Hektoen International

A Journal of Medical Humanities

Howard A. Knox and intelligence testing on Ellis Island

Carine Tabak
Kansas City, Kansas, United States


Interview during the mental examination of an immigrant on Ellis Island, conducted by two PHS officers and an interpreter. US National Library of Medicine Digital Collections. 

Between 1892 to 1924, twelve million men, women, and children entered the United States through the Ellis Island Immigration Center, making it the largest health screening facility in the US at the time.1,2 At first, immigrants were inspected to identify medical conditions, but changing economic and political forces shifted the screenings’ focus to judging them worthy or unworthy of admission to the country. When Howard Andrew Knox began to work on the island in 1912 as an assistant surgeon for the Public Health Services (PHS), he sought to create new, more objective methods for intelligence screening, yet the outcomes bore different results.3

The initial goal of the medical inspection was to screen those entering the American labor force.4 In the 1850s, the United States economy boomed, and the desire for cheap labor grew exponentially. The public welcomed these immigrants, and their role in America’s growing economy was celebrated4,5; however, rising economic inequality in the 1880s created a shift in perceptions.5 Immigrants were accused of being dangerous to the religion, politics, and morality of the nation’s urban centers,1 and politicians such as Henry Cabot Lodge and nativist groups such as the Immigration Restriction League argued vehemently that immigration flows could not be controlled by the medical inspection then in place.4,5 The concurrent rise of the eugenics movement in the US drove the inspection’s focus away from immigrants’ health and towards their racial stock.

Leading eugenicists and scientists at the time, including physicians at the PHS, expressed growing concern over the “racial quality” of the American population.6-8 Eugenicists used emerging scientific theories to justify their belief that human traits were inherited and that one’s hereditary “stock” dictated all human behaviors, including criminality and intelligence.6,9 The immigration stream, then mainly composed of southern and eastern Europeans, was seen as a large source of “inferior” individuals.9,10 Prominent eugenicists, such as Madison Grant, argued strongly against immigration, stating that “we Americans must realize that the altruistic ideals which have controlled our social development […] and the sentimentalism that has made America ‘an asylum for the oppressed,’ are sweeping the nation toward a racial abyss.”11

Thus, the mental examination of immigrants became a large debate in the field of public health because of this concern for the “mental hygiene” of Americans.8,12-15 Through their political presence, eugenicists pushed their racial ideas of social hierarchy into law.14 They argued it was the state’s responsibility to ensure the genetic quality of the American race by limiting the entry of “constitutionally inferior” immigrants. The subsequent immigration restriction legislation passed altered the medical inspection and called for the deportation of any incoming immigrant who did not meet mental standards.8,14 Instruction manuals specific to the mental examination of immigrants, in contrast to just the medical inspection, openly presented the PHS’s views on the “mentally defective,” stating that such an alien is “an impossible burden which tends to perpetuate itself.”13

PHS officers such as Knox performed the inspection.1,3 It is of note that physicians only played an advisory role in cases of exclusion and were therefore shielded from the ultimate consequences of their evaluation. They were expected to examine and possibly diagnose patients, but all final decisions on immigration were made by the US Immigration Services.8,13 While a medical diagnosis of being “mentally inferior” could directly lead to the exclusion of an individual, the physician could always argue that the decision was made by government officials, not them.

The literacy test passed in 1917 was the first official screening that tested specifically for intelligence.16,17 Supporters of the literacy test had little to say about the necessity of reading in American society but rather condemned the upbringing and values that had led to an immigrant’s illiteracy; “illiterates” exhibited innate and hereditary characteristics that made them undesirable.16,17 As the years went on, the inspection acquired a focus for specific disorders that the country wanted to exclude, including the “socially unfit” and “mentally defective” individuals.

These literacy tests were gradually considered to be too dependent on language proficiency, so Knox instead created puzzle-based performance tests.3,18-20 He published several age ranked scales, similar to those used in the Binet and Simon scales of intelligence, in which specific requirements were listed from age three to thirteen.18 Knox and the other PHS officers used these measurements of “mental age” to compare an immigrant’s test performance with what they expected individuals at a certain age to achieve.13,18 A period of testing for one person would include multiple tests, including counting tests, block tests, and forms of logic tests called stories.3

The performance tests provided scientific reasons why certain groups were excluded. However, Knox was a firm believer in the eugenics theories and took pride in his duty to “maintain the high physical and mental status of our race,”18 and the tests left room for personal interpretation and prejudice. In this context, and considering disparities in their outcomes, the tests became a way to scientifically “prove” eugenicists’ beliefs of mental inferiority rather than were mere objective tests used for health screening. The tests embodied their makers’ beliefs of human hierarchy and used medicine to discriminate against specific races and religions.

As a whole, the medical inspection on Ellis Island reflected the period’s changing political and social beliefs about immigration and were the consequences of blaming immigrants for overcrowding, unemployment, and the corruption of America’s “mental hygiene.” While it is easy to classify physicians’ role in an immigrant’s exclusion as purely advisory, it is important to recognize that Knox and the PHS used medicine to validate their actions. Ultimately, these physicians misused medical inspections to discriminate, as well as focus on the undesirable qualities of immigration, rather than the benefits it brought to the nation.



Special thanks to Dr. Christopher Crenner, MD, PhD, the Department of History and Philosophy of Medicine at KUMC, and the staff at the Clendening Library for all their help with this project.



  1. Birn AE. Six seconds per eyelid: The medical inspection of immigrants at Ellis Island, 1892-1914. Dynamis: Acta Hispanica ad Medicinae Scientiarumque Historiam Illustrandam 1997;17:281-316.
  2. Yew E. Medical inspection of immigrants at Ellis Island, 1891-1924. Bulletin of the New York Academy of Medicine Jun 1980;56(5):488.
  3. Richardson J. Howard Andrew Knox: Pioneer of intelligence testing at Ellis Island. Columbia University Press; Nov 29, 2011.
  4. Fairchild AL. Science at the borders: Immigrant medical inspection and the shaping of the modern industrial labor force. JHU Press; Jun 4, 2003.
  5. Higham J. Strangers in the land: Patterns of American nativism, 1860-1925. Rutgers University Press; 2002.
  6. Cohen A. Imbeciles: The Supreme Court, American eugenics, and the sterilization of Carrie Buck. Penguin; Mar 7, 2017.
  7.  De C. Ward R. National eugenics in relation to immigration. The North American Review Jul 1, 1910;192(656):56-67.
  8. US Bureau of Public Health and Marine Hospital Service. Book of Instructions for the Medical Inspection of Aliens. Washington: Government Printing Office, 1910. Accessed via: https://curiosity.lib.harvard.edu/immigration-to-the-united-states-1789-1930/catalog/39-990063864900203941
  9. Bashford A, Levine P, eds. The Oxford handbook of the history of eugenics. OUP USA; Sep 24 2010.
  10. Jacobson MF. Whiteness of a different color. Harvard University Press; 1999 Sep 1.
  11. Grant M. The passing of the great race. C. Scribner’s Sons; 1916.
  12. US Bureau of Public Health and Marine Hospital Service, Wyman W. Book of Instructions for the Medical Inspection of Immigrants. GPO; 1903. Accessed via: https://archive.org/details/bookinstruction01servgoog/page/n12/mode/2up.
  13. US Public Health Service. Manual of the Mental Examination of Aliens. GPO; 1918. Accessed via: https://archive.org/details/manualofmentalex00unit/mode/2up.
  14. Laughlin HH. Biological aspects of immigration. House of Representatives Committee on Immigration and Naturalization, Apr 16, 1921:3-26.
  15. Parascandola J. Doctors at the gate: PHS at Ellis Island. Public Health Reports Jan/Feb 1998;113(1):83. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308373/pdf/pubhealthrep00036-0085.pdf.
  16. Hoyt H. The relation of the literacy test to a constructive immigration problem. Journal of Political Economy May 1, 1916;24(5):445-73.
  17. Foster MH. Methods of examination of illiterates for mental defectiveness. Journal of the American Medical Association Apr 4, 1914;62(14):1068-71.
  18. Knox HA. Tests for Mental Defects: How the Public Health Service Prevents Contamination of Our Racial Stock by Turning Back Feeble-Minded Immigrants—General Characteristics Noted and Progressive Series of Tests Applied to Determine Exact Mentality. Journal of Heredity Mar 1, 1914;5(3):122-30.
  19. Knox HA. A scale, based on the work at Ellis Island, for estimating mental defect. Journal of the American Medical Association Mar 7, 1914;62(10):741-7.
  20. Knox HA. Measuring human intelligence. Scientific American Jan 9, 1915;112(2):52-8.



CARINE TABAK is a medical student at the University of Kansas and holds a Bachelor of Science in Molecular, Cellular, and Developmental Biology from the same. She is interested in pursuing a residency in internal medicine.


Submitted for the 2022–23 Medical Student Essay Contest

Spring 2023  |  Sections  |  History Essays

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