Tobacco Documents Online

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. lt 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 oi cancer of the lung, demonstrates the same re- lationship which v:e 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 tlie ]tm;, 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

are very unwilling to have an exploratory thoracotomy for a symptomless tumor that they look at in an x-ray. It takes quite an effort to teach them that this is the proper procedure. (Slide) Here again you see what symptoms mean in cancer of the lung. You will notice that in this group with symptoms only one ol ten has a chance of having negative lymph nodes, whereas in the patients who do not have symptoms, seven out cf ten have negative nodes. This means that there is a great differ- ence in the final statistics in the two groups. Our five year statistics in the patients with symptomless cancer shows 40 percent to be alive. (Slide) This is the real big clinical prob- lem. Here is a small carcinoma without phys- ical signs, without symptoms and in this par- ticular instance unchanged over a period of one year as judged by its appearance in the x-ray films. It was a symptomless cancer dis- covered at a time in the evolution of the disease when the patient could be saved. When patients develop symptoms we have very little .chance to pull them out of the fire. We feel that these people should be explored, as early as possible to establish the diagnosis of the x-ray shadow. CiHAIRMAN FORIiNER: Will you point that out to us, Dr. Wilson? DR. WII,soN: These films were taken 14 months apart and you have to take my word for it that the x-rays taken every two months showed no demonstrable change. We feel that this demonstrates the clinician's and the sur- geon's problem today with these cancers. When a patient is presented to you with an unex- plained lesion in his chest, even though it is very small, we feel that you have only one of two roads to send him down. You can send him down that dark road over there without any lights on it, which means you are going to wait and see if it grows or causes symptoms and if it does, then you cannot have much chance of saving him, or you can do what you would do with any other tumor. You can ex- plore it and have a frozen section performed by your pathologist. Statistically you have jus- tification for early exploration because the risk of having cancer in unexplained peripheral lesions, which contain no calcium, is about 40 percent. The risk of exploration in a patient in good condition is definitely under 1 percent. Early exploration really represents not only the intelligent but also the conservative approach to this rapidly increasing problem. CHAIRMAN FORKNER: Dr. Wright, will you tell us about the cardio-vascular aspects of smoking? DR. WRICxT: I think we ought to consider first the normal reaction of the circulatory sys- tem to the use of tobacco. The question is often raised as to whether effects can be meas- ured from absorption from the mucous mem- branes of the mouth and perhaps the nose with- out inhalation. In other words, does the person have to inhale deeply in order to obtain a re- sponse which can be measured from the view- point of the circulation? As it was brought out before, our interest is primarily not with the tars but primarily with nicotine. If there are other agents in tobacco which have an effect on the circulation we are not aware of them and have not been able to demonstrate them. It is true that nicotine is readily absorbed from the mucous membranes of the mouth. So it is not important whether the patient smokes cigarettes, cigars or pipes, or whether he chews. He can absorb enough nicotine to get a profound effect. If you doubt this, place a drop or two of nicotine sulphate solution 1: 1000 dilution on the gum of a dog and watch him die within a half minute as a result of absorption from the gum. During smoking the average individual shows some increase in pulse rate. Many show an increase in blood pressure, the blood sugar character- istically rises temporarily. That may in a way account for the feeling of a "lift." Many people do develop cardiac premature contractions, which are not in themselves serious but may be annoying. There is a decrease in the periph- eral blood flow as evidenced in most normal persons by a drop in the surface temperature of the finger tips and tips of the toes. (Slide) There is often a profound drop of from 3-9 degrees in the temperature of the fnger following the smoking of a single ciga- rette. This curve is characteristic not only for normal standard brands but also for men- 374 NEW YORK MERIC/NE

tholated cigarettes. The results were identical when denicotinized cigarettes were smoked. In the so-called denicotinized cigarette the drop is just as precipitous. A number of filters thus far tested have also been ineffective in block- ing this effect even though they quite obviously appear to reduce the tar carried into the mouth. Measuring the circulation at the periphery by plethysmography, as determined by Lamp- son, confirms this general observation. There are a few individuals who show no response of this nature but the majority show some degree. Some patients, more commonly those with cor- onary insufficiency, have an increase in anginal pain. We do not always understand the exact mechanism. There are individuals who, when they stop smoking, have a striking diminution or cessation of this anginal pain and for them it is unwise to continue. This pain response may be due to spasm of the coronary arteries but it is difficult to prove beyond doubt. How- ANS1ER TELEPHONES... ever, in some patients, it is possible by smoking to produce definite transient changes in the electrocardiograms, such as negative T waves, which are not due to deep breathing alone. In those individuals the evidence appears more convincing. When we consider the peripheral vascular diseases, thrombo-angiitis obliterans, the dis- ease seen in the first patient, is the most clearly related to tobacco. It is a relatively rare disease, yet there are thousands of such patients in the United States. I do not think anyone knows the statistics on thrombo-angiitis obliterans be- cause most of these patients do not die from the disease but if they die they die after they have had it for many years. It would be inter- esting to know whether or how these figures compare with the number of patients who have carcinoma of the lung. There might be quite a similarity, yet in my experience I have yet to encounter a patient with carcinoma of the lung and thrombo-angiitis obliterans, which DOCTORS TELEPHONE SERVICE • 224 East 38th St., New York 16 Pictured above is our office at 205 East 78th Street, one of our 14 neighborhood Answering Offices. In this office we handle Doctor's Emergency Service sponsored by the New York County Medical Society. In our 29 years of service to the physicians and dentists of New York, we have done everything in our power to create happy and congenial working conditions for our girls. This is reflected in their work. Our reputation for courtesy, intelligence and efficiency is unsur- passed. We are honest, dependable and accurate. Telanserphone has come to be known as the "voice" of experience. Nominal rates -Monthly basis-No contract. Phone for l nformation U r r a H i l l 1-6 5 0 U Telanserphone Inc. y MAY 5, 1954 375

again makes me suspect we are dealing with different agents rather than tobacco as a whole, or similar agents. I would like to show a few slides illustrating patients who have had this disease and their problems. (Slide) Here is an individual who came to see us in 1933 with amputation of the left leg at the age of 19 for gangrene. He stcpped smoking at that time but resumed smoking and developed gangrenous ulcers of the right foot and changes in the vessels of his hands. (Slide) This is a closeup of the gangre- nous ulcers which he developed in his right foot, which had been his good foot. This was ex- tremely important to this man because he already had lost one leg. (Slide) This is the so-called Allen test, which in brief indicates, by the pallor of the right hand when the ulnar artery is open and the radial artery is occluded, that the ulnar artery is already affected. (Slide) The next slide illustrates another patient with thrombo-angiitis obliterans with multiple 'ulcers involving the fingers. (Slide) These are close-up pictures. These are extremely painful small ulcers but will con- tinue to develop into a gangrenous condition if the patient continues to smoke. (Slide) These are the hands of a physician. This individual came to us with gangrene of the fingers of both hands, a very advanced situ- ation. It looked as though he were going to lose his hands. He did lose part of the tips of the fingers of his left hand and it looked as though he were going to lose the third finger of the right hand. That finally healed. He stopped smoking and was treated with typhoid vaccine for a while. (Slide) This shows a picture of his foot which was involved. (Slide) This is a picture of another indi- vidual, a woman who had had a sympathec- tomy and was never told to stop smoking. She proceeded to develop gangrene and lost the fourth toe. (Slide) This man has lost his leg because of arteriosclerosis associated with diabetes mel- litus. There is no evidence whatsoever that arteriosclerosis obliterans is produced by smok- ing. However, once the patient has a marked diminution in circulation, it is very important that the spasm be not produced in the col- lateral vessels that are endeavoring to take over the load in lieu of the loss of the major vessels. This case is demonstrated as an ex- ample of that. (Slide) Some years ago several of us made some studies at Macy's of individuals who had followed a similar course in reference to their occupation for many years. Among other sta- tistics of interest, was the incidence of arterio- sclerosis, as we are measuring it, in tobacco users versus non-users; for the sake of general interest alcohol was also studied. As you can see there is no significant difference in the in- cidence of arteriosclerosis between the two groups. I think that this is sufficent evidence in our view to indicate that: a. patients with thrombo-angiitis obliterans should never smoke. Even a single cigarette may produce a recurrence in their gangrene as long as several years later. We see many ex- amples of this. b. if they have an impaired circulation from another serious disease they should not smoke, not because the disease is associated with to- bacco in terms of etiology, but because it may aggravate the disease by producing constric- tion of the small collateral vessels when they are needed to save the tissues. CHAIRMAN FORKNER: Thank you, Dr. N1'right! Dr. Boyd, what about the nasopharynx and perhaps the larynx? DR. Bovo : An average of one-half pack of cigarettes is smoked daily by every person over 15 years of age in the United States. It seems that the public may not be well informed about the harmful effects of tobacco because news sources carry tobacco advertisements that are deceptive. The public, however, senses some danger as shown by the 1949 Gallup Poll, in which more than 50 percent of smokers thought it harmful and had tried to quit. Another evidence of this is shown in the r.se of the slang terms such as "Coffin nails," "Gaspers," "Weeds," "Pills," "Lung Dusters," "Dope sticks" and "Poison Sausages." The use of mis- leading endorsements by ball players and actors 376 NEW YORK MEDICINE

, k I and such statements as "Leading doctors find no nose, throat or sinus irritation or harmful effects," are still being used, in spite of the Federal Trade Commission's efforts. I think as far as the prevalence of symptoms is concerned there are more in the nose and throat than from any other effect of tobacco. Of eighteen leading otolaryngologists inter- viewed prior to this meeting, 100 percent be- lieved tobacco smoking to be irritating to the nose and throat. They believed, that tobacco caused sore throats, cough, post-nasal drip, and redness of the throat. Other adverse effects were: mechanical irritation, hot smoke, foreign body effect, vasomotor symptoms, nasal ob- struction, leukoplakia, edema, dryness, staining of the teeth, nicotine hypertrophy of the palate, gagging, hoarseness, vertigo, asthmatic wheez- ing, hearing loss and Meniere's disease. There is a tremendous amount of difference in individuals as to the way they respond to irritation and I think that is also true of tumor response in the throat and mouth. In the throat the amount of smoking makes a great deal of difference. My discussion will be divided into three primary parts. One is the irritation of tobacco on the throat primarily producing a red, thickened mem- brane with increased secretion, post-nasal drip, cough, morning gagging, etc., that smokers have. Also there is a definite entity called smoker's larynx-in which a fibrous polypoid condition occurs in the larynx. On removal it is found to be an inflammatory rather than al- lergic type of hypertrophy of the vocal cords. It occurs most often in individuals who have short necks and who smoke from 20 to 120 cigarettes daily. Other results of smoking are gingivitis and leukoplakia that occur in the mouth. This is common in all types of smoking. Cigar smoking particularly causes cancer of the palate. Ciga- rettes, however apparently do not cause as much cancer in the mouth as does the smoking of a pipe or of cigars. I think there is not any great evidence that the cigarette smoking itself causes very much cancer of the mouth. To- bacco chewing has been reported to be asso- ciated with cancer. The third point I wish to mention is the effect on the nose and the question of allergy. MAY 5, 1954 The consensus of opinion is that in a fair num- ber of patients the main effect from smoking is the secondary irritation of tobacco on the nose in allergic people. It aggravates the symp- toms and results in congestion of the nose fol- lowed by poor sinus drainage and sinusitis secondarily. In the ear an occasional case of Meniere's and toxic deafness occurs from to- bacco. Those people who have the latter con- dition are generally smokers and drinkers at the same time. Anesthetists feel that anes- thesia in smokers is more prone to be associated with bronchial complications. Toxic amblyopia is one of the results of the use of tobacco. Loss of smell or diminished sense of smell may occur. What about filters and King size cigarettes as far as the nose and throat are concerned? I think the length of the cigarettes and the use of filters do the same thing, namely reduce the amount of smoke. How little smoke do you want to get at the other end? If you put enough filter in you won't get any smoke and you won't get any irritating effect from the cigarette. I think the fancy brands or special kinds of cigarettes sold today do not make a great deal of difference. DR. WILSON: May I ask a question? Maybe Dr. Wynder and Dr. Boyd might take part in answering it. I wonder if you know of any evi- dence to indicate a difference in the potential- ity of the mucosa of the nose as compared with that of the bronchus for developing metaplasia? DR. WYrrnFx: We are currently investigating this problem at Memorial Center. For the past two years we have interviewed routinely every patient on the Head and Neck service of Me- morial Hospital. In addition we have inter- viewed patients at the Radiumhemmet in Swe- den and the Tata Memorial Hospital in Bom- bay to get differences in national levels on tobacco habits. I think the data indicates that tobacco chew•ing in certain parts of the world is associated with carcinoma of the esophagus, carcinoma of the tongue, buccal mucosa and larynx. As yet I can not tell whether cigarette smoking is less or more responsible for these types of lesions of the oral cavity than cigar smoking or chewing tobacco. Bronchial epithelium seems particularly susceptible to metaplastic changes. 377