Migratin g tech n iques,
m ultiplyin g diagn o ses:
th e con tribution of
Argen tin a an d Brazil to
early ‘detection policy’ in
cervical can cer *
Técnicas que m igram ,
diagnósticos que se
m ultiplicam : a contribuição
de Argentina e Brasil para a
política de ‘detecção precoce’
do câncer cervical
Yolanda Eraso Wellcome Trust Research Fellow,
Oxford Brookes University La Coruña 1482, 5014 – Córdoba – Argentina
yolyeraso@yahoo.co.uk
Recebido para publicação em julho de 2009. Aprovado para publicação em março de 2010.
ERASO, Yolan d a. Migratin g tech n iq u es, m u ltip lyin g d iagn oses: th e
con tribu tion of Argen tin a an d Brazil to early d etection p olicy in cervical can cer. História, Ciências, Saúde –
Manguinhos, Rio d e Jan eiro, v.17,
su p l.1, Ju ly 2010, p .33-51.
Ab s t r a c t
Th is article on th e early d etection of cervical can cer focu ses on th e d evelop m en t of two lead in g d iagn ostic tech n iq u es – colp oscop y an d th e Pap sm ear test – an d th eir h istories in Argen tin a an d Brazil. It exp lores h ow d iagn ostic tools were tran sferred between Eu rop e an d th e Am ericas, wh ile exam in in g th e in tersection of cu ltu ral an d m ed ical asp ects an d th e p rocesses of ad ap tation an d resign ification in th e receivin g cou n tries. Colp oscop y received little atten tion in th e m ain Western m ed ical cen ters u n til Sou th Am erican cou n tries reasserted its sign ifican ce in th e 1950s. ‘Perip h eral’ cen ters p layed a cen tral role in early d etection p olicies an d th e com bin ed u ses of th ese m eth od s gave rise to a n ew stage of ‘cu m u lative con fid en ce’ in cervical can cer d iagn osis an d screen in g.
Keyword s: tran sn ation al h istory; colp oscop y; Pap test; cervical can cer; d iagn osis.
Res u m o
Este artigo trata da detecção precoce do câncer cervical. Coloca em evidência as duas principais técnicas diagnósticas, a colposcopia e o teste de Papanicolau, e m ostra suas trajetórias no Brasil e na Argentina. Analisa o m odo com o se deu a transferência de m étodos diagnósticos entre a Europa e as Am éricas, procurando perceber a interseção de aspectos m édicos e culturais e ainda os processos de adaptação e ressignificação nos países que acolheram as novas técnicas. A colposcopia recebeu pouca atenção nos principais centros m édicos ocidentais até os países sul-am ericanos validarem sua im portância nos anos 1950. Centros ‘periféricos’ desem penharam papel crucial nas políticas de detecção precoce, e o uso com binado desses m étodos deu lugar a novo estádio de ‘confiança cum ulativa’ no exam e e diagnóstico do câncer cervical.
T
h is article an alyzes th e h istory of th e two m ain m eth od s of cervical can cer d etection – co lp o sco p y an d t h e Pap sm ear t est – an d h o w t h eir h ist o ries in Argen t in a an d Brazil con tribu ted to red efin in g can cer categorization an d d iagn osis arou n d th e world . Th e stu dy is firm ly rooted in a tran sn ation al p ersp ective an d u ses th e n otion of tran sfer to in terp ret th e m igration of m ed ical id eas an d tech n ologies across n ation al bord ers. Exp lorin g broader asp ects of social h istory, th e stu dy of socio-cu ltu ral in teraction s between cou n tries – n am ely, com p arative h istory, transfert culturel, an d , m ore recen tly, histoire croisée – h as attracted a wid e ran ge of sch olarsh ip for over twen ty years (Wern er, Zim m erm an n , 2006). However, it h as on ly been recen tly th at tran sn ation al exch an ges h ave in terested h istorian s o f m ed icin e an d scien ce. Th e id ea t h at Lat in Am erican m ed icin e an d h ealt h care h ave been h eavily in flu en ced by Eu rop ean an d Am erican id eas an d m od els is alm ost a self-evid en t id ea for h istorian s, yet th e actu al, com p lex p rocess by wh ich th is wid ely recogn ized in flu en ce h as taken p lace in con crete cases h as been u n d erestim ated . Likewise, th e in flu en ce of foreign id eas on th e h istories of th e m ain Western m ed ical system s h as rarely been addressed, in an overtly n ation -cen tered p ersp ective.If we fo cu s o n a d isease like can cer, t ran sn at io n alism feat u res largely in it s h ist o ry, d esp ite cou n tries’ efforts to m ain tain an association between ‘m ed ical in n ovation s’ an d ‘n ation al h istories.’ Th is p ap er p rop oses th at th e h istory of th e diagn osis of cervical can cer cou ld be read as a story of acad em ic exch an ges, m igratin g p eop les, p erson al con tacts, an d n ation alistic zeal. Sp ecifically, I argu e th at its h istory can be better u n d erstood if atten tion is d rawn to syn ch ron ic d evelop m en ts in several cou n tries at a given m om en t.
Over th e p ast few d ecad es, m ost p reven tive cam p aign s for th e early d etection of cervical can cer in Argen tin a an d Brazil h ave relied on th e u se of colp oscop ies an d Pap tests as ‘rou tin e p roced u res,’ wh ile in th e Un ited States an d in Eu rop ean cou n tries, colp oscop ic exam in ation h as been reserved as a follow-u p to abn orm al Pap tests. In ven ted by Germ an gyn eco lo gist an d p at h o lo gist Han s Hin selm an n in 1925, t h e t ech n iq u e o f co lp o sco p y received little atten tion in th e m ain Western m ed ical cen ters u n til th e 1950s. However, relian ce on h is tech n iq u e d id sp read to Argen tin a an d Brazil, wh ere it is said to h ave been saved from oblivion d u rin g World War II. In th is sen se, th e article exam in es th e in tersection of a series of elem en ts in th e above-m en tion ed cou n tries in ord er to exp lore h ow th ese diagn ostic tools were tran sferred . It first focu ses on th e cu ltu ral an d m edical settin gs wh ere th e p rocess of tran sfer took p lace, with sp ecial focu s on th e in term ed iary ch an n els in h eren t t o gyn eco lo gy (in st it u t io n s, co n gresses, an d p u b licat io n s). Seco n d , it ex am in es t h e developm en t of colp oscop y in a con text wh ere th e d iagn osis of can cer at an early stage becam e a wid ely accep ted n otion am on g sp ecialists. Th is th en lead s to an an alysis of th e ‘m ed iators,’ or agen ts an d in d ivid u als wh o, accord in g to Ch ristop h e Ch arle (2004, p .199-200), p lay t h ree d ist in ct ive ro les: im p o rt in g an d exp o rt in g kn o wled ge an d m et h o d s; tran sm ittin g su ch kn owled ge by settin g u p sch ools, learn ed societies, an d jou rn als; an d , fin ally, ad ap tin g tran sferred kn owled ge to th e local cu ltu re.
often im p lies ch an ges in th e origin al p ractice th at will ad ap t it to its n ew en viron m en t, so th at its foreign origin is n o lon ger visible” (Te Veld e, 2005, p .208). Sign ifican tly, th is cou ld im p ly p ercep t ible ch an ges su ch as lin gu ist ic o n es (i.e., t h e t ran slat io n o f t erm s o r t h e in trod u ction of n ew term in ology) or, m ore im p ortan tly, ch an ges observable at th e level of p ractices. I argu e th at m ean in gfu l ch an ges in can cer d iagn osis were p erceived as a resu lt of th e tran sferred d iagn ostic tools, wh ose im p lication s wen t beyon d th e bord ers of th e cou n tries an alyzed .
Transnational academic exchanges and international networks: the case of obstetrics and gynecology
In tern ation al academ ic exch an ges h ave n ot occu rred con tin gen tly bu t rath er th rou gh a ran ge of ch an n els th at h ave m ad e con tacts p ossible, n am ely: acad em ic travels to foreign in stitu tion s, th e circu lation of sp ecialized p u blication s, exch an ge p rogram s for in tern ation al stu den ts, th e organ ization of in tern ation al con feren ces, an d th e dissem in ation of kn owledge b y in t ern at io n al o rgan izat io n s (Ch arle et al., 2004, p .13). In t h e m ed ical field , So u t h Am erican stu d en ts h ave gon e abroad to com p lete sp ecialized m ed ical train in g. In th e case of obstetrics an d gyn ecology, stu d en ts h ave traveled to d ifferen t p laces d u rin g d ifferen t p eriod s. Sin ce th e en d of th e n in eteen th cen tu ry, Fran ce an d Germ an y were th e m ain m ed ical sch o o ls t h at d rew st u d en t s in t h e West ern wo rld . Fran ce b ecam e p art icu larly ren own ed in th e area of obstetrics an d p u ericu ltu re d u rin g th e first d ecad es of th e twen tieth cen tu ry. For th ose sp ecializin g in gyn ecological can cer, a visit to th e Cu rie In stitu te to gain fam iliarity with th e latest tech n iq u es d evelop ed in rad ioth erap y an d rad iu m also becam e m an d at o ry.
Alth ou gh Fren ch m ed icin e con tin u ed to in flu en ce Latin Am erican m ed ical ed u cation , th e 1930s witn essed an in creasin g re-en gagem en t with Germ an m ed icin e, esp ecially in th e areas o f gyn eco lo gy an d su rgery. Th is p ro cess was facilit at ed t h ro u gh t h e creat io n o f in st it u t io n s o n b o t h sid es o f t h e At lan t ic. Th e Argen t in ean Co m m it t ee o f Un iversit y In form ation was set u p in Berlin in 1931 to assist stu d en ts in gain in g acad em ic exp erien ce at Germ an u n iversities. Between 1935 an d 1938, with in th e Th ird Reich ’s h ealth system , it was t h e Deu t sch -Ibero -Am erikan isch e Ärzt e-Akad em ie (Germ an -Ibero am erican Med ical Acad em y) th at best p rom oted coop eration , exch an ge, an d ed u cation for Latin Am erican d octors. Th e Acad em y’s work was very in ten se, as d em on strated by its cycles of con feren ces an d h osp ital train in g, its fin an cial aid for d octors (gran ts an d sch olarsh ip s), an d its action as an in term ed iary wh en d octors wan ted to acq u ire p recision in stru m en ts, on e of Germ an y’s m ain exp ort in du stries (Reggian i, 2005). Between 1936 an d 1938, h u n dreds of Latin Am erican d octors visited Germ an y u n d er th e au sp ices of th e Acad em y an d , in th e case of Brazil an d Argen tin a, th e sp on sorsh ip of th e Bayer p h arm aceu tical com p an y (Sá et al., 2009). Th e ad ven t of Nation al Socialism th u s seem s to h ave rein forced th e ch an n els for d issem in atin g Germ an m ed icin e in Sou th Am erica, at least u n til th e start of World War II.
an d Argen tin ean d octors workin g to com p lete th eir sp ecialization stu d ies at p restigiou s h osp itals an d in stitu tes. Alth ou gh th e Fou n d ation h ad m ain tain ed su p p ortin g p rogram s an d fellowsh ip s in p u blic h ealth an d ep id em ic con trol an d erad ication sin ce its in cep tion in 1913, in th e 1940s its p olicy sh ifted to su p p ortin g scien tific ed u cation an d focu sin g on th e work of recogn ized research ers an d in stitu tes in biom ed ical in vestigation (Cu eto, 1994, p .128-131). In 1941, an in tern ation al h ealth d ivision office for Latin Am erica was set u p in Bu en o s Aires, alt h o u gh t h e m ain su p p o rt given t o t h e co u n t ry was alm o st exclu sively con cen trated in p h ysiology, an in vestm en t th at su bseq u en tly h elp ed to d evelop th e field in Brazil. Toward s th e en d of 1941, Brazil rejected its form er n eu tral stan ce toward s th e Axis cou n tries, p u ttin g th e circu lation of Germ an sp ecialists an d in stru m en ts on h old . As Alexan d re Ribeiro d e Carvalh o h as st at ed , t h is sign aled “t h e en d o f Germ an t ech n ical p red om in an ce in can cer su rgery an d rad ioth erap y in Brazil, an d th e start of th e p revalen ce of Am erican tech n ology in th e n ewly created su b-field of Brazilian m ed icin e”, (Ribeiro d e
Carvalh o, 2006, p .92).
Du rin g th e 1940s, Latin Am erican n etworks in obstetrics an d gyn ecology also served as im p ortan t veh icles for th e tran sfer of m ed ical id eas, as we will see th rou gh ou t th is p ap er. With World War II forcin g isolation from Eu rop ean cen ters, Latin Am erican cen ters an d d octors forged closer lin ks am on g th em selves. In tern ation al con gresses an d con feren ces p layed a m ajor role in th e exch an ge of m ed ical exp erien ces bu t so too d id th e gen eration of n etworks an d relation sh ip s th at later resu lted in fu rth er collaboration . In tern ation al con gresses in obstetrics an d gyn ecology started to be celebrated with regu larity from 1931 o n , wh en Argen t in a o rgan ized it s first n at io n al co n gress in b o t h sp ecialt ies, wit h t h e p articip ation of Sou th Am erican sp ecialists. In ad d ition , h eld an n u ally sin ce 1940, th e River Plate m eetin gs origin ally organ ized by Uru gu ay an d Argen tin a were atten d ed by an in creasin g n u m b er o f Lat in Am erican d o ct o rs. Mo reo ver, t h e d irect p ro d u ct s o f t h ese con gresses, like p roceed in gs an d sp ecial jou rn al issu es, were in stru m en tal in tran sm ittin g t h e n o t io n o f a Lat in Am erican p ersp ect ive in t h e sp ecialt y, a m essage t h at was m ad e cen tral to th e jou rn al Obstetricia y Ginecología Latino-Am ericanas wh en it first ap p eared in 1943. Toward s th e en d of th e d ecad e, th e Latin Am erican Fed eration of Societies of Obstetrics an d Gyn ecology (Fed eración Latin o-am erican a d e Socied ad es d e Obstetricia Y Gin ecología, or Flasog) (1949) sign aled th e cu lm in ation of a lon g p rocess of p rofession al coh esion in th e field. As we will see, th is m edical in tegration also p rovided th e con text wh erein diagn ostic tools for th e early detection of gyn ecological can cer circu lated .
Hinselmann and the visualization of precancerous lesions
colp oscop e, with th e h elp of Leitz tech n ician s. Th e d evice con sisted of a fixed bin ocu lar in stru m en t m ou n ted on a trip od an d eq u ip p ed with a ligh t sou rce an d a m irror to d irect th e ligh t. Sin ce th en , a wid e variety of im p rovem en ts h ave been m ad e to op tim ize th e fu n ction in g an d cap abilities of th e colp oscop e, m an y of wh ich were in trod u ced by th e in ven tor h im self. Th e m agn ified im ages sh owed Hin selm an n th at leu kop lakia d isp layed d ifferen t sh ap es an d featu res, an d h e com p leted h is an alysis with th e h istological correlation of each im age. He con clu d ed th at in m ost cases leu kop lakia con stitu ted sm all carcin om as.
W ith regard to so-called early can cers, we can n ow say th at colposcopy en ables detection o f co n sid erably earlier cases. Even a t in y d o t -like t u m o r sh o u ld n o t escap e d et ect io n . In p rin cip le we can d et ect lesio n s as sm all as o n e co u ld care t o t h in k o f (Hin selm an n , in Bu rgh ard t, 1998, p .4).
Un til th en , gyn ecologists cou ld on ly d etect visible tu m ors of th e cervix of arou n d 4cm , a size th at in d icated localized can cer (classified as stage I), th at is, th at th e d isease h ad n ot been sp read beyon d th e u terin e cervix. Even in su ch id eal cases, 5-year su rvival rates were n o t sign ifican t ly h igh . Hin selm an n also en h an ced t h e co lp o sco p ic view o f ab n o rm al ep ith eliu m by stain in g th e cervix with acetic acid , wh ich tu rn ed abn orm al cells wh ite. By 1928, th e tech n iq u e was im p roved by a test in ven ted by Sch iller, in wh ich th e su rface of th e cervix was p ain ted with an iod in e solu tion to con trast th e im ages of p oten tial abn orm al cells d u rin g colp oscop ic exam in ation . Norm al ep ith eliu m tu rn s m ah ogan y brown , wh ile atyp ical (ben ign or m align ) lesion s ap p ear u n stain ed or wh ite, in th e latter case becau se th e cells are d eficien t in glycogen , cau sin g th em to react d ifferen tly.
In t a n d e m w it h t h e se im p r o v e m e n t s in v isu a liza t io n , H in se lm a n n d e v e lo p e d term in ology to d escribe th e variou s lesion s h e observed with th e colp oscop e. He d rew atten tion to th ree d etected im ages: leu kop lakia, p u n ctu ation (wh ich h e called ground of leu kop lakia), an d Felderung, n ow kn own as m osaic leu kop lakia. Histological stu d y of th ese ch an ges led h im t o classify t h e ep it h eliu m in t o t wo larger gro u p s, “at yp ical o r sim p ly atyp ical” an d “m arked ly atyp ical or can cerou s,” each of wh ich corresp on d ed to d ifferen t m at rixes o r st ages o f t issu e t ran sfo rm at io n s. Mo re im p o rt an t were t h e co n clu sio n s h e d rew from h is d etailed observation s: “excep tion ally with th e n aked eye bu t certain ly with th e colp oscop e, it is p ossible to d etect ep ith elial ch an ges wh ich ap p ear as leu kop lakia an d wh ich in tim e m ay p rogress to carcin om a” (Hin selm an n , in Bu rgh ard t, 1998, p .4).
con testation , as sh own by th e n u m erou s classification s th at followed d own th rou gh th e years. Ult im at ely, p o lit ical circu m st an ces also p layed an im p o rt an t ro le in t h e fat e o f colp oscop y as a d iagn ostic tool. Alth ou gh Hin selm an n ’s in volvem en t in cervical can cer exp erim en ts d u rin g th e Nazi p eriod was n ever p roved , h is collaborators – Ed u ard W irth s (a d o ct o r at Au sch wit z) an d h is b ro t h er Helm u t (a co lleagu e o f Hin selm an n ) – were co n d em n ed fo r u sin g “t h e co lp o sco p e t o co llect sam p les o f cervical t issu e fro m cam p in m ates, wh ich were th en sen t back to Ham bu rg for exam in ation by Hin selm an n an d Helm u t” (Proctor, 2000, p .33). Hin selm an n was, h owever, sen ten ced to th ree years in p rison in 1946 by a British Military Govern m en t Cou rt in Ham bu rg for th e sterilization of six gyp sies. Du rin g th is tim e, on ly ‘p erip h eral’ cen ters like Switzerlan d , Au stria, Brazil, an d Argen tin a ad op ted colp oscop y as a d iagn ostic tech n iq u e.
Argentina
Colposcopy
In 1 9 2 8 , Dr. Ah u m ad a, t h en assist an t at t h e G yn eco lo gic C lin ic at Bu en o s Aires Un iversit y, in t ro d u ced t h e first co lp o sco p e in t o clin ical p ract ice d u rin g a p erio d o f ren ovation an d im p rovem en ts in trod u ced by th e n ewly ap p oin ted h ead of th e clin ic, Dr. Ju lio Iribarn e (Ah u m ad a, 1935). At th e Prim er Con greso d e Obstetricia y Gin ecología in 1931, Ah u m ad a h igh ligh ted th e efforts in th e early d iagn osis of can cer in Germ an y (th e co u n t ry w h ere h e t ra in ed ) a n d p resen t ed co lp o sco p y a s a lea d in g m et h o d fo r t h e visu alization of wh at h e called th e leu kop lakia p eriod (De la Vega, 1931, p .491).
An oth er im p ortan t lan d m ark in th e broad er u se of colp oscop y in Argen tin a an d in d eed in Latin Am erica was p u blication of a d etailed , fu lly-illu strated article on th e tech n iq u e by Dr. Roberto Gan d olfo Herrera, p u blish ed in th e jou rn al Revista Médica Latino-Am ericana in 1934. In it, h e d escribed Hin selm an n ’s classification of colp oscop ic im ages an d d rew sp ecial atten tion to recogn ition of th e ‘p re-leu kop lakia states’ an d th eir h istological classification . He warn ed, “It is n ot en ou gh to be beh in d th e colp oscop e to do a colp oscop y: it n ecessarily en tails p ain stakin g, len gth y p ractice th at is on ly ach ieved th rou gh rep etitive observation s” (Gan d olfo Herrera, 1934, p .852). In d eed , u se of th e colp oscop e as a tech n ology im p lied th e id ea of th e ‘train ed eye’; as h e p u t it, “we n eed to accu stom ou r eyes to seein g th at wh ich is o b served .” Th is im p lied , in t u rn , “t rain ed ju d gm en t ,” wh ich , as Dast o n an d Galison h ave stated, defin ed th e figu re of th e exp ert in twen tieth -cen tu ry scien ce as som eon e “with a train ed eye th at cou ld p erceive p attern s wh ere th e n ovice saw con fu sion ” (Daston , Galison , p .328). I h ave su ggested elsewh ere th at th e p arad igm of th e ‘train ed eye’ was cru cial in m akin g t h e gyn eco lo gist in t o a can cer exp ert , as h is p ract iced eye wit h t h e colp oscop e en abled h im to q u ickly read or in terp ret a p ortion of th e cervix as n orm al or atyp ical, with ou t resortin g to th e kn owledge of oth er p rofession als (Eraso, 2009).
th at abn orm al ep ith eliu m resu lted in can cer in a relatively sh ort p eriod of tim e. In an y case, colp oscop y, alon g with Hin selm an n ’s classification of p recan cerou s lesion s, fou n d en th u siastic su p p orters am on g gyn ecologists in Bu en os Aires, wh o gradu ally adop ted it as a reliable tech n iq u e for early can cer d etection .
A secon d p h ase in th e h istory of th e tran sfer of colp oscop y tech n ology took p lace in t h e 1950s an d was ch aract erized b y Hin selm an n ’s t ravels t o So u t h Am erica. In 1951, Ah u m ada, th en h ead of th e gyn ecology clin ic at Bu en os Aires Un iversity, in vited Hin selm an n to offer stu d en ts train in g cou rses in colp oscop y. Hin selm an n exten d ed h is visit for fou r m on th s, d u rin g wh ich tim e h e atten d ed con feren ces, gave p ractical d em on stration s, an d t ravelled t irelessly t o t h e m ain clin ics o f Brazil, Argen t in a, an d Uru gu ay. Th e fo rm er asym m et rical sit u at io n , wh ere So u t h Am erican d o ct o rs t rain ed at Germ an clin ics, h ad som eh ow been reversed . In th e 1950s, it was Hin selm an n ’s jou rn ey to Sou th Am erica an d h is n u m erou s p u blication s in Brazilian an d Argen tin ean jou rn als, wh ere h e com m u n icated on im p rovem en ts in th e tech n iq u e, th at gain ed colp oscop y th e n ecessary in tern ation al reco gn it io n d en ied it in p o st -Wo rld War II Eu ro p e an d t h e Un it ed St at es. Fin ally, t h e d irection of acad em ic exch an ges is also revealin g, in d icatin g h ow th e old er, u n d isp u table Eu rop ean p rom in en ce in Latin Am erican m ed icin e was n ow a sp ace to con q u er, given Am erican in terests an d en d eavors in th e area. In th e sp ecific case of can cer d iagn ostic tools, th e Pap test was sp read in g rap id ly, th an ks to p rom otion by Un ited States can cer agen cies an d to th e fin an cial su p p ort th at Sou th Am erican d octors received to train with Pap an icolaou in New York, as we will see later.
In vited to give a p resen tation at th e Med ical Circle in th e Argen tin ean p rovin ce of Córdoba, Hin selm an n took th e op p ortu n ity to ch allen ge th e Un ited States for its “absolu te ign oran ce in th is scien ce” [colp oscop y] an d p oin ted ou t “th e lack of en ou gh cases” to p rove th e u tility of th e Pap test in th e d iagn osis of p recan cerou s lesion s (Hin selm an n , 1952a, p .14). He also m en tion ed th at Pap an icolaou d id n ot resp on d to a letter h e h ad sen t, askin g for in form ation on th is m atter. Fu rth erm ore, h e argu ed th at a p ositive Pap test wou ld lead to m u ltip le biop sies, wh ich cou ld n ot d em on strate th e existen ce of can cer if th e tissu e was extracted from th e wron g p lace. More im p ortan tly, h e q u estion ed th e n ew in tern ation al classification of cervical can cer (1950), wh ich in corp orated th e n otion of “st age 0 can cer” t o refer t o t h e cat ego ries o f “in sit u can cer,” “p rein vasive can cer,” o r “su p erficial can cer.” In all t h ese cases, t h e wo rd “can cer,” Hin selm an n righ t ly argu ed , p resen ted an “eviden t con tradiction ,” becau se can cer im p lies in vasion ; th erefore, with ou t in vasio n (p rein vasio n ), t h ere co u ld b e n o can cer. He so m eh o w p ro p h et ically warn ed , “Th e term ‘can cer’ sh ou ld n ot be abu sed in th is way; th e con seq u en ces are u n p red ictable” (Hin selm an n , 1952a, p .14). In d eed , on e of th e con seq u en ces was an in crease in su rgical activism . W h ile th e correlation between d etected cell an d tissu e ch an ges an d clin ical can cer rem ain ed con troversial, p rop h ylactic su rgery gradu ally becam e th e m ost com m on p reven tive m easu re to cou n teract th e risk of cervical can cer.
term s also becam e a way of ap p rop riatin g th e tech n iq u e in receivin g n ation s, n ot m erely in its role of accessibility/ com m u n ication al valu e bu t in th e sen se of p rofession al recogn ition an d exp ertise. Th e atten tion occasion ally given to th e u se of th ese term s is revealin g. For exam p le, a rep ort d etailin g colp oscop ic im ages in Argen tin a read s: “Feld eru n g, recu ad rad o (Ah u m ad a), en rejad o (Jakob) o m osaico,” wh ere th e first term is Hin selm an n ’s origin al Germ an n am e; th e secon d an d th ird term s are th e tran slation s u sed by th e gyn ecologists n am ed in p aren th eses; an d th e fin al word is th e com m on , colloq u ial tran slation of th e term in Sp an ish (Ceru tti, 1952, p .181).
By th e 1950s, th e m ain gyn ecological clin ics in Bu en os Aires, alon g with a few oth ers in t h e p ro vin ces (Sa n Ju a n , Sa n t a Fe), w ere p ra ct icin g co lp o sco p y, w h ile m a n y m o re gyn ecologists across th e cou n try kn ew of th e tech n iq u e an d referred p atien ts to cen ters th at p ossessed th e in stru m en t. Colp oscop y th u s becam e th e first screen in g m eth od before th e Pap sm ear test, as it was first p erform ed on an asym p tom atic p op u lation .
The Pap smear test
Exfoliative cytology as a can cer d iagn ostic tool was su ccessfu lly in trodu ced by zoologist Georges Pap an icolaou in collaboration with Herbert Trau t between 1941 an d 1943, after o verco m in g t h e scien t ific co m m u n it y’s in it ial in d ifferen ce w h en Pap an ico lao u first p resen ted h is fin d in g in 1928. Th e tech n iq u e im p lied th e m icroscop ic exam in ation of cells scrap ed from th e cervix, p reviou sly fixed on a slid e with th e stain in g m eth od . As Ilan a Löwy h as argu ed , th e in itial aim of th e Pap test was d iagn osis of in vasive can cer, bu t it soon becam e “a screen in g test th at d etects p oten tially p recan cerou s lesion s an d p reven ts can cer” (Löwy, 2009).
Th e st ro n g su p p o rt an d p ro m o t io n t h at t h e Pap t est received in t h e Un it ed St at es d u rin g th is p eriod was th e resu lt of th e reorgan ization of th e Am erican Can cer Society (ACS), wh ich in 1945, eq u ip p ed with an im p ressive bu d get, sou gh t to en cou rage early in terven tion rath er th an p reven tive p olicies in can cer care. Accord in g to Casp er an d Clarke, d esp ite th e fact th at th e Pap test was n ot an accu rate, fast, or ch eap d iagn ostic tool, it “ap p ealed to ACS lead ers as a sim p le tech n iq u e th at cou ld h elp fu lfill th eir slogan with ou t th e n eed for elaborate or exp en sive n ew tech n ologies – th e righ t tool for th e ch osen job” (Casp er, Clarke, 1998, p .261). Wit h t h e su p p o rt o f t h e ACS, t h e Pap t est was q u ickly d issem in ated arou n d th e world via in tern ation al con gresses, train in g p rogram s, an d large-scale screen in g stu d ies in th e Un ited States.
or vagin al sm ear, wh ich is n ot u p settin g or h arm fu l to th e p atien t” (Sch tirbu , 1948, p .209). He em p h asized p resen tin g th e Pap test as a d iagn ostic tool with a “p resu m p tive” valu e, wh ich n eed ed to be “con firm ed ” by a biop sy, wh ich in tu rn h ad to be p erform ed u n d er colp oscop ic exam in ation (d irected biop sy). Som e years later, Hin selm an n ’s p resen ce in Sou th Am erica rein forced , am on g gyn ecologists, th e id ea of a n ecessary com bin ation of diagn ostic tools. As a resu lt, in th is region th e Pap sm ear did n ot develop in to a u n iq u e screen in g tool for can cer diagn osis n or did its u se rep lace th at of colp oscop y, as we will see lat er.
Fu rth er im p rovem en ts in th e Pap test, n otably th e in trod u ction of Ayre’s sp atu la to scrap e t h e cells, len t t h e t ech n iq u e ren ewed vigo r, t h an ks also t o t h e in t ern at io n al p rom otion ch am p ion ed by its in ven tor. In 1955, Ayre accep ted an in vitation to p articip ate at t h e Nin t h Argen t in ean Co n gress o f O b st et rics an d Gyn eco lo gy, an o p p o rt u n it y h e en th u siastically u sed to visit Brazil as well. By th en , Ayre was d irector of th e Can cer Cytology Cen ter in Miam i, a p rivately fu n d ed cen ter th at received th e su p p ort of th e Wash in gton Can cer In stitu te. His arrival at th e Gyn ecology In stitu te (In stitu to d e Gin ecologia) in Rio d e Jan eiro was p reced ed b y t h e in st it u t e’s celeb rat io n o f t h e t h irt iet h an n iversary o f co lp o sco p y. Du rin g h is visit , Ayre st ru ck Brazilian d o ct o rs as a m an o n a m issio n : h e offered gran ts to train with h im in Miam i an d in vited d octors to atten d th e First Pan -Am erican Can cer Cytology Con gress in 1957, an in vitation th at several sp ecialists from both cou n tries accep ted .
W h ile p h ysician s were fam iliarizin g th em selves with th e Pap sm ear test, com p arison s between th e two d iagn ostic tech n iq u es soon cam e u n d er scru tin y. Jakob an d th e p ath ologist Dr. Dard o Escalan te p u blish ed a book with a com p ilation of resu lts an d exp erien ces with colp oscop y coverin g 20 years of p ractice at th e Sard á Matern ity Hosp ital, en titled El cáncer preinvasor del cuello uterino (Prein vasive can cer of th e cervix). An overview of th e ad van tages th at Jakob claim ed for colp oscop y gives u s in sigh t in to som e of th e d ebates p rom p ted by in trod u ction of th e Pap test with in th e m ed ical p ractice: a) it was argu ed th at a p ositive Pap test wou ld sim p ly n ot in d icate wh ere to extract sam p le tissu e for a biop sy; b) a p ositive test m ean t th at m ore exam in ation s wou ld n eed to be p erform ed before a fin al d iagn osis cou ld be m ad e (th is cou ld take weeks), wh ile with colp oscop y, on ce th e lesion h ad been id en tified visu ally, a sam p le cou ld be taken im m ed iately, with th e p atien t very rarely n eed in g to be re-exam in ed ; c) th e Pap test m ean t organ izin g n ew laboratory facilities an d staff, in tu rn req u irin g m ore resou rces, wh ile, accordin g to Jakob’s estim ates, a colp oscop y req u ired on ly 10 good in stru m en ts an d 20 colp oscop ists in ord er to d iagn ose 1,000 wom en p er d ay, a n u m ber im p ossible to ach ieve in a laboratory; in ad d ition , Jakob claim ed th at th e cost of large-scale colp oscop ic exam in ation s was con sid erably ch eap er th an th at of cytological exam s; an d , lastly, d ) reliability was a h igh ly con tested issu e. Jakob’s resu lts with cytological an alysis were n ot p rom isin g: ou t of 8 p rein vasive can cers d etected by colp oscop y, on ly 5 tested Pap p ositive. Colp oscop y was con sid ered a m ore efficien t an d econ om ic m eth od for d etectin g p recan cerou s lesion s in a system atic way.
with Pap rates, alleged to stan d at 1:74. Not su rp risin gly, Jakob d rew atten tion to th e ever h igh er rat e o f can cer d et ect io n t h ro u gh cyt o lo gy, as rep o rt ed in t h e Un it ed St at es. He believed th at “an y large statistics th at p u sh ed th is valu e below 700 sh ou ld be q u estion ed ” (Jakob, 1958, p .60).
Th e im p o rt an ce o f co lp o sco p y lo o m ed large fo r Argen t in ean gyn eco lo gist s. Th e p rofession alization of its p ractice an d th e creation of n ation al societies an d in tern ation al federation s en su red th e tran sferred tech n iq u e a p erm an en t statu s. In 1964, th e Argen tin ean an d Am erican so ciet ies fo r co lp o sco p y an d cervical p at h o lo gy were fo u n d ed . In 1972, Argen tin a h osted th e First World Con gress for Cervical Path ology an d Colp oscop y in Mar d el Plata; with fou r n ation al societies in atten d an ce, th is even t led to th e creation of th e In t ern at io n al Fed erat io n o f Cervical Pat h o lo gy an d Co lp o sco p y. In t h e n ext sect io n , I will co n sid er t h e t ran sfer o f co lp o sco p y an d Pap t est s in t o Brazil, st art in g wit h t h e gyn ecological service wh ere t h e tech n iq u e was first u sed an d t h e in terlin ked n etworks w h ere b o t h t ech n iq u es w ere d issem in a t ed . Fin a lly, a n o verview o f t h e p ro cess o f ap p rop riation exp erien ced with both tech n iq u es will lead to an assessm en t of h ow th e field of can cer d iagn osis was tran sform ed .
Brazil
Th e 1930s witn essed th e growin g sp ecialization of gyn ecology as a bran ch sep arate from obstetrics, p ressu rin g doctors to becom e sp ecialists in on ly on e of th e discip lin es th at societies, con gresses, an d som e teach in g p rogram s still m ain tain ed u n d er on e u m brella. Th e case of Brazil’s m ain referen t in gyn ecology in th is p eriod , Dr. Arn ald o d e Moraes (1893-1961), is in stru ctive. After grad u atin g with a m ed ical th esis in obstetrics in 1916, h e in itiated h is p rofession al career as a Lectu rer in Obstetrics (1924) an d later train ed in th e Un ited States in organ izin g m atern al an d ch ild assistan ce u n d er a gran t from th e Rockefeller Fou n d ation (1927). He also train ed in obstetrics an d gyn ecology in Fran ce, Germ an y, an d Au stria, as was th e p ractice for an y sp ecialist wh o wan ted to h old a p lace of n ote in th e p ro fessio n .
Early in th e 1930s, h owever, h e steered h is teach in g an d clin ical work sh arp ly toward s gyn ecology, wh ere h e becam e in stru m en tal in th e p rocess of sp ecialization th at th e d iscip lin e u n d erwen t in th e followin g d ecad es. In 1931, h e was ap p oin ted h ead of Clin ical Gyn ecology at Rio d e Jan eiro’s Flu m in en se Sch ool of Med icin e (Facu ld ad e Flu m in en se d e Med icin a), bu t it was h is 1935 ap p oin tm en t as h ead of th e n ewly created Gyn ecology Dep artm en t at th e Un iversity of Brazil (Un iversid ad e d o Brasil) th at earn ed h im wid e recogn ition as a lead in g exp ert in th is field . Un til th en , gyn ecology was n ot tau gh t as a regu lar cou rse bu t fo rm ed p art o f t h e gen eral su rgery cu rricu lu m . Th is w as b o t h an ad van t age an d a d isad van t age in t h at Mo raes h ad am p le o p p o rt u n it y fo r d evelo p in g t h e d ep art m en t ’s p rofile an d teach in g con ten ts, wh ile h e likewise grap p led with th e lack of in frastru ctu re an d teach in g facilities – for exam p le, it was on ly in 1936 th at teach in g room s were assign ed at th e u n iversity’s teach in g facility, Estácio d e Sá Hosp ital.
callin g fo r h ealt h au t h o rit ies t o creat e a can cer cen t er. Th is fin ally cam e ab o u t wh en con stru ction of a can cer in stitu te at Estácio d e Sá Hosp ital was ap p roved in 1937. Th e Can cer In st it u t e (In st it u t o d o Cân cer) was in au gu rat ed t h e fo llo win g year u n d er t h e d irection of its p lan n er, Kroeff; it offered can cer d iagn osis an d treatm en t in all sp ecialties an d also p rovid ed electro-su rgery, rad ioth erap y, an d rad iu m -th erap y. Accord in g to Lu iz A. Teixeira an d Crist in a Fo n seca, t o ward s t h e en d o f t h e 1930s, Krö eff’s am bit io n was t o en large th e scop e of th e In stitu te from a local to a n ation al facility (Teixeira an d Fon seca, 2007, p .73). His p rom in en t p osition in p olitical an d acad em ic circles en abled h im to secu re th e 1941 creation of a Nation al Can cer Service (Serviço Nacion al d o Cân cer, or SNC) as p art of th e Can cer In stitu te, with th e aim of cen tralizin g can cer p olicies across th e cou n try, with an em p h asis on can cer research , ep id em iology, d iagn osis, p rop h ylaxis, an d treatm en t. However, in 1942, th e Brazilian govern m en t tu rn ed Estácio d e Sá Hosp ital in to a facility fo r t h e m ilit a r y p o lice , le a v in g t h e C a n ce r In st it u t e t o b e h o u se d in u n su it a b le acco m m o d at io n s (Teixeira an d Fo n seca, p . 74-77). Th at sam e year, Mo raes m o ved t h e u n iversity’s Gyn ecology Clin ic to Mon corvo Filh o Hosp ital, a ch ildren ’s h osp ital fou n ded b y p ro m in en t p ed iat rician Dr. Carlo s Art h u r Mo n co rvo Filh o , wh ere t h e clin ic is st ill based tod ay. From 1940 on , Mon corvo Filh o Hosp ital d ep en d ed on th e Nation al Ch ild ren ’s Dep art m en t (Dep art am en t o Nacio n al d a Crian ça), b eco m in g a lead in g in st it u t io n in m at ern al an d ch ild care, sp ecialt ies t h at co n st it u t ed Mo raes’ first p ro fessio n al areas o f m ed ical p ractice.
Th e d iversification of services at Moraes’ clin ic reflected th e d egree of sp ecialization in gyn ecology back th en , at a tim e wh en an y p olicy on can cer in wom en wou ld be su bject to n ego t iat io n am o n g exp ert s. In t h is sen se, t h e p ro cess o f in st it u t io n alizat io n p ro ved fu n dam en tal. In 1947, Moraes tran sform ed th e clin ic in to th e Gyn ecology In stitu te (GI), wh ich com bin ed clin ical an d research work on a ran ge of gyn ecological ailm en ts, p rovid in g room for con su lts in en d ocrin ology an d sterility, roen tgen th erap y services, a laboratory for em bryology an d exp erim en tal research , a d iscu ssion foru m , an d an arch ive.
More im p ortan tly, in Jan u ary 1948, th e Am bu latório Preven tivo d o Cân cer d a Mu lh er was created as a sp ecial ou tp atien t clin ic focu sed on th e p reven tion an d early d iagn osis of wo m en ’s can cer. “Ho w can we d raw p at ien t s t o t h is o u t p at ien t clin ic,” Mo raes asked , “wh ere we h ave in ten tion ally u sed th e term ‘p reven tion ’ of gyn ecological can cer, rath er th an u sin g th e term ‘d etection ’, as th e Am erican s d o?” (Moraes, 1950a, p . 247). Th e n u an ced u se of word s reveals th e lack of con sen su s am on g gyn ecologists abou t wh at con stitu ted p recan cero u s lesio n s an d w h at t h eir d et ect io n act u ally m ean t : t h e d et ect io n o r t h e p reven t io n (avo id an ce) o f can cer. In eit h er case, I will argu e t h at su ch co n t ro versies exp an ded th e op p ortu n ities for m akin g th e d iagn osis rath er th an th e treatm en t of cervical can cer a distin ctive area of in terven tion . In th is con text, th e role of diagn ostic tools was h igh ly sign ifican t, as we will see n ext, with th e recep tion of colp oscop y an d th e Pap test.
Colposcopy
treatise Gynecology and obstetrics, p u blish ed in En glish by th e Am erican Carl H. Davis in 1934. Th is raises t h e q u est io n o f wh y co lp o sco p y d id n o t p ro sp er at t h is t im e in t h e Un it ed St at es, sin ce it h as been argu ed t h at t h e “early d escrip t ive t erm in o lo gy was in Germ an an d was n ot read ily u n d erstood in En glish -sp eakin g cou n tries” (Ferris et al., 2004, p .4). Th is rem in d s u s th at, beyon d th e lin gu istic com p eten ce req u ired for an y tran slation wo rk, d ecid in g wh at t o t ran slat e an d wh ich fo reign t ext s t o in t ro d u ce in a scien t ific cu ltu re is con tin gen t on m ore com p lex strategic decision s.
Accordin g to Moraes, h e tau gh t h im self h ow to p erform a colp oscop y after p u rch asin g two colp oscop es from th e Leitz Com p an y, on e for th e ou tp atien t ward at th e u n iversity clin ic an d o n e fo r h is p rivat e p ract ice. He so o n realized t h at a go o d co m m an d o f t h e tech n iq u e req u ired sp ecialized train in g, an d so h e assign ed on e of h is assistan ts to learn th e tech n iq u e, p robably in Bu en os Aires with Jakob. However, it was an oth er d octor, João Pau lo Riep er, wh o train ed with Hin selm an n in Ham bu rg an d becam e a sp ecialist in th e tech n iq u e. He was ap p oin ted assistan t at Moraes’ u n iversity clin ic in 1940. His m ed ical th esis “Valor p rático da colp oscop ia” (On th e p ractical valu e of colp oscop y, 1942) earn ed h im in stan t recogn ition as a lead in g figu re in th e p ractice of colp oscop y in Brazil. Riep er’s ap p oin tm en t p roved sign ifican t to th e dissem in ation of colp oscop y am on g gyn ecologists, as h ad been th e case with Jakob in Argen tin a. For both m en , it was th eir p erson alized train in g in Germ an y with th e in ven tor of th e tech n iq u e th at gave th em d istin ctive exp ertise d u rin g th e 1930s an d 1940s. Hin selm an n ’s d iscip les th u s becam e th e “m ed iators” in th e p rocess of tran sfer, a role th at im p lied m ed iation between a m an ifested d esire to receive (exem p lified by d ep artm en t h ead s Ah u m ad a in Argen tin a an d Moraes in Brazil) an d th e d egree of assim ilation of foreign id eas an d tech n iq u es.
As m en tion ed above, a secon d p h ase in th e h istory of th e tran sfer of colp oscop y in Sou th Am erica took p lace in th e 1950s an d was p recip itated by Hin selm an n ’s travels to th e region . Alth ou gh it is u n likely th at con tacts were easy d u rin g Hin selm an n ’s im p rison m en t between 1946 an d 1949, h e accep ted an in vitation by Moraes sh ortly after h is release an d arrived in Rio d e Jan eiro in Decem ber 1949 to give train in g cou rses in colp oscop y at th e GI. Hin selm an n ’s d em on stration s were wid ely atten d ed by d octors from Rio, São Pau lo, Belo Horizon te, Bah ia, an d Porto Alegre. A sp ecial issu e of th e Anais Brasileiros de Ginecologia h on ored h is visit with th e p u blication of a brief au tobiograp h y, fou r origin al articles, an d exten sive n otes an d discu ssion s from h is cou rses. Sign ifican tly, h e lectu red in En glish .
In h is biograp h y, Hin selm an n briefly referred to th e en d of th e Nazi regim e, wh ich led to h is im p rison m en t. He stated u n com p rom isin gly th at,
My research an d teach in g activities were abru p tly in terru p ted by th e p olitical u n rest of Cen t ral Eu ro p e, d esp it e bein g n o t in t erest ed , I was cau gh t u p an d alm o st cru sh ed by it . Bu t m y co lleagu es fro m Germ an y an d ab ro ad h ave h elp ed m e, ab o ve all t h e Brazilian Society of Gyn ecology, an d , esp ecially, its m agn an im ou s p resid en t an d very d ear frien d , Prof. Arn ald o Moraes (Hin selm an n , 1950, p .210).
Hin selm an n was in vited by Dr. Clovis Salgad o, d irector of th e gyn ecology clin ic at th e Un iversity of Min as Gerais (UGM) in Belo Horizon te, to p articip ate in a con gress an d later by Dr. Ah u m ad a to offer train in g cou rses in Bu en os Aires, as m en tion ed earlier (Hin selm an n , 1952b, p . 988). On th is occasion , Dr. Roch a recalled th e Germ an d octor’s visit to Belo Horizon te as “d ecisive”:
It was aft er h is visit t h at we were ab le t o eq u ip t h e clin ic wit h t h e n ew co lp o sco p e m o d els, st an d ard , an d flu o rescen t , w h ich great ly facilit at ed t h e accep t an ce an d d issem in ation of th e colp oscop ic m eth od , given th e great facility brou gh t to its learn in g t ech n iq u e an d t h e rem arkable im p ro vem en t s in t ro d u ced in t h e ap p arat u s in Germ an y after th e War (Roch a, 1955, p .221).
Th e d issem in ation of th ese n ew m od els was fu n d am en tal to Hin selm an n , for h e felt th at th e lack of fam iliarity with early version s of th e colp oscop e was a real obstacle to accep t an ce o f t h e t ech n iq u e. Th e p erfect io n o f t h e in st ru m en t ’s visu al cap ab ilit ies (m agn ification in creased from 10x to 20x) an d th e u se of a m ercu ry lam p an d flu oroch rom es to in crease im age con trast revealed n ew form s of m align an t ep ith eliu m . Hin selm an n d rew atten tion to th e observation of th e atyp ical p roliferation of blood vessels, wh ich in dicated in creased m etabolism of can cerou s cells. In ad d ition to com m u n icatin g th ese im p rovem en ts, Hin selm an n con vin ced Brazilian gyn ecologists as to th e im p ortan ce of h istological an alysis as a fu n d am en tal p art of colp oscop y. Followin g biop sy, every su sp ected im age was su bject to a p rocedu re h e devised , in volvin g th e observation of at least on e th ou san d serial section s p er biop sy. Followin g a req u est from Moraes, Hin selm an n sen t two Germ an p ath ologists, Gerh ard Fran z (1951) an d Han s Lim bu rg (1953), to organ ize th e p ath ology laboratory at th e GI an d to su p ervise an d in stru ct p ath ologists in h is h istological tech n iq u e.
Perh ap s d rawin g on th e gen d ered d ivision of labor com m on in th e Pap test laboratory, wh ere fem ale tech n ician s read slices, Hin selm an n th ou gh t th at wom en tech n ician s wou ld offer an in valu able con tribu tion to th e p ractice of h istological section s. He attem p ted to d issem in ate th is p ractice in Brazil by sen d in g two Germ an fem ale assistan ts to p erform th e serial section s at th e p ath ology laboratory at Salgad o’s gyn ecology clin ic at th e UMG. By 1953, th e UMG’s laboratory of an atom o-p ath ology em p loyed a wom an tech n ician , Licy Teixeira, wh o was resp on sible for serial section an alyses from all gyn ecology clin ics in th e state of Min as Gerais. At th e GI in Rio d e Jan eiro, two wom en d octors were credited for t h eir p ro fessio n al ach ievem en t s: Dr. Hild egard St o lt z sp ecialized in co lp o sco p y, wh ile Dr. Clarice d o Am aral Ferreira h ad p rim e resp on sibility for cytological exam in ation s an d in 1956 becam e fou n d er of th e Brazilian Cytology Society (Socied ad e Brasileira d e Citologia). Notably, th ey were m ed ical d octors, n ot tech n ician s, as was th e p ractice with Pap tests at laboratories in th e Un ited States; fu rth erm ore, u n like Argen tin ean fem ale gyn ecologists, th e Brazilian s h eld p osition s at p restigiou s clin ics.
honoris causa from th e Un iversity of Brazil, wh ich con stitu tes th e h igh est academ ic distin ction a w a rd ed b y a u n iversit y. Th e o cca sio n o n ce a ga in o ffered t h e G erm a n d o ct o r t h e o p p o rt u n it y t o co n vey fu rt h er t ech n ical im p ro vem en t s, in clu d in g h is in cu rsio n s wit h vid eo colp oscop y. Ah ead of th eir Argen tin ean colleagu es, th e Brazilian s m ad e in n ovative in road s in to th e p rofession alization of wh at h ad becom e a n ew sp ecialty, with th e 1958 creation of th e Brazilian Colp oscop y Society (Sociedade Brasileira de Colp oscop ia). Alth ou gh all th ese elem en ts reflected th e existen ce of a solid Germ an -Brazilian bon d in th is p eriod , Brazilian gyn eco lo gist s resp o n d ed flex ib ly yet n o t su b m issively t o t h e recep t io n o f Hin selm an n ’s tech n iq u e, as th e n ext section will d em on strate.
Colpocytology
Exfoliative cytology as a m eth od of can cer d iagn osis was in trod u ced in Brazil by Dr. An ton io Vesp asian o Ram os, wh o worked as an assistan t at Moraes’ u n iversity gyn ecology clin ic. Followin g th e p roced u res of Pap an icolaou an d Trau t, as first p u blish ed in 1941, Vesp asian o Ram os p resen ted h is m ed ical th esis ju st on e year later, en titled “Novo m étod o d e d iagn ó st ico p reco ce d o cân cer u t erin o ” (New m et h o d o f early d iagn o sis o f u t erin e can cer), wh ich gives u s in sigh t in t o t h e p ervasiven ess o f t h e early d iagn o sis go al as it sp read alm o st sim u lt an eo u sly t h ro u gh o u t West ern m ed ical cen t ers. Mo raes len t great im p ortan ce to cytology, as evin ced by h is visit to Pap an icolaou in New York in 1950 an d by h is assign in g h is assistan ts, in clu d in g Dr. Dig Gebara, to train in New York with th e in ven tor of th e test. Accord in g to Riep er, Gebara becam e th e lead in g figu re in cytology in Brazil, train in g n u m erou s cytologists an d d octors from lead in g in stitu tes on th e tech n iq u e. After h is d eath , a wom an – Dr. Clarice d o Am aral Ferreira – took th e lead an d becam e “th e best q u alified in cytology in Brazil” (Riep er, 1959, p .270).
In t erm s o f t h e t ran sfer o f d iagn o st ic t ech n iq u es, t h e early in cep t io n o f exfo liat ive cytology at th e GI led to m ore sign ifican t d evelop m en ts. As Hen k Te Veld e h as p ercep tively n oted in th e tran sfer of p olitical p ractices, “Th e m ost n ovel con tribu tion s cou ld be exp ected from an alysis of th e agen ts of tran sfer, an d esp ecially of th e sim u ltan eou s d evelop m en t of th e in tern ation al com m u n ication ch an n els an d th e tran sfer itself an d of th e p rocess of ad ap tation an d ‘tran slation ’” (Te Veld e, 2005, p .211).
a t yp ia .” M o ra es co n clu d ed t h a t “co lp o sco p y, co lp o cyt o lo gy, a n d h ist o p a t h o lo gica l exam in ation h ave th eir own valu es an d on ly th e sim ultaneous u se of th e th ree p rovid es a sat isfact o ry an d reaso n ab ly safe resu lt ” (Mo raes, 1950b , p .435; em p h asis ad d ed ). Th e observed in crease in diagn osed cases resu ltin g from th e com bin ation of both m eth ods is n everth eless revealin g: 175 d etected cases of p recu rsor stages of can cer. “Th e n u m ber seem s an exaggeration ,” Moraes observed . “In fact, on ly 73 cases were d efin itely labeled as m align n eop lasias” (Moraes, 1950a, p .249).
Aware of th e stren gth th at th e sim u ltan eou s u se of th ese d iagn ostic m eth od s m ean t for th e in tern ation al p restige of Brazilian gyn ecology, Moraes sou gh t to in trodu ce fu rth er in n ovation s in th e area of can cer d iagn osis. In 1951, togeth er with on e of h is assistan ts, Dr. Nisio M. Fon seca, h e p u blish ed an article on a stu d y th at Fon seca was con d u ctin g on th e detection of cervical can cer with th e u se of a p h ase-con trast m icroscop e. Th e aim of th e research was to con d u ct a com p arative stu d y between th e u se of th is n ew Germ an t ech n iq u e an d t h e Pap an ico lao u t est . W h at is in st ru ct ive in t h is case is t h e scien t ific, m ed ical n etwork th at th e GI d irector h ad bu ilt u p over th ese years. Fon seca h ad train ed in p ath ological an atom y Fran z, wh o h ad been sen t by Hin selm an n to organ ize th e laboratory a t t h e G I. Aft er M o ra es received t h e d o n a t io n o f a p h a se-co n t ra st m icro sco p e, h e com m ission ed Fon seca to train in cytology at th e In stitu te of Biological In vestigation s (In st it u t o d e In vest igacio n es Bio ló gicas) in M o n t evid eo , an in st it u t e creat ed b y t h e Ro c k e fe lle r Fo u n d a t io n , w h ic h a lso a w a r d e d Fo n se c a a fe llo w sh ip . M o r a e s a lso com m ission ed Dr. Orlan d o Baiocch i, from th e laboratory of exp erim en tal gyn ecology, to st u d y t h e d iagn o sis o f exo -cervical can cer b y glyco gen an alysis in Paris an d t o st u d y p ath ological an atom y with th e ren own ed sp ecialist Dr. Jean Lerou x-Robert. Cru cially, it was th is style of scien tific work, wh ich com bin ed an d ad ap ted available foreign m eth od s an d tech n ologies, th at earn ed th e GI in tern ation al recogn ition for its work.
Conclusions
Th rou gh ou t th is p ap er, I h ave p oin ted to th e im p ortan ce of th e con cep t of tran sfer in a n a ly zin g t h e m igra t io n o f m ed ica l id ea s a cro ss n a t io n a l b o rd ers. Th e h ist o ry o f gyn ecological can cer is illu strative at several levels. First, th e tran sfer of d iagn ostic tools (colp oscop y an d Pap test) in Argen tin a an d Brazil illu strate h ow foreign m ed ical kn owled ge an d p ractice h elp ed to sh ap e n ation al m ed icin e. Secon d , it in d icates th at m ost d evelop m en ts in can cer kn o wled ge, sp ecifically in t h e d iagn o sis o f gyn eco lo gical can cer, can n o t b e u n derstood with ou t p arallel develop m en ts in several cou n tries. Th ird, th e p rocess of tran sfer of m ed ical id eas an d tech n ologies from Germ an y an d th e Un ited States to Sou th Am erica an d later from Sou th Am erica to Eu rop e an d th e Un ited States con tribu ted sign ifican tly to th e n atu ralization of th e n otion of early d etection in can cer care.
m ore balan ced assessm en t of its so-called ach ievem en ts (p rom otion of Pap tests in th e Un ited States) an d n eglection . (Hin selm an n ’s colp oscop y). Cru cially, in tim es of p erceived com petition am on g th e m ain Western scien tific m odels (Fran ce, Un ited States, an d Germ an y) in an effort to h old sway over Latin Am erica, Sou th Am erican cen ters an d scien tists seem to h ave h an d led th eir m ed ical borrowin gs m ore op p ortu n istically. As we h ave seen , th e recep tion , im p lem en tation , an d ad op tion of d iagn ostic tools was n ot a p assive p rocess. Th e st ren gt h o f Argen t in ean an d , m o re clearly, Brazilian gyn eco lo gy was p recisely t h e com bin ed u sed of both d iagn ostic tools.
Som e of th e con seq u en ces in h eren t to th e m igration of colp oscop y an d th e Pap test h ave b een h igh ligh t ed in t h is p ap er. O n t h e o n e h an d , d iagn o st ic m et h o d s h ave t o n ego t iat e an d co m p en sat e fo r each o t h ers’ fallibilit y. In t h is case, t h ree m et h o d s were con sid ered to be n eed ed , givin g rise to a n ew typ e of “cu m u lative con fid en ce” based on th e com bin ed u se of colp oscop y, th e Pap test, an d biop sy. On th e oth er h an d , th is m ean t an in crease in th e n u m ber of cases d iagn osed . In th e Brazilian case, for exam p le, d u rin g 1943-1947, wh en system atic colposcopy was n ot used, 7 cases of precan cerous lesion s (stage 0) were d iagn o sed in 4,000 wo m en . Du rin g 1948-1955, wh en syst em at ic co lp o sco p y an d cytology were em p loyed , 40 cases were d iagn osed in 7,000 wom en (Stoltz, 1955, p . 214), th u s elevatin g th e ratio from 1:571 to 1:175.
Th e way gyn ecologists treated an d d ealt with th ese bord erlin e lesion s lies ou tsid e th e scop e of th is p ap er; h owever, regardless of th eir p referred th erap eu tic treatm en t, th e diagn osis of p recan cerou s lesion s wou ld h ave con fron ted th em with th e sam e d ilem m a p osed som e d ecad es later by p ath ologist Robert Hu tter: “Is cu red early can cer tru ly can cer?”
* Research fo r t h is p ap er was gen ero u sly fu n d ed b y a Research Fello wsh ip award ed b y t h e Wellco m e Tru st
(W T082964). Early versio n s o f t h e p ap er were d iscu ssed at t h e can cer wo rksh o p s h eld in Maiso n Fran çaise d ’O xfo rd , O xfo rd Un iversit y, Feb ru ary 2009, an d in CERMES an d t h e In st it u t Nat io n al d u Can cer, Paris, Ap ril 2009. Th is wo rk h as b en efit ed fro m t h e gen ero u s feed b ack p ro vid ed b y Ilan a Lö wy, Vivian e Q u irke, Jo h n Pickst o n e, Pat rice Pin ell, an d t h e p art icip an t s o f b o t h wo rksh o p s. I am also in d eb t ed t o t h e jo u rn al’s ed it o r, Jaim e Ben ch im o l, fo r h is su ggest io n s an d t o An n a vo n Villiez fo r h elp in g wit h t h e Germ an t ran slat io n s.
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