Gender and Pain in Nineteenth-Century Cancer Care.

Abstract

In the 1850s, an American surgeon Dr J. Weldon Fell appeared in London claiming to possess a new cure for cancer. Soon after his arrival in the metropolis in 1856, he applied to the Middlesex Hospital's cancer ward to trial his treatments on the patients held within. The ward had, since its foundation in 1792, adopted the unusual policy of ‘rendering [itself] available for the trial of every new method of treatment which could with safety and propriety be adopted’.11. Alexander Shaw, Charles H. Moore, Campbell de Morgan, and Mitchell Henry, Report of the Surgical Staff of the Middlesex Hospital, to the Weekly Board and Governors, Upon the Treatment of Cancerous Diseases in the Hospital, on the Plan Introduced by Dr. Fell (London: John Churchill, 1857), p. 2. The surgical staff, ‘ever alive to the importance of doing all in its power to advance the treatment of this intractable complaint’, agreed and wrote up their assessment of his ‘plan’ in their minutes before publishing it as a separate volume. This article will look at this ‘plan’ alongside another account of Fell's treatment, written by the naturalist Philip Henry Gosse about his wife, Emily Bowes Gosse.22. Philip Henry Gosse, A Memorial of the Last Days on Earth of Emily Gosse (London: J. Nisbet & Co., 1857). Both accounts record intense physical and emotional suffering, and this article will explore what purpose these textured narratives of pain served and what they can reveal about the dynamics of Victorian masculinity in the context of incurable disease. Both the Report of the Surgical Staff of the Middlesex Hospital and Gosse's account, A Memorial of the Last Days on Earth of Emily Gosse, were published in 1857. The former was produced by the prominent English medical publisher, John Churchill, and the latter by James Nisbet & Co., of Berners Street, London. Fell's treatment and the surgical staff's report were discussed widely in the medical press and The British Medical Journal reviewed the report positively: ‘The result of their labours reflects on them great credit. It is remarkable for its candour, and offers a most satisfactory justification’.33. ‘Reviewed Work: Report of the Surgical Staff of the Middlesex Hospital to the Weekly Board and Governors upon the Treatment of Cancerous Diseases in the Hospital on the Plan Introduced by Dr Fell’, The British Medical Journal 2 (1857), pp. 888–889, here p. 888. Gosse's account is a slim, pocketbook-size volume that was ‘at first intended…only for private circulation among friends’ and only five copies are thought to exist.44. L. R. Croft, ‘Edmund Gosse and the “New and Fantastic Cure” for Breast Cancer’, Medical History 38 (1994), pp. 143–59, here p. 144. However, while he claimed that the ‘simple record’ might just be useful ‘for the stirring up of the faith and love’ of those who did not know his wife, the tone and content of the account suggest that he intended for it to be read by people with some degree of medical knowledge.55. Gosse, A Memorial of the Last Days on Earth of Emily Gosse, p. ix. In what follows, I will argue that the surgical staff of the Middlesex Hospital used their patients’ descriptions of agony, disgust and incapacity to assess the therapeutic efficacy of Fell's treatment. This process was particularly important because the surgical staff believed Fell's intervention to be palliative rather than curative and so could not rely on observable, clinical signs of therapeutic success or failure. Instead, doctors had to depend on a complex calculus of pain and suffering and consider an expansive and holistic interpretation of health and wellbeing to decide whether to incorporate Fell's treatment into their clinical arsenal. I will also suggest that both the hospital's surgical staff and Philip Henry Gosse used their affective narratives of female suffering to construct an image of caring and invested professional men; in doing so, I argue, they subverted or complicated traditional ideas of Victorian masculinity and scientific detachment. This article, therefore, supports the insistence in masculinity studies that it is more accurate to speak of a plurality of masculinities rather than a stable, hegemonic singularity. John Tosh argues that ‘the dominant code of Victorian manliness’ emphasised self-control, stoicism, hard work and independence.66. John Tosh, ‘What Should Historians Do with Masculinity? Reflections on Nineteenth-Century Britain’, History Workshop Journal 38 (1994), pp. 179–202, here p. 183. However, that identity shifted across the period and Stefan Collini calls for a ‘more diverse, flexible and just plain ragged’ conceptualisation of normative masculinity in the nineteenth century.77. Stefan Collini, ‘Having Emotions the Manly Way’, Times Literary Supplement, (June 4, 1999), here p. 6. Indeed, the practitioners’ interest in the emotional state of their patients runs counter to conventional ideas of the nineteenth-century surgeon – who has been portrayed by historians as detached, uninterested or even sadistic.88. See Lindsey Fitzharris, The Butchering Art: Joseph Lister's Quest to Transform the Grisly World of Victorian Medicine (London: Penguin, 2017). While we might have attained a more nuanced understanding of nineteenth-century masculinity broadly defined, we have done less well in complicating our narratives of nineteenth-century scientists and doctors. Similarly, Gosse's highly emotional account of his wife's death and dying cuts across our expectations of Victorian masculinity and scientific detachment. Both the surgical staff and Philip Henry Gosse married medical and scientific skill and interest with compassion and care. Gosse was a naturalist, populariser of science and a Plymouth Brethren. In 1848 he married Emily Bowes, a forty-one-year-old member of the Brethren and in 1849 she gave birth to their only son, Edmund.99. L. R. Croft, ‘Gosse, Philip Henry (1810–1888), Zoologist and Religious Writer’, Oxford Dictionary of National Biography, 1 December 2017. Much has been written about Gosse as a naturalist, theologian and the ‘father’ in the Edwardian memoir Father and Son (published by Edmund in 1907) in which his son described him as unloving and oppressive.1010. Edmund Gosse, Father and Son, ed. Michael Newton, (Oxford: Oxford University Press, 2004). With respect to his professional characteristics, historian Aileen Fyfe writes that Gosse, ‘won himself a reputation for observational accuracy and election to the Royal Society’1111. Aileen Fyfe, ‘Conscientious Workmen or Booksellers’ Hacks? The Professional Identities of Science Writers in the Mid-Nineteenth Century’, Isis 96 (2005), pp. 192–223, here p. 193., and Michael Newton suggests that his ‘writings reveal a genuinely sweet character’.1212. Gosse, Father and Son, p. xvii. However, his account of his wife's death and dying has been subjected to less historical scholarship and has not been considered in the context of his scientific, masculine identity, or against the backdrop of mid-nineteenth-century cancer theory and practice.1313. An exception is, Croft, ‘Edmund Gosse and the “New and Fantastic Cure” for Breast Cancer’. However, this article focuses more on the public reception of Fell and his questionable status as professional physician, rather than the emotional dynamics and the gendered nature of the doctor-patient relationship. This is partly because the history of pre-modern cancer remains understudied. While some scholars have made inroads into medieval, early modern and nineteenth-century Britain, far more have traversed the disease's twentieth-century terrain. This asymmetry can be partly explained by how studies of cancer and chronic disease have been constrained by a version of periodisation that serves to tie certain maladies – or malady-types – to specific epochs.1414. Scholars have conceptualised the nineteenth century as the ‘epidemic century’, with infectious diseases occupying the forefront of historical investigation. This periodisation is most clearly articulated by Abdel Omran, ‘The Epidemiological Transition: A Theory of the Epidemiology of Population Change’, The Millbank Quarterly 83 (1971), pp. 731–57. Recently, however, some historians have turned their attention to malignancy in nineteenth-century Britain and considered the gendered nature of the disease in that period. For example, in her book and article, both on cancer and gender between 1860 and the 1940s, Ornella Moscucci explores the construction of cancer as a peculiarly ‘female’ disease.1515. Ornella Moscucci, Gender and Cancer in England, 1860–1948 (London: Palgave Macmillan, 2016). She draws on the arguments of historical sociologist Tammy Duerden Comeau who claims that early-nineteenth-century cancer was defined according to its supposedly ‘female’ characteristics – for example, she argues that its capacity for growth and extension was conceptualised as reproductive and generative.1616. Tammy Duerden Comeau, ‘Gender Ideology and Disease Theory: Classifying Cancer in Nineteenth Century Britain’, Journal of Historical Sociology 20 (2007), pp. 158–81. However, neither scholar addressed the role gender played in discussions of therapeutic efficacy and professional identity, or looked at the gendered expressions of pain and suffering in the cancer clinic. This lacuna reflects a broader asymmetry in the history of nineteenth-century science and medicine. While historians of masculinity have produced innovative work exploring the formation of masculine identities in many areas of life in Victorian Britain, as Heather Ellis argues, the ‘world of science has remained curiously unexamined’.1717. Heather Ellis, Masculinity and Science in Britain, 1831–1918 (London: Palgrave Macmillan, 2017), p. 2. Before the publication of Ellis's book, Masculinity and Science in Britain, 1831–1918 in 2017, relatively little attention was paid to male self-fashioning and, instead, gender historians focused on the exclusion of women from scientific cultures and knowledge-making. An exception is Jan Golinsky, who argues that the archetypical scientist was ‘associated with distinctly masculine character traits, whether he is a man of action or cool rationalist, benevolent patriarch or glamorous young hero, saint or devil’.1818. Jan Golinski, ‘Humphry Davy's Sexual Chemistry’, Configurations 7 (1999), pp. 15–41, here p. 15. Ellis critiques the tendency of some historians to reify the male scientist in nineteenth-century Britain as ‘a completely secure masculine persona, in control of discourse performance, structures, languages and theatres of power’.1919. Ellis, Masculinity and Science in Britain, 1831–1918, p. 3. However, and as Golinsky noted, scientific masculinity was a construction and was, therefore, inherently unstable and vulnerable to attack.2020. Jan Golinski, ‘The Care of the Self and the Masculine Birth of Science’, History of Science 40 (2002), pp. 125–45, here pp. 126–7. Michel Foucault argued that ‘care of the self’ was crucial to the construction of male scientific authority and gestured towards the centrality of the ‘preparatory exercises of self-preservation’ that worked to present a coherent and powerful image of the masculine scientists to critics and detractors.2121. Golinski, ‘The Care of the Self and the Masculine Birth of Science’, p. 128. For example, the chemist Humphry Davy was often accused of effeminacy and critics associated his scientific interests with a form of ‘diminished masculinity’.2222. Jan Golinsky, ‘Humphry Davy: The Experimental Self’, Eighteenth Century Studies 45 (2011), pp. 15–28, here p. 24. Ellis and Golinsky present a range of different ‘ideals of the man of science’. He could be a fashionable gentleman, effeminate, humble, moral, civically minded and lacking in empathy. Here, I add another image and ideal: the compassionate and affective scientist and surgeon. This article thus dialogues with a recent body of historical scholarship that explores the place of pain and suffering in nineteenth-century surgery.2323. Michael Brown, ‘The Compassionate Surgeon: Lessons from the Past’, The Bulletin of The Royal College of Surgeons 98 (2016), pp. 28–29. Historian Lynda Payne argues that by the end of the eighteenth century a culture of emotional detachment suffused operative surgery.2424. Lynda Payne, With Words and Knives: Learning Medical Dispassion in Early Modern England (London: Ashgate, 2007). Various historians – both popular and academic – have reconfigured this detachment into insensitivity and dispassion and concentrated on the gendered nature of the relationship.2525. See: Fitzharris, The Butchering Art (London: Penguin UK, 2017); and, Ornella Mosuccci, The Science of Woman: Gynaecology and Gender in England, 1800–1929 (Cambridge: Cambridge University Press, 1993). The nineteenth-century surgeon, immune to the suffering of his patient, is a familiar caricature. Building on arguments made by Joanna Bourke and Michael Brown, this article will suggest that this conceptualisation is unsatisfying and leaves out the many and various ways that mid-nineteenth-century practitioners made use of ‘compassion and intersubjectivity’ in the formation of their culture and identity.2626. Joanna Bourke, ‘Pain, Sympathy and the Medical Encounter Between the Mid-Eighteenth and the Mid-Twentieth Centuries’, Historical Research 85 (199), pp. 430–52; Joanna Bourke, Pain and the Politics of Sympathy: Historical Reflections 1760s to 1960s (Utrecht: Universiteit Utrecht, 2011) and Michael Brown, ‘Redeeming Mr. Sawbone: Compassion and Care in the Cultures of Nineteenth-Century Surgery’, Journal of Compassionate Health Care 4 (2017). This article will begin by looking at cancer and its care in the mid-nineteenth century before moving on to outline the nature and scope of Fell's ‘trial’. Then, I will explore the gendered nature of the ‘calculus of suffering’ practitioners deployed to assess the therapeutic efficacy of the treatment.2727. I borrow the phrase a ‘calculus of suffering’ from Martin S. Pernick, A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-century America (New York: Columbia University Press, 1985). In the second part of the article, I will look at Fell's care of Emily Bowes Gosse and her husband's account of that process. In both cases, I will consider the surgical staff of the Middlesex Hospital and Philip Henry Gosse, and interrogate their use of female suffering in their constructions of scientific masculinity and professional identity. Finally, and in line with the themes of this forum, I will show how male surgeons positioned themselves as expert analysers of their female patients’ pain and how gendered attitudes towards the suffering experienced by individual women are inextricable from broader ideas about social class. In November 1791, Mr. Howard of Argyll Street appeared at the Middlesex Hospital's weekly board meeting ‘and read a Paper on the Subject of Cancers’. He informed the governors ‘that a Friend proposed a contribution of three Thousand Pounds for establishing a Fund for the endowment of a Ward for the reception of Persons afflicted with that disorder, and four Hundred Pounds to fit up the Ward provided they should agree to the Plan contained in that Paper’.2828. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, 29 November 1791. The board accepted, and Howard's paper was reproduced in full in the hospital's minutes. He wrote, ‘I take the liberty to observe that two principal objects present themselves to my Mind on this occasion…the relief of Persons afflicted with Cancer, and the Investigation of a Complaint’.2929. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, 29 November 1791. In doing so he encapsulated the two explicit aims of the board: to provide care, palliative or otherwise, for cancer patients and to research the disease. Howard cited the ‘deplorable situation of cancerous Paupers’, and he called the disease ‘extremely common’ albeit ‘both with regard to its natural history, and cure, but imperfectly known’.3030. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, January 10, 1792. Howard outlined a detailed plan for how the ward would be set up and managed. To relieve ‘persons afflicted with Cancer’ he suggested ‘that an airy Ward of the Middlesex Hospital might be appropriated to this specific Disease and to this Disease only, that the diseased might there find such alleviation of their sufferings as their respective situations should require, and that for an unlimited time’.3131. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, January 10, 1792. He proposed that the ward be divided into two sections, one side for men and the other for women, ‘containing ten or twelve Beds…[and] the usual function of…bowls, candles, board’. They predicted that there would be about 40 in-patients per year.3232. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, January 10, 1792. The investigation of the disease was equally as important to Howard as was the care of its sufferers. As part of this research, Howard advocated the keeping of a detailed case history for every patient admitted: ‘In order to improve a subject…I propose, that a faithful account of the history and circumstances of every case be kept, its antecedents and consequences should be marked, the effects of medicines and of Operations, when necessary, noted, together with all the collateral details’.3333. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, January 10, 1792. Howard believed that ‘much useful knowledge may be disseminated, and that we may in no great length of time be furnished with documents on the Disease and its cure, much more authentic than any we are at this time in possession of’.3434. UCLH Archive, London, ‘Weekly Board Meeting’, Middlesex Hospital Minutes, January 10, 1792. While the Middlesex treated both men and women, most of the patients cared for in the hospital were women. As suggested in the introduction, gender has been a key category of analysis for historians of cancer. The prominence of breast cancer in contemporary culture and society has made the disease a fertile ground for historians of medicine, both popular and academic. Frances Burney's account of her 1811 mastectomy has proven particularly alluring for feminist critiques of the medical gaze, and investigations into her words and experience form a substantial part of our knowledge and understanding of nineteenth-century cancer.3535. Burney was an English gentlewoman who lived in France at the beginning of the nineteenth century who recorded a vivid account of her own pre-anaesthesia mastectomy. J. E. Epstein has looked at Burney's narrative, exploring issues of gender and maternity. (J. E. Epstein, ‘Writing the Unspeakable: Fanny Burney's Mastectomy and the Fictive Body', Representations 16 (1986), pp. 131–66.) Most cancer patients in the nineteenth century were women – a fact observed and problematised by contemporaries – and their over-representation was partly because their tumours more often appeared in easily accessible and visible organs: breasts and genitals. Thus, while men were treated at the Middlesex and encountered Fell's ‘cure’, women and their bodies are prominent in this article and most of the clinical interactions I interrogate took place between a male surgeon and his female patients. Gender was not, however, the only category that structured the ‘cancer experience’ in the nineteenth century. The men and women who sought care at the Middlesex mostly walked the short distances from the surrounding areas of intense urban poverty. The ward was intended for the ‘cancerous pauper’, and across the period most hospital patients were drawn from the lower orders as wealthier Londoners preferred to pay doctors to attend to them in the comfort of their own homes. Most of the women examined in this article were, therefore, doubly disempowered – their vulnerability exacerbated by both their gender and their class. In contrast, Emily Bowes Gosse was educated, middle class and married to a teacher, naturalist and populariser of science. Unlike the patients of the Middlesex Hospital, she could afford personal care for her cancer and visited the surgeon in his own home. The Middlesex's commitment to scientific investigation alongside the provision of care prompted the surgical staff to regularly invest in the appraisal of new and innovative treatments for cancer. Throughout the century, the ward received letters from people seeking the hospital's legitimising expertise and promising new cures. Fell was but one of many. In 1817, a ‘gentleman’ named Ashby applied to the Middlesex to trial his ‘remedy for cancer’ on the housed patients, ‘under the inspection of the medical officers’.3636. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 3. Following their investigation, medical officers rejected Mr. Ashby's treatment, but this early failure did little to dampen their successors’ enthusiasm for experimentation. Thus, when Fell arrived in London in 1856, the Middlesex readily accepted his trial and were roundly praised in the press for their enlightened and ‘scientific’ approach to the ‘cancer problem’.3737. Mrs. Valentine Bartholomew wrote, ‘His heart seems filled with sympathy to overflowing for the sufferers of his race’. Valentine Bartholomew, ‘Dr Fell Versus Cancer’, The Ladies’ Cabinet, 1 November 1856, p. 268. The report produced by the surgical staff – containing lengthy and detailed case histories for each patient plus a narrative assessment of Fell's innovation – provides us with unusual insight into the clinical experience of poor women in the mid-nineteenth century. However, I do not want to suggest that this document gives us unmediated access to these women's thoughts and feelings. Their words were rendered by the surgeons who took their histories, listened to their complaints and interpreted their emotional and physical responses. Moreover, while the text is replete with ‘quotations’ from patients undergoing Fell's treatment, the practitioners had control over the words retained in the archive, and we have no way of knowing if they are accurate. The hospital is also an unusual environment, with strict gendered and classed hierarchies of power, and we can only speculate as to whether the female patients reported their true feelings to the male doctors. Nonetheless, I think we can derive a version of events and emotions from the surgical staff's report and disentangle some of the complex feelings and sensations that accompanied Fell's application. The report contains a diversity of patient responses – both positive and negative – and the accounts are often idiosyncratic and filled with individual personality. Finally, we can also determine that practitioners considered the patient voice valuable in their assessment process – this reveals something about intersubjectivity and the doctor-patient relationship, irrespective of the authenticity of the descriptions of suffering. The report includes a detailed account of the treatment. Nitric acid was applied ‘by the means of a small bit of sponge tied to the end of a stick’ to the whole surface of the affected breast…the object of this application was to remove the skin’.3838. The use of corrosive substances to remove breast tumours is part of a long tradition. See Carroll Smith Rosenberg and Charles Rosenberg, ‘The Female Animal: Medical and Biological Views of Woman and Her Role in Nineteenth-Century America’, Journal of American History 60 (1973), pp. 332–356; Ornella Moscucci, The Science of Woman: Gynecology and Gender in England, 1800–1929 (Cambridge: Cambridge University Press, 1990). On the following day, the surgeon would slice with a scalpel, on the surface of the now exposed flesh, a series of parallel scratches, about half an inch apart, reaching from top to bottom. Then, he spread a ‘purple mucilaginous substance’ over the incisions.3939. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 5. This substance was a paste made up from flour, chloride of zinc, and the sanguinaria root, described by Fell as ‘a root used by the North American Indians on the shores of Lake Superior, which the Indian traders told me was used by them with success in these affections’.4040. J. Weldon Fell, A Treatise on Cancer, and its Treatment, (London: John Churchill, 1857), pp. 56–7. In deriving legitimacy from the natural knowledge of the Native Americans, Fell was turning the perceived vice of his American citizenship into an exotic virtue since anti-Americanism was rife amongst British medical men who believed that their counterparts across the Atlantic were subjected to less rigorous training and registration.4141. Broadly speaking, medical training and practice was less regulated in the United States than in Britain. See George Weiss, ‘Medical Directories and Medical Specialization in France, Britain, and the United States’, Bulletin of the History of Medicine 71 (1997), pp. 29–31. The next day, the scalpel was passed again along the scratches, and the purple substance was reapplied. After a few days of this repeated exercise, narrow strips of linen rag, soaked in this purple substance, were inserted into the long parallel scores. Every day these strips of rag were renewed, and the scores were made deeper and deeper. This process killed the cancerous flesh, transforming it into ‘a woody hardness, and a deep black colour’.4242. Gosse, A Memorial of the Last Days on Earth of Emily Gosse, pp. 31–2. Once the incisions had reached the bottom of the tumour, the surgeon scored no deeper, and instead applied a ‘girdle’ around the line where the growth met living, healthy flesh. Gradually, the tumour would detach and eventually drop out of its cavity. For reasons left unexplained, none of this was conducted under chloroform. Fell was offering this treatment as a curative intervention. He wrote long tracts defending its ability to remove the disease from the body entirely, and compared it favourably with the knife. Fell professed ‘to cure cancer by a new process, without the need of an operation’. He was committed to the curative effects of the sanguinara root – his ‘secret medicament’ – which would leave his patients ‘healed’ and ‘well’. He provided favourable figures: ‘out of every 100 cases treated [by him], not more than twenty instances occurred of a return or reappearance of the disease’.4343. Fell, A Treatise on Cancer, and its Treatment, p. 56. The textured accounts of pain in the Middlesex's report contrast dramatically with the cases Fell published from the same trial. One woman he reported on was ‘in excellent spirits. She says she never felt better, and all her friends say that she looks ten years younger than she did’.4444. Fell, A Treatise on Cancer, and its Treatment, p. 68. Another patient was described as ‘very comfortable and happy; no pain’.4545. Fell, A Treatise on Cancer, and its Treatment, p. 71. Yet another was quoted as saying, ‘I am able to make myself useful in my family, and to take moderate exercise without pain or tire’.4646. Fell, A Treatise on Cancer, and its Treatment, p. 77. Under this, as under previous modes of treatment, Cancer retains its notoriously malignant character; that is to say, its capacity for spontaneous and destructive growth in its primary seat, for obstinate recurrence after what has appeared to be the most complete extirpation, and for progress, if not for reproduction, in other and, it may be, distant organs of the body.4747. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 35. Surgeons were profoundly troubled by the likelihood of recurrence, and already at the beginning of the nineteenth century practitioners were speaking of their cancer patients in terms of years gained, rather than complete cures procured. Sufferers might be alive six months later, one year, or two, but only very rarely was this cancer-free life permanent. In theory, too, cancers could be cured by the knife if caught very early – before they had spread to other organs and into the constitution. Surgeon Walter Hayle Walshe suggested, ‘the earlier the morbid mass is removed the stronger are the chances of ultimate recovery’.4848. Walter Hayle Walshe, The Anatomy, Physiology, Pathology, and Treatment of Cancer (Boston: [Publisher?], 1844), p. 151. If the surgeon could intervene when the tumour was still small, still local, then they might be able to entirely prevent relapse. Italian surgeon Antonio Scarpa argued that if the ‘morbid seed’ remained ‘latent and inert’ the disease would be ‘purely local’ and, as a result, could be ‘susceptible of a favourable and permanent cure by extirpation’.4949. Antonio Scarpa, Remarks and Practical Results of Observation on Scirrhus and Cancer, trans. James Briggs, (London, 1822), p. 29. However, this transition from phase to phase – from local to general – was unpredictable and difficult to identify from physical examination or narrative histories. It was, therefore, somewhat unsurprising that the Middlesex surgical stuff determined that in all the cases treated by Fell ‘cancer…remains as ruthless and as unassailable as ever’.5050. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 50. And yet, the report also concluded that the method was ‘ingenious, safe, and easy of application’.5151. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 8. Despite its inability to arrest the malignancy of cancer or prevent recurrence, Fell's treatment was effective. They claimed it was ‘a clear advance upon the past’, and that this was an ‘efficacious and so manageable’ method of treating cancer.5252. Shaw et al, Report of the Surgical Staff of the Middlesex Hospital, p. 42. Thus, while it failed o