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; with specific 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 Quakers were not welcome in the land of the Puritans, 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 a vital role in America's national life, it must be carefully scrutinized to admit the desirable.
The medical aspect of immigration was brought to public notice about 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 passed 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 the power to regulate commerce was vested in Congress and not in any state.
For many years each state dealt with the problem of limiting the entry of diseases, aliens as best they could. Of course, this wasn't easy, owing to the ease of passing from one state to another. This was probably the first restrictive policy that was actively started. Still, of course, the whole earlier history of the country showed that economic pressure tended to restrict newcomers to those nearest the region's race, language, and ideals.
When the Federal Government supervised the matter in 1882, they adopted a general rule to reject those who suffered from physical defects liable to make them public charges, note being made of insane, idiots and persons unable to take care of themselves. In 1891 they further extended this law 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 United States extended the law to exclude people with epilepsy, feeble-minded. 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 genitourinary 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, ensure 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 one must understand 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 Medical 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 the 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 considered, he gets the best end of the doubt, for the rules require the certificate to be based on conclusive evidence. For example, a pulmonary tuberculosis case cannot be 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 the cabin and steerage passengers. United States 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 classified under Class A but present some defect or disease affecting the ability to earn a living, as hernia, heart disease, inadequate nutrition, varicosities, presenility, specific conditions of the nervous system, chronic joint disorders, observed impaired vision, and tuberculosis of the skin, glands, and joints.
Class C. Aliens that present defects or diseases of less seriousness but must be sure for the information of the immigration officers that they may pass intelligently on the ease.
To prevent any alien from slipping by without examination by a 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 any delay, a slight abnormality such as a scar of the face from a burn is noted by the doctor, and a slip given to the alien noting the condition and stamped "Special Medical Passed." The steerage usually being examined onshore is checked by attendants to prevent any oversight. At Ellis Island, an attendant stamped the steerage passengers' inspection cards in ink.
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 an examination must vary somewhat with local conditions. To accomplish this without undue annoyance to travelers, without delaying traffic requires care and tact on the part of the medical officer. Before the inspection, two sources of information are at hand; the manifest sheet and the ship surgeon's report. How reliable this information depends on the type of men filling the forms.
When one considers that nearly all immigration is carried in foreign ships crewed 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 under artificial light. Certain diseases involving different hues or alterations in the skin cannot be noted accurately.
The medical examination is divided into two parts, primary and secondary. In the primary, the examiner's efforts are directed toward segregating from those presented those suspected of having disease, defect, or abnormality of any kind to enable the healthy to proceed without unnecessary delay.
Secondary; to make a systematic inquiry into the signs and symptoms in those turned aside 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 as even illumination as possible. One must avoid direct sunshine in the face or reflected from the water.
To facilitate the work, the line should make a right-angle turn in front of the examiner to secure a good view of both sides and back with the least effort.
Standing with the light falling over his shoulder, he begins his study of the alien at about twenty feet distant. Starting with the feet at that distance, the eye gradually rises from the feet to the head without effort as the alien draws near. The examiner then proceeds systematically to examine the line as it approaches. 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, the immigration physician may note undue prominence of or about the groins, the hands as they furnish essential 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, ascites, splenic enlargement, pregnancy, and abdominal tumors in general.
The chest is examined for asymmetry, undue prominence, defective development, and the back for evidence of spinal disease and deformity. The neck is surveyed for goiter, abnormal pulsations, enlarged glands, tumors, and malformations.
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 and the skin. The oral and ocular membranes act as an index for anemia, 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 to detect 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 shaky 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 while sight is taking in conditions about the month. Response to a simple question provides an index of hearing and mental reaction. At the same time, the sense of smell simultaneously may arouse suspicion of uremia, ozaena, favus, foul discharge from the 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. In infants, one may note one of the most apparent signs of respiratory changes 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 down 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 one may have noted something to cause his detention.
The above gives a general idea of what observation shows on the preliminary examination. The secondary examination is the regular medical procedure to confirm a diagnosis or pass the alien.
To the casual visitor, it may seem a common 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 do the same if their suspicions are aroused. They are 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 were getting in. Still more important are the mental disorders, 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.
It 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 a 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.
Knowledge of racial types and their peculiarities is essential, for, without this, a great many normal persons would be detained. Hence ethnology plays a vital 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, one can safely state that almost no serious organic disease can have a hold on an individual without stamping some evidence of its presence upon the patient's appearance 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 a 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 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 mentally unfit, it may be a matter of surprise to know that about 1.5 percent, 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 will be described in the following paragraphs.
It takes considerable experience to know what constitutes a 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. Seasickness may readily leave harmful effects for some days, and the pallor and weakness suggest some severe constitutional disease.
Pulsating blood vessels in the neck are often caused by fright, increasing the heart action. One can readily note that all or nearly all immigrants pale before the doctor in a high state of nervous tension, for they believe that the battle is nearly over once by the medical officer.
This is not their first medical examination. They have seen others weeded out before leaving. In contrast, 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 ironworkers, bakers, coal miners, and line workers, may cause 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, at 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 the 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 manifested 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 exact reason for light remark and laughter as the girl from Ireland.
Some races are incredibly emotional, others slow, and it is impossible to pick the abnormal unless the normal is known. 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 with the Syrian peasant type to form an opinion of his mental caliber 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 complete mental examination.
Under the present law and facilities, it is impracticable to consider every alien a possible mental defective and subject him to complete examination unless there were some signs of mental disorder on primary inspection.
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.
Due to the lack of agreement among experts on where the normal ends, 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. Still, on slight stress such as being found in a new country with disappointments, its strange language and customs become mentally disordered.
Inveetigatoni that have carefully studied the subject agree that the medical inspection is no farce. Examiners with years of experience in the service have seen a marked increase in efficiency due to experience and increased facilities. It is not 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 facts to give a good story foundation.
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. 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 is undoubtedly 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 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 contagious diseases.
MEDICAL INSPECTION OF IMMIGRANTS.
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 shows that the most critical function of the immigration inspection lies in the medical examination. If an alien is of sound body and mind, he is not likely to do much harm.
A careful appraisal of our human imports then is a serious matter requiring 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 undesirables have been attracted to this country; as communities grew, restrictions followed just as naturally against the alien as the foreign goods in the trade market.
Among the early adventurers were persons sent to America to serve out penal offenses, escape prosecution, and suffer 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, particularly when American institutions gained the reputation of dealing more kindly with the inmates than the home asylums.
It is essential to understand that it is only since 1903 that a financial penalty has been placed upon the steamship companies and returning the alien to the port of embarkation of his hometown. 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 mandatorily restricted.
Microscopical evidence must be present to certify certain conditions, like Tuberculosis, gonorrhea, favus, ringworm, etc. Any physician thus can understand how many incipient tuberculous persons may be admitted. In the meaning of the law, Tuberculosis refers only to the lungs, genitourinary, and intestinal tracts. Persons suffering from tuberculosis of the bones, joints, skin, glands, etc., may be landed. 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 traveled 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, someplace has to be sought that may not delay the ship or passengers. Doing this without slowing traffic, without putting passengers to inconvenience, passengers who are often 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. The spectacular linework seems to be about all there is to the visitor, but he rarely follows behind the scenes and learns what happens to those who turned into the detention rooms. The most challenging work is often between ships when eases have to be carefully recorded, after due examination that carries 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 be 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. Most of Boston's immigrants came from Northern Europe and the British Isles not many years ago. Today southern and eastern Europeans predominate, and emigration begins from Turkey, Asia, and Persia.
Boston is sadly in need of a proper immigrant station, both for the 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 shipboard until room can be made by either landing or deporting those detained on Long Wharf.
One should remember that detained aliens are not felons but human beings waiting to prove their right to land or waiting for the ship's sailing 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 jackknife, 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 in some newspapers and magazines, there has been built a false situation, either by those who do not understand or those who are prejudiced against restriction.
Suppose 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. In that case, the taxpayers might learn something not hitherto realized.
There is only one reason for restricting immigration: 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. Still, 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 their 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 more precise 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. Papers for publication, and all other communications for the Editorial Department, should be sent to the Editor of the Boston Medical and Surgical Journal, 809 Paddock Building, 101 Tremont Street, Boston. All orders for reprints must be sent in writing to the Ediotr on or before the day of publication.