Negotiating disease: power and cancer care, 1900–1950 Barbara Clow Montreal and Kingston: McGill-Queen's University Press, 2001 237 pp $65 (cloth) ISBN 0-7735-2210-7 $27.95 (paper) ISBN 0-7735-2211-5
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Figure. Photo by: Fred Sebastian
Barbara Clow's account of early 20th-century Canadian cancer campaigns is a welcome addition to the growing historical literature on cancer. Hers is a tale of how orthodox medical visions of cancer control intersected with those of patients and unorthodox practitioners to shape the emergent crusade in Ontario. The nature of the orthodox vision, with its focus on early detection and treatment and its attack on “quackery,” ignorance and fear is familiar from studies of crusades elsewhere. Traditionally, historical accounts have been content to stop there, telling the tale of cancer from the orthodox point of view and reproducing its portrayal of patients as ignorant, overly fearful and prone to delay seeking help, and of alternative healers as charlatans. Clow questions such stereotypes. She not only provides us with a valuable account of orthodox visions of cancer and its control, but also tries to explain the responses of alternative healers and cancer sufferers to such visions. What counted as a rational cancer policy to the orthodox leaders of the crusade in Ontario was sometimes quite unreasonable to sufferers and to alternative healers.
Clow places these varied perspectives on cancer within the context of the early 20th-century medical marketplace. She argues that medical practitioners did not monopolize health care but shared the market with a vast army of alternative practitioners. At one end of the spectrum was the orthodox physician with his or her medical qualification; at the other was the itinerant “quack.” Although both of these were clearly delineated, in the middle was a blurred grey area. So-called quacks often turned to science to evaluate, explain and justify their techniques, while many otherwise orthodox practitioners were sympathetic to and practised what other physicians regarded as quackery. Thus, in some (although by no means all) geographic areas, cancer sufferers had a range of practitioners to whom they could turn, who might be sound by prevailing standards, unsound, or somewhere on the spectrum in between. Thus emerges a complex picture of early 20th-century cancer campaigns, shaped by market forces and muddied by disagreements over what constituted legitimate practice. Clow illuminates this picture with case studies of three Ontario practitioners (Hendry Connell, John Hett and Rene Caisse) who, in different ways, blurred the distinction between alternative and orthodox healer and who all had different relationships with the medical establishment.
This picture of early 20th-century campaigns is further complicated by Clow's attempt to understand the treatment choices that people made within the marketplace. Physicians may have depicted the public as ignorant cancerophobes who were likely to delay seeking help, but Clow finds this picture inadequate. In her view, most people responded to their symptoms rationally. They expected to get ill and were therefore not unduly alarmed by the onset of lethargy, wasting, indigestion or even rectal bleeding. They responded to symptoms by drawing on broader cultural understandings of illness, often treating themselves with home remedies until pain or debility shattered their equanimity and forced them to seek help elsewhere. Clow does not dispute the claim that such responses meant that patients often arrived in the doctor's office too late for effective help, but she also points out that there were good reasons why people avoided doctors. Some may have feared the diagnosis and the treatment, but orthodox physicians were often pessimistic about the outcome of treatment, no matter what the stage of the disease. Clow suggests that by the end of the 1950s people were probably more aware than before of the symptoms that might indicate cancer, but many physicians continued to provide inadequate care even by the standards of the day.
Some aspects of the situation in Ontario were unique, notably the provincial government's concern in the 1930s not with promoting orthodox treatments but with evaluating alternatives. Nevertheless, Clow uses this local study to tell a tale that has much wider interest. She challenges the view that alternative treatments were more popular because they were cheaper than orthodox medicine (some were, but others were quite expensive); that it flourished among the lower rather than the upper social orders (contemporary opinion suggests the opposite); that people turned to alternative therapies because they were relatively painless compared with orthodox surgery and radiation (sometimes, but alternative treatments could be painful); that the flourishing of alternative medicine represented a distrust of authority in general and of the medical profession in particular (there is some evidence of both forms of distrust but, Clow suggests, the public was not particularly interested in fomenting a broad challenge to orthodox medicine); and that sufferers were shamed and silenced by their experience of cancer (Clow suggests, contra Susan Sontag, that the evidence for such claims is problematic, and that there is considerable evidence of individuals who were neither shamed nor silenced by their affliction with cancer). The book also provides a useful overview of the sorts of diagnostic and therapeutic techniques available in the early 20th century. Clow shows how the value of these methods was disputed during this period, as was the prognosis of the disease, the fact of a rise in mortality and the nature of cancer causation. It was quite unsettled whether cancer was caused by heredity, infection, metabolic problems or chronic irritation, and none of these theories offered much guidance for diagnosis or treatment.
This book will not appeal to everyone. Those who prefer their history to focus on a few enlightened physicians and scientists battling heroically not only against disease, but also against the darker forces of ignorance, fear and commercial exploitation may find it an unsatisfying read. There are no obvious heroes or villians in this account. Instead, Clow tells a story of many groups and individuals struggling with uncertainty, limited knowledge and an awful disease — and all too often failing. It is not as exciting a tale as the moral fable of good science struggling with evil quackery, but it is probably closer to the truth. It should become essential reading for anyone interested in the history of efforts to control this group of diseases.
David Cantor National Cancer Institute Bethesda, Md.