Methodological Considerations on the Example of

Methods and Issues/Probl~matiques et methodes Perspectives on Patients' History: Methodological Considerations on the Example of Recent GermanSpeaking Literature EBERHARDWOLFF

Abstract. Patient-history is a recently developed branch of medical-historical research, and its methodology has not yet been suf4iciently developed. In particular, the specific character of patient-centred research still has not received sufficient attention. What kinds of questions can, and should, such research attempt to answer, and from which perspectives? This contribution to the discussion offers some help towards the development of ways of orienting such research towards achieving proximity to the patients' viewpoint. This aim is best achieved when the mental picture of patients is reconstructed and, in addition, the specific point of view of the patient is adopted. The article illustrates some possibilities and problems of this branch of research by citing the example of relevant recent German-language studies, especially in the field of the relationship of patients to approved doctors in the nineteenth century. I

R h m & L'histoire des malades est un secteur recent de l'histoire medicale et les probli?mesm6thodologiques qu'elle pose n'ont pas encore et6 entierement analyds. En particulier, le charactsre specifique des etudes cenFes sur le patient lui-meme n'a pas encore r q u toute l'attention qu'il merite. A quelles questions cette histoire put-elle et doit-elle e o n d r e ? Quelles perspectives doit-elle prendre en compte? Cette contribution se propose d'aider au dheloppement de cette orientation de recherche en explorant les etapes et les moyens par lesquels on peut appdhender au mieux le r61e du patient dans l'histoire. L'arEberhard Wow, Institute for the History of Medicine of the Robert Bosch Foundation, Straussweg 17,70184Stuttgart, Germany.Translatedby JohnFowler, Stuttgart. CBMWBCHM / Volume 15: 1998 / p. 207-28

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ticle montre que cette demarche reussit d'autant rnieux que l'on fait du malade lui meme l'objet central de la recherche, que l'on reconstitue son univers mental et que l'on adopte son point de vue. Pour montrer les possibilit6s et les probkmes de cette orientation de recherche, l'article s'appuie sur de rkentes et rernarquables etudes publiees en allemand qui ont surtout au comportement des patients face aux m$decins approuves au XIXe siecle.

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It has long been known that the subject of patients was strikingly neglected in medical-historical research written in German until a few years ago.' The paucity of resources, to be sure, renders the writing of any history of the patient laborious, and limits the possibilities of research that can be undertaken. But this still does not explain why. medical-historicalresearchers, neglecting such sources as do exist, have all too rarely even attempted a history of the patient. This neglect has been due chiefly to a narrow definition of the subject "medicine" often as no more than medical treatment, and also a tendency to deal mainly with academic-medical ideas, discoveries, and inventions and the medical personalities responsible for these. As late as 1986, Weindling in his survey of the research carried out in the social history of medicine in Germany noted the lack of "a history of health seen from below."2 But the patient has, in the meantime, long ceased to be the "terra incognitaH3of the discipline, even though there are still plenty of gaps to be filled. The patient as subject now plays a significant role in medicalhistorical research at least when this has a social ~rientation.~ This is due to a broader understanding of "medicine" as comprising not merely doctors, but as a historically formed network comprising all concerned. "Medicine" thus is no longer defined as the sum of scientific findings. The application of medical science, its diffusion, and society's reception of it lie now at the focal point of such research. In Germany, this development was encouraged by changing trends in historiography itself. The earlier approach, marked by an emphasis on political history and the history of ideas, was broadened to include the perspective of those directly affected by such factors. Everyday life, the domestic and cultural aspects of history, increasingly became the subject of historical research. History opened up to ethnological and anthropological approaches. Finally the discipline increasingly turned away from its earlier preoccupation with "facts," and therefore from the notion of an objectively "existing" history, and attended to questions of interpretation, and especially of different modes of perception, and the creation of "meani~~g."~ In the wake of this trend, a series of studies appeared in Germanlanguage research into the social history of medicine, works which in a

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wider sense belonged to the "history of the patient." These studies pay special attention to the nineteenth century. The question of the patients' relationship to what the academic medicine of the time could offerthat is, as practised by tried and tested doctors-plays an important role. These more recent studies are the basis of the present study, although questions will be posed that go beyond this scope. New approaches in research of this kind initially cannot boast a highly developed methodology. This must grow from subsequent critical reflection on the research practice actually adopted. This article attempts to contribute something to this process, and hopes thus to be of some significance to medical historiography in other lands and languages as well. In particular, the specificcharacter of patient-oriented research seems to have received too little attention as yet. What perspectives does such. research adopt, what questions can it answer, and in what manner, and what contribution can it make to the totality of medical-historical research? The literature in this area generally fails more or less to deal explicitly with these questions. Consequently, studies intended as contributions to the history of the patient unconsciously drift away from the subject, reach their conclusions in rather questionable ways, or lose sight of the Specificresult origrnally aimed at, by taking several perspectives at once. Such problems are present particularly in the more recent patient-oriented history (in German) of nineteenth-century medicine. The present contribution accordingly will plead for a more methodologically conscious approach to patient-history, by offering preliminary ideas of systematic procedures and guidelines to better approach the perspective of the sufferer. The present contribution deals with three separate questions. What they have in common is that all three interrogate patient-oriented research methods as to their proximity to the patient. The first section distinguishes broadly between historical studies which are only in a loose sense patient-oriented, and ones which are so in a more exact sense. The classification is arrived at by seeing what role is accorded to the patient in the definition of the topic, and in the more general interest of inquiry. The second section investigates which questions are posed by patienthistory in the more exact sense of this term. A schema of various question areas will be presented (concerning the patients' "circumstances," "relationships," "behavior," and "ideas") and the attempt will be made to give a broad structure to the research field by means of this schema. This should facilitatethe recognition that studies with different emphases within these question areas differ in their proximity to the patient. Finally, in the third section the methodological aspect of the whole undertaking will be debated. At this point a distinction will be made be-

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tween two research perspectives. One of these considers the subject (i.e., the patient) from the outside, while the other investigates patienthistory as seen from the perspective of the patient himself. The article as a whole pleads for a historiography that investigatesthe patient as comprehensively as possible and therefore is required to come close to the patient in the three dimensions indicated above.

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Medical-historical studies subsumed under the topic of "patienthistory" deal, in the broadest possible sense, with aspects of the following questions. How did people behave with regard to what in their time was understood as the health, sickness, or healing, either of themselves or of those close to them? How did they perceive these phenomena? What were their attitudes to the various healers? What were their no-. tions of sickness and health? How did they evaluate diagnostic, therapeutic, or preventive offers from others, and how did they use them? Clearly this description neither can nor should define the field of study precisely. The topic of dealing with pain,6 for example, merges into adjacent research areas such as the history of the body. Furthermore, patient-history also can overlap with the history of basic everyday needs like nutrition, clothing, accommodation, or the provision for the poor. Thus it is usual to subsume under the concept "patient-history" a much broader and less clearly defined field of study than the term itself properly indicates. According to the exact meaning of "patient," patient-history in the narrow sense should be defined as "the writing of the history of the sick when these are being treated by healers of any kind." What is known as "patient-history," however, investigatesa notably broader group than the sick recipients of therapeutic services, and a much broader subject field than merely "patients" in the sense of "the enforcedly passive objects of professional-medical interventi~ns."~ For patient-history is also interested in people under treatment from a wide variety of therapists, or who treat themselves, or who are treated by family members. In addition, patient-history reaches beyond the scope of therapy altogether. For, in the last analysis, people who are not sick at all are just as interesting to patient-history. This mismatch between subject matter and nomenclature cannot, moreover, be resolved by simply adopting alternatives to the term "patient." The concept "lay-person" entails the disadvantage of defining reductively the persons being researched, as "those without professional training." Even the concept of "sick person" (implyingtreatment by doctors) is still too restrictive, as, by including only the sick, it excludes questions of, for example, health preservati~n.~

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Finally, the collective term "medical-cultural research" has been used in German-speaking countries in recent years in studies that often develop the corresponding theoreticalconcept? But this description identifies yet another facet of the research field, namely, the investigation of what people imagine about and expect from medicine, and how they behave in relation to it. By contrast, the present study is concerned with describing the selection of social groups for investigation. Similarly, the concept "folk medicine" usually denotes something different again, including, as it does in its accepted sense,therapeuticactivitiesoutside of and beyond contact with professional healers.1° These are the problems that deliver the strongest argument for the label "patient-history" to designate this field, notwithstanding its drawbacks. What all approaches within this research area share in common is the change in perspective-the conscious turning away from a medical. history that concentrated upon therapists, especially doctors, and the redirection of attention towards those whose health is in question. The most meaningful contrasting term to express this latter category is "patient," which is why it has become generallyaccepted despite its inexactitude. RESEARCH INITIATEDBY PATIENTS, RESEARCH IN THE FIELD OF PATIENTS, AND RESEARCH MRECTLY ON PATIENTS

Just as patient-history cannot, as subject matter, be exactly defined, so can no precise distinction be drawn between questionswhich belong to patient-history and others that do not. If all historical research in which patients play some role were to count as patient-history, then most medical-historical research would have to be included in this category. Such a comprehensive interpretation of the term would obviously blur the specific focus here envisaged as necessary to this line of research. On the other hand, no exact boundaries can be drawn to decide when a particular line of inquiry falls outside the topic. Exact distinctions generally result in inclusions and exclusions that fail to do justice to the complexity of the material. On the other hand there is indubitably, as will be shown, a sliding scale upon which the "patient-centredness" of a piece of research may be placed. One study may be "patient-history" even in the narrow sense, and another only if the subject is defined more broadly. A look at the questions posed by a given research study, or at the exact object of the inquiry, is generally sufficient for a rough categorization. To what extent does the study aim at learning something about patients? Are patients the real target of the inquiry, or do they merely provide the "material" with which other questions may be asked? In this regard, Reinhard Hickmann's investigation of Antonie Volkmann's therapy-as part of the history of homeopathy-provides a

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clear example." In this analysis of a pathological case, the intention is not to discover what the patient herself actually did or felt. Even the question as to what was done to this patient is only indirectly spoken about. Instead, the author's purpose is to show, through the treatment given over many years to a patient, how Samuel Hahnemann, the founder of homeopathy, developed his form of therapy during this time. By contrast, an example from the eighteenthcentury, Sabine Sander's analysis of the medicd biogra hy of the pietistic clergyman and inventor Philipp M a W u s Hahn? does indeed take an approach belonging much more to patient-history. From the evidence of Hahn's diaries the author has worked out the great importance this man attributed to his own health. In doing so she threw doubt upon the hypothesis that pietists felt themselves aloof from their own bodies. In contrast to Hickmann, Sander in her work places the thoughts and actions of the patient himself at the centre of her inquiry.13 The same may be said of the studies carried out in the last 20 years in the general field of the medicalization of society. Earlier studies dealt mainly with the question of how the state, the doctors, or various social elites, tried to modify the behavior of the populace, in matters regarding health, in the direction desired by those same elites14- or how these guiding groups debated over the matter.15In these studies, patients appeared principally as objects, that is, as the people at whom the attempts under investigation were directed. Only incidentally did patients ever appear as thinking and active subjects. Later studies, by contrast, have paid more attention to patients' reactions to these activities, and therefore are to be classified as patient-history even in the narrow understanding of the term.16 Also studies dealing with "society's" notions of sickness and health, for instance, are to be classified as marginal at best to what can properly be called patient-history. One reason For this is that "society"is a general category and could include therapists as well. Another is that individual ideas about sickness or health (based on personal experience for instance) are investigated less often than abstract ideas and concepts.17 Three more recent studies on the subject "patients and the hospital" show that there are many possible degrees of "patient-centredness" in medical-historical inquiry. Bleker, with others, published in 1995an investigation into "patients and diseases in the Julius Hospital, Wiirzburg, 1819-1829."18 The authors did not inquire into the role of patients in the hospital. Instead, they used data about the social structure of the patient population (e.g., how long patients stayed in hospital, what their sicknesses were, the results of their treatment) to investigate the character of the institution. Nor did the study describe itself as "patienthistory" but, fittingly, as "patient-oriented hospital hi~tory."'~The

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questions posed in Barbara Elkeles' inquiry into the relationship between patient and hospital, by contrast, focused more on the patient, as she intended at any rate to deal with the atient's evaluation of the hospital and his or her "expectations" of it. In fact however the author often drifted away from this perspective and described what lay in wait for the patients in hospital (the "tones of the barracks-courtyard," for example), and the way in which corresponding problems that arose in hospitalsgot publicly discussed. Lachmund and Stollberg, in their analysis of autobiographies,wrote more consistently from the patients' perspective, investigating the various concepts of hospital entertained by different patients, their experiences there, and their perceptions of the situationin hospital. The authors came to various conclu~ions.~' Studies in the field of the doctor-patient relationship provide further examples of how inquiries can come closer to a patient-historical approach, or fail more or less to do so. Claudia Huerkamp, for instance, described the patient-doctor relationship in the nineteenth century almost exclusively on the basis of the notions and behavior practices of doctors. In contrast to doctors, patients appeared in her work hardly at all as thinking or actively involved subjects, but were alluded to, indirectly at most, in accusationsexpressed by contemporary doctors.22 Further examples of patient-history in a sometimes narrower, sometimes broader sense, are provided by two more recent studies on the interdependence of medical concepts and the corresponding doctorpatient relationship. In 1994 Heinz Schott published an essay investigating the typology of the doctor-patient relationship between the Enlightenment and the Romantic era, in relation to contemporary medical concepts like Brownianism, Mesmerism, and the corresponding therapeutic principle^.^^ In the course of the study he compared the Enlightenment concept of "correcting" the sick patient with the Romantic notion of influencing the organism's own self-healing power by means of "sympathy." Taking this approach, the author placed in the foreground of his inquiry not the patient-doctor relationship, but rather the medical concept. Consequently, he could do no more than speak of one of the many possible factors influencing the patient-doctor relationshipnamely, the role into which doctors, in accordance with their ideas, tried to put patients. As a result, the insights here attained into the patient-doctor relationship are very meagre. Michael Stolberg recently dealt with similar subject matter, but approached it from the opposite direction.24In this work he developed further the theses of N. D. Jewson on the domination exercised by wealthier patients over their doctors who, in the eighteenth century, were financially dependent on them. From the evidence of patients' letters, Stolberg was able to demonstrategraphically and with copious ev-

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idence, how these influential patients, from their position of strength vis-h-vis the doctors, imposed upon the latter medical concepts which suited the patients' own concepts and felt needs.25 Stolberg's approach-in contrast to Schott's-placed the doctor-patient relationship, and still more the patient himself, in the foreground of the inquiry. Conclusions about the diffusion of medical concepts were secondary. Both approaches are legitimate in themselves; their respective value for patient-history is very AREAS OF INVESTIGATION IN PATIENT-ORIENTEDRESEARCH

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Even when medical-historical research describes patient-history in the narrower sense described above (that is, by inquiring into patients themselves), the "proximity" to the patient achieved by the approach can still vary. The degree of such closeness can be assessed by noting what particular aspects of the patient are studied. These are what I call, in the following pages, the four areas of investigation looked into the course of patient historiography. These areas of investigation do not all attain the same degree of vicinity to the patient. To explain this, an overview must first be given of the areas of investigation that have generally been handled by specialized studies on this subject. More recent studies in patient-history deal, in general, with four areas of inquiry: (1) the health-related or social circumstances of patients; (2) patients' relationships to other people actively concerned with health issues; (3) the patients' behavior patterns in relation to sickness, health, and healing; and finally, (4) the ideas and expectations of patients in health-related issues." The first category of the four above constitutes, in fact, a domain of classical historical social inquiry, that is, into the history of social structures. The second is a research field typical of historical-sociological research.The third is of more importance in day-to-day history. The last is particularly prominent in humanistic studies inspired by an ethnological-anthropological approach. These mutually interlocking topic areas are, however, seldom analytically disintegrated in the more recent interdisciplinary literature. Though this variety of perspective is to be welcomed, some difficulties are presented by the relevant literature through its lack of adequate consciousness as to the very different kinds of answers obtained by these variously conceived modes of questioning. This problem makes it very difficult to take an overview of these studies.An example of this is Lachrnund and Stollberg's interesting and important analysis of the health-related testimonies to be found in autobiographies written in German from the late eighteenth to the early twentieth century.28From these autobiographies the authors deduce, on the one hand, the subjectivepoints of view of the patients, and on the

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other, "objective" aspects of medical history. The authors do not, however, in the text, distinguish systematically between the two tasks, but jump frequently to and fro between the two.29 In the following pages the areas of investigation will, for the sake of clarity in analysis, be handled separately. What kind of concrete research questions can grow naturally out of these areas of investigation can now be made clear by means of a sketch. Let us take as an example the questions about contact (or lack of it) between patients and healers in the event of illness. Many of the questions to be mentioned here are taken for granted in social-medicalhistoriography, but the systematization of them is not. The health-related circumstances of the patient can, in the chosen example, be investigated through a whole series of possible questions. What categoriesof therapists were available to a particular group of pa- . tients? How free were they to accept or refuse consultation (for example, when inoculating soldiers)? What diagnostic, therapeutic, and preventative knowledge could be offered to the patients, and by which healers? What sort of behavior was the patient confronted with in the healer? The social relationships of patients are reflected principally in the field of the doctor-patient relationship, though other active healers may take the place of doctors. One important question is whether certain patients felt themselves fundamentally aloof from, or close to, certain healers. Was there an unequal distribution of power in this relationship? Were doctors in a dominant position vis-a-vis their patients, or was it, on the contrary, the patients who were dominant, being free to choose their doctor? Beyond the dimension of power and lack of it, the question also might be put as to how healers and patients co-operated to overcome sickness. On the topic of patient behavior, the main question to be posed in our example is whether a particular category of patient consulted healers at all. If so, which healers were consulted, and which not? In this matter a particular distinction could be made on the basis of the trained or untrained status of the healers (doctors,barber-surgeons, lay healers) and similarly the scholarly status of the treatments offered (e.g., academic medicine and non-academic or "alternative" medicine, healing). A further question could be asked as to whether the patients requested the available therapy or merely reacted to the offer with indifference, whether they were persuaded to accept the treatments offered, or refused them. When medical measures were ordered, how did patients react to such invasions of their autonomy? How did patients behave to their healers? Did they exploit whatever position of strength they may have enjoyed (being able, for instance, to change doctor or at least to so

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threaten) effectively in their own interest? Did they adopt themselves to a subordinate position, or did they offer resistance? And beyond the narrow perspective of power and lack of it, questions could be put as to what patients actually said to their healers? Did they negotiate with these as to the measures to be taken, and if so, with what strategies? An analysis of circumstances, relationships, and behavior patterns alone, however, would still cast no light on the causes of such behavior. To this end, recourse may be had to an investigation of the broad complex of topics that might be termed the patient's expectations-his concepts. What matters here were the subjective impressions, perceptions and interpretations, assessments or evaluations of illnesses, healers, institutions, practices and so forth, present in the patient's head-whereby these were naturally determined by the particular experience and stage of knowledge of the individualpatient. These expectationsand attitudes, in turn, provide insight into the more general atterns of belief, thought, ethical norms, and "mentalities" of patients.3 r This would mean, in the example we have chosen, deducing from the specific matters mentioned above, the criteria by which healers were chosen, and inquiring in this way into the patient's needs and interests. Many different criteria can operate as determinants here: the academic professionalism of the healer, or the practical experience that the patients believed the healer to have, the extent to which the healer was held to be "progressive," "holistic," "natural," "gentle," or "drastic," the familiarity or otherwise of the proffered therapy, or simply the speed or convenience of the therapy. From judgments based on criteria like these, certain patients' mental image of the "ideal healer" can be synthesized. Non-medical factors can, however, also play a role-the social proximity of patient to doctor, and even pragmatic questions like geographical proximity or cost. From the application of such criteria, the intrinsic logic of the patients' behavior can be worked out. This in turn enables the researcher to develop a model of the thought patterns, values, and attitudes that determined the choice of healer. One might envisage, under this heading, feelings of affinity or hostility to science and to doctors, progressive or traditional orientation, the wish for patient autonomy or a high esteem for specialized competence, being highly interested in health matters or indifferent to them, being positively disposed towards technology or to a natural lifestyle, pragmatism or its opposite. Less patient-centred studies limit themselves, as a rule, to the first two of the four areas of investigation detailed above. But the patients' role in history can be ever more fully understood, the more the scope of patient-centred research is broadened to include not just the circumstances, relationships, and behavior patterns of patients, but their ideas

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and concepts as well. But a broad approach of this kind does more than merely expand the thematic repertoire of medical history to include new and long-neglected subject matter. A research procedure that pioneers the investigation of ideas, concepts or expectations offers the additional advantage of integrating the various perspectives all bearing on patient-history, for the four areas of investigation mentioned above are, while closely related to each other, yet not of identical sigruficance. They are ordered in such a way that each, in a way, provides the basis from which the one after can be investigated--each in turn must be understood, as the prerequisite for understanding the next. The external circumstances must be known, if the relationship to healer or healers is to be understood. For instance, an understanding of the relevant power relationships is essential if one is to interpret the patients' behavior to healers. Finally, only on the basis of such understanding can anything . be said as to which notions and evaluations or interpretationsor forms of medical culture are represented by particular categories of patient. Conversely, the expectations and concepts of medicine (inquiry area 4) entertained by patients determine, to a certain degree, their behavior to the healer (3)-which determines, in turn, the patients' relationship to other people involved (2); and both then influence at least the external social circumstances of the patient (1). By means of such models of the thought patterns, evaluations, and mental attitudes of particular categories of patients, the whole complex pattern of patients' relationships and behavior can be described and comprehensively presented against the background of what was possible in the relevant period. Let us take as a hypothetical example of this, patients who in choosing their healer adopt as their main criterion academic-scientific competence (their ideal expectation [4]).Confrontedby health problems they will have recourse primarily to academically qualified doctors, preferably of high repute (patients' behavior pattern [3])-when, that is, they can (which depends on their circumstances [l]). They will accept as authoritative the views of such doctors rather than those of healers they rate less highly (relationships [2]). If patientcentred medical history is to see itself not merely as a descriptive,but as an interpreting and hermeneutic historical science?l then an essential element in its research must be the investigation of precisely this-the ideal expectationsand concepts entertained of doctors, of medicine. PROXIMITYTO THE PATIENTTHROUGH A CHANGE OF PERSPECTIVE

Research into patients should, however, extend its scope to include the behavior, concepts, and mentality of patients for another reason as well, which is that it thus enables itself to deal as comprehensively as possible with its proper, specific subject field. For in each of the four areas of in-

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vestigation the role of the individual patient has a different significance, which means that the "closeness" to the patient there achieved is also different.The circumstances (1)in which the patient lives, when considered in isolation, tell us little about the patient-nothing about how he/she behaves, or what he/she thinks. Investigation in this area of inquiry yields, at best, information about the framework of behavioral possibilities in which the patient was contained. Research of this kind treats the patient as raw material, as data, rather than as a subject in his or her own right. In itself, patient-history thus written encourages a view of patients as passive objects of external circumstances,even when this is not the intention. Investigation of the patients' relationships (2) allows patients to appear at least as involved individuals, interacting with others. It still remains true, however, that research into the patient-doctor relationship in the narrower sense hardly casts doctors or patients in an irnportant role as people, as responsible agents, because the centre of interest is usually the relationship between two groups (a relationship of "dominance," or "dependence"). The individuals or groups themselves are dealt with only indirectly.Only when research (on, for example, the distribution of power between doctors and patients) investigates how the people involved actually strove for, then attained, and wielded such power--or experienced subordination and perhaps reacted against itonly then do the people involved become visible in the way they perceive, the way they behave (3), and turn into conscious, active individuals. However research in this area (doctor-patient relationships) often runsthe risk (because of the greater availability of source material about doctors) of writing in the first place about doctors and their relationship to patients rather than, conversely, about patients and their relation to doctors. In such studies patients still remain for the most part passive, speechless, rather vague ciphers.32If, on the other hand, patients' behavior becomes properly the object of medical-historical research, then the patients themselves automatically win recognition as responsible agents. Moreover the final step, the investigationof concepts (4), allows a still closer approach to the patient inasmuch as research of this kind concentrates more intensively upon the patient. One might, in figurative language, say that such an approach facilitates access to the patients' inner lives. This can be illustrated through what is meant with terms as "use," "demand," and "need." The question of how the medical services offered are used or "consumed by the patient, coincides with the study of his or her behavior patterns, while investigation of the patients' demand for such services can entail the study not only of external relation-

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ships, but of patients' concepts and expectations as well. In any case, studying the patients' needs of professional services means examining personal concepts, both those relating to medicine, and those of wider scope. But the mere inclusion of "concepts" in patient-centred research affords no automatic guarantee that a comprehensive "closeness" to the patient is achieved. For a proper comprehension of the patient, a further step towards him--or her-must consciously be taken, not this time a thematic, but rather a methodological advance. The thoughts and actions of patients must be interpreted in the framework of the patients' specific situation and the logic of that situation as the patient understands it.33This step is analogous to that from the notion of an objective "disease" to the subjective perception of the patient's own "illness." This does not mean that the subjective point of view of the patient always should be uncritically accepted as the only possible truth. It means rather recognizing that, against a background of different conditions of life, interests, and needs, a patient may see his or her situation differently from the way the doctor sees it. This is the factor that is described in the literature by the concept of the "perspective determined by one's real-life situation" or the perspective of the "life-world."34 When patients' behavior patterns are perceived from this point of view, they often reveal a different inner logic from what can be ascertained by an examinationfrom outside. This point could be illustrated from a number of themes dealt with in more recent literature.35I will describe it here using as example the issue already introduced above-the choice of healer. The social history of medicine written in German frequently took the view, up to the 1980s, that most of the population, especially in rural areas, in the period before the introduction of universal medical insurance, largely went without consulting doctors at all, turning rather to unqualified practitioners. The reasons for this were assumed to lie not only in such external circumstances as the distance from the nearest doctors and the cost of treat~nent,~~ but in the rejection in principle of professional doctors as being socially and culturally aloof from the mass of the p ~ p u l a t i o n . ~ ~ The reason for this rejection was mostly seen, by the authors of such studies, in the irrationality characterizing society in the premodem period. Annette Drees, as a typical exponent of the dominant opinion at that time, held that a "profound mistrust of doctors' treatment" as well as the "notable abyss" between doctors and countryfolk had its causes in, among other factors, the ignorance, superstition and fatalism of the rural populace.38 Claudia Huerkamp too evaluates the behavior of patients at that time essentially by applying criteria like "gloomy superstition" and "sheer unreason."39

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Studies in the following decade have largely rejected this thesis of doctors having been traditionally mistrusted. They have contrasted to this view much subtler modes of interpretationwhich do not attribute a principal irrationality to the country-dwellers. But this development was important in one respect, which the critics of the older interpretations of patient-history have hardly illuminated. Both the above interpretations are essentially the result of their respective approaches to patient-history. The one group tried rather half-heartedly, the other much more consistently, to come close to the patients' point of view. It was, to be sure, the intention of authors oriented on the "cultural distance" thesis to reconstruct the patients' mental world. In fact, however, these authors have hardly achieved this because they failed to take the methodological step of a change of perspective.* Their picture of their patients was developed from a point of view external to that of the subjects under study. The sources for such studies were generally doctors' complaints that "the common people" often failed to come to them, but went instead to the doctors' competitors-the lay healers. The main problem is not, however, the fact in itself that the authors cite such doctors as sources, but rather that they adopt the latter's perspective, often uncritically. The concrete result is that they asked not so much why patients wanted or chose such healers, but rather how the doctors explained to themselves why (in their own view) too few patients from among the common people came to consult them. In this respect Francisca Loetz in treating this theme has come closer to the patienL4l By using, for example, the mortality lists containing data on surgical and medical treatment prior to death, she was able to reconstruct the patients' behavior much more directly than this can be done on the basis of doctors' complaints.Further sources, such as medical reports, administrative archives, forms, minutes of consultations, and meetings provided her with the basis for understanding not only the opinion of doctors discontented with patients' behavior, but for understanding this behavior in itself. Thus she was able to investigate more systematically, and from the patients' perspective, what sort of illnesses prompted what sort of patients (of what age, and whether capable of work or not) to want to consult, or actually to consult, what type of healers. It was not merely the change from normative to descriptive sources that considerably modified and refined the picture of a traditional aloofness subsisting between doctors and common people. It was also the accompanying change in perspective that made this possible. Loetz was unable to discover any absolute hostility to doctors in the lower classes of society, but on the contrary a certain degree of demand for consultations with academic doctors or semi-professional surgeons.

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Healers were chosen in a relatively pragmatic fashion on the basis of the patientsf own experience. Rather than geographical distance, the reputation for effectiveness enjoyed by a healer among certain patients determined how many went to that healer-and also the latter's expectation (or lack therein) of a trusting, partner-like relationship to the healer.* Lachmund and Stollberg similarly discovered in the lower levels of society a combination of, on the one hand, well-documented patronage of doctors and their services, and on the other, the maintenance of a certain aloofness from them.* By using the autobiographies of middle-class patients these authors have shown even more clearly the advantages of adopting the patients' perspective. This research approach produces a picture of the patient that is not only subtler, but also reflects the interests of the people investigated more than is the case in the traditional literature." Here are a few of the findings. Such middle-class patients not only regularly consulted a doctor as soon as they fell seriously ill, but regarded this as the universally accepted norm. Their subjecting of themselves to the doctor's authority as specialist went hand in hand with a trustful familiarity with that doctor. These patients preferred to seek out a doctor familiar with their "constitution1' and their specific illness.The doctor was to share the patients' preference in matters of treatment, should be similar to the patients in character and educational level, and should prescribe no "heroically" drastic medication. Middle-class patients did not, in principle, distinguish between doctors and barber-surgeons, although their relationship to the latter tended to be irnper~onal.~~ Such a relatively patient-centred perspective when adopted in this area of research can contribute to a more finely differentiated picture of the doctor-patient relationship. The rigid dichotomies of dominance and subordination can be superseded to develop a view of patient and doctor co-operating in quite various negotiations to arrive at a diagnosis. This process was illustrated by the authors by citing much mutual criticism and attempts by each to convince the other in exchanges between doctors and patients.46 But such more sophisticated depictions in no way lead to an "objective" patient-history. Pictures provided by patients (as indeed those produced by all others involved) are still "constructed" history. They remain the products of the specific interests and research approaches of the respective historians. In the example before us, this means, in concrete terms, that the researchers can in each case throw into relief the obstinacy, the rationality, or the puzzling many-sidedness of the patients they study-yet it remains important to guard consciousness that all historical notions of "patients" are constructions against degeneration into methodological arbitrariness. Even if patient-history written from

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the patients' perspective (in the sense described above) cannot lead to a "true" historical picture of the patient, it can certainly provide a picture less marked by the interests of others concerned, less marked by the assumptions of researchers, and a picture, therefore, more differentiated, altogether more adequate than we had before. This change in perspective certainly can be carried through more easily by means of direct or so-called "ego-sources" such as autobiographies than from indirect sources. "Ego-sources" lay bare the thought and behavior patterns of patients, despite such fictitious elements as they may also contain, more immediately than sources which detail the desired data by the mediation of other parties, doctors for example." But the problem basically arises, not from the nature of the source, but rather from the perspective brought to bear by the interpreter. Doctors' reports, for example, can very well be evaluated and used as long as the personal interest of the authors is allowed for in the interpretation.* Johanna Bleker and Eva Brinkschulte a few years ago cited two sources in which doctors reported an outbreak of smallpox or chicken pox in 1825, in Randersacker, near Wiirzburg. The population had kept the One of the doctors interpreted this secrecy as sickness partly ~ecret.4~ "ill will" on the part of the people. The other was of the opinion that the people had in this way tried to forestall quarantine procedures that would have entailed financial loss. Both doctors wanted to explain the peoples' behavior, but only the second succeeded in liberating himself from the logic of his own category (medical man and public authority) to see, and therefore better to understand, the behavior of the patients from their own points of view. Above all it is important to interpret the sources that should allow the patients' perspective to be adopted with great care. A recent example can be used to illustrate this point-an example drawn from research published in English. Barbara Clow tried in 1997 to explain the attraction of the North American "alternative" doctor Mahlon Locke to his large following of patients. She pleaded for the consistent adoption of a patient's perspective in answering such questions, arguing that substantial gains in understanding thus would be achieved. The sources she used were for the most part newspaper reports and the literature of the "movement" that had grown up around the doctor himself. But these sources contain not only the presumably genuine interests of Locke's patients, but also the self-portrait tactically prepared by the movement itself for presentation to the outer world-a picture that need by no means coincide with the patients' own viewse50 A consistently executed patient-history meanwhile can do more than simply provide better delineated pictures of patients. It can provide the impulse for a fundamentally different understanding of medical his-

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tory. In patient-history and its attendant literature in German, the important insight that sources such as autobiographies are subjectively colored and present only a distortion of historical reality, is expressedbut as yet merely as a pr~blem.~' It remains however a problem only as long as it remains the purpose of research to reconstruct "objective circumstances" by means of such sources. But if the trend now becoming increasingly general in history is followed-the trend of inquiring into alternative perceptions and styles of interpretation, expectations, and concepts52- then the subjectivity of these sources ceases to be a defect. Instead, that very subjectivitycan open the door to an understanding of historical phenomena. Traditional medical history generally took cognizance of patients' behavior when this did not answer to the views of the doctors of the time. Such behavior was then described, as a rule, as wrong-headed, bad, or at least as in some respect defective. When medical history is written from a broader perspective inclusive of the patients' viewpoint, it becomes clear that hasty estimatesas to "objectivity" and "correctness" are extremely dubious. Behavior judged from the doctor's standpoint to be defective ("irrationality") can seem to the patient comRecognition of this makes it pospletely reasonable ("effectivene~s'~). sible to understand how dependent judgments always are on the frame of reference they imply. An awareness of the subjective or individual situations can provide a valuable opportunity for medical-historical research as it can broaden one's view of history. It can nudge towards the abandonment of the search for the one and only "objective" view of history, and instead, promote an understanding of history as the sum of subjective, individual, and therefore at the same time historically, and culturallyconditioned per~eptions.~~ The consequences of such a shift in perspective lead far beyond the provision of different pictures of the patient. The professional exponents of scientifically oriented medicine are, when considered as a historical phenomenon, also agents who have, because of their specific and culturally determined standpoint, chosen one among many possible ways of perceiving and shaping reality. This has been shown in, for ex~ ~ a methodologically ample, the discipline of "Science S t u d i e ~ . "But conscious patient historiography could deliver an impulse to the general history of medicine prompting it to follow approaches which should pay due attention to the "culture" factor. ACKNOWLEDGMENT

I am indebted to discussions with many German colleagues, as well as to the comments of an anonymous referee, for important suggestions that found their way into this manuscript.

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1 C.f. as present-day example of this complaint, Alfons Labisch and Reinhard Spree, "Entwicklungen und aktuelle Trends in der Sozialgeschichteder Medizin in Deutschland-Riickschau und Ausblick" ("Developments and Present Trends in the Social History of Medicine in Germany-A Review of the Past, and a Prognostication"), Vierteljahrschrtftfiir Sozial- und Wirtschaftsgeschichte, 84 (1997): 171-210,305-21, and for the present topic, p. 174. Certainly there are isolated exceptions, e.g., Walter Artelt and Walter Riiegg, eds., Der Arzt und der Kranke in der Gesellschaft des 19. Jahrhunderts (The Doctor and the Patient in Nineteenth-centu y Society) (Stuttgart:Enke, 1967).But the criticism formulated in this article applies to them, too, sometimes with particular severity. 2 Paul Weindling, "Medicine and Modernisation: The Social History of German Health and Medicine," Histoy of Science, 24 (1986):277-301, and for thispoint p. 287f. 3 This is Roy Porter's description of the state of research in the anglophone countries in his early plea for patient-historiography.Roy Porter, "The Patient's View: Doing Medical History from Below," Theory and Society, 14 (1985): 175-98; Roy Porter, "Introduction;' in Roy Porter, ed., Patients and Practitioners: Lay Perceptions of Medicine in PreIndustrial Society (Cambridge: Cambridge University Press, 1985), p. 1-22, especially p. 16. Compare with Katharina Ernst, "Patientengeschichte. Die kulturhistorische Wende in der Medizinhistoriographie" ("Patient-History: The Cultural-Historical Turn in Medical Historiography"), in Ralf Br&r and Wolfgang U. Eckart, eds., Eine Wissenschaft emanzipiert sich. Medizinhistoriographie von der Aufilarung bis zur Postmoderne (Pfaffenweiler: Centaurus, 1999),97-108. 4 Sander had already noticed this earlier on (SabineSander, "Medizin und Gesundheit im 18.Jahrhundert.Forschungsbericht und Bibliographie des internationalen Schrifturns [1975-19891" ["Medicine and Health in the Eighteenth Century: Research Report and Bibliography of the International State of Written Research, 1975-1989"], Das achtzehnte Jahrhundert, 14 [1990]: 223-52, esp. 232f). In non-historical medical sociolology in Germany this has earlier been the case. See Uwe Flick, ed., Wannfiihlen wir uns gesund? Subjektive Vorstellungen von Gesundheit und Krankheit (When Do We Feel Healthy? Subjective Conceptions $Health and Disease) (Weinheim: Juventa, 1998). 5 C.f. Daniel's instructive overview, "Clio unter Kulturschock. Zu den aktuellen Debatten der Geschichtswissenschaft" ("Clio under Culture Shock: On the Present Debate in Historiography"), Geschichte in Wissenschajl und Unterricht, 48 (1997): 195-218, 259-78, esp. p. 195-210.See also Ernst, "Patientengeschichte," p. 104-106. 6 See various contributions inMedizin, Gesellschaft und Geschichte, 15 (1996).Volume on "rain." 7 To avoid taking this narrowed perspective, the popular term of a medical history "from below" is, however, not employed here either. See, for example, Porter, "The Patient's View"; Barbara Elkeles, "Der Patient und das Krankenhaus" ("The Patient and the Hospital"), in Alfons Labisch and Reinhard Spree, eds., "Einem jeden K r a h in einem Hospitale sein eigenes Bett": Zur Sozialgeschichtedes Allgemeinen Krankenhauses in Deutschland im 19. Jahrhundert ("A Bedfbr Every Patient in a Hospital": Towards a Social Histoy of the Public Hospital in Nineteenth-Century Germany) (FrankfuWMain, New York: Campus, 1996),p. 357-73, esp. p. 357f. 8 C.f, alsoJensLachmund and Gunnar Stollberg, Patientenwelten. Krankheit und Medizin vom sph'ten 18. bis zum friihen 20. Jahrhundert im Spiegel von Autobiographien (Patients' Worlds: Sickness and Medicinefrom the Lute Eighteenth to the Early Ruentieth Centuy as Reflected in Autobiographies) (Opladen: Leske und Budrich, 1995), p. 21; and Porter, 'The Patient's View," p. 181. 9 Volker Roelcke, "Medikale Kultur: Moglichkeitenund Grenzender Anwendung eines kultunvissenschaftlichen Konzepts in der Medizingeschichte" ("Medical Culture: Possibilitiesand Limitations in the Applicationof a Cultural Studies Concept to Medical History"), in Norbert Paul and Thomas Schlich, eds., Medizingeschichte: Aufgaben,

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Probleme, Perspektiven (Medical History: Tasks, Problems, Perspectives)(Frankfurt/Main, New York: Campus, 1998),p. 45-68. 10 Michael Stolberg, "Probleme und Perspektiven einer Geschichte der 'Volksmedizin' " ("Problems and Perspectives of a History of Folk Medicine"), in Claudia Wiesemann and Thomas Schnalke, eds., Die Grenzen des Anderen. Medizingeschichte aus postmoderner Perspektive (The Boundaries of the Other The History of Medicinefrom a Postmodern Perspective)(KoIn:Bijhlau, 1998),p. 49-73. Eberhard Wolff, " 'VolksmedizidAbschied auf Raten. Vom definitorischen zum heuristischen Volksmedizinbegriff" ("Folk Medicine-A Step-by-step Farewell: From a Definitory to a Heuristic Reading of theTerm 'Volksmedizin' Zeitschriftfilr Volkskunde,94 (1998):233-57. 11 Reinhard Hickmarin, Das psorische Leiden der Antonie Volkmann. Edition und Kommentar einer Krankengeschichteaus Hahnemanns Krankenjournalen oon 1819-1831 (The Psoric Ailment of Antonie Volkmann:Edition, with Commentary, ofa Patient's Case Histoyfrom Hahnemann's Case]ournals,1819-1831)(Heidelberg:Haug, 1996). 12 Sabine Sander, " '. ..Gantz toll im Kopf und voller Blllhungen ...' Kilrper, Gesundheit und Krankheit in den TagebiichernPhilipp M a W u s Hahns" (" 'Feeling Crazy in My Head, and Full of Swellings.. ." Body, Health, and Disease in the Diaries of Philipp M a W u s Hahn"), in Christian Wterlein, ed., Philipp Matthdus Hahn 1739-1790-Auf- . satzband (Stuttgart:Wurttembergisches Landesmuseurn, 1989),p. 99-112. 13 C.f. as further examples Angelica Baum and Brigitte Schnegg, " 'Cette faiblesse originelle des nos nerfs'. Intellektualiat und weibliche Konstitution-Julie Bondelis Krankheitsberichte" (" 'This Constitutioml Nervous Weakness of ows'..Intellectuality and the Constitution of Women-Julie Bondelie's Sickness-Reports"), in Helmut Holzhey and Urs Boschung, eds., Gesundheit und Krankheit im 18. fihrhundert (. ..) Amsterdam, Atlanta: Rodopi, 1994),p. 5-17; and Leo Gosteli, Urs Boxhung, and Peter Brosche, eds., Astronom, Weltburger, Blasensteinpatient. F.X. Zachs Brrefe an R.A.v. Schifferli (Astronomer, Citizen of the World, Patient of Bladder Stones. F.X. Zach's Letters to R.A.v. Schifferli)(Basel:Schwabe, 1998),p. 61-77. 14 Ute Frevert, Krankheit als politisches Problem 1770-1880. Soziale Unterschichten in Preujkn zwischen medizinischer Polizei und staatlicher Sozialversicherung (Diseaseas a Political Problem, 1770-1880:The L m r Social Classes in Prussia between Medical Police and State Insurance) (Gbttingen:Vandenhoeck und Ruprecht, 1984). 15 Gerd Gikkenjan, Kurieren und Staat machen. Gesundheit und Medizin in der biirgerlichen Welt (Curing and Statecrajt: Health and Medicine in the Bourgeois World) (Frankfurt/ Main: Suhrkamp,1985). 16 Francisca Loetz, Vom Kranken zum Patienten. "Medikalisierung" und medizinische Vergesellschaftung am Beispiel Badens 1750-1850 (From the Sick Man to the Patient. "Medicalization" and "Medizinische Vergesellschafhmg" as Exemplijied by the State of Baden 1750-1850) (Stuttgart: Steiner, 1993);Eberhard Wolff, Gesundheitsaerein und Medikalisierungsproze$. Der Hombbpathische Verein Heidenheim/Brenz zwischen 1886 und 1945 (Health Association and the Medicalizution Process: The Homoeopathic Lay Association of Heidenheim/Brenz between 1886 and 1945) (Ttibingen: Tubinger Vereinigung fiir Volkskunde, 1989);Marita Mek-Becker, "Die Sicht der Frauen. Patientinnen in der Marburger Accouchieranstalt um die Mitte des 19. Jahrhunderts" ('The Women's Perspective: Female Patients in the Marburg Obstetrical Hospital around 1850"), in Jiirgen Schlumbohm et al., eds., Rituale der Geburt. Eine Kulturgeschichte (Rituals of Birth: A Cultural History) (MCinchen: Beck, 1998) p. 192-205; for France see Olivier Faure,Les Fraqais et leur mgdecine au XIX s2cle (Paris: Belin, 1993). 17 Z. B. Walter RUegg, "Der Kranke in der Sicht der biirgerlichen Gesellschaft an der Schwelle des 19. Jahrhunderts" ('The Patient, from the Viewpoint of Bourgeois Society at the Threshold of the Nineteenth Century"), in Artelt and Riiegg, eds., Der Arzt, p. 35-49. An explicit distinction between the two perspectives is to be found in Claudine Herzlich and Janine Pierret, Kranke gestern, Kranke heute. Die Gesellschajt und das Leiden (TheSick, Yesterdayand May: Society and Suffering) (Miinchen:Beck, 1991). l'),

18 Johanna Bleker, Eva Brinkschulte, and Pascal Grosse, Kranke und Krankheiten im Juliusspital zu Wiirzkrg 1819-1829. Zurfruhen Geschichte des Allgemeinen Krankenhauses in Deutschland (Patients and Diseases in the Juliusspital at Wiirzburg 1819-1829: On the Eady History oftheGeneral Hospital in Germany) (Husum: Matthiesen, 1995). 19 Bleker, Brinkschulte, and Grosse,Kranke und Krankheiten, p. 11. 20 Ekeles, "Der Patient," p. 358f., 369. 21 Lachmund and Stollbei&Patientenwelten, p. 152-78. 22 Claudia Huerkamp, "Arzte und Patienten" ("Doctors and Patients"), in Alfons Labisch and Reinhard Spree, eds., Medizinische Deutungsmacht im sozialen Wandel des in the 19. und frilhen20. lahrhunderts mK Pwer ofMedica1lnteruretation in Social Chan~e Twentieth centuries) (6om ~sychiahieverla~, l989), p. 5 7 h . ~inetehthand 23 Heinz Schott "Das Arzt-Patient-VerMtnis zwischen Aufk&ung und Romantik" ('The Doctor-Patient Relationship between the Enlightenment ana the Romantics'), Medizin, Gesellschnftund Geschichte, 12(1993):9-20. 24 Michael Stolberg, "'Mein Lkulapisches Orakel!' Patientenbriefe als Quelle einq Kultqeschichte der Krankheitserfahrung im 18. Jahrhundert" ("'My Aesculapian Oracle!' Patients' Letters as Source Material for the Cultural History of Experience of Sickness in the Eighteenth Century"), Osterreichische Zeitschriftfir Geschichtmissenschaften,7 (1996): 385-404. 25 Stolberg, "'Mein &kulapischesOrakel!' "esp. p. 390-392. 26 C.f. a similar investigationof the doctor-patientrelationshipfrom the patient's point of view in Lachmund and Stollberg,Patientenwelten, p. 67-130,esp. p. 99-106,p. 123-25. 27 C.f. a similar though cruder distinction in Porter, 'The Patient's View," p. 185;Porter, "Introduction," p. 4f.; and DeborahLupton,Medicineas Culture: Illness, Disease and the Body in Western Societies(London:Sage, 1994)p. 80. 28 Lachmund and Stollberg, Patientenwelten. As an Englishexamplesee Lupton,Medicine as Cultule, p. 79-86. 29 For this reason therather vague title of the book ("Patients' worlds'') is appropriate. 30 Francka Loek, "Histoire des mentalit& und Medizingeschichk:Wege zu einer Sozialgesduchk der Medizin" ('The History of Mentalities and Medical History: Ways towards a Social History of Medicine"), Medizinhistorisches Journal, 27 (1992): 272-91, esp. 274f. 31 "Understanding" does not mean here "justification," but "interpretation" (Daniel, "Clio unter Kulturschock," p. 210-13). 32 E.g., Huerkamp, " b e und Patienten." 33 Robert Jiitte,"Sozialgeschichte der Medizin: Inhal+Methoden-Ziele" ('The Social History of Medicine: Content, Methods, Goals"),Medizin, Gesellschaftund Geschichte, 9 11990k 149-64.e~~. D. 158. 34 Eberlkd W&: ''Medizinkritik der Impfgegner im Spannungsfeld zwischen Medical Criticism of Anti-vacciLebenswelt- und W ~ t s o r i e n t i e r u n g ("The " nationistsin the conflictbetween an~rienta'tiontowards the Lifeworld and Scientific Orientation"), in Martin Dinges, ed., Medizinkritische Bewegungm im Deutschen Reich (ca. 18701.a. 1933) (Medicine-Critical M m e n t s in the German Empire [c. 18701.. 19331) (Stuttgart Steiner, l%), p. 79-108. 35 On concepts of the body in the early modem period, c.f. Robert Jiitte, "Die Frau, die Kriite und der Spitalmeister. Zur Bedeutung der ethnographischen Methode fiir eine Sozial-und Kulturgeschichte der Medizin" (''The Woman, the Toad, and the Hospital Director: On the Si(3nificanceof the EthnographicalMethod for a Social and Cultural History of Medicine"), Historische Anthropologie, 4 (1996): 193-215; on the taking of temperature see Volker Hess, "Die Normierung der Eigenw-e. Fiebermessen als kulturellePraktik" ("The Measuring of Temperature as a Cultural Practice"), invoker Hess, ed., Die Normierung von Gesundheit. Messende Verfnhrender Medizin als kulturelle Pmktik (The Standardization of Health: Methods of Measurement in Medicine as Cultural Practice) (Husum: Matthiesen, 1997), p. 169-88; on auscultation, see Jens Lachmund, Der abgehorchte Kiirper. Zur historischen Soziologie der medizinischen Untersuchung (The

ail^

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37

38

39 40 41 42 43

44 45 46 47

48

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Body Listened To: Towards a Socwlogical Histoy ofMedical Examinatwn) (Opladen:Westdeutscher Verlag, 1997)p. 229-41; and on smallpox vaccination, Eberhard Wolff, Einschneidende Ma$nahmen. Pockenschutzimpfung und traditionale Gesellschajl im Wiirttemberg des frrihen 19. Jahrhunderts (Smallpox Vaccination and Traditional Society in Early Nineteenth-Centuy Wiirttemberg)(Stuttgart Steiner, 1998). Francisca Loetz has recently demonstrated the need to relativize considerably both of these arguments, in her "Andere Grenzen: Faktoren iirztlicher Inanspm+dune in Deutschland, 1780-1830. Empirische Ergebnisse und methodologische Uberlegungen" ("Other Boundaries: Factors in the Use of Doctors in Germany, 1780-1830. Empirical Results and Methodological Considerations), in Wiesemann und Schnalke, eds.,Die Grenzendes Anderen, p. 25-48,esp.p. 32-4. Huerkamp, " h t e und Patienten," p. 40; Claudia Huerkamp, Der Aufitieg der Ante im 19. Jahrhundert. Vinn gelehrten Stand zum profissionellen Experten-Das Beispie1 Preuj3ens (The Rise of the Doctors in the Nineteenth Centuy : From Learned Rank to Professional Expert-The Example o f Prussia) (Gottingen:Vandenhoeck und Ruprecht, 1985), p. 58; andFrevert, Krankheit als politisches Problem,p. 274. Annette Drees, Die Ante auf dem Weg zu Prestige und Wohlstand. Sozialgeschichte der wiirttemb+schen h t e im 19. Jahrhundert(Doctorson the Way to Prestigeand a C o m m able Lifi: The Social History o f Doctors in Wiirttemberg in the Nineteenth Century) (Mhster: Coppenrath, 1988)p. 135,141-44. ~ u e r k a m"kzte ~, und Patienten," p. 58f. E.g.,Drees, Die Ante,p. 135. Loetz, Vom Kranken zum Patienten, p 12336,227-52. C.f. Loetz, "Andere G m , " passm. Lachmund and Stollberg, Patientenwelten, p. 74f.Studies on cities in the early modem period by means of this changein perspective attained similar refinements of analysis (Robert Jiitte, Ante, Heiler und Patienten. Medizinischer Alltag in der w h e n Ne-t [Doctors,Healers, and Patients: Medicine in Everyday Lifi in the Early Modem Period] [Miinchen, Ziiririch: Artemis und Winkler, 11991, p. 90,100,105,226; and Annemarie Kinzelbach, Gesundbleiben, Kmnkwerden, A n p i n in derfriihneuzeitlichen GesellschaP. Gesunde und Kranke in den Reichsstiidten Uberlingen und Ulm, ISM-1700 [Staying Healthy, Getting Sick, and Being Poor in Early Modern Society: Healthy and Sick People in the Imperial Cities iiberlingenand Ulm, lS@l-l700][Stuttgart:Steiner, 19951~. 295300). Lachmund and Stollberg,Patientenwelten, p. 6740,136-39. Ladunund and StoUberg,Patientenwelten,p. 80-83. Lachmund and Stollberg, Patientenwelten, p. 99-106. This is not the place to detail further kinds of source material for quantified, oftendemographic data from which behavior patterns but also, to some degree, attitudes can be worked out. C.f. Reinhard Spree, Soziale Ungleichheit oor Krankheit und Tod (Social Inequality in Respect to Sickness and Death) (Gattingen: Vandenhoeck und Ruprecht, 1981).For an attempt to quantifyqualitativedata on the "health concern" in nineteenth-century Norwegian society, see Oivind Larsen, "Health Challenges in a Changing Society-Regional Patterns of Epidemic Diseases, and the Attitudes towards Them,1868-1900," in Oivind Larsen, ed., The Shaping ofa Profession: Physicians in Nomay, Past and Present (Canton, M A : Science History Publications, 1996),p. 87-%. See, for more detail, Eberhard Wolff, "Der 'willkommene Wiirgeengel'. Verstehende Innenperspektiveund 'genaue' Quelleninterpretation-am Beispiel des eMriinschten Kindertodes in den Anf'bgen der Poclmwchutzimpfung" ('The Well-met Angel of Death': Inner Perspectives Adopted with Understanding, and the 'Exact' Interpretation of Sources-As Exemplified by the Desire for Children's Death in the Early Days of Smallpox Vaccination"), in Martin Dinges and Thomas Schlich, eds., Neue Wege in der Seuchengeschichte(New Paths in the History of Plagues) (Stuttgart Steiner, 1995). Johanna Bleker and Eva Brinkschulte, 'Windpocken, Varioloiden oder echte Menschenpocken?-Zu den Fallstricken der retrospektiven Diagnostik. Eine Untersuchung anhand der Patientendateien des Wiirzburger Juliusspitals 1819-1829"

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("Chicken Pox, Varioloid, or Genuine Smallpox?--On the Trickinessof Retrospective Diagnosis: An Investigation Based on Patient Archives of the Wtirzburg Juliusspital I8l9-1829"),NTM, n.s. 3 (1995):97-115, esp. 99. Barbara Clow, " 'Swapping Grief', The Role of the Laity in Alternative Medical Encounters,"Journal of the History of Medicineand Allied Sciences,52 (1997):175-201. Elkeles, "Der Patient," p. 358. Daniel, "Clio unter Kulturtxhodc," p. 200f. Stolberg, "Probleme und Perspektiven." Thomas Schlich, "Wissenschaft: Die Herstellung wissenschaftlicher Fakten als Thema der Geschichtsforschung" ("Science: The Production of Scientific Facts as a Topic in HistoricalResearch), inPaul and Schlich, eds.,Medizingeschichte, p. 107-29.