Popularizing the Work at Ellis Island
Popularizing the Work at Ellis Island
Abstract and Keywords
This chapter focuses on the performance tests developed by Howard Andrew Knox and his colleagues and administered to mentally deficient emigrants at Ellis Island in New York, and how they brought such tests to the attention of a much wider audience. Prodded by the office of the surgeon general, Knox and his colleagues began to popularize their work through articles in newspapers and magazines, presentations at conferences and to local medical associations, and through a manual for the mental examination of emigrants. In one event where he was speaker, Knox described the procedures being used at Ellis Island and emphasized the need for the physicians to be absolutely certain in their diagnoses of mental deficiency. In May 1914, he submitted a paper for presentation at the second annual meeting of the Eugenics Research Association. He also wrote a paper entitled “A Broader View of Mental Deficiency in Aliens,” published in the New York Medical Journal in October 1915, while he was temporarily detailed to work as an assistant physician at the Psychiatric Institute of the New York State Hospitals.
Prodded by the office of the surgeon general, Knox and his colleagues began to popularize their work through articles in newspapers and magazines, presentations at conferences and to local medical associations, and finally through a manual for the mental examination of emigrants. Nothing had come of the letter Knox had received in October 1912 asking him to suggest three articles on matters relating to hygiene and the public health. The surgeon general had sent the form letter to all commissioned officers in the Public Health Service. Knox had duly suggested three titles, but there is no evidence he ever wrote the articles.
Less than a year later Knox received a personal letter in July 1913 from the assistant surgeon general, William Colby Rucker, suggesting that Knox write a popular article based on his paper that had just appeared in the New York Medical Journal, “A Diagnostic Study of the Face” (Knox 1913c). Rucker proposed that it “might be of great value to the reading public, and might also serve as a scheme for bringing before the people in concrete form, an evidence of the splendid work which our corps is now doing at Ellis Island…. If you will forward me the manuscript, … I will endeavor to get some of my magazine friends in this city to place it.” Once again, there is no evidence that Knox ever wrote this article, but he appears to have taken this as encouragement to disseminate the work at Ellis Island more widely.
Two months later Knox published “The Differentiation Between Moronism and Ignorance” in the New York Medical Journal. This was the article that featured his account of a “general method of examination” and the Geographical Puzzle. The following day, September 21, the New York Herald carried an article about the puzzle and a summary of the method of examination. The article was unsigned but was probably written by Knox himself. The headline read “Jig Puzzle Used at Ellis Island to Test Intelligence of Aliens,” and the article itself began: “Suppose yourself landed on the shores of a foreign country and asked to solve a puzzle in two minutes and twenty seconds just to tell whether you were feeble minded!” Accompanying it was the picture of the Geographical Puzzle that had appeared in the New York Medical Journal.
On October 13 Knox was one of the speakers at an event in support of a campaign to set up a “clearing house” for monitoring mentally defective people, and the New York Times reported his remarks the next day. Knox described the procedures being used at Ellis Island and emphasized the need for the physicians to be absolutely certain in their diagnoses of mental deficiency. As a result, some emigrants were given the benefit of the doubt, with the risk that they and their progeny might become a social and financial burden. As an example, he cited an Englishman aged twenty-four who was asked a question based on one of Binet and Simon’s tests: “A man walked into the woods. He saw something hanging from a tree that frightened him, and he ran back to notify the police. What did he see?” The emigrant, apparently a London cockney, answered, “A brawnch” (branch). According to Binet and Simon (1908:55), the only correct response to this question was “A person hanged.” Nevertheless, Knox reported that the man had been permitted to land under bond.
Two weeks before Knox described his Inkblot Imagination Test in the Medical Record on April 25, 1914, the World Magazine had carried an article about the test, including illustrations of the inkblots that Knox had used and a photograph of Knox himself. The article was both unsigned and untitled, but it gave an accurate idea of the use of the test:
Have you got an imagination? If not, read no further on this page or you may scare yourself into believing you are mentally defective.
These are splashes of ink—just such blots as you make when writing with a tired hand or with a rusty pen. They mean nothing, but if you have an imagination each of them will suggest something to you.
It is an old game, this of making blots with ink on paper and trying to find out what ideas they arouse in the minds of different people. It is no longer a (p.144) mere game, for in the hands of psychologists and specialists in mental diseases it has become a scientific test of the intelligence of persons suspected of being below normal.
“What does this splash suggest to you?” is the question they ask. And they time the response with a stop watch, for the speed with which the mind acts is as important to them as is the nature of the reply.
Dr. Howard A. Knox, assistant surgeon, United States Public Health Service, is using this—with several other tests, of course—as a gauge of the intelligence of immigrants at Ellis Island. Getting suspected defectives to play the game of ink blots and making a record of how they succeeded was his own idea….
If you are fond of self-analysis and do not fear the results, try the game yourself. You will not only get some fun out of it, but may learn something about your own mind.
Even so, claims that the physicians at Ellis Island were admitting large numbers of mentally deficient immigrants were frequent. The Medical Society of the State of New York discussed the issue in the closing session of its annual meeting on April 30. The following day the New York Times reported the outcome:
Congress was appealed to yesterday by the Medical Society of the State of New York to provide more stringent measures for the enforcement of the immigration exclusion law against insane and mentally defective immigrants. The physicians who ended their annual meeting in the Hotel Astor said that the present system of admitting immigrants was a menace to the public health of the country and placed an unjust burden upon the State for the care of the mentally defective.
The physicians adopted unanimously a resolution urging congress [sic] to provide for the mental examination of all arriving immigrants by physicians of the United States Public Health Service; for adequate facilities for the detention and mental examination of immigrants by experts in the diagnosis of insanity and mental disease at all the large ports of entry, with a detail of American officers on all immigrant ships, and for an equitable share by the Federal Government of the cost of maintenance of insane immigrants who are now cared for by the State. Expeditious deportation methods are asked for to relieve the State institutions of the care of insane aliens.
By this time, however, the chief medical officer at Ellis Island, Surgeon Louis Williams, seems to have thought that he could mount a more aggressive defense (p.145) against such claims. In late May 1914 he addressed the annual meeting of the American Medico-Psychological Association (now the American Psychiatric Association) in Baltimore. He began by emphasizing the sheer scale of the task confronting his physicians, that of “examining daily, between the hours of 9.30 a.m. and 4.30 p.m., from 2000 to 5000 immigrants” (Williams 1914:259). Next, he reminded his audience of the procedure that was followed:
As the immigrants pass through the primary inspection line each is inspected by two physicians, one of whom takes special note of any indication of mental defect or disorder and addresses to each alien a few questions in his own language. All who in appearance or behavior excite suspicion, or who give irrelevant or stupid replies, are set aside for further inquiry. The suspects thus turned aside are at once given a brief preliminary examination for the purpose of sifting out and discharging those among them who are obviously of sound mind. Of those who remain each one appears before a board of at least two medical officers, who examine him by every available test which experience has proved to be useful and prepare a record of their findings.
Williams went on to report with evident satisfaction that the proportion of emigrants who had been identified as mentally deficient had increased from 18 per 100,000 in the fiscal year ending June 30, 1912, to 50 per 100,000 in the fiscal year ending June 30, 1913, and to 91 per 100,000 in the first ten months of the fiscal year ending June 30, 1914. More specifically, a total of 555 people had been deported from the United States as mentally defective during the fiscal year ending June 30, 1913, which represented a threefold increase in the number of people who had been excluded in each of the previous five years. Moreover, in April 1914 alone, 157 in every 100,000 emigrants had been identified as mentally deficient. Most of this increase was a result of the increased number of emigrants who had been classified as feebleminded rather than as idiots or imbeciles.
In fact, a short item in the New York Times of April 19 had reported that the officers of the Bureau of Immigration were finding it hard to accommodate the numbers of emigrants who were being detained as mentally defective. However, instead of attributing this to the increased efficiency of Surgeon Williams’s staff, an immigration official was quoted as blaming European families who wished to get rid of mentally deficient relatives or unscrupulous immigration agencies that were busy booking mentally deficient people in increasing numbers in anticipation of the introduction of more draconian immigration laws.
In May 1914 Knox submitted a paper for presentation at the second annual meeting of the Eugenics Research Association. William F. Blades, the association’s secretary-treasurer, then wrote to the surgeon general of the Public Health Service to request that Knox be allowed to attend the meeting to describe his work at Ellis Island, and permission was duly granted. The meeting was held at Columbia University on June 19 and 20.
The program was made up largely of individual presentations, including contributions from two professors in the department of psychology at Columbia, James McKeen Cattell and Robert Woodworth. However, the main event was a symposium, “The Most Pressing Topics for Research in Eugenics,” introduced by the association’s first president, Charles Davenport. A subsequent report identified four main points that emerged from the discussion:
That more emphasis must be placed on the study of the mental traits of the individual;
That the psychologist is not willing to grant the proof of the existence of unit characters or traits now used in describing the mental activities of man;
That tests for intelligence need closer standardization;
That a better definition of feeble-mindedness, or, as Dr. C. B. Davenport suggested, “feeble-mindness,” must be made.
The first point simply acknowledged that much previous work in eugenics had been based on the study of physical rather than mental traits. The last two points recognized that intelligence tests were still evolving and that definitions of feeblemindedness based on performance in intelligence tests needed to be improved. However, the second is a more subtle point.
Davenport was influenced by the German biologist, August Weismann, who argued that the inheritance of traits was mediated by specific kinds of cells that he called the germ-plasm. Gregor Mendel’s findings on the inheritance of physical traits, especially as they had been interpreted by the British geneticist William Bateson, had indicated that traits should be regarded as independent unit characters carried by different “determiners” (or what today are called genes) and that the determiners inherited from different parents remained distinct and did not blend with one another. Davenport put these ideas together into three principles:
(p.147) The principle of independent unit characters states that the qualities or characteristics of organisms are, or may be analyzed into, distinct units that are inherited separately…. The principle of the determiner in the germ-plasm states that each unit character is represented in the germ by a molecule or associated groups of molecules called a determiner …. The principle of segregation of determiners in the germ-plasm states that characteristics do not blend.
Davenport talked in terms of the presence or absence of determiners that in themselves might be dominant or recessive. For instance, on the one hand, he claimed that the determiner for brown eyes was dominant, so inheriting it from one parent would be sufficient to yield brown eyes, and only children who failed to inherit it from either parent would have blue eyes. On the other hand, the determiners for certain congenital abnormalities were recessive, so these conditions would be apparent only in those children who had inherited them from both parents (10–14). (Today these would simply be referred to as different forms, or alleles, of the same gene rather than the presence and absence of a single form.) Davenport’s view was that this latter analysis applied to the inheritance of mental deficiency (14–16), but this depended critically upon the assumption that feeblemindedness was a “unit character.” If that assumption were false, it would be harder to establish whether mental deficiency was inherited.
Charles Spearman (1904) had of course concluded that intelligence tests defined a central trait or factor that he called general intelligence. In his book Feeble-Mindedness: Its Causes and Consequences, Goddard (1914:556–57) interpreted Spearman’s results as consistent with his own ideas about the nature of intelligence. As Goddard asserted in the preface, “Normal intelligence seems to be a unit character and transmitted in true Mendelian fashion” (ix). However, some psychologists had already cast doubt on this assumption. Edward Thorndike (1903) had argued that intelligence was simply a multitude of specific capacities. Subsequently, some researchers obtained evidence for Spearman’s position (Burt 1909; see also Krueger and Spearman 1907), and others obtained evidence for Thorndike’s (W. Brown 1910; see also Thorndike, Lay, and Dean 1909).
Binet’s (1909) view had been similar to Thorndike’s: “Intelligence is not a single function, indivisible and with a distinctive essence, but … the combination of all those lesser functions of discrimination, observation, retention, etc.” (143). By the time of the Eugenics Research Association’s meeting, the matter was still far from resolved. In a brief report of the meeting the Journal of Heredity observed that considerable dissatisfaction had been expressed with the idea that feeblemindedness was a unit character. Indeed, Woodworth had gone so far as to declare (p.148) that eugenics could not hope to gain the support of psychologists until it had either proved or abandoned this hypothesis.
In the formal business of the meeting, Cattell was elected as association president to succeed Davenport, and William Blades was reelected as the secretary-treasurer. Knox presented his paper on current methods for detecting mental defectiveness among emigrants. During his talk he digressed to talk about an emigrant whom he described as closely resembling the “missing link.” The New York Times reported this part of his presentation the following day:
“This man was a Finn, 39 years old, and his occupation was linesman for a telephone or telegraph company,” he [Knox] said. “One familiar with the reconstruction of the man of the Stone age could not help but note the close resemblance. The head was one, the external anatomy of which I will never be likely to forget. The forehead was low and receding. The supra-orbital ridges [above the eyes] were sharp and prominent. The eyebrows were long and shaggy. The eyes were sharp and piercing. The nose was saddle-shaped, with a prominent tip. The lips were thick and protruding, while the chin was massive and heavy.
“The teeth articulated at an outward angle and the canines were particularly well developed. The ears were almost entirely below the line drawn horizontally backward from the external cantle of the eye. The arms were unusually long, and the olecranon processes [i.e., the bony points of the elbows] were largely prominent. The hands were remarkable. Each little finger was virtually a thumb that could be used with any other finger. The little fingers were consequently very short.
“The body was round and short. The feet were large, and flat with prehensile toes. If you will exercise your imagination, you will see that the man’s occupation was particularly well chosen for his physical make up, since he may have inherited the characteristics of his ancestors who perhaps often found it necessary to climb to the tree tops to escape some giant animal of their time. The man’s mentality was of a low order, although he was able to read and write.
“I simply mention this case here for the reason that it is one of a great class who possess atavistic features, indicative of a physically retrogressive make-up that is not good for our racial type and from the presence of which we must sooner or later suffer. The waste basket diagnosis of constitutional inferiority applies quite well, but this is not a mandatorially excludable condition, and all or any of such cases may be admitted at the discretion of the immigration officials who are not themselves physicians.
“At this point it might be well for me to state, for it is not pertinent to the rest of the paper, that the people from certain countries who are coming here at the present time are almost all physical inferiors, and with the present laws we are (p.149) absolutely powerless to stop them, and that it would be a very simple matter to do this if we had different physical standards.”
Knox’s presentation was also reported by the New York Tribune, and the Daily Express of London carried an interview with Knox the next day. Despite Knox’s insistence that “constitutional inferiority” was “not a mandatorially excludable condition,” both these accounts confirmed that the man had in fact been deported two weeks earlier on precisely those grounds.
“Constitutional inferiority” was a “waste basket diagnosis” because it was used by physicians of the time to cover a wide variety of conditions of which antisocial behavior was a common feature. In the 1890s Julius Ludwig August Koch, a German physician, suggested the alternative terms psychopathic inferiority and psychopathic personality in order to avoid the implication that the underlying cause was necessarily constitutional in nature. The latter of these terms was progressively adopted by other German physicians, including the eminent psychiatrist Emil Kraepelin. Kraepelin’s writings became influential in English-speaking countries, so that by the end of the 1920s psychopathic personality had replaced constitutional inferiority in those countries, too (Sass and Felthous 2008). However, even psychopathic personality later proved to be unsatisfactory (Karpman 1948), and the preferred expression among physicians in the United States today is antisocial personality disorder.
Even so, it seems to have suited Knox and his colleagues to use the term constitutional inferiority to justify the exclusion of emigrants on the ground that they were likely to become a public charge. On May 14, 1914, Knox had made the following statement at a board of special inquiry that was held to determine whether a female emigrant should be admitted:
The constitutional inferiority is aside from the psychopathic personality—is apart from it. The constitutional inferiority implies that the entire organism, physical and mental, is below par, below what it ought to be. That the resistance to insanity and the resistance to physical diseases is less than that of the normal person. The normal individual will go through life with health upon which the ordinary disease or sickness and various infectious diseases of childhood suffers very little permanent harm, but the health with any difficulty of these kind of individuals, will succumb to these diseases. They fall down more commonly than normal people. It is used in Germany a great deal and we are going to use it in this country more than formerly…. They designate it as an inferior make up of tissues, both the nerves and physical. That is, the individual is not made up of good stock, the physical make up is not what it should be. The brain is made up of cells and those cells from their lack of functionating, lack of proper formation, (p.150) or lack of proper development—that enters into it more—these cells are not as fully developed as they might be and consequently they cannot be expected to functionate as normal cells would…. The psychopathical personality implies that while the individual is not insane she has many of the characteristics of the insane person. Now certain individuals are inclined to believe that the world is down on them. That hard luck seems to follow them around more than the ordinary individual. Now these people are not insane, but that characteristic is a characteristic of insanity, one type of insanity, so that they cannot be considered normal, and that would be one kind of psychopathic person. Now there are other people who are non-responsive—who are unsociable, who stick around by themselves. They may not be exactly insane, but those are the characteristics of dementia praecox. The lack of ability to beget normal offspring—that is the fundamental characteristic of the individual. It is absolutely a hereditary thing. They will often beget individuals worse than themselves.
(I will discuss the significance of the term dementia praecox later in this chapter.) Knox’s deposition was considered sufficiently authoritative that it was cited at subsequent boards of inquiry to justify the deportation of other emigrants.1
Immediately after the meeting of the Eugenics Research Association, William Blades wrote to Knox: “Permit me to say that I considered it a very excellent paper and I have heard a great deal of comment all of which was very flattering to me for having secured you for the program. I have the honor also to inform you that you have been elected a member of the Eugenics Research Association.” Subsequently, Knox exchanged publications with the superintendent of the Eugenics Record Office, Harry Hamilton Laughlin, and entertained visiting parties of trainee fieldworkers that Laughlin brought to Ellis Island.
In September 1914 the secretary of the Mississippi Valley Medical Association asked the Public Health Service to send an officer to its next meeting to deliver a twenty-minute presentation titled “Mentally Defective Aliens: A Medical Problem.” The surgeon general asked Knox to undertake this task. The meeting was held in Cincinnati on October 27–29, and on the way Knox stayed for the night of October 26 at Army and Navy Headquarters in Washington, D.C. According to a letter that he sent his mother that evening, he was still writing his paper. Nevertheless, it was of a sufficient standard to be accepted by a local medical journal and was published the following year (Knox 1915b).
(p.151) In his presentation Knox reviewed the legal authority for requiring emigrants to undergo mental examination, described his scale for measuring intelligence, and talked about the results of administering such tests at Ellis Island. He mentioned that 1,114 people had been detained at Ellis Island during the fiscal year ending June 30, 1914, of whom 1,064 had subsequently been deported. Of this number, 957 had been classified as mentally defective, reflecting a substantial increase on the figure of 555 people that Surgeon Louis Williams (1914) had reported for the previous fiscal year. This was partly the result of an increase in the number of emigrants examined at the Port of New York (more than one million in 1914) but partly also because by this time nearly one emigrant in a thousand was being deported as mentally defective.
Knox’s Scientific American Article
In January 1915 Knox published yet another account of his scale in Scientific American (1915a). Then as now Scientific American was aimed at a general readership interested in scientific matters. Knox’s article was accompanied by a column of classified advertisements as well as advertisements for scientific and technical books, the National Sportsman magazine, real estate gold bonds, Sanatogen vitamins, and Whitaker’s Peerage, Baronetage, Knightage and Companionage. (The last advertisement was aimed at Americans related to prominent families in Britain or its colonies who might even inherit such titles as the result of the deaths of the incumbents in “the present great but sad war in Europe.”)
Knox began by explaining the purpose of his instrument:
The measuring scale to be given further on only determines the intellectual power, that is, the ability to think, to reason, to judge, to adjust one’s self to the social requirements of the world around him and to exist harmoniously in it, in conformance to its laws and customs….
The purpose of our mental measuring scale at Ellis Island is the sorting out of those immigrants who may, because of their mental make-up, become a burden to the State or who may produce offspring that will require care in prisons, asylums, or other institutions.
Or, as the article’s subtitle put it, the scale contained “a progressive series of standardized tests used by the Public Health Service to protect our racial stock” (52).
Knox pointed out that the scale included questions and tests appropriate for different ages from three to thirteen and that older people should be able to meet the requirements for thirteen-year-olds:
(p.152) In other words, for the purposes of examination 13 years is adult or maximum development so far as the scale is concerned. The “mental” age of a given individual is the point in the scale beyond which he can go no farther; suppose for example that a man of 40 years could only do the things that a 9-year-old should do, we would say that this man was but 9 years old mentally, and this is a very common place for the mentally retarded to stop, in fact, a great many tramps such as the ones that go to make up the “hobo” armies that travel about the country and annoy church gatherings are actually less than this age mentally. They are easily led and influenced.
As he had in one of his earlier papers (Knox 1913g), Knox was again expressing the view that mental deficiency was tantamount to mental retardation.
He then presented “a scale for estimating mental defects in illiterates and others.” This was essentially the same as the original account published in the Journal of the American Medical Association almost a year before (Knox 1914c; see table 6.1) and included the seven “make-up tests” for adults whose mental ages
Table 7.1 Additional Tests For Educated Emigrants
Repeat a spoken sentence of ten words.
Write from dictation a sentence of ten words.
Make a sentence using the words man and dog. Give the opposites of good, right, white, wise, giving an illustration such as “tall—short.”
Make a sentence of not less than ten words, using the words man, dog, and gun. The answer must show some thought and not be simply, “I saw a man, dog, and gun the other day.” This would be almost a failure.
Make a sentence using the words man, dog, gun, and rabbit, showing each of these taking an active part.
Test the person in the spelling of such words as he commonly uses. Then have him give the multiplication tables from 4 to the table of 8, inclusive.
Thirteen years onward
The degree of education must be ascertained and questions improvised that will tend to show how much the man profited by his education and, in short, whether he knows as much as he ought to.
Source: Adapted from Knox 1915a:57–58.
As was (and still is) common for articles published in Scientific American, Knox’s piece contained copious illustrations. These featured all the performance tests and included a group photograph of the physicians at Ellis Island (figure 7.1). The original caption read:
Surgeon L. L. Williams and staff of the United States Public Health Service, at Ellis Island, N.Y. These officers stand guardian to our national health, and the colossal piece of preventive medicine carried on by them saves the country (p.154) untold millions of dollars each year and helps to maintain the high physical and mental standard of our race. The officers of the United States Public Health Service are commissioned by the President in the same manner as are the officers of the Army and Navy, and the scheme of the Service as regards rank, pay, duties, and social life is in general the same.
Perhaps most strikingly, however, Knox’s Scientific American article was illustrated with photographs of apparently genuine emigrants attempting to carry out some of the performance tests. For instance, the original caption to figure 7.2 read:
A mentally defective immigrant woman attempting to perform the fourth, or d, line of the cube test, with which she had but little success, having failed in three out of four trials. She was the mother of three children, one of which was defective also, and the other two, while normal intellectually, were, of course, capable of transmitting feeblemindedness and neuropathic tendencies to their offspring.
Similarly, the original caption to figure 7.3 read:
There is practically nothing in the physiognomy of this immigrant that indicates the gross mental defect that he possesses. The alien is performing, with considerable difficulty, the Seguin formboard, a task which should not require more than 20 seconds in normal adults; this alien required anywhere from 45 seconds to 4½ minutes, and his performances did not improve with practice and repeated trials.
At the Psychiatric Institute
In the summer of 1915 Knox was temporarily detailed to work as an assistant physician at the Psychiatric Institute of the New York State Hospitals (today part of the Columbia University Medical Center), which was located in Manhattan State Hospital on Ward’s Island. He took the opportunity to write a paper, “A Broader View of Mental Deficiency in Aliens,” which was published in the New (p.156) York Medical Journal that October (Knox 1915c). He commented that the physicians of the U.S. Public Health Service had adopted “a constantly broadening view of what really constitutes mental deficiency” (755) and that this explained the drastic increase, from 25.1 per 100,000 in 1908 to 50.8 per 100,000 in 1913, in the proportion of emigrants who had been certified as mentally deficient.
This much broader conception of mental deficiency included the feebleminded, paupers, inebriates, criminals, epileptics, the insane, those with congenital asthenia (i.e., weakness) and poor physique, “the diathetic class” (those predisposed to acquire certain diseases), and “persons possessing stigmata and deformities” (752–54). Knox seems to have been especially interested in congenital deformities of the hands as signs of mental deficiency. He later wrote to the Journal of Heredity, enclosing two x-ray photographs to illustrate a case of polydactylism (having extra fingers or toes) in an Italian emigrant. The journal used these in an unsigned editorial (“Extra Fingers and Toes” 1916), but its author considered that the condition had no link with mental deficiency and consequently “possesses no eugenic significance” (324).
While he was at the Psychiatric Institute, Knox also wrote a short paper about dementia praecox. This was eventually published in late 1917 in a series of articles (referred to as a “medical symposium”) that was appended to a book by Maximilian Paul Eugen Groszmann, The Exceptional Child (Knox 1917e). The term dementia praecox had been adopted near the end of the nineteenth century by the German psychiatrist Emil Kraepelin to refer to a disorder seen in late adolescence or in early adulthood that was characterized by progressive intellectual deterioration. Kraepelin believed that the disorder was organic in nature and probably caused by some kind of hormonal abnormality following puberty.
The visit of Sigmund Freud and Carl Jung to the United States in 1909 had prompted an interest among American physicians in psychoanalytic accounts of such diseases. In particular, many were influenced by the view of the Swiss psychiatrist, Eugen Bleuler. Bleuler argued that the notion of dementia praecox was too narrow, and he put forward the new term of schizophrenia. He also suggested that the disease had psychodynamic origins. Other American physicians, such as Adolf Meyer, argued that schizophrenia resulted from a complex interplay of biological, social, and psychological factors.
Knox himself had published a paper advocating the application of psychoanalytic ideas in general medical practice (Knox 1913b). It is not particularly surprising, then, that in the paper that he wrote at the Psychiatric Institute Knox took a view similar to Meyer’s. As Knox put it, “Dementia præcox has a toxic [i.e., organic] origin with a superimposed psychosis of psychogenic derivation” (1917e:650). However, he also felt that once the disease was established, any attempt at treatment was “a more or less useless endeavor”; the only hope was to (p.157) spot the disease before its full onset, in what he called the stage of “predementia præcox” (649).
In some cases, Knox argued, dementia praecox was mainly an organic disease, in which case hormone therapy might be needed. In other cases it was particularly a problem of psychic maladjustment, in which case it would be necessary to investigate its psychological origins by a variety of means, including psychoanalysis. Knox commented: “It is in this direction that I have already made some endeavors. It will take years to determine whether or not these have been effective, and even then I shall not know with certainty that the cases would have developed dementia præcox if it had not been for my efforts” (650).
Subsequently, the expressions dementia praecox and schizophrenia have tended to be used interchangeably, but American clinicians define them more broadly than their counterparts elsewhere in the world, and schizophrenia is more commonly used by those who maintain that the primary origins of the disease are psychodynamic (as the etymology of the term—”splitting of the mind”— would suggest). Nevertheless, research using brain imaging and other modern technology has identified neurological abnormalities not only after but even before the onset of the disease. This has led to calls to drop use of the term schizophrenia altogether and to reinstate Kraepelin’s original notion of dementia praecox (Adityanjee et al. 1999).
Marketing the Ellis Island Tests
Knox’s paper in Scientific American attracted a good deal of interest from academic researchers, clinical practitioners, and educationalists. He received not only numerous requests for reprints but also a number of requests for copies of the actual apparatus used in his performance tests. Knox seems to have originally assumed that others would simply make their own copies. For instance, he advised that the various form boards should be backed with a thin sheet of wood or cloth to stop the pieces from slipping through (Knox 1915b). However, at some point during 1915 he arranged for copies of the Ellis Island tests to be produced and distributed by C. H. Stoelting Company of Chicago, an established and well-known supplier of laboratory equipment and test materials. The leaflet describing the “Apparatus and Supplies for ‘A Scale for Estimating Mental Defects’” bears the date November 15, 1915 (Knox 1915d).
The cost of a complete set of the materials, including a “Book of Instructions” and fifty blank record cards “used by the U.S. Public Health Service at Ellis Island, N.Y.,” was $41.69. “Book of Instructions” was, however, something of a misnomer. It was officially entitled Alien Mental Defectives: A Collection of Papers Descriptive of (p.158) the Tests and Methods Employed by the United States Public Health Service, Ellis Island, N. Y. (Knox 1915e). In fact, it consisted simply of a set of reprints of three of Knox’s previously published papers (Knox 1913e, 1914c, 1914f). These had been reset and repaginated to fit on statement-size paper (5.5 inches by 8.5 inches), and each set of reprints was presented in a “Photomount Pamphlet Binder” supplied by Gaylord Brothers of Syracuse, New York.
One can assume that Knox’s superiors were content with the idea of his work’s being made available in this way, because they subsequently arranged for copies of the commercial versions of the performance tests to be purchased for use at Ellis Island. Illustrations of the tests, many bearing Knox’s name, were included in the Manual of the Mental Examination of Aliens (1918), which I discuss next. In chapters 10 and 11, I describe how the tests were used by many other researchers and practitioners between the two world wars.
The Manual of the Mental Examination of Aliens
This project had a tortuous history and took more than five years to come to fruition. Although new medical officers had long received a book of instructions for the inspection of emigrants, this did not take into account the increased interest in mental examination. In February 1913 the Public Health Service therefore agreed that there should be a new manual specifically on this topic. Senior Surgeon Stoner assigned passed assistant surgeons Eugene Mullan and Marshall Crapon Guthrie to take the matter forward. However, Guthrie left Ellis Island soon afterward, and little work appears to have been done in the next six months.
In August 1913 Mullan went to Surgeon Williams, who by then had replaced Stoner as the chief medical officer, with a rather different proposal. He suggested that an officer should be detailed to administer mental examinations to normal emigrants in order to build up a body of normative data with which the performance of other emigrants might be compared. Mullan reported that a small start had already been made, in that he had tested eighteen Italian emigrants, while his colleague Bernard Glueck had tested fifty Polish emigrants. Their other responsibilities had prevented them from doing more than this; however, if an officer were assigned to this task as a sole responsibility, two thousand emigrants could be tested in a year, Mullan claimed.
He justified his proposal on two grounds. First, the physicians were currently in a position to identify those emigrants who were patently mentally deficient. However, the only normative data available were from children in France or the United States and were inappropriate for use with emigrants. In the absence of valid normative data, the physicians were unable to make more subtle decisions (p.159) and exclude those emigrants who were only moderately deficient. Second, if the Public Health Service did not take the initiative in this area, physicians and psychologists elsewhere (he mentioned the New York State Psychiatric Institute and the Vineland Training School, in particular) might well do so, Mullan argued.
Surgeon Williams forwarded Mullan’s proposal to the surgeon general in Washington, saying that it had his “cordial approval” and that, if approved, Mullan should be designated to take on the work. Moreover, Williams suggested that it would form an important part of the proposed manual of mental examinations and that all the physicians at Ellis Island engaged in carrying out mental examinations should be asked to contribute material to this project. He added that he had asked Passed Assistant Surgeon Thomas Salmon to assist in editing the work. Salmon was at this time on leave of absence from the Public Health Service and was working for the National Committee for Mental Hygiene, but he had nevertheless agreed to help with this project.
The surgeon general, Rupert Blue, replied that he approved the plan as a whole, and he wrote to Salmon to invite him to chair a board to be responsible for preparing the manual. In his letter Blue referred to the proposed manual as a pamphlet, implying that he was not expecting a substantial piece of work. He added that Salmon’s role would have to be an unofficial one since there would be no remuneration. He then asked Williams to meet Salmon to discuss the membership of the board but added that he, Blue, would be unable to spare anyone to replace Mullan while he was engaged in testing normal emigrants. Williams replied that he could manage without a replacement for Mullan but needed four or five additional interpreters.
Members of the initial board convened to prepare the manual for the mental examination of emigrants were
- Passed Assistant Surgeon Thomas W. Salmon (chair)
- Passed Assistant Surgeon Eugene H. Mullan
- Assistant Surgeon Grover A. Kempf
- Assistant Surgeon Howard A. Knox
- Assistant Surgeon George Parcher
- Acting Assistant Surgeon Bernard Glueck
They did not meet as a board until the beginning of December 1913, when they came up with two recommendations. First, they endorsed Mullan’s proposal for the collection of normative data “to enable us to formulate adequate standards for determining mental deficiency in different types of immigrants.” They suggested that this work could be carried out while other portions of the proposed manual were being prepared. Second, they requested that Assistant Surgeon (p.160) Walter Lewis Treadway be appointed to the board to replace Bernard Glueck, who had returned to his regular position at the Government Hospital for the Insane in Washington. Knox mentioned the board’s work in an article that he published in the New York Medical Journal in January (Knox 1914a).
Mullan had previously sought advice on the selection and administration of tests from Robert Woodworth and one of his colleagues at Columbia University, Henry Alford Ruger, and in early January Mullan embarked on the collection of data. He worked with an interpreter who spoke Italian, Spanish, and German, and Mullan initially proposed to focus on emigrants of those nationalities. After spending a week developing their procedures, Mullan and his interpreter selected cases from among the emigrants who had been detained for at least twenty-four hours in the detention rooms or from the ambulatory cases in the hospital on Ellis Island. (It is unclear what inducements, if any, the emigrants were given to participate.) However, Mullan and the interpreter excluded emigrants who had been detained as possible cases of mental deficiency.
Toward the end of May 1914 Surgeon Williams mentioned Mullan’s study during his address to the annual meeting of the American Medico-Psychological Association in Baltimore. He explained that the study’s aim was to “aid in standardizing the tests in use, and assist in establishing at least approximately a practical standard upon which certification may be based” (Williams 1914:266). With the outbreak of World War I in Europe in September 1914, finding suitable examinees became difficult. However, Mullan concluded that they already had collected sufficient data, and he discontinued the study with a total of 296 emigrants examined. Three turned out to be mentally deficient, so their data were dropped from the analysis.
The tests that Mullan had used were predominantly verbal. They seem to have been based on the test battery that Mullan had previously advised Glueck (1913) to use in his work with Polish emigrants (see table 5.1) and included tests taken from or similar to those in Binet and Simon’s 1908 scale. However, they also included the Healy Frame Test and the Geographical Puzzle, as well as a version of the Cube Imitation Test, modified in certain respects:
The cubes were tapped with a spool instead of a block “so as to draw the subject’s attention from the exact way in which the cubes were struck and to the essential nature of the problem, the order in which the different cubes were touched by the examiner” (E. H. Mullan 1917b:39).
After six trials in which each of a line of four cubes was tapped once, a fifth cube was added to the line, and the examinee underwent four trials in which each of the five cubes was tapped once (see figure 7.4). (p.161)
A contemporary account by one of Mullan’s colleagues, Milton Hugh Foster (1914), implied that in this version of the test all five cubes were the same color: “The cube test … consists in placing four or five ordinary wooden blocks of the same size and color in a row on the table before the subject” 1069). However, neither Mullan nor Foster specified the color.
The examinee was allowed two attempts in the first trial but only one attempt in all other trials. Although the cubes were generally tapped at a constant rate of one per second, a longer pause (between one and a half and two seconds) was interposed after the second or third item in each sequence. Mullan found that 75 percent of examinees could copy four trials with four cubes and one trial with five cubes.
In September 1914 Knox received a request for reprints from Adolf Meyer at the Johns Hopkins Hospital in Baltimore. Knox sent some reprints but commented in a cover letter that “they do not, however, represent our advanced work or findings.” He explained that “a complete report of our work will be published by the Public Health Service in the near future in the shape of a manual for the mental examination of immigrants.” It would be based on the research that Eugene Mullan had been carrying out during the previous year “and also upon the practical work done by myself and others.” At least two sections had already been written, one on psychiatry by Walter Treadway and another on working with interpreters by Grover Kempf.
Early in 1915 Thomas Salmon resigned as chair of the board that had been convened to prepare the manual. This may have been because of the pressure of his work for the National Committee for Mental Hygiene, where he was responsible for commissioning surveys of mental health provision in particular states (p.162) and, indeed, was carrying out some of these surveys himself (Bond 1950:55–58). Nevertheless, he may also have been dissatisfied at the lack of progress on the manual. To try to speed matters up Surgeon Williams, the chief medical officer at Ellis Island, wrote to the surgeon general on March 1 to suggest that surgeons Ezra Sprague and Milton Foster should be added to the board and that, as the senior officer, Surgeon Sprague should be asked to replace Salmon as its chair.
During this time, of course, Howard Knox had not been idle. His article had appeared in Scientific American less than two months before and had attracted a good deal of attention. On March 1 he wrote to the surgeon general, offering to prepare a brief monograph describing the use of his intelligence tests. The assistant surgeon general, Leland Eggleston Cofer, replied by asking whether it would be feasible for him to prepare such a monograph for publication in the Public Health Service journal, Public Health Reports. Knox agreed to prepare this publication, and Surgeon Williams forwarded Knox’s reply to Washington with the following comment:
A monograph of this kind, if published by the Bureau, would be regarded as an authoritative statement of the settled practice in the examination of defective aliens and should therefore represent the concensus [sic] of opinion of the officers engaged in such work. It would also be, to some extent, a forecast of the manual the preparation of which is now being pushed. For these reasons it is suggested that Dr. Knox’s article, before publication, be submitted for criticism and discussion to the board detailed by the Bureau to prepare a manual for the examination of mental cases.
The surgeon general, Rupert Blue, approved the preparation of the monograph on this basis. Knox did indeed prepare such a monograph, but it was never submitted to the Public Health Service for publication and was never, indeed, formally published at all.
The board met on May 26, 1915, to discuss the preparation of a manual for the mental examination of immigrants and agreed an outline of contributions together with the names of authors who would take responsibility for each chapter. On June 18 Surgeon Sprague forwarded to the surgeon general a contribution from Eugene Mullan with the title “Psychology of the Arriving Immigrant.” Sprague pointed out that it contained results from 293 subjects, or one and a half times as many as Binet and Simon had tested in devising their 1908 scale. Sprague thought that the contribution was not too long for the proposed manual but that, if the work were regarded as too voluminous to be included, he recommended “that it be published separately as a valuable original contribution to the subject and for use of others engaged in work along the same lines.”
(p.163) In July the chapters by Knox (“Mental Deficiency and the Use of Certain Intelligence Tests in the Examination of Immigrants”) and Treadway (“A Guide to the Psychiatric Examination of Immigrants”) were also forwarded to the surgeon general’s office. Like Mullan’s chapter both were longer contributions, and Sprague thought the board would need extra time to consider them. After a further exchange of correspondence with the surgeon general’s office, the remaining chapters were completed in August and early September. Nevertheless, Assistant Surgeon General Cofer was not entirely satisfied with the manuscripts that he received, and he turned for advice to Surgeon Claude Hervey Lavinder.
Lavinder had graduated from the University of Virginia in Charlottesville in 1895 and had initially trained as a radiologist. However, he had been assigned to a variety of locations after he joined the Marine Hospital Service in 1897, and his most recent work in New York City had been mainly concerned with the epidemiology of pellagra. This disease is manifested in lesions of the skin, but it also gives rise to alimentary and neurological symptoms and eventually death. Previously, it had been relatively rare in the United States, but it had become increasingly prevalent, especially in the South, since 1907. Lavinder had written about the prognosis and treatment of pellagra, and in 1913 he had produced a report on its prevalence and geographic distribution. Even so, the task of investigating the cause of pellagra was given to his colleague in the Public Health Service, Joseph Goldberger, who eventually showed that it resulted from a dietary deficiency of the vitamin niacin in people who subsisted chiefly on maize.
In September 1915 Lavinder was appointed to work in the laboratories at Ellis Island. It is not clear whether the true purpose of his appointment was for him to advise on the manual for the mental examination of emigrants, but immediately on his arrival he was appointed chair of the board responsible for the manual, replacing Sprague. Soon afterward Surgeon Williams left Ellis Island, and Senior Surgeon James Clifford Perry was appointed as chief medical officer in his place. The membership of the board was now reduced to Lavinder, Mullan, and Treadway. By December, however, Treadway had left the Public Health Service, and Mullan had temporarily been assigned elsewhere, leaving Lavinder in sole charge of the project. On December 18 Lavinder wrote to Assistant Surgeon General Cofer in a personal rather than an official capacity:
I have gone over all of the manuscripts. If all is published it will make book (octavo size) of not less than 500 pages, profusely illustrated, both with cuts and charts etc. Some of the mss. are all right, some are indifferent and some I do not think suitable as they now are. I do not feel sure from the language of our instructions as to whether the board is expected or permitted to express any opinion as to the quality of the material, or whether it is simply expected (p.164) to arrange the material submitted for the printer. I am sure however that this book, when issued, will be closely scrutinized by many outsiders, and of course the Bureau desires to get out a creditable publication. Hence I take the liberty of offering some opinions. Besides the quality of the mss. there is an evident lack of consistency and coherence in the whole thing. The various articles do not hang well together. I think this is necessarily the case in any book written in this manner, that is the assignment of a subject to various writers without any editorial supervision. An editor in chief would have had in mind the completed book and required things so arranged as to make a coherent and consistent whole.
I venture to suggest the advisability of appointing some man editor in chief with full powers to do whatever is necessary to get out the book, even to the extent of selecting some other man to write an article if necessary. In no other way will the thing be satisfactory, I fear. Of course the selection of such an editor in chief should be done with care, and if necessary he can have an advisory board, but he must have broad powers.
Cofer referred the matter to Blue, the surgeon general, who wrote to Senior Surgeon Perry, the new chief medical officer, on December 22:
The Bureau is desirous of expediting in every way possible the completion of this manual, and it has been suggested by Surgeon Lavinder that the whole mass of MSS. should be put in the hands of an editor in chief, who could arrange the material to the best advantage so far as economy and efficiency are concerned. The Bureau, having special confidence in Surgeon Lavinder’s abilities along these lines, is desirous of making him the editor in chief, but before doing so it was thought that you should state, as a result of a conference with him, whether this work would necessitate his giving his whole time to it, or whether by assistance of some kind, his laboratory duties could be carried out at the same time he was arranging and editing the manuscript. In this connection the desires of the Bureau are as follows:
The book or manual should be arranged as if it were written by one person, but due notice should be given on the covers and in the press that the material has been contributed by the officers who have done so. In other words, it is not desired that it should be simply a collection of articles, for various reasons not necessary to mention here.
Again, while the Bureau desires illustrations, and believes them to be necessary, it must be borne in mind that every illustration adds distinctly to the expense attending the publication of the book, and also adds to the size of the latter, which so far as general utility is concerned, should be kept as small as possible.
(p.165) Lavinder was duly appointed editor-in-chief of the proposed manual, but within a few months his work was interrupted, not by his laboratory duties but by a major epidemic of poliomyelitis in the northeastern United States.
In the early years of the twentieth century, poliomyelitis had been endemic throughout the United States. It had been estimated that, across the entire country, there were between five thousand and twelve thousand cases per year, roughly one-fifth of which proved fatal. There had been sporadic peaks in its incidence, but these had been mainly local. However, in May 1916 an epidemic of poliomyelitis began in Brooklyn and spread to the other boroughs of New York City. The number of new cases peaked in the second week in August, then declined to normal levels by the end of October. Altogether, 9,345 individuals were affected, 80 percent of whom were children younger than five. Twenty-four percent of all people affected—98 percent of whom were younger than fifteen—died. Moreover, the disease spread to the surrounding states, affecting New York, New Jersey, Pennsylvania, Delaware, Maryland, Connecticut, Massachusetts, Rhode Island, Vermont, New Hampshire, and Maine, so that the total number of cases attributed to the New York epidemic was put at twenty-three thousand.
In early July the Public Health Service offered to monitor the progress of the epidemic. Lavinder was ordered to suspend his other duties and was assigned the task of investigating its epidemiology, together with two colleagues based in Cincinnati and with the support of a team of experienced physicians. Although Lavinder and his colleagues gathered a substantial amount of evidence, the distance between them impaired their collaboration. It was disrupted yet further when the United States entered World War I in April 1917. After one or two brief meetings Lavinder was left with the task of completing their report, which he submitted on September 8. It was eventually published the following July (Lavinder, Freeman, and Frost 1918) and is today regarded as a major work on the epidemiology of poliomyelitis (see, for example, Trevelyan, Smallman-Taynor, and Cliff 2005).
Once the epidemic was past its peak, Lavinder was able to devote time to working once more on the proposed manual for the mental examination of emigrants, and Senior Surgeon Perry submitted a revised manuscript to the surgeon general on January 31, 1917. After explaining the reason for the further delay, he commented:
The editor does not believe the manuscript is ideal and it may be stated that an ideal result could not be expected under the conditions. It is believed, however, that the publication will provide a book not discreditable to the Service, and one that will be highly useful.
It can be improved in a second edition as experience with it, no doubt, will suggest many changes of importance. However, immediate publication of the (p.166) present manuscript is recommended, and it is believed that the work will produce a satisfactory working manual.
Much modification has been made in the material, and a considerable portion of manuscripts has been rejected in order to prevent overlapping, and to provide a suitably sized book.
The article of Dr. Treadway and that of Dr. Knox has not been used, except in a very small part. They were rejected not on account of their quality, but simply for lack of space, as it was the desire of the Bureau to reduce the size of the manual. I have returned the manuscripts of Doctors Treadway and Knox so that they may use it in some other publication if they should so desire.
As part of the revision, it was also agreed to use Sprague’s suggestion that Mullan’s chapter be published as a separate report: It appeared in October 1917 in the Public Health Service series Public Health Bulletins, entitled Mentality of the Arriving Immigrant (Mullan 1917b). Perry also enclosed a memorandum stating, among other things, that the various sections of the manual would not be described as “chapters” and that no credit would be given to any particular officer: The introduction would simply state that the manual was the result of a process of evolution in which all the officers who had served at Ellis Island had had a part.
Despite Lavinder’s work, the manual was not yet complete. The surgeon general referred the revised manuscript for further editing, and Passed Assistant Surgeon Lawrence Kolb was given the task of producing the final version. He made further extensive changes aimed at removing any repetition and ensuring that the text was current. He rewrote the section on performance tests, which in the final manual ran only six pages (30–35). Photographs of eight tests were provided, and readers were referred to Mullan’s (1917b) report for further information. The Cube Imitation Test was mentioned but was not described in detail nor listed as a performance test (29). Senior Surgeon Perry submitted the final manuscript on August 20, 1917. The surgeon general sent it to the Government Printing Office three days later, but, under wartime conditions, it was not published until the following year, when the anonymous Manual of the Mental Examination of Aliens appeared as “Miscellaneous Publication No. 18” of the Public Health Service.
By modern standards manual is once again a misnomer. It did not prescribe when or how to use particular tests or how to evaluate an emigrant’s performance. Instead, it left considerable discretion to individual examiners. For instance, it only was suggested that “each immigrant should be given one or two performance tests” (30). Elsewhere, Mullan (1917a) recommended that initial screening of individual emigrants should include tasks such as counting, addition, and the Cube Imitation Test, but thereafter he commented,
(p.167) There is individuality in each officer’s method of conducting a mental examination. There is also a great deal in common about the various examination methods. Some tests and questions are used by all, while individual preference obtains in regard to other tests. As time goes on, new tests and methods are tried, and the ones that are found to be of value are adopted by all. Other tests are tried, found to be useless, and are given up.
Mainly as a result of Knox’s own endeavors, the Ellis Island tests soon became widely known among physicians, psychologists, and educationalists across the United States, and copies of the tests were readily available from C. H. Stoelting Company. Nevertheless, Lavinder dropped Knox’s chapter from the Manual of the Mental Examination of Aliens, and only a brief description of the Ellis Island tests remained. According to Knox’s family, this engendered in Knox a lifelong resentment toward Lavinder.
Knox considered turning his chapter into a book. In January 1916 the superintendent of the Eugenics Record Office, Harry Laughlin, wrote to ask whether Knox had made any progress in this regard, suggesting that such a book would be a valuable contribution to the field, and Knox sent him the manuscript of the rejected chapter. With Knox’s agreement Laughlin submitted it to Warwick and York, a publishing house in Baltimore, and Laughlin promised to seek another publisher if they did not wish to take it. However, nothing seems to have resulted from these efforts on Knox’s behalf. His unpublished papers do contain parts of a manuscript, but these are mainly photographs of the Ellis Island tests, together with photographs of emigrants arriving at Ellis Island and being interviewed and tested by the physicians.
(1.) Knox’s deposition may be found in the records of the Immigration and Naturalization Service, Record Group 85, Accession 60A600, box 679, file 53791/126, National Archives, Washington, D.C.