- Historic Sites
In the past seventy years, while several major diseases have been eradicated, one has risen from obscurity to take its place among the nation’s leading killers
December 1992 | Volume 43, Issue 8
The patient at Barnes Hospital in St. Louis, in 1919, might have wondered during his last days why all the physicians were so peculiarly interested in his case. When the man died, Dr. George Dock, chairman of the department of medicine, asked all third-and fourth-year medical students at the teaching hospital to observe the autopsy. The patient’s disease had been so rare, he said, that most of them would never see it again. The disease was lung cancer.
Dr. Alton Ochsner, then one of the students, wrote years later, “I did not see another case until 1936, seventeen years later, when in a period of six months, I saw nine patients with cancer of the lung. Having been impressed with the extreme rarity of this condition seventeen years previously, this represented an epidemic for which there had to be a cause. All the afflicted patients were men who smoked heavily and had smoked since World War I. … I had the temerity, at that time, to postulate that the probable cause of this new epidemic was cigarette use.”
At the beginning of this century, most smokers chose cigars; the cigarette was seen as somewhat effete and faintly subversive. Smoking was an almost wholly male custom. In 1904 a New York City policeman arrested a woman for smoking a cigarette in an automobile and told her, “You can’t do that on Fifth Avenue!” Smoking by female schoolteachers was considered grounds for dismissal. At an official White House dinner in 1910, Baroness Rosen, wife of the Russian ambassador, asked President Taft for a cigarette. The embarrassed President had to send his military aide, Maj. Archie Butt, to find one; the bandleader obliged.
The commercial manufacture of cigarettes had been a cottage industry until 1881, when James A. Bonsack invented a cigarette-making machine. In 1883 James Buchanan Duke, who had inherited his father’s tobacco business in Durham, North Carolina, bought two of Bonsack’s machines. Within five years Duke’s company was selling nearly a billion cigarettes annually, far more than any other manufacturer.
Until World War I, cigarette production in America remained stable. But after the United States entered the conflict, in 1917, Duke’s company and the National Cigarette Service Committee distributed millions of cigarettes free to the troops in France, and they became so powerful a morale factor that General Pershing himself demanded priority for their shipment to the front. The war began to fix the cigarette habit on the American people: between 1910 and 1919 production increased by 633 percent, from fewer than ten billion a year to nearly seventy billion. Contemporary literature reflected the change. O. Henry’s carefully observed turn-of-the-century stories almost never mention cigarettes. But by the time of Ernest Hemingway’s expatriates in The Sun Also Rises , published in 1926, men and women alike smoke constantly.
It was the consequences of this growing habit that physicians began to notice in the 1930s. As the first cases of lung cancer began to appear, doctors struggled to find ways to cope with the disease. Surgery was the only effective treatment for major internal cancers, but at the beginning of the century no method existed to maintain a patient’s respiration under anesthesia when the chest was opened, so opening the chest almost alwavs meant immediate death.
The problem began to yield in 1904, when two German surgical investigators pioneered the use of enclosed chambers to maintain differential air pressure. One version enclosed the patient from the neck down, together with the surgical team, in a chamber with lower than normal atmospheric pressure; since the patient was breathing higher-pressure air from outside, his lung wouldn’t collapse when his chest was opened. The other researcher simplified the design by reversing it: his apparatus put the patient’s head in a pressurized chamber. The systems allowed the beginnings of modern chest surgery. Before long the chambers were superseded by a tube passed into the windpipe.
The first lobectomy—removal of a lobe of the lung—for lung cancer was accomplished in London in 1912. (The right lung has three lobes; the left, smaller to make room for the heart, has two.) The patient was a forty-four-year-old laborer with a chronic coueh and pain in his right chest wall. The record does not say whether he was a smoker, but X rays showed a rounded density at the base of the right lung, and the blood-tinged sputum he was coughing up contained malignant cells. His surgeon, Hugh Morriston Davies, removed the right lower lobe by a technique virtually identical to that used today. The patient did well at first, but without the hard-won experience of others to draw upon, Davies couldn’t know that the chest cavity must be drained after the operation. The patient died from an infection eight days later. Davies’s omission wasn’t corrected until 1929, when Dr. Harold Brunn of San Francisco began draining the chest cavity through a rubber tube, applying intermittent gentle suction to evacuate all air and fluid. Brunn reported six lobectomies with only a single death. (Only one of the six operations was for cancer)