RAILWAY NEURASTHENIA.*

BY THOMAS OSMOND SUMMERS, M. A., M. D., F. S. Sc., LONDON.

Editor St. Louis Clinique, and Professor Anatomy and Histology, College of Physicians and Surgeons, St. Louis.

Occupation means the environment of organic metabolism-that upon which all structural development depends. We must all admit that we become under development just what environing influences determine. Even the strictest of the orthodox agree that character itself is under the influence of conditions. A fortiori, how greatly must the physical organism, the great medium of mental expression, the photograph of the ego, to speak in modern parlance, receive impress from its surroundings, and in its development express the result of its environment.

Bernardino Ramazzini, of the University of Padua, in the first year of the eighteenth century, wrote a work in Latin, entitled De Morbis Artificum Diatriba, and it is somewhat singular that in referring to this work Dr. James Henrie Lloyd of Philadelphia has expressed exactly the ideas of the author of this paper, so far as to criticise the work as desultory, digressive and pedantic-painfully pedantic-as Dr. Lloyd well reniarks. But, as has been well said, he is to be "commemorated as the first physician who saw this great subject as a whole, and attempted to treat it in a systematic way." We shall not take up the time of this body in historical references, however; we are after facts; not who made or developed the facts.

In entering upon the discussion, therefore, of diseases which arise from occupations, we are met by the necessity, as indeed in all practical issues, of defining the subject. What do you mean by a "disease of occupation?"

It would be absurd to ascribe under this nomenclature every disease that might affect an individual devoted to any special pursuit. The ordinary diseases of humanity may affect all artisans or professional men alike, and yet there are conditions which determine pathological relations and focalize those influences upon the organism in action, which disturb its balance and even superinduce permanent disease. Aside from the daily occupations

*Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May 1, 1896.

which make up the ongoings of humanity, we are called upon also to differentiate between the pathological effects of latitude, surroundings, etc., and yet we are bound to admit that there are diseases which, however possible in all conditions of race, clime or other environment, nevertheless, are precipitated, if not indeed originated, by the character of occupation in which the individual may be engaged. For instance, it is well known that mining favors rheumatism; silk weaving, tuberculosis; file making tends to produce lead poisoning; gilding brings on mercurial poisoning when the ventilation of the workroom is deficient; constant writing, paralysis; wool sorting, anthrax; and a most signal example of the effect of the steady pursuit of a special occupation was shown right here in St. Louis at the time the caissons were sunk for the building of our great bridge, which stands to-day as a model of modern engineering unsurpassed in all the land. When we are daily brought in contact with men who occupy those positions which expose them to pathological effects or conditions which are entirely due to their occupation, it behooves us to condone many of those incivilities which are the outcome of a morbid strain upon the organism, since a sana mens, as all must admit, cannot exist except in sano corpore. It would be impossible in the limits of this paper to even enumerate the causes incident to special conditions, yet as a recent writer upon a subject germane to this has remarked, there is a temptation to carry out this plan by many authors, the obvious facts that locality, race, age, customs, habits and country affect artisans quite as much, even more, than do their occupations, are too readily ignored, e. g., the butchers of one town or race may be more healthy than those of another, although following identical occupations; or, as Altridge

states, the cotton spinners of one mill may have a great advantage over those of another because they happen to work upon a special fabric for which there is a greater demand in the market, hence receiving steadier wages and leading healthier and more secure lives. While statistics are worthy of most careful and respectful consideration, nevertheless, they fail to establish a principle of scientific accuracy in conditions so variable as these which form the subject of discussion in this paper. We shall, therefore, pass them by, and

reach at once the salient or rather the practical issues involved.

Among all the various occupations which are necessary to the conditions of civilized life there is none which makes such a draft upon the vital energy of the organism as railway service. This arises from four causes incident to this line of life.

1. Rapid and constant transit.

2. "Rattle of the Rail."

3. Irregularity of diet and the ordinary life habitudes.

4. The worry incident to the calling.

I. Rapid and Constant Transit. This acts in two general ways to bring about pathological conditions:

a. The constant and sudden change of climate made necessary by the very rapid movements of our modern railway trains could not but produce a vibratory effect upon organisms subjected daily to it. It is no uncommon sight to see a train covered with snow roll into lands of perennial bloom where snowflake never fell, and on the other hand to see a car decorated with palms and tropic flowers fresh in their beauty sweep through the icy forests of the North and lay their recent tributes at the foot of winter's throne. And yet this is not good hygiene-such changes shock the system. They must disturb the balance of the organism.

b. The change of nerve influences: A debt of eternal gratitude is due to Dr. Beard for his origination of the term Neurasthenia. No term ever introduced into medical nomenclature so completely fulfills all of the pathological expressions which are covered by its use. But we are preceding our limit of discussion and shall have to refer to this remark in our summing up of results.

II. "The Rattle of the Rail."-While the St. Louis Republic lays claim to this formulated alliteration we hardly believe that they fully appreciate from a practical, physiological and pathological standpoint the intense significance involved therein. There is always a continual quiver of the auditory filamentous spread. Of course you may say, "Well, a man becomes used to that!" Has the man who offers such reply ever considered the almost infinite changes the necessary molecular adaptations to conform the organism which is perfectly interactional to the physiological plane? I cannot believe it if he has thoroughly cov

ered the field of investigation involved. We remember once how seriously the roar of Niagara's cataract affected the nerve systems of tourists, especially bridal tourists. Now it may be the fact that such constant vibratory motion may affect the organism constitutionally, nevertheless we must admit that there are incidental influençes which largely determine the character and ultimate expression of the disease. Aside from railway employes themselves who are subjected to all of these patho-neurotic conditions, there are also those who are compelled to be constantly upon the rail in commercial transit. Now it is very evident that this constant change of nutritive gauge-if we can speak thus ex medica cathedra-must necessitate an alteration in the normal functional expression of the organism.

Nothing is more sensitive to experimental test than the ultimate filaments of the optic and olfactory nerves, and a quiver in audation makes a disturbance in nutrition. So is it with all physical influences.

We could carry out this subject to an almost indefinite extent, but the limits of this paper before you forbids my discursive tendency.

III. Now comes the irregularity of diet and the ordinary life habitudes dependent upon railway environment.

It is hardly necessary to show to any modern traveler that the change of diet to which he is subjected in transitu, to say nothing of the character of substance incident to the change, must perforce produce profound and permanent impression. And it is always and ever the nerve centers that receive the impress. Under this influence the inhibitory nerves of the pneumo-gastric are the great formers and distributers of function. This we suggest as the key to unlock the pathological issues of such molecular disturbance.

IV. The Worry Incident to the Calling.It is not a very strange fact that apart from specific diseases fatal in their character there are extraneous conditions, produced by irritable relations such as cannot be controlled by physical causes alone. We firmly believe that we state an axiomatic fact when we say that "worry kills more men than work." Work-Steady outdoor work under the clear open sky by the bright waters, under the conditions laid down for us by nature, is just as

much a necessity to the organism as nutrition itself. But let anyone consider the interminable, constant brain harrowing influences which press in upon the railway service, and he will feel that a master of modern motion is a martyr to modern methods.

This is not confined to the steam railway service alone; indeed in the street railway service of our great cities we are confronted with a tremendous shadow of neural death if you will permit such a license of methephoric expression.

I have often felt in my very heart an active sympathy for the thousand and one irritative influences which wear away the life of the conductor and the motorman like vultures feeding upon the lives of Prometheus bound to the everlasting rock. It is but necessary before a body of such intelligence to bring out these salient facts in a short and formulated manner as we have endeavored to do in this paper.

Now it remains to give the Hamlet of the play, i. e., the remedial agencies necessary to control or even modify the conditions set forth above.

Time would fail us to enter into the full therapeutic indication set forth in our fundamental principles, but there are, thanks to the ingenuity of pharmacal and chemical devotees -certain combinations so constructed as to enter without further digestive action distinctly into the several tissues of the body, supplying the waste without draft upon the normal cellular activity of the organism. I believe, yes, I even know, that these conditions have been met in the preparation called melachol, which not only contains the normal inorganic constituent of the wasting nerve organism, but also by its steady peristaltic action opens the pathway of excrementitious function.

We are in the very vestibule of physiologic temple. There is much yet of glory to be seen behind the veil behind the veil.

Think of the thousands and tens of thousands of railway servants who are wearing out their lives upon the grindstone of greed! Think, too, of those who as passengers must suffer the constant roll and rattle and rumble of the railway rush in the mighty ongoings of modern commercial life. Well it is a fearful problem. We do believe that the time has come to look this important issue in the face and meet it with the stern facts of science.

As to the organic conditions developed by railway pathology, they are fully met by that almost perfect physiologic combination of nucleins-the very essence of physiologic principles-protonuclein, so peculiarly adapted to railway use.

DISCUSSION OF DR. SUMMER'S PAPER.

Dr. W. B. Outten: I expected to have heard the doctor touch upon railway spinal shock, but he has not done so. I want to say that while I appreciate very much what the doctor has said in his paper, if he were to say all those things to that gentleman who handles the lever, who sits on the box, he would turn around to Dr. Summers and say, "What in thunder are you talking about? Do you think I am green?" I have been in the railway service for years, and when I first started I was very eager to find a railway disease. I will give you my word of honor, that no man ever hunted for it more than myself, and I have not found one yet.

In the paper I read last year I gave the results of the study of a hundred and fifty-three thousand cases, and I believe Dr. Gant, who has since written a book on rectal surgery, went over these reports with me. They were compiled from the reports of the Missouri Pacific Hospital Department, and the only disease which could be said to be due to the occupation, was constipation, in consequence of irregularity of living, jolting of cars, etc. I think Dr. Adam Smith was the one who stated that about one-fourth or more of railroad engineers had diabetes. Out of one hundred and fifty-three thousand cases there were only one hundred and three cases of diabetes among these employes. I have searched for railroad kidney, but have never found one in my life that was really ascribable to the occupation of railway employes.

Dr. Cyrus Edson, who claims to cure consumption, wrote an article in which he stated that he had found railroad kidney, shortly after which I wrote 870 odd personal letters to the engineers on the Missouri Pacific system, and from the replies I received, I must unhesitatingly say that none of them had railroad kidney. In the number of years I have been engaged in railway surgery (since 1876), it has been my good fortune to mingle with employes in every position. I have sat with them at the bedside, held communion with them in every direction, where there was noth

ing secret between us, and they were just as free to express themselves on any point as two railroad men can be. Picture to yourself the average man who runs on a railroad train, and you will find that all nature aids him to keep well. There is a continuous change of scene; there is that excitement which is healthful in itself, and when these men are sick we cannot ascribe the basis of their disease to their occupation.

President Murphy: After hearing the remarks of Dr. Outten, I am certainly justified in calling upon Dr. Patrick Henry Hoy to discuss this paper.

Dr. W. S. Hoy: I do not know how I came to be dubbed Patrick Henry Hoy. I do not know whether to blame Dr. Thorn or my friend Dr. Outten for it, but it is certainly a misnomer.

I desire to say one thing in regard to the paper, which was so beautifully and eloquently read for our gratification and pleasure. The speaker was away off in dreamland. I have made a special inquiry among the employes on the C. H. & D. system regarding railway kidney, and I have yet to see the first case in which a railroad man has Bright's disease of the kidney, or any acute disease of this organ as a result of his occupation. While Dr. Summer's language was beautiful, his theory was bad. There is not a railroad man to-day in this country who has any disease incident to the occupation which he follows. If fresh air, change of scene, change of occupation, mean anything, it is certainly for the good of the railway employes' health.

Dr. John Punton: I have listened with a great deal of interest to Dr. Summer's paper, part of which I can agree with, and part of which I cannot. I believe that there is such a thing as occupation neurosis. I am satisfied that there are conditions which dispose to nervous troubles, that are peculiar to men connected with railroads. I refer more especially to telegraph operators and clerks. A great many telegraph operators have writer's cramp, and so also do clerks. I have had occasion to treat quite a number of such cases and some were employes on the Missouri Pacific road, and I think their troubles were largely due to their occupation. Skepticism in regard to these nervous troubles sometimes is a sign of weakness, and I am inclined to think that when we sneer at conditions of

neurasthenia, we are sneering at something which we do not fully understand. I am perfectly willing to take the doctor's idea of this subject, if he will accept his closing sentence, that "we must look this subject squarely in the face and meet it with scientific facts." I am willing to meet him on that ground. I believe that there is such a thing as neurasthenia, and that it can be met with facts of scientific importance. I think, also, that there is not only an honest, but an erroneous side to neurasthenia.

Dr. P. Daugherty: Dr. Outten spoke of constipation as being common to railway men and I agree with him. I have also found that engineers and firemen suffer from lumbago. It is an affection peculiar to them and to many other trainmen. I find more cases of lumbago, than of any other one disease. I have, therefore, put down lumbago as an affection peculiar to railroad men.

Dr. Emory Lanphear: I beg to call the attention of Dr. Outten and Dr. Hoy to a very recent report upon the condition of the motor nerves. Since the introduction of electricity as a motor force in street transportation, there has developed a peculiar neurasthenic condition in the men who have taken the place of the old drivers upon the slow-going street cars, and it is a nervousness which may very aptly be termed railway neurasthenia, because so far as investigations have gone, the affection is never found in any other occupation. This condition of neurasthenia is characterized by peculiar symptoms, the first noticed being insomnia. The motorman finds that he cannot sleep, and consults the surgeon of the street railroad for some remedy to overcome it. Not only is he affected with sleeplessness, but there is often a delicate tremor of the upper extremities. It is accounted for upon the theory of the intense nervous strain put upon the motorman as he oftentimes approaches the thickly populated parts of the city at a tremendous speed, where he is compelled to look upon one side for a time, then upon the other, for pedestrians in front or for obstacles in his way. All of these things taken together making such a strain upon the nervous systhem, that prostration of the nerves is the result, the first symptom being insomnia, and the second a nervous tremor. These cases have come to light within the last few months, and have been described as an intense nervous strain, which is to be met with in men of probably no other occupation. This is completely in the line of railway neurasthenia, the term being applied to them by a neurologist, who has already reported cases.

We have just received a reprint of the "Report of the Committee on Car Sanitation," presented at the meeting of the American Public Health Association at Buffalo in September last by Dr. Granville P. Conn, and deem its contents to be of sufficient interest for review at this time. Dr. Conn first called attention to the fact that the retrenchment and general economy necessary since the publication of the last report have made it impossible for the railways to make many changes or improvements not absolutely necessary, but he shows that the agitation of the subject has attracted the attention of railway managers and set them thinking of ways and means for the realization of better sanitary arrangements. Many letters have been received by Dr. Conn, as chairman of the committtee, from railway men, indorsing and commending the work and offering suggestions. In March last a circular letter containing the following questions was sent out to the management of different American rail

ways, inviting discussion of the various propositions:

"1. Can passenger coaches of all classes be constructed in such a manner as to secure more satisfactory ventilation, heating, closet accommodation, and cleanliness than now obtains, without any considerable increase in the cost of construction?

"2. Do you have on your road any person educated in hygiene and sanitation, who can be held responsible for the sanitary condition of passenger coaches, or to whom the corps of car cleaners are held accountable for the strict performance of their duty? And in your opinion is it practical or good policy to have such a person?

"3. Do you believe a car cleaning department, organized under a person fully educated in such work, the same as the general freight or passenger agents should be in their respective bureaus, would increase the efficiency of the system, and with his experience, be able to cooperate with the superintendent of rolling stock, in giving information that might be incorporated into specifications to be observed in the construction of new coaches, thereby giving improved conditions without additional expense?

"4. It may not be practical to reject or set out passenger coaches coming from other roads, that are unclean, untidy, and unwholesome by reason of the filthy condition of closets, floors, etc., yet is it unreasonable to establish a system of sanitary inspection that would place the full responsibility of these conditions where it rightfully belongs, the same as is now done in cases of structural defects in rolling stock?"

A gratifying number of replies were received. The following from the general manager of the Grand Trunk lines is a fair sample: "To the Committee on Car Sanitation of the American Public Health Association:

"I have your favor of March 25, with pamphlet upon the subject of car sanitation, and, replying to the inquiries you make in the order they are named, will state:

1. The present system of ventilation obtained by means of sashes in the roof of the car, and by the opening of the doors and windows, fairly meets the requirements, having regard to the expense. I am afraid that the term 'ventilation' is too often held to cover the question of car temperature. There is no serious difficulty in properly ventilating a car and keeping it at an even temperature, if ice is used in the summer and warm air in the winter, but arrangements would have to be made to prevent the passengers from interfering with the inlets and outlets. Anyone who travels must notice what different views are held by the passengers as to what constitutes