Lessons from history #3: From railway spine to whiplash

‘Railway spine’ was the name given to the widespread finding of chronic back pain and disability associated with railway injuries, and reaching near epidemic proportions in mid and late nineteenth century England. It has many similarities with other post-traumatic conditions and provides lessons about chasing physical diagnoses, and the role of psychosocial factors (in particular, the role of compensation). Lessons that we never seem to learn.

Railway spine was characterised by a variety of physical disorders attributed to a railway accident, in patients with no significant organic injury. The symptoms varied and included back pain, limb pain, headache, fatigue, dizziness, memory loss, and sensory changes and weakness in the limbs. At the time, the mechanism for the condition was still thought to be organic, but without identification of an organic process, theories developed which matched the thinking of the time. The condition was thought to be a form of neurasthenia: irritation of the nervous system secondary to the physical shock of the accident. Various terms were used for this such as spinal concussion, traumatic neurosis and nervous shock.(1)

In the nineteenth century, neurosis, neurasthenia and nervous shock were seen as physical disorders of the nervous system, separate to mental or emotional conditions. Although the mechanism was thought to be through the physical impact of the collision, some element of exaggeration was suspected in claims for railway spine.(2) Later, near the end of the nineteenth century, psychological theories were developed for conditions like railway spine.

Whatever the mechanism behind railway spine, the association with compensation was indisputable. By validating the physical nature of the disease (albeit with theories only), the medical community smoothed the way for sufferers to successfully sue the railway companies and by the 1860’s the railway companies were paying out large sums in compensation for this condition and were losing almost every personal injury case that went to court.(3,4)

The difficulty with assessment of the cases (due to lack of physical evidence of injury) was noted at the time and, interestingly, a proposal for an independent review panel, consisting of physicians, surgeons and a legal advisor was suggested,(2) similar to solutions proposed and implemented for compensation cases today. When the theories regarding the cause of the condition turned towards psychological factors rather than physical, claims became harder to support and the reporting of railway spine subsided.

The bottom line

Railway spine was a constructed condition that had no physical basis and was completely determined by psychosocial phenomena. Doctors explained it in physical terms and falsely attributed the symptoms to a mechanical cause (the railway injury), no matter how slight that injury. Does anybody else see the similarities with whiplash?

1. Trimble MR. Post-traumatic neurosis: from railway spine to whiplash. New York: John Wiley & Sons; 1981

2. Railway injuries: a medico-legal subject, The Lancet, 1861, Sept 14, 255-6

3. Cohen ML, Quinter JL. The derailment of railway spine: a timely lesson for post-traumatic fibromyalgia syndrome. Pain Reviews. 1996;3:181-202.

4. Harrington R. The railway accident: trains, trauma and technological crisis in nineteenth century Britain.  York: University of York, Institute of Railway Studies; 2004. Available from: http://www.york.ac.uk/inst/irs/irshome/papers/rlyacc.htm.