PSYCHOMETRY AND POSTOPERATIVE COMPLAINTS IN SURGICAL PATIENTS

Transcription

1 Brit. J. Anaesth. (973), 45, 879 PSYCHOMETRY AND POSTOPERATIVE COMPLAINTS IN SURGICAL PATIENTS M. CRONIN, P. A. REDFERN AND J. E. UTTING SUMMARY One hundred general surgical patients were subjected to a form of personality assessment (Eysenck and Eysenck, 964) the day before operation. Anaesthesia was standardized using light general anaesthesia, a muscle relaxant and controlled ventilation. The day after surgery patients filled in a standardized postoperative questionnaire about complaints concerning their visit to theatre. The patients were more "neurotic" (had higher N scores) than the general population; they also had a higher lie (L) score, and this tended to increase with age. The N score was greater in those awaiting upper abdominal operations than in those awaiting other procedures, and greater in females than in males. Pain was the most conspicuous postoperative complaint, despite the use of conventional analgesia. Preoperative anxiety was also prominent, as were complaints related to the passage or presence of a nasogastric tube. There was a positive correlation between N score and complaints of anxiety, and between N score and total number of complaints, but not between N score and complaints of pain. Surprisingly little is known about the things which patients find distressing or unpleasant when having surgical operations. This is so because the subject is difficult to investigate scientifically. Any attempt to obtain accurate information by asking the patient questions about his experiences is beset with many difficulties. For example, the patient may not understand the questions which have been asked, and he may not tell the truth even if he does. The answers given to the questions will depend on the time at which they are asked; it is clearly unlikely that the same answer would be given to a question about postoperative pain 6 weeks after operation as would be the case a few hours after returning from the operating theatre. These difficulties can be minimized by using a simple questionnaire administered at a fixed time after surgery by an experienced investigator. A further degree of simplification can be obtained by using the same type of premedication, anaesthesia and postoperative medication in every case, and then observing the effect of such factors as the type of operation, the age and sex of the patient, and so on. Previous work (Brice, Hetherington and Utting, 97; Harris et al., 97) has been concerned with questioning surgical patients about thenexperiences related to operations involving a standardized anaesthetic technique based on the use of light general anaesthesia with muscle relaxant drugs, and it was decided to take the results obtained from this as the basis for a postoperative questionnaire. It was thought likely that the personality of the patient might influence the results obtained from postoperative questionnaires, and it was decided to try to find out if this were so. Unfortunately the assessment of personality is a complex and difficult problem, and it was clearly only possible to use a simple form of personality inventory. The Eysenck personality inventory (Eysenck and Eysenck, 964) commends itself as one of the simplest and best validated methods in this field of study, and this was chosen for the current study an attempt being made to see if the results obtained from this inventory administered preoperatively could be correlated in any way with the patients' complaints as indicated by a postoperative questionnaire. METHODS One hundred patients were included in this study; they were presented for general surgical operations which were thought likely to last for half an hour M. CRONIN, M.B.,CH.B., F.F.A.R.C.S.; P. A. REDFERN, M.B., CH.B., F.F.A.R.C.S.; J. E. UTTING, M.A., M.B., F.F.A.R.C.S.; Department of Anaesthesia, University of Liverpool. Requests for reprints to J.E.U. Downloaded from at Pennsylvania State University on September 7, 26

2 88 BRITISH JOURNAL OF ANAESTHESIA or more, so that an anaesthetic technique involving light anaesthesia with a non-depolarizing muscle relaxant would be appropriate. The patients were selected by inspecting operating lists; but their inclusion or exclusion from the trial was ultimately dictated by the availability of the three investigators to distribute the personality inventory preoperatively and the questionnaire postoperatively. Each patient was asked to take part in the investigation. Three refused to do so. Two other patients were excluded from the trial: one because poor sight prevented her from completing the form preoperatively, and another because there was gross postoperative confusion. Personality measurement. The work on which the Eysenck personality inventory is based has been extensively reviewed (Eysenck and Eysenck, 964). The inventory is designed to give an assessment of the psychological variables of extroversion and neuroticism (E and N), and a lie scale (L) is also included. Two alternative forms, A or B, are available; these enable retesting to be carried out quite soon after a previous test. The first 28 patients filled in a personality inventory week after operation in addition to the preoperative inventory. Of these patients 6 were presented with form A preoperatively, and form B postoperatively; for the other 2 patients the order was the opposite. The scores from both forms were standardized for the purposes of comparison. When the results from the first 28 patients had been reviewed, however, it was decided to abandon postoperative psychometry because the changes between preoperative and postoperative values were small and showed no consistent trends. Accordingly the remaining patients received only a preoperative assessment, and for these form A only was used. Anaesthesia. The technique of anaesthesia has been described in detail elsewhere (Brice, Hetherington and Utting, 97). No premedication was used, though promethazine (25 or 5 mg) was given orally the night before operation. Anaesthesia was induced with thiopentone (up to 25 mg) given rapidly intravenously, immediately preceded or followed by tubocurarine (3-45 mg). Pulmonary ventilation was controlled throughout, and anaesthesia was maintained with nitrous oxide in oxygen (respectively 6 l./min and 2 l./min initially, reducing to 5 l./min and 2 l./min initially shortly after induction); no gaseous or volatile adjuvant was used, and no opiate administered during the anaesthetic. Incremental doses of tubocurarine (5 mg) were given as required. Intubation of the trachea was effected with a cuffed oral endotracheal tube. At the end of the operation atropine and neostigmine (.2 and 5 mg respectively) was administered, and anaesthesia lightened. Finally the endotracheal tube was removed after the patient had been breathing % oxygen for a minute or so. Postoperative analgesic drugs were prescribed before the patient left the operating theatre. No attempt was made to change the usual regimen of postoperative medication on the wards, and the ward staff were unaware that these drugs were relevant to the current study. The usual postoperative analgesic regimen for upper abdominal operations was morphine mg given up to 4-hourly for pain relief. In some patients (4) pethidine mg was prescribed instead. Some of the more painful of the other operations had the same prescription as for upper abdominal operations; some others (e.g. most breast biopsies) had only minor analgesics prescribed for them. Postoperative questionnaire. The day after operation (i.e hours after returning from the operating theatre) the patients were questioned about the unpleasant features associated with anaesthesia and surgery. He or she was asked to grade each of the complaints as follows: Grade 3 Very unpleasant indeed; would be very upset if I had to go through this again. Grade 2 Unpleasant; worrying at the time. Grade Mildly unpleasant; didn't bother me much. Grade Not felt or experienced at all. The list of complaints presented to the patient was: Being anxious before the operation. 2 Being anxious after the operation. 3 Pain after operation. 4 What happened as I was waking up. 5 What happened just as I went to sleep. 6 Having a tube passed down my nose. 7 Feeling sick after operation or being sick. 8 Dreams during anaesthesia. 9 Sore throat. Others please say what. The questionnaire ended by asking those patients who had complained of preoperative anxiety to specify the time at which they thought this was worst. The choices presented to them were: In the ward just before the trolley came. In theatre waiting for operation. Day before operation. Before going into hospital. Downloaded from at Pennsylvania State University on September 7, 26

3 PSYCHOMETRY AND POSTOPERATIVE COMPLAINTS 88 The interviewer went through each question with the patient, asked the patient whether they had slept during the night before operation, made a note of the surgical procedure which had been performed, found out whether a nasogastric tube had been passed before or during surgery, and recorded the amount of potent analgesic drugs which had been given to date. RESULTS Operations. Of the patients, 45 were females (age range 7-72 years; mean 45.9) and 55 were males (age range 9-73 years; mean 48.9). For purposes of comparison the series was divided into those having upper abdominal procedures and the remainder. The 62 upper abdominal operations consisted of partial gastrectomy or vagotomy with a drainage procedure (32; 23 males, 9 females), cholecystectomy (24; males, 4 females), repair of hiatus hernia (2), laparotomy (2), and adrenalectomy (2). Of the 38 other procedures 22 were on males and 6 on females. Three were major (2 patients having prostatectomies and female a thyroidectomy). The remainder were more minor, e.g. herniorrhaphy (3), a biopsy of breast (4), simple mastectomy (3), excision of pilonidal sinus (2). Psychometry. (a) Before and after operation. As described in the section on Methods, psychometric assessment was performed both before and after operation on the first 28 patients only. There was little difference in the results obtained pre- and postoperatively. The mean N and L score went down slightly (by.3 and.2 respectively) and mean E score rose, again slightly (by.7). These differences between pre- and postoperative testing were not statistically significant at the usual confidence levels. After the results from the first 28 patients had been reviewed, postoperative psychometry testing was abandoned. The results reported below refer exclusively to preoperative psychometry. (b) Surgical patients and normal subjects. A comparison of the E, N and L scores obtained in the present study and those given for a normal population (Eysenck and Eysenck, 964) is shown in table I. The surgical patients have a higher N score and L score and the difference is significant (P<. in both cases). Note, however, that the TABLE I. Comparison of E, N and L scores of the present study with the normal population (Eysenck and Eysenck, 964). The standard deviations are shown in brackets. The differences between N and L scores for surgical patients and normals is significant (P <.), but see text. Present study Normal population Extroversion Neuroticism "Lie" No. (E) (N) (L) 2.4 (±4.3) 2.7 (±4.37) *65 subjects only. 2.4 (±4.64) 9.6 (±4.78) 3.94 (±2.7) 2.26* (±.57) "normal" population has a different average age from the surgical population here presented, and that there are additional differences in sex, social class, etc., between the two groups. (c) Effect of type of operation and sex of patient. Examination of the results shows that there is no statistically significant correlation between E score and L score and the sex of the patient or the type of operation (table IT). N score, however, is higher in females than in males and this difference is statistically significant (P<.5). N score is also TABLE II. Mean E, N and L scores according to type of operation (upper abdomen or "other") and sex. The standard deviations are shown in brackets below each number. Extroversion Neuroticism "Lie" No. (E) (N) (L) Upper abdomen Male Female Other operations Male Female Totals: Male Female Grand total (3.73).47 (3.59).8 (3.9).75 (4.52) 9.94 (4.8).4 (4.85).2 (3.35).8 (4.37).4 (4.3) 2.92 (4.37).98 (4.48) 4.4 (3.67).85 (4.83) 9.4 (5.23) 2.2 (4.43).9 (4.85) 3.29 (4.73) 2.4 (4.64) 3.73 (2.5) 3.32 (2.6) 4.38 (2.6) 4.29 (2.6) 4.24 (2.7) 4.33 (2.3) 3.6 (2.7) 4.36 (2.9) 3.94 (2.7) higher in those awaiting upper abdominal than it is in those awaiting other forms of general surgery (P<.5). It was found that there was no statistically significant difference between the scores obtained from patients awaiting biliary and gastric surgery. The number of complaints of grade 3 severity was greater in the case of upper abdominal surgery than in the rest (table HI). Downloaded from at Pennsylvania State University on September 7, 26

4 882 BRITISH JOURNAL OF ANAESTHESIA 4 -, 3 2 r 6' Question number Q. l FIG. - F 2 I 9 if) O FIG.. The percentage of patients finding each of the various complaints featured on the postoperative questionnaire to be the worst thing about their visit to the operating theatre. Note that for no. 6 (the nasogastric tube) the number of patients is 56 only. FIG. 2. The percentage of patients placing the various complaints in the postoperative questionnaire in the various grades, 2 or 3. Note that for complaint no. 6 (the nasogastric rube) the number of patients is 56 only. The order (from left to right) is that used in figure (i.e. except for the miscellaneous group, in descending order of frequency from left to right). TABLE III. The incidence of the number of complaints of grade 3 severity is shown for the total series, and for upper abdominal operations and others separately. No. of complaints of grade 3 severity / /o patients Upper abdominal % complaining Other operations (d) Effect of age of patient. There was no correlation between the age of the patient and E and N scores. There was, however, a significant increase in the L score with advancing years (P<.5). For example, over half the 27 patients aged 6 or more had an L score greater than 5 but of the 34 patients aged less than 39 less than % had an L score as high as this. The postoperative questionnaire. The results of the postoperative questionnaire are shown in summary form in figures and 2. The percentage of patients finding each of the various complaints featured on the questionnaire to be the worst thing about their visit to the operating theatre is shown in the histogram in figure in descending order of frequency from left to right c CD L X C Preop. a 6* Question number N.G.tub a => Waking (/] X ccd Sicknes Postop. FIG. 2 The same order (from left to right) is used in figure 2 which shows the grade in which the patients placed each of the complaints. The high incidence of complaints of postoperative pain, preoperative anxiety, and the passage or presence of a nasogastric tube calls for special mention. (a) Postoperative pain. The results of the question about postoperative pain are shown in detail in table IV. It will be noted that only one patient (who had an excision of a mixed parotid tumour) did not complain of pain; 42% of all patients described their pain as being of grade 3 (very unpleasant indeed, etc.) and the percentage of patients having upper abdominal incisions so complaining was 57%. Nearly 4% of all patients described pain as being the worst feature of their operation (fig. ) and this is over twice as great an incidence as the next commonest cause of worst complaint. Dreams c Inductic 9 CD O Sorethi Others Downloaded from at Pennsylvania State University on September 7, 26

5 PSYCHOMETRY AND POSTOPERATIVE COMPLAINTS 883 TABLE IV. Analysis of complaints of pain according to type of operation (upper abdomen or "other") and sex. Upper abdomen Males Females Other operations Males Pain Pain Total worst incidence admitting No. feature grade 3 pain Females 2 Grand total Males Females (39%) 2 (32%) 2 (5%) (29%) 7 (4%) 4 (9%) 35 (35%) 9 (35%) 6 (37%) 35 (57%) 2 (53%) 5 (63%) 7 (8%) 4 (24%) 3 (4%) 42 (42%) 24 (44%) 8 (4%) 62 (%) 38 (%) 24 (%) 38 (%) 6 (94%) 2 (%) 99 (99%) 54 (98%) 45 (%) The difference between the incidence of those giving pain as grade 3 (see Methods above) for upper abdominal operations and those giving grade 3 for other operations is statistically significant (P<.). The differences with regard to sex do not appear to be important. It was found that there was a correlation between those giving pain as grade 3 and the number of doses of powerful analgesic administered, those complaining of pain of grade 3 having more doses of analgesic than those of other grades; this difference is statistically significant (P<.). There was, however, no association between complaints of anxiety and complaints of pain. The number of doses of analgesic administered to each patient varied considerably; the mean value was about three doses for upper abdominal operations. The number of doses which could have been administered according to the prescription when the postoperative questionnaire was given was five or six. It can be seen, therefore, that the patients did not usually get the maximum number of doses of analgesic which had been prescribed for them. Nevertheless it seems unlikely that even had they been given the full dosage of analgesic and the dose increased the results would have been changed radically. The analgesic regimen seems to be basically inadequate for upper abdominal surgery. (b) Preoperative anxiety. The results of the question about preoperative anxiety are shown in detail in table V. The total number of patients admitting to some degree of anxiety is high (83%), and though the total incidence of complaints of anxiety is about equal for both sexes, females are more likely to assess their anxiety as being in the highest grade (i.e. as 3). The difference between males and females in relation to anxiety is significant (P<.5). Of the 3 patients who gave preoperative anxiety as grade 3 only 29 stated when they were most anxious. Of these 29, 8 (62%) gave the time as being in the ward just before the trolley arrived to take them to the operating theatre or in the theatre itself. Of the remaining (38%), 4 said that they were most anxious the day before operation and 7 before coming into hospital. Those who gave anxiety as grade 3 were more likely to say that they did not sleep the night before operation than were the rest. TABLE V. Analysis of complaints of anxiety according to type of operation (upper abdomen or "other") and sex. No. Upper abdomen 62 Males 38 Females 24 Other operations 38 Males 7 Females 2 Grand total Males Females Anxiety worst feature 7 (%) 5 (3%) 2 (8%) 8(2%) (6%) 7 (33%) 5 (5%) 6 (%) 9 (2%) Anxiety incidence grade 3 8 (29%) 7 (8%) (46%) 3 (34%) 4 (24%) 9 (43%) 3 (3%) (2%) 2 (45%) Total admitting anxiety 53 (85%) 32 (84%) 2 (88%) 3 (79%) 2(7%) 8 (86%) 83 (83%) 44 (8%) 39 (87%) (c) The nasogastric tube. The question about the nasogastric tube is ambiguous: thus "Having a tube passed down my nose" may be taken to refer to the process of passing the tube, or to its presence after operation even when the tube itself was passed when the patient was asleep. That the answers given were probably meant to refer to the total experience of having a tube passed and having it in place after operation is indicated by the fact that many patients who had the tube passed whilst anaesthetized still complained under this heading. In all, 4% of the 55 patients who had a nasogastric tube passed at some stage found this to be the worst feature of their visit to the operating dieatre and 32% classified the passage or presence of a nasogastric tube in category 3; only a quarter of those who had the tube passed at some stage did not complain about it at all. It is probable that those who had the tube passed under anaesthesia were protected from the most unpleasant part of the experience. Thus 4 patients Downloaded from at Pennsylvania State University on September 7, 26

6 884 BRITISH JOURNAL OF ANAESTHESIA out of 29 who had the tube passed during anaesthesia did not complain at all about the tube, whereas of those who had the tube passed before the operation only 2 out of 27 did not complain. (d) Experiences on waking up. The process of regaining consciousness appears to have been more unpleasant than the induction of anaesthesia, being placed in grade 3 by 22% of patients. Common complaints were pain, nausea, cold and transfer to or from trolleys. Two patients were aware of oral tubes and pharyngeal suction and one patient, who had some extra sutures inserted after reversal of the muscle relaxant, thought that he felt "a knife across his wound". Odier patients mentioned sensations of disorientation, faces and bright lights appearing and receding, and noises in the ears. (e) Sickness, etc. Nausea and vomiting was also an important source of complaint in this series, nearly half the patients experiencing these to some degree or another (fig. 2). It was not related to the number of doses of analgesic administered. (f) Postoperative anxiety. Postoperative anxiety was less conspicuous than preoperative anxiety. Nevertheless over a third of patients admitted to postoperative anxiety of some degree. (g) Dreams. Unpleasant dreams were recorded by 6% of patients and for 4% of the total this was the worst feature of their procedure. One of these patients probably had a short period of awareness due to technical difficulties after transfer to theatre from the anaesthetic room, a brief conversation at this time between surgeon and anaesthetist featuring in his dream. (h) Experiences on induction of anaesthesia. Induction of anaesthesia did not appear to be at all unpleasant for almost 8% of patients. Of the two patients who found it to be the worst part of their procedure, one mentioned nausea and panic, and the other a feeling of being held down. The placing of the mask on the face was remembered and found to be very unpleasant by one patient. Other complaints were of noises in the ears and feelings that the room was revolving. (i) Sore throat. Over half the total number of patients had some degree of sore throat. In 6 patients this was the worst part of their procedure; none of these 6 patients had upper abdominal operations. (j) Others. Complaints volunteered under this section included headache, discomfort due to abdominal distension or "wind", the long wait preoperatively, hunger, thirst, injections and sleeplessness. Complaints correlated with psychotnetry. An attempt was made to correlate E, N and L scores widi the patients' complaints. No correlation was found between E or L score and complaints of anxiety or pain, nor with the number of complaints the patient put in category 3 (scores for nasogastric tube being excluded from consideration). It was found, however, that the N score showed a positive correlation with complaints of anxiety, and with the total number of complaints which the patient classified in category 3 (P<.5 in both cases). Thus it was found that patients with a high N score were more likely to complain of anxiety, and more likely to give a large number of complaints in category 3 than those who had a low N score. No correlation was found between E, N and L scores and complaints of pain, or the number of doses of postoperative analgesic administered. DISCUSSION The Eysenck Personality Inventory is designed to measure what are often considered to be the two most important dimensions of personality, "extroversion" and "neuroticism". The questionnaire has a good test-retest ability, in other words the results are consistent in individuals and the values obtained correlate well with assessments by other methods (Eysenck and Eysenck, 964). Extroversion and neuroticism are considered to be basic traits of personality which are not likely to change much, except under the influence of drugs. Because of the wide spread of E and N scores in any population, and the known influence of age, sex and social class on these scores, conclusions from the comparison of such groups as the one here presented with so-called normal subjects must be tentative. The high N scores of the patients in this study, however, require some explanation. Perhaps surgical patients are selected from a population which is more neurotic than normal. But if die surgical group was selected from what was basically a normal population then N scores must have been increased by illness, admission to hospital, or some other factor or factors. From the results here presented it is not possible to differentiate between these two possibilities. Downloaded from at Pennsylvania State University on September 7, 26

7 PSYCHOMETRY AND POSTOPERATIVE COMPLAINTS 885 Kissen (964) has suggested, however, that the N score specifically is influenced by environmental factors in patients admitted to hospital, though the E score remains more constant, a finding also supported in the current study. It can be speculated that with a "normal" population under the stressful conditions of this study, measurement of the basic trait of neuroticism is contaminated by anxiety. It is, of course, possible that these results were obtained because of an association between N score and the type of surgery required; and further work would be required to disprove or substantiate this hypothesis. The high lie (L) scores obtained from these patients is surprising. The L scale is included to detect individuals "faking good". One of the questions on the L scale, for example, is "Are all your habits good and desirable?" An affirmative answer contributes to the L score nobody can honestly maintain that all their habits are good and desirable. Eysenck (964) suggests that "an L score of 4 or 5 would be considered to constitute the cutting point where inventory answers ceased to be acceptable". By excluding those patients with L scores of 6 or over, however, the results from 28 patients in the present series would have been rejected; it will be noted, too, that the mean L score in this current series is higher than what is considered normal. Knowles and Kreitman (965) have questioned this use of the lie scale, and claim that rejection of an individual inventory because of a high L score is unjustified and wrong. Not only are the L scores of the patients in this series high, but there is a correlation between this score and age of the patient, older patients tending to have higher L scores. But lying (if lying it be) is a complex process and "attempts to interpret lie scales are unlikely to be successful in the present state of knowledge" (Knowles and Kreitman, 965). Complaints of pain are conspicuous in this series. Over a third of all patients found pain to be the worst feature about their operation, and some 4% ascribed it to category 3; when upper abdominal operations are considered alone the incidence is higher still. The postoperative questionnaire was administered at a time when pain was likely to be prominent in the patient's mind doubtless a less gloomy picture would have been painted had the questionnaire been administered a week or a month after operation. Nevertheless the results here presented appear to indicate that from the patient's point of view the results of the conventional postoperative analgesic regimen with opiates are far from satisfactory. The total incidence of those complaining of anxiety in this (unpremedicated) group was similarly very high (85% of the series). It is worth mentioning that most of those patients who categorized anxiety in grade 3 said that their anxiety was worst just before the operating theatre trolley arrived to pick them up, on the way down to the theatre, or in the theatre itself. Thus the conventional premedication given hour before operation might be of some use in ameliorating the worst of this anxiety. Postoperative anxiety is much less prominent than is preoperative anxiety. It seems that once the operation is over anxiety diminishes considerably. The prominence of complaints about passage of the nasogastric tube is worth noting. That nearly one-third of patients who had a nasogastric tube should grade this in category 3 is both surprising and disturbing. Clearly the passing of a nasogastric tube can be much more unpleasant than medical staff commonly realize. A tube should be passed only if it is really necessary and then, if possible, while the patient is anaesthetized. If it be necessary to pass a tube on a patient who is awake great care should be taken. Though most patients had no complaints about the induction of anaesthesia, in 5 gave their experiences when waking up as grade 3, and 8% found this to be the most unpleasant feature of their surgical experience. Nearly half the patients experienced nausea and/or vomiting, and sore throat was even more frequent, though it does not seem to have been particularly troublesome. Dreaming was the worst feature in 5%, and this accords well with the figures produced by Brice, Hetherington and Utting (97). It is, perhaps, not surprising that those with a high N score were more likely than those with a low N score to complain of preoperative anxiety, and to complain of a greater number of factors. More surprising was the fact that no correlation was found between preoperative N score and complaints of pain. ACKNOWLEDGEMENT We gratefully acknowledge the help of R. R. Hetherington, B.sc, PH.D., F.B.PS.S., throughout this study. REFERENCES Brice, D. D., Hetherington, R. R., and Utting, J. E. (97). A simple study of awareness and dreaming during anaesthesia. Brit. J. Anaesth., 42, 535. Downloaded from at Pennsylvania State University on September 7, 26

8 886 BRITISH JOURNAL OF ANAESTHESIA Eysenck, H. J., and Eysenck, S. B. G. (964). Manual of Kissen, D. M. (964). The influence of some environthe Eysenck Personality Inventory. London: University mental factors on personality inventory scores in psyof London Press. chosomatic research. J. psychosom. Res., 8, 45. Harris, T. J. B., Brice, D. D., Hetherington, R. R., and.,, n *cn -n. c, Utting, J. E. (97). Dreaming associated with anaes- Knowles, J. B., and Kreitman, N. (965). The Eysenck thesia: the influence of morphine premedication and personality inventory: some considerations. Brit. J. two volatile adjuvants. Brit. J. Anaesth., 43, 72. Psychiat., Ill, 755. NORFOLK AND NORWICH INSTITUTE FOR MEDICAL EDUCATION A SYMPOSIUM ON CURRENT TRENDS IN ANAESTHESIA AND INTENSIVE CARE will be held at Norwich on Saturday, October 27,973 Speakers: Dr S. M. Laird Professor H. A. F. Dudley Dr D. D. Moir Professor A. Crampton Smith Dr G. Smith Dr A. A. Spence Details from The Secretary, Norfolk and Norwich Institute for Medical Education, Norfolk and Norwich Hospital, Norwich, Norfolk, NOR 53A. Downloaded from at Pennsylvania State University on September 7, 26