to be discarded. The significance of such an observation can be illustrated in the case of a wound freely bleeding. The best time for a dressing is at the time when hemmorrhage is freest. Just at time when bleeding ceases, then can extraneous material, which we call bacteria, easiest find ingress. Because of ignorance, the bacteria-laden waste or the filthy rag is applied to this freshly received wound. What the result of such ignorance might be, we could all easily imagine. It means blood poisoning in non-technical language, perhaps a permanent disability, perhaps an operation with loss of limb. This, to be sure, is an extreme case, but serves to illustrate our position. It is then of paramount importance that the first dressing should be clean, surgically clean, as is the dressing in the first aid packet. Again, a little elementary knowledge of the nature of fractures and their first aid treatment will stand in good stead. The pupil of first aid instruction recognizes a simple fracture, and appreciates the importance of preventing that simple fracture from becoming a compound one. That is, he knows that through improper manipulation a sharp point of the fractured bone may penetrate the overlying tissues and produce an open wound into which bacteria may find their way, with the sequence of blood poisoning and perhaps amputation. He knows that all this can be avoided, or, at least, bad results minimized by the ready application of a splint made of a board, a pillow, twigs, umbrella ribs, a piece of carboard, one of which will always be at hand. He knows, too, how to transport a patient suffering from shock; he knows how to apply the tourniquet in the case of severe hemorrhage. In short, he knows with little expenditure of energy and mental effort on his part, simple yet efficient means of alleviating and shortening suffering and preventing fatal terminations to accidents.

Recognizing the utility of such knowledge, the question arises as to how it is to be disseminated and properly impressed upon your employees. In different localities various plans have been in use, many have been found wanting, a few have yielded desired results. Wherever first aid has been instituted and discarded, the fault has not been with first aid per se, but with the plans and system of organization. Many establishments have the outward sign of first aid equipment by having printed instructions placed here and there throughout the works. Others again satisfy themselves with instructions and equipment carefully locked up in the office safe. Such systems offer no adequate information and excite no individual interest. The most satisfactory, because the most efficacious way, it would seem, is the one by which each man receives personal attention and instruction in the art. The system used by one of the great western railroads commends itself as a model and I can do no better than to give you in substance the plan followed. The division superintendent was asked to fix a date for organization and to provide a meeting place, both of which were announced by a bulletin posted in conspicuous places. The men assembled and elected their own officers. The chief surgeon of the road delivered the first lecture, which was mainly preliminary and introductory. He told of the objects of first

aid, its history, its development and its benefits. Those present were enrolled as pupils and given a first aid manual. The assistant surgeon then assumed the duties of instructor and held the examinations at the end of the course, which consisted of five lectures and demonstrations. The examinations were either oral or written, as the candidate himself elected. The reason for this is obvious. The names of the successful candidates were forwarded to the chief surgeon, who together with the general manager signed the certificate indicating proficiency in first aid to the injured. The first difficulty experienced by the men was that the terms used in the lectures were too technical, and the second, that an attempt was made to teach too much. Again at times, it was impossible for the mèn to attend regularly a sequence of the five lectures and an opportunity, therefore, was given to make up the lost one or ones in a subsequent course. All this was soon modified, the language was simplified, the men were encouraged to ask questions, which brought out practical points. The lectures were followed by practical demonstrations. These excited interest, and all desired to do a dressing or adjust a bandage or appliance. It is at once apparent that the scheme of this plan cannot be effected in all places, because all men cannot be interested to the same degree. Where the above is not practical, there can be elaborated a plan by which certain chosen men from each department are selected and given full instruction in the principles of first aid. It can then be made known that these men of the various departments are at the beck and call of those requiring ready aid. This plan will perhaps commend itself in many establishments. Added to these, many other plans suggest themselves but it is not our purpose to consider them at this time.

As has been suggested before, corporations are not so likely to take up with a new feature like first aid unless there be shown a business side to the proposition. Likewise from the viewpoint of the employee, we must admit that these men are not interested in medicine and surgerythey are interested in good salaries for the work they render the company. But what is the business side of the question from the company's view? The employee is an asset of the company. His ability to work six days of the week is a source of revenue for himself and company. In the shop he is protected from injury by certain mechanical devices -protected from the standpoint of humanity or commercialism, as you please; or perhaps, because the law makes the declaration. Warnings are posted here and there as to the dangers existing in the operation of certain machines and machinery. Safety devices have been installed and apparent freedom from accident is assured. In spite of these adjuncts of safety, injury befalls many an employee. What now have humanity, the law or conscience done for him as pertains to his immediate cure? Perhaps, in a small number of cases, everything that I have indicated that should be provided in a well-maintained establishment. On the other hand, nothing, and because of ignorance and because of misdirected assistance his injury is aggravated. He is a loss to the company for a more prolonged period than would have been with a little knowl

edge of first aid. He is a man who can with difficulty be spared from his particular work. A trained man at an increased expense must be secured. The company, perhaps, pays the expenses of the disabled man during his enforced absence. Perhaps the man upon his recovery institutes suit for damages, which suit must be defended, with consequent added expense. All of these considerations entail a drain upon the resources of the corporation. Again, when we consider accidents in which railroad passengers are concerned, a knowledge of first aid on the part of the crews would be of undisputed service, in lessening suffering and decreasing the number of aggravated conditions, with the consequence that there is less reason for the commencement of a damage suit. The number of deaths from accident on American roads is reaching a frightful total each year and over four thousand deaths are to be credited against them. In passing, it is interesting to note that the roads of Great Britain and Ireland transported over a billion passengers in 1904, to our three-quarters of a billion; killed twentyfive persons to our four thousand, and injured seventy-six to our fifty thousand! These figures stand out in bold relief, and the remarkable showing is to be attributed to various agents of safety and prevention, first aid included. It certainly is false economy and poor business for roads to consider that it is cheaper to pay what they are compelled to for injuries and deaths than it is to make expenditures for the installment of first aid equipment. The viewpoint of the employees is similar to that of the company. These men want to be in a position to earn good and constant wages, and have no desire, certainly, to be laid off indefinitely as a result of some bad Samaritan whose intentions were of the best but who was sadly lacking in intelligence. Such enforced absence means evidently a financial loss to him and perhaps a loss of the position to which he had risen through years of competent service. Perhaps it means a permanent disability, because the simple first aid had not been understood and its value not appreciated. It is at once apparent that first aid is more direct benefit to these men than to the companies, and it is surprising that their unions have not seen fit to insist in a more general way upon these measures of safety. If these unions exist because of true and sincere purposes, then it is clearly their duty to take precautions necessary to the physical well-being of their members as well as to their financial conditions. In conclusion, permit me to express, even at the risk of being declared too enthusiastic and over zealous, the hope that the time may come when railroad companies in general will fully appreciate the meaning of first aid, and that they will demand a certificate of proficiency in the art in the same manner that they require evidences of proficiency in the art of mechanics, from the lowest to the highest positions.

The PRESIDENT-Dr. Sellenings, the author of the paper, desires to make a few practical demonstrations a little later in the evening, after we have given an opportunity to some others present to discuss the paper. The discussion of the paper will be opened by Dr. J. M. Wainwright, of Scran

ton, Pa. In view of the large number present who desire to speak upon this subject, the discussion will be limited to ten minutes for each speaker.

DR. WAINWRIGHT—Mr. President and gentlemen: My brief discussion of this valuable paper is from the standpoint of a central surgeon in charge of a large company hospital who sees the injured only after the first-aid treatment has been administered or perhaps omitted. The local surgeon who frequently goes to the place of accident will have a different point of view.

It is my experience, and I think that of every one who is doing the same kind of work, that each year I see a number of fatal cases that could be saved if the first-aid treatment had been more efficient. I think that this statement that "many cases die from lack of efficient first-aid treatment" might well serve as the text for all discussions on this subject. These deaths come from failure to protect wounds from blood poisoning, from failure to stop severe hemorrhage, from failure to prevent increasing shock, or sometimes simply from the fact that the injured man did not reach the hospital soon enough.

I can perhaps be most practical by describing the equipment of my own road, the Lackawanna. We have at Scranton, which is nearly the midpoint of the road, a large hospital, The Moses Taylor, which is entirely devoted to the road. The hospital is situated right among the company's coal mines and the largest of their shops. I shall omit the arrangements at the mines, as they are not, I presume, of a special interest at this meeting. Many of our shops are within ten minutes of our ambulance and it is not necessary to have any special equipment. In one large shop which is further away we have a well-equipped hospital room where the injured are taken and cared for until the ambulance arrives by employees who have received special instruction.

In this connection I would like to emphasize Dr. Sellenings' remarks as to first-aid instruction. It should be quite elementary in character. I have always tried to impress the men to whom I have talked with the fact that they are not to try to repair the injury but simply to prevent more harm from being done. That is, in the case of an open wound they are to prevent more dirt from getting into it, they are to prevent more hemorrhage, more shock from continued exposure, and more displacement of broken bones.

Arrangements are now being made to have first-aid boxes placed in all stations and large yards. These will, I am sure, prove of great value.

One of our most important items is our hospital car. This is stationed at Kingston, about 20 miles from Scranton, where there is an important yard and a large group of mines.

The history of this car has been interesting. While our operating officials have always been not only willing but anxious to provide any firstaid equipment that was needed, they considered our request for a hospital car with much scepticism. It was said that while a hospital car is all very well in its way, it is never in the way. Whenever an accident requiring it occurs, the car is sure to be at the other end of the line and any number

of special trains with dozens of doctors can be brought to the scene before the hospital car.

It so happened that the first serious accident that the Lackawanna has had for years, when five people were killed and some twenty injured, the hospital car, under charge of Dr. Lake, to whom is due the credit of its existence, was on the scene in 50 minutes, long before any wrecking crew or other relief. The condition in which the injured reached the hospital by means of this car was a pleasant contrast to that in which most railroad accident cases are received. Asceptic dressings were on wounds, broken limbs were properly supported, and even broken ribs were strapped up. Some of the dressings applied in the car were allowed to remain permanently in place. Many of those having minor injuries were attended to in the car and then sent on to their destination. I think that the work of the car that one day paid for the cost of its establishment.

I think that a good idea of the benefit of our first-aid system can be obtained from the fact that with the four hundred or five hundred accidents which we have each year (including those from the mines), we have not had a damage suit for the five years that I have been connected with the road and I don't know for how long before that.

Of course a number of cases have been settled, but these have been where the company was clearly liable and glad to help as a simple matter of equity to aid an injured employee. Even these sums, I think, are much less than would have been required if we did nothing for the men but simply left them to shift for themselves from the time of accident to that of return to work.

It must be remembered that the requirements of first-aid equipment vary very much with the special character of the road. What is necessary in a Western road which runs for very long distances through plains or thinly-settled regions is very different from what is needed in an Eastern road with high intensity of traffic running through frequent large cities with well-equipped general hospitals. While any surgeon may know just what his own road needs, it is idle for him to speak of the needs of a road which he has never seen.

I feel quite sure that railroad managers all over the country are anxious to provide the equipment which their respective roads need. These needs can best be determined by the surgeons connected with the road. I think that besides the National or State Meetings of Railroad Surgeons the surgeons of each road should meet at least once a year to keep their organization active and intact, to discuss professional papers on accident work, and especially to make suggestions to the managers as to the real needs of equipment for first aid.

If this were a meeting of such surgeons, I would especially urge them to ask for nothing but that which is simple, practicable and sure to be of use. Nothing can do more harm to the advance of first-aid work than for surgeons to ask managers for elaborate and expensive outfits which are never used. A manager who has been led to provide equipment which he