Immigration And The Prevention Of Insanity (Note 1)

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 that come into this country in possession of immigrants are quite as interesting for us as those 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. Many causes influence this vast movement of population, and these causes are rooted in the economic and political history of Europe.

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

Few people realize what an enormous source of population immigration constitutes at present. 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 the population from immigration is more significant than that from births.

This is the direct contribution of immigration to the 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? All measures of protection against any of the dangers of immigration must fall under one of three principal methods. We may arbitrarily stop immigration altogether, restrict large general groups of immigrants, or select immigrants according to various tests and standards of individual fitness.

The first means of protection only needs to be mentioned. It is the abandonment of the immigration question, not its solution. The second, the restriction of immigration, has been thoughtfully considered 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 contemporary 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. This the President has the right to do under the quarantine laws of the United States, but all physicians are proud 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 considerable proportion of eases of mental disease and defect; so arbitrary restrictive measures cannot be advocated by physicians solely upon the grounds that they are needed to exclude insane and mentally defective immigrants.

Of course, one cannot deny that any restrictive measure that significantly diminished the tide of immigration would necessarily decrease 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 that 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 ought to be.

Before discussing any changes in the immigration law, it may be worthwhile to consider the existing provisions that one may utilize to exclude 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 try to suppress small-pox by sanitary laws at the same time neglecting vaccination.

The Immigration Law provides (Section 17) that all arriving aliens' physical and mental examination shall be made by medical officers of the United States Public Health Service. The medical examination of immigrants used to be made by civil physicians. Still, 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 call 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. The scientific work in which the Public Health Service is engaged fits its officers for the pathological examination, which forms a part of the work at some ports of entry. They are commissioned officers of the Government and entirely outside the influence of polities.

This provision is an excellent one, but, unfortunately, the law fails to define the scope of the medical examination, provide primarily for a mental examination, or provide that there shall be 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 precarious footing.

Indeed, those familiar with the significant 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 required law.

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 examining 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 crossing the ocean and presenting himself at one of our ports.

If medical examination at the principal ports of embarkation were authorized, it would be 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, American medical officers should make a mental examination 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 one would not admit immigrants without such an examination, these governments would quickly recede from their position, for immigration means significant 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 medical 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 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 is revocation of the Italian Government's license 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 the power to enact a "passenger act," we should have the means to enforce it.

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

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

Another means 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 potent weapon of oppression in the hands of foreign officials.

There is no doubt of the great value to this country of immigrants of type I of Carl Schurz. Still, 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. Therefore, it seems that the danger would offset the slight advantages of this plan that one might use to oppress intending immigrants.

Another disadvantage is that it would be of little avail in detecting 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 be stationed in various countries in Europe to conduct studies in heredity. Only those immigrants should be admitted who possess certificates that such field workers had examined their family history found satisfactory.

The objections raised to this procedure are so numerous that it cannot be considered 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 high. Still, it would be insignificant compared with the significant sums spent to support 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 responsibility rests with the federal government, however, as every attempt of the states to regulate immigration has been declared unconstitutional.

The cost of the examination takes on a new aspect when it is learned that the immigrants themselves pay for the enforcement of the Immigration Law, including their medical examination. The "head-tax" of four dollars apiece 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 special 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."

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

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

It may be challenging to secure a sufficient number of young physicians with training in psychiatry. Still, it would be effortless to ensure 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.

Such organizations have approved them 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 Breeders Association.

What can be the source of opposition to those 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 any state's budget that provides adequately for its insane.

There are many unprovided for even in such states, and overcrowding is a general evil. Who desires to see this significant 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 profits so greatly through immigration that they are indifferent to these considerations?

There are two sources from which one might expect oppositions to such measures 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 employers responsible for child labor, insufficient housing, unsanitary working conditions, and many other social and economic evils; but insane and mentally defective immigrants do not make profitable workmen; opposition to measures for the better selection of immigrants come from a different source.

The most active and potent 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 tremendous immigrant-carrying lines, according to its advertising circulars, exceeds the tonnage of the French navy.

This is the source of the opposition, which outweighs the warnings of those devoting their lives to studying mental diseases. This opposition will continue to be effective until people generally realize that 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 be 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, Ireland, and Scandinavia found political, social, 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 forming this significant decision.

With the purely industrial factors that govern the more significant part of the new immigration, glowing accounts of high wages, unfailing work, and other advantages have a very marked effect.

For many, immigration does not mean relinquishing 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 present in most countries in Europe.

As a result of studies undertaken in Europe, this commission 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 mighty one. When steamship companies are taxed with making false statements about 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 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 cases of dangerous contagious diseases, which could have been detected by a competent medical examination at the port of embarkation.

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

A significant number of cases of mixed infections, with very high mortality, is the usual result. Even the provisions of our ''passenger act" of thirty years ago, which are recognized as 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 passengers is vigorously resisted. Every effort to secure more effective legislation to protect the health of immigrants or 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 most significant influence upon immigration, .especially in its relations to public health. The public has not fully realized this aspect of the question.

In any measures that one may undertake in the future to control unfavorable or dangerous immigration, the immigrant-carrying steamship lines will be found the most potent factor to be reckoned with, and it is well worth recognizing the fact. Some steamship companies do not engage in these practices, only show that all could abandon them.

The exclusion of insane and mentally defective immigrants is a public health question. It is not a political question. It is only incidentally an economic question, but it affects the welfare of coming generations of Americans as profoundly 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 firearms should have in the protection of songbirds.

If this vital question is to be dealt with following the requirements of broad humanity, one must seek something more than efficiency in examination methods.

I believe that excluding insane and mentally defective immigrants is necessary. Still, it should be performed humanely and kindly, and, at every step, one should carefully consider the safety and comfort of a particularly helpless class of immigrants.

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 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 the care of the sick, and I think that there 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 engaged in this society's work will, I feel confident, carry much weight. Suppose you agree with me as to the measures needed. In that case, I urge you to use your influence to secure the enactment of an immigration law that will efficiently and humanely accomplish the purposes I have outlined.

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

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, THURSDAY, AUGUST 28, 1913.