Medical knowledge and the intractable patient: the case of chronic 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 paid to 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 about the relationship between pathological signs and expressed symptoms from the 1820's to the 1930's, and then placing these developments in the context of postwar notions of `somatization'. We point to the extent to which the disparity 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 the extent to which medical ideas themselves have been constructed in intimate linkage with socio-legal questions of compensation 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.