Scientific Medical Inspection At Ellis Island
By Alfred C. Reed M.D., Ellis Island, NY.
The functions of the physician are by no means limited to the diagnosis and cure of physical ailments. There are diseases of society, of politics, and of industrial life which demand most strongly the application of his keen insight and well-trained intellect, to advance the understanding of their pathology, prevention, and cure.
In a wide sense the obligation of the physician lies along this line, as well as in the routine treatment of individual. cases. No government and no society is absolutely best. In general, each is best suited to the immediate needs of the people who have created it.
To change social and economic conditions to .meet the changing needs and the changing ideals of the people; is indeed the highest of civic functions. Few other questions so intimately concern this country to-day in this regard, as the influence of immigration on our American life.
Precisely here the medical profession has a great opportunity and a -great duty. No one is better qualified than the physician to say which immigrants arc desirable. Moreover, under the law the most important feature of immigrant inspection devolves upon physicians.
The medical inspection of all immigrant aliens is performed by the Public Health and Marine Hospital Service, at the 82 immigration stations of the United States and its dependencies. In the fiscal year 1911 there came thru all ports of entry 1,032,649 immigrants. of whom 749,642 entered thru Ellis Island.
The press, lay as well as medical, has recently had free discussion regarding the large number of mental defectives and insane who pass Ellis Island. It is true that of the nearly 33,00o insane in the New York State Hospitals, nearly 8000 are aliens. It is equally true that of the 10,000 feebleminded children in the New York City public schools, over 3000 are aliens, and that 3o percent of all the feebleminded persons in the United States can be safely assumed to be aliens or of alien parentage.
In place of criticising the Ellis Island inspection for this state of affairs, it would be well to keep clearly in mind that any person found within three years of landing to be feebleminded, can be deported, and that this provision of the law extends to imbeciles, idiots, and insane where the insanity depends on causes existing prior to landing.
It is also to be remembered that feebleminded infants and young children are extremely hard to recognize with the best of facilities. The work of the medical officers at Ellis Island is far in advance of what might be expected in view of their number and the facilities offered them. They work under the conscious disadvantage of insufficient space, lack of time for thorough examination, lack of enough interpreters, and too few officers.
In spite of all this, they certified 209 mental defectives in the fiscal year 1911.
Under the direction of men specially trained in the diagnosis of mental disorders, a unique investigation is being conducted at Ellis Island, which promises a means of recognizing feeblemindedness in aliens, where now such recognition is attained with the greatest difficulty. The principle employed is that of the well-known Binet-Simon system of tests for intelligence, or of tests for mental age as compared to physical age, which in a modified form has been so successfully used by Dr. Goddard.
Each group of tests furnishes an index of the mental status of the normal child of a corresponding age. Those who fall below the test group of appropriate age, are rated as feebleminded, imbecile or idiot, according to the degree of deficiency.
This system is not applicable to immigrants because of the different conditions under which they have lived, which vary greatly with different races. Hence it is sought to determine a standard of normal intelligence for the adult of each race. The investigation is being conducted on normal illiterates only, in order to establish a minimum standard of normal-mindedness for each race.
Obviously all who fall below this standard of mentality can be classed as defective. Such a standard of normal-mindedness will afford a quick, fair, and comparatively accurate means of examination. To apply the method to children, a long continued series of observations will be necessary to establish a standard for different ages.
Those who are familiar with mental defectiveness, will realize the enormous difficulties under which the medical officers labor in detecting these conditions. They will even be surprised that as many are found as at present, and they will recognize the value of this attempt to establish a minimum standard of normal-mindedness for each race.
It is obviously impossible that an examination at New York should discover all cases of insanity, when it is recalled that no case with very marked symptoms would have been allowed to embark in the first place, and that these persons are adroit in concealing their disorders. Even so, a large per cent. of insane were stopped at Ellis Island in 1911.
What has been said regarding the deportation of mental defectives applies with still greater force to those who become insane within three years, from causes existing prior to landing. A grave condition associated with the increase of alien insane in this country is that no matter how careful or how skillful the medical officer may be in his diagnosis of insanity which has developed within the three year limit, from causes existing prior to landing, the strange vagaries of legal reasoning often nullify the entire case.
This is illustrated by Decision 120 of the solicitor of the Department of Commerce and Labor. An officer of the Public Health Service, a member of the New York State Board of Alienists, and the physicians of the Manhattan State Hospital had concurred in a diagnosis of manic-depressive insanity in this case. It is recognized by psychiatrists that manic-depressive and analogous forms of insanity are due primarily and only to constitutional psychopathic tendencies and mental instability existing from birth.
In the face of this belief, the decision in question concludes that while the diagnosis is correct, this case of insanity developed subsequent to landing, and hence could not be deported! A legal opinion in evident contradiction to medical facts, and illustrating the folly of a layman passing judgment on a question in the most abstruse field of medicine, namely psychiatry!
This decision prevents the deportation of a class of cases which formerly .furnished 350 deportations annually. Other illustrations could be cited of the setting aside of unquestioned medical evidence, by some twist of the law or legal technicality. One may well ask why the medical examiners should seek to detect even greater numbers of the physically and mentally unsound, when their work is disregarded and discredited in a large number of cases which they do detect.
The annual report of the Chief Medical Officer at Ellis Island for the fiscal year 1909 showed that 1544 cases were certified to have conditions which the law declares positively shall be excluded. Exclusive of those occurring in citizens, in the native born, and of cases which were cured in the hospital or died, 66 of these were landed.
In other words, 4.2 per cent. of the cases which the law absolutely excludes, were landed in spite of the medical certificate. For 1910, the proportion landed was 2.3 per cent. and in 1911 it was 3.4 per cent. It would seem that those prone to criticise the medical inspection at Ellis Island would do well to consider just how efficiently the present deportation laws are administered, and how often the medical diagnosis is disregarded.
In reviewing hastily other fields of special endeavor in the medical work at Ellis Island, mention must be. made of the anthropological investigation now being conducted by the Public. Health Service officers in collaboration with the Smithsonian Institute. The stream of immigrants of all races and nations passing through Ellis Island offers a rare opportunity for the collection of physical measurements of the greatest anthropological value.
It is difficult work and requires instruments and methods of the nicest precision. It should yield results of interest alike to the pure scientist and to the student of American physical development and of the factors which must enter into the formation of the best national type of the future.
A large number of cases are found showing a lack of physical and sexual development corresponding to the age, especially among immigrants from southern and southeastern Europe. To determine the reasons for this, and its relation to definite endemic diseases and to local conditions, is the subject of another line of inquiry being pursued.
The well-known economic importance of hook-worm disease emphasizes the value of the examinations for uncinaria now made of immigrants showing pronounced anemia. Those having a hookworm infection are excludable under the law. A recent investigation in the immigrant hospital on Ellis Island indicates that 4 per cent. of all immigrants are infected with the hookworm. It may be noted that at San Francisco 90 per cent. of the Hindu coolies on one ship harbored this parasite.
There is no larger trachoma clinic in the United States than at Ellis Island, and the officers there become unusually expert in its recognition. It is safe to say that very little real trachoma escapes detection, and yet the intricacies of legal interpretation again nullify the medical diagnosis in some cases.
A line of laboratory investigation has been pursued on trachoma aiming to elaborate an accurate clinical test for the disease, as well as to discover the real etiology. The immigrant hospital on Ellis Island admitted over 6000 patients last year. It presents an unusual and valuable opportunity for the intensive study of contagious, parasitic, and skin diseases.
There is very thoro routine examination of all cases which on the primary inspection show any evidence or suspicion of defect or disease. Urinalysis, vision tests, and the ophthalmoscope are frequently employed. Officers are detailed from time to time for special courses of instruction at various large institutions especially for the study of insanity and mental defectiveness.
The medical features of the Ellis Island inspection are of vital interest, and every physician should know what is actually being done there, and take an intelligent interest in the efforts being made to apply the latest medical science t0 the detection of the physically and mentally unsound. As the sole national agency operating to combat epidemic disease, and t0 promote preventive medicine, the Public Health Service stands high in the medical profession, and deserves its hearty sympathy and support.
Medical Review of Reviews, VOL. 18, No. 8, AUGUST 1912