
 the glow of healthy energy and vitality is lost, and there is no 
 longer the picture of perfect health. Be the bodily derange- 
 ment thereby great or be it infinitesimally small, health and 
 vigor are restored, and work is resumed, as soon as it is no 
 longer incumbent on the man to appear ill and to remain idle, 
 and when the requisite effort to return to a natural mode of 
 life is once more allowed. The man has nursed himself into a 
 state of illness, and has thereby generated a condition of spu- 
 rious nervous shock, and if he only has the prudence to com- 
 plain of his back, his case becomes a grave one of so-called 
 concussion of the spine. 
 
 Examples of this induced illness are far from uncommon, 
 and the very fact that the patient seems really ill places an 
 additional difficulty in the way of an accurate diagnosis of the 
 
Railway Injuries. 131 
 
 cause. Apart from the necessity of learning what was the 
 precise nature of the accident, and how the man was hurt, it 
 is very essential to know how he passes his time, and what 
 are his habits and occupations day by day. It is of para- 
 mount importance to separate objective signs from subjective 
 symptoms. The absence of signs, and the presence of subjec- 
 tive symptoms alone, may fairly warrant a suspicion, which 
 ought to entail the most careful inquiry into all the circum- 
 stances of the case. Why is that man in bed ? why does he 
 stay for weeks in-doors ? why is he taking hardly any food ? 
 why is he pale and thin ? why does he sweat ? — questions such 
 as these the surgeon should ask himself, and he should not 
 rest satisfied with a tacit belief in what he hears or sees. 
 
 In other cases there may be a combination of obscure sub- 
 jective symptoms and of precise objective signs which throw 
 mutual light upon each other, or which perchance may tend 
 to make a diagnosis still more difficult. 
 
 Case XXXH. — No Injury — Prolonged Complaints — Im- 
 mediate Recovery on -SeftZeinen^.— A traveller by occupation, 
 aged fifty- three, out of employ, took to his bed and called in 
 a doctor three days after a most trifling bump against the 
 stop-blocks in a station. He made the usual complaints of 
 pain, of shock to his nervous system, dimness of vision, loss of 
 memory, and the like, but there was never any sign whatever 
 of ill-health or functional derangement beyond what might be 
 fairly attributed to some atheroma of the aorba. The extrav- 
 agance of his language and his exaggerated estimate of all 
 his complaints were in themselves enough to raise suspicion 
 as to their reality. Objectively he complained of loss of power 
 in the right arm with stiffness of the right elbow, and of a 
 putty-like sensation of the left leg below the knee and stiffness 
 of that joint. In all ordinary movements, such as undressing 
 or helping himself out of bed, he used the right arm quite as 
 much as the left. It presented no difference from its fellow, 
 though when speaking to him about it he always held it 
 against his side. He resisted with great force when you at- 
 tempted to bend it, and he called out loudly, as if from pain, 
 when you touched the arm, however lightly, about the elbow- 
 joint. His left leg showed no physical signs of injury or dis- 
 ease about the knee. Held usually rigid and stiff, he resisted 
 
132 Railway Injuries. 
 
 any attempts a-t passive flexion. Flexion to the slightest de- 
 gree, he said, caused him great agony, although his face 
 showed no sign of suflfering. On another occasion he com- 
 plained of excessive hyperaesthesia of the left knee, however 
 gently you touthed it with the finger, although he pulled up 
 and put down his trousers over it with perfect composure. 
 He complained of great agony in his bladder, although he 
 only passed water at natural intervals and in proper* quantity, 
 and he could hold it for six, eight, or even twelve hours. He 
 stayed in bed about ten weeks, and took, as he admitted, 
 hardly any food. Toward the close of the twelve months, dur- 
 ing which this state of things went on, he had become some- 
 what weak and thin. Quite early he had made an exorbitant 
 claim, and the natural result was litigation. While waiting 
 for his action to come on the man was to be seen walking 
 about Westminster Hall with the lame stiff leg, and the flexed 
 arm held rigid to his side. His action over, he there and then 
 resumed a natural gait, all trace of lameness having passed 
 away. Were the subjective symptoms less unreal than those 
 which so quickly vanished ? 
 
 Case XXXIII.— P^frpos^we Vomiting — ImjnediatQ Re- 
 covery on Settlement. — Now let us take another case which 
 offers, perhaps, greater difficulties in diagnosis. Omitting 
 details of the usual subjective ailments, the objective signs of 
 illness were frequent vomiting, and such apparent weakness 
 of the legs that walking was only slow and labored. The 
 surgeon who saw the man on behalf of the railway company, 
 and who gave me the history of this case, felt sure from all 
 he saw that the symptoms were far from genuine, and among 
 them that the vomiting itself was a deliberate volitional act. 
 It was, to say the least, a suspicious feature in the case that 
 the patient had been seen, when he thought he was out of 
 sight, to start off at a natural pace, swinging the stick on 
 which he had been compelled to lean only a moment before. 
 Knowing all this, the surgeon felt it his duty to tell the pri- 
 vate medical attendant what he thought about the case, and 
 he resolved to do so on the next occasion when they were to 
 meet at the doctor's house to see the patient. Having told 
 his opinion, the doctor pointed out the utter impossibility, in 
 his belief, of so grave a sj'-mptom being' voluntary, and took 
 him into his own yard to show how the man had vomited since 
 
Railway Injuries. 133 
 
 he came to his house not long before. The surgeon's opinion, 
 nevertheless, remained unchanged, and the result of the case 
 justifiedjand confirmed it. Infirm of body and mind, incapa- 
 ble of work, vomiting up to the day of his action for damages, 
 the man immediatelj' recovered when litigation was over. 
 
 In the case of a horse-dealer who rapidly wasted and be- 
 came extremely ill, and in whom the most prominent symp- 
 tom was sweating, the man subsequently acknowledged, when 
 his speedy recovery after compensation -excited his doctor's 
 surprise, that he had deliberately sweated himself by violent 
 exercise in thick clothing in order to reduce his weight and 
 size. 
 
 To those who have never seen such cases it may appear 
 almost incredible that symptoms like these can be volitional 
 and unreal. (Some remarkable instances of factitious vomit- 
 ing are recorded by Gavin, op. cit., p. 356 et seq.) Take, how- 
 ever, into consideration every circumstance and feature of the 
 case; learn what has been the original injury; recognize how 
 singular it is that a symptom, alarming in itself, should be 
 by itself independent, and without ill result; remember how 
 powerful is the motive for deception; inquire what steps the 
 patient is taking to gain the desired end, and there are the 
 means, if you will only use them, of arriving at a right diag- 
 nosis. 
 
 The character of the original accident and injury is far too 
 often forgotten in the later examination of these cases, and a 
 trifling bump is magnified into a serious collision. 
 
 Case XXXIY.— Slight Injury— Gross Exaggeration— 
 Rapid Recovery after Settlement. — A man received an alto- 
 gether trivial blow on his side, from the manner in which he 
 happened to be sitting, when the train attached a carriage at 
 a station, and the so-called accident ultimately became a severe 
 collision, in which the train had been backed into a. carriage 
 at the great speed acquired in a run of half a mile, with a 
 crash like thunder. This was the story upon which those 
 were asked to form an opinion who were called in to see him, 
 when, after several months, he had nursed himself into a con- 
 dition of much weakness, nervousness, and malaise, and when 
 his very obvious illness seemed almost to demand a serious 
 
134 Railway Injuries. 
 
 accident as its cause. It is very natural that there should be 
 some distrust in the statements of railway servants as to the 
 precise violence of a collision or other accident. The absolute 
 and unvarnished truth as to the real severity of the accident 
 was known, at any rate, in this case, and was somewhat 
 different from the alarming catastrophe to which testimony 
 was borne in a court of law, where a jury is supposed to get 
 at the actual facts. A large sum of money was awarded to 
 this man in compensation, and he instantly invested it in a 
 business which he proceeded forthwith to carry on himself, 
 with all the appearances of perfect health, and without any 
 further need for medical treatment. 
 
 Case XXXV. — Simulation of Spinal Injury and False 
 Statement as to Accident. — A highly respectable frequenter 
 of the turf took to his bed after a very trifling collision. He 
 was unable to give any account of the accident, having been 
 knocked insensible, and been carried in an unconscious state to 
 the waiting-room of a station, distant a quarter of a mile. 
 He had, however, been able to make a long journey home two 
 days after the accident, that is to say, when the races were 
 over; and he at once took to his bed. I saw him on the eighth 
 day. When asked what he complained of, he answered with 
 ready assurance, " Shock to the nervous system, and injury to 
 my spine." He could give no other account than this of his 
 complaints, except that he was wholly unable to get out of 
 bed. Examination, which failed to discover the slightest trace 
 of injury or constitutional disturbance, accidentally revealed 
 that this gentleman had a chancre; and the discovery afforded 
 the excuse for promptly ordering him to get up and walk. 
 His doctor had regarded it as a case of very serious spinal 
 injury. The claim was forthwith settled for a small sum. 
 
 Case XXXVI. — Alleged Spinal Injury — Gross Impos- 
 ture. — This same man subsequently appeared as a witness on 
 behalf of a friend, who had brought an action for damages 
 for a like alleged injury in the same accident. He was a most 
 valuable witness, for he swore that he and another man had 
 carried their friend, then perfectly unconscious, from the scene 
 of the accident to the waiting-room at the station. The friend, 
 an even more outrageous impostor, had had a slight bruise on 
 one hip. He also finished his mission at the races, came home, 
 and at once took to his bed, complaining of his spine. " The 
 
Railway Injuries. 135 
 
 pain in his back," so ran my report some weelcs after tlie acci- 
 denti "is so bad that a longer stay than half an hour oub of 
 bed is, he says, almost more than he can bear. His pulse is 
 perfectly tranquil, his temperature normal, his aspect not that 
 of ill-health or urgent suffering, and the appetite and bodily 
 functions are as good as can be expected in any one who has 
 so long been without appetite and in-doors. It is my convic- 
 tion that he is grossly exaggerating his symptoms and com- 
 plaints. There is no evidence whatever of injury to his nerve- 
 centres, either cerebral or spinal; nor is there any ground for 
 believing that there is any real tenderness of his spine, for 
 wherever I touched him, whether on the spine itself, on the 
 muscles near it, or on the ribs far away from it, there was the 
 same unreal hypersensitiveness and manifestation of suffering. 
 That he has some pain here and there is quite probable; but 
 there is no disease such as to call for his stay in bed or in the 
 house for another day." It need hardly be said that litigation 
 ended this case, which was a highly profitable one for the 
 lawyers. 
 
 Three years afterward it was learned from this man him- 
 self — perhaps in the circumstances the least trustworthy 
 source of ' information — that his case from beginning to end 
 was a fraud, that he was never hurt at all, and that no amount 
 of money would induce him to go through such a course of 
 illness and confinement again, or to endure such suffering as 
 he had at the hands of those who deemed it necessary to run 
 pins into his legs and to apply the " electric test " to measure 
 his assumed insensibility. I venture to say that no such 
 " tests " were ever needed, and that their tendency was only 
 to confuse and obscure what ought to have been sufficiently 
 obvious to ever^' one who saw the patient. How fallacious 
 they are, and in this case were, it is superfluous to point out, 
 and yet they were solemnly given in evidence in court as con- 
 clusive signs of the serious nature of the man's disease. 
 
 Then, again, there is a class of cases where the patient 
 may simulsite the mimicries of disease. There are none in 
 which it is more imperative to know something of the patient's 
 history, of his previous health, his position in life, his condition 
 immediately or soon after the accident, the nature and extent 
 of the accident itself, and the whole aspect of the case from 
 beginning to end. 
 
136 Railway Injuries. 
 
 Case XXXVII. — Slight Injury — Prolonged Simulation 
 and Rapid Recovery after Settlement. — T. J., aged forty- 
 three, was in a slight accident, in which he had a small bruise 
 on one cheek and also at the back of the head. He was seen 
 shortly after the accident, but there was no sign either of in- 
 jury, beyond the bruises named, or of constitutional disturb- 
 ance. In about ten days he was " taken worse," but in no very 
 definite way. He gave notice of a claim, and then began to 
 complain indefinitely of pain in the back, of pain in the legs, 
 and oppression in the head. There was still, however, no evi- 
 dence of illness or constitutional disturbance. He continued 
 to get worse, and two months after the accident took to bed. 
 He had not been in b'ed many days when he had a " bilious 
 attack," with constipation and vomiting. A month elapsed, 
 and he then was seized, so he said, with a " convulsive attack " 
 in which his legs were drawn up, and he was very violent. 
 From that time forward he professed to be troubled with 
 " contractions of the limbs and severe pain in the legs, aggra- 
 vated by attempting to sit up." He also complained of queer 
 sensations all over, numbness in his tongue, for example, 
 crcepings in his legs, tenderness of the palms of the hands. 
 Pulse and temperature alike remained perfectly normal. Five 
 months after the accident he was still in bed complaining of 
 great pain in his back, of pain and tenderness in the legs, and 
 of inability to stand if he got out of bed. He held his hands 
 out somewhat in the position of tetany, but the contraction 
 immediately disappeared when he ceased to direct attention 
 to it. Although when he first got out of bed he allowed his 
 legs to slip away and himself to fall, he only had to be en- 
 gaged in conversation to show that his legs were amply strong 
 enough to support his whole body. There were no objective 
 signs whatever of paralysis, nor was any illness to be discov- 
 ered about him, except such as might fairly be accounted for by 
 his having been in bed for three months. Thus his muscles 
 were somewhat flabby, his face was pale, and this tongue was 
 furred. Temperature and pulse, however, were normal; his 
 pupils were of healthy size; his mind was perfectly clear. So 
 his state continued until the close of a year, when his claim 
 was settled hj compromise on the verge of litigation, it being 
 held that he had received a very severe injury to his nervous 
 system, that prospect of recovery was very small, and that it 
 
Railway Injuries. 137 
 
 was wholly impossible for him to appear and give evidence as 
 plaintiff at the action. His evidence was indeed taken by 
 commission, the man being quite unfit to leave his bed. He 
 had made a verj' large claim— not the first in his life, for he 
 had received compensation for alleged injuries some years 
 before. Mark the sequel. In ten days he was out-of-doors, in 
 a fortnight he went away for change of air, and in two months 
 he resumed his usual work. He has continued at work since 
 that time in the enjoyment of good health. 
 
 In instances such as this it is often difficult, and well-nigh 
 impossible, to say whether the condition is one dependent on 
 genuine neurotic disturbance or is altogether feigned. And 
 the difficulty is largely due to the fact, that a disorder of this 
 character may be more or less under the control of the patient 
 himself, as it has been pointed out on a previous page. It is 
 therefore of the greatest importance to search for some symp- 
 tom, which may rightly be placed in the category of hysteri- 
 cal or emotional disorders. Every objective sign that you 
 discover may be under the patient's own control, may be a 
 physical condition altogether assumed, and the clue to the 
 whole case may be entirely wanting until some symptom be 
 found, which is outside, and beyond his voluntary control, or 
 is even unknown to him. Analgesia or anassthesia, for exam- 
 ple, may form the only indication of the real character of the 
 disease. Dr. J. Putnam has admirably dealt with this aspect 
 of the subject in a paper on " Eecent investigations into the 
 pathology of so-called concussion of the spine, with cases illus- 
 trating the importance of seeking for evidence of typical hys- 
 teria in the chronic as well as in the acute stages of the dis- 
 ease " (" Boston Med. and Surg. Journal," Vol. CIX., Sept. 6th, 
 1883). After recording two cases of hemianaesthesia in men, 
 he says that this is a symptom which shows that the nervous 
 system has, in all probability, been subjected at some past 
 time to a considerable perturbing mfluence, and its presence 
 or absence might prove a welcome aid to diagnosis. A symp- 
 tom of this kind may throw light upon a case, but it does not 
 necessarily exclude a considerable degree of wilful exaggera- 
 tion or even downright fraud in the other symptoms and 
 signs. A deliberate impostor, for example, lost all tactile sen- 
 .sation over the mucous surface of his nares, a symptom which 
 
138 Railway Injuries. 
 
 it would surely be impossible to feign, and which was a clear 
 evidence that some ett'ect had been wrought, somehow and 
 somewhere, upon the nervous system. Eegions of anaesthesia, 
 moreover, which follow no recognized anatomical distribution 
 of nerves, say of one leg up to a precise limit at the knee or 
 half-way up the thigh, are occasionally present, and it is obvi- 
 ously very desirable that no symptom of the kind should be 
 overlooked in the examination of those cases where absence of 
 the ordinary indications of illness and disease may suggest 
 malingering. Marvellous and deeply interesting are such 
 manifestations of the close interdependence of mental and 
 bodilj'' states, and, freed from the incubus of compensation and 
 the temptation to malinger, it maj^ be said of the nervous 
 consequences of railway accidents, that they are not unworthy 
 of the study of the ablest and most philosophical men in the 
 profession. 
 
 We have nothing to do here with the pathology of morals,, 
 nor need we gauge the different degrees of moral obliquity in 
 undoubted feigning and assumption of disease, and in wilful 
 exaggeration of real conditions as a means to compass some 
 aim in view. Were all cases of simple exaggeration to be in- 
 cluded under the same head as cases of fictitious and feigned 
 disease,'the material would from very bulk become unmanagea- 
 ble. If, as it has been said, the motive be so strong and so pre- 
 vailing, it is natural and only human that exaggeration should 
 be met with in a large proportion of the persons injured in 
 railway accidents. But, on the other hand, it must be remem- 
 bered that exaggeration may not be, nay, very often is not,, 
 altogether wilful or assumed. Exaggeration is the very es- 
 sence of many of those emotional or hysterical disorders,, 
 which are so common in both sexes after the shock of collisions. 
 Here it may be an idiosyncrasy of the individual; there it may 
 be the outcome of mental disturbance from the fright and 
 alarm amid which the injury was received. It is only by a. 
 consideration of ever.y feature and aspect of the case — clinical, 
 pathological, social, and moral — that you can rightly estimate 
 the kind of exaggeration or malingering with which you have- 
 to do. 
 
CHAPTEE YIII. 
 
 THE MEDICO-LEGAL ASPECT OP RAILWAY INJURIES. 
 
 It may not be altogether without advantage if a few con- 
 cluding remarks are made upon those circumstances which are 
 special in, and peculiar to, the class of cases considered in this 
 book, and which are commonly absent from the ordinary ac- 
 cidents and diseases met with in every- day practice. Everj' 
 case of railway injury is more or less the subject of medico- 
 legal inquiry, for the extent of the injury itself and the loss 
 which it entails have to be estimated, as far as possible, by a 
 money value which is paid as compensation, and difficulties or 
 disputes, which may arise in arriving at this estimate, may 
 occasionally entail an appeal to a court and jury by process 
 of litigation. All this may verj"- materially modify the clinical 
 aspect of individual cases and symptoms, and no right esti- 
 mate of any case can be made if these circumstances are 
 ignored. 
 
 At first sight, perhaps, it is not very clear why compensa- 
 tion should be an element of importance in the course and his- 
 tory of the spinal and other injuries received in railway col- 
 lisions. Let us picture for a moment the change which would 
 come over our hospital patients if a pecuniary value were to 
 be placed upon every injury they sustained. The probability 
 that many of them would see only the worst side of their 
 ailments, that they would lay undue stress upon their pains, 
 and would exaggerate the term of prospective disablement 
 from work is at once obvious, were these to have a place in 
 calculating the money-worth of the injury received. When a 
 man has been prostrated by illness or injury, and convales- 
 cence has at length set in, we know that he must make some 
 voluntary effort to regain his former activity both of body and 
 mind. His habit of work and the daily routine of his life have 
 both been interrupted, and it depends very largely upon his 
 own efforts how soon and how successfully the thread shall be 
 
140 Railway Injuries. 
 
 taken up again. It is clearly to iiis interest to get well as 
 soon as he can^ and experience tells us that so keen is the 
 desire for recovery and renewed activity, that many a man's 
 restoration to perfect health is often retarded by his having 
 begun work too soon. Suppose, however, that compensation 
 is to be awarded for every ache and pain, and for every day 
 that he is absent from his work, it is only natural that the 
 keenness of his desire to resume his work should be very much 
 diminished. If our hospital patients were to be compensated, 
 we may be sure that the features of many a case would be 
 completely changed, and that the whole clinical history of 
 disease would wear a very different aspect from that which is 
 usually seen. And changed for this reason, that compensa- 
 tion acts as a let and hindrance to the natural and very neces- 
 sarj' effort, which each person must make for himself toward 
 convalescence and resumption of work. It may do so quite 
 unconsciously, for the knowledge that compensation will cer- 
 tainly be paid him for the injuries sustained in a railway ac- 
 cident tends from the first day of illness to give a tone to his 
 feelings and to affect his own impressions of the sufferings 
 which he may have to undergo. He is less likelj' to take a 
 hopeful view of the future, is more prone to be despondent 
 about the prospects of his recovery, and insomuch will his own 
 personal efforts be weakened. It is well that this matter of 
 compensation has no place in every-day hospital practice, and 
 you will always do wisely, in endeavoring to form an estimate 
 of the cases which involve medico-legal inquiry, to revert to 
 your hospital experiences, and to recall the usual history of 
 your hospital patients, both as to suffering and disablement, 
 and the prospects of recovery. 
 
 It is not sought here to establish any doctrine so absurd 
 as that settlement of claim can of itself be a curative agent, 
 in the sense that it can hasten the setting of a fracture, re- 
 move the pain which is an inseparable concomitant of sprain 
 of the vertebral muscles and ligaments, or restore the nervous 
 tone which has been upset by the shock of a collision. The 
 natural forces here, as elsewhere, tend to restoration of health; 
 and recovery is, happily, as perfect after the injuries com- 
 monly received in collisions, as it is after any other kind of 
 injury which the surgeon may be called upon to treat. There 
 is this difference, however, and it is a great one, that when the 
 
Railway Injuries. 141 
 
 immediate effects of injury are passing away, and there is 
 every sign that convalescence has set in, compensation holds 
 out an inducement to the patient not to make the requisite 
 effort to resume his work and his ordinary avocations, which 
 are in themselves the best means of crowning the period of 
 convalescence and of restoration to health. Had the ordinary 
 injuries of hospital and every-day practice to contend with this 
 element, convalescence would be very much hampered and 
 prolonged, while if there was no question of compensation to 
 enter into the contemplation of railway injuries, these in their 
 turn would be recovered from with no less certainty and with 
 much greater promptitude. 
 
 Human nature would not be what it is if compensation did 
 not exercise this influence in delaying recovery, and it may do 
 so even in the case of those who have been really hurt, and 
 who are genuinely anxious to get well. Too much stress 
 ought not, however, to be laid uponi compensation itself, for 
 very often it is the unsettlement of mind incidental to the ar- 
 rangement of the claim, rather than the prospect of pecuniary 
 gain, which is exerting an injurious influence. Happily the 
 medical man is not often called upon to determine whether 
 his patient is consciously making use of his injuries for the 
 purpose of profit, or is the unconscious victim of this mental 
 unsettlement, but he very frequently has to determine whether 
 it is likely to be for his good that his claim should be arranged. 
 Suppose, for example, that several months have elapsed since 
 the accident, and that while there are no fresh indications of 
 injury the symptoms nevertheless continue without ameliora- 
 tion, experience shows that settlement of claim is, in all prob- 
 ability, the one and only thing required to start the process of 
 convalescence with reasonable hope of speedy recovery. Every 
 now and then, however, there will come a case in which it is 
 desirable that the claim should be settled soon after the acci- 
 dent. Money may be wanted to tide over the period of dis- 
 ablement and to insure the comforts necessary during a time 
 of illness, or it may be obvious that there is great worry and 
 anxiety as to the prospects of recovery and the future support 
 of the family. In such circumstances it will not be the less 
 beneficial to a man to have his claim settled, but additional 
 care is necessary that in doing so he suffer no mjustice I 
 think that a claim for severe injury ought never to be settled 
 
142 Railway Injuries. 
 
 at this time, whatever be the want of money, unless there is 
 reasonable ground for honestly believing that no fresh symp- 
 toms indicative of a more serious injury than is then apparent 
 are likely to become developed. Given such conditions, how- 
 ever, arrangement of claim is likely to be advantageous to the 
 patient, provided that a fair basis for settlement be made by 
 allowing for a certain period of probable future disablement. 
 And this period has to be defined by the medical men after an 
 impartial consideration of all the facts of the case. To lay 
 down here in a book any hard and fast rule is manifestlj' im- 
 possible, as likewise it is well-nigh impossible to describe the 
 indications for arrangement of claim as a remedial agent. At 
 the bedside, however, there is not much difficulty in deciding 
 whether arrangement of claim is advisable, and likely to be 
 followed by good, or the reverse; nor is it I think very difficult 
 to say beforehand whether the settlement of claim will be 
 followed by immediate recovery, or will only act remedially by 
 conducing to settlement of mind. It is, at any rate, quite 
 erroneous to jump to the conclusion that a man is a swindler, 
 simply because he recovered soon after getting a check from 
 the railway company; and there need not be the smallest im- 
 putation upon a man in telling him that he had very much 
 better arrange his claim, and that in all probabilitj' if he does 
 so he will soon be well. I have many times been assured by 
 compensated persons themselves, that the moment they got 
 the thing settled they felt quite different beings, and, simply 
 because the matter was off their minds, at once began to im- 
 prove. And this, too, in cases where there has been severe 
 and genuine disturbance of health. Here is a case in point. 
 
 Case XXXVIII. — Slight Injury and Nervous Shock — 
 Anxiety as to Claim and Delayed Convalescence. — W. A., a 
 stout elderly man, was in a rather severe collision. He was 
 unable to continue his journey after the accident, but in two 
 or three days he began to have pains in the back and to feel 
 himself shaken, weak, and ill. He then returned home, a jour- 
 ney of four hours, and went to bed. There were no signs of 
 injury other than those of slight sprain of the muscles of the 
 back, with general nervousness and loss of tone. He steadily 
 improved, and in two months it was thought that he was suf- 
 ficiently well to arrange and settle his claim. He then, how- 
 
Railway Injuries. 143 
 
 ever, began to complain more ; ai^d four months after the ac- 
 cident he looked worse than hitherto, appeared ill and anxious, 
 expressed himself unable to leave the house, and wholly unfit 
 even to think of resuming his business. This went on for sev- 
 eral months, and instead of any improvement taking place, he 
 began to look more aged and worn, and not having been oub 
 of doors for a long time, lost appetite and weight, became 
 prone to cry, and altogether presented an aspect so unhappy, 
 that an opinion was given that he was permanently injured 
 from " concussion of the spine," and would never be fit to do 
 anything again. There were, however, no symptoms of serious 
 illness or disease, and settlement of his claim was confidently 
 anticipated as the one thing essential to restore him to health. 
 Nine months passed without a shadow of improvement, and 
 his claim was at length arranged. In a very short time he 
 was perfectly well, looked in good health, and "ten years 
 younger" than before his claim had been settled. Nor was 
 this improvement transitory. He continued in perfect health, 
 and five years after the accident was following his occupation 
 with his usual vigor and in his former state of health. 
 
 A case, it may be suggested, devoid of all color, and want- 
 ing any tangible symptom at all, if we exclude the pain in the 
 back which in former times was pretty sure to conjure up 
 " concussion of the spine." But it is just these colorless cases 
 which are often the most difficult of diagnosis, especially to 
 those who have never seen anything like them before "I 
 cannot make out," his doctor says, " why this patient does not 
 get well. He seemed to mend at first, and I thought he was 
 going to get over it soon, but now he appears to have no 
 energy at all. Medicines don't do him any good. I urge him 
 to make an efl'ort to get about and try a little business, but 
 he says he cannot; or if he does, that he breaks down again 
 almost before he has begun." Complaints like this would not 
 be heard guite so often, perhaps, were this clinical fact more 
 fully recognized, that settlement of claim is frequently the 
 most important agent to bring about recovery. 
 
 You need not seek to inquire too closely into the rationale 
 of the change which may be thus induced. There is a release 
 from the mental worry and annoyance inseparable from any 
 long dispute, and a feeling that now, the whole trouble being 
 
144 Railway Injuries. 
 
 over, a fresh start is possible, and that persistent effort may 
 once more be made to move about and resume work. Doubt- 
 less also there is some satisfaction in placing a good round 
 check to your balance at the bank, which, in this age of prog- 
 ress and poverty, exerts a stimulus which no pharmacopoeial 
 preparation can supply. The attitude of the patient's own 
 thoughts is wholly altered. Before compensation was effected 
 he held out a goal to himself, and thought, and said : " When 
 my claim is settled I will try and resume work; but I will 
 wait and see how I am." When his claim has been arranged 
 he argues thus : " Now I must begin my work again, and do 
 the best I can." The effort, at all events, can at length be 
 made, and with each succeeding hour of activity and occupa- 
 tion there grows up a healthier tone, and the role of the in- 
 valid is laid aside. 
 
 It is not only in cases like these, however, that settlement 
 and repose of mind conduce to speedy recovery. A like result 
 maj' be seen elsewhere; and it is a well-known fact, that the 
 health of prisoners in jail has unquestionably improved after 
 they have received their sentence, even though the sentence 
 may have been far more severe than they had expected. 
 
 While, then, we cannot ignore the influence of this restora- 
 tive agent, we must be more careful than ever that our knowl- 
 edge of its efficacy be not improperly applied. An accurate 
 history of the injury, and of the accident in which it was re- 
 ceived; a careful observation of the patient's condition imme- 
 diately after the accident, and of his progress in the days and 
 weeks which followed; an impartial comparison of his case 
 with others of a like kind which have been met with before — 
 these things will guide to a right estimate of the facts when 
 recovery seems to be unduly slow, and when examination re- 
 veals no signs of disease to account for the delay. And, al- 
 though it does not fall within his province or business to deal 
 with the matter in any way, it is yet necessary for the doctor 
 sometimes to know what steps the patient is taking to obtain 
 compensation, and how far this question may presumably be 
 engaging his mind. 
 
 It must be remembered, however, that, although compen- 
 sation has this influence upon the recovery of patients about 
 whose bona fides there may be no suspicion, with others it 
 may act as an irresistible temptation to wrong. Hence arise 
 
Railway Injuries. 145 
 
 some of those difficulties whicli surround the clinical inquirer, 
 and which entail obvious duties and precautions on the medi- 
 cal man. He must endeavor to hold the balance as evenly as 
 ma J' be between the two sides which are more especially con- 
 cerned in every medico-legal inquiry ; and it behooves him, 
 above all things, to take care that no affection of coincident 
 origin, nor anj^ precedent deformity or disease shall be allowed, 
 through ignorance or carelessness on his part, to form an item 
 in the claim which the patient may think fit to make for the 
 injuries he has sustained. 
 
 You can never tell how readily a patient may adopt a sug- 
 gestion whidi has been umvittingly put into his mind, or how 
 soon an unguarded word or opinion may give a tone to the 
 symptoms which they would not otherwise possess. Avoid, 
 therefore, as far as possible all leading questions, because the 
 use of them may suggest symptoms which had no previous 
 existence. In a gross case of fraud which fell under my 
 notice, a grave opinion was formed of the symptoms because 
 a leading question prompted an answer which was wholly un- 
 true. The man complained of giddiness; and as vertigo was 
 known to be often the result of diplopia, the patient was 
 hastily asked if he saw double. "Yes," was the reply; and 
 led on by further leading questions, a very serious train of 
 alleged symptoms was revealed. Not one of them was true. 
 
 The clever impostor who, some years ago, went the round 
 of the hospitals, and simulated many nervous disorders with 
 varj'ing degrees of success, lacked in his marvellous exhibition 
 of tetanus the usual rigidity of the abdominal muscles. A re- 
 mark was made at his bedside, when he was in one of the 
 worst of his seizures, that it was strange the tetanic spasm, 
 so extreme elsewhere, should not also afl'ect the muscles of 
 the abdomen. The next day they were as hard as a board. 
 
 Not less important, also, is it to avoid the unnecessary use 
 of leading methods of examination. I would not in the small- 
 est degree detract from the value of instruments of precision, 
 but their use is often quite unnecessary, the cases being singu- 
 larly few and far between which demand the whole armamenta 
 of the specialist, who with dynamometer, jEsthesiometer, audio- 
 meter, lenses, and battery, finds out some trifiing departure 
 from the normal which may be made the unfair groundwork 
 of a claim. ("Were a pathologist," writes Dr. Moxon [Croo- 
 
146 .Railway Injuries. 
 
 nian Lectures, "Lancet," Vol. I., 1881, p. 068], "with a grave 
 microscope to spy through all our brains as we sit here in 
 states of satisfaction, he would certainly see a great deal in 
 the way of tortuous capillary and dots of yellow pigment — a 
 great deal that under the microscope would look very alarm- 
 ing.") Of what earthly use are observations by the dynamo- 
 meter, for example, unless you know that the patient is telling 
 you the truth ? You discover, forsooth, that he squeezes with 
 a force of fifty pounds with his right hand and of ten pounds 
 with his left, and you forthwith create the scientific and incon- 
 trovertible basis of a lie. A little common sense is often of 
 more use in diagnosis than all these instruments put together. 
 Nor is electricity, as a method of precise and scientific ex- 
 amination, at all exempt from these remarks, unless it shall 
 have been made use of by those who are perfectly conversant 
 with it in all its details, and with the numerous fallacies which 
 underlie its application. Years ago, when railway injuries 
 were more often the cause of litigation than they are now, it 
 was by no means uncommon for evidence to be given in court 
 that the " electric test," as it was called, had been applied, and 
 that the patient, because he could not feel, was of necessity 
 suffering from incurable central disease. Scientific evidence 
 has happily improved, arid it is recognized now that cutaneous 
 anaesthesia has no such deadly meaning, a,nd that in order to 
 make proper use of electricity in diagnosis it is essential to 
 exclude those states of the skin, which prevent the reaction of 
 the muscles being determined by application of electricity to 
 them through the cutaneous surface. For when patients have 
 been long confined to bed, and from one cause or another, from 
 genuine fear of moving, from a supposed inability to move or 
 from a resolve not to move, have kept their legs at rest, there 
 is likely to be considerable diminution or even loss of cutane- 
 ous sensibility. The " electric test " is, of course, useless in 
 such circumstances, and because there is no response it is al- 
 together erroneous to conclude that there is grave organic 
 disease. We may perchance have to do with a case of hys- 
 terical anEesthesia, and we must look to accompanying condi- 
 tions to help in diagnosis. The reflexes are present, there is 
 no trophic disturbance in any part of the limbs, and above all, 
 if the electric stimulus be brought into contact with them, 
 either directly by needles, or after proper preparation of the 
 
' Railway Injuries 147 
 
 skin, it will be found that the reaction of the muscles is quite 
 natural. Hear what Dr. Buzzard has to say on this point. 
 After describing a case of hysterical paralysis, he writes : " In 
 this case, as I have seen in many belonging- to the class of 
 hysteria [the very cases that are so often seen after railway 
 collisions, functional disorders of motion and sensation, and 
 occasionally real imposture], the epidermis, which had arrived 
 at extraordinary thickness, apparently from disuse of the 
 limbs, offered great resistance to the passage of electric cur- 
 rents. In these circumstances a more than usual amount of 
 care in thorough soaking and rubbing of the skin, as well as 
 in selecting the motor point, is necessary in order to avoid 
 fallacies." ("Clinical Lectures on Diseases of the Nervous Sys- 
 tem," p. 118, Lecture V., " On the Differential Diagnosis be- 
 tween certain Hysterical Conditions and Myelitis.") The dif- 
 ficulties involved in the application of electricity are well 
 indicated by the same author in a passage worthy of quota- 
 tion : " We never see in hj^steria the various muscles of one 
 limb showing differing degrees of abnormality in their response 
 to faradaism, from a condition of total absence of reaction in 
 some, to nearly a natural state in others. Moreover, in hys- 
 teria, according to my observation, applications of electrical 
 stimulus (and especially of the voltaic current) on one or two 
 occasions usually sufHce to restore the natural excitability of 
 the muscles (equally in all) which has simply declined through 
 disuse. A difficulty can only arise where the observer has 
 but one opportunity of testing the electrical condition, and it 
 is then quite possible to occur. It must be remembered that, 
 as a distinct lowering of faradaic excitability almost invaria- 
 bly signifies organic change in a nerve trunk or centre, a diag- 
 nosis of hysteria can never safely be arrived at while that 
 condition persists. On the other hand, I need scarcely remind 
 you that the preservation of a completely normal faradaic 
 excitability in the muscles of a limb does not show that that 
 limb is not paralyzed. ... In cases of paralysis, it is only 
 Avhen the integrity of the gray matter of the anterior horn is 
 disturbed, or when there is some lesion of the anterior root or 
 trunk of the nerve, that you find decided loss of electric excit- 
 abihty. You frequently meet with complete paraplegia and 
 yet all the muscles will respond normally to electric currents" 
 (Dp. cit., p. 100). 
 
148 Railway Injuries. 
 
 In the use of electricity for diagnostic purposes, therefore, 
 we must not be content with the negative evidence merely of 
 cutaneous insensibility, or absence of response in the muscles: 
 we must look for some such indication as is given 'by the 
 reaction of degeneration, or by the different reactions of vari- 
 ous muscles in the same region. If these and similar points 
 are borne in mind there will be little likelihood of the electric 
 test being vaunted as an infallible witness in a court of law, 
 and the real position of electricity as a means of diagnosis 
 will be less liable to be shaken by conflict of testimony. 
 
 Conflict of testimony, in other words differences of opinion, 
 must inevitably arise in many cases of injurj^ or disease, and 
 the maladies considered in this book are not exempt from it. 
 It might be well, perhaps, when litigation has been resorted 
 to for the settlement of the pecuniary compensation, if medi- 
 cal men were to be freed from the necessity of giving evidence 
 on medical matters in open court. I do not intend, however, 
 to say what are my views upon the subject in this place, nor 
 how in my judgment the practice of the courts might be im- 
 proved. Suffice it that testimony has still to be given in 
 court, and that in giving it the medical witness ought never 
 to forget that the reason for his evidence is to enable the 
 court to arrive at a just and impartial conclusion. If he is 
 himself a partisan, it is obvious that his testimony is of small 
 value for the purpose named; and of one thing he may be cer- 
 tain, that, if a partisan, he is tolerably sure to reveal his bias 
 almost as soon as he opensh is mouth, and that his testimony 
 will be estimated accordingly. Judge and jury will alike put 
 it aside. "Expert testimony" ("North American Revievv," 
 1884, p. 609, "Expert Testimony," by W. W. Gooding, quoted 
 from Dr. Wilbur, of Syracuse, N. Y.), it has been well said, 
 "should be the colorless light of science brought to bear upon 
 any case when it is summoned. It should be impartial, un- 
 prejudiced. There should be no half truths uttered, and sup- 
 pression of the whole truth is in the nature of false testimony." 
 It is true that our present methods render the position of the 
 doctor very often difficult, for the warfai^e of counsel and the 
 arts of cross-examination tend to throw into strong and undue 
 relief the slightest differences of opinion, and lead too often to 
 the witness saying more or less than he intended to say. 
 Patience, impartiality, good temper, a sense of justice, and a 
 
Railway Injuries. 149 
 
 single purpose to give utterance to the truth — these and,- not 
 less than these, a sound knowledge of the matter on which 
 evidence is being given— will together be his best protection 
 in the witness-box, and will make the taunt that doctors differ 
 absolutely harmless to him. This is what Chief Justice Clin- 
 ton said on the evidence of medical witnesses in courts of law 
 (" Buffalo Medical and Surgical Journal," Jan. 1st, 1880) : 
 "As to the delivery of testimony by you as experts, I have 
 very little to say that might not just as properly be said to a 
 witness who is called to testifj' only as to the facts of the case. 
 The difference rests in this: the expert, as such, is asked only 
 for his opinion upon the facts. He may be asked his opinion 
 upon a hypothetical state of facts, and required to give reasons 
 for the opinion he expresses. The cross- examiner is allowed 
 great latitude, and I am sorry to say not infrequently abuses 
 it. But if the witness will only remember the worth and dig- 
 nity of his profession, and that he is there simply to speak 
 truth, as a servitor of justice, no arts or sneers of counsel can 
 disturb him. Calm and self-possessed, he will answer every 
 question, direct or cross, fully and in the plainest and most 
 lucid language in which the meaning of the answer can be 
 conveyed to the jury. To such an answer he will add nothing, 
 unless it be a necessary explanation. He will not air his 
 learning before the court, nor have any the least contention 
 with counsel. The court will, if need be, protect him from the 
 abuse of lawyers. Such a witness will return from the stand 
 as calmly as he went upon it, approved by his own conscience, 
 and respected by the court, the jury, and the bar," 
 
INDEX 
 
 Ab?<^ormal sensations, the, af- 
 fected by the mind, 63 
 Absolute rest, wisdom of, 31 
 Accidents, railway, inj uries caused 
 by, 7 
 railway malingering after, 133 
 railway, nervous effects of, 8 
 Acute hysteria, 58 
 
 myelitis, 27 
 Agent, curative, settlement of 
 
 claim as a, 140 
 Anaesthesia, cutaneous, 146 
 Analgesia, hysterical, in children, 
 
 122 
 Arthritis, rheumatoid, 13 
 Aspect, medico-legal, of railway 
 
 injuries, 139 
 Asthenopia, photophobia, and size 
 
 of the pupil, 50 
 Atropine, Hutchinson on the use 
 
 of, 118 
 Auto-suggestion and traumatic 
 
 hysteria, 80 
 
 Back, injuries of the, 5 
 
 lower, sprains of the, 14 
 the, ironing, 111 
 Bodily injuries, 60 
 
 injury, collapse more danger- 
 ous than, 34 
 injury not a cause of symp- 
 toms, 106 
 states, mental and, interde- 
 pendence of, 138 
 Brain and spinal cord, meningo- 
 
 myelitis of the, 6 
 Bromide of potassium, continued 
 use of, injurious, 113 
 
 Buzzard, Dr., on syphilitic para- 
 plegia, 28 
 Dr., on the application of elec- 
 tricity, 147 
 
 Canal, the osseous, of the spinal 
 
 cord, 23 
 Caries, spinal, 15 
 Cases : 
 
 Alleged spinal injury — gross 
 imposture, 134 
 
 Cervico-dorsal sprain, 9 
 
 Functional motor paraplegia 
 — extrem e emotional disturb- 
 ance — ulitmate recovery. 88 
 
 Functional paraplegia — rapid 
 recovery after settlement of 
 claim, 85 
 
 General nervous shock — great 
 fright, 41 
 
 Hemiansesthesia and hemipa- 
 resis following hypnotic 
 state from fright, 96 
 
 HemiansBsthesia, etc., 98 
 
 HemiansBSthesia, etc. — doubts 
 of perfect genuineness, 99 
 
 Hypnotic catalepsy — delu- 
 sions, 103 
 
 Hypnotic catalepsy, etc., 101 
 
 Late myelitis following ob- 
 scure spinal injury, 25 
 
 Lumbar sprain — very acute 
 pain, 11 
 
 Lumbo-saeral sprain — proba- 
 ble injury to or hemorrhage 
 round pelvic plexuses, 24 
 
 Nervous shook— c ontinued 
 vomiting, 94 
 
152 
 
 Index. 
 
 Cb ses : 
 
 Neurasthenia induced by 
 fright — previous ansemia, 
 44 
 
 No injury — prolonged com- 
 plaints — immediate recovery 
 on settlement, 131 
 
 Old lateral curvature of the 
 spine, 130 
 
 Paralysis from pressure on 
 musculo-spiral nerve, 120 
 
 Physical inj uries — nervo us 
 shock, 138 
 
 Purposive vomiting— immedi- 
 ate recovery on settlement, 
 133 
 
 Severe bodily injuries — ab- 
 sence of prolonged after- 
 symptoms of shook, 66 
 
 Severe general nervous shock 
 — prolonged symptoms — 
 physical injuries slight, 39 
 
 Severe general vertebral sprain 
 —sensations of numbness 
 and tingling, 30 
 
 Severe lumbo-sacral sprain — 
 probable injury to cords of 
 sacral plexus, 33 
 
 Severe shock — death from gen- 
 eral nervous prostration, 56 
 
 Severe shock from fright end- 
 ing fatally, 56 
 
 Shock to nervous system — hys- 
 terical seizures beginniog in 
 syncope, 93 
 
 Simple lumbar sprain— trau- 
 matic lumbago, 8 
 
 Simulation of spinal injury 
 and false statement as to ac- 
 cident , 134 
 
 Slight general nervous shock, 
 
 Slight injuries — prolonged 
 
 complaints, 139 
 Sight injury and nervous 
 
 shook — anxiety as to claim 
 
 and delayed convalescence, 
 
 143 
 
 Cases : 
 
 Slight injury— gross exaggera- 
 tion — rapid recovery after 
 settlement, 183 
 Slight injury — prolonged sim- 
 ulation and rapid recovery 
 after settlement, 136 
 Slight shock — prolonged com- 
 plaints, 139 
 Slight sprain and nervous 
 shock — p retracted symp- 
 toms from wilful starvation, 
 127 
 Sprain of the dorsal and lum- 
 bar vertebras — great surface 
 hypersBsthesia, 17 
 Sprain of the whole vertebral 
 
 column, 10 
 Supposed spinal injury — spas- 
 modic twitchings of one arm, 
 etc., 90 
 Cases difficult of diagnosis, 143 
 types of, differ in various coun- 
 tries, 107 
 Catamenial derangements, 58 
 Causes, psychical, 86 
 Cerebral disorder, hemianaesthesia 
 
 and, 96 
 Cervical spine, injuries to the, 38 
 Charcot on hystero-epilepsy, 77 
 Chronic invalidism, want of occu- 
 pation and, 64 
 Circulation, disturbances of the, 46 
 Claim, physician to determine as 
 to, 141 
 settlement of, as a curative 
 agent, 140 
 Classification of Ogston, 116 
 Clinton, Chief Justice, on evidence 
 
 of medical witnesses, 149 
 Collapse and general nervous 
 shock, 88 
 coincident with railway in- 
 jury, 87 
 fear induces immediate, 36 
 more dangerous than bodily 
 
 injury, 84 
 true shock or, 83 
 
Index. 
 
 IS3 
 
 Collision injuries, complex nature 
 of, 6 . 
 
 Column, spinal, physical structure 
 of the, 9 
 vertebral, strain of the, 11 
 
 Combination of symptoms, 11 
 
 Compensation and imposture, 124 
 an element of importance, 139 
 medico-legal inquiry and, 139 
 the question of, 109 
 
 Complete recovery in cases of ner- 
 vous shock, 68 
 
 Complex of symptoms, the, 57 
 
 Concussion of the spine, Dr. J. 
 Putnam on the pathology of 
 so-called, 137 
 
 Conditions palmed oflf by malin- 
 gerers, 130 
 
 Conflict of testimony, 148 
 
 Consequences, the, of railway in- 
 jury, 6 
 
 Constipation, 14 
 
 Continued vomiting, 94 
 
 vomiting, typical case of, 96 
 
 Convalescence, 59 
 
 Cord, spinal, lesion of the, 39 
 
 Coxalgia, hysterical, 17 
 
 Cutaneous anaesthesia, 146 
 
 Cystitis, residual urine a frequent 
 cause of, 14 
 
 Deception, means of, curiously 
 
 alike, 134 
 Derangements, catamenial, 53 
 Devices of impostors, 117 
 Diagnosis all-important, 109 
 
 cases diflBcult of, 143 
 
 common sense in, 146 
 Differences of opinion, 105 
 Digestion, disturbances of, 113 
 Digestive system, the, 54 . 
 Dilatation of pupil, 118 
 Discs, the optic, 53 
 Disease, real and assumed, 116 
 
 spinal cord, tenderness and, 13 
 
 the mimicries of, 135 
 Disorder, nervous, symptoms of, 
 71 
 
 Disorders, functional, emotional, 
 and hysterical, 30 
 of secretion, 49 
 
 sensory and motor, cerebral 
 defects in, inexplicable, 75 
 Disturbance, neurotic, genuine or 
 
 feigned, 137 
 Disturbances of the circulation, 46 
 
 Electricity as a method of scien- 
 tific examination, 146 
 Dr. Buzzard on the applica- 
 tion of, 147 
 use of, for diagnostic purposes, 
 148 
 Electric test, the, 146 
 Element of importance, compen- 
 sation an, 139 
 Elements, nerve, of the spinal col- 
 umn, 8 
 Emotion, mental, alarm and pro- 
 found, 37 
 psychical commotion and, 80 
 Epididymitis, 37 
 Essential questions as to induced 
 
 illness, 131 
 Exaggeration the essence of hys- 
 terical disorders, . 138 
 Examination, leading methods of, 
 
 unnecessary use of, 145 
 Expectancy, suggestion and, 76 
 Experience confirmatory of opin- 
 ions, 7 
 Experiments, hypnotic, objections 
 
 to, 83 
 Expert testimony, 148 
 
 Facial asymmetry, Wilks on, 133 
 Factitious vomiting, 133 
 Faradization and galvano-faradi- 
 
 zation. 111 
 Fashion in medicine, 113 
 Fear induces immediate collapse, 
 
 36 
 Feigning, the, of paralysis, 131 
 Pood, nutrition and, 114 
 Fright a cause of hysterical phe- 
 nomena, 71 
 neuroses, the, 70 
 
154 
 
 Index. 
 
 Purneaux Jordan on railway in- 
 juries, 36 
 
 Gal VA NO-FARAD izATioisr, faradi- 
 zation and, 111 
 Gavin on tympanites, 118 
 Genito-urinary system, the, 54 
 
 Habits of intemperance, 66 
 
 Headache, 48 
 
 Heidenhain on the hypnotic state, 
 
 83 
 Hemianaesthesia and cerebral dis- 
 order, 96 
 Hemorrhage, intra-spinal, 26 
 Hereditary predisposition, 73 
 History of patients, previous, im- 
 portant to know, 93 
 Hutchinson on the use of atropine, 
 
 118 
 Hypersesthesia, 18 
 Hypnotic experiments, objections 
 to, 83 
 state, the, Heidenhain on, 83 
 Hypnotism, 79 
 Hysteria, acute, 58 
 
 and neurasthenia, 45 
 Dr. WUks on, 99 
 traumatic, 70 
 varieties of, 73 
 Hysterical analgesia in children, 
 133 
 coxalgla, 17 
 disorders, exaggeration the 
 
 essence of, 138 
 disorders, functional, emo- 
 tional, and, 30 
 disorder, traumatic, variety of 
 
 symptoms of, 74 
 melancholia, typical case of, 
 
 107 
 phenomena, fright a cause of, 
 71 
 Hystero-epllepsy, Charcot on, 77 
 
 Imposition, successful cases of, 118 
 Impostors, devices of, 117 
 Imposture, compensation and, 124 
 
 Inflammation, meningeal, 29 
 Influences, mental, continuance 
 
 of symptoms due to, 67 
 Injuries, bodily, 60 
 
 collision, complex nature of, 6 
 of the back, 5 
 
 railway, collapse very pro- 
 found after, 35 
 Injury, bodily, not a cause of 
 symptoms, 106 
 railway, collapse coincident 
 
 with, 37 
 results of railway, psychical in 
 origin, 108 
 Insanity, 100 
 
 Intemperance, habits of, 66 
 Intra-splnal hemorrhage, 36 
 Ironing the back. 111 
 Irritation, spinal, 19 
 
 Jordan, Furneaux, on railway 
 inj urles, 36 
 
 Lesions of the spinal cord, 23 
 Llfelessness, 34 
 
 Life, organic, the sensations of, 61 
 Local pain, stiffness and, 13 
 
 paralysis, 78 
 
 tenderness, 13 
 Loss of memory, 53 
 Lower back, sprains of the, 14 
 
 Malingerers, conditions palmed 
 off by, 120 
 
 Malingering, 116 
 
 Massage, treatment by, 110 
 
 Means of deception curiously 
 aUke, 124 
 
 Medicine, fashion in, 113 
 
 Medico-legal inquiry and compen- 
 sation, 139 
 
 Melancholia, hysterical, typical 
 case of, 107 
 
 Memory, loss of, 53 
 
 Men and women, emotion In, 59 
 
 Meningeal Inflammation, 39 
 
 Meningitis, subacute, 37 
 traumatic, 37 
 
Index. 
 
 IS5 
 
 Mental and bodily rest,' necessity 
 of, 67 
 and bodily states, interde- 
 pendence of, 138 
 emotion, alarm and profound, 
 
 37 
 influences, continuance of 
 symptoms due to, 67 
 Methods of examination, leading, 
 
 unnecesary use of, 145 
 Micturition, 13 
 Mimicries of disease, the, 135 
 Mind, the abnormal sensations 
 
 affected by the, 63 
 Moral obliquity, 99 
 
 obliquity, morals and, 138 
 Myalgia, 110 
 Myelitis, acute, 27 
 
 Nervous disorder, symptoms of, 
 71 
 exhaustion, rest essential in 
 
 cases of, 114 
 shock, 10 
 shock, general, 33 
 shock, general, collapse and, 38 
 shook of the structures of the 
 
 spinal canal, 31 
 state, the unnatural, 82 
 system, shock to the, 130 
 system. Sully on the, 62 
 Nervousness, 49 
 Neurasthenia, hysteria and, 45 
 Neuroses, post-traumatic func- 
 tional, classification of the, 
 45 
 the fright, 70 
 Neurotic disturbance, genuine or 
 
 feigned, 137 
 Numbness, tingling and, sensa- 
 tions of, 19 
 Nutrition and food, 114 
 
 Obliquity, moral, 99 
 
 moral, morals and, 138 
 Observation, personal, of cases, 5 
 Occupation, want of, and chronic 
 invalidism, 64 
 
 Ogston, classification of, 116 
 On treatment, 109 
 Opinion, differences of, 105 
 Opinions, experience confirmatory 
 
 of, 7 
 Optic discs, the, 52 
 Organic life, the sensations of, 61 
 Osseous canal, the, of the spinal 
 
 cord, 22 
 
 Pain, local, stiffness and, 13 
 Pains, spinal, exercise a relief for, 
 16 
 spinal, features of, 16 
 Paralysis, local, 78 
 
 not usual after railway colli- 
 sions, 15 
 sympathetic, 119 
 the feigning of, 121 
 Patients, previous history of, im- 
 portant to know, 92 
 railway and hospital, compari- 
 son between, 65 
 remaining in bed, the question 
 as,to, 109 
 Personal observation of cases, 5 
 Photophobia, asthenopia, and 
 
 size of the pupil, 50 
 Physician to determine as to 
 
 claim, 141 
 Post-traumatic functional neuro- 
 ses, classification of the, 45 
 Potassium, bromide of, continued 
 
 use of, injurious, 112 
 Predisposition, hereditary, 72 
 Prognosis— exceptions to the gen- 
 eral rule, 55 
 Psychical causes, 36 
 
 commotion and emotion, 80 
 Pupil, dilatation of, 118 
 Putnam, Dr. J., on the pathology 
 of so-called concussion of the 
 spine, 187 
 
 Question, the, as to patients re- 
 maining in bed, 109 
 the, of compensation, 109 
 Questions, essential, as to induced 
 illness, 131 
 
IS6 
 
 Index. 
 
 Railway accidents, injuries 
 caused by, 7 
 accidents, malingering after, 
 
 133 
 accidents, nervous effects of, 8 
 and hospital patients, compar- 
 ison between, 65 
 injuries, collapse very pro- 
 found after, 35 
 injuries, medico-legal aspect 
 
 of, 139 
 injury, results of, psychical in 
 
 origin, 108 
 injury, the consequences of, 6 
 Real and assumed disease, 116 
 Recovery, complete, in cases of 
 
 nervous shock, 68 
 Remedies for procuring sleep, 113 
 Rest, absolute, wisdom of, 21 
 
 essential in cases of nervous 
 
 exhaustion, 114 
 mental and bodily, necessity 
 of, 67 
 Rheumatoid arthritis, 13 
 Riegler, statistics of, 7 
 
 Scientific examination, electric- 
 ity as a method of, 146 
 Secretion, disorders of, 49 
 Sense, common, in diagnosis, 146 
 Sensorium, slumber of the, 81 
 Sensory and motor disorders, cere- 
 bral defects in, inexplicable, 75 
 Shook, general nervous, 33 
 nervous, 10 
 nervous, of the structures of 
 
 the spinal canal, 31 
 slight, general symptoms of, 
 38 
 Sleeplessness, 46 
 
 Sleep, remedies for procuring, 113 
 Slight shock, general symptoms 
 
 of, 38 
 Spinal caries, 15 
 
 column, nerve elements of the, 
 
 8 
 column, physical structure of 
 the, 9 
 
 Spinal cord, brain and,^meningo- 
 myelitis of the, 6 
 
 cord disease, tenderness and, . 
 12 
 
 cord, lesion of the, 39 
 
 cord, lesions of the, 33 
 
 cord, system-diseases of the, 
 30 
 
 irritation, 19 
 
 pains, exercise a relief for, 16 
 
 pains, features of, 16 
 Spine, cervical, injuries to the, 38 
 Sprains, vertebral, 15 
 Starvation, wilful, 135 
 Statistics of Riegler, 7 
 Subacute meningitis, 37 
 Successful cases of imposition, 118 
 Suggestion and expectancy, 76 
 Sully on the nervous system, 62 
 Sympathetic paralysis, 119 
 Symptoms, combination of, 11 
 
 tlve complex of, 57 
 Synovitis, traumatic, 13 
 Syphilis, 28 
 Syphilitic paraplegia, Dr. Buzzard 
 
 on, 28 
 System-diseases of the spinal cord, 
 
 3(5 
 System, nervous, shock to the, 130 
 
 the digestive, 54 ; 
 
 the genito-urinary, 54 
 
 Tenderness, local, 13 
 Testimony, conflict of, 148 
 
 expert, 148 
 Test, the electric, 146 
 Thorburn on neurasthenia, 45 
 T ingling and numbness, sensa- 
 tions of, 19 
 Traumatic hysteria, 70 
 
 hysteria, auto-suggestion and, 
 80 
 
 hysterical disorder, variety of 
 symptoms of, 74 
 
 meningitis, 37 
 
 synovitis, 13 
 Treatment, 109 
 
 by massage, 110 
 
Index. 
 
 IS7 
 
 True shock or collapse, 33 
 Tympanites, Gavin on, 118 
 Types of cases differ in various 
 countries, 107 
 
 Unnatural nervous state, the, 83 
 Urine, residual, a frequent cause 
 
 of cystitis, 14 , 
 Use of electricity for diagnostic 
 
 purposes, 148 
 
 Varieties of hysteria, 73 
 
 Vertebral column, strain of the, 11 
 
 sprains, 15 
 Vomiting, continued, 94 
 
 continued, typical case of, 96 
 
 factitious, 133 
 
 Wilful starvation, 125 
 Wilks, Dr., on facial asymmetry, 
 132 
 Dr., on hysteria, 99 
 Witnesses, medical, Chief Justice 
 
 Clinton on evidence of, 149 
 Women, men and, emotion in, 59