The Medical Side Of Immigration - 1912
Perhaps no question is of more paramount and continuing interest to the American people than immigration in all its phases and relations to public welfare. The history of the United States is the history of alien immigration.
The earliest pioneers were themselves, foreign immigrants. Our political, religious, and social institutions have been founded and supported by aliens or their near descendants.
Our country is indeed a melting-pot, into which have been poured diverse varieties of peoples, from all nations and races. Yet, these variant elements have been fused into a more or less homogeneous nation in the face of this.
We have a national life and character. This national or American character is not exemplified in places where the large streams of immigration are pouring in but farther away from where the waters have mixed.
Such a condition, unique in the history of nations, is responsible for particular problems in the past and consequently does not admit a solution according to precedents.
The first rule of national life is self-preservation. Since immigration has had and still has so important a role in American national life, it must be carefully scrutinized to determine which immigrants are desirable, and vice versa, from the standpoint of the betterment and continuance of the American nation.
The choice between free immigration, restricted immigration, and absolute exclusion is increasingly challenging to make. It does not enter our field of inquiry, except to recall a principle as valid from the medical standpoint as from the economic or social. Only those people should be admitted whom experience has shown will amalgamate quickly and become genuine citizens.
Our government should raise the period of residence necessary for citizenship from three to five years. During this time, the immigrant should be literally on probation and subject to deportation if found wanting or unable to meet the citizenship qualifications at the end of that time. The government should decide where the immigrant may settle, and the current immigration should be directed to the western and farming districts and not allowed to stagnate in eastern cities.
The great mass of popular literature on immigration is singularly deficient in discussing and analyzing its medical features. It is true, the United States government bestows on public health and preventive medicine nowhere near the attention it finds necessary for the prevention of disease in stock dud for agricultural improvement, but yet there are certain well-organized and efficiently operated agencies which have for their function the improvement of public hygiene and sanitation, the eradication of preventable disease, and the study of 'causation and methods of control of diseases.
Most of these functions are exercised by the Public Health and Marine Hospital Service, which, strangely enough, constitutes a bureau under the Treasury Department. Some of this work is done under the Department of Agriculture, and other minor lines are scattered elsewhere through the national machinery. It is easily seen how much more efficient it would be the work were all these agencies for federal health protection united under one administrative head, and their various activities carefully coordinated.
The Public Health and Marine Hospital Service operates all national quarantine stations where inspection is made for yellow fever, typhus fever, smallpox, bubonic plague, leprosy, and cholera; maintains hospitals throughout the country for sailors of the American merchant marine; conducts the Hygienic Laboratory at Washington for the study of the causation and treatment of diseases; exercises numerous minor functions of a national board of health; and conducts the medical inspection of immigrants. Certain conditions are frequently found among immigrants, and others are so inherently dangerous as to merit special mention because of their essential relation to public health.
First among these might be placed trachoma, a disease of the eyelids characterized by extreme resistance to treatment, very chronic course, and most profound results. Most of the immigrant cases occur in Russians, Austrians, and Italians, although it is of common occurrence in oriental and Mediterranean countries.
It causes a large percentage of blindness in Syria and Egypt. Its contagious nature, together with the resulting scarring of the lids and blindness, make its recognition imperative.
The hookworm (Uncinaria) has received much, attention lately since it has been found so widely distributed through the mountains of the south, the mines of California, the middle west, etc. It is a minute parasitic intestinal worm about three-fifths of an inch long. Under the microscope, it shows relatively enormous and powerful chitinous jaws utilized, attaching themselves to the intestinal walls.
The saliva of the hookworm has the curious property of preventing coagulation of blood like leech extract. When it is remembered that the worms may vary in number from several hundred to a thousand or- more and that each worm frequently moves from place to place on the intestinal wall, it is apparent how excessive and continuous is the drain on the blood and lymph juices. The result is extreme anemia which brings in its wake a varied multitude of bodily ills and may eventuate fatally, meanwhile having incapacitated the victim for mental or physical work.
Infection can spread rapidly from a single case. Not many hookworm carriers have been discovered among immigrants, probably because the facilities for their detection are so meager. But the heavy immigration from countries where sanguinaria is abundant and the recent suggestive work of Dr. H. M. Manning at the Ellis Island Immigrant Hospital indicate a constant stream of new infections pouring in.
Our government should institute indisputably routine examinations for hookworms. The same can be said of other intestinal parasites like tapeworms, pinworms, whipworms, eelworms, etc. One of the tapeworms, the so-called fish worm (Dibothriocephalus latus), leads to anemia entirely as severe as the hookworm.
One might mention many other diseases, but these are sufficient to illustrate the importance of careful medical inspection of immigrants.
The total immigration into the United States through all ports of entry for the year ending June 30, 1911, was 1,052,649. Of these, 22,349 were debarred for various reasons, leaving a. net increase of 1,030,300. Of course, the chief port of entry is in New York, where the Immigration Service examined 749,642 aliens.
Next in order of importance comes Boston, Baltimore and Philadelphia, and Galveston, Tampa, San Francisco, Honolulu, Miami and Portland, Me at a greater distance. As the laws are uniform and the methods of inspection the same at all ports, consideration of methods and results at Ellis Island, N. Y., will give a clear idea of the entire subject.
The medical inspecting service at Ellis Island is divided into three branches, the hospital, the boarding division, and the line. The hospital division presents an excellently equipped and managed institution and isolated buildings for contagious diseases.
The hospital service is limited exclusively to immigrants, and the patients are those acutely ill upon arrival, those taken sick during their stay on the island, and cases of acute sickness among aliens already landed who, for some reason, have been brought to the island for deportation.
The boarding division of the medical inspection on Ellis Island has for its particular function the inspection of aliens in the first and second cabins onboard the incoming vessels. Those who require a more detailed examination are sent to Ellis Island.
The routine inspection on the line is the part the visitor sees and is the most critical feature of the medical sieve spread to sift out the physically and mentally defective. The incoming immigrants pass in single file down two lines.
Each of these lines makes a right-angled turn midway in its course. At this turn stands a medical officer. He sees each person directly from the front as he approaches, and his glance travels rapidly from feet to head. In this rapid glance, he notes the gait, attitude, presence of flat feet, lameness, stiffness at the ankle, knee, or hip, malformations of the body, observe the neck for goiter, muscular development, scars, enlarged glands, the texture of the skin. Finally, as the immigrant comes up face to face, the examiner notes abnormalities of the features, eruptions, scars, paralysis, expression, etc.
As the immigrant turns, the examiner has a side view in following the line, noting the ears, scalp, side of neck, examining the hands for deformity or paralysis. If anything about the individual seems suspicious, he is asked several questions. It is surprising how often a mental aberration will show itself in the person's reaction to an unexpected question.
As the immigrant passes on, the examiner has a rearview, revealing spinal deformity or lameness. If any positive or suspicious evidence of the defect is observed, the immigrant receives a chalk mark indicating the nature of the suspicious circumstance.
A second medical officer stands at the end of each line who does nothing but inspect eyes. He everts the eyelids of every person passing the line, looking for signs of trachoma. Also, He notes the presence of cataracts, blindness, defective vision, acute conditions requiring hospital care, and any other abnormalities.
All cases marked on the line are separated from the others and sent to the medical examining rooms for careful examination and diagnosis. When it is remembered that often 5,000 immigrants pass in a day, it is clear that the medical officers not only are kept busy but that they see a wide variety of cases.
After careful examination, the nature of the defect or disease found is put in the form of a medical certificate that at least three physicians on duty must sign. It is not within the province of the medical officers to pass judgment on the immigrant's eligibility for admission. The medical certificate merely states the diagnosis, leaving to the immigration inspector in the registry division the duty of deciding the question of admission. The inspector's consideration includes not only the medical report but all other data concerning the applicant, such as age, money in his possession, previous record, liability to become a public charge, and his sponsors.
Most cases of trachoma and mental or organic nervous disease are sent to the hospital and kept under care and observation to facilitate an accurate diagnosis. Seldom indeed does the alien suffer from too harsh a medical judgment. He is given the benefit of the doubt always. For example, if a case of defective vision is 3/20 normal, it would be certified as perhaps 5/20 normal.
The immigration law as it stands since the legislation of 1907, divides all defective immigrants into the following classes:
- Class A, aliens whose exclusion is mandatory because of a definite and specified defect or disease.
- Class B, aliens not under class A but possess some defect or disease that is likely to interfere with the ability to earn a living.
- Class C, aliens who present a defect or disease of still lesser seriousness, not affecting the ability to earn a living, but must be certified for the information of the immigration inspectors.
Under class A, the excluded are listed idiots, imbeciles, the feebleminded, the people with epilepsy, the insane, and persons afflicted with tuberculosis of the respiratory, intestinal, or genitourinary tracts loathsome dangerous contagious diseases. By contagious, the law means communicable.
Loathsome contagious diseases include those whose presence excites hatred in others and are essentially chronic, such as fans, ringworm of the scalp, parasitic fungus diseases, Madura foot, leprosy, and venereal disease. Dangerous contagious diseases include trachoma, filariasis, hookworm infection, amoebic dysentery, and endemic hematuria.
Under class B, diseases and defects not in class A but which affect the ability to earn a living are such conditions as hernia, organic heart disease, permanently inadequate nutrition and muscular or skeletal development, many deformities, varicosities of the lower extremities, premature senescence and arterial degeneration, certain nervous diseases, chronic joint inflammations, poor vision and tuberculosis of the bones, skin or glands.
The immigration law makes no distinction between the cabin and steerage aliens, and the medical officer has no duty beyond the purely medical inspection.
Commissioner of Immigration Williams for the Port of New York, in his recent report (Note 1) for the fiscal year ending June 30, 1911, makes some pertinent observations and recommendations regarding the medical phases of the immigration question at Ellis Island. He finds that the present medical quarters are not large enough to execute the laws relating to physical and mental defectives properly.
Expansion to an appropriate size is prevented by the failure of Congress to appropriate the funds requested. He notes a large number of feeble-minded children in the schools of New York City who have passed Ellis Island and gives as one reason, lack of time and facilities for a thorough examination as to mental condition.
The result is that the law in this particular is practically a dead letter. According to the law, the feeble-minded, as well as idiots and imbeciles, are excluded. It is of vast import that the feeble-minded be detected, not alone because they are predisposed to become public charges, but because they and their offspring contribute mainly to the criminal element.
All grades of moral, physical, and social degeneration appear in their descendants, and it is apparent how grave is the social and economic problems involved. The steamship companies do not exercise proper precautions in receiving immigrants for passage, and this makes all the more necessary a rigid inspection at the port of entry into this country.
The report of the Chief Medical Officer on Ellis Island, Dr. G. W. Stoner (Note 2), shows that during the year ending June 30, 1911, nearly 17,000 aliens were certified for physical or mental defect, and over 5,000 of these were deported. (not necessarily for medical reasons alone). Among those certified were 209 mental defectives, of whom 45 percent were feeble-minded and 33 percent insane.
Under loathsome and dangerous contagious diseases, there were 1,361 cases, of which 85 percent were trachoma. Over 11,000 aliens had a defect or conditions affecting the ability to earn a living, and half of these were due to age and the changes incident to senescence. The medical department rendered more than 4,000 certificates for conditions not affecting their ability to earn a living.
Over 6,000 aliens were treated in the immigrant hospital, besides 720 cases of contagious disease, which were transferred to the State Quarantine Hospital at the harbor entrance before the completion of the present contagious-disease hospital on Ellis Island. Among these 700, there were a hundred deaths, chiefly from measles, scarlet fever, and meningitis.
The medical officers also examined 168 cases that had become public charges in surrounding towns of New York, New Jersey, and Connecticut to determine the nature of the illness and if due to causes existing before landing. The contagious diseases were measles, chickenpox, diphtheria, and scarlet fever.
The quarantinable diseases, cholera, leprosy, bubonic plague, smallpox, typhus, and yellow fever, are removed at the New York Quarantine Station before the vessels are docked.
Statistics such as these inevitably suggest a brief consideration of the different sources of immigration and their relative desirability from the medical standpoint. In general, one may say that the best class is drawn from northern and western Europe and the poorest from the Mediterranean countries and western Asia.
Among the worst are the Greeks, South Italians, and the Syrians, who emigrate in large numbers. The Greeks offer a sad contrast. to their ancient progenitors, as poor physical development is the rule among those who reach Ellis Island, and they have above their share of other defects,
The old question of the desirability of the Hebrew must be, settled on other grounds than those of physical fitness alone. However, the medical evidence is decidedly against him, as Dr. McLaughlin (Note 3) has shown that the proportion of defectives to total landed is most significant among the Syrians, 1 in 29, and next most significant among Hebrews, 1 in 42.
Contrary to popular belief, the Jewish race is far from a pure stock and has been colored by various and repeated admixtures with other blood types. Hence Jews of different nationalities differ considerably in their physical Status and aptitude for American institutions and amalgamation with our body politic. No race is desirable, which does not tend to lose its distinctive traits in the process of blending with our own social body.
From history, it would seem that the Jew only blends inadvertently and against his conscious endeavor and desire. Hence the process of proper assimilation must be very backward. Moreover, in origin, racial traits, instincts, and point of view, the Hebrew race is essentially oriental, and altogether there is at least ground for objection to unrestricted Jewish immigration.
No one can mistake the pressing necessity for a solution to the immigration problem. The problem of New York City in this respect is unique. It differs from that of the rest of the country because, as Walter Laidlaw (Note 4) points out, New York City is, in reality, a foreign city, since in 1910, the native-born of native parents numbered only 193 in every 1,000 inhabitants.
For the country as a whole, great interest attaches to the Panama Canal's influence in diverting immigration lines to southern and Pacific coast points. This preponderating foreign element is due to the concentration of arrested immigration in New York. New local problems will, of course, arise, but the basic proposition always remains the same. Immigration should be restricted absolutely to such races as will amalgamate, without lowering the standard of our own national life.
In general, immigrants from the Mediterranean countries should be excluded, especially those from Greece, South Italy, Syria, and most Hebrews, Magyars, Armenians, and Turks.
Strict enforcement of the present medical laws will automatically exclude these races to a sufficient extent, admitting the fit few. This, combined with a strictly enforced five-year probation period, with deportation as the penalty for any criminal conviction or failure to qualify for citizenship afterward, would go far toward relieving the situation. This need not disqualify aliens from traveling in the United States.
The immigrant per se has no moral or social right to enter this country against the will of its citizens. An enduring commonwealth must of necessity guard rigidly the health of its citizens and protect itself against undesirable additions from without. There was a time when European immigration was free and almost entirely of desirable classes. That time has passed.
The less desirable classes are increasing actually and relatively, and at the expense of the more desirable. It can truthfully be said that the dregs and off-scourings of foreign lands, the undesirables of whom their nations are only too eager to purge themselves, come in hosts to our shores. The policy of those advocating free immigration would make this country the dumping ground of the world.
Exclusion of these undesirables works no injustice to the lands they come from. A significant emigration from a land usually is followed by an increased birth rate, and the net change is slightly affected, if at all. Admitting undesirables to this country will in no wise elevate the world's human standard because those undesirables will multiply as fast here as in their original home, and their stock will only become extinct when it ceases to perpetuate itself.
High requirements for admission to this country reflexly raise living standards and education in those lands from which our immigrants are drawn. This was illustrated in Italy'. a few years ago when the higher requirements for admission caused enforcement of the primary education laws, which were dead letters before. Again, the increase of a poorer class of immigration decreases the number of the better class and reduces the chances of those who do come.
The medical phases of immigration blend very quickly into the subjects of national health protection, national eugenics, and even the future existence of the ideals and standard of life which we are proud to call American. Conservatism and a carefully maintained medium between absolute exclusion, and unrestricted immigration, certainly seems the best policy.
1 Williams, Win., Commissioner of Immigration for Port of New York, Annual Report for year ending June 30, 1911.
2 Stoner, G. W., M.D., Chief Medical Officer, Ellis Island, Annual Report for year ending June 30, 1911.
3 'McLaughlin, THE POPULAR SCIENCE MONTHLY, Vol. 62, p. 234
4 Laidlaw, Walter, New York Times, December, 1911.
Hall, Prescott, F., " Eugenics, Ethics and Immigration." , The Popular Science Monthly, 392
Dr. Alfred C. Reed, Assistant Surgeon, U. S. Public Health and Marine Hospital Service, New York City