Stockings and Chairs

201   “In 1919”: Richard Kluger, Ashes to Ashes: America’s Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris (New York: Knopf 1996). Chapter Four, “The Golden Age of Malarkey,” 109.

Kluger’s book is dedicated—like so many books and papers on subjects related to denial—with a certain pronounced weariness: “With love for Phyliss, who is all too familiar with the subject.”

201   “As usual”: Jesse Steinfeld, M.D., et al (Eds.), Smoking and Health: Proceedings of the Third World Conference On Smoking and Health, Volume II, U.S. Department of Health, Education and Welfare, Public Health Service, National Institutes of Health 1975. 14-5. Dr. Ochsner addressed the Plenary Session, June 2, 1975.

201   “Nine cases in six months”: Steinfeld, Smoking and Health. Lester Breslow, A History of Cancer Control in the United States, 1946-1971 (Bethesda, MD: U.S. National Cancer Institute, 1979), Book One: A History of Scientific and Technical Advances in Cancer Control. 1:170. “The sudden increase in incidence,” Ochsner understood, “represented an epidemic.”

Alton Ochsner, “My First Recognition of the Relationship of Smoking and Lung Cancer,” Preventive Medicine, 2:611-14. 1973.

201   Ochsner brought his suspicions: The way Ochsner later put this was directness itself. “There is a distinct parallelism between the sale of cigarettes and the incidence of bronchogenic carcinoma.”

Alton Ochsner, Paul T. DeCamp, et al, “Bronchogenic Carcinoma, Its Frequency Diagnosis And Early Treatment,” Journal of the American Medical Association, Vol. 148, March 1952.

202      Graham, a heavy smoker: Brandt begins his moving section on Drs. Graham and Ochsner with this sharp observation: Graham was “a heavy smoker who had suffered no apparent ill effects.” Apparent. This must have been how it felt to many mid-century smokers—who were, in effect, beta testers. Allan Brandt, The Cigarette Century, Chapter Five, “The Causal Conundrum,” 131.

202      you could smoke in hospitals then: Marc R. Moon, MD, “History of Cardiothoracic Surgery at Washington University in Saint Louis,” Seminars in Thoracic and Cardiovascular Surgery, Vol 28 No. 3, September 2016. “Dr. Graham himself was a habitual smoker reportedly unless asleep, in the operating room, or on rounds.”

C. Barber Mueller, foreword by Ben Eisenman, Evarts A. Graham: The Life, Lives, and Times of the Surgical Spirit of St. Louis, B. C. Decker, 2002. 393. Recalling the same nicotine schedule: “Graham was an inveterate smoker. I.Y. Olch remembered that ‘he was smoking a cigarette all the time. The only time he never smoked was when he was asleep, when he was operating and when he was making ward rounds.’”

Ochsner recalls Graham as a “very heavy cigarette smoker,” in “My First Recognition of the Relationship of Smoking and Lung Cancer,” Preventive Medicine, 2: 611–614. 1973.

Devra Davis, The Secret History of the War on Cancer, Basic Books 2007. Chapter Six, “Making Goods Out of Bads,” 145–146.

“At the time, most men, including most cancer researchers, smoked. Surgical conventions were full of smokers. A chain-smoker who depended on large doses of nicotine, Graham would not accept that cigarettes could be a hazard.”

202      perhaps the nation’s foremost: Brandt, The Cigarette Century, 131. “The procedure he devised [history’s first successful removal of a cancerous lung] required significant innovations in surgical technique and offered the best available treatment for bronchogenic carcinoma.”

The procedure was known as a pneumonectomy. “Graham was already a giant among American surgeons but the procedure solidified his claim to greatness.” Leora Horn, David H. Johnson, “Evarts A. Graham and the First Pneumonectomy for Lung Cancer,” Journal of Clinical Oncology, Vol. 26, No. 19, July 1, 2008.

As The Journal of Thoracic Surgery notes, “Honors and distinctions of every kind were showered on Evarts Graham.” Tom Buford, “Evarts Ambrose Graham (1883-1957): Eulogy,” Journal of Thoracic Surgery, Vol. 36, Issue 3, September 1958. The same journal explains that Graham “dominated American surgery during the middle third of the 20th century.” Thomas A. D’Amico, “Historical Perspectives of The American Association for Thoracic Surgery: Evarts A. Graham,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 142, Issue 4, October 2011.

202      “has the use of nylon stockings.”: Lester Breslow, A History of Cancer Control in the United States, 1946-1971 (Bethesda, MD: U.S. National Cancer Institute, 1979), Book One: A History of Scientific and Technical Advances in Cancer Control. 1:170-72.

Alton Ochsner, “My First Recognition of the Relationship of Smoking and Lung Cancer,” Preventive Medicine, 2:611-14. 1973.

James T. Patterson, The Dread Disease, Cambridge: Harvard University Press 1987, Chapter Eight “Smoking and Cancer,” 208.

Mukherjee, Emperor of All Maladies, 242. For what it’s worth, Mueller in Evarts A. Graham has it as not nylon but pricier silk stockings. Ochsner himself has nylon: Ochsner adds, likably honest, “Which I could not refute.”

202      “How dumb and stupid”: Charles Barber Mueller, Evarts A. Graham: The Life, Lives, and Times of the Surgical Spirit of St. Louis, B.C. Decker 2002. Chapter 18, “Smoking and Lung Cancer,” 357.

John Wilds, Alton Ochsner, Surgeon of the South. LSU Press, 1990. 180

Allan Brandt, in The Cigarette Century, summarizes the Graham attitude as “skepticism and derision”; he also provides the understandable reason for Graham’s initial doubt. “Given that cancers were typically found in but one lobe, Graham reasoned, smoking was unlikely to be the cause. Why, when the smoke obviously entered both lobes, would only one be affected?” Brandt, Cigarette Century, 131.

202      “our intuitive acuity”: Mukherjee, Emperor of All Maladies, 241

202      Graham aimed to disprove: Mukherjee, The Emperor of All Maladies. 244.

“Graham didn’t believe the connection between smoking and cancer either. The great pulmonary surgeon, who operated on dozens of lung cancer cases every week, was rarely seen without a cigarette himself. But he agreed to help [Ernst] Wynder with the study in part to conclusively disprove the link and lay the issue to rest.”

202      “I may have to eat humble pie”: Moon, “History of Cardiothoracic Surgery at Washington University in Saint Louis,” Seminars in Thoracic and Cardiovascular Surgery. Graham was gracious: “Al, I am afraid I owe you an apology.”

In Evarts A. Graham, Charles Mueller points out just how rare a Graham concession was: “Graham seldom apologized to anyone for anything.” Graham wrote Ochsner, “Recently Wynder, an associate, and I completed a study of our patients with cancer of the lung and as you said, nearly all of them were heavy smokers.” Chapter 18, 357.

202      He cut out smoking: Brandt, Cigarette Century, 157. “Faced with his own research findings, Graham had quit smoking.” Breslow, A History of Cancer Control in the United States, 1946-1971 1:172. Even for a thoracic surgeon, easier said than done. “Persuaded by the evidence, Graham altered his personal smoking habit, decreasing his cigarette consumption to six per day—two after each meal.” A few years later, Ochsner writes in Preventive Medicine, “Dr. Graham then completely refrained from smoking.”

202      “published in 1950”: Ernst L. Wynder, Evarts A. Graham, “Tobacco Smoking As A Possible Etiologic Factor In Bronchiogenic Carcinoma: A Study Of 684 Proved Cases,” Journal of the American Medical Association, Vol. 143 No. 3, May 27, 1950.

202      “approximately parallel”: One of those spots where repeated language keeps sticking. In his JAMA piece, Alton Ochsner saw a “distinct parallelism between the sale of cigarettes and the incidence of bronchogenic carcinoma.”

The way Graham—after once finding the idea dumb and stupid—phrased this is nicely similar. “The enormous increase in the sale of cigarettes in this country approximately parallels the increase in bronchogenic carcinoma.”

This went out to America through Reader’s Digest: Drs. Ochsner and Graham, making the case, sounding the alarm, in successive paragraphs. Per Allan Brandt in The Cigarette Century, they became, in the cigarette-carcinoma struggle, “steadfast allies.” 134.

202      on easy terms with personal extinction: Davis, The Secret History of the War on Cancer. 304.

202      “No crowding, please”: “As Evarts Graham humorously explained in a 1954 commentary that appeared in the Lancet. . . ” Brandt, Cigarette Century. Chapter Four, “More Doctors Smoke Camels,” 129.

Quoting Evarts A. Graham, “Remarks on the Aetiology of Bronchogenic Carcinoma,” The Lancet 263, No. 6826, June 26, 1954.

202      for the good of its figure, doctors fed it Lucky Strikes: Mukherhjee, The Emperor of All Maladies, 254; Kluger, Ashes to Ashes, 161.

Lauren Ackerman—who would later give Graham his own diagnosis—reviewed the skin sections. Mueller, Evarts A. Graham, Chapter 18, “Smoking and Lung Cancer,” 362.

203      Dr. Graham published: Ernest L. Wynder, Evarts A. Graham and Adele B. Croninger, “Experimental Production of Carcinoma with Cigarette Tar,” Cancer Research, December 1953.

203      up from 4,000 three decades prior: Thomas Whiteside, “A Reporter At Large: A Cloud of Smoke,” The New Yorker, November 30, 1963.

203      “Every year, cigarettes kill”: Kennedy delivered this address before the First World Conference on Smoking and Health, Waldorf Astoria Hotel, New York City, September 11, 1967. Jane E. Brody, “Kennedy Urges Cigarette Curbs: Will Offer Senate Bills To Extend Advertising Rules and Establish Tax Scale,” The New York Times September 12, 1967.

Jane Brody’s report omits the military comparisons. Richard B. Birrer, Urban Family Medicine, Springer 1997, 181 carries the complete tally. “Every year cigarettes kill more Americans than were killed in World War I, the Korean War, and Vietnam combined; nearly as many as died in battle in World War II. Each year cigarettes kill five times more Americans than do traffic accidents. Lung cancer alone kills as many as die on the road. The cigarette industry is peddling a deadly weapon. It is dealing in people’s lives for financial gain.”

203      In 1956: Charles Barber Mueller, Evarts A. Graham. Chapter 19, “Illness and Finale,” 357. Just before Christmas; the symptoms were “a cough,” plus “malaise and weakness.” 393.

Allan Brandt begins his moving section on Drs. Graham and Ochsner with this sharp observation. Graham was “a heavy smoker who had suffered no apparent ill effects.” This must have been how it felt to many smokers: they were beta testers. Allan Brandt, The Cigarette Century, Chapter Five, “The Causal Conundrum,” 131.

203      sort of flu that sends you to bed: Leora Horn, David H. Johnson, “Evarts A. Graham and the First Pneumonectomy for Lung Cancer,” Journal of Clinical Oncology, Vol. 26, No. 19, July 1, 2008. In a letter to co-researcher Ernest Wynder, Graham said he’d suffered his “bad flu bug” for six weeks, with no “particular progress.”

203      “That cancer must have been”: Horn, Johnson, “Evarts A. Graham,” Journal of Clinical Oncology.

Mueller, Evarts A. Graham, 394. Graham protégé Thomas Buford told Graham protégé Lauren Ackerman, “Lauren, you have to go and tell Dr. Graham. It’s beyond me. I can’t do it.”

203      who pronounced his tumor inoperable: Mukherjee, The Emperor of All Maladies. Part Four, “Prevention is the Cure,” 256. “The surgeon looked at the X-rays and deemed the tumor inoperable and hopeless. Graham then informed him quietly, ‘[The tumor] is mine.’”

203      “the irony that fate has played on me”: Leora Horn, David H. Johnson, “Evarts A. Graham and the First Pneumonectomy for Lung Cancer,” Journal of Clinical Oncology, Vol. 26, No. 19, July 1, 2008. That doctor was research colleague Ernst Wynder; the two had collaborated on the robot and mouse results that so alarmed the tobacco industry.

Wynder later recalled his hospital visit. “When [Evarts Graham] was dying I went to St. Louis. He was lying in an oxygen tent. I remember he pointed to a little sign on the oxygen tent where it said “No Smoking.’ He said, ‘I should have listened.’”

Wynder added, “He wrote me a very moving letter stating that fate had really done him badly for all the work he had done on lung cancer.” Breslow, A History of Cancer Control in the United States, 1946-1971 1:173.

203      “had sneaked up on me like a thief in the night”: Evarts A. Graham to Alton Ochsner, February 14, 1957. In Allan Brandt, The Cigarette Century, Chapter Five, “The Causal Conundrum,” 157.

Brandt quotes Ochsner’s graceful letter back, which must have been difficult to compose. “Thank you for your letter,” Ochsner wrote, “which simply crushed me. It is a perfectly horrible thing to think that you have bronchiogenic carcinoma, a condition for which you have done so much.” Brandt notes, “In the end, he became yet one more data point in the lethal history of smoking.”

203      two weeks later: Ochsner, Preventive Medicine. Mukherjee, The Emperor of All Maladies, 257. “Two weeks later, Graham grew dizzy, nauseated, and confused while shaving.” The famous surgeon “drifted into a coma and died in his room.”

Leonora Horn and David Johnson write in The Journal of Clinical Oncology that Graham’s “death marked the passing of a true titan in the pantheon of American surgeons.” The surgical feat that made Graham’s name was that first pneumonectomy—first successful removal of a cancerous lung. His patient was in the field; James Gilmore, a Pittsburgh gynecologist and obstetrician.

In yet another irony of almost unimaginable proportion, one of Graham’s last deathbed visitors was James Gilmore. The two had forged a relationship that had lasted more than four decades, and the poignancy of this final act of an enduring friendship is heart wrenching. One can only imagine the essence of that final encounter. What did Gilmore say to the man who had cured his lung cancer, and now lay dying of that same illness? Equally intriguing, what did Graham say to Gilmore?

Leora Horn, David H. Johnson, “Evarts A. Graham and the First Pneumonectomy for Lung Cancer,” Journal of Clinical Oncology, Vol. 26, No. 19, July 1, 2008.

203      Alton Ochsner had got his first look: Mukherjee, The Emperor of All Maladies, 257.