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. 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 The 200 at 5 meters through the 1 mm. opening; if the By means of this instrument we are enabled 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. Every 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. 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. ENGINEMEN. 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. FIREMEN. 1. Must have perfect color sense both for day and night signals. 2. Must not use glasses. 3. Must be able to read test card 20-20 (perfect) with one eye and 20-50 with the other. 4. An employe otherwise thoroughly competent, who has lost the sight of one eye in the service of the company, may be continued in the service if the other eye is perfect, but must be examined as required by rule No. 4 under the head of "Enginemen.” 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. CONDUCTORS. 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 re 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 car 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 hereinbefore 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 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 deflected. septum may be said to be almost always purely traumatic. In the majority of cases the history is a clear one. Yet In others it is not. 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. |