Popular Science Monthly/Volume 80/April 1912/The Medical Side of Immigration

by Alfred Cummings Reed

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THE MEDICAL SIDE OF IMMIGRATION

By Dr. ALFRED C. REED

ASSISTANT SURGEON, U. S. PUBLIC HEALTH AND MARINE HOSPITAL SERVICE NEW YORK CITY

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 alien immigrants. Our institutions, political, religious and social, 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 in the face of this, these variant elements have been fused into a more or less homogeneous nation. A national life and character we have. This national or American character is not exemplified in those places where the large streams of immigration are pouring in, but farther away where the waters have mixed. Such a condition, unique in the history of nations, is responsible for certain problems which are also unique in history, and consequently do not admit of solution according to precedents.

The first rule of national life is self-preservation, and 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 difficult to make, and does not enter our field of inquiry, except to recall a principle which is as valid from the medical standpoint as from the economic or social. Only those peoples should be admitted whom experience has shown will amalgamate quickly and become genuine citizens. The period of residence necessary for citizenship should be raised from three to five years, during which time the immigrant should be literally on probation, and subject to deportation if found wanting, or if unable to meet the qualifications of citizenship at the end of that time. The government should decide where the immigrant may settle and the immigration current should be directed to the western and farming districts, and not allowed to stagnate in eastern cities.

The great mass of popular literature on the subject of immigration is singularly deficient in discussion and analysis of its medical features. It is true, the United States government bestows on public health and preventive medicine no where near the attention it finds necessary for the prevention of disease in stock and for agricultural improvement, but none the less 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 would be the work were all these agencies for national health protection united

The Immigration Station, Ellis Island.

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 diseases are found so frequently among immigrants, and others are so inherently dangerous, as to merit special mention because of their important 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 serious 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 the 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, and under the microscope shows relatively enormous and powerful chitinous jaws by means of which it attaches itself to the intestinal walls. The saliva of the hookworm has the curious property of preventing coagulation of blood like leech extract, and when it is remembered that the worms may vary in number from several hundred to a thousand or more, and that each worm moves frequently 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 an 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 uncinaria is abundant, as well as the recent suggestive work of Dr. H. M. Manning at the Ellis Island Immigrant Hospital, indicate that there is a constant stream of fresh infection pouring in. Indisputably routine examination for hookworms should be instituted. The same can be said of other intestinal parasites as tapeworms, pin worms, whip worms, eel worms and others. One of the tapeworms, the so-called fish worm (Dibothriocephalus latus) leads to an anemia fully as severe as that from the hookworm.

Many other diseases might be mentioned, 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. The chief port of entry is, of course, New York, where 749,642 aliens were examined. Next in order of importance come Boston, Baltimore and Philadelphia, and at a greater distance Galveston, Tampa, San Francisco, Honolulu, Miami and Portland, Me. 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 an isolated set of 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.

Landing from Barge at Ellis 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 on board the incoming vessels. Those who require more detailed examination are sent to Ellis Island.

The routine inspection on the line is that part which the visitor sees, and is the most important 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 ankle, knee, or hip, malformations of the body, observes the neck for goitre, muscular development, scars, enlarged glands, texture of skin, and 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, in following the line, the examiner has a side view, noting the ears, scalp, side of neck, examining the hands for deformity or paralysis, and 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 reaction of the person to an unexpected question. As the immigrant passes on, the examiner has a rear view which may reveal spinal deformity or lameness. In case any positive or suspicious evidence of defect is observed, the immigrant receives a chalk mark indicating the nature of the suspicious circumstance.

At the end of each line stands a second medical officer who does nothing but inspect eyes. He everts the eyelids of every person passing the line, looking for signs of trachoma, and also notes the presence of cataract, blindness, defective vision, acute conditions requiring hospital care and any other abnormalities. All cases which have been 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 an unusually wide variety of cases.

After careful examination, the nature of the defect or disease found, is put in the form of a medical certificate which must be signed by at least three of the physicians on duty. It is not within the province of the medical officers to pass judgment on the eligibility of the immigrant 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. In the inspector's consideration are included not alone 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 a doubt always. For example, if a case of defective vision is found to be 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

Lined up, waiting for the Medical Examination.

defect or disease. Class B, aliens not under class A, but who possess some defect or disease which 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 ability to earn a living, but which none the less must be certified for the information of the immigration inspectors.

Under class A, the excluded, are listed idiots, imbeciles, the feebleminded, the epileptics, the insane, persons afflicted with tuberculosis of the respiratory, intestinal or genito-urinary tracts, and loathsome or dangerous contagious diseases. By contagious the law means communicable.

A Cosmopolitan Group on the Roof of the Detention Quarters.

Loathsome contagious diseases include those whose presence excites abhorrence in others, and which are essentially chronic, such as favus, ringworm of the scalp, parasitic fungus diseases, Madura foot, leprosy and venereal disease. Dangerous contagious diseases are such as trachoma, filariasis, hookworm infection, amœbic dysentery, and endemic hematuria.

Under class B, diseases and defects not in class A but which affect ability to earn a living, are such conditions as hernia, organic heart disease, permanently defective 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 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^[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 for the proper execution of the laws relating to physical and mental defectives. Expansion to an appropriate size is prevented by the failure of Congress to appropriate the funds requested. He notes the 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 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 absolutely 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 so largely to the criminal element. All grades of moral, physical and social degeneracy appear in their descendants, and it is apparent how grave is the social and economic problem 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,^[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 per cent, were feeble-minded, and 33 per cent, insane. Under loathsome and dangerous contagious diseases there were 1,361 cases, of which 85 per cent, were trachoma. Over 11,000 aliens had a defect or diseases affecting ability to earn a living and half of these were due to age and the changes incident to senescence. More than 4,000 certificates were rendered for conditions not affecting ability to earn a living.

Over 6,000 aliens were treated in the immigrant hospital, beside 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 which had become public charges in surrounding towns of New York, New Jersey

From Holland.

and Connecticut to determine the nature of the illness and if due to causes existing prior to landing. Chief among the contagious diseases were measles, chicken-pox, 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 it may be said 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, although even here the medical evidence is decidedly against him, as Dr. McLaughlin^[3] has shown that the proportion of defectives to total landed is greatest among the Syrians, 1 in 29, and next greatest 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 bloods. Hence Jews of different nationalities differ considerably in their physical status and aptitude for American institutions, and for 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. It would seem from history that the Jew only blends inadvertently and against his conscious endeavor and desire. Hence the process of true 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 of the immigration problem. The problem of New York City in this respect is unique and differs from that of the rest of the country, because as Walter Laidlaw^[4] points out. New York City is in reality a foreign city, inasmuch as in 1910 the native-born of native parents numbered only 193 in every 1,000 inhabitants. This preponderating foreign element is due to the concentration of arrested immigration in New York. For the country as a whole, great interest attaches to the influence which the Panama Canal will exert in diverting immigration lines to southern and Pacific coast points. New local problems will of course arise, but the basic proposition remains always 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 and Syria, as well as most Hebrews, Magyars, Armenians and Turks. Strict enforcement

Negroes from the West Indies.

of the present medical laws will automatically exclude these races to a sufficient extent, admitting the few who are fit. This, combined with a strictly enforced five-year probation period, with deportation as the penalty for any criminal conviction or for failure to qualify for citizenship afterward, would go far toward relieving the situation. This need not disqualify aliens from travel 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 own 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 in effect the dumping ground of the world.

Exclusion of these undesirables works no injustice to the lands from which they come. A large emigration from a land usually is followed by an increased birth-rate, and the net change is slightly affected, if at all.^[5] 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 standards of living and education in those lands from which our immigrants are drawn. This was illustrated in Italy^[5] a few years ago when the higher requirements for admission caused an enforcement of the primary education laws which were dead letters before. Again, increase of a poorer class of immigration decreases the number of the better class and also decreases 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 free immigration, certainly seems the best policy.

1. Williams, Wm., 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.
5. Hall, Prescott. F., "Eugenics, Ethics and Immigration."