(2) Where a United States Public Health Service medical officer is assigned to a consulate, he may make other exceptions to the validity period of X-ray films if compliance with basic rules above is difficult or impractical because of circumstances or procedures at the visa office. The medical officer shall notify Division headquarters of any local provisions for such exceptions.

Note. All reliable X-ray films in a case are useful as medical data, no matter how old. The time-interval stipulations apply only to the current film.

5. United States Ports. The above instructions apply to arrangements for visa issuance and related medical examinations. There should be no problems on the subject when immigrants arrive at United States ports. However, the following instructions apply if any discrepancies should be noted.

a. If an immigrant presents a form FS-398 dated significantly more than six months before arrival, the quarantine officer issues a medical hold and requires a medical examination.

b. When an immigrant is required by the manual to present an X-ray film, and the most recent film presented is dated significantly more than seven months before arrival, the quarantine officer issues a medical hold and requires an X-ray examination.

c. When action is taken per paragraph "a" or "b," preceding, send Division headquarters a report giving pertinent details including: identification of immigrant; name of examiner and place of examination abroad; dates of form FS-398, X-ray film, and arrival; and results of examination performed on arrival. (Note: Do not issue a medical hold for an immigrant entering under waiver of excludable disease unless the responsible medical officer considers this necessary for special reasons.)

Procedure

6. The medical examination shall be sufficiently thorough to determine the existence of any possible physical or mental disease or defect. In the conduct of the examination precautions should be taken to avoid unnecessary exposure of the alien to the view of others, while undressed. At consulates all examining rooms shall be provided with individual booths with doors or curtains, where aliens undress and remain until called for examination.

a. Males shall be examined divested of clothing.

b. Females shall be required to remove all clothing, except underwear below the waist. They shall be examined first by the female assistant, who shall pay particular attention to the abdomen

and lower extremities. A drape shall be placed over the shoulders before examination by a male physician, which shall be performed in the presence of the female assistant. Pelvic examinations will not be done routinely, on females, but will be done when questioning indicates the possibility of disease. It is particularly important to detect malignancy of the pelvic organs.

7. During examinations, including examination of the eyes, the physician shall exercise all due precautions to prevent spread of disease. Facilities for this purpose shall include an approved antiseptic solution, soap, and a supply of small hand towels for frequent cleansing of the examiner's hands.

8. Urinalysis shall be required only when the history of physical examination indicates the possible presence of any disease, such as diabetes, nephritis, or pyelitis, wherein urinalysis would aid in diagnosis.

9. Requirements for a chest X-ray and serologic test are stated in section 34.4 (b) of the regulations (see chapter 1). (On arrival in the United States, students can be identified by the classification symbol "F" and exchange visitors by the classification symbol "J" in the nonimmigrant visa, stamped in the passport or other authorized document. Quarantine personnel should consult immigration officers as necessary to ensure recognition of nonimmigrant and immigrant visas.)

a. At consular offices. The examiner uses the back of the FS-398 as necessary in recording the complete X-ray findings. Subparagraphs 18 d (2) and 18 d (3) of chapter 3 outline the circumstances under which aliens who are required to have X-ray examinations need not present X-ray films at United States ports.

b. At United States ports.

(1) The examiner reviews all medical reports and X-ray films submitted except films carried by an alien with excludable disease waiver, which may also be reviewed if there appears to be a special need for it (see chapter 8).

(2) Any X-ray examinations and serologic tests required upon arrival of aliens shall be made at Public Health Service facilities or elsewhere at Public Health Service expense. (See par. 33 of this chapter.)

See also paragraph 18 of chapter 3, regarding general requirements for X-ray and serologic test. See chapter 8 for procedures on X-ray examination, and paragraphs 74-93 of chapter 7 for procedures regarding serologic tests.

10. The examination shall include any additional laboratory procedures the examiner deems necessary in individual cases. However, examiners shall not include an additional laboratory procedure

as a routine part of examinations without obtaining approval from Division of Foreign Quarantine headquarters.

11. An alien engrossed in the procedures of a medical examination is more off his guard and more likely to give a clue to some mental abnormality than one who is in the more formal setting of mental testing.

12. Even in the brief time available for a medical examination the physician can obtain considerable information as to cranial nerves, motor status and coordination, reflexes, and sensation. Several neurological findings can be accomplished in one procedure. For example, having an alien walk on toes and then on heels tests (1) ability to understand and carry out instructions, (2) motor power of the lower extremities, (3) function of the pyramidal tract, (4) function of the posterior columns, and (5) integrity of the peripheral nerves to the lower extremities. If there is a defect in the compensatory movements of the arms in walking on the heels, disease of the extrapyramidal system may be suspected.

13. Since deep pain, vibration, and position sense are mediated through the same tracts, an examination of one of these modalities usually suffices in a brief neurological check. Pressure of calf muscles between fingers and thumb or testing position sense in the toe usually will pick up a defect if present.

14. In examination of the deep reflexes in the lower extremity, if ankle jerks are present and equal, knee jerks need not be examined, provided there is no weakness of the quadriceps femoris muscles. A position favoring relaxation necessary to obtain the Achilles response is that of kneeling on a chair with feet and lower part of legs extending over the edge of the chair. The subject faces the back of the chair and steadies himself by holding the back of the chair. There is no difficulty in holding this position. Here again is an excellent example of acquiring a lot of information by doing one thing, namely, determining the character of the ankle jerks. The following are covered: ability to understand and carry out instructions (assuming position on chair); a great deal about motor status and coordination, including the state of the quadriceps muscle; character of reflex response at the ankle; and, by inference, presence or absence of knee jerks. The alert examiner will develop a picture of the range of normal response at all levels of the personality and will be quick to detect deviations from the normal.

15. For the detection of deviations and defects at the level of total personality the usual procedure is for the examiner to have the alien do certain things; these are preferably actions that are a part of the cooperation of the alien in the medical examination. It is well to elicit information as to reaons for the migration; by so doing

the examiner may discover psychotic trends. The part the alien played in becoming a prospective immigrant throws some light on initiative and ability. That is, the "passive" immigrant, the one who is sent for, whose papers have been taken care of and whose passage has been (or will be) paid by some member of the family, need not have a normal intelligence. For the alien to play an active part in the preliminaries, at least average intelligence is needed and there is less reason to suspect mental deficiency.

16. How the alien reacts to and understands instructions in connection with his medical examination is of great importance. Instructions should be clearly given, either by the interpreter or, preferably, by the examiner. Marked cerebral deterioration has been suspected, and later confirmed, when the examiner has observed a tendency to repeat the same act or give the same response, when various commands or questions are given.

17. In most countries reluctance of a male to appear nude before the male examiner is suggestive of some serious emotional disturbance. In most northern European countries nudity or near-nudity for sun-bathing is so universal, at least among urban dwellers, that undressing should have no significance. Resistance, sometimes to the extent of refusal to permit examination of the genitalia, among males, is strongly suggestive of schizoid traits. Naturally, a moderate degree of modesty is not considered an indication of abnormality. The individual's attitude toward exposure of the genitalia may indicate tendencies that suggest homosexual traits.

18. Among females, the female assistant or nurse should be instructed to report any peculiarities and deviations from the norms for the group. For example, with some groups of females exposure of the breasts or complete nudity in the presence of a male physician has no significance. When, in a group of this kind, strong resistance is encountered, this should be an indication for more intensive study.

19. In general, the examining physician should have, or acquire as soon as possible, an empiric knowledge of the norms of behavior in an unusual situation for the various groups to be examined, and should be constantly on the alert for deviations from these norms.

20. Questions and problems are usually concerned with addition of digits, repeating digits, counting backward and forward, and repeating days of the week and months of the year forward and backward. In Germany it was found that having the alien find his city or district on a map of the country gave a good idea of his method of attacking a problem. Naturally, for inhabitants of large cities this was easier than for rural inhabitants. However, the approach to the problem was more informative than mere success or failure. In

examinations at consulates, questions as to the route traveled coming from home to the city where the examination is made are illuminative as to the alien's interest in his environment.

21. As an example of the necessity for acquiring a knowledge of the peculiarities of the group, Germans in the between-war period were found to have little interest in the cardinal points of the compass. Questions as to the direction from the consulate to their homes were almost universally answered wrongly or not at all. The "Ostsee" (the Baltic) was routinely placed east of Germany, even by graduates of the "Volksschule" where geography was taught. However, even with inexperienced and uneducated peasants, information of an exact nature could usually be given as to the train trip to the consulate, with changes of trains and distances (these almost always in hours).

22. In general, a German of normal intelligence could be expected to name the months of the year forward and backward, although the latter might be a new problem. The uneducated Polish peasant, on the other hand, would be considered exceptionally bright if he did this readily. Days of the week backward and counting backward from 20 to one were useful screening tests for these.

23. The physician should be ever alert for evidence of various types of injury, specifically for evidence of biting the tongue, or scars from burns, that might be explainable only on the basis of the individual's being an epileptic and injuring himself during one of his seizures. Degrees of lethargy or mild stupor may be the result of the alien's taking an exaggerated dose of some type of barbiturate or bromide to insure that he would not have an epileptic seizure during the examination. When there is any suspicion of epilepsy, it is important to get an accurate record of whether the individual has a history of previous head injury that might indicate the etiology or nature of his epileptic convulsions.

24. When mental retardation is suspected, it is often advisable to examine the ocular fundi to look for evidences of retinitis pigmentosa or even blindness, which would be clinching factors in establishing the hereditary nature of the mental deficiency.

25. All persons whose reactions or behavior seems abnormal should be given more intensive study.

26. It is advisable, when an examiner first begins work in a new country, to give intelligence tests to some persons who seem to be intellectually normal, or even superior, and retain their records for study. The examiner will thus be able to form an estimate and even derive better standards of performance expectancy of normal aliens. It is especially important to take advantage of slack periods that may occur to test as many "normals" as possible.