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Immigration And The Prevention Of Insanity (Note 1)

BY THOMAS W. SALMON. M.D., NEW YORK, Past Assistant Surgeon, U. S. Public Health Service; Director of Special Studies, National Committee for Mental Hygiene.

A meeting devoted to mental hygiene would be strikingly incomplete 'Without some reference to immigration. As Dr. Lewellys F. Barker has said, the object of the campaign for mental hygiene is to "secure human brains so naturally endowed and so nurtured that people will think better, feel better, and act better than they do now." In such a movement, the brains which come into this country in the possession of immigrants June quite as much interest for us as those which are brought to these shores by native-born babies.

No other country in the world is being as profoundly influenced by immigration as our own. There has been no human migration in history like that which has brought 24,000,000 persons to this country from Europe, Asia and Africa since the close of the Civil War. This vast movement of population is influenced by many causes, and these causes are rooted in the economic and political history of Europe.

The patato famine in Ireland, the revolutionary movements in Germany, the rise of modern. mili- tarism, the "pogroms" in Russia, Turkish misrule hi Albania,—all have been reflected very faithfully in the volume and in the composition of immigration to America.

Few people realize what an enormous source of population immigration constitutes at the present time. Last year 216,141 babies were born in New York, while 239,275 immigrants destined to that state arrived at Ellis Island. In several other states the increment to population from immigration is greater than that from births.

This is the direct contribution of immigration to population: indirectly it contributes even more largely. It was shown some years ago by Walter F. Wilcox that twice as many children are born to foreign mothers in the United States as to native-born mothers. Thus the replacement of the native-born population of the United States by the foreign-born can hardly be estimated by the increment through immigration alone.

What means of protection have we against the admission of insane and mentally defective immigrants and those of inferior mental constitution It is obvious that all measures of protection against any of the dangers of iminigration must fall under one of three principal methods. We may arbitrarily stop immigration altogether, we may restrict large general groups of immigrants, or we may select immigrants in accordance with various tests and standards of individual fitness.

The first means of protection only needs mention. It is abandonment of the immigration question, not its solution. The second, the restriction of immigration, has been seriously eonsidered at many sessions of Congress. The favorite method suggested has been the imposition of an educational test.

Some other means suggested have been to limit the number of immigrants received from each country in a given period, to raise the "head tax" to a prohibitive amount and to prescribe yearly the number of "vacancies" in different occupations, admitting first-comers until such vacancies are tilled, and then closing the doors.

There may be economic or social reasons for such arbitrary restrictive measures as these, but to adopt them solely as a means of excluding insane and mentally defective immigrants would be hardly fair to the resources of modern psychiatry. An analogous situation exists in modern conceptions of quarantine.

As Dr. J. H. White has said, "Modern quarantine is a sieve, not a dam." The former idea of quarantine was to prohibit commerce absolutely. This the President has the right to do under the quarantine laws of the United States, but all physicians are proud of the fact that such a drastic procedure has not been employed in more than twenty years.

Probably it will never be employed again. A year ago many ships bringing cholera arrived at the port of New York, yet after medical officers of the Public Health Service were assigned to assist in guarding the port not one ease of cholera secured admission.

At the same time commerce was but slightly interfered with and the importation of passengers and baggage from infected provinces of Italy was not at any time prohibited.

It is believed that an efficient mental examination of immigrants, with adequate facilities, would be competent to detect a very large proportion of eases of mental disease and defect; so arbitrary restrictive measures cannot he advocated by physicians solely upon , the grounds that they are needed to exclude insane and mentally defective immigrants.

It cannot be denied, of course, that any restrictive measure which greatly diminished the tide of immigration would necessarily diminish the number of insane and mentally defective immigrants. There are fewer people in Maine than in Massachusetts, consequently there are fewer insane people.

The third method is the imposition of various tests of individual fitness. This is the method which has been utilized up to this time. All immigration legislation thus far has aimed at the perfection of methods of individual selection.

There is a widespread belief that the exclusion of insane and mentally defective immigrants is not as successful under the present migration law as it aught be.

Before discussing any changes in the immigration law, it may be worth while to consider for a moment the existing provisions which may be utilized for the exclusion of insane and mentally defective immigrants.

The Immigration Law of 1907 provides that the following persons shall be excluded from the United States: "All idiots, imbeciles, insane persons, and persons who have been insane within five years, persons who have had two or more attacks of insanity at any time previously. . . " The law is sufficiently definite, but immigrants cannot be selected by legislation.

It is nearly as futile to attempt to exclude insane and mentally defective immigrants without providing by law for facilities for the detention and careful mental examination of those in whom these conditions are suspected as it would be to attempt to control burglary by legislating against it and failing to provide a police force with definite powers, or to attempt to suppress small-pox by sanitary laws at the same time neg- lecting vaccination.

The Immigration Law provides (Section 17) that the physical and mental examination of all arriving aliens shall be made by medical officers' of the United States Public Health Scrvice. The medical examination of immigrants used to be made by civil physicians, but this duty was transferred to the Marine Hospital Service (as it was then known) more than twenty years ago.

It would be difficult to find a body of physicians better fitted for this duty than the medical officers of this corps. They serve in all infected ports of the world and are familiar, through personal observation, with the strange diseases of strange lands.

Their quarantine experience gives them special knowledge of ships and ship-sanitation, and the scientific work in which the, Public Health Service is engaged fits its officers for the pathological examination which forms so important a part of the work at some ports of entry. They are commissioned officers of the Government and quite outside the influence of polities.

This provision is an excellent one, but, unfortunately, the law fails to define the scope of the medical examination, to provide especially for a mental examination, or to provide that there shall he proper facilities including the services of interpreters.

All these matters are left to the discretion of the officials who administer the Immigration Law. They are necessarily determined by the funds available, the importance attached to them by lay officials, and the general interest which seems to be taken by the public in this part of the examination of arriving aliens.

There is always to be reckoned with the insistent demand of steamship companies for the shortest detention possible. It is very doubtful if the framers of the Immigration Law intended that ample facilities for such examination should rest upon such preearious footing.

It is certain that those who are familiar with the great problems of the care of the insane and mentally defective and the prevention of mental disorders desire that careful and thorough mental examination of all immigrants and the provision of ample facilities for such examination should be definitely required by law.

It should he explained that the detention of passengers does not involve any interference whatever with commerce. At all immigration stations the steerage passengers are removed from ships as soon as they arrive and are taken to the place of examination; at the port of New York, as everybody knows, this place is Ellis Island, at other ports it is usually quite near the steamship piers.

There would be several advantages if the examination of immigrants could take place at points nearer their homes than American ports of entry. The exclusion of an immigrant at a seaport in his own country would involve far less hardship than his exclusion after he has crossed the ocean and presented himself at one of our ports.

If medical examination at the principal ports of embarkation were authorized it would he practicable for an intending immigrant to present himself or any members of his family at an American Consulate, and to be informed there whether he is likely to be accepted, before he has sold or mortgaged his property or raised money by other means for his passage to this country.

For reasons of humanity, then, if not for greater efficiency, it is very desirable that a mental examination should be made by American medical officers at ports of foreign embarkation.

The principal obstacle thus far has been the refusal of foreign governments to grant the necessary permission, If the immigration law provided that immigrants would not be admitted without such an examination, these governments would very speedily recede from their position, for immigration means great profits to steamship companies. and the relation of steamship profits to the attitude of certain governments is a very close one.

Another means of detecting excludable conditions in immigrants before their arrival in this country would be to detail American medial] officers upon vessels bringing immigrants to the United States.

After the revelation of steerage conditions by investigators employed by the Immigration Commission in 1910, a bill providing for just such an inspection service was introduced by Senator Dillingham. a member of that commission.

Such a provision was in the immigration bill recently passed by Congress but vetoed by President Taft. Every ship, of whatever nationality, which carries a certain number of Italian immigrants must have on board a Royal Italian Commissioner who, almost invariably, is a medical officer of the Italian Navy.

These Royal Commissioners exercise remarkable powers, the penalty for disobeying their instructions being revocation of the license granted by thc Italian Government to sell steamship tickets in Italy.

They supervise the food, accommodations, hospital facilities, medical care and, in short, any conditions which affect the comfort or safety of Italian immigrants, efficiently enforcing the Italian Navigation Act.

This government has ample authority to place medical officers of the United States Public Health Service upon ships bringing immigrants to this country. If we have power to enact a "passenger act," we should have means to enforce it.

It can be seen that such physicians, in their intimate contact with passengers, would have an exceptional opportunity to pick out those with enough evidences of mental defect or disease to warrant detention and careful examination upon their arrival at Ellis Island.

The effect which such a provision would have upon problems of quarantine and ship-sanitation would be far-reaching. It is believed that it would lead to the practical abolishment of detention for observa- tion at United States quarantine stations in the ease of passenger ships arriving from ports free from quarantinable diseases.

Another means which has been suggested to lessen the number of insane and mentally defective immigrants admitted is that certificates of health be required from responsible governmental authorities in Europe stating that the immigrants in question had never been in an institution for the insane. The principal objection to such a plan is that it would place a very powerful weapon of oppression in the hands of foreign officials.

There is no doubt of the great value to this country of immigrants of the type I of Carl Sehurz, for instance, but the chances that Carl Schurz would have obtained a favorable certificate of any kind from representatives of the German Government when he came to America are very remote. It seems, therefore, that the slight advantages of this plan would be offset by the danger that it might be used to oppress intending immigrants.

Anothcr disadvantage is that it would be of little avail in the detection of the mentally defective, very few of whom ever have institutional care in this country and a much smaller proportion in most countries in Europe.

Mr. C. B. Davenport has proposed that social field workers he stationed in various countries in Europe to conduct studies in heredity, and that only those immigrants should be admitted who possess certificates that their family history had been examined by such field workers and found satisfactory.

The objections which might be raised to this procedure are so numerous that it cannot be considered as a very practical suggestion. Our knowledge of the effect of heredity upon the production of mental disease is hardly definite enough to base such an arbitrary administrative measure upon.

The cost of a thorough mental examination of all immigrants such as that which is needed would be large. but it would be insignificant compared with the great sums spent for the support of the alien insane and mentally defective in this country.

Many of the states which bear this heavy burden would very gladly pay much more than the most efficient mental examination would cost to be relieved of the expense of caring for the insane and mentally defective immigrants who now enter the country.

The reaponsibility rests with the federal government, however, as every attempt of the states to regulate immigration has been declarcd unconstitutional.

The cost of the examination takes on a new aspcct when it is learned that the immigrants themselves pay for the cnforcement of the Immigration Law, including their medical examination. The "head-tax" of four dollars apiece, which was collected from the 828,773 immigrants admitted during the year ending June 30, 1911, was $3,315,086.

After deducting the amount appropriated for the enforcement of the Immigration Law, a balance of approximately $1,000,000 was turned into the national treasury. Of the amount appropriated in 1911, $151,659.27, or 16 cents for each immigrant examined, was for the medical examination.

The pay and allowance of twenty additional medical officers of the Public Health Service, with especial training in psychiatry, for duty at American ports would be about eight cents for each immigrant examined.

If to this were added the pay and allowance of ten such officers stationed at foreign ports and thirty detailed from time to time upon vessels carrying immigrants to this country, the total additional cost of providing an adequate and effective mental examination of immigrants would be less than $225,000 per year, or about 25 cents for each immigrant examined—one-sixteenth of the present "head-tax."

Surely this is a small sum for the federal government to deduct from the proceeds of a tax which was never intended for general revenue. It about equals the cost of maintaining, for their hospital lives, one hundred of the 177th insane alien; who are admitted to New York State Hospitals each year.

It is a small price to pay for the exclusion of the insane and mentally defective among those who are to become the parents of future generations of Americans.

It may be thought difficult to secure a sufficient number of young physicians with training in psychiatry, but it would be very easy to secure such training for a sufficient number of commissioned medical officers already in the corps. The Government Hospital for the Insane and many of our best state hospitals would cooperate very effectively if requested to.

The suggestions outlined have been presented frequently to Congress. They have been supported by alienists and others interested in the care of the insane from all parts of the United States.

They have been approved by such organizations as the National Committee for Mental Hygiene, the American Medico-Psychological Association, the New York Psychiatrical Society, the Boston Society for Neurology and Psychiatry, and the Eugenics Section of the American Brecders' Association.

What can be the source of opposition to them t Who are opposed to humane but scientifically effective means of selecting the sound in mind and body from the million immigrants who present themselves for admission to this country every year? The cost of caring for our insane is the chief item in the budget of any state which provides adequately for its insane.

Even in such states there are many unprovided for, and overcrowding is a general evil. Who desire to see this great burden, which is taxing the resources of all the states, made still heavier through the admission of the insane and mentally defective of other lands ? Who profit so I greatly through immigration that they are indifferent to these considerations ?

There are two sources from which oppositions to such messures might be expected to come—the seekers of cheap labor who must have an unimpeded flow of workers from Europe, and the steamship companies which bring these workers here.

it is true that, on every hand, we see the greed of some cmployers responsible for child labor, insufficient housing, unsanitary working conditions, and many other social and economic evils; but insane and mentally defective immigrants do not makc profitablc workmen; opposition to measures for the better selection of immigrants come from a different source.

The most active and powerful factor in defeating efforts to secure better examination of immigrants is the influence of foreign steamship companies. To the foreign steamship companies, immigration means simply an immensely profitable business.

Millions of dollars are invested in the business of bringing immigrants to this country; the tonnage of one of the great immigrant-carrying lines, according to its advertising circulars, exceeds the tonnage of the navy of France.

This is the source of the opposition which outweighs the warnings of those who are devoting their lives to the study of mental diseases. This opposition will continue to be effective until people generally realize that there is at least one phase of the immigration question with which they must deal themselves.

As Professor R. Dee. Ward has put it, the question is whether the parents of future generations of: Americans are to he selected by foreign steamship companies in the interests of their dividends or by American officials in the interests of their race.

The old immigration was a more natural process than the new. Natives of Germany, Ire-, land and Scandinavia found political, soeial or economic conditions at home unendurable and they came to this country with their families, determined to lead their Ems in the new world. The importunities of steamship companies would have had little effect in the formation of this great decision.

With the purely industrial factors which govern by far the larger part of the new immigration, however, glowing accounts of high wages, unfailing work and other advantages have a very marked effect.

For many. immigration does not mean relinquishment of citizenship, transplantation of the home, or severance of ties. The Immigration Commission found that, contrary to the general belief in this country, emigration is by no means an economic necessity at the present time in most countries in Europe.

This commission, as a result of studies undertaken in Europe, concluded that "with comparatively few exceptions the emigrant of today is essentially a seller of labor seeking a more favorable market."

Under such conditions the part of the steamship company in promoting immigration is a very powerful one. When steamship companies are taxed with making false statements as to labor conditions in this country or other matters, the reply is usually made that if this is done it must be by entirely unauthorized sub-agents in the villages of Eastern and Southeastern Europe.

It was stated to the Immigration Commission that two steamship companies had "five or six thousand ticket agents in Gallicia alone" and it was the opinion of that commission that the provision of the United States Immigration Law prohibiting such false representations is "persistently and continuously violated.''

At every stage of the immigrant's journey to this country, precautions for his health and welfare are neglected by many of the steamship companies. It required the imposition of a fine of $100 for each offense to deter them from bringing in the open steerage cases of dangerous contagious diseases, the existence of which "could have been detected by a competent medical examination at the ports of embarkation." and even this procedure has been only partially successful.

During the year ending June 30, 1912, $18,600 in fines was collected from steamship companies for bringing 186 eases of dangerous contagious diseases which could have been detected by a competent medical examination at port of embarkation.

It is the rule for eases of scarlet fever, measles and other contagious diseases at childhood to be permitted to mingle on steamships or to be segregated in a single compartment.

A great number of cascs of mixed infections, with a very high mortality. is the usual result. Even the provisions of our ''passenger act" of thirty years ago, which are recognized to he inadequate and far below the requirements of modern naval hygiene, are persistently violated by the steamship companies.

Every attempt to better the conditions of steerage passcngers is vigorously resisted, and every attempt to secure more effective legislation for the protection of the health of immigrants or for the exclusion of the mentally or physically diseased has met with their opposition.

It seems necessary to describe the position taken by steamship companies, for I earnestly believe that their attitude has the greatest influence upon immigration, .especially in its relations to the public health, and that this aspect of the question has not been fully realized by the public generally.

In any measures which may be undertaken in the future for the control of unfavorable or dangerous immigration, the immigrant-carrying steamship lines will be found the most powerful factor to be reckoned with and it is well worth while to recognize the fact. That some steamship companies do not engage in these practices only shows that they could be abandoned by all.

The exclusion of insane and mentally defective immigrants is a question of public health. It is not a political question, it is only incidentally an economic question, but it affects the welfare of coming generations of Americans as deeply as any question before the people of this country today.

The interests of the capital invested in foreign steamship companies should have just as much weight with Congress in the solution of this question as the interests of the capital invested in the manufacture of fire arms should have in the protection of song birds.

rf this important question is to be dealt with in accordance with the requirements of a broad humanity, something more than efficiency in methods of examination must be sought.

I believe that the exclusion of insane and mentally defective immigrants is an absolutely nccessary teak, but it should be performed humanely and kindly and, at every step, the safety and comfort of a particularly helpless class of immigrants should be carefully considered.

This involves examination as near the immigrants' homes as possible, provision for attendance to the final destination for those whom it is found necessary to deport, provision of detention quarters at our ports which shall be comfortable, sanitary and safe, and rigid supervision over the care which insane and mentally defective immigrants receive on shipboard, during the voyage to this country and during the homeward voyage after their rejection.

For the accomplishment of these purposes it is essential, it seems to me, that medical control shall be adequate at all times. We have in the United States Public Health Service a responsible body of medical men, highly trained in sanitation and in the care of the sick, and I think that therc could be no better trend in the immigration legislation of the future than to place such matters more and more in the control of these medical officers.

In securing the legislation needed, the recommendation of those who are engaged in thc work of this society will, I feel certain, carry much weight, and I urge you, if you agree with me as to the measures needed, to use your influence to secure the enactment of an immigration law which will efficiently and humanely accomplish the purposes which I have outlined.

Note 1: Read at Mental Hygiene Conference, under auspices of Massachusetts Society for Mental Hygiene, Tremont Temple, Boston, April 2, 1913.

Alebitat urgicat
vet. mica THURSDAY, AUGUST 28, 1913.


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