THE "RAILWAY SPL.NE."*
IT is not often that a strictly medical book is reviewed in our pages. Such work is better done as a rule in professional columns,
and is, moreover, if well done, of all analysis that which is furthest removed from the sympathies of ordinary readers. They either trust or distrust the profession, but in neither case do they pretend to understand its reasoning,—if they told truth, would acknow- ledge that they did not fully comprehend its terminology. In the present instance, however, a surgeon of great repute and an experi- ence exceptionally extensive, whose books are quoted by the pro- fession like case-books by the Bar, as if they terminated discussion, has given us, in a form which, though strictly professional, is nevertheless intelligible, a careful opinion upon a point interest- ing to every member of the community. We do not all get diseases with long names, and, of the few ailments which even the healthy fear, the majority occur but once in a life-time, but we all ride on railways, many of us every day, and are all therefore interested in the liabilities of railway passengers and railway medical jurisprudence. The system of compensation, for ex- ample, which now forms the sole check on railway carelessness and greed, is, with one exception, as simple in its working as any other section of the great scheme of law, under which justice and medicine are inextricably commingled, lawyers having to do such justice as medical testimony will warrant, but then this exception is a large one. If anybody is visibly hurt in a railway accident, he is entitled to compensation. If his leg is broken, for instance, he gets the value of his leg, as far as a special jury can arrive at an approximate price for the value of that limb to him. But suppose the hurt is invisible? Suppose, that is to say, that the hurt is of a kind which does not immediately appear, and which, when it does appear, can only be traced back to its source by a surgeon who is of somewhat unusual experience, and who, moreover, has in hint the particular quality—we say it is a quality, despite the protests of the profession,—which enables him to comprehend and, as it were, to follow nervous disturbance. How then ? Incompetent surgeons will contradict one another, to the bewilderment of lawyers. No inconsiderable number even of competent surgeons will hesitate in their testimony, not from ignorance or even scientific scrupu- lousness, bat from a well founded doubt whether they can by any testimony whatever inspire a jury with the conviction so certain to their own minds. The average juryman doubts very much whether it is possible for an accident to have consequences unseen at the time, which can yet after the lapse of six, months be clearly traced back to a special cause, and which are not the results of " nervousness " in the popular acceptation of that term, but of nervous injury.
Mr. Eriehsen has set himself to remove that doubt. In a very little book, wonderfully lucid in phrase, and packed with illus- trations till it gives one a feeling that the pudding would be the richer for fewer plums, he shows that there are forms of injury which are worse than fractures, injuring the mind as well as the body, which reveal themselves after an interval, and which are especially common in railway accidents, so common that they have obtained a slang name in the profession, as if they could be pro- duced only by railway collisions. These injuries are all in, reality spinal, and may be due to any violent shock to the spinal cord, though as a matter of practice they are due most frequently to such shocks when received in a railway collision. A passenger who happens to be present in an accident of that kind frequently gets out with his limbs whole, his body uubruised, and his mind unconscious of any suffering beyond a general weakness and con- fusion, which he sets down vaguely to "a shock" to the system, while his friends charitably attribute it to excessive fright. By and by, however, he finds, and they find, that "he is not the man he was," he "has lost bodily energy, mental capacity, business apti-
• Railway rniuriss. By John Erie Etiohseu. London: Walton and biaborloy. tude," he becomes ill and irritable, grows pallid, loses his memory, finds his sleep disturbed, frets about the state of his eyes, loses his acuteness of touch, and finally displays all the symptoms of paralysis. He has in fact received a concussion of the spine, which has shaken nervous force out of him in a mode which Mr. Erichsen does not pretend to explain, but which he illustrates by a curiously felicitous analogy. "How them Jars, Shakes, Shocks, or Concussions of the Spinal Cord directly influence its action I cannot say with certainty. We do not know how it is that when a mag- net is struck a heavy blow with a hammer, the magnetic force is jarred, shaken, or concussed out of the horse-shoe. But we know that it is so, and that the iron has lost its magnetic power. So, if the spine is badly jarred, shaken, or concussed by a blow or shock of any kind communicated to the body, we find that the nervous force is to a certain extent shaken out of the man, and that he has in some way lost nervous power. What immediate change, if any, has taken place in the nervous structure to occasion that effect, we no more know than what change happens to a magnet when struck. But we know that a change has taken place in the action of the nervous system, just as we do in the action of the iron by the change that is induced in the loss of its magnetic force." The -cause of the injury must remain unknown until at least we have discovered the secret of nervous force, which will probably be postponed yet awhile, say till we have found out the reason for life and for the dwindling away of life, but the modes operandi is clear. Mr. Erichsen has examined a good many spines so affected, and studied the reported phenomena of a good many more, and he decides that the proximate cause of injury is always in one form or another inflanimation of the spinal cord, some- times showing itself in a softening of the substance of the cord, a melting of the marrow as it were, to use ordinary and therefore inaccurate English; "sometimes the nervous sub- stance becomes indurated, increased in bulk, more solid than natu- ral, and of a boiled-white colour, like white of egg ;" sometimes the vessels become turgid with blood, or there is a great effusion of blood upon the membranes of the cord ; of all which results Mr. Erichsen quotes either from his own experience, or that of other surgeons of the highest scientific trustworthiness, numerous and very horrible instances. The symptoms of those injuries "are more or less cerebral disturbance or irritation, as indicated by headache, confusion of thought, loss of memory, disturbance of the organs of sense, irritability of the eyes and ears, &c., symptoms, in fact, referrible to subacute cerebral meningitis and arachnids;" or "pain -at one or .more points of the spine, greatly increased on pressure and on movement of any kind, so as to occasion extreme rigidity of the vertebral column ;" or "painful sensations along the course of the nerves, followed by more or leas numbness, tingling, and creeping, some loss of motor power affecting one or more of the limbs, and giving rise to peculiarity and unsteadiness of gait." Death may be postponed for weeks, months, or even years,—Mr. Erichsen has known cases of the latter—but it is observable that in such cases of conclusion there is never any real intermission of the symptoms. They may remit, or the patient may fancy they remit, but they never entirely disappear, and usually the patient's health bodily and mental declines progressively, the best guide to the surgeon who may mistake spinal concussion for hysteria, that most intermittent of diseases. The chances of complete recovery in such cases are very small, though the patient may live, "and for this reason,—that as the injury is not sufficient of itself to produce a direct and immediate lesion of the cord, any symptoms that develop themselves must be the result of structural changes tak- ing place in it as the consequence of its inflammation, and these secondary structural changes being incurable, must, to a greater or less degree, but permanently, injuriously influence its action." 4' I have never known a patient to recover completely and entirely, so as to be in the same state of health that he enjoyed before the accident, in whom the symptoms dependent on chronic inflammation of the cord and its membranes, and on their consecutive structural lesions, had existed for twelve months. And though, as 011ivier has observed, such a patient may live for fifteen or twenty years in a broken state of health, the probability is that he will die within three or four. There is no structure of the body in-which an organic lesion is recovered from with so much difficulty and with so great a tendency to resulting impairment of function as that of the spinal cord and brain. And, with the exception pro- bably of the eye, there is no part of the body in which a slight permanent change of structure produces such serious disturbance of function as in the spinal cord." Recovery being so improbable, treatment of course becomes difficult, and Mr. Erichsen's rules may almost be summed up in-three orders, one of which at least is directly opposed to ordinary practice. Absoluterest to the body,
to the exclusion of those changes of air and scene which are so often recommended, and are in such casea so illusory— or injurious, absolute rest for the mind, and at a later stage counter-irritation locally applied or the use of powerful drugs, such as bichloride of mercury and strychnine, which let no man touch except under very trustworthy medical direction.
Mr. Erichsen is very careful to show that concussion of the spine is not an accident peculiar to railways, so that the phrase "railway spine " commonly employed in.the profession is a misdescription. Concussion may arise from a fall, or a blow, or a wound, or any other accident of ordinary civil or military life. Still, as hundreds of thousands travel by railway for one who runs any other risk, and while so travelling are exposed to an exceptional series of liabilities, it is not unnatural that spinal concussion should come to be regarded as a "railway disease," more especially while there exists so profound a popular belief—which we wish Mr. Erichsen had noticed —that railway travelling in itself, and without the occur- rence of any noticeable accident, produces mild concussions, unfelt by the strong and fat, but most dangerous to the nervous and the thin. In any case it is certain that railway accidents have about them this additional horror, that they alone among frequently recurring risks endanger the mind as well as the body, a fact which Mr. Erichseu brings out with a startling force that ought to send his work into, the office of every railway director, manager, and working official. Given a careless pointsman and a full train, and part of the quotient will be so many minds destroyed, a fact which, once established, will, we suspect, have a serious effect on divi- dends, and consequently on the carefulness exhibited in railway management.