1066
pation, the emotional factors
must be taken into Work such as the combined St. Thomas’/Great Ormond Street study, designed to assess the psychological and physiological factors, will define more accurately the aetiology and ideal management of this unpleasant problem of childhood. account.
PREMEDICATION TRADITION PREMEDICATION is dominated by tradition. The principles of our use of preoperative drugs survive from the days of ether anxsthesia when the euphoria and sedation of morphine were invaluable in helping the patient
the distress and excitement of the early induction stages and atropine or hyoscine was needed to control the salivary and bronchial secretions induced by ether. Barbiturates, phenothiazines, and tranquillisers were subsequently introduced over the years to replace or supplement the opiates. Now that induction is intravenous in most cases, is any form of sedative premedication necessary, unless a patient is particularly anxious? A preoperative visit by a sympathetic anaesthetist is often the best way of allaying the natural fear that most people have of losing consciousness. Though opinion is divided, injection of an antisialogogue is probably still a useful precaution about an hour preoperatively to avoid the complications of laryngeal irritation by oral secretions. In an effort to promote more rational choice of premedicant drugs, Forrest and others’ have investigated six commonly used premedications-two opiates, two barbiturates, an antihistamine, and a minor tranquilliser. Drugs were administered randomly from identical syringes to 509 patients, in whom subjective responses were scored on 0-9 scales 30 and 60 minutes after premedication. Independent assessments were made by nurse-observers and overall evaluations were recorded by the anxsthetists themselves. The observers tended to credit the antihistamine and the minor tranquilliser with an ability to suppress apprehension, but the patients thought otherwise. The anxsthetists went one better and rated the placebo as satisfactory in facilitating induction. This surely confirms that the induction of anwsthesia nowadays causes the patient little distress. How do you evaluate tradition?
through
SUPPORT FOR DISABLED HOUSEWIVES WOMEN are not fighting hard enough for their rights, and they have only themselves to blame if they are discriminated against and regarded merely as the dependants of their husbands. Thus, Dr Shirley Summerskill, Under-Secretary at the Home Office, told a conference on discrimination in employment on Oct. 19.2 Her words must indeed have seemed very provoking to one group of women-the disabled housewives, who have had to wait 2 years for the non-contributory invalidity pension accorded them under the Social Security Act of 1975. This Act provides for a non-contributory invalidity pension (N.C.I.p.) for men and women of working age who have been incapable of work for at least 28 consecutive weeks and who have not satisfied the contribution condi1. 2.
Forrest, W. H., Brown, C. R , Brown, B. W. Anesthesiology, 1977, 47, 241. Times, Oct. 20, p.6.
tions for sickness and invalidity benefit. Payment of N.C.I.P. for men and single women started on Nov. 20, 1975, and meant little extra charge on Treasury funds, since most claimants were already receiving the money
supplementary benefit. Housewives were originally excluded altogether from the draft legislation considered by Parliament: for them extra money would be needed, since they previously received nothing. Under pressure the (Labour) Government gave way on this point, but the difficulties of identifying the housewives entitled to benefit, and of verifying their claims, were given as reasons why payment of the housewives’ pension (H.N.C.I.P.) should be deferred. The scheme started on Nov. 17, and it is inequitable. The married woman will lose out if her husband is not working, for the value of her pension will be deducted from any sickness or other benefit he receives; and the 2-year delay has meant that some women have been cut out of the scheme altogether, since claimants must be under 60 to qualify (though benefit may continue beyond 60 if the claim is made before reaching that age). But its worst aspect is the claims procedure. Men and single women claim their N.C.I.P. on a short form which asks only for the essential information such as the date when incapacity for work started and the number of dependants being claimed for. On her form the housewife applicant is required to supply information on, among other things, the kind of accommodation she lives in, what adaptations have been made for her, what appliances are available and what help she needs to use them, how far the family or others contribute to doing the household jobs, and whether she is fit to do any paid work and if so to suggest what kind of work this might be. The discrimination does not end with the form, for the Department also requires special evidence to support the claim. A circular to general practitioners which went out in September explains that, while evidence on claims from men and single women normally takes the form of a doctor’s statement on form Med 3, for married women "the need to cover in some detail the physical and mental functions involved in household duties makes it impossible to rely on the use of form Med 3". Doctors will be invited to provide special medical reports, covering the housewife’s fitness for paid work, and her ability to perform household duties; moreover, completion of the form, the circular says, will normally involve a medical examination in the claimant’s home. A fee of 00 for these reports has been agreed with the B.M.A. Originally the Department intended that its own appointed doctors should carry out these- examinations, but it has now conceded that the patient’s own G.P. shall do them. Claims for mobility and attendance allowance have always had to be supported by evidence from a medical examination. But it is difficult to understand why a doctor who is thought capable of judging a person’s fitness to work without observing him actually doing it is yet incapable of similarly judging a woman’s fitness to carry out normal household duties. The Department of Health must have some means of checking dubious claims, but the procedures already in operation for N.C.I.P. would surely do. The system for claiming H.N.C.I.P. is cumbersome and expensive; it wastes medical time and it discriminates against married women. The housewives could have been incorporated into the existing scheme simply by amending the claim form and doctor’s statement. as
pation, the emotional factors
must be taken into Work such as the combined St. Thomas’/Great Ormond Street study, designed to assess the psychological and physiological factors, will define more accurately the aetiology and ideal management of this unpleasant problem of childhood. account.
PREMEDICATION TRADITION PREMEDICATION is dominated by tradition. The principles of our use of preoperative drugs survive from the days of ether anxsthesia when the euphoria and sedation of morphine were invaluable in helping the patient
the distress and excitement of the early induction stages and atropine or hyoscine was needed to control the salivary and bronchial secretions induced by ether. Barbiturates, phenothiazines, and tranquillisers were subsequently introduced over the years to replace or supplement the opiates. Now that induction is intravenous in most cases, is any form of sedative premedication necessary, unless a patient is particularly anxious? A preoperative visit by a sympathetic anaesthetist is often the best way of allaying the natural fear that most people have of losing consciousness. Though opinion is divided, injection of an antisialogogue is probably still a useful precaution about an hour preoperatively to avoid the complications of laryngeal irritation by oral secretions. In an effort to promote more rational choice of premedicant drugs, Forrest and others’ have investigated six commonly used premedications-two opiates, two barbiturates, an antihistamine, and a minor tranquilliser. Drugs were administered randomly from identical syringes to 509 patients, in whom subjective responses were scored on 0-9 scales 30 and 60 minutes after premedication. Independent assessments were made by nurse-observers and overall evaluations were recorded by the anxsthetists themselves. The observers tended to credit the antihistamine and the minor tranquilliser with an ability to suppress apprehension, but the patients thought otherwise. The anxsthetists went one better and rated the placebo as satisfactory in facilitating induction. This surely confirms that the induction of anwsthesia nowadays causes the patient little distress. How do you evaluate tradition?
through
SUPPORT FOR DISABLED HOUSEWIVES WOMEN are not fighting hard enough for their rights, and they have only themselves to blame if they are discriminated against and regarded merely as the dependants of their husbands. Thus, Dr Shirley Summerskill, Under-Secretary at the Home Office, told a conference on discrimination in employment on Oct. 19.2 Her words must indeed have seemed very provoking to one group of women-the disabled housewives, who have had to wait 2 years for the non-contributory invalidity pension accorded them under the Social Security Act of 1975. This Act provides for a non-contributory invalidity pension (N.C.I.p.) for men and women of working age who have been incapable of work for at least 28 consecutive weeks and who have not satisfied the contribution condi1. 2.
Forrest, W. H., Brown, C. R , Brown, B. W. Anesthesiology, 1977, 47, 241. Times, Oct. 20, p.6.
tions for sickness and invalidity benefit. Payment of N.C.I.P. for men and single women started on Nov. 20, 1975, and meant little extra charge on Treasury funds, since most claimants were already receiving the money
supplementary benefit. Housewives were originally excluded altogether from the draft legislation considered by Parliament: for them extra money would be needed, since they previously received nothing. Under pressure the (Labour) Government gave way on this point, but the difficulties of identifying the housewives entitled to benefit, and of verifying their claims, were given as reasons why payment of the housewives’ pension (H.N.C.I.P.) should be deferred. The scheme started on Nov. 17, and it is inequitable. The married woman will lose out if her husband is not working, for the value of her pension will be deducted from any sickness or other benefit he receives; and the 2-year delay has meant that some women have been cut out of the scheme altogether, since claimants must be under 60 to qualify (though benefit may continue beyond 60 if the claim is made before reaching that age). But its worst aspect is the claims procedure. Men and single women claim their N.C.I.P. on a short form which asks only for the essential information such as the date when incapacity for work started and the number of dependants being claimed for. On her form the housewife applicant is required to supply information on, among other things, the kind of accommodation she lives in, what adaptations have been made for her, what appliances are available and what help she needs to use them, how far the family or others contribute to doing the household jobs, and whether she is fit to do any paid work and if so to suggest what kind of work this might be. The discrimination does not end with the form, for the Department also requires special evidence to support the claim. A circular to general practitioners which went out in September explains that, while evidence on claims from men and single women normally takes the form of a doctor’s statement on form Med 3, for married women "the need to cover in some detail the physical and mental functions involved in household duties makes it impossible to rely on the use of form Med 3". Doctors will be invited to provide special medical reports, covering the housewife’s fitness for paid work, and her ability to perform household duties; moreover, completion of the form, the circular says, will normally involve a medical examination in the claimant’s home. A fee of 00 for these reports has been agreed with the B.M.A. Originally the Department intended that its own appointed doctors should carry out these- examinations, but it has now conceded that the patient’s own G.P. shall do them. Claims for mobility and attendance allowance have always had to be supported by evidence from a medical examination. But it is difficult to understand why a doctor who is thought capable of judging a person’s fitness to work without observing him actually doing it is yet incapable of similarly judging a woman’s fitness to carry out normal household duties. The Department of Health must have some means of checking dubious claims, but the procedures already in operation for N.C.I.P. would surely do. The system for claiming H.N.C.I.P. is cumbersome and expensive; it wastes medical time and it discriminates against married women. The housewives could have been incorporated into the existing scheme simply by amending the claim form and doctor’s statement. as
