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c h a p t e r t h re e Borderline Lesions  Radical Solutions: Surgery for Female Cancers Until the last two decades of the twentieth century, the principle of early detection and surgical elimination of precancerous lesions was applied mainly to the detection and preventive treatment of female malignancies. Biopsies continued to be employed to diagnose other tumors (head and neck, lower digestive tract), and, in selected cases, surgeons asked for frozen sections of suspicious tissue during a surgery for variety of conditions, malignant or not. Nevertheless only the management of female cancers (those of the breast and uterus) included systematic efforts to diagnose and to eliminate premalignant lesions.1 In the interwar period, such efforts were hampered by the difficulty of defining what a premalignant lesion of breast or cervix was and how it should be treated. In the nineteenth century, cancer was seen mainly as a women’s disease, a perception linked to the ease of diagnosing women’s malignancies.2 In absence of modern diagnostic methods such as medical imagery, cancers of internal organs—such as the lung, the liver, the stomach, the colon, and the pancreas— were seldom recognized as malignant growths. People with these tumors became very sick and died from an organic failure: shortness of breath, jaundice, bleeding , blocked intestine, or general weakness. Many cancer deaths were accordingly seen as age-related demise.By contrast,female cancers were frequently diagnosed before the patient reached a terminal stage, and they produced visible and highly distressing symptoms: wounds that failed to heal, discharge of blood or pus, ulcers , necrosis, and a foul smell. Cancer, represented as it was by these pathologies but also by head and neck tumors, was indeed a “dread disease”: frightening, degrading , repulsive, and associated with a loss of control. In the early nineteenth century the word “ancome,” which described earlier a swelling or a tumor, was occasionally confused with the word “income,” a curious comment on one of cancer’s main characteristics, reckless growth.3 Social scientists and literary critics put forward the role of cancer as a metaphor of individual failings and societal ills. However, an excessive accentuation of metaphorical meaning of cancer may be misleading.This disease did not unfold in an abstract discursive space but within a living body of a patient, and physicians attempted to cure it with all the concrete means at their disposal. The history of cancer therapies is more closely related to the development of specific medical practices than to broader cultural trends. Doctors who attempted to deal with the harsh manifestations of cancer often felt that they need to be matched by similarly harsh therapeutic means (chasing evil with evil). Halsted’s radical mastectomy became a model of other surgical interventions such as the Wertheim hysterectomy for uterine malignancies. This operation, improved by the Austrian surgeon Ernest Wertheim in the early twentieth century, was seen as a gynecological equivalent of radical mastectomy. Wertheim affirmed that to achieve a cure of a locally extended cervical cancer the surgeon should resect the uterus, the ligaments (parametria), and the nearby lymph nodes. In advanced cases the surgeon also eliminated the surrounding fused organs. The surgery had a high rate of mortality. In Wertheim’s early attempts , nearly 40 percent of the people undergoing the surgery died as a direct consequence of the operation. Later the mortality due to surgery stabilized at around 10 percent. This result was seen as acceptable when the alternative was a painful and lingering death, less so when it became possible to treat cervical cancer through less deadly methods, such as radiotherapy and radiumtherapy.4 In the 1920s and 1930s, the great majority of French and Swedish women diagnosed with cervical cancer were treated with x-rays or radium, as were some (but not all) British patients.5 In these countries, the coexistence of radiotherapy and surgery lessened the pressure for heroic operations. By contrast German and Austrian doctors believed that surgery was the only efficient way of dealing with cervical cancer.Radiotherapy was employed only to treat patients diagnosed with extensive tumors that could not be removed by surgery (e.g., growths that were fixed to the pelvic wall). Important differences in therapies of cervical cancer prompted international comparisons of curative techniques. Such comparisons indicated, however, that radiotherapy and surgery had a similar efficacy. In the hands of the best specialists, 40 percent of women diagnosed with a cervical cancer before...

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