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the patient complained, being the only pressure symptom. Deglutition of liquids was difficult and painful, that of solids impossible. By placing the finger in the posterior part of the mouth, the projection forward of the displaced vertebra was easily felt, so that we believed that the articulation between the two vertebræ, the fifth and the fourth, was torn open, that the supraspinous and the infraspinous ligaments, the ligamentum subflava, and posterior common ligament were torn through, while the ligamentum nuchæ remained intact, drawing the occiput downward toward the vertebra prominens and so increasing the deformity.

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Upon consultation it was decided to deavor to reduce the dislocation, and the dangers incident to such a step were explained to the family, who left the treatment entirely to our discretion. Drs. Burns and Bumster, whom I called upon for assistance, acquiesced in the following plan of treatment:

The patient was placed prone upon the table with his head and neck extending beyond its end, and supported in that position during the administration of ether. As soon as the anæsthetic had produced complete relaxation, extension was made from in front with counterextension at the shoulders, the greatest care being taken that no sudden movement should be made. There was an immediate and gratirying response to these efforts, respiration was not at all affected, and we could then distinctly feel the spinous process of the fourth cervical vertebra in line with those below, while there was complete disappearance of the deformity. Having thus reduced the dislocation, the next problem was to retain the bones in their proper position. The solution decided upon was a plaster of Paris cast, which was applied so as to extend from the occiput and the thyroid cartilage above to the first dorsal vertebra and the sternum below, care being taken to allow sufficient room for the neck. The patient was then placed in bed and watched carefully for three hours, during which time his condition remained satisfactory. allowed to go about in a week, the plaster was removed in three weeks, its place being taken. by roller bandages, and he was discharged, cured in five weeks from the date of the injury. Since then he has been attending to his work as a compositor, and he is apparently none the worse for the accident.-Medical Record.

He was

American Physicians Honored in China.

Dr. Eli Barr Landis, ex-resident physician of the Lancaster County Hospital and Insane Asylum, has recently received the Order of the Double Dragon from the Emperor of China, in recognition of services rendered by him during the war between China and Japan. The

same distinction had already been bestowed on another American medical missionary, Dr. B. C. Atterbury, for work in connection with the Red Cross Society in the late war.—The Medical Record.

BOOKS AND PAMPHLETS RECEIVED.

"Retinitis and Choroiditis," by L. Webster Fox, M. D., from The Medical News, May 23, 1896.

"Management and Treatment of Tuberculosis in the Asheville Climate, with Report of Cases," by James A. Burroughs, M. D., Asheville, N. C. Reprinted from the N. C. Medical Journal.

Gray's Anatomy, Descriptive and Surgical.

An American Text Book of Applied Therapeutics, edited by J. C. Wilson, M. D., assisted by Augustus E. Eschner, M. D.

"Feeding in Early Infancy," Arthur V. Meigs, M. D.

"Ovarian Tumors Complicating Pregnancy, with Report of a Case," by C. S. Bacon, M. D. Reprinted from the Journal of the American Medical Association, September 12, 1896.

"Constipation; Some of Its Effects and Its Non-Medicinal Treatment," by E. S. Pettyjohn, M. D. Reprinted from the Journal of the American Medical Association, August 1, 1896.

"The Differential Diagnosis of Neurasthenia and Its Treatment," by Elmore S. Pettyjohn, M. D. Reprint from American Medical Association Press.

Technic of Abdominal Salpingo-oophorectomy Without Pedicle," by T. J. Watkins, M. D. From the Medical News, August 8, 1896.

"Craniotomy on the Dead Child," by Joseph B. Delee, M. D. Reprint from the American Medical Association Press, 1896.

"Two Cases of Obstetrical Hemorrhage," by J. B. Delee, M. D. Reprinted from Chicago Medical Recorder, September, 1896.

"The Prismatic Perimeter," by Joseph E. Willets, M. D., reprinted from Annals of Ophthalmology and Otology, July, 1896.

"Inguinal and Scrotal Cysts, Simple and Complicated, In Infants or Young Children," by Thomas H. Manley, M. D. Reprint from American Medico-Surgical Bulletin, September 12, 1896.

"Notes of Inguino-Scrotal Cysts," by Thomas H. Manley, M. D. From the Medical News, July 11, 1896.

"Acute Rheumatic Iritis, with Cases," by A. Britton Deynard, M. D.

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President....

First Vice-President... Second Vice President. Third Vice-President.. Fourth Vice-President.

F. J. LUTZ, St. Louis, Mo.

287

279

288 288

W. R. HAMILTON, Pittsburgh, Pa. J. H. LETCHER. Henderson, Ky. ..JOHN L. EDDY, Olean, N. Y.

.J. A. HUTCHINSON, Montreal, Canada
Fifth Vice-President...... A. C. WEDGE, Albert Lea, Minn.
Sixth Vice-President...... RHETT GOODE, Mobile, Ala.
Seventh Vice-President...E. W. LEE, Omaha, Neb.

Secretary...
.C. D. WESCOTT, Chicago, Ill.
Treasurer..
..E. R. LEWIS, Kansas City, Mo.
Executive Committee:-A. I. BOUFFLEUR, Chicago, Ill., Chair-

man:

J.N. JACKSON, Kansas City, Mo.; JAS. A. DUNCAN, Toledo, O.; J. B. MURPHY, Chicago, Ill.; S. S. THORNE, Toledo. O.; W. D. MIDDLETON, Davenport, Ia.; A. J. BARR, McKees Rocks, Pa.

No. 12.

ON BETTER METHODS OF TESTING
THE HEARING OF RAILWAY
EMPLOYES.'

BY ROBERT BARCLAY, A. M. (TRIN. COLL.),
M. D. (COLL. PHYS. AND SURG.,
N. Y.), OF ST. LOUIS.

Consulting Aural Surgeon to the Hospital Department of the
Missouri Pacific; St. Louis Iron Mountain & Southern; and
Missouri Kansas & Texas Railway ompanies; Member
of the American Otological Society; Formerly Assist-

ant Aural Surgeon to the New York Eye and Ear
Infirmary, New York; Aural Surgeon to the
City Hospital, Missouri Pacific Railway
Hospital, St. Louis Baptist Hospital.

St. Mary's Infirmary, South Side
Dispensary, Maríae Consilia
Deaf and Dumb Institute,
House of the Good
Shepherd, etc.

Mr. President and Gentlemen of the Association:

At your second annual meeting, in May, 1889, I had the honor of presenting a paper' directing your attention to the fact that no safe provision had as yet been made against the dangers arising from deafness among railway employes; and raising the question as to how we should dispose of this, that the corporation might not suffer losses through suits for damages to passengers and freight, and that the employe might not meet with injury or death through this cause. In that paper, an earnest effort was made to emphasize the fact "that railroad service tends to the production of deafness, especially in ears already slightly affected; that it may be developed at any time, without the employe's knowledge; may be ignored by him, when recognized, and may become suddenly aggravated, while on duty; and that it may lead to loss of life, limb and property,"-a copious bibliography being appended in evidence thereof. A suggestion was offered, that you present the subject, in suitable form, to the

1 Read before the National Association of Railway Surgeons at its ninth annual meeting at St. Louis on April 30, 1896. "THE WHISTLE SIGNAL: A PLEA FOR THE MORE SAFE MANAGEMENT OF RAILROADS. Journal of National Association of Railway Surgeons, Fort Wayne, Ind., July, 1889, Vol. II, No. 2, PP. 57-65.

proper corporate officers, superintendents, department masters, and others, whose duty it is to employ, superintend and direct the men in the machine shops and on the road; and that the employe be informed of these facts, and of the dangers which deafness brings to those placed under his professional care, to the corporation, and to himself. And the opinion was expressed, that you would do well to make certain suggestions which the corporation should adopt for its own protection, such as the following:

All applicants for employment in the machine shops or on the road,-in consequence of whose deafness, loss of life, limb, or property might occur,-before being engaged, should be pronounced duly qualified by the aural surgeon of the company.

All candidates for promotion from the machine-shops, or elsewhere, to positions on the locomotive-engines; and from the position of locomotive-fireman to that of engineer, before receiving promotion, should be pronounced duly qualified by the aural surgeon.

All employes, in any position whatever, in consequence of whose deafness, loss of life, limb, or property might occur, should report at stated intervals to the aural surgeon for his examination.

If, on examination, deafness be found so profound as to otherwise endanger the life of the employe and that of others placed under his official care, he should be told thereof, warned, and, if necessary, be forthwith relieved. from duty to undergo suitable treatment.

If, in the faithful discharge of his duty to the company, the employe become permanently disabled by deafness, he should not therefore be dismissed from the company's service to earn his daily bread, at the risk of his life and that of others, on some other road; but the company which he has so faithfully served, should consult its own best interests by pensioning him, or else providing remunerative employment for him in some other suitable position where no special danger will attend his deafness.

Lest the services of a qualified applicant or employe be lost, or an unqualified one engaged, the company should take the precaution to have these aural examinations properly made.

The plea was concluded with an exhorta

tion to obey, in this matter, the official order that reads, "REMEMBER THE RULE THAT REQUIRES ALL EMPLOYES, IN ALL CASES OF DOUBT, TO TAKE THE SIDE OF SAFETY."

That paper seemed so far to express your own views as to have been deemed worthy of your own publication and distribution to every Railway Manager in the United States.

Some of the little seed thus widely sown by you seems to have fallen upon good ground, and has sprung up, bidding fair to bring forth fruit an hundred-fold. Many roads, as I have been credibly informed, now require as a qualification for service in their employ a certain degree of hearing power, under prescribed methods of testing. The assurance, by suitable tests, of the employe's hearing power, as essential to the more safe management of railroads then first proclaimed by your respected body has thus been practically acknowledged by Railway Managers--one more confirmation of the prophecy made before your association in 1891 by our esteemed Dr. Outten: "The officials of railway corporations will see the time has come when the physician will not only be an essential, but an economic factor in the operation of any railroad system." They have heard your voice; they have felt your influence; they have acted upon your advice. And as this is a just occasion for felicitation to you, may it stimulate you to speak once more to those who have shown their willingness to act, under guidance of your better judgment, in this matter,-to those who, recognizing the necessity of separating the grain from the chaff, but unskilled in the use of auditory tests, have begun to wield the flail to their own injury and greater danger! "Unqualified activity, of whatever kind," said the great German poet, “leads at last to bankruptcy." Recollect that you suggested this: "Lest the services of a qualified applicant or employes be lost, or an unqualified one engaged, the company should take the precaution to have these aural examinations properly made." How, then, can it take this precaution without your further guidance? It seems that your Association, as such, has not proclaimed its views in pursuit of this end.

Who could have heard unmoved the remarks of Doctors Hoy, Welch, and Outten upon the subject of the inefficacy of the

prevailing methods of testing the hearing of railway employes?

Right here, I beg to disclaim all desire to cast the slightest reflection upon any who approve of and cling to methods of whose disadvantages they have not yet been made sufficiently aware; but would rather direct your attention to certain features of the matter of testing the hearing, which, in my opinion, may be of practical value toward enabling you to solve this problem aright-for, until it is so solved, it will continue to vex all parties concerned. Of the desirability of the end, there is no question; of the means at present employed, there is certainly valid ground for question. And I make that statement for the following reason: If the prevailing methods of testing be such as to afford no guarantee against the loss of the services of a qualified applicant or employe, nor assurance of the rejection of an unqualified one, surely they are inefficacious, or inadequate. Now, such is indeed the fact. For, on careful study of the tests employed by the different railroads, so far as I have been able to learn them, I find that under any of them, you would reject one of the most reliable employes now in service if he applied for a similar position upon your road; that you would accept another, almost totally deaf without the artificial drum-head of cotton which he now wears with hearing beyond exception. Under the prevailing tests, you would have had to retire from service an engineer whose hearing was so impaired as to have rendered his ranking officer unduly, but, fortunately, unnecessarily anxious, who continues in service with safety. And I can cite you a case of a train-dispatcher whose deafness, until quite recently, has been unsuspected; who was relieved of duty at his own request; who can hardly hear a shouting voice a foot or two from either ear; who is wholly deaf to the tick of a forty-eight-inch watch on closest contact; but who claims to hear the "ticker" at his office, and the human voice-as I findby lip-reading, so as to attend to his business without mistake or complaint. Again, if a skilled mechanic or engineer should apply for a position, you could not determine, with the prevailing methods of testing the hearing, whether his marked deafness, if such there be, is due to the usual accommodation

of the healthy ear to his business conditions, or due to a dulling of the auditory perceptive apparatus from perhaps advanced but unsuspected Bright's-disease. With watch and voice tests, you could not distinguish. To do so, you would have to employ also at least tuning-forks. And if you should accept or reject such applicant upon these watch and voice tests alone, you would make either a most fortunate guess or a very serious blunder. Under the conditions imposed upon an ear in railroad service, it becomes modified in susceptibilty and structure, which disqualifies it for normal audition in ordinary quieter surroundings elsewhere. If the ear be perfectly healthy at the time of entering train service, and if no inflammatory action supervene, the functional modification is established slowly, and to a degree advantageous only to him as an employe, since his ear acquires power to resist the noxious influences of exposure, while retaining in its new circumstances ability to hear ordinary sounds-such as, for example, the human voice-a thing which here is beyond the power of an ear whose hearing is normal under other circumstances. This condition is so well defined in metal-hammerers, engineers, and mechanics generally, that it seems permissible to term an ear with such modified functions a "mechanic's-ear." instance of this condition may be found among boiler-makers, who at work converse in an ordinary tone of voice, which is inaudible to another person present whose hearing is normal in ordinary quieter surroundings elsewhere. Perhaps a better illustration is this: if, in a quiet place, a remark in a low tone of voice be addressed to a rather deaf boilermaker and yourself, you, and not he, will hear it; while if you both now go close to boilermakers at work, a similar remark, made in the same low tone of voice, will be heard by him and not by you. Now, to distinguish a "mechanic's-ear" from one affected by disease, is impossible with the office tests by watch and voice alone; and as it is desirable, even essential, to make this distinction, or to determine just how far such changes in the hearing are advantageous, as arising from the adap tation to habitual environment and extraordinary duty, or disadvantageous, resulting from morbid processes, such tests as are necessary to determine this should be em

An

ployed in all doubtful cases, i. e., cases which fail to satisfy the scale of hearing prescribed as qualifying for audition, in ordinary surroundings. In fact, when you consider the cases to which I have already alluded, where the prevailing tests with voice and watch alone. would have proven wholly misleading and subversive of the advantages of testing the hearing at all, it would seem that we cannot be too careful and thorough in our methods; and if the necessary methods are so intricate as to require a special preliminary education therefor on the part of those whose duty it might be to make such examinations, this work should be assigned to such only of the railway medical staff as are willing and able to devote sufficient time and energy to such essential preparation.

In other words, prudence requires that these examinations should be properly made; for an inefficacious or inadequate test is worse than none.

Tests should be made with watch, voice, and whisper; high and low tuning-forks, and suspended steel rods. The ear should always be inspected; and the functional condition of the Eustachian tube should be determined.

As the degree of hearing, in many cases, varies in different surroundings, the examinations should, if possible, be made in the same place-preferably in that identical place where the examiner has tested the normal ears in determining what is normal for his own watch, voice, and whisper, tuning-forks, etc. For, in methodical testing, each observer must test his own instruments upon a large number of healthy adult ears, and therefrom deduce a normal standard, with which to compare the results of all subsequent examinations. A certain percentage of the normal hearingpower having been determined upon as essential to qualification for employment with the company, each examiner can adapt this to his own testing instruments, in due proportions; and he must bear in mind that the hearing-power varies directly as the square of the hearing-distance of a sonorous body from the ear. In using the fractional form of prescribing or recording the degree of "hearing," either "hearing-power" or "hearing-distance" should always be specified, lest mistakes arise from mistaking the meaning of the term,

"the hearing," and substituting the "hearingpower" for the "hearing-distance"—a serious difference, since one of these is the square of the other.

In testing, regard should be had to the fact that the two ears should act in conjunction. The auditory field of each ear overlaps the median plane by about twenty grees. This gives a field of about forty degrees, for normal ears, along the median plane, a field in which double hearing enables the hearer to determine the direction of a sound without turning his head, and in which he is doubly warned against approaching danger from sonorous bodies, both in front and behind. In affections of hearing where these auditory fields, right and left, are so narrowed as not to meet and overlap at the median line, this advantage is lost; and instead of being able to recognize approaching danger best, when head-on, and to direct either ear at will for its best service, without exclusion of the other, by turning it slightly toward the source of sound, the sound is either unnoticed, or, if noticed, the defective hearer must turn one ear toward it so far as to exclude the other ear from joint service. Hence the suggestion, to determine whether the auditory field be contracted, and whether the two ears act best in conjunction; and, if not, whether the defect be of a degree or character sufficient to disqualify. The observer, therefore, should use the watch and voice tests, not only in the axis of best hearing opposite the ear, but clear to the limits of the normal auditory field, both in front and behind.

In testing with the watch, it should be remembered that it gives out but two sounds of a certain pitch, which are ofttimes unheard by an ear whose conducting or perceptive apparatus has been impaired; and yet, this very same ear may hear the tick of another watch of different pitch, and similar sounds,—as with the train-dispatcher mentioned above, who could hear his office "ticker," although deaf to my forty-eight-inch watch, even on pressure-contact. By using a stop-watch, you can readily determine whether or not the examined hears its tick, as he will have nothing but his hearing to aid him in determining whether or not the watch be going.

The watch test alone is of little value; and there is no constant proportion between the

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