Decorated initial T

he history of ZnCl2 (zincane) in medicine might be envisaged as two parallel traditions: a branch of conservative medicine, acknowledging zinc chloride's effects but discounting its value; and another, of chemical medicine, discounting the knife and extolling the chloride. A more precise model, however, would depict a third branch, one that emerged at Middlesex Hospital, beginning in the 1850s and continuing through the 1890s. Workers in this tradition explored the compatibility of ablative and escharotic surgery. Conservative surgeons in the third branch, who refrained from dismissing escharotics entirely, turned to them whenever the knife had failed or was deemed too risky. Many traditionalists, in the late-Victorian period, began to admit zinc chloride and other compounds into their practices either as alternatives or as adjuvants to surgery.

Henry Trentham Butlin (1845-1912)

Henry Trentham Butlin. Courtesy of the Wellcome Foundation. Click on image to enlarge it.

A late-Victorian proponent of combined therapies, Henry T. Butlin (1845-1912), enjoyed a productive 47-year-long medical career (1864-1911). He served as a general and head-and-neck surgeon at three hospitals (St. Ormond's Street Hospital for Sick Children, West London Hospital, and St. Bartholomew's); was a distinguished professor, lecturer, and president (1909-1911) of the Royal College of Surgeons, as well as of the Laryngological Society, the Pathological Society, and the British Medical Association (1910-1911). Dr. Butlin was a prolific author. From 1880 to 1887, while serving at the Royal College of Surgeons as Erasmus Wilson Professor of Pathology, he wrote numerous papers and four books on the pathology, diagnosis, and treatment of head and neck cancers. In 1892, Dr. Butlin received another appointment at the RCS, this time as Hunterian Professor of Surgery and Pathology ("Sir Henry Trentham Butlin"; Shedd [1997], 234-6; and [1999], 37-43; "Butlin," Royal College of Surgeons).

Articles outlining Dr. Butlin's professional life record the outstanding achievements of an establishment physician but omit the fact that his method was aligned with the innovations at Middlesex Hospital, where Drs. De Morgan, Moore, and colleagues, in the late 1860s and early 1870s, had successfully employed both knife and topical substances against cancer. A contemporary of Dr. Butlin, Dr. George Thin (d. 1903), who was a London dermatologist, experimented with a synthetic approach to skin-cancer management. Although skeptical about using caustics alone against cancer, he recognized the quality of zinc chloride (Thin 47; "Dr. George Thin"; Couch 304). In the two breast cancer cases discussed below, Dr. Butlin utilized zinc chloride, in conjunction with older caustics and galvanic-cautery, in place of surgery. Overall, his published works are characterized by a willingness to consider new modalities.

Elizabeth D. & Mary Ann P.

A central pursuit of Dr. Butlin's practice was whether certain homeopathic formulae deserved professional attention. In an 1887 paper, he described two successful procedures involving female patients. Because one patient was elderly and the other feeble, radical surgery was contraindicated for both of them. Butlin turned to escharotic ointments, specifically Dr. Jean Joseph Bougard's paste, and, in both cases, was able to halt advanced mammary cancers. A period of remission was obtained for the first patient. Of the second, zinc chloride destroyed all visible disease.

Elizabeth D., who came to Dr. Butlin's attention in March 1886, had been suffering from an ulcerated carcinoma of the right breast. After assessing her condition, the doctor admitted her, on 22 May, into the Casualty Ward ("Two Cases," 58). The treatment, which was undertaken without delay, proceeded in two phases. In the first, Dr. Butlin brushed Vienna Paste (a compound of hydrate of potash and quicklime) onto the healthy skin surrounding the ulcer (Pereira 131; Van Harlingen 373-4). In less than ten minutes, the skin was destroyed; the preparatory caustic was then removed with cotton, and the surface was dried (58-9). The purpose of the Vienna Paste was to enhance the absorbency of the secondary caustic which would destroy the cancer. Bourgard's paste had 6 active ingredients and was probably the most potent (and toxic) of all available escharotics: zinc chloride (245 grams), arsenic (1 gram), mercury sulfide (5 grams), ammonium chloride (5 grams), and mercury chloride (1/10,000 of a gram). Including the inert permeant of starch and wheat flour (120 grams), a batch of Bougard's paste weighed 376.0001 grams, 65% of which was ZnCl2 (57). A layer of Bougard's paste, one-sixth of an inch thick, was applied over the ulcer, and the circumscribed margin at its base served as a barrier to the migration of cancer cells into healthy tissue. On top of the medication, Butlin successively placed a lint covering, a compress of cotton wool, and a bandage (59). After five or six hours had passed, the doctor, having removed the compress and caustic, then applied a linseed poultice. He reported that twenty-four hours after the procedure had begun, "the eschar, which was about half an inch or more in thickness, was removed by cutting through it with a pair of scissors at a distance about one-sixth of an inch from the margin of the living skin. In some places, it separated easily from the parts beneath; here and there it needed to be loosened with scissors" (59). The applications, a total of 14, were made every day until 10 June. On that day, Dr. Butlin observed that "the disease appeared to have been removed, for the eschar was no longer hard and dull white, as it had been, but much softer and of yellowish colour (59). Judging, too, from the depth to which the disease had extended before the treatment commenced, Dr. Butlin determined that sufficient destruction had taken place. Poultices were then applied until the slough had completely separated, revealing a very healthy granulating wound, smaller than what had been expected (59). On 29 June, the doctor determined that re-application of Bougard's paste was necessary to remove two or three newly-appeared, small nodules. These lesions were also destroyed. On 23 July, Elizabeth D. left St. Bartholomew's Hospital. She returned for a check-up on 20 October 1887, 16 months after the procedure. Upon examination, Dr. Butlin found her to be cancer-free and without pain (59).

Dr. Bultin's second patient, Mary Ann P., was suffering from a large ulcerated growth in her left breast and enlarged axillary lymph nodes. From February 1885 to the narrative present, she reported that the cancer had steadily increased in size. In view of the fact that she was in poor general health and considerable pain, Dr. Butlin initially thought that radical surgery was the best choice; however, in view of her feeble condition, he doubted that she would survive an extensive procedure ("Two Cases," 60). The only viable option was the escharotic method. So, on 30 July, Dr. Butlin commenced with a ten-millimeter application of Vienna paste and then administered Bougard's amalgam. By 11 August, because of high fevers, the doctor had to stop and then restart the process several times, the delay jeopardizing the patient's survival: "Owing to the slow progress which was consequently made, it seemed from time to time as if the growth of the tumour might be more rapid than the action of the caustic, and that we might never succeed in removing the disease" (60-1). It was a race against time: "Even when the prominent mass had been removed, and a healthy granulating wound remained, buttons and nodules of cancer sprang up amongst the granulations at frequent intervals. They were freely destroyed with Bougard's paste as they appeared, and with them a wide area of the surrounding tissues" (61). The last application of the paste was performed on 23 October. The wound healed steadily, and Mary Ann P., with no further evidence of recurrence, was discharged on 22 November to a Convalescent Home at Swanley (61).

These and similar cases helped Dr. Butlin to define the limitations and the value of zinc chloride. Rather than to reject alternative medicine on principle, he urged the medical community to evaluate promising homeopathic substances objectively. A step in that direction was to identify a "class of cases," whose conditions rendered them "suitable for treatment with caustics" ("Two Cases," 61). Breast or skin cancer patients, according to the criteria Dr. Butlin set forth, fell into this class: (1) even if the disease was "of considerable size," as long as it was localized and "within reach of removal or destruction," an escharotic could be a first choice, especially since transection of the tumor risked dissemination of cancer cells (a phenomenon pathologists Carl von Rokitansky (1804-1878) and Rudolf L. K. Virchow (1821-1902), along with the surgeon William J. Mayo (1861-1939), called "seeding“ (512-13); (2) if "the skin was not very widely affected," caustic treatment was suitable, the emphasis being on the breadth, rather on the depth, density, or height of the tumor; (3) if the disease had not spread to regional lymphatic nodes, chemical treatment should be considered; and (4) the overall health of the patient—whether he or she would be able to withstand major surgery—was a determining factor; in addition, treatment by caustics, though painful, was not as dangerous as radical surgery. In Dr. Butlin's view, these criteria were procedural guides, not strict standards: "I do not say that the treatment by caustics should be limited to cases such as these, but I do say that it would be difficult to find more suitable cases" (61).

Dr. Butlin reasoned that, if promising medicines could be culled from the traditional formulary, medical scientists might transform nostrums into bona fide remedies. Culling from the formulary would have additional, salutary effects, divesting the Eclectics of the agents upon which their illicit trade depended, and gradually reclaiming patients, along with profits, lost to unauthorized competitors. An important public health issue was also involved. The popularity of underground medicine stemmed from the expertise they had developed with certain medicines; and the conditions were such that desperate patients, whom conventional medicine had failed, had no other recourse but to consult them. Although some cancer patients experienced short-term relief from zincane, these successes were enough for Eclectics to acquire a degree of respectability; however, because these operators were not formally educated, and because they administered crudely prepared or unsafe substances, the patients were at risk—but a risk some had to take.

Walking a fine line between two opposed schools of thought, Dr. Butlin refrained from explicitly condoning unauthorized practice, as he explained to his colleagues the circumstances that had led to the growth of Eclectic health care. He listed three cogent reasons: (1) alternative medical care developed because allopathic physicians had not been trained to use escharotics in cancer care and were unfamiliar with their positive and negative effects. With the exception of doctors such as Simpson, De Morgan, Moore, and others, most physicians were reluctant to experiment with these substances, even though Middlesex Hospital physicians had made documented progress with them in oncology. Dr. Butlin was very careful not to suggest that the Eclectics might be on to something: "The prejudice against the use of caustics is in our profession very strong, partly because they have fallen for the most part into the hands of quacks, partly because we are not in the habit of employing them, and are in practice ignorant of their vices and virtues. Indeed the feeling is so strong against them, that I write this paper in a kind of fear lest it should be said that I am advocating [non]surgical practices. But I have no hesitation in accepting this risk" (63).

To persuade conservative colleagues to view chemical medicine as an untapped resource, rather than as an economic and public health threat, Dr. Butlin constructed a sensible (though inexact) analogy between two sets of rival branches: the orthopedic surgeons vs. the chiropractic "bone-setters," on the one hand; and traditional vs. chemical practitioners, on the other. Operating without medical training and licenses, the "bone-setters" who had a rudimentary knowledge of anatomy, acquired the manual aptitude to set fractures, to reduce dislocations, and to restore mobility to injured or diseased joints (S. Homola). Bone-setters, such as the uneducated itinerant Sarah Mapp (bap. 1706-1737) and the reputable Robert Howard Hutton (1834-1916), learned their trade well, gained the public trust, and often succeeded where licensed physicians had failed. Dr. Butlin's point was that promising medicines in the hands of the unqualified, be they bone-setters or chemical Eclectics, had to be identified and incorporated into the standard pharmacopeia:

Our relation to the cancer quacks at present is much the same as it was a few years ago to the bone-setters. Again and again patients who had been long under our treatment, and whom we have failed to cure, passed into the hands of bone-setters and were cured forthwith. We listened incredulously to the oft-repeated stories of the ways in which the cures were wrought, and put them aside as idle tales, never thinking it worthwhile to verify them or to make ourselves acquainted with the methods practiced by our successful rivals. Of late years a change has taken place; observation and practice have enabled many members of our profession, to select fitting cases and to apply successfully the bone-setter's manipulations. As time goes on this knowledge will become the property of every medical practitioner, and the field of the bone-setter will be set within narrower and narrower limits, until at length there will be no work for him to do ["Two Cases," 62].

Dr. Butlin had in mind a collaborative relationship in oncology between paraprofessionals and licensed physicians, similar to what Dr. Wharton Peter Hood (1834-1916), an orthopedist, had developed with the bone-setter, Robert Howard Hutton (1840-1887), who had instructed the medical doctor in the art of manipulation and setting. Dr. Hood had spoken respectfully of the latter's manual skills as the product of "sound tradition"(6). Hood, unlike Butlin, was not afraid to enunciate the radical notion that the art of the reputable bone-setter might far exceed the ability of the best London surgeons. Bone-setting, however, was not self-taught. Hood hypothesized that Hutton's forebears had originally been trained to assist real doctors and that the tradition was handed down from generation to generation. The surgeons to whom contemporary bone-setters were indebted "[knew] exactly what could be done by sudden movements and how these movements should be executed" (6-7). Butlin's analogy falters because he omitted the important fact that, although the bone-setters to whom Dr. Hood alluded did not hold professional medical degrees and licenses, the opposite was true of the escharotic practitioners, the majority of whom had credentials.

Pervasive & Continual Influence

Although zinc chloride had lost its pre-1850 aura as a panacea, by the 1870s, both biochemically and clinically, its nature had become more clearly understood. Over a seventy-year period, from its discovery in 1812 to the end of the Victorian Age, ZnCl2's uses had been continually redefined. A reliable destroyer of morbid tissue, an antiseptic, a hemostat, and a preservative, zincane retained its reputation, as British, continental, and American physicians continued to employ the chemical, therapeutically, either as a primary or secondary agent. The testimonies of practitioners and entries in pharmaceutical compendia are primary sources on the subject. Harrison Allen's (1841-1847) 1893 edition of A Handbook of Local Therapeutics is one such index. A collaboration of four medical specialists—Drs. Richard H. Harte, Arthur van Harlingen, George C. Harlan, and H. Allen—it covers general surgery, diseases of the skin, ear, nose, throat, and eyes. The section, "ZINCI CHLORIDUM. Chloride of Zinc," which is incisive and wide-ranging, provides biochemical and historical background (439). Dr. Allen and co-authors outline zincane's properties as caustic, astringent, excitant, disinfectant, and hemostat. Unlike the other formularies of the period, this text elucidates lesser known areas of zinc chloride activity. On the cellular level, the authors explain ZnCl2's effects on living tissues, ascribing its ability to devitalize tissue to its affinity for, and removal of, water from cells. Once morbid tissues had been coagulated, a secondary effect commenced: as a metallic salt with affinity for organic matter, zinc chloride compounded the solids and fluids on the surface of a wound, prevented decomposition and the growth of bacteria, and contributed to healing. In light of these effects, Allen et al. affirmed that the chloride was "a valuable curative agent" (439).

On the pharmaceutical level, the authors consulted a nascent, medico-pharmaceutical tradition to describe zincane's various preparations. To treat a morbid mass involving the skin, Allen et al. recommended zinc chloride paste, especially the formula of the Belgian physician, Dr. Jules Félix (likely influenced by Bougard). Since doctors often functioned as apothecaries, it was essential that they were precise about ingredients and proportions. Thus, Félix's paste, the primary agent designated for superficial lesions, combined bi-chloride of mercury, amylin, camphor, bromide, carbolic acid crystals, iodol, and croton choral. This amalgam, once reduced to powder, was mixed with distilled water and kneaded in a mortar to the consistency of putty. To manage the putty efficiently, one needed a matrix. Immersing a sheet of lint for that purpose in a saturated salt solution, the operator let it dry, cut pieces from the sheet, and form-fitted them to the treated area (439). An alternative formulation was Dr. Alexandre Canquoin's paste; the ZnCl2-covered lint was placed over the tumor for six to twenty-four hours.

The late-Victorian history of zinc chloride involved many medical specializations. To manage gynecological diseases, for example, Drs. E. Van de Warker and C. Haeberlin invented new surgical methods in which zinc chloride had an essential role ("A New Method," 212; "The Treatment," 161, resp.). In Mann's American System of Gynecology, Dr. Alexander J. Skene recommended zinc chloride as both safe and efficient (381). For uterine inflammations and endometriosis, Dr. C. D. Palmer endorsed it as an anti-inflammatory (558, 563, 565, 616); Van de Warker found it to be of diagnostic value in the detection of pelvic hematocele (760); Dr. Paul F. Mundé depended on it as coagulant and antiseptic for endometriosis (Allen 440-41); and the pharmacologist, Sydney Ringer (1836-1910), injected zinc chloride solutions to treat gonorrhea (441). Zincane had also been used to treat conditions of the ear, nose, and throat, in addition to more serious conditions, such as venereal disease and diphtheria, for which it was combined with the alkaloidal extracts of the Yellow cinchona-bark (Lewis and Warner, I. 11-12).

The pioneering work of the De Morgan-Moore branch would greatly influence the breast surgeon, Dr. Charles W. Strobell, an employer of ZnCl2 who made major contributions to surgical oncology in the early decades of the twentieth century. Prior to the 1940s, however, incidents of quackery and public scandals would, once again, injure zinc chloride's reputation.

Work Cited

Allen, Harrison, ed. A Handbook of Local Therapeutics. Philadelphia: P. Blakiston, Son & Co., 1893. Internet Archive. Web. 14 May 2017.

Bougard, Jean Joseph. Sur La Guérison du Cancer; Caustiques et Opérations Sanglantes. Bruxelles: Henri Manceaux, 1868. Google Books. Web. 12 May 2017.

_____. Traitement du Cancer: Caustique & Procédé Nouveaux. Bruxelles: Henry Manceaux, 1872. Google Books. Web. 12 May 2017.

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Butlin, Henry T. "Two Cases of Cancer of the Breast, Treated by Caustics." Reports St. Bartholomew's Hospital (London, England), vol. 23. Eds. W. S. Chamber and W. J. Walsham. London: Smith, Elder, & Company, 1887. Google Books. Web. 10 March 2017.

_____. On the Operative Surgery of Malignant Disease. Philadelphia: P. Blakiston, Son & Co., 1887. Google Books. Web. 10 May 2017.

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"Butlin, Sir Henry Trentham (1845-1912)." Plarr's Lives of the Fellows Online. Royal College of Surgeons (11 May 2006). Plarr's Lives Online. Web. 1 May 2017.

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Hood, Wharton Peter. On Bone-Setting (So Called) and Its Relation to the Treatment of Joints Crippled by Injury, Rheumatism, Inflammation, &c. &c. London and New York: Macmillan and Co., 1871. Internet Archive. Web. 12 May 2017.

Mayo, William J. "Grafting and Traumatic Dissemination of Carcinoma in the Course of Operations for Malignant Disease." The Journal of the American Medical Association. (15 February 1913) 60.7: 512-13. Google Books. Web. 20 May 2017.

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_______. Historical Landmarks in Head and Neck Cancer Surgery. Pittsburgh: The American Head and Neck Society, 1999. 37-43. Google Books. Web. 1 May 2017.

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Stone, William S. “A Review of the History of Chemical Therapy in Cancer." Medical Record. (7 October 1916) 90.15: 628-34. Ed. George Frederick Shrady, Thomas Lathrop Stedman. New York: William Wood & Company, 1916. 628-34. Google Books. Web. 4 April 2016.

"Thiersch, Karl (1822-1895)." Obituary. The British Medical Journal. (15 June 1895) 1.1798: 1360. U. S. National Library of Medicine. Web. 13 May 2017.

Thin, George. Cancerous Affections of the Skin: A Treatise on Epithelioma and Rodent Cancer. London: J. & A. Churchill, 1886. Internet Archive. Web. 18 May 2017.

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_____. "Pelvic Hematocele and Hematomata." A System of Gynecology, vol. 1, 735-69. Ed. Matthew Darbyshire Mann. Philadelphia: Lea Brothers & Co., 1887. Google Books. Web. 19 May 2017.

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Last modified 9 May 2017