A detour or a shortcut? Pathology laboratories in cancer treatment centres

In Transferring Public Health, Medical Knowledge and Science in the 19th and 20th Century. Conference Proceedings. Astri Andresen and Tore Grønlie (eds). Rokkansenteret, Report 2-2007, 47-65.

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A detour or a shortcut?

Pathology laboratories in cancer treatment centres Tricia Close-Koenig

Based on a study of a pathology laboratory in Strasbourg, this paper investigates the

relationship between radiotherapists, surgeons and pathologists in cancer treatment in

the early twentieth century. The guidelines that determined the administration of the

first cancer treatment centres in France (les Centres Anticancéreux) endorsed

multidisciplinary collaboration. I investigate why the pathology laboratory dominated

cancer diagnosis in France in the interwar period and how this subsequently led to

pathologists acting as key members of the cancer treatment unit. I also situate the

French model alongside cancer treatment centres in other European countries.

Cancer, a scourge at the turn of the century alongside tuberculosis, syphilis,

diphtheria and alcoholism, mobilized both medical and political actors. As a cause of

death in western countries cancer was, statistically, on the rise. Cancer received

much attention and the fight against it became a national priority, but it was not always

on the national level that cancer treatment and research were structured: the history

of cancer treatment is rich in local, national and international medical and political

exchange.1 The history of the war on cancer is a history of public health propaganda,2

of clinical trials,3 of screening and prevention,4 but also of hospital reorganisation5 and

of retribution within medical hierarchies.6 These latter dimensions involve medical

technicians, laboratory services, and, simply, questions concerning how to get the job

done – that is, treating the cancer efficiently.

Cancer treatment in hospitals and specialized centres was not a uniform or

internationally regulated practice in the interwar period. In many cases, surgery and

radiotherapy were conflicting practices, or, more precisely, surgeons and

radiotherapists, and other medical specialists, were in conflict over which treatment

was best. In 1923, France became one of the first countries to implement national

standards and guidelines for cancer centres. To understand how the pathology


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laboratory came to dominate cancer diagnosis and direct cancer therapy in France

requires: a) knowledge of the role of teamwork in wartime medicine in France, b) a

sense of how the interactions between doctor and patient changed in the first decades

of the twentieth century, and c) knowledge of what pathologists were doing. The story

of how teamwork was introduced to cancer treatment is essential as it links together a

number of key actors, each representing the conflicting medical specialisations. A

sense of doctor-patient interactions is needed to give the organizational history depth

by propping it against medical practices. The details of what pathologists was doing

are the substance of my case study, as they reveal how pathologists contributed to

the consultation and thereby provided a shortcut in the treatment enterprise.

This paper is divided into six parts. I begin with recent discussions of

specialisation tensions in cancer treatment. Then I detail the history of cancer

treatment and radiotherapy in Strasbourg, as well as the implementation of regional

cancer centres in France. The teamwork approach was central to these centres and I

trace its roots from the First World War to its endorsement by the Cancer Commission

in the early 1920s. The fourth section steps away from the historical account to

provide an overview of the sequence of medical consultation, diagnosis, and

treatment in routine medical practice. The fifth section ties the changes in medical

practice to what was happening in the pathology laboratory at the time. In my study of

the pathology laboratory in Strasbourg, I have found evidence of a new type of activity

that corresponded with the founding of the cancer treatment centre in the mid-1920s.

The reports from the pathology laboratory illustrate how it contributed to, and

ultimately led, cancer treatment efforts. Finally, an overview of practices in other

nations provides a broader view of the hierarchies in cancer treatment and pinpoints

the role of pathologists alongside other actors engaged in cancer research and

treatment.

“Who was to have jurisdiction over the cancer patient?”7

The question at the heart of my inquiry is similar to that of Ornella Moscucci and John

Pickstone in recent articles.8 Moscucci states:


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“As the new radiation techniques found a niche in cancer therapy, questions

arose as to who should determine and carry out treatment. The problem was

usually formulated in terms of effectiveness and expertise, but the underlying

issue was one of control. Who was to have jurisdiction over the cancer

patient?”9

Moscucci concentrates on radiologists and gynaecologists, amongst those to claim

their stakes, while Pickstone considers medical oncologists (who practice

chemotherapy) and clinical oncologists, or radiotherapists, alongside surgeons.

Moscucci has shown that radiologists developed X-ray therapy but that

gynaecologists came to adopt radiation therapy in their own practices. Louisa

Martindale, for example, shared the opinion of her mentors in Freiberg that the

gynaecologist’s diagnostic expertise was the key to success and therefore should be

administering the treatments. The question of dominance of the specialist (radiologist,

radiotherapist or gynaecologist) was more complex for radium therapy as it was the

surgeon who controlled the insertion of the radium into tumours. To a certain extent,

the approach adopted by the London Radium Institute, as well as the Manchester

Radium Institute, sidestepped this debate by not deciding the patient’s treatment. That

is, diagnosis and follow-up care were left to the referring doctor and the treatment

itself to those at the Institute.

The mediations between surgeons and radiotherapists seem more muddled

than those between gynaecologists and radiotherapists, as they varied at different

institutions and for different types of cancers. Pickstone emphasizes the historical

priority of surgical approaches. From the late nineteenth century, surgery was the

established remedy for accessible cancers. Radiotherapies, and other alternatives,

were introduced for inoperable cases. As an example, the Manchester Radium

Institute was promoted by a surgeon in order to avoid “chopping out the tongue and

other parts.”10 Similarly, at the Middlesex Hospital in London, radium therapy for

uterine and breast cancers was developed for the inoperable, but later came to be

offered as an alternative to surgery. Pickstone delineates this liberal model where “all

significant hospitals had surgical radium therapy; X-ray therapy was an annex to


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diagnostic radiology, and radiologists did not control beds.”11 By the 1920s, however,

centralized schemes, where “all radium treatment and most X-ray treatment was to be

given in specialist regional or national institutions which might also be responsible for

major cancer surgery,” were developed.12 There were teams of specialists working

together in these establishments: “pathologists, diagnostic radiologists,

radiotherapists, and surgeons would all be experts on cancer and its treatment (…)

along with physicists and statisticians and special nurses.”13 Moscucci and Pickstone

both stress the general advocacy of teamwork in the interwar period.14 I would like to

develop the role and significance of teamwork in French cancer treatment. As

Pickstone acknowledges, “The nearest approach on paper was the plan in France,

after the Great War, for regional cancer centres that would include surgery.”15

“I brought the radium back to Strasbourg in my pocket”16

In France, aside from some rudimentary equipment in Paris and radiotherapy units

installed in Lyon and Montpellier during the First World War, most hospitals did not

have other cancer treatment facilities than surgery. Patrice Pinell has argued that

France initially lagged behind the United States, England and Germany in this respect

but that the situation was quickly reversed in the post-war years.17

From about 1910, Strasbourg housed radiotherapy services in the radiology

facilities at the Strasbourg hospital.18 The facilities were constricted to say the least.

The radiology service was installed at the upper floor of the building. It consisted of a

miniscule laboratory, closets for storage and for developing the X-ray images, a large

room for X-ray imaging and a small room for radiotherapy.19 The radiotherapy

services were used initially for inoperable cancer cases and in this room, cancer

patients were bandaged, biopsies were taken, blood work done, as well as the

radiotherapy treatment carried out.

Auguste Gunsett, the director of the radiology facilities in Strasbourg and later

the director of the cancer centre, had initially been interested in specialising in

gynaecology and dermatology. Gunsett first learned of the promising effects of radium

for skin cancers while at a dermatology conference in Rome.20 Upon his return to

Strasbourg, in collaboration with gynaecology and dermatology professors, he raised


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funds to purchase enough radium to treat skin and uterine cancers. In 1913, Gunsett,

accompanied by a professor of dermatology, went to Armet-de-Lisle in Nogent-sur-

Marne in France (Strasbourg was German at the time) and brought the radium back in

his pocket.21 The radium therapy was run as a private service independent of the

hospital.

After the armistice, Gunsett emphasized that the quarters were cramped, the

equipment in poor shape, and the radioprotection measures insufficient.22 The

hospital’s financial situation did not allow immediate renovation or expansion of the

facilities, but the radiotherapy services continued to operate. In 1922, Paul Strauss,

Minister of Hygiene, Social Assistance and Welfare, decreed that regional cancer

treatment centres would be a priority in public health measures. The first step was the

creation of the Commission du Cancer (Cancer Commission) dedicated to

coordinating the needed measures of aetiology, pathology, clinical study, therapeutics

and prophylaxis of cancer.23 This Cancer Commission consisted of 84 medical

doctors, administrators of health services, members of the Académie de médecine

and one physicist, Marie Curie.24 The majority were Parisian. Three were from

Strasbourg: Dr Berthelot from the Institut d’hygiène et bactériologie, Professor Pierre

Masson, director of the Institut d’anatomie pathologique, and Professor Auguste

Sartory, who held the chair of bacteriology at the Faculté de pharmacie. The cancer

centres were to be regional and to embrace treatment, teaching and research.25 As

such, a centre could not be opened anywhere or by anyone and stringent conditions

were to be met:: the city had to have a medical school; the centre had to be lodged in

existent buildings; the hospitalisation of cancer patients was secondary; radiotherapy

instruments (min. 200 000 volts) and radium (min. 200 mg) had to be at hand; and the

personnel had to include the teaching staff at the medical school.26 In November

1923, the Centre regional de lutte anticancéreuse (Regional Centre for the Fight

against Cancer) was established in Strasbourg.27 As a regional centre, it was to

receive cancer patients from the Bas-Rhin, the Haut-Rhin, Moselle, the territory of

Belfort, the Vosges, Haute-Saône, as well as Luxembourg, see Figure 1. By 1925,

there were fourteen Regional Cancer Centres in France.


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Lille

RouenCaen

Rennes

Nantes

Angers

Bordeaux

Toulouse

ClermontFerrand

Montpellier

Marseille

Nice

Lyon

Dijon

Strasbourg

NancyReimsParis

VillejuifSaint Cloud

Figure 1. A map of France illustrating the locations of Regional cancer centres. The map is divided into the twenty-one regions of France. The red dots represent the fourteen Centres Anticancéreux opened before 1925. The blue dots represent those after 1925. The shaded yellow and green areas in the insert illustrates the initial constituency under the jurisdiction of the Strasbourg centre (Bas-Rhin, Haut-Rhin, Vosges, Belfort Territory, Haute-Saône, Moselle and Luxembourg). Once the Regional centre opened in Nancy in 1925, Strasbourg’s constituency was reduced to the shaded green area (Bas-Rhin, Haut-Rhin, Belfort Territory and Moselle).

Teamwork

Not only did the Cancer Commission require that the Regional Cancer Centre

personnel consisted of medical school staff, but the competence that had to be united

in order to guarantee adequate treatment of each patient were detailed:

“1. An anatomo-pathologist to determine the nature of the cancer to be

treated;

2. A surgeon to take care of curative and palliative interventions;

3. A medical-electrician, with a thorough knowledge of deep radiotherapy and

brachytherapy, to direct these applications;


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4. A physicist who can contribute, regularly or from time to time, advice on

the operation of the instruments for treatment and measurement.”28

Consequently, the treatment of patients in the regional centres required reconsidering

the organization and collaboration within the hospitals. The structure had to involve

interactions between pathology, surgery, radiotherapy and medical physics. Such

team efforts were not unique to France. As mentioned above, there were for example

incidences of group meetings at the Westminster Hospital in London and the Christie

in Manchester.29 Furthermore, as Pickstone notes, the advocacy of teamwork, as

integral to centralization, was not limited to medicine in the interwar period.30

Perhaps the most vocal spokesman for the importance of teamwork in cancer

treatment was Claudius Regaud.31 In 1913 Regaud joined Emile Roux and Marie

Curie in organising the Radium Institute in Paris.32 They were still soliciting support to

further develop the Institute, but the efforts and plans were interrupted by the war.33

Regaud’s war experience is important to his later policies.34 During the First World

War, Regaud brought together a number of colleagues to improve medical facilities at

the front lines.35 The Groupement de Services Chirurgicaux et Scientifiques initially

stationed in Prouilly and later in Bouleuse, near Reims, comprised medical services,

radiology, bacteriology, haematology and pathology laboratories, alongside surgery

facilities. Boundaries disappeared as doctors, civilians, military, surgeons, radiologists

and biologists acted in collaboration. Regaud brought together a team chosen for their

competency: René Leriche, surgeon; Jean Louis Roux-Berger, surgeon; Thomas

Nogier, medical physicist/radiologist; and Pierre Masson, pathologist. The interaction

within this group was not limited to the war years. Nogier was a friend of Regaud’s

from before the war and had introduced him to radiology techniques in Lyon.36 In fact,

a number of these men may have crossed paths in Lyon, where Leriche, Roux-

Berger, Nogier and Regaud had all spent some time, as had Justin Godart, the

parliamentary under-secretary who appointed Regaud to his war post. Masson was at

the Pasteur Institute in Paris immediately before the war and may have met Regaud

there. In the post-war years, the cancer clinic founded by Regaud at the Radium

Institute employed these acquaintances from the war.37 Both Leriche and Masson


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subsequently held chairs at Strasbourg’s medical school, Masson from 1919 and

Leriche from 1924.38

The resemblance of the list of specialities of the leading members of the

Groupement de Services Chirurgicaux et Scientifiques to that of the expertise required

by the Cancer Commission for the organisation of the Regional Cancer Centres is

remarkable. Both put laboratory pathologists, surgeons, radiologists and physicists on

equal footing. This was not a coincidence. A number of those who participated in

multi-disciplinary military medical teams were also appointed members of the Cancer

Commission and their personal experiences likely contributed to the conditions set by

the commission.

A further element that influenced the conditions set forth was the pre-existing

radiotherapy centres. In 1922, there were three prominent centres that may have

been models for the new regional centres. The cancer treatment unit at the Paul-

Brousse Hospices in Villejuif was founded by Gustave Roussy in 1921. Here research

focused on pathological anatomy was situated alongside the clinic. After radium had

been purchased in 1922, the unit also offered treatment.39 At La Salpêtrière and

Tenon Hospitals, cancer treatment units were annexed to the general surgery wards.

Here, the supremacy of surgeons (over radiotherapists) was notable, and there was

no particular interest in research.40 Finally, the cancer centre organised by Regaud in

1919 as an extension of the Radium Institute, which became the Curie Foundation in

1921, had multiple objectives: teaching, treatment and research.41 At the Foundation

all actors – clinicians, radiotherapists, surgeons, physicists or pathologists – were

complementary and mutually respected. Pinell has suggested that the final model for

the Regional centres was effectively a hybrid of the Parisian examples, as well as

those found in the provinces, in Lyon, Montpellier and Strasbourg.42

Between 1923 and 1925 fourteen regional cancer centres, under the designation

Centres Anticancéreux, were established. Practice in these centres did not always

follow the guidelines.43 Despite the numerous ways of adapting existing facilities to

meet the Cancer Commission’s requirements, the general notion of a multi-

disciplinary team to provide assessment of and treatment to cancer patients was a

national model that was exported. As Charles Hayter, in a recent historical study of


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radiotherapy in Canada, states: “The French system became an influential model for

other countries.”44 This may be attributed, in part, to the relatively early organisation of

cancer treatment and research on a national scale in France. In addition, Claudius

Regaud was an active spokesman, present at numerous international events

promoting the teamwork approach.45 Regaud also welcomed hundreds of visiting

doctors from abroad.46

I will return to the international dimension in the final section, but now allow me to

stray to the medical consulting room and look at what the patient encountered before

entering the cancer treatment framework. The digression is intended to illustrate what

the multi-disciplinary medical approach for cancer treatment implied for medical

practice. The models I will draw elicit the title of the paper by asking if the insertion of

the laboratory was a detour. In the fifth section, the role of pathologists, of teamwork

and of the insertion of the laboratory will be brought together.

Interactions between doctor and patient

In the nineteenth century, the characteristic meeting with the doctor was relatively

straightforward.47 The medical consultation involved the medical doctor and the ailing

patient. If we overlook the role of surgeons, pharmacists and less-reputable healers,

as well as family members and payment modalities, a diagram of the interaction might

consist of a straight line, or a direct path, between the doctor and the patient, see

Figure 2. This illustrates the prominence of the doctor who relied largely on

experience and individual judgement in making diagnosis and prognosis. As such,

cancers were diagnosed from their gross appearance and clinical behaviour.

doctor

patient

Figure 2. A (very simplified) caricature of the interaction between doctor and ailing patient in a 19th century medical consultation.


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In the latter half of the nineteenth century, what was a direct path was redirected or

detoured through the laboratory. Bacteriology and the aetiology of infectious diseases

introduced the laboratory as a place for diagnosis. A patient with suspicious

symptoms could be sent to the lab for differential diagnosis in order to direct proper

treatment.48 The lab contributed to therapeutic decision-making by identifying the

disease microscopically.49 By the mid-twentieth century, the detour through the

laboratory was routine; that is, lab analyses, alongside other tests, were performed

with or without suspicious symptoms, notably on hospitalized patients.50 Sometime

between the introduction and implementation of histo-pathological examinations for

cancer diagnosis at the turn of the century and mid-century, the laboratory became

lodged between doctor and patient. Claudius Regaud’s statement in 1926 is an

indication of this movement:

“In the past, it was not imagined that the executants (who were exclusively

surgeons) would one day need the intervention of specialty laboratories. This

is no longer the case today. Histology, haematology, bacteriology, physics

have become very useful, at times necessary to apply the right

radiotherapeutic methods.”51

Again, a simplified diagram of the interaction thus integrates the insertion of the

laboratory, see Figure 3. The addition of the laboratory to the medical scheme was

accompanied by a number of transformations which I will not detail, including medical

specialisation, medical secretaries, nurses, medical technologies and machines,

patient histories and filing systems, payments systems, medical insurance, public

medical coverage, etc. Instead I wish to point out the route of the information: the

laboratory result is returned to the doctor who redirects and reinterprets the analysis to

the patient, see Figure 4. The doctor, who requests the examination, remains the

authoritative figure in this detour.52


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doctor

patient

pathology

lab

Figure 3. A (very simplified) caricature of the interaction between doctor and ailing patient in 20th century medical consultation. The pathology lab plays an important role in cancer diagnosis.

doctor

patient

pathology

lab

Figure 4. A (very simplified) caricature of the interaction between doctor and ailing patient in 20th century medical consultation. The pathology lab plays an important role in cancer diagnosis, but the medical doctor is the authoritative figure in the exchange.

I have outlined these simple interactions as an illustration of changes in medical

practice. I have referred to the diversion through the laboratory as a detour. But was

this really a diversion or a detour in the sense that it was unnecessary or inefficient?

The activity of the pathologist in my study of the pathology laboratory in Strasbourg

elucidates this.

Pathologists: important team members A 1920s publication titled Centre Régional de Lutte Contre le Cancer: Centre Paul

Strauss briefly outlines the organisation of Strasbourg’s regional cancer centre.53 In

the one-page description, the organisation is detailed in nine points. (The remainder of

the brochure consists of twenty-one photos of the centre.) The first gives the location

of the centre on the hospital grounds.54 The second lists the rooms in the centre. The

third states: “The biopsies are performed at the Pathological Anatomy Institute of the

medical school.” The fourth and fifth note the technical details of the apparatus. The

sixth mentions that surgical operations are performed in the medical school surgery

wards. The seventh says that hospitalisation may be in the centre itself or in the

hospital. The eighth assures that the treatment of every patient is a collaborative effort

of medical professors. The last point describes teaching, which includes instruction at

the medical school and an upgrading course that is offered every two years. This list

can be taken as exemplar of Auguste Gunsett’s conception of the centre’s strong

points and of what is needed to treat cancer patients. It is interesting and revealing to


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note that the pathologist appears in number three and precedes the technical details,

the surgical facilities, as well as the accommodation situation. This list may be

interpreted as implying that treatment is the priority and teaching an afterthought. It

also provides evidence of the primordial role of pathologists and the pathology

laboratory in cancer treatment and of Gunsett’s union with the Pathological Anatomy

Institute and its director, Pierre Masson. The union was also a financial one, the

cancer centre compensating the pathology lab 2000 French francs annually.55

Upon the inauguration of the cancer centre in Strasbourg in 1923, the

laboratories collaborating for cancer treatment and research were threefold: biopsies

were examined for practitioners in the surrounding regions and for the centre at the

Pathological Anatomy Institute by Masson; bacteriology analyses were performed at

Strasbourg’s Pasteur Institute by Amédée Borrel; and further research was conducted

at the Medical Physics Institute by Fred Vlés.56 These three laboratories effectively

participated in meeting the triple objective of the centre: treatment by providing initial

diagnosis and follow-up tests, teaching as these institutes were an integral part of the

medical school, and research as the tissue samples not only provided patient

information, but also furnished laboratory samples for medical students and research

material for professors and research assistants.

Furthermore, there is no evidence of conflict between the team’s medical

specialists. On the contrary, the collaborative publications are numerous between the

director of the Pathological Anatomy Institute, Pierre Masson, and the directors of

surgery, Louis Sencert and René Leriche,57 as are those between the director of the

cancer centre, Auguste Gunsett, and surgeons René Simon and André Boeckel.58

It was the pathologist who effectively bestowed the consulting doctor, the patient

and the radiotherapist with imperative information about the patient and their diseased

tissue. The histo-pathological examination identified microscopic structure of the

tissue with benign and malignant tissue types; it also distinguished the radiosensitive

from the radioresistant, and it provided a means of monitoring the evolution of the

tissue.59 The information imparted in the histo-pathological examination allowed the

treatment to be more exact, thereby saving time and expenses for the specialists and

the centre, as well as limiting the suffering of the patient. That pathologists had the


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tools and the means for doing this was due to several decades of research and study

of the microscopic structure of diseased tissue. Pathologists had a long-running

interest in cancers and the background to recognize and classify tissue structures

morphologically.

The laboratory organisation and activity within the Pathological Anatomy Institute

changed after 1923. The laboratory journals that record the examinations illustrate the

rise in the number of biopsies and surgical samples.60 The samples came from the

whole region that this regional cancer centre was to serve. Furthermore, the

examination report provides details on what type of lesion was observed (i.e. a

diagnosis); at times the reports refer to treatment undergone indicating whether it was

successful or not, and others indicate radiotherapy advice with straightforward

recommendations, such as: “Tumour likely radioresistant. If radiotherapy is

undertaken, use strong doses.”61; “Tumour likely radiosensitive.”62; “Radiosensitivity

low, radium therapy is recommended.”63; “A radical operation is necessary.”64

Although the pathologists did not meet the patient, they provided vital information on

the patient’s condition, thereby warranting and validating the detour through the

pathology laboratory.

European developments

We will now look at a few cases outside France, but before doing so, it is important to

emphasize that Claudius Regaud, Gustave Roussy and Charles Bouchard, all heavily

involved in the first cancer research and treatment centres in the Paris region, were

pathologists. Furthermore, the Pasteur Institute strongly advocated laboratory work.

The influence of non-surgeons in mobilising units that merged research and therapy

for cancer, I argue, is significant to the development of the type of centres that were

found in France. Pickstone has evoked the idea of path dependency to trace such

tendencies and the historical rooted-ness of protocols.65 The potency of the teamwork

in France, for example, is in strong contrast with the surgeon-dominated model of the

United States.

Cancer research laboratories were founded across the United Kingdom from the

turn of the century: Middlesex Hospital Cancer Research laboratories in 1900,


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Imperial Cancer Research Fund in 1902, Manchester University Cancer Research

Lab in 1903,66 Cancer Hospital Research Institute in 1909, Glasgow Cancer Hospital

Research Department in 1910, the Radium Institute in London in 1911, the Radium

Institute in Manchester in 1914.67 As indicated by their names, with exception of the

latter two, these were largely places of research. The two Radium Institutes provided

therapy, but they housed no diagnostic services. Patients were diagnosed by their

consulting physicians and went to the institutes uniquely for the recommended

treatments.68

In the interwar period, cancer centres in England were often directed by

pathologists or radiotherapists as surgery remained within hospital surgery wards.69

Nevertheless, special cancer hospitals in London, such as the Marsden, St.

Bartholomew’s, the Middlesex and the Westminster, were reputed for both cancer

surgery and radiotherapy.70 As mentioned above, there is also evidence of team

meetings at some of these institutes.

Another notable development in the interwar period was the establishment of the

National Radium Trust and Radium Commission of 1929, which acted as a central

dispensary of radium. It was considered a step towards a centrally controlled system,

but Regaud criticized that it also made it possible for under-experienced physicians to

try radiotherapy.71 The Christie cancer hospital, established in the late 1930s, was,

however, considered an exemplary regional service, on a par with centres in France.72

In Sweden, providing therapy was a priority for those who undertook cancer

research as early as 1899.73 The first institutions include the Roentgen Institute in

Stockholm from 1899, the Serafimer Hospital in Stockholm and the hospital in Lund

from 1908, the Radiumhemmet at Schéelegatan in Stockholm from 1910, the hospital

in Gothenburg from 1910, and the Radiumhemmet at Fjällgatan in Stockholm from

1916. The Radiumhemmet was exemplary of a regional research and treatment

centre. It was funded privately (by the Cancer Society in Stockholm) until the end of

1918, but the government contributed by covering patients’ transportation costs until it

became publicly funded in the early 1920s. Richard Pearce, a representative of the

Rockefeller Foundation, claimed the Radiumhemmet (as well as the Radium Institute

in Paris) was different from other cancer centres not least because they hosted the


15

“few competent groups of scientists devoting themselves exclusively to cancer.”74 The

Radiumhemmet was founded by the radiologist Gösta Forssell and a surgeon, John

Berg, but they considered radiation physics, biology and pathology to be equally

important as radiology and surgery. The team came to include a physicist and a

pathologist, and pathology laboratories for research and for diagnosis were integrated

into the Radiumhemmet. In addition, early radiotherapy services outside the

Radiumhemmet were offered in teaching hospitals.

The Radiumhemmet is comparable to the regional centres developed in France in

the early 1920s, and like the Radium Institute in Paris the Radiumhemmet received

visitors from other nations who were interested in developing radiotherapy treatment

centres. For example, Dr Manninger retained the Radiumhemmet as a model for the

Eötvös Loránd Radium and Roentgen Institute in Hungary.75 This centre, opened in

1936, only treated cancer patients beyond the operable stage.

Not unlike the United Kingdom, cancer research centres in Germany

outnumbered treatment centres in the first decades of the twentieth century: Abteilung

für Krebsforschung am Königlichen Institut für experimentelle Therapie in Frankfurt-

am-Main from 1901, Institut für Krebsforschung der Charité in Berlin from 1903,

Institut für Krebsforschung in Heidelberg from 1906, Forschungsinstitut für Krebs und

Tuberkulose in Hamburg from 1912.76 However, perhaps even more than in the

United Kingdom, these institutions concentrated on research. The exception was the

terminal phase treatment that was offered at the Charité in Berlin from 1918 (this was

also the only centre associated with a medical school) and in Heidelberg. It is

suggested that treatment, surgical or other, took place in hospitals. The role of

pathologists in diagnosis was, however, minimal, and few tissue samples were sent

for diagnosis: “Only very few, one could say the remaining rubbish, were sent to the

institute for histological diagnosis.”77

The Netherlands Cancer Institute opened in 1913 was co-founded as a joint effort

by a surgeon and a pathologist.78 It is interesting that they, like Dr Manninger of

Hungary, were professors and thereby situated somewhat closer to the forefront of

research and teaching than most clinicians. The connection to a medical faculty was

also present in Iceland, where all suspected cancers even before the First World War


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were diagnosed by histo-pathological techniques at the pathology laboratory at the

medical school in Reykjavik.79 Samples or excised tumours were sent to Reykjavik

from all over Iceland, while radiotherapy was offered at the Landspitalinn in Reykjavik

and cancer surgery at the general hospitals in Reykjavik and Akureyri. For other

countries, such as Norway, I have found no evidence of cancer treatment facilities that

pre-date the Norwegian Radium Hospital that opened in 1961.

The Strasbourg case and the various European examples put forward in this

article demonstrates that in the interwar period, before mobilization for cancer

treatment became an international issue, whether or not a pathologist was consulted

depended on who controlled radiotherapy in the institution.80 These were often the

same persons who opened the hospital or centre to alternatives to cancer surgery,

and tended to be surgeons and/or pathologists. Surgeons had a long-standing

position in cancer treatment, as tumour extirpation had been the dominant method in

cancer treatment since the late nineteenth century. Pathologists had been studying

the cellular structure of cancerous tissue from the diseased and the deceased since

the mid-nineteenth century. Efforts to organise cancer treatment facilities in the early

twentieth century involved both competition and collaboration between the two

medical specialists; pathologists often joining forces with radiotherapists.

Conclusions

Since the mid-nineteenth century the pathology lab has been a place of research and

of post-mortem study. Although biopsies had long been acknowledged as a useful

(and even necessary) diagnostic method, this acknowledgement was not translated

into practice. The passage of a patient’s tissue sample through a laboratory was

effectively considered a detour by physicians and surgeons. If cancer was suspected,

the tumour or diseased tissue was surgically removed when possible. If it was

inaccessible, the physician prescribed treatment for the pain.81

This pattern changed in the first three decades of the twentieth century in a

process that was not only medically driven, but also political and social.82 The rise in

numbers of examinations performed for diagnosis by the pathologist at the

Pathological Anatomy Institute of the Medical School in Strasbourg demonstrates the


17

changes. In France, the teamwork approach was strongly advocated and supported

by the network of those who had participated in multi-disciplinary medical war units.

The process was not the same throughout Europe, but the different approaches to

cancer treatment became known via international conferences and visiting doctors

and scholars.

The proximity of pathologists to cancer centres influenced how radiotherapy

was embraced. If pathologists were involved, there was a tendency to treat surgery

and radiotherapy as equal options. If pathologists were absent, surgery remained the

main method of treating cancer. More precisely, when a histo-pathological

examination was performed, the information spoke to radiotherapists. In cases where

cancer and treatment were monitored by histo-pathological examinations, pathologists

and radiotherapists accumulated evidence of what had effect upon different cancers.

The pathologists had this morphological database so to speak at their fingertips,

rendering them indispensable. The journey to the laboratory, therefore, was not a

detour if it provided vital information for choosing a therapeutic path (or avoiding one,

if the growth was benign). The time saved for radiotherapists (or surgeons), the

comfort granted to the healthy or alleviated patient and the money saved by the

increased efficiency of the system transformed the extra route from a detour into a

shortcut.

1 Cf. Cantor, David. “Cancer.” In Bynum, W. F. and Roy Porter. Companion

Encyclopedia of the History of Medicine, Volume 1. Routledge, London and New

York 1993: 537-56; Bud, Robert. “Strategy in American cancer research after

World War II: a case study.” Social Studies of Science 8 (1978): 425-459; Maulitz,

Russell. “Rudolf Virchow, Julius Cohnheim and the program of pathology” Bulletin

of the History of Medicine 52 (1978): 162-182; Richards, Evelleen. Vitamin C and

Cancer: Medicine or Politics? Macmillan, Basingstoke and London 1991. 2 Cf. Cantor, David. “Uncertain Enthusiasm: The American Cancer Society, Public

Education and the Problems of the Movie, 1921-1960.” Bulletin of the History of


18

Medicine 81 (2007): 39-69; Krueger, Gretchen Marie. “‘For Jimmy and the Boys

and Girls of America’: Publicizing Childhood Cancers in Twentieth Century

Europe.” Bulletin of the History of Medicine 81 (2007): 70-93; Toon, Elizabeth.

“‘Cancer as the General Population Knows It’: Knowledge, Fear, and Lay

Education in 1950s Britain.” Bulletin of the History of Medicine 81 (2007): 116-138;

Pinell, Patrice. Naissance d'un fléau. Histoire de la lutte contre le cancer en France

(1890-1940). Editions Métailié, Paris 1992, esp. Chapter 9. 3 Cf. Keating, Peter and Alberto Cambrosio. “Cancer Clinical Trials: The

Emergence and Development of a New Style of Practice.” Bulletin of the History of

Medicine 81 (2007): 197-223; Timmermann, Carsten. “As Depressing as It Was

Predictable? Lung Cancer, Clinical Trials, and the Medical Research Council in

Postwar Britain.” Bulletin of the History of Medicine 81 (2007): 312-334; Kutcher,

Gerald. “Cancer Clinical Trials and the Transfer of Medical Knowledge: Metrology,

Contestation and Local Practice” In Timmermann, Carsten and Julie Andersen.

Devices and Designs. Medical Technologies in Historical Perspectives. Palgrave

Macmillan, Basingstoke and New York 2006: 212-230; Löwy, Ilana. Between

Bench and Bedside: Science, healing, and interleukin-2 in a cancer ward. Harvard

University Press, Cambridge 1996. 4 Cf. Clarke, Adele E. and Monica J. Casper. “From Simple Technology to Complex

Arena: Classification of Pap Smears, 1917-1990.” Medical Anthropology Quarterly

(new series) 10 (1996): 601-623; Löwy, Ilana. “Breast Cancer and the ‘Materiality

of Risk’: The Rise of Morphological Prediction.” Bulletin of the History of Science 81

(2007): 241-266. 5 Cf. Murphy, Caroline C. S.. “From Friedenheim to hospice: a century of cancer

hospitals.” In Granshaw, Lindsay and Roy Porter. The Hospital in History.

Routledge, London and New York 1989; Keating, Peter and Alberto Cambrosio.

Biomedical Platforms. Realigning the normal and the pathological in late- twentieth

century medicine. The MIT Press, Cambridge, MA 2003. 6 Clow, Barbara. Negociating Disease: Power and Cancer Care, 1900-1950.

McGill-Queen's University Press, Montreal and Kingston 2001; Pickstone, John.


19

“Contested Cumulations: Configurations of Cancer Treatments through the

Twentieth Century.” Bulletin of the History of Medicine 81 (2007): 164-196. 7 Moscucci, Ornella. “The ‘Ineffable Freemasonry of Sex’: Feminist Surgeons and

the Establishment of Radiotherapy in Early Twentieth-Century Britian.” Bulletin of

the History of Medicine 81 (2007): 150. 8 Moscucci 2007; Pickstone 2007. 9 Moscucci 2007: 150. 10 Pickstone 2007: 172. 11 Pickstone 2007: 173. 12 Pickstone 2007: 173. 13 Pickstone 2007: 173-174. 14 Pickstone 2007: 168 and 174; Moscucci 2007: 153-154. 15 Pickstone 2007: 174. 16 Gunsett, Auguste. “Les Origines du Centre anticancéreux de Strasbourg.

Quelques souvenirs lointains.” Unpublished manuscript , 1970, Archives Paul

Strauss (Translation by T.C-K.). 17 Pinell 1992. 18 On the history of the cancer treatment centre in Strasbourg: Les Centres Anti-

Cancéreux Français. Vingt-cinq ans d'activité. 1945-1970. Imprimerie le Cerf,

Rouen; Voineau, Christophe. Science, technique et médecine: une histoire de la

radiothérapie en Alsace (1913-1940). Mémoire de DEA, Université Louis Pasteur,

Strasbourg 2003; “Le centre anticancéreux de Strasbourg” Lutte Contre le Cancer

54 (1936): 268-274; F. C. “Le centre régional anticancéreux de Strasbourg” Lutte

Contre le Cancer 31 (1931): 860-864; Marchal, Géo. “Le Centre Régional

Anticancéreux de Strasbourg” La Vie en Alsace 1 (1931): 13-17; Héran, Jacques.

L’histoire de la médecine à Strasbourg. La Nuée Bleue, Strasbourg 1997. 19 Gunsett, Auguste. “L’Evolution des différents services de l’hôpital civil de 1918 à

1929: Service central de radiologie.” 1930. Archives Administratives de l’hôpital

civil de Strasbourg. 20 Gunsett 1970. 21 Gunsett 1970.


20

22 Gunsett 1930. 23 Arrêté ministeriel de 31 mai 1922. 24 “Commission du Cancer.” La lutte contre le cancer 2 (1923): 101-108. 25 “Commission du cancer.” La lutte contre le cancer 2 (1923): 101. 26 “Commission du cancer.” La lutte contre le cancer 2 (1923): 104-107. 27 Arrêré ministeriel de 19 novembre 1923. 28 “Commission du cancer.” La lutte contre le cancer 2(1923): 107-108 (Translation

by T. C-K). 29 Pickstone 2007: 178. 30 Pickstone 2007: 174. 31 Hayter, Charles. An Element of Hope. Radium and the Response to Cancer in

Canada, 1900-1940. McGill-Queen's University Press, Montreal and Kingston

2005: 81-84. 32 Lenz, Maurice. “The Early Workers in Clinical Radiotherapy of Cancer at the

Radium Institute of the Curie Foundation, Paris, France” Cancer 32 (1973): 519-

523; Pinell 1992: 107-114. 33 Camilleri, Jean-Pierre and Jean Coursage. Les Pionniers de la Radiothérapie.

EDP Sciences, Les Ulis 2005: 89. 34 The first world war efforts also contributed to the further development of

radiotherapy apparatus (see Laugier, Alain. “Le premier siècle de la radiothérapie

en France.” Bulletin de l’Academie Nationale de la Médecine 180 (1996): 143-160);

on the distribution and training of X-ray diagnosis and therapy material (see

Camilleri and Coursage 2005: 90-92); and cancer centres are organised in Lyon

and Montpellier (see Pinell 1992: 126-131). 35 Camilleri and Coursage 2005: 92-96. 36 Pinell 1992: 110. They also published together: Regaud, C. and T. Nogier.

“Actions des rayons X très pénétrants, filters, sur le derme et l’épiderme de la

peau.” Association française pour l’avancement des sciences, 41e section (1912):

213. (Note: Patrice Pinell indicates that this was Théodore Nogier, but I have only

found trace of a Thomas Nogier.)


21

37 Pinell 1922: 149. Pinell lists Henry Coutard as radiotherapist at the Gerardmer

military hospital; Octave Monod worked with Justin Godart at the Secretary of

State; René Ferroux physicist worked at Bouleuse; Jean Louis Roux-Berger was

surgeon at Bouleuse, and Mary Thurneyssen nurse at Bouleuse. 38 Héran 1997: 503-504 and 524-525. 39 Pinell 1992: 154 and 157-158. 40 Pinell 1992: 158-159. 41 Pinell 1992: 149-154; Camilleri and Coursaget 2005: Chapter 9. 42 Pinell 1992: 160 and 164. 43 For example, in Marseille the cancer treatment centre remained an annex to the

surgical unit. (Serafino, X. Le Nouveau Centre Régional de Lutte Contre le Cancer.

Marseille. Bureau d’expansion et de propaganda, Marseille: 1972. In Reims the

radiotherapy apparatus had been in the surgery unit but were integrated into a new

cancer centre, whose functioning stressed pluri-disciplinary collaboration. (Baud.

Le centre régional anticancéreux de Reims et le traitement actuel du

cancer. Matot-Braine: Reims 1925). In Nancy, the cancer centre facilities

concentrated on pathology diagnosis, radiotherapy treatment and surgery all under

one roof. (Vautrin. Organisation de la Lutte contre le Cancer. Imprimerie Berger-

Levrault, Nancy, Paris and Strasbourg 1925.) The situation in Caen seems unclear.

The centre opened in 1923, received its first patient in 1925, was officially

recognised as a regional centre in 1930, and hired a pathologist later that year,

although it seems that they may have been sending tissue samples to the

pathologist in the autopsy pavilion (Blanchemain-Bouche, Eliane. Naissance et

evolution des centres de lutte contre le cancer en France: L’exemple de Caen de

1923-1973. Origine du Centre François-Baclesse. MD thesis, Faculté de Médecine,

Université de Caen 2003). 44 Hayter 2005: 83. 45 Regaud’s international communications include the international symposium on

Cancer control at Lake Mohonk, NY, USA in 1926 (Regaud, Claudius. “What is the

value and what should be the organisation and equipment of institutions for the

treatment of cancer by radium and X-rays?” Surgery, Gynaecology and Obstetrics


22

154 (1927): 116-136 (translated in French: Regaud, Claudius. “Quelle est la valeur

et quels doivent être l'organisation et l'équipement des institutions pour le

traitement du cancer par le radium et par les rayons X?” In Archives de l'Institut du

radium et de la Fondation Curie, Tome 1. Les Presses Universitaires de France,

Paris 1929: 135-161). Other destinations included: Belgium, Beyrouth, London,

Peru, Columbia, Berlin, etc. (Camilleri and Coursaget 2005: 146-147 and 151-

152). 46 “Report to Authorize the Executive Committee to appropriate up to $252,000 to

the University of Paris, 4/13/1932” RF, 1.1, 500A Université Paris Radium Institute,

Rockefeller Archive Centre 47 These caricatures are based on historical narratives, including: Rosenberg,

Charles E. “The therapeutic revolution: Medicine, meaning, and social change in

nineteenth century America.” In Vogel, Morris J. and Charles E. Rosenberg. The

therapeutic revolution: Essays in the social history of American medicine

University of Pennsylvania Press, Philadelphia 1979: 21; Jewson, N. D. “The

disappearance of the sick-man from medical cosmology, 1770-1870.” Sociology 10

(1976): 228. 48 Historical studies of the medical laboratory include: Amsterdamska, Olga and

Anja Hiddinga. “The analysed body.” In Cooter, Roger and John Pickstone.

Medicine in the twentieth century. Harwood Academic Publishers, Amsterdam

2000, 417-433; Büttner, Johannes. “The origin of clinical laboratories.” European

journal of clinical chemistry and clinical biochemistry 30 (1992): 585-593; Crenner,

Christopher. “Private laboratories and medical expertise in Boston circa 1900.”In

Timmermann, Carsten and Julie Andersen. Devices and Designs. Medical

Technologies in Historical Perspectives. Palgrave Macmillan, Basingstoke and

New York 2006: 61-73; Jacyna, L. S. “The laboratory and the clinic: The impact of

pathology on surgical diagnosis in the Glasgow Western Infirmary, 1875-1910.”

Bulletin of the history of medicine 62 (1988): 384-406; Lawrence, Christopher.

Rockefeller money, the laboratory and medicine in Edinburgh 1919-1930: New

science in an old country. University of Rochester Press, Rochester 2005;

Ranslant, Delphine. The clinical laboratory: A central point of medical practice


23

hidden in the basement. Case study on the convention bound laboratories of

Strasbourg. DEA dissertation, Université Louis Pasteur, Strasbourg 2004; Sturdy,

Steve and Roger Cooter. “Science, scientific management, and the transformation

of medicine in Britain c. 1870-1950.” History of Science 36 (1988): 421-466;

Twohig, Peter. Labour in the laboratory: Medical laboratory workers in the

Maritimes. McGill-Queen’s University Presss, Montreal and Kingston 2005;

Cunningham, Andrew and Perry Williams. The laboratory revolution in medicine.

Cambridge University Press, Cambridge 1992. 49 An example might be syphilis and the Wassermann reaction, see Fleck, Ludwik.

Genesis and Development of a Scientific Fact. The University of Chicago Press,

Chicago and London 1979[1935]. 50 Keating and Cambrosio 2003. 51 Regaud, Claudius. “Quelle est la valeur et quels doivent être l'organisation et

l'équipement des institutions pour le traitement du cancer par le radium et par les

rayons X?” Archives de l'Institut du radium et de la Fondation Curie, Tome 1. Les

Presses Universitaires de France, Paris 1929: 137. (Translation by T.C-K.) 52 Crenner, Christopher. Private practice in the early twentieth century medical

office of Dr. Richard Cabot. Johns Hopkins University Press, Baltimore and

London 2005. 53 Gunsett, Auguste. Centre Régional de Lutte Contre le Cancer. Internal

publication. c.1925. Archives du Centre Paul Strauss, Strasbourg. 54 The Strasbourg municipal hospital consisted of numerous buildings that were

interspersed with the medical school buildings and gardens. 55 “Enquête faite par Ch. Rives, Conseiller Référendaire à la Cour des Comptes.

1934.” DEC. Cour des Comptes. Archives Administratives de la Faculté de Médecine

de Strasbourg. 56 F. C. 1931: 861. 57 For example: Masson, Pierre and Louis Sencert. “A propos d’un cas

d’hypernéphrome métastatique.” Bulletin et Mémoires de la Société des

Chirurgiens de Paris (Mai 1923); Masson, Pierre and Louis Sencert. “Cancer des


24

cellules interstitielles.” Bulletin de l’Association Française pour l’Etude du Cancer

(Juillet 1923). 58 For example: Gunsett, Auguste and René Simon. “Volumineux épithélioma

spino-cellulaire de maxillaire supérieur étendu au sinus maxillaire et à plus de la

moitié de la voûte du palais disparu après radiothérapie profonde.” Le médecin

d’Alsace et de Lorraine (1924): 7; Gunsett, Auguste, André Boeckel, and David

Sichel. “Technique et indications de la pneumo-pyélographie.” Le médecin

d’Alsace et de Lorraine (1931): 22. 59 These three finalities of a pathology examination were cited in literature

recapping the state of cancer treatment in the interwar period. Cf. Bard 1925;

Regaud, Claudius. “Le role du médecin sans spécialité dans le diagnostic du

cancer.” Lutte contre le cancer 10 (1925): 115-116; Regaud 1929. 60 Volume 1, 1919 – Volume 46, 1939, Régistres du Laboratoire d’Anatomie

Pathologique, Archives de l’Institut d’Anatomie Pathologique de la Faculté de

Médecine de Strasbourg. 61 18I. Biopsie d’une tumeur du maeilliaire (gauche). 1.11.1925. Volume 10,

Régistres du Laboratoire d’Anatomie Pathologique, Archives de l’Institut

d’Anatomie Pathologique de la Faculté de Médecine de Strasbourg. (Translation

by T.C-K.) 62 324I. Quelques parties du col de la matrice. 18.1.1926. Volume 10, Régistres du

Laboratoire d’Anatomie Pathologique, Archives de l’Institut d’Anatomie

Pathologique de la Faculté de Médecine de Strasbourg. 63 187J. Ulcération de la bouche. 10.7.1926. Volume 12, Régistres du Laboratoire

d’Anatomie Pathologique, Archives de l’Institut d’Anatomie Pathologique de la

Faculté de Médecine de Strasbourg. (Translation by T.C-K.) 64 503J. Tumeur du sein. 8.9.1926. Volume 12, Régistres du Laboratoire

d’Anatomie Pathologique, Archives de l’Institut d’Anatomie Pathologique de la

Faculté de Médecine de Strasbourg. (Translation by T.C-K.) 65 Pickstone 2007: 168. (Translation by T.C-K.) 66 I suspect that this is the same Cancer Pavilion that, as Pickstone mentions, had

“experimented with X rays and, when disappointed, passed its machine to the skin


25

hospital.” Pickstone continues to state that the Radium Institute in Manchester

focused primarily on mouth and womb cancers, while skin cancers were treated at

the skin hospital. (Pickstone 2007: 171) 67 Austoker, Joan. A History of the Imperial Cancer Research Fund. 1902-1986.

Oxford University Press, Oxford 1988; Murphy 1989; Pickstone, 2007. 68 Pickstone 2007: 176. 69 Pickstone 2007: 169. 70 Pickstone 2007: 176. 71 Regaud 1929: 142. 72 Pickstone 2007: 177. 73 Larsson, Lars-Gunnar. “Organization of Radiotherapy and Clinical Oncology in

Sweden.” Acta Oncologica 34 (1995): 1011-1015; Berven, Elis. “The Development

and Organization of Therapeutic Radiology in Sweden.” Radiology 79 (1962): 829-

841; Pickstone 2007. 74 “Richard M. Pearce to Alan Gregg, 23/07/1929.” RF, 1.1, 500A Université Paris

Radium Institute, Rockefeller Archive Centre. 75 Vikol, J. and C. Sellei. Twenty-five Years in the Fight Against Cancer. Reports of

the State Oncological Institute. State Oncological Institute, Budapest 1966. 76 Eckart, Wolfgang U., ed. 100 Years of Organized Cancer Research - 100 Jahre

organisierte Krebsforschung. Georg Thieme Verlag, Stuttgart and New York 2000,

especially Hecker, Erich. “Historical essay on the general scientific and of an

organized national approach to the fight against cancer.” In Eckart, Wolfgang U.

100 Years of Organized Cancer Research - 100 Jahre organisierte

Krebsforschung. Georg Thieme Verlag, Stuttgart and New York 2000: 5-10; Prüll,

Cay-Rüdinger. “Disease of Cells or Disease of Patients? The Cultural Impact on

Cancer Research in German and British Pathology, 1900-1945.” In Eckart,

Wolfgang U. 100 Years of Organized Cancer Research - 100 Jahre organisierte

Krebsforschung. Georg Thieme Verlag, Stuttgart and New York 2000: 17-22; van

Helvoort, Ton. “Scalpel or Rays? The Struggle for the Cancer Patient in Pre-World

War II Germany.” In Eckart, Wolfgang U. 100 Years of Organized Cancer Research


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- 100 Jahre organisierte Krebsforschung. Georg Thieme Verlag, Stuttgart and New

York 2000: 43-46. 77 Prüll 2000: 19 quotes Hamperl, H. Werdegang und Lebensweg eines

Pathologe., Schattauer, Stuttgart and New York 1972: 163. 78 The Netherlands Cancer Institute:

www.nki.nl/Research/About+the+Netherlands+Cancer+Institute/About+the+Netherl

ands+Cancer+Institute.htm 79 Bjarnason, Olafur and Hrafn Tulinius. Cancer Registration in Iceland 1955-1974.

Acta Pathologica, Microbiologica et Immunologica Scandinavia Supplement No.

281/Icelandic Cancer Society Research Publication No. 1. 1983. 80Maisin, J. H. L'Union Internationale Contre le Cancer. De sa fondation à nos

jours. UICC, Genève 1977. 81 Jacyna 1988. 82 Sturdy and Cooter 1998; Crenner 2006.

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