medical knowledge and the intractable patient: the case of chronic low back pain

Medical knowledge and the intractable patient: the case ofchronic low back pain

Carl May *, Helen Doyle, Carolyn Chew-Graham

Department of General Practice, University of Manchester, Rusholme Health Centre, Walmer Street, Manchester M14 5NP, UK

Abstract

Chronic low back pain (CLBP) is endemic in Western societies, and while a good deal of attention has been paidto the lay experience of such pain, much less sociological attention has been paid to the way in which medical ideas

about it have been formulated. This paper takes the latter course, tracing the development of clinical notions aboutthe relationship between pathological signs and expressed symptoms from the 1820's to the 1930's, and then placingthese developments in the context of postwar notions of `somatization'. We point to the extent to which thedisparity between expressed symptoms, pathological signs and perceived disability in CLBP has led to the moral

character of the su�erer forming a constant subtext to medical discourse about the condition. We also note theextent to which medical ideas themselves have been constructed in intimate linkage with socio-legal questions ofcompensation and worker's insurance. # 1998 Elsevier Science Ltd. All rights reserved.

Keywords: Low back pain; Medical discourse; Somatization

1. Introduction

The extent to which the clinical `reality' of speci®c

health states are contested and constructed within and

through speci®c discourses of practice is one of the

principal lessons of recent medical sociology and his-

tory (Rosenberg, 1989; Brown, 1995). Chronic fatigue

and pain in which no organic pathology is evident is

commonly encountered by the clinician, and commu-

nity epidemiological studies have found it to be wide-

spread (Jenkins et al., 1997). Nonspeci®c back pain

(Chew and May, 1997), chronic fatigue syndrome

(Cooper, 1997) and pelvic pain (Grace, 1998), all fall

under this heading, as do many `subclinical' syndromes

and states which tend to be assumed to have a close

relationship with bodily fatigue, depression and

anxiety. Nonspeci®c chronic low back pain (CLBP),

o�ers us a useful example of such a condition. It is

one of the most commonly experienced forms of dis-

abling pain in contemporary western societies (CSAG,

1994). Since 1945 it appears to have become both

more prevalent and more confusing to clinicians, in

great part because there is no intelligible relationship

between expressed symptoms Ð the embodied experi-

ences that are described by su�erers and pathological

signs Ð the architectural abnormalities that can be

observed in their musculo-skeletal systems (Waddell,

1987).

Our approach in this paper is to explore CLBP

through an examination of the `o�cial discourses' of

medicine, and in particular to examine the ways in

which these have involved the construction and nego-

tiation of moral and psychological categories of

patienthood. At the outset, we should note that the

paper takes as its focus the problem of medical

`doubt', and that it extends only marginally into the

domain of `lay experiences' (see Busby et al., 1997, for

a recent discussion of lay experiences and interpret-

ations of musculo-skeletal pain) and not at all into the

realm of the epidemiology and distribution of back

pain (see CSAG, 1994). Three themes run through this

paper. First that CLBP presents a problem of negotiat-

ing meanings for medicine, and that this problem had

Social Science & Medicine 48 (1999) 523±534

0277-9536/98/$ - see front matter # 1998 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(98 )00372-4

PERGAMON

* Corresponding author.

become `®xed' in more or less its present form by theinter-war period. Second, that subsequent attempts to

conceptualize CLBP as a problem of somatization havee�ectively mysti®ed the problem for medicine. Thirdly,that this mysti®cation of clinical categories provides

patients themselves with a problematic location fortheir pain. Throughout the paper we point to the waysthat chronic back pain has historically been formulated

in a way that poses the character of the patient ratherthan the sickness as the problem that medical knowl-edge and practice attempts to confront.

2. Negotiating the meaning of back pain

In the ®rst part of our discussion we present a his-torical account of CLBP as it was constituted in medi-

cal periodicals in the century after the 1820's. Ourobjective here is to show how medical thought beganby ®xing upon the pathology of the spinal cord and

column, but gradually reconstituted the `problem' ofback pain as one which involved interactions betweenexpressed pain, and the moral, subsequently, the`psychological', character of the patient.

2.1. The emergence of the problem and of clinical doubt:1828±1900

From the 1830's, medical investigators of the pro-blem of back pain and related disability encountered

the problem of its anomalous nature. There seemed tobe no clear relation between the patient's complaint,and observable pathological signs. Interest in such

symptoms was an early product of the growth ofhuman physiology as an academic discipline taught inmedical schools, and distinct from anatomy. In 1828,Brown put forward a theory of spinal irritation, where

back pain was intimately related to pathology of thenervous system (Brown, 1828). Brodie (1837), focusedon the notion of spinal concussion or shock.

There may be changes and alterations in it [thespinal cord] which our senses are incapable of

detecting. (...) These remarks are not less applicableto concussion of the spinal cord than they are toconcussion of the brain. We cannot doubt that thenature of the injury is the same in both of them

(Brodie (1837), quoted by Trimble (1981), p. 7).

The problem here was not so much chronic backpain, but rather disability consequent on an apparentlytraumatic event but with delayed onset. The e�ects of

this were serious and included paralysis, loss of limbfunction, headaches and migraines and a variety ofother disorders (Abercrombie, 1828). Such events

might ultimately be fatal, often after a gap of severalyears. Explanations for this lay ®rmly on the con-

cussed spinal cord, which could be `irritated' or `anae-mic'. The principal explanation which stemmed fromthis, and which held considerable force for the sub-

sequent century, was that a `commotional' shockdamaged the central nervous system in ways whichwere invisible to the investigator. Pain and disability

were organic in origin, but were anomalous, for visibleor otherwise detectable injury was not always apparentin such cases.

This was the view that prevailed. It was ampli®ed bythe emergence of a new complex of diagnostic cat-egories that stemmed from trauma consequent on acci-dents, and which found their way into popular

consciousness as much through legal processes asmedical ones (Trimble, 1981; Young, 1995). The mas-sive growth of the railways after the 1830's exposed

enormous numbers of people to new kinds of acci-dents. The Campbell Act of 1846 had provided forcompensation to be paid to the families of people

killed in railway accidents as the result of second partynegligence; and an amendment to this Act had, in1864, provided for compensation to those injured in

such accidents. Similarly, the Employers Liability Actof 1880, provided for compensation to persons injuredin the course of their employment as a result of thenegligence of others. Compensation in the case of both

Acts was to be paid through private insurance schemestaken out by Railways companies and by employers.The Lancet reported one such case thus:

In the Queen's Bench, Dublin, last Saturday a den-tist claimed £8000 damages from the London andNorth Western Railway for injuries received in a

collision at Holyhead last December. The medicalevidence, as is usual in these cases, was of a mostcon¯icting nature, several surgeons believing that

the plainti� had received a sustained concussion ofthe spine; while others were con®dent that it wasonly a severe nervous shock and that after a littlerest and relaxation he would be as well as ever. The

jury after a short deliberation returned a verdict forthe plainti� for £1750 (Williams, 1880).

It was the issue of compensation litigation and whatthis compensation was for, that formed the impulse todeveloping a more complex view of spinal irritation.

What stemmed from this was the interweaving of thediagnostic act between the law and medicine. Theresult was a condition characterized as `railway spine',

and the debates that followed the invention of thisclinical category were organized around two key prota-gonists, Erichsen and Page. The contest between these

C. May et al. / Social Science & Medicine 48 (1999) 523±534524

two writers is not simply about the pathological basisof back pain, but also about the motives of su�erers.

The ®rst of these protagonists, J.E. Erichsen, hadbeen professor of surgery at University CollegeLondon and was a Fellow of the Royal Society and

President of the Royal College of Surgeons. Heasserted in the introduction to his text that

There is indeed no class of cases in which medicalmen are now so frequently called upon to give evi-

dence in the courts of law, as those which involvethe many intricate actions for damages against rail-way companies for injuries of the nervous system,

alleged to have been sustained by passengers in col-lisions and there is no class of cases in which morediscrepancy of surgical opinion may be elicited.

(Erichsen, 1882; quoted in Trimble, 1981, p. 12).

Much of Erichsen's book was devoted to the com-plex organic results of spinal trauma, where injury andits consequences were both immediately visible and

apparent. However, as contemporary commentatorshave observed (Trimble, 1981; Young, 1995), he wasalso struck by both the frequent disparity between the

injury received by the su�erer and the symptoms thatwere subsequently expressed in many cases, and alsoby the fact that spinal concussion did not seem to be

present in cases where there had not been `visible' or-ganic back injury. The only way that Erichsen couldaccount for this was to construct spinal concussion as

a neurological disease resulting from trauma: molecu-lar disturbances in the spine led to degenerative pro-cesses which were signalled by disorders in other partsof the body.

H.W. Page (1885) was consulting surgeon to theLondon and North West Railway and a Lecturer inSurgery at St Mary's Hospital, London. He objected

to Erichsen's attempt to use a single notion, (spinalconcussion and consequent neurological disease), toexplain the whole range of disorders that arose from

railway accidents and other physical trauma. Pageobserved that Erichsen's diagnostic categories weretheoretical, and evaded the issue of pathological evi-dence, especially from postmortem examinations. He

argued against the notion of `molecular disturbance',asserting that there was no evidence to suggest thatdisturbance and disintegration were synonymous and

that the hypothesis of disturbance was insu�cient toaccount for neurological degeneration in the absenceof lesions Ð although noting that other causes, such

as syphilis, should also be considered. However, heinsisted that pain needed to be understood in a widercontext.

According to Page, the British public was fullyaware of the provisions of the Campbell Act, and

people involved in railway accidents were nowunable to think of injuries in isolations from theirpossible monetary signi®cance. He advises phys-

icians to take care when diagnosing people with tri-vial or invisible injuries: to consider not only thepossibility of conscious fraud but also the possi-

bility that the patient's mind might be a�ected in`wholly unconscious ways' by the desire for com-pensation (Young, 1995, p. 17).

Page did not completely discount the notion that`railway spine' was a neurological disease, but con-trasted the apparent absence of organic disease withthe potential for neuro-psychological explanations. The

patient might not be conscious of the underlying causeof their symptoms. Indeed, the disparity between pre-senting symptoms and pathological signs could only be

explained psychologically, and the patient's motives(assumed or real) were crucial in understanding this.This was not con®ned to Britain. Similar contests took

place in the US, and somewhat later an American rail-way surgeon attested to this in a bitter critique ofErichsen's view in a lecture on patients presenting with

`litigation symptoms'.

The element of fear largely enters into these his-tories. There is a distinct appeal to the mental andthe emotional, and with a certain similarity in clini-cal histories and results they have been, and are by

many, at least, to be peculiar to railway collisions(...) We are, perhaps, familiar with those interestingcases following collisions, called often, `spinal con-

cussion' in which there is no evidence of a patholo-gic or anatomic lesion, by any of the scienti®c testsat our command, but in which the patient com-

plains of persistent pain at some point of the spinalcolumn, attended with the various manifestations of`shock'. These cases never recover until there is a

de®nite ®nancial disposition of them. (...) It is desir-able, as far as possible, to establish the results ofrailway injuries to the spine upon a pathologicbasis. Delayed shock, of which we hear something,

is like one of the manifestations of hysteria,emotional or mental. Those cases with slight com-plaint or manifestations of injury following railway

collisions do not, as a rule, at a late day assumegrave form, but are apt to become litigation cases(Grant, 1898, pp. 956±957).

In Britain, Bramwell (1893) distinguished between`railway spine' as an arbitrary and unsatisfactory entitythat represented psychological symptoms rather than

C. May et al. / Social Science & Medicine 48 (1999) 523±534 525

organic ones, in contrast with the `real' pathologicalsigns to be found amongst coal miners who met with

spinal injuries during the course of their work.Interwoven with the problem of back pain as a patho-logical entity, then, was the problem of the extent to

which the patient's account of pain was morally trust-worthy. Patients might be consciously or unconsciouslyacting out symptoms intended to lead to ®nancial

reward1.

2.2. Hysteria as the reason for doubting

So far, we have observed that the notion that spinalpain and related pathologies were related to the irri-tation of the spinal cord and membranes was ulti-

mately disturbed by the intervention of newtechnologies and the possibility of compensation forthe injuries that they caused. The idea that `railway

spine' was an organic neurological disease was con-tested by those who saw it as a `litigation symptom'and who regarded its symptomatology as the product

of conscious or unconscious manipulation by thepatient. It is in this context that spinal pain is recast interms of hysteria. To turn again to Grant (1898, p.

957): ``No symptom is of less value as indicating dis-ease of the [spinal] cord than spinal pain, yet it is everpresent and often with ill-de®ned nervous manifes-tations''. At the end of the century, these nervous

`manifestations' begin to assume priority in explainingrailway spine.

That hysteria is a cerebro-spinal neurosis is now anaccepted fact. In its many neuromimetic manifes-tations if presents both a psychic and a purely neu-

rotic front. It is a mental trouble, but hasassociated with it undoubted sensory-motor disturb-ances. Sir James Paget used to say that the hysteric

exclaims, Ì can not'; that it looks much as if itwere Ì will not'; but in reality it is, Ì can not will'(Mettler, 1898, p. 1200).

This encapsulates the di�culty that hysteria pre-sented. There was a signi®cant body of thought that

located hysteria as an organic neurological disorder de-rived from disturbances of the relationships betweenspeci®c systems within the body. Mettler, above, used

the term `neurotic' to denote such a problem located inthe central nervous system. However, it is exactly inthis period that hysteria came to be reconstituted as

primarily a mental disorder. It was recognized at thetime that this needed to be distinguished from the or-ganic pathologies that `simulated' hysterical symptoms

Ð such as muscular dystrophy and Freidrich's ataxia(Buzzard (1890), but see also Medawar (1975)). WhereMettler, above, set up hysteria as a disorder of willthat stemmed from some deeper neurological defect,

writers on hysteria swiftly moved to distance the symp-toms from such causes. The French physician,Charcot, commonly regarded as the founding ®gure in

psychological studies of hysteria and neuroses, stillheld to a neurological explanation; it was two of hisstudents, Pierre Janet and Sigmund Freud, whose

work made the conceptual leap into the realm of path-ologies of the unconscious, and ultimately disconnectedhysteria from the organic mechanisms of the brain.

Trimble (1981, p. 46) asserts that:

Both Janet and Freud broadened the notion of hys-

teria, and with ideas on the aetiology of the neu-roses and in particular the posttraumatic neuroses.Janet paid close attention to unconscious factors inthe formation of hysterical symptoms (...) He was

however, unable to take the step made by Freudand still held on to the notion that the brain wasabnormal and weak. He rejected both a neurologi-

cal theory and ideas that suggested that symptomswere faked, considering hysteria a `psychogenic' dis-ease.

Freud went further, of course, and his work attests

to the view that nothing can be `faked', but rather thatany part of the patient's account of symptoms andsigns is resonant with deeper unconscious undercur-

rents. In the face of Freud's work, and that of his fol-lowers, however, the deeply embedded notion thatback-pain symptoms were somatic rather than psychicin origin began to break down. It is in this context

that we ®nd historical accounts of `railway spine' nowconstructed through texts on posttraumatic neuroses(Trimble, 1981) and posttraumatic shock and memory

(Young, 1995).A crucial feature of the explanation of back pain

through ideas about hysteria was that it removed the

patient's motive in expressing symptoms from conten-tion. Indeed, this move medicalized the expression ofsymptoms, and no longer relied simply on observable

1 This notion has by no means gone away. `Compensation

neurosis' in which there is a correlation between the severity

of expressed symptoms and the potential for reward Ð

whether this is symbolic or material Ð remains a substratum

of debate about chronic pain. For example: ``Results of medi-

cal treatment are notoriously poor in patients with pending

litigation after personal injury or disability claims, and for

those covered by worker's compensation programs (...) most

exaggerated illness behavior takes place because of a combi-

nation of suggestion, somatization and rationalization. (...)

eliciting behavior sometimes remains permanent'' (Bellamy,

1997, p. 826).


signs. Whether pain was organic or psychogenic, it wasa medical rather than a moral question. Grant (1898,

p. 957) complained that in a case at which he had beenpresent:

The neurologist testi®ed that this patient, in hisopinion was not su�ering from any nervous disease

whatsoever, but when asked on cross examinationto give an opinion on the claimant's own statementof her condition, he said, ``she might have hys-teria''. `Ànd is not hysteria a serious disease'' he

was instantly asked and he replied ``frequently orsometimes it is''. This statement and that of herown physician, that he could ®nd nothing the mat-

ter unless it was hysteria, was absolutely the onlymedical testimony given in her favor, and the onlyexcuse the jury used (...) for rendering a verdict of

US$700 in her favor.

Contests about the pathological basis of back painincreasingly focused, then, on a distinction between`real' (organic) pain and pain which seemed untrust-

worthy in relation to the traumatic event to which thepatient attributed its cause. The idea that the su�ererpresented idiopathic mental symptoms was perhaps the

only means by which this problem could be resolved.Shorter (1997a) argues that biological psychiatry andneurology were in crisis at the end of the 19th century.

Studies of the brain itself had failed to reveal structuralabnormalities that might represent the signs of themental problems of the day, in part because the tech-nology to do so was absent, but also because the

theoretical underpinnings of biological psychiatry andneurology were deeply faulty in themselves.

2.3. Doubt disturbed: `conversion hysteria', observable

pathology and workmen's compensation

Throughout the late 19th and early 20th century,

`nervous' troubles were seen as aberrant and stigmatiz-ing, because they were related to insanity by a matterof degree, rather than by categorical distinction(Shorter, 1997a). Hysterical patients were thus concep-

tualized in terms of their unreasonably demandingnature (Punton, 1898; Albutt, 1902). The relationbetween psyche and soma was profoundly unclear, but

the existence of an active link between `psychological'and `physiological' state was increasingly taken forgranted.

The idea that the kinds of back pain that wereinvolved in `railway spine' were intimately connectedwith hysteria relied initially, as we have seen, on hys-teria itself being seen as an organic, rather than psy-

chogenic condition. In the period after 1900, this wasreversed: hysteria was reconstituted as a problem pri-marily of the psyche, and associated chronic pain and

fatigue as a function of its `conversion' into somaticsymptoms. The conventional historical view of pain ofnonspeci®c cause, here, is to regard Freudian and

post-Freudian notions of conversion as crucial inreshaping its clinical identity. In this context, somatiza-tion was constructed through processes which `con-

verted' distress into apparently organic symptoms (c.f.Shorter, 1992). In the period after World War I2, thequestion of motive was subsumed into a psychologicaldiscourse involving precisely this `conversion' of

psychological states into somatic symptoms leading topsychological or emotional `gain' (van der Feltz andvan Dyck, 1998). The nature of this gain was, of

course, problematic. However, the move to thinkingabout the ùnconscious' not as a `secret place' in whichmotives might be concealed from conscious awareness

Ð but as an objective `thing-in-itself' which had e�ectsover which the individual had no egoistic control Ð issupposed to have at least partially displaced moral jud-

gements about such patients within the clinical litera-ture. Yet such a shift is by no means apparent in theclinical literature itself. In inter-war Britain, medicaldiscourse about CLBP remained profoundly in¯uenced

by socio-legal considerations. The relationship between`trauma' (largely as the result of accidental industrialor transport injury) and `hysteria' or `neurasthenia'

remained highly contested. In a discussion of `trau-matic neurasthenia' Sir Farquhar Buzzard attestedthat:

It may be labelled the `spinal' or `my poor back'group. The patient invariably walks into your room

2 It is important to acknowledge the importance of `shell

shock' during the First World War on ideas about the re-

lationship between apparently organic disorders and hysterical

reactions. The history of clinical investigations into shell-

shock directly parallels (albeit in highly compressed form)

that of CLBP: beginning with ideas about `commotional'

shock leading to invisible injuries of the cerebellum and spine

(Elliot, 1914; Anonymous, 1916; Mott, 1916) and moving

rapidly to the conclusion that the shock was èmotional' or

psychological (Elliott Smith, 1916; Elliott Smith and Pear,

1917; Mott, 1918; Myers, 1940). The psychogenic origins of

shell shock form a starting point for discussions of nonspeci®c

pain in the decade after the war, (see, for example, Gill,

1929). A survey of the development during this period of

medical concepts of shell shock in Britain may be found in

May (1998). Nor should we neglect the experience of war on

public expectations of medical care in the period after 1919.

The First World War meant that for the ®rst time, very large

numbers of men had their ®rst experience of organized medi-

cal care, free on demand. This played a key role in the devel-

opment of ideas about publicly funded health care (Lewis,

1992).


leaning on a stick in one hand and with the dorsumof the other placed on the lower part of his back.

You know at once that the site of his injury is thespine. As a matter of fact many of these patientshave su�ered only from a sharp attack of lumbago

while making a physical e�ort in the course of theiremployment. In addition to their characteristic atti-tude they often present the symptoms of anxiety

neurosis. Again, examination reveals no sign of or-ganic disease, but there is a super®cial tendernessover a great part of the spinal column (Buzzard,

1923).

Having established the uncertain nature of `trau-matic neurasthenia' in relation to back pain, he contin-ued:

Having given this question much thought, and hav-ing seen and studied a large number of patients suf-fering from traumatic neurasthenia. I have come toregard one factor as having a more profound in¯u-

ence than any other (...) I refer to the question ofresponsibility. Is the patient responsible for theinjury, and has he to shoulder the burden of its

results, or can he shift the burden of responsibilityon to others? (...) We love to shift responsibility,and having done so, we have leisure and liberty to

study the injury in detail and all the results which itentails. More than that, we are ready to shift theresponsibility for recovery onto others, and tacitlyto reserve the right of determining the length of the

illness. What a di�erence there is between slippingand falling downstairs, due to our own carelessness,and doing the same as the result of a push. The

emotion of anger and the sense of injury are addedto physical discomfort and are more than likely toprolong disablement (Buzzard, 1923, p. 1286).

In the inter-war period, the moral character of thepatient assumed as great a signi®cance in clinical ana-lyses of CLBP as it had in the latter half of the 19th

century. However, this in turn had depended on theabsence of e�ective clinical investigations. In theperiod after the First World War, this situation chan-ged as two further factors intervened. The ®rst of these

was the increasingly wide-spread use of X-ray investi-gation, and the emergence of a medical subprofessionwhich claimed the authority to interpret X-ray images

(Pasveer, 1989). This enabled apparently neutral,objective, clinical observations to be made about theexistence or nonexistence of organic pathology. X-rays

o�ered a particular kind of `truth' about the body thatseemed unimpeachable: where no organic pathologywas visible then there could be no spinal damage (since

it was the spine that was opaque to X-rays, and thusthe focus of investigation) and muscular problems

were conceived of as being of secondary importance toskeletal ones. Such clinical observations were notsimply crucial to diagnosis, but also became, after the

inception of National Insurance in 1911, and as theWorkmen's Compensation Act was extended to covernew categories of industrial laborer, evidence in asses-

sing eligibility for state bene®ts. Gill (1929) o�ered acase study and an explanation of precisely such a med-ico-legal problem:

Case 9. Injury to the back seven years ago; constantpain; doubtful X-ray picture; hysterical perpetuation

encouraged by wearing plaster jacket for four years.Ð A laborer, aged 41 fell backwards on December28th 1921 and hurt his back. He continued at work

until April 21st when he gave up because of pain.(...) X-rays have been taken at various times andwhile most of these have reported `nothing abnor-mal' others reported `fracture of the ®fth lumber

spine'. In consequence of this discrepancy a beltwas ordered and despite the fact that he couldmove freely, special exercises and massage were also

given. In April 1924, a plaster-of-Paris jacket wassupplied by a surgeon who is stated to haveremarked, ``Unless you are careful, you will be an

invalid for life''. This jacket was kept on untilremoved by order of the court in May, 1928. MoreX-ray photographs were taken and the radiologistreported: ``No evidence of injury or disease

throughout the entire spinal column'' (...) the manwas granted three months to recover without hisjacket and recommended to try work after that

time. This case I suggest is one of hysterical per-petuation of pain, whether a fracture was originallypresent or not. Failure to cure depended largely on

the unfortunate remark of the surgeon who appliedthe jacket and the prolonged wearing of the latter(Gill, 1929, p. 812±813).

There is no assumption of malingering here. Instead,

responsibility is di�used. On the one hand the patientis culpable for falling into a hysterical trap, but thesurgeon is also held accountable for giving the patientthe means to do so. X-ray examinations formed an

apparently objective benchmark for the existence ofpathology. Where X-rays were `negative' the problemcould clearly be located in the realm of the psychologi-

cal.In the same period, surgical investigation and treat-

ment of back pain became increasingly common-place,

as a result of the postwar expansion of orthopaedicsurgery (see Cooter, 1993) and the consequent growthin interest in the surgical treatment of industrial inju-


ries. (This was not con®ned, of course, to compen-

sation cases. For example, Paramore (1924), had pub-lished a detailed taxonomy of back-pain which stressedthe potential for surgical treatment in that group

which had previously been `given' as that most fre-quently subject to `hysterical' pain, women su�eringfrom `gynaecological' problems). The similarly rapid

expansion of orthopaedics in the United Statesbrought with it a speci®c `discovery' that could

account for `organic' back-pain: the ruptured interver-tebral disc, where the cartilaginous material that formsa lubricating and shock-absorbing pad between each of

the vertebrae might be deformed or broken throughtraumatic strain (Mixter and Barr, 1934). The presence

(or absence) of organic pathology of traumatic causecould thus be de®ned in speci®c terms according to adiscrete pathological sign.

The introduction of National Health Insurance inBritain in 1911 was an important spur to the develop-ment of orthopaedics as a surgical speciality in Britain,

and thus to the parallel emergency of radiology, onwhom orthopaedists depended for diagnostic knowl-

edge about the interior of the body prior to opening itup for surgical investigation and treatment. For the®rst time, free medical treatment was available to the

poor, from `panel' doctors Ð general practitionerswho received payments direct from the state for

accepting non-fee-paying patients onto their lists(Lewis, 1992). The development of patterns of referralto new groups of specialist consultants was dependent

on this expansion of access to general practitioners.However, in this respect, Cooter (1993, p. 214) pointsto the very close relationship that emerged during the

inter-war period between orthopaedic surgeons and thetrades unions: in the face of a 400% increase in indus-

trial accidents in the 25 years after the inception of the1911 National Insurance scheme, the trades unions®nancially supported orthopaedic surgical and rehabili-

tation centers and pressed for state funding for themand for the exclusion of general surgeons and generalpractitioners from the care of such cases. The growth

of orthopaedics was therefore intimately linked intothe system of bene®ts provided by the state and the

trades unions and into the extension of workmen'scompensation schemes imposed upon employers bystatute. However important psychological explanations

of nonspeci®c CLBP might subsequently become, itwas to orthopaedic surgeons that such cases were

increasingly referred for examination. And it was theorthopaedic surgeons who, after the Second WorldWar, began to demand that `psychological' cases be

excluded from their workload: eminent orthopaedistsdemanding in 1947 that a distinction be drawnbetween patients with `real' organic disease, and those

suspected of having `psychosomatic' complaints"(Cooter, 1993, p. 239).

It is in the inter-war period that the moderndilemma of CLBP appears. Clinical investigation

through technologies that could e�ectively view the in-terior of the body raised the question of de®nitive diag-nosis of organic pathology, and orthopaedics made

surgical investigation and treatment increasingly avail-able, while the results of those investigations moreoften than not were ambiguous or negative. At the

same time the moral character of both the patient andthe attending doctor were called into question, throughnotions of responsibility for recovery Ð that assumed

political and economic importance because of theextent to which the determination of eligibility for wel-fare bene®ts and commercial compensation were del-egated to the medical profession by the state and the

courts (and which were ampli®ed by intraprofessionalcontests within medicine itself). The dilemma was, andis, one of disposal within the bounds of socio-legal, as

well as biomedical, categories.Our argument here is that the foundations for

CLBP as a contemporary problem for medical practice

are to be found in the application of ideas about de-®nitive spinal pathology, and a surgical specialism thattook as its focus the skeletal system, during the 1920's

and 1930's. This much is not remarkable; but what isimportant about this is that the expansion of facilitiesfor X-ray examination and the emergence of dedicatedorthopaedic departments in the inter-war period meant

that many patients were now investigated to discountsinister signs and spinal damage, rather than to diag-nose them. The assumption remained that CLBP rep-

resented to some degree mental, rather than organicphenomena, but there were now `objective' bench-marks against which these could be judged. And while

Freudian notions of conversion hysteria have beengiven priority in the recent historiography of `somati-zation' (e.g. Young, 1995), these rate hardly any men-tion at all in the general British clinical literature of

the period, (for example, in the British MedicalJournal or The Lancet). It is only after World WarTwo that such notions begin to enter the professional±

public arena (Anonymous, 1946; Paulett, 1956).However, even then the transition to `somatization' asa concept without Freudian overtones is swift (e.g.

Anonymous, 1956), despite the emergent in¯uence ofpsychoanalytic ideas about, for example, the conductof general practice (Balint, 1957; May and Mead,

1998). British doctors were negotiating political insti-tutions and practices, as much as they were negotiatingchanging biomedical ideas.

3. The contemporary clinical dilemma

So far, we have shown how in commentaries andaddresses in medical periodicals, clinicians addressing


CLBP came to represent the patient as a `social' pro-blem that ultimately had to be explained in terms of

psychogenic rather than organic nature. We haveobserved that the contemporary dilemma in clinicalpractice was established once technologies that could

be portrayed as generative of `neutral' or òbjective'assessments of the spine were brought into widespreaduse, and patients could be divided into `real' organic

and `psychological' cases. We can characterize thisdilemma broadly as follows:

. The patient expresses symptoms which present pain

and fatigue; these are formulated in terms of biome-chanical degeneration or exhaustion of functionalperformance and are undoubtedly real experiences.

The patient interprets these within a strict `biomedi-cal' model of organic cause and expects the clinicianto act upon this basis.

. The clinician investigates potential organic cause,discounts the presence of sinister pathological signsand interprets expressed symptoms in the context ofa psychosocial model. The patient understands this

as casting doubt upon the reality of embodied ex-periences and is demoralized and dissatis®ed. Bothparties are ultimately pessimistic about the extent to

which the other is `willing' to hear their interpret-ation of expressed symptoms.

Our discussion now turns to the conceptual frame-

work on which this dilemma is based, the notion of`somatization' and its underpinnings. Our discussion ofthe problem is a general one, for within the framework

of `somatization' CLBP loses its speci®city, it simplybecomes one of a range of è�ects' of a psychogenicprocess that is productive of `pain'.

3.1. Postwar somatization

Somatization is a process in which it is hypothesizedthat psychological distress is converted into an embo-

died experience of pain, fatigue or some other organicdysfunction. More than any other symptom it empha-sizes the di�culties that contemporary medicine has in

integrating psyche and soma, that is, in seeing themind and body as integral to each other. In historicalterms, this has involved increasing con®dence on thepart of the medical profession that the expression of

symptoms is itself a pathological sign. It is to the waysin which this is understood that we shall turn to next.For contemporary medicine the idea that some

apparently somatic experiences of illness are of psycho-logical origin presents two kinds of dilemma: (a) howto conceptualize the relationship between mind and

body and (b) how to present this to the patient. Whiteand Moorey put it thus in an editorial in the Journalof Psychosomatic Research

`Psychosomatic' conditions such as irritable bowelsyndrome, premenstrual syndrome, chronic fatigue

syndrome, repetitive strain injury and other chronicpain syndromes are common, but do not easily ®tinto a medical philosophy of a separate and divis-

ible mind and body. In this schema, patients su�erfrom either physical disease or mental disease. Thestigma attached to mental illnesses understandably

leads many patients to seek a physical diagnosis.(...) The patient may be told there is nothing physi-cally wrong. This explanation may be angrily

rejected, especially if the physician suggests that thesymptoms are àll in the mind' and the patientshould see a psychiatrist. The patient feels accusedof either madness or malingering (White and

Moorey, 1997, p. 329).

The problem that clinicians are faced with, as Whiteand Moorey (1997, p. 330) freely admit, is that in the

kinds of disorders to which they refer, neither conven-tional explanations grounded in psychiatric nor physio-logical models can explain directly the causal

mechanisms that produce the symptoms that lead thepatient to present, Aetiological theory is thus in-adequate, but this is di�cult to explain to the patient.

Other writers see not the conceptual schema of medi-cine, but that deployed by the patient, as the problem.For example:

The central characteristic of somatization, then, is alack of separation of mind or body, or of the a�ec-

tive and physical aspects of the self. Both are ex-perienced as a unitary whole and discomfort in onearea is readily expressed as symptomatology in the

other. From a psychiatric perspective, somatizationserves the purpose of reconstructing emotional orpsychological problems as physical (Angel and

Idler, 1992, p. 77).

So, either medicine fails to resolve the duality ofmind and body, or the patient does. Either way, what

is important about much current thinking about soma-tization however, is not simply that it fails to resolvephilosophical problems of mind/body dualism, butthat it assumes `gain' on the part of the somatizer.

Somatization is thus, `à process by which the body(the soma) is used for psychological purposes or per-sonal gain'' (Ford, 1983). The problem here is what

that `gain' might be.The kind of `gain' that we might hypothesize is that

`pain' as a function of the relationship between mus-

culo-skeletal and central nervous systems actually ®tsvery well into the biomedical framework that formsthe explicit basis of doctor±patient interaction. The


gain for the patient is thus that by operating withinconventional medical discourses, using symptomatolo-

gies of known utility in dealing with doctors, the pres-entation is understood and can be acted upon. Theidea that some kinds of illness experience are directly

socially constructed in interrelation with biomedicine isby no means novel (Brown, 1995), but it is not, how-ever, unproblematic. Although avowedly and funda-

mentally opposed to `constructivist' explanations, thehistorian Edward Shorter is, ironically, one of its lead-ing exponents in explaining somatization processes

(Shorter, 1992, 1997a,b). In a summary of his argu-ment he asserts that:

At the beginning of the twentieth century patientscertainly became aware that medicine was lookingwith increasing dubiety on the sofa cases and the

young women stricken with paralysis after seeing afrog on the road. Not wishing to seem foolish,these patients began to come up with symptomsthat doctors would ®nd more credible. It must be

emphasized that this process is an unconscious one.We are not speaking of play acting, still less ofcompensation neurosis. Ironically, therefore, it has

been the very progress of medicine that itself hascontributed to the symptom shift. In the patient'sworld the onmarch of science has led to the choice

of sensory symptoms such as low back pain thatcould not be easily disproved. Once medicine dis-covers a good test for detecting organicity in thelower back, the frequency of such complaints will

presumably decline and the great wheel of somati-zation will roll on to new psychosomatic complaintsas yet slumbering in the early dawn (1997b, p. 55).

The point is, of course, that when a `good test' Ð

albeit a historically contingent one Ð for discovering`organicity' in the back was introduced with the wide-spread application of X-ray photography and ortho-

paedic examination during the 1920's, the frequency ofsuch complaints did not seem to decline. To this wecan add that increasingly sophisticated imaging tech-

nologies Ð computer assisted tomography (CAT) andnuclear magnetic resonance imaging (NMRI) Ð havenot had such an impact on numbers of cases. Indeed,as Waddell (1987, 1992) observes, the numbers of such

complaints in the UK have steadily risen since the war,while in the same period `objective' technological in-vestigations have grown steadily more sophisticated.

Shorter (1997b, p. 58) argues that somatizingpatients draw on a `pool' of symptoms that are cultu-rally de®ned as acceptable in relation to medicine and

which are understood within a medical model. These`pseudodiseases' revolve around nonspeci®c symptomsand emphasize chronic fatigue and pain as expressed

symptoms, often in the company of dizziness andmemory loss. Shorter (1997b, p. 59) asserts that:

Practitioners are faced with an abundance of di�-cult to treat patients with chronic pain for the fol-

lowing reasons: (1) the culture increasinglyencourages patients to conceive vague and nonspe-ci®c symptoms such as chronic pain as evidence of

real disease and to seek specialist help for them.Many of these symptoms are historically new. (2)The rising ascendancy of the media encourages

patients to think they have a given illness, often atrendy nondisease such as repetition strain injury orchronic fatigue syndrome.

The problem here is that the symptomatology that

Shorter focuses on is one which seems to be histori-cally continuous Ð chronic pain and fatigue Ð and itis the attributions of clinical identity, the taxonomiclabels that are applied to them, that seem novel.

Although Shorter is forthright about his objection toconstructionist approaches (1997a), this kind of cri-tique does not seem so far from the notion of

Foucault (1982), that discourse de®nes its own objects.There is a second problem with Shorter's view andthat is that patients presenting with nonspeci®c CLBP

do seem to have a good deal of insight into the way inwhich they are involved in negotiating the boundariesbetween organic and psychological categories in theclinical encounter (Chew and May, 1997). The same

obtains to su�erers of chronic fatigue syndrome(Cooper, 1997), or pelvic pain (Grace, 1998), to taketwo topical examples, where contests over the de®-

nition of what is, and what is not, a `real' disease haveassumed political importance.

3.2. Doubt and power

Medical discourses and practices have thus grappled

with mind/body dualism in a way that is ultimatelyunsatisfactory to clinicians (as well as to patients). Wewish to turn now to the problem of doubt and power,

for how to conceptualize CLBP where identi®able or-ganic pathology is absent is a problem for contempor-ary medicine. On the one hand, there is no doubt thatindividuals experience `real' pain; while on the other,

this pain is often inexplicable in terms of knowledgeabout the body as a biomechanical object. What fol-lows from this is the frequent attribution of pain to

somatizing processes, where psychological distress Ðusually depression and/or anxiety Ð is seen to be con-verted, through means that are only partially hypoth-

esized, into an embodied experience of physical pain.As we have observed, a constant feature of clinicalwriting about CLBP has been doubt about the relation-


ship between expressed symptoms and their pathologi-cal origins. In relation to this, Scarry (1985) reminds

us that experiences of pain themselves predicate a formof medical labor Ð that is, the construction oflanguage that itself calls into being not simply patho-

logical entities, but also the problem of doubt itself.She asserts that:

the success of the physician's work will oftendepend on the acuity with which he or she can hearthe fragmentary language of pain, coax it into

clarity, and interpret it (...) Medical contexts, likeall other contexts of human experience, providealarming instances of the phenomenon noted ear-lier: to have great pain is to have certainty; to hear

that another person has pain is to have doubt. (Thedoubt of other persons, here as elsewhere, ampli®esthe su�ering of those already in pain) (pp. 6±7).

The principal feature of the history of nonspeci®c

chronic low back pain, then, is the extent to which ithas faced clinicians with intractable doubt about whatthis pain means and how patients' expressed symptoms

should be interpreted. Good (1994) notes the extent towhich the physician's power relies on the capacity too�er a diagnosis. What is striking about so much ofthe clinical literature relating to CLBP, both contem-

porary and historical, is precisely the absence of thiscapacity to diagnose with certainty. In this paper wehave focused on ò�cial' discourses, which form both

the professional explanation for viewing such pain as aspeci®c kind of problem and the foundation for par-ticular kinds of practices. What precisely CLBP really

is, is contested within such discourses, through dis-agreements about what somatization re¯ects. However,this debate about what somatization really is, is notone that simply takes the `biomedical' as its focus. It is

also shot through with intervening social factors: com-pensation legislation, National Insurance schemes andcontests within and between medical groups.

4. Concluding comment: medical doubt about CLBP and

the problem of the patient.

Our approach in this paper has been to take a longview of CLBP, and to show how medical discourseshave been shaped by social factors that intervene to

problematize the relationship between body and mindin new ways. The history of CLBP can thus be dividedinto three distinct stages:

1. CLBP is a `real' organic disease related to damageto the spinal cord; but doubt exists about the causalmechanisms. Expressed symptoms are regarded as a

report on signs, but doctors are confused aboutwhat these mean.

2. CLBP is a `real' organic disease related to neuro-logical dysfunction; but doubt exists about its hys-terical nature. Expressed symptoms are medicalized,

but doctors are uncertain about their signi®cance.3. CLBP is the `conversion' of psychological distress

into embodied pain; doubt exists about the relation-

ship between expressed symptoms and organicsigns. Expressed symptoms are pathological signs inthemselves, but doctors are confused about how to

interpret them.

Greco (1998) has argued that the central problemthat arises out of ideas about `somatization' is the

extent to which ideas about the òrganic' and the`social' are forced to compete with each other forexplanatory force within the bounds of medical knowl-

edge and practice. In this context, we can see the boththe clinician and the patient making moves in the caseof CLBP which are about the practice of certainty andthe discrediting of doubt (see, for example, Busby et

al., 1997). The power of de®nition here is of a particu-larly fragile kind Ð neither patient nor doctor can dis-credit the other's doubt. As we have noted, Scarry

(1985) emphasizes that an account of pain seems toautomatically entertain the possibility of some òther'having doubt. There is abundant evidence that this is

the case with CLBP, and it is formulated around thedisparate frames of reference that doctors and patientsbring to the clinical encounter. In crude terms, theclinical frame of reference can be formulated thus:

`Real' psychosocial distress 4 experienced pain4 immobilization 4 clinical encounter

That is, the patient's pain can be conceptually dis-posed of, even if the continued concrete presentation

cannot. While in the kind of model that patients pre-sent this doubt is constituted as:

`Real' embodied pain 4 loss of social function 4clinical encounter 4 psychosocial distress

The doctor's complaint is that the patient thus

instantiates her or himself ®rmly within the remit of astrictly biomechanical model of pain and impairment,when this is not justi®ed by the clinical evidence

(Chew-Graham and May, 1998). These practices ofpositioning accounts of ill-health within a particulardiscourse do not occur spontaneously or naturally:

they are products of considered agency. For thepatient, constructing symptoms as e�ects of biomecha-nical dysfunction has real practical utility: ®rst, that is


how they are primarily experienced and understood in

the patient's lifeworld; second, as we have already

noted, such a view ®ts in well with medical discourses

about the body, as these are culturally mediated. This

is not just a matter of relating symptoms to lay health

beliefs, for such a distinction may not be a helpful one

in conceptualizing chronic pain in Western medicine.

The explanations that patients bring to the medical

encounter are, in themselves, powerful social levers

(Salmon and May, 1995). By constructing an account

of experiences of chronic pain, and locating them in a

particular biomechanical system, the patient is also

exercising power. This power, of self-de®nition, is

about asserting a `belongingness' to a category that is

recognizable to medicine and by extension, to a cat-

egory that `®ts' with the wider culture in which the in-

dividual is located.

Conventionally, sociological and anthropological

accounts of somatization have taken as their starting

point the notion that expressed symptoms are symbolic

acts and experiences, as well as representative of other

(psychological or organic) processes. Parsons (1951)

conceptualization of the sick role, for example, is

about the symbolic acts that permit withdrawal from

normative obligations as well as the concrete `belong-

ingness' that actors have to the category of the `sick'.

Indeed, such accounts, as Lieban (1992, p. 186) ob-

serves, emphasize the extent to which illness is itself a

``communication about, inter alia, social factors and

their relation to the patient''. Here, we should see

expressed symptoms not simply in terms of `lay under-

standings' of illness, but more in terms of lay under-

standings of how to meet the demands of a system of

expert knowledge and practice. In this context, it is

worth noting that the attribution of diagnostic cat-

egories by clinicians also communicates through sym-

bolic acts the status and character of the patient.

In positioning themselves within `back-pain',

patients ®nd a `®t' for their expressed symptoms, and

doctors a `®t' for their diagnostic categories, with the

fundamental basis of biomedicine as a secular belief

system: that `real' disease is organic Ð and as Good

(1994, p. 70) puts it: ``fundamentally, even exclusively,

biological'' and `psychological' symptoms are thus not

`real' disease. A�rming the organicity of pain, in such

a context, has practical utility, in the face of prescrip-

tions for analgesics to resolve biomechanical pain; or

of clinical investigations of the body as a biomechani-

cal thing (through X-ray or CAT scans), it hardly

makes sense for the patient to be expected to conceive

of their pain as anything but biomechanical. Patients'

self-knowledge is as intractable to medicine as the pain

they present, but this self-knowledge is at least par-

tially derived from medicine's own diagnostic cat-

egories and institutional practices.

Acknowledgements

CRM thanks the Robert Darbishire Practice,Manchester, UK, for its ®nancial support of his work.We are grateful to Martin Roland, Hermione Lovel,

Christine May and two anonymous referees for theirdetailed and very helpful comments on earlier versionsof this paper.

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medical knowledge and the intractable patient: the case of chronic low back pain

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