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Medical Inspection Of Immigrants At The Port Of Boston

BY J. NUTE, B.S., M.D. BOSTON, P. A. Surgeon. United States Public Health Service.
U. S. Immigration Station, Boston, Massachusetts

While the above heading is given as the subject this evening it applies in general to all aorta of the United States. The story of immigration is as old as the history of the United States; in fact with certain qualifications it is the history of this country. While laws in the early days provided for the restriction of inanimate goods, more or less unwritten and written law restricted the human being from certain localities, which finally grew into organized law for the protection of the community.

For example the Quaker was not welcome in the land of the Puritan and Virginia gradually closed the door to redemptioners. Our institutions have been founded by, supported by, and in turn supported aliens and their descendants. The first rule of national life is self preservation and as immigration still has an important role in America national life it must be carefully scrutinized to admit the desirable.

The medical aspect of immigration was brought to public notice about the year 1824 when New York City attempted to levy a head tax on all foreign passengers arriving in that city; later in 1847 a similar act was pasted by the state. This money was intended for the support of an immigrant hospital. It was declared unconstitutional in both cases by the courts on the ground that tho power to regulate commerce was vested in Congress and not in any state.

This was probably the first restrictive policy that was actively started but of course the whole earlier history of the country showed that economic pressure tended to restrict newcomers to those nearest the race, language and ideals of the region. For many years each state dealt with the problem of restricting the entry of diseases, aliens as best they could. Of course this was very difficult owing to the ease of passing from one state to another.

When the Federal Oovcrnment took supervision of the matter in 1882 a general rule was adopted to reject those who suffered from phisical defects liable to make them public charges, note being made of insane, idiots and persons unable to take care of themselves. In 1891 this law was further extended to include those suffering from loathsome or dangerous contagious diseases.

In 1903 the most radical step was taken when the Government placed a fine of $100 on the steamship company, in addition to exclusion, for each case of a loathsome or dangerous contagious disease that could have been detected by competent medical inspection at the time of embarkation. In 1907 the law was extended to exclude epileptics, feeble-minded and persons who have been insane within five years. or have had two or more attacks of insanity at any time previously, tuberculosis (meaning tuberculosis of the lungs, intestinal tract or the genito urinary system) or those suffering from such mental or physical defect which may affect the ability of the alien to earn a living.

At the same time idiots. imbeciles and the tubercular were placed in the $100 fine class. In 1891 Congress turned the work of medical inspection over to the Marine Hospital Service (now the Public Health Service.) This Service has published definite rules for the medical examination of aliens which if followed insure a uniform system of inspection and records at all ports of entry.

Whether an immigrant belongs to the excluded class or not is a function of the immigration officials. This is often confusing to many for it must be understood that the Immigration Service is a Bureau of the Department of Labor and the Public Health Service is a Bureau of the Treasury Department. Hence the two Bureaus work together; the certificate of the Imedical officer constituting the legal evidence upon which the immigration officials base their action, in mandatory eases and in other eases consider the certificate from the standpoint of affecting ability to earn a living or likely to become a public charge.

Seldom does the alien suffer from too harsh a medical judgment. All things taken into consideration he gets the hest end of the doubt for the rules require the certificate to be based on conclusive evidence. For example a case of pulmonary tuberculosis cannot be so certified unless a microscopical slide showing the bacilli can be demonstrated.

Briefly the law divides all defectives into three classes and makes no distinction between cabin and steerage passengers. United Staters citizens of course are exempt from examination but may be called upon by the immigration officials for satisfactory evidence of citizenship.

Class A. Mandatory exclusion because of definite specified diseases such as idiocy, imbecility, feeble-mindedness, insanity, epilepsy, tuberculosis, loathsome or dangerous contagious diseases.

Class B. Aliens not under Class A., but present some defect or disease affecting ability to earn a living, as hernia, heart disease, defective nutrition, varicosities, presenility. certain diseases of the nervous system, chronic joint diseases, marked defective vision and tuberculosis of the skin, glands and joints.

Class C. Aliens presenting defect or diseases of less seriousness but must be certaind for the information of the immigration officers that they may pass intelligently on the ease.

In order to prevent any alien slipping by without examination by doctor every passenger carries an identification card. In the cabin this card is punched as each alien passes the medical officer so that the inspector can tell at a glance whether or not he has been seen. As the immigration inspectors are on the alert they usually return to the doctor any alien who presents any unusual physical or mental appearance even if his card is punched.

To prevent delay a slight abnormality such as a scar of the face from a burn is noted by the doctor and a slip given the alien noting the condition and stamped "Special Medical Passed." The steerage usually being examined on shore are checked by attendants to prevent any oversight. At Ellis Island the steerage passengers' inspection cards are stamped in ink by an attendant.

In the law contagious means communicable and loathsome contagious mean those whose presence excites abhorrence and are essentially chronic such as favus, ringworm of the scalp, leprosy venereal diseases. Dangerous contagious diseases may be illustrated by trachoma, hookworm and amoebic dysentery.

The method of conducting examination must vary somewhat with local conditions and to accomplish this without undue annoyance to travelers, without delaying traffic requires care and tact on the part of the medical officer. Before inspection two sources of information are at hand; the manifest sheet and the ship surgeon's report. How reliable this information is depends on the type of men filling the forms.

When one considers that nearly all immigration is carried in foreign ships manned by foreign officers it requires experience in dealing with them to estimate, the value of their reports. As far as possible all inspections should be made in daylight for under artificial light certain diseases involving different hue or alteration in the akin cannot be noted accurately.

The medical examination is divided into two parts, primary and secondary. In the primary the efforts of the examiner is directed toward segregating from among those presented those suspected of having disease, defect or abnormality of any kind in order to enable the healthy to proceed without unnecessary delay. Secondary; to make a systematic inquiry as to the signs and symptoms in those turned aside in order to determine a diagnosis and proper certification. The alien may be detained for any reasonable period of observation required to complete the diagnosis and if necessary hospital treatment provided.

Primary inspection is conducted on an even level surface, so that the passenger may not be tempted to look where he is stepping. Care is taken against crowding, to maintain a line evenly spaced and to have as little baggage carried as possible. The examiner stands in a position to secure an even illumination as possible. Direct sunshine in the face or reflected from the water must he avoided. To also facilitate the work the line should make a right angle turn in front of the examiner in order to secure a good view of both sides and back with the least effort.

The examiner then proceeds in a systematic manner to examine the line as it approaches. Standing with the light falling over his shoulder he begins his study of the alien at about twenty feet distant. Beginning with the feet at that distance, as the alien draws near the eye gradually rises from the feet to the head without effort. The character of the gait or other defect of the lower extremities will attract attention such as flat feet, nervous disorders, deformities, abnormalities, joint diseases, or artificial legs.

As the glance sweeps upward undue prominence of or about the groins may be noted, the hands as they furnish important evidence of the general physical development, diseases of the respiratory and vascular system, disordered or impaired nutrition, defective mentality, nervous, contagious diseases besides local defects and deformities. The abdomen noticed for undue protrusion, aseites, splenie enlargement. pregnancy and abdominal tumors in general.

The chest for asymmetry, undue prominence, defective development and the back for evidence of spinal disease and deformity. The neck is surveyed for goitre, abnormal pulsations, enlarged glands, tumors and deformities.

The head is examined for abnormalities such as unusual shape deformity, disproportion, and asymmetry affecting the bones of the face and skull; this includes any signs of disease of the ears as well as the skin. The oral and ocular membranes act as an index for anaemia, while the scalp and beard are scrutinized for evidence of ringworm, favus or other infection. By this time the alien has arrived close enough for the eyes to be taken into close detail and the lids everted for the detection of trachoma.

A feminine voice may further confirm the suspicion of arrested sexual development which has been aroused by noting the absence of beard and the peculiar wrinkles about the upper lip, a tremulous voice often found in alcoholics, scanning speech or hoarseness make us at once turn off at case for more detailed examination.

Not only sight but the sense of touch and smell play a part. The hand against the forehead gives an idea of the presence of fever at the same time sight is taking in conditions about the month. Response to a simple question gives an index of hearing and mental reaction, while the sense of smell simultaneously may arouse suspicion of uraemia, ozaena, favus, foul discharge from ear, abscesses or ulcers concealed by clothing.

Associated with this the examiner acquires a habit of noticing unusual conduct, bearing, language, peculiar facial expression and emotional outbreaks. Febrile changes are constantly watched for, signs of exanthemata and in infants one of the most obvious signs of respiratory changes may be noted by watching the movements of the alae nasi muscles.

Defective vision is often detected by squinting. a desire to keep in the proximity of accompanying persons, a tendency to look downward while walking. avoid the gaze of the examiner, indecision or confusion in the sense of orientation when obliged to make a sudden change in the direction of his course.

By the time the immigrant is face to face with the examiner a general impression has been formed and it has either been so favorable that the alien is passed at once or something may have been noted to cause his detention.

The above gives briefly a general idea as to what observation shows on the primary examination and the secondary examination is the regular medical procedure to confirm a diagnosis or pass the alien.

To the casual visitor it may seem a routine condition and tend to justify the criticism of a writer that I quote from a Boston newspaper.

"The immigrants simply file past them and they look hard at them as hard as they can and that is about all they do. If they are looking for any particular one they switch him off for further examination and they do the same if their suspicions are aroused. They are really very clever at detecting skin and eye diseases and do their best work in that line. They don't see all and thousands get by them.

Diseases like tuberculosis of the lungs are constantly coming in against the law; all except the very advanced cases getting in. Still more important are the diseases of the mind, the feeble minded and the insane which are rarely detected."

Owing to the critic's lack of knowledge of the immigration law, lack of experience in the practical side of the examination and its results, the above is a good description of the impression made and is of about the same value as the opinion of the medical student who after attending a few large surgical clinics, said that all there was to surgery was "Cut it off or cut it out." As matter of fact there is much more to it than the casual visitor ever hers unless he is willing to spend plenty of time in careful investigation of the subject from all sides.

A knowledge of racial types and their peculiarities is essential, for without this a great many normal persona would ho detained, hence ethnology plays an important part.

Since the days of laboratory and other aids to diagnosis we have tended to lose sight of the value of observation and what it may tell us until we are reminded of it by some expert like the late Professor Fits of Harvard. It is of interest to note that over seventy-five years ago Robert Ferguson in a lecture before the students of King's College, London, stated "That there is a right and wrong method of observing is evident since mankind has always observed but rarely discovered." In fact it can be safely stated that almost no grave organic disease can have a hold on an individual without stamping some evidence of its presence upon the appearance of the patient evident to the eye or hand of the trained observer.

It must be borne in mind that owing to certain limitations immigration inspection is a sieve and not it dam, also medicine is not a science like mathematics. It would be decidedly unfair to certify a person on suspicion, hence it is a wise provision in the regulations that calls for definite evidence and gives the alien the right of appeal.

While to those that look on from the outside it may seem as if little is accomplished: if one considers the fact that the stream of men, women and children passing in line is really composed of a body of individuals from whom the physicians in the employ of the steamship companies have already endeavored to eliminate the physical and mental unfit, it may be a matter of surprise to know that about 1.5 per cent, of the total number of immigrants arriving at the ports of the United States have been certified for physical or mental defects that would place them in one of the classes which either rendered deportation mandatory or required the alien to submit satisfactory proof that his disability will not make him a public charge.

To show how experience in this work is necessary to avoid the mistake of confusing racial characteristics with pathological conditions some conditions met with will be described in the following paragraphs.

It takes conaiderahle experience to know what constitutes the healthy color in a given race. A healthy Gypsy might readily be suspected of having Addison's disease, a healthy Greek of suffering from malarial cachexia or malignant disease. A normal West Indian Negro sometimes has the peculiar pallor suggestive of tuberculosis and the temperate Alpine mountaineer often dilated capillaries resembling those seen in chronic alcoholics. Sea sickness may readily leave bad effects for some days and the pallor and weakness suggest some serious constitutional disease.

Pulsating blood vessels in the neck are often caused by fright increasing the heart action and it can be readily noted that all or nearly all immigrants pale before the doctor in a high state of nervous tension, for they believe that once by the medical officer the battle is nearly over. This is not their first medical examination. They have seen others weeded out before leaving, while during the voyage weird tales of all sorts have been poured into their ears as to what may happen with all the local color and exaggeration characteristic of human nature.

Irritation of the conjunctiva caused by certain occupations involving exposure to smoke, dust or heat, such as iron workers, bakers, coal miners and line workers may cause a chronic inflammation and scar formation of the lids simulating an old incompletely cicatrized trachoma.

The face of a muscular able-bodied Italian peasant often is so devoid of fat and muscle tissue that on first sight one would think that the whole body was thin and undeveloped. The complexion of the Slavish peasant woman would be suspicious of chlorosis if possessed by a Scandinavian or English woman of the same class. On the other hand the red cheek of the Scandinavian would arouse thought of a hectic flush if seen in the Polish woman.

The excitably of the southern Italian and the Hebrew are well known. It is easy to excite in them almost maniacal action. The stolidity and indifference of the Slav would suggest melancholia if presented by the Hebrew. The sanity of an Englishman would be questioned if on slight provocation he evinced the external manifestation of emotion that would occur in the Sicilian. The German girl takes her examination seriously and her sanity would at once be suspected if she saw the same reason for light remark and laughter as the girl from Inland.

Some races are extremely emotional, others slow; and unless the normal is known it is impossible to pick the abnormal. In short, in determining mental conditions by inspection the first essential is to determine the race or type of the individual and to have a good knowledge of his racial characteristics. To the trained examiner the facial expression, attitude, mannerism and dress convey an expression of understanding.

It would be difficult for an examiner not familiar say with the Syrian peasant type to form any opinion of his mental calibre from his appearance or attitude alone. A few questions will determine reaction and orientation. If from this nothing is noted the alien may be allowed to pass, otherwise he is held for a more complete mental examination.

It is impracticable under the present law and facilities to consider every alien a possible mental defective and subject him to complete examination unless on primary inspection there were some signs of mental disorder. With the feeble-minded, the facial expression and attitude is a valuable index except in the high-grade types where it is negligible and is them a matter of judgment and experience of the examiner (based upon the normal) to decide how much lower the suspect is in the mental scale, considering all the factors of race, previous environment and education.

Owing to the lack of agreement among experts as to where the normal ends, the mental problem is a difficult one. The term mental instability, psychopathic tendency or constitutionally inferior can be referred to a class whose mental organization is of the weakest, yet showing no definite mental symptom at present, would go on normally in primitive surroundings but on slight stress such as found in a new country with its disappointments, its strange language and customs become mentally disordered.

Inveetigatoni that have given careful study of the subject agree that the medical inspection is no farce. Examiners that have had years of experience in the service have seen a marked increase in efficiency due to experience and increased facilities. It is by no means perfect but is being improved as fast as Congress will grant authority and facilities. There are still many loopholes and any attempt to seal them is naturally fought bitterly by those interested in keeping an open gate.

Rarely are newspaper or magazine articles on the subject tact but rather sentimental fiction with just enough fact to give a foundation for a good story.

Every time a defective is admitted it is an inducement for many more to try. If the public were truthfully informed it would result in the country receiving a better physical and mental type of immigrant and in turn the immigrant would or could have better treatment and protection.

It has been estimated that out of the alien head tax of $4.00 about twelve cents pays the art of the present Inspection. If this is true the public treasury in certainly not being drained by the medical department.

The work is hazardous and requires men of good physique. Furthermore, they must be interested in the subject in order to pay close attention to their work. In the busy season the constant standing and mental concentration tend to produce breakdown and there is always the chance of contracting contagions diseases.


Owing to the recent agitation concerning immigration, the timely subject in this number will bear careful reading. A review of the Immigration Service annual reports show that the most important function of the immigration inspection lies in the medical examination. If an alien is sound in body and mind he is not likely to do much harm. A careful appraisal of our human imports then is a serious matter and one to require thought. Doubtless more aliens are held and appeals taken for medical reasons, directly or indirectly, than any other.

Dr. Nute has had a broad experience in immigration work and a chance to see all sides, having been stationed on. the Canadian border, Ellis Island, N. Y., and at the port of Boston. He shows that from the earliest times undesirables have been attracted to this country; that as communities grew restriction followed just as naturally against the alien human being as; the alien goods in the market. of trade.

Among the early adventurers were persons sent to America to serve out penal offences, to escape prosecution, and persons suffering from the Wanderlust. Among the latter were many types that undoubtedly today would be recognized as mental defectives. Later on those who had acquired settlement, having defective relatives, were naturally anxious to have the defective relative at hand, more particularly so when American institutions gained the reputation of dealing more kindly with the inmates than the home asylums.

It is important to understand that it is only since 1903 that financial penalty has been placed upon the steamship companies in addition to returning the alien to the port of embarkation of his home town. Also that there is always the appeal, hence the chance of a good gamble, as the ship has to return to Europe in the natural course of events. It is only since 1907 that the feeble-minded have been manditorily restricted.

Microscopical evidence must be present to certify certain conditions, as tuberculosis, gonorrhea, favus, ringworm, etc. Any physician thus can understand how many incipient tuberculous persons may be admitted. Tuberculosis in the meaning of the law refers only to the lungs, golito-urinary, and intestinal tracts. Persons suffering from tuberculosis of the bones, joints, skin, glands, etc., may be landed. In fact, persons with pulmonary tuberculosis can be landed according to certain departmental decisions.

The immigration law, like most other laws, has for nearly every rule an exception, and the alien with money and influence may utilize it to his advantage. The doctor never admits an alien, neither does he ever exclude one; that is the function of the immigration officials.

Those who have travelled can readily realize the difficulties of cabin inspection, which often has to be made after dark, with poor light, and even in daylight in cold and stormy weather some place has to be sought that may not delay the ship or passengers. To do this without delaying traffic, without putting passengers to inconvenience, passengers that often are nervous, tired and irritable after a long journey, who resent being asked personal questions, certainly requires tact.

Observation has taught these examiners a great deal both in a knowledge of human nature and the practical recognition of diseased conditions. To the visitor the spectacular line work seems to be about all there is, but he rarely follows behind the scenes and learns what happens to those who turned into the detention rooms. The hardest work is often between ships, when eases have to he carefully recorded, after due examination that carries with it the hard work of any hospital examining rooms.

The mental examination may readily be seem to be a different matter than any institution has to face. Here the examiner must pick out the defectives from the mixed stream flowing past. After picking out a suspect, the doctor receives no aid
from the alien's relatives or friends. Instead, all sorts of pressure will he brought to bear to discredit the examiner.

During the past year the work at Boston has markedly increased. New lines have entered, but the type of immigrant has changed. Not many years ago most of Boston's immigrants came from Northern Europe and the British Isles. Today southern and eastern Europeans predominate and emigration is beginning from Turkey iu Asia and Persia.

Boston is sadly in need of a proper immigrant station; both for protection of the public and in fairness to the detained immigrant. The present quarters are inadequate in every way. It does not require much of a rush of traffic to fill it to overflowing and cause many to be detained on ship board until such time as room can be made by either landing or deporting those detained on Long Wharf.

It should be kept in mind that detained aliens are not felons, but human beings waiting to prove their right to land, or waiting the sailing of the ship to return them to their homes. Boston is fortunate in having a well trained medical staff, but the best carpenter cannot build much of a house with a jack knife, and it is only due to the vigilance of these doctors that serious outbreaks of diseases have not occurred.

As a result of much injudicious talk on the part of some of the newspapers and magazines, there has been built a false situation, either by those that do not understand or those that are prejudiced against restriction.

If every charitable institution, prison, or hospital supported in any part by public funds, would report to the Immigration Service or in an annual, report every inmate who is a public charge or who is seeking free aid, the taxpayers might learn something not hitherto realized.

There is only one reason for restricting immigration, and that is the protection of American institutions. There are many reasons for laxity, such as cheap labor, foreign commercial companies' traffic products, and a cheap vote easily controlled.

The feeble-minded problem is one of the most serious, for it is more open to dispute, and less likely than the insane to become a public charge. Many forms of insanity are curable, and at least usually recognizable; but the feeble-minded are the more dangerous, as they never play the normal in life's competition and often go for years or life unrecognized.

The best remedy is honest enforcement of the law,—make every public office holder seeking to land a defective alien enter his name as a sponsor in the public records, more authority and better facilities for the medical department, a better division of work so that efficiency may not be diminished by speed, even if more medical officers are required, and lastly a clearer understanding on the part of the public that has to pay the bill.

Every alien should be required to show the United States that he is clearly and beyond a doubt entitled to land in this country, instead of requiring the United States constantly to be on the defensive.

THE BOSTON Medical and Surgical Journal, THURSDAY, APRIL 23, 1914.

A Journal of Medicine, Surgery and Allied Sciences. published at Boston, weeky, by the undersigned.

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The Journal will furnish 100 reprints free, if request in writing.

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Remittences should be made by Money Order, Draft, or Registered Letter payable to:

W. M. Leonard, 101 Tremont Street, Boston, Massachusetts


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