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1925. NEW ZEALAND.

MANDATED TERRITORY OF WESTERN SAMOA. ANNUAL REPORT OF THE DEPARTMENT OF HEALTH FOR THE YEAR ENDED 31st MARCH, 1925.

Presented to both Houses of the General Assembly by Command of His Excellency

CONTENTS. General Survey :— page Infectious Diseases . . . . . . . . . . . . . , . . 2 Ankylostomiasis .. . . . . . . . . .. .. . . 2 Yaws .. .. . . .. . . . . . . . . .. 3 Filariasis . . . . . . . . . . . . . . . . 3 Leprosy.. .. . . : . . .. . . .. .. 3 Quarantine .. . . . . .. . . . . . . . . 3 Food and Drugs .. .. .. .. . . .. .. . . 3 Native Sanitation . . . . . . . . . . . . . . 3 European Sanitation .. .. . . . . . . . . . 4 Child Welfare .. . . .. . . . . . . . . . . 4 Vital Statistics .. .. . . . . . . . . . . .. 4 Financial Statement .. . . . . .. . . . . .. 8 General Hospital and Dispensary Statistics .. .. . . . . . . 9 Laboratory Report .. . . .. . . . . . . .. 9 Apia Hospital :— Report of Resident Medical Officer .. . . .. . . . . . . 9 Apia Hospital Statistics .. .. . . . . . . . . . . 10 Appendix •— A. Meteorological Report .. .. . . . . . . . . 15 B. The Treatment of Yaws in Western Samoa . . . . . . . . 16 C. Leprosy in Western Samoa .. . . . . . . . . . . . 20 D. The Control of Mosquitoes in Apia . . .. . . .. .. 22 E. The Clayton Lane Technique used in the Field to control Hookworm Treatment .. 23 F. Health Survey of Western Samoa . . . . . . .. . . 25

REPORT. The Chief Medical Officer to His Excellency the Administrator of Western Samoa. I have the honour to submit the annual report of the Department of Health for the year ended 31st March, 1925. The policy pursued last year of submitting a more detailed report of the activities of the medical department, with the purpose of exchanging with other tropical countries, has been followed this year, and papers dealing with the control of yaws and ankylostomiasis, and the control of mosquitoes in Apia, have been included as appendices. As appendices will also be found a short summary of meteorological conditions ; a questionnaire on leprosy, issued by the British Empire Leprosy Relief Association ; and a Health Survey of Western Samoa, by Dr. S. M. Lambert, of the International Health Board (Rockefeller Foundation), who visited these islands in August, 1924. With the permission of the Government of Fiji, illustrations of the Makogai Leper Asylum, Fiji, have been inserted, to show the conditions under which the lepers sent there from Samoa live. T. Russell Ritchie, Chief Medical Officer.

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General Survey of the Work of the Year. The arrangement made at the beginning of 1923, whereby, at the request of the Natives, a yearly medical charge of £1 per adult male was imposed, and free treatment of all Natives instituted, has proved a marked success. The Natives recognize the value of the new system, and make full use of the opportunities for treatment available. In addition it has enabled the Administration to carry out systematic campaigns against yaws and hookworm, with satisfactory results. The training of boys and girls at the hospital for work in dispensaries and outlying districts las so far proved a success, but it is at times difficult to obtain suitable ones for training. This difficulty will probably grow less as the effects of the present educational system manifest themselves. By arrangement with the Education Department, classes for the Native cadets and nurses are held at the hospital in order to improve their education and so make them better fit to absorb their medical training.

Public Health. The previous year was marred by an epidemic of bacillary dysentery, but this year has been the most satisfactory one experienced for many years. The Territory was singularly free from serious illness or even minor epidemics. The figures given in the table of attendances at the hospitals and dispensaries throughout the Territory do not indicate any increase in sickness. The Natives freely avail themselves of the facilities offered for treatment, and report for very minor complaints. Infectious Diseases. The return given does not include all cases of infectious diseases occurring in the Territory, but only those which have been reported by European Medical Officers Enteric fever .. .. 28 Leprosy .. .. 5 Tuberculosis —pulmonary .. 42 Puerperal fever .. .. 2 Pneumonia—lobar .. 37 Chicken-pox . . .. 5 Pneumonia—broncho . . 29 Mumps .. . . 4 Measles .. .. .. 2 Tetanus .. .. 3 Dysentery .. 8 Gonorrhoea .. 8 Influenza .. . . ... 16 Erysipelas . . 1 Note. —Of the twenty-eight cases reported as enteric fever, in only eight was the diagnosis confirmed by bacteriological or serological investigation. Of the forty-two cases of pulmonary tuberculosis reported, the vast majority are cases diagnosed clinically. Ankylostomiasis.-—During 1923, as reported in last annual report, slightly over eighteen thousand Natives were treated for hookworm. Treatment was then discontinued, as the pressure on the Department for treatment of yaws made it impossible to carry out both campaigns with the staff

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available. During 1924 fresh supplies of drugs were purchased from the International Health Board (Rockefeller Foundation), and treatment was recommenced in November. During the remaining five months of the year 16,205 Natives were treated. The present method of treatment is described in Appendix F (Health Survey of Western Samoa). To test the efficacy of the treatment given, the investigation recorded in Appendix E (the Clayton-Lane Technique used in the Field to control Hookworm Treatment) was undertaken by one of the officers of the Research Expedition of the London School of Hygiene and Tropical Medicine. Yaws (Framboesia tropica). —In April, 1923, as a result of the Natives agreeing to a medical tax of £1 per adult male, free medical treatment was instituted, and steps were immediately taken to organize a systematic campaign against this disease. Although a considerable amount of work bad been done before that date, systematic work was impossible, as most of the Natives were not prepared to pay the charges made for treatment. This preliminary work was of value in disseminating amongst the population a knowledge of the (to them) miraculous results obtained from injections of novarsenobillon. It was found impossible to cover the whole Territory in the year, but in those districts attended to 32,366 injections were given. This year the whole area was covered, and 21,222 injections given. The figures are more instructive when given in a different way. The " first round " —that is, the treatment of the whole Territory for the first time —resulted in 36,304 injections being given, covering a period of fifteen months. The figure for the " second round " was 17,284. During the first round numbers of small children with primary and commencing secondary lesions were not offered for treatment, but during the year under review such children were offered much more freely. Such an impression was made on the Natives by the results of treatment that the Fono of Faipules, or Native advisory body, agreed to the introduction of stringent regulations for the control of this disease, and these regulations, of which a draft is given in Dr. Lambert's Report (Appendix F), have now been passed by Order in Council in New Zealand, and will be enforced during the coming year. In Appendix B will be found an article on the results of the campaign in one carefully recorded area. In another area, the most distant portion of Savai'i, with a population of 3,500, injections to the number of 5,716 were given in 1923. During 1924 only 1,515 injections were found necessary. Filariasis. —The Research Expedition of the London School of Hygiene and Tropical Medicine, under Dr. P. A. Buxton, continued its work during the year. In Appendix D of the report Dr. Buxton gives a note on Mosquito-control in Apia, illustrated with a few photographs. Leprosy. —During the year seven lepers were transferred from Samoa to the Leper Asylum on the Island of Makogai, in Fiji. These consisted of four Samoans, one half-caste French-Samoan, and two Chinese labourers, all males. Two lepers, both male Samoans, died at Makogai during the year. The number of lepers from Samoa under treatment at Makogai at the end of the year under review was : Samoans —5 males, 1 female ; half-castes —2 males, 1 female ; Chinese, 5 males ; Rarotongan, 1 male : total, 13 males, 2 females. In addition to the above, five lepers (one male and two female Samoans and two male Melanesians) are isolated in Western Samoa pending transfer to Fiji after the hurricane season has passed. Whilst awaiting transfer these lepers are under treatment. In Appendix C will be found a copy of the answers given to the questionnaire of January, 1924, sent out by the British Empire Leprosy Relief Association. These answers, together with information given in the annual Medical Report for the year ending 3lst March, 1924, give all the information available in respect of this disease in Western Samoa. Quarantine. During the year eighty-nine visits of inspection were made to vessels arriving from overseas, and in one instance, owing to the prevalence of infantile paralysis in New Zealand, and to the fact that the steamer was only eight days out from that country, quarantine was imposed. This is only the third occasion on which it has been found necessary to refuse pratique since January, 1921. Food and Drugs. The New Zealand Food and Drugs Act, with the regulations made thereunder, is in force in the Territory. During the year the following foodstuffs were condemned : Meat in kegs, 4,440 lb. ; canned meats, 2,629 lb. ; canned fish, 4,480 lb.; canned fruits, 80 lb. ; bacon and ham, 427 lb.; potatoes, 1,980 lb. ; butter, 56 lb. ; biscuits, 120 lb. Native Sanitation. Work on Native sanitation has been continued during the year, and there are now numbers of latrines in most of the villages. At present the pit privy is the chief type of latrine installed, but in the coast villages many drop latrines have been built out over the sea. These are at present rather unsightly structures, but are evidence of a distinct advance on the part of the Natives. Gradually these will be replaced by more permanent, less unsightly, buildings. Where water-supplies are being installed in Native villages it is hoped in time to introduce watercarriage systems. Native regulations will shortly be published bearing on buildings, latrines, rubbish-collection, water-supplies, keeping of animals, and gatherings in villages.

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European Sanitation. The following table shows the advance in European sanitation since 1922. The number of septic tanks in use prior to that year was 31. Number. Septic tanks installed since Ist January, 1922 .. .. .. 40 Houses in which drainage and other sanitary improvements have been installed .. .. .. .. .. .. .. 92 Feet of drainage laid .. .. .. .. .. .. 6,347 Water-closets connected with the forty septic tanks mentioned above .. 109 Sinks .. .. .. .. .. .. .. .. 90 Baths .. .. .. .. .. .. .. .. 25 Shower-baths (chiefly in Native villages in the vicinity of Apia) .. 331 Handbasins .. .. .. .. .. .. .. 31 Wash-tubs .. .. .. .. .. .. .. 13 Plumbing and drainage permits issued for the twelve months ending 31st March, 1925 .. .. .. .. .. .. .. 72 Water-supplies. See Report of the Public Works Department. Child Welfare. The returns given under " Vital Statistics " show clearly where the chief wastage of life occurs in "Samoa. This year's returns are the most satisfactory for many years, and yet the infant-mortality rate stands at 155 per thousand births. Although no definite statistical figures are available, it has been estimated that the infant-mortality rate for past years has been in the vicinity of 200 per thousand births. That child-welfare work was a necessary branch of medical activity in Western Samoa has been recognized since the Territory came under mandate, but systematic work of this nature -had to wait until other work had been accomplished. The two greatest causes of ill health in Samoa were hookworm and frambcesia. Practically every Samoan harboured hookworms, and every child, with very few exceptions, contracted frambcesia in the first two years of life. Mothers suffering from hookworm were in many cases unable to give their infants proper sustenance, and the best child-welfare work that could be carried out for young children was to treat them for frambo3sia. Work on these two diseases has been carried out during the last two years, and now that they are not such factors in producing ill health, the work of child welfare is being undertaken on systematic lines. Workcarried out voluntarily during the last six months by Dr. Roberts, the wife of the Yice-Consul for the United States of America, in a small district in the vicinity of Apia, has shown that much can be accomplished in the saving of child-life, but that the work will necessarily be slow. Even in more advanced communities such is the case. Vital Statistics (Samoan). The year under review has been an exceptionally satisfactory one. The number of live births (1,900) constitutes a record for Western Samoa, and the number of deaths (766), although not a record, is well below the average. The marked absence of serious sickness and even minor epidemics, the provision of dispensaries in outyling districts, and the campaigns against hookworm and yaws, are all factors in helping to bring about the present position. The reduction in the number of adults, due to the influenza epidemic of 1918, and the increase in the percentage of children in the community, tends to an increase in the death-rate, but it is hoped that the child-welfare campaign to be commenced during the coming year will gradually produce the opposite effect. Population. The Native population of Western Samoa at the census of the 17th April, 1921, was 32,601. By the 31st December, 1923, the population had increased to 33,800. During 1924 the natural increase amounted to 1,134, but, as there was a loss of 117 by excess of emigration over immigration, the net increase was 1,017. The population at the 31st December, 1924, was therefore estimated to be 34,817. The average population has been calculated as 34,309. All estimates of population in this report, and rates collected from these estimates, are based on the census taken in 1921. Arrangements are now being made to ensure that the census to be taken during the coming year will be a reliable one, experience having shown where errors are likely to occur in the filling-up of the census forms in the villages. Native Population, Western Samoa. Males. Females. Total. Estimated population on 31st December, 1923 17,157 16,643 33,800 Live births during 1924 .. .. .. 964 936 1,900 Deaths .. .. .. .. 412 354 766 Excess of departures over arrivals .. .. 56 61 117 Estimated population on 31st December, 1924 17,653 17,164 34,817 Net increase .. .. .. .. 496 521 1,017

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Fig. 2. —Leper Asylum, Makogai, Fiji. Photograph showing hospital in foreground and women's quarters in the distance. The leper island is in charge of a Medical Officer of the Fiji Medical Service, and the nursing staff belong to a Roman Catholic order—the Society of Mary.

Fig. 3. —Women's quarters, Makogai Leper Asylum. The women live in quarters at the headquarters of the Asylum and the men in small villages in the vicinity; the Fijians, Solomon-Islanders, Samoans, Indians, and Chinese each have their own villages.

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Fig. 4. —Sport at the Leper Station, Makogai. A model-yacht race.

Fig. 5.—Samoan village for Samoan male lepers at Makogai, Fiji. Each hut houses two men. Note the hurricane supports.

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Bikths. The births of 1,900 living children were registered during the year, compared with 1,701 in 1923, and 1,622 in 1922. This number of births is a record for Western Samoa, the next highest figures being 1,792 in 1912, with an estimated population of 34,239, and 1,701 in 1923. It is interesting to note that the large number of births in 1912 followed epidemics of dysentery and measles in 1911, in which year there were 1,827 deaths, and the record number in 1924 followed an epidemic of dysentery in 1923, with 1,398 deaths. The birth-rate for 1924 was 55-38 per thousand of mean population; the rates for 1922 and 1923 being respectively 48-52 and 50-49 per thousand. (Note : Still-births, of which 32 were registered during the year, are not included either as births or as deaths in the various numbers and rates given in this report.) Births of Samoans, Western Samoa, 1924. Males. Females. Total. Upolu .. .. .. .. .. 645 616 1,261 Savai'i .. .. .. .. .. 319 320 639 Total, Western Samoa .. .. 964 936 1,900

Births by Months.

Deaths. The number of deaths registered during 1924 was 766, as compared with 1,398 in 1923 and 899 in 1922. Last year's figures were abnormally high, owing to an epidemic of dysentery (bacillary). This year the number of deaths is considerably below the average. With a birth-rate of 55-38 per thousand it was to be expected that there would be an increase in the number of children dying in the first year of life. That such did not happen is shown by the infant-mortality rate being only 155 per thousand births, a figure considerably below the average, and one which compares favourably with many more advanced communities. Since the chief loss of life in Western Samoa occurs between the ages of six months and two years, it is anticipated that the coming year will not be as satisfactory as this one, but steps are being taken to reduce the wastage at this period of life. This is referred to more fully under " Child Welfare." The death- rate was 22-29 per thousand of mean population. The new system of registration of births and deaths, described fully in the annual report for the year ending 31st March, 1923, and introduced on the Ist January, 1923, has made it possible to tabulate the deaths under one year of age accurately. In last annual report deaths during the twelfth month could not all be separated from deaths at age " one year," as many of the deaths were of children born before the new system of registration was inaugurated. This difficulty has now disappeared. Ages of children dying are now checked by the Births Register, and thus accurate information regarding age at death is obtainable for those born since the Ist January, 1923.

Western Samoa. —Deaths of Samoans: Ages at Death.

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I Jan. Feb. March. April. May. June. July. August. Sept. Oct. Nov. Dec. Total. I i Males .. 78 66 71 97 77 81 83 73 82 79 80 97 964 Females 92 77 80 80 77 58 80 85 74 80 70 83 936 Total 170 I 143 151 177 154 139 163 158 I 156 159 150 180 1,900 ___ I J

J2 Age in Days. j Age in Weeks. s i 3 ! 0-1. | 1-2. 2-3. 3-4. 4-5. 5-6. 6-7. TotalJ 1-2. 2-3. 3-4. Total. j co _ — — — —y Upolu— Males .. .... 5 2 2 2 ... 2 13 9 1 1 24 Females .. .... 2 2 1 1 J 1 8 5 1 1 15 Total 24 7 4 3 3 1 3 21 14 2 2 39 . . Savai'i — Males .. .. •• 3 3 1 7 2 1 1 11 Females .. .. .. 2 1 2 .. 1 .. 6 .. 1 2 9 Total .. 8 5 4 2 1 1 13 | 2 2 3 20 TOTAL, Western Samoa — Males .. .... 8 5 2 2 .... 3 20 11 2 2 35 Females .. .... 4 3 3 1 1 1 1 14 5 2 3 24 Total 32 12 8 5 3 1 1 4 34 16 4 5 59

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Western Samoa. —Deaths of Samoans: Ages at Death—continued.

Percentage of Deaths at Different Ages to Total Deaths. Deaths. Number. Percentage at lotal Deaths. Under 1 week .. .. .. .. .. 34 4-44 From 1 week to 1 month .. .. .. .. 25 3-26 From 1 month to 3 months .. .. .. .. 28 3-66 From 3 months to 6 months .. . . .. .. .. 44 5-74 From 6 months to 12 months .. .. .. .. .. 164 21-41 Under 1 year .. .. .. .. .. .... .. 38-51 From 1 year to 2 years .. .. .. .. 99 12-93 From 2 years to 3 years .. .. .. .. 31 4-05 From 3 years to 4 years .. .. .. .. 21 2-74 From 4 years to 5 years ~ .. .. .. .. 8 1-04 From 5 years to 10 years .. .. .. .. 25 3-26 1 year to 10 years .. .. .. .. .. .... .. 24-02 Over 10 years .. .. .. .. .. .. 287 37-47 37-47 Total .. .. .. .. .. 766 100-0 100-0 It will be noticed that the deaths under one year (295) account for 38-51 per cent, of the total deaths. If the next year of life is included, the deaths from birth to two years of age are 51-44 per cent, of the total deaths. Of these 34-34 per cent, of the total deaths are accounted for in the period from six months to two years. This is discussed more fully under " Child Welfare." The two graphs (Figs. 6 and 7) given herewith show the population and the births and deaths for the period 1906-1924. In the graph showing population the 1917 census has been rejected, for reasons given in last annual report, and the population estimated from the previous census of 1911. In the graph showing births, the official estimate of deaths due to influenza in 1918, based on the census of 1917, has also been rejected. The question of the population and the death-roll at that time was discussed in last year's report.

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j . 0) Age in Months : Total. Age in Years. 03 5 «5 j mh , 3 a, O § fWpr 0-1. 1-3. 1 3-6. 1 6-12. "S1-2. 2-3. 3-4. 4-5. 5-10. .Y, 1 t ° EH 10. ! H I I Ufolu — Males .. .. .. 24 11 14 60 ! 109 36 8 7 4 4 98 266 Females .. 15 10 14 44 | 83 36 6 5 2 10 | 90 232 I I Total .. 39 21 28 104 192 72 14 12 6 14 188 498 — . . . Savai'i— Males .. .. ..11 3 7 29 50 15 10 3 1 6 61 146 Females .. .. 9 4 9 31 ! 53 12 7 6 1 5 38 122 Total .. ..20 7 16 60 103 27 17 9 2 11 99 268 Total, Western Samoa— Males .. .. 35 14 21 89 159 51 18 10 5 10 159 412 Females .. 24 14 23 75 136 48 13 11 3 15 128 354 Total .. .. 59 28 44 164 j 295 99 31 21 8 25 287 766 . Deaths by Months. j j ~7~ | j f i i i r | Jan. Feb. I March. April. May. June. July. August.j Sept. Oct. j Nov. j Dec. Total. Males .. 37 37 34 : 35 48 33 40 31 29 27 33 28 412 Females 32 33 30 25 51 27 32 27 23 27 28 19 354 Total 69 70 64 60 _ 99 60 72 58 52 | 54 61 47 766 '

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Fig. 7. —Graph showing births and deaths of Samoans, 1906-1924.

Financial Statement, Department of Health, 1924-25. Estimate. r, Actual ii-xpenaiture. (a.) Personal emoluments — £ £ s. d. European staff .. .. .. .. .. .. 9,780 9,712 14 10 Samoan staff .. .. .. .. .. .. 1,857 2,117 12 6 Chinese staff .. . .. .. .. .. 693 .300 15 7 (6.) Other charges— Hospital furniture.. .. .. .. .. . 350 302 19 9 Household accessories .. .. .. .. .. 500 265 7 4 Fire and lighting .. .. .. .. .. .. 500 412 17 6 Instruments, drugs, and appliances .. .. .. .. 4,750 4,160 5 7 Library .. .. .. .. .. .. 50 6 14 6 Leper maintenance .. .. .. .. .. 1,000 932 14 1 Quarantine .. .. .. .. . 100 70 6 6 Rations for patients and staffEuropean .. .. .. .. .. .. 1, 300 1,327 1 1 Samoan .. .. .. .. .. 700 743 11 11 Chinese .. .. .. . . .. .. 500 292 14 5 Transport and travelling expenses .. .. .. .. 1,000 1,247 17 9 Uniform allowances . . .. .. . . .. 200 100 14 ] Hospital Laundry Account.. .. .. .. .. 150 207 1 2 Administration charges Chinese labour .. .. .. 180 66 15 0 Dental subsidy .. .. .. .. .. .. 180 165 0 0 Freights, &c., on goods .. .. .. .. .. 150 114 17 1 Stationery, printing, and advertising .. .. 150 114 8 1 Tropical Research Account.. .. .. .. .. 700 890 16 11 Incidental expenses .. .. .. .. .. 210 191 5 7 Rent, Aleipata Hospital site .. .. .. .. .. 71 0 0 Half-cost Mulifanua dispensary .. . . .. .. .. 255 14 4 Incinerator for hospital .. .. .. .. .. .. 113 10 0 Expenses of health survey .. .. . . .. .. .. 78 16 6 Totals ~ .. .. . ..£25,000 £24,263 12 1

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Hospital Statistics for Period 1st April, 1924, to 31st March, 1925.

'Nationality. Chinese and Europeans. Samoans. Melanesian Labourers. Tn hospital, Ist April, 1924 .. .. . . .. 5 35 12 Admitted during year .. . . . . . . . . 130 773 277 Discharged during year .. .. . . .. . . 122 701 263 Died in hospital .. .. . . .. .. 4 32 8 Remaining in hospital on 31st March, 1925 .. .. 9 15 8 Report on the Laboratory, Government Hospital, Apia.—April, 1924, to March, 1925. By P. A. Buxton, M.R.0.5., L.R.C.P., D.T.M. k H. (Expedition to Samoa from the London School of Hygiene and Tropical Medicine). The laboratory has been mainly busied with research into filariasis and other conditions, and the research work is not included in this report. We have also dealt with such specimens as have been sent in from the wards and out-patient department, and it is these specimens alone which are the subject of this report. The following examinations have been made : —- Blood Examinations. —For filaria, 23 ; for filaria—positive, 7. Red count, 1 ; white counts, 5 ; differential white counts, 25. Blood cultures —negative, 8 ; positive (B. typhosus), \. Agglutinations —negative, 30 ; positive (B. typhosus) 9, (B. paratyphosus A) 3, (B. paratyphosus B) 2. Ftiical Examinations. —For worm-eggs —negative, 53 ; hookworm present, 96 ; trichuris, 55 ; ascaris, 24. For protozoa —negative, 8 ; lamblia present, 1; Entamoeba coli, 3 ; Entamoeba histolytica, 1. For bacteria —Number plated, 26 ; B. pyocyaneus found, 2 ; B. paratyphosus (non-agglutinating), 1. Urine Examinations. —General, 133; for organisms, by smear, 3 ; for organisms, by culture, 2. Various Examinations. —For leprosy —total, 26 ; positive, nasal smears 3, skin-scrapings 3. Pus —cultures, sundry, 15; smears, sundry, 16; smears, urethral, 8; smears, urethral, gonococcus positive, 5. Gland-punctures, 3. Serous fluids examined, 4. Smears from yaws cases, 25. Sections cut, 12. Post-mortem examinations, 4. Fluids for percentage of alcohol, 9. Sputa for T.B.— negative, 32 ; positive, 8 ; streptococci, positive, 1. The following points deserve comment: There are a number of cases which clinically resemble typhoid, but from which no organism can be recovered by blood culture early in the disease : these cases give negative Widal-reactions later on. There is also a common type of enteritis, with or without blood in the stools, which cannot apparently be attributed to any of the organisms which generally give rise to these conditions. The two stools from which B. pyocyaneus (and no other abnormal organism) was isolated were those of mother and child, acutely ill at the same time. A second child died, apparently of the same condition, before the stool could be examined. There is much research yet to be done upon the intestinal bacteria in Samoa. The only case from which Entamoeba histolytica was recovered was a sailor, native of Manahiki, who arrived in port suffering from amoebic dysentery. As O'Connor has already reported, this disease is rare or non-existent in Samoans. He only found E. histolytica in 9-6 per cent, of 229 stools examined. Of the five urethral smears in which gonococcus was found, four were from pure-bred Samoan males. It is sometimes said that Samoans are immune ; but possibly they are infected more often than we realize ; but if so they certainly do not suffer from orchitis, strictures, and grave complications which would bring them into hospital. REPORT OF THE RESIDENT MEDICAL OFFICER, APIA HOSPITAL, 1924-25. Administration. This year we have been able to effect reductions in the clerical staff of the office, as the Treasury Department has taken over the collecting of all accounts for European patients after the bills have been issued. Samoan patients now receive free treatment, requiring no accounts. The European staff in the dispensary has been reduced, as we have now a Samoan cadet who, after five years training, is able to act as a dispensary assistant, making the employment of a European assistant dispenser

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Hospitals. Dispensaries — . a 1 I J i \ _• a • - -S a i S -a % . 3.-3 % 3 ~i 2 ! c3 «3 Is .5 3 c8h ° H ■ to J O co >5 >- H In hospital, 1st April, 1924 .. 47; 3 2 j .. .. .. 52 Admitted during year .. 94! 72 16(i 36 j .. .. .. 1,215 Discharged during year .. 922 70 159 38 .. .. .. .. .. .. 1,189 Died in hospital .. .. 34 5 5 .. j . . . . .. .. 44 Remaining in hospital on 31st 30 2 .. .... .. . . .. . . 32 March, 1925 Outpatient attendances, includ- 24,489| 6,82S 10,353 1,363 4,758 3,777 2,513 4,034 3,583 1,186 28063,164 ing dressings Treatment for hookworm .. 87j 1,816 4,770 736 1,659 .. .. .. .. .. 7,491 16,559 Treatment for yaws (injections 5,843 2,589 4,017 39 2,123 .. .. ... .. .. 6,611 21,222 of N.A.B.) Operations— Major .. .. .. 170 3 17 190 Minor .. .. .. 215 68 157 2 110 550 Visits paid during period to 784 107 73 134 22 15 15' 233 134! 101 .. 1,330 patients in their homes

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unnecessary. Another important change has been effected in the replacement by Samoans of practically all the Chinese labour employed in the European hospital, and for outdoor work on the hospital grounds. Only one Chinaman is employed in the European hospital, acting as assistant to the European cook in the kitchen. The work of the Chinese houseboys is done by junior Samoan nurses, who benefit greatly thereby, as it enables them to receive more practical instruction in the preparation of light diets —especially milk foods—and in the best methods of cleansing feeding-utensils. They also see the type of diet suitable for the different cases, and take more interest in the dieting of their patients when they eventually take over full nursing duties. The heavy work of scrubbing and cleaning is done by Samoan youths, some of whom eventually hope to be accepted as cadets for training as native medical practitioners. This work, with its regular hours, is good for testing the discipline of boys who have not had the advantage of education in one of the residential mission schools, and enables us to ascertain more of their character before we accept them as cadets. Statistics. This year the gross totals of cases treated are given for the financial year Ist April, 1924, to 31st March, 1925, to compare with the expenses incurred, whereas the analysed hospital statistics have been given for the calendar year 1924, which practice will be continued in future reports. Treatment—Medical. The past year has fortunately been free from epidemic disease as far as can be judged by the hospital records. A few sporadic cases of several of the infectious diseases have been admitted, but never in sufficient numbers to indicate the presence of an epidemic. Gastro-enteritis of infants and young children has been prevalent throughout the year, and has been one of the chief causes of death in the hospital. Pneumonia has been responsible for the largest number of admissions of any medical disease, and also has the largest mortality. Of the fifteen deaths that occurred amongst the 108 cases treated for the above-mentioned diseases (in the Samoan wards of the hospital), all but one occurred within twenty-four hours Of admission, showing that if we could get the patients suffering from these complaints brought up for treatment at an earlier stage of the disease we would probably be able to reduce the mortality. Enteric fever was fairly prevalent in the cold season of the year, but only eight of the twenty cases clinically diagnosed were confirmed by bacteriological or serological methods : of these, five were due to the Bacillus typhosus. The beneficial effect of the " malagas " (expeditions) for the eradication of yaws by injections of novarsenobillon is well shown by marked decrease in the number of patients applying for these injections at the hospital, and also in the much larger percentage of patients that received the full course of three injections. Confinement cases amongst the Samoans have come to the hospital in great numbers, but at present we admit only cases of difficult labour, as we have no accommodation for normal cases. Treatment —Surgical. Filarial abscesses still account for the greatest number of cases, but they have decreased in number compared with recent years. Several cases of tubercular peritonitis were subjected to exploratory laparotomy, but only in one early acute case was there permanent benefit; in the others the condition showed only temporary improvement. This may be accounted for by the firm fibrous rolling and matting of the great omentum that appears to take place at an early period jin theTdisease when it affects the Samoan. Chinese Coolies. The number of cases admitted to hospital and reporting for treatment has shown a steady decrease. The most noticeable feature is the reduction in preventable disease, such as beriberi, nil ; dysentery, nil; enteric fever, two cases. Apia Hospital.—Attendance, Operations, etc., for the Year 1924-25. General attendance (includes out-patient attendance, out-patient dressings, N.A.B. injections, and injections for elephantoid fever) .. .. .. .. .. .. 30,419 Out-patient attendance (Europeans and Samoans) .. .. .. .. .. 10,104 Out-patient dressings (Europeans and Samoans) .. .. .. .. .. 12,822 N.A.B. injections—First injections .. .. .. .. .. 3,789 Second injections .. .. .. .. .. .. 1,605 Third injections .. .. .. .. .. .. 449 5,843 Injections for elephantoid fever .. .. .. .. .. .. .. 613 European in-patients .. .. .. .. .. .. .. .. 130 Samoan in-patients .. .. .. .. .. .. .. .. 576 Chinese and Melanesian in-patients .. .. .. .. .. .. .. 277 Chinese and Melanesian out-patients .. .. .. .. .. .. .. 324 Operations —Major .. . . .. .. .. .. .. .. 70 Minor ~ ~ .. .. ~ .. .. .. 15 385

10

A—4a.

Apia Hospital.—Classified Admissions to European Wards, 1924.

11

to „ • I I I G — co | ! . S I ! S ~ .5 —3-1 J an - Feb. Mar. April. May. Jane. July. Aug. Sept. Oct. f Nov. Dec. Totals, "g 8 .§>! I S rt M »| | • fi Alimentary System. Colitis .. .. .. .. .. .. .. 2 .. .. 1 .. .. 1 .. 4 Constipation .. .. 1 1 2 Dental extractions .. . . .. .. . . .. .. .. .. 1 .. .. .. .. 1 Gastritis .. .. .. 1 .. .. .. .. .. .. .. .. 1 2 Gastro-enteritis .. .. .. 1 1 1 .. 1 1 1 .. 6 1* Hepatitis .. .. .. .. .. .. .. .. .. 1 .. .. . . .. .. 1 Peritonitis .. .. . . 1 If 2 If Tabes mesenterica .. .. .. 1 .. .. .. .. .. .. .. .. .. .. 1 Circulatory System. Adenitis .. .. I j 1 .. 1 .. 3 Lymphangitis .. .. .. 1 | 1 Genito-urinary System. Abortion .. .. .. .. .. 1 1 2 Circumcision .. .. .. .. 1 .. .. .. 1 .. .. .. 1 .. .. 3 Confinements .. .. .. 4 1 2 1 2.. .. 1 1 1 2 116.. Cystitis .. .. .. 1 .. .. 1 .. .. 2 Hydrocele .. .. .. 1 .. .. .. . . .. .. .. .. .. .. .. 1 Parametritis .. .. .. .. .. .. .. .. .. .. .. 1 .. .. .. 1 Puerperal fever .. .. .. 1 1 1 .. .. | . .. 3 Retention of urine .. .. 1 .. 1 2 Retroversion of gravid .. 1 1 uterus Nervous System. Concussion .. .. .. I .. .. 1 Neuritis .. .. .. 1 1 2 Respiratory System. Bronchitis .. .. .. 1 .. .. 1 3 1 .. 6 Haemoptysis .. .. .. 1 1 Phthisis .. .. .. 1 .. .. .. .. .. .. .. 1 .. .. .. 2 Pleurodynia .. .. .. 1 .. 1 Pneumonia, bronchial .. .. .. 1 j 1 1 .. .. 3 Tonsils and adenoids .. .. .. .. 1 .. .. j 1 Skin. Burns .. .. .. 1 I .. .. 1 1 Excision of scar .. .. .. 1 J 1 Furunculosis .. .. .. 1 1 Ulcers .. .. .. 3 1 2 2 • .. .. 1 9 .. Supporting Structures. Abscess .. .. 1 •• .. 2 2 3 2 2: 2 .. 2 .. 16 Bursitis .. .. • • 1{ 1J Fractures .. .. .. 1 1 Injuries and cuts .. .. 1 .. •• .. 1 .. .. 2! 1 1 .. 6 Special-sense Organs. Cataract .. .. .. • ■ • ■ • ■ • • • ■ • • .. . • • • 1 .. • • 1 Conjunctivitis.. .. •• 1 1 1.. .. .. .. .. .. .. .. 3 Evisceration of eye .. .. 1 1 Injury to eye .. .. 1 ■. • • .. • • •. .. .. • • .. .. • • 1 Otitis externa.. .. .. 1 .. 1 Pterygium .. .. . ■ . ■ i ■ • •. • • •. . • • • .. .. •. 1 1 Infectious Diseases. Dysentery, bacillary .. 1 .. 3 4 1 Enteric fever .. .. .. .. .. .. 1 1 Influenza .. .. ..j.. .. .. .. .. 1 .. 1 .. .. . . 2 Parasites. Ascariasis .. ■ • ■ • • ■ • • 2 1 .. .. .. .. .. .. .. .. 3 .. Filariasis .. . • 1 1 General. Diabetic .. .. .. 1 1 1 1 Grave's disease .. .. • . ■ ■ • • ■ • • ■ • ■ • ■ • • ■ • • • 1§ • • 1§ .. Poisoning .. .. .. ... 1 1 .. Tumours. Carcinomata .. 1 1 •• •• •• •• 1 1 •• •• •• •• •• 4|j[ Totals .. .. 6 16 10 14 11 9 11 10 8 13 10 11 4 133 4 1 I ' * Admitted moribund, died that night. t Tubercular; gen. following ruptured appendix. J prepatellar, chronic—excision. § Excision of right lobe and isthmus. |j Readmissions of the same patient.

A.—4A.

Apia Hospital.—Classified Admissions to the Samoan Wards, 1924.

12

v -.J I i i 1 : \ M 'flC Jan. Feb. Mar. April. , May. June. July. Aug. Sept. Oct. Nov. Dec. Total. % a i ® # iS Wo3 | | i | Alimentary System. Ascites .. .. .. .. .. .. .. 1 .. .. .. .. .. .. 1 2 1.. Colic.. .. 1 1 1 2 .. .. 1 .. .. 1 7 Colitis * .. .. .. .. .. 1 .. .. 1 1 .. .. .. .. .. 3 Constipation .. .. .. 1 .. 1 .. 1 .. 1 2 .. 1 .. .. 7 Diarrhoea .. .. .. .. 1 1 .. .. .. .. .. .. .. .. .. 2 Gastritis .. .. .. 1 .. .. 1 .. 1 1 .. .. 4 Gastro-enteritis .. 1426083332 10 2 1 51 6* Gingivitis and glositis .. .. .. .. 1 .. .. .. .. 1 .. .. .. .. 2 Hare lip .. .. 1 1 .. .. .. .. .. .. .. .. .. .. .. 2 Hernia .. .. .. If If If Jaundice .. .. .. .. .. .. .. .. .. .. .. .. . . .. 1 1 Marasmus .. .. .. 1 1 1 4 .. 1 .. 1 .. .. .. .. 9 Peritonitis, tubercular .. .. 3 .. .. 2 .. .. 1 6 1 Circulatory System. j Adenitis .. .. 1 .. .. 3 .. 1 .. 1 3 3 1 1 2 16 Cardiac .. .. .. .. 1 .. .. 1 .. 1 1 .. .. 1 .. 5 1 Chyluria .. .. .. .. 1 .. .. .. .. .. . . . . . . .. .. 1 Lymphangitis .. .. .. .. 1 1 Genito-urinary System. Abortion .. .. .. 1 .. .. 1 .. .. .. .. 1 .. .. ! 3 Circumcision, &c. .. .. 1 2 1 1 2 .. 1 .. 8 Confinements .. .. 2 .. .. .. 3 1 .. 1 1 .. .. 1 1 10 Gystitis .. .. .. 2 2 Hydrocele .. .. 4 1 1 .. .. 3 .. 1 1 1 o .. 421 Glycosuria .. .. .. .. .. . • .. 1 .. .. .. 1 Hyperemesis gravidarum .. .. .. .. 1 .. 1 .. .. .. 2 Mastitis .. .. .. 1 1 2 Orchitis .. .. .. 1 .. 1 •• . • .. .. .. 2 Ovarian cyst .. .. .. .. 1 .. 1 1 1 4 Retention of urine .. .. .. .. .. .. .. .. .. . • 1 • • .. .. 1 Uraemia .. .. .. 1 • • 1 Nervous System. Concussion .. .. .. 1 • • 3 ; .. 4 Meningitis .. .. .. .. .. .. •• •• •• •• 2 .. 1 .. 2 5 Mental .. .. .. .. .. .. . • .. .. • • • • 1 • • • • .. 1 Neuralgia .. .. .. 1 1 1 3 Paralysis (functional) .. .. .. 1 .. .. •. •. .. .. .. 1 Respiratory System. Asthma .. .. .. 1 1 Bronchitis .. .. 1 1 1 1 2 1 2 5 1 3 10 1 .. 29 Phthisis .. .. .. 1 2 .. .. 3 2 2 2 1 1 ... 2 16J Pleurisy .. .. 2 .. 1 1 4 Pneumonia .. .. 169757431 6 3 2 3 : 57 9§ Tracheitis .. .. .. .. 1 • • • • • • • • • • • • • • • • • • .. 1 Skin and Subcutaneous Tissues. Burns .. .. .. 1 2 .. .. .. .. .. .. .. .. .. 1 4 Cuts, wounds, &c. .. .. 3 1 3 2 3 .. .. 1 1 1 2 1 18 Cellulitis .. f 1 1 1 1 1 1 1 1 3 1 12 Dermatitis .. .. .. •. 1 1 2 Elephantoid scrotum .. 5 2 7 5 3 4 2 .. .. .. .. .. 1 29 Elephantoid tissue gen. .. .. .. .. .. .. .. •. .. • • . . 1 .. 1 Ulcer .. .. .. •• •• 1 1 2 .. .. 2 .. .. .. .. 6 Urticaria .. .. .. 2 2 Supporting Structures. Abscess .. .. $867775766324 76 1|| Arthritis .. .. .. •. • • • • • • • • • • 1 • • • • • • • • • • 1 Bone necrosis .. .. 1 • • 1 1 • • 1 41] Fractures .. .. • • • • • • 1 ' 2 .. .. .. 1 1 1 .. 7 Injury, sprains .. .. 3 3 2 .. .. 3 2 .. 3 1 .. 2 ,19 Myositis .. .. .. .. •• 1 1 1 2 1 1 ] 8 Periostitis .. .. .. .. •• 1 • • • • •• • • • • 1 Teno-synovitis .. .. 1 1 1 1 •• 1 5 Infectious Diseases. Chicken-pox .. .. .. • • • • 1 1 • • 1 • • • • 3 Dysentery, amoebic .. .. 1 1 Dysentery, bacillary .. 1 . . • • •. • • • • 1 • • • • • • • • • • .. 2 Enteric fever .. .. .. •• 1 2 2 2 3 5 4 1 20 Influenza .. .. •• .. .. .. .. .. 1 2 .. .. .. 1 .. 4 Leprosy .. .. • • • • •• • • 4 1 .. .. 1 .. 1 .. .. 7 Measles .. . . 1 1 P.U.O. .. ..1 .. 5 1 .. 2 .. 1 .. 4 14 Puerperal fever .. .. 1 .. 2 1 .. .. 1 .. 1 6 Septicaemia and pysemia .. 1 1 Tetanus .. .. •• •• 1 1 2 Yaws .. •. •• •• 1 •• 1 •• 11 2 .. .. 2 .. 8 * All within few hours of admission. t Strangulated umbilical. J Eleven clinical, five bacteriological. § Eight within twenty-four hours of admission. || Primary concealed haemorrhage. If Spinal caries.

A.—4a

Apia Hospital.—Classified Admissions to the Samoan Wards, 1924—continued.

Apia Hospital.—Classified Admissions to Chinese Wards, 1924.

13

fcO „ . I a -co .a 1? • . \ % 'es.S p.£j Jan. Feb. Mar. April. May. June. July. Aug. | Sept. Oct. Nov. Dec. Totals, ~ S o\ 1 I i? ® cnri i P P3 Special-sense Organs. Conjunctivitis.. .. 1 .. 1 .. 4 4 1 2 3 .. 1 .. .. 17 Corneal ulcer .. .. .. .. .. 1 .. 1 2 Iritis .. .. .. 1 1 1 .. 3 Otorrhea .. .. .. 1 1 Staphyloma .. .. .. .. .. 1 1 2 Parasites. Ascariasis .. .. .. .. 1 .. .. 1 1 .. .. 1 4 Filariasis .. .. 2 3 .. 3 .. 2 .. 1 .. 1 1 .. 2 15 Hookworm .. .. .. .. .. 1 2 2 5 General. Poisoning (insect-bites) .. .. ! 2 2 Poisoning (chemical) .. .. .. .. .. 1 .. 1 .. .. .. .. .. 10* 12 3* Poisoning (ptomaine) .. 3 1 4 Tumours .. .. .. .. 2 1 2 .. 5 Total deaths .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 22 Total under treatment .. 34 43 53 60 55 69 46 51 53 44 50 25 52 635 * Arsenical; one family.

« • I I 1 es 1—1 co 3 5" I \ & JS-S&JJ Jan - I' eb - Mar - April. May. June. July. Aug. Sept. Oct. Nov.! Dec. Totals. S 2 o J? P3 co i Alimentary System. Colic.. .. . . . . i 1 Constipation .. .. .. 1 1 2 Diarrhoea I .. .. .. 1 1 Jaundice .. .. .. 1 1 Stomatitis .. .. .. 1 1 Circulatory System. Adenitis .. .. .. 1 1 2 Anaemia .. .. .. 1 I 1 Cardiac .. .. 1 .. 1 .. 1 .. 1 1 1 l .. .. .. 7 2 Mumu .. 1 1 .. l ..[.. 3 Genito-urinary System. J Cystitis .. .. 1 1 Epididymitis .. .. .. 1 1 Orchitis (filarial) .. . . .. l .. i Urethritis .. .. . . 1 1 Nervous System. Neuritis .. .. .. 1 1 2* .. Respiratory System. Asthma .. .. .. . . . . 1 .. .. . . .. .. .. .. .... 1 Bronchitis .. . . .. 1 3 1 4 .. 1 ..31.. 13 Haemoptysis .. .. .. 1 I • • 1 Laryngitis .. .. .. 2 1 .. 1 4 Phthisis .. .. .. 1 ! 1 Tonsilitis .. .. .. 1 1 Skin and Subcutaneous Tissue. Cellulitis .. .. .. .. 1 1 1 1 1 .. .. 1 (j Cysts, sebaceous .. .. .... .. .. .. 2 .. .. .. .. .. .. 2 .. Carbuncles .. .. .. 1 1 Dermatitis .. .. .. .. .. 1 1 2 1 .. .. 1 1 2 1 10 Furunculosis .. . .. .. 2 1 .. 3 Psoriasis .. .. .. 1 1 Ulcers .. .. .. 3 .. 9 6 9 3 2 .. 1 1 .. 1 35 .. Wounds .. .. .. 1 2 2 1 .. 2 2 1 2 2 1 2 18 ' .. * One case and readmission.

A.—4a.

Apia Hospital.—Classified Admissions to Chinese Wards, 1924—continued.

Apia Hospital.—Admissions of Melanesian Labourers, 1924.

14

tc „ . CJ --2 CO • fl £ Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Totals. ta a o< £ 3 Wr2 ° p3 "co . . Supporting Structures. Abscess .. .. .. 1 .. .. 4 2 1 1 .. 2 .. 1 2 14 Arthritis .. .. .. .. .. .. .. .. 1 .. .. 1 .. .. . • 2 Fractures .. .. .. 1 1 1 1 4 Injury .. .. .. 3 5 2 2 .. 1 2 2 1 18 1* Myositis .. .. .. 1 1 2 Synovitis .. .. .. 1 • • 1 Special-sense Organs. Conjunctivitis.. .. .. .. .. 2 .. 1 1 .. 1 .. 1 .. 1 7 Corneal ulcer .. .. .. 1 1 Injury to eye .. .. .. 1 1 Scleritis .. .. .. .. .. .. .. .. .. 1 .. .. • • ■ • • ■ 1 Infectious Diseases. Dysentery, bacillary .. 1 .. .. .. .. .. .. .. .. .. . • .. • • 1 Enteric fever .. .. 1 1 .. 1 3 Gonorrhoea .. .. .. 1 ; 1 Influenza .. .. .. .. .. 1 .. .. 2 .. .. 1 4 Leprosy .. .. 2 .. .. .. .. .. .. .. . • ■ • • • . • • • 2 Measles .. .. .. 1 1 If Rheumatism .. .. 1 .. .. .. 1 .. .. .. .. .. .. .. •• 2 Yaws .. .. .. .. .. 1 .. .. .. 1 .. • • •• 2 Parasites. Ascariasis .. .. .. 1 1 Hookworm .. .. .. 1 2 2 1 3 .. .. 1 10 General. P.U.O. .. 3 2 1 .. .. 1 7 Poisoning, bites, stings .. 1 1 1 3 Poisoning, intestinal .. .. .. .. .. 1 . • . • . • • • • • 1 • • • • 2 1J Malingering .. .. .. .. 1 .. .. .. . ■ ■. ■ • •. • • • • • • 1 Totals .. .. 7 8 5 18 26 31 30 23 8 19 11 14 13 213 5 I * Tetanus. t Hemorrhagic type. ; Mushroom.

150 « • fl —Tco | i •a | si I 1 £ I'S S Jan. Feb. Mar. April. May. June. July. Aug. , Sept. Oct. Nov. Dec. Totals. "3 a. s< i s © HH i—• I H l« I Abscess .. ■ • ■ • 2 . . 1 • ■ • • ■ • • • ..... . . .. 3 Adenitis and lymphangitis .. 1 1 2 4 Arthritis .. .. . • 1 1 Bronchitis .. • • • • 3 3 Cellulitis .. .. .. 1 1 •• .. j .. 1 .. 3 1 Conjunctivitis.. .. .. 1 1 2 •• * •• ® Diarrhoea .. .. . • 1 j 1 Epilepsy .. .. • ■ 1 | ' 1 Fracture .. .. 1 1 j 2 Gonorrhoea .. .. . ■ 1 .. ...... .. .. .. .... .. .. 1 Herpes zoster .. . • I " * '' * Hookworm .. .. •• 1 1 • • 2 Injury .. ■ ■ •• • ■ ■ • ■• 2 .. .. . . .. 2 1 1 .. 0 Myositis .. .. • • 1 1 Phthisis .. •• .. .. .. .. .. .. .. 1 .. .. I .. 1 1 Pneumonia, lobar .. .. • • • • • • • • • • • • 1 • • • • ! • • • • 1 Septic sores .. . • ■ • 1 • • 1 • • • • I 2 Tubercular abdomen .. .. 1 •• .. I .. 1 .. 2 1 Yaws .. 1 •• •• j 1 •• Totals .. .. 1 3.. 1 4 4 2 10 1 4 j 2 6 3 41 3

A.—4a.

Apia Hospital.—Surgical Operations performed under General Anæsthesia, 1924.

APPENDIX A. METEOROLOGICAL REPORT OF APIA OBSERVATORY. The following report has been inserted by courtesy of the Director of the Apia Observatory : —

Highest temperature, 90-1° F., on Feb. 7 ; lowest temperature, 68-9" F., on Sept. 26. Highest pressure, 30'04in., on Sept. 9 ; lowest pressure, 29-45 in., on Jan. 19. Greatest rainfall in twenty-four hours, 4-98 in., on Dee. 2,

15

Surgical Operations. j Jan. Feb. Mar. j April. May. June. July. Aug. Sept.) Oct. Nov. Dec. Total. . . j , j | -r " . 7" On skin and cellular tissues— Abscess .. .. .. j 15 6 4 10 1 8 3 10 2 7 4 70 Cellulitis and carbuncle glands .. .. .. .. 1 .. .. .. .. .. 1 .. .. 2 Excision of lymphatic glands .. .. .. 1 2 .. 3 Hare lip .. .. .. 1 .. .. .. .. . . . . . . .. .... .. 1 Plastic .. .. . . 3 1 ) 5 Sebaceous cysts .. .. .. 1 .. j .. 1 .. .. .. .. .. .. 2 Sinuses .. .. 1 1 Wounds sutured .. 2 2 On joints— Arthrotomy .. .. .. .. .. .. .. .. .. .. ..j 1 1 .. .. 2 Excision of prepatellar bursa . . . . . . .. .. .. . . 1 .. .. . . 1 Ganglion .. .. • • • • • • • • 1 1 Tendon sutures .. .. .. .. 1 1 On bones— Amputations .. .. .. .. I .. 1 .. 1 .. .. .. 4 .. 1 8 Fractures .. .. 1 1 .. .. 2 Osteomyelitis .. .. .. .. 1 1 Sequestrotomy .. .. .. 1 I .. .. .. .. .. .. 1 .. .. 1 3 On eyeEvisceration .. .. .. .. .. 1 .. .. .. .. .. 1 .. .. 1 3 Paracentesis oculi .. 1 1 On ear, nose, and throat — Submaxillary cyst .. • • 1 1 Tonsils and adenoids .. II 1 Thyroidectomy .. .. | 1 1 On the abdomen— Appendicectomy .. •' 1 * Laparotomy .. .. .. .. 1 .. | 1 1 .. 1 . . 2 .. .. 1 7 Radical cure, hernia .. .. .. .. j .. .. 1 .. .. .. .. .. .. 1 On male organs — Amputation elephantoid scrotum .. 2 7 4 4 5 1 1 1 1 26 Castration .. .. * * Circumcision .. ... .. 1 3 ... I 2 .. 1 1 ' 1 1 2 .. 1 13 Cystostomy .. .. .. .. .. i .1 1 Hydrocele, radical cure .. .. 1 .. | 1 111 1 1 .. 4 2 3 15 Prostatectomy .. .. .. .. .. j 1 1 On female organs— Curettage .. .. .. 1 .. 1 2 1 | .. | 2 7 .Dijficult labour .. .. .. .. j .. 1 .. .. ....... .. .. 1 2 .. 3 Ovarian cyst .. .. .. •. .... 1 .. ) 1 .. .. .. .. .. 2 On tumours —- Epitheliomata .. .. . • • • .. 1 .. 1 .. .. .. .. .. .. .. .. 1 General — Dental extractions .. •• •• .. .. j 1 .. 1 1 1 .. .. 4 Totals .. .. 25 21 | 17 26 8 1 9 17 6 18 17 14 17 195 Minor surgical operations, usually 34 j 19 J 39 23 19 | 10 23 16 17 11 10 17 238 under local anfcsthesia

Mean \ro»« j Temperature— Mean Humidity Month. Barometric TorY.nornt.irc I Mean Percentage Rainfall. Pressure. .temperature, j |, a j]y Range. Saturation. Inches. °F. °F. | Inches ■ January .. .. .. .. .. j 29-74 | 79-6 10-1 j 85-3 17-70 February .. .. . . .. 29-81 | 79-6 11-5 ' 85-3 14-06 March ... .. .. . • 29-84 1 80-5 11-0 83-1 10-06 April .. .. .. .. 29-84 79-4 11-3 j 83-1 8-30 May . . .. .. • • • • ! 29-87 80-5 11-2 84-0 5-82 June .. .. .. .. •• 29-91 79-7 10-6 81-9 10-05 July .. .. .. .. •• 29-91 78-7 9-7 85-8 9-61 August . . .. . • • • • • 29-92 79-2 10-3 84-3 5-39 September .. .. .. .. 29-92 78-7 11-3 81-6 3-82 October .. .. .. .. .. 29-88 78-9 12-1 81-6 8-08 November .. .. .. .. 29-81 79-2 11-7 j 84-2 10-24 December .. .. .. . • 29-78 78-9 9-9 j 83-4 15-91 Means and total for 1924 .. .. .. 29-86 79-4 10-89 | 83-6 119-04 Means and total for 1890-1923 .. .. 29-83 78-5 .. | 83-3 106-85 Excess of 1924 .. .. .. .. +0-03 + 0-9 .. j +0-3 +12-19

A.—4A

APPENDIX B. THE TREATMENT OF YAWS (FRAMBCESIA TROPICA) IN WESTERN SAMOA By John S. Armstrong, M.8., Resident Medical Officer, Apia. Historical. Wilkes* in 1839 describes an eruptive complaint, called ilamea, which covers many of the children under the age of ten years and particularly attacks the face and head. He says : " The mode in which it is treated is singular : the child is rubbed with the husks of the coconut until all the scabs are removed ; a soft preparation of breadfruit is then applied, after which they are washed." This has been the Samoan method of treating yaw papules until quite recent times, and may even now be practised in some of the outlying districts. The word ilamea was probably used in mistake, as the Samoan uses it only to describe an impetiginous condition of babies. In 1866 Pritchardf describes the disease called tona (the present Samoan word for yaws) " which attacks the Native children almost without exception." Kraemer J believes that the disease has long been endemic in Samoa, because the oldest word that the Samoans have for the disease is patu, which is the word used in the Sunday Islands for yaws. This would indicate that the Samoans acquired the disease when they were in contact with this race —probably before the time of their migration to the Samoan Islands. On the other hand, Pratt§ gives the meaning of patu as " a fatty tumour," and does not mention it in connection with yaws. Konigerjj that the introduction of yaws into the Samoan Islands was quite recent. In trying to arrive at any decision in this matter two points seem worthy of note : —• (1.) That every description of the disease in Samoa states that it is practically entirely a disease of childhood, indicating a long period of endemicity. (2.) The Samoans certainly had an old name of lupani for the disease, which was used before tona —the latter word probably came into use during the Tongan wars, the last of which occurred many years before the recorded arrival of Europeans in Samoa, and this is the only authentic record of an early contact of the Samoans with a foreign race. On the whole, the evidence seems to point to yaws having been long endemic in Samoa, and probably the Samoans either brought the disease to these islands or acquired it soon after they arrived. The Treatment of Yaws in Samoa by European Medicines. Daviesf in 1892 reports that he successfully treated the chronic ulcers of the Samoans. Kraemar J in 1902 used potassium iodide and a local application of salicylate, as he states that he did not like to give mercury to children; but the effect of this treatment was reported successful merely on observations of a single case of secondary yaw rash. In 1910 Poleck** stated that he was obtaining cures in twenty days by the use of potassium iodide 0-59 gramme and calomel 0-01 gramme internally, and mercurial ointment for ulcers. The cures by these methods do not appear to have impressed the Samoans, as they continued to favour their own method of treatment. Shortly before the Great War the German doctors started to give injections of arsenical compounds of the salvarsan type. These injections were probably given to only a very small proportion of the population, but were becoming popular amongst the Samoans. During the military occupation of Samoa by New Zealand troops army doctors were sent round the islands to give novarsenobillon injections whenever it was reported that yaws was prevalent in a district. On these expeditions a single injection was given, and usually no charge was made. This did a great deal to popularize this method of treatment. When the Civil Administration was formed in 1920 these expeditions were continued, but it was noted that the effect of the injections did not last very long in a district. In order to try and make the cures more permament each case was given three doses instead of one, but, as the cost of the drug was becoming a large item in the medical expenditure, it was decided to try and enforce the payment of fees for the injections. This caused a serious falling-off in the number of cases treated. It was then decided to do the children free, but charge the adults the cost of the drug used ; but even this led to very little improvement in the number of cases treated. The desire for this method of treatment played a great part in prompting the support of the Samoans for the passing of the Samoan medical tax, which has enabled us to give free treatment. That the passing of this tax has been of great help in combating yaws is shown by the following incidents : Two Native officials sent requests that a doctor should be sent to their villages to give injections for yaws, as the disease was very bad in the districts. The first official estimated that he had at least one hundred cases ; the second did not mention any number. When the doctor arrived he found that there were eleven cases in the first village and twenty-three in the second ; and on making inquiries he was told that the others had not come, as they could not pay the fee and were

* Charles Wilkes : " United States Exploring Expedition " (Samoa, 1839), p. 124. tW. T. Pritchard : " Polynesian Reminiscences " (1866), p. 424, appendix. j Dr. A. Kraemer : " Die Samoa —Inseln " (1902), Anhang zu Band 11, p. 14. § Pratt: " Pratt's Grammar and Dictionary of the Samoan Language," 4th ed., p. 236. | Koniger : " Über Frambcesia auf Samoa," Arch. f. Path. Anat. Berlin, 1878, p. 419. Rev. S. H. Davies, Medical Missionary, L.M.S. : " Diseases of Samoa," from Intercolonial Medical Congress of Australia, Trans., 3rd session 1892 (Sydney), p. 606. ** Dr. Poleck : " Medizinal —Berichte Über die Deutschen Schutzgebiete," 1909/10, VII (Samoa), p. 577,

16

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ashamed to ask for free treatment. Eventually a few more were collected and given treatment without charge. Under the system of free treatment at the first visit, eighty-six cases were treated at the first and 117 cases at the second village —and this in spite of the fact that injections were being given at villages every three or four miles, so that the cases in question were drawn from a district with a two-mile radius, instead of five or ten miles, as at the previous visits. Treatment. —At the present time we try to give each case of yaws three doses of novarsenobillon, with an interval of a week between each dose. This is the standard treatment given at all our hospitals and dispensaries (on one or two days a week) all the year round. To make certain that the treatment is available to the whole population we send parties, consisting of a European doctor and one to three Samoan assistants, round the islands, who stop at every village, or at the central village when there are several within a short distance, and give the injections. On these medical excursions, or " malagas," as they are called, the name, age, village, and dose of each patient is recorded for future reference. Dose. —The method of administering the drug is to dissolve 0-1 gramme of novarsenobillon in 1-0 c.c. of sterile distilled water, and inject from 0-5 to 6-0 c.c. as a dose, depending on the age and sex of the patient. 0-5 c.c. is given to children under one year that are in poor health, otherwise we start at 1 c.c., and this dose, up to 1-5 c.c., which is given to children of three to five years, has often to be given into the buttock-muscles. The larger doses are given into the arm-veins with 5-0 c.c. as the maximum female and 6-0 c.c. as the maximum male dose. The same dose is given at each of the three injections. Method of Administration. —These injections are practically all given by our Native medical practitioner and the cadets that we are training to become Native medical practitioners. They scrub their hands with soap and water as for a major operation, and then soak them in a solution of biniodide of mercury prior to giving the injections. The dose is given with a 10 c.c. " Record " syringe, and a 2J in. fine-bore rustless-metal needle, which are sterilized in carbolic acid, 1 in 20, then rinsed out in sterile water, and the requisite dose drawn into the syringe. The patient's skin over the vein is painted with tincture of iodine by an assistant, and the arm congested by holding a rubber tube round the upper arm tight enough to obliterate the superficial veins without obstructing the arterial flow. The needle is passed into the lumen of the vein, and a little blood is drawn into the syringe to make certain that the point of the needle is free in the vein ; then the rubber band is released and the injection given. The syringe and needle are washed in carbolic, lin 20, followed by spirit, and the needle is then allowed to soak in spirit or carbolic while the syringe and another needle are rinsed out with sterile water for the next injection. The use of six to twelve needles in rotation allows one operator to give about fifty to sixty injections in an hour. The intramuscular injection for babies and little children is given at a point midway between the crest of the ilium and the great trochanter of the femur. On malagas, when distilled water cannot be carried, the water from the village drinking-well or stream is used after having been boiled in a clean kettle and allowed to cool. The drinking-water throughout these islands sterilized by this method appears to answer- just as well as distilled water. 11l Effects from the Injections. —These may be grouped under two headings : (a) Immediate, within a few minutes or hours ; (b) remote, coming on the following day or after. (a.) These consist for the most part of vomiting or fainting, with occasionally headache. They are almost without exception due to the patient arriving with an overloaded stomach, or having hurried too much coming to the place of injection, with the result that the patient is hot, exhausted, and has a rapid pulse. These cases appear to suffer no ill effects if not injected till the pidse has settled down. (b.) The remote effects maybe classed as —(1.) Skin disturbances, such as erythematous rashes, followed in some cases by desquamation and often associated with a conjunctivitis. (2.) Kidney disturbances, which usually take the form of a subacute but may develop into an acute nephritis. This condition appears to develop much more frequently in the half-caste than with the pure Samoan children, and has caused the only case of death that has been reported which could be attributed to the drug. This patient was very ill before the injection was given, so that the death was not entirely due to the drug. (3.) Abscess formation : this is by far the most common ill effect, and usually occurs in the buttock of the poorly nourished marasmic babies that are often covered with septic sores, but even under the conditions that are encountered on malaga the proportion of these cases is not high. For example, in the malaga mentioned later, where 1,892 injections were given, only one abscess formed. The buttock-muscles often remain brawny for some days, and in a few cases even weeks, after the injections, and the same may occur in the arm if the novarsenobillon leaks from the vein. (4.) Febrile reaction; this may last from one to three days, but as a rule causes the patient little discomfort. On the whole the ill effects are very rare, only one case being affected for several hundred injected. Effect of Treatment on Yaws. —In November and December, 1923, to test the effect of this method of treatment, a district was selected whose population was rather isolated, so that the results would not be affected by the arrival of people from other districts. The outlet of this district led to Apia, so that any cases that sought injection directly after the malaga would be recorded in the hospital books. The total population of the district was 2,782, consisting of 1,387 males and 1,395 females. Of the males, 61 were infants under two years, 615 were classed as boys (two to seventeen years), 711 as adult men (over seventeen years) ; 727 were women over fifteen years of age. Notification was sent to the Native officials that the malaga party would give injections at five selected villages—each on a different day —the village being selected so that approximately five hundred people lived within easy walking-distance. The injections were given in the early morning of each day, and in the afternoon

a—A. 4A.

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the party moved on to the village where the next injections were to be given : in this way injections were given every day from Monday till Friday, and on the Saturday the party returned to the other end of the district in readiness to start the second injections on the following Monday morning. This is the method usually adopted on these malagas. Throughout the district 695 people were injected, consisting of 35] males and 344 females, who received 1,892 injections. The proportion of these cases to the population was slightly less than the average throughout the islands. The age incidence of people receiving injections is shown in the following table. The ages are frequently incorrectly given and have to be estimated, but probably as a whole the table is fairly accurate, except for the first and second age-groups, which shoidd have larger numbers, because most of the primary and early secondary cases were not brought for treatment.: — TABLE OF AGE INCIDENCE. Up to 1 year .. .. 2 Up to 13 years .. .. 32 ~ 2 years .. 26 „ 14 ~ 16 3 „ .. ..36 „ 15 „ .. 14 4 „ .. ..36 „ 16 „ ..12 „ 5 „ .. ..37 „ 17 „ ..8 „ 6 „ .. ..41 „ 18 „ ..10 „ 7 „ .. ..46 „ 19 „ .. ..11 „ 8 „ .. ..40 „ 20 „ ..9 „ 9 ~ .. .. 31 Adults .. .. .. 188 „ 10 „ .... 47 — „ 11 „ .. ..27 695 „ 12 „ .. .. 26 During this malaga the type of each patient's lesion was noted, as well as the dose, and any reason for giving less than the normal amount. In August, 1924, a second malaga was made through the same district, and nearly all the-cases were seen that had received injections on the first malaga, and from this source, together with those that had come to the Apia Hospital, it was found that seventy-seven cases had relapsed, comprising thirty-one females and forty-six males. Number of cases receiving one injection, 24 ; relapses, 4 16-6 per cent. Some of these cases did not belong to the district, and had left before the second or third dose was given, so that the proportion of relapses is certain to be inaccurate. Number of cases receiving two injections, 135 ; relapses, 20 = 14-8 per cent. Number of cases receiving three injections, 536 ; relapses, 53 —10 per cent. Eight of the fifty-three cases received doses that were smaller than our standard dose for age, due to the patient having associated illness, such as mumps. The cases were divided into the following types : (1) Primary sores ; (2) generalized secondary papular rash ; (3) dermatitis, secondary ; (4) " crab " tonas ; (5) secondary ulceration ; (6) gummatous infiltration and ulceration ; (7) synovitis ; (8) dactylitis ; (9) tibial nodes and sabre-blade tibiro ; (10) dermatitis, slaty ; (11) plantar and palmar dermatitis ; (12) hyperkeratosis. The number of each type injected and the number of relapses is shown in the following table : —

Type I—primary1—primary sores : The proportion of relapses in the few cases treated is very high. This is partly explained by the fact that four out of the six cases were so ill that they received only half the dose that they should have had for their age. Another case was a breast-ulcer on a mother nursing a baby which had the primary sore, and a generalized secondary rash, well marked round the lips, which was so ill that it could only have a small dose, 'which did not""cure the condition and probably led to the mother being reinfected. The number of primary and early secondary rashes seen appeared to be so small compared with the numbers in the later stages that at the time of giving the second injection an order was given that all children under two years were to be brought up for inspection. At this inspection only one child was seen that had reached two years of age without being infected, but none was infected under the age of six months.

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Type of Case injected. — _ _ _ — Totals. 1. 2. 3. | 4. 5. I 6. 7. 8. 9. 10. 11. j 12. Cases receiving Three Injections. Number of cases injected .. ..I 6 1 196 j 110 I 89 5 37 1 2 3 28 54 j 5 536 Number of relapses .. .. j 5' 32 6 8 .. 2 I 53 Percentage of relapses . . .. 83 16*3 I 5*45 | 8-9 .. 5*4 . . .. .. . . . . . . 10 Cases receiving Two Injections. Number of cases injected .. .. I 1 1 41 I 30 22 2 ! 14 1 | .. I .. I 9 | 13 2 | 135 Number of relapses . . .. j 1 13 3 1 .. 2 20 Percentage of relapses . . .. 100 ' 41-4 ' 10 4-5 . . 14-3 .. ! .. ! .. I .. . . .. 14-8 Cases receiving One Injection. Number of cases injected .. .. .. 7 8 II II 4 I .. I .. I .. I If ] 1 24 Number of relapses .. .. .. 2 2 ..j .. ..I .. .. .. .. .. .. 4 Percentage of relapses .. .. .. 28-5 25 .. .. .. .. j .. . . j .. 1 . . .. 16-6 I I I I I i I

A.—4A

The reason given by the Samoans for not having brought their young children for the first injection was that they think three crops of frambcesial rash should come out before any treatment is given, and also fear of the effects of injecting a young baby. This belief is gradually dying down, but it will probably be some time before the Samoan realizes that his children should come on the first signs of the disease. The underdosing of the primary cases, although it did not cure the babies, had a marked beneficial effect both on the individual cases and in encouraging the populace to bring their children early, because the cases that we were allowed to inject on the first malaga were so ill that their parents brought them for injection as a last hope, and they all survived and were comparatively healthy, in spite of some secondary rash at the time of the second malaga, which seems to show that the injected children probably derived considerable benefit, although not cured. Types 1 to 3 are practically limited to children in the first decade of life. Types 4, 5, 7, and 8 are rarely seen above fifteen years, while type 9 is usually not active after fifteen years of age, although permanent results are carried throughout life. Types 1 to 9 do not materially differ from the types of lesion described by Spittel* as due to yaws. Type 10 we believe to be a yaws condition. It commences by the skin on dorsum of the hands and feet becoming dry and turning a slaty-blue colour. The superficial epidermis is then shed in large, thin flakes, leaving a tight atrophic skin below. This continues for some months, the proximal border gradually spreading up the foot and hand till it reaches well above' the wrist and ankle ; at the same time all the pigment is extracted from the skin first affected, so that the dorsum of the hand or foot will be leucodermatous while the ankle and wrist are a slaty-grey. The condition usually starts in the third or fourth decade of life, and may continue for many years. In the old standing cases the process may extend half-way up the leg or forearm. On receiving injections all exfoliation and cracking stop, the slaty colour of the skin disappears, and the whole of the skin becomes more supple and healthy. The leucodermatous patches remain permanently. There seems to bo no tendency to recurrence, as is shown by cases that have been injected three years ago without recurrence. Type 11 : Probably many conditions are grouped under this heading, but they all affect either the soles of the feet or the palms of the hands—usually of adults. Generally the condition shows as a thickening of the skin, which is either punched out in what might be described as worm-eaten holes, or may simply have deep and painful cracks ; or the skin may peel off in large, irregular flakes, with occasionally small deep-seated water-blisters in it. The condition is worst in the wet season, and we think that moisture is probably a necessity, if not the only cause, in many of the cases. It shows a great tendency to relapse every year at the same season, and does this in spite of all treatment. The reason for having so many apparent cures was that the first malaga was held in the wet season, while the second was just at the end of the following dry season. The injections seem to always give considerable temporary relief. Type 12 : In this type there is very marked increase in the horny layers of the skin, usually seen in young adolescents in Samoa. The condition is not common and does not appear to be influenced by the season of the year : we believe that it is probably due to yaws. The effect of N.A.B. injections are variable, but usually cause considerable improvement. Type 6 : A large proportion of these cases received treatment with potassium iodide as well as injections, but in cases treated medicinally at their homes it is always uncertain whether the medicines prescribed are taken as directed, or even whether they are taken at all, so that no more mention will be made of this additional treatment. The figures given in the above table show that the percentage of relapses in the earlier stages of the disease is much greater after only two doses than after three doses of novarsenobillon, and probably four injections would give still better results ; but there is always the danger that if we make the cure too complete we may remove the immunity that an attack of the disease conveys against a second infection. At the present time some 51,000 injections have been given on the three-injection system without causing a single case to become reinfected with yaws, so that it may be fairly safely assumed that we are not removing the immunity conveyed by an attack of the disease. If the cases were completely cured and all immunity lost, it would seriously affect our campaign, for at present the primary and secondary stages of the disease are entirely confined to the children amongst the Samoans, and a cure that allowed of reinfection of adults would soon tend to loose favour, however good it might be, for large areas of the population can receive treatment for the condition only once or twice in the year at the most. When the medical service has expanded sufficiently to allow us to have Native medical practitioners in every district of Samoa, so that cases can receive immediate treatment, then complete cure will be safe and will be the ideal treatment. But at the present time we endeavour to keep an immune adult population, by merely treating cases sufficiently to cure the infective primary and secondary rashes, which may also prevent the occurrence of the disabling tertiary conditions. This we. hope will allow a large proportion of the present children to reach adult life without becoming infected, and so gradually exterminate the disease without risking a serious epidemic of yaws amongst the adult population before we have the personnel to control it. The immunity which an attack of yaws gives the Samoans in preventing their infection with syphilis, as stated by Parhamf seems to be very great, as we have never seen a case of syphilis in

*R. L. Spittel, F.R.C.S. : " Frambcesia Tropica," pp. 3-44 ; London, 1923. Parham, J. C.: " Relation between Syphillis and Yaws." American Journal of Tropical Medicine, Vol. 11, p. 347, July, 1922.

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a Samoan ; and we think that it would be a crime to remove that immunity at the present time. By the time that the present children reach adolescence it is hoped that syphilis will have very largely been brought under control by the European races, so that the chance of its introduction will be very much less, and, even if introduced, the population will bo under more close medical supervision, so that any outbreak would be quickly reported and controlled. Conclusions. 1. That in the treatment of yaws, with a view to eradicating the disease, some system of free injections for the patients is essential. 2. That the system of three injections which we practise does not entirely destroy the immunity conferred by an attack of yaws. 3. That at present it is desirable to maintain a certain amount of immunity in the population of Samoa to prevent the introduction of syphilis. 4. That the system of three injections prevents a large amount of the sickness and disability in the Samoan population from yaws, although a small proportion of the cases still relapse, but this is preferable to a more thorough treatment which might remove the patients' immunity and allow of reinfection. 5. That Samoans can readily be trained to administer this treatment, and it has proved to be a safe remedy in their hands. APPENDIX C. LEPROSY IN WESTERN SAMOA. Answer to Questionnaire of the British Empire Leprosy Relief Association, of Date January, 1924. 1. Name of country or area dealt with : The Mandated Territory of Western Samoa. (a.) Area in square miles : 1,133 square miles. (b.) Population by race or religion and its distribution : (1.) Population by Race. Census, Estimated, 1921. December, 1923. Europeans (including half-castes) .. .. .. 2,026 2,124 Samoans .. . . .. . . .. 32,601 33,800 Chinese* .. .. . . . . .. 1,597 967 Solomon Island and Polynesian labourers .. .. 465 208 (2.) Population by Religion (1921 Census). Native adherents London Missionary Society (Protestant) .. .. 21,225 Native adherents Wesleyan Methodist Mission .. .. .. .. 5,806 Native adherents Roman Catholic .. .. .. .. .. 5,284 Native adherents Mormon Mission . . .. .. ~ .. 634 Native adherents Adventists .. .. .. .. .. 4 32,953f (3.) Distribution. As the interior in both islands is mountainous, there are very few inland villages. The Natives live in coast villages scattered round both islands. (c.) Climate and other relevant facts : The following quotation is taken from a brief resume of the meteorological work of the Apia Observatory : — "The annual rainfall at Mulinu'u for the past twenty years is 107-9 in. The driest year was in 1905, when the rainfall was 65-2 in ; and the year with the greatest rainfall was in 1908, with 172-8 in. January is the rainiest month of the year, with an average of twenty-one days with rain, and a precipitation of 16-5 in. July is the driest month, with twelve rainy days, and a precipitation of 2-8 in. In the wet season, from November to April inclusive, 75 per cent, of the rainfall occurs. From 3 p.m. to 6 p.m. is the time of day when rain is most probable. On account of the mountainous character of Samoa, the rainfall varies widely from point to point. In Apia, in the neighbourhood of the Casino the rainfall is 10 per cent, less than at the Observatory. Farther east the rainfall increases. In general, the south coast of both Upolu and Savai'i receives one-third more rain than the north coast. The rainfall in the interior increases about 5i per cent, for every increase of 100 ft. in altitude. Thus Afiamalu, with an altitude of 2,000 ft., has a rainfall almost twice as great as Apia. In the interior of Savai'i, where the mountains reach a height of 5,000 ft., the rainfall exceeds 250 in. a year. About thirty thunderstorms occur each year, largely in the wet season.

* Number decreasing through repatriation. In 1914 number was 2,560. t Slightly over estimated population. (32,601).

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" With a tropical rainfall the humidity throughout Samoa is necessarily high. The annual mean relative humidity at Apia for thirty years is 83-3 per cent., and different stations at various altitudes give about the same value. The difference between the wet and dry season is only 2-6 per cent. During the day the humidity is greatest at 3 a.m. and least at 11 a.m. On account of the equalizing effect of the ocean there is very little variation in the temperature from month to month during the year. The mean temperature at Apia is 784° F., and the coldest month, July, is only 2.3° F. less than the hottest month, December. During the day the average temperature-range is 11-3° F., but temperatures as high as 94-3° F., and as low as 61*5° F., have been recorded at Apia." 2. Census or official rate per mile : Leprosy in Western Samoa is not common. For known incidence during the last thirty years see Annual Medical Report for 1923-24. 3. What legal powers exist as regards — (a.) Compulsory segregation ? There are no special leper regulations in Western Samoa, as there is no necessity for such. Leprosy is indicated in the schedule of infectious disease in the Samoa Health Order, 1921, and can therefore be dealt with under section 27 of the Samoa Health Ordinance, 1921, which reads as follows : — " 27. (1.) The Medical Officers of Health or any Medical Officer, or any Inspector of Health, in any case where in the interests of the public health he thinks it expedient so to do, may make an order for the removal of any person suffering from any infectious disease to a hospital or other place where such person may be effectually isolated. " (2.) An order under this clause shall be made in every case where the Medical Officer of Health or any Medical Officer, or the Inspector, is satisfied that the patient cannot without removal be effectually isolated or properly attended. " (3.) An order under this clause may be executed by the Medical Officer of Health or any Medical Officer, or the Inspector, or by any person authorized in that behalf by the Medical Officer of Health or any Medical Officer, or the Inspector, and may be executed by force if necessary." (b.) Prohibition of occupation concerning food, clothing, and domestic service ? Under the New Zealand Sale of Food and Drugs Act, and its regulations, made applicable to Western Samoa by the Samoa Health Order, 1921, persons suffering from infectious diseases are prohibited from handling foodstuffs. But powers regarding prohibition of occupations are unnecessary, as all lepers are segregated and transported to the leper asylum on the Island of Makogai, Fiji (c.) Are there legal povjers to repatriate leper immigrants and those developing it within a given period after arrival ? Yes, in the case of Asiatics. The Chinese contract labourers introduced into Samoa for work on the plantations can be repatriated on expiry of contract or on determination of contract. These are for all practical purposes the only people for whom legal powers of repatriation are required ; other cases can be repatriated for various offences, but leprosy is not included in the powers of repatriation. (id.) How far are such powers exercised ? They are not exercised in the case of lepers ; such lepers are dealt with in the same manner as those found amongst the indigenous population. 4 to 11. [Note : These questions deal with institutions and treatment, and are not now applicable in the case of Western Samoa.] Prior to 1922, lepers in Western Samoa were isolated, at a leper-station on an outlying island off the east coast of Upolu. The small number of lepers and the lack of facilities for communication made it impossible for adequate medical attention to be given. Arrangements with the Government of Fiji for concentrating our lepers at the leper asylum on the Island of Makogai, Fiji, were completed in 1922, and the lepers were transferred to Makogai in July and August of that year. In future, lepers will be transferred to Makogai once a year. Whilst awaiting transfer they are isolated and treated at the Apia Hospital. From a humanitarian point of view there can be no question of the success of our present policy, and financially the burden is no greater than it was up to the time of transfer. 12. in addition to improving treatment, in what way could the Association best help you? We desire to keep informed of the Association's activities. 13. Have you any suggestions to make regarding the proposed lines of work of the Association? No. 14. Please sup-ply any additional information of interest regarding the prevalence and modes of spread of leprosy. A short article, giving history of leprosy in Western Samoa, in so far as it has been possible to obtain information, was published in the Annual Medical Report for the year 1923-24. 15. Do the indigenous population employ any special remedy against leprosy, and, if so, can you obtain some for inspection ? Not so far as is known. Leprosy is not a disease of long standing in Western Samoa. 16. Do you see the Tropical Diseases Bulletin, or would you like to have abstracts of leprosy papers ? The Bulletin is obtained for our medical library.

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17. Mention any local customs or conditions affectin/f^leprosy work. General lack of sanitation, a condition which is being rapidly improved. 18. How is your area off for hospitals, qualified doctors, and public-health activities ? Adequately provided. For activities see Annual Medical Report. 19. Please stale how you consider the extinction of leprosy could best be affected. In so far as the Native races of the South Pacific are concerned, by —(1) Education of the Natives in hygiene and sanitation ; (2) combing the population for cases of leprosy; (3) segregation and treatment of all cases discovered. 20. What is the prospect in your area of Government and 'public support for an anti-leprosy campaign ? Any activities which will help in freeing these islands of leprosy are assured of support. 21. Please give other relevant facts, if any, not covered by the questionnaire. APPENDIX D. THE CONTROL OF MOSQUITOES IN APIA, SAMOA. By P. A. Buxton, M.R.C.S., L.R.C.P., D.T.M. &H. (Expedition of the London School of Hygiene and Tropical Medicine to Samoa.) I propose to record some observations upon the mosquito (Aedes variegatus, Stegomyia pseudoscutellaris) which carries filariasis in Samoa, and to confine myself rather strictly to what has obvious bearing on the question of reducing the numbers of this very dangerous insect. But before I discuss the specific measures for its control it must be understood that no work directed against this one species will be effective unless general anti-mosquito measures are also prosecuted vigorously. The success of any health campaign depends largely on the interest and help of the mass of the population. The most irritating mosquito is not the day biting Stegomyia, which is our special objective, but the virulent night biting Culex fatigans and F inlay a kochi. As long as the Culex and F inlaya make night unpleasant, so long will people in general say that anti-mosquito measures are useless and irksome, even if a great reduction in the numbers of the more dangerous Stegomyia, is effected. The principal breeding-place of Culex fatigans in Apia appears to be septic tanks and pit privies. It would be a very simple matter to screen with gauze the ventilators of the septic tanks ; it would not be an enormous task to treat the pit privies with cresol once a month. The extermination of Finlaya is a simpler matter, though I doubt if public opinion is ready for it; it can be accomplished by forbidding the growing of taro and tarnu (Colocasia species) within the municipal area. This measure would be entirely successful, and no other measure would be the least use. Every taroplant holds a few ounces of water among the bases of the great leaves, and in every plant one can find the larva; of Finlaya, and this is their only regular breeding-place. It would greatly assist in reducing the amount of taro grown if the water-level of the Taufusi Swamp could be lowered a couple of feet. Speaking as an amateur, I feel hopeful that the control of the mouth of the Mulivai by gates which could be shut at high tide would effect a great deal at small cost. The urgent need of dealing with this swamp must be apparent to any one who gives attention to the matter. It occupies land which must be used as a town-site, and which will greatly increase in value as agricultural land when it is drained ; it makes the proper disposal of sewage almost impossible ; above all else, it is a great potential danger, because if Anopheles were introduced from the New Hebrides or Solomon Islands, Samoa would be faced by -such an epidemic as decimated Mauritius in 1867-68. The evidence tends to show that two species of Anopheles were introduced into Mauritius from Africa, over a much greater stretch of sea than that which separates Samoa from Melanesia ; the result was the ruin of Port Louis and the coastal zone, the emigration of the white population to the hills, and the death of over thirty-two thousand people in two years. Once the Taufusi Swamp is drained, the accidental introduction of Anopheles will be less likely. The present condition of the swamp is shown in figures 8 and 9 —photographs taken from one of the main roads in Apia. So much for the more general mosquito control, which will render life more pleasant, but which will not effectively reduce the numbers of any disease-carrier. Let us turn to the question of controlling the carrier of filariasis, Aedes variegatus (Stegomyia pseudoscutellaris), remembering that a large proportion of Natives (O'Connor found a filarial incidence of. 58-3 per cent, in 2,509 Samoans over fifteen years), are infected by it and suffer from the diseases associated with its presence in the body. The habits of this particular species of mosquito have already been studied by Doane, and more recently by O'Connor. Since our arrival in Apia in January, 1924, my assistant, Mr. G. H. E. Hopkins, and myself have devoted a good deal of time studying its natural breeding-places, but we have done little more than confirm the findings of the earlier workers. The principal breeding-places are — (1.) Coconut-shells, both those which have been opened by man in cutting copra or for drinking, and also fallen green nuts opened by crabs and rats. (2.) Rot-holes in trees. The insect is by no means a domestic insect, and great numbers may be found in every uncultivated part of the island. The commonest rot-holes in town are those in kapok, candle-nut, fao (Hibiscus tiliaceus) and other trees which are pollarded and used as fence-posts. Eig. 10 shows a row of pollard fao-trees full of small cavities. Breadfruit-trees are dangerous because horses gnaw the bark and let in the rot. Mangoes are dangerous because their great forks often hold several gallons of water. The steps cut in the trunks of coconut-palms often contain water and larvae (fig. 11). The mangroves (Rhizophora) in the mouths of the rivers are full of little holes in which Stegomyia breeds in great numbers. This is quite a serious matter in Sogi and the west end of Apia generally.

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Fig. 8. —Taufusi Swamp, showing taro and tamu plants in which Finlaya kochi breeds.

Fig. 10. —Fao-trees used as fence-posts, lopped and containing small rot-holes.

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Fig. 9. —House and taro swamp, close to centre of Apia.

Fig. 11.—Coconut-palms with steps cut in them.

To face page 22.]

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Fig. 12. —Fale at Safotu, built by the Natives as a dispensary hospital. Figs. 13 and 14 show interior views.

Fig. 13. —Interior of fale. Note floor of pebbles, which will be replaced by cement before fale is used as a hospital.

Fig. 14.—Roof of fale. No nails are used, the materials all being bound with 'afa, a string made from the fibres of the coconut-husk.

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(3.) Cacao-pods, gnawed by rats, are an important breeding-place, but hardly matter in Apia,, as so little cacao is grown close to the town. (4.) There are a number of breeding-places of less importance' —holes in rocks (especially when full of rotten leaves) water-butts, old tins, &c. I have no evidence against the crab-holes on Mulinu'u, and I have not yet found larva; in the crown of coconutpalms. After studying the mosquitoes for several months, I arranged with the Chief Medical Officer to attempt the practical control of this insect in that part of the town between the Mulivai and the Vaisigano. The inhabitants are mostly white or half-caste, and were very willing to do their part, and the work was carried on as a large-scale experiment, for six months. I reached, the following definite conclusions :— 1. Aedes variegatus was certainly greatly reduced in numbers. 2. Health Inspectors could very easily carry on the work, but they must be specially trained. It is not sufficient to look for unscreened cisterns, sagging gutters, old tin cans, and obvious breedingplaces of that sort. One must search also for rot-holes, even little ones, and either drain them with a chopper or else fill them with stones and sand. One must also pay special attention to the clearing of scrub in paddocks, &c., around gardens. It is only when it is cleared that the coconut-shells become apparent and can be collected and destroyed. By clearing scrub the general ventilation of houses is also enormously improved and the collection of the copra is facilitated. By attending to rot-holes and the cutting of scrub a very great reduction in the numbers of this mosquito may easily be maintained. 3. It is quite impossible in the present state of knowledge to exterminate this insect, because the great forest areas, with their innumerable little rot-holes, are its stronghold. Any method, therefore, which can be used to reduce the numbers, even a little, is valuable. I propose to search in the New Hebrides for insects which might possibly prey on the larvae of Stegomyia and be capable of breeding in the little rot-holes, &c., in which they are found. If such a predaceous insect could be found, and if it was.not objectionable on other grounds, it would constantly be doing its bit, and doing it at no cost to the community. 4. Public Health Regulation No. 5 is sufficiently clear and wide ; I only made formal use of it on two occasions. If at any time it is revised it might be well (a) to include " rot-holes in trees " among the breeding-places listed in paragraph 4, and (b) to forbid growing taro and tamu within the Apia municipal area —if the time is ripe for doing so. It will also be necessary to take steps to cut the mangroves regularly as often as they are big enough to have rot-holes in them. This would have to be done by the Government. There is presumably no responsible owner of a tidal mangrove swamp. APPENDIX E. THE CLAYTON LANE TECHNIQUE USED IN THE FIELD TO CONTROL HOOKWORM TREATMENT. By G. H. E. Hopkins, 8.A., P.E.S. (Expedition to Samoa of the London School of Hygiene and Tropical Medicine). (Reprinted from Trans. Roy. Soc. Trop. Med. & Hyg.) The author was recently requested by the Administration of "Western Samoa to carry out an investigation into the efficacy of the treatment now in use against hookworm infection among the Native population. The experiments described below were made in fulfilment of this request. The results are thought worthy of publication because the Clayton Lane technique has apparently not often been used in field-work, and the much-used Willis technique is here directly compared with it. The form of the method used was that described by Colonel Lane (" The Mass Diagnosis of Ankylostome Infestation," Trans. Roy. Soc. Trop. Med. & Hyg., March, 1924), who instructed the author in the technique. It was therefore exactly as used by him. Colonel Lane also passed the apparatus used as being correct. It was made by Messrs. R. B. Turner and Co. A series of fifty-four specimens from individuals taken at random from the patients and staff in the Apia Hospital, Samoa, was examined in order to compare the accuracy of the Clayton Lane and Willis techniques. A number of these stools were also examined by the direct smear method. The Willis method is as follows : About a gramme ! of faeces is well mixed with saturated salt solution in the quarter-ounce tin container in which it is obtained from the patient. The tin is then filled to the brim with the salt solution and a glass slide is placed over it. After about twenty minutes the slide is removed and examined under the microscope, smear side up. Malakai, a Eijian assistant of Dr. S. M. Lambert, of the International Health Board of the Rockefeller Foundation, performed the examination by the Willis method, while those by the* Clayton Lane method were performed by the author. Malakai was expert in the Willis technique, having [used it Jin working under Dr. Lambert for a considerable period. Of the. fifty-four individuals examined, the Clayton Lane method showed fifty (92-6 per cent.) to be infected, while by the Willis method the number found affected was forty-seven (87 per cent.). From seven individuals who were lightly infected several specimens (nineteen in all) were examined by both methods on different days. Of these nineteen specimens the Clayton Lane method showed fourteen (seven individuals) positive for hookworm, while the Willis method showed only four specimens (three individuals) positive. It is evident that for very light infections the Clayton Lane technique is much more accurate than that of Willis. One of the cases in which the Clayton Lane method gave a positive result while the Willis method did not was that of Malakai himself. He was

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convinced that this was an error, possibly due to the carrying-over of an egg in the cylinder used for measuring the specimen of faeces, and to prove himself free from infection he took 3 c.c. of oil of chenopodium on his return to Fiji. The result was to demonstrate the accuracy of the Clayton Lane method, for in his first day's stools he passed one male and one female Necalor americanus. On completion of this preliminary work the author examined a long series of Samoans living in Aleipata, a district at some distance from Apia. The district was chosen because it had never received mass hookworm treatment. The population is a fair average sample of Samoans living under normal conditions and not much in contact with Europeans. There are drop latrines over the sea in some of the villages, but the seashore and bush round the village are favourite places for defsecation. Furthermore, the t.aro patches are at a distance of some miles from the villages, and the soil in their neighbourhood must be heavily polluted. The cases were collected at random, except that no children apparently under twelve years of age and no persons who had previously had hookworm treatment were accepted. The procedure was as follows :— Containers (the quarter-ounce tins used by the International Health Board in the Willis technique) were given out to the people through the head man of the village, and brought in by the individuals themselves next day. The number of eggs obtained from 1 c.c. of faeces from each individual by the Clayton Lane method was counted, and each person was treated with a mixture of oil of chenopodium (one part) and carbon tetrachloride (three parts), the dose varying according to the age and health of the individual, but with a maximum of thirty-five minims of the mixture, given in an ounce of magnesium-sulphate solution (one part salts in four of water). After an interval of three weeks a second specimen was examined in the same way, and a second dose of the drug administered to each person. A third examination at the end of a further three weeks gave the result of this second dose. No complaints of ill effects from the drug were received, and several patients stated spontaneously that they were much benefited by the treatment. The preparation of the stools for examination was done by a Samoan medical cadet, who performed the work quite satisfactorily after doing it under supervision two or three times. It was found that a trained microscopist can without difficulty count the eggs in about ten to twelve samples of fseces per hour, but this number varies considerably with the average severity of infection, specimens containing many ova taking much longer to count than those containing few (the heaviest infection found was 1,050 eggs per cubic centimetre of stool). The specimens were centrifuged two at a time, and it was found that the centrifuger was able to keep the microscopist constantly supplied on the first examination, but not on the later ones when the average infection was lighter. If a mere diagnosis of positive or negative were required a much larger number of specimens could be examined in the same time and a centrifuge with a larger number of buckets would be desirable. The apparatus is quite light, and could easily be carried from one village to another by one man. The only piece of apparatus I, required locally is a table on which to fix the centrifuge. Failing this a substitute can easily be improvised. Apart from the preliminary cost of the apparatus, the method is very economical, the only material required being a saturated solution of common salt. The counting of eggs in a heavily infected specimen would be much facilitated by the use of an eyepiece micrometer ruled in 1 mm. squares. A drawback of the technique is that the salt solution used rapidly corrodes the aluminium arms of the centrifuge. This could probably be avoided by giving the arms a thick coat of paint or varnish or (better) using arms made of brass or some other metal not affected by salt. The results of these examinations are shown in the following table. Since Clayton Lane does not claim that his method is accurate for ova of Ascaris, no special search was made for these, but a note was made when they were observed. The figures of Ascaris infection are therefore only approximate.

In the columns headed " Total Eggs " and " Average Number of Eggs per Cubic Centimetre per Person " those individuals who did not come up for all three examinations are ignored. It will be seen from the table that the number of total cures resulting from one treatment was not very great, the percentage of infected persons being reduced to a little less than two-thirds of the previous figure. The reduction in the number of eggs, and therefore, of the number of worms per individual, was, however, very striking, in spite of the fact that in a few cases no change or even increase was observed. Such cases are probably accounted for by migration of hookworms from the lungs to the gut during the three-weeks interval, though it is possible that some were due to substitution of a specimen from a different individual before it was brought to the laboratory, since it was not practicable to actually supervise the filling of the tins, Every precaution was taken to avoid the sharing-out of one stool

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Hookworm. j Ascaris. Average xr 1 vr i Infection j T , , v dumber of Infection Number Number p^ r Total Lggs Eggs per Number I p examined, infected. , " (294 Persons). Cubic infected. centage. v ' n . cent age. ° i (Centimetre r per Person. I . I | i I Before treatment .. 333 322 96-7 21,108 71-8 113 33-9 After first treatment .. 309 j 183 i 59-2 3,201 10-9 | 22 7-1 After second treatment .. 294 110 37-4 585 0-2 2(j 8-8

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amongst several persons, and such points as the colour and consistency of the stool and the presence and severity of Ascaris infection were a useful check in doubtful cases. Such sharing-out was detected in one case, but it probably did not take place to a degree sufficient to vitiate the results. The results of the third examination correspond well with those of the second, the percentage of infection being again reduced by about one-third, while the average number of eggs per specimen was very greatly reduced. It would appear that while the effect of one treatment is very good, it is desirable that it should be followed by a second. It is doubtful if, under conditions of mass treatment, a third dose is desirable. Tt also appears that the Clayton Lane technique can be usefully employed in the field to diagnose the residual infections after treatment lias been given. For this purpose the Willis method is quite unsuitable, owing to its inaccuracy in the case of light infections. APPENDIX F. HEALTH SURVEY OF WESTERN SAMOA, WITH SPECIAL REFERENCE TO HOOKWORM INFECTION. By S. M. Lambert, M.D., of the International Health Board of the Rockefeller Foundation. Introduction. In 1923 the Administration of Western Samoa invited the International Health Board of the Rockefeller Foundation to make a health survey of Samoa, with special reference to hookworm disease. The invitation was accepted, and the survey began 24th July, 1924, and ended 18th August, 1924. Acknowledgments.—We are indebted to His Excellency Major-General G. S. Richardson, C.8., C.M.G., C.8.E., Governor of Western Samoa, for his invitation and for his co-operation in the survey. We thank the Chief Medical Officer, Dr. T. Russell Ritchie, for the courtesies offered us and for the assistance given. Dr. P. A. Buxton, of the London School of Tropical Medicine, placed his laboratory and equipment at our disposal, and Mr. G. H. Hopkins kindly supervised the series of comparative tests during my absence. We thank Dr. Armstrong for permission to use material from a paper of his (our section on transmissible diseases is largely based, on this paper). Dr. Hunt was most kind in selecting and treating patients and affording us facilities for worm-counts. Mr. Griffen, the Native Commissioner, was patient with us in his explanations of Native customs. Mr. Bigg-Wither, Resident Commissioner, Savai'i, was most hospitable during our visit with him. W r e accompanied His Excellency on a two-weeks rnalaga, or journey, around the large island of Savai'i. We saw eleven thousand of the twelve thousand inhabitants of the island, four to five thousand of these being lined up for our close inspection. It was an unequalled opportunity to gain a knowledge of actual conditions at first hand. Part I. —General Survey. 1. History of Western Samoa. The earliest visit paid by Europeans to the Samoas, or Navigators Islands, of which any record has been preserved was by Roggewein, in 1722, in the Dutch " Three Sisters Expedition." The French explorers followed, Bougainville in 1768 and La Perouse in 1787. In 1791 the British vessel " Pandora " visited the Samoas. In 1830 the London Missionary Society established a mission in one of the islands, and followed it up with extensive operations in the Group. The United States exploring expedition, under Lieutenant Charles Wilkes, United States Navy, made the first scientific researches in the islands in 1839. This expedition, consisting of six vessels, was equipped for the particular purpose of surveying and exploring the unfrequented islands of the South Seas. A staff of competent civilian scientists was on board these vessels, which were all navy vessels thoroughly prepared for exact scientific work. The hurried surveys of Samoa made by these men are the basis of our charts. , As early as 1850 England, Germany, and the United States were represented by commercial agents in Samoa. During the next twenty years Englishmen, Germans, and Americans acquired land and entered into intimate relations with the Natives. From 1870 to 1899 the history of Samoa is the history of selfish nationals in their endeavour each to gain the upper hand and have their country assume the control of Samoa. The nationals of one of these might support one Native faction, and another nation another faction, several times nearly precipitating the naval forces of the mother countries in armed conflict with each other. Several forms of Commission were tried with representatives from each country, or with Commissioners from a neutral country, but all were failures. Finally affairs culminated in 1899, when a combined force of British and American marines were ambushed by the Natives and several of the marines were killed. When this news reached Home a Commission of three men was sent out, representing the three countries involved —England, Germany, and the United States —and in 1900 it was decided that the only solution was a partition of the islands among the three Powers. Great Britain and Germany made a separate agreement by which Great Britain exchanged her interests in Samoa for Choiseul, Ysabel, and the Shortlands, controlled by Germany in the Solomons, and a port in Africa. Germany continued in Samoa until the outbreak of the Great War in 1914, when a New Zealand expedition proceeded to Samoa, captured and held it for strategic purposes. At the settlement, former German Samoa was given to New Zealand to be governed under a mandate, with the title of " Western Samoa."

4—A. 4A.

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Western Samoa consists of the islands formerly held by Germany—Savai'i, Upolu, Apolima, and Manono. American Samoa consists of the islands of Tutuila, and the group of three- —Tau, Ofu, and Olosenga —which constitute Manua. 2. Physical Features. Samoa, or the Navigators Islands, lie in the South Pacific in 13|° to 14° south latitude and 168° to 173° west longitude. The area of the four principal islands is about 1,200 square miles. The annual rainfall for twenty years has averaged 107 .in., the driest year, in 1905, with 65 in., and the wettest year, 1908, with 172 in. Samoa is of volcanic origin, with high mountains, which makes a varied rainfall. The south coasts of the islands have one-third more rainfall than the north coasts. As one goes up in the hills the rainfall increases 51 per cent, for every 100 ft., so that Afia Main, with an altitude of 2,000 ft. above Apia, has a rainfall twice as great. In the interior of Savai'i at 5,000 ft. altitude there is a rainfall of over 250 in. a year. The annual mean relative humidity at Apia is 83 per cent. The difference between the wet and dry seasons is about 2-6 per cent. The mean temperature at Apia is 78-4°, and the coldest month, July, is only 2-5° less than the hottest month, December. The south-east trades blow from May to October, and make the climate during this period very pleasant. Savai'i is the largest island —about 150 miles in circumference, with a height approaching 5,000 ft. It is the least fitted of the Group to support a large population, having been so recently the subject of volcanic action, and much of its surface is absolutely sterile. In spite of the high rainfall, Savai'i has only one river, as the soil is so porous. Savai'i has a population of 12,000. Upolu is separated from Savai'i by a channel eight miles wide. This island is forty-five miles long and fifteen miles wide. It has running through its centre a high chain of mountains, whose sides are grooved with rich valleys, some of them miles in width and many miles long, filled with productive plantations of coconuts lying along pleasant streams that flow to the sea. Upolu, said to be the most fertile, is certainly the most beautiful island I have seen in the Pacific. Apia, the capital of Western Samoa, lies on the north coast of Upolu, on the shores of a harbour uncertain in the south-east season, and a dangerous harbour during the north-west season. It is a picturesque town, with many modern appointments, and a most interesting and comfortable place in which to live or visit. Upolu has a population of 19,800. The other two small islands of Western Samoa are Apolima and Manono. Apolima has a population of 126 ; Manono has a population of 668. 3. Population. The Native population in 1923 was reckoned at 33,800. In addition there were about 2,000 Europeans and half-castes and 1,000 Chinese. The earliest estimate of the population of Samoa is that of Wilkes in 1838, who placed the figure at 46,600. In 1843 the London Missionary Society placed it at 40,000. The Rev. J. P. Stair, resident in the islands at the time, considered this an understatement, his figure being 45,000. Captain Erskine, in 1849, reckoned the population at 32,000. In 1854 the London Missionary Society gave the population at 29,237. These figures were probably pretty accurate. These figures show a rapid decline of the population from 1839 to 1854. The missionaries and travellers account for this in their writing by the devastating effects of various epidemics that occurred during this period, epidemics to which the Natives had no power of resistance. Dysentery, influenza, whooping-cough, mumps, and measles are mentioned. In 1886 the population is given as 29,000 by John P. Thurston. Since that time the population has increased rapidly at times, though now and again set back by epidemics which have entered. So much has been written about the Samoan that any long description would be a tedious repetition. He is said to be the true Polynesian, and Savai'i is said to be the distributing-point from which the migrations among the Pacific islands took place. The people are large, with powerful well-formed bodies and handsome intelligent faces, light-copper-coloured, with regular features described as Caucasian, though the work of an expedition from the Bishop Museum of last year would indicate a large Mongoloid element in the population. Samoans are intelligent, goodnatured, and courteous. They are criticized for their indolence by those who forget that with their fertile country in which everything grows so readily they have no necessity for work. No man works ia the tropics without some compelling motive, and the Samoan has none as yet. TTe will not be a worker till such time as population presses upon subsistence, or till he is given some other stimulus by education which will raise his standard of living and create new necessities. The unit of living is the family, which works together and shares under the direction of the family head. 4. Government. Western Samoa is governed by New Zealand under a mandate. The Governor of the Territory is His Excellency Major-General G. S. Richardson, C.8., C.M.G., C.B.E. He is assisted by a Legislative Council, which consists of six heads of departments and of three elected members. The Council of Faipules, thirty-three in number, form a Native Parliament, which convenes twice yearly and advises the Government on legislation for Samoans. These Eaipules are chiefs or orators, selected from amongst the most influential Samoans, and each one is appointed over a district, in which he is the highest Government official, supervises Government in that district, and answers only to the Secretary for Native Affairs. The general idea of government is to teach the Samoans to be, so far as possible, self-governing.

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5. Education. Till the present Administration the education of the Samoan has been in the hands of the missionaries almost entirely, and to them thanks are due for the 85 per cent, of Samoan literacy. They have had a system of schools in each village, taught by pastors who acted in a dual capacity of teacher and preacher. Reading and writing and some arithmetic were taught, and the instruction was largely of a religious nature. Under the present Administration a co-ordination is being attempted between these mission schools and those which have been introduced by the Administration. The scheme plans to leave the education of children from five to ten in the hands of the mission schools taught by dual teachers —i.e., pastor and teacher. There are about six thousand in these schools of the London Missionary Society, Methodist, Catholic, and Morman missions. No English is taught in these schools. From the ages of ten to fourteen these children will pass into the so-called secondgrade schools, taught by full-time Samoan teachers trained in Apia in teaching methods and English by New Zealand teachers. The buildings for these second-grade schools are furnished by each mission for its own second-grade scholars, as are the teachers. These, however, are paid by the Government an annual salary of £25. There are 2,400 children in daily attendance at these second-grade schools. From these each year the best twenty will be chosen by examination, and will be given a course in a Government agricultural school. There are eighty students in the agricultural school. From this school the best boys are taken to two schools, one in Savai'i and one in Upolu, where they are given a finishing course by white teachers to fit them for positions in Government services. In Apia there is a school for European and half-caste children, with an attendance of 240. An interesting feature of the Samoan school system is the publication of a quarterly journal, the Samoan School Journal, illustrated, and filled with short articles printed partly in English but largely in Samoan, the material of which is used for study in school classes. Unusual Educational Features. —The annual malaga, or journey, made by the Governor and some of his staff around the territory is unique in my experience, and remarkable for its simplicity and the results in obtaining the confidence of the Native and his interest and co-operation in measures for his own benefit. In the party there were the Governor, the Commissioner for Native Affairs, the Resident Commissioner of Savai'i, the Chief Medical Officer, the Collector of Customs and Taxes, the Aide-de-camp to the Governor, Dr. Buxton, and myself. The Governor brought with him thirty members of the Fetu o Samoa (Star of Samoa), a modification of the Boy Scouts movement suited to Samoan conditions, under a high chief of Samoa, Faumuina, a leader of the organization. Also, there were a few Native police, and our carriers and attendants. Entering or leaving a village we made a procession, with the Fetu in front with a drum, followed by the flag-bearer, then the General, then the other European members of the party, then the police and the attendants, that must have made a parade impressive to the Native mind, so susceptible to pomp and ceremony. Sometimes we were met miles out by local divisions of the Fetu and by other bodies of boys and girls, sometimes with Native musical instruments, and all marching in order. On arrival at the village we had the usual kava ceremony in the official reception-house of the village, where the usual courtesies of Samoan life w r ero exchanged at some length, sometimes an hour long, and the General announced the programme for the day. A small presentation of food was made at this time. In the afternoon, at 2, the formal reception was given us, in which respective orators for the village and for the party laboured for forty minutes or more in competition to see which one could be more loud in his praises of the other and more abject in apologies for his own humbleness. Then came presentations of food. Each head of a family must give ten taro and one large fish or two small ones, or a fowl, or a pig. The orator for his village called out the head of the family's name as he looked in the basket and praised him if the taro were big and the fish well cooked, or was very frank about the matter if the gift looked stingy, which caused much amusement. After this came the sivas, or dances, by the men or women : there were few of these. Then followed the important part of the afternoon's entertainment. The Fetu came out dressed only in a lavalava (cloth wound about the hips to the knees), bare body (for Samoa believes that the Native is healthier when he wears fewer clothes), with a rakish cap on the front of which is pinned a star, on the five points of which are the five mottoes of the Fetu. These boys then proceeded to demonstrate to the local villagers a number of simple sports that they could have and enjoy with the means at hand. These games were most diverting, and never lost their interest for me, and they were hugely enjoyed by the local youths, who were instructed by the Fetu immediately afterwards. The object of this is to interest the youth in his native village, and make him more content with it and less desirous of seeking the flesh-pots of European centres with the probability of becoming a permanent loafer there. Before the sports every day all youths were lined up, from young adults down to babies, for a presentation of lollies, the presentation of lollies being the lure used to insure a full attendance of all children. As these were lined up the doctors made a rapid survey of the population for ulcers, skin lesions, eye conditions, enlarged spleens, or other signs of disease. In some villages every child from ten years down was stripped, and examined. In the evening the Governor had conferences with the Native missionaries, and at 8 o'clock each night he met the heads of all the families in the district and addressed them. This was no casual talk, but a prepared speech, which also had been printed, and was now distributed to each head of a family. This speech embraced all the activities of the Government with the Natives, and explained what was being done and what was contemplated, and the reason for it. Long sections of it were devoted to disease-prevention, proper water-supplies, and proper latrine installation and their use, the purposes of the hookworm and yaws campaigns, the good' results of which were already visible. The Samoan is patriotic and proud of his blood, and he was told that there mustjbojaabies in the village if they were to increase and assume their former power and grandeur as. a race.. If they wanted improvements in their villages and European comforts they must plant coconuts and cut copra ; they must have bank accounts.

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This is the hardest kind of work, and would be called visionary by the old-timer in the Pacific, and even might be ridiculed by some; but this is not the first of these malagas, and as the proof of the pudding is in the eating, so is the proof of their value seen in the confidence and affection shown by the Samoan for his Government. It is certainly a startling way to increase population, by making personal appeals to the men of the race on more or less patriotic grounds, but I saw in Savai'i lines of women with small babies in their arms, and many of them were again pregnant. The children swarm in these Savai'i villages. 6. Industries. The principal industry in Samoa is the curing of the coconut and export of copra. Samoa exported in 1922 copra to the value of £319,333, and cacao to the value of £44,513 : copra, 16,956 tons; cacao, 765 tons. The total exports for the year were £365,610. In the same period the imports were £282,939. 7. Transportation and Communication. On Upolu, for a distance of thirty miles along the coast, centring from Apia, there are very fair motor-roads. Elsewhere one may travel on horseback or by horse and buggy. Natural difficulties prevent the extension of motor highways through the islands without unwarranted expenditure. Communications between the islands of the Group and with Pagopago are maintained by motorlaunches or cutters. There is a monthly service maintained by the Union Steamship Company which connects with Tonga, Fiji, and New Zealand. There is a monthly service to Pagopago maintained by the Government to connect with the Oceanic Steamship Company's Sydney-San Francisco service. 8. Economic Conditions. Samoans are a happy race of people who should be and generally are care-free. They live a communal life in which each member shares in the industry of the other. The drone has the same right to a share as the industrious worker, and never receives the penalty inflicted on that one in most communities. Nature is here bountiful and returns largely for a little labour. There are plentiful supplies of tropical foods for all. The land is held largely by the Native, who cannot alienate it. Less than 5 per cent, of Upolu is held by foreigners. The Crown lands taken over from the Germans will revert to the Native as increased population requires it. Indeed, already hundreds of acres of this land have been reserved to meet present Native requirements. The large island of Savai'i, according to the present policy of the Administration, is to be held as a Native reserve. The alienation of land on this island has been negligible. The adult male Samoan pays £1 annually in taxes, unless he may be a chief, whose tax is £1 4s. In addition each adult male pays £1 annually for free medical treatment of the Native population. The imposition of this tax originated in the Native Fono, or Parliament. All Samoans are Christians. They live a healthy open-air life, the villages being practically all situated near the coast, and on the banks of a stream if possible, for the Samoans are very fond of bathing in the sea, and especially in fresh water. This practice, together with the habit of using coconut-oil to rub on the skin, apparently suffices to keep away body-insects such as fleas and lice ; but Pediculus capitis is common all over the islands, and in some districts the fales are infested with Chimex rotundata (the bed-bug), which was probably introduced by the Chinese coolie, as it is common in most of the old Chinese coolie quarters on the island. In some cases, especially Savai'i, where streams are not plentiful, on account of the very porous nature of the recently formed lava, the villages have had to rely on wells and small springs, which for the most part are unguarded. The Samoan fale, or house, is a well-built structure that is impervious to rain and yet is well ventilated ; for it is supplied with movable mat curtains on all sides, so that they may be raised or lowered according to the requirements of the inmates and direction of the wind. The Samoans regularly smoke the interior of the roof of their fale in the evening, and by this means pests are kept out of the thatch to a certain extent, and its life prolonged ; but also the smoke, together with the through draughts of air, tend to keep the fale free from mosquitoes, and so diminish the effects of repeated filarial infection which would otherwise occur. The floor of the fale is usually composed of laval pebbles or broken coral, which they cover with strips of coarse matting. Thus, on the whole, they keep very clean, but they have the objectionable and dangerous habit of expectorating on to the stones, under the edge of a mat, which they lift up for this purpose ; and this is probably one of the causes of the spread of phthisis amongst the Native population. That a considerable amount of organic matter must be washed in between the pebbles of the floor in spite of its apparent cleanliness is shown by the fact that the Natives have recognized that the site of an old fale makes an ideal place for cultivating the tobacco-plant. In Samoa there is now a considerable half-caste element in the population, due to intermarriage with European traders, chiefly British and German. Some admixture of Mongolian and negroid blood is traceable to the past alliances of Native women with the imported labourers from China, New Guinea, and the Solomon Islands. Unfortunately, in the process of " civilization " corrugated iron is supplanting thatch, and the healthy open interiors of the fale tend to be encumbered with boxes and all the European furniture available, including bedsteads. The people have also taken to European clothing to some extent, without understanding that it should be changed when wet through. They sleep on mats on the floor, under a mosquito-net, many members of a family together under one net.

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Their cooking is done under a separate roof, and the principal diet is vegetarian, which is well cooked, but their meat is merely superficially charred. The domestic animal of the islands is the pig, many of which were found in every village, but are now being confined behind pig-fences. They are fed, but they also root in the garbage. Dogs are very numerous in most districts ; practically every fale has at least one dog, and frequently more. These dogs roam through the villages in a semi-wild state for the most part, and sometimes become savage, but so far we have had no evidence of there being any rabies amongst them. The Natives of Samoa are accustomed to make long journeys and visits from home, and consequently to spread round all sorts of infectious diseases. Part ll.—Public Health Activity. 1. History of Public Health in Samoa. Up to 1920 there was no definite department devoted to public-health activities apart from the clinical activities of the regular Medical Department. At the end of 1920, as a result of a preliminary survey, it was decided to form a Division of Public Hygiene in addition to the Division of Clinical Medicine. In February, 1921, a Medical Officer of Health was appointed, and sent to Queensland to study the Rockefeller Foundation methods of hookworm control. Till 1923 the attention of the Medical Officer of Health was devoted to the sanitation of Apia, the studying of Native conditions and customs, and the preparation of necessary public-health legislation. In 1923 the offices of Chief Medical Officer and the Medical Officer of Health were combined in the appointment of Dr. T. Russell Ritchie, the present incumbent. In 1921 the Samoan Health Ordinance, based on the New Zealand Health Act, 1920, but modified to suit local conditions, was passed by the Legislative Council. 2. Public Health Organizations. The Department of Health of Western Samoa is headed by the Chief Medical Officer, who is also the Medical Officer of Health. He has a staff of six qualified medical practitioners, two Health Inspectors, one of whom is a registered plumber with qualifications in sanitary science, a Matron and eight other qualified European nurses, nine Samoan nurses trained and graduated from the Apia Hospital, eighteen Samoan nurses in training, one European dispenser, with one Native assistant, and eleven medical assistants and medical cadets in training. Apia, is situated in the most populous part of the Territory. There is a hospital in Apia which is modern and which will accommodate fourteen Europeans, sixty Chinese, and one hundred Samoans. This is staffed by four Medical Officers, the Matron and eight European nurses, and the nurses and cadets in training. Two of the Medical Officers take care of the hospital, one attends to the outside calls of Apia and district (there are no private practitioners in Samoa), and the fourth one spends most of his time visiting outdistricts. The Matron and one nurse, at least, must be qualified maternity nurses. At the eastern end of Upolu, in the Aleipata district, and in the Faasaleleaga district of Savai'i, there are district hospitals, each under the control of a European Medical Officer, who is assisted by a Native medical assistant and two trained Samoan nurses. At four populous centres there are four trained Samoan nurses, who centre at mission stations and act as dispensers, and at one such centre there is a Native medical assistant who acts as dispenser. At one centre there is an unqualified European dispenser, who from years of training is competent to deal with minor ailments. Four other mission stations are provided with free drugs. As trained nurses become available they will be allotted to these stations. 3. Appropriations for Public Health. The amount appropriated each year is £25,000. In addition there is about £3,000 debited against the Department of Health each year for travelling-expenses of officers of the Department and for interest and sinking fund on capital expenditure incurred by the Department. The £25,000 is made up in the following way : The New Zealand Government subsidy to the Department of £14,000 ; an average of from £3,000 to £4,000 revenue from Europeans and Chinese labourers ; and £8,000 a year contributed by the Natives. This £8,000 is a voluntary tax of £1 per adult male, first imposed on the Natives at their own suggestion in return for free medical attention by the Administration. 4. Municipal Sanitation. There is at present no municipality. The sanitation of Apia is governed by the regulations passed by the Administration during the past two years concerning buildings, drainage, privies, mosquito-control, and rubbish and garbage disposal. These are all of a modern and comprehensive nature, and are fully enforced, with the exception of mosquito-control, which is at present the subject of experiment in ofie selected area. 5. Enforcement of Health Laws. Health laws are enforced by the Department of Health. No laws have been passed by Western Samoa till the Administration felt that it was in a position to strictly enforce them. 6. Transmissible Diseases. There is a list of thirty-three transmissible diseases which are notifiable : Anthrax, cerebro-spinal fever, cholera, dengue, diphtheria, erysipelas, enteric fever (typhoid and paratyphoid), leprosy, plague, puerperal fever, smallpox, typhus, scarlet fever, yellow fever, chicken-pox, encephalitis lethargica, influenza, measles, German measles, mumps, ophthalmia neonatorum, acute primary pneumonia, acute

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poliomyelitis, ringworm (scalp), scabies, trachoma, tuberculosis, tetanus, whooping-cough, dysentery, venereal disease, yaws, beriberi. The prevalent diseases are frambcesia (or yaws), hookworm disease, ascariasis, filariasis, bacillary dysentery, measles, chicken-pox, mumps, lobar pneumonia, tuberculosis, leprosy. Skin-diseases, such as tinea imbricata and itch, and eye-diseases are also very common. The Samoans have their own herbal remedies for these diseases, and use massage very largely for the relief of pain. Frambcesia, or Yaws--This disease occurs in every village, and so prevalent was it that one might say that hardly a single Samoan reached adult life without having suffered from the infection. Hookworm Disease. —This will be discussed in a later section. Ascariasis. —In children ascariasis is very common, and is the cause of a considerable mortality to the younger children, producing two types of illness, a form of broncho-pneumonia and an intestinal type, which has high fever, and then suddenly the patients go into convulsions or collapse and dievery much like a case of acute enteritis. In adults the worm does not appear to cause much disability. Filariasis. —This disease is very widely spread through the islands. The most frequent clinical manifestations of the disease are lymphadenitis, with -or without lymphangitis ; filarial abscesses ; while a certain proportion of cases develop elephantoid swellings of the limbs and pudenda, and breasts in females. The large incidence of hydrocele amongst the Natives is probably due to filaria worm. The M. filaria appear in the blood of the peripheral circulation at all times during the twenty-four hours, and of the six species of mosquito in Samoa, Dr. F. W. O'Connor was only able to incriminate one —the Stegomyia pseudoscutellaris —as the intermediate host. This mosquito bites at any time of the day or night, but is most active about sunset. An expedition under Dr. P. N. Buxton, from the London School of Tropical Medicine, will spend two years on the study of the prevention of filariasis in Samoa. Bacillary Dysentery. —This disease is endemic in the islands, and occasionally gives rise to small epidemics, which tend to be fatal to the children, but do not cause much mortality to the adults. A small epidemic in 1923 was due to an organism of the Shiga group. Amsebic dysentery, if it exists among the Samoans, must be very rare, but there is an occasional case from the Chinese labourers, so that there is always the chance of its spreading throughout Samoa. Measles.- This disease is probably endemic in Samoa, and recurs in a mild epidemic form about every four years ; on the whole the disease runs a mild course and has very few complications. Chicken-pox. —Sporadic cases occur all through Samoa, and cause very little disturbance to the patient. Mumps. —This disease is quite common amongst children of four to twelve years, and nearly always affects only the parotid glands ; there are no records of any complications, and the disease does not appear to involve the genital organs of the male or the breasts of the female children. The inflammation of the glands is so slight that there is rarely any appreciable difficulty in opening the mouth. Lobar Pneumonia. —This disease is very common in certain seasons of the year, and practically always seems to pick out the basal lobes. Cases treated in hospital do extremely well, the mortality being very low. Tuberculosis.- -Bone and joint tuberculosis is very rare amongst Samoans, if it exists at all. Tuberculosis of the lungs is fairly common, and a fatal disease to the Natives, and still more so the half-caste population, whose houses are often poorly lighted and badly ventilated. Amongst the Samoans there are lung-infections which cause liEemoptosis and to some extent simulate phthisis, but no acid-fast bacilli can be obtained, and from their complete recovery after the case had been considered from a clinical point of view as hopeless we think that they are probably due to another infective agent, possibly " bronchial spiracheetosis," as spirochetes have beeii found in spare numbers in the sputa of some of these cases. In children tubercular peritonitis often associated with phthisis is fairly common, as also is tubercular meningitis. Leprosy. -The first cases ever diagnosed as leprosy were diagnosed in 1892 : these were two Chinese. The next cases appeared in 1896, and were in people who had come from Hawaii. So far as is known there was no leprosy known in Western Samoa previously, and from the evidence available it is reasonable to conclude that the disease was introduced from Hawaii. Altogether there have been only forty-six cases to date recorded, of whom twenty-three are Samoans. At the present time the Administration is supporting sixteen lepers at Makogai, in Fiji. New cases as discovered are sent to Fiji once each year. Itch. —Scabies is fairly common amongst the children of Samoa, and occasionally it is seen in cases suffering from some chronic ailment who have been neglected by their friends and relatives ; but on the whole the adult population is very little affected. Tinea imbricata..- This and other ringworms are fairly common amongst the Samoans, but the incidence is not nearly as great as it is amongst the Melanesian and Chinese labourers employed on the plantations. Eye-diseases. —Simple catarrhal conjunctivitis is common, but the most serious condition is the true Samoan conjunctivitis, which is very infectious, and spreads rapidly from village to village, beginning with itching, swelling, and marked chemosis of the palpebral conjunctiva, which within forty-eight hours has a purulent discharge, associated with great pain and photophobia. The inflammation soon spreads down the naso-pharynx, having involved both eyes. In default of proper treatment, ulceration of the cornea follows, and then, if the Native treatment of scrubbing with coconutfibre is adopted, the destruction of the eyeball is a very probable result, and is the reason of there being so many cases of blindness in Samoa. Clinically the condition resembles gonorrhoeal ophthalmia, except that there is very little constitutional disturbance. An intracellular gram-negative diplococcus is very constantly found in the discharge. It is very noticeable that villages near a bathing-beach, or

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which have adequate bathing facilities, show few eye-diseases. As soon as one leaves the beach, or where there are few bathing facilities, eye-diseases become much more prevalent. Venereal Diseases. —Syphilis, which has been reported from time to time amongst the Samoans, is probably very rare, if it exists at all; the cases that have been reported having turned out to be a yaws condition. The Chinese coolies have a small percentage of syphilitic cases, but there appears to be no evidence of their having passed the infection on to the Samoans. Gonorrhoea of a very mild type seems to be fairly common, but gives rise to few disabilities, as it does not cause retention of urine in the male or stricture, while no cases of salpingitis of diplococcal origin have been seen in the female. The gram-negative diplococcus, which causes the urethritis, may be the same organism that causes the Samoan conjunctivitis, but Dr. F. W. O'Connor, when working in Apia, found that it was the exception to find any organism in the urethra in the cases of conjunctivitis which would lead one to expect that the conjunctivitis is spread directly from one person to the next, or carried by numerous flies, which are very persistent in their endeavours to alight on the eyelids. 7. Laboratories. In the beginning of 1920 Dr. F. W. O'Connor, of the London School of Tropical Medicine, came to Western Samoa, and spent two years in this and other islands of the Pacific on research on filaria and other tropical conditions. His work was published as Memoir No. 4of the London School of Tropical Medicine in 1923. During his stay in Samoa Dr. O'Connor designed the present modern laboratory attached to the hospital in Apia. At this point it may be suitable to mention that in January of this year another expedition from the London School of Tropical Medicine, under Dr. P. N. Buxton, arrived in Samoa to continue the research of Dr. O'Connor. This expedition intends to remain two years in the islands. Under arrangement with the New Zealand Government, Dr. Buxton's services are available to the Samoan Administration, which pays all expenses of the expedition except salaries. 8. Sanitary Engineering and Construction. Building and construction in Samoa is under the supervision of the Public Works Department, which is responsible that the conditions laid down in the regulations regarding buildings are complied with. Plumbing and sanitary fittings are directly under the control of the Department of Health, which has an officer qualified in plumbing and sanitary engineering. 9. Water-supply. a reticulated water-supply drawn from a conserved area of 5,000 acres back in the hills, four miles from Apia. In several Native districts the Natives have been induced, with the co-operation of the Administration, to install piped supplies of pure water from springs or streams up in the hills. The Natives in these cases pay one-third of the cost of imported materials and furnish the labour, and the Administration furnishes the remainder of the money. Where no such supply is available, 12,000-gallon tanks are being installed, which receive water from the roofs of churches. 10. Millc-supply. The milk-supply of Apia, where most of the European population of Samoa lives, is derived from a modern dairy about two miles outside the town, and is delivered twice daily. The Natives use little milk, and that is obtained from tins. 11. Food-inspection. The New Zealand Sale of Food and Drugs Act and its amendments, with all regulations made thereunder, is in force in Western Samoa. The principal questions that have had to be considered by the Department of Health have been the supplies of imported and fresh meat, rice, and milk. Rice soon becomes weevily, and in former years there were many cases of beriberi among the Chinese labourers. By obtaining fresh monthly supplies of rice, partially milled to a standard, for issue as rations to the Chinese coolies on the Crown Estates plantations, these conditions have been controlled. All rice for Samoa, milled to standard, is admitted free. 12. Sewage-disposal. For a small scattered community like Apia, a water-carriage-sewer system is at present out of the question, because of the large capital cost. The difficulty is being overcome by the installation of septic tanks, thirty-five of which have been installed in the past two years, including two large installations in the hospital and in the Government schools. If a private individual wishes a septic tank the Government furnishes plans and all assistance, except the provision of materials and labour. Except for these mentioned above, all latrines are fly-proof pit privies. It was the desire of the Department of Health to install a panstead system, but consideration of the difficulties entailed by the proper working of this system has led to the matter being held over for the present. Among the villages the matter of sanitation is being pushed forward as rapidly as possible. Most of the population live on the sea-coast, and here and there are being installed over the water privies of a satisfactory type.

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1.3. Soil-pollution. As among all primitive peoples, so in Samoa, there is much soil-pollution. The Samoan is intelligent and receptive to measures for his benefit, and where these privies over the water have been installed this condition is rapidly being improved. The villages in the interior will each offer a problem for the health authorities. 14. Garbage Regulations. The regulations as to rubbish and refuse containers require that all householders must have a flv-proof metal container in which shall be deposited all garbage and rubbish that can not be easily destroyed on the premises. This is emptied twice weekly by the Government garbage-collector. 15. Public Nuisances. All public nuisances that are deleterious to public health are provided for in the Samoan Health Ordinance. Other nuisances are provided for in the Police Offences Ordinances. 16. Public Health Hygiene. The systematic study in the schools of public-health hygiene has only commenced this year. The Department of Education publishes a quarterly school journal in which articles supplied by the Department of Health are inserted. This journal and its articles is used as a text-book in all Native schools. This medium offers an opportunity for the inculcation of the principles of public and personal hygiene. The Government monthly publication for the Natives has so far only been used for the campaigns against yaws and hookworm disease. 17. School Hygiene. Dental inspection of children attending Government schools was begun in 1924. Medical inspection of school-children has not yet commenced. Forms have been received from New Zealand, and the work will be undertaken when a Medical Officer can be spared from other health work for this programme. An inspection of the Government school-children shows them to be clean-skinned and healthy in appearance. A few cases only of eye infection were noted at this inspection. 18. Vital Statistics. Up to the Ist January, 1923, the records of vital statistics can only be taken as approximate. Since that time there have been two independent sources of vital statistics, which must check against each other. First, there is the Pulenu'u, or Mayor of the village, who sends in a record weekly of the births and deaths in his village, each one on a separate form ; second, there is the Faamasino, or Native Judge of the district, who must also get his record from the individual responsible for notification under the regulations and forward it weekly. These two records are checked against each other. This makes an accurate collection of vital statistics. 19. Mortality in Samoa. In 1923 the births of 1,701 living children (Samoan) were registered in Western Samoa, as against 1,622 in 1922. The birth-rate was thus 50-49 per thousand of mean population, as against 48-2 per thousand for 1922. The number of live births in 1923 is the second highest recorded, the highest being 1,792 in 1912, with a population of 24,239. Stillbirths, of which twenty-one are recorded, are not included either as births or deaths. There were registered sixteen pairs of twins, of which both were males in seven instances, both females in six. The number of deaths registered during the year was 1,398, as compared with 899 in 1922. The increase was due to an epidemic of dysentery. The crude death-rate was 41-5 per thousand of mean population. Of the 1,398 deaths, 719 were of children who had not reached the age of two years. Nine women died in childbirth. E-pidemic Years. —A comparison of the returns for 1923 with other years when the country suffered from epidemics may be of interest : —

* Measles first visited Samoa in 1893, and caused a large number of deaths, but, as records were not kept at that time, no definite figures are available. Its second appearance was in 1911,

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Excess of | Excess of Year. Population. Births. Deaths. Births over j Deaths over Epidemic. Deaths. Births. I I I I 1 1907 .. 33,354 ! 1,389 1,584 .. 175 Dysentery. 1911 .. 33,639 ; 1,453 1,827 .. 374 Dysentery and measles.* 1915 .. 35,554 j 1,611 1,451 160 .. j Measles. 1918 .. 38.093 I 1,509 8,437 .. 6,928 Influenza. 1923 .. 33,685 ! 1,701 1,398 303 .. Dysentery (shiga). I . !

A —4A,

20. Maritime Quarantine, The Sarnoan Quarantine Order gives wide powers to the Medical Officer of Health to prevent the introduction into the Territory of any infectious disease, or of any other disease which in the opinion of the officer may be a source of danger to the health of Samoa. The quarantine station is located about two miles from Apia, on the mainland. This is small, and the location is not satisfactory. Weekly wireless bulletins are sent to the Medical Officer of Health in Samoa from the Health Department in New Zealand to keep him informed as to conditions prevailing in the Pacific. 21. Native Health Regulations, 1924. I. Fales. 1. No Samoan-built fale shall be built on any site that is swampy until the site has been filled in, drained, or levelled to the satisfaction of the District Council. 2. No refuse shall be used in the filling-in of any site on which a fale is to be erected. 3. The foundation of every Samoan-built fale shall be at least 1 ft. above the level of the ground immediately surrounding such house. 4. Every fale shall be provided with kitchen accommodation, which shall be separated from the dwellinghouse, and which shall be of approved design and kept in good repair. 5. No Samoan-built fale shall be constructed of less dimensions than 3 utupoto in length and 12 ft. in breadth, and no fale shall be boarded in. 6. No fale shall be erected at a less distance than 30 ft. from any other fale. 7. The floor of every Samoan-built fale shall be made of cement, or shall be composed of a layer of coral or shingle. 8. (1.) Where the Medical Officer of Health, or any Resident Commissioner, or the District Council, is satisfied that any fale is unfit for habitation, or is not built in accordance with the foregoing clauses of these regulations, the Medical Officer of Health, or the District Commissioner, or the District Council, may order that such fale shall be pulled down within fourteen days of the date of such order, and it shall be the duty of the owner of such fale to see that the order is carried out. (2.) Any defective kitchen or cookhouse, or any kitchen or cookhouse which, by reason of its situation, creates or is likely to create nuisance from smoke to any other householder, or causes or is likely to cause damage by fire to any adjacent fale or property, may be dealt with in the manner laid down for dwellinghouses in the preceding subclause of this clause. 9. Any owner or householder, as the case may be, who fails to comply with the provisions of these regulations l shall be liable on conviction to a fine not exceeding £2. 10. Any proceedings arising from a breach of these regulations may be heard before a Faamasino. xx. Latbines. 1. Every village shall be provided with a sufficient number of suitable latrines to the satisfaction of the District Council. 2. Where a pit privy is installed it shall be so constructed as to prevent the access, of flies to such pit, and.for i this purpose the aperture in the seat shall be provided with a cover, which must be kept in place when the privy is not m use. 3. The pit of every pit privy shall be filled with clean earth before the fsecal matter therein rises to within 12 in. of the surface of the ground, and the privy shall thereafter be moved. 4. No pit shall be constructed within 20 yards of any fale or other building, or within the distance of 50 yards from any well, spring, or stream of water used or likely to be used by man for drinking or domestic purposes, or otherwise in such a position as to render any such water liable to pollution. 5. It shall be an offence for any person to deposit any fsecal matter in any place other than the latrines provided for the purpose. 6. Penalties not exceeding £2. 111. Disposal of Rubbish, Refuse, and Dead Animals. 1. It shall be the duty of each Matai to see that house-refuse and other rubbish are daily collected and burnt, and that his house, kitchen, and area surrounding the house are kept clean. 2. It shall be the duty of every Matai to keep his buildings, and the ground around such buildings, in accordance with boundaries laid down by the Village Council, free from all articles (bottles, whole or broken shell, old tins, coconut-shells, cocoa-pods, crockery, and earthenware, whole or broken), and any other things of a like nature which may retain and so become the breeding-place of mosquitoes. 3. No dead animal or refuse matter, solid or liquid, shall be placed on any road or part of a town, or in any place whereby the drinking-water supply, or any bathing-pool, may be contaminated. All dead animals shall be buried or burnt. 4. No dead animal, or refuse, or putrid food or fish, shall be thrown into any latrine. 5. During the breadfruit season no breadfruit shall be allowed to remain rotting on the ground within any village. 6. Penalties not exceeding £2. IV. Watee-supplies. 1. In every village in which the water-supply is from any well or tank the supply shall be protected and covered So as to prevent the deposit of refuse, dead leaves, or other harmful matter, to the satisfaction of the Medical Officer' or other officer authorized to act on his behalf. 2. Any well or water-supply which is injurious to health, or is so liable to contamination as to render it a danger to health, may be closed by order of the Chief Medical Officer or officer authorized to act on his behalf. 3. Where any structural work has been carried out in order to ensure as far as possible a supply of wholesome water for a village it shall be the duty of such village to keep such structural work in a good state of repair. 4. No water-supply shall be installed in any village without the permission of the Administration. 5. Where any water-supply has been installed in any village no alteration in such water-supply shall be made without previous permission having been obtained from the Secretary for Native Affairs. 6. Penalties. V. Keeping of Animals. 1. Pigs shall not be kept within any village, and shall be confined within properly built fences, in the outskirts of each village, and, where possible, not less than 200 yards from the villages. Such pig-runs shall not be placed where they are liable to pollute any water-supply used for cooking or domestic purposes. 2. Any pig found within any town, or on any road, may be destroyed, and the owner of the pig shall in addition be liable to prosecution. 3. If the Pulenuu is unable to trace the owner of the pig destroyed, as in No. 2, he may dispose of it as he thinks fit. 4. On the order of any officer authorized to act on behalf of the Chief Medical Officer, any diseased animal shall be destroyed. 5. Penalties, £2.

5—A. 4A.

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VI. Gathering in Villages. 1. The Village Committee of a village where any gathering of Samoans is held shall be responsible for the proper regulation of such gathering from a sanitary standpoint. . , , ... , , 2. The Village Committee shall take steps to ensure that proper precautions are carried out with regard to cleanliness of buildings, of cookinghouses, and of the malae, and the proper disposal of refuse and rubbish. 3. The Village Committee shall take steps to ensure that sufficient privy accommodation to the satisfaction ot the Chief Medical Officer, or other officer authorized to act on his behalf, is provided, separate for each sex, and that such privies are kept in a clean and sanitary manner. „ 4. The Village Committee shall take steps to prevent the fouling of water-supplies. o. The Pulenuu of the village shall be personally responsible for seeing the instructions of the Village Committee properly carried out. Part 111. —Yaws and Hookworm Control. 1. History of Hookworm Disease in Samoa. In 1920 Dr. F. W. O'Connor, of the London School of Tropical Medicine, carried out a preliminary survey which showed that hookworm infection among the Samoans was almost universal. He reported that he found an infection rate of 85-1 in 286 examined, but this was in some cases from one specimen only, and that among those examined for filaria the eggs of hookworm were eventually always forthcoming. The largest number of worms found by him was 113. 2. Hookworm, Control. The institution of free treatment in April, 1923, made it possible to commence a systematic campaign against this disease. The campaign was based on the International Health Board model, which had been studied in Queensland and Fiji, and with films, lantern-slides, and charts purchased from them a commencement was made to educate the Native to the necessity for treatment and for better sanitation.. This continued till October, by which time 18,057 mass treatments had been given. The work went slowly at first. This was probably due to lack of confidence on the part of the Natives, who still had a vivid recollection of the havoc wrought by the introduction, during military occupation, of anfiuenza in 1918, in which many thousands of lives were lost. In the first three districts treated, with a population of 7,924, only 4,526 offered themselves for treatment, a percentage of 57 ; in the next five districts, with a population of 14,444, they became more alive to the value of the treatment, and there was no difficulty in treating 13,004, or 90 per cent: 925 other people were treated in hospitals. These were all treated with carbon-tetrachloride, 2 minims to the year to the apparent age of fifteen, when the adult dose of 45 minims was given. At first this dose was given followed by a purge of magnesium sulphate in two hours. Later the drug was administered in saturated solution of magnesium sulphate. By October, 1923, the pressure of the Natives on the medical staff for the free treatment of yaws became so great that the hookworm campaign had to be temporarily abandoned for the lack of personnel to handle the two pieces of work. At the beginning of the year the Natives had agreed to an additional tax of £1 per liead of adult males for free medical attention, and the treatment of yaws with its spectacular results appealed to them more than the hookworm work. Their views had to be heard to assure the successful collection of the first tax, and to gain their firm support to the Medical Department. The work of sanitation in connection with the hookworm work has progressed steadily, and plans have been definitely made to treat the whole of Samoa with mass treatments during the month of November, 1924. five units consisting of two men each will be stationed at different points in the islands to cover a definite area, which will complete the whole population in the month. The plan is to repeat these mass treatments at intervals of six months till hookworm disease is controlled. Dr. O'Connor found 35 per cent, of ascaris infection. Future treatments will be given of 25 per cent, of oil of chenopodium to 75 per cent, of tetrachloride to handle this infection as well. The dosage will be 2 minims to the year, with a maximum of 35 minims. 3. Yaws Campaign, The conditions which led to the inauguration of the yaws campaign have been mentioned above. Yaws is probably the greatest cause, direct and indirect, of death among the Pacific races in the first two years of life. Its tertiary effects are the cause of much suffering and ill-health throughout adult life. The treatment of this condition in Pacific-islanders is probably the finest demonstration to them of the value of western medicine. During 1923 the demand for injections was so great that treatment was given to ail offering themselves: no attempt could be made to fine-comb the whole population. The result of the year's work appealed to the Natives so much that the Native Parliament of Faipules, or chiefs, agreed to the introduction of very stringent regulations for the control of this disease. Regulations in bespeox of Yaws. Whebeas yaws is a preventable disease very common in Western Samoa, responsible for much suffering and death: And whereas the Administration of Western Samoa is spending large sums of money in an endeavour to eradicate this disease : And whereas the co-operation of the Samoans is essential to the successful issue of this work: Now, therefore, these regulations are made by the Administration of Western Samoa in pursuance of the Samoa Act, 1921. 1. These regulations may be cited as the Samoa Yaws Control Regulations, 1924. 2. As from the Ist day of April, 1924, the disease known as yaws shall be a notifiable disease. 3. The father or the mother of any child suffering from yaws shall immediately report the sickness to the Pulenuu of the village.

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4. The Pulenuu of each village shall immediately report all cases of yaws coming under his notice to the Resident Commissioner, Savai'i, or the Secretary of Native Affairs, Apia. 5. No child suffering from yaws shall be allowed to travel from its village to any other village, except, for the purpose of heing treated by a doctor. 6. No child suffering from yaws shall be allowed to enter or to remain in any other village than the one in which it usually lives, unless for the purpose of visiting a doctor. 7. The Samoan methods of treating yaws are hereby strictly forbidden. 8. Every child under the age of ten years shall be produced for inspection by a Medical Officer when required. 9. The parents of every child brought to a Medical Officer for treatment for yaws shall see that the child undergoes the full course of treatment prescribed by the Medical Officer. 10. No parent shall refuse to allow treatment to be given to any child suffering from yaws when a doctor is in the district. 11. Any person refusing or neglecting to obey the provisions of these regulations shall be liable to a penalty .of £1 for every such offence. During the first year of the campaign 32,336 injections were given. The work was recommenced in April, 1924, and during the four months ending 30th July 12,000 treatments were given. .The whole of Samoa will have been completed by the middle of October, when the hookworm campaign will be recommenced. A yaws unit consists of a European doctor with two or three Native assistants. They take out a supply of a few thousand doses of novarsenobillon, a sufficient quantity of distilled water, syringes, and a sterilizing outfit. The dose given is 0-6 gramme for an adult male and 0-5 gramme for an adult female, and children in proportion. An area which will occupy a unit for five treatment days is selected. On the first round the doctor examines all cases offering themselves for treatment, selecting those showing any signs or symptoms of yaws, and gives them their first injection, making a careful list of the name and village. Saturday is spent in retracing his steps to the starting-point of the week. The second and third weeks are spent in giving second and third injections to those previously treated. On the second and third occasions the treatments diminish in number, as the first injections in many cases clear up the obvious lesions and the Native can see no reason for further treatment. The matter of more than one treatment was not pressed in the first round of Samoa, as the campaign was intended to be one of education as much as one of treatment. With the new regulations a complete course of three injections is being insisted upon. On the first round it took fifteen months to complete the whole population. The second round, with the improvement shown by the first treatments, will be completed in six months. In treating the whole population it was found that the average dose given was 0-45 grammes. On the first round many young children were not brought forward, as the Samoan considered that the injection would only " drive in the disease." On the second round it is found that parents bring their children forward freely. 4. Present Hookworm Survey. This work was rather limited in Samoa because of the short stay occupied by the trips of inspection, also by the fact that Dr. Buxton, of the London School of Tropical Medicine, had planned to make such surveys a part of his programme. We had the opportunity of seeing the new Clayton Lane direct centrifuge flotation method of diagnosing hookworm-ova. Briefly, a definite amount of faeces, about 1 gramme, is measured by a small metal ring grasped by long-handled forceps, and pressed repeatedly into different portions of the specimen. This, ring and all, is dropped into a centrifuge tube, gently shaken with water, the ring is removed, and the tube centrifuged a thousand times a minute for one minute. The water is decanted. The tube is refilled with saturated sodium-chloride solution to the very top, and is covered with a small thick glass slide, which fits between four horns added to the ordinary container of the centrifuge tube. The centrifuge tube is ground to make close union with the glass slide. This is then centrifuged a thousand times a minute for one minute. The slide is then lifted from the tube and suspended drop downward on two plasticine pillars placed on a larger slide which is in the grasp of the mechanical stage. The eggs are thus usually seen in a clear medium lying close to the glass slide in one even plane. It is the most beautiful demonstration of hookworm-ova that I, have seen. Clayton Lane has shown that the eggs left after the first slide are almost negligible. The smallest infection can be shown by this method, an excellent one of measuring the reduction of hookworm infection of a population in eggs per gramme after mass treatment. The only objection to this would be the difficulty of counting the masses of eggs in the small area in case of heavy infection. Another objection to this method for field-work is that it is unreliable in diagnosing ascaris infection, which has become an important part of hookworm campaigns in many districts, and is unreliable for trichuris eggs. These do not seem to cling to the drop that is brought away by the glass slide after centrifuging, as they do in the Willis method of salt flotation in the usual container. Just, what percentage of accuracy is obtained by the Willis method in the case of ascaris it would be interesting to know, but this is quite certain, that it is far more accurate than the direct smear and centrifuge method, or than the Clayton Lane apparatus. Having the opportunity, I was anxious to try the ordinary field technique of the Willis method against the accurate Clayton Lane method of direct centrifuge flotation, to learn what our percentage of error in field-work might be. I had with me Malakai, a native of Fiji, trained to the microscopic examination of fseces. While I was absent in Savai'i he ran a set of tests, using the ordinary field technique, even to the quarter-ounce containers for specimen. The plan adopted was that Malakai examined persons by this method, which is the Willis technique. A small portion of feeces, about 1 gramme, is well mixed with staurated salt solution in a quarter-ounce container in which it is obtained from the patient. The container is then r filled with the solution, and over it a glass slide is placed for twenty minutes or more, when it is lifted from the r tin r under the microscope smear side up. The eggs are found floating in the salt solution, which adheres to the slide.

6 —A. 4A.

35

A.—4a,

Each specimen examined by Malakai was usually examined by direct smear by a European assistant of Dr. Buxton. When Malakai's specimen was found negative the Clayton Lane apparatus was used by Mr. Hopkins to confirm it. Later a long series were examined, as shown by the table below, by direct comparison.

Comparison of Clayton Lane and Willis Techniques.

This table is a copy of Mr. G. H. Hopkins's records of these tests. Under the heading " Kace," S stands for Samoan, C for Chinamen, B for Melanesian, F for Fijian. The only Fijian examined was Malakai, my assistant, who was sure after his own examinations that he had no hookworms. On the first examination the Lane method and the Willis method found him negative. On the second day Willis found him negative and Lane found one egg. Malakai was a little indignant, and on return to Fiji insisted on 3 c.c. of oil of chenopodium to prove his microscopy correct, thinking that the one egg of the Lane method was an added infection carried in by the long forceps carrying the ring of faeces. However, a very minute examination of two days stools found one female and one male necator passed in the first twenty-four hours' motions. This seems to me a rather brilliant demonstration of the accuracy of the Clayton Lane method. It will be seen in the table that in seven cases specimens were repeated to the number of nineteen specimens : these are bracketed. In five of these seven cases Clayton Lane found a negative and a positive. In three of these cases Willis found a negative and a positive. It seems to me fair to say that where Clayton Lane finds a negative and positive in the same case that the worm content is probably one female. And it seems to me fair to conclude also that the Willis technique is accurate down to the question of a female worm or two as done under ordinarily careful field conditions. In this table we find that fifty-four individuals were examined for hookworm ova by the Clayton Lane and by the Willis techniques. Clayton Lane and direct smear found fifty positives, and Willis found forty-seven positives, respective percentages of 92-6 and 87. Where the question of hookworm-ova alone are concerned, and it seems desirable to show the last one of these, Clayton Lane shows a beautiful accuracy. The Willis technique is accurate down to a worm or two. I am told that the Lane method makes no claim to demonstrate accurately ascaris or trichuris ova, nor did it in Apia. The Willis method does so more accurately than any other method of which I know. In the South Seas specimens have to be examined within twenty-fours hours or flotation methods are useless. Befrigeration is out of the question, and no proper method of keeping specimens for a period that lends itself to ready examination has yet been devised. The Clayton Lane method cannot be operated accurately by the average Native assistant, in my opinion, nor can it be used to advantage away from mixed centres. The Willis method can be used anywhere, and the stupidest assistant cannot hinder its accuracy. The Willis method is several times more rapid than the Clayton Lane method, and infinitely more economical. In selected areas Clayton Lane technique might prove valuable in checking the results of field treatments. The Willis method is the desirable one for fields use where rates of infection are desired for decision as to mass treatments, and time and expense are objects, and where information is sought as to infections other than hookworm,

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j 7 II xt ™ Direct Willis Lane Name - ; ace - Smear. Method. Method, j I A [!_ 3970 .. C .. - 4654 .. C .. -|- + 4256 . . C .. + + Malia .. .. S + + ■■.Mi f - - Sefo .. ■ . S < — + + • • W - + + Fesul .. S + + Suka .. E -f- + Sikinai .. . ■ B + + 4515 .. C + + 4569 ■ • C -f- + Toso .. S + + Sue .. . • S Soelei .. S + + Falaui .. S + + Meki .. .. S + + Kanki .. B .. + + Tauti .. ■ . S .. + f _ _ -|_ Alosina .. .. Si— — + Moe .. . . S + + Baiveri .. S + + Motoi .. S + + -f Talala . • S + + r i i Petelo .. .. S \ ! t * * ~~ + Manogi • • • • S Lafi .. S — + Tauso .. S — + +

at ™ d... Direct Willis Lane JName - ±tace - j Smear. Method. Method. 4609 . . . c { ~ Malaea . ■ S .. + 4Mate .. S — + 4Kaisa . . S .. + -f Taulanga .. . 8 + -f -f Avoga .. S — + Kirita .. • • S <j — — I — + + Tava .. S + + 4~ Niu .. S + + + Pulimau . . S + + + Savali .. S + + + Tuemna .. S -f + H~ Siota .. S — + + Teuila .. S + + + Laneta .. S -i , I ~~ — + Mua .. S + + + Mary .. S + + + Leu .. S — — — Atua •. .. S -J- -|- Faala .. S -f + + Nellie .. .. S 4- -f 4Tonga .. S + 4- + Taea .. S + ' + + Etauti .. S — 4- + Eunati .. S 4 + 4~ Willie .. S — + + Tunga . . S + + + Malakai . . F

A.—4A.

5. Hookworms recovered. Several individuals were treated and their worms recovered. The conditions were such that no opinion could be formed as to effects of dosage. One hundred and sixty-three hookworms were recovered, of which 161 were necators and two were ancylostomes. Some of those treated were Chinamen. The intestines of two pigs were washed and their worms recovered. There were no human hookworms among these. These worms have all been forwarded to Dr. S. T. Darling for more careful survey. Part IV.—Discussion and Conclusions. Discussion. The average white man sits in the shade in the South Seas and talks of the lazy Native, and criticizes Government for not compelling (always the same word) the Native to this thing or that which will benefit him (the white man), with never a thought for the Native himself. In the first place, the Native is not lazy when he is interested nor when he wants to hold a job. Where nature is so bountiful and the necessities of life are so easily obtained as in most Pacific islands, Natives do not seek hard work any more than whites would under the same circumstances ; but where conditions are more difficult, as they are in many districts, then the Native has to work as hard as any white man. In Savai'i some villagers have their gardens at a distance of miles, and must carry in their produce on their shoulders. In many parts of Fiji and other islands Natives have to work and will work at hard labour to support their families. Every colony in the Pacific faces the problem of a decreasing Native population in the face of a need for an increasing labour-supply to develop these islands for their products, which have grown to be necessities of the food-supply of the temperate climates. The causes of the decrease of the population are, broadly, decay of custom and introduced diseases— both due to the entering of white civilizations. The easy answer is the importation of Asiatics. This is undesirable for political reasons, and in almost all cases it will finally produce a problem more difficult th n the present one. And they mean the earlier extinction of the Native races. The true answer to this problem, and the far-sighted one, is the care of the health of these peoples and their protection from new epidemics while we are ridding them of the effects of those already introduced and to which they have little immunity, as well as ridding them of two or more diseases which have been prevalent among them for an indefinite period. We must gain their confidence and trust in western medicine and civilization. We must instil new ideas and ideals of daily life to take the place of such old customs as are incompatible with their new life. The result of such an effort will be the large increase of the population, and the final pressure of that population on the means of subsistence will furnish labour for the development of the islands in an increasing amount. The birth-rate among them is so large under normal conditions that with a deathrate lowered by preventive medicine population figures will soon show a large-enough increase to produce plenty of surplus labour for white plantations or necessitate an enlargement of their plantations by the Natives, with increased exports and imports for the country. Samoa is well along on the road to this happy condition with her increasing population of healthy contented Natives. Conclusions. In Samoa we have a long-visioned Administration which is giving every support to a strong Native Department and a modern Department of Public Health, these two working hand-in-hand. Yaws is well under control, and may be eradicated in the near future. Hookworm-control measures are well advanced, and will now be prosecuted with the vigour given to the yaws campaign. Adequate sanitation, proper latrines, and pure water-supply are gradually being installed in all villages. Definite plans are undertaken for child-welfare work in Native villages with the new year. Even thus early, these measures are being reflected in increasing populations of healthy, happy Samoans. A few years and they will mean dividends on the investment for the country, which, after all, must be the criterion of the success of a humanitarian effort if it is to be enduring.

Approximate Cost of Paper.—Preparation, not given ; printing (1,490 copies, including illustrations), £92 10s.

Authority : W. A. G. Skinner, Government Printer, Wellington.—1925.

Price Is. 3d.]

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