Popular Science Monthly/Volume 83/October 1913/Immigration and the Public Health
THE
POPULAR SCIENCE
MONTHLY
OCTOBER, 1913
| IMMIGRATION AND THE PUBLIC HEALTH |
By Dr. ALFRED C. REED
NEW YORK CITY
I. The Nature of Public Health
THE age has happily passed when patriotism is measured in terms of human life sacrificed, and weighed in the balance of territorial or financial advantage. War has its heroes and mighty men who, fighting for man or cause, regardless of victory are accounted great. But the heroes and mighty men of peace who, for man and man's cause, fight the more terrible foes of ignorance, disease and public wrong, are coming to be accounted infinitely greater. 'No soldier opposing foreign foe was a truer patriot or died more nobly than did Dr. Thomas B. McClintic who, with no panoply of militarism, quietly and unfalteringly with his own life helped pay the price of the conquest of Rocky Mountain spotted fever last summer in the Bitter Root Valley of Montana.
Truly it is sweet to die for one's country. But even in the battles of peace the need of this sacrifice is rare. Greater is the need and grander the opportunity to live for one's country, and wage war against the powers of ignorance, indifference, disease and degeneracy. And this is the essence of the newer patriotism, which in no way removes or lessens the ancient duty of defending the land and honor of one's country, but at once idealizes and transcends that duty. If this be true, it follows that the man who is awake to his civic responsibility and who appreciates the honor of his American heritage will be in hearty sympathy with all agencies engaged in this distinctly modern line of endeavor. He will take part in, and aid to his utmost ability, those influences making for a cleaner and better America, because he realizes that this is not only his opportunity but his patriotic duty.
It appears therefore that the subject of the public health must not 
only interest, but must engage the loyal support of every good American. Yet the name itself means the same to no two people, and there exists an equally diverse opinion respecting the relative importance of the component elements of the public health, and the causal influences controlling it. However, it is unnecessary to bring up disputed points and impractical discussions when there are issues of the most vital concern involved in this question.
The public health, or the health of people en masse, in groups or communities, is more than an adding together of the conditions of health in which each person in the group finds himself. Just as the mob-sense, the group consciousness, or the dominant spirit of the mass, as one chooses to call it, differs from the individual personalities which compose it, so the public health differs from the individual health of each single person. The public health is intangible, though none the less real. It is not a static condition, which can be moved and delimited from without, but it is full of dynamic potentialities, and pregnant with unforeseen complications and denouements. The study of it leads into a bewildering array of intimately related subjects which at first glance seem to bear but a meager relation to it. A survey of its field must begin with an understanding of what is included in the term public health itself.
Public health may be considered to present itself in three phases, as physical, mental and social health. Each is influenced by many factors. Certain features of the Public health are most prominent from the social standpoint. The development of industrial life has brought many problems of most pertinent concern. Among them are industrial diseases, such as arsenic, lead and phosphorus poisoning, child labor, hours of labor, the employment of women in certain industries, sanitation of working quarters, and the responsibility of employers for the life and activities of employees outside of the workroom. The rapid growth of facilities for travel and the enormous number of travelers on railroads and steamships presents some unexpected problems in the sanitation of common carriers. Several instances are recorded of smallpox spreading in Pullman coaches. Mosquitoes, fleas, bedbugs and flies may easily carry an infection over long distances by aid of the railroad. A typhoid carrier can infect every water supply traversed by his train between Los Angeles and New York. The prevention of accidents in mines, and other industries, improved methods of controlling epidemics, and preventable diseases, and of saving the victims of common accidents like drowning, prevention of overcrowding in cities, proper housing of the poor; these are but a few of the numberless problems in the new science of public hygiene, from the standpoint of social public health.
The physical public health is concerned with communicable disease and its direct results, as in epidemics, while mental public health considers the prevalence, prevention and care of mental disorders, and the new science of mental hygiene.
One of the most important of the factors having to do with the public health is immigration. Not in the world's history has so vast an ethnic movement been recorded as that from Europe to America. The tribal migrations of ancient Europe are puny indeed compared to the great tide of a million and a quarter souls coming every year to the
United States. The tremendous bulk of this movement, together with the fact that it is drawn from such diverse and often mutually antagonistic races and nations, produces problems which not only are unique but whose proper solution is a matter of the gravest concern for the welfare and continuance of this country. The population of New York and of many sections elsewhere increases faster by immigration than by birth. These immigrants at best are only imperfectly and superficially sifted, and many enter to whom the privilege should be denied. The reason for this lies in the extreme difficulty of recognizing many physical and mental affections in their incipiency, in the shrewdness so often exhibited by the immigrant in concealing such defects, and in the loopholes that exist in the administration and interpretation of the law whereby many defectives who are detected are nevertheless admitted.
It goes without saying that the development of American ideas and standards in an immigrant foreign population will be inversely proportional to the density and homogeneity of that population in any section. Intermixture is the secret of assimilation. And assimilation is the test of desirable immigration. But not alone is the social and economic advance of the immigrant determined by his relations with Americans, for it is just, as true that the immigrant will affect the standards and ideals of the American. This influence of the immigrant on the native population becomes operative in many ways, but none of these is so important and yet so complicated as the influence on the physical, mental and social health of the general population.
The medical inspection of immigrants is the first, most comprehensive and most effectual line of defense against the introduction of disease or taint from without. It is properly a feature of quarantine, and the two systems, immigrant inspection and national quarantine, might well be combined and condensed to their mutual advantage. Especially is this true since both systems have the same object, require a somewhat similar plant, and are both operated by the federal Public Health Service.
The influence of immigration on the public health thus constitutes perhaps the most serious feature of this vexing and much-discussed problem. Disease or defectiveness of mind or body in the immigrant must be considered from two standpoints. First is the immediate result on those with whom the immigrant comes in contact. Second is the effect on the descendants of the immigrant, and indirectly on the general public; in short, the eugenic aspect.
II. Direct Relations of Immigration to the Public Health
Certain diseases have been considered so dangerous to the individual or to the public as to be included in a list of conditions which are absolutely excluded by the immigration law. Among these are venereal and other dangerous or loathsome contagious diseases, including tuberculosis, trachoma, filariasis, and hookworm infection. Insanity, epilepsy and mental defectiveness are likewise excluded.
There is a growing recognition of the wide prevalence of venereal disease in this country. and of the insidious danger from it. But no
matter how prevalent it may be, and regardless of the few cases that may be found among immigrants as compared with the huge number already existing, the exclusion of those few is a matter of deepest moment. It is extremely difficult to detect venereal disease in the routine examination of immigrants; even with the greatest possible vigilance, it is probable that many cases are not identified.
Acute diseases, including the ordinary contagious diseases, are stopped at the immigration station and kept in an isolation hospital until recovery has occurred. There is no serious danger from these because acute disease is easily recognized and ordinary quarantine precautions serve to prevent local epidemics.
Certain parasitic skin diseases such as favus and tinea tonsurans are excluded. These diseases are caused by a minute fungus which in itself is not dangerous to life or necessarily to health. But the lesions produced by these fungi are disfiguring and loathsome, and the disease is easily transmitted by contact, either directly from the patient or through the medium of domestic animals as cats and dogs, or of common hairbrushes, towels or linen. If the fungus invades the hair follicles and roots of the hairs, its eradication is a matter of the greatest difficulty and often impossible. It is this feature that makes favus and ringworm of the scalp practically incurable. The classification of loathsome and dangerous contagious diseases includes a large group, but the desirability of excluding immigrants possessing any of them rests on a few common principles. These diseases are all communicable and therefore may spread through an ever-widening circle. They are detrimental to the health and usually to the life and normal activity of the host. Occurring in the ordinary immigrant class, they decrease bis productivity and power of self-support, consequently laying an additional and undeserved burden on the rest of the community. Many of them result in the transmission of hereditary taint or predisposition or actual disease to posterity. And finally their admission into this country simply means a gratuitous and unnecessary assumption by this country of a burden belonging properly to the countries from which these persons come, and encourages those countries, as in the past, to unload their decrepit, worn-out and encumbering human stock on us.
Little is heard as to the bearing that immigration may have on the prevalence of tuberculosis. The status of tuberculosis is influenced by immigration in several ways. The disease in its pulmonary form is usually chronic and marked by a slow and insidious onset. Hence only a careful physical examination, often combined with a suggestive clinical history, will reveal the affection in its early stages, that is, in the first three to six months of its course. It must be borne in mind that the medical officer examining immigrants encounters the shrewdest evasion and concealment. Only too often the diseased immigrant is carefully coached by persons having knowledge of the methods of the medical examination. Altogether the task of the medical examiner is most difficult. It is estimated that 150,000 persons die each year in the United States from tuberculosis, and statistics put the death rate from tuberculosis at 10 per cent, of the total death rate. Yet in the fiscal year 1911, but 0.015 per cent, of the immigrants examined were certified for tuberculosis. This may be explained in no small measure by the fact that in the administration of the law excluding tuberculosis it is the rule to diagnose the pulmonary disease only when the tubercle
bacilli have been found in the sputum. Moreover a microscopical preparation showing the stained bacilli must be submitted in substantiation of the diagnosis. The tubercle bacillus rarely appears in the sputum until the disease is well advanced and there has been a certain degree of destruction of lung tissue. To limit the diagnosis to such cases alone as show the bacillus allows numerous cases to pass free in which the clinical diagnosis is practically certain.
In this connection it is to be recalled that many deportation cases diagnosed as tuberculosis are referred to the medical officers for examination to determine if the disease existed or was due to causes existing
at the time of landing. In these cases it is customary for the certificate of tuberculosis to be based on a clinical diagnosis alone with no demonstration of bacilli in the sputum. This is the case even though the deportation of a tuberculous alien is a far more severe and radical procedure than to exclude such an alien at first.
It would be more effective to hold for hospital observation all cases presenting clinical evidence of pulmonary lesions, and to allow diagnosis in such cases as after careful and repeated examination showed a definite lesion, perhaps using the tuberculin reaction as an aid in selected cases. In other words, if the diagnosis of pulmonary tuberculosis could be made by a competent and careful physician, even though there were no bacilli in the sputum, the case should be certified as tuberculosis. In the administration of the law excluding tuberculosis, only tuberculosis of the lungs, genito-urinary tract or gastro-intestinal tract is considered to be indicated. It would seem that an arbitrary limitation of the scope of the law to these three forms leaves out of account the serious nature of tuberculosis of the bones and glands at least. There is no doubt that the widespread popular interest and agitation against tuberculosis has overemphasized the importance of the tubercle bacillus, and the diagnosis and care of tuberculous patients. But equally or even more important is the prevention of the disease by sanitation, personal hygiene and increase of individual resistance to it. The bacilli, as Osler says, are ubiquitous, and practically every person is exposed at some time to infection. One of the very best reasons for placing tuberculous patients in sanitaria, and for scrupulous sanitary care of those who can not be so placed, is that each case, especially in the humbler walks of life, tends to become a constant focus of infection, spreading the germs broadcast. This is prevented by proper care. Linked with this consideration is the fact that the tuberculous patient tends to produce feeble offspring, predisposed to this and other diseases and defects. It is no small advantage to the community to have tuberculous cases in proper institutions where these dangers are averted. The advantages of removing tuberculous patients from contact with the general public in the ordinary activities of life are at least no greater than the advantages of preventing the entrance into the country of tuberculous aliens.
Another consideration which increases the danger of admitting immigrants who are subject to tuberculosis or other communicable diseases is based on the nature of the present-day immigration. More than four fifths of the immigrants entering the United States come from southern and southeastern Europe. As a type these peoples are ignorant of hygiene and sanitation. They live on a low plane. Overcrowding, disregard of privacy, cleanliness and authority, their gregariousness and tendency to congestion along racial lines in cities, are all important factors in the spread of disease among them and by them.
Among the diseases whose prevalence, manner of spread and results constitute a national health problem, trachoma must be reckoned. Trachoma is an inflammatory communicable disease of the eyelids, of unknown causation, having most serious sequelæ of deformity of the eyelids, impairment of vision and blindness. In Europe and Asia it is a terrible scourge. "Egyptian ophthalmia" has a long and famous history. The wide prevalence of trachoma in the United States and its importance in decreasing economic efficiency are only now beginning to be fully realized. It is stated that half of the 64,000 registered blind persons in the United States are needlessly blind and that the maintenance of one blind person for life by the community costs an average of $10,000. Sixty-seven per cent of the blindness in the Ohio State Institution for 
Italians the Blind was found to be due to trachoma. In the Kentucky Institute for the Blind, a year ago, 45 per cent, of the blindness followed trachoma.
It is known that trachoma is a common disease of the American Indians, and its ravages are only equalled in seriousness by tuberculosis. In some sections of the southwest, from 65 per cent, to 95 per cent, of the Indians are trachomatous. Over 800 cases of the disease were operated upon and treated at the trachoma hospital of the Indian Service in Phoenix, Arizona, alone, according to the report of the Commissioner of Indian Affairs for 1911. A recent investigation covering 39,231 Indians in 25 states, one eighth of the total Indian population, showed 8,940 or 22.7 per 
Italian cent, to have trachoma. At this rate there are 72,000 trachomatous Indians in the United States.
In 1911 Surgeon M. H. Foster, of the U. S. Public Health Service, made a survey of conditions of health and sanitation among the natives of Alaska. Of 1,364 Alaskan Indians examined over 7 per cent, suffered from trachoma, and nearly 3 per cent. were blind largely as a result of trachoma. The disease ranked with syphilis and tuberculosis as one of the most destructive to which the natives are subject. Recently Surgeon John McMullen, of the Public Health Service, has conducted a careful investigation as to the prevalence and seriousness of trachoma among the mountaineers of Kentucky. Of almost 4,000 persons examined, 500 or 12½ per cent. had trachoma. From 3 per cent. to 18 per cent. of the school children examined suffered from trachoma. At the semi-annual clinic held by Dr. J. A. Stucky at Hindman, Kentucky, in September, 1912, 374 patients were examined, of whom 113 had trachoma. Over 11 per cent. of the resident pupils of the settlement school at Hindman, and 16 per cent. of the day pupils suffered from trachoma. About one half of all those applying for relief to this clinic suffered from trachoma or its sequelæ.
The management of this newly recognized public health problem includes two features. First is the treatment and cure of existing cases of trachoma, and popular education in the hygienic and sanitary measures which will prevent its spread. Second, and equally important, is the prevention of the development of new cases. Probably the prevention of the introduction of new cases in immigrants is the most important single factor in the prevention of new cases and new foci of contagion. In 1911 a total of 2,504 cases of trachoma were certified in immigrants. Many of these were admitted, however, in spite of the medical certificate. At New York, for instance, where 1,167 cases were certified, 63 cases were landed. In 1912 of the 718 cases certified at New York, 64 were landed. If no inspection were made for trachoma, the victims of the disease would flock to the United States in hordes. We have a weighty and difficult problem in handling the trachoma already existent in this country. Every consideration demands its absolute exclusion in immigrants.
One other disease of national importance for the public health, and which has an intimate relation to immigration, is hookworm infection. The economic and social significance of this disease is well known. The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease in its second annual report shows that a heavy infection exists in Arkansas, Virginia. Tennessee, Alabama, Mississippi, Louisiana, North and South Carolina and Georgia, and that a lighter infection exists in California, Nevada, Oklahoma, West Virginia, Kentucky, Texas and Florida. Maryland is probably also infected. The report states that hookworm disease belts the earth in a zone 66 degrees wide, extending from 36 degrees north to 30 south latitude. Practically no country within these boundaries is exempt.
It is a subtle disease with a chronic course, and it attacks the health and efficiency of its victims insidiously. It is beginning to do in the United States what it has already done in Egypt, China and India. It will be impossible to control the spread of hookworm in the United States as long as any considerable number of new cases are admitted in immigrants. The law rates it now as a dangerous contagious disease, subject to exclusion. The exclusion of Hindus at San Francisco on the certificate of uncinariasis practically stopped the immigration of 
Orthodox Greek Catholic Armenian Clergyman. East Indians through that port. The Rockefeller Commission 
Armenian estimated the rate of infection in India at from 60 to 80 per cent, of the population, and at San Francisco in 1911 65.6 per cent, of the Hindus were found infected. No immigrant should be admitted 
Hebrew from Galicia. who is infected with hookworm. He should be treated until cured in an immigrant hospital or excluded at once.
These few diseases are selected merely as types to show the serious nature of the importation of actual diseases by immigrants. The list is far from exhausted by the instances we have discussed.
The phase of public health which may be termed mental health is susceptible to many influences. There is no doubt that successive ages of inbreeding, "racial incest," as Dr. H. M. Friedman calls it, results in a racial tendency toward, or characteristic of, mental instability and predisposition to a neurotic and psychopathic constitution. This is illustrated in the case of the Jews, where their highly developed emotional nature and predisposition to functional insanities may be laid to absence of fresh blood and to close racial inbreeding for many centuries. New blood is essential for racial or individual development.
If the tide of immigration brought to us only the good blood that this country needs, no restrictive examination would be required. But the mentally diseased and defective come in large numbers, and if the vigilance of the nation's sentries were relaxed ever so little, these numbers would swell to an overwhelming flood. Insanity and mental defectiveness are of grave concern from the standpoint of public health. The individual victim is predisposed to crime, is very likely to be not self-supporting, tends to become a complete public charge and, most serious of all, transmits a tainted heredity or actual mental disease to his descendants. Moreover, where physical disease or defect tends toward extinction, mental disease or defect is prolific and both insidious and far-reaching in its ramifications.
Dr. H. H. Goddard has recently made a complete hereditary study of the descendants of an Englishman of good ancestry who contracted an illegitimate union with a feeble-minded girl. A feeble-minded son married a normal woman and from this pair were descended 480 persons. Of these 480 persons, 36 were illegitimate, 24 were chronic alcoholics, 3 were epileptics, 33 were immoral, 8 kept houses of ill-fame and 3 were criminals; 143 were feeble-minded. In all that family only 46 were apparently normal. The legal union of the same ancestor with a normal woman resulted in 496 descendants, of whom but two showed abnormal mentality. Comment on this record is unnecesary. Its lesson should be kept in mind in considering the fact that the alien population of the United States is furnishing considerably more than its proportionate number of feebleminded and insane persons.
More accurate statistics are available for New York state than elsewhere in the country. But while New York is chiefly concerned with the problem of the alien insane and mentally defective, every other state has or will have the same problem in varying degree. It is authentically reported that about one per cent, of the school population of New York City, or about 7,000 children, are distinctly feeble-minded. In addition to these is an equal number of idiots and imbeciles, and the large class of morally defective children and border-line types. Census statistics show that the parents of 30 per cent, of the feeble-minded children in the country at large are aliens or naturalized citizens. In the first line of defence and prevention lies in a rigid primary examination 
of all applicants for entry. To put this mental examination of this ratio at least 3,000 of New York's 10,000 feeble-minded children are the progeny of the 9,000,000 immigrants of the last ten years.
Dr. T. W. Salmon writes that New York State is the destination of 26 per cent, of all immigrants coming to the United States, but that more than 80 per cent, of the immigrants found on arrival to be mentally defective or insane are headed for that state. He found more than 8,000 aliens in the New York State hospitals for the insane. The New York State Lunacy Commission reported to the legislature on February 14, 1912, that there were 33,311 committed insane cases in the state institutions. According to Dr. Salmon, more than 25 per cent, of these were aliens, who to a large extent had passed through Ellis Island. The capacity of the institutions was exceeded by 3.043.
Enough has been said to show the intimate relation obtaining between immigration and the prevalence and increase of insanity and mental defectiveness in the United States. It is recognized that these conditions are increasing in an alarming extent and the student of public health and preventive medicine must concern himself seriously with the control and eradication of the sources of this increase. So far as the immigration of the insane and mentally defective is concerned, immigrants on a thoroughly adequate basis will cost money in large amount. But it is not only a good and economic investment, it is absolutely essential in order to conserve our national mental health and to ensure a normal mentality to coming generations.
Among the important agencies operating directly to promote mental public health is the present mental hygiene movement. This is a carefully organized effort of national scope, which is being directed and promoted by the National Committee for Mental Hygiene with headquarters in New York City. The field activities of this committee are under the direction of Dr. Thomas W. Salmon, of the U. S. Public Health Service. The object of the committee is to popularize the correct knowledge of the causes of mental impairment, to supply agencies for furnishing advice to persons threatened with, or actually suffering from mental breakdown, and to furnish preventive social service for such cases. Insanity is a disease and a large proportion of the cases are due to preventable causes. The National Committee is also making a medical survey of the country with reference to methods of caring for the 200,000 insane of the country. At present there is a lamentable lack of uniformity in the different states, in the facilities and methods employed in insane hospitals, and the standards of care are very low in many.
III. Importance of the Immigration Station for the Public Health
Any discussion of the relation of immigration to the public health must take cognizance not alone of the mental and physical effect of incoming immigrants on the present population, but must concern itself very particularly with the selection and enforcement of the best methods of excluding the unfit. The relative importance of the leading ports of entry in number of immigrants examined is shown in the following table:
| 1909 | 1910 | 1911 | 1912 | |
| New York (Ellis Island) | 724,757 | 896,015 | 749,642 | 726,040 |
| Boston | 47,895 | 62,075 | 54,759 | 59,893 |
| Baltimore | 20,510 | 31,245 | 23,543 | 22,667 |
| Philadelphia | 15,083 | 39,671 | 46,857 | 47,742 |
| Total for U.S. | 944,235 | 1,198,037 | 1,093,809 | 1143,234 |
It is seen that Ellis Island, the immigration station for New York, is by far the largest port of entry. Hence it is the most representative place to study practical methods of immigrant examination. These methods have been described elsewhere in detail.[1] Certain features only need mention at this time.
Magyar, showing Boots and Sheepskin Coat. Only aliens of the steerage class are taken to Ellis Island. Aliens in the first and second cabin of arriving vessels are examined on board by medical officers of the Public Health Service who board the vessel as it leaves the New York Quarantine at the entrance to the bay. The present force of medical officers at the Ellis Island station is hard pushed to keep abreast of their continually increasing duties and responsibilities. No definite standard has yet been found for the mental and physical examination of immigrants. It is a new and very technical field in public health work.
A Little Russian in a Sheepskin Coat. Experience and practise alone will show what is best. No absolute and ironbound rules can be laid down at present as to methods of administration and examination. These features make especially difficult the task of the medical examiners at Ellis Island. Being by far the largest port of entry, Ellis Island must of necessity have most to do with the determination of the best methods of examination, and of standards of examination which can be used elsewhere after being put to the test of actual trial here and modified in the light of experience. In other words, Ellis Island is peculiarly adapted to be an experimental station in the mental and physical examination of immigrants. There is a tremendous need for such a station. The entire subject is new and, as has been pointed out, there is neither precedent nor experience to guide. It is a sophistical and beclouding argument that such work would be an injustice to the immigrant. In the strictest sense it would be an intensive study of the immigrant under the best possible surroundings to find out the best way of separating the sound and desirable alien from the unsound and undesirable.
Such work would find many definite problems in the diagnosis of disease. An instance in point is trachoma. Probably no better trachoma clinic exists in the country than at the Ellis Island hospital. So far the cause of the disease is unknown. Investigation of the etiology would naturally carry with it investigation of the best means of treatment and cure. Mention has been made of the importance of the hookworm and of its prevalence in the United States. There is a mighty host of intestinal parasites, several of which are fully as dangerous as the hookworm though not distributed so widely. An example of this is the fishworm, the Bothriocephalus latus. To exclude immigrants harboring these dangerous intestinal parasites or to cure them before they enter the country is very important.
Dr. M. W. Glover has noted that of 1,553 immigrants examined at San Francisco, 42.8 per cent, harbored the hookworm, not to mention numerous other parasites. He found that 29.4 per cent, of the 782 Chinese examined were infected, and notes the fact that the most marked evidences of infection were seen in Chinese boys. Dr. Glover makes the interesting suggestion that this apparently explains the puzzling observation of the discrepancy between the apparent age and the age claimed in many Chinese boys. In the fiscal year 1912, 941 cases were certified at Ellis Island for lack of physical development, in addition to 444 cases for poor muscular development and 36 for malnutrition. A large proportion of these cases were boys whose physical development did not correspond to the age claimed. Dr. Friedman notes such a disproportion as of common occurrence in the Mediterranean races and especially in the Greeks. It would be well worth while to institute an investigation to determine whether intestinal parasites or some other agency is responsible for these cases. The determination of this point would not only serve to clarify and give a more exact standard of diagnosis and certification of these aliens, but it would be of untold value in relieving similar conditions not only among our own people, but in the countries from which this class of immigrants comes.
The detection and diagnosis of mental conditions in immigrants is a matter of exceeding difficulty. This is in no small measure due to 
Russian Polish Girl. the fact that no definite standards are available by which each immigrant may be judged as to his mental development and normality. Mental defectiveness or backwardness in the Pole or Russian expresses itself in a very different manner from the same conditions in a West Indian negro or in a Basque, or an Italian. Each is accustomed to a more or less limited and different range of experience. 
Finn. Each has a distinctive hereditary endowment and has grown up with a distinctive training, a peculiar environment and habit of thought and action. Experience and deduction agree that each must be examined by methods peculiarly suited to his own circumstances. Such methods can only be developed from the experience of trained men in the careful examination of many cases. Numerous cases are put through a detailed mental examination and released because no definite and recognizable sign of mental impairment could be obtained. Many have latent symptoms which are indefinite, but which if kept on record for a large number of cases would make possible a more exact standard of diagnosis. If a careful stenographic record were filed of every such examination those cases which later after landing develop some definite psychosis or show positive mental impairment could have this original examination reconsidered in the light of later developments. From a large number of such cases it would be possible to formulate definite methods of original examination and to codify new symptom complexes for different races and classes. Tabulation of such symptom complexes and from them the establishment of definite standards of mental abnormality for the various races, would be in accord with the same principle as that followed in formulating the Binet-Simon measuring scale of intelligence, now used so widely in the diagnosis of mental backwardness, which was codified from a large number of mental examinations of French school children.
A few illustrations have been picked at random to show the enormous field of usefulness of Ellis Island as an experimental station of methods and standards for the physical and mental examination of immigrants. Of course there would be great gain incidentally to the cause of science and scientific medicine, and this gain would be shared directly by the public health conditions of the country. As a suggestion of the opportunity for obtaining data on related topics, it would be feasible to make an exhaustive study of muscular anthropology, or the racial and relative physical development of the living man. Abundant material is available for this at Ellis Island from every race and nation, and that, too, with no hardship and practically no delay to the immigrant.
Space forbids more than a suggestive sketching of what Ellis Island means for the best interests of the public health. Were a larger staff of medical officers available, it would permit the fuller utilization of observation wards in the immigrant hospital in the diagnosis of diseases of the lungs, kidneys, heart, blood, intestinal tract, and others where careful observation and laboratory examinations are essential.
An efficient immigration station requires a staff of specially trained interpreters. It is hard to overestimate the need for thoroughly trained competent medical interpreters. Of course the ideal arrangement would be for the examining physician to be able to address each immigrant in his own tongue, but this is manifestly impossible. It is hard enough to discover mental symptoms ofttimes when the examiner can converse fluently and sympathetically with the patient. Lacking a skilled, intelligent and honest interpreter, his task is well-nigh hopeless.
The medical examination is the only true examination of immigrants that is provided for under the law, or that is possible or even necessary. The real center and necessary essential of an immigration station is the medical division. If an immigrant is in a broad sense the possessor of mental and physical health his entry is desirable. Whether he shall stay, having once been admitted, could well be made dependent on his meeting certain tests of education and financial self-support within a definite period. A healthy immigrant who passes such tests is the only alien who should be eligible for citizenship.
It is essential for the success of the medical examination that it be conducted in quarters especially arranged with reference to the needs of the examination. Well lighted and perfectly ventilated rooms are extremely necessary. For both the physical and mental examination a number of separate rooms are needed sufficiently large to prevent overcrowding. The immigrant is naturally frightened and nervous from
his strange surroundings. Being detained for more complete medical examination increases his perturbation and anxiety. It is most important to allay his fears and remove the sense of strangeness, so far as possible, by avoiding overcrowding, by quiet and kind treatment, and by judicious arrangement of facilities and interpreters. These conditions are of no small importance in the conduct of the medical examination.
As has been stated, aliens in the first and second cabins of incoming vessels at New York are examined on board ship, and are not removed to Ellis Island unless such a course is required for medical attention or diagnosis, or unless the individual is held for a board of special inquiry to pass on his eligibility for admission. The conditions under which 
Slovak. the medical examination must be conducted on board ship are most disconcerting and difficult for the medical officer. The law regards all aliens alike, and the regulations governing the medical examination of aliens expressly make no distinction between those in the cabin and in the steerage. As a matter of fact, the chances of a defective immigrant escaping detection in the cabin are far greater than in the steerage. This depends on many factors of which space forbids more than mention. The aliens of the first cabin are frequently discharged without examination 
Roumanian. by the medical officer. In the confusion and excitement on board an arriving liner not infrequently defective aliens as well as others are passed with no medical examination.
It is not true that immigrants come only in the steerage. On many lines the second and even the first cabin brings a class of alien passengers distinctly inferior to the steerage of such lines as the Scandinavian and Scotch. In his report for 1911 of the medical examination of aliens at Boston, Dr. M. V, Safford says:
Six per cent, of the steerage passengers arriving at Boston were United States citizens, and over three fourths of the second cabin passengers were aliens. About 2.5 per cent, of the aliens arriving at Boston come as cabin passengers. It appears that over 7 per cent, of the alien second cabin passengers were certified as
German Swiss. seriously defective or diseased, while only 4 per cent, of the alien steerage passengers were so certified.
These figures may be taken as representative, although unfortunately similar figures are not available for Ellis Island. No more is needed to show that relatively the cabin examination is at least as important if not in fact more important than the steerage examination.
Dr. Safford very aptly points out that "long-established custom dictates that the medical inspection of cabin passengers must be made somehow on shipboard whenever they may arrive, day or night, 
German Polak. and that they can not be removed to a suitable place ashore for the purpose." This custom is pernicious when made ironclad. In some cases the examination can be conducted satisfactorily on shipboard. An exception should be made by the immigration inspectors in favor of these cases only, and the rule should be that all aliens should be examined in a satisfactory station on shore. The law designates the regular immigration station as the place of examination of all aliens, unless the commissioner of immigration expressly appoints some other.
IV. Deportation of Unsound Landed Aliens
But the exclusion of unsound aliens includes more than a competent medical examination at entrance. Many cases of incipient disease both physical and mental are unrecognizable at the time of entry except by detailed and refined methods of diagnosis which are absolutely impracticable in the routine examination of large numbers of immigrants. Also the cleverness and cunning of defective aliens may easily conceal from the examiner some unobtrusive though important sign of defect or disease. Such cases are very apt to come to light sooner or later after landing, in hospitals or other public institutions. As Dr. Friedman says:
The detection of mental disease among aliens offers the same difficulties in an infinitely larger degree. The goal in this work is to be able to detect from the panorama of people those who have remote or only latently present mental abnormalities. There are no signs by which an examiner can say in any given instance that an individual will develop a mental disease.
In addition it is impossible for an examination at the time of arrival to indicate how successfully a given immigrant will react to the stress and strain of American life, and whether some latent tendency or weakness may not be developed under the new conditions. In short the medical examination at entrance must be supplemented by examination at a period later in case some latent disease manifests itself.
The law takes cognizance of these circumstances by providing for the deportation of aliens who, within three years of landing, become public charges or develop any of the excludable diseases from causes existing prior to landing. An example of the need of this law and of its operation may be seen in the case of pulmonary tuberculosis, due to causes present when the alien landed but not appearing in definitely recognizable form until months later.
Even more striking is the value of this law in insanity, epilepsy and mental defectiveness. These conditions are excludable but often escape detection on the primary examination. Within the three-year limit, however, a large number of such cases develop. Many forms of insanity and epilepsy are known to be due to hereditary constitutional defect and psychopathic tendencies. Hence if one of these becomes apparent within three years after landing, the diagnosis shows that the causes must have existed prior to landing. Of course feeble-mindedness, idiocy and imbecility are congenital and one of these conditions found within three years is evidently under the law.
Feeblemindedness differs from imbecility only in degree, and in its lesser forms in turn shades off into simple backwardness of mental development. A case may have been given the benefit of the doubt on the primary examination, when later conditions indicate it to be feeble-minded. An infant or young child may show feeble-mindedness within 
three years which was not apparent at entrance. Or, especially in the cabin examination on board ship, a feeble-minded person may entirely escape detection. These instances illustrate both the need for the law and its effectiveness. It is the second line of defence against unsound aliens, augmenting and reenforcing the first line of defence at the immigration station.
Unfortunately the effect of this deportation law is nullified in many cases by decisions of the Secretary of Commerce and Labor.[2] Certain of these decisions should have the widest publicity and will be a surprise to many persons.
Decision No. 120 of the solicitor of the Department of Commerce and Labor was published on February 8, 1912, for the guidance of immigration officials and others concerned. Within the legal three-year limit, Yittel Goldfarb, a sixteen-year-old Russian Jewess, was certified to be suffering from manic-depressive insanity by a member of the New York State Board of Alienists, an officer of the Public Health Service, and officials of the Manhattan State Hospital for the Insane where she was confined. The unanimous medical opinion was that, while the insanity had developed after the girl had landed, it resulted from causes in existence before landing. These causes were stated to be constitutional psychopathic tendencies and mental instability. It is held by competent alienists that manic-depressive insanity is always based on hereditary tendencies and mental instability. The apparent or immediately preceding cause acts only as an exciting agent in bringing to fruition what was previously latent. It is to be noted that this decision does not question the diagnosis, but it states the opinion of the lawyer who framed it that the existing condition of manic-depressive insanity did not depend on causes prior to landing. In the light of this decision a warrant was refused for the arrest and deportation of the alien in question. As a consequence deportation is impossible in a class of cases which formerly supplied about 350 deportations annually.
On February 25, 1912, Mariase Lipschutz, aged 25, arrived from Russia on the steamer Campanello. On February 28 she was certified by the medical officers at Ellis Island as being feeble-minded. On March 28 she was ordered landed by the Secretary of Commerce and Labor, for the avowed object of visiting a sick relative. Her visit still continues.
On June 25, 1912, Rewke Palayes, aged 11 years, arrived from Russia on the steamer Rotterdam. A special certificate of imbecility was issued by the medical officers at Ellis Island, this carrying with it a fine of $100 for the steamship which brought her. On July 13 she was ordered landed by the Secretary of Commerce and Labor. The immigration law declares that minor children of naturalized citizens, if these children are dwelling in the United States, shall be considered as citizens. The father of this girl was a naturalized citizen. The Secretary contended that "constructively" she became a resident when she had left her foreign domicile, even though she had not even been admitted into the United States. She was ordered landed.
An exactly parallel case was decided in an opposite manner in an
opinion of the Supreme Court handed down by Justice Day on January 7, 1907, in the case of Charles Zartirian vs. George B. Billings, Commissioner of Immigration at Boston. Here the Supreme Court decided that a naturalized citizen's child was not a citizen and was properly excluded because it was suffering from trachoma, a disease subject to mandatory exclusion. The opinion stated that
The Zartirian case and the Palayes case are just parallel. The Supreme Court decided that the Zartirian child should be excluded. The Secretary of Commerce and Labor decided that the Palayes child should be admitted.
Space is insufficient to dwell further on the loopholes in the deportation of these cases, or to discuss possible improvements in the deportation law. A factor which is far from inconsiderable is that many cases legally subject to deportation, within three years of landing, are not reported to the proper officials. It is earnestly to be hoped that a thoroughly efficient primary medical examination of arriving immigrants may be augmented and reenforced by a strict administration of the deportation laws.
Recapitulation
- ↑ Alfred C. Reed, "The Medical Side of Immigration," The Popular Science Monthly, April, 1912; and "Going through Ellis Island," The Popular Science Monthly, January, 1913.
- ↑ The newly established Department of Labor, with Secretary William B. Wilson at its head, now includes the Bureau of Immigration, and it is probable that this policy will not continue.