When there is no clear cause for the condition, patients suffering from chronic pain are sometimes referred to a psychiatrist for his opinion. When these patients really unburden themselves they often disclose that they are preoccupied in thinking about some wrong they have done in the past. Over the years they have thought about it a great deal, and in thinking about it in this way, the wrong becomes greatly magnified. They have never told anyone about it. “This is something that I always thought I would bring with me to the grave.” And all the time there has been the thought, “Of course I shall be punished for it.” In the first place the pain may have arisen from some quite trivial cause; but once the pain is there, it soon becomes fixed. Only

half-consciously he thinks, “This is what I have been expecting; I knew it had to come; I am glad it has come at last and I shall get it over.” In a sense he is glad of the pain. By suffering the pain he will ease his conscience of the thing that he has done, and his mind will be at rest again.

On the one hand a patient in this situation wants to get rid of the pain because it hurts him, but on the other hand he wants to keep it, as it expiates his feeling of guilt. The pain lingers on, unrelieved by the various medicines he is given. Expiation never seems complete, so it continues until brought to light and worked through in psychotherapy.

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Q. What other forms of medication are used?

A. The Histamine ft-receptor antagonists are currently the most widely used drugs for peptic ulcers. Nevertheless, a form of medication called tri-potassium di-citrato bismuthate (colloidal bismuth) is also claimed to produce very good results. It is said to be about as effective as cimetidine, but until recently the only form available was an unpleasant tasting liquid which had a strong ammoniacal odour. It is now available as a chewable tablet and this has improved patient compliance. There is little doubt that if a person does not like his medication, , he often will not take it. He will invariably lie to the doctor and say he is taking the prescribed medication!

Q. Does it have adverse side effects?

A. Every medication has some side effects in someone as we have already pointed out. However, like cimetidine, these are small and fairly unimportant, at least in the known short term. It may stain porcelain teeth fillings, colour the tongue and cause the stools to turn a strange dark grey. It is taken well before meals. Its effect is negated by the presence in the stomach of food, milk or antacids, so it is essential these are not taken at the same time, or indeed probably within an hour or two either way.

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The operation most commonly used in an effort to permanently cure back troubles caused by one or more discs is spinal fusion. Much more popular in the United States than in this country, this is an operation in which two or more vertebrae are essentially welded together and any troublesome discs between them removed. There are various ways of performing this procedure, but the one used most nowadays involves both anterior and posterior fusion of the vertebrae, the spine being approached from the front (via the abdomen) and then through the back. The damaged disc is then replaced by a bone graft.

Just how good the results of spinal fusion are is still a matter for debate by experts as the operation so far has not been the subject of a properly-controlled trial. Certainly, there are many patients who have benefited greatly from spinal fusion; in other instances, the results have been less favourable. More may be known in a year or two about the true benefits – and risks – of spinal fusion as a trial to compare its results with those achieved through non-surgical rehabilitation programmes is being set up.

Laser disc decompression is an alternative way of dealing with bulging discs that is currently being pioneered in America, but it also remains the subject of some controversy about just how effective and free from long-term side-effects it is.

This method has proven itself useful in dealing with a disc that bulges but where no part of the disc’s soft centre is actually protruding from it, the pressure on the nerves resulting purely from the fact that the disc is larger than it would normally be.

Here’s how this procedure is performed. A silicon optical fibre is temporarily inserted into the disc. Energy from a laser is transmitted into the disc via the fibre and this causes the loss of water and some of the substance that makes up the centre of the disc. As the pressure within the disc is decreased because of the loss of material, it shrinks and pulls the offending bulge off the nerve root, so decreasing or eliminating the pain.

The procedure takes about 15 to 30 minutes, followed by two to three hours in the recovery room. The advantages of this method is that operating time and hospitalisation is kept to a minimum, and that it can be suitable for patients who are surgical risks, for example, those with heart trouble or age-related problems. The proponents of this approach say that there have been no major complications to date and the degree of success is about 80 per cent so far.

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