Whiplash and other useful illnesses Andrew Malleson Montreal & Kingston: McGill-Queen's University Press; 2002 527 pp. $49.95 (cloth) ISBN 0-7735-2333-2
In this remarkable book Andrew Malleson argues that “useful illnesses” have had a long history, ranging from neurasthenia in the 18th century to the most pervasive such complaint in the present: whiplash. He divides his book into four parts. The first, “Finessing whiplash into a permanent disability,” makes the case that whiplash is not a physical problem that can be demonstrated accurately by any available technology. In countries and jurisdictions that do not offer compensation for whiplash, the most severe cases of discomfort and disability last no more than a few weeks and end in full recovery. Malleson provides evidence that there is little connection between the severity of the crash that leads to the injury and the severity of subsequent symptoms, making a persuasive argument that the coalescence of prominent medical specialists who label whiplash as a problem, lawyers who argue the severity of disability from whiplash successfully in court, and patients in search of a somatic diagnosis for their problems have created a situation in which whiplash has become a phenomenon of massive proportions requiring billions of dollars in compensation payments. To support his hypothesis, Malleson has carefully constructed a portfolio of case histories and anecdotes from patients and observers as well as over 1000 references and supporting statements. The strength of the evidence on whiplash and the quality of relevant evidence-based reviews are also evaluated.
In the second section, “The quest for the mythical whiplash injury,” Malleson discusses other conditions that, despite a lack of evidence of any causal connection, have been associated with whiplash: these include posttraumatic stress disorder, temporomandibular joint problems, inner ear problems, minor head injury, fibromyalgia and ocular injury. He goes on to illustrate how legal arguments that these associations are real have been financially beneficial not only to lawyers but also to doctors, dentists, chiropractors and, to a lesser extent, “victims.”
In the third section of the book, “Fraud and the medical–legal quagmire,” Malleson discusses how the legitimation of whiplash as a serious problem requiring major compensation has been fuelled by the mediolegal system. A sample quotation is, “If doctors did as well at making patients better as lawyers do at making them worse, medicine would be a great profession.” There are also chapters on how the system is exploited by fraud (on the part of patients and physicians), malingering and hysteria.
The final section, “Treating the treatment,” highlights the need for the medicolegal system to take responsibility for this situation. Malleson suggests that physicians and lawyers promote disability to build up the need for their services. A number of tables illustrate the marked regional variation in rates of claim for whiplash, variations that correspond with availability of compensation in different jurisdictions. This is quite notable in Canada, where no-fault provincial compensation plans in Quebec and Saskatchewan have greatly reduced the number of claims and amount of compensation.
Malleson challenges many different groups involved in the industry of “useful illness” for their self-interest and their failure to critically assess the medical case for whiplash. These groups are likely to attempt to discredit this book, but the extraordinary amount of research and evidence gathered by the author may make it difficult for them to do so.
This exceptionally well-referenced book is written in a pleasingly readable style that makes frequent use of tongue-in-cheek wit. It offers a sobering view of how self-interest and poor science can spawn a huge industry:
We physicians have taken an entity that existed for centuries, given it a new name, created a major health issue by elevating its importance, researched it and now suggest that it needs disability payments. We have created a monster and it is up to us to make amends.
This is a book that challenges the reader with many gems of information that are unsettling as well as enlightening. The scholarly approach that Malleson takes to such a nebulous problem will hopefully bring common sense and reason to this “monster” that we have all contributed to supporting. As whiplash fades as a “useful illness” over the next few years, what will the next “useful illness” be? Will our profession help to create it? The greatest contribution of this book may be to sensitize us to the concept of a “useful illness,” thus providing an ounce of prevention to obviate the need for a pound of cure in the future.
Walter W. Rosser Professor and Chair Department of Family Medicine Queen's University Kingston, Ont.
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Photo by: Fred Sebastian