Abstract
Stanley Cobb founded the Harvard Departments of Neurology (1925) and Psychiatry (1934) with Rockefeller Foundation funding. Cobb was an important transitional figure in both neurology and psychiatry. He and his friend Alan Gregg were the most visible parts of the Rockefeller Foundation psychiatry project, which prepared American psychiatry for the rapid growth of psychiatric research after World War II. Edward Shorter called him the founder of American biological psychiatry, but this misunderstands Cobb and the Hegelian evolution of twentieth-century American psychiatry. I review the major role of the Rockefeller Foundation in the evolution of American academic psychiatry and the disappearance of Cobb’s teaching and that of his mentor Adolf Meyer, a founding father of American academic psychiatry.
Stanley Cobb (1887–1968) was a Boston Brahmin who became a leader of US neurology and psychiatry in the 1930s and 1940s. He began as a neuropathologist, taught neuropathology to Harvard medical students for more than 30 years and became President of the American Neurological Association in 1949. His teacher, Adolf Meyer, permanently shaped his views, and psychiatry became the major focus of his professional life after 1934. However, he never lost interest in neurology and neurological issues.
A skit presented at the 1949 American Neurological Association meeting showed Cobb trying to ride two horses going in different directions, representing neurology and psychiatry. Cobb loved the brain, Hughlings Jackson’s levels of brain function and neuroanatomical details. He began to promote psychoanalysis in the 1930s, knowing that many physicians scorned it, and conceding that its scientific basis was weak. Cobb focused on mind–body issues and psychosomatic medicine. 1 He insisted that all illness had both mental and physical roots, and minimized the importance of specific diagnoses.
His obituary in the New York Times stated, ‘his principal contributions were in psychosomatic medicine’ (Anon., 1968). Cobb’s most cited psychiatric paper concerned psychiatric aspects of Cushing’s disease, but it was less often cited than three of his more neurological publications. I object to Shorter’s (1997: 238) designation of Cobb as the father of American biological psychiatry, which has been adopted by Wikipedia. 2 This requires discussion of the history of American psychiatry and its changing relationship to neurology. I begin with Cobb’s life and the Rockefeller psychiatry project.
Training
Cobb graduated from Harvard Medical School in 1914. He had opportunities in both neurology and psychiatry after finishing his training. Meyer offered him a position in Baltimore, and Harvey Cushing contacted him about a National Institute of Neurology that he hoped to create, but the institute never materialized. Cobb returned to Boston and became chief of Harvard Neuropathology in 1920, replacing E.E. Southard, Professor of Neuropathology and head of the Boston Psychopathic Hospital, 3 who died suddenly of pneumonia, aged 43. Cobb remained at Harvard throughout his career, except for two Rockefeller-funded trips to Europe.
He had important personal experience with psychoanalysis. He had a close and complex family life. He suffered from severe stammering, which was a social handicap, and dated the stammering to the birth of his younger sister Beatrice (White, 1984: 7). Psychoanalysis seemed more helpful for his stammering than speech exercises. He was encouraged by a brief psychoanalysis with Dr Leonhard Seif, visiting in Boston in 1927.
In 1928, on his second trip to Europe, Cobb stayed in Munich, working with neuropathologist Walther Spielmeyer in the mornings and seeing Dr Seif for psychoanalysis in the afternoons. In 1933–4, Cobb had a longer analysis with Dr Hanns Sachs, the training analyst of the Boston Psychiatric Institute, and he became convinced that psychoanalysis had great therapeutic potential. He always placed psychoanalytic ideas into the holistic framework of biological, social and psychological factors that he had learned from Meyer.
The Rockefeller Foundation repeatedly helped Cobb. Abraham Flexner (of the famous Flexner report) had an important early role, after joining the Rockefeller Foundation. In 1910 the Carnegie Foundation sponsored the publication of his report Medical Education in the United States and Canada (Flexner, 1910). This report identified ‘the better medical schools’, urged them to follow the model of the German research university and facilitated financial help from the Carnegie and Rockefeller Foundations. Flexner joined the Rockefeller Foundation in 1912. His autobiography includes a conversation with Harvard Dean Edsall about developing a Harvard Department of Neurology. 4
Cobb studied in Europe from October 1923 to July 1925, with Rockefeller support. He met many famous physicians, starting with Henry Head at London’s Queen Square Hospital. Cobb published a case report with Kinnier Wilson and worked with Max Bielschowsky and Oskar Vogt in Berlin. In Paris he visited the Salpêtrière, and met Pierre Janet and Carl Jung briefly. He also met Constantine von Monakow in Zurich. Cobb spent much more time with neurologists and neuropathologists than with psychiatrists (White, 1984: 101–23), and the trip led to publications with neurologists Kinnier Wilson, Max Bielschowsky and Georges Schaltenbrand.
Cobb and epilepsy
Cobb’s early interest in epilepsy was fostered by important friendships. The first friend was Alexander Forbes, a Harvard physiologist who studied with Charles Sherrington, a father of neurophysiology, and collaborated with Lord Adrian (Eccles, 1970). Forbes, Cobb and Alan Gregg all spent adolescent vacation time at the Putnam camp. Forbes was called ‘the father of American EEG’ by Goldensohn (1998: 97). That is hyperbole, but Forbes did have important engineering skills, and he designed a vacuum tube amplifier to replace the string galvanometer used by early physiologists. He later pioneered single-unit brain extracellular recording and evoked potential studies (Eccles, 1970). Forbes and other Harvard physiologists, particularly Hallowell Davis, provided critical support for the early electroencephalogram (EEG) studies of William Lennox and Fred Gibbs (Stone and Hughes, 2013).
William G. Lennox was a Harvard Medical School graduate, like Cobb. He went to China as a medical missionary, but decided to devote his life to epilepsy research when his daughter Margaret developed epilepsy. He was told that Cobb’s laboratory was the best place for such work. Here, Lennox extended Cobb’s early studies of thyroid function and metabolic factors in epilepsy, and he studied the effects of the ketogenic diet and acidosis on epilepsy; he and Cobb published a long review paper in 1928 (Lennox and Cobb, 1928). Gibbs joined Cobb and Lennox in 1929, and Lennox and Gibbs later showed for the first time that certain kinds of epileptic seizures were associated with a simultaneous characteristic spike and wave EEG (Gibbs, Davis and Lennox, 1935). 5 This was a breakthrough in epilepsy diagnosis and treatment. Cobb remained Lennox’s close friend and supporter until Lennox died in 1960. Cobb continued to see some epilepsy patients after moving to the Massachusetts General Hospital (MGH), also in Boston, as chief of Psychiatry and to publish occasional papers on epilepsy. The epilepsy work of Lennox and Gibbs brought international acclaim for the Boston City Hospital (BCH) Neurological Unit, which increased after the discovery of Dilantin®. Although Cobb had no direct role in this discovery, his interest in epilepsy made it possible: ‘The epilepsy legacy of the Neurological Unit at Boston City Hospital was literally fabulous’ (Rowland, 2009: 29). 6
Institutions and disciplines
Boston City Hospital (BCH)
Rockefeller approved a $350,000 grant for a Harvard academic department of neurology in 1925, but the new unit was not occupied until 1930 because of construction delays. In the meantime, Cobb travelled again to Europe, neurosurgeon Tracy Putnam (nephew of James Jackson Putnam) joined the Harvard Neurological unit, and Houston Merritt began his neurology residency. The BCH neurological unit blossomed in the early 1930s; Cobb’s talented faculty included Putnam, Frank Fremont-Smith, Harold Wolff, Abraham Myerson and Jacob Finesinger. By the time Cobb left in 1934, Lennox and Gibbs had begun work on the world’s first clinical EEG laboratory; Merritt, who had become an important faculty member, was the only senior neurologist not interested in psychiatry and psychosomatic issues. 7 Cobb was busy with administrative work and had become increasingly interested in psychological aspects of illnesses such as migraine, ulcers, asthma and rheumatoid arthritis. He wrote to an English neurologist friend that he was leaving ‘the big Neurological Unit at the Boston City Hospital to start a smaller Psychiatric Unit at the Massachusetts General Hospital’ (White, 1984: 177). 8
Cobb had become associated with the growing community of Boston psychoanalysts and often attended their seminars. His MGH friendships seemed to promise an easier way to achieve his goals of uniting psychiatry, neurology and internal medicine than continuing at the City Hospital. In addition, he found it easier to deal with the Rockefeller Foundation than with Boston politicians (Aring, 1987: 977).
The MGH Psychiatry Unit
Cobb and James Howard Means, MGH Department of Medicine chairman, were friends. Means had helped William Herman to establish a psychoanalytic practice at the MGH in 1928 because of their joint interest in emotional problems associated with endocrine disorders, also an interest for Cobb. Cobb and Herman were both Meyer trainees and were friends during the years before Cobb moved to the MGH, as Herman became an enthusiastic Freudian psychoanalyst. However, Herman died in 1935. Cobb helped many émigré psychoanalysts to become established in the Boston area. Psychoanalysts who joined Cobb’s new department, including Helene and Felix Deutsch and Eric Lindemann, assumed prominent roles (Gifford, 2003; White, 1984: 201).
Psychoanalysis
James Jackson Putnam was the first Harvard Professor of Diseases of the Nervous System. After graduating from Harvard Medical School, he visited European neurologists such as Theodore Meynert and Hughlings Jackson. Putnam began as a traditional neurologist, but became progressively more interested in psychology, psychiatry and psychoanalysis. He began to explore hypnosis and psychotherapy in the 1890s with his medical school friend William James, physician Morton Prince, philosopher Josiah Royce and a few others. They were spoken of as the ‘Boston School of Psychotherapy’ (Hale, 1971: 117–22).
Putnam hosted Freud, Jung and Sandor Ferenczi at his summer camp in the Adirondack Mountains during Freud’s 1909 visit. Freud received an honorary degree from Clark University in Worcester, MA, and his five lectures on psychoanalysis became famous. Cobb as a young man had spent vacations at Putnam’s camp and met his future wife en route there in 1913 (White, 1984: 50). Cobb maintained a lifelong friendship with Putnam’s daughter, Marian Putnam, a practising psychiatrist and psychoanalyst, and his wife’s cousin.
Putnam began a correspondence with Freud and became progressively more enthusiastic about psychoanalysis. He had been a founder of the American Neurological Association in 1875, and its president in 1888. He helped to found the American Psychoanalytic Association in 1911, and was its first president. Then he started the Boston Psychoanalytic Society in 1914; the group met in his home on Friday afternoons, but dissolved after his death in 1918. Isador Coriat, a psychiatrist associated with the BCH, reorganized the group in 1928; Ives Hendrick, an American trained in Berlin, joined the group in 1930, and organized ‘The Freud Seminar’. A new organization, the Boston Psychoanalytic Society, emerged in 1931, and Cobb often attended their meetings. Franz Alexander, who was trained in Berlin, came from Chicago and played a leading role in the society, but returned to Chicago after only one year.
Robert Powell (1977) distinguished an ‘indigenous American form of psychoanalysis’ from a transplanted German form, citing Adolf Meyer, William Alanson White, Smith Ely Jelliffe and Edward Kempf as representing this ‘American form’. Their emphasis differed from that of Berlin-trained psychoanalysts Sandor Rado, Franz Alexander and Hanns Sachs, who focused on the unconscious and ‘dynamic psychiatry’, while the Americans stressed social factors and were closer to neurology. Meyer and Jelliffe had been presidents of the American Neurological Association, and Jelliffe and White wrote a textbook of neurology and psychiatry (Jelliffe and White, 1935). Adolf Meyer was not a psychoanalyst and, although he was friendly with some psychoanalysts, he often criticized psychoanalytic doctrine (Wallace, 2007). One of the few differences between Cobb’s teaching and that of his mentor Meyer was Cobb’s vigorous promotion of psychoanalysis (White, 1984: 289). Powell’s analysis applies to the period before World War II. The war brought many changes. William Menninger led a movement to Americanize, medicalize and popularize psychoanalysis in the post-war period (Plant, 2005). Cobb, who sought to integrate psychiatry and medicine, was surrounded by analysts such as Ives Hendricks who fought to preserve classical psychoanalysis. The Boston Psychoanalytic Society unanimously opposed Menninger’s proposal to open membership of the American Psychoanalytic Association to psychiatrists who had not undergone a training analysis (Plant, 2005: 192).
Cobb’s successor as MGH Psychiatry chief, Erich Lindemann, was a psychoanalyst. He was replaced by John Nemiah, a Cobb trainee and psychoanalyst, who served only from 1965 to 1967. At that time, ‘a revolt against psychoanalysis’ (Taylor, 2005) brought in Leon Eisenberg, a child psychiatrist who emphasized epidemiology and hyperactivity. He had written about preventive psychiatry, community mental health services, and the harmful effects of large psychiatric asylums on patients (Eisenberg, 1962). These factors interacted with psychopharmacology to change American psychiatry over the next 20 years.
Biological psychiatry, neuropsychiatry and psychobiology
The meaning of these words altered over time. Davidson (1980) wrote about ‘The strange disappearance of Adolf Meyer’. Meyer had been chairman of the first American department of Psychiatry and had dominated American psychiatry from 1900 to 1940, yet few articles mentioned him or his ideas after 1970. Furthermore, the word psychobiology, earlier used for Meyer’s conceptual framework (Lamb, 2014: 21), took on an entirely different meaning. Meyer’s psychobiology assumed that all brain activity had biological bases and that clinicians could not usefully separate mental and physical causes or effects. Treatment involved teaching new more adaptive habits (p. 21). The American Journal of Psychiatry, official journal of the American Psychiatric Association, published a series of papers on ‘Psychobiology’ in 1973, a term that now meant drug treatment of mental illness, but there was no mention of Meyer. The variable meaning of psychobiology may have contributed to Shorter’s claim that Cobb was the father of American biological psychiatry, as we shall see below. Powell’s article on the pre-war schools of psychoanalytic thinking stressed the central role of Meyer and his psychobiology in the development of psychosomatic medicine (Powell, 1977: 139). Powell quoted Bunker’s 1944 opinion that early psychosomatic medicine was defined by ‘the psychobiologic approach of Adolf Meyer’ (Bunker, 1944: 500). Meyer had begun his American career as a neuropathologist in an Illinois state hospital. He had moved to a Worcester, MA, state hospital in 1895 and got to know members of the ‘Boston school of psychotherapy’. Putnam’s (1899) paper reflected Meyer’s holistic ideas.
Most early neurologists, like Putnam, called themselves neuropsychiatrists and saw patients with ‘neurological conditions’, such as epilepsy and head injury, and ‘psychiatric conditions’, such as phobias, anxiety and depression. Cobb often called himself a neuropsychiatrist and, even in retirement, he saw patients as having a large overlap between neurology and psychiatry (Cobb, 1958, 1963). 9
Cobb became increasingly interested in psychosomatic medicine in the 1930s, along with a national wave of enthusiasm for the subject and for a book by Helen Flanders Dunbar of New York, Emotions and Bodily Changes (1935). The Macy Foundation supported Dunbar and her book, and the Rockefeller Foundation supported psychosomatic medicine as part of its plan to integrate psychiatry into general hospitals. Dunbar founded the American Psychosomatic Society in 1942 and was the first editor of its journal, Psychosomatic Medicine. As Powell (1977: 140) stressed, ‘Meyer, White (William A. White) and Dunbar were a different breed of psychiatrist’. Meyer, Cobb and Dunbar shared similar ideas that are incompatible with our era of 15-minute medical visits (Fiscella and Epstein, 2008).
Cobb wrote 21 review articles: ‘Review of neuropsychiatry’, in the Archives of Internal Medicine, almost every year between 1935 and 1959. The major themes, each about 20 pages long, were epilepsy, schizophrenia and its aetiology, the function of the frontal lobes, ‘shock treatment’ (insulin shock and later electroconvulsive shock) and the broad area of psychosomatic medicine. Cobb had reservations about lobotomy, ‘a justifiable procedure only when the patient is old and the prognosis hopeless’ (Cobb, 1940: 1354), and electroshock therapy, which was helpful for depression but overused by unsophisticated psychiatrists. By 1942, he questioned claims that particular personality types were associated with chronic medical diseases: ‘… to the tough minded person it is still quite unconvincing. The psychological descriptions are too much alike and the diseases too obviously different’ (Cobb, 1942: 1020). Cobb never lost interest in psychoanalysis or attempts to develop a unified psychosomatic approach to all diseases, but he admitted to many disappointments. He noted in a 1962 talk: ‘Many clinicians still think in terms of one cause for each disease’ and ‘the concept “disease” is an abstraction too schematic and too static to be accurate’ (p. 303). He hoped that clinicians of all kinds might accept the importance of psychological factors and stated ‘perhaps we will cease to hear anything about psychosomatic medicine’ (p. 304). Cobb’s final 1958 edition of Foundations of Neuropsychiatry discusses the psychoses and the overlap between schizophrenia and manic-depressive disease. He does not mention chlorpromazine or reserpine.
The rising influence of psychoanalysis in the USA separated American from Anglo-European psychiatry. This provoked disputes and ultimately rejection of the psychiatric establishment by the so-called Neo-Kraepelinians, crystallized in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980). The first edition (APA, 1952) categorized psychiatric diseases as reactions to biopsychosocial factors, following Meyer’s views and World War II experience when many psychiatric labels proved irrelevant (Wilson, 1993). The second edition, DSM-II, published in 1968, outlined a different view, eliminating the concept of psychiatric disorders as reactions (Rogler, 1997). During the 1970s, the so-called neo-Kraepelinians became more and more influential (Decker, 2007). They dominated the writing of DSM-III, eliminated the words neurosis and neurotic, and minimized psychoanalytic thinking.
Historian Theodore Brown (2000) reviewed ‘The rise and fall of psychosomatic medicine’, and stressed the role of a few people (Dunbar, Alexander, Cobb and Alan Gregg) and foundations in the growth of psychosomatic medicine in the 1930s and 1940s.
10
He said: I have become convinced that Gregg, with the comparatively vast resources and influence he commanded at the Rockefeller Foundation, was critically important to the development of American psychosomatic medicine … when the American government contributed essentially no resources to medical education and research. (Brown, 2000: 19)
11
Some psychoanalysts claimed that resolution of unconscious conflicts could correct diseases such as ulcers, asthma, etc. (Lipowski, 1986). Popular magazines promoted their views with messages such as ‘your emotions can make you sick’ (Anon., 1945) 12 and ‘mental or emotional shock makes certain organs overactive; the patient’s personality determines which organs will be affected’ (Anon., 1948). 13
Franz Alexander was a post-war leader of psychosomatic medicine, and a member of the committee that created DSM-I. He sought a middle road between physiology and psychodynamics, and conceded a role for standard medical treatments. His well known book, Psychosomatic Medicine (Alexander, 1950) admitted that the specificity of physiological responses to various psychodynamic factors was unproven.
Peptic ulcer was a prototypical psychosomatic disorder in the post-war period. Ulcer patients ‘possess a deep desire to mold their environment, to dominate persons and situations. . . . They are all or nothing folk. . . . They express themselves violently on every subject’, according to Moschcowitz and Roudin (1948: 1377). 14 However, new, more effective anti-ulcer drugs, and then the demonstration that a newly discovered bacterium, Helicobacter pylori, caused many ulcers, devastated psychosomatic ulcer theories (Yeomans, 2011). The 2001 meeting of the American Psychosomatic Society included a ‘great debate’ on the role of psychosocial factors in organic disease. Redford Williams and Neil Schneiderman argued that psychosocial factors were proven to influence the course of common diseases like hypertension, coronary heart disease and HIV infection, while Arnold Relman and Marcia Angell argued to the contrary. The proceedings were published in Psychosomatic Medicine. 15
The intellectual climate had shifted. Ulcers were not mentioned. No speaker mentioned Freud, psychoanalysis, Alexander, Cobb or any of his MGH Psychiatry colleagues. No evidence remained of Cobb’s 25 years of work for the journal, or any trace of Meyer’s even larger role in American psychiatry. 16 Psychosocial factors might be important in precipitation and management of disease, and might influence adherence to medical regimens, but they were no longer central.
Biological psychiatry has also gone through many stages. Psychopharmacology is an important part, but new methods and findings from genetics and imaging studies have become increasingly important. Edward Shorter, an influential historian of psychiatry, divided the history of psychiatry since the 1880s into three periods: biologically-based asylum psychiatry (‘the first biological psychiatry’); an era of psychotherapy and psychoanalysis; and then the second biological psychiatry (‘with medications that truly worked and evidence that psychiatric illness represented a biological phenomenon far deeper than troubled human relations’) (Shorter, 1997: 238). Shorter says: ‘If any single individual should be considered the founder of biological psychiatry in the United States, it is probably Stanley Cobb’ (p. 263). This view has been widely disseminated. Consider the Whiggish 17 quote above (from p. 238), which implies a major role for effective psychopharmacology, and believes that biological factors predominate in most forms of mental illness. This matches neither Cobb’s nor Meyer’s views. Cobb did no psychopharmacological research, nor did anyone in his MGH department. As the psychiatrist David Healy wrote, ‘Stanley Cobb … might have been expected to view matters with a biological slant … Cobb became psychodynamically oriented … gradually the analysts took over the departmental conferences’ (Healy, 2002: 293). Cobb had little enthusiasm for the new ideas and treatments of the 1950s, like many psychoanalytically oriented psychiatrists (López-Muñoz et al., 2005). Cobb rejected the idea of simple causes for any psychiatric diseases. He wrote that human disease results from ‘impacts of the internal and external environments upon what is given by heredity. It is never a question of either heredity or environment’ (Cobb, 1960: 102–3).
Shorter gave several reasons for naming Cobb as the father of American biological psychiatry. First, he cites Penfield’s book on Alan Gregg (Penfield, 1967). Shorter (1997: 263) says that Cobb pursued ‘basic biological research at the Mass General for the next 20 years’ (after starting the Department of Psychiatry in 1934). He quotes Penfield’s statement that Cobb was interested in ‘psychobiology supported by the neurosciences’; the quote is misleading (p. 282). 18 Cobb’s MGH research focused on psychosocial factors and diseases such as hypertension, asthma and mucous colitis. It was not basic research. Second, Shorter says that research by Cobb and Tracy Putnam led to the discovery of the important new antiepileptic drug Dilantin®. That work began in 1935 after Cobb had left the BCH. Shorter’s only Dilantin® reference indicates that Cobb was only peripherally involved (Putnam, 1970). Third, Cobb resident Eli Robins was influential in the DSM-III revision that drastically changed psychiatric practice. Cobb had died 12 years before DSM-III was published; Cobb and Meyer would have opposed Robins’ neo-Kraepelinian ideas. Fourth, Cobb participated in creating the Society of Biological Psychiatry in 1945. However, he never published in its journal or attended its meetings. He gave much time and effort to the journal Psychosomatic Medicine and to the American Psychosomatic Society. Cobb often spoke and wrote about psychosomatic medicine or ‘mind-body questions’, but rarely about other aspects of ‘biological psychiatry’. In summary, Shorter’s claim cannot be supported; he may have misinterpreted statements about psychobiology as meaning interest in genes, molecules and psychopharmacology. Both Meyer and Cobb were interested in biological and social factors in psychiatric illness, but neither can be a father of American biological psychiatry.
Shorter’s view of psychopharmacology appeared to change significantly between his book A History of Psychiatry (Shorter, 1997) and his short article, ‘History of psychiatry’ (Shorter, 2008). In the latter, he now embraced the historical ideas of Thomas A. Ban, who wrote extensively about psychopharmacology and its history, two of his articles being especially relevant (Ban, 2001, 2006). 19 Ban emphasizes the drug industry’s control of psychiatric clinical trials, and the limited progress in psychopharmacology after the breakthroughs of antipsychotic drugs in the 1960s and the SSRIs (selective serotonin reuptake inhibitors) for treatment of depression in the late 1980s. His discussion is more specific than Shorter’s (1997: 238) earlier paean to ‘medications that truly worked’. Cobb is not mentioned in Ban’s papers.
Evolution of Cobb’s writing and teaching
White (1984: 342–70) lists 512 books, articles and pamphlets by Cobb. Only 3 of the first 100 involved psychiatry or psychology, including a brief neuropsychiatric examination of 1141 college freshmen for ‘nervous instability’ (Cobb, 1922). The second 100, from 1935 to 1946, included 54 publications related to psychiatry and psychology. These included psychological studies of patients with bronchial asthma and mucous colitis. There were no book reviews in the first 100 publications, 19 in the second and more than 100 thereafter, mostly for the journal Psychosomatic Medicine. Cobb’s publications included a 1937 letter to the New England Journal of Medicine objecting to an editorial about the benefits of insulin shock treatment of schizophrenia. The treatment was neither new (he cited colectomies in the 1920s for psychosis) nor safe (Cobb, 1937). Cobb’s later publications focus on psychiatry and psychosomatic medicine, but neurological topics continue to appear.
Cobb wrote A Preface to Nervous Disease in 1936, based on his neuropathology course. He revised the book in 1941, added a 12th chapter on psychopathology, and renamed it Foundations of Neuropsychiatry. He now included brief discussions of Freud and schizophrenia and related psychoses. Cobb continued to revise the book until the sixth edition in 1958. He added more material on Freud, repression and unconscious conflicts, but neurological issues always predominated. Cobb’s preface to this sixth edition thanks Lennox and nine other physicians for helping: three neurosurgeons, five neurologist-neuropathologists, and one psychiatrist – his former trainee Frances Bonner; thus of the nine helpers, only one was a psychiatrist.
Cobb’s long article ‘One hundred years of progress in neurology, psychiatry and neurosurgery’ (1948) was based on a talk at the 1947 centennial celebration of the AMA Section on Nervous and Mental Diseases. It was fundamentally different from Foundations of Neuropsychiatry or Cobb’s annual reviews of neuropsychiatry. This was a heart-felt celebration of psychoanalysis. Cobb says:
The academic psychologists, from Wundt to Watson, had failed to make any significant contribution to the knowledge of human nature. It was necessary for psychiatry to gain understanding of social relations, personal motivations and emotions. Now that the battle has been won, it is hard to believe how well entrenched was Kraepelin and his systematic ‘imperial German psychiatry.’ The victory was due to the direct attacks of men like Meyer, Bleuler and Hoch; to advancing knowledge of the physiology of the emotions, and, most of all, to the genius of Freud. (1948: 76)
Modern ‘psychosomatic’ medicine is a reaction against the laboratory teaching of the last half of the nineteenth century … conceived by the coming together of three fertile schools of thought – the physiology of the emotions, psychoanalysis and psychobiology. (p. 75)
Here Cobb saluted the ideas of Sigmund Freud, Adolf Meyer and Walter Cannon, and echoed Putnam’s 1899 Shattuck lecture, which noted that medical leaders had: turned a cold shoulder on the time-honored methods of cure by faith and fear which had worked miracles for ages past … The splendid wave of pathological and bacteriological research that has raised the art and science of medicine to its present position of authority has set physicians trying to solve their problems in terms of pathology alone. (Putnam, 1899: 53)
Cobb also wrote Borderlands of Psychiatry (1946). This short book covered mind–body problems, evolution of speech, vision and intellect, speech and language defects. Psychoneurosis and psychosomatic medicine were allocated 44 of 160 pages. Cobb said, ‘I solve the mind-body problem by stating that there is no such problem’ (p. 19).
Cobb’s A Preface to Nervous Disease (1936) included pyramids of knowledge for both neurology and psychiatry, and he identified a lack of knowledge in the centre of the psychiatric pyramid (p. vi). Scientific support for psychoanalysis was lacking. Psychiatry was young; he hoped that the gap in knowledge would be filled in the future. The neurology pyramid had no gap. The final 1958 edition of Foundations of Neuropsychiatry included another psychiatric pyramid, with sociology now placed between clinical psychiatry and psychoanalysis. The void in the centre of the pyramid of psychiatric knowledge persisted; Cobb (1958: 4) still believed that ‘many of these theories are probably correct’.
Cobb dedicated the last half of his life to attempts to close the gap between mind and body, and to teaching the Meyer–Dunbar–Cobb view of psychosomatic medicine (Powell, 1977). However, psychosomatic medicine changed and became more evidence-based. Cobb’s ideas were more nuanced than those of contemporaries Jelliffe, Moschcowitz, Deutsch and Alexander, but his stubborn rejection of disease categorization limited their value to later generations of clinicians.
Cobb’s pupils
Stanley Cobb was the most visible part of the Rockefeller Foundation’s psychiatry project during the 1930s and 1940s. Paul MacLean was probably his most influential psychiatric trainee. He went to Yale, where he coined the term limbic system and developed his widely publicized theory of the triune brain (Lambert, 2003). McLean’s ideas owed more to John Fulton and James Papez than to Cobb. Like Cobb, he was interested in neuroanatomy, social issues and philosophy.
John Nemiah and Peter Sifneos were Cobb residents who became leading psychotherapists. Nemiah was editor of the American Journal of Psychiatry for 15 years; he told Benjamin White that ‘He [Cobb] was as responsible as anyone else for the ascendancy of the analytic movement, not only in Boston, but nationally’ (White, 1984: 289). Sifneos invented the important concept of alexithymia: impaired ability to feel and describe emotions (Kano and Fukudo, 2013). Psychiatric trainees such as Edwin Gildea (received Rockefeller funding in St. Louis) and Eli Robins were influenced by Cobb, but later promoted Kraepelinian ideas in DSM-III.
Cobb’s neurologist trainees became more visible than the many who became psychiatrists. Raymond Adams and H. Houston Merritt were the most important. Merritt, a renowned clinician and co-discoverer of Dilantin®, became chief of Neurology at the New York Neurological Institute and then Dean of the Columbia School of Physicians and Surgeons. He trained many neurology department chairmen. Merritt’s successful Textbook of Neurology, which first appeared in 1955, remains in print.
Adams came to the MGH with a Rockefeller fellowship, planning to return to Duke as a psychiatrist. His first year as a neurology resident went well, but the second year in psychiatry with Stanley Cobb did not. Adams was repelled by psychoanalysis. After this bad experience, his Duke sponsors sought to arrange a third fellowship year with Adolf Meyer, but that interview went badly (Laureno, 2009: 61–2), so he took another year of psychiatric training at Yale. He was pleasantly surprised by an offer to join Merritt in the BCH neurology department in 1941. Adams did well at the BCH; he described hepatic encephalopathy and other complications of alcoholism. He returned to the MGH as chief of Neurology in 1951. There he described many more neurological disorders, ranging from transient global amnesia to central pontine myelinolysis, oculopharyngeal muscular dystrophy and more, based on clinico-pathological correlation. He built an internationally renowned department with the help of C. Miller Fisher, Maurice Victor and Philip Dodge.
The neurological sections of the first edition of Harrison’s influential textbook of internal medicine were written by Merritt (Harrison, Beeson, Resnick, Thorn, and Wintrobe, 1950), but the editors were dissatisfied and asked Adams to replace him. Adams added additional general medical chapters in the second (1954) edition, and later said: ‘I wrote chapters on those aspects of nervous system disease that every internist and general physician was bound to see, things like disturbances of consciousness, disturbances of sleep …’ (Laureno, 2009: 61–2). Adams reviewed the importance of psychological symptoms and psychological factors in diseases such as asthma, ulcers and colitis. These factors were more likely to be precipitants rather than fundamental causes. He also included chapters on anxiety disorders, hysteria, psychosis and depression, written with a psychiatrist co-author from outside the MGH (Dr Justin Hope). The chapter on schizophrenia and related psychoses in the third edition of Harrison’s textbook (1958) mentioned chlorpromazine and reserpine, not found in the sixth edition of Cobb’s Foundations of Neuropsychiatry, also published in 1958 (Hope, Laird and Adams, 1958: 363–5). Adams’ chapters in Harrison’s textbook included Cobb’s areas of general medical interest. We may say that Cobb kept one foot in neurology, and Adams, even though known as an ‘anti-psychiatrist’ (White, 1984: 319), left a toe in psychiatry.
Adams has far more citations than any other Cobb colleague or trainee; 20 William Lennox is next, Paul MacLean third and Houston Merritt fourth. Cobb and his resident Peter Sifneos are essentially tied for fifth place. Cobb’s most cited paper was on cerebral circulation (Gildea and Cobb, 1930).
Cobb retired in 1954, three years after Adams became chief of MGH Neurology and the year in which Adams’ chapters appeared in the Harrison textbook. However, Cobb remained active, and was especially proud of receiving the Kober award from the American College of Physicians in 1956. 21
Adams rejected psychoanalysis and much of Cobb’s teaching. Years later, he said ‘I always felt contrite about my failure to have a warmer, more understanding relationship to him’ (Laureno, 2009: 44). However, Adams helped continue the chain of psychiatric leaders from Putnam to Meyer to Cobb. Paul McHugh was an influential Chairman of Psychiatry at Johns Hopkins from 1975 to 2001 and is still active. He attended Harvard Medical School and took Cobb’s neuropathology course. Planning a career in psychiatry, McHugh first trained in neurology with Adams and then with Aubrey Lewis (another Meyer trainee and Rockefeller grantee) at the Institute of Psychiatry in London. McHugh espoused one kind of biological psychiatry. He and his colleague Phillip R. Slavney wrote The Perspectives of Psychiatry (McHugh and Slavney, 1983), stressing ideas from Meyer and Karl Jaspers. McHugh inveighed against the idea of ‘Psychiatric diagnosis by checklist’ (McHugh and Slavney, 2012). 22 His 26 years as Hopkins’ Chairman of Psychiatry were a partial Meyer restoration, adding his voice to a few psychiatrists who sought to restore elements of Meyer’s approach (Double, 1990).
Relationships between neurology and psychiatry
Neurologists outnumbered psychiatrists before World War II. Five of ten Presidents of the APA between 1915 and 1925, 5 had published material on neurology and were linked to neurology, whereas this applied to only one in the 1955–65 era. 23
Roy R. Grinker, Sr, was a Chicago neurologist who was sent to Vienna on a Rockefeller fellowship to be analysed by Freud. This reflects the close association between neurology and psychiatry in the 1920s. He became a psychoanalyst, but published a textbook of neurology with editions in 1934, 1937, 1943 and 1949. The fifth and final edition in 1959 included neurologist and neurosurgeon co-authors (Grinker, Bucy and Sahs, 1959). At the same time, Grinker became the first editor of the Archives of General Psychiatry. 24 He was better able to adapt to the changing intellectual climate in the late 1950s and 1960s than Cobb was, and he joined Menninger in the ‘assimilationist’ school of psychoanalytic reformers (Plant, 2005). Grinker’s (1969) review of schizophrenia acknowledged a neuropathological dimension to schizophrenia and noted that the search for morphological changes had been superseded by searches for chemical abnormalities.
Alan Gregg became Director of the Rockefeller Medical Sciences division in 1930. He sought to strengthen psychiatry and related fields and to integrate psychiatry and general medicine. In 1932, the Foundation gave $1,282,652 to McGill University to establish the Montreal Neurological Institute. Gregg turned to fostering centres of psychiatric teaching: at Harvard where Cobb was moving to the MGH; at Colorado, where Franklin Ebaugh (another Meyer trainee) promoted the integration of psychiatry and general medicine; and at Johns Hopkins (for child psychiatry
25
), the University of Michigan and the University of Pennsylvania. Gregg also helped Franz Alexander found the Chicago Psychoanalytic Institute. More centres were added, as a 1937 report to the Rockefeller trustees illustrates: The improvement of psychiatric teaching in the medical schools was chosen as the necessary first move, and measures looking toward such improvement have already been initiated at Chicago, Colorado, Harvard, Hopkins, Illinois, Michigan, Pennsylvania, Tulane, and Yale (under the Institute of Human Relations) … Since 1931 these endeavors to improve the teaching of psychiatry have been the dominating interest of the Division of the Medical Sciences. . . . In the period of the 1940s the plan is to aid in building up a few research centers. (Anon., 1937: 1–2)
The Rockefeller Psychiatry project had major and lasting effects. Many Rockefeller-funded psychiatrists became national leaders in their field: Cobb, Alexander and Leo Kanner most notably, plus Ebaugh and Frank Strecker at Pennsylvania. The Foundation usually avoided promoting any particular line of psychiatric research, although Gregg and his friend Frank Fremont-Smith (Cobb’s BCH colleague who became director of the Josiah Macy, Jr. Foundation in 1936) were sympathetic to psychoanalysis. In 1941, Gregg wrote, ‘(the) most striking indication[s] that the psychoanalysts are on the right road’ was the ‘broad biological basis of their theories’. 26 The Rockefeller Foundation supported only one psychoanalytic institute, in Chicago, and Gregg later felt that this had been a mistake, because psychoanalysis was too speculative. World War II and the National Mental Health Act of 1946 (which created a National Institute of Mental Health) had major effects on the evolution of American academic psychiatry, already primed by Rockefeller (Romano, 1994). By promoting psychiatric units in general hospitals, the Rockefeller Foundation helped to start the movement to reduce inpatient psychiatric hospitalization, which became so strong in the 1960s (Smith, 2016). Psychopharmacology began in Europe and never received much Rockefeller support.
Melvin Sabshin, who was medical director of the APA from 1974 to 1997, selected three turning points in twentieth-century American psychiatry (Sabshin, 1990). The first was the rise of Meyer’s psychobiology after World War I. Next came psychoanalysis aided by the World War II experience and the immigration of many talented European analysts. However, psychoanalysis became rigid and dogmatic and lost favour. The third turning point was the rise of psychopharmacology. Its early success led to extremes. 27 Sabshin never mentioned Stanley Cobb, either as a part of the psychopharmacological wave or as being important in psychosomatic medicine.
Others have written about the history of twentieth-century American psychiatry. 28 Most of them ignore the role of the Rockefeller Foundation, although it was responsible for increasing the number of psychiatric units in American general hospitals from less than 10 to more than 150 in the 1930s (Lipsitt, 2000: 175). The delayed effects of its emphasis on psychiatric research became evident in the 1950s and 1960s.
Biological psychiatry existed in the 1920s and 1930s. Sedatives were widely used in the asylums, insulin coma was introduced in the 1920s and lobotomy in the late 1930s. In 1935, Adolf Meyer organized an APA symposium on ‘The material of human nature and conduct’; this meant the basic material of mind and human nature, the material that psychiatrists work with. 29 Cobb was part of that symposium, and his paper stressed levels of neurological function, but it was far from what anyone today would call biological psychiatry (Cobb, 1935a: 309). As psychoanalysis became discredited, Cobb had no other therapeutic approach to link to his Jacksonian concepts of brain physiology. He focused on understanding individual patients in terms of their life history, but had no interest in dissecting the causes of mental illness.
Conclusion
Many leaders of American military psychiatry during World War II, such as Roy Grinker and William Menninger, were psychoanalysts. Psychiatry and psychoanalysis assumed a much larger role in US medical schools after the war. However, psychoanalysis met resistance and ultimately rejection in the 1960s and 1970s (Hale, 1995). Ban (2006) attributes much of this rejection to the rise of psychopharmacology. 30
Cobb could not resolve the conflict between biological/pharmacological and psychological/psychoanalytic reductionism. He made no major neurological discoveries, but facilitated the pioneering EEG work of Lennox and Gibbs. His 21 annual reviews of neuropsychiatry underline his deep interest in general medicine; he mentioned chlorpromazine and reserpine only once. He acknowledged the major impact of neuroleptics with reservations. They were most useful for large hospitals with high patient to staff ratios (Cobb, 1956: 611). Cobb often wrote about schizophrenia. He never acknowledged the major role that chlorpromazine and related drugs had come to play in the treatment of schizophrenia by 1960, or the likely role of biochemical factors in that disorder. His last paper on the subject insisted that schizophrenia was not a disease: ‘It is an all too common reaction to many kinds of stress’ (Cobb, 1964: 707). Drugs and hormones might provoke psychotic reactions, but he said nothing about drug treatment or searching for biological causes. Cobb’s protests epitomized his losing battle with the new biological psychiatry. 31 Like Freud, Grinker, Meyer, and Putnam, Cobb was a neurologist who devoted progressively more effort to psychiatry and behaviour; he was never enthusiastic about any physical treatments for mental illness. Cobb and the Rockefeller psychiatric project represented a turning point in psychiatric history. 32 Cobb, its most visible grantee, tried to preserve a fading unity of neurology and psychiatry and a simplistic view of psychosomatic illness.
Roy Grinker was better able to merge the new neuroscience with psychoanalysis than was Cobb. Grinker did more to foster the development of biological psychiatry than any others in the Rockefeller cohort of psychiatric leaders. However, his work, like that of Cobb and Meyer, and others in the inter-war Rockefeller leadership cohort, has disappeared. Alan Gregg saw neurology and psychiatry units as partners (Guenther, 2015), but neurology and psychiatry gradually drifted far apart. The Rockefeller emphasis on developing research in psychiatry departments paid off in the long term. Leo Kanner is the only member of the original Rockefeller Foundation psychiatric grantees who remains visible, because of the controversies associated with autism.
Returning to the comment by Healy (2002: 293), Cobb’s emphases were less biological than outsiders might have predicted. The New York Times obituary (Anon., 1968) better summarizes Cobb’s historical place than Shorter’s 1997 claim or its Wikipedia extension.
Footnotes
Acknowledgements
I acknowledge information gained from reviewing Cobb’s papers at the Countway Library of medicine in Boston, and help from librarians at the UCLA Biomedical Library. I thank Verne Caviness, David Preven and Stephen Sagar for reviewing earlier versions of the manuscript, and Dr Paul McHugh for helpful comments.
Funding
This work was funded entirely from personal and departmental sources.