H i ram T. Langston, M. D. STATEMENT - LAUSUNT4

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1 H i ram T. Langston, M. D. STATEMENT - LAUSUNT s80904gg

2 STATEMENT OF HIRAM T. LANGSTON. M.D. I am Hiram T. Langston, M.D., a surgeon by training. Thoracic surgery is my field of special interest and particular expertise. I was born in Rio de Janeiro, Brazil, in 1912 of missionary parents and was educated through the sophomore year of college at the Collegio Batista. I received an A.B. Degree from the University of Louisville (Kentucky) in 1930 at age 18 and an M.D. Degree from the same university in I underwent seven years of hospital training in surgery and pathology. This culminated in 1941 in a Master of Science (Surgery) Degree from the Rackham School of Graduate Studies of the University of Michigan in Ann Arbor, where the bulk of my surgical training took place. I was certified by the American Board of Surgery in During World War Il, I served as a thoracic surgeon in the Mediterranean Theater of Operations ( ), rising to the rank of Major, Medical Corps, Army of the United States and Chief of Thoracic Surgery to the 12th General Hospital. I was awarded the Bronze Star Medal (USA) and the Order of Aeronautical Merit, Officer Grade, Brazilian Air Force S

3 I have held teaching appointments at the University of Michigan, Wayne State University, the University of Illinois in Chicago, and Northwestern University in Chicago from which I retired in 1982 as Emeritus Clinical Professor of Surgery. I served as Chief of Surgery at the Chicago State Tuberculosis Sanitarium, Department of Public Health, State of Illinois ( ) ; and as Consultant and Chief of Chest Surgery, Veterans Administration Hospital, Hines, Illinois ( ). I am a Founder Member of the American Board of Thoracic Surgery and served as an active member from The board sets standards for the medical specialty of thoracic surgery and certifies surgeons who meet those standards as specialists. I am a senior member of numerous professional societies including the International Surgical Society, and the American, Central, Western, Pan Pacific, Illinois and Chicago Surgical Societies. Also, I am a senior member of the,society of Thoracic Surgeons and of the American Association for Thoracic Surgery, where I served on the council as Secretary ( ), Vice President and President ( ). I am an honorary member of the Western Thoracic Surgical Society and the Illinois Thoracic Surgical Society. 2 s8aso4sss

4 I served on the Editorial Board of the John Alexander Monograph Series from 1957 to 1978 and on the Advisory Editorial Board of the Journal of Thoracic and Cardiovascular Surgery from 1962 to I have been a visiting professor at the Mayo Clinic, the University of Missouri, the University of Florida and the University of Michigan. In 1975, t received the Distinguished Service Award from the Surgical Department of the University of Illinois in Chicago. In 1982, I received the Donald L. Kessler Award for leadership from St. Joseph Hospital in Chicago. The new out-patient surgical center at St. Joseph Hospital in Chicago was dedicated in my name in I am a biographee in the Marquis Publications, including Who's Who in the World, Who's Who in America and Who's Who in Science. I am author or co-author of 117 pieces in the scientific literature. These include two books and 27 chapters in books as an invited author. My curriculum vitae and bibliography are attached G

5 When I started in lung surgery in 1939 as a resident at the University of Michigan, the only thing I had heard about smoking and health were things that my grandmother had told. me, such as that smoking would stunt my growth or cut my wind. I had also heard the phrase "coffin naifs", which I understood to mean that smoking a cigarette was equivalent to nailing down the lid on your coffin. But there had been no scientific discussion about smoking and health during my training. Through World War I{ and after, into the late forties, there was little discussion about smoking and health and I wasn't seeing very many bronchiogenic carcinomas in my practice. I was aware of the work of Drs. Alton Ochsner and Richard Overholt. I think Ochsner's first publication in the 1930's dealt with a series of just a handful of cases, and he was one of the early ones to begin to report his experiences with bronchiogenic carcinoma. At the time a statisticaf association between smoking and lung cancer was reported in the early 1950's it was thought that bronchiogenic carcinoma was appearing more often, or at least being recognized more often. The scientific debate focused on the question of whether the increase in incidence was real or whether it was simply due to better diagnostic accuracy. This discussion continued into the mid- or tate-1950's and indeed there is considerable discussion still about lung cancer rates

6 Prior to the interest in lung cancer, tuberculosis had been the principal diagnosis being made of people who had the clinical picture also produced by bronchiogenic carcinoma. This would have been especially true outside of major academic medical centers where the most sophisticated diagnostic equipment was not available. In the 1940's, among thoracic surgeons, Ochsner and Overholt often raised the topic of smoking and health. Their views were not highly regarded, however, because they were considered to be taking an emotional approach and acting as advocates for a view, not as impartial scientists. The thoracic surgeons were not taking seriously their claim that smoking caused cancer. In the late 1950's, Dr. Oscar Auerbach spoke about his view that an autopsy of a smoker who had an invasive carcinoma in one lung would produce evidence of tissue change in the other lung including a high percentage, approximately 15%, of carcinoma in situ. Auerbach was attempting to counter the argument that if smoking caused lung cancer, there would be evidence of cancer in both lungs because both are exposed to smoke. The response of eminent surgeon Dr. William Tuttle was "Oh, Oscar, would you have your lung removed on the basis of that carcinoma in situ?" Auerbach said, "Well, no." Tuttle indicated that Auerbach's findings were not a sufficient basis on which to conclude there was lung cancer in the second lung. 5 s8o9o4ss

7 My own view was and is that the smoking causation hypothesis is too simplistic an explanation because it simply does not fit with my clinical experience. There are numerous contradictions, which I discuss in detail below, between the hypothesis and what I saw in my patients. In the 1960's, more of my colleagues were beginning to listen to and accept the hypothesis that smoking causes cancer and other diseases. It seemed to me, however, that none of them really took the time to look into the matter in any depth ; it was much easier to just go along with the trend. Most of those who came to accept the hypothesis never stopped to examine the literature on which it was based or to do any research of their own. My views were shared by various colleagues like Drs. Thomas Burford, Theron Claggett, Tuttle, John Mayer, John Jones, Brian Blades, Buck Samson, and Duane Carr. Those who disagreed included Drs. Ochsner, Overholt, Evarts Graham, William Adams, Dwight Harkin and William Watson. Their opinions were based on epidemiological/statistical data and never persuaded me because I was considering clinical evidence which was inconsistent with the conclusions they drew from the epidemiological data. Those who shared my views were generally rather quiet ; we didn't try to sell anybody on anything. The salesmanship was coming from the other side. We didn't believe what they were saying but we were not evangelists. We weren't trying to proselytize people or gather adherents to our view as they were. Part of 6 68U.9046"»

8 this was because in science if you don't have something positive to report you normally don't go out and report negatives. So the difference between those who come to the conclusion that smoking causes lung cancer and those who do not -- during this period and, in fact pretty consistently -- has always been the difference between someone who is an activist pushing a concept and someone who is much more discreet and is not prone to advocacy. So in summary, to list some milestones in the development of the smoking and health controversy, 60 or 70 years ago lung cancer was a completely obscure disease and cigarette smoking was damned for various reasons, generally on an emotional basis. Sometime in the 1930's, perhaps, as nearly as I can date it, an apparent parallel between increased use of cigarettes and increased incidence of cancer of the lung began to be observed and discussed. It was not until the late 1930's and the 1940's that the hypothesis that smoking caused lung cancer was advanced, fueled by the theories of people like Ochsner and Overholt. But this did not receive much attention and much of the debate was about whether there was an actual increase in lung cancer, whether the increase was real or whether it was due wholly or in part to improved diagnostic facilities. This occupied us up to sometime around 1950 to 1955 and thereafter. In the early 1950's, with publication of articles by Wynder and Graham and others, the controversy became widely discussed and support of the hypothesis that smoking causes lung cancer 7 ss0904s

9 took on the aspect of a religion for some. That attitude has continued to this day. Despite that attitude, I haven't found reasons to change my views. Those who try to support the hypothesis that smoking causes lung cancer have not offered me any evidence that warrants a change in my views. My own first formal involvement with the smoking and health controversy took place in 1963 when I accepted the invitation of Caesar Portes, the head of the Chicago Cancer Prevention Center, to participate in a panel discussion about smoking and health with Sir Robert Platt, the chairman of a committee appointed by the Royal College of Physicians in London to write the first review of information regarding smoking and health. The panel was convened by the Center because Sir Robert Platt was in this country and it was considered an appropriate time to gather some luminaries to debate the issue. Daniel Horn, who with Hammond was an author of one of the main studies reporting a statistical association between smoking and lung cancer, was one member of the panel. The panel came to no conclusions about the hypothesis that smoking causes lung cancer. 8 sso9o4s'

10 After my participation in the discussion with Sir Robert Platt, my next public statements on this subject were made during a series of appearances at hearings conducted by U.S. Congressional committees between 1964 and The hearings had to do with whether cigarette packages should be labeled and whether cigarette advertisements should be banned or curtailed. Present at each of these hearings were eminent, well-respected scientists and physicians from many disciplines whose views were similar to mine and who testified or submitted statements about their opinion that it had not been scientifically established that cigarette smoking causes cancer and other diseases. The transcrip ;s of those hearings indicate that a total of more than 80 pathologists, surgeons, statisticians, radiologists, cardiologists, pulmonary physicians, in ;ernists and others presented this view to Congress during the hearings that I attended., I testified before the following congressional committees : in June 1964 before the Committee on Interstate and Foreign Commerce of the House of Representatives, in March 1965 before the Committee on Commerce of the U.S. Senate, in April 1965 before the House of Representatives on Interstate and Foreign Commerce, in April 1969 before the Committee on Interstate and Foreign Commerce of the House of Representatives, in 1976 before the Subcommittee on Health of the Committee on Labor and Public Welfare of the U.S. Senate, in 1982 before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce of the House of Representatives concerning the Comprehensive Smoking Prevention Education Act, in 1982 before the Committee on Labor and Human Resources in the U.S. Senate on the Comprehensive Smoking Prevention Education Act of 1981 and, in 1983 before the Subcommittee on Health and the Environment of the Committee on Energy and Commerce of the U.S. House of Representatives concerning the Smoking Prevention Education Act. 9 s8a944s

11 Each of those individuals had different reasons, based on their differing backgrounds, for forming their opinions. My own views are based on my clinical experience as a thoracic surgeon. Although I have read much of the scientific literature relating to smoking and lung cancer, in my capacity as a surgeon I do not feel qualified to respond directly to or to evaluate the methodology of the studies that have concluded that there is a statistical association between smoking and cancer. However, I must respond to the interpretation of these associations as causal because it is inconsistent with the clinical realities of the disease that I have observed for the past forty years. Adopting the old adage "it is the exception that proves (tests) the rule," I identified certain very pertinent "exceptions" by observing firsthand the clinical behavior of lung cancer. These exceptions cast doubt upon the validity of the hypothesis that smoking causes lung cancer. 1. lnhaled cigarette smoke is equally distributed in both lungs. Why, then, as the data show, and as I have observed in my own practice, do lung cancers very rarely appear simultaneously in both lungs? The answer is not known, but this phenomenon is inconsistent with the smoking causation hypothesis. It is of further interest to note that the vast majority of people who have been successfully treated for one malignant tumor in the lung do not develop subsequent lung tumors '

12 2. It is also of note that it is impossible to tell the difference between the cancer that occurs in a smoker from the cancer that occurs in a non-smoker. When the hypothesis that smoking caused lung cancer first was discussed by such people as Auerbach and others, the typical "smoker's lung cancer" was claimed to be a squamous cell carcinoma occurring in a man. Recently, adenocarcinoma has become a more common type of tumor. This has been documented in more than one series. It's very puzzling to me how a supposed etiologic agent, working in the same population, was producing squamous cell carcinomas in men fifty years ago and now is producing squamous cell carcinoma and adenocarcinomas with equal facility in men and women. I don't think the human race has changed that much in fifty years. 3. Cancer rarely occurs in the trachea (windpipe). The trachea is exposed to more tobacco smoke than are the lungs, because all the smoke is inhaled and exhaled through it. Also, the material deposited in the mucous lining of the air passages exits through the trachea. The trachea is anatomically, embryologically and physiologically identical to the rest of the bronchial airway. Therefore, if cigarette smoke were a cause of lung cancer, one would also expect to see a large number of tracheal cancers. The fact is, however, that tracheal cancer continues to be an extremely rare disease

13 4. Cancer of the larynx or voice box has also been statistically linked with smoking. Because cigarette smoke passes through the larynx on its way to the lung, the larynx is exposed to at least the same concentration of smoke as are the lungs. Were the smoking-causation hypothesis valid, one would expect to see a rise in laryngeal cancer similar to the rise in lung cancer. Yet, the data show that there has been little change in the incidence of laryngeal cancer over the past decades. 5. I regard with a certain amount of suspicion the view that we are in the midst of a lung cancer "epidemic" because of cigarette smoking. Any discussion of this "epidemic" mus take into account two frequently overlooked clinical factors that have had a tremendous effect on the reliability of reported lung cancer rates : (1) diagnostic techniques and (2) official certification of cause of death. Even in the time span of my own practice, I have seen remarkable changes in our ability to diagnose lung cancer. When one considers that even diagnostic x-rays were not readily available a scant decade or two before I started practicing, it is hardly surprising that our ability to detect lung cancer has increased dramatically. And as that ability has increased, so naturally have the reported lung cancer rates G'7f

14 Earlier in this century, physicians may have failed to diagnose lung cancer, resulting in rates lower than the actual incidence of the disease. Thus, when these unrealistically low rates are compared with rates for later periods when diagnostic tools were gradually becoming available, one would obtain a false impression of the real increase. The other factor I believe to be important in evaluating whether there is a lung cancer epidemic is the accuracy of death certificate information. Death certificates are the sources for calculating death rates, but unfortunately information in these is extremely unreliable. Most laymen assume that death certificates accurately reflect the cause of death, but in many cases they do not. Coroners and non-treating physicians sign many death certificates, and they may have little or no relevant information about the actual cause of death. Even treating physicians make mistakes. That is why I have refused to consider in my own population studies any case as lung cancer unless there was microscopic confirmation of the diagnosis. Many cases lack that confirmation. This is not to say that there has been no increase in lung cancer. 1 am quite convinced that a portion of it is real. I am equally convinced, however, that we have not yet identified its cause or causes. 13 6t40904GW

15 6. In my review of the literature, I have seen the argument that the epidemiological studies show a dose-response relationship, that is, the greater the exposure to cigarette smoke, the greater the risk of developing lung cancer. Although I cannot directly challenge the statistical methods used to obtain these associations, I have been able to consider another aspect of "dose-response" -- age at diagnosis. The age at diagnosis of lung cancer does no seem to be related to the age at which a person started smoking, nor how long he smoked, nor even the number of cigarettes he smoked per day. I have observed this in my own patients, and indeed I have found it to be confirmed in the literature. 7. Age-specific lung cancer death rates almost always have a special pattern. In most series of lung cancer patients, the greatest rates occur in the 50 to 70 year age group, with a peak at 60 years. The literature also reveals that a certain generation (those born before the turn of the century) may have higher lung cancer rates than other generations. Intrigued by these findings and the possibilities that they suggested, I reviewed approximately 4,000 lung cancer cases spanning 30 years at the Veterans Administration Hospital in Hines, Illinois. All cases carried the diagnosis of lung cancer supported by microscopic evidence. 14 #i809046'

16 I found that (1) the generation born between 1890 and 1900 contributed the largest number of cases ; (2) if this trend continued, this generation would fade from prominence due to old age ; (3) the younger generations did not appear to be replacing this generation in cancer production. Given these points, I predicted that the number of lung cancer cases at the Veterans Administration Hospital in Hines would decrease. In a subsequent investigation of cases through 1983, 1 discovered that the contribution of the generation which had earlier produced the greatest number of cancers at Hines had in fact decreased significantly. In addition, the total number of cases at Hines in the period 1968 through 1983 had dropped approximately 25%. This seems to be a rather significant change which supported my earlier predictions. This observation ultimately spanned 50 years and encompassed approximately 6000 cases. 8. Lung cancer is a dynamic disease in the sense that its occurrence patterns and clinical appearance (cell type) are ever changing. For example, there appears to have been a decline in the rate of increase of lung cancer. Indeed, lung cancer incidence may have, in fact, crested. Other investigators, including some who believe that smoking causes lung cancer, seem to concur with this observation. For instance, in his address before the Health Congress in England in 1977, Sir Richard Doll said, "It is

17 encouraging to find that the total death rate from lung cancer in men decreased in 1975 albeit very slightly, for the first time in 50 years." Perhaps what we are seeing in the case of lung cancer is what is called the "naturat history" of this disease. Natural history has been succinctly described by a British thoracic surgeon as the "long drawn out process of the development and the decline of an individual disease." If you have trouble accepting the idea that a spontaneous decline in lung cancer can occur, I remind you of the documented decline in stomach cancer. The spontaneous decline in stomach cancer over the years is a decline for which no convincing explanation has been offered. Improvements in nutrition or food storage, or diagnostic refinements, or changes in the general health of the population do not adequately explain these changes. What explains the changes in lung cancer rates? As Dr. Belcher has pointed out, the decline in lung cancer's rate of increase started before changes in the cigarette occurred. Is this simply another example of the poorly understood natural history of a disease? Clearly, no simple explanation for these lung cancer changes appears to be forthcoming. 16 s8u90468o

18 Many important questions about cancer causation remain unanswered. For example, precise causal mechanisms have not been identified. Many theories have been proposed, but none have won universal acceptance. I do not agree that cigarette smoking is the major cause of lung cancer, because I believe very strongly that we do not know the cause or causes of cancer of the lung. Charges that smoking causes lung cancer are so familiar that very few people may realize that there is strong evidence to the contrary. I find that evidence to be persuasive. In my estimation, the smoking causation hypothesis is an oversimplification. I also believe that to this day there exists a scientific controversy about whether smoking causes lung cancer. There are many scientists and physicians, some of whom testified at Congressional hearings with me, who do not believe that the hypothesis that smoking causes cancer has been proven

19 LAAKETIETEEN TOHTORI HIRAM T. LANGSTONIN LAUSUNTO Olen laaketieteen tohtori Hiram T. Langston ja olen saanut kirurgian erikoislaakarin koulutuksen. Olen perehtynyt erityisesti thorax-kirurgiaan, josta minulla on laajin asiantuntemus. Olen syntynyt vuonna 1912 Rio de Janeirossa, Brasiliassa. Vanhempani olivat lahetystyontekijoita, ja opiskelin toiseen college-vuoteeni asti Collegio Batistassa. Bachelor of Arts -tutkinnon (alempi korkeakoulututkinto) suoritin 18-vuotiaana Louisvillen yliopistossa (Kentuckyssa) vuonna 1930, ja vuonna 1934 M.D.-tutkinnon (lah. vast. laaket.lis.) samassa yliopistossa. Tyoskentelin sairaalassa seitseman vuotta kirurgiaan ja patologiaan erikoistuvana laakarina, minka jalkeen suoritin vuonna 1941 Master of Science (Surgery) -tutkinnon (lah. vast. kirurgian erikoislaakari) Michiganin yliopistossa (Rackham School of Graduate Studies) Ann Arborissa, missa olen paaosin saanut kirurgikoulutukseni. Vuonna 1942 Yhdysvaltain kirurgian hyvaksymislautakunta (American Board of Surgery) myonsi minulle kirurgian diplomin. Toisen maailmansodan aikana toimin thorax-kirurgina vuosina (Mediterranean Theater of Operations), ja minut ylennettiin Yhdysvaltain armeijan laakintajoukkojen majuriksi ja 12. yleissairaalan thorax-kirurgian osaston ylilaakariksi. Minulle my6nnettiin Yhdysvaltain armeijan pronssitahti ja Brasilian ilmavoimien upseeritason kunniamerkki (Order of Aeronautical Merit)

20 2 Olen toiminut opetustehtavissa Michiganin yliopistossa, Wayne State -yliopistossa, Illinois'n yliopistossa Chicagossa ja Chicagon Northwestern-yliopistossa, josta jain elakkeelle vuonna 1982 kliinisen kirurgian emeritusprofessorina. Toimin kirurgian ylilaakarina Illinois'n osavaltion Chicagon tuberkuloosiparantolan kansanterveysosastolla (Chicago State Tuberculosis Sanitarium, Department of Public Health ) ja thorax-kirurgian konsultoivana laakarina ja ylilaakarina Veterans Administration (veteraanihallinnon) -sairaalassa Hinesissa, Illinois'ssa ( ). Kuulun Yhdysvaltain thorax-kirurgian hyvaksymislautakunnan (American Board of Thoracic Surgery) perustajajaseniin ja toimin sen aktiivijasenena vuosina Lautakunta asettaa thorax-kirurgian erikoisalan koulutusvaatimukset ja vahvistaa nama vaatimukset tayttavat kirurgit erikoislaakareiksi. Olen lukuisten kirurgiseurojen seniorijasen. Naita ovat esimerkiksi kansainvalinen kirurgiseura (International Surgical Society), ja seuraavat yhdysvaltalaiset kirurgiseurat : the American, Central, Western, Pan Pacific, Illinois ja Chicago Surgical Societies. Lisaksi olen seniorijasenena thorax-kirurgien seurassa (Society of Thoracic Surgeons) ja Amerikan thorax-kirurgian yhdistyksessa (American Association for Thoracic Surgery), jossa olen toiminut johtokunnan sihteerina ( ), varapuheenjohtajana ja puheenjohtajana ( ). Olen seuraavien thorax-kirurgiseurojen kunniajasen : Western Thoracic Surgical Society ja Illinois Thoracic Surgical Society. 6809U

21 3 Olen kuulunut John Alexander Monograph Series -julkaisun toimitusneuvostoon vuosina ja Journal of Thoracic and Cardiovascular Surgery -lehden neuvottelukuntaan vuosina Olen toiminut vierailevana professorina Mayo-klinikalla (Mayo Clinic), Missourin yliopistossa, Floridan yliopistossa ja Michiganin yliopistossa. Vuonna 1975 Chicagossa sijaitsevan Illinois'n yliopiston kirurgian laitos myonsi minulle palkinnon ansiokkaasta palvelusta (Distinguished Service Award). Vuonna 1982 sain Donald L. Kesslerin palkinnon toiminnastani Chicagon St. Josephin sairaalan johtavana laakarina. Chicagon St. Josephin sairaalan uusi kirurgian poliklinikka nimettiin minun mukaani vuonna Minut mainitaan seuraavissa Marquis Publications -kustantamon Kuka kukin on -teoksissa : Who's Who in the World (Kuka kukin on maailmassa), Who's Who in America (Kuka kukin on Amerikassa) ja Who's Who in Science (Kuka kukin on tieteessa). Olen julkaissut yksin tai yhdessa muiden kirjoittajien kanssa 117 tieteellista tutkielmaa. Naihin kuuluu kaksi kirjaa ja 27 minulta pyydettya kirjan lukua. Ansioluetteloni ja julkaisuluetteloni ovat liitteena. Aloittaessani keuhkokirurgian erikoistumisopintoni vuonna 1939 Michiganin yliopistossa en ollut kuullut tupakoinnin vaikutuksesta terveyteen muuta kuin sen, minka isoaitini oli minulle kertonut, eli etta tupakointi pysayttaisi kasvuni ja saisi minut hengastymaan. Olin kuullut myos vertauksen 'kirstun nauloista', jonka ymmarsin tarkoittavan sita, etta savukkeen polttaminen olisi sama kuin naulaisi kiinni oman

22 4 arkkunsa kannen. Erikoistumisaikanani ei kuitenkaan viela kayty tieteellista keskustelua tupakoinnin vaikutuksista terveyteen. Toisen maaiimansodan aikana ja sen jalkeen, aina 1940-luvun lopulle asti, tupakoinnin terveysvaikutuksista ei juuri keskusteltu, enka nahnyt tyossani kovinkaan monta keuhkoputkista lahtenytta syopaa eli bronkogeenista karsinoomaa. Olin selvilla tri Alton Ochsnerin ja tri Richard Overholtin tutkimuksista. Luullakseni Ochsnerin ensimmaiseen 1930-luvulla julkaistuun tutkimusaineistoon kuului vain kourailinen tapauksia, ja han oli ensimmaisia niista, jotka alkoivat julkaista kokemuksiaan bronkogeenisesta karsinoomasta. Siina vaiheessa, kun tupakoinnin ja keuhkosyovan valinen tilastollinen yhteys raportoitiin 1950-luvun alkupuolella, arveltiin, etta bronkogeeninen karsinooma oli yleistynyt tai etta tapauksia ainakin todettiin enemman. Tiedemiespiireissa vaiteltiin paaasiassa siita, oliko insidenssin kasvu todellinen vai johtuiko se vain paremmasta diagnostisesta tarkkuudesta. Tama pohdinta jatkui 1950-luvun puolivaliin tai sen lopulle asti, ja itse asiassa keuhkosyopaluvuista kaydaan edelleen vilkasta keskustelua. Ennen kuin mielenkiinto kohdistui keuhkosyopaan, tuberkuloosi oli ollut ensisijainen diagnoosi niilla potilailla, joilla kliininen taudinkuva oli samanlainen kuin bronkogeenisessa karsinoomassa. Tilanne oli tama varsinkin suurimpien yliopistollisten keskussairaaloiden ulkopuolella, missa ei ollut kaytettavissa kaikkein uudenaikaisimpia diagnostisia valineita. Thorax-kirurgien keskuudessa Ochsner ja Overholt ottivat 1940-luvulla usein esiin kysymyksen tupakoinnin terveysvaikutuksista. Heidan nakemyksiaan ei kuitenkaan pidetty kovin suuressa arvossa, silla heidan katsottiin suhtautuvan asiaan

23 5 tunneperaisesti ja olevan yhden asian puolestapuhujia eika puolueettomia tiedemiehia. Thorax-kirurgit eivat suhtautuneet vakavasti heidan vaitteeseensa, etta tupakointi aiheuttaa syopaa luvun lopulla tri Oscar Auerbach toi esiin omana nakemyksenaan, etta tupakoitsijalla, jolla on invasiivinen karsinooma toisessa keuhkossa, havaitaan ruumiinavauksessa kudosmuutoksia myos toisessa keuhkossa, esimerkiksi suurella osalla, noin 15 prosentilla, carcinoma in situ. Auerbach yritti nain vastata vaitteeseen, etta jos tupakointi aiheuttaa keuhkosyopaa, syopamuutoksia olisi molemmissa keuhkoissa, koska molemmat keuhkot altistuvat savulie. Arvostettu kirurgi, tri William Tuttle vastasi hanelle : "Antaisitko sina, Oscar, poistaa keuhkosi tuollaisen carcinoma in situ -muutoksen perusteella?" Auerbach vastasi : "No, en." Tuttle osoitti, etteivat Auerbachin loydokset olleet r.iittava peruste johtopaatokselle, etta myos toisessa keuhkossa oli keuhkosyopa. Oma kasitykseni oli ja on edelleen se, etta olettamus tupakoinnin syy-yhteydesta on liian yksinkertaistettu selitys, koska se ei kerta kaikkiaan sovi yhteen omien kliinisten kokemusteni kanssa. Taman olettamuksen ja potilaista tekemieni havaintojen valilla on useita ristiriitaisuuksia, joita tarkastelen jaljempana luvulla yha useammat kollegat alkoivat kuunnella naita olettamuksia ja hyvaksyivat teorian, jonka mukaan tupakointi aiheuttaa syopaa ja muita sairauksia. Minusta vaikutti kuitenkin silta, etta kukaan heista ei todella paneutunut asiaan perusteellisesti ; oli paljon helpompi vain menna muodin mukana. Useimmat niista, jotka lopulta hyvaksyivat olettamuksen, eivat koskaan pysahtyneet tutkimaan kirjallisuutta, johon se perustui, eivatka tekemaan omaa tutkimusta