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: | Boarders | 104 | ||
| Lodgers | 18 | 122 | ||
| Food: | Bakeries | 4 | ||
| Confectioneries | 4 | |||
| Cook shops | 6 | |||
| Groceries | 73 | |||
| Oyster-parlours | 1 | |||
| Saloons | 13 | 101 | ||
| Clothing: | Laundry work | 222 | ||
| Sewing | 109 | |||
| Millinery | 1 | |||
| Tailor shop | 4 | 114 | ||
| Miscellaneous: | Barbers | 8 | ||
| Basket-maker | 1 | |||
| Cigar store | 2 | |||
| Cleaning and Dyeing | 1 | |||
| Drygoods | 10 | |||
| Second-hand shop | 1 | |||
| Shoemaker | 21 | |||
| Umbrella-mender | 1 | |||
| Wall-paper shop | 1 | 46 | ||
| 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.