The mortality from cancer in the continental United States at the present time is probably not much less than 100,000. When the campaign for the cancer education of the laity was organized the estimated mortality was placed at 75,000. The relative increase in cancer deaths is, therefore, one of the most serious indications of the failure to realize a large measure of control. Cancer, of course, cannot be prevented in the sense that the onset of infectious disease is prevented, but the mortality from cancer can be controlled through the education of the laity as well as the medical profession in the earliest symptoms of the disease and through insuring the best possible method of treatment.

In 1920 the cancer death rate for the registra- . tion area of the United States according to the reports of the Division of Vital Statistics of the Census was 83.4 per 100,000 of the population. It may safely be assumed that the rate at the present time, making allowances for possible failure to properly report cancer cases is not less than 90.0 per 100,000 population. The rate varies widely in different sections of the country, being particularly high in the State of Maine and the State of California.

No thorough study of the subject has been made, and the true state of facts is at present largely a matter of conjecture. Unquestionably local cancer death rates are affected by the age and sex distribution of the population but the methods of calculating such rates are often open to still more serious doubt as to the validity of the conclusions arrived at.

In the general registration area for 1911 to 1920 the cancer death rate has increased from 74.4 to 83.4 per 100,000 population. In the State of California the cancer death rate increased during the same period from 82.0 to 109.0 per 100,000 and in the State of Maine from 99.0 to 122.0.

It is entirely out of the question that possible changes in the age and sex constitution of the

population of the two States during the intervening years could materially affect the conclusion that cancer in the two States referred to is seriously on the increase.

For the registration cities in registration States, or in other words, localities for which rates are most trustworthy, the cancer rate for 1920 as given by the Census is 99.8. I shall limit myself for the present to drawing attention to some recent cancer statistics for American cities, especially compiled for the present purpose, limited to the year 1922. The cities which had a cancer death rate in 1922 in excess of the average for all registration cities in 1920, limited, of course, to such rates as I have been able to secure, are as follows, Boston, Mass., 145.8, Brockton, Mass., 107.7, Cincinnati, Ohio, 120.7, Columbus, Ohio, 115.0, Concord, N. H., 111.9, Grand Rapids, Mich. 113.8, Los Angeles, Calif., 132.0, Manchester, N. H., 105.5, Minneapolis, Minn., 109.0, New Haven, Conn., 125.9, New Orleans, La., 125.4, Newport, R. I., 131.3, Newton, Mass., 142.7, Pittsburg, Pa., 106.7, Portland, Ore., 118.4, Providence, R. I., 135.5, Quincy, Ill., 137.7, Sacramento, Calif., 141.7, St. Louis, Mo., 111.7, San Francisco, Calif., 161.8, Seattle, Wash., 101.4, Springfield, Ill., 132.4, Spokane, Wash., 126.7, Syracuse, N. Y., 102.4, Washington, D. C., 104.6.

Here is a list of twenty-five cities showing a crude cancer death rate all in excess of 100 per 100,000. Accepting these figures derived from authentic sources, it is certainly startling that so many cities in America should exceed the average and in some cases by as much as from 40 to over 60 percent.

No refinement of statistical method of analysis can set aside the evidence that cancer is today one of the most foremost problems in the United States, resulting in the loss of countless lives, of which in the light of modern medicine and surgery a considerable portion should be within range of effective treatment and cure.

Before much progress is likely to be made in this direction, far reaching reforms are urgently called for in the prevailing methods of gathering statistics of hospitals and private clinics, with regard to the results of prevailing methods of treatment. Until collective investigations are made and based upon a sufficient amount of material, it will be impossible to produce proof convincing to the multitude of people that the claim for cancer control rests upon a sound scientific basis.

The average physician and surgeon without experience in the gathering of statistics and the required analysis of statistical results, as a rule presents only evidence in support of particular

cases.

What is required for present day use is an investigation based upon a thoroughly well considered follow-up system that will yield results of unimpeachable conclusivness. What the public wants to know is the chance of success with particular types of operation and the assurance that the surgical prognosis rests upon the basis of trustworthy facts.

There is another and more dangerous phase of the cancer problem which has received inadequate consideration in the United States in the past. Evidences are increasing that alleged cancer cures are gaining in popularity in that the results are frequently at the outset encouraging but disastrous at the end. What is required is a thorough investigation into the whole subject of patent medicine in alleged cancer cures that will get at the root of the matter and establish the truth to the satisfaction of all. There can be no question of doubt that many laymen advocating one treatment or another for malignant disease act in entire good faith but are deceived by indications that will not

bear scientific analysis. It must be determined by those who seek only the truth as to what particular methods may or may not prove effective in cancer cure. If there are other methods than surgical operations or treatment by X-ray or radium that may yield encouraging results it is of the very first importance to the public that the facts should. be known and understood. Cancer investigations require an unusual breadth of vision and a thorough understanding of facts which may be only remotely correlated.

Perhaps the best illustration is to be found in the negative aspects of the subject or in the rarity of occurrence of malignant diseases among native races. As one who has thoroughly gone into this matter with regard to our native Indians in the southwest and certain Indian tribes in the South American tropics, particularly Bolivia, I am absolutely satisfied that malignant disease in any form, and particularly cancer of the breast, is extremely rare among pure native tribes, practically free from the effects of the mode of life common to so-called civilized countries.

Here again one is confronted by the almost inconceivable indifference of those who have made a study of the cancer problem but who have practically ignored the negative aspects of the case. Little that has been written concerning cancer among native races is worthy of serious consideration but it would seem to me equally important to ascertain if possible why cancer does not occur than why it should be extremely common among other people, and possibly the former line of inquiry may yield even more encouraging results

than the latter.

The city of Gothenburg in Sweden will celebrate the 300th anniversary of its foundation from May to September of this year. Part of the Jubilee Exhibition will be given over to the work of the Swedish Red Cross which will also hold a conference. At least 5,000 officials and members of the Swedish Society are expected to attend to discuss

various phases of the programme. The Red Cross exhibit will include a model ambulance train and a model châlet hospital such as are being used by the Swedish Society for remote districts of the north. This service is being extended to many inaccessible parts of the country and even the one on exhibition will afterward be put into use.

In view of the fact that one of the principal aims of the Red Cross peacetime programme is "the prevention of disease, the improvement of health and the mitigation of suffering", it is interesting to examine the possible methods of attaining this object, especially those methods which, having already been employed by Red Cross Societies, can rapidly be extended and improved.

Our French Red Cross Societies have behind them a fine tradition and long experience, both of which are of considerable help in the development of their peacetime activities. After our experience during the war, there is no need to point to the splendid results they have achieved in the training of nurses. Neither can one doubt in face of the health and social work already accomplished by them, their ability to contribute largely to the improvement of public health. The importance of the possible rôle of the Red Cross is best demonstrated by concrete examples, such as the training of public health nurses.

All competent authorities agree in regarding the work of public health nurses as absolutely indispensable, and fundamental to the carrying out of anti-tuberculosis prophylaxis, the campaign against infant mortality, and popular health instruction. They are equally agreed as to the uselessness of those public health nurses who are recruited in haphazard fashion, trained rapidly and accepted without question, and whose lack of technical training risks compromising the profession they are engaged in. I do not deny that, during the war, many educated women adapted themselves with surprising ease to public health nursing and health visit. ing, and did valuable work in spite of the insufficiency of their training, but they were exceptional cases, limiting their activity to a well-defined branch, and their energy was exalted by the dramatic nature of the events then taking place. Apart from such exceptional cases, it must be recognized that, in addition to the necessary moral.

and intellectual qualifications and to a clearlydefined minimum standard of general education, a sufficient period of training should be exacted. Two years of study are necessary, the first to be given up to elementary training in professional nursing, and the second to specialization in public health work. That is the minimum period and is insufficient for a nurse wishing to exercise her profession in every branch of public health work. On the other hand, if recruiting is definitely undertaken for one branch only, such as tuberculosis or child welfare, a period of two years provided the training be systematically organized, and the pupils carefully chosen is sufficient to train useful public health nurses whose skill will increase with practice and who will speedily develop into valuable workers.

This conception of the training necessary for a public health nurse has been accepted in full by the French Red Cross Societies. From the beginning of 1920 they expressed a definite wish "to establish among their own voluntary personnel a corps of nurses fully trained in public health work, which would place them on an equal footing with the professional public health nurses trained in schools recognized by the National Anti-tuberculosis Committee (1)." Two of our societies, the Société de Secours aux Blessés Militaires and the Union des Femmes de France are organizing in Paris special courses in public health nursing for their certificated nurses, with a theoretical and practical syllabus similar to that of the Public Health School of the National Committee. The Société de Secours aux Blessés Militaires has even undertaken the building of a large DispensarySchool of Public Health where pupils can be trained.

It will be seen, therefore, that our Red Cross Societies are making every effort to train public

(1) Memorandum by General Pau, President of the Central Committee of the French Red Cross, April, 1920.