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Introduction to Contemporary Geography (Rubenstein)
Chapter 6 Migration
6.1 Multiple Choice Questions
1) According to the textbook, humans have always migrated, beginning about ________ years
ago
A) 500,000
B) 200,000
C) 100,000
D) 60,000
E) 30,000
Answer: B
Diff: 1
Section: 6.1
Bloom's Taxonomy: Knowledge
Geo Standard: 9
Glob Sci Outcome: 3. Read and Interpret Graphs and Data.
Learning Outcome: 6.1.2: Analyze early human migration and explain how it helps us to
understand human origins.
2) ________ diffusion involves the relocation of people themselves from one place to another.
A) Contagious
B) Demic
C) Normal
D) Preliminary
E) Critical
Answer: B
Diff: 1
Section: 6.1
Geo Standard: 10
1
Copyright © 2013 Pearson Education, Inc.
3) Scientists generally agree that our early (hominid) ancestors evolved from an area in
________.
A) Central East Africa
B) Central West Africa
C) Centra Europe
D) Tigris and Euphrates Rivers
E) Nile Valley
Answer: A
Diff: 1
Section: 6.1
Geo Standard: 17
4) Which of the following is not primary evidence of human diffusion?

A) The archaeological record
B) The examination of skeletal remains
C) Signs of early human presence
D) Similarities in the faces of people thousands of miles apart
Answer: D
Diff: 2
Section: 6.1
Geo Standard: 9
Learning Outcome: 6.1.3: Identify types of evidence used by scientists to trace the diffusion of
humans through the globe.
5) Which of the following was not one of the primary countries to establish colonies around the
world?
A) Spain
B) Portugal
C) Britain
D) France
E) United States of America
Answer: E
Diff: 2
Section: 6.2
Geo Standard: 9
Learning Outcome: 6.2.1: Describe how large scale migration in Europe, Africa and Asia
shaped the modern world.
2
6) During the 19th century, the largest migration stream was that between ________.
A) Northwestern Europe and the United States
B) Africa and Europe
C) Asia and Europe
D) Russia and Europe
E) Mexico/South America and the United States
Answer: A
Diff: 2
Section: 6.2
Geo Standard: 9, 11, 12, 13
Glob Sci Outcome: 2. Demonstrate the ability to think critically and employ critical thinking
skills.
7) About ________ people migrated from Europe to the United States between 1821 and 1920.
A) 55 million
B) 33 million
C) 18 million
D) 21 million
E) 15 million
Answer: B
Diff: 2
Section: 6.2
Geo Standard: 9
8) It is believed that European settlers to the Americas brought diseases new to the native
population, which decimated their number by as much as ________ percent.
A) 90
B) 99.5
C) 70
D) 5
E) 40
Answer: A
Diff: 2
Section: 6.2
Geo Standard: 9, 13
3
9) Between the 17th and 19th centuries, about ________ million Africans were taken to the new
world.
A) 30
B) 14.5
C) 3
D) 50.5
E) 7.5
Answer: B
Diff: 2
Section: 6.2
Geo Standard: 9
10) After slavery was abolished, rather than pay higher wages to freedmen (former slaves),
wealthy landowners and investors claimed that their "labor shortage" could be solved by
bringing in destitute and hungry ________.
A) Chinese
B) Europeans
C) Japanese
D) Americans
E) Mexicans
Answer: A
Diff: 2
Section: 6.2
11) The primary set of push and pull factors shaping global migration are ________.
A) economic
B) political
C) social
D) military
E) psychological
Answer: A
Diff: 2
Section: 6.3
Geo Standard: 9
Learning Outcome: 6.3.1: Compare and contrast push and pull factors in migration.
4
12) The nineteenth century geographer E.G. Ravenstein noted that most migration involves
________.
A) short-distance relocations between neighboring countries
B) short-distance relocations within countries
C) long-term relocation between neighboring countries
D) long-term relocations within countries
E) long-distance relocations within countries
Answer: B
Diff: 2
Section: 6.3
Geo Standard: 9
Learning Outcome: 6.3.2: Define internal migration.
6.4.1: Define Ravenstein's "Law of Migration."
13) International migration has increased considerably in recent decades as:

A) environmental issues dominate the news
B) economic disparities grow narrow between wealthy and poor regions
C) economic disparities grow between wealthy and poor regions
D) political unrest increases in Africa
E) globalization brings television to people's homes in China and India
Answer: C
Diff: 2
Section: 6.3
Bloom's Taxonomy: Comprehension
Geo Standard: 9
Learning Outcome: 6.3.3: Describe the patterns of global migration in recent decades.
14) Most international migrants are:

A) political refugees
B) workers looking for jobs
C) driven away by environmental devastation
D) fleeing from war
E) none of the above
Answer: B
Diff: 2
Section: 6.4
Geo Standard: 9
Learning Outcome: 6.4.1: Define Ravenstein's "Law of Migration."
5
15) About ________ people cross the border at the San Ysidro, California border each year.
A) 100 million
B) 50 million
C) 25 million
D) 10 million
E) 5 million
Answer: B
Diff: 2
Section: 6.4
skills.
Learning Outcome: 6.4.2: Define why the United States, Canada and Europe are prominent
destinations for economic migrants.
16) Although European countries today largely discourage immigration, the region attracts
immigrants from:
A) Russia
B) South America
C) India
D) Africa and the Middle East
E) China
Answer: D
Diff: 2
Section: 6.4
Geo Standard: 9
17) In Paris, and other similar cities in France, ________ do a large share of the menial labor.
A) Chinese
B) North Africans
C) Russians
D) West Africans
E) Portuguese
Answer: B
Diff: 1
Section: 6.4
Geo Standard: 9
6
18) ________ migration occurs when people must migrate or suffer terrible consequences.
A) Forced
B) Political
C) Economic
D) Environmental
E) Push
Answer: A
Diff: 2
Section: 6.5
Geo Standard: 9
Learning Outcome: 6.5.2: Compare and contrast refugees and internally displaced persons.
19) The political causes of forced migration are typically ________.

A) armed conflict or discrimination
B) rigged elections
C) one party rule and a strong leader
D) famine and deforestation
E) mutual distrust by rival clans
Answer: A
Diff: 2
Section: 6.5
Geo Standard: 9, 11
20) Which of the following is defined as: a person who has a "well-founded fear of being
persecuted for reasons of race, religion, nationality,membership of a particular social group or
political opinion, [who] is outside the country of his nationality and is unable or, owing to such
fear, is unwilling to avail himself of the protection of that country"?
A) an economic immigrant
B) a political immigrant
C) a refugee
D) opportunistic migrants
E) transient migrants
Answer: C
Diff: 2
Section: 6.5
Geo Standard: 9, 13
7
21) There are an estimated 15 million refugees in ________ today.
A) the United States
B) North America
C) Africa
D) the world
E) South America
Answer: D
Diff: 2
Section: 6.5
Geo Standard: 9, 12, 13
22) Today, there are more than ________ million internally displaced persons (IDPs) in the
world.
A) 100
B) 50
C) 27
D) 18
E) 8
Answer: C
Diff: 2
Section: 6.5
Geo Standard: 9
23) The number of international tourists has ________ during the last two decades.
A) remained the same
B) shrunk
C) more than doubled
D) more than quadrupled
E) increased ten-fold
Answer: C
Diff: 2
Section: 6.6
Geo Standard: 9
Learning Outcome: 6.6.2: Analyze the environmental and economic effects of tourism.
8
24) About half of the world's international tourists choose ________ as their destination.
A) Canada
B) China
C) Europe
D) The Middle East
E) Japan
Answer: C
Diff: 2
Section: 6.6
Geo Standard: 9, 11
25) By some accounts, tourism is the world's largest industry, with international tourist receipts
totaling ________ in 2010.
A) 300 billion
B) 604 billion
C) 919 billion
D) 1.1 trillion
E) 2.1 trillion
Answer: C
Diff: 2
Section: 6.6
Geo Standard: 9, 11
26) The ability for households to move within a country is defined as ________.
A) residential mobility
B) internal mobility
C) internal migration
D) intra-country migration
E) relocation migration
Answer: A
Diff: 2
Section: 6.7
Geo Standard: 10
Learning Outcome: 6.7.1: Define residential mobility.
9
27) ________ is the relative long-distance movement from one region of a country to another.
A) Interregional migration
B) Intraregional migration
C) Forced migration
D) Regional mobility
E) International mobility
Answer: A
Diff: 2
Section: 6.7
Geo Standard: 9
Learning Outcome: 6.7.2: Compare and contrast interregional and intraregional migration.
28) Movement constrained to within the same region is defined as ________.

A) Interregional migration
B) Intraregional migration
C) Forced migration
D) Regional mobility
E) International mobility
Answer: B
Diff: 2
Section: 6.7
Geo Standard: 9
29) Migration from rural to urban areas began in the 1800s in Europe and North America as part
of the ________.
A) Civil war
B) Industrial Revolution
C) Deforestation
D) Agricultural Revolution
E) None of these answer choices are correct.
Answer: B
Diff: 2
Section: 6.7
Geo Standard: 10
10
30) Most of the immigrants to the United States in the seventeenth and eighteenth centuries came
from
A) the United Kingdom and Holland
B) the United Kingdom and Africa
C) Germany and Norway
D) Germany and the United Kingdom
E) Russia and Germany
Answer: B
Diff: 2
Section: 6.8
Geo Standard: 9
Learning Outcome: 6.8.1: List and describe the three main areas of immigration to the United
States.
31) The two leading sources of immigrants since the late twentieth century to the United States
have been:
A) Latin America and Asia
B) Latin America and Africa
C) Africa and Europe
D) Germany and Asia
E) Asia and United Kingdom
Answer: A
Diff: 2
Section: 6.8
Geo Standard: 9
States.
11
32) It is estimated that about ________ undocumented immigrants entered the United States in
2009, most along the nearly 2,000 mile-long U.S.-Mexican border guarded by about 17,000
federal agents.
A) 1 million
B) 600,000
C) 300,000
D) 220,000
E) 150,000
Answer: C
Diff: 2
Section: 6.9
Learning Outcome: 6.9.1: List and describe the main characteristics of undocumented
immigrants living in the United States.
33) The Pew Hispanic Center estimated that there were ________ unauthorized immigrants
living in the
United States in 2010.
A) 22 million
B) 15.7 million
C) 11.2 million
D) 7.8 million
E) 3.8 million
Answer: C
Diff: 2
Section: 6.9
Geo Standard: 10
12
34) Which two U.S. states have the largest number of undocumented immigrants?
A) California and Arizona
B) California and Nevada
C) California and Texas
D) Texas and New Mexico
E) Texas and Arizona
Answer: C
Diff: 2
Section: 6.9
35) It is estimated that about five percent of the civilian workforce, or ________, are
undocumented immigrants employed in the United States
A) 10 million
B) 8 million
C) 5 million
D) 3 million
E) 2 million
Answer: B
Diff: 2
Section: 6.9
36) Which of the following is not one of the reasons that some governments feel the need to
control illegal immigration?
A) Concern that migrants will themselves become a burden on public resources
B) Concern that migrants will take away jobs from residents
C) Concern that migrants would bring unwanted cultural change
D) Concern that some migrants will be a security threat
E) Concern that migrants will bring disease and infect resident population
Answer: E
Diff: 3
Section: 6.10
Learning Outcome: 6.10.1: Compare and contrast inclusionary and exclusionary migration
policies.
13
37) ________ immigration policies recognize that most immigration benefits the host economy
and that immigrants contribute as much as regular citizens by paying taxes, observing the law,
and even serving in the militaries of their new country.
A) Inclusionary
B) Exclusionary
C) Diffusionary
D) Undocumented
E) Contemplative
Answer: A
Diff: 2
Section: 6.10
policies.
38) Most countries adopt a/an ________ immigration policy that excludes unwanted migrants
and includes more desired ones.
A) selective
B) discriminative
C) inclusive
D) bifocated
E) stepped
Answer: A
Diff: 2
Section: 6.10
Geo Standard: 9, 13
Learning Outcome: 6.10.2: Explain how the United States and Europe implement selective
immigration policies.
14
39) Those who are seeking to indefinitely or permanently immigrate must obtain a visa that will
allow them to eventually ________, or to become a legal permanent citizen of the host country.
A) migrate
B) naturalize
C) relocate
D) win the green card lottery
E) leave
Answer: B
Diff: 2
Section: 6.10
Geo Standard: 9, 13
6.2 True/False
1) Migration has never been a constant part of human history.

Answer: FALSE
Diff: 1
Section: 6.1
Geo Standard: 9
2) Demic diffusion involves the relocation of people themselves from one place to another.
Answer: TRUE
Diff: 1
Section: 6.1
Geo Standard: 9
15
3) Recent advances in the recovery and analysis of human genetics has begun to fill in the map of
early
human migration.
Answer: TRUE
Diff: 1
Section: 6.1
Geo Standard: 9
4) The modern era, roughly the last 1000 years, is characterized by the movement of small
numbers of peoples over much longer distances than ever before.
Answer: FALSE
Diff: 2
Section: 6.2
5) During the modern period, Spain, Portugal, Britain, France, and the Netherlands were the
primary countries to establish colonies around the world.
Answer: TRUE
Diff: 1
Section: 6.2
Geo Standard: 9, 13
6) The forced migration of enslaved persons, primarily from western and central Africa, to the
western hemisphere, began with the earliest colonies in America.
Answer: TRUE
Diff: 1
Section: 6.5
Geo Standard: 9, 13
Learning Outcome: 6.5.1: Give examples of political and environmental reasons for forced
migration.
16
7) The primary set of push and pull factors shaping global migration are political.
Answer: FALSE
Diff: 1
Section: 6.3
Geo Standard: 9, 11
8) International migration has decreased considerably in recent decades as economic disparities

lessen between wealthy and poor regions.
Answer: FALSE
Diff: 2
Section: 6.3
Geo Standard: 9, 11
9) Brain drain is the loss of highly skilled professionals from rich countries to poor countries.
Answer: FALSE
Diff: 2
Section: 6.3
Geo Standard: 9, 11
Learning Outcome: 6.3.4: Predict what effects "brain drain" may have on a country.
10) E.G. Ravenstein considered it a "law of migration" that longer distance migrations would
gravitate away from centers of economic strength.
Answer: FALSE
Diff: 2
Section: 6.4
Geo Standard: 9
Learning Outcome: 6.4.1: Define Ravenstein's "Law of Migration."
17
11) The United States and Canada have been especially prominent destinations for economic
migrants.
Answer: TRUE
Diff: 1
Section: 6.4
Geo Standard: 9, 11
12) Germany, France, Italy, and other western European countries encouraged guestworkers to
immigrate and work in factories, helping to rebuild war-torn economies in western Europe.
Answer: TRUE
Diff: 2
Section: 6.4
Geo Standard: 9, 11
13) Detainee migration occurs when people must migrate or suffer terrible consequences.
Answer: FALSE
Diff: 2
Section: 6.5
Geo Standard: 9
migration.
14) Today, there are more than 27 million internally displaced persons (IDPs) in the world.
Answer: TRUE
Diff: 1
Section: 6.5
Geo Standard: 9, 13
18
15) One of the largest countries in Africa, Morocco's unstable environmental and political
conditions have driven millions from their homes.
Answer: FALSE
Diff: 2
Section: 6.5
migration.
16) The number of international tourists has more than doubled during the last two decades.
Answer: TRUE
Diff: 1
Section: 6.6
Geo Standard: 9, 11
Learning Outcome: 6.6.1: Explain why tourism is a form of temporary migration.
17) In times of economic strength in most countries, tourism is one of the fastest-growing sectors
of the economy.
Answer: TRUE
Diff: 1
Section: 6.6
Geo Standard: 9
18) Internal migrations from part of a country to another are the most common form of
permanent migration.
Answer: FALSE
Diff: 1
Section: 6.7
Geo Standard: 9
19
19) Movement constrained to within the same region is termed interregional migration.
Answer: FALSE
Diff: 1
Section: 6.7
Geo Standard: 9
20) Today most interregional migration in developed countries is from cities out to suburbs.
Answer: FALSE
Diff: 2
Section: 6.7
Geo Standard: 9
21) By some measures, nearly 50 percent of the population in the United States and other
developed countries now live in urban areas.
Answer: FALSE
Diff: 2
Section: 6.7
Geo Standard: 9
Learning Outcome: 6.7.3: Analyze the reasons why people migrate from rural to urban areas and
from urban to suburban or rural areas.
22) Europeans comprised more than 90 percent of immigrants to the United States during the
nineteenth century, and even as recently as the early 1960s, still accounted for more than 50
percent.
Answer: TRUE
Diff: 2
Section: 6.8
Geo Standard: 9
skills.
States.
20
23) The two main sources of early immigrants to the American colonies and the newly
independent United States were the United Kingdom and Africa.
Answer: TRUE
Diff: 1
Section: 6.8
Geo Standard: 9
States.
24) Economically advanced countries, especially the United States, have record low numbers of
people trying to enter to find work.
Answer: FALSE
Diff: 1
Section: 6.9
Geo Standard: 9
25) In the United States, California and Texas have the largest number of undocumented
immigrants.
Answer: TRUE
Diff: 1
Section: 6.9
Geo Standard: 9
26) The United States has constructed a barrier covering approximately 90 percent of the border
with Mexico.
Answer: FALSE
Diff: 2
Section: 6.9
Geo Standard: 9
Learning Outcome: 6.9.2: Describe conditions along the US-Mexican border.
21
27) The United States does not use immigration caps to limit the number of persons coming from
different countries.
Answer: FALSE
Diff: 2
Section: 6.10
Geo Standard: 9
policies.
28) Most countries adopt a selective immigration policy that excludes unwanted migrants and
includes more desired ones.
Answer: TRUE
Diff: 2
Section: 6.10
Geo Standard: 9
29) One way of imposing a inclusionary policy is through government issued visas that require a
migrant to gain permission to enter a country before arriving there.
Answer: FALSE
Diff: 2
Section: 6.10
Geo Standard: 9
policies.
30) Temporary migrants include tourists, commuters (who live outside the country but work
within it), and those passing through the country.
Answer: TRUE
Diff: 2
Section: 6.10
Geo Standard: 9
22
6.3 Essay Questions
1) Briefly explain modern trends in mass migration.

Answer: Migration has been a constant part of human history. There are various reasons why
people migrate. In the modern era, (last 500 years,) there has been movement of large numbers
of people over much longer distances than ever before. The main reason reason for this trend is
globalization
that began with Europe's voyages of conquest and the establishment of colonies around the
world.
In the modern period, Spain, Portugal, Britain, France, and the Netherlands establish colonies
around the world. Settler migration also saw the relocation of European populations to overseas
colonies primarily to extracting natural wealth and trade. During the 19th century, the largest
migration stream was that between Europe and the United States, involving more than 33 million
people between 1821 and 1920.
Forced migration from West and Central Africa followed earlier colonization, leading to about
14.5 million African arriving in the New World as slaves between the 17th and 19th centuries.
The abolition of slavery saw an influx of destitute and hungry Chinese to European colonies.
Diff: 3
Section: 6.2
Glob Sci Outcome: 8. Communicate effectively in writing.
2) Briefly discuss global migration trends in recent decades.

Answer: As economic disparities between rich and poor nations continue to widen, international
migration also continues to increase with the overwhelming majority of migrants moving from
poor to rich countries. With increased and improved communications, information about
destinations, and transportation technologies , we are seeing an accelerated flow of economic
migrants between world regions.
Globally, Asia, Latin America, and Africa have net out-migration, whereas North America,
Europe, and Oceania have net immigration. We are seeing an increased flow of migrants are
from Asia to Europe. We are also outflows from Asia to North America and finally, from Latin
America to North America. We are also seeing substantial in-migration from Europe to North
America and from Asia to Oceania.
Diff: 3
Section: 6.3
Geo Standard: 9, 11
23
3) Briefly discuss international labor migration to Europe since the mid 20th century.
Answer: Since the end of the Second World War, when Europe needed labor to help rebuild its
shattered economies, Europe has been a an attractive destination for immigrants. Germany,
France, Italy, and other western European countries encouraged guestworkers to immigrate and
work in factories, helping to rebuild war-torn western European economies.
Today, European countries largely discourage immigration, but the region still attracts
immigrants from Africa and the Middle East where they tend to do menial jobs that residents do
not want to do. These jobs are relatively low paying by European standards, but for these
immigrants, that is more money than they would otherwise earn in their home countries. These
immigrants not only reduce the unemployment in their home countries, but they also remit
monies back home to support their families.
Diff: 3
Section: 6.4
4) Explain the political causes of forced migration in recent years.

Answer: Forced migration occurs when people must migrate or suffer terrible consequences.
The political causes of forced migration are typically armed conflict or discrimination. It is
estimated that about 44 million people are forcibly displaced persons in the world today.
There are several categories of displaced persons. A refugee as a person with a "well-founded
fear of being persecuted for reasons of race, religion, nationality, membership of a particular
social group or political opinion, [who] is outside the country of his nationality and is unable or,
owing to such fear, is unwilling to avail himself of the protection of that country." (1951 Refugee
Convention.) There are more than 15 million refugees in the world today.
There are more than 27 million internally displaced persons (IDPs) in the world with no
international legal protection. These displaced people often rely on humanitarian relief to survive
away from their homes. Most displaced people are in poor, unstable, and conflict prone regions
in the developing world.
Diff: 3
Section: 6.5
migration.
24
5) Briefly examine the role of tourism in the global economy.
Answer: By some accounts, tourism is the world's largest industry, with international tourist
receipts exceeding $900 billion in 2010. Tourists spend large sums of money in their destinations
on everything from hotels and meals to recreation, souvenirs and taxes. In most countries,
tourism is one of the fastest-growing sectors of the economy and is a ignificant income source for
many poor countries. For example, tourism receipts equal about 14 percent of Cambodia's GNI
and about 7.5 of Egypt's GNI.
Many poor countries are pursuing economic development strategies that exploit areas of natural
beauty. Unfortunately, these are oﬅen areas in which additional visitors may harm the natural
environment. Tourists require hotels, transportation, and food that take up land, create pollution,
and draw on food supplies. Tourists use up scarce potable water suppliesespecially in luxury
hotels, swimming pools, and laundry services. This puts pressure on local natural areas. The
problems are not limited to developing countries dependent on tourism. Resort areas in Europe's
Mediterranean put an enormous strain on scarce fresh water supplies while dumping large
amounts of wastewater into sensitive watersheds.
The number of international tourists has more than doubled during the last two decades.,
reaching about 940 million in 2010. Half of the world's international tourist head to Europe.
China, Turkey, Malaysia,and Mexico are also among the most popular destinations. Europeans
and Asians are similarly the main source of international tourists
Diff: 3
Section: 6.6
Geo Standard: 11, 13
6) How is interregional migration different from intraregional migration?

Answer: Interregional migration is the relative long-distance movement from one region of a
country to another. The most famous example of interregional migration is the opening the
American west. Two hundred years ago, the United States consisted of a collection of
settlements concentrated on the Atlantic Coast. Through mass interregional migration, the rest of
the continent was settled and developed.
Intraregional migration is movement constrained to within the same region. Intraregional

migration is much more common than interregional or international migration. Most
intraregional migration has been from rural to urban areas or from cities to suburbs.
Diff: 3
Section: 6.7
Geo Standard: 9, 11
25
7) Briefly discuss rural-urban migration and the recent trends of suburbanization.
Answer: The industrial revolution (primarily during the 1800s) is credited to be the spark that
began rural-urban migration in Europe and North America. The percentage of people living in
urban areas in the United States, for example, increased from 5 percent in 1800 to 50 percent in
1920. Nearly 90 percent of the population in the United States and other developed countries
now live in urban areas.
In recent years, large-scale rural to urban migration has occurred in developing countries of Asia,
Latin America, and Africa. Worldwide, more than 20 million people are estimated to migrate
each year from rural to urban areas. The principal reason for this rural-urban move is economic.
The trend has now shifted in developed countries. Today most intraregional migration in rich
countries is from cities out to suburbs., leading to a decline in the population of cities. The major
reason for the large-scale migration to the suburbs is not related to employment, , but rather the
attraction of a suburban lifestyle, including large homes, open spaces and privacy. Developed
countries witnessed a new migration trend during the late twentieth century. For the first time,
more people immigrated into rural areas than emigrated out of them. Net migration from urban to
rural areas is called counterurbanization. The reasons are similar to those of suburbanization.
Diff: 3
Section: 6.7
Learning Outcome: 6.7.3: Analyze the reasons why people migrate from rural to urban areas and
from urban to suburban or rural areas.
26
8) Briefly discuss the problem of undocumented immigration to the United States.
Answer: Economically advanced countries, especially the United States, have record high
numbers of people trying to enter to find work. An estimated 300,000 undocumented immigrants
entered the United States in 2009, most along the nearly 2,000 mile-long U.S.-Mexican border
guarded by about 17,000 federal agents. The Pew Hispanic Center estimated that there were 11.2
million unauthorized immigrants living in the United States in 2010, a number that has been
steadily rising in the last few decades.
It is estimated that approximately 60 percent of undocumented immigrants come from Mexico.

The remainder are about evenly divided between other Latin American countries and other
regions of the world. The undocumented immigrants include about 1 million children.
Approximately 8 million undocumented immigrants are employed in the United States,
accounting for around 5 percent of the total U.S. civilian labor force, usually in low wage
positions.
The two states with the most illegal immigrants are California and Texas. Nevada has the largest
percentage.
Diff: 3
Section: 6.9
9) What are selective immigration policies?

Answer: Most countries adopt a selective immigration policy that excludes unwanted migrants
and includes more desired ones. European countries that once maintained inclusionary policies to
attract guestworkers from North Africa and the Middle East are today trying to limit immigration
from these regions in favor of Europeans.
The United States uses immigration caps to limit the number of persons coming from different
countries. At the same time, the U.S. government provides special permission to highly desirable
immigrants. One way of imposing a selective policy is through government issued visas that
require a migrant to gain permission to enter a country before arriving there. Special work or
residency permits may also be used.
Diff: 3
Section: 6.10
27
10) Compare inclusionary to exclusionary immigration policies.
Answer: Inclusionary immigration policies are those that recognize that most immigration
benefits the host economy and that immigrants contribute as much as regular citizens by paying
taxes, observing the law, and even serving in the militaries of their new country. Some
immigrants bring professional skills that are in high demand in the destination country or
contribute to economic growth. Others represent international business interests with
considerable investments that appeal to the host country. In some places, immigrants are also
encouraged to maintain their mother tongue and culture.
In contrast, many countries view migrants suspiciously out of concern for undocumented
immigration, security threats, or the movements of illegal materials. Some governments are
concerned that immigrants will themselves become a burden on public resources, take away jobs
from residents, or bring unwanted cultural change. While many of these fears are overblown,
citizens expect their countries to control migration at their borders. These countries may adopt
anti-immigration or exclusionary policies that punish migrants and those that hire them. Populist
outrage and violence against immigrants may be considered an extension of such policies.Many
countries view migrants suspiciously out of concern for undocumented immigration, security
threats, or the movements of illegal materials. Some governments are concerned that immigrants
will themselves become a burden on public resources, take away jobs from residents, or bring
unwanted cultural change. While many of these fears are overblown, citizens expect their
countries to control migration at their borders (Figure 6.10.1). These countries may adopt anti-
immigration or exclusionary policies that punish migrants and those that hire them. Populist
outrage and violence against immigrants may be considered an extension of such policies.
Diff: 3
Section: 6.10
policies.
28
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Acute Spinal Meningitis.
SYNONYM.—Leptomeningitis spinalis acuta.
By the term spinal meningitis is usually meant inflammation of both

the arachnoid and the pia, the two being, as already stated, in reality
one membrane. In connection with meningitis of the brain it
constitutes a distinct disease which is usually epidemic, and
probably zymotic in its origin. (See EPIDEMIC CEREBRO-SPINAL
MENINGITIS.) Sporadic spinal meningitis is a rare disease. It may be
acute or chronic.
ETIOLOGY.—Among the causes of acute spinal meningitis are injuries

to the vertebral column, such as fracture and dislocation from falls,
blows, etc.; wounds by stabbing or shooting; violent bodily effort, as
in lifting heavy weights, etc. Other causes are local exposure to wet
and cold, as from sleeping on the wet ground or standing long in
water while at work. Like cerebral meningitis, it may complicate
constitutional diseases, as rheumatism, pyæmia, etc., but less
frequently than the former. Syphilitic inflammation of the spinal
membranes is, however, not unfrequently met with, but chiefly of the
chronic form. (See the article on SYPHILIS OF THE BRAIN AND SPINAL
CORD.) In tubercular meningitis of the brain the pia mater of the cord
is often implicated in the disease. Acute spinal meningitis is most
frequently met with in young persons, and is more common in men
than in women.
SYMPTOMS.—The onset of the disease is generally sudden, and it is

rarely preceded by the usual inflammatory symptoms of chilly
sensations, restlessness, headache, etc. A sharp rigor is the first
indication of disease in most cases. This is followed by fever, with
high temperature and a quick, full, hard pulse. Pain in the back
follows, either confined to a limited region or extending throughout
the whole extent of the spine, soon becoming acute, and aggravated
by any movement of the trunk or even of the limbs. There is usually
but little tenderness on pressure upon the spinous processes, and
often none at all. The pain extends around the body and throughout
the limbs. In the course of a few hours muscular contraction in the
region of the back, and also of the limbs, is observed. When the
disease is situated in the cervical region, the head is drawn
backward, and cannot be moved without severe pain. If it occupies a
considerable extent of the spine, the dorsal muscles become rigidly
contracted and the body is arched forward (opisthotonos), as in
tetanus, so that the patient may even rest upon his occiput and
sacrum. Owing to the implication of the muscles of respiration, more
or less dyspnœa is common, and may even cause death by
asphyxia. There is no paralysis of the limbs, unless there be
complication of myelitis, but the patient abstains as far as possible
from any movement from dread of pain. Reflex irritability is
exaggerated. Retention of urine and constipation are common,
probably for the same reason. Hyperæsthesia of the surface of the
body in limited areas is sometimes noticed, owing to the irritation of
the posterior spinal roots. Provided the extent of the inflammation be
comparatively limited, recovery is possible, though rare, at this stage
of the disease.
When the course of the disease is unfavorable, symptoms of

paralysis appear, from compression of the cord by the products of
inflammation. The hyperæsthesia of the skin gives place to
insensibility; the muscles lose their reflex function and their reaction
to electricity; the bladder and rectum become paralyzed. The
invasion of the medulla by the disease, which is announced by
paralysis of the muscles of the œsophagus and of the tongue, is a
fatal complication. The pulse and the respiration become rapid and
irregular from compression of the vagus, the temperature rises to
106° or 108° F., and death ensues through asphyxia or failure of the
heart.
The course of acute spinal meningitis is rapid. It sometimes

terminates fatally within two or three days, and the average duration
of fatal cases is about a week, but exceptionally the disease may last
for several weeks or even months. Even then complete recovery
may take place, though permanent effects are usually left behind,
such as paresis or paralysis of the lower extremities, muscular
contractions, muscular atrophy, etc., from injury to the nerve-roots or
the cord.
The mind is generally clear in the early stage; afterward there may
be delirium, especially along with cerebral complication.
MORBID ANATOMY.—It is rarely that the pia mater is the only tissue
involved in the inflammation. Frequently the inner surface of the dura
is the seat of a fine injection, with delicate false membranes, and the
cord itself—at least its exterior portions—probably always
participates more or less in the congestion. The pia is reddened and
thickened, the surface showing small bloody extravasations, and the
space between its two layers is the seat of a fibro-purulent deposit.
The spinal fluid is turbid and flocculent. The seat and extent of the
morbid appearances vary in different cases; they are always more
abundant in the posterior than the anterior part of the cord, and may
be confined to a limited space or extend throughout its whole length.
It is remarkable that the region of the medulla oblongata is generally
free or only slightly affected; but since bulbar symptoms are often
prominent in grave cases, Leyden6 accounts for it by supposing that
the exudation is washed away by the constant movement of the
cerebro-spinal fluid. If the cord be involved in the inflammation, it is
softened and injected, the nerve-sheaths are destroyed, and the
axis-cylinders swollen in places. The nerve-roots show hyperæmia,
infiltration of the interstitial tissue with round cells, and destruction of
the nerve-sheaths.
6 Klinik der Rückenmarks-krankheiten, von E. Leyden, Berlin, 1874, vol. i. p. 407.
DIAGNOSIS.—Spinal meningitis is easily recognized in most cases by

its sudden onset and the severity of its symptoms. The distinguishing
symptoms are sudden and acute pain in the back, extending around
the body and into the limbs, which is increased by every movement
of the trunk, rigidity of the back, hyperæsthesia of the skin, retraction
of the head, with difficulty of breathing and of swallowing. The
diseases from which it must be distinguished are muscular
rheumatism (so called), tetanus, and myelitis. In rheumatism of the
dorsal muscles the pain is confined to the back, does not extend to
the limbs, and is only excited by movement. The fever is moderate or
absent; there are no symptoms of spinal complication, such as
cutaneous hyperæsthesia, retraction of the head, paresis of the
limbs, etc.; and the result is uniformly favorable. Tetanus is almost
always due to some well-marked traumatic cause; the muscles of the
jaw are usually first implicated (trismus); and the attacks of general
muscular spasm are easily excited by peripheral irritation. Myelitis
can be distinguished by the absence of pain in the limbs and by
paraplegia, but it must be borne in mind that myelitis and spinal
meningitis may coexist.
PROGNOSIS.—Acute spinal meningitis is always a grave disease,

hence a guarded opinion should be given even in apparently
favorable cases. General mildness of the symptoms, with no
indication of extension to the medulla oblongata, would afford ground
for encouragement. The unfavorable symptoms are those showing
compression or inflammation of the cord, such as paresis, paralysis,
twitching of the limbs, muscular contractions, cutaneous anæsthesia,
etc. The extension of the disease to the medulla, as shown by
difficulty of swallowing, speaking, or breathing, is almost necessarily
fatal.
TREATMENT.—During the first stage of the disease an effort should be

made to reduce the hyperæmia of the membranes by the local
abstraction of blood. This is best effected by cupping along each
side of the spine and by the application of leeches to the anus; the
bleeding should be promoted by poultices. Free purging is likely to
be of service, and is best obtained by means of ten grains each of
calomel and jalap (for an adult), followed by saline laxatives.
Counter-irritation to the back may be induced by the application of
blisters or by painting the skin with a strong tincture of iodine (one or
two drachms of iodine to an ounce of sulphuric ether). After the
effusion of lymph and pus, as shown by symptoms of compression of
the nerve-roots and cord, absorbents should be tried, of which the
iodide of potassium, in doses of five to ten grains, four times daily, is
most likely to be of benefit. Pain must be relieved by opium or
morphia and chloral hydrate. The latter, either alone or combined
with hyoscyamus and bromide of potassium, will be useful to allay
spasmodic twitching, opisthotonos, or muscular contraction. The
patient should be enjoined to lie on each side alternately, or on the
face if possible, in order to equalize the hyperæmia of the
membranes and cord. Liquid nourishment must be freely
administered, such as milk, broths, gruel, etc., together with wine
and other stimulants in case of exhaustion and threatening of
collapse. During convalescence the patient should be carefully
protected against cold and fatigue, and the strength must be
supported by quinine and iron with suitable diet.
Chronic Spinal Meningitis.
SYNONYMS.—Chronic inflammation of the pia mater of the spinal cord,

Chronic spinal leptomeningitis.
Chronic spinal meningitis may follow the acute form, or it may arise
from chronic disease of the vertebræ or of the cord, especially
myelitis and sclerosis. It is most apt to accompany sclerosis of the
posterior columns, and it is often difficult to say in any particular case
whether the meningeal affection preceded or followed that of the
cord. Probably some cases of chronic myelitis, especially of the
disseminated form, owe their origin to chronic meningitis.7 It has
been thought to follow blows on the back, and also to arise from
general concussion without traumatism, and has been considered as
a frequent result of accidents from railroad collisions, etc. This view
has been disputed by Herbert W. Page,8 who says: “Of the
exceeding rarity of spinal meningitis as an immediate result of
localized injury to the vertebral column we are well assured.... And
we know of no one case, either in our own experience or in the
experience of others, in which meningeal inflammation has been
indisputably caused by injury to some part of the body remote from
the vertebral column.” Chronic alcoholism and syphilis, especially the
latter, predispose to the disease. In many cases no adequate cause
can be assigned.
7 Leyden, op. cit., vol. i. p. 442.
8 Injuries of the Spine and Spinal Cord, without Apparent Mechanical Lesion and
Nervous Shock, in their Medico-legal Aspects, London, 1883, p. 128.
SYMPTOMS.—Gowers9 remarks that a large number of symptoms

formerly assigned to chronic spinal meningitis have nothing to do
with that pathological state, but are now known to be owing to
alterations within the cord which are frequently associated with it.
The symptoms which are really due to the meningeal inflammation—
namely, those arising from interference with the nerve-roots in their
passage through the thickened membranes—do not differ essentially
from those of chronic pachymeningitis of the spine; the principal are
pain in the back, especially on movement, extending to the trunk and
limbs, hyperæsthesia of the skin in various regions within the domain
of the irritated sensory roots, with diminution or loss of the knee-jerk,
and areas of anæsthesia due to their more complete compression.
The compression of the motor roots gives rise to symptoms which
are similar to those of disease of the anterior cornua, consisting
chiefly of muscular wasting, with impairment of motion in
corresponding regions, without fever.
9 The Diagnosis and Diseases of the Spinal Cord, by W. R. Gowers, M.D., 2d ed.,
Philada., 1881, p. 73.
The anatomical appearances, which are most pronounced in the

posterior aspect of the cord, and diminish from below upward, are
often of considerable extent. The membrane is thickened, opaque,
and often adherent to the cord. On the inner surface are seen
numerous small bodies composed of proliferating connective
tissue.10 These, according to Vulpian, are chiefly found in the lower
dorsal and lumbar region and on the cauda equina. The dura is very
frequently involved in the inflammation; it is thickened, and its inner
surface is adherent to the pia, often showing numerous miliary
bodies similar to those found in the pia.
10 Leyden, op. cit., vol. i. p. 144; A. Vulpian, Mal. du Syst. nerv., Paris, 1879, p. 126.
DIAGNOSIS.—Chronic spinal meningitis so rarely exists apart from
disease of the dura or of the cord that its separate diagnosis must be
mainly a matter of conjecture. Leyden justly says we must usually be
content to diagnosticate chronic meningitis without attempting any
further distinction, except in cases which originate in disease of the
vertebræ or of their neighborhood, and afterward penetrate into the
spinal canal, and which would probably give rise to pachymeningitis.
The diseases with which chronic meningitis of the spine is most likely
to be confounded are posterior sclerosis (locomotor ataxia) and
chronic degeneration of the anterior cornua (progressive muscular
atrophy).11 From the former it is distinguished by the absence of
ataxia; from the latter, by the irregular distribution of the symptoms;
and from both, by the existence of limited areas of anæsthesia and
of extensive spinal pain. It must be remembered that inflammation of
the cord complicating that of the meninges, or pressure upon the
cord by the thickened membranes may give rise to mixed symptoms.
The latter is especially observed in syphilitic cases.
11 Gowers, op. cit., p. 74.
PROGNOSIS.—Simple chronic spinal meningitis is rarely if ever fatal.

How far it is capable of amelioration or of cure is not, in the present
state of our knowledge, known. When complicated with disease of
the cord the prognosis will depend upon that of the latter. Syphilitic
chronic meningitis is to a certain extent amenable to appropriate
medication.
TREATMENT.—The treatment should have for its object (1st) to relieve

pain; (2d) to arrest the progress of the inflammation, and especially
to prevent it from extending to the cord; (3d) to promote the
absorption of the exudation. For the first object the internal or
hypodermic employment of morphia should be combined with
external applications, such as fomentations, liniments, ice, etc.
Counter-irritation by means of dry cupping, blisters, iodine, etc., with
leeches, shampooing, and douches of hot water, may be of some
use in retarding the progress of the inflammation, and should be
aided by the administration of mercurials and the preparations of
iodine. The biniodide of mercury would be useful for this purpose in
the dose of one-sixteenth to one-eighth of a grain three times daily,
its effect being carefully watched in order to prevent salivation. The
same means will also aid in favoring the absorption of lymph. In
syphilitic cases an appropriate specific treatment is indicated.
Spinal Meningeal Hemorrhage.
SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.
Spinal meningeal hemorrhage may take place between the dura

mater and the walls of the vertebral canal, or between the dura and
the pia mater—i.e. into the arachnoid space.
ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures

and dislocations, and violent blows are apt to give rise to more or
less hemorrhage into the spinal canal. Violent convulsions, as in
tetanus, epilepsy, uræmic eclampsia, hydrophobia, may be followed
by meningeal hemorrhage, owing to the disturbance of the
circulation from asphyxia; and excessive muscular effort, as in lifting
heavy weights, etc., has been said to cause it. In cerebral meningeal
hemorrhage and in effusion into the substance of the brain the blood
sometimes escapes into the spinal canal. An aneurism of the aorta
has been known to communicate with the canal; such a case was
reported by Laennec.12 In certain diseases with hemorrhagic
tendency, as purpura and scurvy, spinal extravasation is occasionally
observed.13
12 Traité d'Auscultation médiate, 4th ed., Paris, 1837, vol. iii. p. 443.
13 A case of scorbutic spinal hemorrhage is reported in the British Med. Journal, Nov.
19, 1881.
SYMPTOMS.—These vary according to the conditions under which the

hemorrhage is produced and to the amount of bleeding. In traumatic
cases the signs of hemorrhage are often completely overshadowed
by those of the injury of the vertebræ, the membranes, or the cord,
and are undistinguishable. When a large amount of blood is
suddenly introduced into the spinal canal, it usually gives rise, by
pressure on the cord, to paraplegia, which, however, is sometimes of
only short duration. Thus in Laennec's case the bursting of an
aneurism into the spinal cavity was signalized by a sudden
paraplegia, but in half an hour the power of movement returned,
though sensation did not. The patient died in a few hours from
hemorrhage into the left pleural cavity. The amount of blood in the
spinal cavity is not stated, and, in fact, it would appear that the spine
was not opened. When the amount of blood is smaller the symptoms
indicate irritation of the spinal nerves and of the cord. Pain in the
back is always present, extending into the limbs, and is sometimes
severe. Its seat corresponds to that of the effusion. There may be a
feeling of tingling and numbness in the lower extremities, with
anæsthesia or hyperæsthesia of the skin and more or less paresis. A
feeling of constriction around the waist or the chest is sometimes
complained of. In slight effusions the symptoms may be limited to
numbness and formication of the extremities, with slight paresis.
There is rarely fever in the early stages, unless the amount of blood
is sufficient to give rise to inflammatory conditions of the cord or
membranes. If the extravasation be moderate it is generally
absorbed, with relief to the symptoms, although slight numbness and
paresis of the extremities may continue for a long time.
PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose

cellular tissue between the membrane and the bony canal contains
more or less coagulated blood according to the circumstances of the
case, especially in the posterior region of the canal and covering the
nerve-roots. The dura is reddened by imbibition of the coloring
matter of the blood. When the amount of the effusion is large, as in
traumatic and aneurismal cases, or where cerebral hemorrhage has
extended into the spine, the cord may be compressed by it.
Hemorrhage into the arachnoid sac, except in cases of violence,
etc., is usually of limited amount, sometimes only in the form of
drops of blood upon the surface of the dura or pia. When more
abundant it may surround the cord more or less completely, but in
most cases it is limited in longitudinal extent, being confined to the
space of one or two vertebræ. The cord may be more or less
compressed, reddened, and softened. In all cases the spinal fluid is
discolored and reddened in proportion to the amount of the
hemorrhage.
DIAGNOSIS.—When the complications are such that symptoms

attributable to hemorrhage are not observed, the diagnosis of spinal
hemorrhage is impossible. This may happen in the case of wounds
and injuries of the vertebræ and of the passage into the spinal canal
of blood from an apoplectic effusion of the brain. In the convulsions
of tetanus, epilepsy, etc. the amount of the hemorrhage is rarely
sufficient to give rise to distinctive symptoms. In idiopathic and
uncomplicated cases the chief diagnostic marks are suddenness of
the attack; pain in the back, usually at the lowest part; disturbances
of sensation in the extremities (anæsthesia, formication, etc.);
paresis or paralysis of the legs; the absence of cerebral or spinal
inflammatory symptoms; and, in many cases, the favorable course of
the disease. Sometimes an ostensible cause, such as scurvy,
purpura, suppressed menstruation, or hemorrhoidal flux, will aid in
the diagnosis. The disease for which spinal hemorrhage is most
likely to be mistaken is acute myelitis, but this is not sudden in its
onset, is accompanied with fever, and gives rise to paralysis both of
motion and sensation, and to loss of control over the sphincters, to
bed-sores, etc. Hemorrhage of the cord would be accompanied by
paraplegia and loss of sensation in the lower extremities and slight
tendency to spasmodic manifestations; it is fatal in the majority of
cases, or else is followed by permanent paralysis. Hysteria might be
confounded with spinal hemorrhage, but the history of the case and
the transient duration of the symptoms would clear up all obscurity.
PROGNOSIS.—In traumatic cases the hemorrhage is usually only one

element in the gravity of the situation, which depends chiefly upon
the character and extent of the original injury. In idiopathic and
uncomplicated cases the prognosis, which must always be doubtful,
will vary according to the severity of the symptoms as corresponding
to the amount of the effusion. The danger is greatest during the first
few days; if there should then be diminution of the more important
symptoms, an encouraging opinion may be given. The immediate
effects may, however, be less grave than the remote, such as bed-
sores, cystitis, etc. Except in the very mildest cases the patient is
likely to be confined to bed for several weeks. In more severe ones
the convalescence may be very protracted, and permanent
lameness, etc. may result.
TREATMENT.—In the early stage absolute rest in bed, with cold

applications to the back and moderate purging, should be employed.
Large doses of ergot are recommended, but there is little evidence of
benefit from this medicine. In traumatic cases no rules for treatment
of the hemorrhage can be laid down. If the extravasation evidently
depends upon a constitutional diathesis, as in purpura, scurvy, etc.,
the remedies appropriate for these diseases should be employed,
especially tonics and astringents, such as the tincture of the chloride
of iron, in doses of from fifteen to thirty drops three times daily,
quinine, and the vegetable acids. Should there be evidence of blood-
pressure from suppressed discharge, as in amenorrhœa, arrested
hemorrhoidal flow, etc., leeches should be applied to the anus, and
blood may be taken from the region of the spine by cupping. In the
later stages an attempt may be made to aid the absorption of the
effused blood by the administration of the iodide of potassium or the
protiodide of mercury, and by the application of blisters or strong
tincture of iodine to each side of the spine. Pain must be relieved
and sleep obtained, when necessary, by means of opium, chloral
hydrate, or other anodynes. Electricity, rubbing, bathing, etc. will be
useful for combating the paralytic symptoms which may remain after
the disease itself is relieved.
SPINA BIFIDA.
BY JOHN ASHHURST, JR., M.D.
DEFINITION.—By the term spina bifida is meant a congenital

malformation of the vertebral column, consisting in the absence of a
part—commonly the spinous processes and laminæ—of one or more
of the vertebræ, and thus permitting a protrusion of the spinal
meninges, which, with their contents, form a tumor of variable size
and shape, usually in the lumbo-sacral region.
SYNONYMS, ETC.—Of the various names which have been proposed

for this affection, most are objectionable, as not expressing with
sufficient definiteness what is meant. Thus, hydrorachis (the term
generally employed by French writers), hydrorachitis, spinal
hydrocele, etc., convey merely the notion of an accumulation of fluid
within the spinal canal, and are as applicable to simple serous
effusions in that part, whether occurring as a complication of
hydrocephalus or as the result of injury, as to the special affection
under consideration. Again, myelochysis—pouring out or protrusion
of the spinal marrow—would imply that the cord itself was
necessarily involved in the tumor, which is certainly not always the
case. The terms schistorachis (cleft spine) and atelorachidia
(defective spine—a name suggested by Béclard) would be
preferable, and are really more accurate than the name spina bifida,
since, as a matter of fact, the spinous processes are, as a rule, not
bifid, but totally deficient. The latter term, however, has the
advantage of being more familiar, and may be retained simply as a
matter of convenience. It is said by Itard to have been first employed
by the Arabian physicians.
HISTORY.—Spina bifida does not appear to have been known to the
ancients, the earliest recorded observations of the affection being
found in the writings of Bauhinus (1560-1624), of Tulpius (1593-
1674), of Bonetus (1620-89), and of Ruysch (1638-1731). Good
accounts of the affection may be found in the Dictionnaire des
Sciences médicales (tome xxii., Paris, 1818), and particularly in
Holmes's Surgical Treatment of the Diseases of Infancy and
Childhood (2d ed., London, 1869), in Follin and Duplay's Traité de
Pathologie externe (tome iii.), and in Treves's article on
“Malformations and Injuries of the Spine” in the International
Encyclopædia of Surgery (vol. iv., New York, 1884).
ETIOLOGY.—There are two conditions essential to the formation of a

spina bifida: (1) an arrest of development, or at least a defective
closure, of the vertebral arches; and (2) a dropsical condition either
of the central canal of the spinal cord or of the subarachnoid spaces;
but which of these is the antecedent condition it is, as justly
remarked by Erb, impossible to decide. Spina bifida often occurs as
a complication of hydrocephalus, and is itself often complicated with
an atrophic and deformed condition of the lower extremities—a
circumstance which led Tulpius to suggest that the malformation was
caused by a malposition of the fœtus in utero, an explanation which
it seems hardly necessary to waste time in considering. Salzmann
observed spina bifida in two children born of the same mother, and
Camper noticed it in twins.
SYMPTOMATOLOGY.—Spina bifida forms a tumor—or, more rarely,

several tumors—in the region of the vertebral column, usually
discovered at birth, but occasionally not noticed until a later period.
Thus, Lancisi mentions a case in which the tumor first made its
appearance in a hydrocephalic child at the age of five years, and J.
L. Apin one in which the patient reached the age of twenty before
any swelling was manifested. If these records are accepted as
authentic, the only satisfactory explanation is that of Itard—viz. that
the bony deficiency existed from the time of birth, and that the
dropsical protrusion did not occur until afterward: this seems to me
more reasonable than the suggestion of the younger Andral, that the
vertebræ underwent a process of secondary softening and
absorption. The part most frequently affected is the lumbar region,
but cases are not wanting of the occurrence of spina bifida in the
cervical, dorsal, and sacral regions, and even, in at least one case
(Genga's), in the coccyx. The tumor almost invariably occupies the
median line, and projects directly backward: in at least four cases,
however, recorded by Bryant, Emmet, and Thomas, the tumor
protruded anteriorly from deficiency of the vertebral bodies.
The size of a spina bifida varies from that of a walnut to that of a

child's head, or even larger: in some rare instances, such as those
recorded by Lezelius and Richard, the whole spinal column has been
cleft, and the tumor has extended from nucha to sacrum; but cases
of this kind seldom come under the surgeon's observation, as
children with such extensive deformity usually perish shortly after
birth. The shape of the swelling is rounded, or more often oval; it is
commonly sessile, but occasionally pedunculated; and it is
sometimes lobulated, the lobules being separated by more or less
distinct sulci. The skin covering the tumor is in some cases normal,
with more or less fat in the subcutaneous connective tissue, but
more often thin, tightly stretched, red, shining, and occasionally
ulcerated; more rarely it is thickened and leathery, as in a case
referred to by Sir Prescott Hewett. Sometimes a navel-like
depression is found at some part of the surface, corresponding, as
pointed out by Follin and Duplay, and by Erb, to the place of
attachment, on the interior of the sac, of the terminal extremity of the
spinal cord. The cutaneous investment is sometimes altogether
wanting, the spinal dura mater itself forming the external covering of
the tumor. It is in these cases especially that ulceration and rupture
are apt to occur.
Spinæ bifidæ are usually soft and fluctuating, and occasionally

partially reducible; their tension and elasticity are increased when the
child is in the upright position or during the acts of expiration and
crying, and are diminished during inspiration or when the child is laid
upon its face. When the part is relaxed a bony prominence can be
felt on either side, and the aperture in the vertebral column can be
more or less distinctly outlined. The swelling is apt to be painful on
pressure. If the tumor is of moderate size and covered with healthy
skin, there are usually no constitutional symptoms, and, even where
ulceration and rupture occur, the opening may heal and a
spontaneous cure may possibly ensue. More often, as the tumor
increases in bulk—or at any time if pressure be made upon it—
various nervous symptoms are observed: drowsiness, muscular
twitchings, convulsions, and often paraplegia and paralysis of the
sphincters. Rupture is usually followed by the development of spinal
meningitis, or may prove directly the cause of death by the loss of
cerebro-spinal fluid which it causes; in other instances, however, if
the rupture be a small one, healing may occur (as already
mentioned) or a fistulous opening may persist; in rare cases the fluid
may escape by a process of transudation without rupture, as in an
example recorded by Laborie.
As may be inferred from what has already been said, the course of
spina bifida is usually rapid and toward a fatal termination. In some
instances, however, as in cases observed by Holmes, and more
recently by Lithgow, spontaneous recovery has followed the
obliteration of the channel which unites the sac with the cavity of the
spinal membranes; and in other instances, without a cure having
been effected, life has been prolonged for very many years. Thus,
Behrend reports a case in which a patient with spina bifida lived to
the age of fifty, and Holmes refers to another in which death resulted
from an independent disease at the age of forty-three. But a still
more remarkable case was recorded by Callender, the patient in this
instance having reached the age of seventy-four.
PATHOLOGY AND MORBID ANATOMY.—The most important points for

consideration in respect to the anatomy of spina bifida are the
relations which the spinal cord and spinal nerves bear to the sac,
and the nature of the contained fluid. It is ordinarily said that the
spinal cord itself commonly enters the sac of a spina bifida—the
report of the London Clinical Society's committee gives the
proportion of cases in which it does so at 63 per cent.—and Holmes
figures a specimen from the museum of St. George's Hospital,
London, in which this condition is obviously present; on the other
hand, Mayo-Robson in eight operations only once found the cord
implicated; and the late John B. S. Jackson of Boston—whose name
will be recognized as one of high authority in regard to all questions
of morbid anatomy—once assured me that he had made very many
dissections of spinæ bifidæ, and that he had invariably found that the
cord stopped short of the sac, and that only the nerves entered the
latter: this, as negative evidence, cannot of course contravene such
positive evidence as that of the specimen referred to by Holmes, but
it would seem to show that the condition was a less common one
than is generally supposed, and that in at least a fair proportion of
cases the cord itself did not form part of the sac contents. This
remark applies especially to those cases in which the fluid is
accumulated in the subarachnoid space, and in which, as pointed
out by Sir P. Hewett, the cauda equina or spinal nerves are pushed
by the vis a tergo into the sac; but when the dropsical effusion
occupies the central canal of the cord, this is apt to be flattened and
spread out like a thin lining to the sac, just as the brain is spread
over the inner wall of the skull in cases of internal hydrocephalus;
and, on the other hand, when the accumulated fluid fills the cavity of
the arachnoid the cord is apt to be pushed forward, and the sac may
be entirely devoid of all nerve-structures. Such, too, according to
Giraldès, is the case in spina bifida of the cervico-dorsal region.
The committee of the London Clinical Society classify cases of spina

bifida in three divisions: (1) Those in which the membranes only
protrude (spinal meningocele); (2) those in which the protrusion
involves both the cord and membranes (meningo-myelocele); and
(3) those in which the central canal of the cord itself forms the cavity
of the sac (syringo-myelocele). The last variety is the rarest, as the
second is the most common. In meningo-myeloceles the spinal cord
with its central canal is continued within the median, vertical portion
of the sac, and at this part there is no covering of true skin; the
nerve-roots which traverse the sac arise from this intramural portion
of the central nervous system.
Humphry of Cambridge, England, makes a somewhat similar
classification of spinæ bifidæ, recognizing as the most common
variety the hydrorachis externa anterior, in which the fluid occupies
the subarachnoid space in front of the spinal cord, and in which “the
cord and the nerves are stretched backwards and outwards upon the
sac, and are there confluent, together with the arachnoid, pia mater,
and dura mater, or their representatives, in the thin membrane which
forms the hindmost part of the wall of the sac;” rarer forms are the
hydro-meningocele, or hydrorachis externa posterior, in which the
fluid accumulates behind the cord, which does not enter the sac, and
the hydro-myelocele or hydrorachis interna, in which the fluid
occupies the central spinal canal.
The theory which, according to the Clinical Society's committee, best

explains the pathological anatomy of spina bifida is that which
assumes a primary defect of development of the mesoblast from
which the structures closing in the vertebral furrow are developed.
The fluid of spina bifida appears to be identical in character with the

cerebro-spinal fluid. Bostock found that it was very slightly clouded
by the application of heat, and that it contained, in 100 parts, 97.8 of
water, 1.0 of chloride of sodium, 0.5 of albumen, 0.5 of mucus, 0.2 of
gelatin, and some traces of lime. Five specimens more recently
analyzed by Hoppe-Seyler gave an average of 98.8 parts water, 0.15
parts proteids, and 1.06 extractives and salts. Turner found a
reaction somewhat similar to that of grape-sugar, as had been
previously found by Bussy and Deschamps in cerebro-spinal fluid
itself, but in two specimens analyzed by Noad for Holmes it was at
least very doubtful whether sugar was actually present. “The first
specimen was found to be completely neutral; its specific gravity was
1.0077; it contained phosphates, but no reaction could be obtained
resembling that of sugar. The second specimen ... did give a reaction
with copper like that of sugar, but no trace of fermentation could be
obtained.” Three analyses, however, made by Halliburton for the
London Clinical Society's committee showed uniformly a decided
trace of sugar, with a diminution in the quantity of proteids, which
appeared to consist entirely of globulin.
In some cases the sac of a spina bifida contains, besides nerve-
structures and cerebro-spinal fluid, both fibrous and fatty tissues.
DIAGNOSIS.—Ordinary fatty tumors have been mistaken for spinæ

bifidæ, but such an error could only be committed through
carelessness: more difficult is the diagnosis from certain forms of
congenital cyst, occupying the median line of the back, and still more
difficult the diagnosis from the several affections known as false
spina bifida. In the former case the distinction might be made by
noting the irreducibility, constant shape, and unchanging tenseness
of the cyst, and perhaps, as suggested by T. Smith, by tracing the
line of spinous processes beneath it; some information, too, might
perhaps be gained by chemical examination of the fluid obtained by
puncture. Under the name of false spina bifida Holmes includes
three distinct conditions: these are—(1) a true spina bifida, in which
the connection with the spinal membranes has in some way been
obliterated, the sac then communicating with the vertebral canal, but
not with the theca; (2) a congenital, cystic, or fatty tumor, taking its
origin within the vertebral canal, and projecting through an opening
caused by a gap in the laminæ; and (3) a tumor containing fœtal
remains, and properly regarded as an example of included fœtation.
In any of these cases a positive diagnosis might be impossible, and
the probable nature of the tumor could only be inferred by noting the
absence of one or more of the characteristic symptoms of true spina
bifida.
PROGNOSIS.—The prognosis of spina bifida is without question

unfavorable; at the same time the affection is by no means to be
considered, as it was formerly, one of an invariably fatal character,
for, apart from the fact already mentioned that several cases are on
record in which patients with untreated spina bifida have reached
adult life, and even old age, the modern method of treatment has
proved so much more successful than those formerly employed that
in favorable cases surgical interference affords at least a reasonable
prospect of recovery. The circumstances which especially furnish
grounds for an unfavorable prognosis are the rapid growth of the
tumor, the thinning or ulceration of its coverings, and the occurrence
of nervous symptoms, and particularly of paralysis or convulsions.
TREATMENT.—This may be either palliative or radical. If the tumor be

not increasing materially in size, the surgeon may properly content
himself with palliative measures—applying equable support and
perhaps slight pressure by the use of a well-padded cap of gutta-
percha or leather, an air-pad, or, as advised by Treves, a simple pad
of cotton smeared with vaseline, and a bandage; if the tumor be
small and covered with healthy integument, painting its surface with
collodion may be of service through the contractile property of that
substance. Radical measures are only indicated when the child,
otherwise healthy, seems to have his life threatened by the rapid
growth of the tumor, causing risk of ulceration and rupture, or giving
rise to convulsions or paralysis. The principal modes of treatment to
be considered under this heading are—(1) simple tapping or
paracentesis; (2) injection of iodine; (3) ligation of the neck of the
sac; and (4) excision.
(1) Paracentesis, a simple evacuation of the fluid contents of the sac,

is the only operation ordinarily justifiable in cases attended by
paralysis or other grave nervous manifestations. The puncture
should be made in the lower part of the sac and at a distance from
the median line (in the course of which the nerve-structures are
particularly distributed), and only a small quantity of fluid—a few
drachms or at most one or two ounces—should be removed at a
time, the instrument being at once withdrawn if convulsions follow,
and the wound being instantly closed with lint dipped in compound
tincture of benzoin. Either an aspirator-tube or a small trocar may be
used, and the operation may be repeated if necessary, pressure
being maintained during the intervals. Paracentesis has occasionally
though not often proved curative.
(2) Injection of Iodine.—This mode of treatment was introduced

about the same time by Velpeau and by Brainard of Chicago. The
latter surgeon's method consists in injecting, after only partially
emptying the tumor, a solution of iodine with iodide of potassium
(iodine, 5 grs.; iodide of potassium, 15 grs.; water, 1 fl. oz.), allowing
it to flow out again, washing out the sac with water, and finally
reinjecting a portion of the cerebro-spinal fluid originally evacuated;
and the former's, in completely evacuating the tumor, and then
injecting a mixture of iodine and iodide of potassium, each one part
to ten parts of water. Each of these plans has met with a fair
measure of success;1 but the modification introduced by James
Morton of Glasgow is a great improvement, and affords what is
actually the most successful mode yet devised for dealing with spina
bifida. Morton employs a solution of iodine in glycerin (iodine, 10
grs.; iodide of potassium, 30 grs.; glycerin, 1 fl. oz.), which has the
advantage of being less diffusible than the aqueous solution, and
therefore less liable to enter the spinal canal. The tumor is about half
emptied, and a small quantity—from fluid drachm ss to fluid drachm
iij of the solution—is then slowly injected, and allowed to remain. The
operation is repeated after a few days if necessary. Of 50 cases
known to Morton as having been treated in this way up to May, 1885,
41 were regarded as successful; but of 71 cases collected by the
London Clinical Society's committee, only 39 had been benefited by
the operation.
1 In a case recently recorded by Woltering, however, iodine injection was followed by
death within half an hour.
The introduction of iodine into the sac of a spina bifida is, according
to Morton, only justifiable in cases unattended by paralysis; under
opposite circumstances I should be disposed to try a plan recently
employed with success by Noble Smith in a case of meningocele—
viz. injecting the iodo-glycerin solution into the coverings of the sac,
and as close to it as possible without perforating it.
(3) and (4). Ligation and excision have each occasionally effected a
cure, but more often have but helped to precipitate a fatal issue. A
successful case of ligation followed by excision has been recently
recorded by Löbker. The elastic ligature, applied around the neck of
the sac (if this be pedunculated), has been employed by Laroyenne,
Ball, Colognese, Baldossare, Mouchet, and other surgeons, and of 6

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Introduction to Contemporary

Geography 1st Edition Rubenstein Test

6.1 Multiple Choice Questions

4) Which of the following is not primary evidence of human diﬀusion?

13) International migration has increased considerably in recent decades as:

14) Most international migrants are:

19) The political causes of forced migration are typically ________.

28) Movement constrained to within the same region is defined as ________.

1) Migration has never been a constant part of human history.

8) International migration has decreased considerably in recent decades as economic disparities

1) Briefly explain modern trends in mass migration.

2) Briefly discuss global migration trends in recent decades.

4) Explain the political causes of forced migration in recent years.

6) How is interregional migration different from intraregional migration?

Intraregional migration is movement constrained to within the same region. Intraregional

It is estimated that approximately 60 percent of undocumented immigrants come from Mexico.

9) What are selective immigration policies?

SYNONYM.—Leptomeningitis spinalis acuta.

By the term spinal meningitis is usually meant inflammation of both

ETIOLOGY.—Among the causes of acute spinal meningitis are injuries

SYMPTOMS.—The onset of the disease is generally sudden, and it is

When the course of the disease is unfavorable, symptoms of

The course of acute spinal meningitis is rapid. It sometimes

DIAGNOSIS.—Spinal meningitis is easily recognized in most cases by

PROGNOSIS.—Acute spinal meningitis is always a grave disease,

TREATMENT.—During the first stage of the disease an effort should be

Chronic Spinal Meningitis.

SYNONYMS.—Chronic inflammation of the pia mater of the spinal cord,

SYMPTOMS.—Gowers9 remarks that a large number of symptoms

The anatomical appearances, which are most pronounced in the

PROGNOSIS.—Simple chronic spinal meningitis is rarely if ever fatal.

TREATMENT.—The treatment should have for its object (1st) to relieve

Spinal Meningeal Hemorrhage.

SYNONYMS.—Spinal meningeal apoplexy, Hæmatorrhachis.

Spinal meningeal hemorrhage may take place between the dura

ETIOLOGY.—Penetrating wounds, injuries to the vertebræ, fractures

SYMPTOMS.—These vary according to the conditions under which the

PATHOLOGICAL ANATOMY.—In hemorrhage outside the dura the loose

DIAGNOSIS.—When the complications are such that symptoms

PROGNOSIS.—In traumatic cases the hemorrhage is usually only one

TREATMENT.—In the early stage absolute rest in bed, with cold

BY JOHN ASHHURST, JR., M.D.

DEFINITION.—By the term spina bifida is meant a congenital

SYNONYMS, ETC.—Of the various names which have been proposed

ETIOLOGY.—There are two conditions essential to the formation of a

SYMPTOMATOLOGY.—Spina bifida forms a tumor—or, more rarely,

The size of a spina bifida varies from that of a walnut to that of a

Spinæ bifidæ are usually soft and fluctuating, and occasionally

PATHOLOGY AND MORBID ANATOMY.—The most important points for

The committee of the London Clinical Society classify cases of spina

The theory which, according to the Clinical Society's committee, best

The fluid of spina bifida appears to be identical in character with the

DIAGNOSIS.—Ordinary fatty tumors have been mistaken for spinæ

PROGNOSIS.—The prognosis of spina bifida is without question

TREATMENT.—This may be either palliative or radical. If the tumor be

(1) Paracentesis, a simple evacuation of the fluid contents of the sac,

(2) Injection of Iodine.—This mode of treatment was introduced