A bad back is more than a pain in the neck

Theodore Dalrymple

As an occasional sufferer from lower back pain, I sympathise deeply with David Cameron, whose lumbago currently prevents him from pursuing deer on Jura. A bad back is an utter misery: there is no position that one can adopt for long that remains comfortable. It is like a nagging spouse: it demands attention and cannot be ignored.

Let us hope, for Mr Cameron’s sake and that of the country, that his lumbago is intermittent rather than continuous. For chronic pain, or chronic illness of any description, is seldom an aid to rational decision-making.

Apart from anything else, it leads to self-medication that may cloud judgment. Dr Hugh L’Etang’s books contain a menagerie of world leaders who have made stupid mistakes under the influence of the drugs they have taken to overcome discomfort of one kind or another. Thus we wish Mr Cameron a swift recovery, for our own good as well as his.

No one who has suffered from lower back pain will deny the misery that it inflicts upon sufferers. But it is not straightforwardly caused by physical injury or pathology: though of course it can be.

Regarding myself as psychologically robust rather than fragile, I was once rather humiliated to discover that my bouts of back pain had a considerable, not to say overwhelming, psychological component. I was in India, and due to return home in a few days, when I was stricken by severe pain that made it almost impossible to walk. There was concurrently a problem with my ticket, but I did not connect the two. The ticket had disappeared into the maw of the airline office (no internet then).

Then, unexpectedly, the ticket was delivered to me – and my pain disappeared within the hour. My anxiety had translated itself into muscular tension, a phenomenon known as “somatisation”, to which I had never before realised that I was prone.

I am far from alone in this; there is a large psychological element to most backache. In his wonderful book Whiplash and Other Illnesses – which is not nearly as well-known as it ought to be – Dr Andrew Malleson has a startling graph showing the rise of backache in Britain over the past 50 or 60 years. In 1950, there were 1.5 million days of lost work caused by backache. By 1995, this had risen to 115 million.

This astonishing increase is unlikely to have been caused by an equivalent increase in the number of physical injuries suffered by the working population. On the contrary, work became ever less physical as the years went by. Perhaps bad posture during sedentary employment explains it (and certainly, whenever I have a twinge of backache, sitting at my computer makes it 10 times worse, as does driving a car).

This does not entirely carry conviction, however – for the fact is that the self-employed suffer far less from work-preventing backache. Indeed, to the frustration of those of us in the medical profession, the whole experience correlates very poorly with objective diagnostic signs. Those whose MRI scans reveal bad backs may suffer no symptoms, while those who suffer may have a spine that shows no abnormality (though all spines degenerate with age). For the majority, no objective cause is found – but you cannot say that the pain is exaggerated or unreal, just because you find nothing on the X-rays.

This, of course, makes backache the more or less perfect condition for malingerers, or those who would defraud insurance companies. This has long been recognised. When railways were still comparatively new, passengers involved in accidents or abrupt halts claimed to suffer from “railway spine”. In his book Injuries of the Spine and Spinal Cord Without Apparent Mechanical Lesion, and Nervous Shock, in Their Surgical and Medico-legal Aspects, the surgeon Walter Page wrote in 1883: “Is the condition before us real or feigned? A right answer is obviously fraught with moment to both doctor and patient, and yet the difficulty of giving a right answer may be very great.”

In a giant textbook from 1917 entitled Malingering, dedicated (ironically?) to the author of the National Insurance Act, Lloyd George, we read: “Our views as to the nature of [backache] sadly lack precision, and up to now the condition has not been correlated with any anatomical lesion… It is easy to complain of 'pain in the back’, difficult to establish the truth of the assertion – a fact of which the fraudulent-minded are well aware.” To this day private detectives are probably better at discerning the truth than radiographers.

Between anatomical lesion and fraud, however, there is a large no-man’s land, probably inhabited by Mr Cameron – and by me. Perhaps also he suffers from that well-known phenomenon, illness that comes on when busy people relax. They have had no time to be ill before.

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Toxins warning over chinese medicines

Health regulators have issued a warning over some Chinese medicines, saying they contain "dangerously high" levels of lead, mercury and arsenic.

The Medicines and Healthcare products Regulatory Agency (MHRA) said the unlicensed traditional Chinese medicines included some meant for children.

None have been authorised for use in the UK but investigators have found them readily available on the internet.

One product, which goes by a variety of names, was found to have "extremely high" levels of arsenic by the Swedish National Food Agency (SFNA), the MHRA said.

The product is called Niu-Huang Chieh-tu-pein, Divya Kaishore Guggul or Chandraprabha Vatiand and is used for treating mumps, sore throat, tonsillitis, toothache, skin infections, anorexia and fever in young children.

Another product, Bak Foong Pills, is used to relieve period pain but has been recalled in Hong Kong after it was found to contain up to twice the level of lead permitted by the Hong Kong government.

One product called Hairegenerator, used for hair loss, has also been recalled in Hong Kong after a sample was found to contain 11 times the permitted level of mercury.

The MHRA's head of herbal policy, Richard Woodfield, said people should exercise extreme caution when buying unlicensed medicines.

"The adulteration of traditional Chinese medicines with heavy metals is a significant international problem and can pose a serious risk to public health," he said.

"Natural does not mean safe. To help you choose a herbal medicine that is suitable for you, look for a product that has a Traditional Herbal Registration (THR) or product licence number on the packaging. These products have met the acceptable quality and safety standards.

"If you think you have taken any of these products, please speak to your doctor for advice. If you think you have suffered a side-effect from these, or any medicines, please tell us about it through our yellow card scheme."

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