BRITISH MEDICAL JOURNAL
714
20 DECEMBER 1975
NEWS AND NOTES EPIDEMIOLOGY Cooking the Christmas dinner For most of us Christmas is a time of pleasurable excess. The enjoyment of food is such an important part of the festivities that the subsequent development of gastroenteritis could be described as at best unfortunate and at worst tragic when the occasional patient dies. Yet every year in England and Wales numerous outbreaks of food poisoning after Christmas dinners are reported, and most of them probably go unreported. Moreover, since many of these dinners are annual functions for various societies and clubs, many people may be infected from a single meal. For example, in some of the outbreaks reported in this journal in recent years'"3 numbers of persons involved have been 126 of 229, 209 of 600, 59 of 157, and 160 of 177. In these outbreaks turkey has usually been the source of the gastroenteritis and salmonellas the most common organism, although Clostridium welchii is also responsible on occasions. Why turkey? Because with our present intensive farming and distribution methods a high proportion of birds are infected with salmonellas at source, and because the birds are large and hence seldom receive the thorough defrosting and cooking they require. Moreover, kitchens builtandequipped to cater for a small number of people and which may function perfectly satisfactorily during tihe year are often asked to cope with a far greater bulk of food at Christmas. As a result, short cuts are taken, and food poisoning may result. In the outbreaks already referred to the turkeys cooked have weighed from 20 to 34 lb (9 to 15 kg) and the number of turkeys cooked for one meal from nine to 30. In general, food poisoning can be avoided by sound kitchen hygiene even when the turkey, or other food, is already contaminated before it is bought, and the remarks that follow apply equally to any poultry or other meat. Most food poisoning organisms multiply most quickly at about 37'C (98 6°F), or normal 'human body temperature. At higher temperatures multiplication is slower, and at pasteurization temperatures (60°C (150°F) or more) the nonsporing pathogens such as salmonellas die. The rate of multiplication also decreases rapidly as the temperature falls below 20°C (68°F), until at below about 8°C (46°F) it ceases. Cold temperatures, even if below freezing point, will not of course destroy salmonellas. The spores of C welchii, part of the normal flora of human and animal intestine, differ from vegetative organisms in that they will not all be destroyed at pasteurisation temperatures or even at 100°C (212°F). Although they will not germinate at these high temperatures they will do so once the temperature falls, and will multiply most rapidly at about 45 °C (113 °F). Clearly,
therefore, if there is one essential to observe in the preparation of turkey (or indeed, in any cooking process) it is to avoid holding the food for any length of time at temperatures at which organisms will rapidly proliferate. This rule applies not only while meat is stored but also while it is being cooked or reheated. Hence it is clearly important for pasteurisation temperatures to penetrate throughout the bird, and since it is difficult to cook large chunks of meat thoroughly, 6 lb (3 kg) is the maximum recommended cooking weight. However, as the aesthetic vision of a plump bird, roasted whole and glistening in its reddish-brown skin as it is brought to the festive table, perhaps contributes as much to the enjoyment of the Christmas dinner as its somewhat bland taste, it is difficult to envisage many people following this rule. If a large whole bird must be cooked, it is advisable to introduce further safeguards. Adequate time must be allocated for a frozen turkey to thaw, otherwise it may be impossible to cook it through. For large turkeys this is perhaps best done in an ordinary refrigerator, in which case about 48-72 hours will be needed. A bird of 20 lb (9 kg) will require a minimum of 36 hours at room temperature. It is helpful to remove the frozen giblets first if these have been packed inside the carcass of the bird. Fully thawed or fresh birds must be cooked through to destroy all salmonellas. It is usual to allow at least 20 min per lb (45 min per kg) at 204°C (400°F-regulo 6) plus an extra half-hour at the end. It may be safer to use a meat thermometer to ensure that the internal temperature of the bird reaches 75°C (170°F), particularly in catering establishments. It is important not to stuff the turkey before cooking, otherwise heat penetration may be inadequate and some organisms will survive. Moreover, since herb stuffing itself may contain the spores of C welchii, and sausage meat, a traditional stuffing, may contain salmonellas also, the same precautions must be observed when stuffing is cooked (separately) as with meat. Even if thoroughly cooked, the bird, although it will be free of salmonellas and other vegetative organisms, may still be contaminated with the spores of C welchii. The addition of gravy at temperatures below 65'C (150°F) is likely to accelerate their germination. Hence the turkey should be served as soon as possible after cooking and any leftovers cooled rapidly and refrigerated with less than an hour's delay. Catering establishments need special cooling facilities. Gravy should be added at the table. It is also important that, after cooking, the bird must not be recontaminated by contact with surfaces or utensils used for handling raw meat and poultry; and, to avoid contamina-
tion by staphylococci persons with infected lesions should not be allowed to handle food. Nevertheless, all food handlers should wash their hands before handling food lest human intestinal organisms are transTmitted, and, as a further precaution, bare hands should not be used on cooked meat. In reported outbreaks the storage of meat after cooking is at fault as often as the process of cooking. Reheating leftovers is permissible only if the meat is brought rapidly to top heat from the refrigerator, and kept at a high temperature for long enough to allow full heat penetration. Covering turkey meat with broth or gravy and reheating in a lukewarm -below 65'C (150'F)-cabinet or bainmarie is a dangerous practice. Although turkey is the usual source of food poisoning from Christmas dinners, other traditional foods may also cause gastroenteritis. Sausages, usually served with turkey, are fairly frequently contaminated with salmonellas; they must be cooked through, and as an added safeguard they should be served freshly cooked. Other foods, such as puddings or trifles, should not be handled or allowed to come into contact with surfaces used for raw meat, and, again, s1hould not be left at kitchen (warm) temperatures for longer than an hour or so. If these recommendations are observed your merry Christmas will not include food poisoning. NORMAN D NOAH
Epidemiological Research Laboratory, Central Public Health Laboratory, Colindale Avenue, London NW9 5HT 1 British Medical Yournal, 1973, 1, 559. " British Medical Yoturnal, 1974, 2, 128, 233. 3 British Medical Journal, 1975, 3, 107.
MEDICOLEGAL Hazards of compression
sclerotherapy
FROM OUR LEGAL CORRESPONDENT
There is a widespread misconception among the medical profession that even though treatment is not given negligently doctors may nevertheless be liable to their patients if injury results. Doctors' appreihension is increased if they are using a technique accepted by a substantial body of responsible professional opinion but at the same time regarded as controversial by other informed practitioners. There is therefore reassurance to be found in a recent decision' of Mr Justice Thompson refusing damages
BRITISH MEDICAL JOURNAL
20 DECEMBER 1975
to a man who had sclerosant fluid injected into an artery while undergoing Fegan's compression sclerotherapy behind the medial malleolus. The judgment also supports the argument that a technique's possible hazards or side effects can, if infrequent enough, be justified by the technique's benefits, if great enough.
Facts of case The plaintiff, who had suffered from varicose veins since the age of 18, complained of a sclerosant injection given to him at St Bartholomew's Hospital on 6 March 1973 by Mr J S P Lumley. At the time the plaintiff was 57 and had had a lengthy history of treatment for venous trouble, including phlebitis and ulceration: in particular, he had a long-standing varicose ulcer behind the left lateral malleolus. In late December 1971 it was decided to treat the plaintiff using Professor Fegan's technique of compression sclerotherapy. This technique had first been publicised in 1960, and three years later the professor had written a paper for the Lancet; subsequently it had become widely used-perhaps, said the judge, too widely used by those who were not specialists in the vascular field. In 1971 a warning note was sounded: Martin and Eastcott2 in a letter to the BM7 wrote of intra-arterial injection as "a possible hazard of this otherwise excellent treatment." The defendant had taken over the plaintiff's case in mid-1972, when he had diagnosed severe chronic varicose disease with bouts of thrombosis of the deep veins. Rejecting open surgery, Mr Lumley decided to resume the injections. In November 1972 and February 1973 he injected two incompetent perforators but not a third, lowest one. He ihad tried to do so in February 1973 but had not been satisfied he was in the right place. The plaintiff was therefore asked to return on 6 March to complete the treatment. As soon as Mr Lumley had begun injecting the fluid the plaintiff had cried out and the injection had been stopped. According to Mr Justice Thompson at the time and for a considerable period afterwards Mr Lumley thought that he had gone into the lumen of the posterior tibial artery behind the medial malleolus of the left ankle. Later he had changed his mind and come round to the view of the admitting houseman on the day of the accident that the fluid had gone into the periarterial tissue. But despite there being certain features atypical of previous cases of arterial injection the judge found on the balance of the evidence that the fluid had gone into the artery after all. Hazard of operation At the trial the primary criticism made of Mr Lumley was that an injection behind the medial malleolus was so 'hazardous an operation that no competent vascular surgeon should have tried it and no possible benefit could excuse it. Mr Lunley in his evidence told the judge that between 1965 and 1973 he had carried out two to three dozen Fegan injections at the same level as that on the plaintiff without mishap. There could be no alternative site for the injection, he said, since it was not the surgeon but the
patient who by the location of the incompetent perforators had chosen the site. The defendant stated that after discussion of the Martin and Eastcott letter at Bart's the decision had been taken to continue to inject when necessary near the medial malleolus. There was also evidence that other surgeons consistently injected in that area. Professor Fegan himself was called to support the propriety of Mr Lumley's approach, and told the judge that weighing the dividends the technique paid against the infrequent episodes of arterial injection the risk was justifiable if the operator was skilful and experienced. The professor had no criticism to make of Mr Lumley: "even if I had had the same unfortunate result," he said, "I would not have been deterred from doing the same procedure again in an appropriate case." In cross-examination a paper by Mr N Winstone at a seminar at Stoke Mandeville in 1971 was put to Professor Fegan. Mr Winstone had said that the Medical Defence Union had five cases of intra-arterial injection "on their books," each of which had led to gangrene of portions of the foot. Mr Winstone had commented that "prevention of this type of disaster rested on awareness of the danger and seldom injecting into the veins round the ankle joint." Professor Fegan emphasised Mr Winstone's use of the word "seldom." That meant to him "no more often than necessary," for where the perforator was in that area, he, Mr Winstone, and all injected none the less. Indeed, without the injection, the judge was told, the plaintiff would ,have been hobbling along with a nasty, smelly ulcer.
Judgment In his judgment Mr Justice Thompson recalled from his note that Mr Newcombe had also stated: "I do accept it cannot be said to be incompetent to inject at that site, but I do hold that it is negligent if damage occurs." This, of course, is a fallacy: treatment is either negligent or it is not, and the occurrence of an injury is relevant only to the question of damages. One of the plaintiff's witnesses, Mr Adrian Marston, accepted that there was a division of opinion. He thought that, for the protection of the public, once a few serious complications were reported surgeons were not justified in using such a procedure in the treatment of a ininor condition. The judge clearly thought that Professor Fegan's evidence better reflected the balance between risk and benefit to the patient than did that of Mr Marston. It was not surprising in view of the weight of respectable practitioners marshalled on Mr Lumley's side that Mr Justice Thompson should find it quite impossible to characterise the decision to inject at the lowest perforator as negligent. The judge added that he believed Mr Lumley when he said that he had aspirated and got dark blood. There was evidence that the blood in varicose veins could be so red as to be indistinguishable from arterial blood, but Mr Justice Thompson concluded that on aspiration the needle had been in the vein. He was not impressed by a last-minute criticism of the plaintiff's rhat Mr Lumley must have allowed the needle to move between aspiration and injection. Mr Justice Thompson's decision exempli-
715
fies the courts' acceptance that it is not for them to decide which of two practices is the better one, so long as what the defendant did was in accordance with a practice accepted by responsible persons. No doctor is negligent merely because there is a body of opinion taking a contrary view.3 Nor is it every mistake which imports negligence. In the words4 of Lord Justice Scott, "the standard of care the law requires is not insurance against accidental slips." 1 Moore v Lumley and the Governors of St Bartholomew's Hospital: 19 July 1975. 2 Martin, P G C, and Eastcott, H H G, British Medical Yournal, 1971, 4, 555. 3 per Mc Nair, J, in Bolam v Friern HMC: (1957) 1 WLR at page 596. 4 Mahon v Osborne: (1938) 2 KB at page 14.
PARLIAMENT Questions in the Commons Family planning Dr David Owen, Minister of State, said in a written answer on 27 November that there had been a slight increase in the use of family planning clinics after 1 April 1974 when they had been transferred to the NHS and charges for contraceptives prescribed and dispensed were removed. The increase was partly due to the absence of a parallel free service in general practice until 1 July 1975. Dr Owen was asked about family planning training for GPs and for doctors in health authority clinics. He replied that the DHSS had circulated a Handbook of Contraceptive Practice, and practitioners had to state, when claiming fees, that they had been guided by modern authoritative medical opinion. In the case of clinics the NHS authorities had to decide whether the doctors' previous experience and training were appropriate. The DHSS had advised in May 1974 that the professional staff should have received special family planning training; health authorities' funds to develop family planning courses covered the training of GPs. The Minister of State listed the scale of fees paid in many health authority clinics. Sessional fees from 1 April 1975
£
Ordinary birth control session full session .11-31 7-32 short session. 7-61 clinical assistant. Consultants full session .16-54 short session .10-80 Instructing doctors-all methods (including IUD) when a trainee is present or intended to be 14-33 present Ordinary IUD session full session .13-71 8-62 short session. Marital difficulties session full session .13-71 short session .12-61 Subfertility session .13-71 Research session .13-71 12-61 Mixed birth control/IUD session Vasectomy session Surgeon .27-39 Registrar .18-27 Interviewing doctor .11-31 Domiciliary 2-90 Long visit (over 4 hour) 1-45 Short visit (under 1 hour) .. 094 Unproductive visit rates continue more favourable Staff transferred on to receive them.
716
BRITISH MEDICAL JOURNAL
Abortion Figures for abortion in 1974-5 were given in a written answer on 1 December. Abortions in women usually resident in Great Britain 1974* .. 1128 Risk to life of woman Risk of injury to physical or mental .95 163 health of woman Risk of injury to physical or mental 3369 health of existing child(ren) Substantial risk of child being born 1036 . abnormal. 3 In emergency-to save life of woman In emergency-to prevent grave permanent injury to physical or 9 mental health of woman 756 . . with (4) 513 ..15 with others 116 977
Grounds
(1)
(2)
(3)
(4) (5) (6) (2) (3)
*Provisional.
Abortions in NHS hospitals and the private sector Women Women not usually usually resident in resident in Great Britain Great Britain Total
National Health Service hospitals Approved places
63030 53 947
242 53 443
63272 107 390
116 977
53 685
170 662
20 DECEMBER 1975
TABLE I
Persons employed in the NHS (note 1) .. .. .. General medical practitioners, general dental practitioners, ophthalmic medical practitioners, ophthalmic opticians, . disppensing opticians (Note 2) .. . . .. Total .
. .
1960 453 796
1973 648 348
1974 660 884
40 746
40 997
41 214
494 542
689 345
702 098
Notes:
(1) All figures are whole-time equivalents. In order to provide comparable figures, community health service and school health staff are excluded. (2) Figures relate to number of persons providing services to the NHS under contract. TABLE II
Medical staff employed in the NHS (Note 1) .. .. General medical practitioners, general dental practitioners, ophthalmic medical pra4ctitioners (Note 2) Non-rmedical staff employed in the NHS (Note 3) Ophthsalmic opticians, dispensing opticians (Note 2) .6021 . . Total .
. . ..
1973 26 933 34 976 621 415
.689 345
1974 27 831
35 274 633 053 5940 702 098
Notes:
(1) Medical staff includes all hospital medical and dental staff including those holding honorary appointments. All figures are whole-time equivalents. (2) Figures relate to numbers of persons providing services to the NHS under contract. (3) Non-medical staff includes nurses, midwives, professional and technical staff (such as technicians, para-medical staff etc), ancillary staff (domestics, porters, laundry staff etc) and administrative and clerical staff. Approximately 81 (O of these staff provide services directly related to the care of NHS patients. All figures are wholetime equivalents.
Dr Owen said that the current maximum hospital to hospital and from exam to exam.
Place of residence of women who had abortions in value of a distinction award was £10689 pa The association is planning to resurvey the England and Wales situation and look for ways of improving (Provisional)
1975 to 30 1974 September 81 124 109 432 831 1038 851 1102 1197 1406
Women usually resident in
England and Wales Scotland. Northern Ireland Irish
Republic
Channel Islands and Isle of
373 616 41 36 541 2863 1730 6112 80 4 268 604 24 64 819
275 312 22 13 398 3117 3966 2825 58 2 69 347 11 46 713
163 117
109 164
Man
Belgium.
Luxembourg France
Spain Italy West Germany
Netherlands
Denmark Austria. Switzerland
Canada. United States of America Other countries
..
and that the average value of all awards, including partial awards to part-time con- the facilities available to African doctors sultants, was estimated to be about £3000 pa. working in Britain. Further details are available from Dr A B C Nworah, Staincliffe General Hospital, Dewsbury (tel 0642465105). NHS personnel In a written answer on 4 December the numbers of people employed in the NHS in England and Wales in 1960, 1973, and 1974 were given (table I above). In the same answer the numbers of medical and non-medical staff in the NHS in England and Wales were set out before NHS reorganisation and at 30 September 1974 (table II above).
MEDICAL NEWS Distinction awards The Minister of State, Dr David Owen, gave in a written answer on 4 December the estimated total value of distinction awards, excluding employers' superannuation contributions in England and Wales since 1970 and the approximate distribution of money in percentage terms by regional health authorities in England and Wales in 1974. £C million
1970. 1971. 1972. 1973. 1974.
Northern Yorkshire Trent . East Anglia Oxford. South-western. West Midlands. North-western. Mersey. Wessex. 4 Thames regions Wales
6-1 70 7-8 8-2 91
.
. .
.
..
.
.
.
.
5 5 6 4 5 5 8 7 4 4
. 42 5
Medical examination after rape Among the changes proposed in the Report of the Advisory Group on the Law of Rape (HMSO, price 55p) and prepared for the Home Office is a restriction on discussion in court of the woman's private sexual history. Nowadays, says the report, sexual relationships outside marriage are fairly widespread and a woman's sexual experiences with partners of her own choice are "neither indicative of untruthfulness nor of a general willingness to consent." While recognising, therefore, that medical
examination of rape victims needs to be comprehensive and systematic, the report suggests that if its proposals are accepted At a meeting of the African Doctors' Asso- doctors will no longer need to seek full ciation attended by about 65 members in details of the personal sexual backgrounds of Manchester on 6 December concern was the women alleging rape. expressed over the failure rates of Africans in postgraduate medical examinations in Britain, as opposed to their African counter- Professor of surgery, Dundee parts in Europe and America and to Africans in other acadenmic disciplines in Britain. The Mr Alfred Cuschieri has been appointed to association was also concerned about the the chair of surgery at the University of difficulties African doctors encountered in Dundee from 1 April 1976, in succession to access to large and teaching hospitals, and Professor Sir Donald Douglas. Mr Cuschieri the indifference of consultants and others of graduated from the Royal University of senior rank in directing African doctors in Malta in 1961, and held posts at St Luke's major surgical tedhniques and major medical Hospital, Malta, and hospitals in London decisions and manoeuvres. British trained before moving to Liverpool, where he is at doctors were being excluded from major present reader in surgery in the University responsibilities by postgraduates trained in of Liverpool and honorary consultant surgeon to the Liverpool Area Health Authority. the EEC and East Europe. The association believed these were the His publish&d work includes clinical and exmain factors responsible for the frustratingly perimental studies on the hepato.'biliary prolonged stay of about 80% of African system, postgastrectomy syndromes, and doctors in Britain, constantly moving from cancer of the breast. African Doctors' Association
BRITISH MEDICAL JOURNAL
20 DECEMBER 1975
Chair of community health, Bristol Dr J R T Colley has been appointed to the chair of community health at Bristol University. Dr Colley, who is 45, graduated from London in 1948. After house appointments and National Service he was appointed medical registrar to the Royal United Hospital in Bath, moving to St Thomas's Hospital in 1961. In 1964 Dr Colley was appointed lecturer in epidemiology at the London School of Hygiene and Tropical Medicine, becoming senior lecturer and later reader. Dr Colley is an authority on respiratory disease in children, and his current research initerests also include childhood obesity.
General Medical Council: Disciplinary Committee The Disciplinary Committee of the General Medical Council met in the two weeks beginning 24 November. Mr R B Wright was in the chair. The following doctors were erased from the Register: Dr Kenneth Vincent Deakin (immediately suspended), Dr Harvey Forrester Jackson (immediately suspended), Dr Vangala Venkata Krishnamurti, and Dr Kien-Yao Wei. The following doctors were suspended from the Register: Dr A M Chatelier (12 months, immediately suspended), Dr S J Hepworth (six months), Dr Mohammed Maqbool Ali Khan (six months), Dr Sudarshan Kharabanda (further 12 months), Dr P G Nicolaides (12 months), and Dr F J B Taylor (12 months).
COMING EVENTS Exeter Postgraduate Medical Centre-Details and copies of the programme for the Spring Term 1976 are now available from the Exeter Postgraduate Medical Centre, Barrack Road, Exeter, Devon. (Tel Exeter 70018.)
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the retirement every two years of one-half of the members of the group committee, who are eligible for re-election. Nomination forms are obtainable from the u-ndersigned and must be returned to BMA House, Tavistock Square, London WC1, not later than Friday, 30 January 1976. In the event of a contest arising voting papers will be issued at a later date to members of the
"Food Supplies: Outlook for Britain"Conference organised by the Royal Society of group. Health and the Society of Chemical Industry, 8-9 Both the candidate for election January, Manchester. Details from the Royal person making the nomination and the must be Society of Health, Conference Department, 13 members of the group. Grosvenor Place, London SWIX 7EN. (Tel 01-235 9961.) DEREK STEVENSON,
Secretary King's Fund Centre Mental handicap conference "Professional training," 13 January, London. Details from James Elliott, Associate Director, King's Fund Centre, 24 Nutford Place, Diary of Central Meetings London WIH 6AN. JANUARY 6 Tues Scottish Committee for Hospital Medical Royal Free Hospital-Day meeting, "The Services (7. Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. psychiatric patient in the community-current 7 Wed Council, 10 am. trends," 15 January. Details from Dr T Pastor, 8 Thurs General Purposes Subcommittee (GMS), Academic Department of Psychiatry, Royal Free 10.30 am. 8 Thurs Working Party on Services for the Hospital, Pond Street, Hampstead, London Elderly (Board of Science and EducaNW3 2QG. (Tel 01-794 0500.) tion), 10.30 am. 9 Fri Scottish Committee for Community Royal College of Radiologists-Meeting on Medicine (7 Drumsheugh Gardens, Edinburgh EH3 7 QP), 10.45 am. "Diagnostic ultrasound," 16 January, London, Welsh Committee for Hospital Medical meeting on "Radioisotope imaging and on cancer 11 Sun Services (Hotel Metropole, Llandrindod chemotherapy," 17 January, London. Details from Wells), 2 pm. Welch Committee for Community Royal College of Radiologists, 28 Portland Place, 14 Wed Medicine (Hotel Metropole, LlandrinLondon WlN 4DE. (Tel 01-636 4432/3.) dod Wells), 2.30 pm. 15 Thurs Executive Subcommittee (GCHMS), "The Evaluation of Artificial Joints with 10 am. General Medical Services Committee, Particular Reference to Joint Simulators"- 15 Thurs 10 am. Conference organised jointly by the Biological Engineering Society and the Bioenginecring Group for the Study of Human Joints, University of Leeds, 16 January, Leeds. Details from Professor APPOINTMENTS V Wright, University of Leeds, Rheumatism Research Unit, School of Medicine, 36 Clarendon MANCHESTER AREA HEALTH AUTHORITY (TEACHING)The following consultants have been appointed: Dr Road, Leeds LS2 9PJ. M M Roberts (dermatologist); Dr P S Hasleton
Safety in factories The new Health and Safety at Work Act should lead employers to review their policy about industrial health, says the Chief Inspector of Factories in his Annual Report 1974. "The Act requires employers to apply to matters of health and safety the same managerial techniques that an efficient company applie§ to its commercial activities," he writes. Companies will have to prepare a statement of safety policy, and this will be one of the criteria against which inspectors will judge a firm's performance.
Gerontology bursary The National Corporation for the Care of Old People is administering a Canadian fund which offers bursaries of up to £200 to assist persons professionally concerned with any aspect of gerontology to visit North America. Details are available from the corporation at Nuffield Lodge, Regent's Park, London NW1.
Spread of rabies Stray dogs and cats in the Pas-de-Calais, the part of France nearest to England, are to be caught and shot, according to a report in The Times (15 December) from Lille. This is part of the measures being taken in France to try to stop the spread of the disease westwuards to the ooast. The epizootic of rabies has been spreading across Europe for several years despite preventive action.
Royal College of Physicians of London- (histopathologist). Clinicopathological conference, 29 January, NORTH-WEST THAMES RHA-The following consultants have been appointed: Dr B K Lee London.
72nd Annual Congress on Medical Education -30 January-1 February, Chicago. Details from the American Medical Association, 535 North Dearborn Street, Chicago, Illinois 60610, USA. Fourth International Meeting in Paediatric Neurology and Neurosurgery-18-21 February, Mexico. Details from Instituci6n Mexicana de Asistencia a la Nifiez, Secci6n Congresos, Av Insurgentes Sur 3700, M6xico 22, D F, Mexico. Lebanon Chapter, American College of Surgeons.-7th Surgical Congress, 19-21 February, Lebanon. Details and copies of the programme are available from Dr U Majzoub, Gefinor Medical Center, Maamari Street, Beirut, Lebanon.
"Microbiological safety of cosmetic and 23-25 products"-Symposium, toiletry February, Birmingham. Details from Society of Cosmetic Chemists of Great Britain, 56 Kingsway, London WC2B 6DX. (Tel 01-242 3800.) Society for Radiological Protection-Meeting "The application of the man-rem concept," 3 February, London. Details from Mr H C Orchard, S R P Programme Committee, Room 615, C E G B, Courtenay House, 18 Warwick Lane, London EC4P 4EB. (Tel. 01-248 1202.)
(paediatrician); Dr Mary E Horsey (psychiatrist); Dr R A Sturge (rheumatology and rehabilitation); Mr T P Welch (accident and emergency medicine). SALFORD
AREA
HEALTH
AUTHORITY
Dr A Dalal (consultant anaesthetist).
(TEACHING)-
Corrections Swallowed foreign bodies In the third line of the last sentence of the letter from Dr T Loughnane (6 December, p 583) the word "possibly" should read "forcibly".
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical J7ournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 4 October 1975. Correspondence on editorial business should be addressed to the Editor, British Medical journal, BMRA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WCI. Communications will not be acknowledged unless a stamped addressed postcard is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC1H 9JR, on receipt of proofs.
BMA NOTICES Venereologists' Group Committee Nominations are hereby invited from members of the Venereologists' Group for two vacancies on its group committee for the period 1975-9. The vacancies are caused by
(© British Medical Journal 1975 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British Medical-Journal.
714
20 DECEMBER 1975
NEWS AND NOTES EPIDEMIOLOGY Cooking the Christmas dinner For most of us Christmas is a time of pleasurable excess. The enjoyment of food is such an important part of the festivities that the subsequent development of gastroenteritis could be described as at best unfortunate and at worst tragic when the occasional patient dies. Yet every year in England and Wales numerous outbreaks of food poisoning after Christmas dinners are reported, and most of them probably go unreported. Moreover, since many of these dinners are annual functions for various societies and clubs, many people may be infected from a single meal. For example, in some of the outbreaks reported in this journal in recent years'"3 numbers of persons involved have been 126 of 229, 209 of 600, 59 of 157, and 160 of 177. In these outbreaks turkey has usually been the source of the gastroenteritis and salmonellas the most common organism, although Clostridium welchii is also responsible on occasions. Why turkey? Because with our present intensive farming and distribution methods a high proportion of birds are infected with salmonellas at source, and because the birds are large and hence seldom receive the thorough defrosting and cooking they require. Moreover, kitchens builtandequipped to cater for a small number of people and which may function perfectly satisfactorily during tihe year are often asked to cope with a far greater bulk of food at Christmas. As a result, short cuts are taken, and food poisoning may result. In the outbreaks already referred to the turkeys cooked have weighed from 20 to 34 lb (9 to 15 kg) and the number of turkeys cooked for one meal from nine to 30. In general, food poisoning can be avoided by sound kitchen hygiene even when the turkey, or other food, is already contaminated before it is bought, and the remarks that follow apply equally to any poultry or other meat. Most food poisoning organisms multiply most quickly at about 37'C (98 6°F), or normal 'human body temperature. At higher temperatures multiplication is slower, and at pasteurization temperatures (60°C (150°F) or more) the nonsporing pathogens such as salmonellas die. The rate of multiplication also decreases rapidly as the temperature falls below 20°C (68°F), until at below about 8°C (46°F) it ceases. Cold temperatures, even if below freezing point, will not of course destroy salmonellas. The spores of C welchii, part of the normal flora of human and animal intestine, differ from vegetative organisms in that they will not all be destroyed at pasteurisation temperatures or even at 100°C (212°F). Although they will not germinate at these high temperatures they will do so once the temperature falls, and will multiply most rapidly at about 45 °C (113 °F). Clearly,
therefore, if there is one essential to observe in the preparation of turkey (or indeed, in any cooking process) it is to avoid holding the food for any length of time at temperatures at which organisms will rapidly proliferate. This rule applies not only while meat is stored but also while it is being cooked or reheated. Hence it is clearly important for pasteurisation temperatures to penetrate throughout the bird, and since it is difficult to cook large chunks of meat thoroughly, 6 lb (3 kg) is the maximum recommended cooking weight. However, as the aesthetic vision of a plump bird, roasted whole and glistening in its reddish-brown skin as it is brought to the festive table, perhaps contributes as much to the enjoyment of the Christmas dinner as its somewhat bland taste, it is difficult to envisage many people following this rule. If a large whole bird must be cooked, it is advisable to introduce further safeguards. Adequate time must be allocated for a frozen turkey to thaw, otherwise it may be impossible to cook it through. For large turkeys this is perhaps best done in an ordinary refrigerator, in which case about 48-72 hours will be needed. A bird of 20 lb (9 kg) will require a minimum of 36 hours at room temperature. It is helpful to remove the frozen giblets first if these have been packed inside the carcass of the bird. Fully thawed or fresh birds must be cooked through to destroy all salmonellas. It is usual to allow at least 20 min per lb (45 min per kg) at 204°C (400°F-regulo 6) plus an extra half-hour at the end. It may be safer to use a meat thermometer to ensure that the internal temperature of the bird reaches 75°C (170°F), particularly in catering establishments. It is important not to stuff the turkey before cooking, otherwise heat penetration may be inadequate and some organisms will survive. Moreover, since herb stuffing itself may contain the spores of C welchii, and sausage meat, a traditional stuffing, may contain salmonellas also, the same precautions must be observed when stuffing is cooked (separately) as with meat. Even if thoroughly cooked, the bird, although it will be free of salmonellas and other vegetative organisms, may still be contaminated with the spores of C welchii. The addition of gravy at temperatures below 65'C (150°F) is likely to accelerate their germination. Hence the turkey should be served as soon as possible after cooking and any leftovers cooled rapidly and refrigerated with less than an hour's delay. Catering establishments need special cooling facilities. Gravy should be added at the table. It is also important that, after cooking, the bird must not be recontaminated by contact with surfaces or utensils used for handling raw meat and poultry; and, to avoid contamina-
tion by staphylococci persons with infected lesions should not be allowed to handle food. Nevertheless, all food handlers should wash their hands before handling food lest human intestinal organisms are transTmitted, and, as a further precaution, bare hands should not be used on cooked meat. In reported outbreaks the storage of meat after cooking is at fault as often as the process of cooking. Reheating leftovers is permissible only if the meat is brought rapidly to top heat from the refrigerator, and kept at a high temperature for long enough to allow full heat penetration. Covering turkey meat with broth or gravy and reheating in a lukewarm -below 65'C (150'F)-cabinet or bainmarie is a dangerous practice. Although turkey is the usual source of food poisoning from Christmas dinners, other traditional foods may also cause gastroenteritis. Sausages, usually served with turkey, are fairly frequently contaminated with salmonellas; they must be cooked through, and as an added safeguard they should be served freshly cooked. Other foods, such as puddings or trifles, should not be handled or allowed to come into contact with surfaces used for raw meat, and, again, s1hould not be left at kitchen (warm) temperatures for longer than an hour or so. If these recommendations are observed your merry Christmas will not include food poisoning. NORMAN D NOAH
Epidemiological Research Laboratory, Central Public Health Laboratory, Colindale Avenue, London NW9 5HT 1 British Medical Yournal, 1973, 1, 559. " British Medical Yoturnal, 1974, 2, 128, 233. 3 British Medical Journal, 1975, 3, 107.
MEDICOLEGAL Hazards of compression
sclerotherapy
FROM OUR LEGAL CORRESPONDENT
There is a widespread misconception among the medical profession that even though treatment is not given negligently doctors may nevertheless be liable to their patients if injury results. Doctors' appreihension is increased if they are using a technique accepted by a substantial body of responsible professional opinion but at the same time regarded as controversial by other informed practitioners. There is therefore reassurance to be found in a recent decision' of Mr Justice Thompson refusing damages
BRITISH MEDICAL JOURNAL
20 DECEMBER 1975
to a man who had sclerosant fluid injected into an artery while undergoing Fegan's compression sclerotherapy behind the medial malleolus. The judgment also supports the argument that a technique's possible hazards or side effects can, if infrequent enough, be justified by the technique's benefits, if great enough.
Facts of case The plaintiff, who had suffered from varicose veins since the age of 18, complained of a sclerosant injection given to him at St Bartholomew's Hospital on 6 March 1973 by Mr J S P Lumley. At the time the plaintiff was 57 and had had a lengthy history of treatment for venous trouble, including phlebitis and ulceration: in particular, he had a long-standing varicose ulcer behind the left lateral malleolus. In late December 1971 it was decided to treat the plaintiff using Professor Fegan's technique of compression sclerotherapy. This technique had first been publicised in 1960, and three years later the professor had written a paper for the Lancet; subsequently it had become widely used-perhaps, said the judge, too widely used by those who were not specialists in the vascular field. In 1971 a warning note was sounded: Martin and Eastcott2 in a letter to the BM7 wrote of intra-arterial injection as "a possible hazard of this otherwise excellent treatment." The defendant had taken over the plaintiff's case in mid-1972, when he had diagnosed severe chronic varicose disease with bouts of thrombosis of the deep veins. Rejecting open surgery, Mr Lumley decided to resume the injections. In November 1972 and February 1973 he injected two incompetent perforators but not a third, lowest one. He ihad tried to do so in February 1973 but had not been satisfied he was in the right place. The plaintiff was therefore asked to return on 6 March to complete the treatment. As soon as Mr Lumley had begun injecting the fluid the plaintiff had cried out and the injection had been stopped. According to Mr Justice Thompson at the time and for a considerable period afterwards Mr Lumley thought that he had gone into the lumen of the posterior tibial artery behind the medial malleolus of the left ankle. Later he had changed his mind and come round to the view of the admitting houseman on the day of the accident that the fluid had gone into the periarterial tissue. But despite there being certain features atypical of previous cases of arterial injection the judge found on the balance of the evidence that the fluid had gone into the artery after all. Hazard of operation At the trial the primary criticism made of Mr Lumley was that an injection behind the medial malleolus was so 'hazardous an operation that no competent vascular surgeon should have tried it and no possible benefit could excuse it. Mr Lunley in his evidence told the judge that between 1965 and 1973 he had carried out two to three dozen Fegan injections at the same level as that on the plaintiff without mishap. There could be no alternative site for the injection, he said, since it was not the surgeon but the
patient who by the location of the incompetent perforators had chosen the site. The defendant stated that after discussion of the Martin and Eastcott letter at Bart's the decision had been taken to continue to inject when necessary near the medial malleolus. There was also evidence that other surgeons consistently injected in that area. Professor Fegan himself was called to support the propriety of Mr Lumley's approach, and told the judge that weighing the dividends the technique paid against the infrequent episodes of arterial injection the risk was justifiable if the operator was skilful and experienced. The professor had no criticism to make of Mr Lumley: "even if I had had the same unfortunate result," he said, "I would not have been deterred from doing the same procedure again in an appropriate case." In cross-examination a paper by Mr N Winstone at a seminar at Stoke Mandeville in 1971 was put to Professor Fegan. Mr Winstone had said that the Medical Defence Union had five cases of intra-arterial injection "on their books," each of which had led to gangrene of portions of the foot. Mr Winstone had commented that "prevention of this type of disaster rested on awareness of the danger and seldom injecting into the veins round the ankle joint." Professor Fegan emphasised Mr Winstone's use of the word "seldom." That meant to him "no more often than necessary," for where the perforator was in that area, he, Mr Winstone, and all injected none the less. Indeed, without the injection, the judge was told, the plaintiff would ,have been hobbling along with a nasty, smelly ulcer.
Judgment In his judgment Mr Justice Thompson recalled from his note that Mr Newcombe had also stated: "I do accept it cannot be said to be incompetent to inject at that site, but I do hold that it is negligent if damage occurs." This, of course, is a fallacy: treatment is either negligent or it is not, and the occurrence of an injury is relevant only to the question of damages. One of the plaintiff's witnesses, Mr Adrian Marston, accepted that there was a division of opinion. He thought that, for the protection of the public, once a few serious complications were reported surgeons were not justified in using such a procedure in the treatment of a ininor condition. The judge clearly thought that Professor Fegan's evidence better reflected the balance between risk and benefit to the patient than did that of Mr Marston. It was not surprising in view of the weight of respectable practitioners marshalled on Mr Lumley's side that Mr Justice Thompson should find it quite impossible to characterise the decision to inject at the lowest perforator as negligent. The judge added that he believed Mr Lumley when he said that he had aspirated and got dark blood. There was evidence that the blood in varicose veins could be so red as to be indistinguishable from arterial blood, but Mr Justice Thompson concluded that on aspiration the needle had been in the vein. He was not impressed by a last-minute criticism of the plaintiff's rhat Mr Lumley must have allowed the needle to move between aspiration and injection. Mr Justice Thompson's decision exempli-
715
fies the courts' acceptance that it is not for them to decide which of two practices is the better one, so long as what the defendant did was in accordance with a practice accepted by responsible persons. No doctor is negligent merely because there is a body of opinion taking a contrary view.3 Nor is it every mistake which imports negligence. In the words4 of Lord Justice Scott, "the standard of care the law requires is not insurance against accidental slips." 1 Moore v Lumley and the Governors of St Bartholomew's Hospital: 19 July 1975. 2 Martin, P G C, and Eastcott, H H G, British Medical Yournal, 1971, 4, 555. 3 per Mc Nair, J, in Bolam v Friern HMC: (1957) 1 WLR at page 596. 4 Mahon v Osborne: (1938) 2 KB at page 14.
PARLIAMENT Questions in the Commons Family planning Dr David Owen, Minister of State, said in a written answer on 27 November that there had been a slight increase in the use of family planning clinics after 1 April 1974 when they had been transferred to the NHS and charges for contraceptives prescribed and dispensed were removed. The increase was partly due to the absence of a parallel free service in general practice until 1 July 1975. Dr Owen was asked about family planning training for GPs and for doctors in health authority clinics. He replied that the DHSS had circulated a Handbook of Contraceptive Practice, and practitioners had to state, when claiming fees, that they had been guided by modern authoritative medical opinion. In the case of clinics the NHS authorities had to decide whether the doctors' previous experience and training were appropriate. The DHSS had advised in May 1974 that the professional staff should have received special family planning training; health authorities' funds to develop family planning courses covered the training of GPs. The Minister of State listed the scale of fees paid in many health authority clinics. Sessional fees from 1 April 1975
£
Ordinary birth control session full session .11-31 7-32 short session. 7-61 clinical assistant. Consultants full session .16-54 short session .10-80 Instructing doctors-all methods (including IUD) when a trainee is present or intended to be 14-33 present Ordinary IUD session full session .13-71 8-62 short session. Marital difficulties session full session .13-71 short session .12-61 Subfertility session .13-71 Research session .13-71 12-61 Mixed birth control/IUD session Vasectomy session Surgeon .27-39 Registrar .18-27 Interviewing doctor .11-31 Domiciliary 2-90 Long visit (over 4 hour) 1-45 Short visit (under 1 hour) .. 094 Unproductive visit rates continue more favourable Staff transferred on to receive them.
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BRITISH MEDICAL JOURNAL
Abortion Figures for abortion in 1974-5 were given in a written answer on 1 December. Abortions in women usually resident in Great Britain 1974* .. 1128 Risk to life of woman Risk of injury to physical or mental .95 163 health of woman Risk of injury to physical or mental 3369 health of existing child(ren) Substantial risk of child being born 1036 . abnormal. 3 In emergency-to save life of woman In emergency-to prevent grave permanent injury to physical or 9 mental health of woman 756 . . with (4) 513 ..15 with others 116 977
Grounds
(1)
(2)
(3)
(4) (5) (6) (2) (3)
*Provisional.
Abortions in NHS hospitals and the private sector Women Women not usually usually resident in resident in Great Britain Great Britain Total
National Health Service hospitals Approved places
63030 53 947
242 53 443
63272 107 390
116 977
53 685
170 662
20 DECEMBER 1975
TABLE I
Persons employed in the NHS (note 1) .. .. .. General medical practitioners, general dental practitioners, ophthalmic medical practitioners, ophthalmic opticians, . disppensing opticians (Note 2) .. . . .. Total .
. .
1960 453 796
1973 648 348
1974 660 884
40 746
40 997
41 214
494 542
689 345
702 098
Notes:
(1) All figures are whole-time equivalents. In order to provide comparable figures, community health service and school health staff are excluded. (2) Figures relate to number of persons providing services to the NHS under contract. TABLE II
Medical staff employed in the NHS (Note 1) .. .. General medical practitioners, general dental practitioners, ophthalmic medical pra4ctitioners (Note 2) Non-rmedical staff employed in the NHS (Note 3) Ophthsalmic opticians, dispensing opticians (Note 2) .6021 . . Total .
. . ..
1973 26 933 34 976 621 415
.689 345
1974 27 831
35 274 633 053 5940 702 098
Notes:
(1) Medical staff includes all hospital medical and dental staff including those holding honorary appointments. All figures are whole-time equivalents. (2) Figures relate to numbers of persons providing services to the NHS under contract. (3) Non-medical staff includes nurses, midwives, professional and technical staff (such as technicians, para-medical staff etc), ancillary staff (domestics, porters, laundry staff etc) and administrative and clerical staff. Approximately 81 (O of these staff provide services directly related to the care of NHS patients. All figures are wholetime equivalents.
Dr Owen said that the current maximum hospital to hospital and from exam to exam.
Place of residence of women who had abortions in value of a distinction award was £10689 pa The association is planning to resurvey the England and Wales situation and look for ways of improving (Provisional)
1975 to 30 1974 September 81 124 109 432 831 1038 851 1102 1197 1406
Women usually resident in
England and Wales Scotland. Northern Ireland Irish
Republic
Channel Islands and Isle of
373 616 41 36 541 2863 1730 6112 80 4 268 604 24 64 819
275 312 22 13 398 3117 3966 2825 58 2 69 347 11 46 713
163 117
109 164
Man
Belgium.
Luxembourg France
Spain Italy West Germany
Netherlands
Denmark Austria. Switzerland
Canada. United States of America Other countries
..
and that the average value of all awards, including partial awards to part-time con- the facilities available to African doctors sultants, was estimated to be about £3000 pa. working in Britain. Further details are available from Dr A B C Nworah, Staincliffe General Hospital, Dewsbury (tel 0642465105). NHS personnel In a written answer on 4 December the numbers of people employed in the NHS in England and Wales in 1960, 1973, and 1974 were given (table I above). In the same answer the numbers of medical and non-medical staff in the NHS in England and Wales were set out before NHS reorganisation and at 30 September 1974 (table II above).
MEDICAL NEWS Distinction awards The Minister of State, Dr David Owen, gave in a written answer on 4 December the estimated total value of distinction awards, excluding employers' superannuation contributions in England and Wales since 1970 and the approximate distribution of money in percentage terms by regional health authorities in England and Wales in 1974. £C million
1970. 1971. 1972. 1973. 1974.
Northern Yorkshire Trent . East Anglia Oxford. South-western. West Midlands. North-western. Mersey. Wessex. 4 Thames regions Wales
6-1 70 7-8 8-2 91
.
. .
.
..
.
.
.
.
5 5 6 4 5 5 8 7 4 4
. 42 5
Medical examination after rape Among the changes proposed in the Report of the Advisory Group on the Law of Rape (HMSO, price 55p) and prepared for the Home Office is a restriction on discussion in court of the woman's private sexual history. Nowadays, says the report, sexual relationships outside marriage are fairly widespread and a woman's sexual experiences with partners of her own choice are "neither indicative of untruthfulness nor of a general willingness to consent." While recognising, therefore, that medical
examination of rape victims needs to be comprehensive and systematic, the report suggests that if its proposals are accepted At a meeting of the African Doctors' Asso- doctors will no longer need to seek full ciation attended by about 65 members in details of the personal sexual backgrounds of Manchester on 6 December concern was the women alleging rape. expressed over the failure rates of Africans in postgraduate medical examinations in Britain, as opposed to their African counter- Professor of surgery, Dundee parts in Europe and America and to Africans in other acadenmic disciplines in Britain. The Mr Alfred Cuschieri has been appointed to association was also concerned about the the chair of surgery at the University of difficulties African doctors encountered in Dundee from 1 April 1976, in succession to access to large and teaching hospitals, and Professor Sir Donald Douglas. Mr Cuschieri the indifference of consultants and others of graduated from the Royal University of senior rank in directing African doctors in Malta in 1961, and held posts at St Luke's major surgical tedhniques and major medical Hospital, Malta, and hospitals in London decisions and manoeuvres. British trained before moving to Liverpool, where he is at doctors were being excluded from major present reader in surgery in the University responsibilities by postgraduates trained in of Liverpool and honorary consultant surgeon to the Liverpool Area Health Authority. the EEC and East Europe. The association believed these were the His publish&d work includes clinical and exmain factors responsible for the frustratingly perimental studies on the hepato.'biliary prolonged stay of about 80% of African system, postgastrectomy syndromes, and doctors in Britain, constantly moving from cancer of the breast. African Doctors' Association
BRITISH MEDICAL JOURNAL
20 DECEMBER 1975
Chair of community health, Bristol Dr J R T Colley has been appointed to the chair of community health at Bristol University. Dr Colley, who is 45, graduated from London in 1948. After house appointments and National Service he was appointed medical registrar to the Royal United Hospital in Bath, moving to St Thomas's Hospital in 1961. In 1964 Dr Colley was appointed lecturer in epidemiology at the London School of Hygiene and Tropical Medicine, becoming senior lecturer and later reader. Dr Colley is an authority on respiratory disease in children, and his current research initerests also include childhood obesity.
General Medical Council: Disciplinary Committee The Disciplinary Committee of the General Medical Council met in the two weeks beginning 24 November. Mr R B Wright was in the chair. The following doctors were erased from the Register: Dr Kenneth Vincent Deakin (immediately suspended), Dr Harvey Forrester Jackson (immediately suspended), Dr Vangala Venkata Krishnamurti, and Dr Kien-Yao Wei. The following doctors were suspended from the Register: Dr A M Chatelier (12 months, immediately suspended), Dr S J Hepworth (six months), Dr Mohammed Maqbool Ali Khan (six months), Dr Sudarshan Kharabanda (further 12 months), Dr P G Nicolaides (12 months), and Dr F J B Taylor (12 months).
COMING EVENTS Exeter Postgraduate Medical Centre-Details and copies of the programme for the Spring Term 1976 are now available from the Exeter Postgraduate Medical Centre, Barrack Road, Exeter, Devon. (Tel Exeter 70018.)
717
the retirement every two years of one-half of the members of the group committee, who are eligible for re-election. Nomination forms are obtainable from the u-ndersigned and must be returned to BMA House, Tavistock Square, London WC1, not later than Friday, 30 January 1976. In the event of a contest arising voting papers will be issued at a later date to members of the
"Food Supplies: Outlook for Britain"Conference organised by the Royal Society of group. Health and the Society of Chemical Industry, 8-9 Both the candidate for election January, Manchester. Details from the Royal person making the nomination and the must be Society of Health, Conference Department, 13 members of the group. Grosvenor Place, London SWIX 7EN. (Tel 01-235 9961.) DEREK STEVENSON,
Secretary King's Fund Centre Mental handicap conference "Professional training," 13 January, London. Details from James Elliott, Associate Director, King's Fund Centre, 24 Nutford Place, Diary of Central Meetings London WIH 6AN. JANUARY 6 Tues Scottish Committee for Hospital Medical Royal Free Hospital-Day meeting, "The Services (7. Drumsheugh Gardens, Edinburgh EH3 7QP), 10.45 am. psychiatric patient in the community-current 7 Wed Council, 10 am. trends," 15 January. Details from Dr T Pastor, 8 Thurs General Purposes Subcommittee (GMS), Academic Department of Psychiatry, Royal Free 10.30 am. 8 Thurs Working Party on Services for the Hospital, Pond Street, Hampstead, London Elderly (Board of Science and EducaNW3 2QG. (Tel 01-794 0500.) tion), 10.30 am. 9 Fri Scottish Committee for Community Royal College of Radiologists-Meeting on Medicine (7 Drumsheugh Gardens, Edinburgh EH3 7 QP), 10.45 am. "Diagnostic ultrasound," 16 January, London, Welsh Committee for Hospital Medical meeting on "Radioisotope imaging and on cancer 11 Sun Services (Hotel Metropole, Llandrindod chemotherapy," 17 January, London. Details from Wells), 2 pm. Welch Committee for Community Royal College of Radiologists, 28 Portland Place, 14 Wed Medicine (Hotel Metropole, LlandrinLondon WlN 4DE. (Tel 01-636 4432/3.) dod Wells), 2.30 pm. 15 Thurs Executive Subcommittee (GCHMS), "The Evaluation of Artificial Joints with 10 am. General Medical Services Committee, Particular Reference to Joint Simulators"- 15 Thurs 10 am. Conference organised jointly by the Biological Engineering Society and the Bioenginecring Group for the Study of Human Joints, University of Leeds, 16 January, Leeds. Details from Professor APPOINTMENTS V Wright, University of Leeds, Rheumatism Research Unit, School of Medicine, 36 Clarendon MANCHESTER AREA HEALTH AUTHORITY (TEACHING)The following consultants have been appointed: Dr Road, Leeds LS2 9PJ. M M Roberts (dermatologist); Dr P S Hasleton
Safety in factories The new Health and Safety at Work Act should lead employers to review their policy about industrial health, says the Chief Inspector of Factories in his Annual Report 1974. "The Act requires employers to apply to matters of health and safety the same managerial techniques that an efficient company applie§ to its commercial activities," he writes. Companies will have to prepare a statement of safety policy, and this will be one of the criteria against which inspectors will judge a firm's performance.
Gerontology bursary The National Corporation for the Care of Old People is administering a Canadian fund which offers bursaries of up to £200 to assist persons professionally concerned with any aspect of gerontology to visit North America. Details are available from the corporation at Nuffield Lodge, Regent's Park, London NW1.
Spread of rabies Stray dogs and cats in the Pas-de-Calais, the part of France nearest to England, are to be caught and shot, according to a report in The Times (15 December) from Lille. This is part of the measures being taken in France to try to stop the spread of the disease westwuards to the ooast. The epizootic of rabies has been spreading across Europe for several years despite preventive action.
Royal College of Physicians of London- (histopathologist). Clinicopathological conference, 29 January, NORTH-WEST THAMES RHA-The following consultants have been appointed: Dr B K Lee London.
72nd Annual Congress on Medical Education -30 January-1 February, Chicago. Details from the American Medical Association, 535 North Dearborn Street, Chicago, Illinois 60610, USA. Fourth International Meeting in Paediatric Neurology and Neurosurgery-18-21 February, Mexico. Details from Instituci6n Mexicana de Asistencia a la Nifiez, Secci6n Congresos, Av Insurgentes Sur 3700, M6xico 22, D F, Mexico. Lebanon Chapter, American College of Surgeons.-7th Surgical Congress, 19-21 February, Lebanon. Details and copies of the programme are available from Dr U Majzoub, Gefinor Medical Center, Maamari Street, Beirut, Lebanon.
"Microbiological safety of cosmetic and 23-25 products"-Symposium, toiletry February, Birmingham. Details from Society of Cosmetic Chemists of Great Britain, 56 Kingsway, London WC2B 6DX. (Tel 01-242 3800.) Society for Radiological Protection-Meeting "The application of the man-rem concept," 3 February, London. Details from Mr H C Orchard, S R P Programme Committee, Room 615, C E G B, Courtenay House, 18 Warwick Lane, London EC4P 4EB. (Tel. 01-248 1202.)
(paediatrician); Dr Mary E Horsey (psychiatrist); Dr R A Sturge (rheumatology and rehabilitation); Mr T P Welch (accident and emergency medicine). SALFORD
AREA
HEALTH
AUTHORITY
Dr A Dalal (consultant anaesthetist).
(TEACHING)-
Corrections Swallowed foreign bodies In the third line of the last sentence of the letter from Dr T Loughnane (6 December, p 583) the word "possibly" should read "forcibly".
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical J7ournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 4 October 1975. Correspondence on editorial business should be addressed to the Editor, British Medical journal, BMRA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WCI. Communications will not be acknowledged unless a stamped addressed postcard is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC1H 9JR, on receipt of proofs.
BMA NOTICES Venereologists' Group Committee Nominations are hereby invited from members of the Venereologists' Group for two vacancies on its group committee for the period 1975-9. The vacancies are caused by
(© British Medical Journal 1975 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British Medical-Journal.
