Soviet Psychology

ISSN: 0038-5751 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/mrpo19

The Intrinsic Picture of Illness and Iatrogenic

Diseases

R. A. Luria

To cite this article: R. A. Luria (1987) The Intrinsic Picture of Illness and Iatrogenic Diseases,
Soviet Psychology, 26:1, 25-36

To link to this article: http://dx.doi.org/10.2753/RPO1061-0405260125

Published online: 19 Dec 2014.

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 R. A. LURIA

The Intrinsic Picture of

Illness and Iatrogenic Diseases
llvo circumstances prompted me to to write this book. Long years of
teaching physicians the pathology, clinical aspects, and treatment of
internal diseases have convinced me that as instrument and laboratory
studies of patients improve, we often find that the therapist is ascribing
increasingly less importance to the study of subjective sensations and,
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most importantly, to the patient’s personality. . .

. . . I think that these issues-study of the subjective picture of a
disease and iatrogenic diseases-are two aspects of the same phenom-
ena: the correct approach on the part of the physician to study of the
personality of the patient, a question I pose and attempt to explore here.
I shall just outline the main aspects of the problem, which I consider to
be as important practically as it is theoretically. Later, a series of
extensive studies will be undertaken to develop a method for in-depth
study of what may be called the “internal picture of a disease,” to
study the mechanisms of iatrogenic reactions, and to discover the laws
governing their origin. I should like here only to call the attention of
physicians and students to the tasks with which modern medicine con-
fronts the physician, or anyone who, because of his specialized knowl-
edge, may be called upon to exert an influence on another person-a
patient. . . .
. . . All the achievements of medical technology do not, and cannot,
eliminate the need to study the patient’s personality, i.e., the psycho-
physical processes underlying the patient’s subjective perceptions, his
suffering, and everything that led him to consult a doctor, and that is so
easy to overlook at this stage of illnesss if the physician is equipped
only with an objective, analytical method and undertakes to obtain only
“accurate,” objective signs of illness.
From Vnutrennyaya kartina bolevnei i iatrogennye zabolevaniya [The intrinsic pic-
ture of illness and iatrogenic diseases]. Moscow, 1944.

25
 26 R. A. LURIA

This is why, once again, we are facing the old question of the
importance of the patient’s subjective state and of having a method for
studying it; it is surely no coincidence that a number of contemporary
authors have drawn physicians’ attention to the interrelationship of
subjective and objective study of the patient. . . .
. . . With the tremendous and very fruitful development of medi-
cine, grounded firmly in chemistry, physics, and biology, the personal-
ity of the patient became somewhat eclipsed; and several generations of
physicians, with the exception of a few outstanding physicians of the
clinical schools (G. A. Zakhar ’in and F. G. Benovskii in our country),
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were taught if not to disregard the subjective complaints of the patient,

then at least to avoid methodical, planned study of such complaints,
which I consider a very essential aspect of our understanding of the
patient. That this is the case is indicated best by the latest textbooks on
internal diseases, in which the examination procedure is given a tri-
flingly small amount of space and many pages are devoted to laboratory
methods and tests, often already refuted long ago and justified neither
in the hospital nor, particularly, in medical practice. Is there any won-
der, then, that young physicians-even some who are no longer so
young-not only are unfamiliar with methodical study of the subjective
aspect of a disease but often limit themselves merely to a formal
interrogation of their patients, sometimes thus losing especially valu-
able information for making a diagnosis.
But in modern medical thinking, in which an anthropopathological
[holistic] conception has replaced a localist and vulgar morphological
conception of the pathological process, and in which clinical assess-
ment has begun to be structured around principles of functional psy-
chology, detailed and methodological study of the patient’s subjective
complaints is barely an empirical method, although it is steadily acquir-
ing a rigorous scientific foundation-indeed, scarcely less rigorous
than the methods of an “objective” study. . . .
. . . Thus, everything objective, from physical methods of investi-
gation and the doctor’s evaluation of the patient’s external appearance
to such strictly objective methods as laboratory and instrumental tests
and even roentgenoscopy and endoscopy, is, to a certain extent, rela-
tive, and becomes significant only when it is refracted through the
prism of the critical eye and synthesis of the examining doctor. Berg-
mann is profoundly right when he says: “It is also necessary to have a
good knowledge of the complaints, experiences, and character changes
of a patient, based on an examination of his illness, in order to make the
 INTRINSIC PICTURE OF ILLNESS 27

correct diagnosis and prognosis and, above all, to give medical treat-
ment.”’ It was for this reason that that very same Bergmann, in 1922,
in his report on gastric ulcer with inflammation, spoke about how many
doctors had hitherto neglected to study the subjective complaints of the
patient, despite the fact that a proper, critical interrogation of the
patient-which, to be sure, requires much time and effort-is much
more important for the diagnosis of this disorder than, for example,
determining the acidity of the gastric juices, which at that time was
very popular and attractive to some physicians who were endeavoring
to apply the methods of the exact sciences to clinical studies. . . .
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. . . I think it is wrong to speak of the subjective symptoms of a

disease separately, as we have been accustomed to doing since our
classroom days. Is it not better to examine both the external and the
internal picture of the disease? By the external picture I mean not only
the patient’s outward appearance, with its multitude of details-always
important for a diagnosis, because they provide the small clues that
often must be seized upon to make a diagnosis- but also what older
doctors called “physiognomy,” which they were able to read and
decipher so well. By the external picture of a disease I mean everything
that the physician is able to obtain through all the methods of research
accessible to him, including also the most precise methods of biochemi-
cal and instrumental analysis, in the broadest sense of the word-all
that may be described and in some way or another recorded graphically,
by numbers, curves, roentgenograms, etc.
The internal picture of a disease designates everything that the pa-
tient experiences and feels, the totality of his sensations, not only local
morbid sensations, but his general sense of well-being, his self-obser-
vation, his ideas about his disease, about its causes-all that, for the
patient, contributed to his seeking medical advice, all that enormous
internal world of the patient, which consists of very complex combina-
tions of perceptions and sensations, emotions, affects, conflicts, men-
tal experiences, and traumas.
Of course, this notion of the internal picture of a disease by no means
conforms to the usual understanding of a patient’s subjective com-
plaints, which are only one part of my conception of the patient’s
internal world; it is this world that I think it is necessary to study
thoroughly and in detail and that is so fruitful for diagnosis. Hence, it is
quite obvious that such an examination cannot, and must not, be a
stereotyped examination, which is what happens when the patient’s
past history and subjective state are recorded, but must be a deeply
 28 R. A. LURIA

individual study of the patient’s personality.

The totality of these sensations, experiences, and moods, together
with the patient’s own notions about his disease, is what Goldscheider
called an “autoplastic picture” of the disease, which includes not just
the patient’s subjective symptoms but also the information about the
disease that the patient has from his previous experience with medi-
cine, from the literature, from conversations with others, from a com-
parison of himself with similar patients, etc. Goldscheider examines
the sensitive and intellectual parts of the autoplastic picture of the
disease.
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The first, of course, consists of subjective sensations emanating

from a concrete, localized illness or a pathological change in the pa-
tient’s general condition.
The second is a superstructure created on the sensations by the
patient himself, his thinking about his illness, his sense of well-being,
and his condition. Goldscheider’s notion of the autoplastic picture of
disease addresses differences deriving from a subjective examination
of the patient. In some cases it will coincide with the findings of an
objective examination, and in others it will diverge sharply from the
latter if the intellectual part, which the patient himself fashions. has no
real foundation in an underlying somatic pathological process. Indeed,
the best examples of the internal picture of a disease are iatrogenic
diseases at the point at which the patient acquires a number of new
sensations, e.g., dyspeptic symptoms, under the influence of mental
trauma caused by his physician when the patient is informed that he has
no hydrochloric acid in his gastric juice or when he learns about gastric
sensations, palpitations, pains, and pressure in the chest; dizziness
resulting from the roentgenologist’s informing him that his aorta is
enlarged by half a centimeter, or from a negligible change in blood
pressure discovered by the doctor; etc. I have often observed, in health
spas, cases in which the intellectual part of the internal picture of a
disease had such origins, especially at Essentuka, where patients, total-
ly and solely absorbed with their own treatment and cure, are constantly
sharing impressions about their sensations and, what is even worse,
every sort of notion about the importance of individual analytical
parameters, roentgenograms, etc.
I have also observed this among the wounded in evacuation hospitals
when they devoted their leisure time to exchanging thoughts about their
diseases and sensations of a purely physiological nature, or the results
of ideas they have obtained from doctors. For example, a wounded
 INTRINSIC PICTURE .OF ILLNESS 29

fellow who was recovering well began to think that his heart, lungs,
and, especially often, his stomach and intestines were diseased. Thus
are sensations of a nonexistent disease born, and sometimes they devel-
op impressively in a person’s mind. This, as we shall see below, is a
quite predictable result of the intimate relationship between the pa-
tient’s mental and physical life.
Unfortunately, therapists have traditionally been very little interest-
ed in the subtle nuances of the patient’s mental life. As during the times
of Socrates and Plato, we still divide physicians into those who treat the
body and those who treat the soul, and consider it quite natural that a
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therapist who has proposed to make an “objective” examination of a

patient and has mastered this approach, especially laboratory proce-
dures, to perfection, will, when it comes to an analysis of the internal
disease, limit himself to a mere formal recording of the patient’s past
interests, and merely register dryly the subjective complaints of the
patient, who has presented his entire, vast, internal world to the spe-
cialist: the psychiatrist, neuropathologist , or psychotherapist. Such a
therapist is in fact a consistent upholder of the doctrine of dualism or
parallelism of bodily and mental processes in the human organism.
This is also the origin of the tendency for the therapist to neglect
somewhat the internal picture of a disease, as when he considers the
patient’s mental perceptions to be unimportant, and is convinced that
their analysis could easily set him on a false path and divert him from
his main purpose, which is arriving at a correct diagnosis and prognosis
of the disease. Bleuler called this the psychophobia of the modern
doctor. This explains the formal attitude toward an examination of the
internal picture of the disease that is reduced to a mere gathering of
questionnaire material, registering complaints and the external facts
punctuating the course of the disease, which in that form are of little
value for establishing a diagnosis.
My many years of observations of the work of physicians under a
variety of conditions indicate that examination of the internal picture of
disease (interrogation of the patient and study of his anamnesis) leaves
much to be desired, that, as a rule, it is usually conducted much more
poorly than the objective part of the patient’s examination and does not
reflect the live, dynamic process in the physician’s mind. I shall dwell
below on what I consider to be some of the most important inadequa-
cies in this part of a doctor’s work, and on the principal requirements,
dictated by contemporary clinical thinking, of a proper examination of
the internal picture of a disease.
 30 R. A. LURIA

Conditions with regard to the subjective examination of patients are

not very good. The best doctors in all countries have regularly pointed
this out. Mackenzie, one of the oldest therapists in England, has espe-
cially stressed the abnormality of this state of affairs. Discussing the
research aspirations of young therapists, he thought it inexpedient,
even harmful, for a doctor to begin this work, especially purely experi-
mental work, shut up in a hospital laboratory, too early, in isolation
from patients. Under such conditions, the young therapist deals almost
exclusively with the late stages of illnesses, which are the result of
gross and irremediable morphological changes in the organism, and he
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therefore does not acquire the necessary experience in diagnosing the

early forms of a disease. This applies completely to the state of affairs
in our country. A young doctor’s work in hospitals and clinics is often
limited to hospitalized patients; he does not work at all in a polyclinic or
in an outpatient department under good supervision. Mackenzie rightly
pointed out that the symptoms of the early stages of a disease are so
subtle that much experience, acquired over many years, was necessary
to be able to diagnose an illness at this stage.
Mackenzie has said:

The first symptoms of a disease are of a purely subjective nature, and they
appear much earlier than can be detected by “physical” methods of
examination. It is an extremely difficult task for the therapist to discover
these symptoms and assess them correctly. How can we demand that a
young therapist learn to diagnose these early stages of a disease if he does
not acquire the necessary experience in an outpatient clinic? Study of the
early symptoms of a disease is an urgent problem, and all doctors should
be concerned with it.

Although these words were spoken more than twenty years ago, they
fully describe the most essential tasks in both the training of qualified
therapists and in the correct organization of therapy in our country. If
we do not correctly deal with the problem of enabling young therapists
to participate in the early diagnosis of diseases of the internal organs,
we shall make little progress toward reducing the morbidity rate in our
socialist country. This work involves, in the first place, reorganizing
the procedure for examining a patient and, especially, proceeding to a
deeper study of the internal picture of disease, . . .
. . . The second part of Goldscheider’s autoplastic picture is the
intellectual part, Le., that which has no real concrete substrate in
somatic processes. Is it irrational?
 INTRINSIC PICTURE OF ILLNESS 31

The intellectual part of the picture of a disease includes what the

patient himself constructs from his own sensations, i.e., the way the
somatic process is reflected in his mind. There is a tremendously
complicated aggregate of mental processes about whose essence we
know almost nothing. But we have already seen above how forcefully
mental processes impact upon the functions of a whole series of organs
and their systems: the cardiovascular system, the digestive system, the
urinary organs, metabolic, endocrine, and sexual processes, etc. No
matter how these autoplastic notions may have originated in the ner-
vous system, the intellectual part of them doubtless has, and must have,
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a tremendous influence not only on the functions of organs but also on

the course of the organic process within them. Clinical observations
every day teach us that, in addition to the centrifugal impulses from the
internal organs to the mind, which is also the substrate of the sensitive
part of the autoplastic picture of a disease, there is a powerful centrifu-
gal influence of mental processes on the origin and course of a disease,
on the psychogenesis of the symptoms of internal illnesses.
In this respect, Goldscheider was unquestionably right when he said:
“If a physician wishes to understand a patient, he should devote all of
his abilities, his art, and his desire to an understanding of the autoplas-
tic picture of the disease, for this is indeed the man, the suffering
human being.” For my part, I should say that a physician must first
assess the overall importance of understanding the internal picture of a
disease and learn how to study it methodically.
It is impossible to enumerate the symptoms and pictures of diseases
that are of psychogenic origin. Any doctor sees them at every step in his
practical work. These symptoms of psychogenic origin most often yield
bizarre and peculiar clinical pictures of functional disorders, neuroses
of individual organs and their systems. There are, for example, neuro-
ses of the stomach, the intestines, the heart, etc. However, most impor-
tant of all is that symptoms of psychogenic origin often sharply alter the
picture of a purely organic disease. In such cases they constitute the
major and most essential part of the clinical picture, forming a thick
layer over a frequently minor organic illness. . . .
. . . The very structure of the internal picture of a disease, in both its
sensitive part and its intellectual part, is strongly dependent on the
structure of the patient’s personality and on his psychological profile,
which therapists usually neglect to study, and even substitute for it such
vague terms as neurusthenia, neuropathy, hysteria, hysterical reaction,
etc. But psychologists have long been sensitive to the fact that the
 32 R. A. LURIA

capacity of people to react to stimulation, all their sensations and all

their motor activity, is an outward reflection of internal mental experi-
ences and, as such, provides a rich picture of individual differences as a
function of the person’s neuropsychological status. The early studies
by Fechner, followed by those of Wundt and his school, showed that the
acuity of sensations varied very widely from one person to the next.
Motor activity, i.e., facial expressions, the patient’s movements, his
gait, his posture, etc., which for us are already an objective sign of the
internal picture of a disease, displays a wealth of individual differ-
ences, which have found reflection in the theory of idiomotor phenom-
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ena and expressive movements. The 19th century provided an empiri-

cal psychophysiological basis for the ancient theory of temperaments,
distinguishing typical features of sensations and movements of human
beings; the first quarter of the 20th century gave us a detailed psycho-
logical and physiological foundation for them. The classic studies of
Pavlov and his school established the existence in animals of several
basic types of nervous system, to a certain extent analogous to the
ancient Hippocratic temperaments, and found that animals responded
to environmental conditions differently and varied broadly in the stabil-
ity of their behavior according to what type of nervous system they had.
These characteristics, which are observed quite clearly even under
normal conditions of animal existence, showed up very sharply in more
difficult situations and in pathological conditions in an animal’s life.
Whereas animals with an excitable central nervous system reacted to a
complication in the experimental conditions with a breakdown and
serious neurosis (experimental neurosis), animals with a stable nervous
system displayed no pathological reactions.
Empirical data obtained on human beings have confirmed the exis-
tence of different neurodynamic types. A number of psychological
studies carried out especially in this area have found that under experi-
mental conditions, it is easy to detect and record impairments in reac-
tive processes in unstable psychopathic subjects even in the case of
relatively weak stimuli and minor conflicts. . . .
. . . Therapists are still very poorly acquainted with the modern
currents in experimental psychology, with their prospects for creating a
procedure for investigating the internal picture of disease and provid-
ing a scientific foundation for that psychophysical complex the old
medicine called “human temperament.” The best doctors in all times
and periods have relied on this complex in both diagnosing diseases and
in establishing prognosis and treatment. Perry himself said that it is
 INTRINSIC PICTURE OF ILLNESS 33

often not so important to know what disease a patient has as to under-

stand in what kind of a person the disease is developing.
But this, of course, is still by no means everything. So far I have
been talking about the constitutional traits that create human tempera-
ment. A patient’s psychological profile is a result not only of endocrine
stigmatization but also of an attitude that, in turn, is closely related to
the patient’s intelligence. Who has not often experienced how difficult
it is to evaluate the internal picture of a disease in a patient who
obfuscates the transmission of his perceptions, spending a considerable
portion of his mental activity on it? These patients are usually people of
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high intelligence-artists, performers, scientists, and, especially fre-

quently, lawyers who try to help the doctor understand their feelings
and to show “how intelligent I am” with regard to medical questions.
Instead of precisely conveying their real sensations, i.e., the sensitive
picture of a disease, they often produce artefacts, sharply altered this
time not by emotions, . . . but by deliberation, by their own criticism
and self-criticism, with exaggerated self-observations. Often doctors
themselves impede a correct diagnosis by “helping” their colleague
analyze the picture of the disease when they become ill. These are most
often psychopaths of the asthenic type, constitutional hypochondriacs.
Diametrically opposed to this type are people with a more primitive
intelligence, who, as we know, express their sensations sometimes in
very beautiful metaphors, conveying clearly subtle nuances of the in-
ternal picture of the disease and often better expressing the different
symptoms, sometimes in only one word, than the long speeches of
people of high intelligence. I have many times had occasion to demon-
strate to my listeners, themselves physicians, in seminars, how useful it
is to listen to the images in which the subtle sensations of these patients
are couched, and to remember these metaphors of sensations.
On the basis of vast material from World War 11, I have been able to
observe the direct effect of the patient’s personality on the origin of a
number of illnesses. To illustrate my conception of the internal picture
of a disease, let me draw merely on the combined course of internal and
surgical illnesses that I have called surgical-therapeutic ‘‘mixes.” 2
Among this very numerous group of patients, I was able to discriminate
five different types of combinationsof these two kinds of illnesses. One
of these mixed types consisted of the relatively slightly wounded, most
often with wounds in the soft tissue of the limbs. Just after the wound
had been cauterized, the patient, who had begun to pay considerable
attention to his own sensations as a consequence of mental hyperreac-
 34 R. A . LURlA

tivity would present a number of very diverse complaints and some-

times display an excessively ‘ ‘attentive” relation to the physician.
These were often autonomically stigmatized people whose endocrine
activity was heightened by the emotions of the war. Failure to study the
personality of these patients and the inner picture of their illness result-
ed in their spending long months in hospitals for no good reason,
whereas it was precisely hospital treatment that should have been
contraindicated for them.
I have emphasized enumeration of the major difficulties in analyzing
the internal picture of a disease to show that very complicated work
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remains to be done to reorganize an effective procedure for recording

the patients’ complaints if we wish to bring it up to a level required by
the current state of science. Of course, the data I have here presented by
no means exhaust even the most important aspects of the problem of
finding a rational procedure for studying the inner picture of a disease.
I should like merely to outline the direction our work should take;
providing the psychological foundations must be the object of a special
study. . . .
. . . We must first develop a psychologically sound procedure for
compiling a case history. Young therapists must be made familiar with
the foundations of psychology for this, because we cannot continue to
rely, as we have in the past, solely on the art and natural talents of the
examining physician. The accumulated experience must be based on a
sound theoretical foundation.
The personality of the doctor himself will also always have tremen-
dous importance in study of the mind of a patient. I should like here to
stress in passing the especially sad fact of the “facelessness” of the
physician so widespread in our country-a circumstance that, in my
view, is completely inadmissible in medical practice in general, and for
the therapist in particular. Unfortunately, we so often hear from the
patient that “some doctor or other” had treated him whose name he
does not even know, despite repeated and frequent visits to an outpa-
tient clinic or prolonged hospitalization. The “facelessness” of the
physician should become a part of the past as fast as possible if we want
to raise the quality of medical care to workers, especially in the early
stages of illness, to a higher level.
Let me here dwell on one more circumstancethat often plays a rather
important role in the creation of this “facelessness” of the therapist
and not only interferes with the work necessary for the creation of a
synthesis, i.e., the one correct diagnosis, but also, to a considerable
 INTRINSIC PICTURE OF ILWVESS 35

extent, breaks the psychological bond between doctor and patient with-
out which neither correct diagnosis of the disease nor effective treat-
ment is at all possible. I am referring to the therapist’s work situation.
Speaking of the role of assistance and attendants at operations, Hippoc-
rates defined their behavior as follows: “Everything takes place in
profound silence and in absolute subordination to the orders of the
surgeon. ” Consequently, even in those far-off times a strict discipline,
testifying to the great respect the assistants and attendants had for the
creative work of the surgeon, was established during operations.
What is the situation with regard to the work of the therapist? Even
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in highly qualified polyclinics, not to mention ordinary outpatient re-

ception, it is considered permissible for the nurse, the nurse’s assistant,
the assistant physician, and anyone who wishes, whether he or she has
any business there or not, to enter the therapist’s office any time they
wish. This distracts the doctor from his creative work, diverts his
thinking to something else, interferes with his observation, breaks his
psychological bond with the patients, i.e., just those things that are at
the basis of the physician’s awareness and evaluation of the internal
picture of a disease. It might be objected that this is a “small matter”
that it is out of place to discuss when one is talking about academic
questions of physicians’ synthetic efforts to establish a diagnosis. But I
say that when speaking of these “small matters,” an administrative
style is precisely what should not be used; rather, the work of the
therapist should be considered a research effort in every individual case
of his dealing with a patient. Not only the surgeon but also the therapist,
like any physician, should concentrate during his work on the major
creative task at hand. He therefore has the right to demand an appropri-
ate environment and to eliminate everything that interferes with this
work. Of course, we must also, as soon as possible, get rid of those
“small matters” that fundamentally undermine the creative efforts of
the therapist and, what is more important, the authority of the physician
in the eyes of the patient by continuous education of the intermediate
and younger staff.
The work of hospitals was discussed at a huge meeting of the section
on public health of the Moscow Soviet, and our truly great achieve-
ments in this area were underscored. A worker who had come to the
section directly from his workshop, still dressed in his work clothes,
stated: “I brought a comrade who had received a serious injury during
a machinery breakdown to the hospital for first aid, and the receiving
physician came out to examine the patient with a cigarette in his mouth.
 36 R. A . LURIA

I did not like this hospital.” It seems to me that this worker’s statement
tells better than any academic discussions how profoundly right Hip-
pocrates was in his prescriptions with regard to the behavior of a
physician.
A schema for compiling a case history that would satisfy a thoughtful
therapist will probably never be developed. That this will lead to no
good end we can learn from the rich material of those dead surveys we
often find in disease histories. Which is better, to ask the patient to
describe his sensations freely, or to get right down to a systematic
interrogation of the patient? Neither method can lead, by itself, to the
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desired end. It is best to give the patient the opportunity to first present
his experiences as he wishes and can, and thus to obtain an idea about
his personality and the characteristics of his mental profile; then one
can go on to ascertaining the individual and, especially, the dominant
symptoms of the disease. If the physician behaves in this way, he will
immediately create the necessary rapport with the patient and gain the
patient’s trust-a requisite condition for study of the internal picture of
a disease.
Of course, it is not necessary to use all the techniques of analysis, so
laborious, and so time-consuming, in every particular case; the doc-
tor’s experience will make it possible to shorten and rationalize this
work. . .

Notes
1. Bergmann, Funktsionnelle pathologie. 1932. P . 269.
2. R. A . Luria [Surgical-therapeutic “mixes”]. Sovetskaia Meditsina, 1942,
No. 7 .