CANCER IN JAVA AND SUMATRA C. BONNE Batavia, Java, Netherland East Indies The Netherlands East Indies, which forms the largest part of the Malay Archipelago, has above 60,000,000 inhabitants ; 40,000,000 live in Java, one of the most densely populated parts of the world, and the others are spread out over Sumatra, Borneo, Celebes New Guinea, and thousands of smaller islands. Nearly the whole population belongs to the Malay race, but the presence of a few million Chinese makes it possible to compare the pathology of these two Eastern races. It is not easy to collect reliable information about the incidence of disease in tropical countries, where statistical reports, methods of registration of deaths and births, and a medical organization on the scale to which we are accustomed in Western countries are lacking. Rumors or vague impressions are of no use, especially in studying cancer. In our own experience in the East, and the experience of others elsewhere in the tropics, views of the past on the relative im- portance of different diseases have proved entirely incorrect. We were formerly so impressed by the often dramatic outbreaks of small- pox, cholera, malaria, beri-beri, plague, etc., that these were considered to be not only the characteristic feature but practically the only mani- f estation of tropical pathology. Gradually, however, with the intro- duction of Western methods of prevention, these epidemic diseases have lost most of their importance in the better developed tropical communities. In Java, for example, and in certain parts of Sumatra, tropical disease as we usually understand it, though still playing a certain rhle, is no longer all-important. Small-pox and cholera have disappeared entirely ; ankylostomiasis, though widespread, is only locally important as a disease ; beri-beri has become rare among adults, and although plague has a foothold in certain mountainous parts of Java, it does not occur very frequently. Malaria and dysentery may still occur, occasionally and locally, in the old-fashioned way. This tropical pathology is grafted on a larger body of disease which on first impression seems similar to disease as we know it in colder climates. We find the same problems of tuberculosis, cancer, rheumatic fever, cirrhosis of the liver, cardiac and renal diseases, as elsewhere. More accurate research, however, reveals certain differences, and of these differences one or two bear upon cancer. Snijders and Straub (1) pointed out in 1921 that cancer in general was found to be about as prevalent among the registered Javanese and Chinese laborers in the large tobacco and rubber plantation area of Sumatra’s East Coast as in European countries if care were taken to 811 812 C. BONNE compare the same age groups. Remarkable differences, however, ap- pared in the site incidence of the tumors. The most striking phe- nomenon is the high frequency of primary cancer of the liver in both races. Snijders and Straub's post-mortem statistics showed 30.8 per cent of the cancers of the Chinese and 57.1 per cent of the cancers of the Javanese to be primary carcinomata of the liver. In the combined hospital statistics of Sumatra's East Coast these figures were even ,higher. This primary carcinoma of the liver is nearly always a liver- cdl carcinoma developing in a cirrhotic liver, much like the sporadic (VLSCS of this disease seen in colder climates and in other races. Hcl- minthic infections of the liver are totally out of the question as an etiological factor, as they are unknown among the Javanese and occur in Chinese only when imported from China. It is true that most of the Chinese laborers in Sumatra are immigrants, but as will be seen later, the same frequency of hepatic carcinoma occurs among the Chinese in Java, who for the most part are born on that island and often live therc for many generations, without any possibility of clonorchiasis, schisto- somiasis or any other hclminthic infestation affecting the liver. Another striking feature observed by Snijders and Straub was the scarcity of gastric carcinoma in the Javanese race, for this neoplasm formed only 1 per cent of all cancers found at autopsy in the combined statistical figures of Sumatra's East Coast while among the Chinese it took the second place (19 per cent), corning immediately after primary carcinoma of the liver. These authors were also impressed by the parallel difference in frequency of gastric ulcer between the two races: among the Chinese this condition is very common, among the Javanese it is rare. Intestinal carcinomata were also frequently met with, an observa- tion which is especially noteworthy in view of the frequency of inflam- matory intestinal disease. Cancer of the uterus and cancer of the penis were of rather frequent occurrence. For the two most striking results of their investigation, the fre- quency of primary liver cancer in both races and the difference in incidence of gastric carcinoma and gastric ulcer, the authors could find no satisfactory explanations. They seriously tried to find a clue to these problems in the different age compositions of the Javanese and ('hinese labor populations compared with each other, the Chinese being a somewhat older class, and with European populations. Primary liver cancer, they thought, might occur at an earlier age than most other caneem They did not succeed, however, in finding aiiy age dis- 1rihutioii suitable to cover their percentages even approximately. These classical researches by Snijders and Straub have been geii- erally confirmed by other pathologists in the Netherlands East Indies, and a number of publications in Netherlands Indian medical journals have dealt with the subject. In the departments of pathology in the two medical schools at Batavia and Surabaya and the Cancer Institute at Bandoeng in Java, where for many years thousands of autopsies have been performed, primary carcinoma of the liver is also thc most com- CANCER IN JAVA AND SUMATRA 813 mon type of cancer found and the same racial difference in the fre- quency of gastric cancer and of gastric ulcer is observed. These observations, especially the difference in the behavior of the Chinese and Javanese (Malay) races with regard to gastric disease, seem to be of such importance, that it may be well to give some further details on these more recent studies, and to set forth certain theories that have been offered as explanations. In the writer’s own laboratory (Department of Pathology, School of Medicine, Batavia, Java) attached to a large general hospital, 6043 autopsies were performed between June 20, 1921, and July 1, 1935, in all of which histologic studies were made. For various reasons three periods will be distinguished and only the two largest racial groups represented in the post-mortem records, uix. Malays and Chinese, will be considered. Europeans, Arabs, and other groups are too infre-

TABLEI: DiStTibUtiOn of Tumor Deaths in Malays and Chinese

Number of autopsies Number of tumors MALAYMEN June 20, 1921-July 1, 1927...... 1516 July 1, 1927-July 1, 1932...... 81 1 July 1, 1932-July 1, 1935...... 42 1 MUAY WOMEN June 20, 1921-July 1, 1927...... 568 July 1, 1927-July 1, 1932...... 365 July 1, 1932-July 1, 1935...... 204 CHINESEMEN June 20, 1921-July 1, 1927...... 687 July 1, 1927-July 1, 1932...... 502 July 1, 1932-July 1, 1935...... 364 CHINESEWOMEN June 20, 1921-July 1, 1927...... 117 July 1, 1927-July 1, 1932...... 169 July 1, 1932-July 1, 1935...... 176 quently represented to be of statistical value. During these periods 254 malignant tumors were discovered as the cause of death; 243 of these tumor deaths occurred in Malays and Chinese, being distributed as shown in Table I. In this group are included all sorts of intra- cranial tumors. A gradual increase of the percentages of tumor deaths is quite obvious. It is not permissible, of course, to draw the conclusion from these figures that cancer is rapidly increasing. Like all proportionate figures, they have only a relative value ; every decrease in incidence of other diseases automatically causes an increase in the tumor figures. There has been a gradual improvement in hygienic conditions in Java, which is responsible for a decrease of infectious disease. The attitude of the oriental population with regard to Western medicine is also rapidly changing, and more and more patients come to the hospitals for the internal diseases of the body. Increasing knowledge about cancer 814 C. BONNE among the medical profession, who send in their patients, is also of a certain importance. Older patients come to the hospitals now in larger number than previously, a fact, which is offset, however, by the increas- ing number of children and babies who are brought in. During the last three years the average tumor death rate was 6.0 per cent. While this percentage of tumor deaths in a given number of post-mortem examinations may be lower than is met with in similar

TABLE11: Site Incidence of 243 Tumors, Found at Autopsy in Batavia, 1921-1936, as the Cause of Death

I Malay Chinese Site Total 1 Men Women Women Uterus ...... - 25 31 Breast ...... - 8 10 Liver ...... 18 8 40 Stomach ...... 1 - 6 Esophagus ...... - - - Duodenum ...... - - 1 Jejunum, ileum...... - - - Colon.. . - 1 1 Rectum ...... 1 4 7 Tongue ...... 1 - 1 Lip, mouth, jaw...... 10 10 20 Nasopharyngeal cavity...... 3 1 6 Pancreas ...... - 1 4 Lung ...... 4 _. 8 Bladder ...... 4 1 7 Skin , ...... 16 - 18 Neck ...... 6 5 15 Iritracranial ...... 7 2 10 Prostate ...... 2 - 2 Larynx ...... 1 - 3 Thyroid ...... 1 1 2 Ovaries ...... - 3 3 Vulva...... - 2 2 Penis...... 1 - 1 Other localities...... 3 1 6 ___- _- Sarcomata...... I 2o 6 39 TOTAL 99 79 50 15 243 Number of autopsies 1 2748 1137 1553 462 5900 Tumors in other races 11. Autopsies in other races 143.

statistics of Western countries, it must be borne in mind that the 9.~11- cral mortality of the population is greater (about 25 per cent) and thc higher age groups are less well represented, so that a lower percentage of' tumor deaths may be expected. In Java we do not have at our disposal records for the various diseases giving the cause of death, collected under medical supervision in a registered population, such as we have in Western countries and such as Snijders and Straub and others could collect under almost ideal conditions among the laborers in the tobacco and rubber estate districts of Sumatra, where medical CANCER IhT JAVA AND SUMATRA 815 supervision is excellent, where a very high percentage of the deaths take place in the estate hospitals, and where autopsies are frequently performed. From all we know about cancer in Java, however, there seems to be no reason why the cancer mortality should differ from that in the Sumatran districts, where this mortality is of the same order as in Western countries, when recalculated for a standard population. Snijdcrs and Stranb in 1921 found a tumor death rate of 25.4 per 100,000 living Javanese males, whereas tlie figure for males in Holland based on mortality figures for the period 1907-1912 and rccalculated for the same age-composition is 24.3. For Javanese women and Chinese males these comparative figures were 28.1 vs. 24.5 in Holland, and 44.1 vs. 40. 7 in Holland respectively. The Chinese labor group was older than the Javanese group and therefore had more cancer. Kouwenaar (2) in 1932, in the same district, found a cancer mor- tality of 36.1 for Javanese males compared with 33.8 for males in Holland of the same age groups. For Chinese males the figure was 57.7 as compared to 61.3. In 1932 the average age of the Javanese aild Chinese labor force was higher than in 1921, which makes the cancer mortality higher in 1932 than in 1921. In his post-mortem records Kouwenaar found a tumor as the cause of death in 5.4 per cent of Javanese males, 4.9 per cent of Javanese females, and 8.4 per cent of Chinese males. The site incidence of the 243 tumors discovered at autopsy in my department as the cause of death among Malays and Chinese is shown in Table 11. This tumor list is typical for any of the large hospitals in Java and Sumatra. Although it is uncertain whether or not the site incidence of the tumors in the general population finds a reliable reflection in statistics of this kind, we can not neglect some outstanding peculiari- ties. Among female patients the uterine and mammary tumors cause a considerable part of the tumor deaths. A high incidence especially of uterine tumors is found in general in the records of every hospital in the Netherlands East Indies. Liver carcinoma is the largest group among Malay and Chinese males, and practically all these tumors are liver-cell carcinomata de- veloping in cirrhotic livers. Cirrhosis of the liver is a very common disease in Java and Sumatra. In an extensive study (3) based on an analysis of 12,957 autopsies and prepared by the four leading pathol- ogists of these islands for the First International Congress of the So- ciety for Geographic Pathology, cirrhosis of the liver of the Laennec type was found to have been the cause of death in 3 per cent of all autopsies on Malay men, 1.3 per cent of all autopsies on Malay women, and 1.8 per cent of all autopsies on Chinese men, while primary liver eancer had caused the death of the patieiit in 11 per cent of all autopsies on Malay men, in 3 per cent of all autopsies on Malay women, and in 1.4 per cent of all autopsies on Chinese men. Cirrhosis, whether causing the death of the patient or found in- cidentally, whether combined with a neoplasm or not, was seen in 6.9 816 0. BONNE per cent of all autopsies on Malay men, in 3.5 per cent of all autopsies on Malay women, and in 5.8 per cent of all autopsies on Chinese men. A rough comparison of these figures with similar figures from other localities, as for example California 5.5 per cent (Ophiils), Boston 5.0 per cent (Mallory), Geneva 4 per cent (Askanazy), Jena 1.5 per cent (Rossle), Japan 2 per cent (Kachi), shows them to be large, especially for the Malay men. The general mortality of the population, its age-composition and other factors influence these figures, but while it is impossible here to enter into the statistical details of the problem, the fact remains that the incidence of cirrhosis of the liver among the Malay population, if studied from all sides, is still high, a remarkable thing for a race which consumes very little if any alcohol. The figures do not seem to be large enough, however, to form in themselves a sufficient explanation for the frequency of primary liver cancer, which in every country develops in R small percentage of patients with cirrhosis. Certain theories have been presented in explanation of this high incidence of liver cancer. As mentioned before, the helminthic infesta- tions of the liver are out of the problem. The very strongly spiced food, especially of the Malays, has been considered to contain carcino- genic irritants. This, however, is merely a theoretical suggestion. Any such irritants would be expected in the first place to irritate the wall of the stomach, but, as has been pointed out, instead of being high the incidence of carcinoma of the stomach is extremely low among the Malays. The frequency of intestinal disorders has also been brought forward, but here again, if any abnormal carcinogenic substance were present, the intestinal wall would be the first place of contact, and practically no carcinomata are seen in this site among the Malay race, though sarcoma and lymphogranuloma of the intestine and carcinoma of the rectum do occur. These theories therefore are mere supposi- tions without any sound basis. In contrast to the frequency of primary liver cancer is the scarcity of carcinoma of the stomach in the Malay race. Our list contains only one case in a Javanese (Malay) man. This is a very remarkable case. In the stomach of this patient two ulcers were found near each other and adjacent to the pylorus. One of them led into a kind of pouch or recess about as big as a walnut, filled with a mucous substance. The posterior wall of this pouch was formed by the transverse colon. On histologic examination a cancer of the round-cell type waa discovered in the base of this last ulcer, which could not be inter- preted as a cancer of the colon. It invaded the stomach wall and had to be accepted as a true gastric cancer developing in a gastric ulcer. This Javanese man had emigrated to French Caledonia as a contract laborer. After finishing his contract, he returned to Java and died on his arrival in Batavia from gastric hemorrhage. In Chinese men gastric carcinoma ranks second in frequency. This difference between Malays and Chinese is a constant and most astound- ing phenomenon, met with in every list of autopsies of the Netherlands Indian hospitals. It is paralleled by a similar difference in incidence of gastric ulcer. My autopsy records from July 1,1927 to July 1,1935, CANCER IN JAVA AND SUMATRA 817

show 9 deaths among the Chinese from gastric ulcer, but not a single death from gastric ulcer among the Malays, except the case just men- tioned, in which carcinoma developed in the ulcer. During this period there were 1516 autopsies on Malay men, 568 on Malay women, 687 on Chinese men, and 117 on Chinese women. There is practically no surgery of the stomach done on the Malay race, but there is ample opportunity for gastric surgery in Chinese and Europeans living in Java and Sumatra. There is no imaginable reason why'the Malays should stay away from the hospitals when suffering from gastric ulcer or gastric carcinoma, while they present themselves in large numbers for all kinds of other intestinal disorders, or why they should not come to autopsy if these diseases have been the cause of death. Twenty-three tentative diagnoses of gastric or duodenal ulcer in Chiiiese patients er ere traced in the records of the general civil hospital of Ratavia for the years 1931 to 1933 against three similar diagnoses on native patients, of whom onc was known to have a Chinese mother. Many of these clinical diagnoses are, of course, open to criticism, and the presence of duodenal ulcers complicates the problem, but at all events the proportion 23 : 3 disagrees considerably with the proportion of Chinese and native patients in general in the hospital, which was about 1:3 for these same years, the exact figures being 5937 Chinese and other foreign orientals against 17,292 native patients. We do not know at present whether the prevalence or scarcity of gastric carcinoma depends on constitutional genetic factors or on external factors of irritation, or on both. Pathologists in Holland are not as a rule very favorably inclined towards the view that an ana- tomical relationship exists between gastric ulcer and gastric cancer. The peculiar behavior of these two conditions in Javanese and Suma- tran natives may indicate, however, that they are both related to a common factor of etiological importance. This factor may be an inborn racial character or may be something in the life habits of the Malays. If the presence or absence of gastric carcinoma depends largely on the action of irritants, we have to look far these irritants in the diet. There are substances in Chinese and European foods which are lacking in Malay foods. The Malay food is much more predominantly vege- tarian and the Malays are, besides, nearly all Mohammedans and hence do not eat pork. There are many minor differences, also, in diet, but Eastern diets like others are very complicated. The Mohammedan Lent, which is rather strictly adhered to, may be of influence. The consumption of alcoholic beverages among the Malays is certainly smaller than among Europeans and Chinese. When I brought these figures to the attention of Dr. Louis I. Dublin of the Metropolitan Life Insurance Co. of New York, he saw at once the importance of these observations for the problem of gastric car- cinoma. He had the frequency of gastric carcinoma among the Jews restudied by the statistical department of the Metropolitan Life In- surance Company, but although an extensive survey was made of the 818 C. BONNE

available literature, there did not seem to be any indication that the disease was less prevalent among Jews than among Gentiles, an observation which does not tend to give special weight to the pork-eat- ing habit. Figures of any reliability for vegetarians seemed to bc unobtainable and all data with regard to the possible influence of alcohol consumption were extremely vague. More statistical data on cancer mortality and site incidence espe- cially in the Far East are desirable if we are to be able by comparison of racial customs to eliminate the possible etiological importance of some of the factors mentioned above. Even proportionate figures such as are presented here, preferably based on autopsy records, have a certain value and in the immense unregistered populations of the Far East any other than proportionate figures will probably not be avail- ahlc in most countries for a long time. (yitrciiioma of the esophagus is not represented in Table IT, but is a rare condition generally. I observed a small carcinoma of the esopllzt- pis, whi(~h,however, was not the cause of death, in a Chinese woman and another removed by operation on a Malay woman. In a combined list of 6860 tumors, including 1155 in Europeans, 4823 in Malays, 733 in Chinese, and 149 in other races, collected during the years 1927- 1932 by the pathologists of Medan (Sumatra), Batavia (Java), Band- oeng (Java), and Surabaya (Java) from autopsies and specimens sub- mitted for histologic examination and published by Vos in the report of the Netherlands India Cancer ‘Institute for 1934, there were 8 carcinom- ata of the esophagus in Chinese against 1 in a Malay. This may indicate a difference in frequency between the two races similar to that observed in the stomach. No carcinomata in the small intestine have been found at autopsy in my laboratory in Chinese or Malays, but I have several cases in both races of sarcoma or lymphogranuloma. I have specimens removed at operation from the colon in both races. The rectum is represented by 5 Malay and 2 Chinese cases. In Vos’ combined list there are 18 cases in Malay men, 12 in Malay women, 6 in Chinese men and 5 in Chinese women. The frequency of rectal carcinoma seems to be that usually recorded. The oral mucosa, especially of the cheek, is a frequent site for car- cinoma in the Malay, but not in the Chinese. There are 10 male and 10 female Malay cases in my list but none among the Chinese. Here again a racial difference certainly presents itself. Vos mentions 33 tumors in natives against 3 in Chinese. Whether this is due to betel-diewing or not remains uncertain for the present. Another peculiarity is the high figure for skin carcinomata in male Malays. These tumors are nearly all carcinomata of the leg, develop- ing on neglected skin ulcers below the knee. They invade the tibia or the bones of the feet and lead to amputation or death tl~ronghmetas- tases or complications. The last group calling for attention is constituted by tumors of tlic cervical lymph nodes. Such tumors caused death 10 times in native CdNCER IN J.4V.4 AND SUMATRA 819

Malays and 4 times in Chinese, and are frequently removed at opera- tion. A small proportion of these tumors of the neck, not included in the above list, appear to be cases of lymphogranuloma; a certain num- ber are readily classified as lymphosarcoma or reticulum-cell sarcoma, but a large percentage offer unusual difficulties of diagnosis. Many of them resemble lympho-epitheliomata and transitional-cell carcinomata histologically. However, no primary tumors in the nasopharyngeal cavity were discovered on repeated clinical or post-mortem examina- tions. The subject is too complicated to be casually entered into, but the frequency of this type of tumor in comparison with other tumors certainly forms a problem not only in Java and Sumatra but also in other countries of the Far East. TABLE111: Site Incidence of Cancer in the Far East

BATAVIA SINQAPORE TOKIO(5) MANILA(4) Chinese Japanese Filipinos Native Malays Chinese Liver...... 26 Liver...... ,14 Liver...... 46 Stomach .42.68% Liver and gall- Uterus...... 25 Uterus...... 6 Stomach...... 29 Liver.. ... 6.71% bladder...... 67 Jaw and oral Stomach. ... 5 Esophagus. ... .15 Esopha- Stomach and muco sa ...... 20 Neck ...... 4 Lung...... 8 gus...... 5.45% duodenum. ... .23 Skin...... 16 Lung...... 4 Neck...... 7 Lung.. ... 5.45% Uterus...... 19 Neck...... 11 Pancreas. ... 3 Rectum...... 6 Uterus. .. 4.36% Neck...... 16 Intracranial Breast...... 2 Breast...... 5 Gallblad- Pharynx and tumors...... 9 Bladder. .... 2 Pancreas...... 5 der...... 4.11% esophagus...... 6 Breast...... 8 Rectum. .... 2 Intracranial Rectum . . 3.23% Head...... 6 Bladder...... 5 Skin...... 2 tumors ...... 4 Jaw...... 2.91% Pancreas...... 5 Rectum...... 5 Nasophsrynx . . 3 Bile-ducts 2.78% Retroperitoncal 4 Lung ...... 4 Pancreas. 2.60% Cheek, larynx ovary and pros- tate each...... 3

This series shows a complete absence of carcinoma of the gallblad- der, which may be due to the rarity of gall-stones. In other labora- tories occasional carcinomata of the gallbladder have been observed in both races. Especially in the Malay race pathological conditions of the gallbladder are great rarities, but here again we have a problem too many-sided to be discussed in a few words. It is interesting to compare the site incidence of malignant tumors as found at autopsies in native Malays and Chinese in Java and Sumu- tra with other tumor statistics of the Far East (Table TIT). Dr. Tull, I’rofessor of Pathology of the King Edward College of Aledicine in Singapore, kindly gave me his figures for Singapore. Dr. Vdder (4) described his findings for Filipinos in Manila in 1927. For compuri- son I add a large Japanese collection of statistics compiled under the supervision of Nagayo (5). For each race or locality only the teri tumor sites of highest incidence are given. The frequency of primary liver cancer is very obvious in Batavia, Singapore and Manila. The stomach takes the second place or even the first in every list except the Malay list from Batavia, which is 820 C. BONNE

representative for Java and Sumatra in general, where it drops out entirely, and the Chinese list from Batavia, where it ranks third. It should be kept in mind that among the Chinese in Batavia and Singa- pore the number of males is much larger than the number of females, which together with the usual factors present everywhere, such as discharge to home after treatment, brings down the figure for uterine and mammary carcinoma. Discharge after treatment naturally in- fluences also the reported frequency of cancer of the buccal cavity, the neck, the rectum, the breast, the skin, etc. The combined list of tumors, collected by the four pathologists at Batavia, Bandoeng, Medan and Surabaya in the period 1927-1932 from autopsies and specimens sub- mitted for histologic examination, published by Vos (6), includes 1806 carcinomata in Malays and 404 in Chinese. The regional distribution is a little different here, through the absence of this discharge factor. The ten leading regions for each race are :

Yalays Chinese Skin ...... 538 Uterus ...... 78 Uterus ...... 195 Liver ...... 59 Liver ...... 164 Skin ...... 47 Breast ...... 133 Stomach ...... 88 Eye, orbit, etc...... 100 Breast ...... 24 Jaw, oral mucosa ...... 80 Penis ...... 21 Penis ...... 65 Pharynx ...... 16 Ovary ...... 62 Neck ...... 13 Neck ...... 56 Rectum ...... 11 Salivary glands ...... 54 Eye, orbit ...... 8

From these figures the prominent position of primary liver cancer in certain tropical parts of the Far East is undeniable and the special position of the Malays as regards gastric cancer is again brought out. The unusual frequency of lymphatic tumors of the neck shown here offers another problem of importance.

SUMMARY Outstanding features of tumor pathology in Java and Sumatra are as follows : (1) The extremely high incidence in native Malays and Chinese of primary liver cancer. This form of cancer shows the highest incidence in all statistics of autopsies in Netherlands India. It is nearly always a liver-cell carcinoma, developing in a cirrhotic liver, cirrhosis of the liver of the Laennec type and not due to parasites being prevalent among both races but especially among native Malay males. (2) The great rarity of gastric carcinoma among the native Malays bnt not among the Chinese, associated with a similar difference in fre- quency for gastric ulcer in the two races. (3) A certain frequency of oral carcinoma, especially of the check, in native men and women but not among the Chinese, which may or may not depend on the betel-clicwing habit. CANCER IN JA4VA AND SUMATRA 82 1 (4) The prevalence of carcinomata of the lower parts of the legs in native Malay men, depending on the great number of ulcers present on the legs of these natives. (5) A peculiar frequency of malignant tumors of the cervical lymph nodes in Malays and Chinese, a problem very complicated in its his- tologic aspects. Many of these tumors arise probably primarily from the reticulo-endothelial elements of these glands. (6) Rarity of carcinoma of the gallbladder associated with in- frequency of gall-stones. The most important of these peculiarities were pointed out by Snijders and Straub in 1921. They have been confirmed and substan- tiated by all subsequent researches on these subjects. Similar problems present themselves in other parts of the Far East. The infrequency of gastric carcinoma and gastric ulcer, however, seems to be a special feature of the Malay race inhabiting Java and Sumatra and other islands of the Malay Archipelago. There is much need of a comparative statistical investigation of autopsy records in various Eastern countries with regard to frequency and site incidence of cancer.

1. SNIJDERSAND STRAUB:Geneesk, tijdschr. v. Neder1.-Indie 61: 625, 1921. Trans. 5th Congress of Far Eastern Association of Tropical Medicine, Singapore, 1923 (in English). 2. KOUWENAAR,W. : Geneesk. tijdschr. v. Neclerl.-IndiB 72 : 392, 1932. 3. Geneesk. tijdschr. v. Neder1.-Indie 71 : 506, 1931. 4. VEDDER,E. B.: J. A. M. A. 88: 1627,1927. 5. NAGIFO: Congress of Internal Medicine, Madrid, 1933, Tome 111. 6. VOS,J. J. TH.: Report of Netherlands Indian Cancer Institute for 1934.