- Email: [email protected]
Accidental hypothermia in Hertfordshire during the winters of 1966–7 and 1967–8
Pub/. Hlth, Lond. (1969) 83, 229-239
Accidental Hypothermia in Hertfordshire During the Winters of 1966-7 and 1967-8 W. H. ALLEN B.SC., M.B.. B.C[-I., D.C.H., D.P.H.
Second Deputy (-km#IU' Medical O/ricer, tterrs County Council CounO, ttall, Hertford Introduction FOLLOWINGthe British Medical Association's (1964) memorandum on accidental hypothermia and the Report of the Committee on Accidental Hypothermia of the Royal College of Physicians (1966), considerable attention was given to this condition, and in Hertfordshire widespread publicity was directed to slatutory and voluntary services to make their members aware of,the problem, It was felt that a socio-medical investigation of those persons admitted to hospital with accidental hypothermia might shed additional light on ways of preventing this condition. Aims of Study (I) To measure the incidence of accidental hypothermia by collecting notifications of admissions of cases resident in' Hertfordshire to hospitals serving the county. (2) To carry out socio-medical investigations of the home circumstances of the patients. (3) To determine whether any measures might have been taken to prevent the occurrence of the condition. Method In the first survey covering the period I January to 31 March, 1967, the medical advisory committees of the t3 hospital groups serving the county were invited to inform the County Medical Officer, at the end of the study period, of all cases of accidental hypothermia admitted to hospital. The Divisional Medical Officer of the area concerned then made enquiries into the home circumstances of the patients including whether they were known to the Health and Welfare Department and which services if any were provided; whether the patient considered to be at risk of developing accidental hypothermia; and fi'om discussion with, the family doctor, the general medical background of the patient, The weather preceding admission was also noted. A field worker visited the home to assess the housing conditions and to enquire into the degree of social contact with neighbours and relatives and whether any predisposing conditions were apparent. This retrospective survey served as a pilot study ti)r a prospective survey carried out in the winter of 1967-8.
230
P U B L I C H E A L T H VOL. 83 NO. 5
In addition to requesting the hospital groups again to notify admissions of patients with accidental hypothermia, all general practitioners, following agreement with the local medical committee, were also invited to notify all cases occurring during the period I December 1967 to 31 March, 1968. In this study the information was re,quested as soon as the diagnosis had been made. On receipt of ~he notificatiofi, the patients home was visited by a health visitor and a survey form was completed. As environmental temperatures for different places in the county were not available, the air temperatures at Kew for the day previous to admission and the day of admission were used. Death notifications for residents o f the county for this period were scrutinized to ensure all fatal cases of accidental hypothermia were included in the survey. Results (See Table t) The winter of 1966-7 was extremely mild yet se~,en cases were reported; one male infant and six adults, three ofeach sex. Two ad,ult male and two adult female patients died but in each instance other major disease was present. Both adults who recovered had lain on the floor unable to get tip following a fall but were otherwise well. The winter of 1967-8 was far less mild yet only 18 cases were reported; 12 female and three n?ale adults and three infants. One male infant and ten adults died (nine female and one male). Although it is dilticult to decide whether accidental hypothermia was the primary or contributory cause of death when other significant disease was present, if would appear that of the 15 deaths arising during the two winter periods only three were primarily the result o f accidental hypothermia itself and in these instances the body temperature was 80°F or less. As expected the extremes o f age were affected (mean adult age 79-9 years, m e a n infant age two days (excluding one infant of three months). Three of the four infants with this condition gcere premature. The majority of cases arose during the coldest parts of the winter. The British ' Medical Association's Memorandum (1964) on accidental hypothermia classified preventive measures under the following headings,
kTsiting Fourteen of the 21 adult cases of accidental hypothermia lived alone, nine of the fourteen died. Nine of the 14 living alone were known to the Health and W61fare Departmem and were visited regularly but six died. O f these six persons two had previously reffised hospital admission, two were suffering' from terminal conditions and one fell sustaining a contusion of the brain. Of the five adults who were not known to the Department, the two males survived; one was visited frequently by relatives and friends and the other was relatively young and went out to work. The fatal cases consisted of a relatively
Cardiovascular
Classification of disease
No
Yes
A
R
A
A
F 87
F64
F 76
F 93
H
Q
R
No
Yes
R
No
95 (35)
< 95 (< 35)
< 95 (< 35)
93 (33,7)
82 (27'7)
Myocardial degeneration Arteriosclerosis Chronic bronchitis Normal temp. on admission
Acute on chronic cardiac failure essential hypertension. On admission 94.8 °
Chronic cardiac failure Myxoedema
Auricular Fibrillation Cerebral thrombosis
Coronary thrombosis Arteriosclerosis Gangrene Perforated D.U.
Living with Knov,,n Body Detailed diagrelative (R) to temp. nosis and or alone (A) dept. F ° (C ~') accidental hypoth.
M 77
sex
Age and
E
Reference letter
TABLE 1
6-3
Died 3/52 after admission
Died
Died
1"5
0-5
2-7
2-8
2"5
7"0
3,1
3.0
5'0
6'0
8"6
5.7
7.4
0"8
2'0
6'1
0.2
2.8
Outside temp. at Kew Day before Day of adm. Max, Min.Max. Min,
Recovered 4"8
Died
Outcome
Housebound widow living in an Almshouse in good repair. Heating and bedding adequate. Visited by relatives, voluntary workers, nurses, social workers, home help. She had previously refused admission to hospital.
Not married; no other medico-social information
Housebeund arthritic married lady living with husband. Heating considered adequate. Taken ill during night and husband requested medical attention next day,
Ambulant housebound widow. Heating and bedding considered adequate. Help from neighbours and friends. Found lying under bed.
An active retired accountant who still worked as a part-time company director. Lived in comfort with son. Refused medical and social services.
Notes, including previous treatment
95
F 72
F 79
N
P
A
R
Yes
Yes
85 (29"4)
93 (33.7)
verdict)
Contusion of brain following a fall (coroners
Found lying after a fall. Simple hypothermia
failure
congestive
96.8 ~
accident
Cerebro vascular
Had a fall, Mild
(35)
87
No
Yes
(30.5)
M 78
D
A
R
Trauma
M 74
Detailed diagLiving with Known Body temp. n osis and relative (R) to or alone (A) dept. F ~ ~C~) accidental hypotta,
On admission,
G
RefAge erence and leUer se-x
CTNS
Vascular dis~se of
Classificatior~ of di~ase
Table l---Continued
Died day after admission
Reco',~red
home.
in nursing
5.2
3"6
Recovered 2.7
Now living
3.0
0,2
2-4
4'4
6.9
4,4
2-9
5,3
0.2
4"2
0-8
0
Outside temp. at Kew Day before Day of adm. Max, Min, Max. Min.
Recovered 6"8
OuI~;ome
Frail ambulant living alone since death of husband 6/52 before, Housing satisfactory. Found lying on floor of hall in night clothes.
lysed arm following polio many years before. Living with a younger sister who at the thne was in bed with influenza. Heating satisFactory. Housing satisfactory,
Frail ambulant with para-
Affluent (income £20 per week), lived in wooden cottage. Frequent and regular visits by relatives and neighbours. Had probably sat up all night in a chair and had a fall,
pneumonia.
1[12 later from lobar
Retired sweeper on Part I11 waiting list. Housebound hemiplegic and arthritic. House in good repair with inside toilet. Not heat in bedroom. Had been treated with Prednisone, Lasix, Pot. effervescent. Mist Morph with ipecac. Died
Notes, including previous treatment
Pre-
Diseases of Respiratory system
maturity
F
b
d
M
M 75
31i2
F
3 days
M
2 days
M
I day
R
R
R
R
R
Yes
Yes
Y~
Yes
Yes
82 (27.7)
91 02"7)
89 (31,6)
(32.2)
90
< 95 (< 35)
Acute bronchitis Cancer of bladder
Marasmus Bronchopneumonia
Hyaline membrane disease.
Prematurity (37 weeks)
breech delivery
(36 weeks)
Premature
Prematurity Hypothermia On admission, 97,6°
6-1
7"4
Died day after /ldmission
9-5
Recovered 11-8
Died
Recovered
Recovered 13-0
7-1
0.5
7'3
3.3
6-7
1 1-2 10-2
3.9
0,8 12-3
9-2
5.8
"5 10'7
5.4
Lived at home with a daughter, Had attended outpatient department. Terminal condition.
three children. Hospital delivery on social grounds. Flat in poor condition with inadequate heating, Mother of low intelligence, Father's occupation: scrap merchant.
B.~'. 5lb. 13oz. third o f
tlon: self-employed builder.
repair. Father's occupa-
r o o m e d house in g o o d
Born at home, B.W, 61b. 4oz. 4th child, Three bed-
child in family. One bedroomed fiat with heating by electric fires.
B.W. 41b 12oz. Second
Bori~ prematurely at home.
Born at home following a normal pregnancy and confinement B.W. 5 lb, transferred to hospital alter 10 hours. Modern 3 bedroomed house with adequate heating, Not considered at particular risk by midwife.
Simple hypothermia
Classification of disease
F 87
K
A
R
A
F 8t
M 68
A
Yes
No
No
No
< 80 ( < 26.6)
92 (33.1)
<95 (<35)
< 95 (36.0)-
0'1
2"4 Died on day of admission
Hypothermia
,9
2.7
Died
Hypothern~ia Bronchopneumonia Chronic bronchitis Emphysema Cot pulmonale
1,0
.6
2.7
1,3
1-0
-9
3-6
10-9 2"0
5-4
2-7
0.4
Outside temp. at Kew Day before Day of adm. Max. Min.Max. Min.
Died
Died day after admission
Outcome
Bronchopneumonia
Influenzal bronchopneumonia On admission, 96 °
Detailed DiagLiving w;ith Known Body relative (R) to ,,emp. nosis and or alone (A) dept. F ° (C ~') accidental hypoth.
F 64
T
L
Age Referencc and sex letter
Table I--Continued
Ambulant widow living in an old cottage in poor repair. No heating in bedroom. Outside toilet. Neighbour called in police as she had not been seen for days. Found collapsed on floor of living room.
Single ambulant jobbing gardener living with a brother in a poorly mainrained old cottage. Outside to~,let, No heating in bedroom. Bedding consisted of old coats.
House scheduled for demolition. Single lady living alone. Not registered with a G,P. Outside toilet.
A separated married lady employed as a school cleaner living in a caravan. She went to work the day before~dmission to hospital. Had not seen h e r i'~mily doctor for years prior to day of admission. Deep snow on ground.
Notes, including previous treatment
Miscellaneous
U
No
Yes
A
A
M 64
F 82
<95 (< 35)
93 (33.7)
8O (26-6)
No
R
<95 (< 35)
Yes
A
80 (26.6)
Yes
A
F 76
F 84
A
C
F 91
M
Senility Malnourishment (known alcoholic)
Aural vertigo
Exfoliative Dermatitis
Recovered
8.8
5.2
3-1
3'2
3-3
.i
4.7
3.6
0-2
Recovered 4.8
Died 3 days after admission
Hypothermic conla
Recovered Now living in nursing home
Died day after admission
Simple hypothermia
Hypothennia Cerebral arteriosclerosis
8.0
5.7
6,6
4-4
4.4
5-2
0.2
6"3
0.9
4.2
Fully ambulant. Husband had been admitted to hospital ten days before. House in good condition. Outside toilet.
Active working man. Had attack of vertigo, fell to floor and was unable to rise,
Treated as a hospital outpatient for psoriasis. Lived with husband. She had been treated for confusion with sparine.
Educated elderly recluse. A brother acted as a 'good neighbour'. She had refused help from voluntary and statutory sources. Found lying by an open front door unable to get up.
Blind housebound widow visited regularly by relatives, vol, visitors, health visitor, social worker and home help, Considered at risk. Previously had refused admission to a geriatric hospital.
~2 0
~'~ ~
~..
• ~-~ " ~ ' ~ ~'~_.
-- ~
~, ~
"~r~ e.O
.'~
0
on
e',
*.~
0
.
C',!
c5 e~
2~,
0 °
=~ g~ag c~
0
0
c~
<
m l
l
I
>!
M
~c~
25 ~ l
© r
0
L~Cl
ijn
ACCIDENTAL HYPOTHERMIA IN H E R T F O R D S H I R E
237
young woman living in a caravan who had contracted influenza but normally went ou~ to work, and two old ladies about whom it has proved almost impossible to obtain any detailed medico-social information; one was not registered with a family doctor. All the infants were being visited regularly by members of the nursing stair.
Heating In 12 homes either the system of heating the living room and bedroom was inadequate, or its adequacy is not known. Two fatal cases had no bedroom heating. In the ten homes where the system was considered adequate there is no way of determining whether it had been correctly used. The heating was considered adequate in the homes of three of the four infants.
Nutrition Of the nine adults living alone and known to the l,)epartment, five had home help or good neighbour service and one had a private home help. Three of these adults received Meals on Wheels twice weekly. The remaining three adults were active and ambulant; two received considerable help from relatives and friends.
Clothing In one fatal case, not known to the Department, the bedding was subsequently discovered to consist solely of old coats. hldoDTd
All persons known to the Department had an adequate income (retirement pension with supplementary benefit where appropriate).
Hous#zg I-lousing was unsatisfactory in at least eight cases and one person who died lived in a caravan; six houses had an outside toilet only. Discussion
The Report on Accidental Hypothermia (1966) by the Royal College of Physicians stated that if the incidence of accidental hypothernaia found in admissions to ten selected hospital groups was representative of all hospital admissions in the country during the three-month period of the study, there could have been 9000 patients admitted with body temperatures below 95°F and about 3400 of these would have been fatal. On this basis Hertfordshire, with a population of 900,000 persons, could expect 160 hospital admissions with perhaps 55 deaths. In Hertfordshire in a four-month period during the winter 1967-8, 18 cases were reported with I I deaths. All the death certificates of resi-
238
P U B L I C t t E A L T H VOL.:83 NO. 5
dents of the county were scrutinized for this period and it is fairly certain that all deaths certified as being due to accidental hypothermia (primary or secondary) have been included iri the survey. It is unlikely that these returns of mortality from accidental hypothermia in Hertfordshire are complete. There is no easy way of discovering if a diagnosis has been made unless it h~s been entered on the death certificate and any persons found dead in their own h01nes may not be so diagnosed. Non-fatal cases present a greater problem, with probably a much greater incidence than reported. A survey carried out in Barking and Redbridge in 1967 by the Hypothermia SubCommittee (1968) of the Society of Medical Officers of Health reported that 11.4% of elderly persons living a t home had body temperatures of 95°F or below, 96% of these hypothermic persons had body temperatures of 93.1 and above. No medical examinations were carried out nor was the rate of regaining normal temperatures measured. The British Medical Association Memorandum (1964) drew attention to the high mortality from accidental hypothermia stating that "this is due in part to the underlying disturbance as welt as to the hypothermia itself". Rosin & Exton Smith (1964) considered that at body temperatures of 90 - 95°F if death occured, the cause appeared to bethe primary disease and not the hypothermia and that the prognosis below 90°F was poor. Wollner (1967) has reported that with improvements in technique the mortality can be significantly reduced even for patients with body temperatures below 85°F'on admission. It is difficult tO be certain but in the majority of fatal cases in Hertfordshire, accidental hypotherrn ia seemed to be a terminal rather than a prirnary condition. Macmillan et aL (1967) considered that derangement of the temperature regulating mechanisms is the most likely cause rather than an effcct of accidental hypothernaia when the environment is cold. The survey has shown that accidental hypothermia developed in nine adults living alone and four infants known to the Department despite the field workers being aware of the problem. Four of those not known to the Department were living with relatives. Two were under the age of 65 and were employed. The prevention of this condition req~aires a much :wider knowledge amongst professional and voluntary workers with the very old, and the very young, and certainly amongst the general public. It may well be that the somewhat lower than expected incidence in Hertfordshire was the result of widespread publicity.
Summary With the willing co-operation of colleagues in all branches of the National Health Se~,ice a medico-social survey was held of the home circumstances o'1' cases of accidental hypothermia arising in Hertfordshire during the winters of I966-7 and 1967-8. There wei'e 25 cases reported, 15 of which were fatal. In many of these cases the death appeared to be the result of the primary disease,
ACCIDEN'I A c. HY POTHER MIA IN HERTFORDStl IRE
239
not the hypothermia. It is difficult to suggest any further simple specific measures in addition to thos/e recommended by the B.M.A. M e m o r a n d u m on accidental hypothermia (1964) and the report of the Committee on Accidental Hypothermia o f the Royal Col/~ege of Physicians (1966) to reduce the morbidity and mortality from this condition. My thanks a~,e due to Dr G. W. Knight, County Medical Officer, for his encouragemerit, to the Research Panel (Project No. 68/10) of the Health and Welfare Department for much help~'ul criticism, to colleagues in hospital and general practice for reporting cases and to the Divisional Medical Officers and health visitors who were concerned with this study.
References BRIrls!I MEDICALASSOCIATION]~.4EMORANDUM(1964). Br. reed. J. ii, [255, MACMILLAN, A. L., CORBETT, ,|. L., JOHNSON, R. H., CRAMPTON-S,MITIi, A,, SPALDING, J. M. K. & WOLLNER, L. (1967). Lancet, i, 165. REPORT OF COMMITTEE ON ACCIDENTAL HYPOTItERMIA (1966). London : Royal Coltcge of Physicians. RosIN, A. J. & EXToN-SMrrt4, A. N. (1964). Br. mecL J. i, 16. S.M.O.H. REr'ORTOF HYPOTHERM1ASu~-COMM~TTE~(1968).Publ. Hith. Lond. 82, 223, \VOLL~ER, L. (t967). Geront. clin. 9, 347.
Accidental Hypothermia in Hertfordshire During the Winters of 1966-7 and 1967-8 W. H. ALLEN B.SC., M.B.. B.C[-I., D.C.H., D.P.H.
Second Deputy (-km#IU' Medical O/ricer, tterrs County Council CounO, ttall, Hertford Introduction FOLLOWINGthe British Medical Association's (1964) memorandum on accidental hypothermia and the Report of the Committee on Accidental Hypothermia of the Royal College of Physicians (1966), considerable attention was given to this condition, and in Hertfordshire widespread publicity was directed to slatutory and voluntary services to make their members aware of,the problem, It was felt that a socio-medical investigation of those persons admitted to hospital with accidental hypothermia might shed additional light on ways of preventing this condition. Aims of Study (I) To measure the incidence of accidental hypothermia by collecting notifications of admissions of cases resident in' Hertfordshire to hospitals serving the county. (2) To carry out socio-medical investigations of the home circumstances of the patients. (3) To determine whether any measures might have been taken to prevent the occurrence of the condition. Method In the first survey covering the period I January to 31 March, 1967, the medical advisory committees of the t3 hospital groups serving the county were invited to inform the County Medical Officer, at the end of the study period, of all cases of accidental hypothermia admitted to hospital. The Divisional Medical Officer of the area concerned then made enquiries into the home circumstances of the patients including whether they were known to the Health and Welfare Department and which services if any were provided; whether the patient considered to be at risk of developing accidental hypothermia; and fi'om discussion with, the family doctor, the general medical background of the patient, The weather preceding admission was also noted. A field worker visited the home to assess the housing conditions and to enquire into the degree of social contact with neighbours and relatives and whether any predisposing conditions were apparent. This retrospective survey served as a pilot study ti)r a prospective survey carried out in the winter of 1967-8.
230
P U B L I C H E A L T H VOL. 83 NO. 5
In addition to requesting the hospital groups again to notify admissions of patients with accidental hypothermia, all general practitioners, following agreement with the local medical committee, were also invited to notify all cases occurring during the period I December 1967 to 31 March, 1968. In this study the information was re,quested as soon as the diagnosis had been made. On receipt of ~he notificatiofi, the patients home was visited by a health visitor and a survey form was completed. As environmental temperatures for different places in the county were not available, the air temperatures at Kew for the day previous to admission and the day of admission were used. Death notifications for residents o f the county for this period were scrutinized to ensure all fatal cases of accidental hypothermia were included in the survey. Results (See Table t) The winter of 1966-7 was extremely mild yet se~,en cases were reported; one male infant and six adults, three ofeach sex. Two ad,ult male and two adult female patients died but in each instance other major disease was present. Both adults who recovered had lain on the floor unable to get tip following a fall but were otherwise well. The winter of 1967-8 was far less mild yet only 18 cases were reported; 12 female and three n?ale adults and three infants. One male infant and ten adults died (nine female and one male). Although it is dilticult to decide whether accidental hypothermia was the primary or contributory cause of death when other significant disease was present, if would appear that of the 15 deaths arising during the two winter periods only three were primarily the result o f accidental hypothermia itself and in these instances the body temperature was 80°F or less. As expected the extremes o f age were affected (mean adult age 79-9 years, m e a n infant age two days (excluding one infant of three months). Three of the four infants with this condition gcere premature. The majority of cases arose during the coldest parts of the winter. The British ' Medical Association's Memorandum (1964) on accidental hypothermia classified preventive measures under the following headings,
kTsiting Fourteen of the 21 adult cases of accidental hypothermia lived alone, nine of the fourteen died. Nine of the 14 living alone were known to the Health and W61fare Departmem and were visited regularly but six died. O f these six persons two had previously reffised hospital admission, two were suffering' from terminal conditions and one fell sustaining a contusion of the brain. Of the five adults who were not known to the Department, the two males survived; one was visited frequently by relatives and friends and the other was relatively young and went out to work. The fatal cases consisted of a relatively
Cardiovascular
Classification of disease
No
Yes
A
R
A
A
F 87
F64
F 76
F 93
H
Q
R
No
Yes
R
No
95 (35)
< 95 (< 35)
< 95 (< 35)
93 (33,7)
82 (27'7)
Myocardial degeneration Arteriosclerosis Chronic bronchitis Normal temp. on admission
Acute on chronic cardiac failure essential hypertension. On admission 94.8 °
Chronic cardiac failure Myxoedema
Auricular Fibrillation Cerebral thrombosis
Coronary thrombosis Arteriosclerosis Gangrene Perforated D.U.
Living with Knov,,n Body Detailed diagrelative (R) to temp. nosis and or alone (A) dept. F ° (C ~') accidental hypoth.
M 77
sex
Age and
E
Reference letter
TABLE 1
6-3
Died 3/52 after admission
Died
Died
1"5
0-5
2-7
2-8
2"5
7"0
3,1
3.0
5'0
6'0
8"6
5.7
7.4
0"8
2'0
6'1
0.2
2.8
Outside temp. at Kew Day before Day of adm. Max, Min.Max. Min,
Recovered 4"8
Died
Outcome
Housebound widow living in an Almshouse in good repair. Heating and bedding adequate. Visited by relatives, voluntary workers, nurses, social workers, home help. She had previously refused admission to hospital.
Not married; no other medico-social information
Housebeund arthritic married lady living with husband. Heating considered adequate. Taken ill during night and husband requested medical attention next day,
Ambulant housebound widow. Heating and bedding considered adequate. Help from neighbours and friends. Found lying under bed.
An active retired accountant who still worked as a part-time company director. Lived in comfort with son. Refused medical and social services.
Notes, including previous treatment
95
F 72
F 79
N
P
A
R
Yes
Yes
85 (29"4)
93 (33.7)
verdict)
Contusion of brain following a fall (coroners
Found lying after a fall. Simple hypothermia
failure
congestive
96.8 ~
accident
Cerebro vascular
Had a fall, Mild
(35)
87
No
Yes
(30.5)
M 78
D
A
R
Trauma
M 74
Detailed diagLiving with Known Body temp. n osis and relative (R) to or alone (A) dept. F ~ ~C~) accidental hypotta,
On admission,
G
RefAge erence and leUer se-x
CTNS
Vascular dis~se of
Classificatior~ of di~ase
Table l---Continued
Died day after admission
Reco',~red
home.
in nursing
5.2
3"6
Recovered 2.7
Now living
3.0
0,2
2-4
4'4
6.9
4,4
2-9
5,3
0.2
4"2
0-8
0
Outside temp. at Kew Day before Day of adm. Max, Min, Max. Min.
Recovered 6"8
OuI~;ome
Frail ambulant living alone since death of husband 6/52 before, Housing satisfactory. Found lying on floor of hall in night clothes.
lysed arm following polio many years before. Living with a younger sister who at the thne was in bed with influenza. Heating satisFactory. Housing satisfactory,
Frail ambulant with para-
Affluent (income £20 per week), lived in wooden cottage. Frequent and regular visits by relatives and neighbours. Had probably sat up all night in a chair and had a fall,
pneumonia.
1[12 later from lobar
Retired sweeper on Part I11 waiting list. Housebound hemiplegic and arthritic. House in good repair with inside toilet. Not heat in bedroom. Had been treated with Prednisone, Lasix, Pot. effervescent. Mist Morph with ipecac. Died
Notes, including previous treatment
Pre-
Diseases of Respiratory system
maturity
F
b
d
M
M 75
31i2
F
3 days
M
2 days
M
I day
R
R
R
R
R
Yes
Yes
Y~
Yes
Yes
82 (27.7)
91 02"7)
89 (31,6)
(32.2)
90
< 95 (< 35)
Acute bronchitis Cancer of bladder
Marasmus Bronchopneumonia
Hyaline membrane disease.
Prematurity (37 weeks)
breech delivery
(36 weeks)
Premature
Prematurity Hypothermia On admission, 97,6°
6-1
7"4
Died day after /ldmission
9-5
Recovered 11-8
Died
Recovered
Recovered 13-0
7-1
0.5
7'3
3.3
6-7
1 1-2 10-2
3.9
0,8 12-3
9-2
5.8
"5 10'7
5.4
Lived at home with a daughter, Had attended outpatient department. Terminal condition.
three children. Hospital delivery on social grounds. Flat in poor condition with inadequate heating, Mother of low intelligence, Father's occupation: scrap merchant.
B.~'. 5lb. 13oz. third o f
tlon: self-employed builder.
repair. Father's occupa-
r o o m e d house in g o o d
Born at home, B.W, 61b. 4oz. 4th child, Three bed-
child in family. One bedroomed fiat with heating by electric fires.
B.W. 41b 12oz. Second
Bori~ prematurely at home.
Born at home following a normal pregnancy and confinement B.W. 5 lb, transferred to hospital alter 10 hours. Modern 3 bedroomed house with adequate heating, Not considered at particular risk by midwife.
Simple hypothermia
Classification of disease
F 87
K
A
R
A
F 8t
M 68
A
Yes
No
No
No
< 80 ( < 26.6)
92 (33.1)
<95 (<35)
< 95 (36.0)-
0'1
2"4 Died on day of admission
Hypothermia
,9
2.7
Died
Hypothern~ia Bronchopneumonia Chronic bronchitis Emphysema Cot pulmonale
1,0
.6
2.7
1,3
1-0
-9
3-6
10-9 2"0
5-4
2-7
0.4
Outside temp. at Kew Day before Day of adm. Max. Min.Max. Min.
Died
Died day after admission
Outcome
Bronchopneumonia
Influenzal bronchopneumonia On admission, 96 °
Detailed DiagLiving w;ith Known Body relative (R) to ,,emp. nosis and or alone (A) dept. F ° (C ~') accidental hypoth.
F 64
T
L
Age Referencc and sex letter
Table I--Continued
Ambulant widow living in an old cottage in poor repair. No heating in bedroom. Outside toilet. Neighbour called in police as she had not been seen for days. Found collapsed on floor of living room.
Single ambulant jobbing gardener living with a brother in a poorly mainrained old cottage. Outside to~,let, No heating in bedroom. Bedding consisted of old coats.
House scheduled for demolition. Single lady living alone. Not registered with a G,P. Outside toilet.
A separated married lady employed as a school cleaner living in a caravan. She went to work the day before~dmission to hospital. Had not seen h e r i'~mily doctor for years prior to day of admission. Deep snow on ground.
Notes, including previous treatment
Miscellaneous
U
No
Yes
A
A
M 64
F 82
<95 (< 35)
93 (33.7)
8O (26-6)
No
R
<95 (< 35)
Yes
A
80 (26.6)
Yes
A
F 76
F 84
A
C
F 91
M
Senility Malnourishment (known alcoholic)
Aural vertigo
Exfoliative Dermatitis
Recovered
8.8
5.2
3-1
3'2
3-3
.i
4.7
3.6
0-2
Recovered 4.8
Died 3 days after admission
Hypothermic conla
Recovered Now living in nursing home
Died day after admission
Simple hypothermia
Hypothennia Cerebral arteriosclerosis
8.0
5.7
6,6
4-4
4.4
5-2
0.2
6"3
0.9
4.2
Fully ambulant. Husband had been admitted to hospital ten days before. House in good condition. Outside toilet.
Active working man. Had attack of vertigo, fell to floor and was unable to rise,
Treated as a hospital outpatient for psoriasis. Lived with husband. She had been treated for confusion with sparine.
Educated elderly recluse. A brother acted as a 'good neighbour'. She had refused help from voluntary and statutory sources. Found lying by an open front door unable to get up.
Blind housebound widow visited regularly by relatives, vol, visitors, health visitor, social worker and home help, Considered at risk. Previously had refused admission to a geriatric hospital.
~2 0
~'~ ~
~..
• ~-~ " ~ ' ~ ~'~_.
-- ~
~, ~
"~r~ e.O
.'~
0
on
e',
*.~
0
.
C',!
c5 e~
2~,
0 °
=~ g~ag c~
0
0
c~
<
m l
l
I
>!
M
~c~
25 ~ l
© r
0
L~Cl
ijn
ACCIDENTAL HYPOTHERMIA IN H E R T F O R D S H I R E
237
young woman living in a caravan who had contracted influenza but normally went ou~ to work, and two old ladies about whom it has proved almost impossible to obtain any detailed medico-social information; one was not registered with a family doctor. All the infants were being visited regularly by members of the nursing stair.
Heating In 12 homes either the system of heating the living room and bedroom was inadequate, or its adequacy is not known. Two fatal cases had no bedroom heating. In the ten homes where the system was considered adequate there is no way of determining whether it had been correctly used. The heating was considered adequate in the homes of three of the four infants.
Nutrition Of the nine adults living alone and known to the l,)epartment, five had home help or good neighbour service and one had a private home help. Three of these adults received Meals on Wheels twice weekly. The remaining three adults were active and ambulant; two received considerable help from relatives and friends.
Clothing In one fatal case, not known to the Department, the bedding was subsequently discovered to consist solely of old coats. hldoDTd
All persons known to the Department had an adequate income (retirement pension with supplementary benefit where appropriate).
Hous#zg I-lousing was unsatisfactory in at least eight cases and one person who died lived in a caravan; six houses had an outside toilet only. Discussion
The Report on Accidental Hypothermia (1966) by the Royal College of Physicians stated that if the incidence of accidental hypothernaia found in admissions to ten selected hospital groups was representative of all hospital admissions in the country during the three-month period of the study, there could have been 9000 patients admitted with body temperatures below 95°F and about 3400 of these would have been fatal. On this basis Hertfordshire, with a population of 900,000 persons, could expect 160 hospital admissions with perhaps 55 deaths. In Hertfordshire in a four-month period during the winter 1967-8, 18 cases were reported with I I deaths. All the death certificates of resi-
238
P U B L I C t t E A L T H VOL.:83 NO. 5
dents of the county were scrutinized for this period and it is fairly certain that all deaths certified as being due to accidental hypothermia (primary or secondary) have been included iri the survey. It is unlikely that these returns of mortality from accidental hypothermia in Hertfordshire are complete. There is no easy way of discovering if a diagnosis has been made unless it h~s been entered on the death certificate and any persons found dead in their own h01nes may not be so diagnosed. Non-fatal cases present a greater problem, with probably a much greater incidence than reported. A survey carried out in Barking and Redbridge in 1967 by the Hypothermia SubCommittee (1968) of the Society of Medical Officers of Health reported that 11.4% of elderly persons living a t home had body temperatures of 95°F or below, 96% of these hypothermic persons had body temperatures of 93.1 and above. No medical examinations were carried out nor was the rate of regaining normal temperatures measured. The British Medical Association Memorandum (1964) drew attention to the high mortality from accidental hypothermia stating that "this is due in part to the underlying disturbance as welt as to the hypothermia itself". Rosin & Exton Smith (1964) considered that at body temperatures of 90 - 95°F if death occured, the cause appeared to bethe primary disease and not the hypothermia and that the prognosis below 90°F was poor. Wollner (1967) has reported that with improvements in technique the mortality can be significantly reduced even for patients with body temperatures below 85°F'on admission. It is difficult tO be certain but in the majority of fatal cases in Hertfordshire, accidental hypotherrn ia seemed to be a terminal rather than a prirnary condition. Macmillan et aL (1967) considered that derangement of the temperature regulating mechanisms is the most likely cause rather than an effcct of accidental hypothernaia when the environment is cold. The survey has shown that accidental hypothermia developed in nine adults living alone and four infants known to the Department despite the field workers being aware of the problem. Four of those not known to the Department were living with relatives. Two were under the age of 65 and were employed. The prevention of this condition req~aires a much :wider knowledge amongst professional and voluntary workers with the very old, and the very young, and certainly amongst the general public. It may well be that the somewhat lower than expected incidence in Hertfordshire was the result of widespread publicity.
Summary With the willing co-operation of colleagues in all branches of the National Health Se~,ice a medico-social survey was held of the home circumstances o'1' cases of accidental hypothermia arising in Hertfordshire during the winters of I966-7 and 1967-8. There wei'e 25 cases reported, 15 of which were fatal. In many of these cases the death appeared to be the result of the primary disease,
ACCIDEN'I A c. HY POTHER MIA IN HERTFORDStl IRE
239
not the hypothermia. It is difficult to suggest any further simple specific measures in addition to thos/e recommended by the B.M.A. M e m o r a n d u m on accidental hypothermia (1964) and the report of the Committee on Accidental Hypothermia o f the Royal Col/~ege of Physicians (1966) to reduce the morbidity and mortality from this condition. My thanks a~,e due to Dr G. W. Knight, County Medical Officer, for his encouragemerit, to the Research Panel (Project No. 68/10) of the Health and Welfare Department for much help~'ul criticism, to colleagues in hospital and general practice for reporting cases and to the Divisional Medical Officers and health visitors who were concerned with this study.
References BRIrls!I MEDICALASSOCIATION]~.4EMORANDUM(1964). Br. reed. J. ii, [255, MACMILLAN, A. L., CORBETT, ,|. L., JOHNSON, R. H., CRAMPTON-S,MITIi, A,, SPALDING, J. M. K. & WOLLNER, L. (1967). Lancet, i, 165. REPORT OF COMMITTEE ON ACCIDENTAL HYPOTItERMIA (1966). London : Royal Coltcge of Physicians. RosIN, A. J. & EXToN-SMrrt4, A. N. (1964). Br. mecL J. i, 16. S.M.O.H. REr'ORTOF HYPOTHERM1ASu~-COMM~TTE~(1968).Publ. Hith. Lond. 82, 223, \VOLL~ER, L. (t967). Geront. clin. 9, 347.