February, 1933] EXPERIENCES OF A VILLAGE SETTLEMENT 1 9 9

SOME EXPERIENCES AT A VILLAGE $ETTLEMEHT F011 THE TUBERCULOUS.

By 3. B. McDouGALL, M.D.Glas., F.R.C.P.Ed., F.R.S.E. Medical Director, British Legion V~llage, Preston Hall, AyIesford, Kent.

THE longer one is identified with the organisation and routine of a village settlement for the tuberculous, the more convinced does one become of the impracticability of such organisations being administered by the time-honoured methods of local authorities. There was a time when I cherished the view of a village settlement being attached to most of the largest sanatoria in the country, but the experiences of the past few years have disillusioned me on this point.

The village settlement is born, not made, and local authorities in this country, at any rate, do not excel in such pioneer work as is necessary for the birth and development of a village settlement on orthodox lines. It has been my good fortune to work in the tuberculosis service under local authorities as a dispensary officer, as a medical superintendent of a sana- torimn, and, later, as an administrative officer co-ordinating the tuberculosis work of a large local authori ty; but since February, 1927, the date upon which I took up duties at Preston Hall, I have spent nearly six years in studying closely the mechanism of a village settlement of some size, and I am more than ever impressed by the fact that the latitude, or rather the want of latitude, given to medical superintendents under local authority schemes, would cripple the successful working of any settlement from the financial standpoint.

In every village settlement there should be three distinct uni ts : the sanatorium, the industries, and the estate in which the settlers are housed with their wives and families. These three units are interdependent. On the financial side, if there is by any chance a loss on the year's working on the Sanatorium Account, this may be offset from the profits on the other two accounts, and vice versa.

At Preston Hall we have been singularly fortunate in having the sanatorium fully occupied during the past three years, largely owing to the fact that we are now admitting male dependants of ex-Service men for treatment. s fully occupied sanatorium is a material asset to the industries, for it enables a number of renewals and repairs to be undertaken which, in leaner times, might remain undone. For instance, for the year ending March 31, 1931, a sum of approximately s that is, 4s. 8d. per patient per week, was spent by the Sanatorium Section at Preston Hall on domestic and structural renewals and repairs for the main institution, and of this amount quite 75 per cent. went to the industries for work done.

In referring to the figures published by the Ministry of Health in their Circular of Costing Returns for 1931; I find that at Papworth approximately s that is, 9s. 2d. per patient per week, was disbursed under the same items. I know not, of course, how much of this work was given to the Industries at Papworth, but so well equipped are the Industries there for conducting work which ordinarily comes under the heading of renewals and repairs that one can assume that a considerable proportion of the sum mentioned was paymeut to the Industries for orders carried out in the main institution. I mention this fact merely to show, from the

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administrative standpoint, the value which a satisfactory sanatorium account may be to the industries of the settlement.

I t has been a point in criticism--not always expressed openly-- that the standard of medical work in the sanatorium of the village settlement is likely to suffer from the association with the commercial aspect of the work in the industries. A reference to recent annual reports from Papworth will show that, in addition to the routine clinical work, investigations have been conducted into the effects of tox~emia on enamel formation, the psychology of the consumptive, the value of Hamburger 's ointment in diagnosis; whilst at Preston Hall we have given special consideration to, and have published the results of, work on gas poisoning in relation to pulmonary tuberculosis, on percussion of the chest, and on the defensive mechanism in tuberculosis from the physical and chemical aspects (by Dr. Obermer, my predecessor), and an epitome of Dr. W. I. Walker's work on the monocyte-lymphocyte ratio in tuberculosis appeared in the report for 1931. A comprehensive report on the health and general well-being of the children in the village at Preston Hall is at the present moment being prepared, and an interesting document showing the working capacity of the consumptive in relation to the pathological process in the chest is also about to be published.

:Routine clinical examinations, radiography, artificial pneumothorax, and other methods of diagnosis and treatment, as well as research into individual problems, are just as essential for the success of a village settlement as are markets for the products of the industries, and I can imagine no graver mistake than to inaugurate a village settlement without the fullest and most up-to-date equipment being available for the diagnosis and treatment of both patients and settlers.

The type of patient admitted to Preston Hall is generally regarded as " difficult," and several of my colleagues in the past have expressed the view that the task of keeping nearly 400 ex-Service men " i n order" is in itself a problem in discipline more suited to the Constabulary Force than to a medical man. Looking back upon one's experiences of the past few years, I must admit freely that I had grave fears, in the early days especially, but whether it be that the esprit de guerre has passed and given place to esprit de corps, or whether it is, in fact, the war-time atmosphere being perpetuated in civil life--for where these men are gathered together you will find a camaraderie not too common amongst other sections of the communi ty - - I know not. Suffice it to say that, by a discreet but firm process of elimination, such malcontents as may have been at Preston Hall in the old days have disappeared, and the standard of admission to the Settlement has been raised to such an extent as to preclude the admission of any men other than those who are suitable, temperamentally, for life in the Settlement. Sir Pendrill Varrier-Jones has emphasised the importance of preserving the right spirit amongst the settlers, and amongst the principles which he has laid down for the administration of a village settlement I know of none v~hich is more important.

On the industrial side of Preston Hall we have had our vicissitudes during the past six years. We have encountered that "relentless com- petition," and have wooed the " shy markets" about which Bardswell has written in his experiences with the Spero Leather Factory. Nevertheless, in six years well over s worth of goods have been manufactured in Preston Hall Industries.

At the time of writing the Industries have, in every department, ample

February, 1933] EXPERIENCES OF A VILLAGE SETTLEMENT 201

work on hand to keep the 150 odd settlers fully employed for some weeks to come. As a matter of detail, we have found the demand for portable buildings to be very large indeed ; fibre and leather goods have been sold to large wholesale London houses for sale in this country and in Canada, South Africa, India and Australia; whilst the Printing Department is now equipped to deal with about s worth of " print " per annum. The gross sales for the current year will reach five figures for the first time in the history of that department.

To one like myself, who am a layman in commercial affairs, the amazing experience has been to find so many men--severely disabled though many of them be-- take a real scientific interest in their work and to find them making genuine attempts to familiarise themselves with the intricacies of their work. There are now six maior departments at Preston Hall, and the

FIG. 1 . - -Opera t ives at work in the fibre depar tmen t , where t ravel l ing goods of all k inds are m a n u f a c t u r e d .

necessary investigations are proceeding with a view to the establishment of two new sections for the employment of more men. The industrial unit which, in my experience, has been most beneficial has been one where it is possible to obtain relatively secure markets to the value of s to s per annum. If by any chance a department can obtain larger and guaranteed markets, good and well; but if a relatively large depart- ment is, for one reason or another, stranded even for a few weeks in the year on a rough economic sea the financial consequences in a village settlement are likely to be severe.

How, I often wonder, would a local authority fare when its own patients and settlers proceed to manufacture goods in open competition with local tradespeople who are ratepayers and whose hard-earned money might actually be used either as capital expenditure to expand the industries in open competition to themselves, or, ~lternatively, as a subsidy t~o meet a loss? Have we reached the altruistic age when the local printer and joiner is going to be satisfied to see his own work and calling being under-

2 0 2 T U B E R C L E [February, 1 9 3 3

taken even as a health measure by his own local authority? In certain districts, at least, one can visualise terrible complications. At Papworth and at Preston Hall the ratepayers enter very indirectly into the scheme of things. :No local authority in either case is responsible for the administra-

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tion of the industries. Patients are sent by different local authorities for treatment, and there the responsibility of the local authority terminates. This is one of the factors which compel me to believe that the expansion of the village settlement idea is not to come about by its adoption by local

:February, 1933~ E X P ~ I E N C F , S OF A V I L L A G E S E T T L E M E N T 203

authorities, and when one adds to these difficulties the usual methods of administrative procedure of local authorities I cannot help feeling that such a scheme would be highly impracticable.

~Clinically the 150 odd settlers at Preston Hall may be divided into three

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classes. Firstly, there are those in whom the disease has reached a stage of arrest, and has remained so for a period of at least five years. At present there are some 55 settlers in this category. A second group, numbering approximately 87, comprises those in whom the disease is

.004 TUBERCLE [February, 1933

definitely advanced or ill whom symptoms of activity appear from time to time. Lastly, there are 10 settlers who are able to live in the Sett lement but who are only occasionally able to undertake routine work.

From the clinical standpoint the cases in Group 2 are perhaps the most interesting, and complete details of ten men from this group are being published in a separate communication, when it will be shown that the working capacity of the advanced but quiescent consumptive is, under the conditions prevailing at Preston Hall, very considerable. These ten men, subject to detailed analysis, have earned no less than s 14s. 8d. in wages during the past seven and a half years.

F rom the administrative standpoint, however, the cases in Group 1 present a problem upon which Sir Pendrill Varrier-Jones and I appear to be at variance. The majority of these men have been in residence at Preston Hall for eight years and more, and have apparently completely healed lesions. The moral obligation of continuing to employ such men may remain, but under less favourable economic conditions they would be a very heavy load on the industries. I am strongly of the opinion that arrangements should be made for the transference of such cases as come into Category 1, and as a matter of fact the Council of Management of Preston Hall have definitely decided to intimate to every new settler who is taken on the staff that a five years' security of tenure will be given, but that in the event of the disease in the chest being arrested at the end of that time he may be asked to leave the Village Settlement. Such a decision has in no way limited the number of applications from potential settlers.

I t is indeed fortunate that Preston Hall Industries have been able to carry all the settlers all the time during the past six years. No man in the Settlement has been unemployed for one single hour during the last six years owing to lack of work. That markets have been available, even during the recent economic crisis, for the products of Preston Hall Industries is probably the best tribute to the high standard of workmanship in the different departments of the industries--a standard which appears to rise with the passing of time.

The third group referred to above, and a considerable proportion of cases in Group 2, are "open " cases. Without exception we have found the persistently " open" cases to be those in whom absenteeism is greatest and relapse most frequent. They are, from the purely industrial stand- point, much less dependable, and yet it seems clear--although paucity of numbers makes it difficult to prove-- that life is considerably prolonged in the " open," even in the advanced "open," case under village settlement conditions.

I t is, however, the very absence of mass figures which makes it impos- sible to be dogmatic about the medical results in a village settlement. The combined statistics of Papworth, Preston Hall and Barrowmore Hall would, of course, be more illuminating, bu~ as no standardised returns are available it is impossible to correlate the results of these three organisations in any way. There is good news to the effect that an International After- Care Committee is about to be set up with a view to establishing, i~zter a l i a , village settlements in different European countries, but an even greater need appears to be, as was pointed out in the Report of the :Employment Committee of the Joint Tnberculosis Council, for closer co-operation between existing village settlements, with the object of tabulating results and of discussing the multitude of problems, medical, sociological and industrial, which are peculiar to village settlements for the tuberculous.