Did 19th Century Physicians Think “Mental Disease” Was Merely a Metaphor?

June 23, 2014

A limited sampling presented here lends no support to Dr Thomas Szasz’s claim that 19th century physicians regarded the term “mental disease” as merely a figure of speech; on the contrary, several prominent physicians of this era recognized such conditions as both real and debilitating.

The death of Dr Thomas Szasz (1920-2012) has occasioned a reexamination of many of his controversial views on psychiatry. One of Szasz’s central claims was that the term “mental illness” (or mental disease) is merely a metaphor, ie, a figure of speech with no ontologically “real” referent. And, for Szasz:

. . . if I say that mental illness is a metaphorical illness, I am not saying that it is some other kind of illness; I am saying that it is

not an illness at all

[emphasis added].


There are many logical and semantic problems with Szasz’s claim, as reviewed elsewhere,2 including the multiform and contested meanings of “metaphor,” “illness,” and “disease.” However, Szasz makes a notable historical claim that is relatively easy to investigate empirically. He argues:

When the early (19th century) psychiatrists spoke of mental disease or diseases of the mind, they understood, and often explicitly stated, that these expressions were figures of speech or metaphors.1(p140)

But was this really the case? To support his claim, Szasz cites the statements of 3 psychiatrists: Emil Kraepelin (1856-1926), Ernst von Feuchtersleben (1806-1848), and Maximilian Jacobi (1775-1858). Thus, Szasz quotes Kraepelin as saying, “. . . in the strictest sense, we cannot speak of the mind as becoming diseased.”1(p149) Similarly, von Feuchtersleben is cited as saying, “The maladies of the spirit alone . . . can be called diseases of the mind only per analogiam [by analogy].”1(p148) Jacobi is quoted to the effect that no illness of the mind is truly analogous to that of the body.

While these statements cannot be dismissed, they appear to represent highly selective quotation (and historical analysis) by Szasz. It is clear that other notable 19th century psychiatrists regarded “mental disease” as quite real-indeed, far from being “metaphorical,” mental disease was, in several instances, regarded as inheritable. For example, in his writing on “systematised delusional insanity (paranoia),” Dr Conolly Norman (1852-1908)-perhaps the best-known psychiatrist in Ireland in the second half of the 19th century-argued, “The judgment is impaired in all forms of mental disease.”3(p389) He went on to describe “paranoia” as a “. . . hereditary degenerative mental disease [emphasis added].”3(p389) It is clear that Conolly’s use of the term “mental disease” (as inheritable) cannot be merely metaphorical, in this context.

Similarly, Dr Thomas Smith Clouston, a leading Edinburgh psychiatrist (1840-1915), wrote:

Attacks of mental disease are often determined by the great physiological epochs and “crises” of life. . . . The insanity of adolescence and that of puberty are essentially the same. It is the

most hereditary of all forms of mental disease

[emphasis added].


Finally, Dr William Ford Robertson (1867-1923), a neuropathologist writing at the turn of the century, authored an entire textbook titled
A Textbook of Pathology in Relation to Mental Diseases.5 Robertson’s textbook considered not only well-recognized and specific neuropathological conditions, such as focal lesions of the brain and tertiary syphilis, but also “acute insanity.” Robertson writes:

The present work deals with the pathology of that group of diseases of the nervous system to which the terms “insanity” and “mental diseases” have long been applied. This group is essentially a clinical one, and does not represent a distinct pathological division.


It is clear that in no sense is the term “mental disease” used metaphorically by Robertson. Furthermore, he is willing to consider entities as “diseases of the nervous system” on the basis of their clinical manifestations, and not on the basis of a distinct type of neuropathology.

In sum, this limited sampling lends no support to Szasz’s claim that 19th century physicians regarded the term “mental disease” as merely a figure of speech; on the contrary, several prominent physicians of this era recognized such conditions as both real and

Acknowledgments-Thanks to Prof Hannah Decker and Prof Greg Eghigian for their helpful comments on this piece.


This article was originally posted on 4/4/2014 and changes may have been made since.


1. Szasz TS. Insanity: The Idea and Its Consequences. New York: John Wiley & Sons; 1987.

2. Pies RW. Mental illness is no metaphor: five uneasy pieces. Psychiatr Times. September 13, 2012. http://www.psychiatrictimes.com/articles/mental-illness-no-metaphor-five-uneasy-pieces. Accessed March 6, 2014.

3. Norman C. Systematised delusional insanity. In: Allbutt TC, ed. A System of Medicine. Vol 9. London: MacMillan & Co; 1900:389-460.

4. Clouston TS. The epochal insanities. In: Allbutt TC, Rolleston HD, eds. A System of Medicine. Vol 8. 2nd ed. London: MacMillan & Co; 1910:926-941.

5. Robertson WF. A Textbook of Pathology in Relation to Mental Diseases. Edinburgh: William F. Clay; 1900.