What's in a smear? Cervical screening, medical signs and metaphors

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What's in a smear? Cervical screening, medical signsand metaphorsTina Posner aa Department of Public Health and Primary Care, Royal Free Hospital School of Medicine,LondonVersion of record first published: 23 Sep 2009.

To cite this article: Tina Posner (1991): What's in a smear? Cervical screening, medical signs and metaphors, Science asCulture, 2:2, 167-187

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WHAT'S IN A SMEAR? 167

WHAT'S IN A SMEAR?Cervical Screening, MedicalSigns and Metaphors

TINA POSNER

The cervical screening programme has often beenpresented as a 'campaign' to save women from

cancer - a disease which has been surrounded by stigmaand metaphorical meanings and, until the advent of AIDS,the one which was most feared. Hopes of preventing nearlyall cases of cervical cancer, however, have not been realized.Women have been blamed for not 'coming forward' forscreening, in order to be 'saved' by medical intervention.However, once screened and found to have 'pre-cancerouscells', they may then be blamed for bringing the conditionupon themselves by their own behaviour. This campaign,so replete with moral meanings, is based on the deceptionthat it is fundamentally a matter of life and death -a construction which involves the medical profession'sutilization of cultural meanings and lay fears for its ownpurposes.

Here, apparently, was a rare situation in medicine wherean otherwise fatal condition could be stopped in its tracksby the heroic application of medical science and modernmedical technology. As Prevention and Health: Everybody'sBusiness (DHSS, 1976, pp. 72,73) suggested:

If early diagnosis when we notice something amiss is agood thing, . . . then early detection before we noticesomething amiss must be even better.

The essence of secondary prevention is to go out and lookfor disease at a stage when the victim may not even be

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168 SCIENCE as CULTURE

I

I

The cervical smear test: what you need to know'.

aware that he has it or even that he is liable to get it.

So what's in a smear, if not an ideal example of such earlydetection and prevention?

• MEDICAL V. LAY DEFINITIONSThere is a disparity between the lay and medical aimsin regard to the cervical smear [pap] test. From the layviewpoint, the main benefit of having the cervical smear testis the peace of mind that comes from knowing 'all is well'.Women go for tests in the hope of being told they have nosigns of disease. Lack of symptoms and the normality ofprevious tests lead a woman to expect the reassurance ofknowing that 'everything is all right' on her current smear.The impact of an abnormal finding can be a considerableexistential jolt:

I was well, and felt well. I couldn't believe it. It was justlike a great big cloud that arrived out of nowhere.

I was completely horrified, shocked, devastated. I

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WHAT'S IN A SMEAR7 169

couldn't go back to work that day. I'd never reallyhad any illness. (Posner and Vessey, 1988, p. 44)

What is this great big cloud? What is the screening pro-gramme doing to women?

From the medical point of view, the whole point ofscreening is to find signs of disease - hi the case ofcervical cytology, evidence of cell changes which indicatethe possibility of the development of cancer. Early cellchanges on the cervix produce no symptoms and are difficultto detect on normal clinical examination; the cervix might beperfectly healthy-looking to the naked eye. If it were not forexamination of the cells collected on the cervical smear in thecytology laboratory, such changes would go undetected. Ifthey develop into a cancer, they may not produce symptomsuntil the condition is a serious threat to the woman's health;the condition would have reached a stage at which treatmentmight be unsuccessful and would certainly involve radicalsurgery. Early treatment can save a woman's life, and herwomb. The abnormal cells on the cervix can often beremoved by out-patient treatment, leaving the cervix intact- on the face of it, a clear-cut case of successful medicalintervention.

Increasingly sophisticated diagnostic tools have allowedmedicine to define its sphere of intervention ever morewidely, resulting in treatment of deviations from thenorm, in an attempt to eliminate bodily imperfections.Advances in diagnostic and treatment techniques meanthat abnormalities of the cervical cells can be detected andeliminated at a time when they neither produce symptomsnor yet constitute disease. Describing the place of symptomsas opposed to signs in the biologistic definitional frameworkof disease, Fabrega (1972) has argued that the patient'sverbal reports are, for the most part, neither necessary norsufficient for establishing the presence of disease:

The application of sophisticated technology to human

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biological functioning has the effect of enabling physiciansto slowly replace these reports by indicators that moredirectly and reliably reflect biological processes andchanges.

Screening can be seen as an attempt to assert the dominanceof the medical definition of reality based on objective signsrather than subjective accounts.1 Submitting to screeningimplies a willingness to accept the medical definition ofreality. In the request to the doctor - 'Please confirmthat I am really as well as I feel' - is the implied patientrecognition that the doctor's truth is paramount. Thusthe woman's view that she is well is replaced, when sheis told that abnormal cells have been found on her smear,by acceptance that she has 'something wrong' which needsmedical attention, that something is there which 'shouldnot be there' and needs removing. In medical terms, thepatient's view that she is well is mistaken and needs to beoverridden for her own good.

LJ Disease v. illnessThe implications of this can be best examined by invokingthe disease/illness dichotomy: 'Patients suffer "illnesses";doctors diagnose and treat "diseases" ' (Eisenberg, 1977).Eisenberg defined illnesses as 'experiences of devaluedchanges in states of being and social function' and diseasesas 'abnormalities in the function and/or structure of bodyorgans and systems'. Disease is medically defined; illness,by definition must include the subjective patient view. Thisdistinction allows one to speak of illness without disease -that is, without medically recognizable signs accompanyingthe morbidity; and disease without illness - that is, medicallyrecognized signs of pathology without symptoms. Anabnormal smear is a classic example of the latter: there aresigns of disease but no accompanying illness. The situationis the same for borderline hypertension or impaired glucosetolerance (borderline diabetes). The superior claim of the

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lesti

w&%Cervical screening invites women to a reassuring 'test for health'but often produces anxiety.

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medical definition of reality is based on esoteric knowledge-in the case of the cervical smear, literally inside information!There is no way the woman herself could know of theabnormal cells. After submitting to the smear test, she canonly accept the reading of the smear she is given. She hasno apparent grounds, and often no language with which tocontest the verdict.

Screening is clearly different from the usual medicalsituation in which the doctor is asked to provide relieffor the illness brought to the surgery, where patienthoodis self-defined. The screener, Cochrane (1972, p. 37)suggested, is in 'an evangelical situation'. Use of the terms'campaign', 'coming forward' and 'saving' in the context ofcervical screening certainly suggests this. In screening, themedical profession is seeking out signs of possible disease,attempting to extend its control over future developments;medicine is offering what it claims is an insurance policy andthereby making patients of people who feel Well. Freidson(1970) recognized both the element of moral judgementinvolved (often overlooked, he suggests, because of the highlevel of consensus about the undesirability of what is labelled'disease') and medicine's mission of active intervention:

The profession does treat the illness laymen take to it, butit also seeks to discover illness of which laymen may noteven be aware . . . insofar as illness is defined as some-thing bad - to be eradicated or contained - medicine playsthe role of what Becker called the 'moral entrepreneur'.(Freidson, 1970, p. 252)

Elaborating on the theme of evangelism, he continued:

Clearly the physician neither approves of disease nor isneutral to it. When he claims alcoholism is a disease, heis as much a moral entrepreneur as a fundamentalist whoclaims it is a sin. His mission is to impute social and moralmeaning to physical and other signs. (1970, p. 253)

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• WHAT ABNORMAL CERVICAL CELLS MEANThe biomedical 'meaning' of abnormal cervical cells, inmany cases, however, is far from clear. While changes inthe cervical cells resulting in an abnormal cervical smearmay produce no clinical abnormality, they are recognizedto be statistically and prognostically abnormal. The medicalproblem is to identify those changes which would developinto a significant threat to a woman's health. The evidenceis that a proportion of cell changes, if left untreated, willregress spontaneously; a proportion will remain the same;and a proportion (approximately a third) will develop intoan invasive carcinoma over a period of some years. In eachparticular case it is not possible to know what will happen.

The medical dilemma is thus to know when to treatthe abnormality and when to leave it alone because noharm would result from doing so, whereas intervention canlead to a variety of unintended negative consequences. Inthis area, the ability of modern medicine to diagnose hasoutstripped its ability to prognose: it can detect signs ofabnormality but it cannot be sure of their significance, whatthey mean. In the uncertainty, it errs on what it presents asthe safe side.

LJ Suspect diseaseThis is an example par excellence of a situation of diagnosticuncertainty such as those analysed by Scheff (1963). Scheffdescribed the sort of decision rules for guiding behaviourunder conditions of uncertainty which he suggests becomeestablished in professions such as law and medicine, whereuncertainty is a frequent occurrence. In order to cope withthe uncertainty, informal norms develop, usually basedon unquestioned assumptions that some types of errorare more to be avoided than others. Scheff analysed theunderlying assumptions and consequences of a norm forhandling uncertainty in medical diagnosis: that judging asick person well is more to be avoided than judging a wellperson sick. The more culpable error is to dismiss a sick

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patient than to retain a well one. This amounts to a decisionrule: 'When in doubt, continue to suspect illness.'

The logic of that rule rests on two assumptions: firstly,that disease is 'a determinate, inevitably unfolding process,which if undetected and untreated will grow to a pointwhere it endangers the life or limb of the individual';secondly, that medical diagnosis and investigation are, inthemselves, harmless to the patient. Sheff concluded thatthe operation of this decision rule is likely to result ina bias towards medical intervention: 'Physicians and thepublic typically overvalue medical treatment relative tonon-treatment as a course of action in the face of uncertaintyand . . . this overvaluation results in the creation as well asthe prevention of impairment.'

The first of these assumptions - that disease is a determinateand inexorable process leading from minor abnormality tofull-blown disease unless medicine intervenes - reflectsmedical constructions of reality. It provides the rationale fortreatment of the majority of abnormalities of the cervical cellsonce they are discovered. The second assumption underlyingthe decision rule - that medical diagnosis and investigationwill in themselves do no harm - has been questioned by manywriters. There is now some recognition that the detection,investigation and treatment of abnormal cervical cells can havea considerable negative impact on women going through themedical process. That experience can cause psychologicaland emotional distress, psychosexual problems, and analtered body image and attitude to health status (Posner andVessey, 1988). Besides this, treatment may cause symptomswhere there were none before: pain, discharge, various com-plications. The success of treatment, however, has beenjudged almost entirely in terms of the disappearance of signsof disease - the obliteration of the abnormal cells; the fulfil-ment of the medical aim of intervention.

LJ Cultural meaningsThe costs of this medical intervention have not been

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adequately weighed against the possible benefits. Thisis particularly the case as far as the individual womanis concerned; its meaning for her has seldom been takeninto account. The language used by medical personneltalking to a woman with an abnormal cervical smear andthe information she obtains are all-important in structuringher experience of the condition. In The Birth of the Clinic,Foucault identified the time during which medical discoursebecame nominalist rather than essentialist, writing that:

this was the great discovery of 1816 - the being of thedisease disappears . . . Disease is now no more than acertain complex movement of tissues in reaction to anirritating cause: it is in this that the whole essence of thepathological lies, for there are no longer either essentialdiseases or essences of diseases. (1976, p. 189)

He concluded that it was at this time that 'disease breaksaway from the metaphysic of evil to which it had beenrelated for centuries.' While this may have been the case formedical theory, it was to be much less so in medical practice

A Positive Result

This means that the cells collected from the cervix were not normal. Becausethe changes that occur usually take place over a long period of time there areseveral different degrees of change that can be identified. How advanced thechanges are will vary from woman to woman. It is rare for a positive smear testto indicate that a cancer has already developed.

All changes that show up will need further investigation. Most changes areminor and quite often only require careful follow-up with more frequent smeartests. Other changes require further investigation by a gynaecologist todetermine exactly how far they have developed, and if treatment is required.

Suspect disease: an advice leaflet both warns and reassureswomen about the meaning of 'abnormal' signs.

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and in lay representations of disease. On the everyday ratherthan 'scientific' level of medical reality, our concept ofdisease tends to be essentialist rather than nominalist. Asurvey investigating differences between the concept ofdisease in lay and medical language concluded:

Most people without medical training seem to think ofdisease as an agent causing illness. The common conceptof 'disease' is essentialist: diseases exist, each causing aparticular sort of illness. Doctors tend to adopt a morenominalist position, but they obviously retain remnantsof belief in the real existence of diseases. (Campbell,Scadding and Roberts, 1979)

Thus a particular disease tends to acquire a real existencein our conceptualizations as a thing 'out there' to which weattribute qualities; it acquires a meaning. This meaning, notentirely broken away from the metaphysic of evil in the caseof cervical cancer, affects the experience of the disease.

A woman's conceptualization of the condition of abnormalcells will be shaped by how it is presented to her by themedical profession, by what she herself can find out aboutit, and by the cultural meanings associated with cancer.While there may be doubt about the exact medical meaningof an abnormal or positive result on the smear test, formost people it means the threat of cancer; and cancer isseen as a scourge associated with death and defilement.In the lay view of the cervical smear test, things havebeen set up in very black and white terms: if they arenot white, they are very black. The greyness of the areabetween perfectly normal cells and frankly cancerous cells,and the normality - the commonness, of some degree ofpossibly passing abnormality - is not generally known.Wider knowledge of the possibility that abnormal cervicalcells may spontaneously regress would help to lessenfeelings of panic, as well as alleviating the dominationof women's conceptualizations of the abnormal condition

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by the metaphor of cancer as an inexorable progression tobodily disintegration.

After learning she has signs of a condition which could bea threat to her life, or at least to her reproductive capacity,a woman may have to wait weeks or even months for acolposcopy examination. The likelihood is that the doctorwill be able to reassure her that she does not have cancer,but what exactly she does have may well remain unclearto her. Very seldom is she given the current medical termfor her condition, an impossible mouthful: cervical intra-epithelial neoplasia, or the acronym CIN. The talk is of'abnormal cells', cells 'which aren't quite right' or cells'we're not happy about'. The vagueness of these terms istaken either as a euphemism for the threat or early presenceof cancer, or as naming the symptom without giving a nameto the condition causing the symptom:

I don't know what the problem's called. I haven't got aname for it;

I would have liked a name. It's much easier to deal witha known entity than being left in the dark;

I still don't know what the hell it was. I don't think theyrealise they leave you in the dark. (Posner and Vessey,1988, p. 81)

The devil can be driven out only if his name is known. Thevery namelessness of the condition, from the lay viewpoint,and the ambiguity surrounding it, allows more room foranxiety and for the influence of the metaphor of cancer tocause women to have morbid feelings about themselves,their bodies and health status.

D StigmaWhat's in a name? In this case, even the acronym of a highlytechnical term may be used to convey a whole metaphorical

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The tabloid press associates epidemics of sexual immorality,disease and death — before the AIDS era.

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construction: CIN is frequently and pointedly pronouncedsin rather than C-I-N. The aetiology of cervical cancerand, by implication, possibly pre-cancerous conditions,has been treated in moral determinist terms presentingcancer as a scourge, a retribution for past wrongdoing, andresulting in victim-blaming. Aetiological factors relating tocontraceptive use and the male partner's sexual historyor occupation have not been given so much attention asthe woman's sexual history. The result for women withabnormal smears may be that they come to feel highlyembarrassed because of the implied guilt - the stigma ofhaving an abnormal smear, and that their own versions oftheir bodily history are discounted.

In a recent study (Posner and Vessey, 1988), wherewomen tried to explain to themselves why they mighthave developed a cervical abnormality, many associated iteither with other gynaecological or obstetric episodes theyhad experienced, or with the form of contraception theyhad been using. Some suggested that it was simply 'badluck', 'fate' or 'just one of those things'; a few thoughtthat some stress they had been under was a factor. Aftergoing through the medical process and being exposed tomedia and medical intimations, the women were askedabout predisposing factors thought to be involved in thedevelopment of the condition; their answers covered avery different spectrum. 'Promiscuity', and having sexualintercourse for the first time at an early age, were the mostoften mentioned; 'bad luck' was not mentioned at all.

The stigma associated with the condition has beenunderlined in the media and by the implications ofdoctors' routine questioning about women's sexual history.In asking such questions, doctors are using their authorityto gain access to privileged information, thereby addingto the sense of invaded privacy. Since this information isclinically unnecessary, the invasion of privacy is completelyunjustifiable.

The stigmatized nature of the condition means that women

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180 SCIENCE OS CULTURE

may be hesitant to talk to others about it, embarrassed ifthey have to explain, and very concerned about what othersmight think of them. This is a clear case of stigma as'spoiled identity' (Goffman, 1964), for the public image ofthe condition can make women feel 'tainted'. Several womenin the study had seen a television programme 'insinuatingthat only women who slept about got it'. One of them said:

I felt dirty because of the documentary on TV. . .talkingabout the permissive society and cervical cancer reachingepidemic proportions. I was worried that everybodywould think I'd been sleeping with everybody.

Another said:

I heard on TV it's [caused by] sleeping around. I've onlyever had three men - if that's being promiscuous . . .(Posnerand Vessey, 1988, p. 67)

D Hidden defectsAt an early stage in the medical process, the women in thestudy were asked whether simply knowing that they hadabnormal cells had made them feel differently about theirbodies. Among the 55 per cent who did feel differently, themost common feelings expressed were a sense of defilement,a feeling of alienation from their body and of its being outof control. To have a hidden defect (which represents, inwhatever sense, a threat to one's life and the integrityof one's body) discovered is unnerving. Well women,often in the prime of life, are suddenly faced with theirmortality, vulnerability and the body's imperfection, tryingto reconcile the feeling that they were healthy with the feelingof vulnerability produced by the awareness of abnormal cells:

We all like to think we're perfect and that nothing can gowrong.

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I realised I was just as vulnerable as the next person. I'mnot in an at-risk group and it still got me. In a funny sortof way, it makes me mortal. (Posner and Vessey, 1988,p. 72)

A sense of defilement, hesitantly acknowledged, wasexpressed in terms of a feeling of being 'unclean' or'dirty'. One woman used a very telling metaphor to expressher feeling that she was 'diseased': 'like a leper', saying thatshe did not want anyone to come near her, did not want tobe touched. In many ways, cancer, and anything associatedwith it, is viewed now as leprosy was - a disease with strongmoral and emotional overtones, associated with uncleannessand death. Lepers were treated as both defiled and defiling.Leprosy was a disease of the soul, the outward markingwhich branded the sinner. This sense of contaminationcomes from the view of cancer as a scourge; from thestigma attached to the condition or its precursors becauseof the associations made with promiscuity and sexuallytransmitted disease; and perhaps also from the sense ofviolated private space.

• ERASING IMPERFECTIONSWomen have been carrying the weight of society's anxietyand guilty feelings about sexual freedom- a classic exampleof victim-blaming. The physical state of a woman's cervixhas been taken as a reflection of her sexual history, herintegrity as a woman intimately bound up with the integrityof her cervix. Examining the state of the cervix has beena process of revealing hidden defects and symbolicallyexposing secret transgressions - magnified for medicalexamination. In eliminating the cervical abnormalities, theslate has been wiped clean, the transgressions absolved.Screening is the business of finding disease signs; treatmentis about removing them, and once found the're is an impetusto do something about them. They represent a physicalimperfection, one which is linked in terms of its cultural

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meaning to erroneous sex, to moral imperfection. Thetechnology is available to eradicate the cells and, in sodoing, it erases the imperfection, physical and moral,and the threat to the integrity of the woman which theimperfection represented.

Sontag (1989, p. 14) has pleaded for cancer to be treatedas 'just a disease': 'Not a curse, not a punishment, not anembarrassment. Without "meaning". And not necessarilya death sentence . . . '

How is it possible to strip away the cultural meaningsof cancer, the associations with death and defilement, tooverride the metaphor?2 That task is made all the moredifficult in the case of (possibly) pre-cancerous abnormalitiesof the cervical cells by vague terms such as 'abnormal cells'and ambivalent concepts ('not normal, not cancer, but stillto be treated'). In addition to providing the name for thecervical condition, it can be helpful to have some way oflocating it, both in terms of the degree of abnormality (thegrade of CIN) and in terms of its size and position on thesurface of the cervix (for example, by using a diagram). Inthis way an amorphous doom-laden threat to the future canbe reduced and contained.

By giving a well woman few or no words with which todescribe her condition or to discuss its management, thescreening process renders her a powerless patient. It makesit difficult for her to continue to take responsibility for herown health, or to negotiate treatment. She is obliged toleave decision-making to the medical profession. This iscertainly a case where 'medical technology has devisedinstrumentation . . . bypassing speech, replacing vocalisedsymptoms with a sign language, histories with examination'(Porter, 1983, p. 23):

Women need words in order to out-manoeuvre themedical tendency to dispense with words. Access tolanguage with which to conceptualize their experienceof the situation could reduce the morbid reactions ofwell women to knowing they have this disease sign,

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and to having treatment for it. Rather than somethingbeing done to her 'for her own good', involvement indecisions about management could allow a woman to feelless sense of invasion and loss of control of her own body.Such involvement could enable her to maintain her wellwoman status and responsibility for the preservation of herhealth.

ED Informed consentWhere the rationale for treatment is preventive, there canbe no reason for not involving a woman in a discussionof the balance of risks in the context of her own life.To take account of a woman's view of any choice theremay be between treating the condition or merely keepingit under observation, or of one form of treatment ratherthan another, it is necessary to acknowledge openly therisks of treatment versus non-treatment. Writing aboutthe management of borderline hypertension, Guttmacher

-^sK**"*"

A,

\ kTreatment in the colposcopy clinic: 'It's a bit like having a toothfilled; you're clamped open the same' (patient quoted in Posnerand Vessey, 1988, p. 26).

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et al. (1981) have argued that such openness is ethicallynecessary according to 'the principle of informed consent,which requires presenting to a patient all the therapeuticoptions that any reasonable person would want to weigh'.One option in the face of prognostic uncertainty is 'to waitand see':

Since borderline hypertension is a marginally badsituation that stands a chance of getting better withoutmedication, deferring treatment until the future courseof blood pressure is known appears to be a reasonablealternative. A decision between initiating treatmentshould be settled, we believe, in the light of theindividual's preferences and aversions to risk.

The management of mildly abnormal cervical cells is anarea of current controversy and considerable variation inpractice. A recent British Medical Journal paper (Ismail etal., 1989) detailed how 'experienced histopathologists showconsiderable interobserver variability in grading cervicalintra-epithelial neoplasia' and distinguished grade 1 frominflammatory reactions (with no potential for developinginto cancer). The paper concluded with the suggestionthat the present grading should be abandoned and thata borderline category be introduced entailing follow-upwithout treatment.

To reclaim abnormal cervical cells from the mire ofmorbidity-producing meanings and allow them to besimply risk factors, it will be necessary to acknowledgethe multifactorial aetiology of the condition and of theuncertainty about its biomedical significance. Pre-testinformation about the real nature of the test and post-test discussion of options is ethically imperative. With thetechnology in its hands to detect and eliminate this diseasesign, the medical profession has been reluctant to admit theuncertainty about its significance to patients, and to sharethe language and information with which they could engage

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in a discussion of the balance of risks involved. Such sharingcould undermine doctors' power to try to control futuredevelopments and to deal with the risk in the way theythink is best - removing its source. Their patients' choiceof risk might be different from their own and might causethem anxiety.

LJ Control of uncertaintyThis situation has parallels in a number of medical situationsinvolving screening. As Sontag (1989) writes about HIVantibody testing, 'With the most up-to-date biomedicaltesting it is possible to create a new class. . . of the future ill.'The notion in clinical medicine that the body harbours manyinfections and that you can be 'infected but not ill' is beingsuperseded, she suggests, 'by biomedical concepts which,whatever their scientific justification, amount to revivingthe antiscientific logic of defilement.' In an analysis of themeaning and medical management of breast lumps, Gifford(1986) discusses the differences between lay and medicalviews of risk, and suggests that within current medicalthought and practice one cannot be healthy and at risk atthe same time. When a woman is diagnosed with a benignbreast disease, she is thrown into a liminal state of being atrisk - of being, suddenly, neither healthy nor ill; thus 'riskis an experienced condition of non-health.' For the medicalpractitioner, however:

Risk is understood as representing a sign of future diseasefrom which a woman suffers, and as clinical uncertaintyconcerning diagnosis. Risk becomes a physical realitythat can be manipulated and controlled by treating theaffected individual or physical organ at risk . . . Thisprocess might be thought of as the medicalization of risk,and it results in greater clinical control of uncertainty. . .[and] further removes the power to define states of healthand illness from the individual.

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In cervical cytology screening, medical assertion of thesignificance of a sign unavailable to women is an attemptto control uncertain future developments - to extend clinicalcontrol over risk. In the absence of acknowledgement of theuncertainty and a fuller sharing of information and language,which could allow a discussion of the risks of interventionor non-intervention, medical aims prevail. Women's healthstatus is defined for them in a way that is disempoweringand unhealthy.

• NOTES1. The patient's view, Armstrong (1984) argued, has nowadays become an

essential part of the diagnostic process, at least in medical discourse.This analysis overlooked the situation in which apparently well peopleare screened for signs of 'hidden disease'. Writing of the dominance ofsigns in medical diagnosis reflected in the teaching manuals of the earlytwentieth century, Armstrong described how 'the truth of the disease wascontained only in what the doctor found in the form of a sign , . . the coretask of medicine [was] what the doctor saw in the depths of the body.' Thisis exactly the situation with the discovery and investigation of an abnormalcervical smear at the present time. Cervical cytology, accompanied bycolposcopy (examination of the cervix with a special microscope), isconcerned with the identification and localization of a pathological lesionin the depths of the body. The patient has no symptoms or, if she has, theyare likely to be coincidental. She can neither see nor feel anything wrong.She goes to the doctor not to complain that she is ill, ready to expand onthe context of her illness, but for confirmation that she is well and has nopathological sign.

2. One can feel great sympathy with Sontag's desire to see our conceptual-izations of cancer and AIDS liberated from the metaphors of evil, death anddestruction. However, is 'de-mythicizing', as she has termed it, a possibleanswer? To suggest that illness can be experienced without culturally-determined meaning tends to deny the importance of the symbolic levelof medical reality. From our understanding of the effect of expectationsand belief, we can conclude that the metaphor of cancer is pathogenic, andthe image of the disease is likely to be demoralizing and stigmatizing for thesufferer. However, belief not only kills, it also heals. Despair can be lethal,hope may be life-saving. Metaphors can be used powerfully for bad or good,and aspects of the metaphor of cancer can be used positively. Starting withthe common conception of cancer as a battle between the cancerous, 'bad',and the normal, healthy, 'good' cells, the suggestion can be made that thefar greater number of healthy cells can disarm the cancerous cells. The

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hope of such symbolic manipulation is a parallel development involving themobilization of the body's immunological defences to allow the triumph of'good' over 'bad', life over death.

• REFERENCESArmstrong, D. (1984) 'The patient's view', Social Science and Medicine 18:

737-44.Campbell, E., Scadding, J. and Roberts, R. (1979) T h e concept of disease',

British Medical Journal 2:757-62.Cochrane, A. (1972) Effectiveness and Efficiency: Random Reflections on Health

Services. London: Nuffield Provincial Hospitals Trust.DHSS (1976) Prevention and Health: Everybody's Business. London: HMSO.Eisenberg, L. (1977) 'Disease and illness: distinctions between professional and

popular ideas of sickness', Culture, Medicine and Psychiatry 1:9-23.Fabrega, H. (1972) 'The study of disease in relation to culture', Behavioural

Science 17:183-203.Foucault, M. (1976) The Birth of the Clinic. London: Tavistock.Freidson, E. (1970) Profession of Medicine. New York: Dodd, Mead.Gifford, S. (1986) 'The meaning of lumps: a case study of the ambiguities of

risk', in C. James, R. Stall and S. Gifford, eds, Anthropology and Epidemiology:Interdisciplinary Approaches to the Study of Health and Disease. Dordrecht:Reidel.

Goffman, E. (1964) Stigma. Harmondsworth: Penguin.Guttmacher, S. et al. (1981) 'Ethics and preventive medicine: the case of

borderline hypertension', Hastings Centre Report February: 12-20.Ismail, S. et al. (1989) 'Observer variation in histopathological diagnosis and

grading of cervical intra-epithelial neoplasia', British Medical Journal 298:707-10.

Porter, R. (1983) 'The doctor and the word', Medical Sociology News 9.Posner, T. and Vessey, M. (1988) Prevention of Cervical Cancer: The Patient's

View. London: King's Fund.Scheff, T . (1963) 'Decision rules, types of error and their consequences in

medical diagnosis', Behavioural Science 8:97-107.Sontag, S. (1989) AIDS and Its Metaphors. London: Allen Lane.D

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What's in a smear? Cervical screening, medical signs and metaphors

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