Dear Editor,
In your excellent review of Robert N. Proctor's book, The Nazi War on Cancer (Medical Sentinel, November/December 2000), you postulate that the drop-off in stomach cancer in the earlier 20th Century was possibly related to better methods of meat curing and preservation.

As an amateur student of history, I have always found the reverse parallel between stomach, oropharyngeal and lung cancers to be most interesting. Having trained at the Alton Ochsner Medical Foundation in New Orleans, Louisiana, I came into contact with the writings of Dr. Alton Ochsner, Sr. As a professor of surgery at Tulane University Medical School earlier in the 20th Century, Dr. Ochsner did some of the finest pioneering epidemiological research on the origins of lung cancer ever seen in the medical world. By his research he factually demonstrated and logically deduced that lung cancer was directly attributable to cigarette smoking. And what he learned and wrote about has been scientifically manifested on the altar of human history.

With the discovery of the New World, European traders engaged in a tobacco commerce with the North American Indian nations. Some men would put it into a pipe and smoke it while others chewed it. Now if anyone has ever chewed tobacco, (and I am not one of those), you know that it is axiomatic that if you swallow the tobacco juice for whatever reason you can get a pretty good bellyache and may even "heave your cookies." As the tobacco habit spread and became more socially acceptable, there soon were so many men chewing and spitting that public hygiene became a real problem. In an effort to make the world spittle-free for democracy, spittoons were made and distributed in public houses so that men could expectorate into these vessels rather than on the floors or in the public places in order to avoid an unavoidable breach in public comity that arose from this regrettable social phenomenon. At a time when tuberculosis reached crisis proportions and was killing off large numbers of people in the 19th century in this country and abroad, public health authorities weighed in to combat the very vector of spread --- expectorated mouth and bronchial secretions. It actually became unlawful to "spit on the sidewalk" --- literally. Inasmuch as a sociolegal taboo was applied to tobacco chewing --- if you can't legally spit you can't really safely chew it --- the numbers of men chewing plummeted and so did mouth and stomach cancers.

But vice is nice, and so men had to get their tobacco fix satisfied another way. Now we come to cigarette smoking, first hand-rolled and then machine-rolled, in effect, mass-producing cigarettes in prodigious numbers. So in an eyeblink of time, chewing was almost completely replaced by cigarette smoking, which was not held to be objectionable to the ways and manners of society at that time. Thus, we see at a moment in history when the TB sanitariums were filled to the gunwales and public health officials had condemned as unhealthy and unwise tobacco chewing, there began a steady meteoric rise in lung cancer rates that neatly paralleled the increasing popularity in cigarette usage.

Again, in reference to your review, you postulate that better meat processing was the cause of lower incidence of stomach cancer, history really reveals that one vice was switched for another. And lung cancer eventually eclipsed stomach and mouth cancers when spitting and spittoons went the way of the dinosaur --- unless you play baseball of course.

W. Patrick Flanagan, Jr., MD, FACS
Waukesha, WI

Correspondence originally published in the Medical Sentinel 2001;6(1);1-4. Copyright©2001 Association of American Physicians and Surgeons (AAPS).