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The sanatorium strives to retain its patients until the disease is diagnosed as "quiescent" or "arrested." The patient so released is rarely in possession of his full strength. He has been living an artificially sheltered life, even though he may have been engaged in vocational work for a number of hours daily prior to his discharge. Psychologically and physiologically he is not always fit to resume forthwith the struggle for existence among his fellows. It is at this point that these new institutions fit in, their primary purpose being to bridge the gap, to provide a "hardening" period. A secondary but very important purpose is to continue the vocational training already begun in the sanatorium.

These institutions take various forms. In New York City, after an investigation had revealed the fact that forty-five per cent, of the patients of a certain sanatorium had relapsed or died within six months to two years after their discharge, the Committee for the Care of the Jewish Tuberculous decided on a system of after-care, one of the features of which was the establishment of a factory for employment of some of the cases. Since over sixty per cent, of their charges were needle-workers, the factory was fitted up to enter this field of work. An ordinary well-lighted loft was rented, additional windows supplied, machinery installed. The windows are always kept open, a comfortable temperature is maintained, the strictest hygienic conditions prevail. Only "negative sputum" cases are accepted. For a number of months after admittance, the workers are examined every week or two, later on every three or four weeks, and, after six months, every four or five weeks. Work is paid for on a piece work basis at rates at least as good as those obtained by normal workers elsewhere. The employees work from two to eight hours daily, according to the doctor's ruling.

As a result of this intermediate institution and other after-care -- such as visiting, home-instruction in hygiene and treatment, the provision of financial aid when necessary, and the like -- relapses have been kept down to fifteen per cent. In a recent report by the director of this institution it was emphasized that for the past seventeen months the factory has been entirely self-supporting. It is probable that similar institutions will play a part in the after-care of the military tuberculous.

It will not be long, doubtless, before large industrial establishments will find their way toward cooperating in this work by assigning certain positions -- whole departments, perhaps -- especially suited to the tuberculous as opportunity for either the permanent employment of such workers or for employment during the hardening or post-sanatorium period. One of our largest automobile factories has already undertaken cooperation of this sort.

Great benefit to the community will ensue from successful provision of after-care for tuberculous soldiers, and conversely great injury will result from half-hearted attention to the problem.

CHAPTER XII
BRINK OF THE CHASM

The force of modern high explosives and the strain of trench warfare have added to the old sad list of soldiers' disabilities a new one, known as shell shock. The term is familiar to everybody, but probably many people have no very definite idea of the condition it describes.

You may have seen a Canadian officer home on a furlough, suffering, you are told, from shell shock, and have remarked his haggard eyes, his nervous starts, the resolute grip on his cane by which he tried to conceal the trembling of his hand. Or you may have read of shell shock victims in the hospitals, men who jerk and shake in every limb, whose minds have become a blank, or who are blind and deaf from shock. You have perhaps not realized, however, that shell shock is only a new expression for an old class of diseases, diseases of the nervous system which attack men in peace or in war when they undergo great strain or shock. Shell shock is simply a collective term for the well known psychoneuroses, hysteria, neurasthenia, and the like, brought on by the events of the war. A more accurate term would be "war psychoneuroses" or merely "war-neuroses." The war-neuroses, just as the neuroses of ordinary life, are purely functional nervous affections and are not caused by a physical injury to a nerve or to the brain. A victim of shell shock may be unable to raise his arm or to speak, but his condition is utterly different from that of the man whose arm is paralyzed because the ulnar nerve has been severed by a bullet or who has lost his speech from a shell splinter in his brain. In the shell shock patient the psychic impulse to move the arm or to speak cannot be translated into action; apparently the patient has forgotten completely how to move the arm or how to speak although the physical mechanism for the movement or speech remains intact.

The number of men disabled in the present war by nervous and mental diseases -- shell shock, hysteria, neurasthenia, and insanity -- is large, but perhaps not surprisingly so when one considers the almost superhuman endurance and fortitude demanded of the modern soldier. In British pension statistics dealing with men discharged from the army up to May, 1918, shell shock ranks with the major disabilities, accounting (with insanity and epilepsy) for seven per cent, of the discharges. During the same period rheumatism disabled only six per cent, and tuberculosis eleven. These figures do not, however, represent the full total of the nervously disabled, for many men discharged for other disabilities also suffer from nervous disorders. The number of British pensioners afflicted with nervous diseases is stated by one authority to be nearly twenty per cent, of the total.