THE SCHOOL CLINIC AND THE LONDON COUNTY COUNCIL.

1437

the hospitals THE SCHOOL CLINIC AND THE LONDON COUNTY COUNCIL. (FROM A SPECIAL CORRESPONDENT.) THE debate at the London County Council on Nov. lst concerning the medical inspection of school children and the letter of the Board of Education thereon turned very largely upon the question of treatment. The article on the medical inspection of London school children published in THE LANCET last week mentioned that the Council appeared ready to revise its present system of medical inspection and treatment, and this is certainly so. The necessity of the school clinic was touched upon by every speaker on the Progressive side, while from the Moderate side only Mr. Cohen and Mr. Cyril Jackson essayed Mr. to speak in favour of the hospital system of treatment. Cohen buttressed his defence of the Council’s method by calling in evidence generalities about the charitable motives and good emergency work of the hospitals, but the relevancy of his remarks was somewhat vitiated by the fact that it was not the hospitals, but the Council’s arrangements with them, which formed the subject of criticism. The defence of Mr. Cyril Jackson, chairman of the Education Committee, was remarkable for its moderate tone. Mr. Jackson did not endeavour to deny that mistakes had occurred in the working of the hospital treatment scheme, but suggested that similar mistakes would have been inevitable even had a system of school clinics been established. And the further interesting suggestion was made, in the form one could not help thinking of a broad hint, that when the present hospital arrangements come to an end this year, the whole matter will come up for reconsideration. The arrangements made by the London County Council embrace, among others, Charing Cross, Great Ormond-street, the London, and King’s College hospitals, but exclude such important institutions as St. Thomas’s, Guy’s, St. Bartholomew’s, Westminster, and University College. Quite apart, therefore, from the question of whether hospital treatment is suitable for school children as such, the County Council’s arrangements were almost inevitably bound to be subject to serious faults in working. For instance, children living practically under the walls of a hospital with which no arrangements have been made by the Council have been sent miles away to another hospital for treatment under the scheme. Then some parents who have taken their children to a hospital directly after a medical inspector had indicated to them defects which required remedy, have been given an emergency treatment and told to apply to the head teacher of the school for a London County Council voucher entitling to further treatment. But the head teacher is not supplied with these vouchers, which are only issued after a delay of some weeks by the Education Office. The delay has the purpose of allowing the parent to provide treatment by his own endeavours, but in the cases cited it has the practical effect of considerably delaying treatment, frequently of rendering the emergency treatment futile, and of exasperating the parents and teachers alike. The question of payment further complicates matters. The parent of every child treated at a hospital under the London County Council scheme must be assessed to pay for the cost of such treatment. So that after having been first delayed and subjected to waste of time and annoyance, the parent is secondly presented with a bill for treatment at a hospital at which his children formerly attended free, and at which they still attend free if under ur above school age. And the parent is asked to pay notwithstanding any contribution he may have made to the hospital through his club, place of business, or personally, and despite any gift which he may make to the contribution boxes while actually attending the

hospital. Miss

justice

Adler, in clear and

thrice

a

a well-balanced speech, made this insuggested further that the fee charged to parents was too high, and, in the case of a parent with several children needing treatment, more than a weekly wage-earner could be expected to pay without serious hardship. Another of the points made in the discussion was that some at least of the defects and diseases discovered by inspection are not such as the hospitals can conveniently tackle. The treatment of discharging ears, needing constant syringing twice or

day by

a

nurse, is not

a

treatment for which

have either time or staff, while the treatment of discharging ears at home is admittedly liableto irregular intermissions, disregard of aseptic precautions¢ and lack of efficiency generally. Then there is the question of the operation for removal of tonsils and adenoids. This operation is rarely performed by the general practitioner on any but the wealthier among his patients, whereas the hoshave more of this particular work than they can conveniently manage. In consequence there arise from time to time, cases where the children, after operation, have to be sent home by tramcar or omnibus in a condition, as Miss Adler said, unpleasant to themselves and to all who see them. Both of these groups of defects and diseases appear to call for treatment in special school clinics. Much the same considerations apply to dental treatment, ringworm and other skin diseases, and also to those slighter degrees of dulness, nervousness, anasmia, and digestive’ troubles which are serious from the point of the teacher and school medical officer, but which, by comparison with the more acute and severe affections, do not, from the hospital point of view, warrant detailed and continuous treatment. A further corsideration arises when the question of continuity of treatment in general is considered. There is, to begin with, no method of correlation of thehospital treatment and the school medical officer’s inspection. The hospital does not accurately know what has been diagnosed by the school medical officer, nor in relation to what special school conditions. Nor does the school medical officer know in what way his diagnosis is being followed up by treatment.

pitals

Although the London County Council pays the hospitals, and the parent may have to pay the London County Council, there exists no way in which the parent can be compelled tocontinue regular attendance at the hospital with his child until the child is discharged cured. No organisation but that of a school clinic where the medical information gathered in school will be at the disposal of the physician or surgeon of the clinic, and where the attendance of the child can, if necessary, be compelled by use of the school authority, can get over these difficulties. This is parobvious when we examine the cases of the children of destitute or demoralised slum-dwellers who present a large proportion of defects. Among this class of case regularity of attendance at a hospital is a great rarity, even in severe cases. The parents will not, or often cannot, afford the time necessary to attend an ordinary out-patient department. For this reason children have been found in the schools suffering from tuberculous disease of the hip, with discharging sinuses, severe middle-ear disease, extensive (if under the clothing) skin disease, phthisis, and heart diseaseUnder existing conditions the children of this demoralised slum class do not and cannot get adequately treated, however great the efforts of individual hospitals and individual surgeons and physicians. The debate at the London County Council on Tuesday made it abundantly clear that the treatment of the mass of defects and diseases discovered by medical inspection must be the work of a school clinic. Mr. Hobson, in addition to his carefully critical speech on the inspection question, Mr. Frank Smith, and every other speaker on the Progressive side, emphasised this point of view. In connexion with any system of school clinics organised ’, in London the hospitals must necessarily play a large part. There will be, in the first place, those cases discovered at school, which are too acute, or too severe, or require too specialised a treatment to be dealt with at the clinic. There will also be those cases where the parents of the child prefer to make their own arrangements with a hospital. Again, some of the special hospitals and special departments of hospitals could be arranged with so that what, in fact, would be clinics for school children within the walls of the hospital building could be organised. This applies to refraction, dental, nose, throat and ear, and chest cases. Where a special hospital or department exists in a district conveniently situate as regards surrounding schools, there seems every reason to think that suitable special arrangements could be made within the limits of the school clinic organisation, and as a part of that organisation. The effect of the setting up of school clinics would be materially to disembarrass the out-patient departments of the hospitals, while more effectually treating the diseases found in school children. The effect on the private practitioner

ticularly

1438 be in any case slight, as the organisation sugamounts only to a redistribution for treatment purposes of the hospital population. It is even probable that in would

gested

the redistribution the private practitioner would gain more than he would lose, while the school clinic would be a local organisation of service to him in cases requiring more continuous treatment than he could give, as in cases of discharging ears or minor surgical operations which it is impossible to undertake in poor homes and which now go to

hospital. THE MOTOR EXHIBITION AT LONDON. BY C. T. W.

OLYMPIA,

HIRSCH, M.R,C.S. ENG., L.R.C.P. (Concluded from p. 1364.)

LOND.

noiseless and without vibration, and probably the newer form may claim an advantage in these respects. Anyway, at present the poppet valves can be more easily repaired and adjusted than the slide valve, which seems an important point in favour of the former. Still, both are now so well made that breakdowns on either form are not likely to occur, and if they do-well, personally I should prefer the poppet engine. Some engines, like the Bentall, have overhead valves operated as on this type by an overhead cam-shaft, and other valves are operated by overhead rockers and by the usual crank case contained eccentric shaft. I do not quite see the advantage of the overhead valves, when they are lifted through rocking pieces that need long rods working in guides to reach the lifting cams in the crank case. However, as long as the moving parts are hardened it will be a long time before they wear enough to alter the lift of the valves, and if all the valves are on one side this method permits of larger valves being fitted, and the larger the valves the greater amount of charge, and thus an increase in power. To help to reduce noise the lift of the valves is reduced and the area increased, and that is why on some engines the inlets are on one side and the exhaust on the other, as with the White and Poppe and Austin engines. This, of course, means an extra cam-shaft. On many cars, too, to further deaden sound, the valve-lifting parts are covered in by easily detachable covers, as on the Napier and Austin. The general tendency seems to be in favour of high tension magneto ignition, and this is now so satisfactory that many of the smaller cars rely solely on this method of exploding the mixture. Personally, however excellent it is, I prefer the knowledge that a second method is ready at hand, and the various forms of dual ignition shown by Messrs. Bosch, the Simms Co., and Messrs. Hall are all good, and medical men ordering cars could easily have one of them fitted in lieu of the single method or, what is as good, an already timed spare magneto can be carried. If this is decided on it is as well to see that the magneto is easily removable, and those held in position by a band are the best. On most cars it will be noticed that they are thus fixed. Cooling is still on a good many cars assisted by a pump, but as this is now in all cases gear-driven trouble with this portion of the car’s anatomy need not be anticipated. On many of the smaller cars thermo-syphon cooling is found sufficient. One good feature in the show is that on most cars the water-circulating pipes are of good size and on nearly all the radiator is helped by a circulating fan. Lubrication is now in many cases maintained by some simple and out-of-sight form of pump which keeps a constant level of oil in the troughs under each big end. In some cases, as on the Daimler, the height of the oil in these troughs is varied with the speed of the engine, the throttle being connected, so that as it is opened they become deeper and, as closed, shallower. Simplicity coupled with efficiency in carburetters seems the rule, and there are some excellent multiple jet arrangements. But still the single jet gives such good results that, generally speaking, the multiple jet form seems a needless complication. The spring controlled extra air valves also seem popular, which I believe accounts for the ability of the modern small engine to pull so well at low engine speeds. Of clutches there are many, and the battle still rages between multiple disc and the leather cone. Personally, I prefer the latter, providing that some simple method to Of course, accuracy of ensure slow engagement is fitted. workmanship has more to do with the satisfactory working of a clutch than its form, and most cars by good makers have clutches that are excellent, whether they be multiple disc, leather cone, or expanding. The Metallurgique clutch is a good example of an internal expanding type, and on the Mors will be noticed an external form similar to the ordinary external band brake. The Austin fit a neat kind of ’leather cone, in which the leather is put on in segments, and on the Darracq too the cone is split radially at intervals round its edge, which also assists gradual engagement, and thus obviates fierceness.

THE Ninth International Motor Exhibition is one of the finest representations of cars and accessories that have been held ; but from the reporter’s point of view it does not come up to the exhibition of 1908, in so far as that there is no striking new "copy-producing"" feature such as the bomb which the Silent Knight engine then exploded on the public. Still, the show is certainly a worthy successor of the excellent ones that have preceded it. Buying a motor mount is, of course, not the same as the purchase of, say, a Gillette razor, for with the latter the blade, on account of its cheapness, can be thrown away when worn out. Such is not usually the case with a car, and it is therefore an advantage for intending purchasers to visit the exhibition, where they can see the many types of vehicle fitted for professional use, and consider the difficult question of which one is most suited for their individual needs. And yet, though I advise would-be buyers to go there to choose a car, I rather pity the layman who attempts to do so, because so many makers are represented by sueb good agents, and so many cars are so excellent, and are said to be so suitable for doctors, that the selection must indeed be a difficult matter. The one point above all others that should, I venture to submit, be kept in view by those who belong to what is known as ’’ the motorists of moderate means class," is that the expenses of motoring are largely dependent on the load that is carried, and that there is much in favour of the light two-seater with hood and front wind-screen, at any rate for the doctor who is his own chauffeur. As to the number of cylinders, the tendency is in favour of four. Of course, there are many six-cylinders : probably more than there were last year. But for power, fair silence, and simplicity and efficiency the four-cylinder comes up to the requirements of most people, and a good many, I think, might with advantage, anyway in their early motoring days, be content with a single "lunger" like the De Dion, Rover, Swift, or Cadillac, though, of course, they do suffer in the matter of engine vibration on comparison with a four-cylinder. Mr. Lloyd George has done good to motoring and motorists. His taxes on horse-power based on the bore and discarding the stroke are responsible for the number of smaller powered cars and the diminution in bore, coupled with increase in the length of the stroke. The popular size is undoubtedly 80 mm. bore by 120 mm. stroke, which comes for doctors within the E22s. tax. Such an engine, too, ’ gives all the power likely to be required, and, of course, is economical in the matter of petrol. A good many still cast their engines en bloo. Some makers, however, like the Darracq firm, have reverted to casting the cylinders in pairs. Except that this makes it easier to replace the engine covers, I do not think that it matters. If good oil is used for lubrication, and not too much, it will be of rare occurrence that pre-ignition will make a cleaning of the engine essential. Carbon deposits, too, are said to be removeable by the use of a chemical decarboniser, but opinions are divided as to its advisability. On another occasion I hope to be able to give the results of my own experience of this compound. A large number of makers are using the Silent Knight Ball-bearings are universal for every part except the The Daimler and Minerva companies crank, and some makers, such as the Napier and Darracq, slide-valve engine. started it, and now the Rover, Panhard, and Mercedes- employ them also for the crank. The "F. and S.," Daimler are all building this type. Of course, when any and the Timken seem the favourite kind, and all are engine is run hard, fast, and under load, it is not absolutely certainly of very superior make and likely to give satisfaction

Hoffman,