The Alan Gregg Lecture

1964

SOME ILLNESSES OF MENTAL HEALTH

ROBERT S. MORISON, M.D.*

Everybody who is asked to give the Alan Gregg Lecture must feel honored
and touched. Almost everybody must experience more than a twinge of humility
and many moments of self-doubt. I must feel more honored and more humbled
than my predecessors since Alan set so many of the standards of behavior for
what he liked to characterize as philanthropoids. And, for better or for worse, a
philanthropoid is what I have swmwenty y>ars of my life trying to be.

When my colleague Warren Weaver gave this lecture, he remarked with be-
coming, but' quite unnecessary, modesty that as a layman he felt unable to
comment upon Alan Gregg's impact on medicine. This task he left to some
future lecturer. I do not propose to take on the whole'job, but I do think this is
an appropriate time to say something about his relationship to that part of
medicine known as psychiatry.  Beginning in 1931 and for approximately the
next two decades, Alan Gregg was responsible for the Rockefeller Foundation
program in psychiatry which absorbed approximately $wo-thirds ol the Founda-
tion's expenditures in the medical sciences.  For several years thereafter until
l6 death in 1957, he maintained close contact with many of the leaders of the
field and continued to influence its development by serving on the Council of the
National Institute of Mental Health and other advisory bodies.

During all those years and in the seven subsequent ones, psychiatry has
changed in several unexpected ways. Most unexpected of all perhaps for those
who lived through the stringent thirties, psychiatry and its allied disciplines
recently have fallen heir to large sums of money. Finally, to make the task of
stock-taking easier, there has recently come to hand the detailed report of the
Joint Commission on Mental Illness and Health (1) and in July of this year
the collection of highly personal and impressionistic essays published by the
Atlantic Monthly in a Special Suuplement on Mental Illness.

Toward the end of this talk, we might use Alan Gregg's career as a text to
develop some views of how change takes place-how much can it be consciously

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* Director, Division of Basic Biology, Cornel1 University, Ithaca, New York.

986 Journal of Medical Education VOL. 39, NOVEMBER, 1964

influenced from outside; how much are events determined by some inner
dynamic of their own; and how much do they come about by pure chance.
Incidentally, I am sure that in one of his whimsical after-dinner moments when
Alan was indulging his interest in le mot juste, he must have asked himself or
his companions why we so often refer to chance as "pure."

Alan Gregg's influence on psychiatry was exerted in numerous ways, but it

is convenient to consider two broad categories-his work as an officer of The
                    influence as an
                 more important.

matter of money out of the way. Among other things, it may give us some clue
as to what manner of man Alan Gregg was and from where he felt that
progress in psychiatry might most likely spring.
The first thing that strikes the observer in 1964 is how small the amount of
money really was-a little over $16 million in tw=ears for psychiatry and
related disciplines. As a matter-ct the related disciplines-neurology,
neurophysiology, neuroanatomy, neurochemistry, and psychology-absorbed

    early two-thirds of the funds. As might be imagined by anyone who remembers
d%ow loniik American psychiatry to develop any competence in research,
    virtually all the research supported during this period was in the related dis-
    ciplines and not in psychiatry per se. The grants were few in number and not
    very large in size by today's standards, but they almost all went to men of the
    very first rank: Cannon, Penfield, Yerkes, Richter, Gantt, Bremer, Granit, Pen-
cwi I!, rose, Eysenck, Adrian, Gray Walter, Lennox, and Gibbs. Any study section today

would vote any projects of these men a priority in the very top percentile.

Help to psychiatry itself went largely for the development of full-time teach-
ing departments in medical schools, with smaller portions to training fellow-
ships and some experiments in the application of psychiatry, as in mental
health and child guidance clinics.  Emphasis in the teaching. departments was
on bringing the specialty more fully into the mainstream of medicine, Often
the emphasis was on psychiatry as seen in a general hospital. The hope here
was twofold. On the one hand, it seemed that psychiatry was bound to profit by
breaking out of its far from splendid isolation in the state asylum and coming
to learn some of the new techniques which had proven so effective in medicine
as a whole. Conversely, it was felt that psychiatry had much to do in humanizing
the increasingly impersonal scientific practice of medicine which, excellent
though it had become at prolonging life, still seemed to lack interest and skill
in making life more tolerable for many who sought its help.

Finally, the policy of generous support for the development of teaching
rested on the thesis that the obviously backward state of psychiatry was
directly traceable to its failure to attract and train adequate numbers of
capable young people. The departments which received the most substantial
help during the first half of this period were those at Yale, Chicago, Washington
University in St. Louis, McGill, and the University of Pennsylvania. Only ,pv
grants were made to a psychoanalytic institute as euch-one of $200,000 and

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The Alan Gregg Lecture/Morison 987

the other of $120,000, the first in 1935 and the second in 1938, both to the
institute in Chicago.

What can one reasonably say about the result of the grants made by The
Rockefeller Foundation almost wholly on Alan Gregg's recommendation during
this twenty-year period? So many other things were going on at the same time
that it is very hard to single out the specific results of specific causes. But we
can be fairly sure about some matters. For example, the Montreal Neurological
Institute presumably would not have existed in anything like its present form
had it not been for the help it received from the Foundation. Even more
certain is the influence of this In itute in consolidating and extending the
North American tradition of th J scholarly neurosurgeon pioneered by Harvey
Cushing.
Some of the work in Montreal and even more, perhaps, the devotion of Bill f.
Lennox and his colleagues in Boston turned epilepsy from an almost unmen- 1
tionable horror into an understandable and largely controllable inconvenience. 1 ;
Much of the other research was of a basic nature which laid the groundwork
for the recent great expansion in neurophysiology and neuropharmacology and
the even more recent and even more promising synthesis of these two subjects
with physiological psychology. Certainly the work of such pioneer human
geneticists as Penrose, Tage Kemp, and Kallmann has compelled attention to
the important hereditary element in certain incapacitating types of mental
disorder. Similarly, Jordi Folch-Pi and Heinrich Waelsch in this country and
Derek Richter in England must receive a significant share of the credit for the
recent upsurge of interest in the biochemical background of higher nervous
function. The original memorandum prepared by a subcommittee of the Trustees
which led the Foundation to psychiatry as a field of concentration had stressed
the importance of a biological approach, and the program of research grants as
actually developed reflects this emphasis very strongly. A clear majority of the
grants went to laboratories of genetics, physiology, and biochemistry. Toward
the end of the period, an increasing number involved departments of psychology,
but here again a high proportion supported work firmly based on the experi-
mental method-the studies of Yerkes and Lashley at Orange Park, of Hebb at
McGill, or the classical observations on the behavior of small groups by Elton
Mayo at Harvard.

That part of the program directed at the development of psychiatry as an
academic discipline succeeded in an almost spectacular way. Indeed, there are
those who may feel that the plan to orient teaching more closely around the
emotional problems seen in a general hospital succeeded perhaps almost too
completely. Virtually all American medical schools have now made a large
place in the curriculum for the department of psychiatry, and psychiatrists
are commonly seen either on the general wards or in units closely associated
with the general hospital. But what are we to say about the results of this
successful effort to put psychiatry back into the mainstream of medicine? Has
psychiatry really learned how to do productive research from its colgagues in

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988 Journal of Medical Education VOL. 39, NOVEMBER, 1964

the basic sciences and in the other clinical disciplines? Have internists, sur-
geons, and gynecologists learned how to recognize and to deal with the psycho-
logical aspects of ordinary illness? The answers are not written clearly enough
to be read at a distance, and I can only leave them to you who are nearer to
the situation than I am.
Particularly difficult to trace is the effect of a series of grants to the National
Committee on Mental Hygiene and the National Mental Health Foundation, the
forerunners of the present National Association for Mental Health. Alan
Gregg was enough of an American to recognize the importance of voluntary
association for improving the public welfare. In spite of many discouragements
he continued to foster the efforts of the at times pitifully small group of indi-
viduals dedicated to enlarging public awareness and arousing public participa-
tion in the mental health movement. How much of the recent improvement in
psychiatric care in some of our more progressive states and the increasingly
favorable attitude of Congress can be traced to such efforts is hard to say, but
one suspects that their influence has been considerable.

One thing does seem pretty clear and perhaps rather painful. Academic
psychiatry has found it too easy to become preoccupied with the psychological
pro&ms of reasonably normal people and to leave the hard-core problem of
major mental illness to others. Generally speaking, the big advances in caring
for the really seriously ill have not come from American medical school de-
partments of psychiatry. Many of them have in fact come from the olmned
nerve clinics of Europe.  Some of the more recent and very promising drug
themme aspects of so-called milieu therapy have been developed
in those despised state hospitals in the United States. Actually, Alan Gregg was
aware of these facts, and shortly before his death, I can remember him some-
what ruefully reflecting that it was not too comforting to recognize that most,

from active Foundation interest.

But Alan was far too sophisticated a person to be either surprised or unduly
upset to find that things had not turned out exactly as planned. Indeed, he was
fond of quoting a former colleague (my informed guess is that it was Beardsley
Ruml) who said as he looked back on his career that the only times he had
failed completely were when he had an idea and had gone about hunting for
some individual who would accept a grant to carry it out. Alan knew better
than most men how useless it is to try to force events into some preconceived
mzd. Fated as he was to spend most of his productive years in close association
with a field which is so complicated that it drives many men to oversimplified
solutions, he never became doctrinaire; he never even pretended to see where
the solution was likely to be found. If he favored one path over another, it was
only because he felt that majority opinion might be unduly neglecting an
obvious possibility. At a time, for example, when it was almost un-American
to admit the possibility of hereditary differences, he could be found champion-
ing the importance of human genetics. Incidentally, he publicly deplored the

not all, the apparently effective therapies had originated in places remote

The Alan Gregg Lecture/Morison 989

rather curious fact that at one time the American Journal of Heity had
fewer physicians than lawyers on its subscription lists. Many of his addresses
contain explicit recommendations to pay more attention to this field and the
only time I personally remember his deliberately offering financial support to
someone to work on an ika of his own, the project was one in the field of
genetics and behavioral differences. But on occasion he could be an equally
ti-g champion of psychoanalysis or of the Kinsey studies. In all such
instances his motivation was the same, an anxiety to make sure that a new
approach to an obviously important problem not be held up by irrelevant
prejudice.

It is here, I think, that the really good foundation officer differs most markedly
from the really good research worker. The good research man must believe that
the solution he is working on is obviously better than all the other solutions so
far proposed. The fou-fficer must keep his mind constantly open to many
different possibilities at once.  He must be able to recognize a high quality of
operation more or less regardless of the particular content. Alan was very nearly
sue at this. He gave his support to many different kinds of research, but the
particular projects, whether in genetics, neurophysiology, neurosurgery, clinical Jfp'

leave it to another generation of judges to pick the "best of show."

Actually, he was an outspoken member of that school of thought that holds
that in psychiatry there is little utility in the "best of show" concept. Always
he could be found emphasizing the view that human behavior is the result of a
complex interaction of an almost infinite number of variables. One must be
prepared to look at them all and use every stratagem in the hope of under-
standing the whole.

Indeed, it seemed to many of us that he was happiest when thinking in terms
of medicine as a whole rather than of the specialty of psychiatry to which he
was bound by what the jargon of his trade refers to as "program limitations."
Actually, only a small proportion of the papers or addresses in his bibliography
deal with strictly psychiatric subjects, and he looked to psychiatry perhaps pri-
marily as a means for improving the practice of medicine in general. One of
his finest addresses (2) deals with the experiences shared by each of us on the
way to becoming a doctor, whether in "Buenos Aires or Bangkok, Kyoto or
Karachi, Utah or Uppsala." Widely read and equally widely traveled, he was
more ready than most Americans of his generation to admit that life is after
all a difficult and troubled business. He knew also that in the 20th century, more
and more people are bringing their troubles and difficulties to doctors.  Much
of his energy went into seeing to it that the doctors would be better prepared
for this kind of responsibility. He even went so far as to ask the American Psy-
chiatric Association at its centenary meeting, "Is it not a proper concern of psy-
chiarms to find those conditions and factors both physiological and social which
offer the greatest opportunities for beauty and balance in the life of the spirit?"

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psychology, or, yes, even psychoanalysis were tops in their class. He could well -6

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990 Journal of Medical Education VOL. 39, NOVEMBER, 1964

As final evidence of his devotion to the broadest possible approach to the
doctor's job, we may cite the fact that the only paper I have been able to find
which mixes a measurable amount of acid with its irony is called "Narrative for
a, Specialist." It deals with Preserved Jones who in his fifth decade arrive2
"-disputed status of an experienced specialist, overloaded with work,
too busy to be lonely, and too tired to be able to reflect without falling asleep."
Finally in his sixties, "From his deliberate ignorance he cannot impart wisdom
or, from his embitterment, serenity."

For some minutes past we have been talking about both my first and my
second categories together, Alan Gregg's impact on psychiatry first as a f ounda-
tion officer and second as an individual. We must now turn a little more exclu-
sively to the second. In preparation for this talk, I wrote to a dozen or so
prominent psychiatrists for their appraisal of Alan Gregg's impact on their
field. Most of them responded generously in apparent eagerness to let as many
people as possible know how they felt. I am tremendously grateful for their help
and especially for their perspective since, for the most part, I was too close to
Alan Gregg to see the kind of figure he cut on a wider horizon.
When I received the first of these letters, I couldn't help noticing how
intensely personal it was in tone. It seemed that the writer had interpreted
my question about Alan's impact on psychiatry as actually about Alan's impact
on him. Reaching into my bag of technical terms, I found myself asking whether
my old friend had fallen prey to some newfangled mid-life sort of narcissism
in which he mistook the image of his field for himself. But then the other
replies began to arrive and I found that all my correspondents had interpreted
the question in the same way. Obviously, Alan Gregg`s impact on the field was
mediated through his extraordinary impact on individuals. He was the phy-

,,& sician's physician, the psychiatrist's psychiatrist, the administrator's adminis-
  trator. It seemed that ali of my correspondents had been in trouble at one time
   or another, had had a difficult decision to make, or a tricky personnel problem
   to solve. Without telling them what to do, Alan had shown them what ought
   to be done, or better still had put the problem in such perspective that the
   solution stood out almost automatically in bold relief.

Many of you will remember how often he quoted Robert Walpole's formula
of "good sense, good manners, good humor, and good faith." This typically 18th
century emphasis on form and decorum strikes with particular force in a 20th
century America which prides itself on having reduced etiquette and social con-
vention to a minimum. Doubtless this neglect of the older amenities has enabled
us to concentrate more fully on content and substance in a way which has
greatly advanced the physical conditions of living. But when Alan Gregg first
came into contact with psychiatry (and some of us may feel that it is still true
today), the field had relatively little in the way of agreed upon content and
substance. This Iack of agreed upon substance often led in turn to feelings of
inadequacy, guilt, frustration, and anxiety. The resulting emotional charge in
the psychiatric atmosphere made it difficult to establish sound working relation-

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The Alan Gregg Lecture/Morison 991

ships with the rest of medicine and even within the field itself.  Into this rather
confused set of vortices walked Alan Gregg, if not exactly the glass of fashion
and the mold of form, at least a physician with a very unusual sezse of style  csor*o
ammopolitan urbanity which transcended the ordinary limitations of timc
or space; and he said in effect, "Look here gentlemen, if you are really not very
sure of what you are trying to do, at least you can do it with `good sense, good
manners, good humor, and good faith."' The effect on individuals was very
great, and one may guess that a good deal of the acceptance gained for psy- !&&
chiatry from other branches of academic medicine came from Alan Gregg's
success in making psychiatry look like a reasonable bet.

may not have a wider meaning for us today. If we are frank with ourselves, I
think most Americans of my generation would have to admit that they were
brought up to be just a little suspicious of good manners and even to think of
good sense as being a little bit stuffy. In the development of a new continent
there were occasions in which good manners seemed awkwardly out of place and
when good sense might hold a man back from taking the risk which would
lead to fame and fortune. Even in Europe there was so much that was wrong
with the old society of good manners that it finally broke down in a series of
unmannerly wars and revolutions. Those of us who were especially interested in
science or the creative arts were not particularly struck by the importance of
good manners or even of good humor. It would have seemed incongruous to
have approached a Pasteur engaged in one of his vigorous scientific controversies
with the admonition that "manners maketh man." Those who actually did
attack the first great impressionist painting, "Le DBjeuner sur l'Herbe," on the
ground that it was bad manners look pretty ridiculous now.

But maybe we have begun to push our luck too far. It may well be that a
continent which will soon be bounded by 1,000-mile-long cities on both its
eastern and western coasts will find increasing need for good manners and good
humor.  The doctrine of unconditional surrender which we proudly flaunted in
the faces of our enemies for almost exactly a century was never very good
manners nor good sense. Today it well may be suicide.

Now let us return for a closer look at where psychiatry stands today, how
it got that way, and what we may hope and try for in the future. The two
rather different documents mentioned earlier, Action for Mental Health, the
report of the Joint Commission on Mental Illness and Health, and the Atlantic
Monthly symposium, both agree that we are not doing nearly as much as we
might for sufferers from major mental illness.  Worse than this, we in the
United States are probably not doing as well as several European countries have
already been doing for several years. Even the fragmentary reports we have
from the Soviet Union suggest very strongly that at least a considerable number
of the mental hospitals there are more fully staffed and present a pleasanter,
more friendly atmosphere than one finds in comparable institutions in this
country.

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As I think back on this aspect of his personazy, I find myself wondering if it TpgJs

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992 JozcmaE of Medical Education VOL. 39, NOVEMBER, 1964

On the other hand, visitors from abroad are struck by the amount of time
and effort spent on psychiatry in our medical schools and they marvel even
more at the amount of psychiatric consultation made available in our schools
and colleges. It is interesting to observe that the number of psychiatrists em-
ployed in mental hospitals has increased only rather slowly between 1930 and
1960, while the number at Harvard College has grown from something less than
one to seven, counting only those on the full-time staff. And the Harvard
phenomenon is merely an index of the extent to which upper-class America has
come to rely on the psychiatrist to help it bear the stressf%&
used to be thought of as normal life. To put the matter in its harshest terms,
American academic psychiatry seems very largely to have ignored the already
existing demand for its services and instead has devoted most of its energies
to creating (or at least bringing to light) a demand which was scarcely felt
before 1930. Note that I am not saying that interest in major mental illness
and its care has not increased and improved during the last thirty years. As
*report of the Joint Commission makes clear, improvement has taken place,
marsrelowly than the Commission thinks should have been the case, but improve-
ment'nevertheless. It is not clear how much of this improvement can be credited
to academic psychiatry and how much to the efforts of inspired laymen who in
the tradition of Dorothea Dix and Clifford Beers have constantly sought to
enlighten the public and obtain bigger appropriations for mental health. As we
have seen, technical improvements in patient care have come almost entirely
from outside the country and in a manner which bypassed much of academic

psychiatry-insulin from Austria, metrazol from Hungary, el-m
Italy, the tJL-ty from Holland and Engi'and, the day ward from
the Soviet Union viacaaa, reserp%>rom India, and chlorpromazine from

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France,

Actually, there seems to be relatively little dispute about the facts, uncom-
fortable though they may be. It is not so easy to accept some of the proffered
explanations for these facts. By far the simplest that has so far been offered
is that one put forward for several years by certain English observers, most
recently in the Atlantic Monthly symposium. It is a one sentence explanation and
it leans heavily on the "great man" theory of history which so upset Tolstoy. It
runs like this: The care of the mentally ill in the United States is deplorable be-
cause medical school psychiatry is under the spell of psychoanalysis because, in
turn, The Rockefeller Foundation insisted that all important psychiatric chairs be
filled by persons who had had a training analysis. Again one must accept the
fact that the care of the mentally ill in the United States is not good and we
also must agree that psychoanalysis has played a far greater role in the outlook
of academic psychiatrists in the United States than anywhere else in the world.
Furthermore, most of us will probably have to agree also that psychoanalysis
has contributed relatively little to the care of the seriously ill mental patient in
wite of the work of a few devoted students like Harry Stack Sullivan and his
followers and in spite of the insight psychoanalysis has given into the meaning

The Alan Gregg Lecture/Morkon 993

of certain symptoms. But it seems far too simple to blame psychoanalysis as
the only or even the most important source of American backwardness in the
case of major mental illness. I can think of a numeother reasons, none of
which does us much credit I am afraid. A historian might point at the head-
long, rough and tumble life of the frontier where the enterprising and the
vigorous succeeded and the incompetent disappeared. The sociologist might
point to our weaker sense of community life: Americans are typically on the
move and therefore do not develop deep ties to a given place or a sense of
responsibility for the members of the community who have slipped from sight.
Certainly, family ties are less strong and the feeling of obligation to look after
parents and relatives as they grow older and less competent mentally is far
weaker than in most of the rest of the world.

In addition to being influenced by these general attitudes, the medical profes-
sion in the United States remains curiously preoccupied wit       ractice,
to a far greater extent than is true anywhere else in the wor-y
Latin America. For some reason that is very difficult for the outsider to grasp,
the typical physician in the United States still feels that the only really honor-
able way to be paid is on a fee-for-service basis and that there is something just
a little bit degrading about working for a salary-more than a little bit, if the
salary comes from government. Adding injury to insult, of course, is the fact
that government salaries, especially in mental hospitals, are ~~e$tyJo__wLFinally,
there %ay-F6Xsemnever irrfty expressedto be sure, that the kind of patients
seen in private practice may be more recoverable and potentially more valuable
to society than those seen in mental hospitals. Given this natural bias toward
private practice, it is scarcely necessaiy to invoke a psychoanalytic demon to
explain why so many American psychiatrists have chosen to work in a private
consulting room rather than in the ward of an asylum.  Of course it must be
admitted that the great expense of psychoanalytic training has helped to make
the profession more money minded than it might otherwise have been, and it
is also probably significant that the psychoanalytic training undergone by so
many young American psychiatrists in the last two decades has apparently fitted
them better for private practice than for dealing with the mass problems of
mental illness.

I find, as a matter of fact, that many of my friends who hold faculty posi-
tions are quite willing to agree that psychoanalysis did fo; a considerable time
exert a preponderant influence on the development of academic psychiatry, and 1 /
there is growing satisfaction that this influence is now being increasingly '

Why then did psychoanalysis gain this relative ascendancy?-Was it really the
result of deliberate planning on the part of a single foundation and a single
unusually influential foundation officer? To those who knew Alan Gregg, the
very idea seems so incongruous as to scarcely merit comment. Nevertheless,
it may be instructive to review some of the factors which apparently worked
together to make things turn out the way they did. Among other things, it may

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balanced by a greater interest in basic biological and social factors.

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994 Journal of Medical Education VOL. 39, NOVEMBER, 1964
give us a greater sympathy for that argument about the nature of history
which so laboriously fills the last chapters of War and Peace.
For those of you who find it easier to remember Natasha and Prince Andrey

than Kutuzov and Barclay de Tolly, let me quote a few of paragraphs (3).
". . . the human intellect, unable to search the infinite variety and compli-
cated tangle of conditions accompanying phenomena-every one of which may
seem to be the ultimate cause-seizes on the first and most obvious coincidence,

and says, `This is the cause!"'
Somewhat later on Tolstoy says the same thing in a more forthright fash-
ion (3).

"A locomotive is in motion.  The question is asked, What makes it move?
The muzhik answers, "Tis the devil moves it.' Another says the locomotive goes
because the wheels are in motion.

"A third affirms that the cause of the motion is to be found in the smoke
borne away by the wind.
"The peasant sticks to his opinion. 1n.order to confute him, it must be proved
to him that there is no devil, or another peasant must explain to him that it
is not the devil, but a German, that makes the locomotive go."
If we are reluctant to accept the peasant's explanation for the growth of
psychoanalysis, what other forces shall we look at?
I can think of at least three factors that played important parts in the
ascendancy of psychoanalysis during the period 1934 to perhaps 1954, and I
am sure there are many more: (a) The desire to bring psychiatry more fully into
the "pinstream of medicine"; (b) The desire of American medicine to be
rational rather than "empirical"; and (c) The dterror.

The foundations and especially perhaps the General Education Board and
The Rockefeller Foundation bear a considerable responsibility for fostering
the first two attitudes and on the whole they are proud of it. They were also
involved in the operation of the third factor-the Nazi terror-in that they
helped a number of refugee scientists and clinicians to leave Europe and be-
come established in the United States. Why do I say that the desire to put
psychiatry more fully into the mainstream of medicine had the paradoxical
effect of casting it under the spell of analysis? The argument runs as follows:
Putting psychiatry into the mainstream involved, among other things, the giv-
ing of increasingX€&tion to emotiox and mental disturbances as observed
on the wards of a general hospital. Coupled with this was an interest in,
almost an anxiety for, the increased instruction of medical students and resi-
dents. The syllogism here was that psychiatry was backward because it lacked
a sufRcient number of good people. Good people did not go into psychiatry be-
cause they didn't know how interesting it was nor how to learn more about it.
The obvious way to unwind this vicious spiral was to increase the amount of
teaching and to teach in such a way that mental abnormalities became interest-
ing and understandable rather than frightening or boring.

The Alan Oregg Lecture/Mo&on 995

Certainly the reasoning appears to be sound and few of us can disagree with
it even with the benefit of hindsight. It turned out, however, that the work
of the classical investigators and teachers was not well adapted to these pur-
poses. Such inspired clinical observers as Kraepelin or Bleuler were great
phenomenologists and nosologists, but they tended to base their work on as-
sumptions about disease entities which have not yet been borne out in prac-
tice.. In any case, nosology provides a doubtful framework for persuasive
teaching, as classical zoology and botany have long known. Adolph Meyer
with his emphasis on the many different factors-biological, psychological, and
social-which combine to produce mental disease was perhaps closest to the
present eclectic attitudes of our best teaching clinics, but he never seemed
able to present his ideas in a way that could influence students beyond the im-
mediate circle of his devoted followers in Baltimore. Finally, at the time we
are speaking of, experimental approaches to behavior centered on theories of
learning and such matters as sensation and perception, which seemed to bear
little relationship to mental aberration as observed in the clinic.

Whatever else may be said of Freud, he is endlessly interesting aTd full of
brilliant new ideas, insights, and deductions, all well worked out ant clearly
expressed. Obviously greatly influenced by 19th century physics-especially
thermodynamics, perhaps, and by physiology-he slipped easily into a chain
of cause and effect analysis, simple to understand and, what was more itnpor-
tant, simple for the teacher to reproduce once he had grasped a few basic
ideas like the trinitarian nature of personality structure, the relationship of
frustracion to anxiety, the ambivalence of love, the repression of socially un-
accepta5le wishes, ar.! so on. There seems really very little room to doubt
that psychoanalysis provides an unusually effective framework for understand-
ing the meaning and significance of many of the symptoms of mental illness.
Thus, it made it possible for the ' -acher of psychiatry to talk about his sub-
ject in much the same way that the internist discussed the physiological back-
ground of physical symptoms. The apparent rationality of the analytic ap-
proach proved particularly seductive to American medical teachers who have
long prided themselves on being in the vanguard of the scientific approach to
medicine. Many of us will remember even a generation ago the contemptuous
tone in which our teachers would remark, "Treatment is symptomatic only."  It
was difficult to avoid the conclusion that it was hardly worth while trying to do
anything for a patient if we didn't understand what was wrong with him.

Many of our friends in Europe and especially, perhaps, in Great Britain have
taken a different view and have tended to glorify the practical, empirical ap-
proach as the medical equivalent of the time honored political procedure of
"muddling through." Science was something for queer chaps in laboratories,
but it would be dangerous for anyone contemplating a clinical career to have
too much to do with it.

The two different stereotypes, like all such generalizations, represent ex-
tremes and there is much less difference between the average English and the

I

996 Jouml of Medical Education VOL. 39, NOVEMBER, 1964

average U.S. doctor than one might be led to believe. Great Britain has in
fact contributed heavily to the advancement of scientific medicine ever since
William Harvey first introduced the experimental method into clinical investiga-
tion. Indeed, it is rather hard to think of the country that produced Harvey,
Mackenzie, Lewis, McMichael, and Pickering as zb nation of crude empiricists,
even though George Withering did learn about foxglove from the recipe of a
local wise woman. On the other hand we may not be entirely safe in thinking of
the home of Dorothea Dix and Clifford Beers, or in our own day of Howard
Rusk, as a nation of starry-eyed theorists. Nevertheless, most of us would be
pleased to agree that American academic medicine is typically dedicated to
understanding the natural history of disease, its etiology and pathogenesis,
and to basing its control measures on such understanding. Indeed, to almost
all of us it seems unnecessary to argue that in the long run scientific under-
standing forms the best basis for prevention and treatment.

If psychiatry went wrong in basing so many of its hopes on psychoanalysis,
it did so not because it was seeking. to be rational but for a somewhat more
subtle reason (4). The difficulty appears to have lain in the assumption that
if one understands the cause-or perhaps more accurately the meaning-of
a symptom, one is on the way to understanding the cause of the illness of which
it is a part. To put the matter rather crudely, psychoanalysis has given us an
understanding of the origin of symptoms in the sense that we understand why
most men wish to kill their fathers rather than their mothers. But it has done
rather less well at explaining why so few men actually do kill their fathers
while the great majority do not. In other words, it has not helped us much to
understand why in common sense terms some people are sick and others re-
main reasonably healthy. It is no good trying to get around the problem by
lining up beside the old Philadelphia Quaker and agreeing that everyone is a
little bit queer except me and thee and I have doubts about thee. Admittedly,
there may be a kind of sophistication in recognizing that everyone is neurotic
and that some very celebrated and creative people are very neurotic indeed.
We also may recognize that in a mathematical sense there may be a sickness-
health continuum along which people arrange themselves according to the
rules of Gauss. But as a practical matter, there is a world of difference be-
tween people who get up in the morning, go off to work more or less on time,
get back to help for an hour or two with the children, and make some attempt
to satisfy their wives at night and another elass of people who goof off, slug
the employee at the next bench, lock their children up in dark attics, abandon
their wives, and finally shoot their neighbor, jump off a bridge, or retire to
a world of phantasy.

The funny part of it all is that this distinction-important though it is to
most of us in our role as man in the street and obvious though it is to us as
everyday clinicians-is not very ewy for psychoanalysis to deal with. This fact
should be no more than ordinarily embarrasaing aince no other school of

The Alan Gregg Lecture/Morison 997

psychology has been very good at separating the sick from the reasonably healthy
or at predicting who will break down under stress and who will not.

It may help to understand the problem better if we look at an analogous
situation involving a purely physical illness. Over 300 years of careful clinical
observation and experimental work have given medicine what seems like a
very satisfactory picture of the motion of the heart and blood.  We know, in
other words, a good deal about the dynamics of the circulation.  This knowl-
edge is useful in supporting a cardiac patient on the edge of failure, but only
very indirectly does it tell us much about the cause of his illness or its future
course. Fifty years ago the average doctor had seen so many young people
become incapacitated and die of rheumatic heart disease that he tended to
regard any youngster with an unusual sound over his precordial region as
potentially ill. Innumerable perfectly healthy children were therefore kept from
normal physical development by the restricted activity enforced by physicians
following this hypothesis. Working purely with a knowledge of circulatory
dynamics, the doctor took a long time to discover that in some children a mild
valvular incompetence could be of little or no consequence while in others it
signalized a genetic tendency to develop an auto-immune disorder which would
periodically result in greater damage to the valves of the heart and finally
bring its victim to an early grave. It is becoming clearer to many of us that
just as a knowledge of circulatory dynamics helps us to understand cardiac
failure without solving the problem of rheumatic heart disease, a knowledge
of psychodynamics helps us to understand the Oedipus complex but fails pain-
fully short of solving the problem of schizophrenia.

     `-te our ana'ysis of the factors which led to the luxuriant flowering
of psychoanalysis in this country, it remains only to note that increased in-
terest in and support for the tebchiug of psychiatry naturally increased the
demand for articulate teachers and that tltis increase in demand coincided
with a sharp increase in the supply of experienced psychoanalysts brought
about by the rise of the Third Reich. Hitler and his colleagues were not only
anti-intellectual in general but specifically and bitterly anti-Freudian so that 4 tT L55
by 1939 there was scarcely a single analyst left in the great centers of Berlin
and Vienna. Many of them, perhaps a majority, came here to exert a signifi-
cant influence on the generation of psychiatrists then in training.

It certainly seems unlikely that the members of the Rockefeller Boards, or
the deans and faculties of certain leading medical schools who started work-
ing together in the 1930s to put vigor and life into academic psychiatry, were
planning for a day in which every major chair would be held by a man who
had undergone a training analysis. It seems even more unlikely that the
organizers of the famous Putsch in the Munich beer hall at about the same
time had the future of American psychiatry very high on their agenda.  But
both these groups worked together to produce the situation we have seen.

If it is impossible to foresee events in advance, it is foolish to regret them
after they have come to pass. Kno-wledge is where you find it and we know

To CL

998 JournuZ of Medical Education VOL. 39, NOVEMBEB, 1964

very little about how to schedule the growth of knowledge in an orderly way.
Presumably, fewer children would have died of heart failure during the last
300 years if Pasteur and Fleming had done their work in 1628 when Harvey
was working in circulatory dynamics, but it would certainly be ungrateful to
regret Harvey or to wish that Sir Thomas Lewis had devoted his life to gas
chromatography of the blood lipids instead of fathering modern electrocardi-
ography. When Einthoven provided medicine with the string galvanometer,
it was both inevitable and necessary that a number of first-class investigators
explore every possibility of its usefulness in the diagnosis and treatment of
heart disease. It would be as silly to deplore its limitations as to overrate its
contributions and it certainly is no indictment of electrocardiology to point
out that penicillin has been more useful in controlling luetic and rheumatic
heart disease. Similarly, the power which psychoanalysis apparently gives
us to understand the behavior of certain kinds of disturbed people demanded
an all-out exploration of its potential for understanding and controlling men-
tal illness. We should be neither surprised nor too seriously upset if the re-
sults of this exploration have fallen short of the hopes of its most ardent
supporters. At the very least, we can and should return with renewed vigor
to an even more intense exploration of the genetic, biochemical, social, and
psychological determinants of mental disease and to its treatment with the
ever increasing number of effective procedures placed in our hands by that
sturdy group of investigators who never abandoned a healthy and receptive
eclecticism.

I have gone into some detail to show how plans directed to one objective
sometimes have unexpected effects. I have done so in part because I tend to
follow H. J. Muller (the historian not the geneticist, though both are at the

sity of Indiana) in believing that one of the uses of history is the
ivation of a sense of irony (5). And it is ironic that one of the most urbane,
opolitan, and broadly eclectic philosophers American medicine has pro-
ed should momentarily be cast as a doctrinaire conspirator.

   past needs no defense, but it may have a lesson for the future. As we
come to spend hundreds of millions and even billions of dollars on research,
there is a natural and perhaps growing tendency to want to see that it is spent
in ways that will produce some demonstrable benefit to the taxpayer who sup-
plies the money.  One way of trying to satisfy this wish is to plan and to
package research for sale like a commodity. And some of it comes in very
large packages indeed.  It would certainly be stupid to deny that there are
some very important questions which can only be solved by getting large
numbers of doctors to give the same drug to a large number of patients in
different parts of the world, or by following a large number of mothers
through pregnancy and their offspring through childhood and adolescence.
This kind of thing certainly demands planning and what I have called packag-
ing. Presumably, we will have to find out how to do it properly. All we know
now is that we haven't learned yet. We do know however that reasonable amounts

The Alan Gregg Lecture/Morison 999

of money and modest encouragement given to i      s who think they have
fea way of advancing knowledge will in th      bring returns several
orders of magnitude greater than the original research effort.

If we cannot plan in advance to produce a Harvey, a Pasteur, or a Florey,
we must as deans, foundation officers, and government officials try to recognize
and help them once they are here. If the good administrator has few oppor-
tunities to produce the tides of history, he can and he must do his best to
work with them when they appear.

It seems fitting, therefore, to close this presentation with a quotation from
an informal talk on the support of research which Alan Gregg gave toward
the end of his career. There is nothing particularly original about it, perhaps,
but it reflects a ripeness of wisdom which those of us who are sometimes
tempted to overinterpret history or to overorganize the future might do well
to bear in mind.
"When we can get a first-rate man on a presumptively likely lead or problem,
with good attendant circumstances and good collaboration around him, we
won't make any very sharp distinction as to whether the research problem
is in psychiatry or in geriatrics or in internal medicine or in economics of
medicine, because the fellow's brain and the likelihood of the field providing
good material for him is far more important than anything that a G.H.Q. of
strategy can imagine."

REFERENCES

1. Action for Mental Health. The Final Report of the Joint Commission on Mental
Illness and Health. New York: Basic Books, Inc., 1961.

2. GREGC, A. Our Anabasis. Address presented at the annual dinner of the As-
sociation of American Physicians, Atlantic City, New Jersey, May 4, 1954.
Transmtions of the Association of American Physicbm, LXVII, December, 1964,
Pp. 47-61.

3. TOLSTOY, L. Wur and Peace. New York: Thomas Y. Crowell Co. Copyright, 1927,
by Nathan Haskell Dole.
4. FLEMING, D. The Meaning of Mental Illness. In Atlantic Monthly, Special Supple-
ment on Mental Illness, July, 1964.
5. MULLER, H. J. Uses of the Past. New York: Oxford University Press, 1952.