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In 1891, the U.S. government took control of immigration administration. As it did, the poorer immigrants passed through an increasingly elaborate gauntlet of medical inspection at the nation’s borders. At many American ports, state quarantine officers continued to inspect immigrants, but they did so in compliance with a burgeoning national regime for the processing of aliens. Mass immigration continued unabated, but immigration policy grew increasingly fraught, a battleground for business interests and organized labor, nativists and humanitarians. Global outbreaks of cholera, small-pox, and other diseases kept hygiene central to the administrative process. In laws of 1891 and 1893, Congress assigned the U.S. Marine-Hospital Service responsibility for keeping migrants with contagious diseases from entering the country. Service officers inspected immigrants at port stations from New York Harbor to San Francisco Bay, as well as at designated crossings along the Canadian and Mexican “frontiers.” At a growing number of foreign ports, Service men attached to U.S. consulates inspected immigrant ships before departure, advising steamship companies to refuse passage to those passengers who appeared likely to be turned back for medical reasons upon reaching America.28

U.S. quarantine regulations in force by 1894 made vaccination a prerequisite to entry. Like the older state rules, the federal requirement treated steerage passengers as a class: “All passengers occupying apartments other than first or second cabin shall be vaccinated prior to entry, unless they can show that they have had smallpox, or have been recently successfully vaccinated.” Every steerage passenger bound for America received an inspection card that detailed an elaborate transatlantic process of medical inspection. Boxes on the front of the card recorded the migrant’s passage through inspection by a U.S. consular agent or Marine-Hospital Service officer at the port of departure; through quarantine at the port of entry; and by the U.S. Immigration Bureau. Another box, completed by the ship’s medical officer, called for the passenger’s number on the ship’s manifest list, where U.S. inspectors could find the detailed information on each passenger (including a medical history) required by U.S. law. The back of the card called for an official stamp or signature certifying vaccination. In seven languages, the card warned its holder, “Keep this card to avoid detention at quarantine and on railroads in the United States.”29

A ship entering New York harbor after 1891 first passed quarantine, which remained the province of New York port authorities. The port health officer and his assistants boarded, examining the ship’s manifest and its bill of health—a statement from the U.S. consulate detailing the sanitary condition of the ship and the port of embarkation. The inspectors then searched for passengers infected with any of five quarantinable diseases: smallpox, cholera, plague, typhus, or yellow fever. Smallpox was a constant concern. Unlike the mild form of the virus spreading across much of the country after 1898, the disease making the Atlantic passage was still classic deadly smallpox.30

New York quarantine officials viewed Italian immigrants as a special threat, despite the fact that Italian state medicine had long been in the vanguard of European smallpox control. The Italians had introduced bovine vaccine, and Italian law required all children to be vaccinated within six months of birth and required revaccination for entry into the schools and factory jobs. But none of the nation’s fourteen vaccine-manufacturing establishments could be found south of Rome. And in southern Italy, where most immigrants to the United States originated, vaccination was far from universal. For Dr. Alvah H. Doty, health officer of the port of New York, smallpox arriving on steamships from Naples was a “constantly recurring” problem. Without the quarantine precautions, “a horde