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ANNOTATIONS

AN EXPERIMENT IN PUBLIC HEALTH

ORGANISATION.

IN 1922 the Milbank Memorial Fund selected

Cattaraugus county in New York State as a repre-sentative rural area to take part in a demonstrationof the effect of concerted measures for the improve-ment of the public health. Accordingly they supple-mented with a liberal hand the funds provided bythe State and county administrations, and the newprogramme was launched in 1923. Since then acomprehensive public health organisation has beendeveloped in the county, and it has been thoughtdesirable to make an attempt to ascertain whetherit has justified itself. To this end the technicalboard of the Fund asked Prof. Winslow to undertakea survey of the scheme and to comment on its results.He has now published his report,! in the preparationof which he has had the help of a band of colla-borators. Cattaraugus county has an area of approxi-mately 860,000 acres (about the size of Wiltshire),and a population of 72,649 persons (roughly thepopulation of Westmorland). The scheme elaboratedby the joint efforts of the Fund, the State and thecounty comprises those provisions which are regarded

. on both sides of the Atlantic as essential to a com-plete public health service-viz., sanitary super-vision and surveillance of food traders, control ofacute communicable disease, care of mothers andchildren, inspection and treatment of school-children,domiciliary and institutional care of the tuber-culous, prevention and treatment of venereal diseases,laboratory service, clinics for mental disease anddefect, clinics and beds for cripples, nursing in thehome, and public education in matters pertaining tohealth. For these purposes, staff and premises had tobe obtained, voluntary bodies had to be utilised andencouraged to extend their activities and the coöpera-tion of the private practitioner had to be sought.Some idea of the scope of the activities of the schememay be gathered from the financial outlay, whichreached in 1929$160,000, equivalent to$2.20 perhead of the population, or roughly (with sterling atpar) 8s. 6d., which is rather more than many largeprogressive towns in this country expend on thecorresponding services.

In trying to estimate the gain to the communityof. this intensive public health effort, Prof. Winslowadmits at the outset that the period of the experi-ment is too short to provide a high standard ofreliability, and that the difficulty is intensified bythe absence of accurate controls for the comparisonof social trends. The statistical department of theMilbank Fund, however, have made a careful studyof death-rates in the county before and since theinception of the scheme, more especially from diph-theria, tuberculosis, and those causes in infancywhich are not congenital, and have arrived at theconclusion that there has been a significant decline,as compared with the rates in reasonably similarareas. They estimate that during the period of thedemonstration there has been a’ yearly saving of14 lives from tuberculosis, 20 from diseases of infancy,and four from diphtheria, a total of 38. Taking thevalue of a young adult life as$12,000 and of aninfant’s as$5000, Prof. Winslow computes the finan-cial gain from this saving of life alone, apart from the

1 Health on the Farm and in the Village. By C. E. A.Winslow, D.P.H., Professor of Public Health, Yale School ofMedicine. London : Macmillan and Co. Ltd. 1931. Pp. 281. 5s.

many other advantages in the way of improvedhealth in the community, at$300,000 per annum,or nearly twice the cost of the programme. In viewof the problem of unemployment, in America as inthis country, the validity of this monetary way ofmeasuring a life’s worth is open to question ; thebenefit to the community of saving lives and avoidingdisease can hardly be calculated mathematically.

In this country there has been much greateruniformity of public health progress than over thewater, and it is correspondingly more difficult todecide how much of our improvement in health isdue to ad hoc administrative effort. The carefullystudied experiences of Cattaraugus county are there-fore of great interest, and Prof. Winslow’s eon-

clusions ought to hearten our sanitary authoritiesand their officers. It will possibly comfort the olderschool of British sanitarians to read in an Americanpublication that " experience in Cattaraugus countyhas shown that sanitation cannot wisely be mini-mised in a county health programme." It is dis-appointing to learn that those responsible for adminis.tering the new services were not entirely successfulin gaining the confidence and cooperation of theorganised medical profession in the county.

MENTAL TESTS: THEIR USE AND ABUSE.

IN a short article in Mental Welfare, the quarterlyorgan of the Central Association for Mental Welfare,Dr. A. Carleton Williams, one of the divisional medicalofficers of London County Council, makes a usefulcontribution to the literature of mental tests.

Defending their use against the criticisms of someauthorities, he claims for such tests in the diagnosisof mental defect a value analogous to that of thestethoscope in chest diseases. It is true of coursethat social inefficiency is the ultimate criterion ofmental defect, and that it is best evidenced in whatis called behaviour or conduct ; but the examiner

only too often has to rely on others for his knowledgeof that behaviour, he can make no first-hand observa-tions of it. Moreover, in certifying he has to recordfacts " observed by himself," and it is here that a

comprehensive scale of tests gives the examinerample material to judge the examinee’s powers ofperception, memory, and reasoning, not merely byactual results but by the quality and manner ofresponse. Even the much despised mental ratio hasits value, as it gives a certain exactness to the

diagnosis which the mere words " imbecile " or" feeble-minded " fail to convey. To diagnose mentalor even moral defect on the mere occurrence ofimmoral behaviour is, as Dr. Williams suggests, torun the risk of gross error. He discusses certainobserved differences, qualitative rather than quanti.tative, in the types of response of defectives as

compared with normals. Those that he quotesillustrate chiefly the purely mechanical or rote-likementality of the defective, and his relative incapacityto rearrange or apply or reason about such parrotknowledge as he acquires. Dr. Williams stresses thespecial value of tests involving reasoning and thoseof a non-verbal character, and very properly insistson the special care necessary in cases where testsreveal a relatively good general intelligence butconduct is unbalanced and uncontrolled. Such casesare the bugbear of even the experienced examiner,but even here, carefully selected tests may prove

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illuminating. In conclusion, Dr. Williams empha-sises the necessity for careful judgment in the useof tests, and careful interpretation of the responsesbased upon medical and psychological knowledge.The article is full of points of interest to all mentaltesters but it might with advantage have been

amplified by the inclusion of more concrete detail.

PROPHYLACTIC PLASMOQUINE ON A TEAESTATE.

Lt.-Col. W. W. Clemesha and Dr. J. H. Moore,after collaborating for six years in anti-malariameasures on the Travancore Tea Companies’ estates,have reported 1 - what they believe to be the first

attempt to use plasmoquine for the eradication ofmalaria from a community. Travancore is a pros-perous Native state on the Malabar shore of Indiabetween the latitudes 7°-9° N. and includes a rangeof hills known as the Western Ghauts rising to aheight of 6000 ft. or so, on the slopes of whichtea is grown between the 2400-4000 ft. contours.Between are ravines and mountain valleys which areinclined to be malarious. The period of maximumanopheline activity and of malarial infectivity beginsabout the middle of March and lasts until June whenthe rains break. Measures were concentrated on

the extremely unhealthy Periyar Valley, 250.0 ft.above sea-level, where the writers were fortunate

enough to have as control two native estates on whichno antilarval measures had ever been carried out.The investigation began in May, 1925, when theoutput of work was frequently as low as 25 per cent.for weeks together, and the cases were all of malig-nant tertian. Arrangements were made for a vigorouscampaign in the malaria season of 1926. Thesemeasures were on the following lines. If it were possibleto cure all gametocyte carriers in any communitymalaria would disappear, it being immaterial howmany anophelines there were. Manifestly the onlycorrect method of stopping reinfections is to procurethe maximum reduction in the number of anophelinesand the maximum reduction in the number of

gametocyte carriers. If conditions are favourablefor an 80-90 per cent. reduction in the number of

gametocyte carriers and a 66-75 per cent. reductionin the number of dangerous anophelines, there shouldbe few reinfections of malaria. In pre-plasmoquinedays the reduction in the number of gametocytecarriers was very difficulty ; now it is comparativelyeasy. The Oriental, particularly the Tamil cooly,is much more susceptible to drugs than is the

European, but plasmoquine compound is harmless

compared with pure plasmoquine. In every patientwho sickened with malaria the following procedurewas adopted :-

Stage .—Whilst the patient is febrile, either cinchonafebrifuge tablets or Major Sinton’s alkaline quinine treatmentwas given, in addition to one tablet of plasmoquine, a totalfor the week of grs. 105 of cinchona febrifuge plus 0-07 g.plasmoquine.

Stage 2.-Two tonic pills a day for one week.Stage 3.-The first week’s treatment is repeated making a

total amount of grs. 210 of febrifuge and 0-14 g. plasmoquine.This constitutes a three weeks’ anti-gametocyte treatment,

which not only achieves its main object, but also preventsrelapses. For children who are quartan gametocyte carrierssmall doses of pure plasmoquine are added to the euquinine.and milk treatment on two days a week.

Col. Clemesha and Dr. Moore consider that with Ithese two weapons-namely, the anti-gametocyte I,

1 Reprint from Indian Medical Gazette, 1930, lxv., 671.

after-treatment for adults, and the euquinine andmilk treatment for children-it has become possibleto make an onslaught on gametocyte carriers up to95 per cent. of success. This they have proved bytaking blood slides at various periods, a malarial

register being kept on the estate with a record ofthick films stained by Giemsa. On examination of95 coolies known to have suffered from malarialrelapses, 45 per cent. had no parasites in their blood,in 20 per cent. the blood corpuscles showed signs ofbasophilic stippling, and in 35 per cent. parasites werefound, benign tertian predominating. The resultsof the pre-plasmoquine period have been comparedwith the plasmoquine period. In the autumn of1928, 73 per cent. of slides were positive and 51 ofthese contained gametocytes. In the periodNovember, 1929, to June, 1930, of the 120 slidesexamined in the non-malarial season, 7 per cent.

only were positive and there were no gametocytes ;whilst in the malaria season during the same periodout of 116 slides 56 per cent. were positive and 3 percent. contained gametocytes. The writers consider thatthese figures go to show : (1) the efficacy of plasmo-quine compound in removing gametocytes from theblood and in preventing relapses, and (2) the influenceof this gametocyte removal upon the incidenceof disease. For during the malaria season of 1930,malaria practically ceased to exist and regularprophylactic dosing of children was discontinued.

SPASM OF THE GASTRO-INTESTINAL TRACT

Dr. A. J. Beams has made a series of observationson the action of certain antispasmodic drugs on themotility of the human stomach and intestine. 1

In 95 per cent. of 200 subjects examined, X raysshowed cessation of peristalsis and diminution oftone after administration of nitrites. A similar effectwas seen in dogs, in which the isolated segments ofgut were found to be depressed through a directaction upon the intestine itself. The effect of anti-spasmodic drugs was then tested upon certain spasticconditions of the alimentary tract such as cardio-spasm, pyloric spasm, and colon spasm. Eighty-threepatients in all were examined. The drug to be triedwas administered during the radiographic examinationand the results were compared. Of five patientssuffering from cardiospasm, only two showed anyrelaxation with either atropine or nitrites. In pyloricspasm, atropine and nitrites were about equallyeffective, though about half the cases failed to respondto either drug. In colon spasm the nitrites provedtheir superiority, for of 30 patients treated withsodium nitrite 22 showed a relaxation of spasm ;whereas of 24 treated with belladonna, only 13 gavean appreciable response. Thus these results indicatethat nitrites have a greater antispasmodic influenceover the colon than over the cardia or the pylorus.Beams goes on to suggest that the use of amyl andsodium nitrite may prove of diagnostic as well as

therapeutic value, since they may be employed indifferentiating pain due to muscle spasm from paindue to inflammatory processes with peritonealirritation, and in distinguishing between organicand functional deformities. In treatment his resultslead him to conclude that for cardiospasm and pyloricspasm belladonna is much more valuable than sodiumnitrite, whereas in colon spasm the latter gives betterresults. A large proportion of his patients sufferingfrom this condition were relieved by sodium nitrite

1 Jour. Amer. Med. Assoc., Sept. 26th, p. 907.