Reprint from St. Louis Medical Review, Nov. ii, 1893. 
Traumatic Neuroses in Court. 
BY DR. L. BREMER,WiST. LOUIS, MO. 
Read before the First Annual Meeting of the Southwestern Asso- 
ciation of Railroad Surgeons, St. Louis, Oct. 27, 1893. 
Of all the diseases which within the last ten years 
have prominently engaged the attention of the medical 
world, there is none that deserves more interest and 
is of greater practical importance, than that group of 
nervous disorders, which have been styled the trau- 
matic neuroses. It is especially since the meeting of 
the tenth International Congress held at Berlin in 
1890, that this question has occupied a prominent 
place in medical thought and discussion the world 
over. The somewhat acrimonious debate, on that oc 
casion not altogether free from personal antagonism, 
had as an immediate consequence, the effect of stimu- 
lating renewed study and producing a flood of litera- 
ture on the subject. 
Oppenheim’s book on the traumatic neuroses had 
not only renewed and intensified the interest, but also 
excited wide spread contradiction. 2 
Oppenheim, in contradistinction to Charcot who 
classed all neuroses following accidents as hysteria, 
tried to demonstrate in his book that there is a type 
of disease quite peculiar in its manifestations parti- 
cularly on the part of the nervous system, a type 
which is only met with after injuries, and railway in- 
juries in particular. 
The opponents of Oppenheim have contended that 
he described a disease which he called the traumatic 
neurosis, meaning thereby a well defined nervous dis 
order, characterized chiefly by concentric narrowing of 
the visual field, anesthesia or hypesthesia, irritability 
of the heart and certain mental anomalies. 
This disease as such, they claim does not exist. 
There are traumatic neuroses, however, resulting from 
injury coupled with shock, for instance, hysteria, neu- 
rasthenia, chorea, epilepsy, shaking palsy, eto. These 
neuroses constitute a family; they are more or less 
closely related to each other. 
Most frequently among these traumatic neuroses are 
found hysteria and neurasthenia or a combination of 
the two, hystero-neurasthenia. 
Whilst Oppenheim claims that predisposition and 
heredity are extremely rare and that the victims to his 
traumatic neurosis were ordinarily robust men before 
the accident, Charcot and with him the French school, 
assert that the injury is only the provoking agent of a 
disease which exists in a state of latency. Without 
the accident the person might have continued in good 
health for the rest of his life; the injury and the 3 
mental shock, however, changed a dormant into an 
active trouble. 
The French claim that Oppenheim’s cases are simply 
hystero-neurasthenic, i. e. graver cases of post-trau- 
matic neuroses, and that they do not represent speci- 
mens of a clinical entity. 
The drift of opinion in neurological circles is in this 
direction and Oppenheim himself seems to have made 
some concessions to the French school of late. 
In France traumatic hysteria seems to be the prevail- 
ing form of the neuroses under discussion. With us, 
traumatic neurasthenia is certainly 'the predominant 
form, the difference being due to racial peculiarities. 
The importance of those lesions, considerable though 
it is from a clinical point of view, has been materially 
increased of late years on account of the ever increasing 
frequency of damage suits resulting from them. 
Owing to the great discrepancy still existing on the 
nature and import of these affections and the diametri- 
cally opposite views given by the physicians of the liti- 
gating parties, these suits generally form very knotty 
problems for the jury to solve. 
The difficulty in the way of a righteous verdict 
lies in the very nature of the affections under discussion. 
If there is a visible injury, a fracture for instance in any 
part of the body, or lesion of the integuments or the 
deeper tissues, it is to the layman a comparatively easy 
matter to comprehend, how such an injury may be fol- 
lowed by transient or lasting nervous symptoms, which 
may constitute, as they do in the traumatic neuroses, 4 
the chief ami prominent sequelae of the injury. This 
difficulty is increased by the too frequent occurrence of 
exaggeration or downright shamming on the part of the 
injured in cases where damage suits are brought. 
The trouble will, I am afraid, go on increasing owing 
to the spread of knowledge on the subject among the 
masses of the people. To this dissemination of knowl- 
edge is to be added the prevailing tendency to fleece 
the soulless corporations; on the other hand, the real 
victim to a traumatic neurosis will have a difficult task 
of convincing a skeptical jury, which through doctors 
and lawyers have been made acquainted with the great 
prevalence of simulation of nervous disorders. 
Unfortunately the symptoms of tha disease are in the 
vast majority of cases of a subjective nature. Hence 
very frequently the veracity of the claimant supported 
by the testimony of a physician viz. that such and such 
symptoms may result from the alleged injury, form the 
exclusive evidence in the case. 
One of the commonest complaints of the sufferer from 
a traumatic neurosis is pain. How can this be demon- 
strated? If we possessed an instrument, by which we 
could gauge the pain, an algesiometer, ananogously to 
the aesthesiometer matters might be considerably sim- 
plified. As it is, pain is a relative and indefinite quan- 
tity. Mucius Scaevola puts his hand into the burning 
coal without flinching, Charles XII smokes a pipe 
whilst the surgeon removes by deep incisions a bullet 
from his leg, but the impressionable weakling will con- 
voke a medical faculty for an ordinary belly-ache. 5 
Almost equally difficult of determination is the degree 
of anesthesia or hypesthesia which are so frequently com- 
plained of by such patients. It is a very easy matter to 
detect contradictory statements in regard to the inten- 
sity of anesthesia; and a person must not be set down as 
an impostor when the result of the examinations of one 
sitting does not tally with that of a preceding one. The 
degree of attention and the varying condition of the 
patient himself are responsible for these discrepancies. 
On the whole, it may be stated as a general proposi- 
tion that a claimant for damages is not to be looked 
upon as an impostor by the examining physician, be- 
cause contradiction in regard to his present condition 
and that of the past are discovered. For a defective 
memory and an instability of the perceptive faculties are 
among the commonest symptoms of the traumatic neu- 
roses. Again, if the case begone of traumatic hysteria, 
the phenomena are often almost incredible, especially to 
him who has no neurologic or psychiatric training. A 
knowledge of this latter branch of medicine, is above 
all requisite for the correct interpretation of the symp- 
toms and behavior of the traumatized neurotics. For it 
is not the peripheral nerve, nor the spinal cord which is 
principally affected in these neuroses, but the mind. It 
is a psycho neurosis which the examining physician has 
to deal with. This mental anomaly, the hypochondrio- 
melancholic tinge which almost invariably is met with 
in the traumatic-neurotics, has been used as an argu- 
ment against the hysterical nature of the trouble, since 
the hysteric have generally an air of hopefulness or in- 6 
difference about them and are notorious for their 
abrupt changes from one mood to another. But it is as 
strange a fact as it is incontestable, that the male hys- 
teric is morose, despondent, embittered, quite in con- 
trast with the female victim of the disease. 
Taken for granted now, that a certain proportion of 
the traumato neurotics are afflicted with hysteria or in 
worst cases hystero neurasthenia, it becomss apparent 
at once, why it is that the symptoms presented by such 
a case seem so incredible and out of keeping with what 
is ordinarily observed in injury and disease. Expert 
examinations as to eye, ear, heart, lungs, etc. and the 
tests usually employed to unmask imposition have, as a 
rule, a very bad effect on such patients and not unfre- 
quently, what has been a simple neurosis at first, has by 
injudicious, overzealous activity on the part of the ex- 
amining physicians, been converted into a psycho- 
neurosis of a grave character. It will not do, to tell 
such a patient that he is only hysterical and that, being 
a man he has no business to be so. Hysteria may be a 
grave disease, and male hysteria, especially that due to 
injury is apt to be particularly obstinate and intractable. 
The same holds true of traumatic neurasthenia which is 
generally less accessible to treatment than the non- 
traumatic variety. 
In all these conditions now, there is a general tenden- 
cy to exaggeration of the symptoms. It is physiological 
to the disease as it were, and ought not to be put down 
as an unfailing sign of shamming with the intent of 
increasing the award of damages. 7 
We ought always to bear in mind, as stated before 
that the disease is psychogenous in character and that 
its proper diagnosis belongs therefore to the domain of 
the psychiater and neurologist. And even he is apt 
to be misled, in cases of this class unless he has paid 
strict attention to the literature on this subject for the 
last 4 or 5 years, during which a considerable stride 
towards better and exact knowledge has been made. 
It is not my object in this paper to describe traumatic 
neuroses in all their details, their fundamental and 
secondary symptoms. My intent and purport is, to 
point out the difficulties surrounding this matter, 
specially in cases of litigation. • 
The exaggeration of originally existing, and the ac- 
quisition of new symptoms through examinations made 
by a number of physicians, each of them asking about, 
and thereby suggesting some new symptom generally or 
exceptionally met with in traumatic neuroses, has led to 
quite a new nosological species of morbid phenomena, 
the litigation symptoms, so called. To reduce them to 
their proper level and to eliminate them from the legiti- 
mate clinical picture, is one of the most difficult tasks 
of the examining physician. 
As a rule, patients who have their claims in court, 
get worse mentally and physically. The worry and 
anxiety which even the healthy and vigorous individual 
has to undergo in a lawsuit, which is to decide on his 
financial future, is a particularly hard strain on the 
nerves of the traumato neurotic. 
The excitement incident to litigation renders his case 8 
progressively worse, and many a claimant would have 
fared much better in health and happiness, had he 
settled at a reasonable figure instead of undergoing the 
harassing wear and tear of a lawsuit. Not the most 
liberal award will repay such a man for the often deep 
and lasting damage his brain has sustained from pro- 
longed litigation. 
On the other hand, it is often astonishing what 
amount of elasticity and recuperative power is exhibited 
by the successful claimant. Nowhere has the gold-cure 
celebrated greater triumphs than on the field of trau- 
matic neuroses, if administered by a benevolent jury. 
There dwells a familiar figure in the memory of those 
who frequently have to deal with these cases of the 
neurotic cripple, who has to be assisted to ascend the 
witness stand and gives bis testimony in a feeble and 
broken voice, an utter, pitiable wreck, physically and 
mentally, who a few weeks later is capable of carrying 
the weight of several thousand dollars in silver, the 
award of damages, without any apparent difficulty. 
Again, cases are on record where successful litigants 
openly bragged after having secured their booty, how 
they duped the doctors, judge and jury. 
Such occurrences are not frequent, but their reality is 
incontestable. The unjustifiable benefit which one un- 
deserving individual derives through such practice ne- 
cessarily redounds to the detriment of the deserving 
victim. 
In order to exclude any possible errors of diagnosis, 
the aim of all original investigation of the subject has 
been, to establish the objective signs of the neuroses 9 
and, if possible, such symptoms, as cannot be simulated 
and which are characteristic enough to exclude other 
diseases. Unfortunately, there is no objective sign 
which cannot be successfully simulated by one who 
through association with real traumato-neurotics has 
become sufficiently familiar with the leading symptoms. 
The only exception seems to be the concentric narrow- 
ing of the field of vision, so much insisted upon by 
Oppenheim (according to Charcot this is one of the 
most valuable, though not constant, stigmata of hys- 
teria, whether ordinary or traumatic), the accelera- 
tion of the pulse, especially on pressing the painful 
spots, as a rule situated at one or more of the spinous 
processes, (Mannkopf’s sign) and the difference of the 
pupil, the one on the affected side (in cases of hemianes- 
thesia or hemiplegia e. g.) being larger than the other. 
But it may be broadly stated that all these symptoms 
are not characteristic of the traumatic varieties of hys- 
teria, neurasthenia, and hystero-neurasthenia, that they 
are as frequent in the non traumatic forms, hereditary or 
acquired, and that as a matter of fact they are observed 
in quite a variety of other neuroses and chronic affec- 
tions in general. 
It would devolve then on the defense to prove that 
the person sueing for damages was neurotically tainted 
before the accident, which, of course, is generally a 
matter of difficulty and impossibility, since every’ 
claimant will insist on his previously perfect health; 
and there are scores of witnesses to prove it. My ex- 
perience is that in quite a number of such patients a 10 
pre existing neurasthenia could be elicited. Of course, 
this name does not figure in the patient’s previous 
record; as a rule the terms biliousness and dyspepsia are 
named which generally are nothing more nor less than 
symptoms of genuine neurasthenia. 
On the other hand, it devolves on the examining phy- 
sician to establish as to their proper value, the symp- 
toms observed in the claimant and to find out, how 
much of them is due to the accident and what may have 
existed before. A very difficult task indeed. 
To illustrate the obstacles besetting the subject, 
especially when complicated by litigation, I shall briefly 
mention a few of the cases with which I have had per- 
sonally to deal. 
I believe that one of the most curious instances in 
forensic medicine, and thus far a unique one, where the 
problem of the causation of diseases was involved, is 
that of a woman who, several years ago claimed that 
she had been permanently injured while ascending in 
an elevator of one of the large drygoods houses of this 
city. She contended that the machinery had come to a 
sudden stop, throwing her forward and causing her to 
land on her head. Since that moment she was paralyzed 
in her lower extremities. The damages were laid at 
$20,000. The defense, however, convinced the jury 
that the claimant, had had hysteria all her lifetime, that 
the alleged injury received by the sudden stoppage of 
the elevator, which could not be proven, was in reality 
one of the attacks common to hysteria usually called 
hystero epilepsy, and that a disease remained which has 11 
the uncommon and formidable name of hysterical asta- 
sia abasia, but which is in spite of this name a reality. 
The jury found against the claimant. 
In another instance a railroad was sued also for 
$20,000 damages by a traveling salesman who had 
jumped from a train to avoid the effects of a collision. 
Since that time, or any rate several months later (as is 
often the case in traumatic neuroses), he had evinced a 
number of neurasthenic symptoms which he claimed 
were caused by the accident. The train had moved at 
the time this occurred, with a velocity of six to eight 
miles an hour; in jumping plaintiff had landed on a 
heap of gravel and had fallen on his knees, bursting his 
pants at that point. There had been no injury except 
an insignificant abrasion, nor had anybody else been in- 
jured, not even the engineer who remained on the 
engine at the time of the collision (the engine had been 
damaged only to the amount of one hundred dollars). 
The defense succeeded in convincing the jury that the 
injuries were too insignificant to be looked upon as the 
cause of the neurasthenia (despondency, rachialgia, in- 
ability to work, etc.), from which plaintiff was un- 
doubtedly suffering, there being data enough in the 
previous history of the patient pointing to a very strong 
neurasthenic diathesis. 
In a third case which may be briefly mentioned, a 
man, known to be an alcoholic of a pronounced type, 
had been struck by the beam of the barrier at a railway 
crossing through the negligence, it was alleged, of the 
watchman in attendance. The pole which, owing to 12 
the counterweight at one end did not descend with 
great velocity grazed the man’s head, who stumbled, 
but did not become unconscious. There was not the 
“traumatic narcosis” in the language of Bergman, so 
ominous an occurrence, as a rule in accidents of this 
nature. The man, after the accident, if it was such, 
visited several bar-rooms and had later on leeches ap- 
plied to the site where the beam had struck the head. 
Two days later a surgeon examined him, after he had 
returned home (the accident befell him while on a visit 
to this city) found nothing to indicate an injury either 
to the scalp or bone, not even the evidence of a contu- 
sion. The only lesion visible was the leech bites. This 
man soon after the injury developed symptoms of men- 
tal alienation. The symptoms were such as are gener- 
ally observed in alcoholic insanity. His friends, how- 
ever, thought that the disorder of his mind was refera- 
ble to the injury sustained from the pole, and after he 
had partially recovered, he sued the company, the pro- 
prietor of the barrier where the accident and happened. 
It was learned that the medical experts that were to ap- 
pear for plaintiif hinted at a depressed fracture as the 
cause of the mental trouble. The claim of damages was 
$20,000. The case never came to trial. It was com- 
promised at $1,000. It was plainly one where the 
trauma did not play the least of a pathogenic role. 
These three cases taken at random from the cases of 
my own experience show the importance of hysteria, 
neurasthenia and alcoholism in the development of 
traumatic neuroses and psycho-neuroses. They demon- 13 
strate the importance of the diathesis or predisposition 
and reduce to its proper value the injury, as simply the 
provoking agent of a dormant trouble. The task of the 
examining physician will be to ascertain in the first 
place the gravity of the existing nervous disorder and 
next the probability or improbability of a connection as 
to cause and effect between it and an alleged accident. 
If anywhere a reform is needed in the administration 
of justice, it is in the suits for damages. Nowhere in 
the whole machinery of the law are there more farcical 
performances found than in the courts where damage 
suits are tried for personal injury; and nowhere is there 
such an opportunity for the profession to exhibit their 
chronic disagreement, as on the question of traumatic 
neuroses. As a rule there are two opposing sets of 
doctors One is trying to prove to the jury that the 
plaintiff is a damaged man and incapacitated for life, 
the other set will try to prove that there is not much 
the matter with him, that he is exaggerating or putting 
on and feigning disease which does not exist. This 
war of experts who as a rule are not familiar with even 
a rudimentary knowledge of the neuroses is generally a 
source of great amusement to the lawyers and the jury, 
but does not redound to the good name of the profes- 
sion; much less is it calculated to help the jury distin- 
guish between right and wrong. Ready wit and repartee 
is too often counted for knowledge and the testimony 
of an ill-informed tyro may outweigh that of the experi- 
enced physician. Not, until trained and trustworthy 
experts are appointed by the state to pass on doubtful 14 
cases and instruct the jury in accordance with their 
finding, will there be an improvement in the defective 
and erroneous method of arriving at verdicts in cases of 
traumatic neuroses claiming damages. Under existing 
conditions the true medical expert is generally hampered 
by counsel of the opposing party in his effort to eluci- 
date the case. The prevailing custom that only the ex- 
perts for plaintiff are allowed to examine his person is 
certainly not calculated to help the jury in their effort 
at reaching a just verdict. The fact is that there is too 
much hedging and dodging done by medical experts, to 
help the side for which they happen to be engaged. 
They thus run the risk, or rather are necessarily ex- 
posed to, the danger of turning advocates, where they 
ought to be impartial witnesses. 
Quite reprehensible is the practice which has been 
actually resorted to by some experts, of going into a 
law suit for damages on the plan of sharing in the 
profits resulting from the verdict. This is lowering the 
already low standard of our profession. What for a 
lawyer to do under such conditions may be legitimate 
and proper, is utterly impardonable in a physician. 
Some facetious observer has divided prevaricators in 
court into three classes, liars, blank liars and experts. 
Let us try to help to get the medical experts excluded 
from this category.