And this leads me to the subject of railway-ambulance arrangements, now so completely defective. First, (a) every railway porter should be taught the elements of ambulance aid, in lifting injured persons. It is easily learnt.

(b) Every railway station needs a carrying chair, for carrying invalid travellers from their conveyances to the carriages.

(c) A stretcher should be kept by order in every railway station throughout the length and breadth of the land, ready for use.

(d) In the guard's-van of every train of every class, such a stretcher should be kept folded up and put away, but ready for use, and iron clamp stanchions, after the "Hamburgh system" (to be described afterwards), kept ready also for suspending the stretchers.

(e) To all breakdown trains should be added proper ambulance carriages, fitted up for the conveyance of those maimed in our railway accidents, and similar carriages should be available for passengers, if needed, at fair rates. Charitable societies might well supply the carriages and keep them in order. This would be really practical humanity.

In country districts the Poor Law unions furnish a ready machinery for ambulance aid. At every central union hospital, ambulance carriages, both for sickness and for infectious disease, should be kept; and in all the outlying parishes, stretchers and smaller-wheeled ambulances. Telephone communication would connect the outlying districts with the central hospital. Examples will be given further on of all these systems.

In mining districts and in all our great factories, stretchers should be kept by the owner, and either hand-wheeled ambulances or horsed-carriages be available for aid. The absolute saving of money to the world by preventing a simple fracture becoming compound, would well pay for all appliances a hundred times over.

On our rivers and harbours, ambulance launches and steamers, specially constructed for the injured or the sick,

should be placed by the Local Board responsible for the sanitary police of the river.

We will now describe with more detail some of the existing systems of civil ambulance arrangements.

MUNICIPAL AMBULANCE SYSTEMS.

Arrangements of the Metropolitan Asylums Board, London. Vide Plan, Fig. 4.

The Metropolitan Asylums Board of London has now at work in the Metropolis a system of ambulance arrangements well worth studying.

This Board, amongst other important duties, is responsible for the medical care and hospital accommodation of all cases of infectious disease occurring amongst the pauper class in greater London.

Its schemes of work are yet in the stage of development, and not completely worked out, but they may be explained in general terms, and the lines of work broadly indicated.

Previous to the formation of this Board, the various parishes dealt or did not deal with their own infectious cases. The Metropolitan Asylums Board have now in greater London five infectious disease hospitals. (Vide plan, Fig. 4), viz.: Hampstead, Homerton, Fulham, Deptford, and Stockwell. In these central hospitals the pauper sick of the districts are received up to a certain number, and with special reference to the class of cases. Practically these central hospitals are for grave acute cases, which cannot stand the fatigue or risk of removal to the outlying hospitals, of which we shall speak directly.

A limited number, probably not more than fifty serious cases of small-pox, would be kept in these central district hospitals, and of fever cases a somewhat larger number, but no excessive number will ever remain in them.

Outside London proper, in the country districts and amidst healthy open surroundings, great overflow hospitals for the reception of mild, or convalescing, or convalescent cases, are or will be formed for fever at Winchmore Hill,

by Enfield; and for small-pox, in the three hospital ships, Atlas, Endymion, and Castalia, moored at Long Reach in the Thames River by Dartford and Purfleet, with a further reserve hospital on the shore at Darenth close by the hospital-ships' moorings.

This shore hospital at Darenth will be a great overflow hospital, available for first admission in case of an epidemic, and also as a convalescent hospital for ordinary cases in ordinary times.

To convey patients to these central and outlying hospitals the system is as follows:

When a case of infectious disease occurs in a locality, the medical officer reports to the district relieving officer. This official telegraphs to the Central Asylums Board office, Norfolk Street, Strand. This office is connected by telephone with the ambulance stations existing and under construction at Deptford, London Fields, and Fulham.

These ambulance stations are admirably organized, and, so far as we have seen them, well worthy of study as patterns of ambulance stations.

A staff of superintendents, drivers, and subordinates are on duty in each station. Suitable (sick-transport) ambulance waggons for conveying infectious disease stand ever ready to be horsed. The horses are in stables close by, ready for hooking in. The whole disciplinary, sanitary, disinfecting, and precautionary organization of the station leaves nothing to be desired, and seem to us to be in every way a model worth copying. When one reads the ghastly record of the style of conveyances used only five or six years ago in London, to convey those unfortunate sufferers stricken with contagious disease to the proper hospitals, one rejoices beyond measure that so successful an effort has been made to render human misery less. Let us fancy the pauper sick of the Plumstead, Woolwich, and Charlton districts, who, up to 1877, when stricken with small-pox had to drive sometimes fifteen miles, sitting on a board, in a conveyance in which they could not lie down. These conveyances used for small-pox were never disinfected,

and stood in sheds with other carriages. Of Shoreditch we read, "In the small-pox cab the patient cannot lie down or even stretch his limbs;" of Marylebone, “The patient cannot lie down;" of Hampstead, "The patient must lie on the floor of the vehicle;" of Clerkenwell and Holborn, "The patient cannot lie down," "never disinfected." St. Pancras, "Patient cannot lie down." What comfort to know this wretched misery is now past and gone!

At these perfect ambulance stations, which we now possess, night and day, on the receipt of a telephone message from the central office, in three minutes a carriage starts for the infected house. As it leaves the gate, a nurse with a basket of restoratives in her hand steps in, and proceeds to the house to superintend the removal.

From the house the patients are taken, if grave cases, at once to the district hospitals. If they be of milder type, small-pox cases are carried to the river ambulance stations, which are or will be formed at Blackwall, Fulham, and Deptford.

At wharves at these stations the special ambulance steamers-one of which, The Red Cross, is now at work, and another is under construction-will convey the cases down the river to the hospital ships at Long Reach.

In detail, further on, we will describe the various matériel used in this work, but the general outline is as we have described. It will be seen at once that an identical system suitable for non-infectious ordinary disease can one day be developed in London. The existing hospitals will become receiving houses for grave cases and sudden illnesses; and round London, overflow hospitals, combining treatment and convalescence, will be founded. Ambulance sick-transport waggons will collect the sick from the districts for the London central hospitals, and regularly organized ambulance trains will convey the invalids who are relegated to the country outlying hospitals to their destination.

All that is needed to start this important work is a central municipal authority.