Andrew Malleson McGill-Queen's University Press 2002 ISBN: 07735 2333 2 Price: £31.00 Pages: 527 pp

How often do you find a medical book which you can read right through like a thriller? Well this is such a book and hopefully will sound the death knell to whiplash and other fashionable illnesses.

The author is a Toronto psychiatrist who trained in England and who has considerable expertise in medico-legal assessments. The description and discussion of copycat pseudo-illnesses or fashionable illnesses or occupational mass psychogenic illness includes whiplash, repetitive strain injury, neurasthenia, chronic fatigue syndrome, fibromyalgia, environmental hypersensitivity, the Gulf War Syndrome, tempromandibular joint disorder, chronic pain syndrome, entertaining and erudite discussions of Victorian spinal cord disease, railway spine, masturbation and even Koro – the Chinese disappearing penis syndrome. Other topics covered include post-traumatic stress syndrome and postconcussion syndrome.

A major part of the book, as the title indicates, deals with whiplash.

The term whiplash was probably first used in 1928 by Crowe, an American orthopaedic surgeon who, much later, made a telling statement: ‘This expression was intended to be a description of motion, but has been accepted by physicians, patients and attorneys as the name of a disease, and the misunderstanding has lead to its misapplication by many physicians and others over the years’. Davis, in 1945, described a number of cases of whiplash although many of these in fact had quite gross injuries. The most famous article of course was in the Journal of the American Medical Association in 1953 and following this it rapidly became an epidemic and an enormous financial industry. It is a true epidemic. The number of cases of whiplash injury is not known but in the USA the estimate is somewhere between 1 and 5 million new cases annually. Why is this? It has been pointed out over and over again that most of these so-called whiplash injuries are mild and recovery takes place in the same way as it does after muscle strain anywhere else in the body. Anomalies have been pointed out over and over again by many different authors. For example, it is said that women are more likely to have neck injuries than men in automobile accidents because of the less well-developed neck musculature in women. However, this does not make a great deal of sense since children's necks are even thinner, particularly when compared to the weight of the head, yet they rarely get whiplash. Men drive more recklessly, spend more time on the road and are involved in more collisions yet the number of women with whiplash is much greater than in men and these are mostly middle-class women aged 20–40 years: a similar distribution to neurasthenia, chronic fatigue syndrome, ME, and RSI. The Quebec Taskforce which carried out an epidemiological study in 1995, examined over 10,000 publications and found only 62 which were ‘relevant and scientifically meritorious’. A number of other conditions have been grafted on to whiplash, with very little scientific evidence. For example, back pain, migraine, dizziness and dysequilibrium …

There were few cases of whiplash injury in New Zealand compared to Australia and this was attributed to social copying and different insurance reimbursement. A study from Lithuania published in the Journal of Neurology, Neurosurgery and Psychiatry in 1999 showed that in a country where there is no preconceived notion of chronic pain arising from rear-end collisions, and thus no fear of long-term disability, and usually no involvement of the therapeutic community, insurance companies, or litigation, symptoms after whiplash injury tend to be self-limiting, brief and do not appear to evolve into the so-called late whiplash syndrome. Malleson deals with all these anomalies and many more. He points out that in stock car racing and demolition derbys and fair ground bumper cars, collisions are intentional. In demolition derbys collisions may occur at up to 50 mph. Three quarters of the drivers may report symptoms of pain and discomfort in the neck and shoulders within the first few hours or 1 or 2 days, but the symptoms only last for a few days. Fair ground bumper car riders, even though the collisions occur at the same speeds as collisions that apparently cause whiplash in highway accidents, do not get whiplash symptoms, and bumper cars have no head restraints.

Malleson ascribes the enormous increase in whiplash to the medico-legal interest and, indeed, for most of the other conditions that he describes.

But this is not all that he does in this excellent book. There is a large section which deals with incentives other than financial rewards and is a thoughtful discussion of victimhood, and the plight of women even in the Western world.

I have some relatively minor criticisms of this book. I would very much like to have seen a summary and conclusions at the end of each chapter. With head injury, I think that retrograde amnesia and post-traumatic amnesia could perhaps be better defined and the classification of severity of head injury depends on which review you use. I think he is rather hard on the postconcussional syndrome. Even in mild head injuries diffuse axonal injury has been demonstrated particularly by Sabina Strich (Journal of Neurology, Neurosurgery and Psychiatry, 1956). A minor point: On p.205 he says ‘Until the days of Mrs Thatcher, private medical practice in the United Kingdom was minimal…’. My memory is that when Barbara Castle, who ran the Department of Health from 1974 to 1976 attempted to separate private practice from the NHS the result was disastrous. Instead of the income generated by private practice coming into the NHS, there was an enormous expansion of private hospitals and private practice (I was a full-time consultant neurologist and senior lecturer engaged in basic research at that time) as private wings in NHS hospitals were closed.

Why review this book in Spinal Cord? The answer quite simply is that it deals with conditions which are of importance and of interest to all medical practitioners and, of course, whiplash allegedly affects the spinal cord and nerve roots. The book is wonderfully cynical, well referenced and easy to read. It is full of good sense and I would like to make it essential reading for all medical students and law students. Indeed, instead of the ghastly medical ‘soaps’ which flood our television sets, Chapter 19 on Fraud could be turned into a long running TV series to rival CSI or Law and Order.