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THE SCHOOL CLINIC AND THE LONDONCOUNTY COUNCIL.

(FROM A SPECIAL CORRESPONDENT.)

THE debate at the London County Council on Nov. lstconcerning the medical inspection of school children and theletter of the Board of Education thereon turned very largelyupon the question of treatment. The article on the medical

inspection of London school children published in THE LANCETlast week mentioned that the Council appeared ready to reviseits present system of medical inspection and treatment, and thisis certainly so. The necessity of the school clinic was touchedupon by every speaker on the Progressive side, while from theModerate side only Mr. Cohen and Mr. Cyril Jackson essayedto speak in favour of the hospital system of treatment. Mr.Cohen buttressed his defence of the Council’s method bycalling in evidence generalities about the charitable motivesand good emergency work of the hospitals, but the relevancyof his remarks was somewhat vitiated by the fact that itwas not the hospitals, but the Council’s arrangements withthem, which formed the subject of criticism.The defence of Mr. Cyril Jackson, chairman of the Educa-

tion Committee, was remarkable for its moderate tone. Mr.Jackson did not endeavour to deny that mistakes hadoccurred in the working of the hospital treatment scheme,but suggested that similar mistakes would have been inevit-able even had a system of school clinics been established.And the further interesting suggestion was made, in theform one could not help thinking of a broad hint, that whenthe 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 excludesuch important institutions as St. Thomas’s, Guy’s, St.Bartholomew’s, Westminster, and University College.Quite apart, therefore, from the question of whether hos-

pital treatment is suitable for school children as such,the County Council’s arrangements were almost inevitablybound 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 theCouncil have been sent miles away to another hospital fortreatment under the scheme. Then some parents who havetaken their children to a hospital directly after a medicalinspector had indicated to them defects which requiredremedy, have been given an emergency treatment and told toapply to the head teacher of the school for a London CountyCouncil voucher entitling to further treatment. But thehead teacher is not supplied with these vouchers, which areonly issued after a delay of some weeks by the EducationOffice. The delay has the purpose of allowing the parent toprovide treatment by his own endeavours, but in the casescited it has the practical effect of considerably delayingtreatment, frequently of rendering the emergency treatmentfutile, and of exasperating the parents and teachers alike.The question of payment further complicates matters.

The parent of every child treated at a hospital underthe London County Council scheme must be assessedto 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 presentedwith a bill for treatment at a hospital at which hischildren formerly attended free, and at which theystill attend free if under ur above school age. And theparent is asked to pay notwithstanding any contribution hemay have made to the hospital through his club, place ofbusiness, or personally, and despite any gift which he maymake to the contribution boxes while actually attending thehospital.Miss Adler, in a well-balanced speech, made this in-

justice clear and suggested further that the fee charged toparents was too high, and, in the case of a parent with severalchildren needing treatment, more than a weekly wage-earnercould be expected to pay without serious hardship. Anotherof the points made in the discussion was that some at least ofthe defects and diseases discovered by inspection are not suchas the hospitals can conveniently tackle. The treatment of

discharging ears, needing constant syringing twice or

thrice a day by a nurse, is not a treatment for which

the hospitals have either time or staff, while thetreatment of discharging ears at home is admittedly liable-to irregular intermissions, disregard of aseptic precautions¢and lack of efficiency generally. Then there is the questionof the operation for removal of tonsils and adenoids. This

operation is rarely performed by the general practitioner onany but the wealthier among his patients, whereas the hos-pitals have more of this particular work than they can con-veniently manage. In consequence there arise from time totime, cases where the children, after operation, have to be senthome 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 con-siderations apply to dental treatment, ringworm and otherskin 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 medicalofficer, but which, by comparison with the more

acute and severe affections, do not, from the hospitalpoint of view, warrant detailed and continuous treat-ment. A further corsideration arises when the ques-tion of continuity of treatment in general is considered.There is, to begin with, no method of correlation of the-

hospital 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 towhat special school conditions. Nor does the school medicalofficer know in what way his diagnosis is being followed up bytreatment.

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 to-continue regular attendance at the hospital with his childuntil the child is discharged cured. No organisation butthat of a school clinic where the medical information

gathered in school will be at the disposal of the physicianor surgeon of the clinic, and where the attendance of thechild can, if necessary, be compelled by use of the schoolauthority, can get over these difficulties. This is par-ticularly obvious when we examine the cases of the childrenof destitute or demoralised slum-dwellers who presenta large proportion of defects. Among this class of case

regularity of attendance at a hospital is a great rarity, evenin severe cases. The parents will not, or often cannot, affordthe time necessary to attend an ordinary out-patient depart-ment. For this reason children have been found in theschools suffering from tuberculous disease of the hip, withdischarging sinuses, severe middle-ear disease, extensive (ifunder the clothing) skin disease, phthisis, and heart disease-Under existing conditions the children of this demoralisedslum class do not and cannot get adequately treated, howevergreat the efforts of individual hospitals and individual sur-geons and physicians.The debate at the London County Council on Tuesday

made it abundantly clear that the treatment of the mass ofdefects and diseases discovered by medical inspection mustbe the work of a school clinic. Mr. Hobson, in additionto his carefully critical speech on the inspection question,Mr. Frank Smith, and every other speaker on the Pro-gressive side, emphasised this point of view.

In connexion with any system of school clinics organisedin London the hospitals must necessarily play a large part.There will be, in the first place, those cases discovered atschool, which are too acute, or too severe, or require toospecialised a treatment to be dealt with at the clinic. Therewill also be those cases where the parents of the child preferto make their own arrangements with a hospital. Again,some of the special hospitals and special departments ofhospitals could be arranged with so that what, in fact,would be clinics for school children within the walls of thehospital building could be organised. This applies torefraction, dental, nose, throat and ear, and chest cases.Where a special hospital or department exists in a districtconveniently situate as regards surrounding schools, thereseems every reason to think that suitable special arrange-ments 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 thehospitals, while more effectually treating the diseases foundin school children. The effect on the private practitioner

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would be in any case slight, as the organisation sug-gested amounts only to a redistribution for treatment pur-poses of the hospital population. It is even probable that inthe redistribution the private practitioner would gain morethan he would lose, while the school clinic would be a localorganisation of service to him in cases requiring more con-tinuous treatment than he could give, as in cases of dis-

charging ears or minor surgical operations which it is

impossible to undertake in poor homes and which now go tohospital.

THE MOTOR EXHIBITION AT OLYMPIA,LONDON.

BY C. T. W. HIRSCH, M.R,C.S. ENG., L.R.C.P. LOND.

(Concluded from p. 1364.)

THE Ninth International Motor Exhibition is one of thefinest representations of cars and accessories that have beenheld ; but from the reporter’s point of view it does not comeup to the exhibition of 1908, in so far as that there is no

striking new "copy-producing" " feature such as the bombwhich the Silent Knight engine then exploded on the public.Still, the show is certainly a worthy successor of the excellentones that have preceded it. Buying a motor mount is, ofcourse, 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 thecase with a car, and it is therefore an advantage for intend-ing purchasers to visit the exhibition, where they can see themany types of vehicle fitted for professional use, and con-sider the difficult question of which one is most suited fortheir individual needs. And yet, though I advise would-bebuyers to go there to choose a car, I rather pity the laymanwho attempts to do so, because so many makers are repre-sented by sueb good agents, and so many cars are so excellent,and are said to be so suitable for doctors, that the selectionmust indeed be a difficult matter. The one point above allothers that should, I venture to submit, be kept in view bythose who belong to what is known as ’’ the motorists ofmoderate means class," is that the expenses of motoring arelargely dependent on the load that is carried, and that thereis much in favour of the light two-seater with hood and frontwind-screen, at any rate for the doctor who is his ownchauffeur. As to the number of cylinders, the tendency isin 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-cylindercomes up to the requirements of most people, and a goodmany, I think, might with advantage, anyway in their earlymotoring days, be content with a single "lunger " like theDe Dion, Rover, Swift, or Cadillac, though, of course, theydo suffer in the matter of engine vibration on comparisonwith a four-cylinder.Mr. Lloyd George has done good to motoring and

motorists. His taxes on horse-power based on the bore anddiscarding the stroke are responsible for the number ofsmaller powered cars and the diminution in bore, coupledwith increase in the length of the stroke. The popular sizeis undoubtedly 80 mm. bore by 120 mm. stroke, which comesfor doctors within the E2 2s. 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 thecylinders 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 beof rare occurrence that pre-ignition will make a cleaningof the engine essential. Carbon deposits, too, are said to beremoveable by the use of a chemical decarboniser, but opinionsare divided as to its advisability. On another occasion I

hope to be able to give the results of my own experience ofthis compound.A large number of makers are using the Silent Knight

slide-valve engine. The Daimler and Minerva companiesstarted it, and now the Rover, Panhard, and Mercedes-Daimler are all building this type. Of course, when anyengine is run hard, fast, and under load, it is not absolutely

noiseless and without vibration, and probably the newerform may claim an advantage in these respects. Anyway, atpresent the poppet valves can be more easily repaired andadjusted than the slide valve, which seems an importantpoint 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 overheadcam-shaft, and other valves are operated by overhead rockersand by the usual crank case contained eccentric shaft. I do not

quite see the advantage of the overhead valves, when theyare lifted through rocking pieces that need long rods workingin guides to reach the lifting cams in the crank case. How-

ever, as long as the moving parts are hardened it will be a

long time before they wear enough to alter the lift of thevalves, and if all the valves are on one side this method

permits of larger valves being fitted, and the larger thevalves the greater amount of charge, and thus an increase inpower. To help to reduce noise the lift of the valves isreduced and the area increased, and that is why on someengines the inlets are on one side and the exhaust on theother, 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 andAustin.The general tendency seems to be in favour of high tension

magneto ignition, and this is now so satisfactory that manyof the smaller cars rely solely on this method of explodingthe mixture. Personally, however excellent it is, I prefer theknowledge that a second method is ready at hand, and thevarious forms of dual ignition shown by Messrs. Bosch, theSimms Co., and Messrs. Hall are all good, and medical menordering cars could easily have one of them fitted in lieu ofthe single method or, what is as good, an already timed sparemagneto can be carried. If this is decided on it is as wellto see that the magneto is easily removable, and those held inposition by a band are the best. On most cars it will benoticed 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 thisportion of the car’s anatomy need not be anticipated. On

many of the smaller cars thermo-syphon cooling is foundsufficient. One good feature in the show is that on most carsthe water-circulating pipes are of good size and on nearly allthe radiator is helped by a circulating fan.

Lubrication is now in many cases maintained by somesimple and out-of-sight form of pump which keeps a constantlevel of oil in the troughs under each big end. In some cases,as on the Daimler, the height of the oil in these troughs isvaried with the speed of the engine, the throttle being con-nected, so that as it is opened they become deeper and, asclosed, shallower.

Simplicity coupled with efficiency in carburetters seems therule, and there are some excellent multiple jet arrangements.But still the single jet gives such good results that, generallyspeaking, 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 smallengine 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, Iprefer the latter, providing that some simple method toensure slow engagement is fitted. Of course, accuracy of

workmanship has more to do with the satisfactory working ofa clutch than its form, and most cars by good makers haveclutches that are excellent, whether they be multiple disc,leather cone, or expanding. The Metallurgique clutch is agood example of an internal expanding type, and on theMors will be noticed an external form similar to the ordinaryexternal band brake. The Austin fit a neat kind of ’leathercone, in which the leather is put on in segments, and on theDarracq too the cone is split radially at intervals round itsedge, which also assists gradual engagement, and thusobviates fierceness.

Ball-bearings are universal for every part except thecrank, and some makers, such as the Napier and Darracq,employ them also for the crank. The Hoffman, "F. and S.," and the Timken seem the favourite kind, and all are

certainly of very superior make and likely to give satisfaction