TEMPERATURES IN AMBULANCES

1257

council services under local government would be to go outside its terms of reference. Nonetheless, there can be little doubt that the Royal Commission favours such a

Special Articles

step : it would have merit in more democratic control of the service and in more efficient administration. The report notes that if other kinds of body were to administer the N.H.S. special arrangements would be needed to ensure cooperation between these bodies, the new local-authority social-services departments, and those public-health functions remaining with local government. Finance would not be a bar to this proposal since elsewhere in their report Lord Redcliffe-Maud and his colleagues argue the need for alternative sources of revenue for local government. The more efficient managerial units proposed would, the report says, be sensitive to the wishes of the people both in regard to the standard and humanity of the service and to its cost. To reorganise the N.H.S. under local government need not mean that general practitioners and hospitals would be under the direct control of local councillors. The elected representatives could be responsible for general policy and " for coordination : the executive, consisting mainly of professionals ", would take charge of building and running the hospitals and administering the general-practitioner service within this policy. However, if the nominated-boards idea wins the day the new local authorities should at least appoint a substantial proportion, if not a majority, of the board members ", and it would be essential that the boundaries of any such boards should be coterminous with those of the new local authorities, singly or in combination.

TEMPERATURES IN AMBULANCES L. E. MOUNT

TREVOR P. MANN

FROM THE ROYAL ALEXANDRA HOSPITAL FOR SICK AND THE AGRICULTURAL RESEARCH

CHILDREN, BRIGHTON,

COUNCIL INSTITUTE OF ANIMAL

PHYSIOLOGY, BABRAHAM, CAMBRIDGE

VARIATIONS in temperature inside an ambulance are clearly related to the external temperature and to the frequency with which the doors of the vehicle are opened and closed, but it is not clear how far these temperature fluctuations are affected by variations in the mean radiant temperature in the ambulance as opposed to the air temperature. We measured air and surface temperatures in a modem Bedford-Wadham ambulance on Feb. 27, 1968, between 2.31 and 3.55 P.M. During this period, the ambulance

TIMING

should be carried out simultaneously the whole country, and the new system should come into force as soon as possible after the necessary legislation has been passed. On one Appointed Day, the new representatives would be elected, and after a period of coexistence with the old authorities, the new ones would take over. The interval might be about a year. Welcoming the report in principle, the Government has announced its aim of producing a white-paper by the end of this year.3 The introduction of a new structure by 1974 cannot be ruled out.

Reorganisation

over

DISSENT

Three members of the Royal Commission had reservations about some of the details of the report, but a fourth, Mr. Senior, disagreed profoundly with the principles on which the plans had been drawn up. His dissenting memorandum 4 describes a different structure, and his views on the N.H.S. are more forthright than those of his colleagues. He suggests a predominantly two-tier structure comprising 35 regional and 148 district authorities, with " common councils " at the grass-roots level and provincial councils above. Paving the way for the unification of the N.H.S. was, in his view, " a cardinal purpose of any restructuring of local government". Now that the unification of the N.H.S. and the radical reform of local government had become practicable simultaneously it was, he says, inconceivable that local government should be reshaped but still left unfitted to be the administrative framework for a unified service. In his scheme the directly elected district authorities would be responsible for the personal social services and for the Health Service. 3. Hansard (House of Commons), June 11, 1969, col. 1460. 4. Royal Commission on Local Government in England 1966-1969: report, vol. II, memorandum of dissent by Mr. D. Senior. Cmnd. 4040-I. H.M. Stationery Office. Pp. 275. 27s. 6d.

Air, roof, and window temperatures in an ambulance travelling between hospitals; external temperature, 6°C. R.A.H.=Royal Alexandra Hospital for Sick Children.

B.G.H.=Brighton General Hospital.

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Mental Health

was travelling between hospitals in Brighton; for part of the time the ambulance was taking an infant from one hospital to another. Two adults were inside the ambulance for most of the period, and they were joined by a third for the remainder (2.49 to 3.00 P.M., and 3.19 to

3.30 P.M.). The day was clear, crisp, and sunny, with a mean temperature during the run of 6°C and a wind speed of approximately 7 m.p.h. (about 11 k.p.h.). Air temperature in the vehicle was measured by a thermistor suspended centrally. The internal surface temperatures of the windows and roof were determined from thermistors attached to the surfaces by adhesive tape. The results obtained are given in the figure. Variations in the weather are referred to along the time-axis of the figure, and in addition the occasions when the ambulance heater was on or off and when the doors were open or closed are also indicated. The chief variations in air temperature were associated with the opening and closing of doors, and with the operation of the heater. The changes in air temperature (maximum minus minimum 17’2°C) were greater than the variations either of the internal-roof-surface temperature (maximum minus minimum 9-4°C) or of the window temperature (maximum minus minimum 3’9°C). The mean air temperature over the period of recording was 16-9°C, the mean roof temperature was 156°C, and the mean window temperature 10-8°C. These may be combined to give an " environmental temperature ", which incorporates the effects of both convective and radiant heat transfer,’ of about 16°C. The largest component of environmental variation was associated with changes in air temperature, and not with changes in surface temperatures. These surface temperatures determined the mean radiant temperature, but this was less than air temperature. Considering now an incubator carried in the type of ambulance studied, if the mean environmental temperature in the ambulance was considered to be 16°C and the incubator air temperature 32°C, the incubator wall2 would be at about 25 °C. The mean environmental temperature for the baby inside the incubator would therefore be approximately (32+25)/2-i.e., 28-5°C, considerably below the temperature indicated by the incubator thermometer. For practical purposes, the ambulance was like a room at about 16°C (i.e., mean of radiant and convective effects) with doors opening and closing and letting in draughts of cold air. The effects on adults and on incubators and the babies inside them would be those to be expected under such conditions-that is, not extreme, but perhaps uncomfortable for the adults, and potentially serious for babies. In this connection the high incidence of hypothermia amongst babies with congenital malformations of the central nervous system3 is important. We thank Dr. W. S. Parker and Mr. A. J. Sumpter for their interest and cooperation. Air and surface temperatures were measured by thermistor probes supplied by Light Laboratories, Brighton. Requests for reprints should be addressed to T. P. M., Royal Alexandra Hospital for Sick Children, Brighton BN1 3JN,

THE GAS-LIGHT PHENOMENON RUSSELL BARTON FROM SEVERALLS

HOSPITAL, COLCHESTER,

AND PRESTWICH

HOSPITAL,

MANCHESTER

THE play Gas Light by Patrick Hamiltonis a classic piece of 20th century victoriana. Its theme is a husband’s plot to get rid of his wife by driving her into a lunatic asylum. The medical literature does not appear to have many accounts of plots of this type. A select committee of the House of Commons in 1763 concluded that some people were committed to asylums as a method of solving family and social problems.2 Several workers have put forward various ideas on rejection as a cause of mental illness; and in 1965 some concern was shown over misuse of Section 29 of the Mental Health Act 1959.3-6 We describe here two cases in which there were definite plots to remove an unwanted and restricting relative by securing admission to a mental hospital, and one case of an old lady admitted to a mental hospital following induced incontinence. Unimportant details in the case-records have been changed to prevent identification of the patients and their families by people connected with them but unaware of what happened. CASE-RECORDS

Case 1 Mr. A.

admitted one evening to a psychiatric hospital as His general practitioner, when asking for his admission, had said he was mentally "ill and had attacked his wife. He came into hospital as an informal " patient but was accompanied by a mental welfare officer, who confirmed the story of violence. On admission the patient said he had felt tense and depressed for about six months and related this to his wife’s changed attitude towards him. He said she had become " cold ", and he thought she might have been seeing another man. He denied he had been violent and thought he had been sent into hospital because of his " nerves ". He was a mechanic of 48 who had been married for ten years and had three children. He had never been ill before and did not think there had been any mental illness in his family. He described symptoms of anxiety and depression which fluctuated according to his wife’s behaviour. He felt better when she was affectionate and worse when she was " cold " towards him. His wife said he had changed during the previous six months, and had become irritable, bad-tempered, and liable to unprovoked violent outbursts in which he sometimes hit her and once struck her with a hatchet. She also claimed that his he lost his way in places had deteriorated and that memory previously familiar to him. She denied having changed in her attitude towards him and said there was no truth in his accusation that she had been associating with another man. When examined, the patient was found to be rather tense but otherwise there was no clinical evidence of either mental or physical disease. He remained in hospital for twelve days and became more relaxed without any specific treatment. No signs of irritability or violent behaviour were observed, and he appeared to function at a fairly normal level. Investigations were all normal; and psychological testing produced results within the normal range. an

was

emergency.

1. 2.

Hamilton, P. Gas Light. London, 1939. Leigh, D. The Historical Development of British Psychiatry. Oxford,

3. 4. 5. 6.

Barton, R., Haider, I. Lancet, 1965, i, 912. Enoch, M. D., Barker, J. C. ibid. p. 760. Whitehead, J. A. ibid. p. 865. Barton, R., Haider, I. Medicine, Sci. Law, 1966, 4, 147.

1961.

Sussex1. Mount, L. E. The Climatic Physiology of the Pig. London, 1968. 2. Hey, E. N., Mount, L. E. Archs Dis. Childh. 1967, 42, 75. 3. Accidental Hypothermia. Royal College of Physicians of London, 1966.

J. A. WHITEHEAD