Early Years at the Public Health Service, 1909-1923
Lawrence Kolb received his MD from the University of Maryland in 1908. After a one-year internship at the University of Maryland Hospital, he joined the Public Health and Marine Hospital Service (as it was then called) in 1909. In a 1963 oral history interview, Kolb recalled that he knew nothing about the PHMHS at the time, but that a Dr. Cordell at the University of Maryland Hospital, who was "a historian on medical matters," suggested that he apply to the agency. Kolb passed the PHMHS examinations with high scores (fourth in the class, according to the notification letter) and was commissioned as an Assistant Surgeon. His first ten years with the service coincided with rapid growth of medical science, public health, and psychiatry, as well as unprecedented immigration and the First World War.
Quarantine and Immigration Inspection
When Kolb joined the U.S. Public Health and Marine Hospital Service, it was a small but growing federal agency. It had been established as the Marine Hospital Service (MHS) in 1798 to provide shore care for sailors serving on merchant and U.S. Navy ships. Captains of ships docking at American ports were required to withhold a small amount from each crew member's wages and turn the money over to the customs collector; the collected funds were then used for setting up marine hospitals and providing medical care. After the Civil War, the service was reorganized, with a more centralized collection and distribution of funds and a Supervising Surgeon General. The first Surgeon General, John Woodworth, instituted exams for applicants, made appointments only to the general service (not specific locations), and put the medical officers in uniform, creating a mobile career corps with a central, non-political administration. The Commissioned Corps of the Marine Hospital Service was established by law in 1889.
The responsibilities of the MHS expanded after 1870. Commerce and shipping increased as America's population and economy grew, with a corresponding need for marine hospitals. With more immigration and more densely populated cities, the risk of epidemic diseases such as cholera, smallpox, and yellow fever also grew. Medical practitioners were only starting to accept the "germ theory" of disease, i.e., that microbes (bacteria, viruses, etc.) caused many illnesses; medical researchers were only beginning to identify the microbes that caused specific diseases. By the early twentieth century the causative organisms of many diseases (including cholera, tuberculosis, typhoid, diphtheria, plague, and pneumonia) would be identified, and advances in microbiology would yield vaccines or anti-toxin treatments for some of them. But this took several decades to achieve. Meanwhile, the experiences of early public health workers, military doctors and nurses, and others had demonstrated that cleanliness and proper handling of waste could reduce the transmission of many diseases, even if it wasn't clear what caused them. Quarantine of ships, cargo, and passengers--one of the oldest ways to limit infectious disease spread--became more effective as local, state, and federal officials applied the new public health knowledge. In 1878, the National Quarantine Act made the MHS responsible for all maritime quarantine, and for general disease surveillance. In 1887, a Hygienic Laboratory was established at the MHS hospital on Staten Island to conduct bacteriological testing for diseases such as cholera and do research. It was moved to Washington, DC in 1891 and soon expanded its activities to include bacteriological training for federal and state public health officers, production of antitoxins, regulation of vaccine production, and field investigations of diseases ranging from plague to Rocky Mountain spotted fever.
Immigration inspections also became part of the MHS responsibility after 1890. Between 1870 and 1900, over 11 million people immigrated to the U.S., many drawn by opportunities for industrial or farming work and some fleeing persecution in their native countries. While employers were glad for their labor, the vast number of immigrants provoked several concerns. Many, especially public health officials, worried that they might be carrying diseases when they arrived, and provide breeding grounds for disease in the overcrowded and dilapidated urban neighborhoods where they often settled. Likewise, proponents of recent evolutionary and hereditary theories worried that immigrants might bring undesirable genetic legacies, heritable mental or physical disabilities that they might pass on to the next generation, thereby degrading America's "racial stock." Government officials feared that any of these problems might render immigrants unable to support themselves in their new home, placing economic burdens on the community. A new immigration law passed in 1891 mandated the health inspection of all immigrants and stipulated that Marine Hospital Service officers should do the inspections. The law specified that "all idiots, insane persons, paupers or persons likely to become public charges, persons suffering from a loathsome or dangerous contagious disease" were to be excluded, as were criminals.
Two years later, a new quarantine act required ships bound for U.S. ports to obtain a bill of health from the local American consulate and PHS officers to be detailed to foreign consulates to make the inspections. All ships arriving in U.S. ports needed to have cargo and passengers certified by federal quarantine officers. The act also required the Surgeon General of MHS to examine all state and municipal quarantine regulations and revise them if inadequate. Surgeon General Walter Wyman (1891-1911) also established a policy of assigning officers to strategic observation posts in Asia and South America as well as Europe, to keep up on information about epidemics in those regions.
In 1912, the Public Health Service Act changed the agency's name and gave it authority "to study and investigate the diseases of man and propagation and spread thereof, including sanitation and sewage and the pollution either directly or indirectly of the navigable streams and lakes of the United States."
Dr. Kolb's first duty station was at Reedy Island on the Delaware River south of Wilmington. As a quarantine officer, he was responsible for boarding ships going up the river to Philadelphia, and inspecting their cargo, crew, and passengers, detaining any that might show signs of active disease. When disease was found, quarantine officers also had to disinfect the ship holds, cargo, cabins, and baggage, and sometimes exterminate rodents.
In 1913, Kolb was reassigned to the immigration station at Ellis Island, in New York harbor. Opened in 1900, it was the second facility there (the first had opened in 1892, but burned down in 1897) and much larger, with a main processing hall, a hospital, dormitories for detainees, administration offices and staff housing, laundries, kitchens, a powerhouse, and other buildings.
Kolb and the other PHS medical officers spent much of their days doing "line" inspections of steerage (third class) passengers ferried over from incoming ships. (First- and second-class passengers didn't need to leave the ships, but were inspected on board before docking, and only sent to the island station if medical officers detected disease or other cause for concern.) As passengers walked through one of two or three single-file lines, one medical officer examined passengers quickly for a comprehensive list of conditions and diseases and marked their clothing with codes in chalk. A second officer checked them again, noting anything missed by the first examiner. Chalk-marked immigrants and those suspected of "mental deficiencies" (now called intellectual disabilities) were detained for further examination; the others proceeded to a registry office where immigration clerks checked their documents and asked further questions to clear them for entry. During the peak years between 1905 and 1914, immigration to the U. S. averaged one million per year. At Ellis Island, teams of medical inspectors might examine several thousand people per day. Traumatic as this process was for prospective immigrants, only about 1 percent of arrivals between 1891 and 1930 were denied entry due to medical problems.
The medical staff conducted follow-up exams of physical and mental problems during the times between ferry arrivals. Kolb soon became interested in the process for evaluating both psychiatric illnesses and intellectual disabilities. In 1915 he was able to get additional clinical training at the New York Psychiatric Institute, and during 1916-1917 he had a part-time appointment at the Vanderbilt Clinic as a clinical assistant in the Department of Neurology. This training introduced Kolb to an emerging psychiatric diagnostic framework focused on "psychopathology." Based on a social model of mental illness that defined mental health as a measure of an individual's adjustment to social roles, "psychopathology" became a broad term for those who lacked symptoms of severe mental illness (e.g., delusions) but nonetheless couldn't maintain the self-restraint and social conformity demanded by a complex society. Kolb's later work on drug addiction would incorporate this framework.
Mental Testing of Immigrants
Kolb joined the staff at Ellis Island soon after PHS officers began developing important tools for assessing immigrants' intelligence so that intellectually disabled people (who might become public charges) could be denied entry. The measurement of intelligence was of great interest (and concern) to a range of people in the early 1900s: educators who needed to assess their students' potentials and needs, directors of institutions for "feebleminded" children and adults, and researchers seeking to determine whether "intelligence" was a heritable quality that could be increased in the population through eugenic strategies. From the 1880s, starting with Francis Galton, researchers were devising various simple performance tests (and the statistical tools to analyze them) but were not able to achieve meaningful results. In 1905, French psychologists Alfred Binet and Théodore Simon developed a series of thirty tests designed to identify French public-school children who would need special education. The tests included following direction to perform simple tasks, and assessed basic knowledge, counting ability, language facility, comprehension, reasoning, and memory skills. Their scale, they warned, didn't give a measure of absolute intellectual capacity, but rather placed individuals in a "ranking or hierarchy among diverse intelligences." Simon and Binet expanded and revised their test series during the next few years to include criteria determining various age-related competencies, and suggested that the Binet-Simon instrument might be used with adults as well.
In 1908, Henry H. Goddard, director of research at the New Jersey Training School at Vineland, an institution for intellectually disabled people, introduced the Binet-Simon test in the United States. In the Binet-Simon scale, Goddard believed he had found a precise and reliable method of identifying and classifying three types of intellectual disability: "idiots," "imbeciles," and "feebleminded." Goddard developed the term "mental age" to describe intelligence levels, along with the term "moron" to describe those who were only slightly intellectually disabled (and to replace the term "feebleminded" which he felt had become too broadly used to be diagnostically useful.) On Goddard's scale, "idiots" had a mental age of two years or less, "imbeciles" a mental age of three to seven, and "morons" a mental age of eight to twelve. Goddard did further work with the Binet-Simon scale, working with both normal and intellectually disabled subjects. Unlike Binet, however, he assumed that intelligence was a fixed, heritable quality; he did several studies of the family histories of his Vineland students, in which he tried to demonstrate that "feeblemindedness" was a recessive inherited trait.
In 1911, immigration officials at Ellis Island asked Goddard to visit and advise them on better ways to evaluate intellectual disability in arriving immigrants. The PHS immigration medical inspectors had recently been criticized for admitting too many insane or "feebleminded" foreigners who, allegedly, were placing an intolerable burden on public institutions here. Goddard had no immediate suggestions; the immigration commissioner then asked him to find evidence of intellectually disabled immigrants who had escaped detection. Goddard checked the family histories of his Vineland students, and then surveyed other institutions for information on the number of immigrants they housed. He concluded that of some 11,000 individuals in 16 institutions, less than five percent were foreign-born; so increasing populations of intellectually disabled people weren't likely to be attributable to faulty immigration screening. Other writers disputed these findings.
In 1912, Goddard proposed that the Binet-Simon test could be given to immigrants at Ellis Island, in part to check on the accuracy of the PHS medical officers' assessment of "mental deficiencies." He did several studies at the station during the next few years, and recommended that mental exams be done by a team of testing specialists rather than the PHS medical officers. The PHS immigration inspection staff acknowledged the need for formal intelligence testing of immigrants, but felt they were likely to do a better job with it in the immigration station environment. They also recognized that language-based, culturally-specific tests such as the Binet-Simon (which were developed for French or American schoolchildren) wouldn't be reliable for people who came from very different cultures, spoke different languages, and were often illiterate. Psychiatrist Bernard Glueck joined the Ellis Island staff in 1913 to consider this problem and devise a better approach. He noted that there were two "modes" of defining intelligence: a social mode, i.e., an individual's ability to fulfill his role in a given social context, and an artificial one, i.e., the ability to solve a certain set of artificial problems. Any definition of mental deficit, he said, must be made within an individual's social context. Together with his colleague Eugene Mullan, Glueck did some studies with immigrant groups to determine a baseline for "normal" abilities, using a test series based on the Binet-Simon. The results were not very helpful, and convinced him that non-verbal performance tests would be the key to accurate mental assessment of immigrants.
Accordingly, for several years the Ellis Island medical staff tested a variety of existing performance tests, such as form boards (which required accurate fitting of shapes into corresponding holes in boards), picture form boards and construction tests (much like simple jigsaw puzzles). They also devised new tests, such as Howard Knox's Cube Imitation Test, which required watching the examiner tap a row of wooden blocks in a given sequence then accurately repeating the sequence. As they worked with the tests, the medical officers discarded some, modified others, and developed standard scales. For most performance tests, the key element was the time required to complete each one.
During this time, the PHS officers began drafting a manual for the mental examination of immigrants, based on their line-inspection experience and the various tests they developed. It took about five years, partly because the drafting committee members came and went and there were always other demands on their time. Kolb was not part of the initial committee for this project; however, in early 1917, he was tasked with doing the final revisions on a large, rather unwieldy manuscript. According to John Richardson's biography of Howard Knox, Kolb "made extensive changes aimed at removing any repetition and ensuring that the text was current. He rewrote the section on performance tests . . . " and made other improvements. The final manuscript was submitted in August 1917, but wasn't published until the following year, due to wartime restrictions. Ten years later, during a three-year tour of duty in Europe, Kolb would again work with intelligence assessments.
Public Health Service Hospital #37
The end of World War I brought Kolb his first administrative assignment. In 1919, after nearly six years at Ellis Island, Kolb was appointed Medical Officer in Charge of a new neuropsychiatric hospital--PHS Hospital #37--in Waukesha, Wisconsin. This facility, lodged in the Resthaven Sanitarium (a former spa), was one of dozens established to accommodate veterans needing care. In 1917, a new law had expanded the responsibilities of the War Risk Insurance Bureau (which insured vessels, cargo, seamen and officers' personal property against war risks) to include granting compensation to disabled military personnel and charged the Public Health Service with their hospital care. The PHS operated 22 marine hospitals with a total of 1,500 beds in 1917; during the next three years the agency scrambled to set up enough facilities to meet post-war needs. By 1920, there were 50 PHS hospitals around the U.S., with a total of 12,500 beds, and still more would be opened. Most of these were general hospitals, but five specialized in treating veterans with tuberculosis, and seven, including Kolb's, specialized in neuropsychiatric disorders. The PHS operated the hospitals until the Veterans Bureau (now the Veterans Administration) was established in 1922.
Kolb arrived in Waukesha in April 1919 to begin organizing the 400-bed hospital. His challenges included converting the former spa building to a medical facility and hiring PHS officers with expertise in psychiatry as well as sufficient nursing and support staff. He found it particularly difficult to recruit and retain good doctors, as PHS salaries were very low, and new medical officers were not immediately eligible for permanent status. The patients themselves, many suffering from some level of "war neurosis" or "shell shock" (now called post-traumatic stress disorder--PTSD) were sometimes disruptive and hard to manage as well.
Shell shock was a new military medical entity, presenting acute neurotic symptoms--e.g., staring eyes, violent tremors, terrified looks, acute sleep disturbances--among combat troops. Army medical officers in all the combatant nations had recognized shell shock as a serious, incapacitating condition quite early in the war. It was clearly associated with exposure to the terrible conditions of modern warfare, including high explosives, poison gas, flamethrowers, tanks, aerial bombing, and "warfare of attrition" in the trenches. Tens of thousands of cases were recorded, and special psychiatric units were set up at many base hospitals. Medical officers varied in their approach to shell shock diagnosis and treatment, however, and some were skeptical of its legitimacy as a medical condition. Some believed that shell-shocked soldiers broke down because they were innately weak, inferior, degenerate, etc. (following the popular idea that some people came from inferior stock, with physical and/or psychological defects.) Some thought the condition was caused solely by battle experiences, or might be simply a manifestation of cowardice. Some military physicians theorized that officers (drawn from the "better" social classes) experienced different symptoms of breakdown than the rank and file. And, importantly, medical officers sometimes suspected shell shock victims of malingering: faking or exaggerating shell shock symptoms in order to be invalided out and collect a disability pension. As the U.S. Army began preparing to join the conflict in 1917, induction officers benefited from early English and French experience with "war neurosis" and worked hard to screen out recruits with "inferior constitutions" to reduce the chances of breakdown.
Treatment of shell shock cases at the front had often been simply rest and "suggestion" (telling the patient that the condition would resolve soon), sometimes with hypnosis or sedation. Because medical officers' priority was to return soldiers to duty as quickly as possible, some supplemented "suggestion" with persuasion, explanation, pep talks and scolding. In neuropsychiatric hospitals after the war, besides psychotherapy, much of the treatment involved occupational therapy and training, such as woodwork, carpentry, machine work, pattern-making, auto mechanics, bookkeeping, drafting and design, agriculture, printing, and other activities.
Kolb's administrative work at the Waukesha hospital was complicated at times by the relative newness of shell shock, his staff's lack of experience with it, and the lack of medical consensus regarding its diagnosis and treatment. Several patients accused two of Kolb's medical officers of treating them with disdain or even cruelty, as though they were malingering, instead of kindness and respect. These patients also complained to local American Legion chapters that the PHS medical officers--who not only cared for armed forces patients but determined their eligibility for military disability benefits--tried to cheat them of those benefits by downplaying the degree of their disabilities. In 1921, a Milwaukee newspaper, the Wisconsin News, published an exposé-style series on the hospital, and Kolb received worried inquiries from his PHS superiors. He eventually sorted out the situation, working with leaders of the veteran groups and the PHS. He had to get one of the medical officers re-assigned, but his own conduct in the affair--and his general management of the hospital--was praised. The following year, the death of several patients from pneumonia prompted the state commander of the American Legion to claim, with no evidence, that they were poisoned; he denounced conditions at the hospital, and demanded an investigation. Again, there was publicity, and again Kolb disproved the accusations. Kolb's early experience at Waukesha would help him in organizing and managing two other hospitals for PHS in the 1930s--the Hospital for Defective Delinquents in Springfield, MO, and the Lexington Narcotic Farm in Lexington, KY.