POSSIBLE CEREBRAL ORIGIN OF THE SYMPTOMS USUALLY CLASSED UNDER “ RAILWAY SPINE.” IlY G. L. WALTON, M. D. [Reprinted from the Boston Medical and Surgical Journal.] CAMBRIDGE : Printeb at tl)c Rincrsibe press. 1883. POSSIBLE CEREBRAL ORIGIN OF TIIE SYMP- TOMS USUALLY CLASSED UNDER “ RAIL- WAY SPINE.” BY G. L. WALTON, M. D. Recent investigations have shown that the terms “spinal concussion” and “railway spine,” long in use to designate a set of symptoms following severe injury, are not only inexact, but misleading, in that they di- rect attention to the spine as the seat of a disturbance which may lie, in part at least, situated in the brain. In the extensive literature on “ railway spine ” atten- tion seems for a long time to have been drawn away from the fact that the brain is at least as liable to in- jury from ajar as the spinal cord, while under the ambig- uous name “spinal concussion” have been grouped all the nervous symptoms following accident, even in those cases in which organic lesions have been found in the spine on post-mortem examination. This is evidenced, for example, in the work of Erichsen on this subject. In 1881 Dr. Ilodges1 made an important step to- wards the classification of these injuries by insisting on the separation of the organic from the inorganic affections of the spinal cord following accident. Page 2 has shown that the former are exceedingly rare as long as the vertebral column remains intact. With regard to inorganic injuries to the cord in an accident he regards the term spinal concussion as one having little or no support in fact, and is inclined to class the symptoms hitherto attributed to spinal con- cussion under hysteria without committing himself to any exact theory as to the physiological sequence giving rise to the hysterical condition. 1 Boston Medical and Surgical Journal, vol. civ., p. 361. 2 Injuries of the Spine and Spinal Cord, Herbert W. l’age, A. M., M. C. Philadelphia. 1883. 4 “ Railway Spine.'’'' Dr. J. J. Putnam,1 after reporting two eases in which typical hysterical symptoms were found follow- ing injury, has emphasized the importance of seeking among the seemingly vague set of symptoms those which are typical of hysteria, a disease generally ac- knowledged to have its seat in the cerebral (certainly not in the spinal) centres.2 That the brain should he the chief sufferer from an accident rather than the spinal cord seems reasonable, both in consideration of its physiological and of its anatomical relations. With regard to the former, the cerebral centres rep- resent a far higher development of function, and to perform this function must have a more delicately organized intimate structure than the lower centres of the cord, which preside over the more simple reflex activities of the body. This fact alone should render them more liable to derangement from a jar as result- ing from a fall or collision in which both brain and cord must participate. With regard to the anatomical relations of the two organs, the spinal cord hangs suspended in a cavity much larger than itself, and is surrounded by an amount of loose areolar adipose tissue and fluid so great in relation to its own weight as to diminish materially the liability to injury from a shock; the brain, likewise enclosed by an unyielding case of bone, and itself much heavier than the cord, lies in compar- atively intimate connection with its case, the dura mater of the brain forming, in fact, the periosteum of the skull. Certainly the facts bear us out in the suppo- sition that the cerebral centres do suffer, whether directly or reHexlv, for although pain in the back, weakness in the extremities, etc., seem generally to draw attention to the spine, these symptoms are 1 Boston Medical and Surgical Journal, September 6, 1883. 2 Dr. Putnam informs me that since the publication of his article he has met with a third case suffering from typical hysterical hemi- anaestbesia after accident (railway). “ Railway Spine.” 5 rarely unattended by irritability, fretfulness, emo- tional tendency, and inability to confine the attention. These can only be the result of derangement in the higher cerebral centres. Now if careful search elicits such abnormalities of sensation and motion as can only be attributed to cerebral disturbance, it must be ac- knowledged that the brain rather than the spinal cord is to be credited with being the chief seat of the difficulty. This conclusion is alone a great step to- wards clearing up these cases, whether the disturbance of function in the cerebral centres be considered due to simple concussion, vaso motor irregularity, or to reflex influence from injury to other (for example, abdominal) organs. The physiological arguments on the latter points are still so obscure as to render it hardly advisable to discuss them here. The practical importance of seeking to classify the nervous symptoms resulting from injury is evident. “Railway spine” has offered and will continue to offer a frequent subject for litigation, and any classification of symptoms which will enable us to bring it, if only in part, under a form of disease already understood, and which will enable us to distinguish the real from the feigned, must be of the greatest practical value. That such symptoms really do exist is shown, for example, by a case recently reported in its main par- ticulars by Dr. Putnam,1 and fully by the writer.2 The case wras that of a fireman, not a claimant for damages, who, after a severe fall on his side from his engine, suffered, amongst other symptoms, from mental excitability and despondency, with a tendency to weep on slight provocation. Examination revealed left- sided hemiparesis and hemianaesthesia limited sharply by the median line. lie also had lost to a certain de- gree, and in the manner characteristic of hysteria, the senses of sight, hearing, smell, and taste on the left side. The temporary disappearance of the symptoms 1 Boston Medical and Surgical Journal, September G, 1833. - Archives of Medicine, New York July, 1883. 6 “ Railway Spine." on the application of the magnet showed that they were of functional, not organic, origin, and their seat (involving the head and special senses) absolutely precluded spinal origin. In this case at least these symptoms enabled us to classify the nervous injury under the head of hysteria. Not the vague hysteria of former times, but the func- tional disturbance of the cerebral centres which mod- ern research, as set on foot by Professor Charcot, has shown to follow given laws, and to offer pathoguo- monic characteristics. The importance of always searching for hysterical hemianesthesia in cases of injury is the greater in that just this set of symptoms, besides failing to attract the patient’s attention, may, and frequently does, pass under the eyes of careful medical observers unnoticed unless especially sought for. It. may be well at this point to mention briefly the chief symptoms to be looked for in establishing hemi- anesthesia in a hysterical patient or in a sufferer from ‘‘railway spine.” It is not in place here to mention the numerous pre- cautions and counter-tests always necessary in examin- ing into subjective conditions. The left side is by far the oftener attacked. On the side affected loss of sen- sation appears, varying in degree from inability to feel a light touch to complete loss of feeling, so that a pin can be thrust through a fold of the skin while the patient’s eyes are closed without his knowledge. It is, perhaps, not superfluous to remind the observer that the eyes must invariably be closed during the testing, for if the patient sees, he is apt to think he feels, that his skin is touched. This is, perhaps, the principal reason why the anesthesia generally escapes the patient’s notice. If doubt exists as to loss of sen- sation, comparison with the corresponding point on the other side of the body is an essential aid unless that side happens to be also anesthetic. The disturbances of special sense (though rarely suspected by the pa- “ Railway Spine.” 7 tient on account of their unilateral character), when present, offer marked peculiarities. Substances readily smelled with both nostrils open are unperceived (sup- posing the anaesthesia to affect the left side) with the right nostril closed. If the tongue be protruded with the eyes shut and the patient told to draw it back when he tastes anything, it remains quiet while quinia, for ex- ample, is placed on the affected side, but is drawn back instantly when it is placed on the other. The sight with the affected eye is feebler than with the right, the field of vision is concentrically retracted, and the patient is unable to distinguish certain colors with the unaffected eye closed. The first to disappear is generally violet, then green and yellow ; red and blue usually persisting unless the degree of anaesthesia is excessive. The hearing (allowance being of course made for disease of the ear itself) is less acute on the affected side, perception for sounds conveyed through the bone and that for high tones being lirst lost. Symptoms not to be overlooked are mental irritabil- ity and emotional tendency. In order to absolutely establish the diagnosis a large horse-shoe magnet, or electro-magnet, should be placed near some spot of the anaesthetic side and left quietly there for say an hour. In the majority of cases the anaesthesia will be diminished, and perhaps entirely disappear or pass to some other part of the body, ofteu- est to the corresponding spot on the other side, which constitutes the so-called transfer. The fact that many observers claim that the mind and not the magnetism is the potential factor in this phenomenon does not lessen its diagnostic value, as its presence in either case absolutely establishes functional auiesthesia. With regard to the motor functions iu this disease, there exist as a rule a certain degree of paresis affect- ing all the muscles of the side involved, so that the grasp, for example, as measured by the dynamometer, is decidedly feebler than on the sound side. 8 “ Railway Spine." The reflexes are generally altered in character, de- gree, or both, the tendency being towards exaggeration. The writer has recently had opportunity to exam- ine a patient exhibiting the symptoms of hysterical hemianaesthesia in a characteristic manner, with no plausible explanation of their origin except the explo- sion of a shell in the patient’s vicinity. The case, though not coming under the class ordinarily desig- nated “railway spine,” is interesting in connection with the discussion of that subject, as strengthening one link in the chain of evidence, in that it substantiates the fact that hysterical hemianaesthesia may follow a mechan- ical shock. It should also be remarked beforehand that the purely functional symptoms in the case were compli- cated to a slight degree by the presence of certain organic changes for which no other plausible origin can be found than the concussion produced by the ac- cident. These organic changes are atrophy of the optic nerves (probably secondary to the concussion), rupture of both drumheads and purulent inflammation of both middle ears, and (probable) haemorrhage into the inner ear on the right, which was the side on which the shell exploded. The temptation is great to assume an organic origin for the symptoms which have been classed as hysteri- cal, but careful study of their nature renders such an assumption extremely improbable. The patient, examined in conjunction with Dr. II. W. Bradford and Dr. E. D. Spear, is a man forty-one years of age, an American, formerly a lamplighter. There seems to be nothing in his family history pointing to nervous or mental disease. lie was himself well and stout until he entered the army in 18G1. Up to this time his sight and hearing were good. In 18G2 a shell exploding near him he staggered to a tree unable to see or hear. Sight was recovered, and hearing to a certain degree. From this time on the patient ex- perienced recurring “ blurs ” before his eyes, with in- “ Railway Spine.” 9 tervals during which he saw very well. From the time of the accident the hearing remained so poor that the patient’s neighbor had to pluck his sleeve in order that he might answer to his name at roll call, and he became unlit on this account for single picket duty. The hearing was from the lirst worse on the right. In October, 18G4, he was shot through the left thigh, the ball doing also some injury to the testicle. Patient remained about three months in the hospital, during which time he remembers numerous attacks of blindness similar to those experienced after the bursting of the shell. When he began to walkabout in the hos- pital he was troubled by pains in the back, running down the leg, and in the testicles. On attempting to walk at that time he found that motion was greatly impaired in the left leg, which was atrophied, felt numb, and was drawn up so that the heel could not be put to the floor. The leg shook violently on attempts at motion. The flesh and strength returned in the left leg in perhaps two years, though the patient has noticed ever since the war that motion was not so strong in the left as in the right limb, and that the toe is inclined to drop in walking, lie complains now of no pain anywhere, but of occasional “drawing” and “crawling” sensations in the back of left leg, numbness in the left hand and fore arm, and sometimes a sensation of being struck in the back. No shooting pains, never saw double, no gastric symptoms, never headache. Occasional attacks, of short duration, of dizziness with tendency to whirl round (he does not know in what direction), nausea, and buzzing in the left ear. Patient is much more ir- ritable than before the war, but shows no loss of mem- ory or power of concentration. There is a history of loss of sexual desire and pow'er dating from time of the War. lie has noticed ever since that time that the strength of the left arm, formerly nearly or quite as good as that of l ight, is much inq uired. Patient denies venereal infection, even gonorrhoea, and says that he has never been subject to sore throat, and has neither had 10 “ Railway Spine.” eruption on his body, nor falling out of hair. He relates that while soldering about two years ago some of the hot solder ran through the Hy of his pants and burned the back of his penis. The only history of severe injury to be elicited, other than the explosion, is that some months after leaving the hospital in 1862 he was struck on the head by a freight train drawn by mules. He was knocked down, somewhat stunned, but was able to get upon the car. Recovery said to be rapid, and with- out nervous or other symptoms. Physical examination. The patient is a short stout man of intelligent mien and good muscular development, excepting that all the muscles of the left arm are decid- edly smaller and less resistant than those of the right. On the scalp exists a cicatrix high up in the occipital region a little to the left of the median line. This cic- atrix is broadly linear, two and one half centimetres in length, non-adherent, non-sensitive, and shows no loss of substance. On the dorsum of the penis, well back from the glans, appears a superficial white oblong cicatrix, 0.7 centimetre in length. The cicatrices representing the course of the shot received in the thigh are as follows: a horizontally linear cicatrix 2.5 centimetres in length, situated at the outer extremity of the fold of the left buttock, and showing considerable loss of substance ; a horizon- tally linear cicatrix 1.5 centimetres long on the inner side of anterior surface of the left thigh, opposite the scrotum, representing considerable loss of substance, quite sensitive, pressure on it causing tingling sensations down the leg ; a linear cicatrix four centimetres in length on the outside of the left scrotum, running down- wards and inwards from a point opposite the cica- trix on the thigh, and forked at its upper end; a small cicatrix in the posterior perineal region (where the ball was extracted). No enlarged glands found. The pupils are of aver- age size, alike, and react both to light and to (attempts at) accommodation. The patient’s gait is somewhat “ Raihvay Spine." 11 uncertain on account of blindness, but is not ataxic ; the only peculiarity noticed is a slight tendency to scrape the left toe in walking. Motion. No ataxia. On testing the strength of the various muscles all muscles on the right side prove very strong, those of the left arm and leg only fairly so. The grasp as measured by the dynamometer bears the relation of (left) 22 to (right) 40, repeated trials giving the same result. Measurements of the upper arm show (right) 30.5 centimetres, (left) 29.5 centimetres. Fore-arm (right) 27.5 centimetres, (left) 20 centimetres. Calf (right) 33.5 centimetres, (left) 33.5 centimetres. Reactions to the faradic current, strong on the right, are lessened on the left. Patellar reflex is increased on both sides, especially on the left. Sensation. All forms of sensation are markedly diminished on the entire left side to the median line, with the exception of an area over the abdomen bounded above by the line of the ribs, below by Poupart’s liga- ment, and outwardly by the axillary line (the line of demarkation is y the hone on the right renders it not improbable that still further lesion of the auditory structures took place, perhaps a haemorrhage into the inner ear. The deafness in the left ear is about that which would naturally result from a purulent inflam- mation, excepting, perhaps, the slight deafness by the bone. Whether this is due to the inflammation, to the hysteria, or to deeper lesion, similar to that on the right, it is impossible to determine, but the latter seems eliminated hy the fact that all tones are heard up to 35,000 vibrations. The blindness (which is so excessive as to mask the amblyopia characteristic of hysteria which would have been expected on the left) is of course due to the atrophy of the optic nerves, a result of cerebral con- cussion not without precedent.1 That this atrophy is due to an attack of typhoid fever from which the patient suffered two years ago is negatived by the fact that atrophy was diagnosticated at the Eye and Ear Infir- mary previous to that sickness. The fact that this patient was a claimant for legal restitution can have but little influence on the genuineness of the symp- toms. In the first place the hysterical symptoms were not at all essential to his claim, and in the second place they were so absolutely typical of a disease as yet lit- tle known, even amongst the medical profession, as almost to preclude simulation, to say nothing of the repeated unsuccessful attempts to expose deceit. The fact being tolerably well established that the patient’s condition results from injury, it is not impor- 1 Erichsen (Concussion of the Spine, 1875, page 23G) says: “If such serious organic mischief can declare itself in the interior of the globe as a consequence of a general jar or shake of the head, it is not unreasonable to suppose that in many of those cases witness, in which, after a general shock to the system, obscuration and impairment of vision gradually manifest themselves, and in which white atrophy of the optic disk is discovered by ophthal- moscopic examination, the injury to the eye, functional and organic, is due to a shake or jar of its nervous structures, by which their nu- trition becomes seriously but slowly impaired, and organic changes become secondarily developed in them.” 14 “ Railway Spine." tant for us to discuss the question whether the accident on the railway or the explosion of the shell was the aetiological factor. The apparent greater severity of the latter shock, together with the fact that the deaf- ness and other symptoms, as far as can be learned, dated rather from the time of the explosion, seem, however, to throw the weight of evidence in favor of that accident. With regard to the question of syphilis, there is no way of deciding absolutely whether the alleged is the real cause of the cicatrix on the penis, but in the ab- sence of other symptoms we have no right to assume that this disease exists, because of the cicatrix.