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2—* T he Or ily Recent Rea 1 Advances in t! be Treatment of Tuberculosis * Dr. Irving Wilson Voorhees, the Distinguished Surgeon, Summarizes the Effective Work Against the Disease, and Points Out the Great Flaw in the Friedmann Turtle Theory. Junior Surgeon I T was the great Pnsteur who said, “It is within the power of man to cause all para sitic diseases to disappear from tho world Since this astounding but altogether reasons ble postulate was formulated, physicians and scientists the world over have stood shoulder to shoulder in the great fight against the rav ages of illness and death caused by preventable diseases. Of all these tuberculosis stands out first and foremost, because it is probably the greatest single scourge of civilization at the present day. It is not surprising, therefore, that since the great discovery by Koch of the tubercle bacil lus, thousands of Investigators in the labora tories the world over have gone to work with microscope and “retort” and chemical reagents to study very intimately the characteristics of this bacillus, both within and without the body In the hope of ultimately conquering the great destroyer. Following out the work of the great blood specialists on infection and immunity, I)r. Koch, after an exceedingly exhaustive study on lower animals, produced a substance which he called tuberculin. It was hoped and, in certain quarters, loudly acclaimed that tubercu lin was a specific remedy against tuberculosis, and that by Injecting it Into the blood stream of patients suffering from this disease an Im munity would be obtained which would anni hilate or render forever Inert the hardy bacil lus and Its harmful products known as toxines. Reasoning by analogy, the observers thought that it should be no more difficult to induce Immunity against tuberculosis than against diphtheria, which in these latter days Is so nearly under our absolute control, in this they were, however, mistaken, for it was soon found that while the problems at long distance seemed much alike, they are at close range absolutely and unqualifiedly different. For instance, while diphtheria is an active disease of short duration, lasting at the most only a few days, tuberculosis is a slow Insidious af fection, coming on usually without stormy Bymptoms, and passing on to the chronic stage before Its true nature is ascertained It became apparent very shortly, therefore, that the analogy would not hold, and, although tuberculin was given a very thorough trial, It did for the most part very little good, and in some cases, at least, was actually harmful, be cause of the very violent reactions which it aroused when introduced into the body. It was consequently almost abandoned, but re cently has been taken up again by a few authorities who have been refining and chang ing it in order to do away with its poisonous and dangerous effects. At this point one may say * word about the recent attempts of Dr. F. F. Friedmann, of Berlin, to cure tuberculosis by the use of ac tive living tubercle bacilli from the turtle. The writer met Dr. Friedmann in Now York, and studied both his cases and his methods very carefully. Of Dr. Frleumann’s absolute sincer ity and belief I have no doubt. It seems, however, that he has failed to take into account all of the factors in his problem. Most Important of these is that tuberculosis is a localized and not a blood disease. It causes destruction of tissue at the site of its York. origin, and tends to remain there unless new foci are formed by contact or by diseased tis sue being swept along the lymph and blood paths. The bacilli are not found in the blood until the advanced stages of the disease are reached, and very often not even then. The fever, emaciation and general illness are not due to the tubercle bacillus directly, but to the poisons (toxines) which are thrown off as a result of the life, multiplication and death of these germs. Therefore, about all one can ex pect from a tuberculosis anti toxin or serum or vaccine is an improvement in the patients’ symptoms. The local process goes merrily on, and finally produces death through weakness, heart failure, pneumonlu, etc. It may farther he said without wishing to throw cold water on Dr. Friedmann's splendid efforts, that one of the highest authorities holding an administrative office in the German Government has written privately that "The product Is viewed here (In Germany) with skeptical eyes, and its real value is probably so insignificant as to be ignornd.” lie goes on to say that in his own judgment he feels compelled to express an urgent warning against the use of the remedy in human beings. However, we In America should give Dr. Fried mann every opportunity to prove the worth of his. treatment, and we ought also to remember that it will take at least one or two years be fore its uselessness or usefulness can be es tablished as a scientific fact. It is Impossible and unreasonable to expect a cure in one or two weeks. Here in New York a great work Is being done in the cure of tuberculosis by placing so-called “camps" on the roofs of houses and hospitals. At the Vanderbilt Clinic, Fifty-ninth street and Amsterdam avenue, we have a day camp on the roof which ‘is open from 9 to 5. Here pa tients are given steamer chairs, blankets, suit able food and just the kind of nursing and doc toring which they would receive In a famous resort. They go home at night, and a visiting nurse sees to it that the advantages gained by the open air day treatment is not negatived in their own quarters. The New York Nose, Throat and Lung Hos pital, in West Fifty-seventh street, has estab lished a night camp for workers. Here patients nre made to sleep out of doors, and are obliged to take baths, exercise, proper food and medi cine. They are awakened at a definite morn ing hour, and are sent away to work if they are able to go. They are weighed, examined and tested frequently by the staff physicians, and a careful record is kept of the progress of the disease toward healing or the contrary. Thus fa rthe results have been excellent. At the foot of Fast Twenty-sixth street, ad joining the grounds of Bellevue Hospital, the city of New York has maintained for a long time an open-air school for children. This is located upon the old Southfield, a ferryboat, long since doomed by the steamboat inspectors, but now serving an exceedingly useful pur pose. Any child of school age may come to this school. Most of the pupils are trom ver; poor homes, and a large proportion are or phans. A great deal is being done for bone tubercu losis in children at the Sea Breeze Hospital, Coney Island. One of the slow-going chronic By IRVING WILSON VOORHEES, M. S., M. D., in the Vanderbilt ( linic Nose and Throat Department, New The Old “Hyper-Extension” Treatment for Little Sufferers from Bone Tuber culosis—A Method Superseded by Dr. Albee’s Operation. Diagram Illustrating Dr. Albee’s Treatment for Vertebra (A) Is Split and Then Appears as Placed the Splinter of Healthy Leg Bone C. monary tuberculosis is that of "artificial pneu mothorax.” Pneumothorax means simply in troduction of air through the chest wall into the space between the lung and the wall itself. There is a membrane known as the pleura which covers the entire lung surface like the skin of an orange, save that instead of enclos ing the entire organ, it is reflected over the Inner surface of the bony thorax, or chest wall. There is, therefore, a chink between that part of the membrane covering the lung and the reflected portion. Now, it was discovered after an accident in which a tuberculosis pa tient fractured a rib that air had entered this chink, had separated the two layers of pleura or lung covering described above, and had com pressed the lung, causing it to collapse. It takes some time for this air to be absorbed, so that the lung can again expand, and during this time it was seen that the patient in question had greatly improved. His cough had stopped, his expectoration was scantier, he began to gain weight and to improve generally. A bold surgeon, observing this fact, resolved to bring about pneumothorax by operative means, but it seemed better for several reasons not to use ordinary air. Accordingly, he plunged a fine needle into this so-called pleural cavity or space an dintroduced nitrogen gas. He used this for two chief reasons—because it is one of the most harmless and inert gases in nature, and because it is slowly absorbed; therefore,. he found that he could keep the lung quiet as if in a splint for a long time. This complete disuse of the lung gave it the required rest, so that the conservative forces of the body could go to work to repair the destruction caused by the tuberculous focus. One important condi tion is. however, necessary, viz., that the un treated lung shall be healthy, for if not the pa tient cannot properly oxygenate the blood, and will die auickly of suffocation. There are some special dangers to be guarded against in this treatment, but it marks a very distinct advance in the treatment of pulmonary tuberculosis, especially so since it can be used in advanced cases to the very great relief of the general symptoms. In view of the very earnest study and ex perimentation that tuberculosis is now receiv ing, it is possible that we are just approaching the dawn of a rational and thoroughly efficient cure. How a Diseased Lung Is Made to Collapse and Absorb Nitrogen Gas in the “Artificial Pneumothorax” Treatment. Tubercular Children Lying Naked in One of the Swiss Outdoor Sanitariums. forms of bone tuberculosis is Pott's disease of the spine, a condition which, when healed, leaves the patient badly deformed, and In popular language, a “hunchback." This type of tuberculosis attacks the bodies of the ver tebrae, which makes up the spinal column. Usually the focus involves from one to four of these, and, when extensive, causes knuckling of the spinal column, with pressure on the spinal cord leading to paralysis and great wasting of the body and limbs. Formerly these little patients were treated in "hyper- extension”--that. is, by bending the body far backward over an iron frame, strapping It in this position and holding it there for several months. Recently Dr. Fred H. Albee, of New York City, an exceedingly clever orthopedic surgeon, has devised an operation which shortens the treatment to six weeks or even less. Dr. Albee studios the exact condition of tho patient's spine with the X-Ray. He then cuts through the muscles of the back directly in the middle line of the body, exposes the tips or spinous processes of the vertebrae, and splits them longitudinally with a chisel. This done, the operative field is protected temporarily, and a piece of bone about one-half inch in thickness and as long as the diseased area required is removed from the shinbone of the leg. This is then Inserted into the groove made by the splitting of the vertebrae, and Is sewed in posi tion by means of kangaroo tendon. In a few days the patient is allowed to get up and walk around without any heavy plaster cast or sup port, and recovery usually takes place within a few months. The results from this treatment have been excellent. Dr. Albee has also de vised a bone-grafting method for tuberculous joints, which has been successful in several cases. The advantages of air and sunlight have al ways been known and used in the treatment of tuberculosis, but at the Tuberculosis Congress in Rome last year a Swiss physician described ,, a sunlight treatment which has produced re- i markable results. The sanatorium where this work is done is located at Laysin, a village hidden away in the rugged slopes of the pic turesque mountains of Switzerland. The ele vation here is from 4,100 to 4,500 feet, and the climate more than 30 degrees Fahrenheit at the snow level. There Is ample protection from the north and west by the natural configuration of the place. Children are purposely provided with very little clothing, and romp and play in the snow to their heart’s content. During the first eight days the patient is not exposed to direct sunlight, because of the danger of severe burns and inflammation of the skin. The feet are first exposed, then the legs, knees and gradually the entire body, save the eyes, which must be protected. The skin takes on a peculiar brownish color, which increases its elasticity and resistance, and the child’s condi tion speedily improves. Blondes do not stand the rays as Well as brunettes, and if the sun light ceases for a few days before healing is complete there is a marked return of bad syunp- toms. Healing is due to a predominance of ultra-violet rays. . Quite recently high frequency currents of electricity have been used with success. This is especially so if the trouble is on the exterior of the body or in a limb. In the lung, however, it is difficult to secure good results, because of the danger of severe burns to the skin and chest wall, which are very difficult to heal. If the chest could be opened and the lung treated directly this treatment might help, but it is well known that if the chest is opened, the at- mospfieric pressure causes the lung to collapse, and consequently the patient is likely to die from suffocation. This obstacle has been par tially overcome by so-called "positive pressure” apparatus, by means of which air is forced constantly through a tube inserted into the mouth and down the windpipe. Thus the lungs are kept expanded. We may, therefore, soon have a very valua-* ble aid from high frequency currents in lung tuberculosis. This high frequency method was originated by De Keating Hart, of Paris, is known as “fulguration,” and is being extensive ly used in the treatment of cancer by Dr. W. S. Bainbridge, at the New York Skin and Can cer Hospital. A voltage of 500,000 units is used, and the spark played upon the diseased area must be 10 or 12 centimetres long. One of the latest methods of treating pul Spinal Tuberculosis. The Diseased Shown in B. Into This Slit B Is How the Business Men of America Can Save Two Millions a Day [Editor’s Note.—The author of this article is president of the Business Bourse, editor of the Efficiency Magazine, an active member of the Efficiency Society, and is retained as advising expert by many of the leading concerns as coun sel upon questions relating to office and execu tive efficiency. Mr. McCormack s the inventor of the original typewriter tabulator, the unit voucher system, etc.; in fact, he has possibly invented more labor-saving devices and systems for the office than any other man. He is well known throughout the country as a lecturer on office efficiency, having given illustrated lectures upon the subject in all the leading cities, and is an acknowledged authority upon all subjects relating to office management and office efficiency.] By H. S. Me Cormack. president of the Business Bourse. F you raise pigs, the 1’nited States Government places at your disposal an elaborate staff of specialists who are backed by a very com prehensive system o£ experimental stations, and these experts will supply you with pamphlets and booklets of instructions and will otherwise help you along scientific lines. If you are troubled or perplexed upon a ques tion which relates to forestry, mining, navigation or, in fact, almost any subject, the Government Is back of you and you are forced to appreciate that you are living in an age full of wonderful opportunities. But If, on the other hand, you are trying t<> establish a business of any kind, don't expect to receive any assistance from Uncle Sam. It is the business of the country that gives • ployment to the millions that makes the Govern ment possible. When business is good, i n, !«• Sam Is well; but when business is poor, he is very, very siefi. And yet this most important part of the country's activities is ignored by Uin ie Sam Business men are left to blaze their own trails No lecturers are seut through the country to show them how business can be made more scientific; no special trains with data and with instructors are despatched about the country—such neces sities are denied to business men, although they pay the greatest revenues to the country. The waste through inefficient business manage ment and failures (a large percentage of which can be avoided) has been terrific, for there is an enormous waste volume of office business done. Every business has at least one office; many businesses have dozens of offices. There are 3,948,013 separate business offices in the country (as shown by offices having telephones), or an office to each 27 inhabitants. Two million dollars a day is my conservative estimate, based on detailed personal knowledge of the situation, of the amount of money need lessly expended in offices throughout the country. Eliminate one-third of three million offices as being too small to be efficient, and eliminate an other million, for the sake of argument, us being 100 per cent efficient, and it is only necessary to save $1 a day per office to conserve two million dollars a day. This estimate of $1 saving does not represent each person, hut instead represents an entire office force; and, for the purpose of being conser vative to a fault, but one-third of the efficiency that might be asked lor is to be considered. Even to those who have made but a limited study of office work, the estimate of only $1 a day will appear ridiculous, because the simplest analysis shows, for instance, that the average cost of business letters is from 7c. to 11c. apiece, and that it is only tlie highly efficient offices which handle correspondence at a cost of 5c. or 6%c. per letter. Eliminate one-third of the unnecessary work that is performed daily in business offices throughout the country, and the saving will be nine times greater than the saving proposed through tile revision of the tariff. Capitalize the energy lost through waste ef fort or the needless work performed in business offices, and there is enough energy available to turn over the Bahama Canal without expense to the nation. The number of useless needless letters written dally cannot easily be computed, but the actual loss In this direction runs into the hundreds of thousands. / Business men who would not fill their pockets with silver dimes each morning and scatter them right and left through the streets do countenance and encourage the employment of clerks who thoughtlessly and needlessly write letters which bring no return whatever to the senders. Business men borrow money and pay 5 or S per cent per annum for its use, and then day by day destroy the earning power of those dollars by negligence, carelessness and thoughtlessness. A hundred dollars is invested In a business which is supposed to earn 6 per cent, or $0.00, in 365 days; and the man .who makes the invest ment engages an extra clerk to do unnecessary detail work and pays the clerk $12 a week, thus destroying every week the annual earning power of $200. This means that the earning power of $S0O is lost every month, or the earning power of approximately $10,000 every year. Make an analysis of the simplest office routine, and it is astounding to ascertain how much work is done over and over. Writing and rewriting ap pear to be the order of the day. The fact that a man says he has a system does not make it so—if a man believes himself or his office efficient, it does not reduce his expenses, and no one is fooled but himself, while he is busy making preparations for the receiver to step in. When a man starts to analyze what is going on in his own office it is a healthy sign, if he begins with the operation of making checks, he may find that his bookkeeper does the following: (1) . Writes the check. (2) . Copies the same information upon the stub. (3) . Makes an entry on bills or on voucher cover of distribution. (4) . Prepares some acknowledgment or receipt or enters details in distribution record. The various forms for making payments by checks vary to such an extent that no set rule governs the handling of these transactions; but repeated Investigations prove that from 3 to 7 op erations are usually performed in connection with every bill and in some offices these op erations are repeated day after day in the hand ling of hundreds of bills passed for payment. A set of unit forms will, without repetition of any kind, eliminate two-thirds of the work now performed in the payment of bills, by combining the following operations into one: (1) . Writing of check. (2) . Writing of receipt. * (3). Writing of voucher cover. (4) . Writing of register. (5) . Writing of bookkeeper’s distribution record. It is, indeed, rare to find a firm with an effici ent telegram system. The customary method is to write the telegram and retain a duplicate for the files; then write a letter and repeat therein the contents of the telegram, which is but a repetition of the work just done. At the end of the month that becomes one of the great factors in increasing the cost of clerical work necessary to check up the bills from the telegraph office to find out who sent the various telegrams. A system of form duplicate copies will at one writing take care of the following operations: (1) . Telegram. (2) . Office copy. (3) . Confirmation. (4) . Office register. For many years business concerns could not get away from the old custom of filling orders from original orders. So much delay and contusion were caused through this method that finally the more progressive firms saw- the advantage of tak. ing two copies. The results secured were so sat isfactory that the plan was extended to three and four copies, and many concerns are now making from five to twelve copies, so that no rewriting of orders is necessary. , While the agitation has been going on about shop management, and efficiency engineers have been lowering the cost of production, the execu tive office expenses and the selling expenses have been mounting higher and higher, until now it is a well-known fact that it costs 66 cents to sell and distribute articles which cost only 33 cents to manufacture. A sale can be made in an office—it may be a doctor’s office, a broker’s office, or a real estate office. It is immaterial whether the sale amounts to 10 cents, $10 or $10,000; the custom is to make a charge slip of some kind, according to the transaction. The charge slip goes to the book keeping department, where the juggling process really starts. The amount is entered, possibly in a sales book, then becomes a journal entry, gets into the ledger, is carried to some distribution record, gets upon a bill and goes down the line, is accumulated in a sales report; and, it may be that the same amount is placed to the credit of some department. With every juggle of this item, it is 'hoped that when the totals of the various combinations of figures are added together the correct grand total will be secured. If not, then it means the old story of going back and taking trial balances, then checking oft until the dis crepancy is shown and all of the various ac counts show uniform balance. During the past fifteen or twenty years, un fortunately, there has been a tendency toward cumbrous systems which entail a lot of book keeping and furnish a multiplicity of records, and while these various reports and statistics are all used in some cases, little thought has been given to having the various operations combined so as to be accomplished at one writing or with one transaction. A machine has been Introduced Into the Gov ernment Census Office which dispenses with hun dreds of clerks; the work that formerly took ten years to accomplish is now performed at less ex pense in ten months. What has been done by the Government in the matter of handling the census can he done in business houses. It will be possible to have little punching machines, so that the 10 cent, $10 or $10,000 item can be punched into a card, which card can be fed into an automatic machine, and. without transcriptions of any kind, these little punched holes in a card will take care of the seven or nine operations, which some firms con sider so necessary and which entail so much work in re-writing and re-copying for the purpose of securing their various records. From the time the raw material is ordereS there is little else but office work—executive! buying goods, salesmen selling them, clerks writ ing orders, others writing letters about the goods, attending to the billing and keeping the books. The railroads furnish office help to write many bills for raw material, the refined material, the finished material; and the goods, from their raw state to the time they are ready for delivery to the consumer, are subjected to re-writing and are paid for by check possibly ten times, because goods in their different stages must be paid for, as well as transportation charges on them. When the Government investigated the express companies, they found that there were eleven transcriptions, in part or in whole, that took place from the time Jones delivered a package to the company until it was received and receipted for by Smith. The Government regulations have eliminated a lot of that red tape and the publio are getting better service. One of the leading textile concerns recently conducted a test to ascertain the cost of writing each bill. It was found to he 7 cents, and this amount was independent of all selling costs, telegrams, salesmen, bookkeeping, etc. President Wilson took a big step in the right direction a few days ago, when he placed the stamp of approval upon the work of the Efficiency and Economy Commission. 1 The reports of this commission covered th$ various departments in Washington which had undergone an inspection. The investigations have already resulted in the saving of hundreds of thousands of dollars in Government offices through the elimination of needless work There should be established a Government eftl ciency bureau to gather data and statistics for the business man to use in his office—the.re must be time studies, tests and experiments along the same scientific lines as are conducted in any other Government department which has been established along economic lines. Retailers must be shown how inefficient man agement and inefficient distribution are one of the great factors in increasing the cost of living.