Some results of medical researches in the Western Pacific

28

SOME R E S [ J L T S

OF

MEDICAL RESEARCHES

WESTERN

IN T H E

PACIFIC.

B:~" F R £ N C I S W. O'CONNOR, M.R.C.S., D.T.M. & H.

Wandsworth Scholar', London School o f Tropical Medicine.

The work, of which the following is a brief summary, was conducted from January, 1920, to July, 1921, in the Samoan, the Tokelau or Union, and the Ellice groups of islands under the direction of the London School of Tropical Medicine.

The Samoan Group.,-Population, 38,186. Lat. S. 13 deg. 3 min. to 14 deg. 20 min., and. long. W. 169 to 173 deg. Comprises nine islands, of which eight are volcanic and inhabited, and one an uninhabited coral atoll. Of the former, four--Savaii, Apolima, Monono and Upolu--are administered by New Zealand under mandate, and four--Tutuila, 0fu, Olesega and T a ' u - - a r e under the protection of the United States. The Tokelau Group.--Populationbetween 900 and 1,000.. Lat. S. 8 deg. 38 min., and long. W. 171 deg. 5 min. to 172 deg. 28 min., N.N.E. of Tutuila, from which it is distant about 285 sea-miles, consists of four coral atolls, of which Fakaofu, Nukunono and Atafu are permanently inhabited. The Ellice Group.--Populahon, 3,000. Lat. S. 5 deg. 32 rain. to 11 deg. 20 rain., and long.E. 176 to 180 deg. : is composed of nine coral atolls, of which the following eight possess an indigenous population--Nukulailai, Funafuti, Nukufe~au, Vaitupu, Nui, Niutao, Nanomaga and Nanomea. The group is about 500 miles west of the Tokelaus. It is separated from the Gilbert or Kingsmill group on the north by the equator, and to the

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IN T H E

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29

south lie the Fiji group, of which Vanua Levu is 450 miles south of Funafuti. The natives of the three gL'oups are Polynesians, and in physical characters, language and customs the people of the atolls Show a similarry to the Samoans. From the industrial standpoint, however, there is a marked difference in the natives of the three groups. Beyond the care of their plantations the Samoans are not disposed to much manual labour, a n d they seem incapable of prolonged exertion. The ]~llice islanders, besides working the plantations, e n g a g e m u c h in fishing, and they labour well t~t public works of long duration. The Tokelau islanders are the best workers of the three groups,-and they tire less quickly. Though the superiority of the atoll islanders, in this respect, may be due to their having been longer under administrative discipline, and to the greater struggle for existence, yet, there is evidence to show that prevalence of indigenous disease plays a part. Certain habits and customs, common to the natives of the three groups, have an important bearing on disease. Journeys (Native, Malaga).--From childhood each individual is accustomed to make frequent and long visits to other villages and islands. In Samoa, owing to better facilities, these visits are especially frequent. Since the transmitting mosquito of filariasis is present in all the villages and their surroundings, it is obvious how generally the infection becomes disseminated ; at the same time, it is impossible to be certain where any filariated individual acquired his or her infection. In the atoll groups, owing to the difficulties of inter-island communication, such visits are not so frequently possible, and so greater reliance can be placed on incidence figures. Sanitation.--One or two sheltered drop-latrines may be seen, supported on poles over the low-water level on the shore in front of each village. These are, unfortunately, never present in sufficient numbers, and are only used by the people occupying the houses close to the shore. Most of the natives defecate in the bush adjacent to the village, or in the pig-run near by. At night they also defecate on the shore" above water level. Cooking. Close to the houses small open sheds are erected for cooking; in and around these flies abound, and they are a great pest in native houses.

30

SOME RESULTS OF MEDICAL

Though vegetables are generally well cooked, meats are merely charred on embers. Fish are not cleaned before cooking, and the entrails of pigs, after a preliminary washing,~ are cooked, as above, with the carcass for consumption.

Dress.--Untitfairly recently the natives simply wore a girdle of leaves (titi) or a loincloth (lavalava), and they relied on smearing the body with cocoanut oil for protection against exposure. At present the women wear singlets and overalls ; many men wear shirts, and some even coats. Unfortunately, neither sex appreciate the importance of changing their clothes when saturated with moisture.

Sleepi~g Arrangeme~ts.qMany members of a family sleep on a mat on the ground under one mosquito net. Before going to sleep, each individual generally covers the :body, including the head, with a sheet. Frequently the mosquito-net is.patched with pieces of calico or linen, and sometimes these materials are used instead of ordinary netting. A native wishing to expectorate while in a house, simply raises the mat covering the ground, and does so on the coral or l a v a p e b b l e s underneath. Though native villages outwardly appear tidy and clean, nevertheless the bush immediately behind them is generally used as'a dumping-ground for all kinds of d6bris, in which flies breed in great numbers. The most prevalent diseases in the three groups are ankylostomiasis, filariasis, yaws, tuberculosis and skindiseases, especially Tinea imbricata. In Samoa eye diseases are common, and, in the Southern" Ellice, fish poisoning. While leprosy is not uncommon in Samoa, there were no cases in the Eltice or Tokelau Islands during m y stay in these groups. FILARIASIS.

Periodicity.---The examination of the blood of a iarge number of individuals, during the day and during the night, shows that there is no evidence of periodicity, of the microfilaria in man in the three groups. In many cases the microfilarial,counts were slightly lower between the hours of 2 and 6 a.m., but this was not constant. Morphologically the microfilaria in all these islands is similar in appearance. Arthropod Host of the Parasite.--In two series of experiments conducted in the Ellice and Samoan g~oups, with hatched-out mosquitoes

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31

fed o n infected human blood, I found that SteTontyia pseudoscuteUaris acted as a suitable host of the human filaria, and that in these islands development of the parasite in the insect may be completed in from ten to thirteen days. Working with Culex jepsoni in t h e Ellice and with Finlaya kochi in the Samoan Islands, arrest of developme~at of t h e parasite in these insects was generally observed On the fourth or fifth day after the latter had fed on infected blood. Since S: pseudoscutellaris is the only mosquito found by me, or known to the traders and natives in the Tokelau Islands, it is reasonable to assume that this insect is the carrier in this group. MANSo~-BA~R has shown (1910) that this moscluito is the principal carrie r in the Fiii group, and as it occurs in the Gilbert Islands, Niue (Savage Island), Wallis Island and Tonga, it is probably the transmitting agent of the human filaria in these islands also. An experiment was performed with larval filarise from the head and probpscis of an infected Stegomyia, to see if they might enter human skin from water, but no parasites were seen to do so~ and the examination of serial sections of the area of skin experimented on failed to reveal the presence of parasites in the tissue. S. pseudoscutellaris--Causes of Prevalence; its Control. While studying the life history of this mosquito, I found that the most essential conditions for its multiplication are fresh water in small quantities, with woody or dexayed vegetable contamination for the larvae, arid, in all stages of its life cycle, protection from bright light and wind. The nature of the breeding-places occasions their limitation, and the worst o f these, are _of man's construction. They are found in (1) the empty shells in the interior of cocoanut husk and shell stacks formed in the preparation of copra ; by far the greatest number of larvae are_found in__these situations._ _ (2) In the holes in living cocoanut trees excavated to hold rainwater by the natives in the Ellice Islands. (3) In cocoa pods, the (~interior of which has been eaten by the Pacific rat (Mus exulans))in Samoa. And, less commonly, (4) in small holes made by various means in trees, in cups formed by breaking of the stem of the bamboo, or decayed bread-fruit trees, and in spare cocoanut shells thrown into dense shaded bush, etc. The adult mosquito is most numerous in thick bush, from which wind is largely excluded. It is not very prevalent on those plantations on which the ground is kept well cleared. These conditions

3~

SOME R E S U L T S OF MEDICAL

are largely influenced by the arrangement of the land, and as this is nowhere so apparent as amongst the coral atolls, these are worth while considering briefly. The Tokelau and Ellice atolls may be described under two headings : - 1. L a r g e lagoon atulls m which a lagoon of considerable extent is surrounded by a rim of reef supporting, at intervals, narrow strips of cultivated land of varying lel~gths. On these the bush is light and airy, being swept by the south-east trade and westerly winds, and, in consequence, Stegomyia axe not; found in great nmnbers. (Nukulailai, Funafuti, Fak:mfu, Nukunono.) 2. Small or closed lagoon atolls in .which the lagoon is small, or merely represented bv a swainp, surrounded by broad lands containing dense and shaded bush, to the interior of which winds cannot penetrate. This bush is warm and dark, and Stegomyia are generally present in large numbers. (Vaimpu, Nui, Niutao, Nanomaga, Nanomea.) ]ntervening stages in the development of atolls exist between these extremes, and the degree of development shows a striking relation to the numbers of Stegomyia. present. (Atafu, Nukufetau.) The breeding places of S. 2ose*tdoscutellaris enumerated above, as well as otl~¢,r.~ le.~.~ commonly seen by me, are all within the scope of sanitary control, ~md the natives are always willing to remove them when they realise the mena¢:e. I have demonstrated at Funafuti that the clearing of bush in the strops of land on the bu:ge lagoon atolls is a simple measure, and it was followed b y a m-~rked reduction in the number of Stegomyia. in Samoa and the dense northern Ellice Islands, the clearing of each plantation by the owner and his family should result in reducing Stegomyia, but more intensive measures might be instituted with benefit. Planters have agreed that the measures suggested by me should improve the nut-producing power of the cocoanut l)lantations, so that opposition should not be anticipated in carrying out measures for the control of the mosquito, nor shoNld considerable expense be entailed thereby. From my observations I believe that t)y a eolnbination of ~dministrative and sanitary methods S. psetldoscutellari.~ (:an be eontr()lled, and that in these islands human filariasis is a preventable disease. General Bemarks on the Fil(eri, t Incidence.---The amount of blood

RESEAaCHES IN THE WESTS~N PACIFIC.

33

examined in each case was 20 c.mm. This was examined while fresh in many cases, and always after being deh~emoglobinised, fixed and stained. Microfilarial counts were made in all positive cases. In the Tables for ray final report, I have given the incidence in three sections for individuals of all ages : - - ' Section I . = T h e microfilarial incidence. Section II. = Section I. plus cuses of elephantiasis without microfilaria in the blood. Section I I I . = S e c t i o n II., plus clinical filariasis without microfilaria in the blood, The Tables here given represent Section III., but are standardised for persons of sixteen years and over, since more children were examined in some localities than in oghers. The results of my examinations show t h a t - 1. The mie,rofilarial incidence is in direct relation to the prevalence of S. pseedoscutellaris. 2. The incidence of clinical filariasis is in relation to the microfilarial incidence. 3. :Elephantiasis is usually prevalent where the clinical filarial incidence is greatest. 4. Where the incidence in 1, 2 and 3 is high, t h e n (a) A greater number of young children are found with microfilaria in the blood. (b) In any given family, a greater number of individuals are found with one or other of the signs of filariat infection. 5. Where the foregoing conditions predominate, the following signs of hyperfilariation are frequently observed : - (a) Multiple elephantiasis of limbs and appendages in the same individual. (b) The greater frequency with which mierofilaria in the blood is found associated with elephantiasis. (c) The greater number of persons with high counts of microfilarim in a standard quantity of blood. Fami!ylncidence.--The maiority of my examinations were made according to family grouping. The results show that some families are much more heavily infected than others. This is much more clearly demonstrated amongst half-caste (Euronesian) families than amongst

34

SOME R E S U L T S OF MEDICAl5

native families. Native families have generally one or two members Showing some signs of filarial infection. Euronesian families may have either nearly all the members infected or none at all (Appendix Tables). The reason for this variation appears to me to be as follows: Euronesians usually live in nofi-mosquito proofed Europecbn houses. The latter afford l~mple protection from wind and bright light to Stegomyia, which, in consequence, may remain permanently about the premises. If there is an individual with microfilaria in the blood, in the family, the dissemination of the infection would naturally follow, and vice versa. In native houses, on the other hand, since the interior is very exposed to prevailing winds, mosquitoes would be Jess liable to remain long in any particular house. This view is supported by the results of my examinations of captured mosquitoes. In Stegomyia, captured in Euronesian houses where there was an occupant with microfilaria in the blood, the percentage of insects found to be infected was much higher than in native houses under similar conditions. When a family shows a high filarial incidence, the sequence of the signs of infecLion is similar to those found in examination of the general population : thus very young children show no signs ; older children have microfilaria without marked symptoms. Still older children and adolescents, and adults, suffer from clinical filariasis with or without parasites in the blood, and people of twenty years and older may have elephantiasis. The clinical signs of filariasis, in order of frequency, are : - 1. Lymphaderfitis and lymphangitis. This is most common in the limbs ~nd then i n (a) The scrotum in the male, frequently resulting in hydrocele after successive attacks. (b) The breast in the female, this being one of the commonest manifestations in women. Females, the subjects of filarial mastitis, generally assert that the attacks recur with greater frequency, and are more severe, during pregnancy and lactation. The condition is also frequently seen in women who never have been pregnant. 2. Abscess. 3. Chronically enlarged lymphatic glands, especiutly in the groin, axillary and epitrochlear regions. 4. :Elephantiasis.

RESEARCHES

IN T H E

WESTERN

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35

5. Filarial fever without localised symptoms. 6. I have seen two cases of lymphuria, but chyluria was not observed. 7. Cystic diseuse of lymphatic glands was occasionally seen. 8. Cystic disease of the female breast was found on one occasion. 9. Fugitive swellings, probably filarial, were seen in one case. 10. Thrombosis. Some old people with lnicrofilaria in the blood and enlarged glands had never experienced filarial symptoms. Earlier Sign,~ of FNlariasis.--Owing to the accidental infection of my assistant, Mr. C. E. BERRY, from the tenth to the thirteenth day of my feeding experiments with S. pseudoscutellaris in Samoa, the followi~ng observations were made : April 17th, 1921.--M:osquitoes feeding on the patient's arm were found with larval filarise in the head and proboscis. Numerous swellings were present on the patient's arm at the site of recent mosquito bites; each of these varied in size from a shilling to half-a-crown, and consisted of a pale centre with hard, brawny red surroundings, fading into healthy tissue. The inflammation, which was accompanied by continuous irritation, lasted for five to seven days. These signs differ markedly from the mild, transidnt reaction usually following the bite of S. pseudo-

seutellaris. May 30th, 1921.--Slight tenderness over the right epitrochlear gland, now found to be enlarged for the first time, i.e., forty-three days after date of probable infection. July 7th, 1921.--The gland had become much larger, though without marked tenderness or constitutional disturbance. It was removed by Dr. FARQUAR M~THESO~, under local 8,n~esthetic, fixed in Schaudinn's fluid, and serial sections were made of alt the tissue. Examination of the gland.--There was engorgement of the vessels, and heemorrhages had taken place between the gland substance and the capsule. There were hsemorrhages into the gland substance, displacing and disorganising the lymphoid tissue, which was otherwise not altered in appearance. No giant cells were seen, but large masses of eosinophile

leucocytes were present in places, e~pecially in the periphery of the gland. No worm was found: some spaces however, amongst the hmmorrhages, near the periphery in many of the sections, are suggestive of the recent presence of a worm.

36

SOME

RESU:LTS

OF M E D I C A L

At the time of possible infection the eosinophile count was 3 per cent. The following observations were made by the patient himself : September 20th to October 6th.---Patient had a severe attack of lymphangitis, clinically filarial. The right axillary glands became tender and enlarged; red lines extended on the skin down the arm to the elbow, and then further down to the wrist. The whole arm became enlarged and brawny, the redness becoming diffused. The patient felt ill, but did not go to bed, and the temperature at the acutest stage was not elevated above 100 ° F. The eosinophile count was now 6 per cent. October 26th, 1921, and January 11th to 21st, ] 9 2 2 . - - P a t i e n t had lymphangitis of the right upper arm. January 16th to 22nd, 1922.--Slight pain and swelling of the left epididymis. The eosinophile count was now 11'5 per cent. No helminthic ova have been found on repeated examinations of the stools. Mierofilaria have not yet been found in the blood. • On March 1st, the cosinophile count was 16 per cent. Since this case first showed symptoms I have seen several cases of lymphadenitis, witb or without mild lymphangitis, in Europeans and in imported Chinese only a few months resident in Samoa, and Dr. 5[ATttESOl~ has just sent me the account of another definite case recently under his care. I believe that lymphadenitis of the glands draining the area of infection is a very early and common symptom of filarial infection, and that it is often missed owing to the mildness of the symptoms accompanying the condftion. Effects of Teml)erature on the Human l~'ilaria in the Pacific.~MAI~SOI~]3Atilt, working with microfilaria in vitro, has shown that the parasites live for six hours at a temperature of 104°F., his room-temperature controls living for three days. The following case shows that the Pacific filaria in man may survive high temperatures for a considerable period. A European patient, whom I was observing for an infection of microfilaria, developed a severe attack of enteric fever. The temperature was above normal for forty-three days. On three occasions it was 105°F., and it was frequently 104°F. and higher. Patient was delirious for three weeks. Microfilari~e became scanty, and were not observed after the thirtieth day of the disease till the end of convalescence, but they have since reappeared in the blood. T/te Treatment of Filariasis.--As far as possible, for purposes of

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87

treatment, cases were selected which, in addition to having microfilarim in the blood, were suffering from frequently recurring attacks of filarial or elephantoid fever. The following drugs were used : Preparations of salvarsan. Novarsenobillon. Galyl. Kharsivan. Antimony. Ammonium tartrate. Stibenyl (acetyl p. amenophenyl stibiate of soda). The collosols of copper, selenium, and manganese. Quinine hydrochloride. Emetine. W i t h none of these drugs administered intravenously, or intramuscularly, or by mouth was any change observed in the numbers, activity or m o r p h o l o g y o f the microfilaria in the circulating blood. Although in some eases there was an improvement in the Clinical condition, notably with tartar emetic, this may have been due either to the rest necessitated by treatment, or to the treatment of associated ankylostomiasis infection, or to a combination of these circumstances. The most recent information on the progress of these cases, which are still being controlled,* leads me to believe that none of these drugs exercise a curative effect on the disease. We may now consider a few of the more prevalent conditions, as they occur in the three groups under consideration. EL:LICE

ISLANDS,

Filarial Incidence.--For the whole group the percentage of infection in males is higher than in females, and this is tru~ for the different islands except Nanomaga, where the female percentage exceeds the male. The lowest incidence was found among females in Nukulailai. On this island no children younger than seventeen years were found to be infected. The highest figures shown are for males in the island of Nui. In this island, of fifty-one children under fifteen years whose blood was examined, microfilarise were found in ten. Clinical filariasis was no~ ~By Dr. FARQUAR MATHESON a n d Mr. C. E. BERRY.

38

SOME R E S U L T S

OF MEDICAL

very common in Nukulailai oi- Funafuti, and in these islands filariasis of the scrotum, in the male, and of the breast, in the female, was rare, but the same cbnditions were very prevalent in all the northern islands. High microfilariat counts were very comInon in the islands north of Nukufetau: they were especially high in Vaitupu, where, in two women, the maximum counts were made of 1,595 and 1,256 microfilarim respectively, in 20 c.mm. of blood. Some of t h e cases at Funafuti, though long resident in this island, were born in the northern islands, and these may have been originally infected elsewhere. TabLE I. ELLICE ISLANDS.

FILARIAL [NCIDENCE--PERSONS OF SIXTEEN YEARS AND OLDER.

Island.

Males

Females.

Totals.

No. exa .mined - { No. infected P e r cent. infected

67 38 56"71

76 32 42"1

No. examined { No. infected P e r cent. infected

32 14 43"75

45 16 35"5

77 30 38"96

No. examined N u k u f e t a u - { No. infected P e r cent. infected

47 32 68"08

48 22 45"83

95 54 56"84

No. examined " ( No. infected P e r cent. infected

101 62 61 '38

No. examined - { No. infected P e r cent. infected examined - {No. No. infected P e r cent. infected

F.tmafuti

Nukulaitai-

Vai~upu

Nui

-

-

Niutao-

No. examined N a n o m a g a - { No. infected P e r cent. infected Nanomea

No. examined - { No. infected P e r cent. infected

Ellice Group

No examined infected { No. P e r cent. infected

143

70 48"95

99 55 55"5

200

68

58

57 83"82

35 60"34

126 92 73'01

72 55 76"38

69 44 63"76

141 99 70"21

45 '28 62"2

62 44 70~96

107 72 67"28

113

117 58"5

167

280

81 71"68

101 60'47

182 65

545 367 67"33

624 349 55"92

1169 716 61"24

Elephantiasis Rate.mA glance at the accompanying table (IA) will show the very much greater prevalence of elephantiasis as compared to Samoa. The greatest number of cases were found in the five northern islands, and, probably, four of the F u n a f u t i cases were originally infected at Niutao. Amongst the northern islands, the highest rate was found at

P~ES:EARCHES

tN

THE

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PACIFIC.

Nut, where, of 179 persons of all ages examined, 38 had elephantiasis. Throughout, the r a t e was higher amongst males than females. The lower limbs were more commonly affected than the upper limbs, but elephantiasis of the ~rms was still very common. Both sides of the •body seem to be affected with about the same frequency, thus, in limb affections we get the following figures : Right arm ... 23 cases. Left arm ... 23 cases. Right leg ... 68 cases. Left leg ... 69 cases. The scrotum was affected in 48 cases, most frequently in association with elephantiasis of the lnnbs. Multiple affections of arms, legs and scrotum were more commonly observed than in Samoa. TABLE ELLICE

ISLANDS.

][A. ELEPHANTIASIS.

Cases examined. N u m b e r ' o f eases e x a m i n e d ,,

,,

with elephantiasis

E l e p h a n t i a s i s w i t h m i c r o f i l a r i m i n blood ,, withoat ,, ,, ,, right arm . ,, ,, ,,

,, ,, ., ,, ,, . ,, , ,, . . ,, ,, ,,

,,

only

Totals,

Males.

Females.

1417

687

730

122 46

78 36

44 10

76 3

.t2 !

34 2

2 2 9 4 8

--9 12 7

left arm both arms r i g h t leg. lef~ l e g b o t h lefts both legs, both arms left arm, left leg r i g h t a r m , r i g h t leg left arm, both legs

,, ,, ,, ,, ,, ,.

2 2 18 16 15 7

i

,,

2

2

--

,, ,,

1

--

1

scrotum

.

21

21

--

.

scrotum~ both legs scrotum, both arms, both legs scrotum, left leg scrotum, right leg breasts breasts, both legs breasts, right leg breasts, right arm, legs breasts, left leg

1 --

6

1

II

II

--

~,

9

9

--

.

5

5

--

,, ,, ,, ,, .

2 2

2 --

1

--

1

2 1

-m

2 1

.

1

--

1

.... 2

Intestinal Helminthiasis.--In the Report of the Medical SeL'vice of t h e Gilbert and Ellice Protectorate, 1913-1914, thirteen cases of ankylostomiasis are mentioned in the statistics for t h e Gilbert, Ellice and Tokelau groups, but it is not stated in which of the groups the infection was found. I n the yearly reports since t h a i : t i m e no cases of ankylostomiasis are mentioned in the Ellice Islands returns.

40

SOME R E S U L T S OF M E D I C A L

TABLE ELLICE ISLANDS.

IB.

INTESTINAL HELMINTHiC OVa.

Males.

Females.

Totals.

Cases examined 112 110 ... 222 Ankylostomum ova 99 (88"4 per cent.) ... 92 (83"6 per cent.) ... 190 (85"5 per cent.) Trichuris trichiuraova - 10l (90"2 , ) ... 101 (91"8 ,, ) ... 202 (90"9 ,, ) -

Ankylostomiasis. people e x a m i n e d

T h e table (IB) includes cases of all ages a m o n g s t at F u n a f u t i . E i g h t e e n of the cases negative for

a n k y l o s t o m u m were u n d e r four years of age, a n d m a n y of these were less t h a n one year old. F r o m an e x a m i n a t i o n of fifty-six girls f r o m all islands in the Ellice a n d Tokelau groups it is probable t h a t ankylostomiasis varies considerably in incidence in the different islands. I t was very c o m m o n in girls f r o m Nut, Niutao, Vaitupu, und N a n o m a g a , a n d m u c h less f r e q u e n t l y observed in girls f r o m Nukulailai, Nukufet~u, a n d N a n o m e a . T h e w o r m f o u n d was Necator americanus. T h e r e is plenty of clinical evidence of the presence of this infection a m o n g s t the islanders. Cases of anmmia, treated w i t h tonics, are frequently seen in the island hospital returns, and dyspepsia is c o m m o n .

Ascariasis.--In one child, aged two years, born in a n d recently arrived f r o m P a p u a , I found ova of Ascaris lumbricoides. I n no o t h e r case h a v e I found ova of this parasite. I n view of this parasite in Samoa, t h e fact is a striking one. had ova of Ascar~s in t h e i r stools in Samoa, I could t h e y h a d been some m o n t h s in the Ellice Islands. the sweet husk of a y o u n g cocoanut, called by the

the h i g h incidence of I n two natives w h o not find the ova a f t e r I n the Ellice Islands, natives " U~agau," is

f r e q u e n t l y chewed like s u g a r - c a n e (which it m u c h resembles in taste) by the islanders. T h i s n u t does not flourish in Samoa, and the s p e c i m e n s s h o w n to m e were not of t h e s a m e quality as the Ellice ones. I t h i n k it is possible t h a t the husk of this n u t in the Eltice I s l a n d s m a y contain s o m e principle antagonistic to Ascaris.

Trichuris trichiura.~This parasite was prevalent in m u c h y o u n g e r children t h a n was a n k y l o s t o m u m , and was f r e q u e n t l y found in children aged one year, or less. Strongyloides stercoralis a n d Oxy'aris vermicularis were n o t seen. No cestodes or t r e m a t o d e s w e r e found.

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TABLE IC.

ISLANDS.

INTESTINAL

PROTozoA.

No. of cases e x a m i n e d

225

E n t a m ~ b a eoli ,, histolytieaE n d e l i m a , v ~utna I o d a m w b a biitsehli - O i a r d i intestinaIi,~" Chilom.astie mesnili I r i c h o m o n a s hominis .

18

8"0 per c e n t .

3 9 3 7 14 17

1"3 4"0 1"3 3'1 6"2 7"5

-

.. ,,

,, . ,, .

Intestinal protozoa were found much less frequently than in Samoa and the infections were invariably small ones. Protozoa were rarely found in grown-up people, and those recorded in the table (Ic) were mostly found in children. Though Enteromonas was not found in the series, it was present in a Tokelau islander staying in the Elliee Islands, and it probably does occur in this group. The absence of Balantidium coli in these examinations is interesting. The Ellice islanders spend quite as much time amongst their pigs as the Samoans do, and their methods of 'cooking that animal and eating it half raw, partaking also of the entrails, is the same. I did not find balantidium in the fseees of seven pigs examined on Funafuti. No eoccidia were found in this or the other groups. Although the cysts of Entam~ba histolytica were found three times, the free form was not observed, and I could not get any reliable histories of cases of amoebic dysentery, nor is there any reference to liver abscess in the Funafuti reports from 1913 to 1 9 1 7 . . Tuberculosis.--There are no reliable figures of the incidence of this infection, but the ravages of the disease are everywhere apparent, and frequently many and sometimes all the members of a family are affected. Peritonitis and general tuberculosis are very common in children, and are the most frequent causes of infantile mortality. I found general tuberculosis, post mortem, in one child of two years. The mother, who suffered from phthisis and who was pregnant, had lost two other children with identical symptoms. The father suffered from hsemoptysis. Tubercular glands of the neck, with or without discharging sinuses, are very common amongst older children and adolescents, and amongst adults phthisis is prevalent.

42

SOME RESULTS OF MEDICAL

The dissemination of this factors : - -

disease is assisted

by the

following

1. The custom of many persons sleeping together trader one mosquito net, often made of unsuitable materials. 2. The native custom of spitting on the floor under the ~ a t s in houses. 3. The tendency of the people to sit about in garments saturn.ted with moisture. 4: The native practitioner's custom of simply incising suppurating tubercular glands, without otherwise treating the disease: flies are often to be seen in clusters round the sinuses which result. Y a w s . - - T h e condition is prevalent in all the Ellice Islands, but is more so in the northern isles. Since the absence of a European medical officer in the group, treatment by salvarsan has been largely discontinued, and this accounts for the aggravated condition of many of the cases. In children and young people yaws of the face and limbs are most commonly seen. Adults usually complain of cracked feet. Juxta-articular swellings are fairly frequently seen in persons who have suffered from yaws. Fish Poisoning.--Though this condition was once frequently seen in the Tokelaus, and still occurs occasionally in Samoa, it is only very prevalent at the present time in the southern Ellice Islands, where it is responsible for much invaliding. • Natives still living remember when the condition was first noticed, about fifty years ago. At that time large quantities of pumice drifted towards the south-east aspects of the reef. Shortly after this some species of fish were noticed to become fatter and others became more plentiful, and at the same time' fish poisoning was observed for the first time. It is worth noting that about this time there was a violent submarine volcanic disturbance between Olesega and Ta'u, about 700 miles south-east of the Ellice Islands. The following points a r e of interest :--1. The poison is not limited to specific fish, and a species poisonous in one locality may be perfectly harmless in another. 2.

Only rock-fish are poisonous.

Shoal and deep-sea fish are not so,

RESEARCHES IN THE WESTERN PACIFIC.

43

but the liver of the shark when eaten may sometimes produce the same symptoms. 3. Cooking the fish does not affect the potency of the poison. 4. The head and the liver are the most poisonous parts of an affected fish. The body is less so, and the tail end little or not at all. 5. Cats, dogs, fowls, ducks, and even pigs, are very susceptible, and with cats the condition is liable to be fatal. 6. In cats which succumb, the pathological changes found are intense congestion of the mucous membrane of the large and small intestine, hyper~emia and engorgement of the vessels supplying the membranes of the brain and spinal cord, and engorgement of the lungs with blood. 7.

The symptoms of poisoning in man are : - -

General.--Prostration and depression, with subnormal temperature and bradycardia.

lntestinal.--Abdominal pain, nausea, vomiting and diarrhoea. Central Nervous.--~mpaired movement of the lower limbs with cramp and tenderness of the muscles. Spinal tenderness and backache ; severe headache in the temporal and post-orbital regions. A sense of puffiness in the legs and lips. Some time after the onset, the symptoms may abate for an hour or so, to return with increased severity. These remissions in the acuteness of symptoms are frequently seen. W h e n a patient is going to improve the remissions become longer 8nd the symptoms milder, the abdominal signs generally disappearing first. Severe cases may be incapacitated for nine to twelve days. In cats the same symptoms occur, but they are much more severe, extending to the fore-limbs, and chest muscles, and. producing rigidity of the whole body. The treatment--which, if early adopted, is found effective--is purging with Epsom salts. TOKELAU

OR U N I O N

to be usually

ISLANDS.

Filariasis.--The filarial incidence is much lower than in Samoa or the Ellice Islands. Clinical filariasis was not often complained of, and inflammation of the breast in the female was exceedingly rare.

44

SOME

RESULTS TABLE

OF M E D I C A L II.

T O K E L A U ISLiNDSo FI~ARIAL INCIDENCE--PERSO]NS AGED SIX[PEEN YEARS AND OLDER. Island. Male~. Ferneries. Totals. -

No. examined No. infected P e r cent. infected

35 15 42'8

47 11 23"4

72 26 36"1

Nukonono -

t No. examined No. infected P e r cent. infected

2? 6 22"2

----

27 6 22"2

I NO ex&mlned N o . infected Per cent. infected

63. 31 49"2

83 29 34"9

No. examined No; infected Per cent. infected

125 52 41"6

120 40 33"3

Fa~.uofu

Atafu

Tokelau Gzoup

-

-

-

145 60 41"1 245 92 37"5

i found no cases of elephantiasis and I ascertained definitely that there were none in the group at the time of m y stay, and that there had been none for a long time before. One or two cases are recorded in the past, but the disease was always rare.

Other Conditions--Intestinal Parasites.--The number of cases examined is too small upon which to base statistics, but it is sufficient to demonstrate the rarity of some affections common in the neighbouring groups. I n the stools of nineteen adults examined, ankylostoma ova were found in three and T~ichuris triehiura in six: Ascaris was not found. The intestinal protozoa were seen only in three cases, Entam~ba colt, Trichomonas hominis and Enteromonas being each found on one occasion only. The following factors probably contribute to the rarity of intestinal helminthiasis in the group : - 1. The islet on which each village is built is so small that all the available ground is required for houses; the ground is bare, without bush, and there is no privacy. 2 . The village, at all times, being nearly surrounded by water, the beach is easily accessible for purposes of defecation to the inhabitants of every house. 3. The inhabited islands are on a h i g h e r elevation from the reef than is the case in the EIHce Islands, and the drop latrines built over the sea-margins of the village are more commonly user] by the natives. Tuberculosis and yaws are as prevalent in this group as they are in the :Ellice.

RESEARCHES

IN TJ-IE W E S T E R N

PACIFIC.

45

Tines imbricata is much more comnlonly seen than in either Samoa or the Elliee Islands. THE

SAMOAN

GROUP.

Evidence of indigenous filarial infection was found i n every village where examinations were made in the eight islands of the group. Although in some of the villages (Ira, Talus, Palauli and Satupaitea in Savaii ; Ofu island ; and the village of Ta'u on the Island of 'l.'a'u) the condition is much more prevalent than in others, yet, on the whole, there is nowhere the striking variation in the different villages which is such a marked feature of the Elliee and Tokelau Islands. The lower percentage of infection in American Samoa is affected by the fact that on the island of Tutuila many of the blood-fihns were collected for me, and the medical officers who kindly undertook this h a d not facilities for making exhaustive examinatmns for evidence of clinical filariasis. I n my final statistics this will be rectified by excluding Tutuila from the Samoan figures. The incidence of the whole group is probably about 60 per cent. TABLE SAMOAN ISLANDS.

IIi°

FILARIAL INCIDENCE--PERsONS

Island.

OF SIXTEEN YEARS A.~D OLDER.

Males,

Females.

Totals.

A m e r i c a n Samoa, ~ No. examined Tutuila, and the ~ No. infected Manua Group - [ Per cent. infected

174 1t~7 61'5

268 102 38

442 209 47'3

Western Samo~ : Upoh - - -

No. examined No. infected Per cent. infected

349 23(; 67'6

162 74 45"7

511 310 60"7

Savaii . . . .

No. e x a m i n e d No, infected Per cent. inf e c t e d

717 484 67'5

839 460 54"9

1556 944 {;0"7

Samoan Group -

No. e x a m i n e d 1240 No. infected 827 Per cent. infected 66"7

1269 {;36 50"1

2509 1463 58"3

EleFhantiasis.--The present elephantiasis rate is probably much lower than it was a few years ago, because during the influenza epidemic in Western Samoa in 1918 a great number of the older people, including many with elephantiasis, succumbed,

45

SOME

RESULTS

TABLE SA]KOAN

GROUP.

OF

MEDICAL

IIIA. ELEPHANTIASIS.

Cases examined. N u m b e r of cases e x a m i n e d .

,,

Elephantiasis

with elephantiasis with

microfilaria.' in blood ,,

,,

T.tals.

Males.

3476

1~47

Fenmles. 1729

115

89

26

44

38

6

71

51

20

,,

without

,,

right arm

only

1

--

l

,,

left ann

,

5

3

2

,,

both arms

,,

2

2

--

,,

r i g h t leg'

,.

16

14

left leg

,.

22

18

t

,,

both legs

.

23

15

8

,,

both legs, both arms

,:

12

l0

2

,

b o t h a r m s , r i g h t leg'

,

2

---

,,

l e f t a r m , r i T h t le,~

,,

1

,,

right arm, left leg

,,

1

--

1

,,

right arn b both legs

,,

1

- -

1

left arm, both legs

,,

~

'2

scrotum

,:

10

10

- -

- -

,,

,:

s c r o t u m , arlns~ l e g s

!1

S C l ' O t [ l l l l ;

1

2

2 --~

-

.

l

I

legs

.

7

7

--

scrotum, left arm, legs

.,

1

1

- -

,,

s c r o t u m , r i g h t a r m , lett'~

.,

2

2

.--

,,

s c r o t u m , lefi, l e g

,~

1

1

--

both breasts

,,

2

rig'ht breast

.~

1

,,

., Two

-

cases ( m a l e s ) . o n e a r m

a n d o n e leg', i n w h i c h

- -

-

2 1

the side of the body was not added

t,o t h e n o t e s .

As in the Elliee Islands, the lower limbs were m u c h m o r e frequently affected t h a n the upper, and the ratio of u p p e r a r m to leg affections is about the sam(~. T h e condition was observed a little m o r e f r e q u e n t l y on the left t h a n on the right side, thus : The The The The

right a r m was affected in 22 cases. left a r m .... 26 right leg .... 68 ,, left leg .... 73 ,, ,,

T h e s c r o t u m was i n v o l v e d in 22 cases. A girl of fourteen years was seen in the village of Malaeola, in Savaii, with elephantiasis of the left leg and thigh. T h i s is the youngest age at which the condition was seen in the three groups.

I{ESEAI{CHES

D~testinal Helminthiasis.

IN

[I_'i1£ W E S T E R N

47

PA(_If"IC.

TABLE I I I K

MMes Cases e x ~ m i n 6 d

: -. .-

AJakyldstomum-bW,

:"

.AXearL~ I;ambri~,oide,sovu l~.;eh ~ris gri dt iuru ov~

.

.

.

.

Females.

TerMs.

336

235

101

2 0 0 (85"1 p e r C e n t ) .,. 9;I (3.9"6 , , ~ )" ..,

,s6 (85"1 p e r c e n t . ) ~,7 (2t;'7 )

125 (53"2

79 ( 7 S ' 2

,

Strmtgyloides stere~,'alis embryos

it; ( 6"8

,,

)

...

~i ( l i P 9

... 286 (85"1 percent.) ... 12o (35"7 _ )

)

) ..

2o/ (6O'7

,.

27 ( :~-

) )

Ankylostomiasis. T h e worm most frequently found was Necator americanus. A. duodenale was less commoI~. After weat, mem~ the n u m b e r of worms recovered varied between-a few and 1t3, the !argest count.

Generally between 10 and 25 were fotmd in t,wo or three .%o~Is

~fter one t r e a t m e n t .

The number of ova was often very scanty, ~3~d

frequently were only found after Successive examinM.ions.

Some cases

were only definitely .diagnosed on ~rea~ment. Clinically, ankylostomiasis is manifested by the general lassit~de of the people, enormous appetites and great tendency ~o sleep, by lack of resistance in illness, and by rapid fatigue on exertion.

An~,mia and

dyspepsia are c o m m o n , and menstrual disorders, especially ame~orvhc~,a, are frequent in women.

dscariasis.

F r e q u e n t l y the presence of this worm w~s only detected

on t r e a t m e n t of ankylostomiasis with thymol, so the figures probably i;.~li far short of the actual degree of infection. Only a few worms w ~ ~ generally found, and unfertilised eggs were ~ c o m m o n fe,'mwe. several

cases of pronounced depresskm

I sa:',

improved by removal ~

t.hi~,

parasite, and one case of lunacy in a w o m a n who, after treatment re': ankytostomiasis and

aseariasis,

followed

by tonic t r e a t m e n t ,

beca.~_~(-

mentally normal.

Trichuris trichiura.

T h e figures show a m a r k e d drop from those in

the Eltiee Islands, where I was able go c o m m a n d a greater n u m b e r of examinations in each c a s e ; as the n u m b e r of eggs found was generally very small, some cases were probably missed.

Oxyuris v e r m i c u l a r i s . - - A d u l t s aI~_d ova were found in two cases of half-caste children. No cestodes or t r e m a t o d e s were observed.

48

SOME

IIESULTS

OF

MEDICAL

! ~ e s t i n a t .Protozoa .,~ TABLE I IIC. SAMOAN

GROUP.

~vrcsr[~'A~. P~ovozo*.

No. o f c ~ s e s e x a m i n e d 1,2utamwba ,'oli

229 101

41'1

h i.~tol!/twa l,J,M./ima,r Im m~ i o d a m w l m biitsehli ( / i a r d i a inte,4imtl~x

22

9"6

,,

48

20'9

,.

'd

3"9

,,

13

5"7

,,

('h ihmm.~'tie m e s n i l l lm'homo~lax h o m b d x 15'lt[g,,rOl//OltaX ]tOtll i tl la B a l a M h l b t m ctdl

29

12"7

,,

30

13"1

13

5"7

,,

t

l '7

.,

per cent.

Am(~.t)ic D,tse,tery.---This disease was only seen twice, both times in imp,.)r~ed ('hinese labourers I n one British S a m o a n (Euronesian), liver abscess was seen but though the discharges f r o m the wound were examined &ally. following two operatmns, a m m b m were never found. T h e 1)ahmtidium eases were found d u r i n g routine examinations. The parasites did not appe:Lr to have caused a n y trouble to their hbsts, although, in one ea.se, a very heavy infection persisted for some time. One of the infections occurred in a boy aged between two and a half and three years. Tuberculosis. -This disease is very c o m m o n , and is responsible for m u c h invaliding arid death, and especially infantile mortality. I n several instances ! found whole families affected V,wtutmtelv. m a n y cases go Lo hospital for service i.~ doing much t,o preven~ the f u r t h e r disease scented w be oapeeiallv prevalent

with clinical tuberculosis. t r e a t m e n t , and the medical spread of the disease. T h e in certain areas where the

ha,lives lived in s e m i - E u r o p e a n houses. Ya, w s . - - T h o u g h t,his disease is still very prevalent in Samoa, salvarsan treataneHt at t.he hospital in Apia has become very popular, and large nu,,ttbers of natives resorlG thereto twice weekly for t r e a t m e n t . I n consequence, one does no~ now see the a g g r a v a t e d eases so p r e v a l e n t s o m e t i m e s in the

Elliee

Islands.

r~

r~

4~

r~

3.

Reef over which Landing is made ia ~Native Canoes.

4.

N o r t h e r n Ellice and elsewhere.

Interior of Samoan I~Iohse. Mats over lava pebbling

5.

Drop L a t r i n e plaoed over low water in front of village.

Ellice Islands.

6.

7.

Samoan House in which?~tegomyia l~seudoscutellaris do not remain lon~ owin2" to good ventilation.

Euronesian House. Dark interior and well protected from wind, where S. TseudoscuteZZaris remain permanently.

tS. Uncleared B u s h - - ~ u t i v e Plantu~ion.

9.

S. Tseudoscutellaris

n u m e r o u s owing" to shelter.

Cleared P l a n t i i t i 0 n i n F i j i w i t h no shelter. S. pse{tdoscuteUaris absent. (Phot, o, by Dr. P. H. MANSON-BAH~.)

10.

11.

Cocoa-nut H u s k and Shell Stacks.

I n t e r i o r of same.

Exterior.

No Breedin~'-places visible.

Showing nut-shells which contain larvae ~nd pupae.

12

Nu~ve Tree Well in Ellice Islands, mudeto store ruinwater~

13.

Tree ttole resulting from injury.

S,~v,~'~,dost~u[ett~,t'i,~breeding" pi~¢.

S. pseudascutellari,~ breeding-pluee.

Hole in Lava Rock, c o n t a i n i n g dec'~yin~' leaves and w a t e r in w h i c h ,~'.l~xeudosc~ztell~tris breed

~. Native " T a r o " (~blocttsitL).

Breeding-place of ~'i;daya lwc]d in cups formed by j u n c t i o n of leaf and stem.

;~.~

~

•~ ~ ,~ .~ m 0

o a~1

5~

,.o4~

0.~

IS.

Three a'enerations shox~,ing family incidence of Elephantiasis.

19

Females--Ellice Islands.

Elephantiasis

Northern Elliee.

20.

21.

lY[ales--Ellice Islands.

Elephantiasis.

Natives--Relatives. Elephantiasis.

Ellice Islands.

l

i

(6) M. 9 b. F u n a f u t i . aged 65. E. arms. legs.

M. 9 aged28. Vaitupu, Zympha~qiti.~ breasts, E. arms. legs. Four other children b u t no histories available.

I

b. Niutao. d. h-iutao, married T. (native). h: r. arm. legs. No history.

(5) D. g b. F u n a f u t i , aged 30. No history, No examination.

[

[

IV.

FAMILY

A. E,

]

t

E. = Elephantiasis.

(7) P. 9 b. F u n a f u t i . aged 63. E. left leg.

I

t

D a u g h t e r P. 9 aged 20, b. F u n a f u t i . E x a m i n a t i o n negative.

E. r. leg, scrotum.

(4) H. 3 b. F u n a f u t i , aged 43, 2;ilz~riasis arms, legs,

(9 &il0) Sisters. died w h e n aged 5. No history. No examinations.

(3) L. g b. Niutao. aged 40, E. r. leg, scrotum.

[

(8) B. 9 b. F u n a f u t i , aged 40. !g~er~'la.ria +~12.

Son T., b. New Guinea, aged 2. E x a m i n a t i o n negative. (2) ~I. $ aged 31, b. lqiu~ao, F~larh~i.~ r. Ieg, ~ c r ~ ' l a r l a + 32. (3) P. 9 b. F u n a f u t i , aged 21, M~erojilaria + 21.

I

(1) 3/[. 9 b. F u n a f u t i , aged 29,

(2) D. ~ b. Niutao. married F , b. Nintao, aged 52, aged 40. lives F u n a f u t i . live~ FunafUti. Filo r~asis legs. ,~lic~.ofilaria + 33.

[

3.. b. Australia, d. F u n a f u t i , aged 60, m a r r i e d S (native), b. Niutao. d. F u n a f u t i . 20 years Niutao, 20 years F u n a f u t i . " No examination. E. legs, scrotum. No history.

TA~L~

¢D

QQ

50

SOME R]~SULTS OF M E D I C A L

TABLE IVA. THE F. F A M I L Y (EURONESIAN). Father Mother 1. D a u g h t e r 2. D a u g h t e r 3. S o n 4. S o n 5. S o n : 6. Daughter 7. S o n 8. Daughter

Age

Mr.

56 41 30 17 22 14 11 10 6 3

20 -22 20 52 20 2 24 --

TABLE THE B..FAMILY

--

Clinical.

-both legs r i g h t leg -r i g h t arm left leg -----

Enlarged Epitrochlears.

both both right both both both right !eft both left

Iy . (EURONESIAN).

Father, aged 60, Mother, aged 50, and children, aged 14, 14, 13, 12, 10, 7, 1½, w i t h no mierofilari~e and no history of clinical symptoms. One or o t h e r epitrochlear gland enlarged except in one girl, aged 14, and child, aged 1½ years. CONCLUSION.

Space does not permit me to allude to a large number of subjects which have been investigated : the blood picture in man in the Pacific ; the morphology of the microfilari~e ; the pathology of filariasis ; infection with larval filaria of captured mosquitoes; the examination of blood and f~eces oi a large number of various kinds of animals; as well as other human disease conditions, some fairly common and some rare, which occur in the different groups. These, with an account of the entomology and helminthology, will/ be fully discussed in my final report, now in prepal~tion. The main problem, so far as health in these islands is concerned, is tuberculosis, which requires being dealt with promptly and thoroughly, and, as a preliminary measure to attain that end, those diseases which cause so much debilitytankylostomiasis, • yaws and filariasismdemand attention. Happily, these diseases are all preventable, and the two former respond to treatment. In any measures that may be attempted, the co-operation of the Polyfiesians may be relied on, f o r they are an intelligent people, quick to lear~, and, when they understahd the value of methods resulting in benefit to themselves, prompt to obey. Both men and women show enthusiasm in acquiring medical knowledge, and ~he

RESEAI~CI~nS IN T]~I'~ WESTEI~N I~AClFIC.

51

training of Polynesians as medical students and nurses has given satisfactory results. In the groups visited by me there are three medical services. In Western Samoa there is a central Government Hospital at Apia. Since 1920 the Hospital has been enlarged, a laboratory has been built, and the staff, medical and nursing, has been doubled. One district hospital has been working for some time at Tuasivi, in Savaii, and others, much needed, are to be erected. A Medical Officer of Health has been appointed to deal with quarantine and the big problems of tuberculosis and ankylostomiasis. If the generous plans provided by the Samoan Health Act now in force can be carried out, t~here should be an early improvement in the health of the natives: but Dr. S. TRAIt,, the P.M.O., and his department have experienced many difficulties locally in getting these plans develope& In American Samoa, under the United States Naval Medical Service, there is a European hospital and a native hospital at Pago Pago. There are also dental and X-ray departments. In every island of the group there is an island hospital under the charge of a trained Petty Officer of the United St.ares Naval Medical Department. The fact that all treatmertt to ,.~atives is (rec goes far to popularise European medicine. In the lgllice and Tokelau Islands the people are tess fortunate. During my stay there was no European medical officer, and, in any case, one such officer, with headquarters at Tarawa, in the Gilberts, is not sufficient for even a casual inspection of the very scattered islands (~f the Gilbert, Elliee, and Tokelau groups. Though a good worker, the Polynesian requires supervision, and, left to their own responsibility, the native pr~mtitioners and dressers do more harm than good. Transport in these islands is rare and irregular, and this may have accounted for the depletion of the medical stores on the different islands during my stay. There is ample work for a medical officer in the Ellice Islands, and another in the Toketaus; and, till transport can be better regulated, a large supply of drugs should be placed at some central island for these groups. It a~ppears to me that a united medical service, with its base in the Pacific, on the lines of our other great tropical services, having an ~dequate staff, so that a sufficient number of men could be detailed where the requirements, from time to time, became greatest, and capable

52

MEDICAL RESEARCHES IN THE WESTE~:N PACIFIC.

of frequently organising supervision of all the islands, would ensure the best possibilities, for the future health of these peoples. In my final report I will gladly acknowledge the generous help of many friends who have helped me at home and abroad. Here only I must state my gratitude for the never-failing help of my assistant, h/It. C. E. BERRY. Owing to postal di~culties, instructions from Fiii, granting me the necessary facilities, did not reach the Ellice :Islands for seven months after my arrival, when I had arranged to leave the group. H a d it not been for the great assistance generously given by the New Zealand and Samoan Governments, much of the work could not have been accomplished. Dr. O'CoNNo~'s paper was illustrated by a large number of lantern slides prepared from his own negatives and those of Mr. BERRY by the staff of the Wellcome Bureau of Scientific Research, through the courtesy of the Director, Dr. ANDREW BALFOUR. A number of Dr. O'CoN~oR's microscopical specimens were arranged by Mr. W. J. MUGGLETON. These included one showing invdsJon of lymphatic glands with eosinophile cells forty-three days after patient (Mr. C. E. BERRY) was infected with filaria.

DISCUSSION.

Dr. P. H. MANSoN-BAHR: I congratulate Dr. O'ConNoR on the magnificent piece of work he has accomplished. I have been intimately associated with him for many years, and have been in correspondence with him during the whole of his recent interesting trip through the Pacific. Dr. O'CoNNoR's work may go down to posterity as that of a medical :Robert Louis Stevenson. You have, as yet, heard but little of the wonderful things he has seen or done. To me it is naturally a source of great satisfaction, because in many ways he has amplified and confirmed the work which, twelve years ago, I was sent out to Fiji to do. It seems that this Stegomyia pseudoscutellaris is the vector of filariasis throughout the Pacific; and it appears, from what 1 have been ~old by Dr. C~L~,~To, of the Australian Public Health Service, that, wherever t h e non-periodic microfilaria is found in the Bismarck Archipelago, or New Guinea, this S~egomyia is found, and wherever the Microfilaria

DISCUSSION.

53

nocturna is present, as in the Solomon Islands and the N e w l~ebrides, S. pseudoscutellaris is absent. I think that, in order t o carry out research on this suggestive fact, much more work is necessary; but it would appear, from the data we have at present, that the filaria of the Pacific is to be considered, in a phys:iological o r pathological sense, a different species from the classical Filaria bancrofti, which is found in different parts of the world. All the factsl so far collected, make it more apparent that what Sir PAT~ICX MA~SON originally suggested to me, twelve years ago, will come to be true, that this is a different variety of filaria, not only in regard to its intermediary host, but in its pathological effects on man. One of the main symptod~s of fil~riasis in other parts of the world is chyluria, but in the thousands of cases of filariasis Dr. 0'Co~Noa observed he saw not a single case. The same I found to be true in Fi]i. Dr. O ' C o ~ o ~ has run to earth the mum breeding-piaces of S.pseudoscutellaris. I failed to find its natural breeding haunts, although it appears, from what we have heard, that they were lying underneath my nose. I found the mosquito breeding in wells and in small accumulations and pools of water, and I thought also that it bred in brackish creeks, but I did not succeed in finding it breeding in these elnpty cocoanut husks, probably because I had not the enterprise to examine the deeper layers. Dr. O'CoN~oa has suggested that filariasis of the Pacific is easily preventable, and if Dr. ANDERSON goes out to Samoa to carry out this great work, he will assuredly show us whether this can be done. I do not think the disease is curable, but cannot we prevent it '? If we take a small island, like one of the Elliee or Samoan group, and burn systematically all the cocoanut husks, cut down all trees which have holes in them, and tilt up the native wells, we shall be able to stamp out filariasis in the smaller islands of the :Pacific. Of course, proper cisterns must be supplied. The Polynesians are extremely intelligent, and take up the white man's medicine readily if they know it to be good. I am sure that with proper tact, which Dr. A~DERSO~ possesses in a high degree, this can be brought about. Other insects than S. loseudoscutellaris are found to be unable to transmit filaria to man, and it is with very great hope that the work of our great prototype, Sir PAT~mK MaNSON, is within measurable distance of being accomplished that I again congratulate Dr. O'CosNo~ on the paper he has given us.

54

DISCUSSION.

Dr. G. C. L o w : I also wish ~o congratulate Dr. O'CoNNoI~ on his most interesting demonstration, and on the excellent work he has carried out in the Pacific. My own work on filariasis was curried ou~ mostly in the W e s t Indies and Africa on Filaria banc'rofti, ~nd the chief intermediate host in these par~s is Culex fatigans. I t was m y original intention to go on to the Pa,cific from the West Indies to study the disease in those parts, and the idea that the Pacific filaria might be ~ different species was discussed by Sir I)A~RIC~: MANSON and myself. [ am inclined to agree with Dr. MANSON-13AI-I~ that there is good evidence ~hat this is so. T h e intermediate host of the two is different : C.fatigans for F. bancrofti ; S. pseudoscutellaris for the Pacific filaria. Dr. MANSO~-BAHn found C.fatigans in Fiji, but, even so, the optimmn i n t e r m e d i a t e host was S. pseudoscutellaris. Again, the periodicity o f the ~wo is quite different, and, pathologically there are differences also. Chyluria and l y m p h u r i a are practically never seen in the Pacific form, while epitrochlear gland enlargemenL, c o m m o n in it, is exceedingly rare in F. bancrofti. After all, however, the main point is a f u r t h e r careful examination of adults ~o determine whether they differ from each other or not. T h e question of prophylaxis is a very interesting one, and I think it would be easier to stamp out S. pseudoscutellaris than the house-infesting

C. fatigans. Dr. 0'CoNsort's work will be of great use to Dr. A~DERSO~. who is going out to carry on the work. H e will have full knowledge of the breeding-grounds, and will be able to take up prophylactic measures ~t once. Colonel C~JA¥:roN LANE: 1 have to thank Dr. O'CoNNoI~ for having given me the privilege of e x a m i m n g the material which he has brought home. A m o n g it are two female filarim from man. I t has been suggested that the species here concerned is different from Filaria bancrofti. T h e latter was originally described by COI~BOLD from Australia, so that if t h e r e be a difference in species I take it that it is likely that the species from the :Pacific islands will be F. bancrofti ; the other species, if t h e r e be one, will b e , s o m e t h i n g else. T h e intestinal m~terial consists almost entirely of Necator ameri-

DISCUSSION.

55

canus. In 1,500 hookworms there are 1,480 necators, one specimen of Ankylostoma duodenale and one of A. ceylanicum. F r o m the conjunerival sac of a fowl Dr. O'CoNNOI~ recovered a number of specimens of Oxyspirura mansoni. This find is of particular interest this evening, for in 1878 MANSON sent home from Amoy the head of a chicken, and COBBOLI) n~med the. nematodes which he found in the conjunetival sac ~. mansot~i. This species is of world-wide distribution on sea coasts. There are also two Strongylat~ from the pig. The m~terial is important from the point of view of zoology, in that it helps to clear up a dispute which has been going on for many years as to the difference between the genera Crassisonla and Globocephalus. I believe that each of these forms is a new species; they cannot, at least, be made to correspond with the existing descriptions of known species. One of them I am designating Globocet)halus connorfilii, as a slight mark of my appreciation of Dr. O'CoNNol~'S generosity. Dr. P. H. ~/[ANSON-BAI-m (in further comlnent) : In Northern Queensland and Australia generally it is the noctm'nal filaria that is found, aud the non-periodic filaria begins only when we reach the outer archipelago. The adult non-periodic worIns were described by Dr. LEIPER, and his description appeared in my report in 1912 ; in it he said he could find no morphological difference between the non-periodic Fijian adult worms and the true type of F. bancrofti. I anl now in great hopes that, as Dr. LEII'~R brought back so many adult periodic filarim from British Guiana, these two types will once more be compared. My adult worms were procured from human subjects by excision of the glands during life, and I hope my specimens will again be dug out and scrutinised. I do not think that any microscopical difference between bancrofti and the Pacific filaria will be found. T h o u g h morphologically identical, yet it is conceivable that the symptoms produced by these two varieties may be different, and it may be that through long transference through different generations of inter.mediary hosts they may have become distinctive in the pathological sense. Another point not, sufficiently emphasised is that probably filariasis is the root of all evil in the Pacific. There are three diseases there : ankylostomiasis, filariasis, and, finally, tuberculosis. Destruction of glandular tissue and the lowering of bodily resistance by the filaria may predispose

56

DISCUSSION.

to tuberculosis, which is such a scourge in the Pacific. Clearly, we must endeavour to clear out ankylostomiasis, prevent filariasis, and the tuberculosis will then look after itself. The PRESIOE~T said he had listened to Dr. O'CoNNo~'s discourse with great interest , and almost with envy, for it reminded him how unprepared and ill-equipped he was for the treatment of tropical disease when he first joined MANSON in Hong Kong. He wished to thank Dr. O'CONNOR for his most instructive paper. Dr. F. W. O'CoNNor: Replying to Dr. Low, said that only a few adult filaria had been collected and these were females. It had been difficult to get the Polynesians to consent to operations. There was ~ill lately a dread on their part, not only to the use of the knife but also the needle. Now, however, in Samoa, owing to the tact and enthusiasm of the :Principal Medical Officer, Dr. S. TRAIL, and his colleagues, Drs. MATttESON and MAIL, surgerY was becoming more popular, and it is to be hoped that soon plenty of specimens will be forthcoming.