Sir Thomas Spencer Wells. Photograph by C. Pietzner, Vienna.
Courtesy of Wellcome Images. Click on image to enlarge it.
Dr. Thomas Spencer Wells (1818-97), Surgeon to Queen Victoria, medical professor, and President of the Royal College of Surgeons, wrote a scathing report on Dr. Fell's conduct but still recognized the beneficial effects and possibilities of zinc-chloride medicine ("Wells, Sir Thomas Spencer"; figure 1). Although he exposed Fell's false claims, incomplete disclosures, and ethical violations, in the assessment of zinc chloride as a cancer treatment, Wells remained impartial.
Censure & Acknowledgment
ells contested Fell's claim that the scarification method the latter had advertised was original. The Middlesex Staff had accepted Fell’s word on this, but Wells, familiar with the history of such methods, had not. He cited the originator as J. O. Justamond, a contemporary of Dr. John Davy who, c. 1810, had "hastened the action of caustic by scarifying the destroyed surface and inserting the caustic [arsenic] into the scarifications" (Cancer Cures, 43). Dr. Fell affirmed that he had scored the surface of devitalized tissue each day and, to enhance penetration of the tumor, inserted zincane-treated calico strips. In this way, Dr. Fell hoped to suffuse the entire tumor with the coagulant over a five-to-seven-weeks' period, after which the paste applications were to be discontinued, and the eschar was then expected to detach itself (Fell, A Treatise, 16-17). Fell's text was short on quantitative evidence and on acknowledgements. But this was not necessarily being dishonest or evasive: Dr. Fell might simply have developed the method independently or was not careful about sources. Wells, however, did not give his colleague the benefit of the doubt. Researching the recent history of escharotic medicine, he identified a contemporary who had used this method three years before Dr. Fell had entered medical school. Dr. Girouard of Chartres, in the January 1857 edition of the Archives Générales de Médicine, described the very same procedure which he had been employing since 1841. Girouard's formula, called "Vienna" paste, contained caustic potash, a compound of calcium oxide (CaO) and potassium hydroxide (KOH). After spreading the compound on calico strips (1/8-inch thick), he routinely implanted them in the incised lines (Bennet 524). Wells provided another instance of Fell's tendency not to credit the work of predecessors fully: a late-1856 paper by MM. Salmon and Manoury, in the Union Médicale, had also alluded to escharotic operations using Girouard's Vienna-paste compound. Salmon and Manoury, using zincane-imbued alum strips, had also incised the mortified skin (45).
Wells harshly criticized Fell for having advertised a false cancer cure, as a way of securing Middlesex Hospital's authorization for a trial (Wells called it: "the Sanguinaria delusion"). To emphasize the shortcomings of Fell’s method at Middlesex, Wells quoted passages from the "Report of the Surgical Staff" that recorded the dismal rate of recurrence Cancer Cures, 45-46). To provide insight into what a patient had to endure, Wells went so far as to reproduce passages from A Memorial of the Last Day on Earth of Emily Gosse, by her Husband, Philip Henry Gosse, F.R.S., a graphic account of his wife’s death from breast cancer while under the care of Dr. Fell. Emily Bowes Gosse (1806-1857) described how Dr. Fell had bragged about having a "secret Medicament," capable of removing cancer completely (figure 2). She quoted Fell's assurance that 80% of his patients were cured (a suspicious assertion) and that surgery alone could only offer a 20% survival rate (49). Mrs. Gosse accused Fell of having assured her and her husband that, in the event of a recurrence, the tumor could be eradicated (49).
From clinical and ethical perspectives, the narrative to which Wells referred is quite revealing. To coagulate a breast tumor, Dr. Fell had prescribed for Mrs. Gosse three self-administered ointments, to be used alternately during a 29 August-to-2-October 1856 vacation. With no extensive change in the tumor, and beset with weakness and pain, the patient had little choice but to return to Dr. Fell (Cancer Cures, 49-50). On 11 October, Dr. Fell tried to remove the remaining tumor chemically with the bloodroot-zincane compound (50). Unable to sleep because of the pain, the patient was sedated (51). After nitric acid removed the epidermis, the doctor cut parallel lines, one-half inch apart, on the tumor surface; and, over the ulcerated surface, he fixed a mucilaginous plaster (52). The procedure that the French physicians had developed was administered each day. Instead of applying a plaster, Dr. Fell decided to deepen the scarified channels in order to implant narrow strips of medicinal linen. The ointment (presumably the bloodroot-zincane compound), which had antiseptic as well as caustic properties, destroyed the malignant tissue, reducing it incredibly to a black, woody mass. Once the incisions had reached a depth of 1½ inches, Dr. Fell placed an annular plaster at the base of the dead tumor to protect healthy adjoining skin. The objective was to allow the dead tumor to slough off and to detach from the chest completely.
On 23 November 1856, after six weeks of intensive treatment, the tumor finally separated (52). At a follow-up examination, however, Dr. Fell found suspicious tissue on the edge of the cavity. With the exception of nitric acid, the process had to be restarted (53). Three weeks of "grinding, wearing away agony" ensued. On 17 December, a hen’s egg size tumor, under treatment since 23 November, finally separated itself. But, by this time, the disease had spread to the inner and outer side of the wound and the lymph nodes were swelling. On 22 December, Dr. Fell informed Mrs. Gosse that an area on her arm had to be cauterized as well, along with the inner and outer side of the gaping wound. The original tumor had spread, despite the doctor's alleged, earlier assurance that the disease had been confined to the breast (54). Mrs. Gosse died on 7 February 1857. Fell's escharotic method, though it had topical benefit, simply could not keep pace with an aggressive form of cancer.
Dr. Fell subscribed to zinc chloride, but, as a marketing tactic, had camouflaged its presence under exotic foliage. The case reports outlined in his book cited bloodroot, rather than zinc chloride, as the active ingredient. What was clearly an instance of deceptive advertising and of fraud, was also construed as quackery. In the primary sense of quackery, ordinarily reserved for an ignorant pretender treating people with folkloric remedies, the epithet did not apply to Dr. Fell: he was an allopathic, licensed physician, trained at a prestigious American medical school. Quackery, in the secondary sense of term, was indeed applicable to his conduct: he had ascribed false properties to his formula ("quack," OED. II: 2379).
The Ruse of Dr. Fell & the Promise of Zincane
Though Fell's prevarications and motives warranted chastisement, fortunately, the short-term clinical benefits of his method, along with the potential for research on, and development of, his system, were not abandoned. In the 27 June 1857 British Medical Journal review of Fell's A Treatise on Cancer (1857), the unidentified author enumerates the positive results of Fell's work: “it is certain that Dr. Fell has given to caustics a position and a value, in the treatment of cancer-growths, which they have never yet obtained in legitimate surgery" (A Treatise [Review], 546). No commendation, however, could erase Dr. Fell's culpability: "He placed himself in a false position in his manner of coming before the profession, and he must be contented to reap the results in golden honoraria, it may be, but not in a dignified professional status" ("Review," [547]). In a 24 October 1857 assessment of Dr. Fell's investigation at Middlesex Hospital, another reviewer did not mince words: "What we mean . . . by quackery, is the using and administering of a secret remedy, puffing it the while as a wondrous agent, and falsely ascribing to it, when administered in particular diseases, the possession of curative powers above all other existing remedies" (890).
Ironically, Dr. Fell's stratagem, its exaggerated claims notwithstanding, helped to define the real value of ZnCl2. The state of treatment in the 1850s, especially with respect to breast cancer, was static, with the only available treatments, ablation or cauterization, unable in most cases to achieve long-term remission. Under such conditions, and because the Surgical Staff welcomed genuine innovations, Dr. Fell appeared to have spied an open, exploitable market. His mixture of a plant alkaloid and a metallic salt, however, was not snake oil. Though experimental and contested by the mid-Victorian surgical community, coagulant regimens, since the later sixteenth century, had retained a legitimate place in pharmacology (Munro 409-411). Breast-cancer therapy had also begun to make enormous strides, in the late 1860s, as more effective modes of treatment began to appear (Donegan 7). Relative to Dr. Fell's milieu, however, the concepts of radical mastectomy, of radiological, hormonal, and chemical therapies, and of public-health campaigns, were decades away. Since he practiced at a time when some thought the ablation of breast tumors ineffective, even injurious, chemical cauterization in some cases appeared to be the only alternative (Fell, A Treatise, 44-8, 56). Hence, Dr. Fell took advantage of the opportunity, providing temporary relief, while advertising, and profiting from, unrealistic hopes. Despite dramatic, short-term evidence (the complete destruction of tumors), with respect to recurrence, the knife and the paste were both judged ineffective (long-term survival being the exception, not the norm). Where the chloride had the edge over the knife was in short-term care or when the patient could not endure conventional surgery, which was painful, crude, and prone to infection. Thankfully, reputable members of the Middlesex Hospital staff—Drs. Alexander Shaw (1804-1890), Campbell De Morgan, Charles H. Moore, and Mitchell Henry (1826-1910)—remained impartial and open-minded, even though Fell’s results had not, nor could have, fulfilled expectations entirely. The immediate and palliative activity of the paste impressed them enough to call for further study.
Although Wells emphatically rejected Fell's 1857 self-assessment, he did not obfuscate the favorable results and methods of the trial. For example, Wells accepted Dr. Moore's testimony, in 1860, that the caustics employed in advanced, inoperable cases were palliative; and that, whenever the decision was made to treat with caustics exclusively, surgeons were enjoined to observe "general rules" as they proceeded: the cancer must be "primary, solitary, and uncomplicated with evident constitutional disease or infection of the parts around it" (Moore, "Cancer," 566); and, in the case of palpable lymph nodes, the knife was preferred over caustics; but the latter was not entirely ruled out: a liquid caustic (zinc chloride lotion or paste) could be used: the tumor had to be circumscribed by a cylindrical gutta-percha tube, glued to the edges of the lesion, so that the agent could then "burn through the diseased mass, the depth of its action being determined beforehand by the quantity of the caustic employed" (Moore, "Cancer," 566). Inarguably, this procedure belonged to the tradition of Alexandre Canquoin: the paste was applied to a blistered surface, "through incisions deepened daily as the slough extends"; and fresh quantities of caustic were introduced, "until the whole tumor was perforated, destroyed, and cast off. In the case of recurrence or of residual tumor, the process could be recommenced but was less likely to be effective against "rapidly growing cancer" (Moore, "Cancer," 567). Fell’s treatment, in Moore’s view, definitely had a place in cancer care, but one that was limited. Hypodermic injections of caustics directly into the lesion also had a place in Moore’s treatment (568). The most acute and objective appraisal of the Middlesex trial was written by the Surgical Staff, and it is to their contributions that our survey will turn.
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Last modified 6 May 2021