Morphine, cocaine, and 19th century cancer care

Abstract

Herbert Snow worked at the London Cancer Hospital (later known as the Royal Marsden Hopsital, London, UK) as a surgeon from 1877 to his retirement in 1906. Like a handful of his contemporaries, Snow was interested in the administration of strong opiates for the relief of pain and exhaustion in advanced cancer. An advocate of early surgical intervention for malignant disease, he also believed that cancer, in many circumstances, had a neurotic origin and sought to treat it by inducing an “opium habit” in his patients. By the 1890s, he was arguing that the conjunction of both morphine and cocaine could not only relieve the symptoms of advanced cancer but could indeed slow the progression of the underlying disease. His 1896 paper, published in the British Medical Journal and entitled “Opium and cocaine in the treatment of cancerous disease”, argued that the two drugs had the power of “inhibiting tissue metabolism” and “sustaining the bodily powers under excessive and protracted strain”. He presented several case histories in support of his argument, stating that the morphine was eff ective in relieving pain, whereas the cocaine had value in “sustaining vitality”. Snow might have been confused about some of the eff ects of his prescribing methods, but his importance from the modern perspective was in highlighting the place of opiates for symptom management in advanced cancer. By the 1920s, an elixir of morphine and cocaine was in use in several London hospitals and came to be known, in various guises, as “the Brompton Cocktail”. In the early 1950s, it began to appear in print, and Cicely Saunders, founder of the modern hospice movement, in her fi rst publication, referred to a remarkable formulation of the mixture, which included: nepenthe or liquor morphini hydrochloride, cocaine hydrochloride, tincture of cannabis, gin, syrup, and chloroform water. Over the next 20 years, in her subsequent writing and lecturing, Saunders did much to promote this and other variants of the Brompton Cocktail. In the USA, the psychiatrist and pioneer of end-of-life care, Elisabeth Kubler Ross also became one of its supporters and it was widely used in the burgeoning practice of hospice care on both sides of the Atlantic. For a while, there was tendency to endow the Brompton Cocktail with almost mystical properties and to regard it as the panacea for terminal cancer pain. But, quite suddenly, its credibility came into question. Two sets of research studies, both published in 1979, raised doubts about its effi cacy. Melzack and colleagues showed that pain relief equivalent to that produced by the mixture was obtained without the addition of cocaine and that there were no diff erences with respect to confusion, nausea, or drowsiness. Twycross noted that morphine was just as effi cacious when given in a solution by mouth, and that the withdrawal of cocaine had no eff ect on the patient’s alertness. Despite the new evidence base, Snow’s combination of morphine and cocaine did persist in use for some time, though it is has now largely passed into the annals of modern-day cancer pain relief.