This chapter on the Traumatic Neuroses by
Sir William Osler was taken from his 1916 Edition of his Textbook
on the Principles and Practice of Medicine. Although this was
published during 1916, it was apparent that Osler had failed to update
the chapter as there was no mention of war neuroses nor the effect of
the conflict upon the combatants.
Dr M. Geoffrey Miller
THE TRAUMATIC NEUROSES
(Railway Brain and Railway Spine; Traumatic Hysteria)
Definition - A morbid condition following shock which presents the symptoms of neurasthenia or hysteria or of both. The condition is known as "railway brain" and "railway spine."
Erichsen regarded the condition as the result of inflammation of the meninges and cord, and gave it the name railway spine. Walton and J. J. Putnam, of Boston, were the first to recognize the hysterical nature of many of the cases, and to Westphal's pupils we owe the name traumatic neurosis.
Etiology. - The condition follows an accident, often in a railway train, in which injury has been sustained, or succeeds a shock or concussion, from which the patient may apparently not have suffered in his body. A man may appear perfectly well for several days, or even a week or more, and then develop the symptoms of the neurosis. Bodily shock or concussion is not necessary. The affection may follow a profound mental impression; thus, an engine-driver ran over a child, and received thereby a very severe shock, subsequent to which symptoms of neurasthenia developed. Severe mental strain combined with bodily exposure may cause it, as in a case of a naval officer who was wrecked in a violent storm and exposed for more than a day in the rigging before he was rescued. A slight blow, a fall from a carriage or on the stairs may suffice.
Symptoms.-The cases may be divided into three groups: simple neurasthenia, cases with marked hysterical manifestations, and cases with severe symptoms indicating or simulating organic disease.
(a) SIMPLE TRAUMATIC NEURASTHENIA - The first symptoms usually develop a few weeks after the accident, which may or may not have been associated with an actual trauma. The patient complains of headache and tired feelings. He is sleepless and finds himself unable to concentrate his attention properly upon his work. A condition of nervous irritability develops which may have a host of trivial manifestations, and the entire mental attitude of the person may for a time be changed. He dwells constantly upon his condition, gets very despondent and low-spirited, and in extreme cases melancholia may develop. He may complain of numbness and tingling in the extremities, and in some cases of much pain in the back. The bodily functions may be well performed, though such patients usually have, for a time at least, disturbed digestion and loss in weight. The physical examination may be entirely negative. The reflexes are slightly increased, as in ordinary neurasthenia. The pupils may be unequal; the cardiovascular changes already described in neurasthenia may be present in a marked degree. [The cardiovascular symptoms are the most distressing, and may occur with only slight disturbance of the cerebro-spinal functions, though the conditions are nearly always combined. Palpitation of the heart, irregular and very rapid action (neurasthenic tachycardia), and pains and oppressive feelings in the cardiac region are the most common symptoms. The slightest excitement may be followed by increased action of the heart, sometimes associated with sensations of dizziness and anxiety, and the patients frequently have the idea that they suffer from serious disease of this organ. Attacks of pseudoangina may occur.] According as the symptoms are more are more spinal or more cerebral, the condition is known as railway spine.
( 2 ) CASES WITH MARKED HYSTERICAL FEATURES.-
Following an injury of any sort, neurasthenic symptoms like those described above, may develop, and in addition symptoms regarded as characteristic of hysteria. The emotional element is prominent, and there is but slight control over the feelings. The patients have headache, backache, and vertigo. A violent tremor may be present, and, indeed, constitutes the most striking feature of the case. In the case of an engineer who developed subsequent to an accident a series of nervous phenomenon the most marked feature was an excessive tremor of the entire body, which was specially manifest during emotional excitement. The most pronounced hysterical symptoms are the sensory disturbances. As first noted by Putnam and Walton, hemianaesthesia may occur as a consequence of traumatism. This is a common symptom in France, but rare in England and in the United States. Achromatopsia may exist on the anaesthetic side. A second, more common, manifestation is limitation of the field of vision, similar to that which occurs in hysteria.
(3) CASES IN WHICIH THE SYMPTOMS SUGGEST ORGANIC DISEASE OF THE BRAIN AND CORD.-
As a result of spinal concussion, without fracture or external injury, there may subsequently develop symptoms suggestive of organic disease, which may come on rapidly or at a late date. In a case reported by Leyden the symptoms following the concussion were at first slight and the patient was regarded as a simulator, but finally the condition became aggravated and death resulted. The post mortem showed a chronic pachymeningitis, which had doubtless resulted from the accident. The cases in this group about which there is so much discussion are those which display marked sensory and motor changes. Following an accident in which the patient has not received external injury a condition of excitement may develop within a week or ten days; he complains of headache and backache, and on examination sensory disturbances are found, either hemiamesthesia or areas on the skin in which the sensation is much benumbed - or painful and tactile impressions may be distinctly felt in certain regions, and the temperature sense is absent. The distribution may be bilateral and symmetrical in limited regions or hemiplegic in type. Limitation of the field of vision is usually marked in these cases, and there may be disturbance of the senses of taste and smell. The superficial reflexes may be,diminished; usually the deep reflexes are exaggerated. The pupils may be unequal; the motor disturbances are variable. The French writers describe cases of monoplegia with or without contracture, symptoms upon which Charcot lays great stress as a manifestation of profound hysteria. The combination of sensory disturbances - anaesthesia or hyperaesthesia - with paralysis, particularly if monoplegic, and th occurrence of contractures without atrophy and with normal electrical reactions, may be regarded as distinctive of hysteria.
In rare cases following trauma, and succeeding to symptoms which may have been regarded as neurasthenic or hysterical, there are organic changes which may prove fatal. That this sequence occurs is demonstrated clearly by recent post mortem examinations. The features upon which the greatest reliance can be placed as indicating organic change are optic atrophy, bladder symptoms, particularly in combination with tremor, paresis, and exaggerated reflexes.
The anatomical changes in this condition have not been very definite. When death follows spinal concussion within a few days there may be no apparent lesion, but in some instances the brain or cord has shown punctiform hemorrhages. Edes has reported 4 cases in which a gradual degeneration in the pyramidal tracts followed concussion or injury of the spine; but in all these cases there was marked tremor and the spinal symptoms developed early, or followed immediately upon the accident.
Diagnosis.—A condition of fright and excitement following an accident may persist for days or even weeks, and then gradually pass away. The symptoms of neurasthenia or of hysteria which subsequently develop present nothing peculiar and are identical with those which occur under other circumstances. Care must be taken to recognize simulation, and, as in these cases the condition is largely subjective, this is sometimes extremely difficult. In a careful examination a simulator will often reveal himself by exaggeration of certain symptoms, particularly sensitiveness of the spine, and by increasing voluntarily the reflexes. Maunkopff suggests as a good test to take the pulse rate before, during, and after pressure upon an area said to be painful. If the rate is quickened, it is held to be proof that the pain is real. This is not, however, always the case. It may require a careful study of the case to determine whether the individual is honestly suffering from the symptoms of which he complains. A still more important question is, has the patient organic disease? The symptoms given under the first two groups of cases may exist in a marked degree and may persist for several years without the slightest evidence of organic change. Hemianaesthesia, limitation of the field of vision, monoplegia with contracture, may all be present as hysterical manifestations, from which recovery may be complete. In our present knowledge the diagnosis of an organic lesion should be limited to those cases in which optic atrophy, bladder troubles, and signs of sclerosis of the cord are well marked—indications either of degeneration of the lateral columns or of multiple sclerosis. Examination by the X-rays is an important aid and has showed in some cases definite injury to the spine.
Prognosis.—A majority of patients with traumatic hysteria recover. In railway cases, so long as litigation is pending and the patient is in the hands of lawyers, the symptoms usually persist. Settlement is often the starting- point of a speedy and perfect recovery. On the other hand, there are a few cases in which the symptoms persist even after the litigation has been closed; the patient goes from bad to worse and psychoses develop, such as melancholia, dementia, or occasionally progressive paresis. And, lastly, in extremely rare cases organic lesions may occur as a sequence of the traumatic neurosis.
The function of the physician acting as medical expert in these cases consists in determining (a) the existence of actual disease, and (b) its character, whether simple neurasthenia, severe hysteria, or an organic lesion. The outlook for ultimate recovery is good except in cases which present the more serious symptoms above mentioned.
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