434 S.A. MEDICAL JOURNAL 20 April 1963

i.e. ovary, stomach or breast, is invariably less accurate. the particular method with which he has had most Tentative suggestions may be proposed, but exact deter­ experience. Papanicolaou preparations provide excellent mination is not always possible. This finding conforms nuclear detail upon which the diagnosis of malignancy with the difficulty of interpretation of histological sections is primarily based. In acridine orange and Giemsa tech­ of some metastatic tumour. Similarly, undifferentiated niques there is a greater concentration of cells in the malignant cells which may be derived from sarcoma, less smears. Immature cells in the malignant lymphomas and common varieties of carcinoma, and other miscellaneous reticulum-cell sarcomas are more easily typed with Giemsa tumours, present as anaplastic malignant tumours in stains. Fluorescence microscopy reduces the screening histological section. Again it may not be possible to arrive time, particularly in the negative smear. It has proved help­ at a definite conclusion, in spite of the use of special ful in distinguishing malignant cells from atypical meso­ techniques. thelial cells in some cases. Both the morphology and stain­ The negative smear does not necessarily exclude ing characteristics must be considered in assessing the cells. malignancy. An effusion associated with a malignant In obvious smears each technique provides confirmatory tumour may occur in the absence of serosal metastases. evidence. In the problem smear the various methods may Fibrin covering the tumour may prevent the exfoliation contribute additional information and facilitate diagnosis. of cells into the fluid, or the tumour may not shed Degenerate material is generally unsatisfactory. malignant cells. These factors, or the inability to recognize SUMMARY the cells as malignant, account for the 'false' negative Exfoliative cytology applied to serous effusions is of result. In suspected cases further specimens should be definite value as a diagnostic adjunct. Preparations from examined. the specimens are stained with Papanicolaou, May­ The problem smears have atypical ceLls on which a Griinwald Giemsa, and acridine orange stains. Distinctive definite opinion cannot be expressed. Proliferating meso­ features permit classification of the preparations into thelial cells with active nuclei and increased cytoplasmic recognizable cell types. Correlation with the site of the RNA synthesis, which occur in congestive cardiac failure, primary tumour is less exact. Active and immature cells pulmonary infarction, virus pleurisy and cirrhosis of the in chronic inflammatory and proliferative conditions may liver, may simulate malignant cells. The cytological picture be confused with malignant cells. The various staining of malignant lymphoma may be difficult to differentiate techniques confirm and facilitate diagnosis. from a tuberculous effusion in which there are many I wish to express my thanks to Miss D. Weintroub for her immature lymphocytes. These conditions are responsible assistance and to Mr. M. Ulrich for the photography. for false-positive reports. In conjunction with all the REFERENCES available data further specimens should be examined in I. Papanicolaou. G. (1954): Arias of ExfoUmive Cytology, p. 12. an attempt to provide a final diagnosis. Cambridge. Mass.: Harvard University Press. 2. Spriggs. A. I. (1957): The Cytology of Effusions, p. 27. London: Heinemann. As regards staining techniques, the cytologist relies on 3. Bertalanffy. F. D. (1962): Arch. Path., 73, 3D.

REGIONAL VARIATIONS IN THE FREQUENCY OF BANTU OESOPHAGEAL CANCER CASES ADMITTED TO HOSPITALS IN SOUTH AFRICA

A. G. OElTLE, Cancer Research Vnit of the National Cancer Association of SOlllh Africa, South Afriran lnstitllle for Medical Research, Johannesburg

In a number of centres in Africa it has become apparent registers.*9,JO This requested current information on the that cancer of the oesophagus, once a rare disease in the number of beds available for Bantu patients, records of Bantu, is now very common. References to this increase cases of cancer of the oesophagus by race and sex, whether are all of later date than 1950, as evidenced in South the disease was thought to be common and, if so, whether Africa by a succession of reports from the TransvaaI,l'~ any cause was suspected. Details of the diagnostic pro­ East London,3 Natal.' Johannesburg,5,6 Durban,? and the cedures were not asked for. Transkeis Therefore, in 1961, the Executive of the ational The results are open to many errors, resulting from Cancer Association of South Africa requested the Cancer such varied causes as failure to distinguish Bantu from Research Unit to determine to what extent this trend was other non-White patients, misdiagnosis, counting of general throughout this country or whether it was confined admissions rather than cases (and so failing to distinguish to specific regions. re-admissions), poor recording of diagnoses (e.g. by diag­ nosis on admission rather than on discharge), and multiple Materials and Methods registration of cases where patients have been admitted to several hospitals in succession. The results are presented, Permission having been obtained from the Directors of nevertheless, because they confirm experience from other Hospital Services in the four provinces, a questionnaire sources. such as histological series from diagnostic labora- was circulated in July 1962 to superintendents of those " Omitting mine hospitals, and including nursing homes con­ South African general hospitals listed in available cerned with non-V/hile patients. 20 April 1963 S.A. TYDSKRIF VIR GENEESKUNDE 435

tories, death registers, and personal experience of visits have been provided by the Bureau of Census and Statistics to hospitals in Johannesburg, Pretoria, the Transvaal Low­ (Table lIl). The results of the ho pital survey are also v~ld, and the Transkei (for the latter 1 am indebted to given in Table III and are illustrated in Fig. I. Dr. R. J. W. BurrelI). The differences which this survey A high frequency of oesophageal cancer is evident in -demonstrates between regions, furthermore, are too great all the large urban centres.~· The extent varies to which to explain away on random or systematic errors. Crude this reflects an increased incidence in local residents or .as our measuring instrument may be, it is evident that merely indicates transfer of cases. In Johanne burg the the incidence of oesophageal cancer varies profoundly­ majority of ca es are residents, in Cape Town the majority its relative frequency in the Sir Henry Elliott Hospital, are transferrd. The rate lies between 4 and 5 per 100 beds Umtata (40 per 100 beds), for example, being 200 times that recorded from Swaziland (0'2 per 100 beds). 8cI"It.J Oe~ cancer CMI'" !'" - "j'\ .,.-..... M)() ~e-tal cect$ I96l Where hospital statistics did not distinguish Bantu from other non-Europeans, we were obliged to treat all the non­ Q. iTIID ,. ~ c 2>- _ "- European bds as available for Bantu patients. In such I instances the figures will be abnormally low for regions o· _ i 20· _ i such as the Western Cape, where other races predominate, ! but this source of error does not appear to be important. r---.1 i The large hospitals inevitably receive many cases trans­ I ferrd from outlying districts, e.g. at Groote Schuur Hospital in Cape Town the majority of cases of -oesophageal cancer are transfers from the Transkei, 600 - 700 miles away as the crow flies. In such hospitals a correction will have to be made - if only as a mental reservation - until precise figures are available for rates in local residents. Results have been stated as an annual rate per 100 beds, rather than the traditional 'rate per 1,000 admissions'. The former rate is easier for the average doctor to grasp since it enables him to compare mentally what would be expected in any given hospital, whereas the total number of admissions is an unfamiliar denominator. It also facilitates correction for the weighting effect of special beds, e.g. paediatric, obstetrical or tuberculous, which are seldom distinguishable in figures for total admissions. Thirdly, ·cases of oesophageal cancer are all likely to be admitted, " if only for diagnosis or special feeding before being referred to a larger centre, irrespective of the pressure of Fig. 1. Frequency of Bantu cases of oesophageal cancer -other cases on the hospital. Increased turnover of cases per 100 hos!,ital beds per annum up to 1962 in South ·other than of oesophageal cancer would result in increased Africa and the Protectorates (see Table Ill). admissions and would affect the denominator if the in Pretoria and Pietermaritzburg, between 5 and 10 in traditional rate were employed. Thus, in Johannesburg, Cape Town, Port Elizabeth, East London and Johannes­ Baragwanath Hospital, with 2,200 beds and 50,000 burg, while Bloemfontein reaches the figure of 12·6. The admissions, would have an average of 16· I days per latter figure was provided by the single thoracic surgeon patient, as against an average of only 10·7 days for there, and does not include all cases admitted to hospital. ·Coronation Hospital, with 435 beds and 14,816 admissions. It is identical to that calculated from the figures of the As sex was not always distinguished in the replies, the histological laboratory, and so is almost certainly an combined figure for both sexes was used for rate cal­ understatement. culations. Sex ratios were calculated where details were For many rural areas, viz. Zululand, the Lowveld, .available. orthern Transvaal, Sekukhuniland, Western Transvaal, Because of the inherent deficiencies of the procedure Orange Free State, Western Cape, Basutoland, SwaziIand, it has not been thought necessary to give the replies of and Bechuanaland Protectorate, the incidence is below individual hospitals. Instead, hospitals have been grouped I per 100 beds. Other regions show a higher frequency. in geographical regions possessing some socio-economic It lies between I and 2 in the Eastern Cape, orth-Eastern -or climatic uniformity (Table I). Thus the Western Cape Cape, Eastern Transvaal, rural atal and orthern Trans­ rural group consists of all those magisterial districts where kei (Emboland and Pondoland). It rises to 2 for the the density of the Bantu population is less than 1 per 'remainder of the orth-Eastern Cape' and the industrial square mile. areas of the Orange Free State gold-mining group; to ResulTS between 4 and 5 in the Ciskei. In the Southern Transkei Replies were obtained from more than 85% of t Except Durban, where oesophageal cancer is nevertheless hospitals. The proportion by region is indicated in Table regarded as common. There the proportion recorded is pro­ 11. The population figures for these districts (1960 census) bably artificially lowered by the large total of hospital beds. 436 S.A. MEDICAL JOURNAL 20 April 1963

Zululand probably represents the original or basal level and all other regions represent areas of increasej incidence. Consequently the picture presented here is only of transient validity. In fact it is already clear that in some hospitals ~ --.' '. the situation has since changed from that reported, e.g. "- " , ~"'. -~. "':.- Pietersburg Hospital, which has subsequently encountered a much increased frequency of cases. (c) The carcinogenic STimulus is neither peculiarly urban nor peculiarly rural. High incidence is noted in both rural " and urban populations. The urban cases (apart from transfers) cannot be accounted for by recent migrations from rural areas, for in the Johannesburg survey the average length of urbanization of male patients with oesophageal cancer was 19·5 years compared with 16·8 years in controls with cancers of other parts of the body, matched for age. Burrell has registered cases in patients who have • never left the Transkei. These facts suggest that the cause or causes are not limited to either town or country, unless it be postulated that entirely different carcinogens are re­ sponsible in the different areas - which seems improbable. (d) Patchy distriblllion wiThin areas. Incidence within regions is not necessarily uniform, and certain hospitals stand out as having a higher rate than their neighbours, e.g. St. Konrad's Mission Hospital (60 beds) at Taung, which reported 21 cases in 5 years. In the Transkei Burrells has reported that the condition 'is particularly rife in Fig. 2. Frequency of cases of oesophageal cancer in scatterd circumscribed localities'. His detailed regional Negroes in African hospitals in 1960. maps of this phenomenon are awaited with interest. In the meanwhile our register of cancer of the oesophagus it rises to the extraordinary figure of over 20 cases per in mineworkersll indicates that it is common in those 100 beds. from Emboland and Pondoland. Patches of high incidence The sex ratio (Table IV) has been calculated where the evidently occur in the Northern Transkei, where the total information was adequate, and shows striking variation rate is low. with incidence. Where cases are rare there is usually a (e) OTher parTs of Africa. A high incidence of cancer far greater masculine preponderance than where cases are common. This correlation is not very close, but since the of the oesophagus has recently been recorded from certain regions in Africa (Fig. 2), whereas in other parts the sex ratio changes also with time" and with ageS this disease continues to be rare. This does not imply that variability is not unexpected. In Bloemfontein, however, the disease is still rare in females (ratio 17: I) despite it will always remain rare, for an epidemic may still be its high frequency there. brewing in these parts, assuming a similar period of latency. Regions of high incidence are particularly common DISCUSSION in Southern Rhodesia (Salisbury, Bulawayo, Rusapi, Fort Victoria), Nyasaland (Blantyre) and Kenya (Nairobi, (a) Influence of attiTudes TOwards WesTern medicine. The KisUI,lU and Mombasa), while in Mo~ambique (Louren~o question wiil naturally arise what proportion of Bantu Marques, Beira) Uganda (Kampala), Northern Rhodesia patients with oesophageal cancer are likely to present (Abercorn, Fort Jameson), and Tanganyika (Dar es Salaam) themselves at hospital. In the large cities I believe that it remains low (Table V). In West African Negroes there almost all will do so. The survey of 1953 - 55 in Johannes­ is no evidence of any increase. In the Sudan, however, at 12 burg showed that 95 % would attend hospital whereas, 13 s Khartoum, in a non-Negro population, Professor Lynch in a uniquely intensive survey of the Transkei, Burrell informs me that cancer of the oesophagus is commoner found that 69·7% of the male cases registered and 48'2% than cancer of the stomach. of the female had been to hospital. The Transkei probably is representative of the unsophisticated areas. Unwillingness (I) Other races in South Africa. Mortality figures for to attend hospital thus may make the incidence in one Whites, Coloureds and Asians have been obtained from area appear to be half that of another with the same the Department of Census and Statistics for the period true incidence. It cannot, however, explain such differences 1949 - 58 for the first two groups, and for 1950 - 5S as those recorded here, where the highest rate is 200 times for the Asian group. Mortality rates standardized the lowest. to the United States population of 1950 show that the (b) Recent nature of epidemic. There is an abundance Coloured male rate is sLightly increased, and other infor­ of evidence that this high incidence of oesophageal cancer mation suggests that this represents a genuine increase. is of recent origin.H The incidence seen in areas such The Asian male rate is low and the Asian female rate is as Swaziland, Bechuanaland Protectorate, Basutoland and slightly increased, as expected in view of the greater 20 April 1963 S.A. TYDSKRIF VIR GENEESKUNDE 437

prevalence of betel-chewing in Indian women. Regional Keiskama Hoek, Middeldrift, King William' Town, Stullerheim, studies of mortality reveal that among White males the Cathcan, Glen Grey, QueenslOwn, Herschel, Komgha) 4. Transkei proper (B'Jlteilvorth, Idutywa, Kentani, qamakwe, incidence of oesophageal cancer is very low in the Orange Tsomo, Willowvale) Free State and very high in atal- a difference that 5. Tembuland (Elliotdale, Engcobo, Mquanduli, SI. Marks, parallels the mortality from lung cancer, probably reflecting Umtata, Xalanga) the well-known association between oesophageal cancer 6. Pondoland (Bizana, Flagstaff, Libode, Lusikisiki, Ngqeleni, and smoking. Pon SI. Johns, Tabankulu) 7. Efl/boland (Griqualand Easr) (Matatiele, MI. Ayliff, Ml. CONCLUSIO Currie, Ml. Fletcher, Ml. Frere, Qumbu, Tsolo, Umzimkulu) 8. Norrh-Easrern Cape (Ma/eking region) (Mafeking, Vryburg, The striking nature of the regional distribution of thi Kuruman, Taung) disease, and its epidemic character, provides a most pro­ 9. Norrh-Easrern Cape (Kimberley region) (Po tmasburg, Barkly voking epidemiological problem in cancer aetiology, apart West, Hay, Herbert, Warremon) from the humanitarian aspects. The subject demands far NATAL more intensive study, and might justify central registration I. Naral ewcastle, trecht, Paulpietersburg, gOlshe, Vry- of cancers in South Africa. heid, Babanango, Dundee, Kliprivier, Bergville, Msinga, Weenen, The survey has revealed that the record systems of many Kranskop, ESICourt, Umvoti, Lions River, New Hanover, large hospitals in this country are exceedingly defective. Ndwedwe. Mapumulo, ]mpendle, Inanda, Lower Tugela, Camper­ down, Pinetown, Underberg, Polela, Richmond, Umlazi, Jxopo, If better kept, they would be treasuries of information Alfred, Umzinto, Pon Shepstone) of great demographic interest. 2. Zululand (Eshowe, Hlabisa, Ingwavuma, Lower Umfolozi, Mahlabatini, Mtongjaneni, Mtunzini, Nkandla, Nongoma, Nqulu, SUMMARY Ubombo) TRA SVAAL A questionnaire to South African hospitals revealed differences in the relative frequency of Bantu cases of I. Easrern Transvaal (Witbank, Belfast, Carolina, Heidelberg, cancer of the oesophagus which varied more than one­ Belhal, Ermelo, Standerton, Volksrust, Amersfoort, Wakker­ stroom, Piet Retief, Delmas) hundredfold between the regions of highest and lowest 2. Lowveld (Letaba, Pilgrim"s Rest, elspruit, Barberwn) frequencies. 3. Sekukl/llniland (Bronkhorstspruil, Groblersdal, Lydenburg, The maximum frequency occurred in the Southern Middelburg) 4. Norrhern Transvaal (Potgietersrusl, Pietersburg, Soutpans­ Transkei, but the disease was also common in all large berg, Sibasa) cities, being commonest in Bloemfontein. 5. Wesrern Transl'aal (Waterberg, Warmbad, Brits, Rusten­ This patchy distribution suggests a carcinogenic exposure burg, Marico, Lichtenburg, Ventersdorp, DelareyvilIe, Schweizer­ that is neither peculiarly rural nor peculiarly urban, to Reneke, Wolmaransstad, Bloemhof, Christiana) which males are usually but not invariably more heavily ORA 'GE FREE STATE exposed than females. The disease is common in other regions of Africa, and the epidemiological features suggest I. Orange Free Srare (Sasolburg, Parys, Vredefort, Viljoens, a cause or causes of recent origin and wide but somewhat kroon, Bothaville, Koppies, Heilbron, Frankfort, Vrede, Reitz­ haphazard distribution. Lindley, Wesselsbron, Hoopstad, Boshof, Bulfontein, Theunissen, Virginia, Ventersburg, Senekal, Bethlehem, Harrismith, Brandfort, Among the non-Negroes an increase in cancer of the Winburg, Marquard, Ficksburg, Fouriesburg, C1ocolan, Lady­ oesophagus would appear to be occurring among Coloured brand, Thaba' 'chu, Jacobsdal, Fauresmith, Edenburg, Redders­ males, Asian females, and possibly the Sudanese. Among burg, Dewelsdorp, Wepener, Trompsburg, Philippolis, Bethulie, RouxviJle, Smithfield, Zaslron) South African Whites provincial differences in mortality from oesophageal cancer have been noted. TABLE 11. PROPORTION OF GENERAL HOSPITALS REPORTING TABLES ADEQUATELY

TABLE I. RURAL REGIONS DISTINGUISHED IN THIS ANALYSIS, (Replies sraring rhar information was not available, or that all cases WITH THE CONSTITUENT MAGISTERIAL DISTRICTS were transferred, are lIot counred) CAPE PROVINCE SOUTH AFRICAN RURAL HOSPITALS I. Western Cape (Gordonia, amaqualand, Kenhardt, Prieska, Hopetown, Phillipstown, van Rhynsdorp, Calvinia, WillislOn, Hospirals Carnarvon, BritslOwn, De Aar, Victoria West, Richmond, Clan­ reporting Toral Percenrage william, Sutherland, Beaufort West, Fraserburg, Murraysburg, CAPE PROVINCE Aberdeen, Piketberg, Ceres, Laingsburg, Prince Albert, Willow­ 1. Western Cape 29 38 76 2. South-Eastern Cape 17 21 81 more, Steytlerville, Vredenburg, Hopefield, Tulbagh, Malmesbury, 3. Ciskei 9 9 100 Simonstown, Wellington, Paarl, BeUville, Stellenbosch, Somerset 4. Transkei proper I I 100 West, Caledon, Worcester, Robertson, Montague, Bredasdorp, 5. Tembuland 4 5 80 Swellendam, Ladismith, Heidelberg, Riversdale, Calitzdorp, 6. Pondoland .. I 3 33 Mossel Bay, Oudtshoorn, George, Uniondale, Knysna) 7. Emboland .. 9 9 100 2. South-Eastern Cape (Colesberg, Hanover, Venterstad, Albert, 8. North-Eastern Cape AliwaJ North, Lady Grey, Barkly East, Maclear, Steynsburg, Mafeking region 7 7 100 Wodehouse, Jndwe, Elliot, Molteno, Middelburg, Maraisburg, 9. orth-Eastern Cape Sterkstroom, Tarka(stad), Graaff-Reinet, Cradock, PearslOn, Kimberley region 4 5 80 Jansenville, Somerset East, Bedford, Adelaide, Albany, Uitenhage, Kirkwood, Alexandria, Bathurst, Humansdorp) 81 98 83 3. Ciskei (Peddie, Fort Beaufort, Stockenstrom, Victoria East, 438 S.A. MEDICAL JOURNAL 2.0 April 1963

Hospirals TABLE Ill. RESULTS OF SURVEY: POP LATIO S OF REGIO S reporring Towl Percentage ACCORDtNG TO 1960 CENSUS, UMBER OF NON-WHITE NATAL BEDS rN HOSPITALS COOPERATI G, AND CASES OF 1. Natal r/lral OESOPHAGEAL CANCER REPORTED, WITH A UAL Industrial 1I 12 92 NUMBER AD RATE PER 100 BEDS PER ANNUM Remainder 33 36 92 Total Total Annual Cases 2. Zululand 17 18 94 Population beds cases cases p" 100 1960 reporting reported reported beds 61 66 92 SOUTH AFRJCAN RURAL HOSPITALS CAPE PROVINCE TRANSVAAL 1. Eastern Transvaal 6 7 86 I. Western Cape 134,834 878 21 6·9 0-8 2. Soutb-Eastern Cape 369,057 535 14 7 1·3 2. Lowveld 1I 11 100 3. Ciskei .. 458,625 785 89 35·4 4·5 3. Sekukhuniland 4 6 67 4. Transkei .. 281,347 97 40 20 25·8 4. 'orthern Transvaal 7 8 88 5. Tembuland .. 328,158 198 239 50·3 25·4 r.. Pondoland .. 402,734 60 1 0·6 1-0 5. Western Transvaal 10 12 83 7. Emboland.. 388,945 565 12 8·5 1·5 8. North-Eastern Cape 38 44 86 Mafeking region _ 215,707 371 21 4·2 -I 9. orth-Eastern Cape Kimberley region.. 68,359 53 7

ORANGE FREE STATE J. Orange Free State 21 23 91 NATAL I. Natal 1,357,236 3.667 73 36·8 1·0 TOTAL RURAL 201 231 87 General 3,090 69 33·5 1·1 Industrial 577 4 3·3 0·6 2. Zululand 550,195 2,002 30 10·4 0·5

SOUTH AFRICA URBAN HOSPtTALS TRANSVAAL CAPE PROVINCE I. Eastern Transvaal 526,874 599 11 6·5 1·1 1. Cape Town 4 4 100 2. Lowveld 450,641 895 5 2'5 0·3 2. Port Elizabeth 1 I 100 3. Sekukhuniland 372,475 1,136 10 7 0·6 I I 100 4. orthern Transvaal 712,587 1,108 9 6·7 0-6 3. East London 5. Western Transvaal 604,238 774 9 5·(\ 0·7 4. Kimberley I 1 100

ATAL ORANGE FREE STATE 1. Durban 2 4 50 I. Orange Free State 822,813 943 5·8 0·8 2. Pietermaritzburg 1 I 100

SOUTH AFRICAN URBAN HOSPITALS TRANSVAAL 1. Johannesburg 4 4 100 CAPE PROVlNCE 2. Pretoria 3 3 100 I. Cape Town 65,635 610 201 34 5-6 3. igel 1 I 100 2. Port Elizabeth 135,547 440 36 21·8 5-0 4. Springs 1 3. East London 108,609 241 14 • 14 5·8 o o 4. Kimberley 91 3·3 5. Boksburg-Benoni-Brakpan I I 100 36,134 5 3 6. Germiston .. I J 100 7. Roodepoort 1 1 100 NATAL 8. Krugersdorp I I 100 I. Durban 174,825 2,020 119 19·3 1·0 9. Potchefstroom 1 I 100 2. Pietermaritzburg 96,128 525 124 24·8 4·7 10. Klerksdorp 1 1 100 11. Vereeniging-Vanderbijlpark I I 100 TRANSVAAL I. Johannesburg 645,268 2,874 186 186 6'5 ORANGE FREE STATE 2. Pretoria .. 299,037 839 33 33 3·9 1. Bloemfontein 100 3. Nigel .. .. 37,870 45 2 0·7 1·5 2. Industrial areas 4. Boksburg-Benoni.. 175,328 302 12 6 2·0 5. Germiston 154,886 145 4 13 0·9 Kroonstad 6. Roodepoort 67,337 102 3 I 1·0 Welkom 3 3 100 7. Krugersdorp 129,159 139 2 2 1·4 Odendaalsrus } 8. Potchefstroom 51,400 -60 I I 1·7 9. Klerksdorp 113,800 244 5 2·5 1-0 to. Vereeniging- TOTAL URBA 29 32 90·63 Vanderbijlpark 145,915 107 23 4·6 4· 3

ORANGE fREE STATE SOUTH AFRICAN TUBERCULOSIS HOSPITALS I. Bloemfontein .. 96,995 163 36 20·5 12·6 2. Industrial areas: .. 164,078 241 16 4·9 2·9 Government tuberculosis hos­ Kroonstad 60,817 175 9 2·3 I· 3 Welkom .. 74,493 36 5 1·7 4·6 pitals .. 7 7 100 Odendaalsrus .. 28,768 30 2 t 3·3

PROTECTORATES SOUTH AfRICAN TUBERCULOSIS HOSPITALS Government tuberculo­ 1. Basutoland 10 14 71 sis hospitals .. 2,610 48 10·2 1·8 2. Swaziland 5 7 71 3. Bechuanaland Protectorate 8 12 67 PROTECTORATES

TOTAL PROTECTORATES 23 33 70 I. Basutoland approx.750.000 667 5 2·0 0·3 2. SwaziJand approx.250,000 554 4 1·0 0·2 3. Bechuanaland TOTAL SOUTH AFRICA, 260 303 86 Protectorate approx. 350,000 683 3·0 0·4 20 April 1963 S.A. TYDSKRIF VIR GENEESKUNDE 439

TABLE IV. SEX RATIO OF CASES OF OESOPHAGEAL CANCER ADMITTED TO HOSPITAL FOR WHICH DETAILS WERE AVAILABLE TABLE V. OTHER REGIONS OF AFRICA WHERE EVIDENCE OF FREQUENCY OF OESOPHAGEAL CANCER IS FORTHCOMING REGARDING SEX (1960 OR LATER) Ratio Sollthern Rhodesia Tanganyika Male Female Total male/ Salisbury Common" Dar es Salaam Rare" cases female Bulawayo Common" Moshi Rare" Fort Vicroria Common" Kagondo Common" Rusapi Common" dolage Rare'· INCIDENCE LESS THA ' I PER 100 BEDS Umtali Rare" Kibondo Unknown" Kasulu Unknown" Western Cape 18 3 21 6·0 Northern Rhodesia Heru Unknown'· Zululand 29 I 30 29·0 Abercorn Unknown" Kigoma Unknown'· Lowveld 5 0 5 Mbereshi Unknown" Tukuyu Unknown'· Sekukhuniland 8 2 10 4·0 Kasama Unknown" jombe Unknown" Northern Transvaal 6 1 7 6·0 Fort Jameson Unknown" Western Transvaal 9 0 9 Kasala Unknown" Congo Orange Free State 6 2 8 3·0 Kivu Rare'· Basutoland 4 1 5 4·0 Nyasaland Burundi Rare'· Swaziland 4 0 4 Blantyre Common" Rwanda Rare'· Bechuanaland 3 0 3 Karonga Unknown" Total Protectorates 11 1 12 11·0 Ekwendeni Rare'· Uganda Genniston 4 0 4 Port Herald Unknown" Kampala Not high"

Total · . 107 11 118 9·7 Mo(:ambique Sudan Lourem;o Rare" Khartoum Possibly Marques common13 rNCIDENCE BE1WEEN I AND LESS THAN 2·5 Beira Rare" Nigeria Kenya Ibadan Rare" Emboland 9 2 11 4·5 Nairobi Common'· Pondoland 0 II Mombasa Common" Senegal Northern Cape 20 I 21 20·0 Kisumu Common" Dakar Rare" South-Eastern Cape .. 13 1 14 13·0 Eastern Transvaal 9 2 11 4·5 Durban 104 15 119 6·9 I wish to acknowledge the encouragement and interest of Boksburg-Benoni 10 2 12 5·0 the Executive of the ational Cancer Association, and of Krugersdorp .. 2 0 2 Dr. J. H. S. Gear and Prof. 1. F. Murray of the South African Nigel ·. 2 0 2 Institute for Medical Research. I am grateful to the Superin­ KJerksdorp 5 0 5 tendents of the South African hospitals and their assistants Industrial area ofOrange Free for their willing cooperation, and the Director of Census and State 6 7 6·0 Statistics for population figures. Total 25 7·2 ·. 180 205 REFERENCES I. Higginson, J. (1951): Cancer (philad.), 4. 1224. INCIDENCE BETWEEN 2:5 A.TO LESS THAN 5 2. Dettle A. G. (1955): S.A. BioI. Soc., no. 17, 40. 3. Burrell. R. J. W. (1957): S.Afr. Med. I .. 31. 401. Ciskei .. 61 28 89 2·2 4. Wainwright, J. and Roach. G. G. (1957): S.Afr. Cancer Bull., 1, 162. Port Elizabeth 29 7 36 4·1 5. Higgmson, J. and Dettle, A. G. (1958): Acta Un. int. Cancr., 14, 554. Kimberley 5 0 5 6. Idem (1960): J. Nat. Cancer 1nst., 24. 589. Pietermaritzburg 109 15 124 7·3 7. Boulle, J. R. and Kark. A. E (1%0): Med. Proc., 6. 357. Vereeniging-Vanderbijlpark .. 23 0 23 8. Burrell. R. J. W. (1962): J. Nat. Cancer Inst., 28, 495. WeLkom 4 I 5 4·0 9. MacCanhy. H. (1959): Hospital and Nursing Year Book of SOli/hem Africa. Johannesburg: MacCanhy. Total ·. 231 51 282 4·5 10. Archer, B. C. (1960): Medical Directory of South Africa, p. 360. Durban: Knox Publishing Co. 11. Dettle. A. G. (1%3): Unpublished data. rNCIDE CE BE1WEE' 5 AND LESS THA ' 20 12. Idem in Raven. R. W. ed. (1960): Cancer Progress, pp. 232 - 240 London: Butterworlhs. Torth-Eastern Cape 5 0 5 13. Lynch, J. B. (1961): Personal communication. Bloemfontein 34 2 36 17·1 14. Buchanan, W. M. (1962): Personal communication. Cape Town 162 39 201 4·2 15. Palmer. P. E. S. (1962): Personal communication. East London .. 9 5 14 1·8 16. Burkitt, D. P. (1961): Personal commun'cation. Johannesburg .. 6·0 17. Pilbeam. S. T. H. H. (1961): Personal communication. 18. Prates M. D. (1958): Brit. J. Cancer, 12. 177. Total ·. 210 46 256 4·6 19. Central Laboratory (1960): Annual Report of the Central Laborotory, p. 48. Oar es Salaam. CIDE 'CE OVER 20 20. Linsell, C. A. (1%1): Personal communication. 21. Turner P. P. (1%2): E.Afr. Med. J., 39, 121. Transkei proper * 40 0 40 22. Cathro, A. J. M. (1962): Personal communication. 2·0 Tembuland 4 2 6 23. Davies, 1. P. (1961): E.Afr. Med. J., 38, 486. Total .. 44 2 46 22·0 24. Edingtoo, G. M. (1962): Personal communication. 25. Camain, R. (1962): Personal communication. • This sex ratio should be regarded with reserve in the light of Burrell's 26. Clemmesen, J .. Maisin, J. and Gigase, P. (1962): Cancer in Kivu and findiogs.' Rwanda·Urundi. p. 125. louvain: Universite de Louvain.