Did Szasz Misunderstand Virchow’s Concept of Disease?

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COMMENTARY

“Canst thou not minister to a mind diseased?”—Shakespeare, Macbeth to the Doctor in Act V scene iii.

As I enter my 70s, I have concluded that there are only 3 certainties in life: death, taxes, and endless debates over the term, “disease.” Evidence of this last claim may be found in several interviews and discussions posted by my colleague, Awais Aftab, MD.^1,2

One point of contention over the past 60 years or so—ignited by the appearance of the late Thomas Szasz, MD’s 1961 book, The Myth of Mental Illness³—has been the claim that “disease” must necessarily be predicated of bodies, not minds; and that the existence of genuine disease requires the demonstration of an anatomical lesion or physiological abnormality. I have characterized this as the “lumps and bumps” model of disease. As Sir Martin Roth tartly observed, “…if illness is a matter of lumps, lesions and germs,” most individuals with schizophrenia “are perfectly healthy.”⁴

Yet the presence of cellular pathology as the “objective (materialist) criterion of illness”⁵ was Szasz’s holy grail in virtually all his writing until his death in 2012. (Disclosure: Szasz was one of my teachers during residency). In large part, Szasz based his claim on the seminal work of the great German pathologist, Rudolf Virchow (1821-1902), often considered the father of cellular pathology. More on Virchow presently.⁶ 

In contrast, I and others have argued that (a) there has never been (and is not now) a single, universally accepted definition of “disease,” even among physicians; (b) the term lacks an “essential definition” (one specifying its necessary and sufficient criteria); (c) the most clinically useful identifying features of disease (dis-ease) are suffering and incapacity, not lesions or cellular pathology, though these are frequent concomitants of disease; (d) the term “disease” is defined in different ways in different contexts; for example, in pathology vs epidemiology; and finally, that (e) ordinary language has always recognized disease as a condition of both body and mind, as Macbeth’s question to the doctor suggests. (For purposes of this essay, I am using the terms “disease” and “illness” more or less synonymously, as Szasz himself generally did. However, some scholars have emphasized significant differences between the terms.)^7-10

What Did Virchow Believe About Disease?

For Szasz, Virchow was something like an ideological hero who shows up in nearly all Szasz’s books. For Szasz, Virchow was a true medical scientist, in contrast to "...men like Kraepelin, Bleuler and Freud [who] were psychiatric conquistadors.”¹¹ Szasz consistently refers to cellular pathology as “the Virchowian criterion of disease.”⁵ Indeed, an entire generation of psychiatry’s critics, steeped in Szaszian ideology, readily embraced this supposed sine qua non of disease. These critics used Szasz’s interpretation of Virchow as a cudgel to attack psychiatry as unscientific. Yet, in my view, there is good reason to suspect that Szasz had misread Virchow; or, at best, had missed some of Virchow’s important statements and enormously oversimplified his nuanced view of disease.

To the best of my knowledge, Virchow did not assert, as Szasz implies, that cellular pathology is the “objective (materialist) criterion of illness.”⁵ To be sure, Virchow did assert that, “All diseases are in the last analysis reducible to disturbances, either active or passive, of large or small groups of living units,” namely, cells.¹²

Fine. But to say that specific diseases are “reducible to” cellular pathology is not to say that we ordinarily understand or identify disease per se in this way. Consider this analogy: Water is “reducible” to hydrogen and oxygen atoms, but our everyday identification of water does not depend on any knowledge of its molecular composition. Neither does our ordinary language. We can say, “I’d like a glass of water” without having the faintest idea of water’s chemical composition. Similarly, as physicians, our clinical identification of disease does not depend on our knowing its underlying cellular mechanisms.

Based on my reading, Virchow does not explain how he, as a medical doctor, would decide that a patient is ill or diseased in a general sense. If cellular pathology represents the last analysis, what is the first? As I have argued elsewhere,^7,8 the concept of disease (dis-ease) is pre-biological and is intimately connected to our every-day recognition of certain patterns of suffering and incapacity. Parents, not pathologists, are often the first to sense that their child is sick, ill, or diseased. By the time pathologists get involved, the disease process has often taken a dire turn.

For all his emphasis on cellular pathology, Virchow seems to have regarded disease itself (Krankheit) as something over and above mere cellular or tissue pathology. This becomes apparent when considering how radically Szasz and Virchow differ on the matter of cadavers.

For Szasz, "Every 'ordinary' illness that persons have, cadavers also have. A cadaver may thus be said to 'have' cancer, pneumonia, or myocardial infarction."¹³ From the perspective of ordinary language,14 this claim is trivially risible. For if cadavers can indeed have illnesses, it would follow that cadavers can be slightly ill, severely ill, desperately ill, etc. We had better laugh, lest we cry!

In contrast, Virchow writes that "Disease presupposes life. With the death of the cell, the disease also terminates." Cells “produce disease” only so long as “they do not destroy life.”¹² In short, for Virchow—contra Szasz—cadavers can certainly have lesions or cytopathology, but not disease or illness.

For Virchow, Mental Illness is Real

For all his invocations of cellular pathology, it is clear that Virchow believed in the reality of mental illness, or what he called “psychic disease.” Since, in Virchow’s time, practically nothing was known about the cellular pathology of mental illness, Virchow could not possibly have relied upon that as the sole criterion for the recognition of mental disease.

More importantly—and again, contra Szasz--Virchow appears to have viewed mental and bodily illness as essentially the same. Thus, he writes that:

"When...somebody becomes mentally or bodily ill, which, to our mind, is not essentially different, we always have before us the same life, with the same laws, only that these become manifest under other conditions."

Virchow goes on to say that, "...individuals have their somatic and psychic diseases, which represent the expression of normal laws of life and thought under abnormal conditions..."¹⁵

And remarkably—considering his lifelong focus on cellular pathology—Virchow provides a description of manic-depressive illness that would stand up reasonably well even today. He writes that¹⁵:

"...psychic disease may start in some individuals with a melancholic stage, then usually progresses to one of rage, [and then] reverts to a depressive stage... Recovery is usually deceptive; it is brief; and usually new exaltations will result in a melancholic stage of greater intensity, interrupted by periods of fury...”

Disease Categories as Social Constructions?

Virchow did not view diseases as discrete, independently existing things in nature—what philosophers would call substances or natural kinds—but rather, as “reflections of deranged function” that differ only quantitatively from normal bodily function.¹⁶

Quite surprisingly, Virchow went so far as to consider all medical disorders as “social constructs.”¹⁷ This is what he wrote in 1854, first shown in German and then in English translation^18,19:

“Was wir Krankheit nennen, ist nur eine Abstraction ... womit wir gewisse Erscheinungscomplexe ... des Lebens aus der Summe der uebrigen heraussondern, ohne dass in der Natur selbst eine Sonderung bestaende.”

‘‘What we call disease is solely an abstract concept with the help of which we separate particular phenomena of daily life from all others, without there being such a separation in nature itself.”

This view emerged relatively early in Virchow’s long career, but to my knowledge, he never repudiated it. Based on this Virchowian perspective, those who criticize psychiatric disease categories as being mere social constructs must perforce criticize the whole of medicine and all its disease categories.

Szasz—who claimed that schizophrenia “…was a social construct created by the therapeutic state to control and remove offensive persons from society”²⁰—might well have agreed with Virchow with respect to mental illness categories. But it is very doubtful that Szasz would have considered all disease categories, such as cancer or coronary artery disease, as mere social constructions. (CV Haldipur MD, personal communication, 2/7/24).

And yet, as Virchow stated, allcategories of disease, disorder, or illness are, to some degree, socially constructed.⁷ But as psychiatrist and philosopher Dan J. Stein writes, this simply means that¹⁷:

“…categorizing any particular phenomenon as a disorder reflects cultural and historical theories and values, rather than any underlying universal truth about the relevant phenomenon.”

The Originalist Fallacy

To be clear: none of the foregoing means that medical and psychiatric disease states are merely myths or metaphors; or that the names we give to conditions of extreme suffering and incapacity have no objective correlates or real-world referents. As Aftab notes, “…Disorder status is not a fact of nature that can be scientifically discovered, but it is grounded in facts of nature.”²

Indeed so.Disease categories throughout the entire House of Medicine may be socially constructed, but they point to, and are grounded in, very real facts of nature. For Virchow, these were facts about cellular pathology. For rheumatologists, they are facts about inflammation. For psychiatrists, they are facts about human nature when severe mental illness takes hold; namely, the presence of suffering and incapacity in the realm of cognition, perception, emotion, and behavior.

A philosopher might put it this way: the ontological status of the patient’s psychic impairment—its “is-ness” or reality—is not vitiated by the socially constructed origin of the designated disease, such as schizophrenia. Claims to the contrary amount to what I call the originalist fallacy.

Think about it this way: most societies have developed some concept of an omnipotent deity, god, or Creator. This concept is the end result of social construction, in so far as it reflects cultural and historical theories and values. But this socio-cultural origin in no way disproves the existence of such a deity. In short, origin does not dictate ontology.

Similarly, even if we stipulate that schizophrenia is a socially constructed term, it does not follow that the term points to a nullity, a metaphor, or a myth—akin to, say, a unicorn. Of course, there are a multitude of associated biological findings that firmly anchor schizophrenia to the natural world.²¹

Virchow: A Harbinger of Biopsychosocial Medicine?

Szasz focused almost exclusively on Rudolf Virchow as a pathologist. But recent scholarship has greatly broadened Virchow’s resume. As Klaus Lange has noted²²:

“Virchow’s achievements are threefold: he was a founder of scientific biomedicine; he characterized medicine as a social science as much as a biological science; and he promoted and improved public health…He proposed radical social reform and stated that, “medicine is social science and politics nothing but medicine on a grand scale.” The task of medicine was therefore not merely to treat disease but also to contribute to the health of the entire population. Virchow realized that, in order to improve the health of the public, medicine must attend to both its biological and social underpinnings.”

Concluding Thoughts

It is ironic that in his zeal to isolate and marginalize psychiatry from the rest of medicine, Thomas Szasz mistook Rudolf Virchow as an ideological ally. It is not clear that Szasz ever read or addressed Virchow’s statements quoted above, regarding the essential similarity between bodily and mental illness, or the social construction of medical disease (CV Haldipur, MD, personal communication, 2/7/24). It is unfortunate that we will never know Szasz’s responses to these statements.

Nonetheless, we may conclude that—contra Szasz—Virchow not only recognized and affirmed the reality of mental illness (psychic disease), but also prefigured George Engel’s biopsychosocial model of medical care.²³

Acknowledgment: Thanks to Dr C.V. Haldipur for his helpful comments and personal recollections of Dr Thomas Szasz.

References

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