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VILLAGE SETTLEMENTS FOR THE TUBERCULOUS. By P. C. VARRmR-Jo~s. (Medical Director, Papworth Village Settlement.) HE treatment of tuberculosis during the last twenty years has followed lines laid down by those great pioneers who, convinced of the soundness of their ideas, dared to put them into practice in the face of intense opposition. Such a pioneer was George Bodington, of Sutton Coldfield in Warwickshire, who, nearly a hundred years ago, started open air treatment. He was laughed to scorn and ridiculed by his fellows. Another was Henry MacCormac, of Belfast. In 1840 Bodington was without honour or following in his own country, but in Germany his teaching was accepted, and sanatoria were built. The success of this method in the hands of Brehmer at Gorbersdorf, in 'Silesia, in 1859, of Herman Weber, who advocated the ~reatment of consumption at high altitudes in Switzerland, of E. L. Trudeau, who commenced san.atorium treatment in the Adirondacks in 1873, and subsequently of Otto Walther of Nordrach, stimulated others to follow the same road. Curiously enough, it was adopted in England as an entirely new idea, aud it was not until 1899--fifty years after Bodington's pioneer example--that the Brompton Hospital established open-air wards and decided to build a sanatorium in the country. That a system of treatment should be practised in every country must mean that it has some solid basis for approval, and such, of course, is the case, but we hear on all hands the strongest criticism of the system, and sanatorium treatment is being condemned, not in this country only, but in every civilised country in which it is practised. To condemn a system wholesale in this way is unjust, for we must admit that for specially selected early cases there is no treatment more effective than that of a properly conducted sanatorium. The fact of the matter is that our sanatoria are filled with cases for the majority of which sanatorium treatment is not a cure, and many of our sanatoria in consequence are not rul~ as .sanatoria'for early cases should be, but as a mixture of sanatorium and convalescent home. What a state of affairs, and why have we reached this pass ? The success of the early German sanatoria was due to the fact that only early cases were selected; all others were excluded, the utmost care was exercised in carrying out the strictest r~gime: result, success. Now, sanatoria in England (and I have no doubt also in all other countries) are filled as to two-thirds of their beds with middle and advanced cases. With what result ? They break down almost immediately they go home, and their last state is worse than the first. We have

T

* An Addres~ ~iven at. the Royal College of Su,rgeons, Dublin, on Monday, Februsry 8, 1980.

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painted a picture of the tuberculosis w.orld which does not exist. I f our dispensaries were devoted solely to the detection of early cases of tuberculosis, if our sanatoria were employed for the complete arrest of these early cases, all would be well, but the facts are entirely different. Our dispensaries ,are crowded with men and women in a considerably advanced stage of the disease. They are given placebos of cough mixtures and doles of food; some are sent to sanatoria for a short p e r i o d - - t h e idea being to give a little of the good thing to as many as possible. T hey r e t u r n home, and I need not tell the story of what happens. We all know the long agony of illness and want, and what is worse, the infecting of another member of the family, who must go along the whole long weary road again. .Sanatorium treatment is not to blame for this. W hat is to blame is our blindness in not visualising correctly the tuberculosis problem and making plans to deal with it accordingly. Dispensaries are excellent when properly equipped for the detection of early cases of pulmonary tuberculosis, but. the hard fact is that the working man or working woman cannot afford to be an early ease of tuberculosis and refuses to go away for treatment. So f a r we have no provision to enable such a person to benefit by long treatment. W hat happens ? He or she works on until all hope of cure is passed: then, instead of providing an environment in which a damaged organ can work without detriment to himself or his neighbour, we send him to a ~anatorium for a few months and then back to the very conditions in which he hopelessly breaks down. We have not given the sanatorium a chance; therefore we cannot blame it. It is our own stupid mentality we have to blame, and until we visualise the problem as it really is, so we shall have misery and infection marching on side by side. I t is too true that if our sanatoria were to refuse all cases except early ones, not one-third of the beds would be occupied; wh y keep up the farce of sanatorhun treatment when it is nothing of the kind ? W h y keep on talking about early cases if we find t h e y cannot take advantage of the treatment offered ? Let us perfect our methods for the detection of early cases of tuberculosis by all means, let every effort be made to ensure t hat those physicians who are skilled in diagnosis become more skilled still, let no expense be spared in this direction, but remember that if it is our object by so doing to get the early case of tuberculosis in the working man and woman under treatment at the earliest possible opportunity, then it must be understood that we are doing only half the job unless we make it possible for such men or women to avail themselves of such treatment. The question is largely economic. The well-to-do can immediately put into practice the advice of the skilled physician, the working man cannot. This is the root of the matter. Let us no longer talk of the failure of sanatorium treatment, let us rather talk of the failure of our own understanding of the problem. We

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carelessly thought t hat what the well-to-do could undertake the poor could do likewise. W hat a mistake! And this mistake has caused the expenditure of millions of pounds in buildings designed for the t r e a t m ent of such cases, and they ,are not there. .We have locked up millions of money in bricks and mortar and we have the failures of treatment, men and women, unemployed and unemployable, a source of infection in our large towns and cities. To make matters worse, w~ have no plans for after-care. In some areas we have the heroic and self-sacrificing v o l u n t a r y workers struggling with ver y inadequate or no funds to relieve the sufferings and trying to stop the spread of infection. We have the guardians doing what they can in the m at t er; we have little workshops here, and little training schemes there, no coordination, no vision as to what is necessary to meet the case. The size of the problem seems to paralyse us. 77,881 new cases were notified in 1928; death from tuberculosis totalled 36,623 in 1928 ; at the end of 1927 there were 344,244 definitely diagnosed oases under treatment or supervision at the various dispensaries. (I am referring, of course, to England and Wales.) Sir George Newman says: " Many deaths from tuberculosis have occurred amongst cases not previously notified," so nobody really knows how many consumptives there are walking about and spreading the disease everywhere they go. We are spending millions annually upon the treatment of the disease, but next to nothing upon its prevention. Much of the good work is entirely wasted, and the disease, which is now well enough understood to be checked and controlled, is continuing its cruel ravages. What happens to the cases which are discovered and sent to sanatoria ? I f th ey are " early " cases it is probable that a stay in a sanatorium will effect permanent arrest of the disease. On discharge they can return to their homes, and so long as nothing occurs to start the disease again, they will infect nobody and be quite fit. I f they are advanced cases, t hey will very probably be kept at the sanatorium for a time, and then sent home to die. The excuse for this is that their room is needed for other cases who may hope to recover. Whether this is sufficient justification for sending dying patients back to their homes, where they often cannot obtain any comforts at all, and where they are almost certain to infect their relatives and friends, I leave my readers to say. " Middle " cases are the most numerous, and it is for them more than any that adequate provision is now lacking. A stay in the sanatorium will often improve their condition enormously. But it will not produce permanent arrest of the disease, unless f o r the rest of their lives they live very carefully, and in healthy surroundings. Now we reach the crux of the problem. How can a consumptive working man, with perhaps others dependent upon his

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labour, live carefully or in healthy surroundings ? To live he must work, and how can he, with the stigma of the sanatorium upon him, pick and choose a job ? He has to take whatever he can get. If it makes him ill again, he sticks to it as long as he can, and then breaks down again. The disease advances, and he becomes dangerously infectious. Privation drives him from a poor lodging to one yet poorer. Perhaps his wife, still young and healthy, becomes the wage-earner, ceasing work for a few weeks each year to give birth to a child. The consumptive father minds the children, gives them their mid-day meal, and warms the milk for the baby, taking little or no precaution against infection. If the children are below school age, and the weather doubtful, the whole family remain indoors breathing infection. The man dies, and then his wife and children, infected b y him, go through the same dismal process. This is a typical history of a " middle " case. Dispensaries and Care Committees are well-intentioned, but drugs cannot change an unhealthy environment, nor kindness create suitable employment. Nothing can force him to keep his windows open in cold weather, nor can anything prevent people from staring at him if he uses a sputum flask instead of spitting unashamedly on to the pavement or the floor. Our present scheme of sanatorium treatment does not solve the vast problem of the ~' middle " ease. It patches him up, and then sends him back ~o the very conditions in which he became infected, fortified with much excellent .advice which he cannot possibly follow. The whole medical profession knows that a ~ middle " ease after sanatorium treatment requires good food and plenty of it, fresh air, graduated work, freedom from economic pressure, and a healthy home, if he is not to get worse, spread the disease, and die. But what is the use of telling a man what he needs if he cannot get it ? The rich consumptive can create his own environment to suit his health. The poor consumptive cannot, and until a suitable environment is created for him the scourge of tuberculosis will continue to spread. I f it were impossible to create a suitable environment for these eases, we should have no need to reproach ourselves, but it is not impossible. Such an environment has been created, and b y its results has shown that the spread of infection can be stopped, that consumptives can support themselves by their own labour and live normal family lives without infecting their children, and that the whole scheme need cost nothing more beyond the original capital outlay. This we have attempted at Papworth Village Settlement, near Cambridge. A nmnber of " middle " cases, having received treatment in the Papworth sanatorium, have been given permanent employment in the village. They work in twelve different industries, managed by ex-patients who, being consumptive themselves, can gauge and appreciate the sufferings of others. Medical attention is always immediately available. The unmarried

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settlers live in hostels, the married ones in cottages; and they receive wages which enable them to have the good, nourishing food they need. Breakdowns are few, but when they occur, the man knows he will not lose his job. The windows of Papworth are open, so that no concentration of bacilli can occur to infect anyone. When a man uses a sputum flask it attracts far less notice than if he were to spit on the ground. There is a clinic for children, so t h a t from their birth their health is cared for and they have a chance of growing up into firm healthy citizens. I t is a model village, especially designed to give expression to the whole of the teaching of the medical profession in regard to tuberculosis. Papworth makes practical the advice which otherwise is unpractical, and maintains the benefit received from sanatorium treatment, which is otherwise utterly wasted. And it does not send advanced cases home to die. We think and believe that Papworth points the way to the mitigation or solution of a grave problem, and that it is an after-care scheme which embodies all the essentials. Until early diagnosis is the rule and not the exception, or until a " miraculous cure " for tuberculosis is discovered, there will be a crying need for places in which the environment is suited to the sub-standard man and woman. ~Papworth has tried to recognise and solve these difficulties, with what success I must leave my readers to decide. But, recognising that the man or woman who is suffering from tuberculosis is a damaged person and recognising that the necessary conditions for employment and rehabilitation are unattainable in the outside world, no effort has been made at Papworth to train patients for an occupation to be followed outside the settlement. On the contrary, all endeavours have been directed to providing permanent occupation in the settlement. To what extent this has been accomplished may be gathered when I say tl~at the ex-patients resident in the village have risen from one to one hundred and fifty, and the sales have expanded from s in 1918 to over s last year. Instead of a diminishing number of settlers under these conditions, the number has increased steadily year by year, and the turnover in the industries which support them has increased correspondingly. In the village settlement there must be, above all, the guarantee of a living wage. When a man contracts tuberculosis he does not necessarily become a philanthropist or a saint, and now that he is disabled it is the more urgent that he should be able to purchase an adequate food supply and be able to live under hygienic conditions. To provide a suitable house without proriding the means to pay the rent goes but a very little way along the road to success. To pay the man's rent for him takes away his self-respect, and unless care is taken, the result will be a panperised individual. Some means must be devised, therefore, to maintain his earning capacity. To enable him to do this, certain conditions must be provided.

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In the first place, work must be such that his strength is equal to it, it must be congenial, and it must be serious. I f there i8 one thing which the working man can detect quicker than another, it is the sham industry set up by the amateur for his benefit. He quickly detects it, and he quickly responds. I f his employer is playing at a game, so will he. The next important consideration is the avoidance of all exploitation of his labour. I t seems self-evident that a scheme for the employment and benefit of the tuberculous man should be for his sole benefit, but this is by no means understood or acted upon. There is no need for healthy overseers to take the bes~ positions, and leave the disabled in the position of serfs. Because a man has a disability he should not be debarred from improving his social and financial position in an environment in which this should be possible--nay, in which it must be possible, if it is his right environment. The true village settlement for t~he tuberculous will be one in which there ia opportunity for alI to attain to a better position, just as it is possible in a modern well-managed business. A village settlement should be regarded as a self-contained community, its inhabitants sub-standard men and women. They can compete with one another and are stimulated by such competition, but they must not be in the bondage of the healthy. They know they cannot make good in the world at large, but they can and do make good when they have the right environment. That their outlook is but human cannot be a matter for surprise. The disabled man requires the opportunity to put his talents to good use; the provision of that opportunity is our business. This is quite a different thing from charity. Charity is barren--it paralyses effort. The provision of opport u n i t y is rather the protection of the disabled from fierce and unequal competitio~ than anything else. To introduce such competition into the village settlement in the form of a healthy overseer is to court disaster. This is hardly ever realised. The healthy overseer demands good pay, but he rarely earns it. Unless he is a man of exceptional character he looks upon the reduced working capacity of his men as a reason for reducing his own ; he comes down to their standard, rather than attempting to bring them up ~.o his, which--as a rule--is dangerous or impossible. His salary becomes a drag on the industries. The overhead charges increase, and it is those overhead charges which the disabled man cannot meet out of his industry. He can earn his own wage, but little more. Herein lies the reason for the non-employment of any large number of disabled men in ordinary industry. A sympathetic employer can afford one or even two, but the point is quickly reached at which the subsidy required to keep these men equals the profits of the firm. A donation of s or s a year to charity is an easy way of avoiding such disaster. It is important, therefore, to understand the general atmosphere which must be created in a village settlement, and it will then be seen that such a settlement is much more than a

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collection of workshops or a collection of houses. Without a spirit of co-operation workshops would soon be idle, the houses would become almshouses, and the whole scheme an interesting relic of the past. It is the spirit of organisation which counts. While business methods neglected would mean financial ruin, these business methods must be altered and adapted to the special needs which exist. Herein lies the difficulty of making the business community understand that a village settlement for the tuberculous is much more than an organised industry. Economics play a vital part, and so do medical matters. One element shoulcI not overshadow the other; rather should they go systematically hand in hand, and herein is the chief difficulty with the medical profession. All re-adaptation of the disabled is applied economics. The disabled cannot stand alone, but that does not necessarily mean the bald intrusion of charity; it means the unobtrusive aid of charity in an economic guise--the provision or opportunity in an environment where a specifically damaged organ can function without an increase of that damage. It has been admitted that the village settlement is the ideal scheme for the after-care of the tuberculous worker. There is a certain amount of agreement as to the ideal, and it remains therefore largely a matter of detail and of application. Obviously, i f the scheme were too costly it would defeat its objects. Let me remind you what these objects are. In the first place, the treatment and econolv,ic settlement of the diseased person, and secondly, the prevention of infection, not only of the family, but of the comumnity at large. If these two objects can be attained for the cost of either one of them, then surely the scheme is justified. This is actually the case. Year by year financial statements have been published showing the exact cost in capital and in mainteuance charges of the combined hospital, sanatorium and village settlement known as " P a p w o r t h . " To take the capital expenditure first, it will be found that although there is more provision for workshops, the cost per bed does not exceed the average in similar institutions. 90 regard to the maintenance of patients in the institution, the figures are available in th~ official reports of the Ministry of Health, and are substantially the same as for institutions of a similar size. Some few large institutions show an average weekly cost of a shilling or so less, while there are many which show an average cost much higher. There is no need to quote these figures, for they are readily obtainable and indeed are freely circulated by the Ministry of Health to their officers all over, the country. (Memo. 122/T). To come next to the housing of the settlers in the village; the houses have been built at an average cost of s per house. Whether the family resided at Papworth or elsewhere, the expenditure would have to be incurred by some local authority. The various building schemes of local authorities show the cost of providing such houses, and the figure I mention will be found to compare very s

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It is of the utmost importance that the campaign against ~uberculosis should be pushed on with the utmost vigour. Whilo money is spent on the treatment of tuberculosis, so far there is no definite policy for the spending of money on the prevention of the disease. Treatment and prevention go hand in hand, and the greatest method of prevention is the segregation of diseased persons and their proper treatment in a suitable environment. It will be seen that the village settlement is ,gradually evolved from the sanatorium. To start a settlement d e n o v o would not meet with success. A village settlement grows as naturally as any village would when an industry which offers employment springs up. The difference between a village settlement and the ordinary village is that the industries are specially run for the benefit of the inhabitants of the village settlement, and for no one else. The spirit of co-operation, once implanted, grows and increases; selfhelp, self-guidance, follow. The institutional spirit is transformed into that spirit of self-reliance without which no community can stand. The village settlement, with the hospital for advanced cases, the sanatorium for those suitable for this form of treatment, and the village, with its hostels and houses, workshops and recreation hMls, form a complete unit. The opportunity for medical research must not be lost sight of, and this aspect, combined with the opportunities for investigation into industrial and social conditions make the whole scheme an entirely new departure. What are the results ? (1) A complete absence, during twelve years, of clinical tuberculosis in the 43 children born in the Papworth Village Settlement, of men and women who are definite clinical cases of the disease, and who in most instances show tubercle bacilli in the sputum from time to time. (2) A village community of over 400 maintained by the work of the industries. (3) A total of s paid in wages to the settlers since 1918. (4) An aggregate of sales of goods produced by the settler~ amounting to s during that time. (5) The arrest of the disease process to such an extent as to justify an expectation of life three times as long as that usually given in sanatorium statistics. (6) The removal of a number of chronic infective cases from the homes and workshops of the general community. The question was once asked: "What effective contribution can ~ e h permanent village settlements be said to make towards the solution of the problem? It is true the question was asked some years ago. The answer is that the contribution is exactly what it was expected to be, when the advice of the medical profession could be put into actual practice. The Papworth Village Settlement vindicates in a remarkable manner the truths which the medical profession have so persistently and so rightly advocated.