Recent works have analysed the history of the disease in Brazil, focusing on the . the Anais Brasileiros de Ginecologia and the Brazilian Gynaecology Society. Title: Wellcome History 47, Author: Wellcome Trust, Name: Wellcome History 47, This led him to create the Instituto de Ginecologia (IG), where he encouraged. Keywords: transnational history, colposcopy, Pap test, cervical cancer, diagnosis . Obstetricia y Ginecología Latino-Americanas when it first appeared in

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From gynaecology offices to screening campaigns: Brasil,sala This paper discusses the knowledge and medical practices relating to cervical cancer in Brazil.

It analyses the growing medical interest in the disease at the beginning of the twentieth century, the development of prevention techniques in the s, and the emergence of screening programs in the s. It argues that the development of knowledge on cervical cancer was related simultaneously to a number of factors: The article concludes by identifying a number of issues that are still proving to be obstacles to hlstorian of the disease.

Medical interest in cervical cancer grew in the final decades of the nineteenth century with the emergence of theses and articles on the topic in medical journals.

For a long time, though, medicine would remain without an effective weapon to histkrian prevent or hstorian the disease, relying mainly on radical forms of surgery, involving amputation of the uterus, that very often proved lethal, and palliative care. Women, for their part, easily fell prey to the disease due to their reluctance to make their medical complaints public, whether because of social pressures or modesty, and only turning to doctors for help when their discomfort, pain and suffering became unbearable, by the time when the disease had advanced too far to be controlled.

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Until the s, in spite of the development of gynaecology and, in particular, the use of radiotherapy to treat cancer, the lack of a method for preventing cervical cancer meant that the search for early diagnosis through frequent gynaecological exams was limited to the few women with access to private medical practices.

Following this period, the development of exfoliative cytology the Papanicolaou test or Pap smear binecologia colposcopy as techniques for early detection and later prevention altered this scenario, allowing the actions taken to combat the disease to reach a larger number of women.

However, reflecting the pattern in which Brazil’s public health system historically developed, prevention techniques disseminated slowly and unequally in the country, transformed into large-scale actions only from the s with the implantation of screening campaigns and later the emergence of a national program for controlling the disease. Cervical cancer is directly associated with infection by human papillomavirus HPV – in most cases transmitted via unprotected sexual contact – and indirectly related to other factors such as a high number of sexual partners, tobacco smoking and lack of hygiene.

These factors increase the risk of the disease among more disadvantaged sectors of the population, leading to its association with poverty and lower levels of education. The disease is a serious public health issue in Histodian America, one of the regions with the highest occurrence rates in the world Guerra et al.

Despite the long process of developing control actions, cervical cancer is still a major public health problem in Brazil, primarily affecting poorer women with less access to health services Ginecilogia, As the second most common type of cancer among Brazil’s female population after breast cancer, the disease corresponds to the fourth highest cause of death of women from cancer in the country.

Over recent decades, academic researchers working internationally on the history of the sciences, sociology and collective health have produced a diverse set of analyses concerning cervical cancer. Works in this field have focused on topics like the problems involved in standardizing the analysis of cytology slides and the difficulties of recruiting and training cytology technicians Casper, Clarke, ; the organization of screening campaigns; the controversies surrounding the cost and effectiveness of these programs Hakama et al.

These studies diverge considerably in their evaluation of specific elements of the history of cervical cancer screening, providing a range of different contributions to the topic. Recent works have analysed the history of the disease in Brazil, focusing on the different models involved in developing techniques for its control along with its local specificities.

The study on the control of cervical cancer in Argentina and Brazil produced by the Argentinean researcher Yolanda Eraso is a pioneering example of this approach, demonstrating how the two countries followed a different trajectory to most of the western medical world by using colposcopy 2 as a basis for detecting cervical abnormalities until the s.

Her work shows that the interest in this technique developed out of the relations of cooperation between German, Brazilian and Argentinean gynaecologists in the years prior to the Second World War. After the end of the conflict, ties of cooperation were re-established between the German gynaecologists and their Latin American colleagues and a de facto network was instituted which disseminated colposcopy as a technique for detecting cervical cancer in these countries.

Our study looked to profile the use of colposcopy and cytology by Brazilian medical science, discussing how the longevity of this disease prevention model was related to particularities of the public health model and medical knowledge existing in the country. During the period when cervical cancer was treated only by private medicine and philanthropic initiatives of limited range, the broad use of colposcopy was an adequate solution for its prevention.

Our premise was that the different forms of technico-scientific development and their outcomes in the field of the medical actions and health policies within each period and local context are shaped by the range of possible alternatives, related to the different socioeconomic configurations, the forms in which powers circulate between actors, and the distinct modes of scientific and professional organization Latour, We believe that the analysis of this multiplicity of variables in its temporal continuum – a dimension made visible by the adoption of a historical perspective – can enrich the set of studies on the theme and shed some light on present-day actions to control the disease.


For a long time cervical cancer was a disease little known among Brazilian doctors. Between the mid nineteenth century and the beginning of the twentieth, the few works on the topic, published in medical journals, discussed the possibilities for diagnosis of the disease, surgical techniques suited to ablation of the uterus, and therapies making use of abrasive substances to cauterize the tumour Gurgel, In the subsequent two decades, following the development of radiotherapy and radical hysterectomy techniques, doctors began to give more attention to the problem, divided between those advocating the use of one of these techniques as a treatment, or a combination of both, or even the use of radioactive substances like mesothorium.

Regardless of the therapy used, the percentage of cure was tiny, limited to cases involving very small tumours. All the other cases, where other organs and tissues had been invaded, were incurable as a rule. During the period in question, medical care was provided to the population by a small number of philanthropic institutions – such as the Holy Houses of Mercy – and mutual fund societies, or by private and clinical physicians who provided care to wealthier sectors of the population.

Public health services were confined to actions against epidemics and the regulation of urban life: In this context, the large majority of Brazil’s female population during the period had little or no access to doctors, succumbing to the disease without knowing what was killing them, or the best form of treating it Teixeira, During the first decades of the twentieth century, the medical discussions on cervical cancer intensified as part of a general growing concern over cancer.

The scant knowledge available on the disease’s evolution initially led specialists to think that seeking out medical assistance as soon as the first symptoms appeared – abnormal bleeding, pains etc.

A paper presented to the Brazilian Gynaecology Society in reveals the persistence of this form of thinking. Its author, Nabuco de Gouveia, asserted that his experience in American and European scientific centres showed how it was impossible to successfully treat the disease once established. In order to get round this problem, doctors should make women aware of their own key role in controlling the disease since only they could perceive the first symptoms of the initial cancer and seek medical advice.

To achieve this aim, it was essential to instruct them properly in identifying the first signs of the disease, stressing the importance of early treatment. Nabuco pointed to the systematic efforts being made in European countries and the USA to this purpose. Some time before Nabuco’s paper, at the beginning of the s, research in the field of gynaecology conducted in European and American centres had begun to indicate ways of controlling cervical cancer.

Inthe German gynaecologist Hans Hinselmann developed a type of binocular magnifying glass and adapted it to observing the cervix. The apparatus, named the colposcope, assisted in the diagnosis of cellular anomalies in the cervix and other gynaecological pathologies. Inan Austrian gynaecologist, Walter Schiller, discovered that applying diluted iodine Lugol to the cervix made alterations easier to observe since the altered regions did not absorb the solution.

These methods were used in Germany, Austria and Switzerland in the s, but did not spread beyond these countries, with the important exception of Latin America where they arrived through the German scientific influence by the end of the decade. During the same period, pursuing his own distinct line of research, George Papanicolaou, a Greek physician working in the USA, discovered that by examining smears taken from the cervix he was able to detect the presence of lesions that could transform into cancerous growths.

Inin collaboration with the pathologist Herbert Traut, he published his first work on the technique of cytological diagnosis, which became known by his name Papanicolaou, Traut, The observation of pre-cancerous abnormalities through the Papanicolaou test or Pap smear would then be followed by more specific examinations – such as colposcopy and directed biopsy – capable of confirming the seriousness of the problem.

Despite the initial technical difficulties, the work of Papanicolaou and Traut quickly spread through the medical community as a core tool in preventing the disease, offering a low-cost and non-invasive method for detecting pre-cancerous abnormalities in women Casper, Clarke, In much of the western world, the triad of cytology, colposcopy and biopsy – in that order – represented the model for preventing cervical cancer from the s onwards. The first Brazilian studies in the field of cytology and colposcopy, directed towards preventing cervical cancer, started to be developed in university research institutions at the end of the s within a wider context of a revival in gynaecology.

Ina chair in the discipline was created at the Rio de Janeiro Faculty of Medicine, making it a distinct area from surgery, the discipline to which it had previously been attached. Moraes was a gynaecologist of considerable renown.

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He had specialized at Johns Hopkins University with a scholarship from the Rockefeller Foundation in and had also worked with Hinselmann in Germany for a time. In the latter post, as well as gaining experience in colposcopy techniques, he enhanced his professional status and strengthened his scientific ties with German science.

Moraes’s first undertaking at the Faculty of Medicine was the organization of a new clinic for his professorship. It was a conceived as a cutting-edge historan, capable of attracting researchers interested in new diagnostic techniques being developed outside of Brazil. He had previously worked at the Gynaecological Clinic of Berlin University and had also studied colposcopy with Hinselmann.

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Rieper was recruited by Moraes to introduce the new diagnostic technique at the clinic. In JanuaryRieper published his first article extolling the value of using colposcopy in the early discovery of cervical cancers.

In his conclusions, ginecologoa proclaimed:. A campaign to educate both the public and physicians is needed, the systematic use of Hinselmann’s colposcopy and Schiller’s test, the installation of a larger number of easily accessible and free special preventive clinics, and, finally, visiting nurses who ensure continued control of the sick Rieper, Sthel Filho,p.

InRieper published a thesis on the uses of colposcopy in giencologia diagnosis of gynaecological diseases. The same year, Antonio Vespasiano Ramosanother assistant from the Gynaecological Clinic of the Faculty of Medicine, presented a ginecklogia on the use of the Pap smear for early diagnosis of malignant cervical neoplasms.

Ramos applied the method described a year earlier by Papanicolaou and Traut Papanicolaou, Traut, The combined work of specialists in these different techniques played a key role in shaping the clinic’s institutional profile. The gynaecology clinic expanded rapidly, transforming into a research centre and an outpatient unit for ginecologa general public.

To advance the studies of cervical cancer, Moraes and his collaborators set up the Cancer Prevention Ginecolgoia Clinic in the following year. As well as producing research, the latter worked intensely ginecoloogia provide healthcare to women with the disease or suspected of having it.

Unlike American and European institutions, which were based on preventing the disease through either cytology or colposcopy, the detection model used by the outpatient clinic combined these two techniques. The “triple model” involved using colposcopy and cytology in all preventive exams.

Moraes and his ginecollgia argued that the systematic combination of colposcopy, cytology and biopsy in the outpatient clinic greatly boosted the efficiency in detecting cervical lesions since each technique allowed the observation of different atipias in the cervical cells Moraes, In the s, the group of gynaecologists pioneering the implantation of colposcopy and cytology in the country also worked hard to consolidate their professional field, proving highly productive in publishing articles and organizing technical meetings.

Both societies were fundamental in the early histofian of cervical cancer prevention practices in the country. The use of the colposcopy-cytology pairing in the discovery of malign cervical abnormalities became the consensus among the gynaecologists.

In the s, cervical cancer detection was conducted in gynaecological offices located in universities, local public healthcare institutions and private gynaecological clinics or those partnered with the healthcare services of the pension institutes existing at the time, as well as hospitals and public and philanthropic outpatient units financed by resources from the National Cancer Service.

In ten preventative outpatient clinics existed in Rio de Janeiro Coutinho, However the range of these initiatives remained severely limited for historan long time. To extend tinecologia coverage of this preventive care, the gynaecologists associated with colposcopy argued for an expansion gijecologia the training of physicians specialized in colposcopy. The objective was to transform each gynaecology ginscologia into a specialized medical centre for detecting the disease Salgado, Rieper, This control model would never come into effect, though, since as the efforts to extend the coverage grew, so the intensive use of colposcopy as a first exam lost ground to the Pap smear, which could be done more gineco,ogia at a lower cost.

Dispensing with the need for specialist physicians or expensive high-precision equipment, the Pap smear allowed a larger number of women to be gineccologia and facilitated the introduction of mobile clinics and one-off prevention campaigns. At the start of the s, histoorian number hidtorian cervical cancer detection campaigns were launched based on the use of the Pap smear on a large scale.

The strategy now was not to conduct exams on women visiting health clinics in relation to other problems. The aim rather was to encourage healthy women to visit the clinics to perform the test or even to take the tests to them.

The Social Pioneer Women played a prominent role in controlling the cancer. As well as formulating campaigns in diverse areas in partnership with other institutions, they worked to train technical staff to implement these initiatives.

Their cytotechnical training school, created inas well as pioneering, served as a model for training these professionals in Brazil Teixeira, Porto, Souza, ; Temperini, Initially its work was conducted on the same bases as the other outpatient clinics already described above, including the use of colposcopy as an initial exam for identifying lesions.

In the search to broaden its area of activity led the hospital to set up provisional clinics to examine women in the countryside of the state, opting to use the Pap smear as a primary method and colposcopy used when further clarification was needed.

The tests were conducted in the ginecoolgia clinics and analysed at the hospital’s main unit in Salvador. These centres operated intermittently, developing specific disease prevention campaign Lana,p.

During the s and early s, cervical cancer prevention initiatives continued to expand. Prevention services in public hospitals, universities, health departments, preventative outpatient clinics sponsored by leagues against the disease and a number of campaigns became included in the scenario for controlling the disease.

For their part, the gynaecologists and cancerologists increasingly perceived cervical cancer as a public health issue, advocating the amplification of initiatives for its control, particularly in the more remote regions of the country. In the mid s, the utilization of exfoliative cytology as an initial test to detect cervical cancer was already a point of consensus among the medical community.