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Health and Immigration


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TRACHOMA

 



Immigration officials perform medical examinations on each arriving passenger.
(courtesy of the National Park Service, as found on www.ellisisland.org)

The 1911 Encyclopaedia Brittanica, in its definition of trachoma, states that it is a "contagious disease, associated with dirty conditions, and common in Egypt, Arabia and parts of Europe, especially among the lower class of Jews. Hence it has become important, in connexion with the alien immigration into the United Kingdom and America, and the rejection of those who are afflicted with it. It is important that all cases should be isolated, and that the spread of the infection should be prevented."

It is easy to infer that there were a number of would-be immigrants who might have been diagnosed with trachoma when they probably had another eye condition, such as a moderate to severe conjunctivitis (inflammation of a mucous membrane of the eye), caused by the conditions that existed during their ship voyage. A diagnosis of trachoma would automatically be grounds for sending the immigrant back to where they came. This would not be the case if the immigrant had a moderate case of conjunctivitis. When one considers the anti-immigrant sentiment during this time, particularly against the Jews, it is not hard to imagine many immigrants being turned away with this misdiagnosis.

What then is trachoma? It a chronic infection of the eye, caused by an organism called Chlamydia trachomatis. Worldwide, it is the second leading cause of blindness, after cataracts. It is so not because there is no treatment available, but because many of those who develop trachoma live in the poorer countries, lack proper health care, and cannot afford such treatment. Thus it is really the leading cause of preventable blindness throughout the world. Trachoma is especially prevalent in countries where it is endemic, where many people have it and can spread it to others. Trachoma may occur where there are great public health deficiencies such as malnutrition, poor public sanitation, poor insect control, e.g. flies, and housing conditions that lead to overcrowding and filthy conditions. This, along with poor personal hygiene and a lack of clean water, makes a person even more prone to trachoma and other such diseases.
Trachoma is endemic in much of Africa, as well as parts of Asia and Latin America.

Trachoma is a disease that is highly contagious in its initial stages and can be transmitted by direct contact with someone who is infected or by contact with other articles that may come into contact with this organism. It first presents itself as follicles or "bumps" under the upper eyelid. Usually, trachoma is insidious in its onset, i.e. few if any symptoms appear that might indicate the seriousness of the condition. On the other hand, a disease such as adult inclusion conjunctivitis presents itself with an acute onset, i.e. tearing, light sensitivity, discharge, pain, lid swelling, often like a bacterial infection of the eye. With the progression of the disease, trachoma will cause scarring in the underlining (conjunctival membrane) of the upper lid, and fine, white, linear scars may appear. What is especially troubling about this disease is its potential for corneal involvement. The signs of corneal involvement may include a myriad of conditions such as inflammation of the upper cornea, corneal ulcers, new blood vessel formation on the cornea that may all contribute to the eventual scarring of the cornea. Such severe scarring may occur which may cause tear duct closure, trichiasis and entropion (i.e. the eyelashes begin to turn inward as do the eyelids, which subsequently rubs against the cornea causing more inflammation.) This can be pretty nasty business. So with the corneal ulceration and scarring, blindness may occur. The final result of such a condition as trachoma is called xeropthalmia (you can look this one up on the internet.) Today, the treatment of choice for trachoma is the systemic administration of the antibiotic tetracycline or erythromycin. Such treatment may take a few months to achieve maximum effect. Back in the early days of immigration, there were no such antibiotics to treat the potential immigrant and the possibility of spreading the disease was considered too great to permit the person to enter the country. Penicillin, the first antibiotic, was not discovered until 1928. Erythromycin was not commercially available until 1952, tetracycline in 1955. Azithromycin may also be used to treat this condition (azithromycin was patented in 1981.)

The question then, of course, is what diagnostic equipment (and training) did these health inspectors have to become qualified to examine these immigrants. Were they all medical doctors? What was their training with regard to eye diseases? Did they just invert the upper eyelid, i.e. turn it inside out of did they just life it to see underneath? Did they just check for large follicles and arrive at a diagnosis?
I am pretty sure that the inspectors didn't have a "biomicroscope" at ports like Ellis Island that they could use to view the condition of the eyelids and corneas under a high magnification. Also, would the immigrant be able to respond properly to questions so that a basic case history could be established that would aid the examiner in making a diagnosis, e.g.  "Have you had an discomfort in the eyelid above your eye?" Perhaps there may have been questions about possible symptoms or about their living conditions and their family history. How would the inspector be able to acquire an adequate knowledge of the subjective symptoms of the immigrant, especially if there was a language barrier? There were not always people available there to assist in translating questions and answers. What could the medical examiner see with the naked eye, with his instruments (see photo below)--just follicles under the upper lid or obvious signs of corneal scarring? A person also may have had a corneal ulcer or even a "pterygium" or "pinguecula" (growths that occur from the outer border of the cornea toward the pupil that are non-contagious, etc.) This would not be grounds on its own to send an immigrant back to their home country, but this may have certainly contributed to any misdiagnosis. It is hard to know exactly what was going on in the minds of each of these inspectors, how fully they were trained for such inspections, what their actual medical training was that qualified them to make such a diagnosis, and what percentage of these immigrants truly had trachoma.
 


V. DiPietro - NPS
Buttonhook collection. U.S. Public Health Service used items like these to conduct immigrant eye exam at Ellis Island.

The "Buttonhook".  Device used by women during the 19th and 20th centuries to complete the lacing and buttoning of shoes/boots, blouses and gloves. 

Doctors of the U.S. Public Health Service at Ellis Island often used these devices to check immigrants for trachoma, a highly contagious and difficult to cure eye disease.  Eyelids were inverted or pulled outward to see if immigrants displayed symptoms of this dreaded disease.   Today, trachoma is still the most common form of preventable blindness world-wide.  Nearly 300 million people are estimated to have the contagious disease and many never get properly treated.

Material courtesy of National Park Service, Statue of Liberty National Monument.



Also read about how many hopeful immigrants were taken advantage of at European port cities,
told that their trachoma could be cured. To read this 1905 New-York Tribune article, click here.




 

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