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of 7.3 and a spleen index of 7.9. This is a, ratio of parasite to spleen index of 1 to 1.08. The writer found a parasite index for the county of 5.4 and a spleen index of 5.9, or a ratio of 1 to 1.09.

Barber and Coogle (2), working in Mitchell County, Ga., during January, February, and i rch, 1921, report a spleen index of 2.0 per cent among the white boys of the county. This is low, but it followed a summer and fall of intensive quinine medication. In two schools they found a spleen rate of 4.9 among the boys and a parasite rate of 4.7 among the boys and girls combined. This is a ratio of 1 to 1.04. The number so examined was small and not entirely the same group; yet the figures are indicative of what might be expected.

Table IV.—Percentage of positive blood smears and of enlarged spleens in children of the present study, according to age distribution.

[graphic][table]

Table IV shows the age distribution of the children in the present study with positive blood smears or palpable spleens. In this group age seems to have no effect on the frequency of either condition. This is not in .agreement with the findings of Stephens and Christophers (3), who found that in children under 2 years of age the parasite rate is considerably above the spleen rate. With the increase in age, the ratio of the two indices gradually reverses until, after the age of 10, the spleen rate is much higher than the parasite rate. These figures are based on data obtained in India, where cinchonization is probably not very widespread. It may be said that the enlarged spleen of chronic malaria is to a certain extent the accumulative result of one or many infections. Its development and disappearance is gradual. In Dunklin County, Mo., we are dealing with a population which is partially cinchonized from time to time. This certainly has the effect of distorting the age distribution curve as compared with a population not so treated.

In estimating the amount of malaria in a community from either the parasite or the spleen index, it is important to know something of the antinialaria medication in the community, whether the medicine taken is "chill tonic" or quinine, and if the latter how near it comes to being standard treatment.

Table V.

-Prevalence of antimalaria medication among children vtiih positive malaria histories.

[table]

Of 313 children having a positive malaria history within two years who were questioned regarding the taking of medicine, 296, or 94.6 per cent, stated that they took either quinine or "chill tonic" or both. About one-half of this group took quinine, but none in quantities even approaching standard treatment quantities. At the Beech Corner school over 85 per cent of the children gave a history of having taken quinine in some form during the previous year, regardless of any chills during that time. In other words, quinine medication in some form is nearly universal in the heavily infected sections of Dunklin County, Mo.

Table VI.—Hemoglobin readings (Tull'/uist) on 751) school children in Dunklin

County, Mo.

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The hemoglobin count (Table VI) is presented merely as offering more evidence of the destructive effect of malaria on the blood hemoglobin. The lowest percentage of hemoglobin found in the children examined was 35 per cent (Tallquist). Most of the positive cases gave a reading between 60 and 70 per cent. The possible presence of intestinal parasites was not ruled out by microscopic examination; it may be stated, however, that some of the most anemic children were given quinine, and their hemoglobin promptly increased.

DISCUSSION.

It is not necessary here to go into all the causes of splenic enlargement or the frequency with which it occurs. Reference is made to the Public Health Reports (4), where will be found a good abstract of the literature dealing with this subject. In children of grammarschool age infected with malaria, splenic enlargement occurs at some time in practically 100 per cent of the untreated cases. There is no other disease causing splenic enlargement sufficiently prevalent in the United States to give an appreciable percentage of enlarged spleens among the school children. Other causes for splenomegaly have been variously reported as less than 1 per cent for this country and for England (5). It is safe to say that a marked increase over this 1 per cent in a community where malaria is known to be endemic will be due to that disease.

It must be remembered that the present study was made on a school population which is more or less cinchonized. These children have been taught that quinine is a " cure all." The amount of quinine taken, however, was usually small. Quinine medication influences the parasite index; small quantities are oftentimes sufficient to render the peripheral blood parasite free. Complete sterilization causes the enlarged spleen to return to normal size. Apparently relatively small doses of quinine taken at irregular intervals during the course of an infection will prevent the spleen from becoming palpable in many cases. As an illustration, three boys at the Beech Corner school were found to have definitely enlarged, hard, and nontender spleens and positive blood smears, both in 1921 and 1923. After one month of small, irregular doses of quinine their spleens had so reduced as to be scarcely palpable. In two acute cases the enlarged spleen disappeared after a few doses of standard treatment.

SUMMARY.

Data relative to the percentage of enlarged spleens and positive bloods were collected from a portion of the school children in Dunklin County, Mo., by independent investigators, working at the same time of the year but in different years. A summary of these two investigations reveals that the spleen and parasite indices at each investigation closely approximate. Also that the parasite-spleen ratio was essentially the same in the two studies. From this we may conclude that in this particular community, at least, the two indices have the same value in measuring malaria prevalence. The ease and rapidity of application of the spleen method are much in its favor.

REFERENCES.

(1) K. F. Maxcy and C. P. Coogle: Methods for Determining Malaria Prevalence: The Spleen Rate of School Boys. Southern Med. Jour. 16:4, April. 1923.

i.2) M. A. Barber and C. P. Coogle: Spleen Examinations of School Boys in Mitchell County, Ga. Public Health Reports, 36, 14, April 8, 1921. Reprint No. 653.

(3) Stephens and Christophers: Practical Study of Malaria. Liverpool, University

Press. 1908, p. 211.

(4) Public Health Reports, April 22, 1921, pp. 884-888. Reprint No. 653.

(5) Ross, Christophers, and Perry. Ind. J. M. Res., i:385, 1914.

THE EAST HARLEM HEALTH CENTER DEMONSTRATION.

Successful Coordination of the Health Activities of 22 Organizations in a Large City.

An increase of 81 per cent in the services of health agencies to 112,000 people, with an increase of but 9 per cent in cost, is the record announced by the East Harlem Health Center, which is experimenting in the coordination of health work by bringing together for cooperative effort 22 health and social agencies. This announcement is made at the end of the first half of the experimental period of three years, for which time the New York Chapter of the American Red Cross, sponsor for the demonstration, has guaranteed its existence by providing $168,000.

These agencies have been housed in one building, and, headed by the New York City Department of Health (which maintains the largest group of services), include the following:

Health agencies.—The American Red Cross, the American Social Hygiene Association, the Association for the Prevention and Relief of Heart Disease, the New York Committee on Dispensary Development, the Jefferson Auxiliary, the New York Tuberculosis Association, and the New York State Charities Aid Association.

Nursing organizations.—The Association for the Aid of Crippled Children, the Henry Street Visiting Nurse Service, the Maternity Center Association, the New York Diet Kitchen Association, and the East Harlem Nursing and Health Demonstration.

Family welfare.—The Association for Improving the Condition of the Poor, the Catholic Charities, the Charity Organization Society, and the United Hebrew Charities.

The work has been carried on by a council of representatives from each of the cooperating agencies and a selected group of neighborhood leaders.

The district included is bounded by the Harlem River, Ninetyninth Street, the East River, and Third Avenue, covers 87 city blocks, and has a population of 112,000 people.

Among the outstanding accomplishments of this demonstration are (1) successful practical coordination, (2) greatly increased efficiency with only slight increase in cost, (3) enlistment of interest of the people, (4) intensive demonstrations, and (5) highly successful follow-up in school health work.

In regard to practical coordination it is stated that the 22 health and allied agencies worked together for the period under report with no important difficulties.

An increase in efficiency of 81 per cent in health service with less than 10 per cent additional cost is shown by a comparison with the records of all the cooperating agencies for the three-year period 51375°—23 2

immediately preceding the opening of the center. It is stated that the amount of this gain in efficiency is based on such tangible services as a nursing visit to a home, or a visit to a clinic, and that if educational work were included, such as the distribution of pamphlets or the attendance at meetings, a much larger gain would be shown.

It is believed by the officers of the center that so-called "health education" by means of exhibits and literature is not the most effective means of educating the people; and so the workers have gone out to the homes of the 20,000 families and have interested the members of these families through friendly visits, advice, and practical help.

As the health center could not give the full service needed by 112,000 people, because, as the report states, "this would take vastly more money than the public has yet learned to invest in its local health work," a demonstration is being conducted within the health center area in order to determine what might be considered adequate nursing and health service for a district of 40,000 people, what such sen-ice costs, and how the work can best be done. In order to do this the East Harlem Nursing and Health Demonstration has been established, combining four agencies. Intensive work is being carried on in two of the eight sanitary districts of the area. The annual budget is $65,000, half of which is contributed by the four cooperating organizations and half by the Rockefeller Foundation.

In school health work, the nurses of the center assist the school physicians in their physical examinations of the children; and during the summer, physical defects that have been discovered in the school children arc followed up for correction by the nurses.

The East Harlem Health Center has evidently demonstrated successful cooperation of health agencies and a readiness of the local community to enter into health work under the leadership of an active health center. The work of this center, in which all of the local health and allied agencies of a large city have come together and worked together in one building for the common welfare, should be a matter of keen interest to other health and welfare organizations and, more especially, to all of the larger cities of the country.

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