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]]