Journal of the Royal Society of Medicine Volume 85 September 1992
Should
we
553
ban the mercury thermometer? Discussion paper
I Blumenthal MRCP DCH
The Royal Oldham Hospital, Rochdale Road, Oldham OLl 2JH
Keywords: mercury; clinical thermometry; body temperature; environment; ecology
Not long ago only an iconoclast would have called for a ban on the mercury thermometer. Society has since become much more environmentally conscious creating strong pressure for such action. A ban on the import or sale of mercury thermometers is being considered in Denmark from 1992 and they have been banned in Sweden from 1 January 1992. Is there a case for a ban in Britain? History The first mercury in glass thermometer was invented in 1659 by a French astronomer and priest, Ismael Boulliau. It was two centuries later in 1866 that Sir Thomas Allbut made the short clinical thermometer, the forerunner of the thermometer we use today. Ever since the classic monograph on body temperature by Carl Wunderlich in 1868 temperature measurement of the ill has become routine'. The mercury thermometer could be said to have stood the test of time and is still regarded by many as the 'gold standard' for measurement of body temperature. What are its disadvantages?
Mercury Since the removal of Calomel (mercuric oxide) from teething powders reports of acrodynia have become rare. Most cases reported result from the use of mercury in the home or the breakage of mercurycontaining domestic appliances. Of particular relevance are reports of acrodynia following breakage of a thermometer in a child's bedroom and evidence of mercury exposure in the children of thermometer plant workers2'3. In 1985 the Department of Health reported the results of a survey in 14 NHS regions in England4. Unacceptable levels of mercury vapour were recorded not only in incubators but in the room atmosphere of special care baby units. Such high levels in the rooms and in some incubators were attributable to breakage of clinical thermometers. Despite firm European Community regulations (Control of substances hazardous to health, 1988) which were adopted by the British government in 1989 the vast majority of hospital personnel and the public remain woefully ignorant of the procedure in the event of a mercury spill. This poses a significant public health risk. The scale of the problem can be appreciated by a report of the breakage of as many as 1600 glass thermometers over a 6-month period at a Glasgow Children's Hospital5. At the Royal Oldham Hospital, one of the largest in the North West of England (1000 beds) about two glass thermometers are purchased per bed annually. Spilled mercury disperses into tiny droplets which are difficult to see and easily become entrapped emitting a toxic vapour which is inhaled or absorbed through the skin. The vapour may persist for months
or even years. In animals mercury levels in the blood correlate poorly with tissue concentration and in a child with frank acrodynia urinary concentration may be normal2'6. Mercury poisoning could be more common than is generally realized. The neurotoxic effect of prenatal exposure mimics other forms of brain damage and because the early effects of poisoning in children and adults are subtle suspicion is not easily aroused. Moreover, poor correlation between tissue and blood or urine concentration makes detection difficult.
The hazards of glass and the risk of cross infection Thermometers may break and be retained in the rectum7. Rectal perforation and peritonitis can occur8. Thermometers have been swallowed whole or bitten and a fragment aspirated9. There are no reports of glass breakage in the mouth causing poisoning from swallowed or aspirated mercury. Elemental mercury is not toxic when ingested'0. Although there is a dearth of information in the literature specifically incriminating thermometers as a cause of spread of nosocomial infection, they are a potential vector. The lack of information probably owes much to the difficulty in retrospectively documenting a thermometer in the face of so many potential sources. The risk of cross infection from thermometers is likely to assume added importance with the anticipated increase in HIV infections. Disinfection with antiseptic solutions is both cumbersome and inefficient". Most hospitals now use disposable sheaths. Thermometer contamination may occur from puncture of the sheath by teeth'2. In the home most thermometers are rinsed after use, a wholly ineffective practice'3.
Accuracy, ease of use and cost The accuracy of the mercury thermometer is generally regarded as the yardstick against which others are compared. Should this be so? Maximum accuracy in the mouth requires placement for about 10 minutes, clearly impracticall4. The time recommended in standard nursing texts varies between 2 and 7 min. Accurate measurements can be obtained in the axilla of neonates'5. Despite an unacceptably low sensitivity in older children it is surprising that most paediatric wards record temperature in the axilla'6. The axilla being the preferred site for both aesthetic and safety reasons, seemingly at the expense of accuracy. For most accuracy placement should be for 5-7 minutes. Rectal placement for 3 minutes is shorter, but may be more difficult to maintain in a wriggling child. The lowest reading on a low range thermometer is 250C. Many adults, particularly the less educated, experience difficulty in reading a mercury thermometer. To circumvent this problem a thermometer with colour zones has been developed'7.
0141 0768/92
09o553O03/$02.0o/O
© 1992 The Royal Society of Medicine
554
Journal of the Royal Society of Medicine Volume 85 September 1992
The hospital price of a glass thermometer is £0.57 and the cost of a disposable sheath is £0.01. Assessment of cost per use should allow for the 'life' of the thermometer. The alternative Two thermometers suitable for both hospital and community use are the battery operated electronic thermometer and the single use chemical thermometer. Most brands of electronic thermometer retail at about £7.00 (includes battery). The battery will provide about 300 hours of use allowing many thousands of recordings to be made. When maximum temperature is reached the thermometer beeps. The average time taken in the mouth and rectum is one min and 2 min in the axilla. Axillary measurements with this type of thermometer are inaccurate as are oral measurements in children who hyperventilate18"19. The lowest setting is 320C. The electronic thermometer has a digital display making it easy to read. Unlike the sterile single use thermometer the risk of cross infection, particularly in the home, is not avoided. Furthermore, it is not as environmentally friendly in that most miniature batteries contain mercuric oxide. High levels of mercury have been found in the blood and urine after battery ingestion by children20. The single use thermometer (Tempa-DOT®, Pymah Corporation) is currently marketed in Britain only for hospital use. The lowest cost is about £0.06 if purchased in boxes of 2500. It consists of 50 dots encased in a resilient plastic. Each dot is a combination of 2 organic chemicals and a dye, which changes colour at a specific temperature. The manufacturer recommends its use for both the mouth and axilla. However, should rectal temperature be required it is inserted in a transparent plastic sheath provided by the manufacturer. The sheath (price about £0.05) is flexible making rectal damage less likely than with a glass or electronic thermometer. The time recommended for rectal and axillary use is 3 min and one min for the mouth. The manufacturer has data on file attesting to its accuracy in the axilla. This is a distinct advantage over other thermometers and needs to be confirmed by independent clinical studies. No hazards have been reported from the use of this thermometer; however, a disadvantage is the need for instruction. The user needs to know which coloured dot reflects the temperature and should allow 10 seconds for colour stabilization. The relatively cheap price and other advantages render the single use thermometer the alternative of choice. The increase in environmental plastic from a widespread substitution of re-usable with disposable thermometers would be a small ecological disadvantage. In a laboratory survey the single use thermometer was found to be more accurate than the mercury thermometer21. Similarly, its accuracy has been confirmed in a clinical setting5. Discussion From the ecological perspective a ban on the mercury thermometer in favour of an equally if not more accurate alternative would seem desirable. A ban would be difficult to enforce for a variety of reasons, most notably the public perception of the mercury thermometer as a harmless instrument. At the very least the Department of Health could recommend its withdrawal from routine use in hospitals. Department of Health imprimatur would have a major impact on
public preference for alternative thermometers. Ultimately the net effect would be the same as a ban in that the mercury thermometer would fall into disuse through lack of demand. Attempts are currently being made to 'green' the National Health Service. Annual purchase of thermometers accounts for one tonne of mercury. The use of an environmentally friendly product with only a marginal increase in expenditure would accord with such policies. An exact estimate of the cost of such a change is difficult because of the need to allow for the variable 'life' of a mercury or electronic thermometer. Very premature infants by nature of both their short gestation and skin permeability are a high risk group. The warm environment required for their care facilitates mercury vaporization and absorption. We know from mass population exposure to environmental mercury pollution that the fetus is particularly susceptible to the neurotoxic effect of mercury22. Furthermore, recent work by Yoshida et al. in guineapigs gives reason for caution23. They found that mercury stored in the liver in utero is not excreted after birth by the kidney but is redistributed to other organs mainly the brain and kidney in much higher concentration that occurred in utero. Incubator manufacturers have shown responsibility in this regard by removing mercury thermometers from incubators. The Department of Health should do likewise by issuing a directive recommending the removal of mercury thermometers from neonatal units. The higher minimum temperature on alternative thermometers would at first sight appear to be a clinical disadvantage. This need not be so because precise temperature measurement below the minimum has little relevance to the practical management of hypothermia. Moreover, should an exact temperature be required low reading (2500) electronic thermometers in modern incubators could be used. References 1 Wunderlich CA. On the temperature in disease: a manual of medical thermometry. London: The New Sydenham Society, 1871 2 Miihlendahl KE. Intoxication from mercury spilled on carpets. Lancet 1990;336:1578 3 Hudson PJ, Vogt RL, Brandom J. Elemental mercury exposure among children of thermometer plant workers. Pediatrics 1987;79:935-8 4 Mercury vapour in baby incubators. Health Equipment Information 1985;31:7-10 (DHSS publication) 5 McAllister TA. A single use clinical thermometer. Scot Med J 1975;20:300-4 6 Lorscheider FL, Kimy MJ. Mercury from dental amalgam. Lancet 1990;336:1578-9 7 Lau JTK, Ong GB. Broken and retained rectal thermometers in infants and young children. Aust Paediatr J
1981;17:93-4 8 Anonymous. Hazards of temperature taking. BMJ 1970;3:4-5 9 Olivero J. Oral temperature recording in coronary care units: a risk factor? JAMA 1976;236:1936-7 10 Martyn A, Van Loon JKM. Radiological case of the month. Ingestion of mercury frm a broken thermometer. Am J Dis Child 1990;144:204-6 11 Litsky BY. A study of temperature taking systems. Supervisor Nurse 1976;7:48-53 12 Valenti WM, Takacs KM. Infection control and clinical thermometry: perforation of soft plastic thermometer sheaths during temperature measurement. Am JInfect Control 1981;9:1-5 13 Davis AE, Korczynski M. Hospital disinfection of thermometers. Supervisor Nurse 1975;6:23-7
Journal of the Royal Society of Medicine Volume 85 September 1992 14 Nichols GA. Measurements of oral temperature in children. J Pediatr 1968;72:253-5 15 Mayfield SR, Bhatia J, Nakamura KT, Rios GR, Bell E. Temperature measurement in term and preterm neonates. J Pediatr 1984;104:271-5 16 Kresch MJ. Axillary temperature as a screening test for fever in children. J Pediatr 1984;104:596-9 17 Banco L, Perry A. Reading a thermometer by use of temperature zones. Am JDis Child 1990;144:1011-12 18 Ogren JM. The inaccuracy of axillary temperatures measured with an electronic thermometer. Am J Dis Child 1990;144:109-11 19 Tandberg D, Sklor D. Effect of tachypnoea on the estimation of body temperature by an oral thermometer. N Engl J Med 1983;308:945-6
20 David TJ, Ferguson AP. Management of children who have swallowed button batteries. Arch Dis Child 1986; 61:321-2 21 Beck WC, St Cyr B. Oral thermometry. The Guthrie Bulletin 1974;43:170-85 22 Clarkson TW. Mercury - an element of mystery. N Engl J Med 1990;323:1137-9 23 Yoshida M, Satoh H, Kojima S, Yamamura Y. Retention and distribution of mercury in organs of neonatal guinea pigs after in utero exposure to mercury vapor. J Trace Elem Exp Med 1990;3:219-26
(Accepted 12 November 1991)
Forthcoming events
2nd International Psychiatry Convention: Riviera Dei Fiori 5-8 October 1992, Bordighera Further details from: Dr G Spinetti, Ospedale Civile, GF Novaro Costarainera, Imperia 18017, Italy (Tel: 0183 91524)
Practical Urodynamics and Female Urinary Incontinence 15-16 September 1992, RCOG, London Further details from: Postgraduate Education Dept, Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, London NW1 4RG (Tel: 071 262 5425)
Hydrogels: Specialty Plastics for Biomedical and Pharmaceutical Applications 22-23 October 1992, Basel, Switzerland Further details from: Programme Division, Technomic Publishing AG, Missionsstrasse 44, CH-4055 Basel, Switzerland (Tel: 061 43 52 26; Fax: 061 43 52 59)
Computer Appreciation Course 18-19 September 1992, RCGP, London Further details from: The Royal College of General Practitioners, Corporate Development Unit, 14 Princes Gate, Hyde Park, London (Tel: 071 581 3232; Fax 071 225 3047)
Registration of Pharmaceuticals in Europe 26-28 October 1992, Toronto, Canada Further details from: IBC Technical Services, Gilmoora House, 57-61 Mortimer Street, London WlN 7TD (Tel: 071 637 4383; Fax 071 631 3214)
Anxiety: Basic Science, Treatments and Clinical Trial Design 22-23 September 1992, London Further details from: ROSTRUM, Lewis House, 1 Mildmay Road, Romford RM7 7DA (Tel: 0708 735191; Fax: 0708 734876)
Confectionary Formulations as Dosage Form 27-28 October 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992)
17th International Symposium on Blood Transfusion: Immunology and Blood Transfusion 23-25 September 1992, Groningen, The Netherlands Further details from: Symposium Secretariat, Red Cross Blood Bank Groningen-Drenthe, PO Box 1191, 9701 BD Groningen, The Netherlands (Tel: 31 50 137777; Fax: 31 50 137777)
Rehabilitation, Transitional and Community Care of Persons with Neurological Disabilities 25 September 1992, Oswestry Further details from: Erica Wilkinson, Symposium Secretary, Institute of Orthopaedics, Robert Jones & Agnes Hunt Orthopaedic & District Hospital, Oswestry SY10 7AG (Tel: 0691 655311)
Diagnosis and the Initial Total Care of Persons with Spinal Injuries 26 September 1992, Oswestry Further details from: (see entry for 25 September 1992) Introduction to Regulatory Affairs 29-30 September 1992, National Heart & Lung Institute, London Further details from: (see entry for 22-23 September 1992)
Neurofibromatosis - From Phenotype to Genotype 1-2 October 1992, St John's College, Oxford Further details from: Colonel John Blackwell CBE, General Secretary, The Neurofibromatosis Association, 120 London Road, Kingston Upon Thames KT2 6QJ (Tel/Fax: 081 547 1636)
Management of Infertility 28 October 1992, RCOG, London Further details from: (see entry for 15-16 September 1992)
Technology and Applications for Polysaccharides 29-30 October 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992) Inaugural Meeting of the European Gait Analysis Group 30-31 October 1992, Oswestry Further details from: Mrs G M Thomas, ORLAU Movement Analysis Laboratory, Robert Jones & Agnes Hunt Orthopaedic & District Hospital, Oswestry SY10 7AG (Tel: 0691 655311)
Therapeutic Immunomodulation by Intravenous Gammaglobulin and Other Means 30 October-1 November 1992, Mar del Plata, Argentina Further details from: Dr E Rewald, Fundacion Hematologica, Estado de Israel 3698, Casilla Correo 51, 7600 Mar del Plata, Argentina
UCSF Otolaryngology Update: 1992 5-7 November 1992, San Francisco, California Further details from: Extended Programs in Medical Education, University of California, Room LS-105, San Francisco, CA 94143-0742, USA (Tel: 415 476 4251) IVth International Conference of the Society for Minimally Invasive Therapy 8 10 November 1992, Dublin Further details from: The Society for Minimally Invasive Therapy, 47 Eccles St, Dublin 2, Ireland (Tel: 353 1 308530; Fax: 353 1 300345)
(continued on p 559)
555
Should
we
553
ban the mercury thermometer? Discussion paper
I Blumenthal MRCP DCH
The Royal Oldham Hospital, Rochdale Road, Oldham OLl 2JH
Keywords: mercury; clinical thermometry; body temperature; environment; ecology
Not long ago only an iconoclast would have called for a ban on the mercury thermometer. Society has since become much more environmentally conscious creating strong pressure for such action. A ban on the import or sale of mercury thermometers is being considered in Denmark from 1992 and they have been banned in Sweden from 1 January 1992. Is there a case for a ban in Britain? History The first mercury in glass thermometer was invented in 1659 by a French astronomer and priest, Ismael Boulliau. It was two centuries later in 1866 that Sir Thomas Allbut made the short clinical thermometer, the forerunner of the thermometer we use today. Ever since the classic monograph on body temperature by Carl Wunderlich in 1868 temperature measurement of the ill has become routine'. The mercury thermometer could be said to have stood the test of time and is still regarded by many as the 'gold standard' for measurement of body temperature. What are its disadvantages?
Mercury Since the removal of Calomel (mercuric oxide) from teething powders reports of acrodynia have become rare. Most cases reported result from the use of mercury in the home or the breakage of mercurycontaining domestic appliances. Of particular relevance are reports of acrodynia following breakage of a thermometer in a child's bedroom and evidence of mercury exposure in the children of thermometer plant workers2'3. In 1985 the Department of Health reported the results of a survey in 14 NHS regions in England4. Unacceptable levels of mercury vapour were recorded not only in incubators but in the room atmosphere of special care baby units. Such high levels in the rooms and in some incubators were attributable to breakage of clinical thermometers. Despite firm European Community regulations (Control of substances hazardous to health, 1988) which were adopted by the British government in 1989 the vast majority of hospital personnel and the public remain woefully ignorant of the procedure in the event of a mercury spill. This poses a significant public health risk. The scale of the problem can be appreciated by a report of the breakage of as many as 1600 glass thermometers over a 6-month period at a Glasgow Children's Hospital5. At the Royal Oldham Hospital, one of the largest in the North West of England (1000 beds) about two glass thermometers are purchased per bed annually. Spilled mercury disperses into tiny droplets which are difficult to see and easily become entrapped emitting a toxic vapour which is inhaled or absorbed through the skin. The vapour may persist for months
or even years. In animals mercury levels in the blood correlate poorly with tissue concentration and in a child with frank acrodynia urinary concentration may be normal2'6. Mercury poisoning could be more common than is generally realized. The neurotoxic effect of prenatal exposure mimics other forms of brain damage and because the early effects of poisoning in children and adults are subtle suspicion is not easily aroused. Moreover, poor correlation between tissue and blood or urine concentration makes detection difficult.
The hazards of glass and the risk of cross infection Thermometers may break and be retained in the rectum7. Rectal perforation and peritonitis can occur8. Thermometers have been swallowed whole or bitten and a fragment aspirated9. There are no reports of glass breakage in the mouth causing poisoning from swallowed or aspirated mercury. Elemental mercury is not toxic when ingested'0. Although there is a dearth of information in the literature specifically incriminating thermometers as a cause of spread of nosocomial infection, they are a potential vector. The lack of information probably owes much to the difficulty in retrospectively documenting a thermometer in the face of so many potential sources. The risk of cross infection from thermometers is likely to assume added importance with the anticipated increase in HIV infections. Disinfection with antiseptic solutions is both cumbersome and inefficient". Most hospitals now use disposable sheaths. Thermometer contamination may occur from puncture of the sheath by teeth'2. In the home most thermometers are rinsed after use, a wholly ineffective practice'3.
Accuracy, ease of use and cost The accuracy of the mercury thermometer is generally regarded as the yardstick against which others are compared. Should this be so? Maximum accuracy in the mouth requires placement for about 10 minutes, clearly impracticall4. The time recommended in standard nursing texts varies between 2 and 7 min. Accurate measurements can be obtained in the axilla of neonates'5. Despite an unacceptably low sensitivity in older children it is surprising that most paediatric wards record temperature in the axilla'6. The axilla being the preferred site for both aesthetic and safety reasons, seemingly at the expense of accuracy. For most accuracy placement should be for 5-7 minutes. Rectal placement for 3 minutes is shorter, but may be more difficult to maintain in a wriggling child. The lowest reading on a low range thermometer is 250C. Many adults, particularly the less educated, experience difficulty in reading a mercury thermometer. To circumvent this problem a thermometer with colour zones has been developed'7.
0141 0768/92
09o553O03/$02.0o/O
© 1992 The Royal Society of Medicine
554
Journal of the Royal Society of Medicine Volume 85 September 1992
The hospital price of a glass thermometer is £0.57 and the cost of a disposable sheath is £0.01. Assessment of cost per use should allow for the 'life' of the thermometer. The alternative Two thermometers suitable for both hospital and community use are the battery operated electronic thermometer and the single use chemical thermometer. Most brands of electronic thermometer retail at about £7.00 (includes battery). The battery will provide about 300 hours of use allowing many thousands of recordings to be made. When maximum temperature is reached the thermometer beeps. The average time taken in the mouth and rectum is one min and 2 min in the axilla. Axillary measurements with this type of thermometer are inaccurate as are oral measurements in children who hyperventilate18"19. The lowest setting is 320C. The electronic thermometer has a digital display making it easy to read. Unlike the sterile single use thermometer the risk of cross infection, particularly in the home, is not avoided. Furthermore, it is not as environmentally friendly in that most miniature batteries contain mercuric oxide. High levels of mercury have been found in the blood and urine after battery ingestion by children20. The single use thermometer (Tempa-DOT®, Pymah Corporation) is currently marketed in Britain only for hospital use. The lowest cost is about £0.06 if purchased in boxes of 2500. It consists of 50 dots encased in a resilient plastic. Each dot is a combination of 2 organic chemicals and a dye, which changes colour at a specific temperature. The manufacturer recommends its use for both the mouth and axilla. However, should rectal temperature be required it is inserted in a transparent plastic sheath provided by the manufacturer. The sheath (price about £0.05) is flexible making rectal damage less likely than with a glass or electronic thermometer. The time recommended for rectal and axillary use is 3 min and one min for the mouth. The manufacturer has data on file attesting to its accuracy in the axilla. This is a distinct advantage over other thermometers and needs to be confirmed by independent clinical studies. No hazards have been reported from the use of this thermometer; however, a disadvantage is the need for instruction. The user needs to know which coloured dot reflects the temperature and should allow 10 seconds for colour stabilization. The relatively cheap price and other advantages render the single use thermometer the alternative of choice. The increase in environmental plastic from a widespread substitution of re-usable with disposable thermometers would be a small ecological disadvantage. In a laboratory survey the single use thermometer was found to be more accurate than the mercury thermometer21. Similarly, its accuracy has been confirmed in a clinical setting5. Discussion From the ecological perspective a ban on the mercury thermometer in favour of an equally if not more accurate alternative would seem desirable. A ban would be difficult to enforce for a variety of reasons, most notably the public perception of the mercury thermometer as a harmless instrument. At the very least the Department of Health could recommend its withdrawal from routine use in hospitals. Department of Health imprimatur would have a major impact on
public preference for alternative thermometers. Ultimately the net effect would be the same as a ban in that the mercury thermometer would fall into disuse through lack of demand. Attempts are currently being made to 'green' the National Health Service. Annual purchase of thermometers accounts for one tonne of mercury. The use of an environmentally friendly product with only a marginal increase in expenditure would accord with such policies. An exact estimate of the cost of such a change is difficult because of the need to allow for the variable 'life' of a mercury or electronic thermometer. Very premature infants by nature of both their short gestation and skin permeability are a high risk group. The warm environment required for their care facilitates mercury vaporization and absorption. We know from mass population exposure to environmental mercury pollution that the fetus is particularly susceptible to the neurotoxic effect of mercury22. Furthermore, recent work by Yoshida et al. in guineapigs gives reason for caution23. They found that mercury stored in the liver in utero is not excreted after birth by the kidney but is redistributed to other organs mainly the brain and kidney in much higher concentration that occurred in utero. Incubator manufacturers have shown responsibility in this regard by removing mercury thermometers from incubators. The Department of Health should do likewise by issuing a directive recommending the removal of mercury thermometers from neonatal units. The higher minimum temperature on alternative thermometers would at first sight appear to be a clinical disadvantage. This need not be so because precise temperature measurement below the minimum has little relevance to the practical management of hypothermia. Moreover, should an exact temperature be required low reading (2500) electronic thermometers in modern incubators could be used. References 1 Wunderlich CA. On the temperature in disease: a manual of medical thermometry. London: The New Sydenham Society, 1871 2 Miihlendahl KE. Intoxication from mercury spilled on carpets. Lancet 1990;336:1578 3 Hudson PJ, Vogt RL, Brandom J. Elemental mercury exposure among children of thermometer plant workers. Pediatrics 1987;79:935-8 4 Mercury vapour in baby incubators. Health Equipment Information 1985;31:7-10 (DHSS publication) 5 McAllister TA. A single use clinical thermometer. Scot Med J 1975;20:300-4 6 Lorscheider FL, Kimy MJ. Mercury from dental amalgam. Lancet 1990;336:1578-9 7 Lau JTK, Ong GB. Broken and retained rectal thermometers in infants and young children. Aust Paediatr J
1981;17:93-4 8 Anonymous. Hazards of temperature taking. BMJ 1970;3:4-5 9 Olivero J. Oral temperature recording in coronary care units: a risk factor? JAMA 1976;236:1936-7 10 Martyn A, Van Loon JKM. Radiological case of the month. Ingestion of mercury frm a broken thermometer. Am J Dis Child 1990;144:204-6 11 Litsky BY. A study of temperature taking systems. Supervisor Nurse 1976;7:48-53 12 Valenti WM, Takacs KM. Infection control and clinical thermometry: perforation of soft plastic thermometer sheaths during temperature measurement. Am JInfect Control 1981;9:1-5 13 Davis AE, Korczynski M. Hospital disinfection of thermometers. Supervisor Nurse 1975;6:23-7
Journal of the Royal Society of Medicine Volume 85 September 1992 14 Nichols GA. Measurements of oral temperature in children. J Pediatr 1968;72:253-5 15 Mayfield SR, Bhatia J, Nakamura KT, Rios GR, Bell E. Temperature measurement in term and preterm neonates. J Pediatr 1984;104:271-5 16 Kresch MJ. Axillary temperature as a screening test for fever in children. J Pediatr 1984;104:596-9 17 Banco L, Perry A. Reading a thermometer by use of temperature zones. Am JDis Child 1990;144:1011-12 18 Ogren JM. The inaccuracy of axillary temperatures measured with an electronic thermometer. Am J Dis Child 1990;144:109-11 19 Tandberg D, Sklor D. Effect of tachypnoea on the estimation of body temperature by an oral thermometer. N Engl J Med 1983;308:945-6
20 David TJ, Ferguson AP. Management of children who have swallowed button batteries. Arch Dis Child 1986; 61:321-2 21 Beck WC, St Cyr B. Oral thermometry. The Guthrie Bulletin 1974;43:170-85 22 Clarkson TW. Mercury - an element of mystery. N Engl J Med 1990;323:1137-9 23 Yoshida M, Satoh H, Kojima S, Yamamura Y. Retention and distribution of mercury in organs of neonatal guinea pigs after in utero exposure to mercury vapor. J Trace Elem Exp Med 1990;3:219-26
(Accepted 12 November 1991)
Forthcoming events
2nd International Psychiatry Convention: Riviera Dei Fiori 5-8 October 1992, Bordighera Further details from: Dr G Spinetti, Ospedale Civile, GF Novaro Costarainera, Imperia 18017, Italy (Tel: 0183 91524)
Practical Urodynamics and Female Urinary Incontinence 15-16 September 1992, RCOG, London Further details from: Postgraduate Education Dept, Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, London NW1 4RG (Tel: 071 262 5425)
Hydrogels: Specialty Plastics for Biomedical and Pharmaceutical Applications 22-23 October 1992, Basel, Switzerland Further details from: Programme Division, Technomic Publishing AG, Missionsstrasse 44, CH-4055 Basel, Switzerland (Tel: 061 43 52 26; Fax: 061 43 52 59)
Computer Appreciation Course 18-19 September 1992, RCGP, London Further details from: The Royal College of General Practitioners, Corporate Development Unit, 14 Princes Gate, Hyde Park, London (Tel: 071 581 3232; Fax 071 225 3047)
Registration of Pharmaceuticals in Europe 26-28 October 1992, Toronto, Canada Further details from: IBC Technical Services, Gilmoora House, 57-61 Mortimer Street, London WlN 7TD (Tel: 071 637 4383; Fax 071 631 3214)
Anxiety: Basic Science, Treatments and Clinical Trial Design 22-23 September 1992, London Further details from: ROSTRUM, Lewis House, 1 Mildmay Road, Romford RM7 7DA (Tel: 0708 735191; Fax: 0708 734876)
Confectionary Formulations as Dosage Form 27-28 October 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992)
17th International Symposium on Blood Transfusion: Immunology and Blood Transfusion 23-25 September 1992, Groningen, The Netherlands Further details from: Symposium Secretariat, Red Cross Blood Bank Groningen-Drenthe, PO Box 1191, 9701 BD Groningen, The Netherlands (Tel: 31 50 137777; Fax: 31 50 137777)
Rehabilitation, Transitional and Community Care of Persons with Neurological Disabilities 25 September 1992, Oswestry Further details from: Erica Wilkinson, Symposium Secretary, Institute of Orthopaedics, Robert Jones & Agnes Hunt Orthopaedic & District Hospital, Oswestry SY10 7AG (Tel: 0691 655311)
Diagnosis and the Initial Total Care of Persons with Spinal Injuries 26 September 1992, Oswestry Further details from: (see entry for 25 September 1992) Introduction to Regulatory Affairs 29-30 September 1992, National Heart & Lung Institute, London Further details from: (see entry for 22-23 September 1992)
Neurofibromatosis - From Phenotype to Genotype 1-2 October 1992, St John's College, Oxford Further details from: Colonel John Blackwell CBE, General Secretary, The Neurofibromatosis Association, 120 London Road, Kingston Upon Thames KT2 6QJ (Tel/Fax: 081 547 1636)
Management of Infertility 28 October 1992, RCOG, London Further details from: (see entry for 15-16 September 1992)
Technology and Applications for Polysaccharides 29-30 October 1992, Basel, Switzerland Further details from: (see entry for 22-23 October 1992) Inaugural Meeting of the European Gait Analysis Group 30-31 October 1992, Oswestry Further details from: Mrs G M Thomas, ORLAU Movement Analysis Laboratory, Robert Jones & Agnes Hunt Orthopaedic & District Hospital, Oswestry SY10 7AG (Tel: 0691 655311)
Therapeutic Immunomodulation by Intravenous Gammaglobulin and Other Means 30 October-1 November 1992, Mar del Plata, Argentina Further details from: Dr E Rewald, Fundacion Hematologica, Estado de Israel 3698, Casilla Correo 51, 7600 Mar del Plata, Argentina
UCSF Otolaryngology Update: 1992 5-7 November 1992, San Francisco, California Further details from: Extended Programs in Medical Education, University of California, Room LS-105, San Francisco, CA 94143-0742, USA (Tel: 415 476 4251) IVth International Conference of the Society for Minimally Invasive Therapy 8 10 November 1992, Dublin Further details from: The Society for Minimally Invasive Therapy, 47 Eccles St, Dublin 2, Ireland (Tel: 353 1 308530; Fax: 353 1 300345)
(continued on p 559)
555
