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This ratio is for in-patients only. The nativity of out-patients at the Out-patient Department of the Massachusetts General Hospital and at six large dispensaries in New York City embracing 245,013 cases, and covering the years 1860 to 1886 is Natives.
This gives a ratio of about seven to nine; if we were to exclude children, it would be as high as seven to ten. (It may be said incidentally that all the reports show a rather rapid increase in late years of native medical paupers, this increase being due largely, I believe, to the presence of the children of the foreign born.)
The figures above given show that among the sick poor there is a considerable excess of the foreign born. The fact that a great many dispensary patients are children lessens the apparent number of foreign-born very considerably.
Does the same ratio hold for those sick with nervous disorders ?
This is a very difficult question to answer positively. I have, however, collected the statistics of nativity of 4217 cases of nervous disease, as follows:
1060 Post Graduate School, 1883-86,
732 Bellev. Hosp.,Out Pt. Dept., 1877 and 1886, 425
This gives a ratio of a little over two to three, a proportion slightly in excess of that for general diseases. The difference, considering the smaller number of children in this class, is small. In other words, more foreign-born patients, proportionately, seek treatment for nervous disorders than for general diseases, and there is a slight special tendency to nervous disorders among the poorer immigrants.
I should place very little value on such statistics, though laboriously and carefully collected, if they were not in accord with my own personal observations, with the results of other inquiries and with a priori considerations. In my own practice it is true that the bulk of my patients are Americans, but, considering the number of the foreign-born who can afford to seek private medical advice, the proportion of it is decidedly large.
Furthermore, the Americans suffer much more from functional nervous disease and immigrants from organic. Whether or not this is due to the relatively better social condition of natives, it is a fact in which, I think, all neurologists will agree.
But though immigrant population is at first less subject to functional disease and more subject to organic nervous diseases, in the succeeding generation when they have accumulated sufficient to live better, the functional diseases appear, and in some classes in excess.
Such views above stated are quite in accord with the fact that the immigrant has, as a rule, duller and more insensitive nerves. He belongs to the class that works most with the body and that lives an animal life. It is not the nervous system which gives out first under conditions of poverty and bad living, but rather the vascular, digestive and eliminative organs. Later, when the stomach and general nutrition are better cared for, the nerves yield to the stress of competition work.
It will be seen, I think, that I have taken a conservative view of the relation of immigration to insanity and nervous diseases. I think that the figures which have heretofore been given exaggerate the share of immigrants in increasing insanity.
The influence exists and is important, but it is not immediately and directly a large one.
Similarly, the direct influence of immigration in increasing nervous disease is not great, and it acts in a peculiar way. It increases organic nervous diseases. The chronic functional nervous disorders occur mostly among natives, and the children of immigrants. But - and here is an important point -- certain classes of immigrants in the second and third generation develop I believe, the functional neuroses as well as insanities to a large extent. Not all do this in the same degree, and the variations depend upon the races which are imported here. Some mix with the native population, improve, and grow strong. Others do not seem to thrive, but rapidly develop nervous and mental disorders.
Besides this, it is to be remembered, as Dr. Kiernan has pointed out, that our country attracts a considerable number of errabund lunatics of criminal, artistic and socialistic types.
With regard to their racial tendencies to nervous and mental disease, I speak with much caution ; but I venture to suggest that the following facts are approximately true :
The Celtic, including the Gaelic, Welsh, Irish and North French races represent an early offshoot of the Indo-Germanic peoples. They left their home in Asia early and travelled to the shores and islands of north-western Europe before they had reached the maturity that would enable them to earn a livelihood and at the same time make intellectual progress. They were never able to reach a full development. These races, unless they have mixed with others, have never furnished the ripest and noblest examples of human or national development. Witness the history of the Highlanders, the Irish, the Welsh, and of the Celts of Northern France. These are relatively immature races. They have never organized stable government or contributed largely to human progress. Brought to this country and placed in contact with the whirl of an intensely active civilization, they succumb to nervous disorders. The Irish are not an introspective race and do not easily become hypochondriacal, or neurasthemic. But they do develop insanity and organic nervous diseases largely.
The French, though a race to whom national genius has been given by mixture of Celtic, Gallic and Roman blood, has become intensely neurotic. Originally developed from an excitable race, it seems to be burning itself out and to be nearing now a premature climacteric. The Iberian race of Spain, and perhaps Portugal, is apparently decadent. The Portuguese in this country seem to suffer excessively from nervous disorders. (Putnam.)
Of the Arabic-African race, two branches, the African Semites, including the Egyptians, Nubians, and Abyssinians, and the Asiatic Semites, including Syrians, Hebrews and Phænicians have made a name in the world's history. They have, for the most part, staid near their place of origin ; there they have had full opportunities in a salubrious climate to mature, to accomplish national work, and then to decline. These races are now in an apparent decadence, the more surely, the more pure the blood has been kept.
Certain branches of the Hebrew race, and the Syrians and Egyptians, show this very distinctly. The Hebrew race has by inter-breeding produced some of the most brilliant minds the world has known, but many branches of it are rank with neuroses.
The foregoing will suggest, what, to my mind are the factors that are to be considered in studying the subject of our nervous hygiene in relation to immigration. Keep out inferior races, immature races, decadent races as much as possible. Restrict immigration sufficiently to prevent our having an undue proportion of paupers and of the lowest classes.
The mixture of races who are on the same plane makes a stronger race; witness Anglo Saxon and low German. The mixture of higher races with the inferior makes a product worse than either. The mulatto's brain for example is smaller than that of the negress or the white man. (Quatrefages.)
The Negro and the Mongolian are inferior races; we cannot make them better by intermixture with the Indo-Germanic. Keep out the African and the Chinese and Turks, therefore.
Of the Caucasian race the Asiatic and African Semites are most remote from us racially and most difficult to mix with safe results.
The Celtic race, whether found in Ireland, Scotland, Wales, North France, is an immature one, and of highly sensitive organization. It is not a good one to introduce into this country in large quantity.
I have already in the last pages of this paper practically summarized my conclusions. To repeat they are :
1. The statements as to the excessive influence of immigrants in increasing nervous disease are based on an incorrect study of statistics.
2. The immigrants do slightly and directly increase the amount of insanity out of proportion to this native population.
3. Immigration increases insanity indirectly through influence on social life and through introduction of poor nervous stock.
4. Only a portion and certain special races have these tendencies to nervous and mental disease.
5. The portion probably includes all Mongolians, the Asiatie and African Semites, Celts and Iberians.
6. Immigrants develop a slight excess of organic nervous diseases, but fewer functional nervous diseases proportionally than natives.
7. Portions (the neuropathic races), however, soon develop functional nervous diseases to excess in their children.
8. In studying the subject of regulating immigrations, racial tendencies to disease should be considered.
DISCUSSION OF DR. DANA'S PAPER.
[It should be remarked, before giving an abstract of the debate on this interesting Paper, that its statistical portion has been rewritten to some extent since it was read, and therefore that the criticisms then made do not fully apply now.
But there are still discrepant and perplexing statistical assertions,- as, for example, this : “ The ratio of foreign-born insane to the foreign-born adults is 7.5 per cent., and the ratio of native insane to native adults is 7.2 per cent." The figures previously given do not show this, for while the whole adult population (over fifteen years) in 1880 was about 30,212,000, and the foreign-born adults less than 6,200,000, the foreign-born insane are given as 26,346, out of a total of 91,997 insane persons. The ratio of this aggregate to the whole adult population is, therefore, .00304 ; while the ratio of the foreign-born is .00425, and that of the native born only .00273. The ratio of the foreign-born insane to the native is, therefore, 425 to 273, or nearly double. In fact, however, the relation to insanity of the persons of foreign parentage, is nearly the same as that of the foreign born; and, as the latter, in 1880, were only 6,679,943, while the former were estimated by the census-bureau at 13,011,646, or nearly twice as many, it is evident that ratios based only on the distinction between American born and foreign born cannot have much statistical value. And herein lies the tendency to error in the calculations, both of Dr. Dana and of Dr. Pratt.
ABSTRACT OF THE DISCUSSION. Mr. F. B. SANBORN: The valuable paper to which we have just listened, deals with a subject of extreme statistical difficulty, and it is doing Dr. Dana no injustice - I appeal to you, Mr. President, if I am wrong — to assure this audience that, if he will examine his figures carefully and comparatively, he will find that they do not bear out all his conclusions. The Census of 1880, although more accurately taken and tabulated than any other, cannot be depended on to give the exact percentage of native and foreign population in any single State, much less in the whole country.
When we come to the vital statistics of this census, - those which relate to disease and death, - we shall find them so imperfect, from the very nature of the case, that no important conclusions, except of the most general nature, can be drawn from them. If it should be