Post Traumatic Stress Disorder (PTSD) following
railway accidents in the nineteenth century.
Post Traumatic Stress Disorder (PTSD) is
today a well recognised condition. It has
though taken many decades to reach this position.
Historically the medical profession and the
military have been slow to reach a full understanding
of its nature, prevalence and the need to
help those affected. Only as recently as
1980 did the American Psychiatric Association officially
add PTSD to its Diagnostic Manual of Mental
Disorders.
The condition may occur when a person is
exposed to an event involving actual or anticipated
death or injury triggering a feeling of intense
fear. The person then starts to avoid anything
that will cause them to re-experience the
event. There is a numbing outlook on life
which interferes with personal relationships.
They are less able to cope with normal daily
life challenges and may be unable to do their
job effectively. The affected individual
tends to be in a constant state of arousal
and is easily startled. The traumatic event
persists as a dominating psychological experience
causing flashbacks, disturbed sleep and nightmares.
In the UK it was soldiers returning home
with “Shell Shock” from the trenches of WW1 that brought
about a general public awareness of a disturbance
to the mind following exposure to frightening
experiences. Perhaps most people still associate
PTSD with soldiers but it can develop in
anyone, in any walk of life, who experiences
a very dangerous, terrifying, extremely stressful,
or life threatening event.
In the second half of the nineteenth century
railway accidents were a common cause of
PTSD - but only now with the benefit of hindsight
is this realized and understood.
In the 1880’s and 90’s the railways
of Britain were killing around 500 employees each year. They were dangerous places for passengers
too. Train speeds were increasing and carriages
often loose coupled and of flimsy wooden
construction. When accidents did occur there
were often many death and injuries.
The medical profession was aware that some
of those who survived these accidents did
suffer a mental illness. However the consensus
view of the time was that any disturbance
to the mind was a direct result of,
and linked to, the physical injury sustained
in such an accident. Injuries to the back
were very common. It was estimated that over
60% of railway injuries involved some hurt
to the back. This was particular the case
when passengers were subject to sudden acceleration
or decelerations as in shunts or collisions
causing what today would be termed “whiplash”. Indeed back injuries were so common
that “Railway Spine” became a recognized medical term.
The explanation for a disturbance to the
mind was that as the back (spinal column)
contained the spinal cord, which was connected
to the brain, then an injury to the back
could cause a disturbance to the mental functioning
of the brain.
Herbert W Page was one who began to question
this explanation. He was Surgeon (Chief Medical
Officer) to the London and North Western Railway for 17 years and had the opportunity to
travel around the railway system interviewing
and examining accident survivors. In particular
he noticed that sometimes the disturbance
of the mind occurred in patients who’d
experienced an accident but had suffered
no significant physical injury. He developed
the hypothesis that this psychiatric condition,
which he termed “General Nervous Shock”,
was an entity in itself and not a manifestation
of a physical injury; though the two could
exist together. He wrote up his views, with
supporting evidence, in a book published
in 1891 entitled, “Railway Injuries:
in their Medico-Legal and Clinical Aspects”. The medical terminology is different
from that used today but in essence what
he was describing was PTSD.
In his attempt to describe the condition
he writes:
“In these purely psychical causes lies,
I believe, the explanation of the remarkable
fact that after railway collisions the symptoms
of General Nervous Shock are so common, and
sometimes so severe, in those who have received
no bodily injury, or who have presented little
sign of collapse at the time of the accident.
The collapse from severe bodily injury is
coincident with the injury itself, or with
the immediate results of it, but when the
shock is produced by purely mental causes
the manifestations thereof may be both prolonged
and delayed. Warded off in the first place
by the excitement of the scene, the shock
is gathering, in the very delay itself, new
force from the fact that the sources of the
alarm are continuous, that they may recur
for days, and for a time be all potent for
evil in the patient’s mind.”
He gives the details of several case histories
but I quote here just one which I think illustrates
many features of the condition.
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Case 10 – Severe General Nervous Shock –
prolonged symptoms – physical injuries
slight.
S.W. , aged 46, a tall, somewhat powerful
man, was in a very severe and destructive
collision. He received bruises over both
arms and legs, and also a blow upon the face
which abraded the skin over, and fractured
the bones of, his nose. He was not stunned.
He lay for several days after the accident
in a state of great nervous depression, with
feeble and rapid pulse, an inability to eat
or sleep. He suffered at the same time much
distress from the fact that a friend sitting
beside him in the carriage had been killed;
and things seemed to prey constantly upon
his mind.
The bodily injuries proceeded rapidly towards
recovery, and in 17 days after the accident
he was able to be moved home. Nine weeks
after the accident he had fairly well recovered
from his local injuries, and made no complaint
of bodily suffering. Examination at this
date discovered no structural disease, but
he was evidently in the most feeble and wretched
state. The ordinary functions of the body
were natural, but his mental condition showed
extreme emotional disturbance. He complained
that he had suffered continually form depression
of spirits, as if some great trouble were
impending.
“He is easily upset and prone to cry.
He says he used to cry whenever he spoke
to anyone, but that now he has rather more
control. He has been out of doors for a few yards,
but was stopped by a sudden sensation as
if his breathing were very short. His voice
is very weak and indistinct, and occasionally
he says it is almost inaudible. There is
no disease of the larynx or adjoining parts.
He sleeps very badly, waking frequently,
and being constantly troubled by distressing
dreams. His pulse is weak, 104. He occupies
himself by a little reading and by occasionally
going out, but he feels so shaken and weak
that he is unable to do anything more. In
many respects, however he is improving. The
weight he lost is being regained. He can
walk a little further, is not so ready to
cry, and his voice is stronger.”
He remained in much the same condition for
several months, though with undoubted tendency
towards improvement. Fifteen months after
the accident, several months, that is, after
his claim had been settled, I learned that
he was better, though yet very far from right,
and he was considered wholly unfit for work.
His history, given four years after the accident
by his medical attendant, is as follows:
“In my opinion he will never be anything
like the same man again. His appearance is
much altered. He looks much older, haggard,
and has become very bald. His voice is very
weak, almost gone at times, For some time
he went about in search of health, but improved
very slowly, if at all. Lately he obtained
two posts, the work at which is of a very
light nature.
I just jotted down the following symptoms
as he mentioned them, and I feel sure he
would not willfully exaggerate them. Very
depressed spirits, sometimes palpitations,
loss of sleep, bad dreams, very easily tired,
can’t walk more than 2 miles, then
gets very tired and quite loses his voice.
Did nothing for two years after the accident.
He lost all his energy. Sometimes has a great
dread of impending evil.
He can travel by railway without feeling nervous,
but can’t drive without feeling frightened
all the time. Always gets very upset if dining
in company or if many people are talking
near him. I knew him well before the accident,
and he was a very energetic and very honourable
man.” Three years later his symptoms
were still subsiding. Since he began more
regular work he has continued more markedly
to improve.
It must be pretty obvious from this history
that this man’s prolonged illness was
due in only small measure to the bodily injuries which he received. From these injuries,
indeed, he had recovered, as soon as if they
had been inflicted in any other accident
and in any other way. The cause of his illness
and of his altered condition, even after
the lapse of several years, was the mental
shock, call it fright or what we may, which
the whole circumstances of the accident wrought
upon him.”
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Today life threatening railway accidents
are thankfully rare. Few passengers board
their train with any sense of fear. This
was not so in the nineteenth century as the
author explains:
“It is this element of fear, this great
mental shock, which in railway collisions
has so large a share – in many cases
the only share – in inducing immediate
collapse, and in giving rise to those after
symptoms which may be almost as serious as,
and are certainly more troublesome than,
those which we meet with shortly after the
accident has occurred. The reasons for this
are not far to seek. The incidents indeed
of almost every railway collision are quite
sufficient – even if no bodily injury
is inflicted – to produce a very serious
effect upon the mind, and to be the means
of bringing about a state of collapse from
fright, and from fright alone. The suddenness
of the accident, which comes without warning,
or with a warning which only reveals the
utter helplessness of the traveller, the
loud noise, the hopeless confusion, the cries
of those who are injured ; these in themselves,
and more especially if they occur at night
or in the dark, are surely adequate to produce
a profound impression upon the nervous system,
and, even if they caused no marked shock
or collapse at the time, to induce a series
of nervous disturbances at no distant date.”
Though not recognised or described in terms
we would use today Post Traumatic Stress
Disorder was certainly a real, and maybe
not uncommon, entity in the late Victorian
railway age.
The dangers of working on Britain's railways
continued into the early twentieth century
as evidenced by the following extracts from
the records of Springs Branch depot in Wigan.
These incidents can be multiplied across
the hundreds of such depots in existance
at the time:
