Some Points in the Diagnosis 
of Certain Simulated Mental 
and Nervous Diseases. 
J. T. ESKEIDGE, M. D., 
DENVEB, OOL., 
P08T-GR ADU ATE INSTRUCTOR IN NERVOUS 
DISEASES IN THE JEFFERSON MEDICAL COLLEGE, 
AND PHYSICIAN TO THE HOSPITAL OF THE 
COLLEGE, BTC. 
REPRINTED FROM 
ffifte Neto Iforfc fRe&tcal journal 
for July 26, 1890. Reprinted from the New York Medical Journal 
for July 26, 1890. 
SOME POINTS IN TIIE DIAGNOSIS OF 
CERTAIN SIMULATED MENTAL AND 
NERVOUS DISEASES* 
By J. T. ESKRIDGE, M. D., 
DENVER, COL., 
FORMERLY POST-GRADUATE INSTRUCTOR IN NERVOUS DISEASES IN THE 
JEFFERSON MEDICAL COLLEGE, AND PHYSICIAN TO THE 
HOSPITAL OF THE COLLEGE, ETC. 
Tiie symptoms exhibited by a shrewd malingerer or a 
clever hysterical patient may so closely simulate organic 
disease of the nervous system that the best diagnostician 
will at times hesitate in some cases before giving an opin- 
ion. In some instances persons suffering from actual disease 
of the nervous system may feign, for reasons best known 
to themselves, a different trouble, or the hysterical may 
simulate a certain organic nervous affection and at the same 
time be suffering from some other organic disease; and, on 
the other hand, we not infrequently find an array of so- 
called hysterical phenomena in patients who are afflicted 
with some serious organic brain lesions. The hysterical 
should not be confounded with the malingerer, but it is 
rarely we see a case of hysteria without some elements of 
malingering. The causes for the latter are different from 
those that result in hysteria. 
* Read before the Colorado State Medical Society at its annual 
meeting. 2 
SOME POINTS IN THE DIAGNOSIS OF 
Malingering.—In civil life the causes for malingering 
are found among the mercenary, who feign injury for the 
hope of gaining remuneration, from a corporation most 
commonly ; among the criminal class, who hope to escape 
their deserved punishment; and among the tramp class, who 
are trying to “dead-beat” their way, in order to gain sus- 
tenance in hospitals, or to eke out a miserable existence by 
imposing upon the charitably inclined. Among the crimi- 
nals and tramps epilepsy and insanity, according to the 
writer’s experience, are the most common affections of the 
nervous system feigned ; but among the mercenary feigners 
organic diseases of the spinal cord, and sometimes of the 
brain, are more or less imperfectly simulated. 
The object of this paper is not to go into a lengthy 
discussion on the points in the differential diagnosis be- 
tween real and feigned disease, but to call the attention ot 
the members of the society to the subject of the paper in 
the hope of eliciting discussion and the narration of similar 
cases. I will illustrate the tramp, criminal, and mercenary 
malingerers by the following: 
Tramp Class. Case I. Feigned Epilepsy.—A boy, eighteen 
years old, gave a history of convulsions dating over a period of 
three or four years. He professed to he a telegraph operator, 
lie was found on the streets of Denver in a convulsion, and 
taken to a police station in an apparently unconscious condition. 
He was taken to the County Hospital the next day. He was 
having, on an average, two or three convulsions daily, but none 
of the attacks since his admission into the hospital had been 
witnessed by a physician. He was given large doses of sodium 
bromide, but his attacks continued and seemed to increase in 
frequency. This fact was reported to me and at once aroused 
my suspicion of their genuineness. On further inquiry, I found 
he did not bite his tongue, and that the attacks usually only 
occurred in the presence of certain persons whose sympathies 
he had enlisted in his favor. On getting a detailed history SIMULATED MENTAL AND NERVOUS DISEASES. 
3 
from him of his attacks, I found his mental condition at the 
time of their occurrence and the seizures themselves did not 
correspond with the phenomena of epilepsy. I requested Dr. 
Baker, the resident physician, to have the nurses or attendants 
notify him of the attacks, and for him to study them. At my 
next visit the doctor reported that he had seen an attack in 
which the patient assumed grotesque positions, and that the eyes 
turned upward when he raised the lids to examine the pupils. 
I immediately had his bromide discontinued, and gave him, in- 
stead, large doses of milk of asafcetida by the mouth. lie protest- 
ed that he had no control over his seizures. Not long after this 
I witnessed one of his attacks. lie frothed at the mouth, threw 
his limbs in every conceivable direction, and assumed an opis- 
thotonic position. At this stage I made firm pressure over each 
supra-orbital nerve with the ball of each of my thumbs, and, as 
the pressure increased, it caused him so much pain that he 
struggled to free himself from my grasp, and caught bold of 
my hands and pulled them away from his face. On my again 
renewing the pressure, and this time with redoubled energy, he 
jumped up, and the spasm (?) was over. From this time he 
took the precaution to have no more convulsions when a physi- 
cian was around. Only a few attacks occurred during the re- 
maining weeks of his stay in the hospital, and these were 
always in the presence of persons whose sympathy he had en- 
listed in his favor. A few days after he was dismissed from 
the hospital he was again found by the police lying on the street 
in an apparently unconscious condition. He was returned to 
us for treatment. This time, from the first, he was treated as 
“a suspect,” and denied many privileges of the hospital which 
the other patients enjoyed. No bromide was given him. He 
had a few attacks at chosen intervals, but these always oc- 
curred in the presence of certain persons, and away from the 
presence of the attending physician. After remaining at the 
hospital for a few days, he suddenly left to escape arrest for 
theft. 
Case IT.—An inmate of the hospital for one or two years, 
about forty years old, says that he has been subject to epileptic 
convulsions for three or four years, the attacks dating from the 4 
SOME POINTS IN THE DIAGNOSIS OF 
time when his left knee, which is now ankylosed, first became 
affected. The patient is addicted to drunkenness, is disagreea- 
ble, quarrelsome, repulsive, and believed to be a masturbator. 
I first began to study his case in November, 1889. At that time 
he was taking large doses of potassium bromide, and was re- 
ported to be having one or two attacks during the day, and at 
times as many as three during the night. The night in Novem- 
ber immediately preceding my seeing him he had had several 
seizures, and had kept the patients in his ward awake most of 
the time. Two or three persons had been engaged in holding 
him. I saw him about 4 p. m. He was then in an attack, and 
the nurse stated that he had had them almost continuously for 
hours. Ilis face was flushed, and his movements were an ad- 
mirable imitation of an epileptic attack. I had never suspected 
the genuineness of his malady, and now supposed he was in a 
condition of status epilepticus. On inquiry, however, I learned 
that he would sometimes throw himself from the bed in an 
attack and thrash himself around the room at a furious rate un- 
less restrained. On raising the eyelids the eyes turned upward 
and the pupils reacted to light. The pulse was not much accel- 
erated above the normal. I immediately made firm pressure 
over each supra orbital nerve; the convulsive movements stop- 
ped, and the patient expressed his surprise by a silly laugh. He 
then admitted that he had been feigning “fits,” but contended 
that he was subject to regular epileptic paroxysms. I had the 
bromide discontinued, and no convulsions occurred for several 
days. In a short time the nurse reported that he was again 
occasionally having a convulsion, but I did not have the good 
fortune to witness any more attacks, and Dr. Haker, the resi- 
dent physician, said he had not seen any of them. He was ur- 
gent for medicine for his epilepsy. I ordered twenty grains of 
sodium chloride to be given him three times daily. As the 
medicine tasted salty, but different from his usual bromide 
mixture, he thought it was composed of potassium bromide and 
iodide, and again his paroxysms ceased, and have recurred only 
a comparatively few times since. At the present writing he has 
not had a convulsion for nearly ten weeks. I have a suspicion 
that this man may have true epilepsy, w ith a large element of SIMULATED MENTAL AND NERVOUS DISEASES. 
5 
“ pure cussedness.” On one occasion, Dr. Baker informed me, he 
acted strangely in a dazed kind of manner, and afterward seemed 
to have no recollection of what he had done during this time. 
Criminal Class. Case I.—In the spring of last year a man 
by the name of T., whose paramour, with whom he had lived 
for ten years, claiming her as his wife, left him and became 
intimate with a man by the name of K. T. threatened 
to kill K. and the so - called Mrs. T., and purchased ten 
grains of strychnine at a drug-store in the name of I\. T. 
soon left Denver and went to Omaha. A few weeks later T. 
arrived in Denver about four o’clock, p. m., and secreted him- 
self until dark, when he went to the rear of the house in 
which K. and Mrs. T. were staying. He there met K. and 
fatally shot him. He remained in the city twenty-four hours 
and escaped to Kansas City. He was arrested and brought 
back to Denver. At the trial, at which he was convicted of 
murder in the first degree and sentenced to be hanged, he gave 
me the details of the killing, the causes that led to it, and many 
of the particulars quite connectedly. He is a man below the 
average intelligence, but cunning, and shows an infatuation for 
his unworthy paramour. There certainly was no evidence of 
insanity, and I so testified. A short time after T. was removed 
to the State Penitentiary at Cation City he was alleged to be 
insane. He was brought to Denver early in the fall of 1889— 
this time in order to have the question of his insanity tested. 
He then professed to have forgotten almost everything; he 
had never heard of a man by the name of K.; never heard of 
a place called Denver; never knew that he had been tried for 
killing any one; did not know where he had been staging, lie 
gave expressions to delusions of depression and expansion at 
one and the same time. He at times very feebly and imperfect- 
ly imitated the paretic dement, but usually best played the role 
of a dement. This was done so poorly as to expose the decep- 
tion to any one at all conversant with mental diseases. He 
deigned to have forgotten everything connected with the past— 
especially everything connected with his crime, things that 
stamp themselves almost indelibly upon a mind capable of re- 
membering anything. But, at the same time, he could relate 6 
SOME POINTS IN TIIE DIAGNOSIS OF 
what was given him to eat, how he was treated, and little occur- 
rences in prison life. This man is still in the State Penitentiary, 
and is alleged by some to be insane. 
The diagnostic points in this case are: First, the char- 
acter of the delusions. No one, sane or insane, can be de- 
pressed and animated at one and the same time. An insane 
person can not have delusions of expansion (mania) and 
depression (melancholia) at one and the same time. Such 
delusions may alternate, but there is always a change in the 
person’s actions while possessed of an expansive or de- 
pressed delusion. 
Second, as regards memory : In dementia, memory of 
past events is always retained after memory of recent events 
have faded away. 
Case II.—A male criminal, about thirty years old, was con- 
fined in the Arapahoe County jail, accused of obtaining money 
under false pretenses. He had been incarcerated for several 
months, and seemed to he in fair health. About four weeks 
before the time set for his trial he began to have convulsive 
paroxysms. These continued for three weeks, although he was 
taking large doses of potassium bromide. The attendants at 
the jail were up with him night and day, two or three being re- 
quired, they thought, to prevent his injuring himself against the 
iron bars, as he threw himself about at a violent rate. Dr. Mc- 
Lauthlin, the county physician, had seen him a number of 
times and pronounced the attacks hysterical or feigned. He re- 
quested me to see him. I visited him early one morning, found 
him strapped down and three attendants by him. They stated 
that he had been having convulsions every few minutes all night, 
and that it was with great difficulty that they could prevent 
him from injuring himself. His pulse was 110; breathing 
rapid; temperature normal. Ilis face was pale and haggard. 
While I was talking with him he said: “Now it is coming 
again,” and began to roll his eyes upward. His face was twisted 
from side to side, not spasmodically jerked by individual mus- 
cles. Soon his arms and legs were involved and he assumed an SIMULATED MENTAL AND NERVOUS DISEASES. 
7 
opisthotonic position. I spoke to him; he neither answered nor 
gave the least sign of hearing. I opened the eyes and found 
the pupils reacted to light. Without further examination I 
placed the balls of my thumbs over the supra-orbital nerves at the 
point of their emergence from their foramina, and pressed with 
considerable force. The result was marked and almost instan- 
taneous. He at once endeavored to turn his head from me, but, 
failing in this, he clinched my hands with both of his and pulled, 
and at the same time freed his head from my grasp by a volun- 
tary rotation of his head. I requested the attendants to leave 
the cell. I then told the prisoner that I had caught him feign- 
ing, and that if he had another such spell while he was in jail 
I would go into Court, if called upon to testify in his case, and 
swear that he was feigning, which would prejudice the jury’s 
mind against him. He promised to desist from another attempt. 
I had him unstrapped and dismissed his attendants, assuring 
them that he had no further need of their services. His epi- 
lepsy was cured. His object in feigning epilepsy was to be 
transferred to the County Hospital for treatment, from which 
he knew he could etfect bis escape. 
Mercenary Class. Case I.—Miss O. fell, in stepping from the 
car of the Denver Tramway Company in January, 1889, striking 
the back of her head against the ground. She seemed to be dazed 
or semi-unconscious, and was taken into a house a few yards 
distant, where she remained in about the same condition until 
transferred to Saint Luke’s Hospital the next morning. She 
was in the hospital two to three weeks, and about one week of 
this time she seemed to be semi-unconscious, but irritable and 
cranky all of the time. Jt was learned that there was some 
bruising of the soft tissues over the occipital bone just to the 
left of the prominence of this bone. It was thought by the sur- 
geon under whose care she was at the time she remained at the 
hospital that there was a fracture of the occipital bone, with 
depression of the fracture. 
By order of the Court, Dr. H. A. Lemen, Dr. II. A. Baker, 
and the writer were appointed to examine into her condition, 
The examination took place October 17, 1889. Her history, as 
she gave it to us, was as follows: She said she had always enjoyed 8 
SOME POINTS IN TIIE DIAGNOSIS OF 
good health up to the time of the accident, but since that time 
she had lost just forty pounds by actual weight; she had grown 
nervous; suffered much from pains in the back and head, espe- 
cially in the occipital region; was sleepless; could not see the 
largest letters on the street signs, and it was with great diffi- 
culty that she could walk. We found her temperature, includ- 
ing that of the surface of the head, normal. The motorial and 
sensory phenomena showed no deviation from health. The elec- 
trical reactions and reflexes, deep and superficial, were good and 
equal on both sides. Touch, taste, smell, and hearing were well 
preserved and about equal on both sides. We now came to the 
eyes. She contended that before the accident she could read 
fine print and signs at a distance, as well as the ordinary per- 
son, without the use of glasses. We found the pupils equal, re- 
acting well to light and accommodation, and about normal in 
size. The ophthalmoscope showed healthy fundi. The fields 
seemed contracted, but, on repeating the examination several 
times, the size of the fields varied very considerably. She was 
shown a book and professed to be unable to see whether or not 
there was any print in it. Of large letters, which the normal eye 
will read at a hundred feet distance, she said she could not see 
what they were when held only a few feet from her eyes. 
Glasses, plus 36, about one dioptre, were placed before each eye. 
She then read fine print at the ordinary distance. The fields of 
vision were enlarged, and she read at a distance as well as the 
majority of persons. This was positive proof that she was 
feigning poor vision. As we had found no evidence of any or- 
ganic disease, we felt justified in excluding any, especially after 
detecting her in feigning imperfect vision. She was nervous, 
irritable, and not very well nourished. After excluding every- 
thing except spinal irritation, we next proceeded to test the 
truthfulness of her statements regarding her health before the 
accident. We weighed her and found that she was nearly ten 
pounds heavier than she professed to have been two days before 
her examination. Upon inquiry of her employer at the time of 
and before the accident, we learned that she had not been well, 
lie said that she looked as well in October as she did in Janu- 
ary before the accident, and that while she was living in his SIMULATED MENTAL AND NERVOUS DISEASES. 
9 
family she had been nervous, irritable, and poorly nourished, 
and required to rest in bed one day every week or two on ac- 
count of pain in tbe lower portion of the body. The physicians 
who had treated her before she came to Colorado stated that 
she was irritable and nervous, and suffered from uterine trouble 
while under their care. Since our official report we have seen 
her on the streets of Denver walking as briskly and nimbly as 
one in perfect health. 
Case II.—Mrs. H., aged thirty-three, was a passenger on the 
Santa F6 train at the time of the Fountain explosion from giant 
powder in May, 1888. Her face and hands were cut with glass, 
and she was shaken up considerably. The explosion took place 
about 4 o’clock, a. m., while the passengers were all asleep. She 
stated that before the accident she had enjoyed perfect health, 
but since that time she has been nervous and sleepless, and has 
suffered from pain in the head and spine. She has brought suit 
against the railroad, and, as with most persons who are waiting 
the award for damages, every symptom is exaggerated. The 
first examination, in August, 1889, was highly unsatisfactory, as 
she complained of the slightest contact of substances with any 
portion of the body. After a prolonged examination I could 
find no evidence of any organic trouble, and so informed her. 
She presented herself a few months ago, and still no symptoms 
of any organic lesion were found. On May 16, 1890, she again 
presented herself for examination, with the following account of 
her symptoms: She says she has constant pain from the middle 
of the back, running through to the stomach; has great difficulty 
in rising from the sitting to the erect posture on account of pain 
in the back. The pain in the back runs from below upward. 
Complains of pain and a drawing sensation in the legs and feet 
at night. She is exceedingly nervous and feels as if something 
was going to happen. Says she is unable to read fine print, and 
a bright light is painful; is deaf in the left ear, and can hear 
only imperfectly with the right. Says that conversation carried 
on in an ordinary tone of voice she does not hear; complains 
of buzzing in the head and a dizzy sensation, a feeling likened 
to lumps in the back of tbe neck, and a drawing sensation of the 
post-cervical muscles, causing her to bend her head backward. 10 
SOME POINTS IN THE DIAGNOSIS OF 
Examination.—Gait good ; no ataxic symptoms; knee-jerks 
equal, but slightly exaggerated. All the other deep reflexes 
normal, as are the superficial reflexes. A thorough and pro- 
longed electric test, both with galvanism and faradism, showed 
normal reactions. The results of testing the sense of touch 
were curious and significant. Some time was spent in trying 
to ascertain the condition of this sense. At one time it was 
normal; the next minute it would vary greatly from the nor- 
mal, or she would profess not to be able to feel anything. There 
was no paresis, paralysis, or wasting of any muscles. She was 
able to bend the back in various positions without complaint if 
her attention was kept engaged, but her movements became 
limited and painful when her attention was directed to what 
she was doing. 
The dynamometer registered R. 80 ; L. 80. On requesting 
her to try the instrument again, it registered, only a few minutes 
after the first trial, R. 110 ; L. 104. 
The examination of the special senses was not completed 
when I had to postpone it until the next day. As yet, two 
weeks having elapsed, she has not presented herself.* 
Whatever real trouble the outcome of this case may result 
in, it is now evident that she is hysterical and feigning, and thus, 
by her over-anxiety to appear injured, she may be preventing 
the detection of some organic lesion. 
Case III.—Mr. M., a nervous, slenderly built man, about 
forty-five years old, was injured on the Denver Tramway Road 
by being struck on the back by a wagon while in the act of 
getting on a car. He was knocked down and rendered uncon- 
scious for some hours. lie remained in bed about a week. 
About six months after the accident Dr. Parkhill and I exam- 
ined him at his request, for the purpose of testifying in court. 
He professed to have considerable pain in the back throughout 
the entire length of the spine. He complained of the slightest 
touch on most of the spinous processes. He had a limping, halt- 
ing gait, walked with a cane, and said he had most pain in the 
lower portion of the back and in the left leg. After two pro- 
* Her suit has since been decided in the U. S. District Court. She 
sued for $25,000, and was awarded $750 damages. SIMULATED MENTAL AND NERVOUS DISEASES. 
11 
longed and thorough examinations we found movement much 
more free and extensive than lie had stated. Sensation in every 
portion of the body was normal. The reflexes and electrical 
reactions showed no deviation from health. We could find no 
positive evidence of any organic lesion, and one of us, the other 
not being called, so testified in court. 
In conclusion, I will discuss only a few of the points 
suggested by the case histories that form the foundation of 
this communication to the society : 
First, the detection of feigned epileptic convulsions. 
Under ordinary circumstances, the dilatation and immobile 
state of the pupils, the insensibility of the corneae, the char- 
acter of the muscular contractions, the onset of the attack, 
the stages of the seizure, and the subsequent sequela? will 
serve to distinguish the true epileptoid or epileptic fit 
from the feigned. But we must remember, as Romberg 
long ago pointed out, that there may be some reflex irrita- 
bility in true epilepsy, such as to produce winking when the 
cornea is touched. During the past year I saw an account 
of the observations of a German physician, whose name I 
have forgotten, on the detection of feigned epilepsy in crimi- 
nals. This observer had detected simulated epilepsy in sev- 
eral hundred criminals simply by pressing with the ball of 
each thumb over the supra-orbital nerves. Ilis position is 
behind or at the head of the “ suspect,” with his face looking 
toward the simulator’s feet. In this position one can exert 
considerable pressure on the supra-orbital nerves, and if the 
patient is not unconscious he is unable to bear the pain, and 
soon endeavors to free himself from the operator’s grasp. 
I have not had the opportunity to try this test in attacks of 
true epilepsy, but here a corrugation of the forehead would 
not be sufficient to pronounce the case feigned, because 
there may be some reflex action of the muscles even when 
a person is unconscious. I have had the opportunity of 12 
SOME POINTS IN TIIE DIAGNOSIS OF 
employing this method in detecting feigned epilepsy in 
four malingerers, and in each the attack was cut short, and 
the simulator exerted himself voluntarily in order to get 
relief from the pressure. 
Before leaving the subject of feigned epilepsy I wish to 
utter a caution—viz., that because a person is caught feign- 
ing epilepsy we must not at once conclude that he does not 
suffer from real epilepsy. Real and feigned epilepsy, I 
think, were exhibited by at least one of the persons whose 
cases have just been narrated. 
Feigned Insanity.—In the majority of cases of simulated 
insanity the deception is comparatively easy to expose. It 
is self-evident that the task is made easy in proportion to 
the familiarity of the examiner with the different types of 
insanity and their differential diagnosis, and in proportion 
to the amount of clinical study he has given to the insane. 
It sometimes happens that an asylum superintendent is a 
poor diagnostician of insanity, because, in many instances, 
of the large amount of executive work devolving upon him, 
thus leaving him insufficient time to devote to the intelli- 
gent and systematic study of minute peculiarities of indi- 
vidual cases and groups of cases. It is rarely that a simu- 
lator of insanity is sufficiently informed in regard to the 
diagnostic symptoms of the different varieties of the disease 
to prevent his confounding them. Ilis task is especially 
difficult when he attempts to simulate mania, melancholia, 
or dementia. In mania or melancholia the patient may be 
boisterous or quiet, but in the former the delusions are 
always of an expansive character, while in the latter they 
always take a depressive form. In dementia, a form of in- 
sanity probably one of the most difficult to feign, the fail- 
ure of memory is just the opposite to what the ordinary 
layman, when he attempts to simulate, will assume. In this 
form of insanity memory for recent events is first lost or SIMULATED MENTAL AND NERVOUS DISEASES. 
13 
affected, while that for occurrences which took place before 
the mind became impaired is often retained with great 
minuteness for details; and this holds good until the mind 
becomes almost a total blank. The patient is usually quite 
talkative unless harassed by depressive delusions. Recent 
events, unless of an extraordinary character, make no or 
but little impression. He is unable to tell what occurred 
the day before, or what he ate the previous or probably 
the same day. Any one who has studied the diagnostic 
symptoms of dementia and is at all conversant with the 
symptoms exhibited by T. must realize that by deception 
this criminal has thus far cheated justice. 
In stuporous insanity malingering is sometimes hard to 
detect. A case of feigned stupor reported by Field in the New 
York Medical Journal for May 3, 1890, will illustrate this: 
“Since his admission he had not spoken or made any 
voluntary movement; would follow where he was led; if 
put in a chair, would remain there; would not partake of 
any food or water uidess they were put in his mouth ; would 
swallow mechanically. Sometimes he would wet his cloth- 
ing or the bed. lie had a fixed, staring expression, only 
occasionally winking. He was not cataleptic, although two 
physicians had so certified to the District Attorney. Noth- 
ing would startle him out of his condition—neither prick- 
ing, nor dashes of cold water, nor pressure on the supra- 
orbital nerves. He lost thirty to forty pounds of weight. 
Subsequently he was sent to the Jefferson Market prison, 
from which he escaped by sawing out a bar in conjunction 
with another prisoner. His associate was recaptured and 
told how he had aided the malingerer in his deception. 
The feigning of the prisoner had been carried on for three 
or four months.” 
Real or Pretended Traumatic Cerebrospinal Affections, 
especially such as follow Railroad Accidents.—That cases 14 
SOME POINTS IN THE DIAGNOSIS OF 
of severe and permanently disabling nervous injuries follow 
upon and are caused by the physical and mental strain in- 
cident to severe railroad collisions are as well attested as 
that cases claiming such injuries have been suddenly and 
permanently cured after damages for the same have been 
settled by the company sued. In the few remaining min- 
utes for which I crave the society’s indulgence I shall not 
attempt to discuss the positions taken by three classes of 
writers on the so-called “ cerebro-spiual shock.” One class, 
represented by the railroad surgeon, who often becomes 
in these suits for damages railroad advocates, contend that 
most of the symptoms are simulated. The second class is 
formed by Charcot and his disciples, who at one time 
maintained that all of the symptoms might be accounted 
or on the theory of hysteria, especially the class which he 
designates traumatic hysteria. And the third and last 
class is composed of the over-enthusiastic so-called medical 
expert, who is too apt to accept the statements of the pa- 
tient implicitly and attribute all of the symptoms to some 
obscure organic disease of the nervous system. Practically 
we meet with applicants for remuneration the symptoms of 
whose injuries are mostly, if not entirely, feigned; and 
others whose ailments are purely of an hysterical nature, 
and yet others whose symptoms are due to organic disease 
of the nervous system. On the other hand, it is not infre- 
quently that we may find the simulated, the hysterical, and 
the organic symptoms combined in the same patient at the 
same time. 
We may ask, What should be the testimony of the 
medical witness when called upon to testify in regard to 
nervous injuries, real or feigned, alleged by parties suing 
for damages? He should be unbiased, and base his testi- 
mony on demonstrable facts and not upon possibilities. It 
is well to bear in mind that the central nervous system may SIMULATED MENTAL AND NERVOUS DISEASES. 
15 
have sustained permanent injuries and no objective symp- 
toms be manifest to the most careful examiner until several 
months, or perhaps one or more years, after the accident. 
This should teach the claimant caution. In such cases, if 
the patient’s health is not being injured by delay of legal 
proceedings, the suit should be deferred as long as possible. 
The examinations should be made jointly by at least two 
physicians—one for the plaintiff and the other for the de- 
fendant—and these should consult together simply to arrive 
at the truth. The examinations should be thorough, and 
repeated sufficiently often to prevent erroneous conclusions. 
The patient’s body should be bared, the spines of the ver- 
tebrae and the muscles of the back carefully examined—the 
former for tenderness and deformity, and the latter for 
tenseness or rigidity. We should look for wasting of mus- 
cles. Next, the patient should be required to bend the 
back in different positions, and the freedom or restraint of 
motions observed and carefully noted. The gait of the 
patient should be scrutinized, and all of the tests for ataxic 
symptoms carefully employed. The reflexes, deep and su- 
perficial, should be thoroughly investigated, after which a 
careful electrical test for the condition of the nerves and 
muscles should be used. The tactile, muscular, temperature, 
weight, and pain senses should be carefully examined and 
compared on the two sides of the body. This is sometimes 
of the greatest importance, especially when hysteria or feign- 
ing is suspected. I have some cases of organic lesion of the 
cord under my care at present in which, in certain porfions of 
the body where the senses of touch and pain are present, the 
sense of temperature is abolished. There should never be 
less than two thorough examinations, and the results of the 
second examination should be compared with the first. 
The condition of the special senses should never be neg- 
lected. The patient’s own story of his sufferings should be 16 
SIMULATED MENTAL AND NERVOUS DISEASES. 
duly considered, but only in connection with the results of 
the examination. In other words, we should never be led 
into the error in these cases, where heavy damages are 
claimed, of making a diagnosis on subjective symptoms 
only, as has occurred in a recent case in this city. The 
health of the patient prior to the accident should be ascer- 
tained, if possible. If, after careful and repeated examina- 
tions, we find no objective evidence of disease of the nerv- 
ous system, it seems to me that the only thing left for the 
medical witness to do is to so testify; for, if we have to 
base the diagnosis entirely on subjective symptoms, unaided 
by physical signs, we are placing the companies sued, so 
far as our testimony is concerned, on the honesty of the 
claimant for damages. Some of our courts of this city have 
decided, and it seems to me properly, that if the medical 
man has to base his opinion of the case entirely upon what 
the patient tells him, such testimony in those cases is inad- 
missible, and the claimant’s statements must go direct 
to the jury without being interpreted for them by a physi- 
cian. 
I wish to say, in conclusion, that the physician who has 
carefully studied these cases and compared the results of 
different examinations will soon be able to sift the truth 
from the feigned symptoms of disease. Especially is this 
true when the physiognomy of the patient is studied dur- 
ing the examination and compared with its appearance when 
his attention is not absorbed by the examiner’s method of 
procedure. REASONS WHY 
Physicians Should 
Subscribe 
FOK 
The New York Medical Journal, 
Edited by FRANK P. FOSTER, M. D., 
Published by D. APPLETON & CO., 1, 3, & 5 Bond Si 
1. BECAUSE : It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medical 
men of this country. 
4. BECAUSE : Its “Original Articles” are the results of scientific 
observation and research, and are of infinite practical value to tbe 
general practitioner. 
5. BECAUSE : The “Reports on the Progress of Medicine,” which 
are published from time to time, contain the most recent discov- 
eries in the various departments of medicine, and are written by 
practitioners especially qualified for the purpose. 
6. BECAUSE: The column devoted in each number to “Therapeu- 
tical Notes ” contains a resume of the practical application of the 
most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number con- 
tains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the resuits 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement of the sci- 
ence of medicine, as viewed from a standpoint looking to the best 
interests of the profession. 
9. BECAUSE : Nothin" is admitted to its columns that has not some 
bearing on medicine, or i3 not possessed of some practical value. 
XO. BECAUSE : It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, #5.00 per Annum. Volumes begin in January 
and July.