Sm. Sci. Med. Vol. 18, No. 9, pp. 737-744. 1984 0277-9536184 $3.00 + 0.

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Printed in Great Britain Pergamon Press Ltd

THE PATIENTS VIEW

DAVID ARMSTRONG
Unit of Sociology, Guys Hospital Medical School, London SEl, England

Abstract-Deference to the importance of the patients view has recently become a major feature of much
medical practice and social science research. This paper, however, argues that attempts to establish the
authentic version of what the patient says is misplaced as investigation can only reveal what is heard, not
what is said. The changes in perception which enable some things to be heard, and not others, are traced
through medicine and the social sciences during the last 50 years and it is suggested that recent interesl
in the validity of the patients view are no more than artefacts of these changes in perception.

In 1935, in the 10th edition of his teaching manual
Clinical Methods, Sir Robert Hutchison provided
details of how to go about case-taking [l]. The
taking of any case, he pointed out, consists of two
parts: I. The interrogation of the patient. II. The
physical examination. He further subdivided the
former into the general and the special interrogation,
prefaced with some advice on the purpose and tech-
niques of interrogation.
The purpose of the interrogation was to elicit
information regarding (the patients) present illness
and the state of his previous health and that of his
family. Although the interrogation was directed by
the doctor, the patient was to be allowed as far as
possible, to tell his story in his own words. Leading
questions, which might force an opinion on the
patient, were strictly forbidden as was asking the
same question twice (which only made the doctor
look foolish).
The general interrogation itself involved establish-
ing the patients name, age, occupation, whether
single or married and exact postal address before the
two crucial questions, Of what does he complain?
and How long have the symptoms been present?
were asked. The answers to these were supplemented
by a family history on the state of health and cause
of death of family members, a personal history-
what together may be grouped together as the
patients environment or surroundings or habits-
and the patients previous history, which was to be
enquired after indirectly except for syphilis.
It is, of course, quite possible that by 1935 this
particular approach to case-taking had become
quite dated but, in as much as the preceding editions
of the book (first published in 1897) covered similar
ground. it is probably fair to say that these techniques
elicited what might be described as a patients view in
the earlier decades of this century. In countless
meetings between doctors and patients up and down
the country. patients were constantly invited
report on their complaint, its longevity and
immediate context.
This paper is based on a contribution to a seminar series at
the Wellcome Institute for the History of Medicine,
London. on The patients view: lay attitudes to medi-
cine. disease and doctors.
Some 40 years later, in 1975, the 16th edition of
Hutchisons Clinical Methods was published under
new editors [2]. Case-taking was not mentioned,
except in the chapter title, and in its place the student
was advised on how to take a history. At the same
time it was never suggested that history-taking was
other than a constant feature of clinical practice.
History-taking is still and art, it was explained, and
it was a special form of the art of communication. it
is necessarily a two-way business. Indeed itwas even
suggested that history-taking might be improved
by active participation in sensitivity groups as
pioneered by, (the GP-psychoanalyst), Balint.
In 1975, as in 1935, the patient was invited to speak
while the doctor listened; but it is clear that between
these two dates the form of the invitation had
changed. Did the reformulated exhortation to speak
have an effect on the words that were spoken? Did the
newer methods more accurately establish the pa-
tients view? Such questions are undoubtedly im-
portant for a concerned social science or an enlight-
ened medical practice but they are misplaced. What
changed between 1935 and 1975 was not simply the
form of the incitement to speech but the very struc-
ture of perception: it was not what the patient said
but what the doctor heard which established the
reality (and accuracy) of the patients view.
THE CLINICAL GAZE
In his seminal work, The Birth of the Clinic, Michel
Foucault identifies a major shift in medical percep-
tion, or what he calls the medical gaze, as occurring
at the end of the 18th century [3]. In its old form
clinical reading implied an external, deciphering
subject, which . . . ordered and defined kinships.
This medical gaze had been directed upon the two-
dimensional areas of tissues and symptoms. In its new
form, however, the gaze had to map the three-
to dimensional volume of the human body because
its disease was seen to have a specific anatomical lo-
cation: Disease is no longer a bundle of characters
disseminated here and there over the surface of the
body . . . ; it is a set of forms and accidents . . . bound
together in a sequence according to a geography that
can be followed step by step. It is no longer a
pathological species inserting itself into the body . .
it is the body itself that has become ill [4].
737
738 DAVID ARMSTRONG
It was at this point that the now familiar tech-
niques of clinical examination were embedded into
medical practice. The clinician had to map the vol-
ume of the body by use of ear, touch and sight so as
to localise and identify the pathological lesion which
was inserted therein. Under the old medicine signs
and symptoms are and say the same thing . . . every
symptom was a potential sign and the sign was simply
a read symptom [5]. In the new perception sign and
symptom were separated: the symptom might well
remain silent, the truth of the disease was contained
only in what the doctor found, in the form of the sign.
Symptoms, what the patient said, could provide a
guide or a hint or a suspicion of which organ or
system might be involved but were only preliminaries;
the core task of medicine became not the elucidation
of what the patient said but what the doctor saw in
the depths of the body.
The teaching manuals which were published early
in the 20th century reflected the dominance of signs
in medical diagnosis. Stevens Medical Diagnosis of
1910 offered 3 pages out of 1500 to the interrogation
of the patient [6]. Cabots Physical Diagnosis, from
its first edition in 1905 until its 12th in 1938, ignored
even a token statement on interrogating the patient,
concentrating entirely on the physical examination
[7]. Emersons Physical Diagnosis of 1928 could only
manage a one page outline of advice on the lay-out
of the consultation room as a preliminary to the
details of the examination [8].
In the various texts which offered advice on inter-
rogating the patient the format was almost identical.
The patients age, sex, occupation, address and mar-
ital status were noted before asking about the main
complaint and its duration. This was followed by
questions on the patients previous medical history,
family medical history and the so-called personal
history which tended to be restricted to health
hazards of the occupation, past residence abroad and
habits such as consumption of tea, alcohol and
tobacco. It is clear that the patient-construed as a
whole person [9]-was virtually absent from the
advice on how to conduct clinical practice; indeed as
the body of the patient was seen as co-terminous with
the space of the illness [lo] it was impossible to
conceptualise the patient and lesion as separable. In
effect as the lesion could not communicate in words,
the patients identity in the interrogation was pro-
vided by the ability to speak for the otherwise silent
pathology. The lesion spoke through the patient,
though it only finally yielded its secret in the physical
examination.
To provoke the lesion to speech, through the
patient, was not an easy task. Indeed Keith, in his
Clinical Case-Taking of 1918, while offering a schema
for case-taking, pointed out that it was exceedingly
difficult to reduce the skill of interrogatory method to
print [ 1I]. Perhaps the commonest advice was that the
patient should be allowed to tell his story in his own
words when it came to identifying the main com-
plaint. Yet this did not signify the existence of a
patient identity or measuring system independent of
the lesion; the patients own words were only required
because they might express in purest form the com-
munication of the pathological lesion itself. Such was
the importance of these words that it was recom-
mended that they were written down verbatim:
notes, advised Gibson and Collier in 1927, should
be made during this recitation [12].
The patients own words, however, were not
necessarily free from background distortion; as
Horder and Gow observed this does not mean that
the observer is to set down words or phrases which
are meaningless or equivocal [13]. Indeed an addi-
tional question was justified if the patient tends to
stray into irrelevant matters [14]. If the patient was
the intermediary who stood between the disease and
the medical gaze then the doctor, of necessity, had to
look behind the words the patient spoke. Some
common words such as the patients ready-made
diagnosis were never to be taken at face value [15];
others were only thought to be accessible by being
dug up from the patients unconscious [16]; others
were to be postponed if the history is completely
disjointed or the patient be well set for a three hour
monologue [ 171.
The patient as an idiosyncratic person was not
entirely absent from this dialogue between doctor and
disease. The doctor could recognise in patients
different abilities to enunciate the lesions truth: as
Boume noted in 1931 The human being is a record-
ing instrument of uncertain and variable power [IS].
Thus the doctor had to assess the competence of the
patient to speak for the pathology. As the patient
describes his complaint, Gibson and Collier ex-
plained, his mentality will become clearer, whether
he is intelligent or dull, accurate or given to exagger-
ation, if his memory is good, or if there is evidence
of mental aberration [19]. Noble Chamberlain sug-
gested that the interrogator should be alert to these
possibilities and formulate specific questions for each
patients intelligence [20] while Hutchison went so far
as to advocate leading questions for patients stupid
either by nature or as the result of symptoms [21].
The general proscription of leading questions in
these texts gives a further indication of the limited
identity accorded the patient. Hutchison only allowed
them for stupid patients, to trap malingerers and to
elicit subjective symptoms (the morbid sensations
experienced by a patient as the result of the disease
of some organ or system) when the doctor felt he
was engaging the pathology in dialogue [22]. In other
circumstances leading questions were dangerous be-
cause of the suggestibility of many patients [23]. If
they were used, Horder and Gow argued, then a
record of their use should be kept and the patients
reply appropriately qualified [24]. In effect patients
had no independent views or autonomy, they spoke
on behalf of the pathology and, without precautions,
simply reflected back the leading question.
At the beginning of this century the patients view
was, in essence, the unformed words of the disease.
The interrogation was concerned with the character-
istics and life history of the symptom. . . . To get a
clear picture- of the symptom so that it stands out as
if it had a personality is the ideal to be sought for
[25]. Beyond the disease, the patient only had exist-
ence as a good, bad or indifferent historian.
AN INCHOATE PATIENT
In the 12th edition of his Physical Diagnosis,
 The patients
published in 1938, Cabot made two additions: he
introduced a new first chapter on history-taking (a
subject too often omitted from books on diagnosis*)
where before there had been none, and his chapter on
the examination of the diseases of the nervous system
for the first time included a two page discussion of the
neuroses and the psychoses [26]. Similarly the 8th
edition of Elmer and Roses Physical Diagnosis (re-
vised by Walker) of 1940 added a chapter on history
taking and a few pages on psychiatric examination
despite their total lack in the 1938 edition [27].
There had been a hint in Boumes An Introduction
to Medical History and Case-Taking of 1931 that the
history was beginning to change its alignment in the
cognitive map of medicine [28]. He noted, for exam-
ple, that history-taking receives scant attention in
other detailed books on physical examination. In
addition, he offered a discussion of the relative
importance of history and physical examination and
concluded that their importance in diagnosis or prog-
nosis varied greatly with different diseases. Although
his advice on history-taking followed familiar lines
his attempt to compare history and examination
represented a fundamental challenge to the old cog-
nitive ordering of medicine. This challenge was fur-
thered in Noble Chamberlains text of 1938 which
offered the observation that structural changes may
exist without functional derangement and vice-
versa. In other words the lesion might be unmarked
by the sign so that the patients words were not
merely preliminaries but a primary access route to the
lesion-hence his statement on the importance of
history-taking [29].
This new analysis of disease and its indicators was
characterised by a reassessment both of the patients
view and of the importance of psychiatric illness,. In
1940, Elmer and Rose had extended their list of
patient questions by elaborating on the old personal
history [30]. In the new schema, personal history-
which had been more concerned with the patients
physical environment and habits-was replaced by a
marital history (domestic relationship, whether
happy or unhappy, compatible or incompatible and
the reasons for unpleasant relations, if they exist),
an occupational history and a social history, which
enquired after such personal experiences as worries,
adjustments and disappointments.
While Noble Chamberlain did not significantly
alter his history-taking plan until the 6th edition of
his book in 1957 when The home life was introduced
(Is the patient happy and contented or are there
sources of friction or worry?), the 1938 edition did
suggest a new goal for the history [31]. Whereas
Horder and Gow in 1928 had in the main ..
followed the well-proven principle of endeavouring to
determine first the site of a lesion and then its
probable nature [32], some 10 years later Noble
Chamberlain was suggesting that at the end of the
history the physician should have a mental picture
not only of the patients presenting symptoms, but of
the manner in which these developed and of the type
of background of personal and family life upon which
they have been grafted. Too often we are rightly
accused of studying the disease rather than the
patient.
In similar fashion, the 12th edition of Hutchisons
view 739
Clinical Methods of 1949 extended the interrogation
of the patient [33]. In this case the patients personal
history was replaced by a social history which
includes the patients mental attitudes to his life and
work.. . . One should endeavour to visualise the life
of ones patient, sharing his emotions and viewing
step by step his daily habits. . . . Sometimes one
should inquire into a patients business affairs, his
ambitions, anxieties, quarrels . , . his domestic re-
lationships, his psychological make-up, his interests,
his hobbies, his hopes, his fears. . ..
The second element in the reconstruction of the
patients view was the changes which were occurring
within the field of psychological medicine. During the
1920s and 1930s the medical gaze had been focusing
on the mind of everyone [34]. In the 19th century
when rationality had seemed all-important psychiatry
was concerned with those patients, few in number,
who were insane. During the 20th century the central
problem of mental functioning had become coping
and medicine had discovered the generalised preva-
lence of the neuroses-particularly anxiety and de-
pression. By the 1930s many doctors were well aware
of the ubiquity of the neuroses and the need for
a general mental hygiene. In consequence patient
anxieties and personalities together with notions of
psycho-somatic unity began to become important
features of much clinical practice. These concerns
made themselves felt in the gradual inclusion in
manuals on clinical methods of sections on
psychiatric examination. Noble Chamberlain, for ex-
ample, first included a section on the diagnosis of the
neuroses in his chapter on the examination of the
nervous system in 1938 though it was somewhat
rudimentary [35]. He outlined the symptoms of the
neuroses (hypochondria, neurasthenia, anxiety neu-
roses, compulsion neuroses and hysteria) but devoted
most attention to the appropriate physical signs: in
hysterics, he noted, the ear lobes were ill-formed and
were fused to the skin near the mastoid process
instead of hanging freely.
By about 1950 the old medical gaze seemed to be
in a state of transition [36]. An important component
of disease still existed within the human body and
this, as of old, demanded interrogation through the
patient. But there was now a second strand to
medical perception which identified a part of illness
as existing in the shifting social spaces between
bodies, and clinical method required techniques to
map and monitor this space. The patients view was
no longer a vicarious gaze to the silent pathology
within the body but the precise technique by which
the new space of disease could be established: illness
was being transformed from what was visible to what
was heard.
The patients view was not, in this sense, a discov-
ery or the product of some humanistic enlightenment.
It was a technique demanded by medicine to illu-
minate the dark spaces of the mind and social
relationships. Whereas the pathological lesion could
be seen if it was given a neutral field, the illnesses of
social spaces required the incitement of a patients
view. At first the patients view was a fragile flower
which had to be gently cultivated: as Hutchison noted
in his 1949 edition one may defeat ones own ends
by wounding the sentiments or conscience of the
740 DAVID ARMSTRONG
patient long before the physical examination starts
[37]. Later it was to move to the centre of the medical
gaze.
PATIENT SURVEYS
In 1954 Earl Koos published a book entitled The
Health of Regionsville: What the People Thought and
Did About It which was hailed as the first systematic
explanation of what people think and why they
behave as they do in regards to health [38]. Koos
and his colleagues interviewed more than 500 families
over a 4 year period in an American town which they
gave the name Regionsville. Respondents received
some 16 interviews, each one with a different focus.
For their views on illness patients were provided with
a checklist of 17 readily recognisable symtoms and
asked which they thought should be brought to the
attention of the doctor. Those who reported no
disabling illness in the previous 12 months were also
asked whether they had experiencti any of the
symptoms from the list. In addition respondents were
provided with a series of questions on some suggested
disadvantages of a national health insurance pro-
gramme (such as People would take advantage of the
doctors time or Medical care would be impersonal) the social, made its appearance.
and asked whether they disagreed or not.
Most of the Regionsville interviews were concerned
with use of services and the sub-title of the book
what the people thought and did about it perhaps
overstates the extent to which peoples thoughts were
elicited. Nevertheless the analysis of what the people
thought marked the beginning of an increasing inter-
est in the patients view by medical sociology during
the ensuing decades which almost exactly paralleled
the growth of the requirement for an extended
history in medicine. Whether medicine or the human
sciences had priority in this new discovery of the
patients view is unimportant. The fact that in-
vestigation of the patients view was conducted in
parallel by two or more distinct disciplines simply
shows the irrelevance of traditional disciplinary
boundaries for structures of perception. After the
War the medical gaze was no longer an analytic
framework employed almost exclusively by medicine
but embraced a series of disciplines, many new,
which, by way of comprehensive health care delivery,
the health care team and socio-medical research
sought to analyse a new configuration of disease and
illness with a variety of refined techniques.
Under the old structure of perception illness had
been located to a specific point inside the body of an
individual patient; in the new regime illness became
distributed in the gap between bodies, in the inter-
stices of the social, in the space which was to become
known as the community. The extended medical gaze
therefore required the mapping of this social space
just as a century and more earlier the medical gaze
had mapped the threedimensional depths of the
human body by the techniques of physical exam-
ination so as to locate the pathological lesion.
There had been rudimentary attempts in the inter-
war years to map morbidity in the community, such
as the Pioneer Health Centre at Peckham, but it was
not until the war-time Social Survey, which involved
asking a random population sample about prevalence
of symptoms, that more refined techniques were
developed [39]. In the immediate post-war years,
surveys within a range of medical specialties-
paediatrics, general practice, psychiatry, geriatrics,
social medicine-become relatively commonplace.
Surveys such as those by Koos in 1954, Wadsworth
et al. in 1971, Dunnell and Cartwright in 1972, Banks
et al. in 1975 and Hannay in 1979 represent some of
the social scientists contributions to the mapping of
symptom prevalence and the patients view in the
community [40].
A concomitant of the spread of morbidity surveys
in the post-war years was the redefinition of the
patient. Under the old regime the patient was no
more and no less than the body which enclosed the
lesion. The surveys on the other hand embraced
everyone, and found that almost all experienced
physical symptoms or that most were mentally ill.
The concept of the clinical iceberg which described
those under health care as only the tip of an enor-
mous mass of morbidity in the community was first
advanced in 1963 and was confirmed and reconfirmed
in subsequent studies [41]. The conceptual and meth-
odological correlation between the patients views
and the lesion began to fragment as a new referrent,
SOCIAL FRAMEWORKS
The survey destroyed the old distinction between ill
and healthy bodies by generating a new form of
patienthood, namely the person at risk (as well as a
commensurate discourse on medicalisation which at-
tempted a critical analysis of this process [42]). But if
the survey could not measure the diseased body
through identification of the lesion then it required
other concepts of health and illness. Koos in his
survey of 1954,had made an initial attempt to obtain
a measure of illness through the use of the social body
as a referrent. Other attempts followed. In 1960
Mechanic and Volkart studied the propensity to visit
the doctor by providing 614 college students with a
checklist of symptoms and asking them whether-they
would take them to the university health service
(certainly, probably, not very likely or very likely) if
they had them [43]. In the same year Apples descrip-
tion of how laymen define illness involved giving 60
respondents eight descriptions of people with health
problems and asking Are these people sick?, What
might the illness be? and What should be done
about it? By varying the degree of ambiguity and
time of onset of the problem Apple was able to show
the significance of various aspects of an illness for
promoting patient action [44]. Similarly in 1961 Bau-
mann invited 201 patients (and 262 medical students,
acting as controls) to answer the question What do
you think most people mean when they say they are
in very good physical condition? The replies were
subjected to content analysis to establish th.ree
elements: general feeling of well-being, absence of
general or specific symptoms of illness and what a fit
person would be able to do [45].
While at one level these studies attempted to obtain
a new definition of health through patient views, in
terms of the new configuration of illness it had
already been decided. Illness was constituted by those
 The patients view
experiences judged serious enough to warrant seeking
formal medical advice. Illness was not defined by a
lesion so much as by a certain behaviour pattern.
A further element in the new regime were the
analytic frameworks which were deployed to inter-
rogate illness. In his study, Koos established a check-
list to determine differences between respondents:
some people said they would report a loss of appetite
or persistent headaches to the doctor while others
would not. Yet although individual responses were
noted-to the extent of providing some case-histories
in the text-the analytic frame used to make sense of
the data was social class. Supposed individual
differences were not individual but had a meaning
only within a particular social context which pre-
sumably informed them. In effect, Koos did not hear
individual respondents in his interviews-no more
than the old doctor saw different pathologies in a
dozen patients with gastric ulcer. Social class was
accessed through the patients view and conversely
the patients view was a product of social class.
Whereas before, illness had been located in the solid
threedimensional space of the human body, in the
post-war years it began to be realigned in a multi-
dimensional conceptual space whose axes were the
psycho-social determinants of attitudes, beliefs and
behaviour and which could only be monitored by
constant elicitation of the patients view.
If disease was increasingly located within a social
space it was matched by the growth of psycho-social
models of causation. Social class became seen as a
major determinant of ill-health and of patient behav-
iour. Stress, despite the paucity of empirical support,
became the great hope of a socio-medical gaze (as did
its antidote of social support) from the 1950s on-
wards [46]. And not only did psycho-social factors
play a direct aetiological role but via a discourse on
labeiling and stigma from the early 1960s the illness
state was held to arise at times without any physical
mediation [47].
Under the old regime treatment success was evalu-
ated by the disappearance of signs. In the new, the
patients attitudes were important. In 1947, for exam-
ple, Dukes carried out the first survey of patients with
permanent colostomy to see how they coped [48]. His
object was to examine patient response in the light of
the operative technique as otherwise, he noted, there
was no other means of establishing which was the
best technique. Some 5 years later however two
papers had appeared which, though conducting
similar surveys, had different objectives [49]. As
Sutherland noted: In the recent past, interest has
extended from the colostomy to the problem of living
created by it and the methods by which the patient
solves those problems [SO]. In effect the patients
view, from being a measure of effectiveness, was
moving to be a problem in its own right.
In similar fashion some of the earlier sociology
surveys were concerned with patient satisfaction as
measures of medical effectiveness. Freidson, in 1961,
in his Patients Views of Medical Practice contended
that performance of staff could not be understood
very clearly without reference to the expectations of
patients [51] while Cartwright in her large survey of
patient attitudes to hospital care of 1964 observed
that the successful application of medical knowledge
741
depends on what patients think and feel about
doctors, nurses and hospitals [52].
The reconstruction of patients views, from being
a measure of medical effectiveness, to become the
location of a major problem in its own right-
through the notions of coping and adjust-
merit-began to take effect from the late 196Os,
though its beginnings can be identified in the exten-
sion of psychological medicine in the immediate
post-war years. The open door policy of the 1950s
marked the symbolic end of the segregation of the
insane and their final eclipse by the more generalised
problem of the neuroses. Large American community
studies of psychiatric morbidity such as the Midtown
Manhattan and Sterling County studies identified
upwards of 60% of the population as being mentally
ill-with the remainder having many transient psy-
chological disturbances [53]. Further research found
that between 30 and 90% of so-called organic com-
plaints had a psychiatric component [54].
Psychiatric examination, as has been noted above,
gradually found its way into the clinical method texts.
At first it was simply an extension of the neurological
examination to embrace a perfunctory psychiatric
overview as in Noble Chamberlains inter-war treat-
ment [55]. By the 5th edition of his text in 1952 he
offered a more sophisticated analysis: Something
more is required to establish this diagnosis (of the
neuroses). It is necessary to assess the patients per-
sonality, a task which comes more easily with age.
By 1967 the formal schema for conducting history
taking and clinical examination-for all patients-
included a section of taking the psychiatric history
and, in 1974, the introductory chapter titled The
foundations of our art, which provided a potted
history of the diagnostic process, was amended with
a new paragraph on Freud and Jung.
A NEW MAP
In the 7th edition of his teaching manual published
in 1961 Noble Chamberlain added a new section and
diagram in an attempt to show the complex re-
lationship between signs and symptoms. For some
diseases in different stages of their development
he acknowledged that symptoms could be more
important than signs. This reassessment of the
significance of symptoms had been growing since the
war. In the foreword for Sewards Be&de Diagnosis
of 1949 Cohen poured derision on the student who
diagnosed by structural resemblances [56]. Instead,
Cohen claimed that disease was a disturbance of
function which may or may not be accomplished by
structural changes, the traditional mind-body di-
chotomy was largely artificial and both psycho-
somatic disturbance and somatopsychic dysfunction
were real phenomena.
Perhaps one of the most successful attempts at a
new integrated medicine was that of Balint in the
mid-1950s [57]. He reconstructed the field of medicine
by arguing that the traditional search for a localised
pathological lesion was only a part-and often a
small part-of clinical practice. The role of the
doctor, he suggested, was to organise unorganised
illness: the doctor had to reorganise the patients
problems, symptoms and worries so as to make sense
742 DAVID ARMSTRONG
of them. This might require symptoms being linked
with pathological lesions in the classical triangulation
method but it also required the construction of a
dense web of interconnections between feelings,
symptoms and social context such that the lesion was
reduced to a single nodal point within a network of
more abstract relationships.
This reconstruction had various implications for
the patients view. First, it established a series of
different needs which required expression. Thus for
example, in her study of patients and their GPs
published in 1967 Cartwright could think of the
effectiveness of general practice in terms of meeting
patients clinical, social and emotional needs [58].
Second, the patients view was not only a part of the
diagnostic process but also part of the therapeutic. At
the very least, patient talk helped adjustment through
the organisation of problems while, as a form of
psychotherapy, it acted as a more formal treatment
regime.
In this new theoretical context the patients view in
the consultation underwent further changes. In the
inter-war years the patients view on anything, in-
cluding the possible diagnosis, not directly related to
the lesion was excluded; thirty years later it had
changed. Patience is necessary, suggested Noble
Chamberlain in 1967, when.the patient tries to make
his own diagnosis. This may be irritating but not
unreasonable as it stems from a natural desire to find
a cause for the illness which perhaps can be. avoided
in future. . . [59]. A decade later it was not simply
tolerance which was required as it was possible,
suggested Kleinman and his colleagues, that the
patients views-which were so coherent as to form
lay theories*ould be valuable diagnostic and ther-
apeutic tools [60]. A flurry of work in the early 1980s
on patients lay theories and of their importance for
a penetrating medical gaze, was further evidence of
the elevation of the patients view from an irrelevance
to a theory [61]. The patients view had been elicited
in the interrogation; in the post-war years a less
threatening term, history-taking, became more com-
mon while in many recent texts the even more secular
medical interview has been employed. Clinicians
are likely to consider the term medical interview as
synonymous with which is called history-taking
wrote Enelow and Swisher in 1972 1621.The medical
interview is much broader than that.
The medical gaze had engaged with a new problem:
the patients view itself. The patients words were
therefore more robust and the dangers of leading
questions were minimised; by and large they should
not be used but the student may observe an experi-
enced clinician will sometimes disregard this rule
[63]. Whereas before, the patients words which did
not signify the lesion were dismissed as irrelevant or
suspected of representing malingering, the new advice
was that it was important to realise that apparent
evasiveness on the part of the patient is almost never
deliberate [64]. The doctors first task was to listen
and to observe, not only to obtain information about
the current problem but also to understand the
patient as a person [65].
It rapidly became apparent however that the pa-
tients view was not constituted simply by the words
themselves as words were merely signifiers. The view
lay behind the words and further refinement of
technique was necessary to make it accessible. At
first, in the 1960s and 1970s it was through non-
verbal communication: the eyes sometimes convey
more information than words; the clenched fist
may demonstrate latent tension, and touch may be
equally important [66]. By the late 1970s the gaze
beyond that which was spoken, began to focus
with more intensity on the subjectivity behind the
words.
Pain had been the archetypal symptom, the direct
record of a lesion based on stimulation of sensory
nerve endings; some reassessment of this view had
occurred in the early 1960s with the increasing im-
portance ascribed central processing in the percep-
tion of pain [67], and by the late 1970s McLeod
suggested that pain was a purely subjective com-
plaint and that, moreover, Its subjective nature is
such that it is only through personal experience of
pain that a doctor can have insight into the meaning
of the descriptions given by patients [68]. This
reliance on self-experience to grasp the meaning of
symptoms was also found in a book published in
1977 of sociologists accounts of their own illnesses
[69]. The authors criticised previous sociological stud-
ies of illness as being too formal, objectified, de-
tached and scientifically rigorous . . . each illness
experience and encounter with organised care is
unique; the only means of transcending the inter-
pretation of meanings, of achieving authenticity, was
to observe not the illness of others but the illness of
self. The patients view, caught in a dense web of
subjectivity, was becoming a reflection, another man-
ifestation even, of the self-view.
It was therefore no longer possible to distinguish
separate realms of experience for doctor and patient.
The meeting between doctor and patient was not
between an enquiring gaze and a passive object but
an interaction between two subjects. In many ways
the notion of a doctor-patient relationship failed to
capture the essentially contingent and precarious
scenario contained within the term doctor-patient
interaction [70]. The patients view and the doctors
view were shadows of each other. On the medical side
Browne and Freeling likened the interaction to a
game (drawing on transactional analysis) [71] while,
in the same year, from the sociological side, Wads-
worth and his colleagues set out to investigate the
rules, routines and procedures that doctors and pa-
tients use to organise consultations [72]. Perhaps
McLeod, in his Clinical Examination of 1976 spoke
for both sides when he wrote: In addition to the
patients response to his problem the interactions
between the patient and the doctor have also to be
considered. This relationship is very complex as a
result of the interplay between different personalities
in potentially unstable situations [73]. The claim of
Locker, in his 1981 study of patients interpretation
of symptoms, that illness is a social phenomenon
constituted by the meanings actors employ to make
sense of observed or experienced events could be
applied to either patient or doctor [74].
The doctors opening question Whar is your
complaint? was replaced by Now please tell me
your trouble [75]. Illness, which had been consti-
tuted by the lesion deep in the body, was transformed
 The patients view
into the idiosyncratic meanings of the patients (and
doctors) biographical space.
CODES OF PERCEPTION
What then is the patients view? What is it that the
patient says? The problem is one of perception, of the
difference between hearing and saying. The patients
view cannot be described or isolated simply as what
is said, fundamentally the patients view is bound up
with what is heard. In this sense the patients view is
an artefact of socio-medical perception.
In his discussion of the massive changes which
occurred in medicine at the end of the 18th century,
Foucault argues that it was neither the conception of
disease nor the signs which indicated its presence
which were changed first; both field and gaze were
bound together by codes of knowledge [76]. Thus the
developments of the late 18th century were not the
product of enlightenment, of better methods, of finer
perceptions: new objections were to present them-
selves to the medical gaze in the sense that, and at the
same time as, the knowing subject reorganises him-
self, changes himself, and begins to function in a new
way.
In similar fashion the relationship between the
patients view (in its various forms, both verbal and
non-verbal) and its interrogation constitute a field
and a gaze, and the two are bound together by a new
code of knowledge. This paper has emphasised the
role of the gaze in constituting a field, but the field,
in the form of what the patient says, nevertheless
confirms and consolidates the gaze. A medical inter-
rogation, for example, which probes for patient feel-
ings and relationships cannot function if the space it
examines is constituted by specific physical items of
patient morbidity [77]. In this sense field and gaze are
mutually self-supporting.
This paper has examined aspects of the medico-
social analysis of a common space which establishes
for these sciences the reality of the patients view. It
is still possible however that there are in modem
society alternative structures of perception which
might apprehend a different reality. Insofar as the
social sciences are concerned, this paper has sug-
gested that claims for an analysis of the patients
position which transcend medical understanding are
unfounded. So what of other less formalised tech-
niques of hearing? Can lay cultures, the social net-
work, the popular novel hear what socio-medical
perception cannot grasp? Is there a form of experi-
ence and expression which escapes the confines of
medicalised illness? In part this is an empirical ques-
tion; but it also raises the question of whether
patienthood can exist in spaces other than those
traversed by medical perception.
At each historical point medical analysis has an
object and an effect: the object is the patients view
(in its contemporary form) and the effect is the
person who holds those views. When the doctor
searched for pathological lesions, the view was the
symptom and the patient was both receptacle for
pathology and unreliable translator; when the doctor
acknowledged the importance of the emotions in his
search for illness, the view was both the symptom and
the feeling, and the patient was an emotional and
743
somewhat less than perfect setting for pathology;
when the doctor enquired of patient meanings, the
view became the lay theory and the patient a subjec-
tive being.
This does not mean that the discourse which is the
vehicle for this new perception necessarily has imme-
diate or real effects on clinical practice. Despite the
widespread endorsement of an extended patients
view in the literature reviewed above, most clinical
practice today-particularly hospital-based-
probably relies on an older scheme of interpretation.
There are of course tensions between a perception
and a practice, some due to a cohort effect as older
clinicians (and possibly older patients too) reject the
new methods, others due to a more fundamental
conflict between levels of theory and of experience.
Nevertheless the conditions of possibility for an
extended patients view, whatever its empirical sup-
port, have begun to occur over the last few decades
and this of itself (besides its ramifications into patient
representation, community politics, patients rights,
and so on) signifies a change in the status of patient-
hood.
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