CHAPTER XVIII

Home Occupations of Consumptives—Sewing and Sweatshop Work—Food—Milk and Cream—Lunch Rooms and Eating-Houses—Laundry Work—Boarding- and Lodging-Houses—Miscellaneous Occupations—Summary—The Consumptive Outside the Home—Cooks—Personal Contact in the Factory—Supervision Outside the Home.

Home Occupations of Consumptives. Up to this point we have considered the patient solely in relation to his own family, or to those with whom he comes in immediate, constant contact. The people surrounding him are in their turn infected, transmitting the disease to others who in like manner are intimately exposed. Roughly speaking, all of this infection takes place within the four walls of the home. The home, therefore, is the centre of infection,—the focus from which tuberculosis radiates into the community. The further one is removed from this focus, the less the danger.

There are certain ways, however, in which danger from the home threatens people who live outside, people in no wise connected with the patient, and unaware of his existence. This occurs when the patient leaves his home to seek employment in the community, or when he makes or handles certain articles which go forth into the community as carriers of bacilli. Infections of this sort may be termed accidental. They are infrequent as compared to house infections, but infrequent as they are, they should be prevented.

In Baltimore, nearly fifty per cent. of the patients under supervision are able to work. They seek a livelihood in office, factory, shop, hotel, and private home. We also find that nineteen per cent. of the families under supervision carry on some sort of gainful occupation within the confines of their own homes. As a rule, the patients who conduct these little home industries or occupations are more advanced cases than those able to find employment in shops and factories. In some instances, this home industry was carried on before the patient became ill; in others, by far the greater number, it is the direct result of an illness which has modified his earning power and compelled him to eke out a scanty income by this means. In many cases the actual work is not done by the patient himself but by some other member of the household. Sometimes these industries are not dangerous to other people, or the risk is so slight as to be negligible. At other times, the menace is grave. Each case must be considered upon its individual merits—one must not generalize and condemn in wholesale fashion.

Sewing and Sweatshop Work. A number of our patients are dressmakers, or do factory sewing at home. Much has been written about the danger of clothing made under such conditions, either by the patient himself or by other members of his family. This output is not as dangerous as many people suppose, although such an admission would deprive the campaign of much picturesque photography. Much of this clothing is of washable material, such as cotton shirts, blouses, overalls, and the like, therefore any germs they might carry would be removed in the first washing. The danger has also been exaggerated in the case of woollen materials, such as coats, trousers, etc. Any organisms contained in these articles would soon die, or their virulence become so attenuated that little harm would result. This also applies to artificial flowers. It is not the occasional dose of bacilli, conveyed in this or any other manner, but the large and repeated implantations which do the damage.

Infected clothing doubtless plays considerable part in the spread of the acute contagious diseases, such as measles, diphtheria, and scarlet fever, but in tuberculosis the risk is so slight that it may almost be called non-existent. Under such conditions, the danger is not to the wearers, or probable buyers, but to workers who make this clothing while in contact with the consumptive himself.

Food. There are other home occupations about whose danger to the public there can be little doubt. Many patients keep small grocery stores, confectionery shops, and lunch rooms, and prepare and handle foodstuffs of all kinds. Again we must discriminate. The consumptive who sells tinned foods (which he does not handle), or meat, fish, or vegetables which are cooked before they are eaten, is not necessarily spreading disease among his customers. On the other hand, he who sells and handles milk, cream, ice-cream, bread, cake, candy, and so forth, is a decided danger to all who buy his wares. The alimentary tract is one of the main portals of entry for the tubercle bacilli, and every precaution must be taken to prevent the contamination of food. The patrons of these little shops are the people of the neighbourhood, who are regular customers, and their health is endangered not by occasional but by repeated doses of germ-laden food.

Milk and Cream. There is an ordinance in Baltimore forbidding the sale of milk and cream in a house where there is an infectious disease; this includes tuberculosis. In order to sell milk, it is first necessary to obtain a permit from the Health Department, but this permit may be revoked whenever occasion demands. If the nurse finds that one of her patients is selling milk (as is often done in connection with a small grocery business), she reports this fact to the Health Department. It may be that the patient himself never comes near the shop, and is out at work or away all day. This sometimes happens, but not often. Usually he waits upon the customers himself, selling milk in penny amounts, with a dirty finger inside the measuring cup. Or he may be too ill to attend the shop, but sits or lies in an adjoining room, so that his wife may wait upon him and upon the customers alternately. Under such conditions, the danger may be almost as great as if he himself handled the milk, since she does not take time for proper cleanliness.

To revoke a permit usually occasions considerable hardship, and the reduction of an already pitiful income. Yet summary measures must be taken unless the milk is sold without risk to the purchasers. The patient should be removed to a hospital, and the family must choose between letting him go and giving up the permit. When there are no hospital facilities and the permit must be withdrawn, leaving the family under financial stress, the nurse should ask assistance of the Federated Charities. This assistance, however, should never be offered as an alternative to removing the patient to a hospital.

There are other foods besides milk and cream liable to contamination, the sale of which is not controlled in any way. Thus as we have seen, while a consumptive may be prohibited from selling milk, he may sell ice-cream without let or hindrance. And furthermore, an ice-cream cone or “snow-ball,” handled by dirty, germ-laden fingers, is most often sold to the most susceptible of all customers—the child.

Lunch Rooms and Eating-Houses. Many patients earn their living by keeping eating-houses, oyster-parlours, ice-cream saloons, and so forth. There is danger to the customer whenever the cooking and serving of food are done by a consumptive, or by those in contact with a consumptive. A community to be well protected should enact comprehensive legislation controlling every aspect of the food supply, and special emphasis should be laid upon the handling of food by those with a transmissible disease.

Laundry Work. Another home occupation is laundry work—unskilled labour requiring no capital and largely resorted to, especially among negroes. This is heavy work, hence not always done by the patient, but often by some other member of the household. Whether the patient irons the clean clothes or sits coughing in the same room where this is done (we have often seen newly ironed clothes spread upon the bed of a last-stage case), the result is much the same. Under such circumstances clothes become contaminated. Since this sort of laundry work is usually done for regular customers, they week after week wear clothing that has come from an infected house. It is dangerous to sleep constantly on pillow cases that have been coughed on by a consumptive, and to use towels and napkins that have been subjected to a like infection.

Since there are no laws to govern conditions of this sort, the question arises, what is the nurse to do in such a case? Must she look on and say nothing, or must she warn those for whom this laundry work is being done? It would be futile to argue with the patient’s family—they would refuse to recognize the danger to others, seeing instead the financial loss from giving up the work. The nurse must first try to remove the patient to a hospital, thus doing away entirely with the danger. Failing in this (through lack of hospital facilities), the family may be willing to give up the work on condition that an income be substituted by some charitable agency. Simple as the latter course may seem, so many obstacles to procuring this aid will arise, that it offers no practical solution of the matter. If the home surroundings cannot be altered and the danger reduced, then the patrons or customers should be told of the conditions under which their laundry work is done. It is not always possible, however, to locate these customers, since the patient is very wary of giving information upon this subject. Whenever possible, nevertheless, they should be told; if they prefer to continue the risk, they are at least not in ignorance of it.

It is deeply regrettable that exposure to infection by tuberculosis is still an optional matter, and that the necessary curtailment of individual liberty has not yet been made in regard to all opportunities for it. In the case of impure milk, for instance, the law at least makes an effort to curb the preference which any individual may entertain for it.

Boarding and Lodging Houses. There are other home occupations in which the menace is of a personal nature, and does not come through contaminated articles. Many patients take in boarders—an occupation which frequently entails considerable overcrowding of the home. This brings healthy individuals directly within the danger zone, and subjects them to the same risks incurred by the family itself. Other patients take in lodgers; here the risk is less, because meals are not included. In either case, there is great personal exposure, with equally great opportunities of infection.

Summary. To sum up: Among 3107 patients under supervision, we find 608, or 19 per cent., carrying on some sort of gainful industry within the confines of their own homes. The resultant danger is of two kinds: from personal contact with the patient, and the remoter possibility of infection through articles which he makes or handles. The most serious risk is that incurred in boarding- and lodging-houses, where the inmates are subjected to a high degree of personal exposure. In other occupations there may be some personal risk, but it is slight and transitory, and therefore insignificant. In considering contaminated articles, we find there also two classes: those dangerous to a high degree, and those but slightly so, if indeed they may be called dangerous at all. Among the former, the most harmful are the contaminated foodstuffs, in which the risk is almost as great as through personal contact. Next comes laundry work, where the risk is in the repetition of infection, as in the use of household linen. Then comes the output of clothing, cotton and woollen, where also the risk is slight. In the case of other articles handled by the consumptive the risk involved is so insignificant as not to be worth mentioning.

The following table shows the nature of these various Home Occupations, ranged in order of their risk to the community:

Personal:Boarders104
Lodgers18122
Food:Bakeries4
Confectioneries4
Cook shops6
Groceries73
Oyster-parlours1
Saloons13101
Clothing:Laundry work 222
Sewing109
Millinery1
Tailor shop4114
Miscellaneous:Barbers8
Basket-maker1
Cigar store2
Cleaning and Dyeing1
Drygoods10
Second-hand shop1
Shoemaker21
Umbrella-mender1
Wall-paper shop146
Total, 605

The Consumptive Outside the Home. We must now consider the patient who is employed outside the home. As we have said before, nearly fifty per cent. of our patients are able to work. The danger to the public is of two kinds, that arising through personal contact, and through certain articles which the consumptive may make or handle. In the latter case, just as we find it among the home occupations, the risk to the community depends upon the articles themselves. Whatever affects food, is far more dangerous than the contamination of articles not taken into the alimentary tract.

To prevent the possibility of food infection, we should enact and enforce laws forbidding the employment of consumptives in any factory, shop, or establishment of any kind in which food is either prepared or sold. This would include candy factories, bakeries, cake, biscuit, and cracker factories, canning and preserving establishments, as well as dairies, restaurants, lunch rooms, sodawater stands, candy shops, and the like. We must never forget that the home is the chief centre of danger, the place responsible for the vast majority of infections, and that every infection which occurs outside the home is accidental, so to speak. Yet accidental infections, while relatively few in number, are still plentiful enough to make it necessary to safeguard the community in every way. An effective tuberculosis campaign demands the stoppage of all leaks.

For example: on our visiting list was a girl employed in a biscuit factory, packing cakes. She was an advanced case, and every now and then had a hemorrhage which compelled her to stop work, though sometimes only for a few hours. Between hemorrhages, she worked steadily. The cakes packed under these conditions doubtless carried a full quota of germs. We tried to induce her to go to a hospital, but she declined. The manager was appealed to but he wanted to keep her—she was a quick worker; besides, he did not have to eat the cakes—so he refused to add his influence to ours to get the patient to an institution. The public should be protected by law from the possibility of such infection.

The saving phase of the situation is this: while the patient who keeps a bakeshop and sells his wares day after day to practically the same customers, fulfils the condition that repeated implantations are necessary to contract the disease; on the other hand, the cakes distributed by a factory cover a wider range of territory—thus, while many more people get doses of germs, the doses themselves are probably too small to be harmful. This also may be said for other kinds of foodstuffs, handled in factories by tuberculous persons; these articles are distributed so widely that no individual consumer is really endangered. In this way, the risk is minimized. But still we must remember that every factory in the country has its tuberculous employees, with their output of bacilli to be reckoned with. The consumer is thus threatened on every side. No wise community should tolerate such chances of infection.

Cooks. There is considerably more danger from the tuberculous cook employed in a private family. Under such conditions the household is steadily infected day by day, not through personal contact, but by small, repeated doses of bacilli received into the alimentary tract.

If typhoid fever permitted a patient to work—if it were a chronic instead of an acute disease—we should consider it a highly dangerous expedient to permit such a patient to handle food in any way, and we should be exceedingly wary of restaurants which employed typhoids as cooks or waiters. This argument applies with equal force to tuberculosis. In typhoid, there is but one portal of entry—the digestive tract. In tuberculosis there are two—the respiratory as well as the alimentary—and they are equally important.

Personal Contact in the Factory. While the patient in the factory is a menace, he is less dangerous than the patient in his home. A man well enough to work is seldom in the most advanced and infectious stages of tuberculosis. Moreover, his fellow-workers, unlike the members of his household, are not in constant but rather in casual and intermittent contact with him. These two conditions tend to diminish the risk to his associates; still, it always exists. The consumptive does not seek employment from a malicious desire to spread tuberculosis—he seeks it because of economic conditions compelling him to work until he falls in harness. We must recognize this driving necessity, but at the same time we must protect the workers who perforce surround him. They too are impelled by the same need, and their rights equal his.

When a patient is visited at home, he and his family are often stimulated to a high degree of carefulness. The patient uses a sputum cup for his own convenience, and the family insist upon this for their own interest and safety. The result is a lessening of danger, and an improvement upon a neglected and uninstructed case. In the factory, these conditions are reversed. His cup is no longer a convenience, and he dreads being conspicuous through its use. Moreover, since his illness is unknown to his fellow-workers, there is no one to insist upon precautions of any kind. The result is that we maintain in the factory conditions which we seek to abolish in the home. We give one set of people information whereby to protect themselves, and we withhold this information from another group of people who need it almost as much, which is illogical and stupid and costly. Enormous sacrifices have been made to this policy of silence, and it is time for these sacrifices to cease.

Those in contact with a consumptive, whether this contact takes place in the home or in the factory, are entitled to know the nature of his disease. It is not the degree of consanguinity, but the degree of contact which should determine this knowledge. We cannot trust the patient to protect others—it is a trust too often violated. We must surround him in the shop with a public opinion even more potent than that which he finds at home. His fellow-workers will be less tolerant of breaches of technique, will make less excuse for whims and temper, than does the tired family. We knew of one patient who insisted on spitting on the floor—at home; when his wife remonstrated, he knocked her down. In the shop, such conduct would cost him his place, and rightly.

Supervision Outside the Home. Whenever the infectious case is at large in the community, his whereabouts should be known to those most exposed to the danger. This applies alike to employer and employee. The head of the department in which the consumptive is at work should see that those in contact with him know of his condition. The patient should be compelled to use his sputum cup when he expectorates. Knowledge of the patient’s condition does not necessarily mean that he should be dismissed—it should merely mean that he will be held up to the required standard of carefulness. For example: the Baltimore Health Department received a letter from a certain firm in the city, stating that many cases of tuberculosis had developed among the employees on a certain floor in their factory—and on this one floor alone. This led them to suspect that a consumptive might be among these workers, distributing the disease. A list of all the employees was submitted. Investigation promptly showed that on this particular floor was a chronic case of tuberculosis of long standing, a man who had been under supervision at home for several years. In his home, this patient was exceedingly clean and punctilious in the use of the sputum cup; at his work, however, he was absolutely the reverse. On receipt of this information, the employer had a sound talk with this man, which resulted in the use of the sputum cup and all other precautions. The patient did not lose his place, but he was no longer permitted to jeopardize the health of his fellow-workers.

Patients with chronic tuberculosis are also found in domestic service, and go in and out of private homes, carrying infection with them. This danger is especially great in the South, where there is a large negro population, and we constantly find consumptives employed as cooks, housemaids, nursemaids, and butlers, as the case may be. For the most part, the employers are entirely ignorant as to their condition. In these cases, just as in the factory, office, department store, and so forth, the employer should be notified of the presence of tuberculosis.

To give this information should be the duty of the Health Department. The municipal nurses are aware of the facts, and they also know when a patient changes his occupation, or place of employment. But to give this information without following it up, would not be enough. To notify an employer of the presence of a tuberculous worker, would not necessarily mean that any action resulted. A poor workman might be summarily dismissed, and a good one retained, without those in his vicinity being enlightened as to the nature of his disease. To make this information of value, it would be necessary to supervise the patient in the factory, just as he is supervised in the home. This double supervision would demand a greatly increased staff of nurses, since factory visiting should not be done through curtailment of the nurse’s other duties. We must once more emphasize the fact that the home is the fountainhead of tuberculosis, and that every infection which occurs outside the home circle (or its equivalent) is practically an accidental infection. But, as we have already said, a comprehensive plan for checking tuberculosis must include the stoppage of all leaks, and the unknown, unsupervised consumptive, at large in the community, is a leak which should be recognized by common-sense.

Yet certain conditions must be complied with before we can extend this municipal supervision. Outside-the-home supervision will create an enormous amount of phthisiphobia. Consumptives are now tolerated because their presence is either unknown or but dimly guessed at; when this ignorance is dispelled—as it must be if the nurse visits them at their places of employment, and their presence and numbers are made known, a great wave of fear will spread over the community. Such a result is inevitable when for the first time the public realizes, suddenly and concretely, the extent to which it is threatened. Tuberculous workers will be discharged by hundreds, and there will be widespread suffering in consequence.

On the other hand, however, thousands of non-tuberculous workers will be relieved of a great danger. Our factories already produce workers so worn out and devitalized as to fall ready victims to any disease that presents itself. Would not these same factories be somewhat less dangerous if swept clear of consumptive employees?[[9]]

[9]. However bad certain factory conditions may be, these of themselves cannot produce tuberculosis any more than they can produce scarlet fever or diphtheria. The disease itself must be brought into the factory by a carrier—someone who is himself infected.

Outside-the-home supervision is the next logical step in the anti-tuberculosis campaign. But valuable as this would be, from the point of view of the general health, it cannot be done until the community is prepared to care for all who would undoubtedly suffer as a result. Some patients, of course, would not lose their situations, but the majority would be turned adrift without a moment’s hesitation. These the community must take charge of. Therefore, before we can supervise tuberculosis beyond the boundaries of the home, we must have ample hospital facilities. Hospital accommodation must be so extensive, so complete, and so excellent that institutional care can be given to all who need it.

In this way, the community will be relieved automatically of a vast amount of danger. Patients will either seek institutional care, or, if they continue at work, will do so under conditions which do not jeopardize other people. For the reaction from the first intense phthisiphobia will be a demand for carefulness on the part of the consumptive, and sane toleration of him.

The one objection to this policy of supervision and publicity is the seeming interference with the personal liberty of the individual, but to curtail the liberty of the patient to transmit a communicable disease, is to increase the liberty of hundreds to escape it. There should be no question as to which has the superior claim.