Durham, North Carolina, United States
The first passenger railway journey resulted in the death of a prominent British politician.1 During the 1830s and 1840s,2 railway travel became a popular means of transport in Victorian Britain. By the 1850s, it was clear that this revolutionary advance in transportation also caused many injuries that resulted in significant litigation. One notorious accident occurred in 1865 when Charles Dickens was traveling to London and his train derailed while crossing a bridge at Staplehurst. The ensuing symptoms of post-traumatic stress disorder (PTSD) never fully abated and left him with anxiety and phobic avoidance of travel.3
Sizeable awards were made in favor of plaintiffs, often on the presumption that they had suffered spinal cord injury. A new branch of forensic medicine emerged with medical practitioners brought in by both sides to provide testimony. One contentious issue centered around claims by plaintiffs who had not suffered any clear physical damage. Their problems were defined more by what the patient said rather than that what could be observed on examination. Among the matters of debate was the question of attribution: what caused the condition and what was the nature of the pathology? Since the alleged disorders were claimed to arise from physical injury, the medical authorities called upon in this emerging field were often surgeons. One early pioneer was John Erichsen (1818–1896), who was on the staff at University College Hospital, president of its council, and author of three seminal textbooks.4,5,6 The Science and Art of Surgery5 was widely read and handed out by the US government to all federal doctors serving in the US Civil War. Erichsen published a later edition of his book on spinal concussion in 1875,6 entitled On concussion of the spine, nervous shock, and other obscure injuries of the nervous system in their clinical and medico-legal aspects. His two books4,6 on spinal injury were influential and for a while, the condition he described was known as Erichsen’s Disease.7 Erichsen believed that some injuries caused spinal concussion without damage to the vertebral column and that such concussion then gave rise to progressive inflammatory changes in the cord, which he referred to as chronic meningitis or subacute myelitis. A degree of public alarm and anxiety over the safety of rail travel was created by Erichsen’s influence and by the many awards given to injured plaintiffs. To deal with this rising anxiety, a commission was appointed and its findings published in Lancet.8
As attitudes began to change, Erichsen himself eventually accepted the role of psychogenic factors and acknowledged that his term “spinal concussion” had been replaced by the term “traumatic neurasthenia.” “Traumatic neuroses” was another kindred term that had been adopted by many.9 Erichsen was saying that the term “spinal concussion” was chosen for want of any good alternatives and an imperfect understanding of nervous system pathology and injury at that time.10
Herbert William Page (1845–1926)
Between 1866 and 1896, other surgeons and physicians entered the fray, disagreeing with Erichsen. One of the foremost revisionists was Herbert William Page, whose biography is well summarized by Plarr.11 He was born in Carlisle on December 22, 1845 and raised in a medical household. He entered the University of Edinburgh in 1864 and then transferred to Christ’s College, Cambridge, graduating as Bachelor of Arts in 1868, M.B. in 1870, F.R.C.S. in 1871 and M.Ch. in 1875. He received his medical education at the London Hospital, where he was house surgeon to Sir Jonathan Hutchinson (1828–1913). From another teacher there, Hughlings Jackson (1835–1911), Page acquired his strong interest in neurology.
Page spent time in Europe, first studying in Vienna and then obtaining a commission in the German army at the outbreak of the Franco-Prussian War, serving with the Hessian division at the Princess Alice Hospital, Darmstadt. After returning to England, he obtained the Fellowship of the Royal College of Surgeons England (F.R.C.S.) and was appointed surgical registrar at the London Hospital before moving to St. Mary’s Hospital in 1876, where he remained for the next thirty years, rising to the position of consulting surgeon.12
Page earned a reputation for being “earnestly conscientious and very cautious.” According to Plarr, he was the first surgeon at St. Mary’s to sterilize instruments by heat rather than antiseptic. In 1887, he performed the first gastro-enterostomy at St. Mary’s on a case of pyloric obstruction, and followed this with a paper at Royal Medico-Chirurgical Society on thirty-eight cases. He advocated greater use of this procedure to relieve distress and prolong life, a position considered to be greatly in advance of its time.11 Page also wrote papers on abdominal section for intussusception, subperiosteal hemorrhage, and other surgical subjects. Of note was his description of tabetic arthropathy affecting the foot and ankle and linked to peripheral nerve damage, which is believed to have been the first such description. Charcot, however, made claim to the discovery of “Charcot foot,” despite knowing of Page’s report.13
Page was integrally connected with the Royal College of Surgeons, as member of council from 1899–1907, member of the court of examiners from 1894–1902, and examiner in surgery at the Universities of Oxford, Cambridge, and Birmingham. At the Carlisle meeting of the British Medical Association in 1896, he was vice-president of the surgery section. Unusual recognition was given when he served as president of the Neurological Society in 1883, an appointment rarely made to a surgeon. This honor was largely the result of Page’s Boylston Prize award two years earlier.
In its obituary, the Lancet noted Page’s mastery of the power of speech—“a wonderful choice of words, a clear diction and a melodious voice gave to his speeches, a distinction which was still further enhanced by his clarity of thought and by a touch of whimsical humour.” The obituarist went on to observe that a speech by Page “decorated any occasion” and, along with his intimate knowledge of the subject, made him an irresistible and persuasive expert witness on behalf of the railway companies in litigation. In 1879, the Lord Chief Justice Coleridge opined that “Mr. Page is . . . such a comprehensible and intelligible witness as I have seldom heard in the witness box.”
Page’s involvement with railway medicine began soon after taking up his appointment at St. Mary’s Hospital in 1876, when he accepted positions as surgeon to the London and Northwestern and Great Western Railways. In 1881 he submitted the winning essay to Harvard University for the Boylston Prize. The essay was titled “Injuries of the back without apparent mechanical lesions, in their surgical and medico-legal aspects.” This submission was based on Page’s personal experience as a railway surgeon and was incorporated into his 1883 analysis of railway injury cases, Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects.14 In this book, Page described railway spine as a largely psychological disorder of the brain and central nervous system caused by fear or fright alone, which then brought about the secondary and lingering effects of the disorder from what he termed “general nervous shock.” He did recognize that there may have been painful muscle or ligament injury and apprehension on the part of the patient that unknown consequences might arise, as well as insufficient compensation. According to the Lancet obituary, Page’s conception “displaced the view that symptoms…were due to a concussion of the spinal cord.” The obituary saluted Page’s courage as a young surgeon in challenging the establishment, and noted that following publication of his 1883 book, Page’s view of railway spine as a psychogenic condition began to be increasingly accepted, with the use of diagnostic terms such as traumatic neurosis, traumatic neurasthenia, traumatic hysteria, and general nervous shock.
Page’s understanding of functional states caused by traumatic injury and based on fright formed an important step in the way that traumatic neurosis came to be understood. His clinical description resembles the current definition of post-traumatic stress disorder (PTSD).15 In his 1883 book, symptoms were presented in order of frequency: sleeplessness, circulatory disturbances (feeble, slow pulse, palpitations upon excitement, flushing), headache, nervousness (increased startle, tremor on excitement, melancholy, hopelessness toward the future, avoidance of noise, desire to be alone), excessive sweating, polyuria, diarrhea, menorrhagia, ocular fatigue (exhaustion while reading), and loss of memory (i.e. incapacity for sustained attention and thought).
The far-reaching impact of Injuries of the spine and spinal cord is noted by Caplan, who stated that Page’s book accomplished the remarkable feat of appealing to both surgeons and neurologists, psychiatrists, and alienists. Neurologists began to take the matter of railway injury seriously and there was greater medical interest in the psychogenesis of certain disorders arising from physical trauma and their treatment with psychotherapy.16
Page retired in 1906 and spent the remaining twenty years of his life at Sedgecombe House, Farnham, Hampshire with relatively little contact with the Royal College of Surgeons. Indeed, it was said of Page that he never sought the limelight and stayed clear of public affairs. He died after a long illness on September 9, 1926. Following his death, an executor of his will gave to the College two silver loving-cups that had been presented to Page when he retired from St. Mary’s Hospital, with the intention that they would be used at College banquets.
- C. Winn, “First fatalities,” History Today 62:9 (2012).
- P. Marsden, Rising ground (Chicago: University of Chicago Press, 2014): 178.
- MR Trimble, Post-traumatic neurosis: From railway spine to the whiplash (London: John Wiley & Sons, 1984): 27.
- JE Erichsen, On railway and other injuries of the nervous system (London: Walton and Maberly, 1866).
- JE Erichsen, The science and art of surgery (London: Walton and Maberly, 1853).
- JE Erichsen, On concussion of the spine, nervous shock, and other obscure injuries of the nervous system in their clinical and medico-legal aspects (London: Longmans, Green & Co., 1875).
- T. Keller and T. Chappell, “The rise and fall of Erichsen’s disease (railroad spine),” Spine 21(1996): 1597–1601.
- “Report of the Commission: influence of railway traveling on public health,” Lancet 1(1862): 79-84.
- JB Andrews, “Traumatic hysteria from railroad injury,” Am J Psychiatry 48 (1891): 37–42.
- JE Erichsen, “Railroad spine,” Tex Sanitarian. 3 (1894): 448–449. Correspondence.
- Royal College of Surgeons, “Plarr’s Lives of the Fellows.” https://www.livesonline.rcseng.ac.uk.
- Herbert William Page obituary, Lancet 1(1926): 626–628.
- LJ Sanders, ME Edmonds, and WJ Jeffcoate, “Who was the first to diagnose and report neuropathic arthropathy of the foot and ankle: Jean-Marie Charcot or Herbert William Page?” Diabetologia 56 (2013): 1873–1875.
- HW Page, Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects (London: J & A Churchill, 1883).
- American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (Arlington: American Psychiatric Association, 2013).
- EM Caplan, “Trains, brains and sprains. Railway spine and the origins of psychoneurosis,” Bull Hist Med 69 (1995): 387–420.
JONATHAN DAVIDSON, MBBS, trained at University College Hospital, London, and practiced psychiatry at Duke University Medical Center. He has published extensively in the areas of post-traumatic stress, anxiety, depression, resilience, psychopharmacology, complementary and alternative medicine, medical history and biography.
Highlighted in Frontispiece Volume 14, Issue 4 – Fall 2022