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ORIGINAL ARTICLES |
From the Melanoma and Sarcoma Unit, Department of Surgery, The Royal Marsden Hospital, Fulham Road, London, United Kingdom.
Correspondence: Address correspondence and reprint requests to: J. Meirion Thomas, MS, FRCP, FRCS, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK; Fax: 02-07-808-2232; E-mail: josephmeirion.thomas{at}rmh.nthames.nhs.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONREFERENCES |
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Key Words: History • Snow (Herbert Lumley) • Node dissection • Melanoma
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONREFERENCES |
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Herbert Snow
Although little is known of his early life, Herbert Snow graduated from the University of London in 1869 with First Class Honors in Medicine, Forensic Medicine, and Midwifery. Two years later, he obtained his Membership in the Royal College of Surgeons of England (MRCS) and Licentiate of the Society of Apothecaries of London (LSA). He was also awarded a Doctorate of Medicine (MD) in the same year.1 Snow never obtained a Fellowship from the Royal College of Surgeons (FRCS). It is perhaps for this reason that his writings on cancer are little known.
He was the House Surgeon at South Staffordshire General Hospital and subsequently became Resident Surgeon at Birmingham General Dispensary. In 1876, Snow was appointed to the Cancer Hospital, Brompton, London—the hospital set up by William Marsden (and subsequently to bear his name) and the first hospital in the world specifically founded to treat patients with cancer. The Cancer Hospital (Figs. 1 and 2
) was granted Royal Charter by Edward VII in 1910 and was renamed the Royal Marsden Hospital after the formation of the National Health Service, because it was believed that "the word cancer was too frightening and a deterrent to patients."2 Snow worked at the Cancer Hospital for three decades as a Staff Surgeon until 1905. At this time, he was one of six surgeons on the unit, the senior surgeon being Mr. Thomas Stoneham, FRCS. He was based at Number 6 Gloucester Place, Portman Square.
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Melanoma in the 19th Century
The first published account of a patient with melanoma—in fact, a nodal metastasis—has been attributed to John Hunter in 1787, and the resection specimen is preserved to this day in the Hunterian Museum at the Royal College of Surgeons of England.8 René Laennec subsequently described the disease process of cancer noire, the black cancer, in 1806.9 Laennec also identified deposits in the lungs, abdominal viscera, and peritoneum, as well as the eye and pituitary. By 1812, he was using the term melanosis, and others subsequently settled on the then-accepted term. It was left to William Norris in 1820 to publish what he called in retrospect "the first genuine good case of melanoma" (although his original term was "fungoid disease").10 Here, a changing mole developed into a fungating tumor with subsequent satellitosis. When removed, it recurred rapidly in the scar; groin nodal metastases preceded the development of multiple subcutaneous lesions, a cough, and death.
As the 19th century progressed, further descriptions of melanoma appeared in the literature. These included the first case of melanoma in a black patient, described by Pemberton11; subungual melanoma, described by Hutchinson12; and Tennent’s description of amelanotic melanoma.13 In 1851, Fergusson described removal of a secondary deposit of melanoma from the groin. The patient did well, and the case was reported in The Lancet.14
Snow and Melanoma
Herbert Snow’s writing on melanoma eloquently described, years ahead of its time, inguinal lymph node dissection for melanoma. Although this was somewhat of a Halsteadian concept, Snow strongly advocated the concept of anticipatory gland excision (what we would now consider prophylactic or elective lymph node dissection), outlined below:
"...it is essential to remove, whenever possible, those lymph glands which first receive the infective protoplasm, and bar its entrance into the blood, before they have undergone increase in bulk. This is ‘Anticipatory Gland-Excision’, a simple common-sense measure, adding nothing to the gravity of a surgical operation, while most materially enhancing its efficacy.A radical cure is alone thus rendered possible in the more common instance of the more common forms of ‘Cancer’. It was, and unfortunately, too often still is, the custom to neglect the infected glands unless palpably enlarged. (So far as the writer is aware, the general principle of ‘anticipatory’ excision has not been promulgated by any other author, although the modern practice of axillary evacuation affords an approximation.)"15
Snow believed that the best hope for progress in cancer surgery lay in adoption of his approach of anticipatory surgery, arguing that "[once cancerous cells had passed through] such ‘traps’ into the blood current; then death, with multiple visceral metastases, ensues."16
The following extract from his article "Dr H Snow on Melanotic Cancerous Disease" (Fig. 3) clearly outlines the natural history of cutaneous melanoma:
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"The apparent triviality of the pigmented [lesion] ...commonly fails to excite suspicion of danger until there is extensive implication of the lymph glands and it is too late to effectually extirpate the affected area....In respect of surgical treatment...the skin tumor...has little appreciable effect on the duration of life. The danger lies in the diffusion of malignant particles from this primary focus; these always implicate the nearest lymph glands....Palpable enlargement of these glands is unfortunately but a late symptom of deposit therein; by the time it occurs there is almost always implication of deeper organs or tissues. We thus see the utter futility of operative measures which are addressed to the primary lesion only....We further see the paramount importance of securing, whenever possible, the perfect eradication of those lymph glands which will necessarily be first infected..."16
However, even at this early stage in the history of melanoma, lymph node dissection was controversial, and Snow’s theories on cancer were criticized widely at the time.1 He believed that cancer could not be due (as was publicly held) to a microorganism, although it would be many years before the seminal theories on cancer-gene theory were advocated. Clearly on the path to such a concept, Snow wrote in 1890 that to prevent recurrence of cancer, the surgeon must achieve
"...the perfect eradication of every cell nucleus or nuclear particle which has thus apparently become endowed with independent vitality; and which, therefore, if undestroyed, must continue its independent growth at the expense of the remainder of the organism, and must multiply in a constantly increasing ratio..."5
Much of Snow’s writing about cancer remains true today, particularly regarding the prevention of cancer recurrence. He described the need for prompt and early diagnosis, before widespread dissemination, if cancer were to be cured and the importance of avoiding delayed presentation to effect a cure. Snow was also an advocate of palliative care: this was unusual for both a surgeon and a doctor at the time he practiced. He advocated the use of narcotic analgesia for incurable cancer and published one of his lectures in 1890 entitled The Palliative Treatment of Incurable Cancer: With an Appendix on the Use of the Opium Pipe.17
Opinions of Other Aspects of Medicine
A number of other strongly held viewpoints of Snow’s were contentious. Snow publicly condemned as fraudulent the (by-then) well-established theory that germs cause disease, saying that "as for Lord Lister, he should be remembered, only because he got surgeons to wash their malodorous hands."18
Even more controversial were his views on vaccination:
"In recent years many men and women in the prime of life have dropped dead suddenly, often after attending a feast or a banquet. I am convinced that some eighty percent of these deaths are caused by the inoculation or vaccination they have undergone. They are well known to cause grave and permanent disease of the heart. The coroner always hushes it up as ‘natural causes.’ "19
In light of the current debate on the risks of the measles/mumps/rubella vaccine, there is an interesting echo in Snow’s words.
In the 1890s, Snow received a degree of notoriety in the United States for writing a pamphlet entitled "The Barbarity of Circumcision as a Remedy for Congenital Phimosis," in which he deplored the then-routine use of circumcision as a treatment for phimosis.20 Referred to as "Sir" Herbert Snow by the American press, he was never so honored.
Snow was a vocal opponent of animal research, a theme revisited in his later life. Ardently believing that basic surgical science would not provide the answers that medicine sought, he thought that physiological research was a futile means of promoting medical science. He maintained that experiments on animals "...are not dealing with cancer at all [, but that] which has been reported as cancer in mice is a totally different thing from the cancer of humans."21
Subsequent Controversies
Snow was also a controversial character in his professional dealings. He infamously became embroiled in a very public dispute with one of his surgical colleagues, resulting in a High Court libel case.2 Superficially, the case seems to have arisen over a disagreement on the management of a patient, a certain Mrs. Clark, listed for amputation of the arm for a long-standing tumor. However, it was more likely that the dispute was related to ongoing interpersonal difficulties within the surgical department at the Cancer Hospital. The judge ruled against Snow, and eventually the Hospital found the funds to settle the judgment of approximately 600 pounds. The court case brought significant adverse publicity to the Hospital and resulted in the loss of some of the Governors. Of particular interest, the defendant (a Mr. Jennings) claimed that someone from the staff had leaked information about him to the Anti-Vivisection Society, accusing Jennings of being a "horrible man in doing some experiments on animals."2 In 1908, Snow was appointed as the surgeon to the National Anti-Vivisection Hospital in Battersea. One wonders, in light of this later association, whether Jennings was indeed justified in his libel action naming Snow.
In contrast to his medical career, Snow’s retirement was not characterized by any major controversy. He died in November 1930 at St. Leonards-on-Sea at the age of 84.1
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Received for publication February 23, 2004. Accepted for publication June 24, 2004.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONREFERENCES |
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This article has been cited by other articles:
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  B. Cady Regional Lymph Node Metastases; a Singular Manifestation of the Process of Clinical Metastases in Cancer: Contemporary Animal Research and Clinical Reports Suggest Unifying Concepts Ann. Surg. Oncol., June 1, 2007; 14(6): 1790 - 1800. [Abstract] [Full Text] [PDF]
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