d complains of pain in his back and limbs. There
is rarely any sign of local injury. For a few days he may be able to
attend to business, but eventually feels unfit, and has to give it up.

The symptoms that subsequently develop are for the most part
subjective, and it is difficult therefore either to corroborate or to
refute them; it will be observed that while some of them are referable
to the cord the greater number are referable to the brain. They
usually include a feeling of general weakness, nervousness, and
inability to concentrate the attention on work or on business matters.
The patient is sleepless, or his sleep is disturbed by terrifying
dreams. His memory is defective, or rather selective, as he can
usually recall the circumstances of the accident with clearness and
accuracy. He becomes irritable and emotional, complains of sensations
of weight or fullness in the head, of temporary giddiness, is
hypersensitive to sounds, and sometimes complains of noises in the
ears. There are weakness of vision and photophobia, but there are no
ophthalmoscopic changes. He has pain in the back on making any
movement, and there is a diffuse tenderness or hyperaesthesia along the
spine. There is weakness of the limbs, sometimes attended with
numbness, and he is easily fatigued by walking. There may be loss of
sexual power and irritability of the bladder, but there is seldom any
difficulty in passing urine. The patient tends to lose weight, and may
acquire an anxious, careworn expression, and appear prematurely aged.
Special attention should be directed to the condition of the deep
reflexes and to the state of the muscles, as any alteration in the
reflexes or atrophy of the muscles indicates that some definite
organic lesion is present.

As the symptoms are so entirely subjective, it is often extremely
difficult to exclude the possibility of malingering; it is essential
that the patient should be examined with scrupulous accuracy at
regular intervals and careful notes made for purposes of comparison,
and also that the doctor should retain an impartial attitude and not
develop a bias either in favour of or against the patient's claim for
compensation.

So long as litigation is pending the patient derives little benefit
from treatment, but after his mind is relieved by the settlement of
his claim--whether favourable to him or not--his health is usually
restored by the general tonic treatment employed for neurasthenia.

INJ