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EPIDURAL MORPHINE
673 AGEING: THE INTRUSIVE "E"
SIR,-1write to remonstrate against your policy of spelling "aging" with an "e" (e.g., Feb. 10, p. 308). Or am I rageing in vain and wageing a losing battle? The unreflective might retort that "aging" would be pronounced "agging", or that it is an Americanism. In fact a "g" is soft before "e", "i", and "y" in English words of Greek, Latin, or Romance origin, and the long "a" sound is preserved by the single consonant. "Aging" is the form proper to the English Language, but the Americans recognise this more readily than do the British, having paid greater attention to principles, following the lead of Noah Webster.I The basic rule is that a mute "e" at the end of a word is dropped before a suffix beginning with a. vowel; the vowel of the suffix keeps the preceding vowel long. However, if the mute "e" follows a "c" or a "g", the "e" is retained before an "a" or an "o" to keep the "c" and "g" soft. With suffixes beginning with consonants, the mute "e" is always retained. Hence "aged" and "aging", but "ageable"and "ageless". "Aging" is preferred by several British dictionaries; unfortunately the Oxford English Dictionary, and consequently the Shorter O.E.D., seem to prefer "ageing". However, when the Fowlers prepared the Concise Oxford Dictionary, they expunged the "e" spelling, although the last two editions have restored it, and actually give precedence to it. Since "aging" is a term in medical science, you, Sir, should lead, not follow, 2 over its spelling, as you did for "fetus".
ing against operating heavy machinery or performing potentially dangerous task for the same 48 h period. Department of Surgery Western Infirmary, Glasgow G11 6NT
SHERRIDAN L. STOCK
G. S. ROUTH
EPIDURAL MORPHINE
SIR,-The preliminary communication from Dr Behar and colleagues (March 10, p. 527) on the use of epidural morphine will undoubtedly lead others to use this route for the injection of drugs in the treatment of pain. For the local anaesthetic drug used in their trial they state the proprietary name, official name, and the name of the manufacturer but do not give any information about the preparation of morphine injected. The commonly used preparations of morphine contain presePVa= tives;’ these include chlorocresol, chlorobutanol, and methylhydroxybenzoate. The ability of chlorocresol to impair transmission in sensory nerves is well known;2 chlorobutanol has local anaesthetic activity3 and so has methylhydroxybenzoate.4 If larger amounts of morphine are to be administered by the epidural route it is essential to know exactly the preparation of morphine used. The inadvertent use of preparations containing preservatives for epidural5 and intrathecal6 injection have been reported to cause paralysis. Anæsthetics
50 Thong Lane, Gravesend, Kent
any
Department,
Queen Elizabeth Hospital, Birmingham B15 2TH
EDWARD MATHEWS
HAZARD OF HIGH-DOSE FENTANYL
GENERAL ANÆSTHESIA AND DRIVING
SIR,-Dr Baskett and Professor Vickers (March 3,
p.
490),
of the anaesthetists’ subcommittee of the Central Committee for Hospital Medical Services and of the Association of Anxsthetistson fitness to drive after anaesthesia, state "... an interval of 24 h or ’after a night’s sleep’ would normally be regarded as sufficient." It is, indeed, traditional that patients are advised to refrain from driving for 24 h after aneesthesia, but, to my knowledge, there is little evidence to support this advice. Several studies3have shown a surprisingly high incidence of postoperative symptoms after anaesthesia. In my surveys of 200 patients receiving general anxsthesia for surgery, 82% of respondents complained of some postoperative symptoms, lasting up to 3 days. The commonest symptoms in all studies are headache and drowsiness-both of which would be expected to impair driving ability. The incidence of postoperative symptoms appears to have little relationship with the anaesthetic agents of anxsthetic. used, but depends to some extent on the Only 10 patients in my group reported feeling "back to normal" within 24 h, and the average time for this subjective assessment of recovery was 2-5 5 days. It would seem that an overnight rest or even 24 h is insufficient time to allow full recovery from anaesthesia and ensure "road-worthiness", and that 48 h might be a more reasonable period. It must be remembered that a significant proportion of patients will ignore any advice they are given no matter what precautions are taken.6 Perhaps it is time to reconsider current anaesthetic practice in this respect, and indeed extend our advice to include a warn-
expressing the views
.
day-care
length
.
1. Stoddart, W. Ciba-Geigy J. 1976, no. 2, p. 20. 2 Lancet, 1969, ii, 1194. 3. Fahy, A., Marshall, M. Br. J. Anœsth. 1969, 4. Ogg, T. W. Br. med. J. 1972, iv, 573. 5. Routh, G. S. Anœsthesia (in the press). 6. Malins, A. F. ibid 1978, 33, 832.
SIR,-We suggest that the problem described by Dr, Hey and Dr Mollah (March 10, p. 552) may be attributable to causes other than the anaesthetic technique used. First of all they did not use high-dose fentanyl as described in your editorial (Jan. 13, p. 87). High-dose fentanyl (10-50 .g/kg) consists of giving an initial large single bolus of fentanyl in order, among other things, to obtund the stress response which is normally greatest at the start of surgery. Both the duration and nature of the surgical stimulus will determine whether additional doses of fentanyl will have to be given. Postoperative respiratory depression, allegedly caused by fentanyl, has been reported two hours or more postoperatively,’ -but opiate premedication and postoperative analgesics may also contribute to such depression. The fact that the patient described by Hey and Mollah was "conscious and cooperative and speaking to the nurses" and, after being apparently totally obstructed by a blood clot, "rapidly returned to a normal colour and respirations", makes it unlikely, in our view, that the protective laryngeal reflexes were obtunded significantly by fentanyl. A much more likely explanation would seem to be postoperative bleeding, a not uncommon event after surgery, which was not observed immediately. This would seem to be confirmed by the finding that the patient’s "mouth and pharynx were seen to be full of clotted blood". Asphyxia is usually associated with cyanosis and bradycardia, and often depression of protective reflexes, and it is not necessary, therefore, to invoke the role of fentanyl in this respect. Even if fentanyl was involved, the intravenous administration of 1.0 mg of naloxone (manufacturer’s recommended
maxillofacial
1. Mathews, E. Lancet, 1977, i, 1004. 2. Maher, R. M. M. ibid, 1963, i, 965. 3. United States Dispensary (edited by A.
Osol, R. Pratt, and A. R. Gennaro),
p. 290. Philadelphia, 1973. 41, 433.
4. Nathan, P. W., Sears, T. A. Nature, 1961, 192, 668. 5. Craig, D. B., Habib, G. G. Anesth. Analg. 1977, 56, 6. Saiki, J. H., and others Cancer, 1972,29, 370. 7. Adams, A. P., Pybus, D. A. Br. med. J. 1978, i, 278.
219.
SIR,-1write to remonstrate against your policy of spelling "aging" with an "e" (e.g., Feb. 10, p. 308). Or am I rageing in vain and wageing a losing battle? The unreflective might retort that "aging" would be pronounced "agging", or that it is an Americanism. In fact a "g" is soft before "e", "i", and "y" in English words of Greek, Latin, or Romance origin, and the long "a" sound is preserved by the single consonant. "Aging" is the form proper to the English Language, but the Americans recognise this more readily than do the British, having paid greater attention to principles, following the lead of Noah Webster.I The basic rule is that a mute "e" at the end of a word is dropped before a suffix beginning with a. vowel; the vowel of the suffix keeps the preceding vowel long. However, if the mute "e" follows a "c" or a "g", the "e" is retained before an "a" or an "o" to keep the "c" and "g" soft. With suffixes beginning with consonants, the mute "e" is always retained. Hence "aged" and "aging", but "ageable"and "ageless". "Aging" is preferred by several British dictionaries; unfortunately the Oxford English Dictionary, and consequently the Shorter O.E.D., seem to prefer "ageing". However, when the Fowlers prepared the Concise Oxford Dictionary, they expunged the "e" spelling, although the last two editions have restored it, and actually give precedence to it. Since "aging" is a term in medical science, you, Sir, should lead, not follow, 2 over its spelling, as you did for "fetus".
ing against operating heavy machinery or performing potentially dangerous task for the same 48 h period. Department of Surgery Western Infirmary, Glasgow G11 6NT
SHERRIDAN L. STOCK
G. S. ROUTH
EPIDURAL MORPHINE
SIR,-The preliminary communication from Dr Behar and colleagues (March 10, p. 527) on the use of epidural morphine will undoubtedly lead others to use this route for the injection of drugs in the treatment of pain. For the local anaesthetic drug used in their trial they state the proprietary name, official name, and the name of the manufacturer but do not give any information about the preparation of morphine injected. The commonly used preparations of morphine contain presePVa= tives;’ these include chlorocresol, chlorobutanol, and methylhydroxybenzoate. The ability of chlorocresol to impair transmission in sensory nerves is well known;2 chlorobutanol has local anaesthetic activity3 and so has methylhydroxybenzoate.4 If larger amounts of morphine are to be administered by the epidural route it is essential to know exactly the preparation of morphine used. The inadvertent use of preparations containing preservatives for epidural5 and intrathecal6 injection have been reported to cause paralysis. Anæsthetics
50 Thong Lane, Gravesend, Kent
any
Department,
Queen Elizabeth Hospital, Birmingham B15 2TH
EDWARD MATHEWS
HAZARD OF HIGH-DOSE FENTANYL
GENERAL ANÆSTHESIA AND DRIVING
SIR,-Dr Baskett and Professor Vickers (March 3,
p.
490),
of the anaesthetists’ subcommittee of the Central Committee for Hospital Medical Services and of the Association of Anxsthetistson fitness to drive after anaesthesia, state "... an interval of 24 h or ’after a night’s sleep’ would normally be regarded as sufficient." It is, indeed, traditional that patients are advised to refrain from driving for 24 h after aneesthesia, but, to my knowledge, there is little evidence to support this advice. Several studies3have shown a surprisingly high incidence of postoperative symptoms after anaesthesia. In my surveys of 200 patients receiving general anxsthesia for surgery, 82% of respondents complained of some postoperative symptoms, lasting up to 3 days. The commonest symptoms in all studies are headache and drowsiness-both of which would be expected to impair driving ability. The incidence of postoperative symptoms appears to have little relationship with the anaesthetic agents of anxsthetic. used, but depends to some extent on the Only 10 patients in my group reported feeling "back to normal" within 24 h, and the average time for this subjective assessment of recovery was 2-5 5 days. It would seem that an overnight rest or even 24 h is insufficient time to allow full recovery from anaesthesia and ensure "road-worthiness", and that 48 h might be a more reasonable period. It must be remembered that a significant proportion of patients will ignore any advice they are given no matter what precautions are taken.6 Perhaps it is time to reconsider current anaesthetic practice in this respect, and indeed extend our advice to include a warn-
expressing the views
.
day-care
length
.
1. Stoddart, W. Ciba-Geigy J. 1976, no. 2, p. 20. 2 Lancet, 1969, ii, 1194. 3. Fahy, A., Marshall, M. Br. J. Anœsth. 1969, 4. Ogg, T. W. Br. med. J. 1972, iv, 573. 5. Routh, G. S. Anœsthesia (in the press). 6. Malins, A. F. ibid 1978, 33, 832.
SIR,-We suggest that the problem described by Dr, Hey and Dr Mollah (March 10, p. 552) may be attributable to causes other than the anaesthetic technique used. First of all they did not use high-dose fentanyl as described in your editorial (Jan. 13, p. 87). High-dose fentanyl (10-50 .g/kg) consists of giving an initial large single bolus of fentanyl in order, among other things, to obtund the stress response which is normally greatest at the start of surgery. Both the duration and nature of the surgical stimulus will determine whether additional doses of fentanyl will have to be given. Postoperative respiratory depression, allegedly caused by fentanyl, has been reported two hours or more postoperatively,’ -but opiate premedication and postoperative analgesics may also contribute to such depression. The fact that the patient described by Hey and Mollah was "conscious and cooperative and speaking to the nurses" and, after being apparently totally obstructed by a blood clot, "rapidly returned to a normal colour and respirations", makes it unlikely, in our view, that the protective laryngeal reflexes were obtunded significantly by fentanyl. A much more likely explanation would seem to be postoperative bleeding, a not uncommon event after surgery, which was not observed immediately. This would seem to be confirmed by the finding that the patient’s "mouth and pharynx were seen to be full of clotted blood". Asphyxia is usually associated with cyanosis and bradycardia, and often depression of protective reflexes, and it is not necessary, therefore, to invoke the role of fentanyl in this respect. Even if fentanyl was involved, the intravenous administration of 1.0 mg of naloxone (manufacturer’s recommended
maxillofacial
1. Mathews, E. Lancet, 1977, i, 1004. 2. Maher, R. M. M. ibid, 1963, i, 965. 3. United States Dispensary (edited by A.
Osol, R. Pratt, and A. R. Gennaro),
p. 290. Philadelphia, 1973. 41, 433.
4. Nathan, P. W., Sears, T. A. Nature, 1961, 192, 668. 5. Craig, D. B., Habib, G. G. Anesth. Analg. 1977, 56, 6. Saiki, J. H., and others Cancer, 1972,29, 370. 7. Adams, A. P., Pybus, D. A. Br. med. J. 1978, i, 278.
219.