PRELIMINARY AND FINAL REPORTS

O F T H E

DEPARTMENT OF PUBLIC HEALTH

RELATIVE TO THE

CARE AND TREATMENT OF PERSONS SUFFERING FROM CANCER

[C o m m it t e e o n P u b l ic H e a l t h . D e c . 15, 1926]

BOSTON WRIGHT & POTTER PRINTING CO., LEGISLATIVE PRINTERS 32 DERNE STREET 1927

TABLE OF CONTENTS.

PAGE

R eport of C ommissioner of P ublic H ealth . . . 5

A uthorization ...... 1 0

I. Introduction ...... • • • . 1 1

II. R e s u l t s o f S t u d y ...... 1 3 Hospital Survey . . • • .13 Number of Cases and Deaths (Table 1) . . . .1 4 Length of Hospital Stay (Table 2) . . .1 4 Number of Hospital Beds used . . . .1 5 Number of Hospital Beds needed ..... 16 New Bed Resources ...... 17 Hospitalization by Counties (Table 3) . . . . .1 8 Treatment given (Table 5 ) ...... 1 8 Disposition of Cases (Table 6) . . . . .1 8 Comparison of Hospitalization: By Cities and Counties (Table 7) . . . . .1 9 By Density of Population (Table 8) . . .1 9 B y T ype of Cancer (Table 10) . . 2 0 Cost of New Hospital Construction . . . .2 1 Maintenance Cost ...... 25

III. Policy o f the Department o f Public H ealth Regarding C a n c e r ...... 27 Hospitalization Program ...... 27 Clinic Program ...... 31 Educational Program ...... 35 Further Cancer Studies ...... 37 Diagnostic and Treatment Facilities ..... 38

IV. Immediate Needs o f the Departm ent ..... 3 8 Legislation for the Purchase of Radium . . . .3 9

V . S u m m a r y ...... 40

VI. T a b l e s a n d C h a r t 42

Cl)c Commontoealtf) of egassacfwsetts

D e p a b t m e n t o f P u b l i c H e a l t h ,

S t a t e H o u s e , B o s t o n , O ctober 15, 1926.

To the General Court of Massachusetts : In chapter 391 of the Acts of 1926, section 1, the Depart­ ment of Public Health is “ authorized and directed to formu­ late a plan for the care and treatment of persons suffering from cancer, with a view to taking any necessary initial steps toward the establishment of necessary hospital facilities for such care and treatment by the construction of new hospital buildings, by the use of existing buildings, or by additions to existing buildings. The department shall, from time to time, submit such plan to the governor and council and to the budget commissioner, and shall report its final plan to the general court not later than October fifteenth in the cur­ rent year, with drafts of such legislation as may be neces­ sary to carry the same into effect, and shall at the same time file copies thereof with the said budget commissioner.” In compliance with this the following study has been in­ stituted to determine the present hospitalization of cancer patients. A representative of the Department has visited some eighty of the leading hospitals in the State and has obtained from the hospital records the following informa­ tion for the years 1923 to 1925, inclusive: (a) number of bed days of all cancer patients in the hospital; (b) number of bed days of all cancer patients who died in the hospital; (c) number of operations; (d) number of X-ray and radium treatments; (e) type of cancer; (/) residence of patients; (g) final disposition of patient to institution, home, etc. The considerable mass of data is still in process of tabulation which will give information as to the principal hospital facili­ ties used by the various towns and cities in the State; the types of cancer now being hospitalized; the number of beds now used for cancer cases both in the early and late stages; and the available X-ray and radium facilities. House Document 1200 of 1926 shows that there is a need for additional hospital facilities for the terminal cases. This will be met in part by the utilization of the Norfolk State Hospital as authorized by chapter 391, Acts of 1926, re­ ferred to above. Renovations and repairs are now being made which will furnish bed facilities for about 85 patients. By a further outlay of some $75,000 this number could be increased to about 120. This institution will be available for patients early in 1927. A study has been made of existing hospital maintenance costs throughout the Commonwealth in order to arrive at some figure of what adequate hospitalization of cancer pa­ tients shoidd cost. Inasmuch as the General Court desired information regarding construction costs of a hospital pos­ sibly in Boston, such figures are being compiled. With our present knowledge the only hope for the cancer patient is early diagnosis and prompt treatment. At the present time, some ten months elapse between the first symptoms and rational treatment. If this interval can be decreased, the lives of an appreciable number of cancer pa­ tients will be saved. Both physicians and the general public need further education regarding the disease. This can be furnished to a large extent by means of community cancer clinics as directed in section 2 of said chapter. The phy­ sicians will improve their knowledge through consultations and observing the results obtained by the close cooperation of various specialists in cancer therapy. The general public will be educated to the value of early diagnosis and treat­ ment by seeing a considerable number of actual cures. The Department is endeavoring to establish cancer clinics in a number of centers. Inasmuch as the success of the clinic depends to a large measure on the amount of local interest, the efforts of the Department are being first di­ rected to those communities where well organized welfare work is already under way. One member of the staff is de­ voting full time to coordinating the community organiza­ tions and arousing them to what can be accomplished in cancer control. Hospitalization will care for the terminal cases needing institutionalization; well-functioning clinics should lower the cancer mortality so that fewer cases will come to the terminal stage, but these steps will not lower the incidence of the disease. Further research is needed. It would be unsound for the State to attempt clinical or laboratory research on any large scale, nor is such endeavor indicated as many laboratories and hospitals throughout the world are working on these problems. The Commonwealth can, however, furnish a form of research not available elsewhere. This consists of compiling data regarding cancer morbidity. Morbidity reports are not now available and all statistical research has to be done with mortality records. Plans are under way for establishing a morbidity reporting area in the Commonwealth. The records obtained from the area as well as from the clinics and the mortality records will furnish important contributions which will be of material help in accurately judging of the size of the problem medically, socially and economically, and in intelligently directing further steps towards its solution. All of the above measures are under way but none of them are sufficiently advanced at the present time to war­ rant submitting the completed report called for in chapter 391 of the Acts of 1926. It is respectfully requested that this statement be accepted as a preliminary report and that an elaborated report be accepted on January first next.

GEORGE H. BIGELOW, M.I)., Commissioner of Public Health.

€bc Commontuealtf) of SgassaciHigetts

D e p a r t m e n t o f P u b l i c H e a l t h ,

S t a t e H o u s e , B o s t o n , M a s s , December 15, 1926.

To the General Court of Massachusetts. In compliance with section 1, chapter 391, Acts of 1926, directing the Department of Public Health to formulate a plan for the care and treatment of persons suffering from cancer, we have the honor to submit herewith the results of certain investigations conducted by the Department together with a plan which, in the opinion of the Depart­ ment offers most in the way of benefit both to the individual afflicted with cancer and to the Commonwealth.

Respectfully,

GEORGE H. BIGELOW, M.D., Commissioner of Public Health. AUTHORIZATION.

[C h a p t e r 3 9 1 o p t h e A c t s o p 1 9 2 6 .)

A n Act to Promote the Prevention and Cure of Cancer and t h e E x t e n s io n o f R e s o u r c e s f o r it s C a r e a n d T r e a t m e n t .

Whereas, it is important for the protection of the public health that immediate steps be taken for the further prevention of cancer and the cure and treatment of persons afflicted with cancer, therefore this act is hereby declared to be an emergency law, necessary for the immediate preservation of the public health.

Be it enacted, etc., as follows:

Section 1. The department of public health, hereinafter called the department, is hereby authorized and directed to formulate a plan for the care and treatment of persons suffering from cancer, with a view to taking any necessary initial steps toward the establish­ ment of necessary hospital facilities for such care and treatment by the construction of new hospital buildings, by the use of existing build­ ings, or by additions to existing buildings. The department shall, from time to time, submit such plan to the governor and council and to the budget commissioner, and shall report its final plan to the general court not later than October fifteenth in the current year, with drafts of such legislation as may be necessary to carry the same into effect, and shall at the same time file copies thereof with the said budget commissioner. Section 2. The department shall establish and organize cancer clinics in such parts of the commonwealth as it may deem most ad­ vantageous to the public health and shall conduct such clinics with or without co-operation on the part of municipalities, local physicians and other agencies. S e c t i o n 3. Subject to appropriation, the department may expend during the current fiscal year for the purposes of sections one and two a sum not exceeding fifteen thousand dollars. Section 4. For the purpose of providing immediate care and treatment for persons suffering from cancer, the department is hereby authorized to make use of the Norfolk State Hospital and may suitably condition and equip the same. Subject to appropriation, there may be expended for the purposes of this section during the current fiscal year a sum not exceeding one hundred thousand dollars. [Approved M ay 29, 1926. REPORT RELATIVE TO THE CARE AND TREAT­ MENT OF PERSONS SUFFERING FROM CANCER.

I. INTRODUCTION.

The problem presented to the State Department of Public Health has various aspects. These include immediate hospital facilities for the terminal cancer cases, a future program for amplifying such resources, clinics for early recognition and treatment with the hope of reducing the number needing care in terminal stages, education of both the public and physicians, and studies which shall give facts to guide further development. As the problem involved great responsibility from medical, social, and economic standpoints and as the knowledge which the Department held regarding cancer was necessarily meagre, it was felt advisable to call into consultation some of the outstanding people who were interested and exper­ ienced in the various phases of the subject. An advisory committee, therefore, was appointed which consists of the following individuals:

Mr. Edwin H. Allen, Medical Director, John Hancock Life Insurance Co. Mrs. Edith R. Avery, Chairman of Public Health Department of State Federation of Women’s Clubs. Dr. Franklin G. Balch, American Society for the Control of Cancer. Dr. Walter P. Bowers, Boston Medical and Surgical Journal. Mr. W. J. Bell, House Chairman, Legislative Committee on Public Health. Dr. Walter L. Burrage, Secretary, Massachusetts Medical Society. Miss Ida M. Cannon, Social Service Department, Massachusetts General Hospital. Mr. Richard K. Conant, Commissioner, Department of Public Welfare. Dr. Francis G. Curtis, Board of Health, Newton, Mass. Dr. William Duane, Ph.D., Research Fellow in Physics, Harvard Cancer Commission. Dr. Kendall Emerson, Cancer Committee, Massachusetts Medical Society, Worcester. Dr. Robert B. Greenough, Huntington Memorial Hospital, and Di­ rector Harvard Cancer Commission. Mr. James B. Hayes, St. Mary’s Infant Asylum. Mr. Robert W. Kelso, Boston Council of Social Agencies. Dr. Francis X. Mahoney, Health Commissioner, Boston Health Department. Dr. G. Forrest Martin, Trustee, Tewksbury State Infirmary, Lowell. Rev. George P. O’Conor, Catholic Charitable Bureau. Miss Florence M. Patterson, Director, Community Health Associa­ tion, Boston. Miss Gertrude W. Peabody, Mass. Ass’n. of Directors of Public Health Nursing, Cambridge. Dr. Henry M . Pollock, Superintendent Massachusetts Homoeopathic Hospital. Dr. Stephen Rushmore, Dean, Tufts Medical School. Dr. J. W . Schereschewsky, United States Public Health Service. Dr. James S. Stone, President, Massachusetts Medical Society. Dr. William J. Taylor, Massachusetts Homoeopathic Hospital. Dr. E. E. Tyzzer, Harvard Cancer Commission. Dr. E. P. Truesdale, Cancer Committee, Massachusetts Medical Society, Fall River, Mass. Dr. Shields Warren, Instructor, Department of Pathology, Harvard Medical School, and Chief Pathologist, Palmer Memorial Hospital. Mr. H. S. Wellman, Massachusetts House of Representatives, Tops- field. Prof. Edwin B. Wilson, Department of Vital Statistics, Harvard School of Public Health. Dr. J. Homer Wright, Pathologist, Harvard Cancer Commission.

From this committee, sub-committees were appointed to deal with certain aspects of the problem: a Hospital Com­ mittee, with Dr. Henry Pollock, chairman; an Educational Committee, with Mr. Robert W. Kelso, chairman; a Clinic Committee, with Dr. Robert B. Greenough, chairman; and a Cancer Study Committee, with Prof. Edwin B. Wilson, chairman. These committees have constant’y advised the Department in various phases of the cancer problem, and have made possible an otherwise almost hopeless task. The joint report on cancer of the Departments of Public Welfare and Public Health (House Document 1200, General Court of 1925) included a limited study on hospital facilities for cancer patients in Massachusetts. A much more exten­ sive survey has been made in the present investigation, con­ sisting of an examination of the original records in 91 hospitals in Massachusetts, for the years 1923 to 1925, in­ clusive. The data collected include:

(а) Number of bed days of all cancer patients in the hospital. (б) Number of bed days of cancer patients who died in the hospital. (c) Number of operations. (d) Number of X-rays and radium treatments. (e) Type of cancer. (/) Residence of patients. (;g) Final disposition. (h) Cost of institutional care.

Estimates have been obtained from several sources regard­ ing the cost of new hospital construction. While the use of the Norfolk State Hospital removes the immediate need for any additional hospital construction, the possibility of future expansion is realized. Certain mortality studies dealing with hospitalization and cancer incidence which were made in 1925 have been brought up to date. The Norfolk State Hospital is being renovated and equipped for the care of cancer patients. Steps have been taken in various communities to arouse interest in inaugurating a local cancer clinic. Several projects are now under way which will furnish statistical material to aid in the study of cancer. These include the establishment of a cancer morbidity reporting area; visiting nurses’ questionnaire; uniform records for the clinics; and the continued study of mortality records.

II. RESULTS OF STUDY.

H o s p it a l S u r v e y .

The original records of 91 hospitals in the Commonwealth have been examined by members of the Department. These comprise about 85 per cent of all general hospitals in the State with a bed capacity of over 35, four smaller general hospitals, and those special hospitals which deal with cancer or chronic diseases. Mental disease hospitals, the State In­ firmary at Tewksbury, the State Farm at Bridgewater and convalescent homes, all of which care for a part of the terminal cancer problem have been omitted, as the time allotted made selection necessary, and a comprehensive study of general hospitals seemed more pertinent to the questions involved. In 80 of the hospitals records were obtained for 1923, 1924, and 1925; in 6 hospitals records were for two of the years; and in the remaining 5 hospitals, for one year only. Average figures were computed for those hospitals furnishing more than one year’s records, while in the hospitals with one single year record, that figure was used in place of an average. In the hospitals examined, the average number of deaths for one year was 877, which is 70 per cent of the average total cancer deaths which occurred in all hospitals in the Commonwealth in the three years 1923, 1924, and 1925. Thus, in the hospitals which were not surveyed, 30 per cent of the cancer deaths occurred. There is no accurate way of checking up the percentage of cases in the hospitals examined to the total cases in hos­ pitals, as there are no figures which give the total number of cases in hospitals, and the time was not adequate to ob­ tain them. However, it is probably fair to assume that if the cancer deaths in the surveyed hospitals were 70 per cent of the total cancer deaths in hospitals, the same ratio might exist for cases. We are making this assumption although fully realizing the possibility that either a smaller or larger figure might be better. Table 1 shows that for 1923, 1924, and 1925, in the 91 hospitals surveyed, there was an average of 4,193 cancer pa­ tients, with 877 terminal cases of whom 249 died in the hospitals after staying there over thirty days. If the ter­ minal cases are omitted there remain 3,316 who left the hospital alive. Table 2 shows the number of days that the cancer patients remained in the respective hospitals. The average for the three years is 88,271 days for total cases; 29,457 days for total terminal cases; and 20,395 days for the terminal cases that remained in hospital over thirty days. Therefore the average length of stay of all cancer cases in hospitals is 21.1 days; of all terminal cases, 33.6 days; and of the long­ time terminal cases, 82.0 days. If the terminal cases are deducted from the totals, the average length of stay of the cancer patients who did not die in hospitals is 17.7 days. At the end of Table 2 is given the number of cancer year beds, that is, the number of beds that would have been used in hospitals constantly by cancer patients if the patients had been evenly distributed over the year. This figure was ob­ tained by dividing the hospital days by 365. At one time a hospital might have several cancer patients and at another time none, but to find the exact number of beds used by the hospitals the average for the year is used. The total beds in the Commonwealth which were used for cancer patients was 243.12; for total terminal cases, 80.44; and for long­ time terminal cases 61.74. If the beds used for terminal cases are deducted from the total number of beds used throughout the year for patients, 162.68 beds remain, which represent those used for patients who left the hospital alive. As our sample is considered to be about 70 per cent of the total, we have about 350 beds in constant use for cancer patients; of these about 230 are for patients who leave the hospital alive, and about 115 for terminal cancer cases, with 88 for the long-time terminal cases. This does not include the beds used by patients who died in institutions such as almshouses, convalescent homes and State institu­ tions. These comprise about 12 per cent of those who died in hospitals, and would increase appreciably the total avail­ able cancer beds in all institutions in the State, though from this study it is impossible to say just how much. In the 1925 study an attempt was made to estimate the number of cancer cases in Massachusetts alive at any one time, and a figure of 9,300 was estimated. In the present study no improvement upon this estimate could be made. About 5,000 of the 9,300 cases die annually, and about 500 are cured. While this latter figure is not precise, 10 per cent is generally accepted as the present figure of cures for cancer of all types and stages of the disease. Therefore in Massachusetts about 15 cases of cancer have their origin on any one day. If these cases went to a hospital at the first symptoms our present hospital facilities of 350 beds would be more than sufficient to handle them. The average cancer hospital case remains in the hospital 21.1 days. The cases who leave the hospital alive remain 17.7 days. If the hospital beds were constantly in use it would require from 270 to 320 beds, depending upon whether the average stay was 17.7 or 21.1 days. It is, of course, Utopian to hope that all patients will ever go to the hospital at the moment of the earliest symptom, but the above calcula­ tions only strengthen the finding of the 1925 survey, that, in general, ample facilities are available for the hospitaliza­ tion of all cancer patients in the operable stage. Table 3 shows the hospitalization of cancer cases that died in hospitals, subdivided into the group that had an operation in the hospital in which they died and the group that did not. The group operated upon is further subdivided into those remaining in hospital under and over thirty days. Average length of stay of all these groups have been obtained. The group which died in hospital in less than thirty days had an average length of stay of 11.5 days. This group is considered to constitute the operative fatalities and the cases upon whom the surgeon operated against his own better judgment, so the beds used by this group should not properly be classified as belonging to the chronic terminal class. The individuals operated upon and living in hospital over thirty days are placed in the chronic group, for the hospitals probably kept them longer than the operations themselves warranted. The average length of stay of the cases with no operation was 42.6 days, of those operated upon who remained in hospital over thirty days 63.4 days, and of the combined group 45.9 days. In the joint report of 1925 an attempt was made to estimate the number of beds needed for terminal cases and a figure of 340 beds was obtained. A similar calculation has been made using the more complete figures of the present study. This estimate is a most difficult one to compute, as it depends upon three items, two of which are not definitely fixed. These are the number of patients needing terminal hospitalization; the length of terminal stay in hospital which may be considered adequate; and the present length of stay of patients who now die in hospital. The per cent of patients needing hospitalization was estimated by different individuals in House Document 1200 as from 23 to 50 per cent. The average length of terminal stay considered adequate, as expressed by members of the profession varies from three to six months. The average stay in hospitals actually caring for chronic terminal patients can be fairly well determined at forty-six days. In House Document 1200 it was stated that the most probable estimate for the per cent of cancer deaths that needed terminal hospitalization was 30 per cent and the most probable average duration for their stay was four months. Using these figures together with the present average stay of patients in hospitals as forty-six days gives a figure of 400 as the most probable present bed need for terminal cancer cases. While this figure is subject to limitations, it is apparently much more accurate than the 340 estimate of the 1925 survey. There are under way at the present time several projects which will tend to lessen the cancer load for the inoperable case. The Palmer Memorial Hospital is erecting a new building which will increase its capacity by about 30 beds. The Holy Ghost Hospital is building a new wing with a capacity of about 100 beds. While this hospital makes no selection in its admissions of chronic cases, and so the exact estimate of the number of beds used by cancer patients is impossible, yet a minimum of 10 additional beds seems very conservative. The Barnstable County Tuberculosis Hospital has been granted permission by the Legislature to care for other chronic patients as well as those with tuberculosis. Other county tuberculosis institutions are considering the same step. In Lowell a fund will be available with which to build a hospital for chronic invalids which will, of course, include cancer. It is impossible to predict when this chronic hospital in Lowell will be available or the extent of its use for cancer. Boston is also considering how best to meet its hospital problem in regard to chronic diseases, which, of course, include cancer. All of these projects will tend to lessen the cancer load locally, while the Norfolk State Hospital, which will be available in the early part of 1927 will furnish about 90 beds for those individuals who are unable to receive adequate care elsewhere. The construc­ tion now under way will care for at least one-third of the present need for beds for chronic cancer, while the con­ templated constructions will increase this. Table 3 shows the distribution by counties of the terminal cancer cases. In the non-operated group, Middlesex shows the longest average stay. Norfolk County shows the shortest average stay. In the operated group remaining over thirty days, Berkshire has the longest stay, while Hampshire has no patients in that group. Table 4 shows the same grouping of terminal cases for certain hospitals which kept their chronic cancer for longer periods than the other hospitals. Table 5 shows the types of treatment which are used at the various hospitals. With the exception of those hospitals that care for cancer only in its terminal stage, and the almshouse hospitals, the per cent of operations among cancer admissions is fairly large. Six hospitals operated upon 100 per cent of their cases and 72 of the 91 hospitals operated on 50 per cent or more of their cases. Radium was used by 57 of the hospitals. The per cent of cases on which radium was used varied from 0.7 to 89.3. Over half of the hospitals using radium used it in less than 13 per cent of their cases. Thirty-eight hospitals used X-ray in the treatment of cancer. The per cent varied from 0.8 to 77.0. Over half of the hospitals that used X-ray did so in less than 6 per cent of their cases. From the findings it would appear that there is no unity of procedure in the treatment of cancer by radiation in the Massachusetts hospitals, although in the majority of the hospitals radiation is being used only in a small per cent of the cases. Table 6 shows the disposition of cases that were referred to some other institution from the surveyed hospital. Of the 12,184 cases investigated, only 292, or 2.4 per cent, were referred by the hospital at which the patient was treated to some other institution. This low percentage would apparently indicate either that other institutions were not available for accommodating the chronic cases, or that the social service of some of the hospitals should be extended, or perhaps both. Table 7 gives the hospital admissions per cancer death for the cities and counties in Massachusetts. Both the hospital admissions and the deaths are here given by the residence of the patients, and this table gives some idea of how the residents of the different sections of the State are utilizing hospital facilities. The figures are subject to the errors of sampling. If those hospitals which have been omitted in the survey were included the results might be radically different for the several localities. The figure for the city of Newburyport is not representative of that city, as no record could be obtained from either of the hospitals. The city of Cambridge is also somewhat low, as one of the important hospitals furnished no data. The counties of Dukes, Nantucket and Barnstable are low for similar reasons. Boston, Brockton and Waltham had more cancer admissions to hospitals than cancer deaths. Newton, Peabody, Pittsfield, Quincy, Woburn and Worcester had over 0.9 admissions to each death. In the county tabula­ tion Suffolk and Plymouth had the highest ratio with Worcester County next. In Table 8 the State has been divided into six groups, according to density of population, and the ratio of hospital admissions to deaths in the same localities has been com­ puted for these groups. The very rural communities with a density of less than 50 people per square mile have the smallest ratio (.52); the next two larger groups, but both within the rural classification, are somewhat larger. The upper three groups increase as the size of the communities increase until in the distinctly urban group the ratio is .85, which means 85 hospital admissions per every 100 deaths. This shows that the larger communities are taking advantage of the hospital facilities to a much greater extent than the smaller communities. The second part of the table shows the ratio of patients admitted to Boston hospi­ tals to those admitted to all hospitals for each group. Aside from the fact that those living in the density group over 3,000 go to Boston more than those from other densi­ ties, there is nothing distinctive in this part of the table. This would be expected as Boston constitutes a large part of this density group. It would appear that citizens from all the five lower density groups make use of the Boston hospitals with nearly equal frequency. Table 9 shows the per cent of non-resident hospital admis­ sions for the various hospitals. The per cent varies from 0 to 100 per cent, with a median of 42.8 per cent. Of the 14 hospitals which have a non-resident cancer admission rate of 70 per cent or over, 12 are in either Boston or Cambridge. The percentage distribution of cancer admissions by type for the State varies considerably with the cancer deaths in the hospitals themselves. The types described are those of the International Classification, with the substitution of “ male genitals” for a part of “ other organs.” As the rates are on a proportionate basis, an increase or decrease in any one type would alter the rates for all the other types, and would, therefore, cause considerable fluctuation. There are, however, a few variations from the normal so marked as to be considered. In Table 10 and Chart 1, cancers of the buccal cavity, female genitals and breast show a consider­ ably higher admission rate in hospitals than the correspond­ ing deaths from these diseases, both in the hospitals and the State as a whole. On the other hand, cancers of the stomach and peritoneum are much lower. This emphasizes the state­ ment that a considerable per cent of individuals with cancers of the buccal cavity, of the female genitals, and of the breast are being cured. In dealing with the individual counties, Table 11 shows that Suffolk County has a high buccal cavity cancer admis­ sion rate. This is probably influenced by the quality of the Boston hospitals. Norfolk County has a high female genital rate and a correspondingly low rate for other types. This is caused by the large number of admissions at the Free Hospital for Women in Brookline. Franklin County is low in cancer of the female genitals and high in cancer of the breast. Hampshire County is high in cancer of the breast. Plymouth County is high in cancer of the skin. These rates do not imply that the inhabitants of the respective counties have higher or lower rates than elsewhere, but that those types are being hospitalized to a greater or lesser extent than other types of cancer in the county.

C o st o f N e w H o s p it a l C onstruction .

Inasmuch as the Joint Committee on Public Health of the General Court of 1926 reported out of Committee, House Bill No. 1455 which called for the erection for advanced cancer cases of a 250-bed hospital in the Fenway at a cost not exceeding $50,000 for the land and not exceeding $500,000 for the construction, it seemed wise to study the construction cost of such an institution. The present plans of the Department do not call for the erection of such an institution for the care of terminal cancer cases, but it is realized that the experience of the Department at Norfolk State Hospital in the next few years may be such as to warrant additional hospital construction. A number of individuals familiar with hospital construc­ tion have been interviewed and rough estimates obtained of the costs of the construction of such a hospital. The fire regulations in the Fenway demand that only fireproof con­ struction be used. The estimates range from $4,000 to $8,500 per bed, not including land or equipment. These figures depend both on the type of construction and the opinion of the man making the estimate. A hospital which would give only home care with no facilities for operations or radiations could be built at a much less cost than one fully equipped for all types of cancer therapy. Land in the Fenway would probably cost from $1.50 to $2 per square foot. From 40,000 to 80,000 feet would be re­ quired. The land cost, therefore, would vary from $60,000 to $160,000. The construction cost for a home type of hos­ pital would lie between $1,000,000 and $1,350,000. The construction cost of a hospital designed to furnish complete treatment and research would be between $1,250,000 and $2,100,000. The cost of equipment would vary from 8100,- 000 to $200,000. The following is an excerpt from a letter received from a prominent firm of architects familiar with hospital con­ struction :

I hand you herewith a general idea as to the cost of a new institution for the care of cancer patients based on a total bed capacity of 250. Certain general assumptions are necessary, of course, in order to do any figuring at all, and therefore I have made the following: The general type of institution considered is a condensed hospital group with a central administration building and wings for patients, with service building, laundry and power house detached. The nurses’ homes would be separate buildings connected, perhaps, by corridors or tunnels such as the site would doubtless dictate. About half the patients are assumed to be ward cases, in small units, not larger than ten in a room, and the balance in single or two-bed rooms. The single rooms are assumed to be simple in equipment and com­ paratively small in size, about 9' x 13' for a standard. Equipment for treatment and care would be about equal to that of a medical hospital of like size, which would, of course, include ample laboratory equipment, X-ray and radium treatment, operating rooms and their accessories, medical library, etc., as well as the more common utilities connected with the hospital. The employees, superintendent and officers could, of course, be housed in some part of the institution building at a saving in cost of $50,000 or more. This arrangement is quite common in our institu­ tions, but, as you know, has nothing to recommend it except the econom y in first cost. Item No. 10 (roads and landscape work, $50,000) is, of course, dependent on the site, and is probably large, any way. Item No. 11 (general furnishing) is to include movable furnishings for patients, nurses and officers. It includes beds, furniture, linen, rubber goods, dishes, tables, laboratory equipment, operating room equipment — in fact, everything which cannot be termed fixed equipment. Fixed equipment, such as elevators, sterilizers, kitchen equipment, laundry machinery, lighting fixtures, plumbing fixtures, etc., is in­ cluded with the figures given for the building. Nothing is included, as you will notice, for the purchase of the land, as this item would vary both in cost and size, depending upon the locus chosen for the plant. In the urban district a tract of 2 acres, or about 80,000 feet, would be ample, but in a rural district more land would be possible and quite desirable. 19:27.] HOUSE — No. 400. 23

i . Administration building, containing offices, records, treat­ ment, X-ray, laboratories, etc. . $150,000 00 2. Patients’ wings — 250 beds ...... 750,000 00 3. Kitchen and Service Building — kitchen, nurses’ dining room, staff dining room, cold storage, general storage, steward, etc...... 100,000 00 4. Laundry, including equipment ..... 80,000 00 5. Power house, including stack and equipment 100,000 00 6. Nurses’ home — 100 beds ...... 200,000 00 7. Officers’ home ...... 50,000 00 8. Employees’ home ...... 50,000 00 9. Superintendent’s house ...... 25,000 00 10. Roads and landscape work ...... 50,000 00 11. General furnishings and equipment ..... 175,000 00 Total ...... $1,730,000 00

The following is an excerpt from a quite detailed state­ ment on new hospital construction, kindly prepared for the Department by a member of the Advisory Committee who has had wide experience in the field:

Cubic Feet per Patient.

A recent survey of general hospitals indicates that about 7,000 cubic feet per patient’s bed is required to properly house the patients and several departments; this, exclusive of accommodations for nurses and employees. The hospital under consideration, however, is a special hospital with an out-patient department of fair size, with a proportionately large number of single rooms and cubicles and with smaller wards than are found in the average general hospital, and also with greater space than is customarily assigned to X-ray and other laboratories. Therefore, in the opinion of the writer, it is necessary to increase the usual 7,000 to 8,000 cubic feet per patient occupant. It is quite possible, in his opinion, when plans are finally completed, that it will be found that even a larger cubic feet area per patient is demanded and that the unit of 10,000 cubic feet per patient may be approached. Eight thousand cubic feet per patient occupant and 10,000 cubic feet per patient occupant are the two factors that are here employed in computing the probable building cost, and which appear in the estimated cost under the two headings: (1) Minimum Cost, (4) Maximum Cost. Cost per Cubic Foot. A general hospital of good construction can be built in Boston at a cost of 75 cents per cubic foot. This unit price should be found sufficient to cover the building itself, fixed equipment and all necessary apparatus and furnishings. However, 75 cents per cubic foot is re­ garded by the writer as the positive minimum. 24 HOUSE — No. 400. [•Jan.

The writer feels that 85 cents per cubic foot may be expended and that this unit should be employed in arriving at a figure which may be regarded as the maximum cost.

Estimated Cost of Building.

(1) Minimum cost, using minimum factors throughout: 250 patients. 8.000 cubic feet per patient. 75 cents per cubic foot. 250 x 8,000 x .75 = $1,500,000

(2) Estimated cost, using the following factors: 250 patients. 8.000 cubic feet per patient. 85 cents per cubic foot. 250 x 8,000 x .85= $1,700,000

(3 ) Estimated cost, using the following factors: 250 patients. 10.000 cubic feet per patient. 75 cents per cubic foot. 250 x 10,000 x .75= $1,875,000

(4) Maximum cost, using maximum factors throughout: 250 patients. 10.000 cubic feet per patient. 85 cents per cubic foot. 250 x 10,000 x .85= $2,125,000

It will be observed that the above figures show an estimated minimum cost of 81,500,000 and an estimated maximum cost of $2,125,000, with price ranging between $1,700,000 and $1,875,000.

(5) The uniter's estimate: The writer’s estimate would be based upon the following factors which he believes will be closelj* approximated when final plans are made and actual bids secured:

Factors used: 250 patients. 9.000 cubic feet per patient. 85 cents per cubic foot. 250 x 9,000 x .85= $1,912,500

(6) Site not included.

It should be remembered that the above prices are exclusive of site. M a i n t e n a n c e C o s t .

The maintenance cost for an institution treating cancer with radium and X-ray as well as furnishing operating facil­ ities will be more nearly comparable to the costs of general hospital maintenance than to those of tuberculosis and mental disease hospitals. In order to obtain some idea of what the maintenance cost for a cancer hospital would be, the Department has prepared the following list of hospital maintenance costs in the Commonwealth. The majority of the figures are for 1925, a few for 1924 and several the aver­ age for 1923, 1924 and 1925.

H o s p it a l s w i t h o v e r 100 P a t i e n t s p e r D a y . Weekly Cost.

Hospital A ...... $47.15

Hospital B ...... 44.07

Hospital C ...... 39.99

Hospital D ...... 39.85

Hospital E ...... 34.60

Hospital F ...... 31.15

Hospital G ...... 30.77

Hospital H ...... 29.96

Hospital I ...... 29.05

Hospital J ...... 27.44

A v e r a g e ...... $35.40

M e d i a n ...... $32.87

H o s p i t a l s w i t h 50-100 P a t i e n t s p e r D a y . Weekly Cost.

Hospital A A ...... $40.46

Hospital B B ...... 37.17

Hospital C C ...... 35.72

Hospital D D ...... 31.08

Hospital E E ...... 30.80

Hospital F F ...... 30.38

Hospital G G ...... 28.00

Hospital H H ...... 27.30

Hospital I I ...... 26.95 26 HOUSE — No. 400. [Jan.

H o s p i t a l s w i t h 50-100 P a t i e n t s p e r D a y . Weekly Cost.

Hospital J J ...... $26.46

Hospital K K ...... 26.25

Hospital L L ...... 25.97

Hospital M M ...... 25.75

Hospital N N ...... 25.46

Hospital O O ...... 25.06

Hospital P P ...... 24.50

Hospital Q Q ...... 19.25

Hospital RR ...... 17.97

A v e r a g e ...... $28.03

M e d i a n ...... $26.70

H o s p i t a l s w i t h u n d e r 50 P a t i e n t s p e r D a y . Weekly Cost.

Hospital A A A ...... $88.57

Hospital BBB ...... 49.12

H ospital CCC ...... 40.04

Hospital D D D ...... 38.57

Hospital E E E ...... 37.78

H ospital F F F ...... 37.45

Hospital G G G ...... 37.17

Hospital H H H ...... 32.34

Hospital III ...... 31.78

Hospital JJJ ...... 31.22

Hospital KKK ...... 29.54

Hospital LLL ...... 28.82

Hospital M M M ...... 28.28

Hospital N N N ...... 28.00

Hospital OOO ...... 28.00

H ospital PPP ...... 28.00

H ospital QQQ ...... 27.02

Hospital R R R ...... 24.85

A v e r a g e ...... $35.81

M e d i a n ...... $31.50 III. POLICY OF MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH REGARDING CANCER.

The necessity of adopting a definite policy before begin­ ning any comprehensive program in cancer is obvious. The Department of Public Health, with this in view, appointed an advisory committee of outstanding individuals, both professional and lay, and after numerous conferences drafted the following program. The cancer situation falls into three main divisions: first, hospitalization for those individuals unable to obtain such care; second, measures to insure earlier recognition of can­ cer cases and adequate treatment, and thus decrease the number of terminal cases; and third, investigations to in­ crease our knowledge of the disease in Massachusetts.

H ospitalization P r o g r a m .

The hospitalization program is subdivided into two groups: the one dealing with immediate care for the patient; the other, with the determination of a long-time policy for such cases. The Norfolk State Hospital will meet, in part, the first of these needs. This institution originally built for the care of alcoholic and narcotic addicts and unused for some years, is now being renovated and will be opened early in 1927 for the care and treatment of cancer cases. The central building will contain the operating room, X-ray equipment for diagnosis and treatment, and quarters for the application of radium. A wing will connect this building with the north pavilion which, between them, will have something over 50 bed patients. The detached south pa­ vilion will have room for about 30 ambulatory patients. The cottages will house the staff and dining quarters for the ambulatory patients. Perhaps the most important part of the project as far as quality of service is concerned is the consultative staff which it is planned will visit regularly from Boston. Every effort will be made to admit as many diagnostic and therapeutic cases as possible, in order to keep down the death rate and minimize the stigma likely to attach to an institution serving largely incurable cases. This type of case can be sent from near-by clinics as they are developed. Also only patients not otherwise able to obtain institutional service will be taken. Should institutions al­ ready handling incurable cancer begin transferring their patients, the 80 to 90 beds made available at Norfolk would soon be filled without in any way meeting the need for which it was meant. While cancer has certain aspects which force it to our attention, it does not differ from other chronic diseases in the demands made for hospitalization. It is only a matter of time when the question of hospitalization for other chronic diseases such as arthritis, chronic heart disease, and neph­ ritis will be raised. The way in which the Commonwealth handles its cancer problem may shape its future policies regarding these far more numerous maladies. The Depart­ ment is, therefore, attempting to project a future hospitali­ zation policy based on facts rather than fancy. In the past, the population of Massachusetts has been growing younger. In 1850, 63.5 per cent of the inhabitants of the Commonwealth were under fifty years of age, while in 1920, 76.4 per cent were in this group. As all problems involving public care of individuals must be financed by the productive portion of the population, we have arbitrarily divided the adult population into two groups, — the pro­ ductive from twenty to sixty years, and the retired, over sixty years. It is realized that neither of these age limits depict the true situation, but they are sufficiently accurate for this discussion. In 1900 the ratio of the productive group to the retired group was 2.8 to 1. In 1920 this had increased to 3.8 to 1. With the number of individuals in the productive group increasing at a greater rate than the retired group, the question of care for the aged from a finan­ cial standpoint is not likely to be particularly serious. But with a population in which the ratio between these groups is decreasing the future is more ominous. There is every reason to believe that conditions are now changing in Massachusetts population. Immigration is re­ stricting the number of young adults who enter this country. The Massachusetts birth rate is falling. (It has dropped about 16 per cent in the past ten years.) Public health measures are prolonging the lives of individuals; and the assumption that Massachusetts has grown older since 1920 seems sound. This could have been easily shown had the State census of 1925 been taken with the thoroughness of that of 1915. The lack of data in the 1925 census has made many parts of our work much less effective and the infer­ ences drawn less sound. This is to be greatly regretted, as the only available statistics on many items which may have a direct bearing on the causation of cancer are now ten years old. If our assumption is correct, and if the population con­ tinues to grow older, the ratio of the number of workers to the number in the group needing to be cared for will decrease, and the burden on the workers will correspondingly increase. This should be taken into consideration in all long-time programs for the expansion of the care of the aged and the infirm, for while it is realized that provision should be made for these individuals, economics demand a program, whether national, state, or local, which will care for the sick individual with the least burden on the tax­ payer. While statistics are available which furnish information concerning the number of deaths from cancer, heart disease, nephritis, etc., our knowledge of the actual disability caused by these diseases is meagre. If the State policy was to provide for all those needing institutional care, how many would wish to receive it? What proportion of the popula­ tion over sixty (and in the case of cancer forty may be substituted for sixty) need to receive such care? These and other questions should be answered. The maintenance of the institution at Norfolk should furnish light on the problem. The volume of cancer patients who seek admission can be a direct guide to any further program of expansion for cancer cases, as well as furnish a lead toward a policy for other chronic diseases. The question of centralization versus decentralization as applied to hospitalization can be fairly answered after a few years of experience at Norfolk. Will the patient come to a central institution to die or will he prefer to remain near home? In tuberculosis it has frequently happened that the dying patient insists on re­ turning home. Before embarking on a large program of central hospitalization for cancer, we must know whether our experience with this disease will be the same. The local committee of laymen and women in each com­ munity where there is a clinic will have many cases of cancer brought to its attention. It will be called upon to make arrangements for individuals who either cannot or will not avail themselves of the facilities at Norfolk or elsewhere. One of the functions will be to study commu­ nity resources and see in what way such problems can best be met. With sufficient interest aroused, money may be­ come available for beds or wards added to existing institu­ tions in some instances, and for special hospitals in others. The Lowell situation is a fair example of what may occur in other parts of the State. How much can be done for the cases in their homes? Hospitalization for chronic cases is the most expensive form of care. It is estimated that adequate hospitalization for a cancer case will cost at least $35 per week. If more patients could be handled in their homes this cost would be less, and the sick individual would be near relatives and friends. The possibility of extending home nursing care is being considered. It has been suggested that the American people are gradually divorcing themselves from the vital issues which they formerly considered indispensable. Births are becom­ ing less frequent in the home, with a corresponding increase in hospitalization. More people are dying in hospitals and the funeral home is replacing the home funeral. Do we, as American people, need to be brought into a more close relation with such experiences? Is it our duty as well as our privilege to care for our loved ones rather than to sidestep such issues? Sociological problems such as these must enter into the discussion even if we are unable to furnish the answers. With some of the most thoughtful citizens in each community studying the problem of how best to care for the terminal cancer patient, the possibility of a rational solution is more promising.

C l in ic P r o g r a m .

With over 5,000 deaths annually from cancer in Massa­ chusetts, and with the cancer death rate steadily on the increase, it seems absurd to complacently await the dis­ covery of some medical cure for cancer before undertaking measures for the control of the disease. Such an interval of waiting in tuberculosis would have been inexcusable and in the interim countless lives would have been sacrificed. For the State merely to furnish a hospital or home for the individual with cancer to pass his last days in some degree of comfort is equally short-sighted. A State cancer program must be broader and must include measures which attempt to reduce the volume of hopeless cancer. With our present knowledge, the cure for cancer is only possible when diagnosis is made at an early stage of the disease and prompt treatment instituted. In the joint study of 1925 it was found that the average cancer patient came to his physician eight months after knowledge of the first symptoms, and that in the case of those cancer patients who had surgical treatment and ultimately died, an interval of 10.3 months elapsed between first symptom and operation. It is admitted that both these figures are somewhat crude and may be subject to change as our data increases; but they are sufficiently accurate to establish beyond doubt two significant facts: first, that the average patient does not come to the physician until long after he is aware of some abnormal condition; and second, that there is a consider­ able interval between the first visit to the physician and the institution of rational treatment. A part of this second delay is doubtless due to the apathy of the patient in taking the advice of the physician, but in far too many cases it is due to a spirit of temporizing on the part of the physician himself. The Pennsylvania report found 10 per cent of the medical profession to be backward in the treatment of cancer. Even this backward group of physicians is not wholly to blame. M any of their numbers are sincere in their attempt to treat the disease medically. There are organizations and commercial concerns that are circularizing the practicing physician to persuade him to use their methods of treatment. Many of the pamphlets which are sent out are most alluring in appearance and are so worded as to give the physician who is removed from medical centres an erroneous view of the subject. Quota­ tions from eminent surgeons are inserted, and as these extracts give a far different impression than the entire paper from which they are quoted, they add weight to the statement of the advertising concern. Is it any wonder, then, that many well meaning physicians with little time for intensive study are thus led to attempt methods of treatment which are harmful either in them­ selves or in that they delay instituting adequate therapy? Any program which will successfully lower the cancer rate must attack the delay on the part of the public, to­ gether with the delay on the part of the practising phy­ sician. The most rational method of attacking these ob­ stacles is by means of the cancer clinic, which will act in a variety of ways to accomplish its results. The clinic will first give an opportunity for individuals to receive expert diagnostic advice. It will be composed of a group of physicians who are all thinking in terms of cancer. Any individual may receive an opinion from this group regardless of his financial standing. Those able to pay will be referred from the clinic to the private physicians, while those unable to pay will be referred elsewhere. That expert advice on cancer is needed for early diagnosis can be readily appreciated when it is realized that the aver­ age physician in Massachusetts sees between four and five cancer cases per year and these of different types. (House Document 1200 gives 1.78 in five months.) As each type demands a different kind of skill in its diagnosis, a physician seeing less than one case a year of a given type cannot be expert. The staff of the clinic will be composed of a group each one of whom will see many cases of the type of cancer peculiar to liis own specialty. The advantage to the prac­ tising physician of obtaining such consultation service is enormous. It not only assures his patient of sound advice, but improves his own knowledge of cancer through his contact with the clinic group. The cancer interest among the profession will be further increased by consultation visits supplemented by forum discussions by experts from the larger centre. Such group specialization in fractures, goiter therapy, etc., has accomplished much in improved quality of service. A physician thus having cancer constantly brought to his attention will be better able to handle this disease when a suspicious case comes to his attention. Moreover, the surgeon will find the people more readily accepting his advice when it is supplemented by that of the clinic group. In some of the localities where clinics have been functioning it has been found that many persons who refused to take the surgeon’s advice regarding early operation, after attend­ ing clinics and having the same advice given them, returned to their surgeon for treatment. The community spirit aroused by a clinic will have a tendency to keep cancer before the lay public, and can react only favorably in getting patients under treatment at a much earlier stage in the disease than at present. The Department is endeavoring to establish cancer clinics in a number of strategic centres. Since a cancer clinic demands not a single physician, but a group of specialists including the surgeon, the general medical man, the patholo­ gist, roentgenologist, nose and throat man, urologist, gyne­ cologist, etc., and since its needs are not limited to the four walls of the clinic room but demand the full resources of a modern hospital, the Department decided to further clinics first, in those communities that had the most to offer in professional co-operation and hospital resources. First an opportunity is asked to present the program to the organized medical profession of a given city. It is usually planned that a few representative men and women be present at this initial meeting since an adequate service for cancer will tax to the limit the social as well as the medical resources of the community. If it seems suitable, the local medical profession passes a vote of support to the program and authorizes the appointment of a local medical cancer com­ mittee. This committee is responsible for determining where the clinic or clinics shall be held, for outlining the policies, for organizing the staff, for supervising the quality of service, and for directing the growth. The Department meets with this committee to determine how, in this par­ ticular instance, it can best assist with its resources in personnel, supplies, and funds. The medical committee should also appoint a local lay cancer committee. This latter committee must determine such matters as education of the local public in regard to available resources and their proper utilization, and must face the unutterable tragic social and economic problems which will be uncovered, as well as decide the best solution of home or hospital care for the incurable, since many will not want to die in a remote institution. The Department has personnel and other resources for these committees of lay people, but each community must be sufficiently stirred to the need of largely meeting its own problems. T oo many sound pro­ grams have failed because of local indifference or antago­ nism. In order to assure some uniformity in the various clinics, and also a high quality of service, the Public Health Council has adopted a set of minimum requirements for clinics.

Minimum Requirements for Cancer Clinics.

A cancer clinic may be described as follows: A hospital, a separate department of a hospital, or a group repre­ senting more than one hospital and having access to the resources of these hospitals, organized and equipped with facilities for the diag­ nosis and treatment of cases of cancer by accepted methods. Such a hospital, department or group should have resources for giving free diagnosis and treatment to patients unable to pay, in addition to those patients able to pay in whole or in part. Material Equipment. — Space should be available for the reception and examination and treatment of ambulatory cases, and for the hospitalization of at least a limited number of bed cases either for diagnosis or for treatment. Operating room facilities should be avail­ able with all of the equipment of a modern surgical hospital, including special diagnostic apparatus for nose and throat work and genito­ urinary examinations. X-ray equipment of a modem type is needed, capable of giving both low-voltage and deep therapy as well as for doing diagnostic work. A sufficient supply of radium should be avail­ able either continuously or on special order; 500 milligrams of radium should be sufficient for ordinary purposes. A modern and complete record system should be available and uniformity of classification and of record forms among the different clinics operating under this organization should be secured. An up-to-date follow-up system is essential. Personnel. — There should be a surgeon in charge of each clinic who is familiar with (1) the surgical pathology of tumors, (2) the surgical treatment of malignant disease and (3) the use of radiation therapy. The staff of the clinic should include representatives of the departments of pathology, surgery, general medicine, nose and throat, skin, genito-urinary, gynecology and X-ray and radium departments, and it should be the effort to select representatives of those depart­ ments interested and qualified in the diagnosis and treatment of tumors. The co-operation of visiting nurses’ organizations and social service workers is essential.

E d u c a t io n a l P r o g r a m .

While results from clinics are expected to have far more educational value than other projects, all legitimate forms of publicity which will bring home to the individual the facts regarding the possibilities of cure of cancer in its early stages should be used. The Department has appointed an advisory committee to determine the best methods of publicity. One member of this committee is the State Chairman for Massachusetts of the American Society for the Control of Cancer. This organization is doing an excellent piece of work in lay pub­ licity, and can greatly aid in the State’s program. At present the State’s program in this respect is limited to dis­ tributing literature on cancer to interested individuals and furnishing selected groups with lecturers. Efforts are being made to get into closer touch with local organizations and interest them both in the State’s program and the disease itself. In the clinic centres the local lay committees, which will be formed as adjuncts to the clinics will have charge of all the publicity in their respective communities. One of the important functions of these committees is to see that the individuals in the communities not only know what to do when suspicious lesions occur, but also do it. While it is difficult to evaluate educational campaigns, the meagre statistical material available on the subject points toward some very definite results. The Pennsyl­ vania report states that “ Thirteen years of education have cut down the average time between discovery of first symp­ toms in superficial cancer and the first call on the doctor from 18.0 months to 14.6 months, or 20 per cent. In cases of deep-seated cancer, the interval has been reduced nearly one-half. And in these thirteen years, the doctors of Pennsylvania have learned the importance of prompt action sufficiently to have reduced the interval between the patient’s first appearance and the institution of the treat­ ment required from 13.0 months to 4.5 months, or 65 per cent, in superficial cancer, and from 12.0 months to 3.9 months, or about 70 per cent, in deep-seated cancer.” The educational campaign should be sufficiently stressed to bring home to all thoughtful people the following facts regarding cancer: 1. Cancer is a disease largely confined to late adult life. 2. Cancer is often preceded by long-continued chronic irritation. Measures used to prevent such irritation should be adopted. Among these may be mentioned: improved dentistry, abstinence or limited use of tobacco and alcohol, treatment of chronic mastitis, repair of lacerated cervix, more exercise and less food. 3. Cancer is at first a local disease and if completely removed as such, cancer can be cured. 4. From its local site of origin, cancer tends to spread to other parts of the body. 5. Any continued irritation, any lump, any abnormal discharge, any sore that does not readily heal, any wart or mole that changes in size and appearance should arouse suspicion and send the individual to his physician. 6. Pain is not a symptom of early cancer, and patients should not wait for its appearance before consulting a physician. F u r t h e r C a n c e r S t u d i e s .

Hospitalization should care for the terminal cases; clinics should aid in reducing the volume of hopeless cancer, but these steps will not lower the incidence of the disease. Further study is needed. It would seem unsound for the State to attempt clinical or laboratory research, nor is such endeavor indicated as many laboratories and hospitals throughout the world are working along these lines. The Commonwealth can, however, furnish a form of research not available elsewhere. This consists of compiling data regarding cancer cases. Cancer morbidity reports at the present time are not available, and statistical research has to be done with mortality records. Plans are now under way for establishing a morbidity reporting area in the Com­ monwealth. The physicians of Newton have voluntarily agreed to aid the Department by reporting their cancer cases. These records should be of inestimable value. The Visiting Nurse Associations are also assisting in the work by filling out questionnaires regarding cancer patients whom they visit. This material will cover items regarding the mode of life of the individual, and an effort will be made to ascertain whether the individual with cancer differs from the well one, regarding his habits of food, exercise, housing, use of tobacco, and social life, as well as such additional factors as economic status, environment, heredity and nationality. If consistent differences occur in the lives of the cancerous and the non-cancerous, it may be very signifi­ cant. Sociological problems regarding the disease will also be studied. Records from the clinics will be obtained and incorporated in the series of studies. The mortality records will augment these various sources of information, and the total data obtained should furnish leads for developing the Commonwealth’s cancer program, even if the contribution to the sum total of knowledge about cancer be slight. D ia g n o s is a n d T r e a t m e n t .

Since 1919 the State Department of Public Health has co-operated with the Harvard Cancer Commission in fur­ nishing free diagnostic service of pathological material. From a small beginning the service has increased until at the present time surgeons in over one hundred towns and cities in the State are taking advantage of this oppor­ tunity to obtain expert advice on tissues. It is the policy of the Department to continue and extend this service. A cancer hospital must have a sufficient amount of radium to properly treat all patients needing this form of therapy. The clinics established throughout the State should have access to radium as soon as men experienced in its use are available. It will require about two grams of radium at a cost of at least 8120,000 to purchase sufficient radium to furnish emanations for the N orfolk Hospital and the clinics. In order to care for this radium as well as extract and dis­ tribute the emanations, a yearly expenditure of $10,000 is necessary.

IV. IMMEDIATE NEEDS OF THE DEPARTMENT.

In order to conduct the program outlined in this report, certain appropriations are necessary. Funds must be pro­ vided for the maintenance of the Norfolk State Hospital, for the purchase of radium, for the cancer clinics, for the diagnostic service, for educational work, and for research studies. The Norfolk State Hospital must be run as a Class A institution. The service given should be adequate in every respect and the care and treatment furnished cancer patients should equal or excel that obtained elsewhere. It is difficult to estimate the exact cost, but from the studies of general hospital maintenance, together with that of special cancer hospitals, the estimate of $37.50 a week per bed has been reached. While the policy regarding cancer clinics is to make them a local community responsibility, it is necessary for the State to maintain such supervision as will insure service of an approved type. It will be necessary, at least in the beginning, for the State to pay for a part of the service given at these clinics. This will make State supervision less onerous, as well as enable some communities to main­ tain clinics which could not otherwise do so. Appropriations are also needed to continue the free diagnostic service of pathological material, the educational work, and the statistical studies. To cover the cost of the above, the Department has asked for the following appropriations in its budget:

Maintenance of Norfolk State Hospital . . . $155,264 C l i n i c s ...... $46,805

The appropriation of $100,000 granted by the General Court of 1926 was not sufficient to properly renovate and equip the Norfolk State Hospital. An additional appro­ priation of $83,000 is needed. Radium must be available for the Norfolk State Hospital, as well as for the clinic patients. In order to furnish the same, the Department is presenting the following bill:

A n A c t t o p r o v i d e f o r t h e P u r c h a s e o f R a d i u m b y t h e C o m m o n ­

w e a l t h TO ALLEVIATE DISTRESS CAUSED BY CANCER.

Be it enacted, etc., as folloios:

S e c t i o n 1. The department of public health is authorized to pur­ chase radium for the benefit of persons within the commonwealth afflicted with cancer. This radium, or the radio-active substances derived therefrom, are to be used at the Norfolk State Hospital and elsewhere as the department of public health may designate under such rules and regulations as it may promulgate. The department of public health may entrust the radium to the institution or institutions that are in its j udgment best equipped for the proper care and handling of the same. For the purchase of said radium the sum of one hundred and twenty thousand dollars is appropriated.

S e c t i o n 2. Each year for a period of not less than ten years there shall be an appropriation made of not less than ten thousand dollars in order to provide for the care of the radium and the extraction, purification and distribution of the radio-active substances in such forms as may seem most advantageous to the department of public health in order to guarantee the continuation of service. V. SUMMARY.

The following summarizes the cancer situation in Massa­ chusetts : 1. There are approximately 230 beds being constantly used for cancer patients who leave the hospital alive. There are approximately 115 beds being used for terminal cancer patients. This does not include the beds used by patients who died in institutions such as convalescent homes, almshouses, etc. These comprise about 12 per cent of those who died in hospitals. 2. The average length of stay in hospital of the cases that leave the hospital alive is 17.7 days, and of those that die in hospital, 33.6 days. If the patients who died shortly after an operation are omitted, the average duration of chronic terminal cases in hospitals is 45.9 days. There is considerable difference in the length of stay in various hospitals. 3. In general, there are facilities for handling the cancer patient in need of an operation. 4. There is need of about 400 more beds for the chronic terminal case. New hospital construction is now under way which will reduce this need by at least one-third. Other contemplated construction will still further reduce this need. Experience at the Norfolk State Hospital, as well as service which may be developed locally, should direct further extension of State service in this direction. 5. Operative treatment of cancer is quite uniformly available throughout the State. Radiation is much less so and is used in only a small percentage of cases. 6. Only a few7 cases are referred from hospitals to other institutions. 7. The rural community has fewer hospital admissions per cancer death of residents than has the larger community. As the size of the community increases the ratio of hospital admissions to deaths increases. About one-third of the inhabitants of rural communities vdio do make use of hospital facilities go to Boston hospitals. This same ratio applies to the larger communities with the exception of the population group containing Boston where the ratio is larger. 8. The ratio of hospital admissions of cancers of the buccal cavity, female genitals and breast to all hospital admissions for cancer is greater than is the ratio of the corresponding deaths. This is particularly interesting since cancer of these organs is prevalent among the types in which early cure is most hopeful. 9. The Massachusetts Department of Public Health is inaugurating a cancer program, consisting of the following phases: (1) Hospitalization. (2) Cancer Clinics. (3) Education. (4) Cancer Studies. (5) Diagnosis of Pathological Material. (6) Radium Treatment. TABLES AND CHART.

T a b l e 1 . — Hospitalization of Cancer Cases—-Number of Cases.

[X means no record.]

L o n g - t i m e T e r m i n a l C a s e s T e r m i n a l C a n c e r C a s e s . T o t a l C a n c e r C a s e s . (O v e r 30 D a y s ). H o s p it a l .

1923. 1924. 1925. Average 1923. 1924. 1925. Average 1923. 1924. 1925. Average 400. No. —HOUSE

Addison Gilbert (G lou cester) ...... 16 19 12 16 5 8 2 5 2 2 - 1

Beth Israel ( B o s t o n ) ...... 30 26 17 24 2 7 2 4 1 1 - 1 2 Beverly H ospital ...... 24 27 27 26 8 13 10 10 - 6 -

B enjam in Stickney ( I p s w i c h ) ...... 2 8 7 6 - 2 2 1 - --

Boston C it y ...... 380 403 341 375 118 132 112 121 31 27 21 26

Brockton H ospital ...... 27 56 31 38 7 10 14 10 2 4 3 3

Burbank Hospital (F itch b u rg ) ...... 29 30 26 28 9 14 6 10 4 3 3 3

Cambridge City H o sp ita l ...... X X 28 28 XX 8 8 X X 1 1 1 1 Cambridge R e lie f ...... 7 2 5 5 5 1 2 3 1 - 9 0 Carney Hospital (South B oston ) ...... 102 155 125 127 19 21 28 23 3 4 1 1 Charlesgate Hospital (Cambridge) .... 51 55 68 58 6 3 4 4 1 - X 1 1 Chester Hospital (C am brid ge) ...... X 14 10 12 X 1 3 2 _ Charles Choate Memorial (Woburn) .... 7 8 17 11 3 2 3 3 - - ~ 2 2 2 1 1 1 Clinton IIoBpital ....•••• 10 9 10 10 3 - 1927.] Cooley Dickinson (Northampton) . 18 3 23 15 3 1 2 2 1 --- Deaconess (B o s to n ) ...... X 143 130 137 X 22 18 20 X 2 2 2 Emerson Hospital (Concord)...... X X 3 3 X X 1 1 X X --

Eye and Ear Infirmary (B oston ) ...... 108 89 108 102 6 8 2 5 - - -- Fall River General...... 34 42 22 33 16 17 10 14 - 7 •4 4 Fairlawn Hospital (W orcester) ...... 8 10 9 9 - - 1 --- 1 - Farren Hospital (M ontague)...... 7 9 X 8 2 - X 1 1 - X - Framingham Hospital ...... 6 7 6 6 3 2 2 2 2 - 1 1 OS — o 400. No. —HOUSE Franklin County (G reen field ) ...... 14 16 21 17 5 8 4 5 2 - 1 1 Faulkner Hospital (B oston ) ...... 31 28 30 30 2 - - 1 - - - - Free Hospital for Women (Brookline) .... 38 60 45 48 6 11 6 8 4 7 3 5 Gale Hospital (H a v erh ill) ...... 25 42 35 34 7 11 10 9 3 3 1 2 Goddard Hospital (B ro ck to n ) ...... 36 44 32 37 1 4 5 3 1 - -- Good Samaritan (B o sto n ) ...... 69 59 62 63 47 38 41 42 36 27 25 29 Hale Hospital (H av erh ill) ...... 15 16 9 13 3 4 2 3 - 1 -- H ahnem ann H ospital (W o rce ste r)...... 2 4 17 8 - 2 2 1 - 2 1 1 Harley Hospital (B o s to n ) ...... 9 8 27 15 1 3 2 2 - 1 - - Hart Hospital (B oston) ...... 14 11 9 11 4 1 - 2 1 --- H. Heywood Memorial (Gardner)...... 21 25 14 20 5 13 8 9 2 4 3 3 Hillcrest Hospital (P itts fie ld ) ...... 6 9 28 14 2 - 6 3 -- 5 2 Holy Ghost Hospital (Cambridge) .... 45 40 25 37 42 34 21 32 27 21 17 22 Holyoke City Hospital ...... 41 27 18 29 6 7 6 3 5 - 1 1 L o n g -t i m e T e r m i n a l C a s e s T o t a l C a n c e r C a s e s . T e r m i n a l C a n c e r C a s e s . (O v e r 30 D a y s ). H o s p i t a l . 1923. 1924. 1925. Average 1923. 1924. 1925. Average 1923. 1924. 1925. Average

House of Mercy (P ittsfield) ...... 35 34 33 34 9 10 7 9 1 4 3 . 3

Huntington Memorial (B o s to n ) ...... 327 359 318 335 13 7 6 9 - --- OS — o 400. No. —HOUSE 2 J. B. Thomas Hospital (Peabody)...... 11 7 12 10 1 2 5 3 1 - 1

Jordan Hospital (Plym outh)...... 4 4 1 3 1 1 - 1 - 1 - -

Lawrence City Hospital...... 9 8 9 9 3 6 6 5 1 1 3 2

Lawrence General H osp ital ...... 33 30 39 34 9 10 11 10 5 1 2 3

Lawrence Memorial (M e d fo rd ) ...... X X 14 14 XX 1 1 XX 1 1

Leominster Hospital ...... 6 6 10 7 - 1 5 2 -- 1 - 9 14 Long Island H ospital ( B o s t o n ) ...... 23 25 14 21 21 22 13 19 17 17 1 Lowell Corporation H ospital...... 43 36 41 40 9 2 5 5 3 - - 8 10 2 2 3 2 Lowell General H o s p ita l ...... 55 55 47 52 13 9 12 10 3 2 6 4 Lynn H osp ital ...... 32 29 45 35 9 8 6 6 6 ” 1 1 1 Malden H ospital ...... 24 29 21 25 6 38 48 7 3 2 4 Massachusetts General Hospital (Boston) 403 410 378 397 48 58 39 35 11 10 5 9 Massachusetts Homoeopathic Hospital (Boston) . 218 237 214 223 34 33 1 1 Massachusetts Women’s Hospital (Boston) . X 10 15 13 X - " 23 3 . 8 3 5 2 1 1 Melrose Hospital . . . . • • • ■ 14 1 36 18 — 1927.] M ercy H ospital (S p rin g fie ld )...... 16 18 25 20 - 4 5 3 - 1 2 1 Milford Hospital ..... 17 1414 15 3 2 3 3 1 - - - Miller’s River (W inchendon)...... 7 1 4 4 -- 2 1 -- 2 1 Moore Hospital (B rockton ) ...... 23 47 45 38 9 9 10 9 1 - 1 1 Morton Hospital (T aunton) ...... 15 16 11 14 2 3 2 2 - 1 New England Baptist (B o s to n ) ...... 7 8 29 15 1 2 5 3 - 1 1 1 New England Hospital for Women (Boston). X 19 37 28 X 1 1 1 X 1 1 1 New England Sanitarium (Melrose) .... XX 6 6 X X 2 2 X X - OS — o 400. No. —HOUSE Newton Hospital ...... 54 36 47 46 17 10 12 13 4 5 3 4 Noble Hospital (W estfield) ...... 9 15 9 11 1 2 3 2 - - 1 N orth Adam s H o s p it a l ...... 14 27 25 22 - 2 6 3 - - 2 1 Norwood Hospital ...... 3 3 12 6 -- 2 1 -- - ' - Palmer Memorial (Boston) 25 25 41 30 23 20 33 25 11 10 20 14 Phillips’ House (B o s to n ) ...... 100 129 138 122 10 15 11 12 3 4 3 3 Peter Bent Brigham (B o s t o n ) ...... 167 161 160 163 72 66 40 59 17 17 12 15 Plunkett Hospital (Adams) 4 12 9 8 - 2 2 1 - --- Providence Hospital (H o ly o k e ) ...... 25 34 39 33 12 17 15 15 4 8 3 5 Quincy H ospital ...... 24 29 19 24 7 8 1 5 1 1 - • 1

Robt. Breck Brigham Hospital (Boston) 2 7 7 5 i i il Salem H osp ita l ...... 56 42 39 46 14 8 4 9 1 1 2 1 Somerville Hospital 12 16 17 15 3 4 4 4 - 1 - - Springfield Hospital 129 126 114 123 12 10 5 9 4 1 1 2 L o n g -t i m e T e r m i n a l C a s e s T o t a l C a n c e r C a s e s . T e r m i n a l C a n c e r C a s e s . (O v e r 30 D a y s ). H o s p i t a l . 1923. 1924. 1925. Average 1923. 1924. 1925. Average 1923. 1924. 1925. Average

St. Ann’s (Fall R iv e r ) ...... 19 16 25 20 9 4 5 6 2 1 3 2

St. Elizabeth’s (Boston)...... X 76 74 75 X 16 15 16 X 4 9 7

St. John’ s (L o w e ll) ...... 13 7 7 9 4 3 2 3 2 -- 1 400. No. —HOUSE

St. Luke’s (New B e d fo rd ) ...... 43 67 60 57 3 8 11 7 1 1 1 1

St. Vincent’s (W orcester) ...... 96 92 125 104 15 12 11 13 1 1 4 2

Sturdy Memorial (Attleboro)...... 16 16 14 15 3 3 1 2 - 1 - -

Symmes Hospital (A rlin g to n ) ...... 6 9 10 8 2 4 1 2 --- -

Truesdale Hospital (Fall R iv e r ) ...... 39 57 34 43 5 28 15 16 2 5 3 3

Union Hospital (Fall R iv er) ...... 31 15 43 30 6 6 10 7 - 1 2 1 2 Union Hospital (Fram ingham ) ...... 4 11 12 9 1 3 5 3 2 1 4

Union Hospital (L ynn) ...... X 9 16 12 X 2 1 2 X - - - 2 1 Waltham Hospital ...... 24 29 25 26 8 8 5 7 1 -

Wesson Hospital (S p rin g field ) ...... 11 38 36 28 1 3 3 2 1 -- 5 1 2 1 Winchester H o s p i t a l ...... 12 20 11 14 4 7 5 33 11 22 7 13 Worcester C ity H o s p ita l...... 132 143 102 126 35 45 20 12 14 2 4 1 2 Worcester Memorial Hospital ...... 74 112 98 95 7 24 3,698 4,321 4,165 4,150 813 947 805 877 253 264 233 249 1927.] J a b l e 2. Hospitalization of Cancer Cases — Number of Hospital Days. fX means no record.]

T o t a l C a n c e r D a y s . T e r m i n a l C a n c e r D a y s . L o n g -t i m e T e r m i n a l D a y s (O v e r 30 D a y s ). H o s p i t a l . 1923. 1924. 1925. Average 1923. 1924. 1925. Average 1923. 1924. 1925. Average

Addison Gilbert (Gloucester) 279 283 167 243 142 129 14 95 94 80 _ 58 Beth Israel (Boston) 647 401 325 458 70 118 23 70 68 43 - 37 OS — o 400. No. —HOUSE Beverly Hospital .... 502 899 669 690 83 577 100 253 - 464 - 155 Benjamin Stickney Memorial (Ipswich) 16 201 63 93 - 34 15 16 - - - _ Boston City Hospital 8,832 9,066 7,426 8,441 3,202 3,087 2,161 2,817 2,375 1,951 1,239 1,855 Brockton Hospital .... 449 993 601 681 150 264 324 246 94 146 178 139 Burbank Hospital (Fitchburg) 534 705 524 588 267 288 204 253 234 185 183 201 Cambridge City Hospital X X 442 442 XX 110 110 X X 45 45 Cambridge Relief Hospital 159 12 185 119 107 8 75 63 57 - 57 38 Carney Hospital (South Boston) . 2,335 2,782 2,938 2,685 314 482 794 530 137 253 633 341 Charlesgate Hospital (Cambridge) . 615 488 862 655 108 23 89 73 61 - 69 43 Chester Hospital (Cambridge) 260 167 214 - - 69 18 44 - 69 _ 35 Charles Choate Memorial (Woburn) 107 77 290 158 20 28 22 23 - - __ Clinton Hospital .... 270 139 59 156 114 50 8 57 113 43 - 52 Cooley Dickinson (Northampton) . 421 40 528 330 95 1 52 49 65 - - 32 Deaconess Hospital (Boston) . - 2,471 2,384 2,427 j - 317 270 294 - 105 103 104 T a b l e 2. — Hospitalization of Cancer Cases — Number of Hospital Days Continued.

L on g -t i m e T e r m i n a l D a y s T o t a l C a n c e r D a y s . T e r m i n a l C a n c e r D a y s . (O v e r 30 D a y s ).

H o s p it a l . Average 1923. 1924. 1925. Average 1923. 1924. 1925. \verage 1923. 1924. 1925.

14 14 - - - - Emerson Hospital (Concord)...... - - 48 48 - -

9 50 — - 400. No. —HOUSE Eye and Ear Infirmary (B oston ) ...... 1,245 1,204 935 1,128 51 90 357 - 434 172 202 Fall River General...... 569 1,278 560 802 215 611 245 43 14 - 43 14 Fairlawn (W orcester) ...... 82 184 115 127 - - 69 114 - - 56 Farren (Montague)...... 186 118 - 152 137 - - 52 100 233 1 1 Framingham H ospital ...... 352 122 192 222 234 13 _ 163 161 36 66 Franklin County (G reen field ) ...... 377 289 828 498 214 169 106 - 10 ~ “ Faulkner (B oston) ...... 410 555 535 500 29 - " 321 659 606 978 268 617 Free Hospital for Women (Brookline) .... 1,404 2,436 1,070 1,637 631 1,025 246 146 199 190 165 66 140 Gale Hospital (H a v erh ill) ...... 790 965 621 792 204 86 61 65 49 ~ 16 Goddard Hospital (B ro ck to n ) ...... 1,025 822 502 783 49 3,997 3,076 3,889 4,439 3,796 2,854 3,696 Good Samaritan (B o s to n ) ...... 6,222 5,592 4,344 5,386 4,595 43 209 6 86 ! 143 ~ 48 Hale Hospital (H av erh ill) ...... 339 449 113 300 172 103 60 54 - 103 46 50 H ahnem ann H ospital (W orcester)...... 33 133 349 - 18 53 10 27 - 41 14 Harley Hospital (B o s to n ) ...... 133 100 338 190 169 62 4 22 36 12 Hart Hospital (Boston) ...... 256 145 107 - — — 1927.] H . H eyw ood (G a r d n e r )...... 466 477 293 412 177 311 235 241 144 215 193 184 Hillcrest Hospital (P itts fie ld ) ...... 96 137 1,365 533 27 - 574 200 -- 548 183 Holy Ghost Hospital (Cambridge) .... 5,478 2,636 2,564 3,559 5,405 2,391 2,412 3,403 5,234 2,246 2,380 3,287

Holyoke City H ospital ...... 636 726 372 578 168 330 114 204 - 287 47 111

House of Mercy (P ittsfield) ...... 604 1,155 871 877 127 302 289 239 71 208 253 177

H untington Memorial ( B o s t o n ) ...... 2,555 2,213 1,920 2,229 105 52 60 72 J. B. Thomas Hospital (Peabody)...... 294 117 280 230 87 7 183 92 87 - 149 79 Jordan Hospital (Plym outh)...... 30 104 13 49 1 52 - 18 - 52 - 17 OS — o 400. No. —HOUSE Lawrence City Hospital...... 252 134 153 179 134 88 110 111 103 57 106 89 Lawrence General Hospital ...... 768 404 646 606 298 123 312 244 239 51 197 162 Lawrence Memorial (Medford) ..... X X 240 240 X X 36 36 X X 36 36 Leominster Hospital ..... 72 238 296 202 - 15 139 51 - - 67 22 Long Island Hospital (B o s to n ) ...... 4,508 2,725 1,410 2,881 3,182 1,777 1,331 2,097 17 17 9 14 Lowell Corporation Hospital . 807 472 559 613 357 26 61 148 284 - - 95 Lowell General Hospital 1,311 1,087 904 1,101 330 333 337 333 203 204 298 235 Lynn Hospital .... 583 347 794 575 177 135 304 205 139 68 251 153 Malden Hospital .... 355 416 488 419 115 98 269 161 - 57 223 93 Massachusetts General Hospital (Boston) 6,684 6,282 6,800 6,589 620 755 544 640 252 104 148 168 Massachusetts Homoeopathic Hospital (Boston) . 3,874 4,557 3,132 3,854 1,195 858 733 929 896 651 336 628 Massachusetts Women’s Hospital (Boston) . X 157 227 192 X- 10 5 Melrose H osp ital ...... 300 630 234 388 133 91 33 86 118 40 - 53 Mercy Hospital (Springfield)...... 377 285 398 353 - 65 109 58 - 43 79 41 o T a b l e 2. — Hospitalization of Cancer Cases — Number of Hospital Days — Concluded.

L o n g - t i m e T e r m i n a l D a y s T o t a l C a n c e r D a y s . T e r m i n a l C a n c e r D a y s . (O v e r 30 D a y s). H o s p i t a l . 1923. 1924. 1925. Average 1923. 1924. 1925. Average 1923. 1924. 1925. Average

Milford H osp ital ...... 226 131 188 182 61 31 46 46 52 - - 17

Miller’s River (W inchendon)...... 212 1 233 149 - - 203 68 - - 203 68 OS — o 400. No. —HOUSE Moore Hospital (B rockton ) ...... 270 346 460 359 127 31 343 167 32 - 265 99

Morton Hospital (Taunton) ...... 122 171 256 183 4 47 117 56 - - 109 36

New England Baptist Hospital (Boston) 165 259 604 343 18 49 192 86 - 36 136 57

New England Hospital for Women and Children (Boston) X 303 621 465 ' X 40 17 29 X 40 17 29

New England Sanitarium (Melrose) .... -- 136 136 - - 48 48 - ---

Newton H ospital ...... 1,103 1,197 1,024 1,108 362 582 317 420 236 538 186 320

Noble Hospital (W estfield) ...... 151 279 151 194 23 17 81 40 - - 49 16

North Adams H ospital ...... 170 226 265 220 - 18 102 40 -- 77 26

Norwood H ospital ...... 80 63 291 145 - - 15 5 - - - -

Palmer Memorial (B o sto n ) ...... 1,216 1,700 2,263 1,726 1,194 1,385 1,861 1,480 964 1,300 1,644 1,303

Plunkett Hospital (A dam s) ...... 157 240 99 165 - 3 14 6 - -- -

Phillips House (B o s t o n ) ...... 1,899 2,191 3,116 2,402 398 530 385 438 279 404 268 317

Peter Bent Brigham Hospital (Boston) .... 3,539 3,167 3,356 3,354 1,553 1,621 1,078 1,417 781 844 798 808 Providence Hospital (Holyoke) ..... 796 1,477 942 1,072 353 929 272 518 236 842 125 401 Quincy Hospital ...... 355 356 223 311 116 71 7 65 1 63 31 - 31 1927.] 62 Robt. Breck Brigham Hospital (Boston) 370 510 159 346 185 3 - 63 185 - - 224 51 141 198 130 Salem H osp ita l ...... 962 959 882 934 171 238 262 47 43 14 Somerville H o s p ita l ...... 262 224 320 269 27 83 30 - 213 283 49 71 134 Springfield H o s p ita l ...... 3,160 1,928 1,906 2,331 384 153 103 85 274 151 St. Anns Hospital (Fall R iv e r ) ...... 475 396 647 506 171 130 295 199 93 X 143 533 338 St. Elizabeth’s Hospital (B oston) ...... X 1,782 1,812 1,797 X 285 614 449 305 89 137 177 135 40 28 68 108 - - 36 St. John’s (Lowell)...... 726 1,594 1,346 1,222 75 80 159 105 40 34 89 54 St. Luke’s (New B e d fo rd ) ...... 400. No. —HOUSE 37 45 210 97 St. Vincent’s (W orcester) ...... 1,612 1,775 2,444 1,944 173 172 293 213 35 12 Sturdy Memorial (A ttle b o ro ) ...... 215 252 222 230 20 42 23 28 -

Symmes Hospital (Arlington) ..... 74 92 213 126 14 32 3 16 - - -

Truesdale Hospital (Fall R iv e r ) ...... 887 1,205 758 950 100 669 321 363 82 329 190 200

Union Hospital (Fall River) ...... 1,099 202 773 691 45 114 153 104 - 90 93 61

Union Hospital (Fram ingham ) ...... 36 243 438 239 11 91 318 240 233 65 292 197

Union Hospital (L ynn) ...... X 92 153 122 X 30 2 16 X - --

Waltham H ospital ...... 324 494 710 509 126 104 214 148 46 - 174 73

Wesson Hospital (S p rin g field ) ...... 235 404 343 127 92 9 13 38 92 - - 31

Winchester H o s p i t a l ...... 250 550 140 328 89 193 36 106 39 100 - 46

W orcester C ity H o s p ita l...... 4,478 3,692 2,341 3,503 1,281 1,660 527 1,156 914 1,367 880 1,054

Worcester Memorial H ospital...... 1,166 1,898 1,319 1,461 211 760 191 387 175 634 41 283

Total cancer day b e d s ...... 84,736 88,701 83,537 88,271 31,311 30,132 25,306 29,457 21,934 20,494 18,234 20,395 61.74 Total cancer year b e d s ...... 235.85 244.89 229.20 243.12 87.52 82.61 69.39 80.44 1 69.09 60.55 53.51 D e a t h s i n H o s p i t a l , H o s p i t a l D a y s . 1923, 1924, 1925. A v e r a g e S t a y p e r P a t i e n t .

WITH OPERATION, WITH OPERATION, C o u n t y . WITH OPERATION, HOSPITALIZED. HOSPITALIZED. W ith no HOSPITALIZED. W ith no With no Operation. Operation. Operation. Under O ver U nder O ver U nder O ver 30 D ays. 30 D ays. 30 D ays. 30 D ays. 30 D ays. 30 D ays. OS — o 400. No. —HOUSE

Barnstable, Dukes, N a n tu ck et ...... ______

B erkshire ...... 25 14 5 899' 138 419 36.0 9.8 83.8

B r i s t o l ...... 66 76 21 1,478 866 1,208 22.4 11.4 57.4

E s s e x ...... 106 72 23 2,291 753 1,612 20.6 10.5 70.2

Franklin ...... 8 7 4 176 145 305 22.0 20.7 76.2

H a m p d e n ...... 64 41 15 2,093 404 805 32.7 9.9 53.6

H am pshire ...... 4 1 - 104 18 - 25.9 18.0 -

M i d d l e s e x ...... 198 113 18 12,637 1,236 1,326 63.8 10.9 73.6

Norfolk ...... 6 10 2 56 59 94 9.3 5.9 47.0

P ly m o u th ...... 21 33 6 529 442 239 25.2 13.4 39.8

S u f f o l k ...... 714 451 144 32,341 5,430 9,252 45.3 12.0 64.3

W orcester ...... 134 97 33 4,562 1,057 1,920 34.1 10.9 58.2

T o t a l s ...... 1,346 915 271 57,166 10,548 17,180 42.6 11.5 63.4 T a b l e 4. — Terminal Cancer Cases in a Selected Group of Hospitals.

D e a t h s i n H o s ­ A v e r a g e S t a y p i t a l s , 1923, 1924, H o s p i t a l D a y s . p e r P a t i e n t . 1925.

H o s p i t a l . With With With With With With Operation Operation Operation no O p­ no O p­ no O p­ (Over 30 (Over 30 (O ver 30 eration. eration. eration. D ays). D ays). D ays).

Boston City Hospital 205 28 5,141 1,605 25.1 57.3

Free Hospital for Women 1 18 161 2,141 161.0 118.9

Holy Ghost Hospital 94 - 9,458 - 100.6 -

Long Island Hospital 49 4 5,629 528 114.9 132.0

Massachusetts Homoeo­ 38 15 1,099 1,094 28.9 72.9 pathic Hospital. Palmer Memorial Hospital 76 - 4,449 - 58.5 ”

Good Samaritan 126 - 11,668 - 92.6 -

T a b l e 5. — Type of Treatment of Cancer Cases.

Average Per Cent Per Cent Per Cent H o s p i t a l . Total with with with Cases. Operations. Radium . X -ray.

Addison Gilbert (Gloucester) . 16 75.0 --

Beth Israel (Boston) .... 24 37.5 - 4.2

Beverly Hospital ..... 26 73.2 1.2 38.4

Benjamin Stickney (Ipswich) . 6 50.0 -- Boston City Hospital .... 375 39.7 16.8 77.0

Brockton Hospital « 38 55.2 7.1 -

Burbank Hospital (Fitchburg) 28 57.0 - 1.1

Cambridge City Hospital 28 50.0 - 10.7

Cambridge Relief Hospital 5 14.0 - 20.0

Carney Hospital (South Boston) 127 45.6 18.1 -

Charlesgate Hospital (Cambridge) . 58 50.0 46.6 -

Chester Hospital (Cambridge) 12 83.4 - -

Charles Choate Memorial (Woburn) 11 63.6 6.4 -

Clinton Hospital ..... 10 70.0 10.0 7.0

Cooley Dickinson (Northampton) . 15 53.4 - 2.0

Deaconess (Boston) ..... 137 78.8 5.1 5.8

Emerson Hospital (Concord) . 3 100.0 - -

Eye and Ear Infirmary (Boston) 102 61.8 12.7 16.6

Fall River General ..... 33 39.4 ??

Fairlawn Hospital (Worcester) 9 44.5 11.1 - 54 HOUSE — No. 400. [Jan,

T a b l e 5. — Type of Treatment of Cancer Cases — Continued.

Average Per Cent Per Cent Per Cent H o s p it a l . Total with with with Cases. Operations. Radium. X-ray.

Farren Hospital (Montague) . 8 100.0 - _

Framingham Hospital .... 6 50.0 - -

Franklin County (Greenfield) 17 76.5 1.9 -

Faulkner Hospital (Boston) 30 76.6 4.3 7.7

Free Hospital for Women (Brookline) 34 x 98.0 89.3 1.0

Gale Hospital (Haverhill) 34 61.8 14.7 20.§

Goddard Hospital (Brockton) 37 100.0 2.7 21.1

Good Samaritan (Boston)2 63 -- -

Hale Hospital (Haverhill) 13 76.9 7.7 15.4

Hahnemann Hospital (Worcester) . 8 75.0 12.5 -

Harley Hospital (Boston) 15 93.3 --

Hart Hospital (Boston) .... 11 100.0 --

H. Heywood Memorial (Gardner) . 20 60.0 --

Hillcrest Hospital (Pittsfield) . 14 57.2 --

Holy Ghost Hospital (Cambridge). 37 - --

Holyoke City Hospital .... 29 38.0 4.5 -

House of Mercy (Pittsfield) 34 91.2 - -

Huntington Memorial (Boston) 335 61.4 62.6 35.2

J. B. Thomas Hospital (Peabody) . 10 80.0 - -

Jordan Hospital (Plymouth) . 3 53.9 - -

Lawrence City Hospital . . . . 9 7.7 - -

Lawrence General Hospital 34 61.8 1.0 2.0

Lawrence Memorial (Medford) 14 78.6 - -

Leominster Hospital .... 7 85.6 - 31.8

Long Island Hospital (Boston) 21 9.5 - -

Lowell Corporation Hospital . 40 60.0 22.5 2.5

Lowell General Hospital .... 52 61.5 69.3 5.8

L yn n H o s p i t a l ...... 35 54.3 20.0 7.8

Malden H osp ital ...... 25 64.0 9.3 2.7

Massachusetts General Hospital (Boston) 397 75.6 3.3 14.8

Massachusetts Homoeopathic (Boston) . 223 54.1 22.0 17.9

Massachusetts'Women’s Hospital (Boston) 13 96.0 4.0 -

Melrose H osp ita l ...... 23 60.8 18.7 -

Mercy Hospital (Springfield) . 20 45.0 5.0 -

Milford H osp ita l ...... 15 53.4 6.7 ------

1 This figure is for the Free Hospital for Women alone. Figures for the Parkway Hospital which is included in the bed tabulations are not available for operations, X-ray and radium. 2 The Good Samaritan sends their patients to other hospitals for special forms of treatment- T a b l e 5. — Type of Treatment of Cancer Cases — Concluded.

Average Per Cent Per Cent Per Cent H o s p it a l . Total with wnth with Cases. Operations. Radium . X -ray.

Miller's River (Winchendon) . 4 100.0 - -

Moore Hospital (Brockton) 38 21.1 81.5 7.9

Morton Hospital (Taunton) 14 64.2 7.1 7.1

New England Baptist (Boston) 15 86.6 6.7 -

NewEngland Hospital for Women (Boston) 28 60.8 39.3 3.6

New England Sanitarium (Melrose) 6 50.0 --

Newton Hospital ..... 46 71.8 0.7 0 .7

Noble Hospital (Westfield) 11 54.5 11.8 -

North Adams Hospital .... 22 45.4 50.0 5.9

Norwood Hospital ..... 6 83.4 - -

Palmer Memorial (Boston) 30 ---

Phillips House (Boston) .... 122 68.8 7.4 -

Peter Bent Brigham (Boston) 163 56.4 4.7 11.7

Plunkett Hospital (Adams) 8 75.0 12.5 -

Providence Hospital (Holyoke) 33 48.5 21.3 1.0

Quincy H osp ital ...... 24 66.7 5.5 -

Robt. Breck Brigham (Boston) 5 40.0 - 6.2

Salem H osp ita l ...... 46 74.0 --

Somerville Hospital ..... 15 53.3 - -

Springfield Hospital .... 123 60.3 12.2 0 .8

St. Ann’s Hospital (Fall River) 20 65.0 1.7 -

St. Elizabeth’s (Boston) .... 75 85.3 2.0 -

St. John’s (L o w e ll) ...... 9 66.7 - -

St. Luke’s (New Bedford) 57 48.8 22.9 3.5

St. Vincent’s (Worcester) 104 51.8 16.3 -

Sturdy Memorial (Attleboro) . 15 86.5 6.7 -

Symmes Hospital (Arlington) 8 87.4 - -

Truesdale Hospital (Fall River) 43 90.8 16.3 0 .8

Union Hospital (Fall River) . 30 73.4 13.3 3.3

Union Hospital (Framingham) 9 55.6 7.4 -

Union Hospital (Lynn) .... 12 100.0 12.0 -

Waltham H ospital ...... 26 61.5 6.4 -

Wesson Hospital (Springfield) 28 57.4 16.8 -

Winchester Hospital .... 14 95.4 2.3 -

Worcester City Hospital .... 126 44.4 13.5 1.0

Worcester M em oria l...... 95 61.0 25.3 3.5 56 HOUSE — No. 400. [Jan.

T a b l e 6. — Disposition of Cancer Cases.

[Hospitals to other hospitals or institutions.]

1923. 1924. 1925.

Eye and Ear In firm a ry ...... 5 5 -

Good Samaritan ...... 20 5 6

Holy Ghost H ospital...... 3 3 1

Huntington Memorial H ospital...... 35 43 27

Massachusetts General Hospital .... 17 19 26

Palmer Memorial Hospital...... - 3 4

State Infirm ary ...... 6 6 4

All o t h e r s ...... 10 17 27

T o t a l ...... 96 101 95

T a b l e 7. — Hospital Admissions in Cities and Counties.

Hospital Ad­ Total Deaths. Total Cases. missions per Cancer Death.

Cities.

A t t le b o r o ...... 84 50 .60

B e v e r l y ...... 93 78 .84

B o s t o n ...... 2,924 3,056 1.05

B r o c k t o n ...... 240 252 1.05

C a m b r i d g e ...... 389 206 .53

Chelsea 128 105 .82

C h ic o p e e ...... 98 46 .47

E v e r e t t ...... 133 84 .57

Fall R iv er...... 392 327 .83

F i t c h b u r g ...... 140 115 .82

Gardner 69 45 .65

G l o u c e s t e r ...... 107 84 .79

H a v e r h ill...... 219 166 .76 .78 H o l y o k e ...... 206 161

L a w re n ce ...... 337 180 .53

Leominster ....•• 69 37 .54 .82 L o w e l l ...... 375 309 .65 L y n n ...... 369 240 .86 Malden ...••• 195 167 .60 M arlborough ...... 43 26 T a b l e 7. — Hospital Admissions in Cities and Counties — C o n clu d e d .

Hospital Ad­ Total Deaths. Total Cases. missions per Cancer Death.

Cities.

Medford 178 127 .71

Melrose 78 52 .67

New Bedford 364 179 .49

Newburyport 68 18 .26

Newton 180 167 .93

North Adams 49 38 .78

Northampton 86 48 .56

Peabody . 49 45 .92

Pittsfield . 95 89 .94

Q uincy 174 165 .95

Revere 97 76 .78

Salem 143 99 .69

Somerville 408 256 .63

Springfield 423 351 .83

Taunton 121 84 .69

Waltham . 118 123 1.04

Wrestfield . 61 34 .56

Woburn 54 49 .91

Worcester . 618 607 .98

Counties.

Barnstable 162 74 .46

Berkshire . 361 220 .61

Bristol 1,212 746 .62

Dukes 31 9 .29

Essex 1,913 1,175 .61

Franklin 171 108 .63

Hampden 913 676 .74

Hampshire 244 121 .50

Middlesex 3,031 2,199 .72

Nantucket 9 4 .44

Norfolk 967 685 .71

Plym outh 593 532 .90

Suffolk 3,208 3,261 1.02

Worcester . 1,619 1,292 .80

Totals 14,434 11,102 .77 T a b l e 8 . •— Hospital Admissions by Density of Population.

A l l H o s p i t a l s S u r v e y e d . B o s t o n H o s p i t a l s S u r v e y e d .

P o p u l a t i o n Boston p e r S q u a r e H ospital Admissions Hospital M i l e . Total A d ­ Total Admissions Total A d ­ to Boston Admissions missions. Deaths. per Cancer missions. Hospitals. per Total Deaths. Cancer Ad­ missions.

(1) 1-50 . 164 317 .52 51 164 .31

(2) 50-150 608 997 .61 235 608 .39

(3) 150-500 690 1,130 .61 234 690 .34

(4) 500-1,500 . 1,727 2,587 .67 643 1,727 .37

(5) 1,500-3,000 . 1,007 1,254 .80 392 1,007 .39

(6) O rer 3,000 . 6,906 8,152 .85 4,102 6,906 .59

Totals 11,102 14,437 .77 5,657 11,102 .51

T a b l e 9 . — Hospitalization of Non-Residents.

Average Per Cent Average Average Non- Non- Resident H o s p i t a l s Total Resident Resident Cases. Cases. Cases. Cases.

Addison Gilbert (Gloucester) .... 16 14 2 12.5

Beth Israel (B oston ) ...... 24 18 6 25.0

Beverly H ospital...... 26 14 12 46.2

Benjamin Stickney (Ipswich) .... 6 3 3 50.0

Boston City H ospital ...... 375 355 20 5.3

Brockton H o sp ita l ...... 38 26 12 31.6

Burbank Hospital (Fitchburg) .... 28 22 6 21.4

Cambridge City H ospital ...... 28 18 10 35.8

Cambridge Relief H ospital...... 5 1 4 80.0

Carney Hospital (South Boston) 127 63 64 50.3 98.3 Charlesgate Hospital (Cambridge) 58 1 57

Chester Hospital (Cambridge) .... 12 - 12 100.0 36.4 C. Choate Memorial (Woburn) .... 11 7 4 60.0 Clinton H ospital ...... 10 4 6 60.0 Cooley Dickinson (Northampton) 15 6 9 79.5 Deaconess Hospital (Boston) .... 137 28 109 66.7 Emerson Hospital (Concord) .... 3 1 2 74.4 Eye and Ear Infirmary (Boston) .... 102 26 76 3.4 Fall River General Hospital .... 33 32 1 22.2 Fairlawn Hospital (Worcester) .... 9 7 2 T a b l e 9. — Hospitalization of Non-Residents — Continued.

Average Per Cent Average Average N on- N on- H ospitals. Total Resident Resident Resident Cases. Cases. Cases. Cases.

Farren Hospital (Montague) .... 8 4 4 50.0

Framingham Hospital ...... 6 5 1 16.7

Franklin County (Greenfield) .... 17 10 7 41.1

Faulkner Hospital (Boston) .... 30 12 18 60.0

Free Hospital for Women (Brookline) . 48 12 36 70.0

Gale Hospital (H averhill) ...... 34 27 7 20.6

Goddard Hospital (Brockton) .... 37 18 19 51.4

Good Samaritan (B oston ) ...... 63 31 32 50.8

Hale Hospital (H averhill) ...... 13 10 3 23.1

Hahnemann Hospital (Worcester) 8 6 2 25.0

Harley Hospital (B oston ) ...... 15 11 4 26.6

Hart Hospital (B o s to n ) ...... 11 6 5 44.4

H. Heywood Memorial (Gardner) 20 9 11 55.0

Hillcrest Hospital (Pittsfield) .... 14 10 4 28.6

Holy Ghost Hospital (Cambridge) 37 4 33 89.1

Holyoke City H o s p ita l ...... 29 22 7 24.1

House of Mercy (Pittsfield)...... 34 17 17 50.0

Huntington Hospital (Boston) . . . . 335 64 271 80.8

J. B. Thomas Hospital (Peabody) 10 5 5 50.0

Jordan Hospital (Plymouth) .... 3 2 1 33.3

Lawrence City H o s p ita l ...... 9 8 1 11.1

Lawrence General H ospital...... 34 23 11 32.4

Lawrence Memorial (Medford) .... 14 12 2 14.3

Leominster H osp ital ...... 7 6 1 14.3

Long Island Hospital (Boston) . . . . 21 21 - 0.0

LoweU Corporation Hospital .... 40 37 3 7.5

Lowell General H o s p i t a l ...... 52 37 15 28.9

Lynn H ospital ...... 35 29 6 17.2

Malden Hospital ...... 25 17 8 32.0

Massachusetts General Hospital (Boston) . 397 88 309 77.8

Massachusetts Homoeopathic (Boston) 223 84 139 62.3

Massachusetts Women’s Hospital (Boston) . 13 9 4 30.8

Melrose H ospital ...... 23 10 13 56.5

Mercy Hospital (Springfield) .... 20 12 8 40.0

Milford H ospital ...... 15 6 9 60.0

Miller’s River (Winchendon) .... 4 1 3 75.0 T a b l e 9. — Hospitalization of Non-Residents — Concluded.

Average Average Average Per Cent N on- Non- H o s p it a l s . Total Resident Cases. Cases. Resident Resident Cases. Cases.

Moore Hospital (Brockton)...... 38 15 23 60.6

Morton Hospital (Taunton) .... 14 11 3 23.6

New England Baptist (Boston) .... 15 1 14 93.3

New England Hospital for Women and Children 28 16 12 42.8

New England Sanitarium (Melrose) 6 1 5 83.4

Newton Hospital...... 46 24 22 47.8

Noble Hospital (W estfield)...... 11 7 4 36.4

North Adam s H o s p i t a l ...... 22 11 11 50.0

Norwood H osp ita l ...... 6 3 3 50.0

Palmer Memorial ( B o s t o n ) ...... 30 11 19 63.4

Phillips House (B o s to n ) ...... 122 24 98 80.3

Peter Bent Brigham (Boston) .... 163 100 63 38.7

Plunkett Hospital (Adams)...... 8 7 1 12.5

Providence Hospital (Holyoke) . . . . 33 26 7 21.2

Quincy City H ospital...... 24 22 2 8.3

Robt. Breck Brigham (Boston) .... 5 1 4 80.0

Salem H ospital ...... 46 22 24 52.2

Somerville H osp ita l ...... 15 12 3 20.0

Springfield H osp ita l ...... 123 81 42 34.2

St. Ann’s (Fall R iver) ...... 20 17 3 15.0

St. Elizabeth’s (B o s to n ) ...... 75 31 44 58.6

St. John’s (L o w e ll) ...... 9 9 - 0.0 St. Luke’s (New B ed ford) ...... 57 42 15 26.4

St. Vincent’s (W orcester) ...... 104 40 64 61.5

Sturdy Memorial (Attleboro) .... 15 11 4 26.6

Symmes Hospital (Arlington) . . . . 8 5 3 37.5

Truesdale Hospital (Fall River) . . . . 43 24 19 44.2

Union Hospital (Fall River) . . . . 30 28 2 6.7

Union Hospital (Framingham) .... 9 3 6 66.7

Union Hospital (L y n n ) ...... 12 6 6 50.0

Waltham H o sp ita l ...... 26 15 11 42.3

Wesson Hospital (Springfield) .... 28 15 13 46.4

Winchester H osp ita l ...... 14 5 9 64.3

Worcester City H o s p ita l ...... 126 97 29 23.0

Worcester Memorial Hospital .... 95 43 52 54.7

M e d i a n ...... - - - 42.8 1927.]

T a b l e 10. — Hospital Admissions by Type of Cancer. [Percentage distribution.]

Buccal C o u n t y . Female Other C avity. Stom ach. Peritoneum. Skin. Male Genital. Organs. Genitals. Breast. Unspecified.

Barnstable, Dukes, Nantucket - - _ . Berkshire ...... 6.8 9.7 14.8 20.8 .8 19.1 2 .6 21.6 3 .8 B ristol ...... 5 .7 18.9 13.9 23.8 1.7 400. No. — HOUSE 13.9 3 .5 18.1 .6 Essex ...... 5 .8 18.2 15.6 17.6 1.5 15.5 3 .8 19.4 2.8 Franklin ...... 10.5 9 .0 14.9 4 .5 4 .5 12.0 6.0 37.3 1.5 H am pden ...... 3 .8 17.5 12.3 23.8 2.2 10.3 4.1 21.9 4.1 H am pshire ..... 2.3 18.2 20.5 9.1 2.3 13.7 2.3 25.0 6.8 M iddlesex ...... 6 .8 15.4 14.9 22.9 2.0 14.1 4 .6 17.5 1.9 N o r f o l k ...... 9 4 .7 13.4 62.9 - 3 .9 .9 10.8 2.6 P l y m o u t h ...... 9.4 11.1 8.0 20.8 10.8 16.9 4.3 18.0 .6 S uffolk ...... 12.8 18.4 11.9 18.0 2 .8 15.7 3 .2 14.0 3.3 W o r c e s t e r ...... 7.0 17.1 14.5 21.8 2 .0 13.1 4.4 18.5 1.6 Total for State .... 9.6 17.2 12.9 20.4 2.6 14.6 3.5 16.3 2.8

Deaths for S ta te ...... 5 .6 31.4 18.2 13.9 2.1 12.2 3 .4 10.8 2.4 Deaths in hospitals .... 5.0 26.4 18.9 13.7 1.0 16.3 4.9 7.4 6.2 TYPE OF CANCER PERCENTAGE DISTRIBUTION AVERAGE 1923-192,5.

H P e r c e n t a g e o f t o t a l d e a t h s f r o m c a n c e r in M assachusetts ■ P e r c e n t a g e o f t o t a l c a s e s o f c a n c e r in h o s p i t a l s