I. HISTORICAL PERSPECTIVES

The following article is a reprint of the first-edition article "Therapeutic Relationship: History of the Relationship" by the same author, with only minor changes.

We give the name "therapeutic relationship" to the link established between an individual (the patient) and another individual or group (the healers), with the aim of curing or relieving the disease suffered by the former. Our problem is to describe as exactly as possible the various forms this relationship has assumed throughout history.

The Empirico-Magical Stage

Ever since records have existed concerning the treatment of the sick, we may distinguish the following four chief forms:(1) the spontaneous or instinctive, (2) the empirical, (3) the magico-religious, and (4) the scientific. In all periods of history, all of these forms have had their practitioners. The mother who holds her feverish child on her lap, embracing it to protect it from the cold air, illustrates the first form, spontaneous or instinctive help. The second form, empirical help, consists in using a remedy because it has provided some relief in similar cases—that is, without asking why the remedy has those particular healing qualities. Medicine owes some very important discoveries to therapeutic empiricism. The treatment of wounds from firearms, discovered by chance by Ambrosio Paré (c. 1510–1590); the introduction of quinine into the Western world; and Edward Jenner's vaccination against smallpox are three superb examples. Generically speaking, in magico-religious treatment both healer and patient believe that the cure is due to the action of "supernatural" or "divine" powers available for the purpose. In some cases the curative effectiveness of these powers depends on "who" uses them (medicine man, shaman, witch doctor, etc.); in others, on "how" they are applied (magic ritual); and in others, upon "where" the cure takes place (in localities "singled out" or "favored" for their healing powers—some shrine, island, or spring).

Since scientific treatment in the strict sense began in Greece in the fifth century b.c., we can definitely state that from the origin of the human race and for many thousand years thereafter, the therapeutic relationship was empiricomagical in character, with either the "empirical" or the "magical" element of the healing process dominant, according to circumstances. It is known that in the most highly developed pre-Hellenic cultures of ancient Egypt, China, and India, a form of medicine existed in which strictly "magical" or magico-religious elements were minor compared with the empirical and theoretical. However, a careful study of these three methods of understanding and practicing the care of the sick would reveal to some extent attitudes of the doctor that can only be called "magical" and that, above all, show a lack of principles capable of initiating a way toward purely "scientific" medicine.

The Ancient Scientific Stage

As Aristotle taught, treatment of the sick is scientific ("technical") in the strictest sense when it depends on the knowledge of why it is being done, what is being done, and by what means it takes effect (in other words, what is the disease, what remedy is being used, and by what therapeutic procedure is it administered). Thus the healer's ability to cure does not depend on the agent who applies the remedy, nor on the ceremony accompanying its application, nor on the privileged place where the cure takes place—that is, not on a magical "who," "how," or "where," but on a series of "whats" concerning the illness and its remedy.

Taking as their starting point the most important cosmological idea of the pre-Socratic philosophers—the idea of physis, or "nature"—the group of physicians, the Aesclepiades, known as Hippocratics, originated the technical concept of illness a century before Aristotle formulated the conceptual definitions just mentioned. Consequently, a doctor would try to cure a patient or to alleviate the patient's pain in the rational or scientifically definitive knowledge of the "nature" of humans, of illness in general, of the special disease he was treating, and of the remedy being used—while at the same time having the knowledge and skill to perform everything required by the treatment. This is not to say that Hippocratic medicine—apart from its inevitable deficiencies—was free from some serious errors and superstitious practice but to affirm that it already contained various principles: the notion of physis as the basis of all technical knowledge, the concept of medicine as téchne iatriké, the idea of a method of knowing whose first rule is the attentive sensory examination of the patient's body—as a result of which defects and errors would be gradually corrected.

From Hippocrates to Galen (a.d. 130?–200?)—while the ancient view of technical medicine remained in force—the therapeutic relationship can be described under four heads.

BASIS OF THE THERAPEUTIC RELATIONSHIP. Ideally considered, this basis is philanthropia, the "love of man," because, according to a famous saying, "Where there is love of man, philanthropia, there is love of the art [of healing], philotechnia" (Hippocrates, Praeceptiones, L.IX, 258). Of course, this saying belongs to a later, post-Stoic period; but the study of much earlier medical texts, such as the Epidemias, gives grounds for the belief that the Hippocratics, as they were called, practiced philanthropia before the word was invented. In any case, the "love of man" of ancient Greece was the same as "love of nature," of the divine physis, as is specifically and individually realized in the name given to the subject in question: physiophilia. It is not necessary to add that less noble interests, such as love of money and thirst for fame, in practice often obscured this ethical and technical ideal of "physiological philanthropy" as the basis of the therapeutic relationship.

DIAGNOSTIC ASPECT OF THE RELATIONSHIP. As scientific and effective "knowledge" was the first premise of the technical concept of medicine, the therapeutic relationship required—as it has of doctors since—that the Greek physician should reach a diagnosis by rational means. During the period in the history of medicine here called "ancient scientific," this diagnostic activity appears to have consisted of (1) a fourfold desire to discover whether the illness is determined by an insuperable and necessary cause (kat'ananken) or by some controllable contingency (katà tychen); to identify the typical form (tropos, eidos) of the suffering; to determine its causes, both remote and immediate (aitia, prophasis); and to establish a well-founded prognosis; (2) a series of exploratory maneuvers (anamnesis, study of the surroundings, examination of the patient's body by means of sight, touch, hearing, smell, and taste); and (3) adequate inductive reasoning (logismos).

CURATIVE ASPECT OF THE RELATIONSHIP. After some deliberation, the therapeutic activity of the Greek doctor was subjected to the following rules: (1) to help the patient, or at least to do no harm to the patient (Hippocrates, Epidemias, I, L.II, 634); (2) to refrain from interfering if the illness were incurable and inevitably mortal, because in that case the doctor, by intervening, would commit the sin of hybris, or rebellion against an edict of the divine and sovereign physis; and (3) insofar as possible, to attack the cause of the disease therapeutically. Diet, drugs, surgery, and to a lesser degree "psychotherapy" were the four great healing methods of ancient medicine.

ETHICAL AND SOCIAL ASPECTS OF THE THERAPEUTIC RELATIONSHIP. One must avoid the common error of seeing the oath contained in the Corpus Hippocraticum as the ethical code of Greek medicine; in all probability it was not in force outside the Pythagorean order (Edelstein). However, it is possible to trace the outline of the medical ethics and social medicine of the ancient Greeks:

The doctor's duties to the patient: to help or not to harm, to abstain from the impossible, to adjust the fees to the patient's income.
Duties toward other doctors: The ideal principle of regarding colleagues as brothers (Hippocrates, Praeceptiones, 4, IX, 258) was very infrequently infringed by the competitiveness of which doctors of antiquity are so often accused (Edelstein).
Duties toward self: A doctor should give attention to personal appearance and behave in a manner that would be called "beautiful and good" (Hippocrates, Medicus, L, IX, 204). To serve nature through the application of professional skill (Hippocrates, Epidemias, I, L.11, 636) should be the physician's paramount principle.
Duties to society: Though clearly stated by Plato (Republic, Laws), these are given much less importance in strictly medical writings; in any case (Plato, the Hippocratic treatise On Diet), it is certain that there was "medicine for the rich" and "medicine for the poor" in the ancient world.

Christianity and the Therapeutic Relationship

The propagation of Christianity was not motivated by the need to reform the conduct of doctor toward patient, insofar as this conduct could be held as technical, but because the medical technique prevailing at the time had been created by pagans. Because the Christian concept of love was relatively new, Christ's religious message influenced both the problem and the form taken by the therapeutic relationship in various ways.

Could the pagan medical technique have been accepted without more ado by Christians? Out of excessively vehement opposition to paganism, some of them—Tatian the Assyrian and Tertullian, for instance—gave a negative answer to this question. But the good sense of others prevailed in the end; and thus, from the fourth century to the increasingly strong anti-Galenism of the sixteenth and seventeenth centuries, the medicine of Christian peoples (e.g., in Byzantium and medieval Europe) showed a progressive intellectual effort to relate the art of healing, inherited from ancient Greece and culminating in the work of Galen, to the Christian worldview.

One can note the novelty of the Christian concept of love and its decisive effect on the form taken by the therapeutic relationship. When this was the direct, pure expression of the evangelical message—in other words, before Constantine's edict led to the primitive Christian communities' becoming involved with the civil power—there were two chief features of its structure.

IDEAL BASIS OF THE THERAPEUTIC RELATIONSHIP. We are no longer facing love of physis or universal "nature," as individualized in the sick person; rather, we are confronting his or her unique persona as a "neighbor" (parable of the good Samaritan). Moreover, in helping an ailing neighbor, one is helping Christ (Matt. 25: 39–40).

THE THERAPEUTIC RELATIONSHIP AS HELP. Herein lie the most significant new developments in primitive or pre-Constantinian Christianity.

In the assistance given to the sick person there should be no "natural limits," thus putting an end to the Hellenic imperative to refrain from therapy in cases of "necessarily" mortal or incurable disease. Here, although there is no place for therapeutic technique, the patient can always be helped by spiritual advice.
The egalitarian nature of treatment: No difference should be made between Greeks and barbarians, free people and slaves, friends and enemies.
The necessity of giving free help: Within a community governed by the principle that possessions are shared (see the texts of Acts of the Apostles), the basic motive of help for the sick was charity, not only on the part of the doctor but also on the part of other people (widows acting as nurses and, later, "deaconesses"). The Greek doctor would give free treatment in exchange for some favor received or to acquire prestige in the town (Hippocrates, Praeceptiones, L.IX, 258); the Christian doctor should give help free, on principle.
Such practices of the Christian religion as prayer and extreme unction were incorporated into the care of the sick.

The Medieval Scientific Stage

After Constantine's Edict of Milan (c.e. 312), the links between Christianity and the civil power became increasingly strong, and this gave rise to public awareness that the Christian life, such as was led outside the new conventual communities, was losing at least some of its original purity. This is shown by a brief examination of the two main politicosocial forms of Christianity, during the historical period that we call the Middle Ages, in the Byzantine Empire and medieval Europe. Exigencies of space allow no more than a mention of the third great cultural ambit of the Middle Ages: the world of Islam.

THERAPEUTIC RELATIONSHIP IN BYZANTIUM. The theocratic fusion between the Christian religion and civil power has never been stronger than in the Byzantine Empire; never has religious error or heresy been more methodically and sternly treated as "political crime." From this are derived the two main characteristics of the therapeutic relationship in Byzantine society: its doctrinal basis and its importance as help. The doctrinal basis of the therapeutic relationship in the Byzantine world was essentially the result of a juxtaposition that never turned out well. On the ethical plane, Byzantine medicine went on accepting and proclaiming the Christian concept of helping the sick; on the technical plane it accepted in principle everything described by the Greeks as "practical," and refused to acknowledge (as pagan and evil) the basic "theoretic" concepts of Hippocratic-Galenic medicine—for example, the notion of physis as "divine" and the denial or negation of a personal, spiritual God, creator of the world and transcending it. The doctors of Byzantium did not succeed in connecting the dogmas of their Christian faith with the scientific and philosophic basis of Hellenic téchne iatriké.

The most important contribution made by Byzantine Christianity to medical care was the creation of hospitals to treat poor invalids; among them was the famous "hospital city" of Caesarea, founded about the year 370. (Earlier institutions did not strictly deserve the name "hospitals.") In those institutions there were specialists, male and female nurses, surgeons, assistant doctors (parabalani), and servants. Charity was the ruling principle in their activity, but that did not prevent the distinction between "medicine for the rich" and "medicine for the poor" from being clearly observed in Byzantium. And finally, we must mention the magical and pseudoreligious cures, which particularly attracted poorer patients.

THE THERAPEUTIC RELATIONSHIP IN MEDIEVAL EUROPE. The historical period we call the Middle Ages covers the millennium between the invasion of Rome by the Germanic races and the conquest of Constantinople by the Turks in 1453, and is far from uniform in character—suffice it to compare the life in a feudal castle in the ninth century with that of a Flemish or Italian town in the fifteenth. It is shown also by the gradual changes in the therapeutic relationship throughout this period.

Doctrinal basis of the therapeutic relationship. Two chief aspects must be distinguished—the technical and the ethical. Until the School of Salerno became famous (in the eleventh and twelfth centuries) and the Scholastic medicine of the thirteenth to fifteenth centuries was flourishing, medieval medicine hardly deserves the term technical or scientific in the strict sense. Mainly practiced by monks ("monastic medicine") either inside or outside monasteries, it was based solely on a certain amount of experience and the extremely scanty remains of ancient learning that had survived the destruction of the Roman Empire.

There was a marked change at the beginning of the twelfth century: Secular doctors with professional degrees became more common; from the time of Roger of Sicily in 1140, Greco-Arab learning began to spread from Salerno, or from Toledo, and became truly "technical" medicine, an authentic ars medica. By means of the intellectual resources provided by the theology and philosophy of the period, the Scholastic European doctors of the thirteenth and fourteenth centuries achieved something not attained by Byzantine medicine; they systematically adapted Hippocratic and Galenic thought to the needs of the Christian faith.

From the ethical point of view, medieval medicine continued to base itself ideally on the Christian concept of aid for the needy and sick—ideally because in practice the pressure of economic interest was not uncommon, nor, sometimes, free from corruption.

Diagnostic aspect of the therapeutic relationship. Though it had become impoverished and schematized in comparison with that of ancient Greece, the diagnostic relationship between doctor and patient—examination and establishment of "genus" and "species" of the affliction observed—remained much the same. Two techniques gained prominence and were gradually perfected: examination of the urine (uroscopia) and taking of the pulse. There were also two doctrinal guidelines to help the doctor pass from clinical experience to reasoning, treatises that systematically described the different species of disease (de passionibus, deaffectionibus) and the didactic descriptions of individual cases of disease (consilia).

Curative aspect of the therapeutic relationship. From a technical standpoint the Middle Ages added little that was new to the treatment of the sick as taught by Greek and Arab doctors. Diet, the use of drugs, surgery, and "psychotherapy"—with a Christian orientation—remained the principal methods of treatment. As to theory, the chief concept of Galenic therapy, the "symptom" (endeixis), became latinized and scholasticized under the name of insinuatio agendi. On the other hand, the problem arose of how to harmonize "technical" requirements derived from the Galenic concept of symptoms with the "moral" rules imposed by the Christian idea of the person: the bond between ars and caritas. However, medieval physicians did not succeed in solving this delicate human problem coherently or systematically.

Ethical and social aspects of the therapeutic relationship. As to principles and ideals, medieval medical ethics are as faithfully Christian as the society to which they belong; but individual and social realization of this sincere Christianity was very different from that prevailing in pre-Constantine communities. Four reasons contribute to this:

The avarice of many clerical and secular doctors: "Doctor, do not be afraid of asking good fees from the rich," wrote Lanfranc in the eleventh century.
The growing interference of the civil power in regulating doctors' duties by means of ordinances—relating not only to the healer's technical behavior but also sometimes to his religious conduct—infringement of which was punished.
The frequent critico-burlesque attitude of society toward the doctor's greed for gain or lack of skill (John of Salisbury's Metalogicus and Petrarch's Invectivae).
The marked difference between "medicine for the rich" and "medicine for the poor"—in monasteries, the distance separating the infirmarium from the hospitale pauperum; in cities, the even greater gap between the treatment of those in power—politicians or churchmen, nearly all of whom had their own private doctors—and the almost purely religious treatment given to the unfortunates in hospital beds. Not everything in the Christian Middle Ages was in fact Christian.

Modern Scientific Stage: Christian Modernity

It is a platitude to say that the "modern world" began with the Renaissance or even in the fifteenth century. However, a thorough study of the various characteristics of this modernity—greater knowledge of classical antiquity, importance of worldly matters, new conceptions of science, rationalization of life, awareness of historical progress—clearly shows the roots of all these developments to be present in the transition from the thirteenth to the fourteenth century, when the voluntarism and nominalism of Franciscan thought (e.g., William of Occam, 1285?–1349?) began to influence European culture. When human freedom (and hence human creative ability) was seen as a person's chief similarity to God, the idea of "natural" and "necessary" limitations to human scientific and technical capacity with regard to the cosmos disappeared in principle, and the human mind began to entertain the idea of "indefinite progress." Science and modern techniques took their first steps, in the belief that knowledge of the sensible world consisted in creating abstract symbols—they would soon be called mathematical symbols—by means of which the external world could be understood and dominated. Many years had to pass, however, for these germinal concepts to be converted into strong, widespread social customs. Only in the secularized society of the eighteenth through the twentieth century would a great tree grow from the tiny seed of the fourteenth century.

Two periods must be distinguished in the history of the modern Euro-American world: In the first, from the fifteenth to the second half of the eighteenth century, by far the largest proportion of society was still nominally Christian, although the form of religion, whether Catholic or Protestant, was growing away from that of the Middle Ages; in the second, the nineteenth and twentieth centuries, society was becoming secularized.

BASIS OF THE THERAPEUTIC RELATIONSHIP. Whether Catholic or Protestant, modern Christian doctors still saw the injunction to give charitable help to those in need as the basic ideal of healing activity: They thought of Theophrastus Paracelsus, they remembered the ritual oath taken by newly graduated French doctors in front of the altar of Notre Dame. But the diversity of religions in Europe and America, and the growing esteem both for the reality of worldly values and for increasing civil power, led to two new features in this ideal: (1) greater respect for the personal religious life of the patient; and (2) an increasing and sharper separation between the spiritual and material worlds, the latter being known and governed by the beginnings of modern science and the technology founded upon it. Two examples of this spiritual–material separation will suffice: Hermann Boerhaave's teaching of the distinction between the mind and the body (De distinctione mentis a corpore) and Friedrich Hoffmann's significant anthropological contrast between the physical (cor corporale) and the spiritual (cor spirituale).

DIAGNOSTIC ASPECT OF THE THERAPEUTIC RELATIONSHIP. The principle of understanding nature in order to master it (Francis Bacon, René Descartes) gained strength in modern society and led to the physician's concern to make diagnoses that were objectively correct. Very briefly, the following are the chief characteristics of the diagnostic aspect of the therapeutic relationship during this period:

Understanding of the disease being treated became more individualized, as was very clear in the form taken by case histories (Giovanni Battista Montanus, Boerhaave, etc.).
Numerical measurement gradually began to figure in examinations, leading to the first use of instruments such as watches and thermometers.
Diagnosis was increasingly used to guess at the existence of an anatomic lesion, which could be proved by an autopsy (Giovanni Maria Lancisi and Hippolyte Albertini, Hermann Boerhaave, Giovanni Battista Morgagni).
A more lively and objective interest was evinced in the influence of the social environment on the disease (Paracelsus, Bernardino Ramazzini, Johann Peter Frank).

CURATIVE ASPECT OF THE RELATIONSHIP. The spread and strength of the modern scientific mentality required a doctor who wished to keep up with the times to validate by experimentation the efficacy of the available remedies. On the other hand, awareness of human power over natural phenomena demanded a constant increase in the number and curative scope of those remedies. Paracelsus thought that every natural substance could be an efficacious medicament, if convenient means of using it could be discovered; God had disposed the world thus when it was created, and this the inquiring and inventive intelligence of the doctor should be able to make plain. Consequently, doctors no longer saw themselves as "servants of nature by means of their skill," as in ancient Greece but also during the Middle Ages in a Christian interpretation of the words as the true "collaborators of God." Whether Paracelsists or not, the most eminent doctors of the fifteenth to eighteenth centuries made use more or less consciously of this concept of therapeutic activity. But at the same time there was increasing distrust of the healing qualities assumed to belong to many of the remedies traditional practice had recommended.

The main therapeutic methods were still the four employed in Hippocratic medicine: diet (adapted to new ways of life), cure by drugs (enriched by various new medicines), surgery (whose technique had advanced considerably, from Ambrosio Paré to William Cheselden, Percival Pott, and Hunter), and, on a distinctly lower plane, psychotherapy, whose later triumph was unconsciously heralded by Franz Anton Mesmer at the end of the eighteenth century. The separation of healers into "doctors" (or "physicians") and "surgeons" was daily becoming more clear.

ETHICAL AND SOCIAL ASPECTS OF THE PROFESSIONAL–PATIENT RELATIONSHIP. Since both doctor and patient were Christians, it was natural for doctors to find their ethical principles in those of the Christian life; but at the same time, since the creation and rational order of the world had gained greater stature as explanations of the world, it was also natural for the form in which these principles were individually and socially realized to change to some extent. There should have been, and indeed there was, a relationship between religion and medicine that was both theoretical and practical. As religion was concerned with the life of the spirit and medicine with the life of the body (or what human knowledge tells us about the cosmos), the scientist and the physician did their best to discover and establish points of direct communication between those two worlds. In regard to theory, such communication was guaranteed by the "harmony" between Holy Writ and science, for example, in Francisco Valles's Sacra philosophia (sixteenth century) and Friedrich Hoffmann's Dissertatio theologico-medica (eighteenth century). Naturally, such communication and the bridge establishing it had to take a different form on the practical level. There the communication gave rise to "medical deontology," a collection of ethical precepts that were to be respected in the healer's technical activity. Examples of both early and mature forms of them are found in certain parts of the Quaestiones medico-legales of Paulo Zacchia (1621–1635) and the Embriologia sacra of Francesco Emmanuel Cangiamilla (1758).

Between the fifteenth and the seventeenth centuries, and therefore during the ancien régime, the bourgeois structure of society in Europe and America was being developed, and three distinct strata began to emerge: the "upper classes" (aristocrats, magnates of church and state, rich merchants), the "middle classes" (artisans, officials, and members of various professions), and the "lower classes" (laborers, the poor). Parallel strata could be observed in medical care. Ill persons of the upper classes were looked after in their luxurious homes and had a monopoly on more expensive treatments (one need only think of the distribution of quinine in the seventeenth century). The lower classes still went to hospitals for the poor, although during the eighteenth century those were altered or completely rebuilt on a larger scale. But the care of the sick inside those hospitals was far from acceptable (as to dirt, parasites, smell), as can be seen from denunciations by some socially and philanthropically sensitive doctors, like James René Tenon in 1788 and Howard in 1789. Nor was the medical care of the middle classes entirely satisfactory.

Modern Scientific Stage: Secularized Modernity

The process of secularizing society advanced at progressive speed during the nineteenth and twentieth centuries. Certainly there were still many Christians in the cities of Europe and America, but their individual and social style of living, their habits, were affected by this secularization; and it was in the eighteenth century that distinct groups came to be known as "intellectuals" and "aristocrats," and later (from the second half of the nineteenth century) a class came to be known as "proletarian."

Combined with this increasing secularization of behavior, we find that in the nineteenth century, life was becoming more technical, and in consequence of the industrial revolution an urban proletariat made its appearance. Sub-missive at first, the proletariat afterward organized itself as the "workers' movement" and asserted its rights more effectively, so that in one way or another it has decisively contributed to shaping the social scene of the twentieth century. How was the therapeutic relationship to be interpreted in this secularized world, part bourgeois, part proletarian?

DOCTRINAL BASIS OF THE RELATIONSHIP. As had been the case ever since Hippocratic medicine, the doctrinal basis of this relationship had two essential aspects, one ethical, the other scientific or technical. First, from an ethical standpoint, the ideal motive of medical care of the sick was "philanthropy," the feelings and the rules of conduct in which Christian charity was secularized. But modern philanthropy was radically different from the Hippocratic form (which had as its ultimate goal the divine physis, or universal nature), in that it was concerned with the "individual persona" of the patient—although the doctor's theory of humanity might not be formally "personalist." During the nineteenth and twentieth centuries many doctors have been "naturalist" in theory (in their scientific concept of human nature) and "personalist" in practice (in their therapeutic relation with the patient). Not until Marxist socialism did there appear a philanthropy based on the notions of "social or civil nature" and "state of nature." Second, from a scientific point of view, the ideal basis of medical care was the concept of medicine as the application of pure natural science. "Medicine should be natural science—in other words, what the second half of the nineteenth century understood as natural science—or it will be nothing" was the oracular saying of Hermann Helmholtz. The sick person was scientifically considered as a fragment of the cosmos, acted on by biological evolution and governed by the laws of physics and chemistry. Scientifically, because in practice nearly all doctors obeyed the rule of Joseph Frédéric Bérard and Gluber: Guérir parfois, soulager souvent, consoler toujours (heal sometimes, relieve often, always console). This does not, of course, preclude the usual corruption of the medical profession—desire for gain, thirst for social prestige—often contaminating that philanthropic and scientific ideal.

DIAGNOSTIC ASPECT OF THE RELATIONSHIP. The diagnostic relationship with the patient now conformed to the following principles:

The patient was seen, above all, as an individual, capable of being rationally understood.
This understanding was increased by means of the instrumental aids to clinical examination (stetho-scope, sphygmograph, ophthalmoscope, chemical analysis, X rays, etc.).
The disease was scientifically understood by applying rules that were anatomoclinical (diagnosis of anatomical lesions), physiopathological (diagnosis of disorders typical of the functional and material processes of life), or etiopathological (diagnosis of external causes, microbes, poison, etc., of the disease process); or the doctor could try to coordinate these three approaches.
Neurosis, whose frequency increased from the second half of the nineteenth century as a result of industrial civilization, was understood by natural scientific medicine by reference to anatomoclinical (Jean-Martin Charcot) or physiopathological rules (German practice since Friedrich Frerichs and Ludwig Traube).
To sum up, the diagnosis was, or tried to be, at the same time natural-scientific and individualist.

CURATIVE ASPECT OF THE RELATIONSHIP. When medicine was considered as applied natural science, the doctor's powers of healing (by experimental pharmacology, surgery enhanced by the development of anesthesia and antisepsis, synthesis of new drugs, serum therapy, vaccination, etc.) were progressively and wonderfully increased. Moreover, giving broad social expression to what was merely a slight and theoretical germ at the end of the thirteenth century and the beginning of the fourteenth, doctors freed themselves from the Hellenic concept of "natural force" (ananke physeos) and began to think of humans as not being, in principle, subject to diseases that were mortal or incurable "of necessity." What could not be cured today might well be curable tomorrow. In fact, the doctor ceased being "the servant of nature by means of skill" and became instead nature's "guardian, master, and sculptor."

Alongside dietetics, now scientifically regulated, increasingly rich therapy by drugs, and increasingly effective surgery, the psychotherapeutic element in treatment was acquiring more importance through several different methods and interpretations. In the history of this renewed importance of psychotherapy, the most distinguished names are those of the Englishmen Daniel Tuke, Alfred John Carpenter, and Hughes Bennet; the Frenchmen Jean-Martin Charcot and Bernheim; and, above all, Sigmund Freud, whose work had already reached maturity at the start of World War I in 1914.

ETHICAL AND SOCIAL ASPECTS OF THE RELATIONSHIP. Something has already been said about medical ethics in the society of the nineteenth and twentieth centuries. Like the society to which it belonged, this ethics became more secular, as is shown by the attempts to codify it, beginning with Percival's in 1803. From an ethical and social point of view, medical care was a service purchased at different prices or given free to the poor in hospitals supported by charity and inspired by the new philanthropy. The poor received medical care as a gift.

The sick were cared for in three different ambits.

Hospitals were supported by charity, the state, the municipality, or the church. Here the patient was one of two things in relation to the doctor: either an object that could be scientifically understood and modified, combined with a human being who was unknown and indifferent (if the doctor was a cold and matter-of-fact person), or an object that could be scientifically understood and modified, combined with a person suffering and in need of compassion (if the doctor was a person of feeling and carried out the rule of Bérard and Gluber).
The patient's own home. The patient visited at home was an object that could be scientifically understood and modified, combined with a well-known person—a friend.
The doctor's private consulting room. Here the patient was, according to circumstances, an object that could be scientifically understood and modified, combined with a person to whom the therapist was indifferent (purely "scientific" doctors); an object that could be understood and modified, combined with a person who paid the fee asked (doctors dominated by desire for gain); or an object that could be understood and modified, combined with a friend in need of compassion (generous, sympathetic doctors).

These three ambits, with certain exceptions, correspond to the three strata into which the bourgeois and proletarian society of the age are divided, and to the three socioeconomic methods of providing medical care: "medicine for the rich" (private consulting rooms for specialists), "medicine for the middle classes" (attendance in their homes), and "medicine for the poor and proletarians" (charitable hospitals). The injustice of this social organization of medicine becomes flagrant and untenable when the proletariat becomes conscious of its right to health and proper medical care, and when, one may add, medical treatment is both efficient and expensive.

Since the second half of the nineteenth century there has been a visible rebellion against this injustice with its politicosocial and clinical aspects. Since Turner Thackrah in 1831, Sir Edwin Chadwick in 1842, and Louis René Villermé in 1840, some doctors have denounced the terrible effects of industrial poverty on health; and workers' movements have included the right to put an end to this painful and unjustifiable situation in their programs for social reform. The great vogue of Friendly Societies in the United Kingdom between 1800 and 1875, the institution of the zemstvo system in tsarist Russia in 1867 after the liberation of the serfs, and the creation of Krankenkassen in Germany by Otto von Bismarck (1882–1884) are examples of the first medical results of the proletarian rebellion.

Among the clinical results of this rebellion may be counted the increase in neurotic forms of illness, which in some cases were direct consequences of social injustice and maladjustment. The "introduction of the subject in medicine" (von Weizsäcker's term), that is, the methodical study of the patient as an individual, both in diagnosis and treatment (penetration of hospitals by Freudian psychoanalysis and psychosomatic medicine) and in social pathology and medical sociology (Grotjahn and various English authors), constitutes the response of scientific medicine to the clinical rebellion of the sick against the medical care of the nineteenth century.

To the layperson as well as to the doctor of today, the present period begins with World War I. From that point on, the historian of yesterday must defer to the chronicler of the present day.

pedro laÍn entralgo (1995)

translated by frances partridge

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Professional–Patient Relationship: I. Historical Perspectives

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