PUBLIC
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THEN AND NOW
From Frontier Surgeon to Industrial Hygienist: The Strange Career of George M. Kober GEORGE ROSEN, MD, PhD When Wilson G. Smillie published his list of 25 outstanding pioneers in the development of American public health up to 1925, one of those included in this select group was George M. Kober, MD (1850-1931).' He was cited as having initiated industrial medicine in the United States, as an active proponent of sanitary housing for low income families, and as a teacher of public health in medical schools. This judgment is undoubtedly correct. Kober's significance for occupational health in this country is attested by the chapter which he contributed in 1921 to A Half Century of Public Health,2 the volume issued by the American Public Health Association in commemoration of its 50th anniversary, as well as by Industrial Health, published in 1924, a massive text edited by Kober and Emery R. Hayhurst.3 Anyone who wants an overview of the state of industrial medicine and hygiene in the third decade of this century cannot afford to overlook this volume to which Kober contributed many chapters. Yet how many public health workers know much about Kober the man, or how a German immigrant youth eventually became a leader in American public health? Probably very few. It may therefore be of interest to recount the story of a physician whose career mirrored the development of America from the period when the Western frontier was still open to its emergence as a major industrial power. George Martin Kober was born in Alsfeld, a town in the Grand Duchy of Hessen, on March 28, 1850, as the son of Jacob and Dorothea (Behr) Kober.* As a manufacturer of woollen cloth, his father occupied a respected position in the community; politically, he was inclined to democratic views, having been an adherent of the republican cause in south Germany during the the 1848 revolution.t Kober received his primary and secondary education in his native * According to the 1960 Baedeker, Alsfeld is an old city with about 10,000 inhabitants. Its most notable features are its magnificent timbered town-hall of 1512-1516, its spacious market place, and its fine timbered houses of the 16th and 17th centuries, the period of its greatest prosperity. t Biographical data in the following sketch have been taken from References 4 and 5.
638 AJPH JUNE, 1975, Vol. 65, No. 6
town, and when he was 16 his parents encouraged him to emigrate to the United States, where several of his siblings had already settled. True to his principles, Kober's father did not want any of his sons to serve in the army of a Gernan ruler, and indeed the parents hoped to follow their children. This hope was never fulfilled as Jacob Kober died on November 7, 1867. On April 27, 1866, George Kober landed in New York where he spent over a year as an apprentice to a barber. The following year, in July, he left for Carlisle Barracks in Pennsylvania with the intention of enlisting in the United States Army. His brother Charles, who served in the Army for many years, was then stationed there and helped him obtain an assignment as hospital attendant. In the course of carrying out his duties, which were those of an orderly and a "medic," Kober learned a great deal about the practical aspects of medical care and developed an interest in medical practice. A bout with lobar pneumonia from which he recovered completely led him to a decision to study medicine. Encouraged by Dr. Joseph J. B. Wright, the post surgeon, Kober embarked on a reading program which included works on chemistry, physics, anatomy, and physiology. After 27 months of theoretical and practical training, Kober was promoted to hospital steward, the highest rank in the medical department for an enlisted man, and assigned to Frankford Arsenal near Philadelphia. Here his chief, Dr. Robert Bums, the attending physician, further encouraged him in his preparation for medicine and acted as his preceptor. Ordered to Washington in September, 1871, and assigned to the office of the Surgeon General, Kober matriculated at the Medical School of Georgetown University. This was possible because classes were held in the evenings "between the hours of five and ten and the dissecting room was not rarely open until midnight." This arrangement was intended to serve the needs of the student body, which, as Kober observed, "was, for the most part, made up of ambitious governmental clerks, who thoroughly appreciated the value of an education and who profited by the erudition of our eight professors" (p. 61 of Reference 4). In addition, Kober was also tutored privately by two of the professors. Two years of course work were required for
FIGURE 1 George M. Kober, MD (1850-1931).
graduation, but for students whose interests went beyond this minimum Washington had other opportunities, and Kober took advantage of them. Thus, in 1872, together with several physicians and fellow students he attended a course in histology and clinical microscopy given by Dr. Joseph J. Woodward and his assistant Dr. E. M. Schaeffer at the Army Medical Museum.* During the course there was a demonstration of Cohnheim's theory of inflammation in which the essential feature is the passage of white blood cells through the walls of the capillaries. The participants were shown the migration of leukocytes in the walls of a frog's mesentery.t They were also introduced to methods * Joseph Janvier Woodward (1833-1884), together with a number of co-workers, produced the monumental Medical and Surgical History of the War of the Rebellion (1870-1888), and was a pioneer in microphotography. In 1879 he wrote an important monograph on dysentery in which he described the ameba causing the disease, but did not recognize its significance. t Julius Cohnheim (1839-1884), a student of Virchow, was an outstanding pathologist, who served as professor at Kiel (1868-1872), Breslau (1872-1878), and
Leipzig (1878-1884). Among his students were Paul Ehrlich, William H. Welch, Albert Neisser, and W. T. Councilman. Cohnheim 's studies on inflammation and suppuration, which began in 1861 with his inaugural dissertation on the inflammation of serous membranes, provided a basic understanding of these processes. His work on this topic was published between 1867 and 1873, so
of urinary analysis, and were taught how to prepare and mount sections of normal and pathological tissue. Kober graduated in March, 1873, with a thesis on urinalysis, a topic of considerable interest to him. Following graduation, he continued his medical studies by attending a postgraduate course organized by several Washington physicians. It was during this period that Kober made his first contributions to medical literature. His efforts to become proficient in urinalysis led him to recognize the need for a concise, reliable laboratory guide. As a result he elaborated his doctoral thesis and published it in 1874 as "Urinology and Its Practical Application," initially in the Richmond and Louisville Medical Journal, and later as a pamphlet.6 The same year Kober reported on a case of "infantile paralysis" which he had treated in 1873-1874, and where the affected child had recovered without residual effects. Accepting the view that the basic lesion was in the spinal cord, he wrote up the case, described the therapy which was conservative, and published his account in a California medical journal.7 t On his arrival in Washington, Kober had been assigned to the Record and Pension Division, headed by Dr. Woodward. This unit was located in Ford's Theater, the scene of Presidents Lincoln's assassination, which also housed the Army Medical Museum, the Library of the Surgeon General, and all the records of the Army hospitals and transports of the Civil War. His first task was to verify pension claims, but after several months he was transferred in the fall of 1872 to the main office of the Surgeon General to index all official communications on file from 1812 onward. While engaged in these activities, Kober gained the confidence of Surgeon General Barnes and of other officers, among the John Shaw Billings, in charge of the Surgeon General's Library, who was creating the Index Catalogue. Kober volunteered to provide the correct titles for articles published in German medical journals, and Billings found this assistance of value. In the course of his work, Kober also brought to light some of the original reports of the experiments by William Beaumont, army surgeon and pioneer physiologist, on Alexis St. Martin, whose gunshot wound of the stomach healed with a gastric fistula.9 10 On July 1, 1874, Kober was honorably discharged as a hospital steward and was offered a position as a contract surgeon with the U.S. Army, an offer which he readily accepted. Kober served in the Army for 12 years, until 1886. During this period he was assigned to various posts in the West, initially as post surgeon at Alcatraz Island in the harbor of San Francisco and then at a number of frontier posts. In the fall of 1875 Kober accompanied the First U.S. Cavalry on an expedition to southeastern Nevada, where there were alleged to be hostile Indians but none were that Woodward's demonstration in 1873 indicates that leading American physicians were abreast of the most recent advances in medical science, and that Kober was receiving as good a medical education as was available at the time. t This paper is in no way original; for the medical context in which it appeared see Paul.8 PUBLIC HEALTH THEN AND NOW 639
D
FIGURE 2 Carlisle Barracks in 1867. Quarters and Recreation Center.
found. In 1877, however, he took an active part in the campaign against Chief Joseph and the Nez Perce people. From July to October, Kober was in charge of the field hospital at Kamiah, on the Clearwater in Idaho. That year he first met George M. Steinberg, then post surgeon at Walla Walla, an acquaintance which developed into a lifelong friendship, in which Stemnberg who was the older of the two advised and helped Kober in many ways.* Aside from these activities, Kober was occupied with his patients, who comprised not only the soldiers, but also the families of nearby ranchers, the local cowboys and sheepherders, traveling prostitutes, and occasionally Indians. Among the varied conditions which he treated were fractures and dislocations, gunshot wounds, rupture of the spleen, delirium tremens, venereal diseases, tuberculosis, as well as emotional disorders such as hysterical catalepsy. In the absence of a midwife, Kober also attended women in labor. The case of one patient, a cavalry sergeant who had sustained a perforating gunshot wound of the knee joint, * George M. Sternberg (1838-1915) became an army surgeon during the Civil War and remained in the service, becoming Surgeon General in 1893. A pioneer of bacteriology in America, he described the pneumococcus in 1880, simultaneously with Pasteur, and became an authority on sanitation and disinfection. Sternberg founded the Army Medical School in Washington, and published the first textbook of bacteriology in the United States in 1892. See his biography by Martha L. Sternberg, Chicago, 1921; also
Gibson.' 1
640 AJPH JUNE, 1975, Vol. 65, No. 6
FIGURE 3 Ford's Theater where President Lincoln was assassinated, and which housed the Army Medical Museum and Library, as well as the Division of Records and Pensions when Kober served there in 1871.
FIGURE 4 Main Office of the Surgeon General in the Annex and second floor of the old Riggs Bank, northwest corner 15th Street and Pennsylvania Avenue, Washington, where Kober served from 1872 to 1873.
was significant enough to be published in 1876 in the American Journal of the Medical Sciences.12 The wound had become infected, and in such situations amputation was usually performed to prevent septicemia. Kober, however, treated the wound with injections of tincture of iodine, carbolic acid, and glycerine leading to complete recovery. This is apparently the first case of its kind on record. On his own initiative and aided by his friends in the Surgeons General's Office, Kober continued his medical studies. Not only did he study his patients thoroughly, but he also obtained the leading American and foreign medical periodicals, among them the Lancet, the British Medical Journal, the American Journal of the Medical Sciences, and the New York Medical Record. Through John Shaw Billings he also purchased a collection of 250 slides, prepared in the laboratory of Carl Ludwig at Leipzig, illustrating normal and pathological histology. In addition, Kober had a chest of chemicals which enabled him to continue his work on the analysis of urine and water. But for his restless, inquisitive mind, even these activities were not enough. Having become interested in the physical and cultural characteristics of the Indians, he collected various materials pertaining to them, including osseous remains, both crania and whole skeletons. Some of this material was collected for the Army Medical Museum, but when Kober learned that Rudolf Virchow, the pathologist and anthropologist, was interested in studying such skeletal remains, specimens were sent to him in Berlin. Virchow described these items in his Crania Ethnica Americana (1892), where he acknowledged Kober's assistance.4"1 3 After leaving military service in 1886, and traveling extensively in the United States and Europe for several years, Kober settled in Washington, DC, where in 1890 he became professor of hygiene and state medicine in the Georgetown University Medical School. Thenceforth he became a prime mover for the improvement of public health in the District of Columbia. Kober first turned his
attention to the prevalence of typhoid fever in Washington and its relation to the pollution of the city's water supply by sewage. In 1890, at the 10th International Medical Congress in Berlin, he read a paper on the etiology of typhoid with particular reference to water-borne epidemics, and this disease continued to occupy him. At the request of the health officer of the District of Columbia, in 1895 he investigated the possible causes of typhoid fever in Washington, and suggested that flies as well as polluted water could transmit the disease. By 1895 he had also begun to study milk as a vehicle for the transmission of disease and particularly in relation to infant mortality. The importance of milk in relation to health and disease was emphasized in a paper read in 1900 before the Section of Epidemiology and Hygiene, 13th Intemational Medical Congress at Paris, which was based on an analysis of 330 outbreaks of infectious diseases spread by milk.' '4 Two years later, to support an effort to have Congress enact a bill to regulate the production and sale of milk and cream in the District of Columbia, Kober prepared a monograph on milk in relation to public health.' 5 This concern with environmental sanitation and its relation to health also brought Kober into the field of housing. From 1897 until his death in 1915, George M. Steinberg, Kober's friend and mentor, was engaged in a campaign to provide model housing for working class families in Washington.1 6 For this purpose, Stemberg organized the Washington Sanitary Improvement Company in 1897, and in 1904 the Sanitary Housing Company, the latter intended to provide housing for poorer workers, chiefly blacks who lived in the capital's alley slums. Kober was associated with Stemberg in this endeavor as cofounder and secretary of both companies, and after Stemberg's death he became president of these enterprises. Rejecting the tenement approach, the houses built by these agencies were small two-flat structures. The flats had two to four rooms, a bath and a toilet, and each family had a backyard and a separate entrance. These efforts gained intemational recognition in 1900 at the Paris International Exposition where Kober received a gold medal for his activities in creating sanitary homes at reasonable rentals for wage eamers. Kober's interest and experience in construction was also linked with his concem for the prevention of tuberculosis. As early as 1889, he had published a paper on the "Etiology and Prevention of Tuberculosis in the Light of Modem Research," and he continued to deal with the problem of tuberculosis subsequently in a variety of publications. In 1904, Kober was one of the founders of the National Association for Prevention of Tuberculosis (later the National Tuberculosis Association), and remained active in its affairs for many years, serving as president in 1914 and as secretary from 1920 to 1927. The construction of a tuberculosis hospital in Washington, which was opened in 1908, was based on plans developed by Kober, for which he was awarded a medal at the Exposition connected with the 6th International Congress on Tuberculosis held in Washington in the same year. Kober had a broad, socially oriented view of public PUBLIC HEALTH THEN AND NOW 641
health, a view which appears most clearly in his reports for the President's Homes Commission set up by Theodore Roosevelt in 1907. The Commission was headed by Stemnberg with Kober serving as secretary and as chairman of the Committee on Social Betterment. The report on "social betterment," issued in 1908, deals with social factors in the health of wage eamers and the poor in Washington. According to Kober, "the question of health is intimately connected with the physical, social and moral welfare of all persons whose income is the product of their daily labor. Health is the chief asset of the working man, and no greater calamity can befall him than when his earning capacity is impaired or arrested, by reason of sickness or disability. It means in many instances the utter financial ruin of the family and is doubtless one of the most potent causes of poverty and distress."' 7 On the premise that illness and disability are most often due to diseases incident to occupation and environment, the report deals with the causes and prevention of industrial diseases and major communicable conditions such as tuberculosis, pneumonia, typhoid fever, and venereal diseases. A separate section is devoted to the causes and prevention of infant mortality. The effect of social conditions on health is presented on the basis of a study of the living standards of 1217 families which covers earnings and expenditures as well as related items. Expenditures are broken down for rent, food, tobacco, alcoholic beverages, patent medicines, insurance, installment purchases, usury, and other matters. Kober's practical bent as well as his knowledge of the circumstances under which workers lived is evident in his discussion of food, which covers not only market prices, but also the preparation of food including recipes. Kober's concern for the health of workers is expressed more directly and comprehensively in the second report of the Committee on Industrial and Personal Hygiene, which also appeared in 1908.18 Covering health hazards in a wide range of industries, and including suggestions for legal and other measures to cope with these problems, it was the first American text on industrial health. Among the industries and products touched on were bleaching establishments, acids, dusts, dyeing and cleaning, mining, patent leather, rubber, quinine, chrome pigments, carbon disulfide, and aniline vapor. Kober also dealt with working conditions involving lighting, ventilation, temperature, and accident prevention. Kober's interest in occupational health had been growing since 1890 when he gave a course on the subject at Georgetown University. Then in 1902 at the request of Commissioner of Labor Wright, he recommended his former student C. F. W. Doehring to investigate the manufacture of white lead, paint, linseed oil, varnishes, and a number of other products. The results of this study, the first of its kind in the United States, were published in January, 1903. In 1907, on a visit to Berlin, he discussed problems of industrial hygiene with German physicians who had been studying them, a further indication of the growth of Kober's interest in the investigation of the occupational causes of illness among industrial workers and how to prevent them. 642 AJPH JUNE, 1975, Vol. 65, No. 6
With the publication of his monograph in 1908, Kober
emerged as a leader in this field. By 1916, in association with W. L. Hanson, a physician who had studied the health hazards of dusty trades, he was able to publish Diseases of Occupation and Vocational Hygiene, to which he contributed the chapters on the etiology and prophylaxis of occupational diseases as well as a chapter on the effects of diminished air pressure with particular reference to flyers.* In 1912, he served as chairman of the section on Industrial and Occupational Hygiene of the 15th International Congress on Hygiene and Demography, and delivered an address on the hygiene of occupations. Two years later, the president of the American Public Health Association invited Kober to address one of the general sessions of the annual meeting on the "History and Development of Industrial Hygiene in the United States," as part of a symposium on occupational health. At this meeting the Executive Committee of APHA approved the creation of a Section on Industrial Hygiene, and somewhat later Kober was appointed president of the section, with Alice Hamilton as vice president and Emery R. Hayhurst as secretary. The section met for the first time, with Kober in the chair, at the Rochester meeting of the Association in 1915. The following year he was elected first vice-president of the APHA. The in 1924, at the age of 74, Kober saw the appearance of Industrial Health, his magnum opus. In addition to his writings and investigations, Kober contributed to the advancement of occupational health through his teaching at the Medical School of Georgetown University. Appointed professor of hygiene in 1890, he then became Dean in 1901 and served in both posts until his retirement in 1928. Throughout this period he saw to it that preventive medicine and industrial hygiene were a part of the medical curriculum. Kober viewed these subjects as forming part of a standard medical curriculum, a goal for which he worked actively in the Association of American Medical Colleges, an effort which this organization recognized by approving his plan, and electing him as its president in 1906. Although occupational health was Kober's major interest during the last decades of his professional life, he also continued to concem himself with other health problems, among them venereal diseases, tuberculosis, school hygiene, infant mortality, cancer, and alcoholism, as well as various clinical aspects of medicine. The tributes paid to Kober during the last decade of his life give an indication of the range of his interests. Thus, on the occasion of his 70th birthday in 1920, in addition to tributes from colleagues and friends in the health field, the American Journal of Physical Anthropology lauded his contributions to that field. Then in 1927, at a meeting of the Association of American Physicians, William H. Welch summed up Kober's professional career by noting "his * This was not the first text on occupational diseases in the United States. In 1914, W. Gilman Thompson had put out Occupational Diseases, and in 1902, J. H. Lloyd had written "The Diseases of Occupation" for the Twentieth Century Practice of Medicine.
important contributions and services to medicine, surgery, hygiene, public health and charities." Kober died in 1931 at the age of 81. The preceding year had seen the publication of the first volume of his Reminiscences, which dealt with his experiences to 1876. Unfortunately the second volume never appeared, but had this happened it would have completed the story of the German immigrant youth whose initiative, ability, and energy had enabled him to become a leader of American public health and medicine, and to contribute so much to the health and welfare of his fellow Americans. References 1. Smillie, W. G. Public Health. Its Promise for the Future, pp. 482-483. Macmillan Company, New York, 1955. 2. Ravenel, M. P. (ed.). A Half Century of Public Health, pp. 361-411. American Public Health Association, New York, 1921. 3. Kober, G. M., and Hayhurst, E. R. (eds.). Industrial Health. P. Blakiston's Son & Company, Philadelphia, 1924. 4. Kober, G. M. Reminiscences, Vol. I. Kober Foundation of Georgetown University, Washington, DC, 1930. 5. Tondorf, F. A. Biography and Bibliography of George M. Kober, M.D., LL.D. Washington, DC, 1920. 6. Kober, G. M. Urinology and Its Practical Application. Richmond Louisville Med. J. 18:229-256, 357-387,
469-490, 580-609, 1874. 7. Kober, G. M. Infantile Paralysis. Pacific Med. Surg. J. 16:261-273, 1874. 8. Paul, J. R. A History of Poliomyelitis, pp. 61-70. Yale University Press, New Haven, 1971. 9. Rosen, G. William Beaumont. In Dictionary of Scientific Biography, edited by Gillispie, C. C., Vol. I, pp. 542-545. Charles Scribner's Sons, New York, 1970. 10. Rosen, G. The Reception of William Beaumont's Discovery in Europe. Schuman's, New York, 1942. 11. Gibson, J. M. Soldier in White. Duke University Press, Durham, NC, 1958. 12. Kober, G. M. Report of a Case of Gunshot Wound of the Knee Joint and Right Hand Treated with Antiseptic Injections of Iodine and Carbolic Acid. Am. J. Med. Sci. n.s., 72:427-431, 1876. 13. Virchow, R. Crania Ethnica Americana. Sammlung 14. 15.
16.
17.
18.
auserlesener Amerikanischer Schadeltypen. A. Ascher, Berlin, 1892. Kober, G. M. Am. J. Med. Sci., Vol. 121, 1901. Kober, G. M. Milk in Relation to Public Health. U.S. 59th Congress, First Session, Senate Document 441. U.S. Government Printing Office, Washington, DC, 1902. Lubove, R. The Progressives and the Slums. Tenement House Reform in New York City 1890-1917, p. 176. University of Pittsburgh Press, Pittsburgh, 1962. Kober, G. M. Report of Committee on Social Betterment, p. 3. President's Homes Commission, Washington, DC, 1908. Kober, G. M. Industrial and Personal Hygiene. A Report of the Committee on Social Betterment. President's Homes Commission, Washington, DC, 1908.
CALL FOR PAPERS The new Journal of Community Health, the official publication of the Association of Teachers of Preventive Medicine and Community Health, will be published quarterly beginning in the Spring, 1975, by Behavioral Publications. Dr. Robert Kane, Professor of Family and Community Medicine at the University of Utah, is the Editor of the Journal. The Journal will devote itself to original articles on the practice, teaching, and research of community health. This field encompasses the delivery of health care services, preventive medicine, analysis of environmental factors affecting the health of groups or individuals, and the study of health maintenance and health insurance programs. Serving as a forum for the exchange of ideas and clarification of issues about health care practice and policy, the Editorial Board of the Journal of Community Health is now actively seeking well executed studies and descriptions of projects making an impact on the health of communities or the education of health care personnel. Position papers and other articles on community health issues are also welcomed. Manuscripts should be between 10 and 25 double-spaced pages and should follow the style outlined in Index Medicus. Submit manuscripts in triplicate to: Dr. Robert Kane, Editor Journal of Community Health University of Utah Medical Center 50 North Medical Drive Salt Lake City, Utah 84132 Subscriptions are available through the publisher, Behavioral Publications, 72 Fifth Avenue, New York, NY 10011, on a calendar year quarterly basis; $15 per year for individuals, $30 per year for institutions. PUBLIC HEALTH THEN AND NOW 643
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From Frontier Surgeon to Industrial Hygienist: The Strange Career of George M. Kober GEORGE ROSEN, MD, PhD When Wilson G. Smillie published his list of 25 outstanding pioneers in the development of American public health up to 1925, one of those included in this select group was George M. Kober, MD (1850-1931).' He was cited as having initiated industrial medicine in the United States, as an active proponent of sanitary housing for low income families, and as a teacher of public health in medical schools. This judgment is undoubtedly correct. Kober's significance for occupational health in this country is attested by the chapter which he contributed in 1921 to A Half Century of Public Health,2 the volume issued by the American Public Health Association in commemoration of its 50th anniversary, as well as by Industrial Health, published in 1924, a massive text edited by Kober and Emery R. Hayhurst.3 Anyone who wants an overview of the state of industrial medicine and hygiene in the third decade of this century cannot afford to overlook this volume to which Kober contributed many chapters. Yet how many public health workers know much about Kober the man, or how a German immigrant youth eventually became a leader in American public health? Probably very few. It may therefore be of interest to recount the story of a physician whose career mirrored the development of America from the period when the Western frontier was still open to its emergence as a major industrial power. George Martin Kober was born in Alsfeld, a town in the Grand Duchy of Hessen, on March 28, 1850, as the son of Jacob and Dorothea (Behr) Kober.* As a manufacturer of woollen cloth, his father occupied a respected position in the community; politically, he was inclined to democratic views, having been an adherent of the republican cause in south Germany during the the 1848 revolution.t Kober received his primary and secondary education in his native * According to the 1960 Baedeker, Alsfeld is an old city with about 10,000 inhabitants. Its most notable features are its magnificent timbered town-hall of 1512-1516, its spacious market place, and its fine timbered houses of the 16th and 17th centuries, the period of its greatest prosperity. t Biographical data in the following sketch have been taken from References 4 and 5.
638 AJPH JUNE, 1975, Vol. 65, No. 6
town, and when he was 16 his parents encouraged him to emigrate to the United States, where several of his siblings had already settled. True to his principles, Kober's father did not want any of his sons to serve in the army of a Gernan ruler, and indeed the parents hoped to follow their children. This hope was never fulfilled as Jacob Kober died on November 7, 1867. On April 27, 1866, George Kober landed in New York where he spent over a year as an apprentice to a barber. The following year, in July, he left for Carlisle Barracks in Pennsylvania with the intention of enlisting in the United States Army. His brother Charles, who served in the Army for many years, was then stationed there and helped him obtain an assignment as hospital attendant. In the course of carrying out his duties, which were those of an orderly and a "medic," Kober learned a great deal about the practical aspects of medical care and developed an interest in medical practice. A bout with lobar pneumonia from which he recovered completely led him to a decision to study medicine. Encouraged by Dr. Joseph J. B. Wright, the post surgeon, Kober embarked on a reading program which included works on chemistry, physics, anatomy, and physiology. After 27 months of theoretical and practical training, Kober was promoted to hospital steward, the highest rank in the medical department for an enlisted man, and assigned to Frankford Arsenal near Philadelphia. Here his chief, Dr. Robert Bums, the attending physician, further encouraged him in his preparation for medicine and acted as his preceptor. Ordered to Washington in September, 1871, and assigned to the office of the Surgeon General, Kober matriculated at the Medical School of Georgetown University. This was possible because classes were held in the evenings "between the hours of five and ten and the dissecting room was not rarely open until midnight." This arrangement was intended to serve the needs of the student body, which, as Kober observed, "was, for the most part, made up of ambitious governmental clerks, who thoroughly appreciated the value of an education and who profited by the erudition of our eight professors" (p. 61 of Reference 4). In addition, Kober was also tutored privately by two of the professors. Two years of course work were required for
FIGURE 1 George M. Kober, MD (1850-1931).
graduation, but for students whose interests went beyond this minimum Washington had other opportunities, and Kober took advantage of them. Thus, in 1872, together with several physicians and fellow students he attended a course in histology and clinical microscopy given by Dr. Joseph J. Woodward and his assistant Dr. E. M. Schaeffer at the Army Medical Museum.* During the course there was a demonstration of Cohnheim's theory of inflammation in which the essential feature is the passage of white blood cells through the walls of the capillaries. The participants were shown the migration of leukocytes in the walls of a frog's mesentery.t They were also introduced to methods * Joseph Janvier Woodward (1833-1884), together with a number of co-workers, produced the monumental Medical and Surgical History of the War of the Rebellion (1870-1888), and was a pioneer in microphotography. In 1879 he wrote an important monograph on dysentery in which he described the ameba causing the disease, but did not recognize its significance. t Julius Cohnheim (1839-1884), a student of Virchow, was an outstanding pathologist, who served as professor at Kiel (1868-1872), Breslau (1872-1878), and
Leipzig (1878-1884). Among his students were Paul Ehrlich, William H. Welch, Albert Neisser, and W. T. Councilman. Cohnheim 's studies on inflammation and suppuration, which began in 1861 with his inaugural dissertation on the inflammation of serous membranes, provided a basic understanding of these processes. His work on this topic was published between 1867 and 1873, so
of urinary analysis, and were taught how to prepare and mount sections of normal and pathological tissue. Kober graduated in March, 1873, with a thesis on urinalysis, a topic of considerable interest to him. Following graduation, he continued his medical studies by attending a postgraduate course organized by several Washington physicians. It was during this period that Kober made his first contributions to medical literature. His efforts to become proficient in urinalysis led him to recognize the need for a concise, reliable laboratory guide. As a result he elaborated his doctoral thesis and published it in 1874 as "Urinology and Its Practical Application," initially in the Richmond and Louisville Medical Journal, and later as a pamphlet.6 The same year Kober reported on a case of "infantile paralysis" which he had treated in 1873-1874, and where the affected child had recovered without residual effects. Accepting the view that the basic lesion was in the spinal cord, he wrote up the case, described the therapy which was conservative, and published his account in a California medical journal.7 t On his arrival in Washington, Kober had been assigned to the Record and Pension Division, headed by Dr. Woodward. This unit was located in Ford's Theater, the scene of Presidents Lincoln's assassination, which also housed the Army Medical Museum, the Library of the Surgeon General, and all the records of the Army hospitals and transports of the Civil War. His first task was to verify pension claims, but after several months he was transferred in the fall of 1872 to the main office of the Surgeon General to index all official communications on file from 1812 onward. While engaged in these activities, Kober gained the confidence of Surgeon General Barnes and of other officers, among the John Shaw Billings, in charge of the Surgeon General's Library, who was creating the Index Catalogue. Kober volunteered to provide the correct titles for articles published in German medical journals, and Billings found this assistance of value. In the course of his work, Kober also brought to light some of the original reports of the experiments by William Beaumont, army surgeon and pioneer physiologist, on Alexis St. Martin, whose gunshot wound of the stomach healed with a gastric fistula.9 10 On July 1, 1874, Kober was honorably discharged as a hospital steward and was offered a position as a contract surgeon with the U.S. Army, an offer which he readily accepted. Kober served in the Army for 12 years, until 1886. During this period he was assigned to various posts in the West, initially as post surgeon at Alcatraz Island in the harbor of San Francisco and then at a number of frontier posts. In the fall of 1875 Kober accompanied the First U.S. Cavalry on an expedition to southeastern Nevada, where there were alleged to be hostile Indians but none were that Woodward's demonstration in 1873 indicates that leading American physicians were abreast of the most recent advances in medical science, and that Kober was receiving as good a medical education as was available at the time. t This paper is in no way original; for the medical context in which it appeared see Paul.8 PUBLIC HEALTH THEN AND NOW 639
D
FIGURE 2 Carlisle Barracks in 1867. Quarters and Recreation Center.
found. In 1877, however, he took an active part in the campaign against Chief Joseph and the Nez Perce people. From July to October, Kober was in charge of the field hospital at Kamiah, on the Clearwater in Idaho. That year he first met George M. Steinberg, then post surgeon at Walla Walla, an acquaintance which developed into a lifelong friendship, in which Stemnberg who was the older of the two advised and helped Kober in many ways.* Aside from these activities, Kober was occupied with his patients, who comprised not only the soldiers, but also the families of nearby ranchers, the local cowboys and sheepherders, traveling prostitutes, and occasionally Indians. Among the varied conditions which he treated were fractures and dislocations, gunshot wounds, rupture of the spleen, delirium tremens, venereal diseases, tuberculosis, as well as emotional disorders such as hysterical catalepsy. In the absence of a midwife, Kober also attended women in labor. The case of one patient, a cavalry sergeant who had sustained a perforating gunshot wound of the knee joint, * George M. Sternberg (1838-1915) became an army surgeon during the Civil War and remained in the service, becoming Surgeon General in 1893. A pioneer of bacteriology in America, he described the pneumococcus in 1880, simultaneously with Pasteur, and became an authority on sanitation and disinfection. Sternberg founded the Army Medical School in Washington, and published the first textbook of bacteriology in the United States in 1892. See his biography by Martha L. Sternberg, Chicago, 1921; also
Gibson.' 1
640 AJPH JUNE, 1975, Vol. 65, No. 6
FIGURE 3 Ford's Theater where President Lincoln was assassinated, and which housed the Army Medical Museum and Library, as well as the Division of Records and Pensions when Kober served there in 1871.
FIGURE 4 Main Office of the Surgeon General in the Annex and second floor of the old Riggs Bank, northwest corner 15th Street and Pennsylvania Avenue, Washington, where Kober served from 1872 to 1873.
was significant enough to be published in 1876 in the American Journal of the Medical Sciences.12 The wound had become infected, and in such situations amputation was usually performed to prevent septicemia. Kober, however, treated the wound with injections of tincture of iodine, carbolic acid, and glycerine leading to complete recovery. This is apparently the first case of its kind on record. On his own initiative and aided by his friends in the Surgeons General's Office, Kober continued his medical studies. Not only did he study his patients thoroughly, but he also obtained the leading American and foreign medical periodicals, among them the Lancet, the British Medical Journal, the American Journal of the Medical Sciences, and the New York Medical Record. Through John Shaw Billings he also purchased a collection of 250 slides, prepared in the laboratory of Carl Ludwig at Leipzig, illustrating normal and pathological histology. In addition, Kober had a chest of chemicals which enabled him to continue his work on the analysis of urine and water. But for his restless, inquisitive mind, even these activities were not enough. Having become interested in the physical and cultural characteristics of the Indians, he collected various materials pertaining to them, including osseous remains, both crania and whole skeletons. Some of this material was collected for the Army Medical Museum, but when Kober learned that Rudolf Virchow, the pathologist and anthropologist, was interested in studying such skeletal remains, specimens were sent to him in Berlin. Virchow described these items in his Crania Ethnica Americana (1892), where he acknowledged Kober's assistance.4"1 3 After leaving military service in 1886, and traveling extensively in the United States and Europe for several years, Kober settled in Washington, DC, where in 1890 he became professor of hygiene and state medicine in the Georgetown University Medical School. Thenceforth he became a prime mover for the improvement of public health in the District of Columbia. Kober first turned his
attention to the prevalence of typhoid fever in Washington and its relation to the pollution of the city's water supply by sewage. In 1890, at the 10th International Medical Congress in Berlin, he read a paper on the etiology of typhoid with particular reference to water-borne epidemics, and this disease continued to occupy him. At the request of the health officer of the District of Columbia, in 1895 he investigated the possible causes of typhoid fever in Washington, and suggested that flies as well as polluted water could transmit the disease. By 1895 he had also begun to study milk as a vehicle for the transmission of disease and particularly in relation to infant mortality. The importance of milk in relation to health and disease was emphasized in a paper read in 1900 before the Section of Epidemiology and Hygiene, 13th Intemational Medical Congress at Paris, which was based on an analysis of 330 outbreaks of infectious diseases spread by milk.' '4 Two years later, to support an effort to have Congress enact a bill to regulate the production and sale of milk and cream in the District of Columbia, Kober prepared a monograph on milk in relation to public health.' 5 This concern with environmental sanitation and its relation to health also brought Kober into the field of housing. From 1897 until his death in 1915, George M. Steinberg, Kober's friend and mentor, was engaged in a campaign to provide model housing for working class families in Washington.1 6 For this purpose, Stemberg organized the Washington Sanitary Improvement Company in 1897, and in 1904 the Sanitary Housing Company, the latter intended to provide housing for poorer workers, chiefly blacks who lived in the capital's alley slums. Kober was associated with Stemberg in this endeavor as cofounder and secretary of both companies, and after Stemberg's death he became president of these enterprises. Rejecting the tenement approach, the houses built by these agencies were small two-flat structures. The flats had two to four rooms, a bath and a toilet, and each family had a backyard and a separate entrance. These efforts gained intemational recognition in 1900 at the Paris International Exposition where Kober received a gold medal for his activities in creating sanitary homes at reasonable rentals for wage eamers. Kober's interest and experience in construction was also linked with his concem for the prevention of tuberculosis. As early as 1889, he had published a paper on the "Etiology and Prevention of Tuberculosis in the Light of Modem Research," and he continued to deal with the problem of tuberculosis subsequently in a variety of publications. In 1904, Kober was one of the founders of the National Association for Prevention of Tuberculosis (later the National Tuberculosis Association), and remained active in its affairs for many years, serving as president in 1914 and as secretary from 1920 to 1927. The construction of a tuberculosis hospital in Washington, which was opened in 1908, was based on plans developed by Kober, for which he was awarded a medal at the Exposition connected with the 6th International Congress on Tuberculosis held in Washington in the same year. Kober had a broad, socially oriented view of public PUBLIC HEALTH THEN AND NOW 641
health, a view which appears most clearly in his reports for the President's Homes Commission set up by Theodore Roosevelt in 1907. The Commission was headed by Stemnberg with Kober serving as secretary and as chairman of the Committee on Social Betterment. The report on "social betterment," issued in 1908, deals with social factors in the health of wage eamers and the poor in Washington. According to Kober, "the question of health is intimately connected with the physical, social and moral welfare of all persons whose income is the product of their daily labor. Health is the chief asset of the working man, and no greater calamity can befall him than when his earning capacity is impaired or arrested, by reason of sickness or disability. It means in many instances the utter financial ruin of the family and is doubtless one of the most potent causes of poverty and distress."' 7 On the premise that illness and disability are most often due to diseases incident to occupation and environment, the report deals with the causes and prevention of industrial diseases and major communicable conditions such as tuberculosis, pneumonia, typhoid fever, and venereal diseases. A separate section is devoted to the causes and prevention of infant mortality. The effect of social conditions on health is presented on the basis of a study of the living standards of 1217 families which covers earnings and expenditures as well as related items. Expenditures are broken down for rent, food, tobacco, alcoholic beverages, patent medicines, insurance, installment purchases, usury, and other matters. Kober's practical bent as well as his knowledge of the circumstances under which workers lived is evident in his discussion of food, which covers not only market prices, but also the preparation of food including recipes. Kober's concern for the health of workers is expressed more directly and comprehensively in the second report of the Committee on Industrial and Personal Hygiene, which also appeared in 1908.18 Covering health hazards in a wide range of industries, and including suggestions for legal and other measures to cope with these problems, it was the first American text on industrial health. Among the industries and products touched on were bleaching establishments, acids, dusts, dyeing and cleaning, mining, patent leather, rubber, quinine, chrome pigments, carbon disulfide, and aniline vapor. Kober also dealt with working conditions involving lighting, ventilation, temperature, and accident prevention. Kober's interest in occupational health had been growing since 1890 when he gave a course on the subject at Georgetown University. Then in 1902 at the request of Commissioner of Labor Wright, he recommended his former student C. F. W. Doehring to investigate the manufacture of white lead, paint, linseed oil, varnishes, and a number of other products. The results of this study, the first of its kind in the United States, were published in January, 1903. In 1907, on a visit to Berlin, he discussed problems of industrial hygiene with German physicians who had been studying them, a further indication of the growth of Kober's interest in the investigation of the occupational causes of illness among industrial workers and how to prevent them. 642 AJPH JUNE, 1975, Vol. 65, No. 6
With the publication of his monograph in 1908, Kober
emerged as a leader in this field. By 1916, in association with W. L. Hanson, a physician who had studied the health hazards of dusty trades, he was able to publish Diseases of Occupation and Vocational Hygiene, to which he contributed the chapters on the etiology and prophylaxis of occupational diseases as well as a chapter on the effects of diminished air pressure with particular reference to flyers.* In 1912, he served as chairman of the section on Industrial and Occupational Hygiene of the 15th International Congress on Hygiene and Demography, and delivered an address on the hygiene of occupations. Two years later, the president of the American Public Health Association invited Kober to address one of the general sessions of the annual meeting on the "History and Development of Industrial Hygiene in the United States," as part of a symposium on occupational health. At this meeting the Executive Committee of APHA approved the creation of a Section on Industrial Hygiene, and somewhat later Kober was appointed president of the section, with Alice Hamilton as vice president and Emery R. Hayhurst as secretary. The section met for the first time, with Kober in the chair, at the Rochester meeting of the Association in 1915. The following year he was elected first vice-president of the APHA. The in 1924, at the age of 74, Kober saw the appearance of Industrial Health, his magnum opus. In addition to his writings and investigations, Kober contributed to the advancement of occupational health through his teaching at the Medical School of Georgetown University. Appointed professor of hygiene in 1890, he then became Dean in 1901 and served in both posts until his retirement in 1928. Throughout this period he saw to it that preventive medicine and industrial hygiene were a part of the medical curriculum. Kober viewed these subjects as forming part of a standard medical curriculum, a goal for which he worked actively in the Association of American Medical Colleges, an effort which this organization recognized by approving his plan, and electing him as its president in 1906. Although occupational health was Kober's major interest during the last decades of his professional life, he also continued to concem himself with other health problems, among them venereal diseases, tuberculosis, school hygiene, infant mortality, cancer, and alcoholism, as well as various clinical aspects of medicine. The tributes paid to Kober during the last decade of his life give an indication of the range of his interests. Thus, on the occasion of his 70th birthday in 1920, in addition to tributes from colleagues and friends in the health field, the American Journal of Physical Anthropology lauded his contributions to that field. Then in 1927, at a meeting of the Association of American Physicians, William H. Welch summed up Kober's professional career by noting "his * This was not the first text on occupational diseases in the United States. In 1914, W. Gilman Thompson had put out Occupational Diseases, and in 1902, J. H. Lloyd had written "The Diseases of Occupation" for the Twentieth Century Practice of Medicine.
important contributions and services to medicine, surgery, hygiene, public health and charities." Kober died in 1931 at the age of 81. The preceding year had seen the publication of the first volume of his Reminiscences, which dealt with his experiences to 1876. Unfortunately the second volume never appeared, but had this happened it would have completed the story of the German immigrant youth whose initiative, ability, and energy had enabled him to become a leader of American public health and medicine, and to contribute so much to the health and welfare of his fellow Americans. References 1. Smillie, W. G. Public Health. Its Promise for the Future, pp. 482-483. Macmillan Company, New York, 1955. 2. Ravenel, M. P. (ed.). A Half Century of Public Health, pp. 361-411. American Public Health Association, New York, 1921. 3. Kober, G. M., and Hayhurst, E. R. (eds.). Industrial Health. P. Blakiston's Son & Company, Philadelphia, 1924. 4. Kober, G. M. Reminiscences, Vol. I. Kober Foundation of Georgetown University, Washington, DC, 1930. 5. Tondorf, F. A. Biography and Bibliography of George M. Kober, M.D., LL.D. Washington, DC, 1920. 6. Kober, G. M. Urinology and Its Practical Application. Richmond Louisville Med. J. 18:229-256, 357-387,
469-490, 580-609, 1874. 7. Kober, G. M. Infantile Paralysis. Pacific Med. Surg. J. 16:261-273, 1874. 8. Paul, J. R. A History of Poliomyelitis, pp. 61-70. Yale University Press, New Haven, 1971. 9. Rosen, G. William Beaumont. In Dictionary of Scientific Biography, edited by Gillispie, C. C., Vol. I, pp. 542-545. Charles Scribner's Sons, New York, 1970. 10. Rosen, G. The Reception of William Beaumont's Discovery in Europe. Schuman's, New York, 1942. 11. Gibson, J. M. Soldier in White. Duke University Press, Durham, NC, 1958. 12. Kober, G. M. Report of a Case of Gunshot Wound of the Knee Joint and Right Hand Treated with Antiseptic Injections of Iodine and Carbolic Acid. Am. J. Med. Sci. n.s., 72:427-431, 1876. 13. Virchow, R. Crania Ethnica Americana. Sammlung 14. 15.
16.
17.
18.
auserlesener Amerikanischer Schadeltypen. A. Ascher, Berlin, 1892. Kober, G. M. Am. J. Med. Sci., Vol. 121, 1901. Kober, G. M. Milk in Relation to Public Health. U.S. 59th Congress, First Session, Senate Document 441. U.S. Government Printing Office, Washington, DC, 1902. Lubove, R. The Progressives and the Slums. Tenement House Reform in New York City 1890-1917, p. 176. University of Pittsburgh Press, Pittsburgh, 1962. Kober, G. M. Report of Committee on Social Betterment, p. 3. President's Homes Commission, Washington, DC, 1908. Kober, G. M. Industrial and Personal Hygiene. A Report of the Committee on Social Betterment. President's Homes Commission, Washington, DC, 1908.
CALL FOR PAPERS The new Journal of Community Health, the official publication of the Association of Teachers of Preventive Medicine and Community Health, will be published quarterly beginning in the Spring, 1975, by Behavioral Publications. Dr. Robert Kane, Professor of Family and Community Medicine at the University of Utah, is the Editor of the Journal. The Journal will devote itself to original articles on the practice, teaching, and research of community health. This field encompasses the delivery of health care services, preventive medicine, analysis of environmental factors affecting the health of groups or individuals, and the study of health maintenance and health insurance programs. Serving as a forum for the exchange of ideas and clarification of issues about health care practice and policy, the Editorial Board of the Journal of Community Health is now actively seeking well executed studies and descriptions of projects making an impact on the health of communities or the education of health care personnel. Position papers and other articles on community health issues are also welcomed. Manuscripts should be between 10 and 25 double-spaced pages and should follow the style outlined in Index Medicus. Submit manuscripts in triplicate to: Dr. Robert Kane, Editor Journal of Community Health University of Utah Medical Center 50 North Medical Drive Salt Lake City, Utah 84132 Subscriptions are available through the publisher, Behavioral Publications, 72 Fifth Avenue, New York, NY 10011, on a calendar year quarterly basis; $15 per year for individuals, $30 per year for institutions. PUBLIC HEALTH THEN AND NOW 643
