fter studying in Vienna and Berlin from 1844 to 1847, Charles Hewitt Moore, M.D. (1821-1870) returned to join the staff at Middlesex Hospital as Demonstrator. Commencing in 1848, he moved rapidly up the surgical ranks at the Hospital from Lecturer, to Assistant Surgeon, and to Junior Surgeon. As a researcher and author, Moore contributed to the general literature, as well as to numerous sub-specializations. In 1851, he wrote an incisive report on pelvic anatomy with respect to a particularly complicated injury case ("An Account of a Case of Fracture"); comprehensive surveys of vascular pathology, of oncology, and of the lymphatic system, for Timothy Holmes' four-volume collection, A System of Surgery (1860, 1862); a groundbreaking 1864 contribution on the management of aneurysms (Moore and Murchison 327-35); studies on skin cancer; and a major, often overlooked, work on the neurophysiology of sleep (1860-1870).
A skilled and dedicated surgeon, Dr. Moore was not reticent about testing new therapies against cancer. The mixed mode of operation, including electro-cauterization and the diversified use of ZnCl2 (as solid, paste, liquid, and injectable), characterized a new and more aggressive approach to cancer. This essay illustrates two of Dr. Moore's improvisations: the knife-caustic combination, in the cases of Mary H. and of George W., and the direct inoculation of zinc chloride into tumors.
The Case of Mary H.
In the spring of 1862, Moore brought one of his patients to the meeting of the British Medical Association. Mary H., a relatively healthy 70-year-old, had recovered from a facial skin cancer. Moore recalled that she had come to one of the Middlesex cancer wards, in December 1861, with "a deep ulcerated excavation between the globe of the eye and the bones at the inner side of the right orbit" ("One Case," 549). According to Dr. Moore, the spreading disease had partially destroyed her eyelids. The cancer had eaten through the sclera, evacuated the aqueous humor, and left her blind in that eye. The margins of the ulcer, reaching the upper and lower edges of the orbit, extended to the bony nasal ridge; and the tumor penetrated the region of the left orbit, to a depth of one inch.
The patient had noticed a rapidly-growing but painless lesion on the inner part of the right eyelid as early as 1858, three and one-half years before seeking treatment. From February 20 to April 14, 1862, prior to her admission to Middlesex, she had been prescribed Donovan's solution (AsHgI4: mercury, iodide, and arsenic), but it did little to arrest the advancing disease ("Donovan's Solution"). The most serious effect was the extent to which the tumor had spread across the bridge of the nose. Reaching to within ⅜-inch of the healthy eyelids, it had moved inwardly, threatening the left eye. After considering the general health of the patient, which was good, Moore concentrated on preventing the disease from destroying the left eye as well.
On 23 April 1862, Dr. Moore anesthetized the patient with chloroform and dissected the healthy skin around the tumor, beyond the margin of the orbit on the forehead and neck and downward on the outer side, through what remained of the right eyelids ("A Case," 192). On the inner side, he cut around all the structures between the lower part of the forehead and the upper part of the nasal cartilages, as well as around the nasal bones, ¼ inch from a tendon extending between the maxilla and orbit (192). After the irregular incision had been completed, Moore severed the tumor from the face and removed the right globe, along with the ulcer and its walls. When examining the cavity, he found that the knife had not removed all of the tumor, which had already perforated the facial bones (nasal, lachrymal, and ethmoid), penetrating deeper into the face. Even though the outer aspects of these parts did not reveal disease, Moore strongly suspected that cancer was beneath the surface. Having reached the limits of what the knife could do, he turned to zinc chloride: “>Over the whole of the surfaces which could be suspected of being diseased, I accordingly laid cotton-wool spread with a paste of chloride of zinc, and took precaution against any of the paste, itself, or diluted with blood and serum, passing into the left eye. Before the patient awoke from the chloroform, I had a minute quantity of a saturated solution of morphia injected under the skin of the arm” ("A Case," 192). The patient, after several hours of sleep, awoke, with neither pain nor bleeding. Once the zinc chloride in the clotted gauze had hardened, Dr. Moore was able to remove it. Underneath the gauze, he found a slough that he would detach five weeks later; the slough contained the unexcised, soft tissue of the right orbit, and orbital and nasal bone fragments. Moore's most important finding was that, "No trace of the original disease appeared in any part of the wide excavation disclosed by the removal of the slough" (193). Although the healing process was delayed at the roof of the orbit, healthy scar tissue formed everywhere else. But the excavation was still deep and deformational. It had reached laterally from the maxillary bone to the right temple and downwards to the middle of the superior maxillary bone and the nasal cartilages. Even though the resulting crater in the patient's face exposed the antrum, the orbital plate of the sphenoid, and a pulsating cranial wall, ethmoidal air cells, parts of the turbinated bones, and inferior turbinated bones on the left side, Mary H. was mostly insensitive to pain (193).
Dr. Moore affirmed that his combination of traditional surgery and escharotics was consistent with De Morgan's mixed-mode of therapy. Although Mary H. was left with a cavitary disfiguration, her life had been prolonged, and facial prosthesis was available. Although Dr. Moore made several vague, etiological distinctions between this case of epithelial cancer and the typical rodent variety, by 1866, when the case study was reprinted in the Appendix to Rodent Cancer, he confirmed that Mary H.'s cancer was, indeed, of the rodent type or what is now known as basal cell carcinoma (Rodent Cancer, 61-73). The modifier "rodent," derived from the Latin verb rodo ("to gnaw"), figuratively conveys the erosive effects of the disease ("rodo," OED, II, 329). A related Latin locution of fourteenth-century provenance, "Noli Me Tangere" ("touch me not"), had also become part of the Victorian medical lexicon. The Cornish writer and translator, John of Trevisa (c. 1326-c.1402), had invented this descriptive clause to impart a sense of the pain and social ostracism associated with the condition ("Noli Me Tangere," OED, I, 1935). Unlike practitioners who made exaggerated and false claims, Moore was circumspect:
As to the prospect of life afforded to this patient by the operation, while I cannot question that it has been prolonged, it does not accord with experience or honesty to represent the disease as annihilated, because the tumour is removed. The purpose contemplated in the operation will have been obtained, if life be lengthened and the left eye be preserved; while some artificial means may be resorted to for adding seemliness of appearance to the comfort the patient now has, in the absence of the morbid and ulcerated deposit ["A Case," 193].
The Case of George W.
George W., age 59, was referred to Dr. Moore on 31 August 1865. His condition is described below:
In the middle of the face was a vast ulcer, laying into one cavity the nostrils, right orbit, and mouth. Its highest part was narrow, and reached a little above the level of the eyebrows: its lowest part was formed by a deficiency of all but the outer half-inch of the upper lip on each side . . . The entire nasal part of the face was gone, with the inner part of the right orbit; and the globe of the right eye, covered only by some thin cellular tissue and conjunctiva was exposed . . . [Rodent Cancer, 92-3].
As the text and graphic photographs indicate, the cancer which had ravaged the patient's face was "a solid, advancing deposit" (93; C Heisch). It is astonishing to learn that the lesion had initially manifested itself, twenty-six years earlier in 1839, as a small red pimple on the right side of George W.'s nose; it ulcerated, spread in all directions, and never entirely healed, although it did respond to treatment intermittently (93-94). By 1862, the lesion had a diameter of a half-crown (32 mm.) (Clayton); however, by Christmas of 1864, "it had lately extended with comparative rapidity," splitting his lip open (94).
Dr. Moore began treatment on 4 September 1865, employing the newly-established system. He began by removing the old deposit with galvanic cautery (Rodent Cancer, 94). The platinum blade, heated electrically, removed much of the tumor, revealing a dry, black trench. Instead of cauterizing the diseased aspects of the nose, which would have risked damaging the healthy eye, he cut away abnormal tissue with scissors. Once that had been completed, he applied zinc chloride paste to the whole surface. All the while, the patient was not anesthetized. By 7 September, pain and swelling developed in the adjoining parts of the face and forehead (94). On 11 September, however, the sloughs began to peel away, revealing healthy granulations. On 14 September, George returned to his home in Cheshire (95).
George W.'s physician, Dr. Beales, referred him to Middlesex Hospital on 23 November for a follow-up. Aside from an eye infection, the patient was found to be in good health. Dr. Moore further observed that the aperture in his face had "remarkably contracted" and that scar tissue had formed (96). Before George W. could be fitted for a vulcanite mask, he needed reconstructive surgery. Dr. Moore began by excising the blind right eye and lower lid; and, to lessen the deformity, he "attached the upper lid to the adjoining part of the cheek" (97). After five days of recuperation in the Hospital, Mr. Turner, the prosthetist, created "an admirable" vulcanite mask for the patient (97).
When George W. returned to Dr. Moore for a 7 July 1866 follow-up, the doctor discovered "a small concave ulcer at the corner of his remaining (left) eye," along with pale and bleeding tissue at the exposed right-superior maxillary bone (Rodent Cancer, 97). Dr. Moore went to work again, removing all of the abnormal tissue he could find, "either by caustic, or by knife and chloride of zinc combined" (97). At the August 1866 Cheshire Meeting of the British Medical Association, Moore examined George W., to find the latest surgery nearly healed.(97).
These and other case studies of the period suggest that routine visits to the dermatologist were not the norm in Victorian England and, judging from the disfiguration Moore's patients had suffered, that the public, having little or no knowledge about skin cancer risks, sought medical care only when the disease had advanced considerably. On the other hand, the cases of Mary H. and of George W. testify to the extraordinary medical advances of the period. In each case, Dr. Moore was able to apply the multi-modal system effectively. In each of these cases, a combination of the knife, electro-cautery, and zinc chloride paste, wielded by a skillful operator, improved conditions. Of the fourteen case-studies Moore included in his book, not all fared as well as the two described above. But combined therapy, especially including zinc chloride topical preparations, benefited several of them.
Perchloride of Iron Injections
In 1860, Dr. Moore reported that, to halt the spread of Lupus exedens (one of several synonyms for basal cell carcinoma), Dr. De Morgan had injected perchloride of iron directly into the face of a young woman ("The Treatment of Cancer," 549; Warren 5-6). This was an experimental therapy, as perchloride of iron had previously been used against tuberculosis and as an antiseptic. The record shows that Dr. John James (d. 1871), of the Metropolitan Free Hospital, in 1862 was one of the first to consider the possibility of its use against cancer (28-29). De Morgan's perchloride injection might also have given Moore the idea of directly injecting zinc chloride. Thus, by 1865, Moore was using the chloride against breast cancer as a solid, as a paste, as a lotion, and as an injectable (549). His rationale for using injections was that the coagulant, if directly introduced in this manner, could thoroughly suffuse the tumor, adjoining tissues, and the axillary lymphatics (549).
For an advanced case of breast cancer, which he began to treat on 10 November 1865, Dr. Moore employed "a long silver cannula, steel pointed, screwed on a vulcanite syringe," containing a solution of ZnCl2 and distilled water (1 grain per ounce). A difficult problem he encountered, during the earliest phase of these experimental treatments, was how to lessen the searing pain of the injected chemical without reducing the potency of the dose (550). In December 1865, he again used a strong concentration of the chloride to stem the progress of skin cancer on the cheek and lips of a patient. On 21 December 1865, he increased the concentration to the upper limit of 40 grains of ZnCl2 per fluid ounce. Apparently, destroying the cancer, in De Morgan's mind, took precedence over palliation. Although the patient experienced great pain, by 25 December, the treatment goal was reached: the injected lesions had shrunk considerably (550). On 4 January 1866, he was able to remove "a thick large slough, the remains of tissue killed by the injection" (551). Moore never ignored the importance of adjusting the strength of the lotion to the part being treated, and this meant considering two factors: the sensitivity of the area and the extensiveness of the diseased part. He made remarkable progress in this critical area over a period of two months and continually worked on ways to manage pain.
Dr. Moore acquired versatility with zinc chloride, using it in various forms and at varying strengths. In "On the Influence of Inadequate Operations on the Theory of Cancer" (April-May 1867), he advised that, where surgery was not possible, solid ZnCl2 could be applied to the edges of the skin, as a paste on open wounds, or as a wash on visibly healthy surfaces; but he also cautioned that strong concentrations of the chloride had attendant risks. Like Canquoin, Dr. Moore calibrated the agent’s strength, ranging from 20 to 40 grains per fluid ounce of water, to achieve the optimal balance: "By these various applications the action of the zinc may be graduated to produce the strongest caustic effect or to merely whiten the superficial [epidermal] textures. Regard must be had to the depth of the subjacent structures in the use of the stronger preparations, especially on the wall of the chest; and in any strength the zinc should not be in contact for more than a moment with the large veins in the axilla" ("Inadequate Operations," 279). The question as to whether a cure was possible through the ZnCl2 system was unanswerable in the short-term since patients had to be closely monitored and their histories followed for years.
Despite the challenges which the condition posed, Moore confidently stated, in 1866, that it was "unnecessary to adopt so gloomy a view of these cases" (52). Even if the tumor was large, the surgeon could use both "knife and caustic" to reduce or remove it systematically, while guarding the patient against excessive pain, shock, and depression with chloroform and morphine, and by promoting emotional recovery with customized facial prosthesis. Thus, surgery, topical chemotherapy, anesthesia (morphine and chloroform), and cosmetic appliances, such as the form-fitted vulcanite masks (India rubber and sulfur hardened by intense heat), became the regimen for what had hitherto been an intractable condition ("vulcanite," OED II, 325). Zinc chloride was the deciding factor. It could be used copiously on "the dense margin of the disease," where it acted directly on the soft, exposed textures, and where, "to any depth which may be deemed requisite," it permeated and destroyed imperceptible cancerous tissues (53). The concern that too strong of a dose of ZnCl2 could damage sensitive tissues was a legitimate one (53-4). In several alarming instances. Moore suspected that zinc chloride accidentally contacting "a diseased surface of the dura mater" triggered epileptic seizures (54); later studies confirmed that the disease, and not the ZnCl2, was the cause (55-6). Moore’s analysis, formed in consultation with De Morgan and others at Middlesex Hospital, was that rodent cancers, even if severe, could be treated "by the combined method of incisions and caustics" (57).
One can only speculate as to how much the J. Weldon Fell trial had influenced Moore and De Morgan to investigate the potential of zinc chloride. Even though Fell’s trial was disorganized, incomplete, and incomparable to a modern, randomized study, the chloride's ability to destroy localized disease was unquestionable. Furthermore, not only had the immediate results of zinc chloride on cancer impressed Moore and De Morgan, but they also appreciated its agreeable effects as a mild antiseptic that hastened healing. In the mid-1860s, as far as mammary and skin cancers were concerned, the ablation-zinc chloride combination therapy had become the standard of care.
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Last modified 9 May 2017