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this company five months and my hospital dues were $2.50, or fifty cents per month. I have always been in favor of compulsory assessments, and I do not see how a hospital, that is, a railroad hospital, could be operated successfully in any other way, and the assessment is so small I do not miss it. I would, under no circumstances, be willing to do away with the hospital. I am of the opinion that the hospital has tended to make the employes more loyal to their employers, and I think the general feelings of the conservative employes are greatly in favor of the hospital system. "Respectfully,
"L. K. Morris, "Conductor."
"Sanford, Fla., February 15, 1896. "Dr. F. H. Caldwell, Sanford, Fla.
"Dear Doctor:-By your request, I gladly write a few lines relative to your hospital system. I have always favored the plan of compulsory assessments of each employe; always advocated it, and shall continue to do so. I do not miss the assessment from my wages and consider it an excellent investment for any employe.
"Since the 9th of January, 1896, I have enjoyed the benefits of your hospital system, and in consequence shall always have a warmer and more proper regard for my employers. I think there is the kindest feeling among the employes toward the Plant System Hospital, and if there are those who do not advocate it, they need only to suffer the misfortune of sickness or injury, and receive the hospital benefits, to be made warm converts to your service. heartily endorse it in its entirety.
“J. E. Stokes, "Section Master."
Dr. Geo. W. Hogeboom, chief surgeon of the Santa Fe, in his annual report to members of the association, makes use of the following language:
"There has been during the year a greater tendency for married men, especially those suffering from injury, to go to our hospitals for treatment instead of to their homes, and I cannot too urgently commend such action, as the chances of recovery and especially of more perfect recovery, are so much greater under the antiseptic treatment furnished in our hospitals, than through effort and often failure to furnish the same treatment at even the best of homes or boarding houses. Besides this, the surgeons of our hospitals are particularly skilled and practiced in the specialty of railroad injuries and ailments and their treatment in hospitals, which fact, together with the advantages of trained and careful attendance, should be the strongest kind of inducement for
all classes of employes to avail themselves of hospital care.
"When it is taken into consideration that these injuries are many of them cases of the worst forms of fractures, contusions and lacerations, and the ailments are more often than otherwise in an advanced stage when reaching the hospital, on account of the employe remaining at his duties as long as possible, this is a very fine showing for the results of well organized hospital treatment for both injuries and sickness."
Speaking of the hospital association, Mr. Stevens, general manager of the C. & O., says: "It is a model of equity and justice.”
Mr. W. B. Doddridge, general manager of the Missouri Pacific Railway, says:
"It operates practically in securing and promoting harmony among all classes and conditions of employes in cases of injury and sickness, the preference, in almost every instance, being in favor of treatment at the hospital, or under its control. Better results are accomplished for sick and injured employes because of the superior facilities the hospital department secures for nursing and caring for the employes, and that at a nominal cost to the employe."
There is a feature of the hospital system which, if properly managed, should become very popular and useful indeed, and that is the transfer system. As yet we are not aware that the transfer system or interchange of patients is in practice between lines having their own hospitals. The transfer or interchange of patients from one system of hospitals to another would greatly increase the popularity and usefulness of the hospital association on such lines. The transfer system not only furnishes the employe with the best medical and surgical service in the land, including all specialists, without extra charge, but provides for him, when indicated, a luxury which only those of means can afford, viz., transportation, change of climate and private hospital service until well. Employes are not looking for positions in the hospital, but fortunate, indeed, is the one whose name is on the assessment roll of the company's hospital when he has need for the service, and especially so where the transfer system is in operation, for by it lives may be saved that otherwise would certainly be lost. Patients recovering from pneumonia, la grippe, rheumatism and other diseases of this class would be taken from the North to the sunny South. Typhoid, malarial
and swamp fever cases would be sent North or to non-malarial sections of the country. The unfortunate consumptive would seek the West and Southwest, where he might not only find relief, but in time, employment; results which he would very likely be unable to secure under any other circumstances. Bring the employe, sick with heart disease, who has been partaking of game and birds, from the plains and mountains to the railway hospital on the coast for surf bathing, clam bakes and shore dinners, and his diseased organ will recover, or at least its condition will be improved.
We would like to ask railway men if they know of any form of relief that will compare with or even approach the hospital association as it now stands? Add to this excellent system the transfer feature or interchange of patients and we have the highest order of charity ever devised by the human mind; a charity which does not humiliate, but which renders the employe independent, furnishing him with a service equal to any private service which his employer is able to secure. It is true that only a small percentage of cases would require this change, but when indicated it will be found to repay a thousand fold for any effort it may cost. Only the best is good enough for our faithful railway men.
On most of our great lines the relations between employer and employe are very close indeed. The employe is contented and satisfied, the employer is pleased with his men and proud of their work. There is an element of friendship or social feature of the very strongest character, and the desire for such to continue is mutual. Nothing could induce either employer or employe to propose a change which might disturb these pleasant relations. When we proposed the hospital system, which reflects the views of the members of the National Association of Railway Surgeons, to our eastern lines for consideration, we were fully conscious of the happy relations above described. We are not the ones to introduce or to propose a disturbing element at any time or place; we incline to the opposite most decidedly. In this matter we are sincere and firmly believe that the humane and beneficent hospital system which we here propose, will prove one of the strongest ties to be found in maintaining that happy union between employer and
employe. The sun of railway surgery and of the hospital system rose in the West, but its brilliant light is rapidly breaking over the East.
"THE VALUE OF EXAMINATIONS OF SIGHT, COLOR SENSE AND HEARING IN RAILWAY EMPLOYES."*
By C. W. TANGEMAN, M. D., OCULIST FOR
For some years past navigation and railway companies, many of them, at least, have been recognizing the importance of examining the eyes of their employes. Devices are patented, and machinery and equipment perfected to reduce the danger of travel and traffic to a minimum, and yet not one will dare to dispute the statements that the requirements that should be exacted of railway employes must necessarily become more and more rigid, in fact, keep pace with the improvements above mentioned. In no capacity of man's employment to-day, do we find it more necessary to select men fitted mentally and physically for their position than in high grade railroading.
No matter what the inventive genius may do in the way of inventing machinery to increase speed, to perfect automatic devices in signally, it will require the guiding hand of man to direct it all. No automaton can be placed in the cab. Dismiss the train crews of the most perfect railway system of to-day and replace them by employes of 40 or 50 years ago, and imagine the result! Men are demanded that are physically perfect; their senses should be acute and their intellect clear, and with all these requisites, long training is necessary to make a good railroad man. Navigation and railway companies have in latter years recognized the importance of determining whether their employes possess sight enough to see form at a sufficient distance, whether they have sufficient range of vision to read orders and rules clearly, whether their color sense is sufficiently acute to readily and correctly determine signals by day or night; and lastly, whether their sense of hear
* Read at the ninth annual meeting of the National Association of Railway Surgeons, St. Louis, Mo., May 1896.
ing is acute enough to receive orders by word of mouth. In some of the states it is statutory law that railway employes must be tested at certain intervals, and no man is to be employed unless he has been tested and is known to possess perfect color sense and good vision. To employ a man who is color blind is a violation of this law, and is punishable by a fine of one hundred dollars. Strange as it may seem many railroads oppose every measure to adopt a uniform standard of color test or any test at all. Opposition was even known to emanate from the ranks of this body, the medical advisors of railway corporations. These conditions are happily changing, roads that have never examined their men heretofore are now making inquiry as to methods, rules and requirements. Having just completed an examination of the employes of the Big Four Railway System, which controls about 2.400 miles of line and employs nearly 5,000 men who handle signals, it occurred to me that to point out the results obtained and the methods used in a brief way, might act as an argument or as an inducement with those who are still in doubt whether railway employes should be tested. All examiners have recognized the importance of adopting some method that is simple, in order that a committee of laymen can make the preliminary tests, under the direction of the division superintendent. In order to accomplish this I had a number of meetings with all of the division superintendents and their train dispatchers, under whose immediate supervision these tests were to be made. I explained to them the object and principle of the various tests, and how to bring out the best results and record the condition found, so that the surgical expert to whom all of these papers were to be submitted could act intelligently. I adopted the form of record blank, devised by Dr. Thomson, with a few modifications, I formulated rules of instruction governing all of the tests, and had them printed on the reverse side of this blank, so that doubtful questions could be referred to at all times. They are brief, and read as follows:
RULES GOVERNING THE TESTING OF EYES AND
No. 1. All test types for distant vision should be placed in a good bright light, twenty feet away from the applicant. Each eye must
be examined separately in all tests, and the result so recorded.
No. 2. If the applicant can read but the first line, record it as 20-200; the second line as 20-100; the third line as 20-70; the fourth line as 20-50; the fifth line as 20-40; the sixth line as 20-30; and the last line as 20-20.
No. 3. Each eye must be tested separately for reading the small type. Nos. 1, 2, 3, 4. Record the shortest and greatest distance that this type can be read. Never use a soiled card.
No. 4. Field of vision: Take a piece of pasteboard, about one foot square, with a circular opening in the center one inch in diameter, and place against a window light at the height of the applicant's eye and at a distance of one foot from him. Direct him to look through the circular opening in the card, at some distant object, and while in this position see how far to right, left, up and down he can see some small object, as the end of a piece of chalk, when moved over the surface of the card.
No. 5. Color Test: Place the applicant in a good light. Throw the first skein marked "test" across the stick. Have the applicant select the colors that match the test in the first division. Record the numbers selected. Repeat this test with the second and third divisions on the stick.
No. 6. Have the test colors named separately. Record whether he selects and names these colors promptly. Have him name the color of the flags used as signals, and mention their use and match the color of the flags with yarns on the stick. He must not be permitted to hold two colors together for comparison.
No. 7. Hearing: Test the applicant in a quiet room. Test each ear separately, both with the watch and conversation, and record the result in inches and feet.
Every new applicant for a position must submit to the above tests before being given employment.
No. 9. Should the applicant not see more than 20-40 (the fifth line) with each eye, he must be at once suspended and referred to the oculist for a more thorough examination. Do not have more than one person present during an examination, and keep your woolens and test cards clean.
No. 10. All employes that have anything to do with signals, flags or lights, must be tested.
No. 11. Each division superintendent must promptly forward records of all examinations to the general superintendent.
No. 12. No employe is to be given a certificate by the superintendent, until the examinations have been passed upon by the surgical expert and returned, marked "approved."
For testing the acuteness of vision two sets of Snellen's test types of different text are used, framed back to back and covered with glass to keep the type clean (a set for each division). By this arrangement the examiner can use the second set whenever he has reason to believe that the applicant has familiarized himself with one set of test letters. We have heretofore attached too little importance to this part of the test; it should be just as conscientiously made as the color test. These tests are all made without the aid of glasses.
Range of vision. The ability to read or see near objects; the greatest and shortest distance at which the patient can see letters of a given size. Men are permitted to wear glasses to perfect their range of vision, should it be found defective.
A great many devices have been suggested for the ready detection of color defect. Colored worsteds, colored glass, colored letters. Lanterns, flags and the spectroscope have all been used and have their advocates. In my experience the Thomson color stick, as we have it here, will answer every purpose in the hands of the lay examining committee. It is easily understood, and not so confusing to the one examined as many of the devices, and, what is of still greater importance, the test can be made with a great deal more dispatch. This is a consideration when you have 5,000 men to examine. The woolens are all tagged or numbered. The large test skein may be shown the applicant and he be then asked to select all the colors on the stick that match it. Record the colors selected under the proper heading. He need not name the various shades of color that he selects. Repeat this test with the green, pink and red. Soiled flags are then shown and the applicant is asked the name of the color, what it means, and match the flag with colors on the
stick. The skeins are numbered from 1 to 40. In the series from 1 to 20 the odd numbers are green, and the even, gray and brown; from 21 to 30 the odd numbers are pink and the even blue, while from 31 to 40 the odd numbers are red and the even numbers are brown. Here now it becomes possible for even the non-professional man to detect color blindness, since, if anything but odd numbers are chosen in any of these tests there is a defect. If you object to the regularity of the arrangement of the colors, thinking that the test is thereby weakened, unlock the stick and rearrange the colors to suit yourself or unhook them and put them in a heap before the patient. A mere glance by an expert at the record of a man tested in this manner would show him that there is a defect; whether it is only a weak color sense or is complete color blindness remains to be seen. In the cases that were found defective the man was at once ordered to report to the expert for special examination. Here the Thomson test was gone through with again and followed by a test with the Donders lantern, made for me by Queen & Co. of Philadelphia.
Donders' instrument has a standard candle in a dark cylinder, with a wooden disc, and pieces of red, green, blue and white glass, so arranged as to be revolved in turn in front of the flame. There is also a metallic slide, with perforations ranging from one to twenty millimeters in diameter. The man is placed five meters away, and while the colors of the light are changed by rotating the disc, he is challenged to designate the colors of the transmitted light. The normal eye recognizes them through the I mm. opening at 5 m.; or, better still, the candle is so placed that the examiner with normal color sense just perceives the color through 1 mm. opening at 5 m. The color blind individual may fail through a series of openings until the 20 mm. one is presented. He may still call white green and red green. If so, he is asked the significance of the green, and answers "caution." He is then requested to approach the light slowly, and as he does this, he may perhaps at one meter or one-third of a meter, by its intensity or size, recognize and call it red. Using the ratio for his color blindness as we employ for his acuteness of vision, we can reason thus: Full color sense enables one to see the lights promptly
at 5 meters through the 1 mm. opening; if the man sees them only after the apertures have been increased, his color sense must be defective. Thus, if an opening of 20 mm. is needed, the color sense equals 1-20; should the man fail with the 20 mm. opening at 5 m. he is told to approach it, and if he sees it one-third of m., or one foot, he has only at I m. he has 1-100 of color sense, and if at 1-300 of the normal power.
By means of this instrument we are enabled to quickly, and positively, convince friends and officials of the man's ability to recognize colors, which is a very frequent necessity. I have not found an instance where the result of the tests with the lantern and the yarns did not agree. Whenever an individual cannot recognize these different colors, or cannot distinguish between them, he is not a safe man to put in charge of a train. Lastly, the original "Holmgren test" was resorted to.
When men are found not to be color blind with the above three tests, we are safe in permitting them to return to their work.
Hearing should be tested with a stop watch, which should be heard at a distance of five feet. The conversation test is the most practical, and on this the question of hearing should be decided. A man should be able to hear an ordinary conversation at a distance of at least 15 feet with each ear. Every test should be made in private, so that men do not become confused. The blanks when filled out by the examining committee are at once sent to the expert, who should look them over carefully. Those that fulfill every requirement are approved and returned to the superintendent, who then issues his certificate. Such as fall below the standard requirements in any part of the examination are sent for and tested by the specialist. Men are protected from the errors of the lay examining committees and do not lose their places until pronounced deficient by the expert. We can safely say, that a layman can detect color blindness, but he might treat some men unfairly who are fit, or who can be fitted by treatment.
I next formulated a standard of requirements for the employes of the various departments, that was adopted by the management of the Big Four Railway System. I beg to read such parts of these requirements as would interest the medical man, and invite criticism
by those who are familiar with the practical part of this subject.
1. Must have perfect color sense both for day and night signals.
2. Must not use glasses in the cab except for reading purposes.
3. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other. 4. An employe otherwise thoroughly competent, with one perfect eye, may be continued in the service, but must be examined every six months by the company's oculist, and if deemed necessary by the division superintendent he may call for further examinations in addition to those already provided for. It is incumbent upon the division superintendents to see that semi-annual examinations as herein provided, are made.
5. Must be able to read and write the English language.
6. Must be able to hear with each ear an ordinary conversation at a distance of fifteen feet.