Tobacco Documents Online

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I THE NEW YORK SURGICAL SOCIETY Wednesday evening, May 12, 1954, 8:30 p.m. The New York Academy of Medicine, 2 East 103rd Street, New York City CASE PRESENTATIONS 1. Dessimated fat necrosis one year following surgical resection of head of pancreas for acinous carcinoma. NELSON W. CORNELL 2. Cholecystectomy for cholelithiasis and inci- dental carcinoma of the gallbladder: Five year arrest. GEORGE M. SAYPOL 3. Aneurysm of the superior mesenteric artery successfully treated by restorative ancurysmorrhaphy. JOHN P. WEST 4.Intcrscapulothoracic amputation for diffuse angiomatous malformation. ELLIOTT S. HURWITT and AUSTIN JOHNSON (by invitation) 5. Avulsion of the scalp. A comparison between modern and old therapy. WILLIAM P. WHALEN 6. Radical resection and reconstruction of the chest wall for chondrosarcoma. WILLIAM I. WOLFF 7. Cholecystitis and kidney cyst stones simulating double gallbladder. D. REESE JENSEN and RUSSEL H. PATTERSON E. JEFFERSON BROWDER, President 200 Hicks Street, Bklyn. 2, N. Y. JERE W. LORD, JR., Secretary 55 East 92 Street, N. Y. 28, N. Y. NEW YORK SOCIETY FOR SPEECH AND VOICE THERAPY, INC. Wednesday, May 12, at 8:45 p.m. Hunter College, Park Ave. and 68th St., Room 1403, N. Y. C. Case Demonstration: Voice Break of Peculiar Origin HELEN BEEBE ~ Discussion Lecture: The Role of Grammar in Normal and Aphasic Speech EMIL FROESCHELS Discussion Guests welcome EMIL FROESCHELS, President HELEN BEEBE, Secretary ADELPHI HOSPITAL STAFF SOCIETY MEETING Wednesday, May 12, 1954, 9:00 p.m. 50 Greene Avenue, Brooklyn 38, N. Y. ANTIBIOTICS AND CHEMOTHERAPY THE INTELLIGENT USE OF ANTIBIOTICS IN MEDICAL CONDITIONS CARL A. BERNTSEN, JR. Research Fellow in Medicine Cornell University Medical College MAY 5, 1954 -IN SURGICAL CONDITIONS LT. COLONEL EDWIN J. PULASKI Director, Division of Surgery Army Medical Service Graduate School Walter Reed Army Medical Center Collation DAVID R. TELSON, President F. PAUL ANSBRO, Secretary THE NEW YORK HOSPITAL PLASTIC SURGERY CONFERENCE Thursday, May 13, 1954, 3:30 p.m. U. S. Veterans Hospital, 130 W. Kingsbridge Road, Bronx, N. Y., 5E Conference Room Surgery of the Hand ERIK MOBERG Guest lecturer of Goteborg, Sweden HERBERT CONWAY Consultant Plastic Surgeon THE NEW YORK CARDIOLOGICAL SOCIETY, INC. Ninety-Fifth Regular Meeting Annual Meeting for 1954, Thursday, May 13 Academy of Medicine, 2 East 103rd Street, Room 441, 8:30 p.m. Practical Problems in Rheumatic Fever in the Young LEO M. TARAN Director of the St. Francis Sanatorium for Cardiac Children. Cardio-vascular Features of the Arthritides and Related Conditions OTTO STEINBROCKER Attending Physician in Rheumatology- Hospital for Joint Diseases and Lenox Hill Hospital Members of the Medical Profession Invited. LOUIS FAUGERES BISHOP, President JOSEPH HENRY HODAS, Secretary NEW YORK SOCIETY FOR THORACIC SURGERY Friday, May 14th, at the Academy of Medicine, Room 440, at 8: 30 p.m. 1. Unusual Foreign Bodies of the Esophagus: Removal by Endoscopy and by Cervical Esophagotomy Case report by GEORGE N. J. SOMMER, JR. 2. Two Cases of Uncommon Malignant Esopha- geal Neoplasm Case report by WILLIAM G. CAHAN 3. Non-specific Granulomatous Esophagitis Case report by FRANK A. GAGAN 4.Intramural Reduplication of Esophagus Case report by HERBERT C. MAIER 365

AMERICAN-HUNGARIAN MEDICAL ASSN. STATED MEETING Friday evening, May 14, 1954, 8:30 p.m. Room 441, Academy of Medicine Building SCIENTIFIC MEETING Case Presentations: Subtotal gastric resection for peptic ulcer in an asthmatic patient. MARCEL , HAAS Cardiac arrest. Resuscitation by thoracotomy and rhythmic compression. ALEXANDER STRELINGER A desperate case of pulmonary tuberculosis. CHARLES BLAZSIK a. Disseminated lupus erythematodes. b. Suba.rachnoid hemorrhage with polycystic kidney and pregnancy. JEROME GERENDASY Extracapsular cataract extraction with Ridley's implant. WILLIAM T. BROWN Two cases, simulating psychoneurosis. EMORY I. WELLS Skin-grafts of the extremities. STEPHEN WAHL General Discussion Collation JOSEPH J. FRIED, President STEPHAN S. ROSENAK, COYr, Secy. COLUMBUS HOSPITAL CLINICAL PATHOLOGICAL CONFERENCE Saturday, May 15, 1954, at 9:00 a.m. Amoroso Conference Hall 227 East 19th Street, New York 3, New York Case Presentation: EMMET A. DOOLEY STAFF BERNARD MARRAFFINO, Chairman THE CLINICAL AND ALUMNI SOCIETY OF MORRISANIA CITY HOSPITAL ANNUAL SCIENTIFIC LECTURE Monday evening, May 17, 1954, 9:00 p.m. Morrisania City Hospital Auditorium, 168th Street and Gerard Avenue, N. Y. 52 Newer concepts of hepatitis and cirrhosis of the liver. ISIDORE SNAPPER Director of Medicine and Medical Education, Beth El Hospital CARL R. ACKERMAN, President, Alumni Soc. MADISON AVENUE HOSPITAL CLINICAL SOCIETY MEETING Monday, May 17, 1954, at 9 p.m., sharp. Madison Avenue Hospital, 30 East 76th Street, New York City-TRafalgar 9-1100 Two Tonsillectomies with unusual post-opera- tive Complications A. LASZLO Reconstruction of Paralytic Feet S. WAI3L Malignant Adenoma of the Thyroid I. BUSCH Post-operative Vesico-vaginal Fistula J. Ricci Climacteric Bleeding G. WEITZNER A Premature Infant H. E. COHEN Interesting x-rays I. WEITZNER General Discussion CoIlation GEZA WEITZNER, Secretary Members of the Medical Profession are cordially invited EAST SIDE CLINICAL SOCIETY Tuesday evening, May 18, 1954, 8:30 p.m. Manhattan General Hospital, 307 Second Avenue, New York City PAPERS OF THE EVENING 1. Surgical, diseases of the small intestine. JUSTUS KAUFMAN 2. Newer drugs in treatment of hypertension. MILTON MENDLOWITZ 3. Medical cases for diagnosis. ARTHUR C. LINDEN Collation will follow the meeting. MAXWELL L. GELFAND, President 60 Gramercy Park, N. Y. 10, N. Y. ARTHUR FEITELL, Secretary 40 Gramercy Park, N. Y. 10, N. Y. HARLEM HOSPITAL TUMOR CLINIC CONFERENCE Wednesday morning, May 19, 1954, 10:45 a.m. Women's Pavilion, Main Floor, 137th St. Ent. The role of surgery in cancer,. HENRY T. RANDALL Clinical Director and Chie f, Department of Surgery, Memorial Hospital Center D iscussion : Louzs M. RoussELOT Director o f Surgery, St, Vincent's Hospital Chairman: ISIDORE ARONS Director, Radiation Therapy and Tumor Clinic, Harlem Hospital LAST LECTURE OF THE SEASON. Lectures will resume again in October, 1954. MEDICAL ARTS CENTER HOSPITAL CLINICOPATHOLOGICAL CONFERENCE Wednesday, May 19, 1954, at 8:30 p.m. Lecture Hall, Medical Arts Center Hospital Second Floor, 57 West 57th Street Report of Medical Board NEW DEVELOPMENTS IN DRUG THERAPY 366 NEW YORK MEDICINE

4 Round Table Discussion Panel: LLOYD'F. CRAVER Prof. Clinical Medicine, Cornell University Medical College. Attending Physician, Memorial Hospital RICHARD H. LYONS Prof. Medicine, Syracuse State University, School of Medicine. HAROLD J. STEWART Assoc. Prof. Medicine, Cornell University Medical College Attending Physician, New York Hospital CHARLES F. WILKINSON, JR. Professor of Medicine, Post-Graduate Medical School, New York University Moderator: CHARLES H. WHEELER Assoc. Prof. Clinical Medicine, Cornell University Medical College Assoc. Attending Physician, New York Hospital Ass't Attend. Physician, Memorial f~ Ewing Hospitals Collation HENRY M. SELBY, Secretary THE ASSOCIATION FOR THE ADVANCEMENT OF PSYCHOTHERAPY Friday, May 21, at 8:30 p.m. N. Y. Academy of Medicine Building 2 East 103rd Street, N. Y. C. 1.New Light on an Old Cause of Reading Disability WILLIAM CALVIN BARGER 2. Discussion ROSE RIEGER, Secretary THE HOSPITAL FOR SPECIAL SURGERY CLINICAL CONFERENCE Thursday afternoon, May 20, 1954 The Hospital for Special Surgery, 321 East 42nd Street, New York, N. Y. STAFF CONFERENCE-3:15 p.m. Analysis of results. SCIENTIFIC PROGRAM-3:30 p.m. Social and emotional problems in orthopedic practice. WILLIAM COOPER HELE:Q- WORTIS Open to the profession. ALEXANDER HERSH, Secretary JEROME LAWRENCE, Chairman GOUVERNEUR HOSPITAL GENERAL STAFF CONFERENCE Thursday evening, May 20th, 1954, 8:30 p.m. 1. a. Unusual tumor of kidney. b. Classification of renal tumors. Presentation: NATHAN, BLOCK Discussion: ALVIN C. DRUMMOND 2. Selection of cases of hyperthyroidism for radioiodine therapy. Presentation: SIDNEY ROSENFELD MAY 5, 1954 3e a. Case of aspirin poisoning in an 11-month old infant. Presentatton: WILLIAM D. IRVING Discussion: JOHN D. CRAIG b. Case of measles encephalitis. Presentation: ANDREW F. TURANO Discussion: JOHN D. CRAIG 4. Bidirectional ventricular tachycardia associated with digitalis toxicity. Presentation: ARTHUR LIND Discussion: EMANUEL HELLMAN New York Academy of Medicine (Continued from page 362) b. A case of re-duplication of jejunum. STANLEY DECKOFF Beth Israel Hospital c. Gastric volvulus. VIRGINIA KANICH St. Luke's Hospital d. Pituitary irradiation for metastatic bone: Disease from carcinoma of the breast. SEYMOUR BRENNER Jewish Hospital of Brooklyn e. Unusual cause for intracardiac calcification. A\T.\ SILVF.RMAN Presbyterian Hospital f. Studies of the biliary tract by intravenous methods. LEWIS IMMERMAI Long Island College Hospital g. The arteriographic study of the anterior choroidal artery ALDO MORELLO, IRVING S. COOPER New York University SECTION ON GENITO•URINARY SURGERY RESIDENTS' MEETING FOR THE PRIZE-WINNING PAPER Wednesday evening, May 19, at 8:30 o'clock. DINNER - MEETING a. An office method of urine culture. ROBERT B. ZUFALL 2nd Division Urology- Bellevue Hospital Discussion: JOHN W. DRAPER b. Erythroplasia of queyrat with carcinoma in situ. HERMAN WECHSLER, LOUIS L. SPIVACK Bronx Veteran Administration Hospital Discussion: ARCHIE L. DEAN, SR. c. The bacteriologic diagnosis of urinary tuberculosis. ARCHIE L. DEAN, JR. Squier Urological Clinic- Columbia-Presbyterian Medical Center Discussion: GEORGE F. CAHILL JoHN K. LATTIMER d. Multiple primary malignancies of the genito-urinary tract. AURELIO C. Uso:. Squier Urological Clinic- Columbia-Presbyterian Medical Center Discussion: JOHN N. ROBINSON 367

Announcement of Award of the Oswald Swinney Lowsley Foundation, Inc., to the Resident presenting the most outstanding paper. SUBSCRIPTION DINNER Dinner at the Academy will precede the Genito- Urinary Surgery Meeting on May 19. Fellows and guests are invited. Subscription $6.00. Checks should be made payable and forwarded to Dr. George A. Fiedler, 111 East 71 Street, New York 21, N. Y. Reservations must be received by Monday, May 17. Dinner at 6:15 o'clock Dress Optional SECTION ON OTOLARYNGOLOGY RESIDENTS' MEETING Wednesday evening, May 19, at 8:30 o'clock PRESENTATION OF CASES: a. Does laminography help in the diagnosis of laryngeal conditions? by 30SEPH ALO read by A. F. FRAGOLA Veterans Administration Hospital, Kingsbridge Discussion: L. R. LAWRENCE b. Case of nose and throat malignancy, presenting two primary lesions. WILLIAM RABBETT Manhattan Eye, Ear and Throat Hosp. Discuss2on : ALEXANDER CONTE c. Local treatment with antibiotics in various forms of otitis. RICHARD FREEMAN Columbia-Presbyterian Medical Center Disc2LSSion: EDMUND P. FOWLER, JR. d. Nasal meningocele-surgical correction ADOLPH WEHRLI N. Y. University-Bellevue Med. Center Discussion: JOHN CARDONA THE HARVEY SOCIETY in affiliation with THE NEW YORK ACADEMY OF MEDICINE Thursday evening, May 20, at 8:30 o'clock The Ninth Harvey Lecture The control of heat loss and heat production in physiologic temperature regulation JAMES D. HARDY Professor of Physiology, School of Med., University of Pennsylvania, Phila., and Director of Research, Aviation Medicine Acceleration Lab., Naval Air Develop- ment Center, Johnsville, Pennsylvania SECTION ON ORTHOPEDIC SURGERY Friday evening, May 21, at 8:30 o'clock PAPERS OF THE EVENING End-result evaluation of open reduction of 60 fractures of shaft of femur. ALEXANDER GARCIA Presbyterian Hospital Discussion: PRESTON WADE Lamppost hip prosthesis (preliminary report, based upon three years of use). ROBERT K. LIPPMANN Discnssion: PHILIP D. WILSON, SR. The role of the orbicular ligament in tennis elbow. DAVID M. BOSWORTH Discussion: FRANK STINCHFIELD POSTGRADUATE RADIO PROGRAM The New York Academy of Medicine Twentieth Series Committee on Medical Information in coopera- tion with Committee on Medical Education and The New York City Cancer Committee Thursdays 9-10 p.m. Station WNYC - FM 93.9 megs. Thursday evening, May 6, 1954 Reticuloendotheliosis. PAUL KLEMPERER ' Pathologist, Mt. Sinai Hospital, N.Y.C.; Professor of Pathology, College of Physicians and Surgeons, Columbia U. Acute leukemia in childhood. A. LEONARD LuHBY Assistant Professor of Pediatrics, New York Medical College, Flower and Fifth Avenue Hospitals Thursday evening, May 13, 1954 The bearing of anthropology upon medicine. BENJAMIN D. PAUL Lecturer, Social Anthropology, School of Public Health, Harvard Univ. The diagnosis of abdominal masses in children. LAWRENCE B. SLOBODY Director and Professor, Department of Pediatrics, Flower and Fifth Ave. Hosp. Thursday evening, May 20, 1954 Methods in hematology. DANIEL STATS, Panel Moderator WILLIAM H. CROSBY MARTIN ROSENTHAL JOSEPH F. Ross MARIO STEFA:IINI Cancer of the esophagus. LINN J. BOYD Director and Professor, Department of Medicine, New York Medical College, Flower and Fif th Avenue Hospitals Thursday evening, May 27, 1954 Where law and medicine meet. DAVID W. PECK, LL.D., D.J.S. Presiding Justice of the Appellate Division of the New York Supreme Court, First Department Jaundice as a symptom of cancer. ALFONSO A. LOMBARDI Assistant Clinical Professor, New York Medical College; Assistant Attending Physician, Flower and Fifth Ave. Hosp. 368 NEW YORK MEDICINE

Tobacco (Continued from page 359) 1951, having been asymptomatic since De- cember of 1950, he came to the United States to live, and was well until September of 1951. He continued to smoke and developed gan- grene of the first toe of the left foot. This was soon followed in November by a cold and tingling sensation of his hands. He was ad- mitted to The New York Hospital in January 1952 for the first time with the physical find- ings essentially as described above, the ampu- tated toes, the gangrene of the left first toe and cold hands. He was placed on a rocking bed, given priscoline, whiskey, local heat, de- bridement of the wound and a course of ther- apy with typhoid vaccine. Smoking was discon- tinued for the first time. An incidental bladder stone was discovered and removed. He was dis- charged after three months and in May of 1953 felt so well and had been so asymptomatic that he decided to stop taking priscoline and started smoking again. He was cautious enough to begin smoking a brand of cigarettes that ad- vertises a micronite filter. In August, about 3 months later, he developed a phlebitis of the right foot which was treated by his private physician. About the same time he injured the fifth finger of his right hand striking it with a hammer, creating a lesion which never seemed to heal. On the 16th of September 1953 he was admitted to The New York Hos- pital for the second time. On physical examination his vital signs were within normal limits. The positive physical findings were restricted to the extremities. The nail beds were found to be quite cyanotic. The brachial pulse on that side was weak. His hand was cold and gangrene of the tip of the fifth finger was noted. Also the ulnar pulse on the left hand was weak. The amputations of the toes on the feet were noted. There was bilateral absence 'of the dorsalis pedis and posterior tibial pulses. The laboratory work at that time was es- sentially negative and the course of therapy was almost identical with the previous admis- sion. He was discharged after three wee'cs. CHAIRMAN FORKNER: Dr. Wright, what does this sound like to you? DR. IRVING S. WRIGHT: It sounds like a perfectly typical history of a person with thrombo-angiitis obliterans who continues to smoke either without periods of intermission or with them. This man has been followed in the Vascular Clinic and we have seen him re- peatedly. We still encounter a number of these patients who have never been told to stop smoking. They frequently submit to multiple sympathectomies which are quite futile if the patient continues to smoke. I think that per- haps now this patient learned that he can- not smoke. I hope he has. It is a very serious matter with him. If he continues he is in danger of losing his legs and his arms. CHAIRMAN FORKNER: You think that peo- ple can stop smoking when they want to, Dr. Wright? DR. WRIGHT: Patients can definitely stop smoking if they make up their minds to. On the vascular clinics and services we have stopped hundreds of patients from smoking in the last 20 years. With some there, has been great diffi- culty due to the vagaries of human nature. CHAIRMAN FORKNER: Are you smoking now? PATIENT: No. CHAIRMAN FORKNER: Are you going to smoke in the future? (Patient shrugs his shoulders. ) DR. WRIGHT: If he does we will have him back in the hospital all too soon. CHAIRMAN FORKNER: Do you think from your own experiences that these troubles you have are related to smoking? PATIENT : Y es. CHAIRMAN FORKNER: What happens when you smoke? Do you notice any trouble with your extremities? Do they change color or do you have pain in your toes or fingers? PATIENT: Not at the time I am smoking but perhaps later. DR. LAWRENCE SONKIN: N'1'Ould you tell us what happened to your hands, sir, after you started smoking cigarettes with micronite filters again? Did you notice some change in color? PATIENT: My hands were turning white. CHAIRMAN FORKNER: Micronite filters did not prevent your trouble? PATIENT: No.... Patient leaves.. . . MAY 5, 1954 369

CHAIRMAN FORKNER: Dr. Wynder, have you anything that you would like to tell us now to develop your point further? DR. WYNDER: As you undoubtedly know a relationship between cancer of the lung and tobacco is believed to exist. I should like to review briefly the extent of the evidence for this association. The subject came into being during the last two decades because cancer of the lung has become the most common can- cer in males, and in many areas of the world accounts for one-third of all cancer deaths in males. There is hardly any disagreement today on the .point that the increase that has taken place in cancer of the lung has been real. The primary reason for this has been the fact that the increase has been primarily in males. To- day the sex ratio of cancer of the lung is up to 20:1 and if you will just take epidermoid cancer of the lung, the ratio may reach up to 40: 1. If it were a question of improved diagnostic means or aging population, we should expect as much increase in women. The fact that the increase has occurred primarily in males leads to the suspicion that it might be due to a factor to which males have been exposed more and over a longer duration of time than women. It stands to reason that to- bacco was considered to be one of these factors. Such an association has been thought to exist first because the curve of increased sales of cigarettes runs closely to the increased in- cidence of cancer of the lungs. This has never impressed us very much because of things now in our environment such as gasoline fumes, nylon stockings, refrigerators, television, etc. Because of the ever increasing incidence of lung cancer Dr. Graham and I began an in- vestigation in 1948 trying to determine whether there could be any association of environmental factors in relation to cancer of the lung. In this study we investigated all possible factors. We investigated occupations. We found a few occupations which seemed to have a higher than expected frequency of lung cancer but they could not account for the great increase in lung cancer. We investigated the urban and rural distribution of lung cancer, about which I want to say a little more later. It must be realized in this regard that cancer of the lung had also increased in farm areas. Finally we found that tobacco was positively associated with cancer of the lung as compared to our control patients. Table 1 shows the summary of our first paper. The two outstanding features of the graph are: 1) that the control patients include considerably more non-smokers than are found among lung cancer patients, whereas among the lung cancer patients there are considerably more excessive chain smokers than in the con- trol group. These patients are of similar age and economic distribution. TABLE I Percent distribution of 870 male patients with epidermoid, undifferentiated, or unclassified bronchi- ogenic carcinomas, and 780 male control patients of similar age and economic distribution, according to tobacco consumption over a 20-year period. Smoking Lung Cancer Control Classification* Patients Patients Total 870 780 Less than 1 1,6 14.6 1- 9 2,6 11.5 10-14 9.2 19.0 15-20 35.1 35.6 21-34 30.8 11,5 35 or more 20.7 7.6 *Equivalent number of cigarettes per day. One cigar has been arbitrarily treated as the equivalent of 5 cigarettes and a pipeful as 2'/•-~ cigarettes. Graph I summarizes this data by showing that the risk of developing cancer of the lung seems to increase in direct proportion with the amount smoked. This was also shown in a study by Cornfield and myself in which we analyzed the tobacco habits of physicians who died from cancer of the lung and we found what was true for the general population is true also for the physicians. The more these patients smoke the greater is the chance of developing cancer of the lung. The lower curve, taken from a study of Doll and Hill in England, which today has been extended to 1,465 cases of cancer of the lung, demonstrates the same re- lationship which we found in this country. During the past three years a large number of difrerent studies have been published compris- ing more than 6,000 patients with cancer of the lun;, an3 a simiiar number of controls. All confirm this type of data; namely, that 370 NEW YORK MEDICINE

GRAPH 1 the more a patient smokes the greater is the chance to develop cancer of the lung and it is exceedingly rare for a non-smoker to develop cancer of the lung. CHAIRMAN FORKNER: How common is cancer of the lung in relationship to other cancers? DR. WYNDER: Cancer of the lung today accounts for about one-fourth of all can- cer deaths in males in England. In Aus- tria it accounts for one third of all cancer deaths in males and it is rapidly increasing. (Slide) Table 2 shows the distribution of cancer of the lung among various types of smokers. I think that the cigarettes have been a little bit unduly regarded as the only type of tobacco related to cancer of the lung. These data show that the mortality among pipe smok- ers and cigar smokers is also greater than among non-smokers. The reason why we be- lieve that pipe smoking and cigar smoking is perhaps less associated is because of the prac- tice of inhaling which is more commonly prac- ticed among cigarette smokers. TABLE II The Present Distribution of Lung Cancer and Control Groups by Type of Smoker Estimated Annual --Mortality per 100,00'0- Among Among General T)pe of Smoker Physicians Population Non-smoker 10 4 Smoker: Total 60 58 Predominately: Pipe 40 16 Cigar 24 22 Cigarette 84 70 (Slide) Table 3 shows a distribution of smoking habits in England among city people and among farm people. A few investigators believe that air pollution is an important fac- tor in cancer of the lung because cancer of the lung occurs more commonly in cities. It is well established that cancer of the lung does occur more in cities, but this does not mean that air pollution is a factor. The British have tackled the problem and showed that city people smoke more cigarettes than farm people and that there are more non-smokers in the rural areas. Differences in smoking habits must be consid- ered before one can condemn air pollution as being a factor in the ~levelopm_ent of cancer of the lung." TABLE III Smoking habits of general male population in greater London (1,393) and rural districts of England (327) (Doll and Hill) Greater London Rural Districts Non-Smokers 5.1 % 10.4C/o Heavy Cigarette Smokers 14.6c7o 7.7% Pure Cigarette Smokers 74.2% 58.4% Cigarette / Pipe Smokers 16.0% 21.5C%o Pure Pipe Smokers 4.8Cib 9.8% Recently, Doll has demonstrated that sta- tistically a non-smoker regardless whether he lives in city, suburban or rural areas has the same change of developing cancer of the lung, a chance which is very low. Therefore air pol- lution does not seem seriously to affect the development of cancer of the lung. Because of the evidence we had at hand, Dr. Graham, Miss Croninger and I proceeded to determine whether cigarette tar could induce cancer in animals. Recently you read some statements in news- papers that animal data, which I shall present, prove nothing as far as human cancer is con- cerned. I should like to state that these animal data were done because of the human evidence already at hand. Furthermore throughout the history of animal cancer re- search there was a close correlation between animal data and cancer in man. This holds true particularly for epidermoid carcinogensis in mice and men. We produced tobacco in a smoking appa- ratus which simulated human smoking habits. The tar obtained from condensed cigal•ette smoke was applied to the backs of mice. 40 mg, three times a week, dissolved in acetone. At the MAY 5, 1954 371

0 N N N N N N N N N N N N N N end of the first year the first carcinoma was noted. This was typical undifferentiated carcinoma with typical mitotic figures. Miss Croninger transplanted one of these cancers through thirteen generations which shows definitely that it was a true neoplasm. Percent Lesions 70 60 50 ALL FIRST GROSS APPEARAfVCE OF PAPILLOMAS AND CARCINOMAS CARCINOMAS PROVED HISTOLOGICALLY 0~,~, . -- -, - --i-; 0 4 8 12 i6 20 Number of Manths of Applfcutfon CAF mice(8)) Cqorefle 1arlAceWne CAF mice (30) Acetone GRAPH 2 10 40 30 20 Graph 2 shows a summary of these data. At the end of two years 44 per cent of 81 mice painted with this condensed smoke developed cancer of the skin, whereas none of the con- trol animals painted with acetone alone de- veloped any cancer. These animal data have proved that tobacco tar does indeed contain carcinogenic elements. It does not prove that it contains elements that are also carcinogenic to man but, as I stated before, these studies were done because of the evidence already at hand in man, and the great significance of these data we believe s is that they give us a working tool with which to examine these tars in order to determine which fraction in these tobacco tar samples is carcinogenic. At the present time we have no idea which fraction or fractions within tobacco smoke is carcino- genic. Experiments are now at hand both in Washington University, Memorial Hospital and New York University and other institu- tions in this country to determine these ele- ments. We believe that if these substances can be identified, and should be removable from tobacco, we would make tobacco less harmful, at least as far as its carcinogenic effect is con- cerned. We believe that any carcinogenic ma- terial is a specific substance. We do not believe that chronic irritation per se is carcinogenic. 11'e have, therefore, instituted these large re- search projects trying to identify the active 372 carcinogen in the tobacco. It would, therefore, seem to us that there is a positive association between cancer of the lung and smoking as far as human data are concerned. At a recent conference in Louvain, spon- sored by the World Health Association and Unesco, the relationship was regarded as es- .tablished. The fact, that cancer of the lun- 0 is so common, that its incidence increases from year to year, and that statisticians tell us that within the next 30 years there will be another five-fold increase of cancer of the lung, makes it one of the most alarming types of cancers we are dealing with today. It is made further alarming, as Dr. Wilson will point out to us, be- cause of the great mortality of cancer, a type of mortality which we may not be able to over- come because of the anatomical locaticn of cancer of the lung. VVe, therefore, believe that the greatest hope that we have in our fight against cancer of the lung consists of pre- ventive measures. I do think that practical preventive measures are at hand. Some day these measures may lead to a startling decrease of lung cancer. DR. GREYDON BOYD: May I ask Dr. Wynder a question? Did not Roffo in 1938, do the same work on rabbit's ears and produce a cancer such as you have in mice? DR. WYNDER: Throughout the 1930's Dr. Roffo published a series of papers based upon tobacco tar obtained from distilled tobacco. It ha,s been claimed using distilled tobacco, one uses a high degree of heat and that there- fore the actual nature of the tars used is changed. Thus his studies were never fully ac- cepted. It is also noticed that Sugiura at The Memorial Hospital and Flory in Chicago, try- ing to repeat the experiments, were unable to do so. The major criticism of his work has been the fact that he used the type of tar which was not the type of tar to which humans are exposed and this is the one factor that we tried to avoid in our own experiment, using a type of tar which simulates human smoking habits as closely as possible. CHAIRMAN FORKNER: Dr. Wilson, Dr. l1'yn- der has spoken something about the irritating effects of these tars. Have you observed them bronchoscopically? NEW YORK MEDICINE N

DR. NORMAN WILSON : I think anybody who looks hard enough at enough smokers can see irritation and observe great disability from it, too. In fact, I am almost as alarmed by the pulmonary patient I see, whose respiratory re- serve has been reduced by his smoking habits, as I am about the cancer problem. Many times a patient with a cancer has so much broncho- spasm and trapped air in the lungs, you have to treat this before you can safely operate for cancer. One can see the irritation bronchoscopically, but not in all people. In many patients, who have severe symptoms, you do not see the vis- ible evidence of irritation yet they have parox- ysmal cough and raise a great deal of sputum. I would like to confirm what Dr. Wynder said about the seriousness of cancer. In our experience cancer of the lung occurs exclusively in people who smoke heavily. The disease is very serious. Only about 8 or 10 percent of patients with carcinoma of the lung are alive five years after the beginning of symptoms. The problem of carcinoma of the lung is rapidly increasing in the experience of all physicians and yet we have not shifted gears in our teaching of students and in our publica- tions to the medical profession at large about the salvable cancer patients. The statistics in textbooks and many articles still cover all can- cers so that the physician, and oftentimes the senior medical student, thinks that 65 per- cent of cancers are visible through the bron- choscope. That is true if you take the many advanced cancers that are sent in but let us take the salvable cancer, the early cancer, the one you and I, as physicians, should be most interested in because it is the one we can pos- sibly cure. This patient is apt to have a nega- tive bronchoscopic examination. He is very apt to have a negative Papanicolaou smear, as you saw in the first case here, and almost rou- tinely lie has no physical signs. The shadow is usually the only evidence of the tumor. I have a few slides that might be helpful at this point. (Slide) In private clinics the general ex- perience in this country is that around 37 per- cent of cancers in the lung can be diagnosed by means of bronchoscopy. However, in "sur- vey cancers" we can get bronchoscopic evi- dence in only 11 percent. That includes those with symptoms. CHAIRMAN FORKNER: What do you mean by "s'urvey cancers"? DR. WILSON: Those who did not know they had trouble until x-rays were taken. If you take the symptomless survey patient the value of bronchoscopy almost fades out of practical value. Likewise the Papanicolaou test is posi- tive in a little better than 60 percent in our experience, but in our "survey carcinomas" in only 25 percent, and those without symptoms much lower than that. I think a very important point to drive home is that the patient who is salvable is a patient who usually has symptom- less cancer and one without physical findings, who will have a demonstrable lesion on x••ray and whose diagnosis can best be proved by ex- ploratory thoracotomy. I have never quite un- derstood why we as a group have a different fundamental concept about the cancer we have to look at in an x-ray and the one we can palpate with our fingers. I f nd that almost routinely my senior students are very willing to explore a breast for a palpable nodule but S" A ALjIEK. to pt #010 0 Pediforme IN~~ ~-~ F 0 0 T W E A R lit MANHATTAN 34 WEST 36th ST BROOKLYN 288 LIVINGSTON ST. FLATBUSH S43 FLATBUSH AVE Other shops in - HEMPSTEAD NEW ROCHELLE HACKENSACK E. ORANGE WRITE FOR SHOE ALTERATION FOLDER ~ 4 MAY 5, 1954 373