incidence of acute rheumatism. TFhere was no such correlation with the incidence of scarlet fever, indicating that the increase in acute rheumatism was not due to an increased incidence of infection by the haemolytic streptococcus. A further social study of children with rheumatic heart disease in 1937 led to the conclusion that if the living conditions of the 30% of the Bristol working class population with the most inadequate incomes were raised to the level of the highest 10% of all working class families the incidence of the disease would be roughly halved.4 Since the end of the 1939-45 war this has probably been more than achieved, and there has been a concomitant fall in the incidence of rheumatic fever so that it is now a rare disease. It is interesting that in Sri Lanka an increase in the disease with increasing urbanisation was reported as late as 1969.) C BRUCE PERRY

Bristol BS9 2RR I Minerva. Views. BrMledj 1989;299:1412. (2 December.) 2 Sasage WG. Inicidence of rheumatic heart disease in childhood (1927-19301) in Glouccstcrshire, Somerset, and Wilts. Br Medj It 1931 ;ii ( supph 37-4 1. 3 Perry CB, Roberts JAF. A study on the sariability in the incidence of rheumatic hcart disease withini the citv of Bristol.

BrAMedj 1937;ii,suppl: 154-8. 4 Daniel GH. Social and ccottotnic conditions and the incidence of rheumatic heart disease. 7ournial of the Roval Statistical Society 1942;105: 197-2 12. 5 Perry CB. Social aspects of acute rheumatism. Bristol iMedico-

Chirurgical Journal 1944;6 1:1- 0I. 6 Mirando EM. Presidential address. Ceylon Med J 1969;14: 159-72.

Interrelations in paediatric day stay surgery SIR,-The paper by Drs N McC Schofield and J B White' will go a long way towards improving the quality of surgical and anaesthetic management of children undergoing short stay surgery. Although children are superficially merely scaled down adults in terms of anaesthetic technique and drug dosage, their management as day cases is, we believe, more crucial than it is in adults. Many children are unaware of what their hospital stay will entail. They come into hospital with a parent, feeling well but apprehensive, and then receive various psychological insults, in particular their anaesthetic induction and postoperative pain. For this reason we have attempted to introduce several features in Chesterfield over the past three years to improve management of these patients. Before admission both parents and children are offered the opportunity to see a short video made in the hospital by the staff of the children's ward and operating theatre which explains, particularly in children's terms, what to expect from their forthcoming stay. The video emphasises the relaxed and friendly ward environment and the pleasant induction of anaesthesia, with a parent present, by a painless injection after the use of Emla cream (a eutectic mixture of prilocaine and lignocaine, Astra Pharmaceuticals). The child is admitted at 8 am and the operation performed as early as possible after the start of the list. The earlv admission time has not presented problems and allows time for a brief preoperative visit by both anaesthetist and surgeon. We have found that this visit invariably negates the need for premedication. Emla cream is used routinely, and its effectiveness has virtually abolished inhalational induction of anaesthesia. Parents are not pressured to come to the anaesthetic room, but many are aware of this option and invariably ask to. No problems have arisen as a result of a parent being at the induction. Indeed, unlike Drs Schofield and White, who reviewed only children never admitted to hospital before, we find that children who are frightened because of a previous traumatic hospital stay are more settled if a parent is present, and a parent is much more BMJ

VOLUME 300

13 JANUARY 1990

In women using epidural analgesia in labour in our hospital careful attention is paid to correcting inefficient uterine action early in labour, and allowance is made for the two phases of the second stage.2 The oxytocin infusion rate starts at 6 mU/min and reaches a maximum of 36 mU/min. We have just reviewed the outcome in primiparous women who have delivered to mid-December 1989. Of the 276 patients who used epidural analgesia in labour, 24 were delivered by caesarean section in the first stage. Of the 252 who entered the second stage, 67% received oxytocin in the first stage and 6% in the second stage of labour. In comparison to the study of Dr Saunders and colleagues, 63% delivered normally, 35% had a non-rotational forceps delivery, there were no rotational forceps deliveries, and 2% were delivered by caesarean section. This suggests that the use of oxytocin in primiM J WOLFE J M SIMMS paras earlier in labour and in higher dosage may Chesterfield and North Derbyshire Royal Hospital, minimise the incidence of rotational forceps Chesterfield S44 SBI deliveries associated with epidural analgesia. Such a policy has previously been associated with a 1 Schofield NM, White JB. Interrelations among children, parents, reduction in the overall incidence of instrumental premedication, and anaesthetists in paediatric day stay surdeliveries in a London population.' gery. BrMedJ 1989;299:1371-5. (2 December.) 2 Armitage EN. Analgesia after circumcision. Anaesthesia 1980;35: Furthermore, the dose of bupivacaine may be 77-8. critical. In a study of 517 patients using epidural analgesia in labour, including women of all parities, patients were randomly allocated to receive 6-8 ml SIR,-As both an anaesthetist and a parent, I was of 0 5%, 10-14 ml of 0 25%, or 6-8 ml of 0-25% particularly interested in the findings of Drs bupivacaine. Patients given the low volume, low N McC Schofield and J B White on the effects of concentration bupivacaine were less likely to need parental presence during the induction of anaes- either a low cavity (p