Social Science & Medicine 73 (2011) 801e807

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Diagnosis and nosology in primary care

David Armstrong
King’s College London, 5 Lambeth Walk, London SE11 6SP, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Diagnosis in contemporary medicine is made using an underlying classification system or nosology, the
Available online 27 May 2011 basis of which was first laid down at the end of the 18th century. The International Classification of
Disease (ICD) was constructed to formalise this nosology and successive revisions have attempted to
Keywords: capture technical developments and new discoveries across the diagnostic landscape. The ICD has proved
Diagnosis particularly applicable in hospital practice where a selected patient population and access to compre-
Classification
hensive diagnostic aids enables a pathology-based diagnosis. When it came to be applied to primary care
Primary care
in the middle of the 20th century, however, it encountered major problems as general practice struggled
ICD
to marry a classification of disease to the rawness of undifferentiated human illness and distress.
Eventually a classification based on the reason the patient consulted emerged to replace that based on
pathology defined disease. Analysis of the frontier zone where a dominant classification system struggles
to maintain order reveals the ways in which medical nosologies, through their application in the process
of diagnosis, attempt to promote and maintain a certain medical reality.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction
In a recent review Jutel (2009) argued that the sociology of
diagnosis was a relatively neglected topic of research and that the
classification of disease which underpins the diagnostic process
had not drawn the attention it deserved. Yet while direct study of
medical classification might indeed be relatively rare, in many ways
its presence has underpinned major swathes of sociological anal-
ysis over recent decades. When Brown (1995) identified the
contestation around certain diagnostic categories (attention deficit
syndrome, homosexuality, obesity, etc) as a central part of a soci-
ology of diagnosis, he encapsulated a broad field of research which
explored why additional disease ‘cells’ were added or subtracted
from the overall classification. The importance of this research
focus was also echoed in Jutel’s paper when she pressed for more
research to reveal how specific diagnoses were first introduced into
clinical practice providing as an example the efforts of Alzheimer to
get his new ‘cell’ of the classification table recognised.
Labelling and deviancy theory e and all their associated analyses
e when applied to medicine inevitably engage with a contextual
classification system even though they might only focus at the
cellular level. Equally research into medicalisation has been mainly
driven by analysis of struggles to incorporate new cells and/or
dimensions into the existing classification table (Conrad & Schneider,
E-mail address: david.armstrong@kcl.ac.uk.
1980; Zola, 1972); and a key concept for analyses of professionalising
strategies is the power of medicine to define illness which implies the
right to apply a system of medical classification (Abbott, 1988;
Freidson, 1970). Even the doctorepatient encounter can be
construed as an engagement between two classification systems,
medical and lay (Tuckett, Boulton, Olson, & Williams, 1985). The
number of sociological studies which engage at least with the ghost
of medical classification is therefore extensive. Most of this research
though has adopted the cellular approach, addressing illness at the
disease level and leaving the classification system as mere context or
background, tacit and assumed, a system of knowledge which both
defines and limits analytic possibilities.
One of the notable exceptions to the cellular approach to
medical classification is Bowker and Star’s monograph Sorting
things out: classification and its consequences in which they
deployed a functionalist analysis to examine the role of classifica-
tion systems in communicating moral values. The used the Inter-
national Classification of Disease (the ICD) to illustrate how the
existence of certain disease categories both reflected, and in turn
sustained, various state interests. In part this was a cellular analyses
of how certain labels, and not others, were accepted as legitimate
within the classification but they also argued that classification
systems as a whole get used as social resources to be deployed by or
fought over by individual actors and interests; they concluded that
the pernicious effects of classification systems could only be over-
come by ‘flexible classifications whose users are aware of the
political and organisational dimensions and which explicitly retain

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.05.017
802 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
traces of their construction’ (p. 326). For Bowker and Star there was
a clear separation between actors and the classification systems
which they created or amended, but a more constuctivist approach
would hold that if classification systems are so fundamental to
social life the individual cannot stand outside of them.
In Elementary Forms of the Religious Life (1912), Durkheim argued
that the basic building block of classification was the division of the
world into sacred and profane. It is the need to maintain a separa-
tion between these two symbolic domains, that of the social and
that not of the social, which established both ‘primitive’ classifi-
cation and formed the basis of all subsequent classifications. In his
collaborative work with his nephew Durkheim and Mauss (1903)
pointed out how classification both reflected and reproduced the
social group: ‘the unity of knowledge is nothing else than the very
unity of the social collectivity extended to the universe’ (1903:84).
In other words, it is less the need of humans to classify, pace
Bowker and Star, than that humanness is itself defined by classifi-
cation. A different sociological analysis of classification therefore
becomes possible: what does medical classification, in its totality,
tell us about who we are?
That medical classification is produced by and reflects
a particular social group is evidenced by the variation of classi-
fication systems by culture and by time. In his book Birth of the
clinic, Foucault (1973) identified a fundamental shift in medical
perception as occurring at the end of the 18th century which in
its turn brought about a revolution in the understanding of
illness. This new medicine e and its accompanying novel classi-
fication e identified illness as existing in an intra-corporal lesion
or abnormality. The search for this lesion through the clinical
examination and post-mortem/necropsy meant that bodies
became the subject of routine examination (previously the
examination consisted at most of feeling the pulse); the idea that
disease grew inside the individual body as a pathological lesion,
often with the result that the patient died, meant that death was
relocated inside the body; and the movement of patients into the
neutral space of the hospital bed for medical and nursing
surveillance ensured the documentation of individuals. The new
pathological medicine, therefore, can be understood as under-
pinning the nature of what it was to be human; ‘humanity’ was
the result of the application of this new classification system and
the classification system was a reflection of that same human-
ness. As Foucault concluded, in the last years of the 18th century
a new structure of knowledge appeared in European culture
which has come to constitute ‘the dark, but firm web of our
experience’ (p.199).
The ICD which emerged in the second half of the 19th century
was therefore more than simply a means of organising and ordering
medical knowledge. As the ICD formalised the principles of the new
medicine by classifying illness according to its pathological types, it
mapped out the anatomical/pathological form of the human body.
Earlier classifications, which had categorised symptoms, reflected
a system of medicine in which disease was neither individuated nor
localised to the lesion inside the patient’s body. Such major changes
in the very nature of the classification system suggest that the
history of diagnostic classification can be concerned with more
than ordering a society’s knowledge or with professionalising
strategies or with struggles over what is to count as a disease; the
underlying classificatory principles e whether of mobile symptoms
or anatomically fixed lesions e both constitute and reflect the very
nature of identity.
The legacy of the ICD
By the mid-19th century the previous classification system
which had ordered patients’ symptoms into genera, species and
types was largely replaced as the ascendant pathological theory of
disease relegated symptoms to mere indicators of disease. The first
International Statistical Congress convened in 1853 formalised this
pathological system into a classification consisting of 139 rubrics or
categories of the various causes of death. This classification, in its
turn, underwent periodic review and revision and in 1893 the
International Statistical Institute, the successor to the International
Statistical Congress, reached a new agreement on an International
List of Causes of Death, based on distinguishing between general
diseases and those localised to a particular organ or anatomical site.
It was also decided to revise the classification every ten years.
The development and refinement of a classification of causes of
death in the 19th century articulated the central relationship that
death held for pathological medicine. As Foucault (1973) noted, in
the new world of pathological medicine ‘It is not because he falls ill
that man dies; fundamentally, it is because he might die that man
may fall ill’ (p.155). The idea that death was contained within the
body (rather than being an external force that demanded entry)
constituted one of the key features of the new medicine and this
propelled the pathological lesion as the potential repository for
death into the foreground. Diagnosis, especially in the post-mortem
room, was underpinned by the figure of death and the emerging
classification systems promoted by international conferences
involved identifying the pathological event that ended life. But at
the First International Conference to revise the 1893 Classification
of Causes of Death held in 1900, a decision was taken to develop
a parallel classification of diseases where the outcome was not fatal.
This parallel classification, derived from the pathological classifi-
cation of death, involved subdividing certain causes of death into
two or three disease groups, each of these being designated by
a letter. Further subdivision followed in subsequent years as
attempts were made to achieve wider acceptance and use.
It was only in 1948 with the publication of the 6th Revision of
the International Lists that non-fatal diseases were finally incor-
porated into the (re-titled) International Classification of Diseases,
Injuries, and Causes of Death (usually shortened to the ICD)
alongside those diseases that caused death. A comprehensive list
for both mortality and morbidity was approved as well as agree-
ment on international rules for selecting the underlying cause of
death; the task of subsequent revisions was placed under the
guidance of the newly formed World Health Organisation (WHO).
The triumph of the ICD marked the success of the pathological
system of medicine. While the ICD had its roots in the task of
classifying the pathological causes of death (which, in the final
analysis, were determined in the post-mortem room when the
specific anatomical lesion was identified), its gradual extension to
embrace non-fatal morbidity during the first half of the 20th
century marked the extension of the pathological principle
throughout the hospital’s wards and clinics. In fact, in many ways
the hospital itself was the physical and organisational expression of
the ICD. Its wards were sub-divided according to its headings and
chapters; its different medical specialties affirmed its various
dimensions; its patients were labelled according to its cells and
rubrics; its post-mortem room and pathology laboratories ensured
the underlying order of the classification system was maintained.
Yet outside the hospital’s walls the process of ordering and
managing illness was relatively untamed: it was a world in which
raw illness appeared, mainly in symptomatic form, disorganised
and unsorted. Could the ICD provide the lens through which this
spectrum of health problems could be made visible?
The ICD and general practice
In an attempt to measure the illnesses presenting in his general
practice just outside London, Fry (1952) devised his own
 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
classification system which, for example, divided upper respiratory
tract infections into the common cold, ‘febrile catarrh’, acute sore
throat, ‘catarrhal children’, influenza, and others (which together
accounted for 25% of his overall workload). Other GPs reported
similar surveys in the early 1950s (Fry, 1952; Horder & Horder,
1954; McGregor, 1950; Pinsent, 1950), all using different classifi-
cations. So when the Research Committee of the British College of
General Practitioners (founded in 1952) decided to carry out
a national survey of morbidity it turned to the ICD as the estab-
lished and widely accepted medical classification system. The
Morbidity Survey, conducted in 1955e56 (Logan & Cushion, 1958)
and covering 108 practices e 120 GPs in total e recorded every
‘item of service’ carried out over one year on a specially designed
record card and these records were forwarded to the General
Register Office where a team of clerical staff checked and coded
them (Graves & Graves, 1957).
The records returned to the coding clerks by the survey’s GPs
contained all manner of illness labels as participating doctors were
invited to use those diagnostic terms to which they were accus-
tomed (Research Committee of the College of General Practitioners,
1958). It was then left to the skill of the clerical staff to assign the
various diagnostic categories used by GPs to the rubrics of the ICD.
The feat of converting the chaos of GP diagnostic terms to the
ordered world of the ICD ‘was a remarkable one’, it was later
observed, perhaps with some irony (Research Unit of the Royal
College of General Practitioners, 1971:609).
The main problem in translating GP diagnoses to the ICD’s
various pathological headings was that often there was no obvious
category to match the general practice label. Minor complaints in
particular proved difficult to code; as Pickles (1955) had observed,
a major problem was ‘the nomenclature of the minor complaints
which occupy the greater part of the general practitioners working
day, for few serious efforts have previously been made to arrive at
any standard terminology for these maladies’. The difficulty of the
coding clerks had in translating from a label such as ‘catarrh’ to an
ICD rubric was compounded by GPs’ use of provisional diagnoses.
Labelling or diagnosis in general practice was often tentative e
a cough might have been a sign of tuberculosis, but most likely not.
Confirmation of more serious illness could only be made when and
if the illness revealed itself. In a small experiment on data collection
it was recorded that 30% of the diagnoses made on the first
consultation were tentative (Research Committee of the College of
General Practitioners, 1958).
For the GP of the mid 20th century many diagnoses seemed to
be closer to the older 18th century symptomatic classification than
to the rubrics of the ICD in that the clinical encounter was
frequently dominated by symptoms often without identifiable
underlying pathology. This meant that many illnesses could only be
designated by labels which were little more than symptoms or
symptoms-complexes, such as headache or dyspepsia. As Walford
(1963) observed, perhaps half the cases in general practice were
either not diagnosable in the strict sense or did not need diagnosis
beyond the symptomatic level as they would get better within
a reasonable time, long before the availability of the results of a full-
scale investigation. Precise diagnosis, moreover, was not an end in
itself as it did not necessarily influence the care provided (Crombie,
1963). A pathologist perhaps ‘might insist on a more clear-cut
definition’, but for a GP the illness label was only a stepping stone
towards better management of clinical problems, noted the
Research Committee of the College of General Practitioners (1958:
119). Indeed, pursuit of a more precise diagnosis carried the ‘real
risk that inappropriate action is taken on the patient’s behalf’
(Robertson, 1970: 312).
The results of the 1955e56 Morbidity Survey made general
practice instantly recognisable to hospital medicine as the data
803
were presented in a language of anatomical site and pathological
process, a list of diagnoses grouped under the 17 main headings of
the ICD e from ‘Infectious and parasitic diseases’ to ‘Accidents,
poisonings and violence’. For GPs, however, this list of pathologies
was a poor reflection of the immediacy and experiential nature of
illness presenting in general practice. To be sure, the Morbidity
Survey ensured there was a new category to accommodate
consultations other than for sickness or injury but the very act of
placing general practice on a pathological map was at once an
indictment of the clinical prowess of GPs as such a large proportion
of their diagnoses were not clearly classifiable. And for a few years
in the 1950s and 1960s a debate raged about the ‘trivia’ that was
dominating general practice workload (Cartwright, 1967).
When a second national Morbidity Survey was under consid-
eration, it was apparent that general practice required its own
diagnostic framework more suited to its own needs ‘rather than to
the clinical pathological department of the hospital’ (Editorial,
1969). A new classification was therefore devised by the College
of General Practitioners which added to the ICD rubrics ‘certain less
precise categories to cater for the less precisely defined or symp-
tomatic diagnoses that were to be made in general practice’
(Editorial, 1969: 3), in particular allowing symptoms and symptom-
complexes such as cough to appear in several categories. And for
each ICD Section there was an ‘other’ category divided into ‘other
known disease not otherwise specified in the section’ and ‘other
symptoms, signs or incompletely diagnosed diseases within the
appropriate section’ (Research Committee of the College of General
Practitioners, 1963: 205).
Yet even this new College Classification, used in an amended
form in a Second Morbidity Survey in 1971 and subsequently
internationally, seemed bedevilled by inconsistencies and defi-
ciencies in its use. Some sections were too long, for instance, and
some categories were not used enough to justify their continued
inclusion (Editorial, 1976). Indeed, any system based too closely on
the ICD was seen as ‘ponderous and difficult to use’ (Hull, 1971: 13)
and ‘unwieldy and impractical for diagnoses made in practice’
(Editorial, 1969: 2). ‘Real patients present the doctor with symp-
toms and problems, but only comparatively rarely will it be possible
to attach the label of a definite disease to the complaint’
(Reichenfeld, 1971: 593).
Symptoms in the ICD
The main problem in adapting the ICD for use in general practice
was how to classify symptoms. Successive adaptations of the ICD
for use in general practice had to establish rubrics for symptoms;
yet these sat uncomfortably with the other pathology-based diag-
noses in the ICD. For example, a cough in general practice might be
classified under ‘respiratory symptoms’ yet the ICD demanded its
location under the pathological cause of the cough: pneumonia,
perhaps, or bronchitis or asthma. Classifications, however, reflect
a medical ‘reality’ and that reality was changing on both sides of the
hospital wall for while general practice was struggling to engage
with a pathological system, hospital medicine, through successive
revisions of the ICD, was itself tentatively beginning to address the
problem of symptoms.
Since its inception the ICD had been based on classifying
pathology though this had never been straightforward: the classi-
fication had followed a ‘necessary compromise between aetiology,
anatomical site, age and circumstances of onset’ (WHO 1948: xiii).
Following only minor changes in the 7th Revision, the general
philosophy of the 8th Revision had been concerned with trying to
assert the underlying pathological principle by ‘classifying diseases
according to their aetiology rather than their particular manifes-
tation’ (WHO 1967: xiii), that is by removing elements of the
804 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
outward appearance of disease and concentrate solely on its
pathological cause. This drive towards a more pure pathological
system, however, did not suit those countries which were strug-
gling to adapt ICD-8 to capture hospital medical records and to
evaluate medical care by, for example, assigning conditions to the
Chapters concerned with the part of the body affected rather than
to those dealing with the underlying generalised disease. The
fracture point in the ICD was Chapter/Section XVI.
All classification systems need a residual category to cover all
those instances which do not fit the main rubrics. For the 6th
Revision of 1948 this residual category was Section XVI: ‘Symp-
toms, senility and ill-defined conditions’ reflecting the undiffer-
entiated nature of symptoms under a system of pathological
medicine. Two decades later, however, in the 8th Revision, Section
XVI was no longer a dumping ground for illnesses not fitting the
main classification but rather reflected ‘the continuing need for
a special section of the ICD for the classification of symptoms which
do not point definitely to a given diagnosis and therefore cannot be
assigned to category in the disease section of the code’ (WHO 1967:
xxii). At the same time the title of the Section was slightly amended
to ‘Symptoms and ill-defined conditions’. In effect, despite its claim
to be intent on focussing even more on pathology, ICD-8 made
a small gesture towards classifying symptoms and the clinical
manifestation of illness (though it was still not possible to classify
23% of health problems arising in general practice using the new
ICD (Westbury & Tarrant, 1969).
ICD-9 addressed these challenges in a number of ways. First, the
former ‘residual’ classification, Chapter XVI, was brought into the
overall framework with a new label ‘Symptoms, signs and ill-
defined conditions including non-specific abnormal findings’. This
included the ‘anomalous’ yet common problem of abnormal
investigation results which seemingly indicated a pathological
process but without any identifiable underlying pathology. Second,
a new supplementary Section (XVIII) of factors influencing health
status and contact with health services was introduced. And finally,
a dual classification which tried to capture both the aetiology and
the important manifestations of disease was permitted: this would
involve the traditional ‘aetiological’ code being marked with a sign
to indicate its primary status and a new code added to reflect the
manifestation of disease which could be signified by an asterisk.
This increasing attention to the importance of symptoms in the ICD
was parallelled by a revised illness classification for general
practice.
Symptoms, problems and illness
When the World Organisation of National Colleges and Acade-
mies of General and Family Practice (WONCA) produced its Inter-
national Classification of Health Problems in Primary Care (ICHPPC)
in 1974 for world use in general practice it attempted to replace the
pathological lesion as the classification principle with the notion of
the ‘health problem’ whilst maintaining some compatibility with
the ICD. The ICHPPC was divided into 18 Sections which corre-
sponded with those of ICD-8 but the 371 diagnostic titles which
sub-divided those sections were more closely aligned to general
practice. Thus the number of diagnostic titles in each Section varied
from one in Section XV ‘Certain causes of perinatal morbidity and
mortality’ to 35 in Section XVI ‘Physical signs, symptoms, and ill-
defined conditions’ reflecting the fact that diagnostic titles were
selected for importance, frequency of occurrence and ability for the
diagnosis to be made in the primary care setting. The ICHPPC was
therefore ‘not merely a shortlist of the ICD’: the realities of primary
care were reflected in its construction both in the diagnostic titles
and in the addition of a section on social problems (not present in
the ICD) to Section XVIII ‘Supplementary classifications’ (Froom,
1976: 452). The new classification also tackled the problem of
‘approximate diagnosis’ e that tentative label which usually held
good while the patient’s problem often resolved e by introducing
code numbers for some symptoms and signs, such as cough,
earache and oedema.
A second version of the ICHPPC, published in 1979, further sub-
divided Chapter XVI: ‘Symptoms signs and ill-defined conditions’
by body part and system; there was a new category for general
signs and symptoms as well as one for investigations with unex-
plained abnormal results; and there was a residual category for all
other signs or symptoms and ill-defined conditions. In addition,
there was a supplementary classification to capture the world of
general practice which had always escaped the ICD, namely,
preventive medicine, family planning, administrative procedures,
maternal and child health, social, marital and family problems and
maladjustment. And finally there was a supplementary classifica-
tion of factors influencing health status and contact with health
services (WONCA, 1979).
The main justification for ICHPPC-2 was the need to respond to
changes introduced into the 9th Revision of the ICD which, as
noted, had itself started to move towards capturing a wider group
of health problems. Both ICHPPC and ICD-9 continued a slow shift
from classifying disease (the pathology diagnosed by the doctor)
towards illness (the sickness experienced and reported by the
patient): ‘Much illness in general practice is transient in nature and
is impossible to validate in terms of the ICD because by its very
nature it is based on the classification of disease’ (Keele, 1973). A
few years later this distinction between disease and illness was
formalised within the social sciences (Eisenberg, 1976, 1977) and
rapidly transferred into general/internal medicine (Barondess,
1979; Kleinman, Eisenberg, & Good, 1978), psychiatry (Kleinman,
1978) and back into general practice (Helman, 1981) as the
medical gaze began to shift from diseases and anatomical bodies to
illnesses and patients. To capture these different ‘readings’ of
sickness the ICHPPC, following the asterisked system of ICD-9,
allowed a dual or bi-axial classification in which the ‘problem’
was classified twice according to alternative principles. One was the
underlying pathology; the other was the symptom or complaint
reported by the patient. Prior to ICD-9, classification had been
hierarchical, one level being subsumed by the next one up so that
thousands of individual diseases could ultimately be reduced to
little over a dozen broad categories. The idea of an axial system,
however, was to introduce a property space with two or more
dimensions in which illness and disease could be plotted (a prin-
ciple also used in DSM-III, published in 1980).
The new emphasis on the medical problem being an illness
signified by symptoms rather than a disease underpinned by
pathology resonated with symptom classifications two centuries
earlier. This shift, however, did not mark a return to the dissection
of symptom types: the conceptual space on which medicine now
began to focus was much wider than the detail of the patient’s
symptom report. To be sure the need to classify multiple symptoms
was part of the new agenda (Krogh-Jensen, 1977), but the dimen-
sions of such a classification also needed to accommodate the
stages in response to illness, the precipitating factors in the deci-
sion to consult, and conditioning factors in the response to illness
(Wright, 1978).
The International Classification of Primary Care (ICPC)
The idea of studying, measuring and classifying symptoms in
their own right had emerged in the early 1970s (Morrell, Gage and
Robinson, 1971). The National Ambulatory Medical Care Survey in
the United States developed a Reason for Visit Classification adap-
ted from existing symptom classifications and based around a body
 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
system similar to the ICD (Schneider, 1979). This symptom classi-
fication could claim to be more suited to primary care as it iden-
tified health problems at a more fundamental level: ‘Primary care is
initiated by a symptom, complaint or request. The result of an
ambulatory visit may or may not be a diagnosis. Perhaps the
symptom will abate before the diagnosis is reached, the patient
may not return, the request may involve preventive action, or the
problem may not indicate the presence of disease. On the other
hand, the reason for visit always exists, no matter what type of visit
or which ambulatory setting is used’ (Schneider, 1979: 77). A
second, re-titled, version, Rationale for Collecting Patient’s Reason
for Visit (RFVCS) expanded the reason for the visit even further in
recognition that sometimes primary care encounters were moti-
vated by non-illness related factors such as preventive care or for
administrative reasons. Thus, not only did the new classification try
and capture the patient’s report of illness in the form of the
symptom but also the patient’s purposefulness in choosing to
engage with healthcare. This patient was not a passive repository of
pathology as construed by much of the ICD but an active, wilful
player in the doctorepatient encounter.
At the 1978 WHO conference on primary healthcare held in
Alma Ata in the USSR (at which the strategy of Health for All by
2000 was conceived) a working party was set up to develop
a classification which would try and capture the reasons why
people sought care at the primary level. The working party devel-
oped a Reason for Encounter Classification (RFEC), itself based on
the Reason for Visit Classification. In parallel, WONCA had been
developing an International Classification of Processes in Primary
Care (IC-process-PC) to capture the ‘activities’ of the GP and in 1987
a number of these classification frameworks e the older ICHPPC-2
and the two new REFC and IC-process-PC e were brought together
as the International Classification of Primary Care (ICPC).
ICPC was a new spatial ordering of health problems. It contained
three organising principles within a single nomenclature: classifi-
cations of the patient’s reason for the encounter, of diagnostic
labels and of primary care interventions. The Reason for Encounter
Classification (RFEC) extended earlier insights that there were
several organising principles around a patient’s decision to consult
with a doctor quite apart from the reporting of symptoms/illness.
These included who initiated the visit (as very often it was the
doctor who invited the patient to attend), whether the visit was for
illness or for other reasons, whether it was an emergency or a non-
emergency, what procedure was involved and who made the
request for the procedure to be carried out. The core of the Reason
for Encounter Classification (RFEC) was an agreed statement of the
reasons why a patient entered the healthcare system, representing
the demand for care by that person. They could be symptoms or
complaints (headache or fear of cancer), known diseases (flu, dia-
betes), requests for preventable diagnostic services (a blood pres-
sure check or an ECG), a request of treatment (repeat prescription),
to get a test results, or administrative (a medical certificate). Many
symptoms and psychosocial problems not available in ICD-9 and
ICHPPC-2 were included as it was recognised that patients
formulated health problems as symptoms and complaints. A small
pilot study looking at the distribution of 7503 problems found that
symptoms and complaints accounted for 57.5% of all reasons pre-
sented (Lamberts, Meads, & Wood, 1984).
The ICPC carried resonances of the ICD and the older patho-
logical classification but whereas the ICD had tried to move away
from anatomical site towards underlying pathological processes
and aetiology, the ICPC used body system in a lay sense reflecting
where patient’s localised their symptoms; consequently there were
no Chapters on infectious diseases, neoplasms, injuries, and
congenital anomalies like those in ICD-9 but Chapters on ‘General
complaints and diseases’, ‘Psychological problems’ and ‘Social
805
problems’ (the latter two being axial in the sense that patients
could be classified both under a body system but also with
a psychological and/or social problem) which reflected the emer-
gent objects of the new clinical gaze. The multi-dimensionality of
the ICPC was further enhanced by seven orthogonal Components
including both illness/disease labels and the reason for the visit
which in turn allowed the GP to make a pathological or symp-
tomatic diagnosis independent of what the patient reported as the
reason for the consultation.
In 1998 WONCA produced a revised version of the International
Classification of Primary Care (ICPC-2) which again enabled
healthcare providers to capture the three important elements of
the healthcare encounter: reasons for encounter in the patient’s
view, assessment (diagnoses or problems) labelled from a health-
care providers’ perspective, and process of care (decision, action, or
plans). The new ICPC-2 was mapped to ICD-10 so that conversion
systems could be used but otherwise the basic structure was
unchanged.
The idea that patient’s own statements e of symptoms, illnesses,
complaints, etc e should be taken as the basis for medical classi-
fication was a major shift from the pathological principle in which
the patient’s report required interpretation so that its true meaning
could be deciphered. For ICD the reason for the encounter was
hardly relevant for the identification of the underlying pathology in
the formal diagnosis. Doctors had been taught not always to ‘accept
patient statements at face value, but should, if they saw fit, try to
help them to understand better their “real, underlying” problem,
and guide them through the sometimes painful process of dealing
with the “question behind the question”, and not to easily provide
“symptomatic” treatment’ (Lamberts & Wood, 2002: 434). The
contrast with the old pathology principle could not be more stark;
as one doctor observed, reacting critically to this new focus on
patient concerns: ‘I find it personally objectionable to ask the
patient why he has come to see me, and then diagnose his problem
in the form of the symptom diagnosis. I have not spent most of my
adult life in medicine to be diminished in this way. I can diagnose
any symptom or complaint of my patients with a proper disease
label.’ (cited in Lamberts & Wood, 2002: 434). Yet the break from
the pathological principle was a liberating one for many GPs: ‘From
our perspective ‘patients’ statements of their reasons for encounter
should, in principle, be taken at face value and the availability of
a wide range of explicit physical and psychological symptoms and
complaints would allow patients to express . what bothered them
in a straightforward manner’ (Lamberts & Wood, 2002: 434).
While the ICD remained the bedrock of WHO’s classification
systems the late 20th century produced a ‘family’ of new frame-
works. ICD-10 was completed in 1992 and allowed more than
155,000 different codes and permitted tracking of many new
diagnoses and procedures, a significant expansion of the 17,000
codes available in ICD-9. The International Classification of
Function Disability and Health (which had itself evolved though
various incarnations) and the International Classification of
Health Interventions both broke new ground in recognising that
medicine was embedded in a healthcare system and that illnesses
had important social as well as biological consequences. And then
there was the ICPC, the core of which was a classification of
patients’ reasons.
Causes and reasons
In 1925 the renowned GP-cardiologist James McKenzie designed
a classification for the morbidity he found in his practice. He
identified six categories of illness (described in McCormack, 1975).
These ranged from ailments ‘most widely understood’ such as an
inflamed eye caused by a foreign body like a grain of sand or the
806 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
colic (pain) caused by the passage of a stone, through diseases
which were recognised only by a single symptom, for example,
constipation, in which ‘the symptom gives no clue at present to the
underlying condition’, to symptoms which seemed to be ‘uncoor-
dinated’ like bilious attacks and neurasthenia.
The principles underlying McKenzie’s classification now seem
curious e the single symptom, uncoordinated symptoms, the
‘widely understood’. And yet these principles no doubt had
contemporary meaning and resonance which allowed medical
perception to apprehend a morbidity spectrum of illnesses unlike
earlier e and later e periods. Similarly, when humoural medicine of
the early 18th century classified imbalances of humours, or when
the medicine of Sydenham classified symptom types, or when the
ICD classified pathological causes of death, they each defined the
limits of what could and could not be seen. An excess of some
humour in the 18th century could not be diagnosed, even less
understood, a century or so later just as no anatomical textbook of
today will provide maps of acupuncture’s meridians. Classification
systems both structure and constrain the world they describe: they
act as the lens of perception, as the mediator of experience, as the
conceptual framework through which medical reality is stabilised
and maintained.
The pathological classification system which for over a century
dominated healthcare (as also marked by the ascendency of the
hospital) depended ironically on the ‘processing’ of raw illness
experience by a cadre of doctors outside the hospital so that
patients referred inside its walls were those who could be incor-
porated, or potentially incorporated, into its classification system.
During the early years of the 20th century general practice was
therefore involved in policing the boundaries of the hospital clas-
sification (as represented by the ICD) by ensuring that the raw and
unorganised experience of illness in the population was sifted to
identify those ‘cases’ which could be referred into the hospital, and
into its pathological space. The attempt to apply the grid of the ICD
to general practice patients, however, brought the pathological
framework into direct confrontation with the often implicit
nosologies which were peculiar to the field of undifferentiated
illness.
But how could any classification capture the heterogeneity of
clinical work conducted at the frontier of healthcare? As
Summerton (2000) noted, patients with no definable disease often
consulted a doctor, while much illness or established disease in
others remained unreported; treatment regarded by the doctor as
important was neglected by some patients, while others constantly
sought treatment for illnesses that were essentially self-limiting;
and some patients were reluctant to share responsibilities and
would not stop work when this was plainly desirable; others were
equally reluctant to return to work, were rehabilitated only with
the greatest difficulty, or remained invalids. Any new classification
would have to address symptoms e the primary report of illness e
but not by a return to the 18th century model of categorising
symptom types. The construct of the symptom iceberg (Hannay,
1979) had shown that medicine needed to address the additional
question of why symptoms were taken to the doctor. The answer to
this question, moreover, implied that the new clinical gaze could
extend to all patients and all symptoms irrespective of whether
they entered the formal healthcare system.
For pathological medicine symptoms had secondary importance.
The logic of hospital-based clinical judgement, based on the findings
of the post-mortem room and a reductionist biomedical research
paradigm, viewed symptoms as often vague and unreliable indicators
of potential disease (especially given their dependence on the vaga-
ries of patients’ self-report): with time the underlying disease would
reveal itself through doctor-identified signs and investigations
though many symptoms simply disappeared, seemingly extinguished
by the body’s defences before the illness could show its true nature.
The late 20th century construction of a classification for primary care,
however, placed symptoms in a different conceptual framework
based on the fact that they were formed from words spoken by the
patient e not the patient as interlocutor for the pathology but the
patient as reflective being. The apparent capriciousness of symptom
presentation e ‘trivial’ symptoms, symptoms not in the medical
textbook, undiagnosable symptoms, etc e could then be re-construed
not as products of unreliable reporting but rather of certain wilfulness
on the part of the reflective patient. Patients might or might not
present with pathology, diseases or illnesses but they always had
reasons (for consulting or not consulting). Diseases were governed by
causes; the primary care encounter was an engagement with reasons.
It was the classification and capture of these reasons in the
1970s which opened up a new space for the clinical gaze, no longer
confined to the interior of the body but expanded to capture the
cognitions and purposes of every patient (a task facilitated by the
apparent ubiquity of symptoms). General practice classification
systems both alerted medicine to this new object/subject but also
confirmed, constantly, its existence in the classificatory space
which had not existed a few decades earlier. This new medical
perception as formalised in the new medical nosology also found
expression in a new patient-centredness in clinical practice (Byrne
& Long, 1976; Levenstein, McCracken, McWhinney Stewart, &
Brown, 1986) and those ‘enlightened’ health strategies and poli-
cies which prioritised patients’ rights.
Yet while the new focus on reasons was justified as taking what
the patient said ‘at face value’ (Lamberts & Wood, 2002: 434),
general practice had in fact introduced its own interpretive
framework to fashion a different sense from the patient’s words.
To be sure, empirical evidence could be gathered to demonstrate
the congruence between what patients said and doctors heard
(Veitch, 1995; Britt et al., 1992) yet this did not change the
underlying logic of the classification system: it was the doctor who
interpreted the symptoms/reasons (or determined when ‘agree-
ment’ with the patient had been reached), reducing them to their
core essence, of which the patient might be unaware. For all the
contemporary rhetoric on patients’ new-found power vis-à-vis
medicine, it was essentially still the doctor who controlled the
diagnostic process.
Major changes in medical classification demonstrate that there
are no diseases waiting in nature to be discovered; there are no
diagnoses which capture an immutable illness state. Diseases and
diagnoses only become apparent through the contemporary classi-
fication systems. But these systems also, as in a mirror, show
something about who we really are. A system of medicine which
advanced the localised pathological lesion as the core of illness
brought in its wake perceptions and practices which emphasised
death and the anatomical body; the patient with a disease was
separated conceptually (and often geographically) from the patient
without. A system of medicine which attempts to classify symptoms
as units of patient experience, which tries to identify the chain of
reasoning which determined the patient’s appearance in the
consultation and which places illness and the individual in a multi-
dimensional classification space crystallises a very different identity.
Why did medical classification change? What explanatory
framework can account for the shift from causes and reasons in
clinical nosology? Alas, when classificatory systems and explana-
tory frameworks are in flux there is no Archimedean point from
which to see things as they really are: neither causes nor reasons
can have epistemological priority. Moreover, in that the classifica-
tion defines identity it is difficult to say the new classification was
‘chosen’ (as choice is a characteristic of a reasoning person) and
equally it cannot be the outcome of a struggle between individuals,
factions, interests or ideologies which are themselves expressions
 D. Armstrong / Social Science & Medicine 73 (2011) 801e807
of classification systems. Better then to see medical classification as
a fossil trace of an identity that is in part lost and an identity that is
in part gained.
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