Chapter 2
Trains, Brains, and Sprains Railway Spine and the Origins of Psychoneuroses

In what has come to be one of the most conspicuous cinematic metaphors of sexual intimacy, directors have readily seized on the image of a train passing into a tunnel. This image, of course, owes itself to the psychoanalytic theories of Freud. That a train, the great nineteenth-century symbol of technology and progress, is the vehicle commonly used to connote unconscious sexual desire is more appropriate than most people have ever dreamed. For it was an experience with trains themselves that unwittingly drove a host of prominent nineteenth-century physicians to discover the human unconscious.

The relationship among trains, brains, and the unconscious is by no means readily apparent. The discovery of the nexus that links these apparently disparate items was more the result of serendipity than design. Train accidents gave rise to what many surgeons regarded as a novel spinal ailment. Further investigation led some to theorize that the brain, not the spine, was the source of the disorder. Eventually, even this brain-based model was discarded for a mind-centered one. My contention that the discovery of traumatic neuroses figured prominently in inspiring psychotherapy will come as little surprise to anyone well versed in the history of psychoanalysis. But the notion that traumatic experience might give rise to psychoneuroses did not originate with Sigmund Freud and Joseph Breuer's Studies on Hysteria .^[1] Indeed, what is rightly regarded as the beginnings of psychoanalysis can likewise be seen as a significant contribution to an already vibrant debate concerning the effects of traumatic experience.

One of the great ironies in the development of psychotherapy in the United States concerns the vital role played by economically and culturally conservative railway surgeons. It was these surgeons—not liberal psychiatrists or even progressive neurologists—who were the leading exemplars not only of a revised psychogenic paradigm but also of a crude form of psychotherapy itself. Spurred by a rising tide of costly litigation resulting from an increasing incidence of railway accidents, they began to question the limitations of the somatic paradigm.

The professional discourse regarding the origins of traumatic neuroses, while not a sufficient cause, was nonetheless a necessary prerequisite for the emergence of what came to be known as psychotherapy.^[2] More than fifty years before the horrors of the First World War brought to light the traumatic origins of various psychoneuroses, a number of prominent physicians on both sides of the Atlantic had acknowledged the possibility that fright itself might give rise to myriad physical and psychological symptoms. Modern travel, not modern warfare, engendered a novel and hitherto unfathomable ailment, the railway spine. Born in 1866 as an exclusively somatic disease, railway spine entered its adolescence in the 1880s as a confusing psychical ailment, began its adulthood in the 1890s in a state of somatic-psychic flux, and suffered an early death in the first decade of the twentieth century. In its short life railway spine contributed both to a fundamental restructuring of the somatic paradigm and to the relegitimation of psychogenic notions of causality.

Railroad track in the United States had grown from 3,000 miles in 1840 to almost 52,000 in 1872.^[3] This was by no means an unmitigated blessing. With the expansion came accidents, injuries, and death.^[4] Walter Licht reports that for every 117 trainmen employed in the United States in 1889, one was killed; for every 12, one was injured.^[5] Workers and their families were not the only parties to be adversely affected; passengers and bystanders were also at risk.^[6] Although the majority of train-wreck victims experienced commonly expected ailments such as broken bones, concussions, and contusions, other victims appeared to escape physically unscathed. But some who literally had walked away from a high-speed wreck soon displayed a host of seemingly inexplicable symptoms. Cases of full or partial paralysis, headaches, and various aches and pains often emerged at a later date. While the immediate cause of these and other apparently somatic symptoms remained a mystery, physicians were often able to trace certain symptoms back to the traumatic experience of the railroad accident itself. But

rather than provide a psychological explanation for what were indisputably post-traumatic symptoms, the overwhelming majority of physicians offered instead a compelling materialistic rationalization for the disorder. The very name of the condition, railway spine, was indicative of late-nineteenth-century medicine's materialistic orientation.^[7]

Not all physicians accepted this somatic interpretation, however. Some argued that those suffering from this disease were in fact conniving malingerers who had feigned their symptoms for the purpose of suing the railroads. Others dissented vigorously from this line of argument. Railway spine, they proclaimed, while perhaps a misnomer, was a mentally induced affliction that could be treated best by psychological intervention. By the 1890s a consensus among physicians regarding railway spine was nowhere to be found. Morton Prince charged that there were "two different and almost radically opposed views."^[8] Proponents of the first insisted that railway spine was an organic disease that would in time reveal itself by way of microscopic inquiry. Advocates of the second maintained that the symptoms associated with railway spine were psychologically induced and bore a stark resemblance to those commonly associated with such functional diseases as neurasthenia and hysteria. This conflict was more than merely an academic matter. It was a much smaller part of a fierce medicolegal debate that had its origins in a now-forgotten 1866 series of lectures delivered by distinguished English surgeon John Eric Erichsen.

The publication of Erichsen's brief 144-page volume set into motion a process that swiftly moved beyond the capacity of any single individual to control. As a later commentator proclaimed, "[To] John Eric Erichsen, of London, belongs the credit of being the first to describe a group of symptoms, mainly nervous, that frequently occurred after a concussion of the spine, even though no demonstrable lesion was inferable antemortem, or discoverable postmortem."^[9] The eminent American neurologist Charles Dana did not exaggerate when he later asserted that Erichsen's lectures had been "epoch-making."^[10] While Erichsen had no way of anticipating the full impact of his doctrines, as the first author to write extensively on the topic of railway spine he had unwittingly defined the parameters of an ensuing medicolegal discourse that would persist long after his death. His thesis became the sole referent against which his critics were forced to respond, and as a contemporary commentator noted, it propelled railway spine into "the public mind as one of the expected events of railway travel ."^[11]

That Erichsen's name is rarely found in the history of psychiatry, neu-

rology, or psychotherapy is not surprising, however. From a scientific perspective his work contained little that could be considered novel. His book's notoriety was attributable not to its contents but to the response it generated.^[12] In offering his lectures, Erichsen's aim appeared modest enough. "My object," he wrote, "has been to describe certain forms of Injury of the Nervous System that commonly result from Accidents of Railways, to which I believe the mind of the Profession has not been directed with that amount of attention which their frequency and the important questions involved in them, appear to demand."^[13]

Erichsen offered a systematic demonstration of an increasingly common ailment that he claimed was primarily, though not uniquely, attributable to railroad accidents. He presented no anatomical or pathological evidence in support of his diagnosis but argued instead by way of analogy and according to clinical observations. Like the brain, the spine, Erichsen argued, was susceptible to a concussion that induced "molecular changes" in the spinal cord and gave rise to a wide variety of subjective symptoms.^[14] In many respects his analysis bore a striking resemblance to George Miller Beard's soon-to-be-articulated conception of neurasthenia.^[15] Like Beard, Erichsen sought to apply a single label to a wide variety of symptoms. But whereas Beard could only speculate as to what factors of modern civilization might cause neurasthenia, Erichsen was able to pinpoint a single, dominant variable that gave rise to what he termed "concussion of the spine." "It must ... be obvious," Erichsen charged, "that in no ordinary accident can the shock be so great as in those that occur on Railways. The rapidity of the movement, the momentum of the persons injured, the suddenness of its arrest, the helplessness of the sufferers, and the natural perturbation of the mind that must disturb the bravest, are all circumstances that of necessity greatly increase the severity resulting to the nervous system, and that justly cause these cases to be considered as somewhat exceptional from ordinary accidents."^[16]

Erichsen's causal analysis joined together an unequivocal physical element, spinal concussion, and certain nonexclusive physical agents, helplessness and mental unrest. Railway spine could be properly diagnosed only by paying careful attention to the patient's symptoms, which included the following: "defective memory; confused thoughts; diminished business aptitude; ill temper; disturbed sleep; hot head; impaired vision; impaired hearing; perverted taste and smell; impaired sense of touch; attitude changes; gait changes; loss of limb power; loss of motor power; modification or diminution of sensation in the limbs; numb-

ness; coldness; weight loss; sexual impotence; variable pulse."^[17] Erichsen's decision to attribute these symptoms to some underlying somatic irregularity can be traced to the prevailing scientific climate of Victorian England. But science alone did not inspire Erichsen's interpretation.

Issues of gender likewise figured prominently in his analysis.^[18] Railway accidents affected women as well as men. But since men were more likely to travel by rail, they were far more likely to be victims of accidents. Of the six cases of railway accident-induced spinal concussion that Erichsen discussed in his work, only one involved a woman. Erichsen was not surprised to observe that following such accidents men and women displayed similar physical symptoms—excepting, of course, disruption of the menstrual cycle. What shocked him, however, was his discovery that both sexes exhibited extreme emotional volatility. Given the prevailing sex-specific views regarding hysteria, the presence of apparently hysterical symptoms in men, more than any other single factor, convinced Erichsen that railway accidents and other traumas that elicited similar symptoms must be indicative of some serious organic disturbance.^[19] Like most other physicians of his day, Erichsen simply could not fathom the possibility of a big, strapping man falling victim to what he and others of his generation held to be an almost exclusively female malady.^[20] To support this view Erichsen included the case of a forty-five-year-old male victim of a railroad accident.^[21] After recounting this man's sordid tale Erichsen asked,

Is it reasonable to say that such a man has suddenly become "hysterical," like a lovesick girl? ... To me, I confess, the sight of a man of forty-five, rendered "hysterical," not for a few hours or days even, but by some sudden and overwhelming calamity that may for the time break down his mental vigor, not permanently so but for months or years would be a novel melancholy phenomenon, and is one that I have neither seen described by any writer with whose works I am acquainted, nor witnessed in a hospital experience of twenty-five years.^[22]

Erichsen's views on these matters were neither unorthodox nor a source of serious contention among his colleagues. In fact, they were simply a reiteration of widely accepted medical views on the subject. Hysterics, as Carroll Smith-Rosenberg observes, were typically denied "the sympathy granted to sufferers from unquestionably organic ailments."^[23]

Whereas prevailing assumptions regarding gender seemed to confirm Erichsen's doctrines, those concerning class appeared to negate them. Unlike neurasthenia, which initially appeared to affect only upper-class

men and women, accident-induced spinal injuries transcended class boundaries. Indeed, the overwhelming number of railroad passengers were from the upper and middle classes. Physicians did not, however, regard the apparent presence of railway spine in all social classes as further evidence of its legitimacy. On the contrary, the apparent frequency of the condition among lower-class victims caused many to question whether some other agency might better explain these cases. "Those who suffer most," a skeptical British physician sarcastically asserted, "are notoriously occupants of the third-class carriages."^[24] That there were neither figures to support these claims nor any consideration of the possibility that third-class carriages might be more dangerous than first- or second-class ones made little difference to those who were intent on discrediting Erichsen's analysis.

Long after he first promulgated them, Erichsen's views remained a source of irritation for the railroad companies and for the lawyers and surgeons who represented them on both sides of the Atlantic. "It would hardly be stating the case too broadly," charged railroad advocate D. R. Wallace, "to say that it is doubtful if there has ever been a damage suit brought against a railroad company for any obscure nervous trouble, real or pretended, either in this country [the United States] or in Great Britain, for the last quarter of a century, in which the book has not figured."^[25] "The extravagant estimate of the money value being 'shaken,' as it is called in England," explained a prominent American surgeon, "is largely due in this country at least to a single work, the only one in our language which enters into a detailed discussion of the so-called symptoms of concussion of the spinal cord."^[26] Criticism was not confined to the British surgeon's writings; it also extended to his character and integrity. "The ingenuity and plausibility with which his book was written," commented railway surgeon John G. Johnson, "spoke more to his skill as a partisan" than it did to his desire to seek the truth.^[27] "I think him worse, and he has done railway corporations infinitely more damage," charged another, "than the fellow who takes his life in his hands and holds up and robs a stage-coach or railroad train."^[28]

Erichsen denied the charge that he had written his book to benefit the interests of the public at the expense of the railroads. In a letter to the British Medical Journal , he challenged the claims of a reviewer who asserted that the "title of Erichsen's little volume is calculated to mislead the casual reader":^[29] "I must add that this particular title—the 'lettering' as it is called—was devised by the publisher and the bookbinder and was arranged with a view to space rather than to accuracy. With it I

had nothing to do."^[30] That his book might occasionally play into the hands of unscrupulous dissimulators and their attorneys, he continued, was hardly his fault. "If the public ... 'believes that there is a specialty in the injuries produced by railway accidents,' that," said Erichsen, "is none of my doing."^[31]

Psychosomatic Backlash

For fifteen years Erichsen's work remained the only book-length study of the topic. Translated into several languages, it sold thousands of copies throughout Europe and North America. Finally, in 1880, Boston surgeon Richard Manning Hodges offered the first serious English-language challenge to Erichsen's somatic doctrines. In contrast to Erichsen's claim regarding the unique capacity of railway accidents to elicit the many symptoms he listed, Hodges argued that railway accidents were just one of several possible mishaps that might give rise to virtually identical symptoms.^[32] Hodges did not dispute the capacity of traumatic experiences to cause a wide array of physical and mental symptoms. What he questioned was why the symptoms attributable to railway accidents were considerably more durable than those caused by other traumatic events. The answer, he wrote, "is due, not to the specific peculiarities of train accidents, but to the annoying litigation and exorbitant claims for pecuniary damage that are constantly the grave result of their existence."^[33] In other words, railway accidents were unique because they alone had the capacity to make their victims instantaneously wealthy.

Soon after the publication of Hodges's article Herbert W. Page, surgeon to the London and North-West Railway, received the prestigious Boylston Prize from Harvard University for an essay on the topic of spinal injuries.^[34] Two years later Page expanded his findings and published the first book that explicitly challenged Erichsen's doctrines.^[35] Building on Hodges's analysis, Page argued that while railway accidents might immediately give rise to a host of subjective symptoms, those that emerged at a later date could only be explained by psychical factors.

In formulating his conception of nervous shock Page relied on the work of his British surgical colleague Thomas Furneaux Jordan, who in 1866 had published his prize-winning essay, "Shock after Surgical Operations."^[36] This article established Jordan's reputation as one of the world's foremost authorities on shock. But it was not Jordan's discus-

sion of surgical shock that Page found intriguing. Rather it was his specific references to railway accidents: "The incidents of a railway accident contribute to a form of a combination of the most terrible circumstances which it is possible for the mind to conceive. The vastness of the destructive forces, the magnitude of the results, the imminent danger of the lives of numbers of human beings, and the hopelessness of escape from danger, give rise to emotions which in themselves are quite sufficient to produce shock or even death."^[37] Although Jordan's analysis did not directly refute Erichsen's conception of spinal concussion, it provided a compelling alternative that Page readily adopted. "Purely psychical causes," Page argued, "[could explain] the very remarkable fact that after a railway collision the symptoms of general nervous shock are so common, and so often severe, in those who have received no bodily injury, or who have presented little sign of collapse at the time of the accident."^[38]

Following Hodges's and Jordan's lead, Page identified fright as the primary agency responsible for the trauma-induced symptoms that Erichsen had earlier attributed to spinal concussion. Page then combined their analyses with the recent findings of distinguished British surgeon James B. Paget. In 1873 Paget had delivered a series of lectures on the topic of neuromimesis, which, he explained, was a phenomenon that arose under certain infrequent circumstances and induced patients to present symptoms that mimicked those of actual structural diseases.^[39] Fright itself, Page thus extrapolated from his reading of Hodges and Paget, was capable of eliciting neuromimetic symptoms by way of some willful hypnotic state.

And, as of the hypnotic state, so of other neuromimeses also, the patients may voluntarily submit themselves to their exhibition, and the manifestations thereof become in themselves not less real. The existence of a certain amount of control is shown moreover by the disappearance of the mimicries, when all cause for their representation is removed. The matter of compensation as we have seen, exerts in many cases a very favorable influence on the symptoms of general nervous shock. It does so in these cases also, and examples are not few in which the typical neuromimesis came to an end shortly after settlement of claim had secured for the patients complete repose of mind, and had freed them from the necessity of any longer allowing themselves to be victims of the mimetic phenomena.^[40]

In suggesting that something akin to a hypnotic state explained not only the persistence of neuromimetic symptoms but also their disappearance following settlements, Page had provided one of the first exclusively psy-

chological explanations for both the cause and the cure of functional ailments.

Page's synthesis was both original and compelling. But despite its many virtues it contained a fundamental contradiction that contemporary commentators could not fail to recognize. His assertion that neuromimesis was a product of human will directly contradicted Paget's original presentation of the subject that emphasized the "unwilling" participation of the victim.^[41] Moreover, Page's statements concerning voluntary submission to hypnotic states likewise failed to consider the most recent French investigations of the subject that had emphasized the possible role played by unconscious factors. For Page, conscious forces, not unconscious ones, were the dynamic variable.

The implications that could be drawn from this volitional model, Page asserted, could not be more clear: "The lesson to be learned from this is very obvious, that the sooner any cause for the representation of the phenomena is removed, the better, and that the patient should as far as possible be freed from the hurtful sympathy of friends."^[42] As a surgeon Page simply could not fathom the possibility of unconscious, involuntary submission to psychical forces. But much to his chagrin Page's volitional model of accident-induced neuromimesis provided the foundation for a newly emerging and increasingly respectable psychogenic paradigm. Except for the element of human volition, the British railway surgeon's explanation for traumatic injuries remained fundamentally intact as it made its journey from the surgical to the neurological domain.

From the Spine to the Brain: A Functional Reassessment

Page had accomplished a remarkable feat. He had written a book that appealed to two distinct and significant constituencies. Both surgeons and neurologists were intrigued by his discussion of psychogenesis and his argument concerning the palliative effects of settlements. Neurologists were happy to see a railway surgeon who neither discounted the legitimacy of neuromimetic symptoms nor claimed that the overwhelming majority of plaintiffs in damage cases were frauds and malingerers. Surgeons, especially those who like Page were employed by the railways, also had cause to be pleased. A prominent member of their

ranks had published a book that not only assailed Erichsen's doctrines but also appealed, so it seemed, to a wide range of medical specialties.^[43]

Charles Dana noted that until the publication of Page's book the topic of railway spine had been exclusively "in the surgeon's hand and studied from a surgeon's standpoint." "It was not until after the appearance of Page's work," he added, "that neurologists took up the matter seriously."^[44] When they did, it swiftly became apparent that there was little consensus to be found. Rather than usher in a new age of medical consensus, Page's work simply shifted the domain of the previously existing conflict from the realm of surgery to that of neurology.

By citing the role of mental factors in the production of accident-induced neuromimetic symptoms, Page unwittingly contributed to a renaissance of medical interest in psychogenesis. Page's work became a clarion call to both European and American neurologists. Initially, an overwhelming majority of neurologists looked favorably on the British railway surgeon's analysis. For instance, Harvard neurologist James Jackson Putnam considered it highly probable that psychical agency alone might produce the hysterical symptoms associated with railway accidents, and he praised Page's work for dwelling "particularly upon the important point that a rapid improvement after the settlement of legal claims is by no means proof that the patient's symptoms were imaginary or assumed, an inference which is often unjustly drawn."^[45]

Still, more important from the medico-legal point of view, is the fact that even in chronic cases where the patient presents no symptoms that might not more or less readily be feigned, it is sometimes possible by careful searching to discover signs of so-called hysterical state, which, although not strictly objective, have almost the same value as if they were so as evidence against malingering. So far as I know, this fact has not previously been noticed, certainly it has not found its way into the literature of the "railway spine."^[46]

But the definition of hysteria to which Putnam and other neurologists subscribed was in many respects dissimilar to the one held by Page. As Putnam's fellow Bostonian, George Walton, explained, when American neurologists spoke of hysteria they meant "not the vague hysteria of former times, but the functional disturbance of the cerebral centers which modern research, as set forth by Professor Charcot, has shown to follow given laws, and to offer pathognomonic characteristics."^[47] It was precisely this physiological interpretation of hysteria that the British medical profession, in general, and railway surgeons, in particular, found so distasteful.^[48]

Page's imprecise conception of railway accident-induced male hysteria and the subsequent American reception of his doctrines figured prominently in Jean-Martin Charcot's analysis of the subject.^[49] According to Mark Micale, "In the period 1885–88, Charcot's work on masculine hysteria was practically synonymous with the investigation of traumatic hysteria."^[50] Moreover, like most physicians of his day Charcot saw little reason to challenge the sanctity of the somatic paradigm and the prevailing medical wisdom concerning the physiological foundation of all diseases. His investigation of hysteria was resolutely somatic in its orientation.^[51] Given his neurological expertise, this perspective was not the least bit surprising. In many respects his doctrines bore a striking resemblance to Erichsen's spinal concussion and Beard's neurasthenia. All three presupposed what Edward Shorter refers to as "a hidden organicity."^[52] Hysteria was exceptional in one critical respect, however. Of the three, it alone was believed to be almost exclusively a matter of heredity.^[53]

Throughout the 1870s Charcot remained committed to his somatic doctrines but acknowledged that "clinical and pathological research is necessary (in the case of the human subject) to a final judgment and the furnishing of proof."^[54] In 1878 he took an audacious step and began a formal investigation of hypnotism.^[55] But rather than consider the possible psychical effects of hypnotism, Charcot concentrated on what he perceived to be its predominant physiological implications.^[56] Just as he had maintained that the presence of hysterical symptoms was itself indicative of some underlying neurological irregularity, he likewise proposed that "hypnosis itself involved physiological changes in the nervous system."^[57] Indeed, the ability to be hypnotized was itself, Charcot insisted, evidence of some underlying hysterical, that is, cerebral, disturbance. Hypnotizing nonhysterical individuals was, by definition, impossible.^[58]

Charcot's reputation added a hitherto absent credibility to the study of both hysteria and hypnotism. Of particular significance in this respect was his conception of male hysteria. Charcot was not the first physician to acknowledge the presence of male hysteria.^[59] Indeed, when he first turned his attention to hysteria in the early 1860s, the notion of masculine hysteria already possessed a long history. But, as Micale notes, "[it] consisted mostly of passing, programmatic statements with little theoretical elaboration, clinical illustration, or academic recognition."^[60]

Charcot's first diagnosis of male hysteria took place in February 1879—only two years before Page submitted his prize-winning essay. Over the next fourteen years Charcot recorded an additional sixty cases

of male hysteria, many of which involved working-class men.^[61] More significantly, however, Charcot did not present his first paper on male hysteria until the spring of 1882.^[62] Although Charcot had earlier insisted that female hysteria was almost invariably a product of heredity, the majority of cases of male hysteria that he recounted during the 1880s were triggered by the destructive influence of a physical trauma.^[63] Charcot himself commented,

Quite recently, male hysteria has been studied in America by Putnam and Walton, principally in connection with and as a sequel of traumatisms, and more especially of railroad accidents. They have recognized along with Page, who has also interested himself in this question in England, that many of those nervous accidents designated under the name of railway spine , which, in his opinion, might better be called railway brain , are in reality, whether appearing in man or in woman, simply hysterical manifestations.^[64]

Charcot did not fail to acknowledge the practical questions that such circumstances posed: "The victims of railroad accidents quite naturally claim damages against companies. The case goes to court [and] thousands of dollars are at stake."^[65] Not surprisingly, therefore, the significance of male hysteria, he noted, had itself become a source of legal controversy and a subject of great interest to the medicolegalist "for he is often called upon to give his opinion, in matters concerning which pecuniary interests are at stake, before a tribunal which would likely be influenced (and this circumstance renders his task the more difficult) by the disfavor which is still attached to the word hysteria on account of prejudices profoundly rooted."^[66]

But to Charcot the medicolegal ramifications of traumatic hysteria were not nearly so significant as the neurological ones. Neither Page's status as a railway surgeon nor his desire to refute Erichsen's somatic doctrines was especially relevant to him. What intrigued the French neurologist about the Anglo-American discourse on the subject was the compelling evidence it offered in support of his view concerning the psychical origins of male hysteria and nothing more. By 1885 Charcot had come to accept Page's psychical conception of the agency responsible for traumatic hysteria. But his willingness to acknowledge the possible mental etiology of the disease did not induce him to abandon a physiological interpretation of its nature. On the contrary, mental traumas, he speculated, in some yet-to-be-comprehended fashion, induced an indiscernible physiological disturbance in the nervous system.^[67] "It is always necessary, alongside of the traumatism," he charged, "to take ac-

count of a factor which very probably has played a more important part in the genesis of these accidents than the wound itself." In language that virtually mimicked Erichsen's original discussion of railway accidents, Charcot maintained, "I refer to the terror experienced by the patient at the moment of the accident, and which found expression shortly afterwards in loss of consciousness."^[68]

Charcot explained this process by expanding on Page's earlier example concerning the apparently hypnotic effect of railway accidents on certain weak-minded individuals. He likened traumatic hysteria to states of drunkenness, drug intoxication, and what he had earlier defined as the somnambulistic state of the hypnotic trance. But unlike Page, who was chary about the possibility of psychical traumas evoking physiological disorders, Charcot insisted that the evidence of somatic disturbances was indisputable. Like Erichsen's spinal concussion and Beard's neurasthenia, Charcot's hysteria was known exclusively by its symptoms. "'What, then, is hysteria?' Charcot asked in his last essay on the subject in 1893. 'We know nothing of its nature, nor about any lesions producing it. We know it only through its manifestations and are therefore only able to characterize it by its symptoms, for the more hysteria is subjective, the more it is necessary to make it objective in order to recognize it.'"^[69] Hysteria, Charcot insisted, revealed itself by way of four factors: emotional volatility, sensory stigmata, motor disturbances, and an "hysterogenic zone."^[70] Charcot's ability to isolate particular physiological symptoms unique to hysteria attracted neurologists in precisely the same manner as Beard's earlier description of neurasthenia. Both men had provided their newly emerging specialty with compelling nosological schemes that promoted their professional development and enabled them to compete more effectively with other segments of the increasingly specialized medical profession.^[71]

Charcot's willingness to ascribe etiological significance to the psychical effects of traumatic experiences in no way diminished the importance he attached to the hereditary and physiological aspects of the disease. Traumatic experiences, he insisted, merely triggered preexisting hysterical tendencies and gave rise to what he maintained was "unquestionably one of those lesions which escape our present means of anatomical investigation, and which, for want of a better term, we designate dynamic or functional lesions."^[72] As Ola Anderson explains, "Charcot conceived of the dynamic lesion as localized in the nervous system in the same manner as the structural lesions that had been observed in connection with a number of organic diseases."^[73] The most striking

feature of these so-called dynamic lesions was not their elusive nature, however. Rather it was that unlike structural lesions they were neither permanent nor incurable.

Despite its initial allure Charcot's analysis of traumatic male hysteria failed to arouse the same degree of interest in other lands as in his native France. Its inability to catch on elsewhere was attributable in part to a pervasive resistance to the concept of male hysteria.^[74] Much of the opposition to Charcot's doctrines was rooted in age-old prejudices regarding the exclusively feminine nature of the disease.^[75] Other factors were also at play—especially those related to national pride and cultural prejudice.^[76] As an eminent American neurologist explained, "The Latin races, the French especially, are much more prone to these impressionable disorders, than is the composite race of this country that has come together from all nations of the world to form a new stock. I don't think we ought to apply the deductions of the Salpêtrière too absolutely."^[77]

Leading German neurologists were equally critical of Charcot's findings. As early as 1878, Carl F. Westphal attributed the symptoms of railway spine to small foci of myelitis or encephalitis caused by the trauma.^[78] Westphal's students, R. Thomsen and Hermann Oppenheim, initially disputed their teacher's somatic interpretation, but further investigation compelled Oppenheim to reconsider his mentor's theory.^[79] "The traumatic neuroses," Oppenheim insisted, "are the result of psychic and physical shock . Both act mostly upon the cerebrum and evoke molecular alterations in the same areas which govern the higher psychic and the motor and sensory functions and those of the special senses."^[80]

The most outspoken Anglo-American proponent of Oppenheim's theory was Philip Coombs Knapp, a Boston neurologist and clinical instructor of diseases of the nervous system at Harvard University.^[81] Knapp detested Page's book. He claimed it "read like the work of a special pleader for the railway companies."^[82] "Most of the cases that I have reported," Knapp proclaimed, "had no pecuniary interest whatever."^[83] Similar views were expressed by several of Knapp's American neurological colleagues. Describing the case of a former hotel waiter who had saved a drowning man but then lost his mental composure, Landon Carter Gray declared, "Now, if he was suing a railroad, the question would come up at once, 'Is he shamming?' But you cannot sue the Atlantic Ocean, and there is no basis for suspicion in this case."^[84] Philadelphia neurologist Francis X. Dercum carried Knapp's and Gray's analyses one step further. "In regard to the disappearance of so-called 'litigation symptoms,' made so much by Page and others," Dercum ex-

plained, "my observation has been that when a claim for damages has been settled, the mental condition improves very much. ... After a while, however, I have seen the old mental condition partly reestablish itself while the physical condition has undergone no change save that which could be accounted for by the slow repair of time."^[85]

The competing theories of Page, Charcot, Knapp, Dercum, and others not only inspired a novel neurological discourse but also heightened the stakes in a fifteen-year medicolegal controversy. The role of expert testimony had become a serious bone of contention among physicians who now had two contradictory sources on which they could base their claims. American neurologist Edward Spitzka explained,

The great difficulty under which both the legal and medical gentlemen, connected with trials growing out of real and alleged injuries to the spinal cord, labor seems to be a belief on the part of the plaintiffs that it is necessary to prove the existence of coarse organic disease of the spinal cord and its membranes in order to convince a court or jury that damage has really been done. On the part of the defense a similar impression prevails, and is aided by an excessive zeal to prove simulation on the part of the plaintiff.^[86]

Writing in the Medical Record soon after the publication of Page's work, Dana began his article on railway spine with the following observation.

The physician who is called into court to testify in a case of spinal injury witnesses a curious spectacle. The lawyer for the prosecution waves before the jury a volume of "Erichsen Upon Spinal Concussion." He reads to them, in impressive accents, the statement that every injury to the spine, however slight, is full of danger to the sufferer. He asks, with sonorous emphasis, if Mr. Erichsen is not a surgeon of world-wide fame; and if he does not say that slight injuries to the back may cause chronic spinal disease of the most serious character. He sneers at the work of a certain Mr. Page, who is known to be professedly only a railway surgeon. He shows that his client has paralysis, anemia, meningitis, in fine, "spinal concussion." On the other hand, the lawyer for the defense brandishes triumphantly a larger work, by Mr. Herbert Page, on "Injuries to the Spine"; he reads to the jury cases of malingering therein related, shows that Mr. Erichsen has for years made a business of being an expert for people with injured spines, but that he has never yet found a case that proved fatal. He quotes Mr. Page's two hundred and thirty four cases of spinal concussion, in most of which recovery resulted, and shows, through his medical expert, that the spinal cord is so admirably protected that it could never possibly be injured by anything so utterly trivial as a railway collision.^[87]

Given these two mutually exclusive and highly antagonistic perspectives, it is no wonder that over the course of the 1880s there emerged

not one but several competing explanations and classification schemes for the symptoms that frequently followed railway accidents.

Railway Surgeons Respond

The evolving medical awareness of the possible psychical nature of railway and other traumatic injuries went largely unnoticed in the greater community.^[88] In many respects the internal medical discourse on the topic was rendered superfluous by the social and cultural circumstances endemic to the rapidly industrializing United States, to say nothing of the overwhelming impact of Erichsen's doctrines in courts of law. In the first decade following the publication of his book, the English railway companies paid over $11 million in damages.^[89] Similar figures were cited for the United States. Of these claims, hundreds came from those seeking compensation for spinal concussion or what an eminent physician soon termed Erichsen's disease.^[90]

Finding for an alleged victim of spinal concussion was one of the few ways that ordinary men could vent their frustration against what many believed to be a rapacious and pernicious industry.^[91] In the eyes of the overwhelming majority of American men and women of the 1890s and beyond Erichsen's original doctrines were alive and well. Harold N. Moyer, writing shortly after the turn of the century, asserted that "the term spinal concussion, as used by Erichsen nearly forty years ago, has served as a foundation for an extraordinary superstructure and one that has maintained itself decade after decade in spite of the advances in our knowledge of neural pathology."^[92]

The role played by juries was a source of special irritation to railway surgeons and the corporations they represented. "Juries," asserted the Philadelphia surgeon Thomas G. Morton, "usually sympathize with the plaintiff and can hardly be said to carefully weigh evidence when their sympathies are aroused by the plea of mental and physical suffering or by the sight of bodily injury or deformity which is always made as prominent as possible."^[93] Moreover, they were, according to John Punton, almost universally unreceptive to the efforts of railway surgeons to attribute an accident victim's symptoms to psychological rather than to physiological factors: "We try to explain what the psychologicopathogenic idea is, and as a result we lose our case."^[94] The rising populist impulses that were spreading across the mid- and southwestern

portions of the United States and the growing labor unrest in the Northeast merely exacerbated the railroad corporations' image as rapacious demons. "Unfortunately, in our section," wrote Georgia surgeon Hugh Burford, "the average juror views railway corporations as a great octopus subject to public prey."^[95] Railway spine, charged D.R. Wallace, was merely a symptom of the present "epidemic of madness and insane furor against the railroads and other corporate enterprises."^[96]

Statistics appear to confirm these observations. At trial plaintiffs won almost 70 percent of their cases against the railroads.^[97] Such findings were rarely overturned on appeal.^[98] Keeping cases of this nature out of the hands of juries thus became a central preoccupation for railroad owners, executives, shareholders, and attorneys. Fortunately for the railroad industry most mid- and late-nineteenth-century American judges shared many of its concerns.^[99] By midcentury, in fact, a majority of American judges had become convinced that a jury could not be depended on to handle most negligence cases "fairly"—particularly when those cases concerned injured workers.^[100] The same, however, could not be said of cases involving injured passengers.^[101] As Philadelphia attorney Christopher Stuart Patterson explained in his 1886 treatise, Railway Accident Law , different standards applied to each category.^[102] Indeed, most American judges readily acknowledged that common carriers owed a higher duty to their passengers than to their employees: "When carriers undertake to convey persons by the powerful but dangerous agency of steam, public policy and safety require that they be held to the greatest possible care and diligence. And whether the consideration for such transportation be pecuniary or otherwise, the personal safety of the passengers should not be left to the sport of chance or the negligence of careless agents."^[103]

Given the pervasiveness of this view and the almost ubiquitous hostility expressed by most jurors, railroad companies concluded early on that they had little to gain by contesting the claims of passengers with broken bones, missing limbs, and other similarly conspicuous injuries in courts of law. As the physician Henry Hollingsworth Smith explained,

So generally is this liability for injury caused by negligence admitted, that most corporations or employers do not hesitate at prompt settlement of a just and reasonable claim, being influenced thereto not only by a proper regard for the suffering induced, but also as an acknowledgment of "the Majesty of the Law"; it being a well settled principle "that they are liable for past and future physical and mental suffering, together with the loss of earning power where the consequences are such as in the ordinary course of nature may be reasonably expected to ensue."^[104]

Not every passenger-injury case was black and white, however. With potentially large sums of money at stake, the possibility of fraudulent claims needed to be taken seriously. Cases of alleged railway spine proved to be especially suspect.^[105]

Prior to the publication of Erichsen's lectures an accident victim who failed to display any clearly discernible anatomical or physiological symptoms was not likely to fare well in a court of law. Erichsen's book forever altered this situation. It lent a hitherto absent credibility to the plaintiff's claims and greatly enhanced the prospects of financial compensation. As Erichsen's surgical colleague Dr. James Syme declared,

A victim of a train accident [need only] to go to bed, call in a couple of sympathizing doctors, diligently peruse Mr. Erichsen's lately-published work on Railway Injuries, go into court on crutches, and give a doleful account of the distress experienced by his wife and children through his personal sufferings, which have resulted from the culpable negligence that allowed him to leave his seat prematurely. Who can doubt that in such circumstances the jury would give large demands?^[106]

Many railway executives rightly feared that the answer to this question was almost no one. "That cities and corporations are robbed of vast sums of money yearly by malingerers, aided by unscrupulous legal talent, and by ignorant or dishonest surgeons," charged an angry American physician, "we all know to be true."^[107]

Had Erichsen written a treatise that advanced the interests of the railways and denounced past, current, and future plaintiffs as conniving malingerers, he might very well have put an end to the controversy. But in choosing the opposite track, he greatly heightened the stakes of an already contentious issue. While railroad accidents were not the only source of spinal injuries, they were, said Erichsen, the most frequent cause. And what made spinal injuries so baffling, Erichsen wrote, was "the disproportion that exists between the apparently trifling accident that the patient has sustained, and the real and serious mischief that has occurred."^[108] It was precisely this claim that infuriated the railroad companies, who refused to accept the possibility that a "trifling accident" could give rise to so severe an injury as Erichsen described. The only merit in Erichsen's argument, they claimed, concerned the alleged "serious mischief" that such accidents might cause, but this mischief concerned not the spine but the deliberate efforts of alleged railway-accident victims to defraud the corporations.

The growing incidence of alleged cases of spinal concussion and the frequent willingness of juries to find for the plaintiffs in such cases con-

tributed to the formation of several regional associations of railway surgeons throughout the 1880s. Local associations of railway surgeons were established as early as January 1882—before the publication of Page's book.^[109] Over the course of the decade more than fifty additional local organizations were established. Finally, on June 28, 1888, more than two hundred members representing several of these organizations met in Chicago and founded the National Association of Railway Surgeons (NARS). Later that year the association issued the first volume of the National Association of Railway Surgeons Journal .^[110]

A number of factors motivated the formation of the NARS. But among the primary causes were medicolegal issues arising from Erichsen's analysis.^[111] Years of costly settlements and damage awards forced the North American railroad industry to take action. As Milton Jay asserted, "There is nothing that is probably of so much importance as the medico-legal aspects of spinal injuries. Out of twenty cases of law suits brought to recover damages from railway injuries, fifteen of them will claim to have sustained injury to the spine, even if the spinal cord has not been touched."^[112]

One of the primary goals of the NARS was to provide its members with information and material that they could employ when testifying on behalf of their lines to assure that surgeons were "better equipped to go on the witness stand and protect the company's rights in courts of justice, and thus increase their annual dividends."^[113] Given proper information, railway surgeons hoped to neutralize the expert testimony offered by neurologists and other medical experts who frequently sided with plaintiffs. R. Harvey Reed elaborated:

The Association does not propose to stop at the mere treatment of the patient, which, to relieve promptly and permanently, is a decided benefit to the company, but they propose to study how to protect the company from impositions at court by studying medico-legal aspects of their cases, and thereby seek to discourage malingery in all its multiplicity of forms, whereby tens of thousands of dollars are fraudulently wrung from our railroad companies usually by so-called courts of justice.^[114]

The association had done nothing radical in denying the reality of spinal concussion. If anything its position in this regard was well in keeping with the one of the predominant strands of the American neurological discourse. In fact, some of America's most distinguished neurologists contributed to the cause of railway surgery.^[115] But examples of harmony between neurologists and railway surgeons were the exception rather than the norm. And in this war of words neurologists had a

decided advantage. Their insistence on the somatic nature of traumatically induced injuries found a receptive home among juries throughout the nation.

Leaders of the National Association of Railway Surgeons were not naive. They realized that the public was little inclined to support their point of view. Public hostility to powerful corporations—particularly to the railroad industry—was a fact that few failed to acknowledge. Efforts to influence public perception regarding the psychical nature of railway spine were therefore largely worthless. Acquiring professional support from the larger medical profession was a different matter, however. If an overwhelming majority of American physicians could be convinced not only of the folly of Erichsen's doctrines but also of the legitimacy of psychogenesis, public opinion would cease to be so significant.

The leader of the NARS's crusade to convert the medical profession to this position was not a physician but an attorney. Clark Bell proved to be one of the most formidable advocates for the railroad industry.^[116] A far more accomplished polemicist than most physicians, Bell delivered one of the most widely quoted speeches in the organization's short history.^[117] Railway spine, he asserted,

is the Nemesis of the modern railway. It is the veritable Old Man of the Sea, that it is on the shoulders and is an ever-present, ever-to-be-dreaded terror to railway commerce and railway managers. Invented by one of the most clever English surgeons as a means of procuring enormous verdicts from the railway corporations in accident cases, it has baffled both railway surgeons and counsel, and, vampire-like, sucked more blood of the corporate bodies and railway companies than all other cases combined. It is the ready refuge of the malingerer, the weapon always burnished bright and sharpened, of the unscrupulous attorney and his partner in profit, the medical expert, and affords advantages for the scheming, avaricious claimant who has suffered an actual injury unparalleled by any other cause of injury known in railway damage cases.^[118]

Bell called on the nation's railway surgeons to take matters into their own hands and put an end to this mockery of justice. "Has not the time come," Bell asked rhetorically, "when the profession of surgery should define this injury so that courts, counsel, and juries may know and locate and apply to it those tests which are insisted upon in regard to all other physical injuries?"^[119] Bell then posed this challenge: "Why should the railway surgeons of the nation hesitate in forming such a consensus of surgical thought as would present an insurmountable barrier to the further spread and advancement of an everywhere recognized evil?"^[120]

What Bell neglected to consider, however, was that such an "evil" was by no means recognized everywhere.

While several physicians were sympathetic if not actually supportive of the NARS's endeavor, they expressed little enthusiasm for Bell's analysis, which, in their eyes, reflected old thinking. The majority of American physicians, including neurologists and railway surgeons, were not nearly so interested in exposing frauds or serving as expert witnesses as they were in treating their patients and discovering the true nature of their ailments. In the eyes of the medical profession—particularly neurologists—attacking Erichsen was simply beating a dead horse.

The only significant issue remaining to be resolved concerned not the etiology of railway spine but its pathology. Several questions still needed to be answered: Did psychic traumas merely trigger some preexisting nervous diathesis? Did they give rise to some unique functional disturbance irrespective of a patient's prior personal and hereditary roots? Or did they simply elicit a psychopathological response with no underlying somatic disturbance? The answers to these questions had substantially greater legal than therapeutic significance. In fact, from a purely therapeutic perspective they were, prior to the first decade of the twentieth century, inconsequential. Nervous disorders, regardless of their perceived etiology and pathology, were treated in virtually identical manners. Legally, however, these distinctions were fundamental. John E. Parson, Esq., commenting on the role of mental distress as an element of damage in cases to recover for personal injuries asserted,

The general principle is well established that in actions of tort, where for the wrong, there is a right to recover damages, mental distress may be taken into consideration in fixing the amount. But the weight of authority seems to establish that when the injury consists in distress of mind alone, or where the mental distress is separate from and independent of the wrong, it does not constitute an element of damage and may not be considered in determining the amount of recovery.^[121]

Given Parson's analysis, it was only fitting then that the National Association of Railway Surgeons would begin promoting a purely psychical conception of railway spine. Rather than expend their energy on the thankless and publicly derided task of exposing fraudulent spinal cases in an effort to increase dividends, railway surgeons, like their fellow physicians, were now free to take such complaints seriously and offer such treatment as they saw fit without having to compromise their medical integrity or their employers' pocket.

Suggestion and American Railway Surgery

J.H. Greene, an Iowa railway surgeon, was one of the earliest American physicians to recognize the role of suggestion in fomenting traumatic neuroses. Citing the work of both Charcot and Hippolyte Bernheim, Greene proclaimed, "I believe with the modern views on this subject, a greater importance will be attached to this doctrine of hypnotic suggestion in the cure [of traumatic neuroses] and that it will eventually come up in the courts."^[122] "This doctrine," Greene added, "reconciles in great part the opposing views of surgeons in these cases and that with the acceptance of the theory of hypnotic suggestion they can meet on common ground, without being regarded one as the tool of the corporation, the other as preparing a case for a prospective fee. It also explains the peculiar efficacy of the 'golden cure,' without throwing the comparatively few people in with the perjurers."^[123] In Bernheim's suggestive therapeutics Greene found exactly what he and other railway surgeons had been seeking.^[124]

While Greene provided a plausible theoretical rationale that supported the power of suggestion, Warren Bell Outten offered a more practical example. Among the most powerful figures in the NARS, Outten had devoted more than thirty years of his professional life to his duties as chief surgeon for the Missouri Pacific Railway. Over the course of his career Outten observed that railway employees and passengers were not equally susceptible to traumatic neuroses.^[125] Outten attributed this difference to two separate, albeit related, factors. Both the employees' "familiarity and experience with dangerous elements" and "the social surroundings of the respective classes" figured prominently in his analysis.^[126] In support of this contention he offered the following example.

A man has been in a collision. He was perfectly conscious that he met with no blow; knows, in fact, exactly what occurred to him when the accident happened; and yet he finds that within a few hours, occasionally much sooner, he is seized with a pain in his back, gets worse, and summons a physician. Cause, railway collision! The physician expresses doubt, and suggests grave consequences. Railway injury; nervous patient; suggestion on suggestion continued; and then there is the development of a serious case—psychic influences possibly leading to traumatic hysteria or neurasthenia.^[127]

A sympathetic surrounding composed of friends and loved ones, Outten continued, merely aggravates the patient's condition by fixing his mind

on his ailments and his suffering. Outten offered the following qualification, however: "All, of course, depends upon the mental strength and integrity of the individual himself, and the integrity of his surroundings."^[128]

The role of the attending physicians figured prominently in Outten's analysis of traumatic neuroses. "It seems rather startling," Outten explained, "that a physician, by virtue of mental superiority, prejudice, and suggestion could create an essentially serious condition, but we candidly believe that it is possible in a weakened and receptive mind to suggest and develop consequences of a very serious nature."^[129] Neurologists, Outten added, were among the greatest culprits in this respect: "When a wreck upon a railway train occurs near a large city, you invariably have railway spine simply for the reason that the neurologists or nerve doctors are always present in the cities, while we can show twenty times the number of accidents occurring upon a road away from a popular center never to have them."^[130] During a neurological examination "the mind of the patient," he charged, "is fed with suggestions to the intensification of the neurotic state, while the principle or rest is ignored."^[131]

Outten and other American railway surgeons had inadvertently generated a novel synthesis regarding hypnosis and suggestion. Not surprisingly, this interpretation favored the interests of the railway corporations. Borrowing from Charcot they argued that traumatic neuroses, while legitimate medical ailments, were typically the afflictions of the hereditarily tainted and morally suspect. The so-called neuropath, charged David Booth, "possesses a susceptibility to suggestion and liability to exaggeration."^[132] Of course, claims that railway accidents merely triggered preexisting tendencies were nothing new. But the further assertion of American railway surgeons that doctors themselves frequently aggravated and, on certain occasions, unwittingly inspired these cases by their suggestive influences reflected not Charcot's physiological doctrines, but a perverse and self-serving reading of Bernheim's psychical ones. "The psychic, suggestive, and auto-suggestive element," asserted R. S. Harnden, "enters so largely into these cases, and in fact into all except graver traumatisms accompanied by objective symptoms, that the nicest degree of skill and tact becomes necessary upon the part of the surgeon."^[133]

Virginia Railway surgeon George Ross captured the extent to which railway surgeons had, in fact, fused the conflicting theories of Charcot and Bernheim in a manner that served their own interests. "Suggestion," Ross maintained, "is a tremendous factor, and I believe the doctor into whose hands the patient first goes can materially influence the

patient in any manner he pleases."^[134] Ross's choice of words revealed far more than he realized and captured the prevailing sentiments of his fellow railway surgeons. For Ross, suggestion operated on both a psychical and a physiological plane. The physician's authoritative stature, not the patient's ancestral or acquired vices, served as the dynamic variable in Ross's confused analysis. What the physician did and, more importantly, what he said "materially" rather than psychically influenced the patient for better or ill.

From Charcot, American railway surgeons learned that a state akin to hypnotic suggestion had the capacity to trigger certain traumatic neuroses among a particular class of hereditarily or environmentally tainted men and women. Their often dismal plight, railway surgeons insisted, bore little or no relationship to any train wreck. To the contrary, men and women of this nature were like dry powder in search of a match. The virtue of Charcot's explanation was that it exculpated the railroads in those instances in which it could be unequivocally applied. Such cases were the minority, however. The overwhelming number of victims suffering from traumatic neuroses were free of any demonstrable ancestral or acquired vices.

In these cases Bernheim's psychical doctrines, despite their failure to stigmatize the victim, were far more enticing. They could be used to shift the blame from the accident itself to the attending physician, sympathetic friends, loved ones, and lawyers. Together, these respective, albeit unwitting, suggestive influences could not help but evoke a full-fledged case of traumatic neurosis. Few railway surgeons denied that the shock of the initial accident might itself have contributed to the patient's heightened suggestibility. But the significance of shock, they insisted, could be greatly mitigated provided that certain safeguards were taken—the most important of which involved removing the victim from the harmful influences inevitable in an overly sympathetic environment.

American railway surgeons argued that the most effective treatment of traumatic neuroses involved a combination of the rest cure, especially its emphasis on isolation, and suggestive therapeutics.^[135] But unlike S. Weir Mitchell and other neurologists who conceived of this therapy in somatic terms, the surgeons argued that it operated on a purely psychical level.^[136] Simply removing the patient from ill-advised sympathizers yielded beneficial therapeutic results. Isolation itself, rather than rest per se, had the primary therapeutic value. A successful cure required neither the production of Weir Mitchell's much-heralded "fat and blood" nor the reduction of what he termed "wear and tear." All it en-

tailed was directing the patient's mind away from hurtful suggestions.

"The law of isolation should be so binding in the treatment of these functional nervous affections due to trauma," Punton asserted, "that failure of its enforcement, in the incipient states, at least, should be sufficient ground to excuse any railroad company from further responsibility of any claims made against them for any subsequent nervous disease."^[137] Punton likewise acknowledged the efficacy of suggestive therapeutics but begrudged the fact that "not all physicians can reap positive results with suggestion and thus choose not to avail themselves of this powerful therapeutic tool."^[138] The final word on the subject came from the most eminent of all railway surgeons, Outten, who in a single sentence captured the prevailing psychogenic and psychotherapeutic synthesis achieved by the NARS: "I maintain that many of these cases are made by suggestion and can be treated by suggestion."^[139]

In advocating the clinical use of suggestive therapeutics and emphasizing the psychological features of the Weir Mitchell Rest Cure, American railway surgeons had unwittingly become the first American medical specialty to achieve a consensus regarding the therapeutic value of what would soon be known throughout the world as psychotherapy. Whereas neurologists and psychiatrists were only just beginning to debate seriously among themselves the possible costs and benefits of directing their therapies toward the mind rather than the body, American railway surgeons, by the turn of the century, had become committed to the theory, if not actually the practice, of pursuing such a course. That their motivation was in large measure dictated by the material interests of their employers did not diminish their considerable accomplishment. More than three decades of conflict had generated a novel and compelling psychical synthesis that would provide the future foundation for the birth of American psychotherapy.

Epilogue

Shortly before his death in 1896 an elderly and long since retired John Eric Erichsen took time to pen a letter to R. M. Swearingen. Earlier that year the Texas physician had defended Erichsen against a series of ad hominem attacks appearing in a variety of NARS publications. An old man now, Erichsen expressed little desire to become engaged in what he termed "surgical polemics," let alone to defend himself

from any personal attacks. Instead, he preferred to reflect on the "most hospitable and friendly reception" he received from his surgical brethren in the United States during a visit some twenty years ago. But despite his statements to the contrary, Erichsen could not resist the temptation to express himself one final time on the subject he had almost single-handedly created.

Nearly thirty years have passed since I first brought the subject of railway and other injuries of the nervous system to the notice of the profession. At that time (1866), the pathology of the nervous system and injuries was very imperfectly understood, and even the nomenclature had not been invented. "Neurosis" and "neurasthenia" even, were unknown terms, and what I then, for want of a better name, called "concussion of the spine," is now universally recognized and described under the more modern appellation of "traumatic neurasthenia." The morbid states are the same, and the symptoms identical; but the name has been changed, and the modern designation is probably more in accordance with modern views than was the older one. In all my writings on this subject, I have pointed out that symptoms arising from railway shocks are identical with those that occur from other and more ordinary accidents of civil life, and that these symptoms so occurring had been described by surgeons many years before railways were dreamt of, and fully a century before I had written a line on the subject.^[140]

What Erichsen failed to consider was that a constellation of ideas and interests vastly beyond his or anyone else's capacity to control had combined to render his original intent nothing more than an interesting historical footnote.