quired by rule No. 4 under the head of "Enginemen." 5. Must, with the use of glasses if necessary, have perfect near vision enabling them to read and write the English language readily and distinctly. 6. Must be able to hear with each ear an ordinary conversation at a distance of fifteen feet. TRAIN BAGGAGEMEN. 1. Must have perfect color sense both for day and night signal. 2. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other, or 20-40 with each eye. 3. May use glasses to bring their vision up to the above standard. 4. An employe otherwise thoroughly competent, with one perfect eye, may be continued in the service, but must be examined as required by rule No. 4 under the head of "Enginemen." 5. Must, with the use of glasses if necessary, have perfect near vision enabling them to read and write the English language readily and distinctly. 6. Must be able to hear with each ear an ordinary conversation at a distance of 15 feet. BRAKEMEN. 1. Must have perfect color sense both for day and night signals. 2. Must not use glasses. 3. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other. 4. Must be able to read and write the English language. 5. Must be able to hear with each ear an ordinary conversation at a distance of 15 feet. YARD FOREMEN, CONDUCTORS AND BRAKEMEN. 1. Must have perfect color sense, both for day and night signals. 2. Must not use glasses. 3. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other. 4. Must be able to read and write the English language. 5. Must be able to hear with each ear an ordinary conversation at a distance of 15 feet. OPERATORS OR EMPLOYES PERFORMING THE DUTIES OF AN OPERATOR. 1. Must have perfect color sense, both for day and night signals. 2. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other, or 20-40 with each eye. 3. May use glasses to bring their vision up to the above standard. 4. An employe otherwise thoroughly competent, with one perfect eye, may be continued in the service, but must be examined as required by rule No. 4 under the head of "Enginemen." 5. Must be able to hear with each ear an ordinary conversation at a distance of 15 feet. TRACK AND BRIDGE FOREMEN. 1. Must have perfect color sense, both for day and night signals. 2. Must be able to read test cards 20-20 (perfect) with one eye and 20-50 with the other, or 20-40 with each eye. 3. May use glasses to bring their vision up to the above standard. 4. Must be able to read and write the English language. 5. Must be able to hear with each ear an ordinary conversation at a distance of 15 feet. 6. Will be held responsible for the proper use of signals in the hands of employes whom they send out to do the flagging. GENERAL. 1. All applicants for promotion or employment must have perfect color sense for both night and day signals. 2. Must be able to read test cards 20-20 (perfect) with each eye. 3. Must be able to read and write the English language. 4. Must be able to hear with each ear an ordinary conversation at a distance of fifteen feet. 5. Regular examinations must be made during July of every second year. 6. Semi-annual examinations, as hereinbe-. fore provided, must be made in January and July of each year. 7. Examination papers must be forwarded promptly to the company's oculist for approval. If approved they will be returned to the division superintendent direct. If not ap proved they must be forwarded to the general superintendent. 8. Certificates will not be issued by superintendents until the examination papers have been approved. 9. Nothing in the foregoing rules shall pre vent the promotion of employes who are defective in sight or hearing, and otherwise competent, to positions in other departments where the use of the signals are not required. Governed by the above rules, about 5,000 men were examined and made to comply with the standard adopted by the management. The result was that nearly 8 per cent. of this number were found to be defective according to the papers of the lay committee. These men were now called to my office and examined carefully in every detail. I found 67 cases reported color blind. Out of this number there. were 48 real cases; the other 19 were errors, a little less than 1 per cent.; 10 cases of defective hearing were reported, 2 of which were real and 8 apparent; 254 cases were reported for defective vision, 95 were errors, while 159 had some defect. Out of this whole number 69 men were discharged, 48 for color blindness, 2 for defective hearing, and 19 for defective sight. All of the color blind cases were re-examined at a subsequent time, but in not a single instance was the first record reversed. In the beginning of this work there was a great deal of opposition on the part of the men, but that gradually wore away, and at the present time I am safe in saying that no one is opposed to it. You not infrequently hear the statement made that there is no case on record where a wreck or damage resulted because of the color blindness of an employe. In the first place this statement is not correct, and in the second place, even if we could not show a case of this kind, no sane man would advocate the retention in service or the employment of an engineer who is positively color blind and not able to quickly and correctly recognize the signals on which the safety of the train depends. If this is true of an engineer, it is equally as dangerous in the instance of any man who has anything to do with the giving or recognition of signals by day or night. DISCUSSION OF DR. TANGEMAN'S PAPER. Dr. J. M. Ball: I believe there are several gentlemen here much more competent to discuss this excellent paper than myself. The subject of color blindness is one of great interest, and has been thoroughly covered by two or three of the papers which we have had at this meeting. Dr. C. D. Wescott: I have been very much interested in the paper to which we have just listened, and I admire the Doctor's system of making the examinations. It seems to me that when it is possible for the laity to commit as many errors as reported by the Doctor in these examinations, that that alone is an indication that the primary examinations should not be intrusted to laymen. I think the local surgeon should make the first examination, and if possible he should have experience in ophthalmic work. I was very glad to notice the plan the Doctor suggests for measuring roughly the field of vision. We all know that the applicant may have most excellent central vision, yet a defective field will make him a dangerous man. That is a very important test, and it is not usually applied. In regard to the matter of glasses there has been a good deal of discussion. I feel that the Doctor is very fair in the allowance he makes in this direction. I do not believe any engineer or fireman should be employed who must wear glasses for distant vision. I know that it works great hardship to discharge a conductor who must wear glasses in order to have good vision, but he should doubtless have 20-40 vision in one eye without glasses. On some roads these men are not permitted to wear glasses while on duty. I know a conductor on the Rock Island road who has vision without glasses equal to 21-100 in each eye, and with glasses about 20-30 with each eye. He wears glasses constantly when off duty, but does not dare to be caught on duty with these glasses. With such defective vision there might arise an occasion when he would be a dangerous man without glasses. I do not think a man should be employed unless he has 20-40 vision in either eye without glasses. The apparatus which the Doctor has shown for the measuring of color sense is as simple a scheme as we have. I think, though, that the apparatus which Dr. Williams showed us a year ago is a more practical one. If we use lanterns, such as are in daily use on the track. for tests, we must have some means of vary ing the degree of light. Dr. Tangeman (closing): There is very little I have to say in closing this discussion. First, with regard to glasses, and compelling men either to lose their job or being able to see a certain amount, it seems a hardship, it is true, but the reason why the management of this road ruled out glasses was this: A brakeman, for instance, has an important position, particularly a freight brakeman. He is exposed to more or less danger in climbing up on the freight cars. Accidentally he loses his glasses after being accustomed to the use of them and learning to depend on them. to see at a distance. Everyone of you have lost your glasses and know the inconvenience, but a freight brakeman is more liable to lose his glasses than you are, because of the kind of work he has to do. Are we to endanger the safety of a train or crew because of the retention of one single employe who may be defective in vision? The company can better afford to put some of these men on the retired list and pension them for life, than to retain them if they are dangerous men. No man but the operator, the baggageman and conductor are permitted to wear glasses, and they begin to wear them as soon as vision is defective. If he goes without them he is afraid he will be discharged; he should be supplied with two pairs, so that he has another pair with him should he lose the other. One of our rules is that no man (making an application for a position) shall be accepted unless he has absolutely perfect vision in both eyes-20-20 -it makes no difference what position he applies for. In this way we will have a good body of men after a while. You will have noticed from the statistics that have been read that the percentage of color blind cases in this test is very low. I presume because all of these men had at some previous time been examined by a lay committee. I agree with Dr. Wescott that it is absolutely essential to take the examination of the eyes out of the hands of a lay committee and put it into the hands of the expert surgeon. This should be done because of errors and misunderstanding, and the only thing that would answer instead, it seems to me, is the preliminary examination of these men by a lay committee. Then refer all of the papers or examination blanks to an expert for approval. Such an aversion and contempt for all manner of innovators, as physicians are apt to have for empirics or lawyers for pettifoggers.Swift. THE DEFLECTED SEPTUM AND ITS SURGICAL TREATMENT.* BY JNO. A. JAMES JAMES, B. Sc., M. D. Professor of Diseases of the Ear, Nose and Throat in the St. Louis In choosing a subject for a paper before your association, I have been guided by the knowledge that it was to be read before an assembly of practical surgeons-before a body of men whose daily work lay in the performance of formidable and serious operations. I feel that it is largely due to the influence of the general surgeon that the treatment of the obstructive diseases of the upper respiratory tract has been rescued from its former thraldom in the hands of specialists whose endeavors were limited to ringing long and wearying changes upon various sprays and other local applications, which left the patient, at the end of his treatment, exactly where he was at the beginning. We have come to realize that upon active surgical intervention depend most of the successful results of treatment in this special field of work. This fact has been particularly apparent in the matter of deformities of the nasal septum, and it is to this purely surgical matter that I invite your attention this after noon. If we inquire into the causes of deflection of the septum, we are struck by the number and variety of agencies asserted to cause the deformity. Among these are many utterly unworthy of serious consideration. Indeed, when one studies his cases, he is soon convinced by an almost unvarying history of an injury to the nose that the cause of the deflectei septum may be said to be almost always purely traumatic. In the majority of cases the history is a clear one. In others it is not. Yet these latter are easily accounted for when we consider the number of bumps and falis that attend our early attempts at walking. An injury too slight to injure an adult nose may easily produce a slight deflection in that of a child, which, increasing with time, becomes a marked deformity as manhood is reached. Indeed, so common are these deformities that it is extremely rare to find an adult male with an entirely normal septum; and a close inspec *Read at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, Mo., May, 1896. tion of the half dozen noses nearest us will show that perhaps not a single one of them occupies the exact median line of the face. Just what deformity of the septum will result as the effect of the injury inflicted must depend upon the character and point of application of the blow. We see those cases wherein, as the result of a powerful blow, not only the cartilaginous, but the bony portion of the septum has been forced to one side. Others again show only a displacement of the cartilage of the septum at its lowermost point, the sharp border of the cartilage projecting into the lumen of one of the nostrils, producing more or less occlusion on that side. In the majority of cases, however, of true deflection, we are concerned with the deformity which involves the entire cartilaginous part of the septum, the deviation involving but slightly the upper and bony portion. With the various forms of septal spurs, ridges, etc., it is not the purpose of the present paper to deal. A well defined deflection of the septum sufficient to occlude one or both of the nostrils even a portion of the time, is fraught in the vast majority of cases with a long trail of evils, which it is our purpose briefly to notice. A septum may be forced to one side and in contact with the turbinate bodies of one of the nostrils. This, while it occludes the one nostril, leaves an excess of space on the other side. Nature abhors a vacuum. She attempts to fill up the vacant space. The turbinates undergo a compensatory hypertrophy on that side, and, in a varying length of time, both nostrils are partially or completely obstructed. Let us study some of the effects of this interference with nasal respiration. We are likely, from our long continued habit of regarding the nose mainly as an organ of smell, to forget its far more important and necessary functions, namely, those of moistening and warming the inspired air, and of assisting in voice formation. We find, then, depending upon the degree of nasal obstruction, a more or less completely enforced habit of mouth-breathing, both when asleep and awake. The inspired air, not properly moistened, passes over the mucous surfaces of the fauces, larynx and bronchii, drying them and rendering them irritable and inflamed. Meanwhile, the natural drainage being interfered with, the patient finds himself annoyed by the presence of an excess of mucus. The usual attempt to dislodge this is by a vigorous blowing. To blow an obstructed nose with all the force of a powerful pair of lungs, is to force the air somewhere; and the eustachian tube feels the force of a strong blast of air as often as the obstructed nose is vigorously blown. Conversely, at each effort to swallow, as all of us may feel by pinching our nostrils together and swallowing, there is a rarefaction of the air in the eustachian tube and the tympanic cavity. In other words, a continued performance of the so-called Toynbee's experiment, broken at intervals by a Valsalvan inflation when the patient blows his The inter-dependence of nasal obstruction and middle-ear disease is too well known to be further referred to. When we add to the above results of nasal stenosis, the frequent existence of severe headaches of clearly demonstrated nasal origin, the loss of purity of certain tones of the voice from the same cause-when we consider at once the discomfort of the individual and the harmful results that accrue from a neglect of this condition-we cast about us for the best means for relief from the trouble. It is not my present purpose to recite to you I the various and widely differing operations that have been put forward for the relief of the deflected septum. The very variety of the procedures tells in unmistakably clear language how unsatisfactory they have all proven. wish to call your attention to an operation which does result in a satisfactory cure of the condition, and a relief from the deformity and inconvenience that arise from the existence of the trouble. This procedure has become known as the Asch operation, having been devised by that well-known operator and modified by his associate, Dr. Emil Mayer. The instruments, which are somewhat elaborate and, for intranasal work, I must admit, somewhat formidable, are before you, and the steps of the operation are as follows: The patient is given a general anæsthetic and the angular shears, (not illustrated. Like Fig. 1, but bent at right angle.) of which you observe there are two pairs, according as the convexity of the GTIEMANN &CO. FIG. 3. septum is toward the right or left, are introduced and the septum cut entirely through at its point of greatest prominence. The scissors are now turned and another incision made at right angles to the first. The forefinger is now introduced into the obstructed side and an attempt is made to push the softened septum over to the median line. Several prominent angles will be found projecting into the lumen of the nostril. These are reduced by the use of the straight-cutting scissors (Fig. 1), of which you observe two sizes, a large and small pair. When the septum has become entirely and completely plastic, it is placed in the median line by the use of the Mayer straightening forceps (Fig. 2), the operator assures himself that the passageway back to the pharynx is clear and free from synechia on both sides, and the drainage tubes (Fig. 3), are inserted. The hemorrhage, which, up to this point, has been very free, is at once entirely controlled by the slight pressure exercised by the tubes. You will observe that the drainage tubes are of red vulcanite, smoothly polished and perforated at numerous points. These tubes are made in varying sizes to fit nostrils of different capacity. I have had them made by an ingenious dentist friend by furnishing him with plaster of Paris models of the necessary forms and sizes. The reaction following the operation is usually not great, and the after-treatment consists in the frequent removal of the tubes and the flushing or spraying of the nose with some simple detergent solution. The tubes are then reinserted. Should this cause pain, a ten per cent cocaine solution may be sprayed into the nostril before restoring them to place. In a few days the shattered septum will have acquired a fair degree of firmness. The patient continues to wear the tubes, however, until the septum is firm and strong, a time lasting from three to six weeks. This entails but little inconvenience, since their presence is not painful at this stage, nor are they as noticeable as would be supposed. I have already alluded to a compensatory hypertrophy of the turbinates on the side of the concavity of the septum. Before beginning the operation proper, just described, these hypertrophies should be thoroughly reduced by the galvano-cautery or removed by the cold snare, lest, when the septum is restored to the median line, the stenosis be simply transferred from the one side to the other. If the details of this operation are properly carried out, the result is an eminently satisfactory one. Faulty results are most likely to occur from a too timid use of the scissors, and a consequent insufficient breaking up of the septum. In such cases the septum resists its reposition in the median line, and the tubes are retained with greater pain and difficulty. The greatest objection that can be urged against the operation is its somewhat formidable and sanguinary character. But this is more apparent than real, and is not a valid objection to the operator accustomed to making serious operations. It is not an operation which requires special knowledge of intranasal work, and since it is successful in its object of relieving nasal stenosis and its consequent train of evils, I urge that it is the best and the most practical operation we possess for the cure of the deflected septum. It has happened to me on one occasion that the angular scissors broke in attempting to perforate a septum, the deflection of which was |