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A NEW TILTABLE BED:
568 information. This can be applied to any organism which, when grown in blood, alters it so that the colonies are recognisable in slide-cells. Most of the pyogenic cocci, haemolytic B. coli, diphtheria bacilli and others can be tested in this way. We suggest that when time does not press it would be good practice to test the sensitivity of the infecting organism to M. & B. 693 or sulphanilamide by the method we have described, either in normal human defibrinated blood or in the patient’s own blood. If the organism is very sensitive the chemical could be administered with the expectation of a good result. If the organism is only moderately sensitive then it is likely that, to obtain a good result, serum or vaccine treatment would have to be combined with chemotherapy, while if the infecting organism is quite insensitive there would be little hope of benefit accruing from the administration of the drug, and the patient might be spared its possible toxic
manifestations.
Summary A method is described by which the sensitivity of a microbe to M. & B. 693 can be tested in vitro. By this method pneumococci have been found to vary enormously in their sensitivity to the drug and this variation is not associated with the type of pneumococcus but with the individual strain. Experiments in mice confirm the results obtained in vitro. It is suggested that wherever possible such a test should be carried out and according to the result obtained forecasts can be made as to the result likely to be obtained with 693 treatment. If the infecting organism is very sensitive simple treatment with the drug will probably be effective ; if it is only moderately sensitive it is very likely that some increase in immunity will be necessary in addition to 693 treatment ; but if the organism is insensitive to 693 in concentrations which can be attained in the human body there is no justification for embarking on a course of 693 treatment, which cannot do good and may have serious toxic effects. In the second part of the paper it is shown that a single dose of pneumococcus vaccine given to mice or rabbits profoundly affects the course of an experimental infection in these animals when treated with M. & B. 693, and a strong case is made out for the combined use of vaccines and M. & B. 693 in all cases of pneumonia in man. In the concluding part experiments are cited which prove that pneumococci can, in an infected animal treated with 693, readily establish a tolerance or fastness to the drug. This makes it essential that the initial doses should be large, and also-as M. & B. 693 merely interferes with the growth of the bacteria and the body has to do the actual killing-it is essential that the immunity should be raised to as high a degree as possible by any means, active or passive, specific or non-specific, so that the destruction of the bacteria may be complete before they have established tolerance to the drug. REFERENCES
Barach, A. L. (1931) J. exp. Med. 53, 567. Cokkinis, A. J., and McElligott, G. L. M. (1938) Lancet, 2, 355. De, S. P., and Basu, V. P. (1938) Brit. med. J. 2, 564. Fleming, A. (1938a) Lancet, 2, 74. (1938b) Ibid, p. 564. Loewenthal, H. (1939) Ibid, Jan. 28, p. 197. de Smidt, F. P. G. (1938) Brit. med. J. 2, 1140. Whitby, L. E. H. (1938a) Lancet, 1, 1210. (1938b) Ibid, 2, 1095. Willcox, W. H., and Morgan, W. P. (1909) Ibid, 2, 471. Wynn, W. H. (1936) Brit. med. J. 1, 45. -
A NEW TILTABLE BED: ITS MEDICAL USES
BY F. C.
EVE, M.D. Camb., F.R.C.P.
SENIOR CONSULTING PHYSICIAN TO THE ROYAL INFIRMARY, AND SENIOR PHYSICIAN TO THE VICTORIA HOSPITAL FOR
CHILDREN, HULL
WE
ourselves clinicians-from the Greek bed-but do we not forget that the bed is xÀv1J, It has remained our chief clinical implement ? unaltered during the twenty-five centuries since Tutankhamen ; hence we are apt to take the all. important bed for granted and to leave it too much to the nurses. True, we now have the excellent cardiac beds which lift the knees and back; but these are costly, complicated, and liable to rust, and wrongly assume a constant length of thigh. Moreover they do not provide the invaluable head-down tilt. Bed-blocks give the very ineffective tilt of 1 in 6 (10 degrees). Hence I have designed a cheap and simple tiltable bed, now manufactured to clinical requirements by Messrs. Siddall and Hilton, of Sowerby Bridge, Yorkshire. The figure shows how it can be tilted and clamped at any desired angle, headA check-cord is an additional, if up or feet-up. call
a
redundant, precaution. I found that such a bed was useless without an efficient and adaptable bed-donkey, which did not exist. This was contrived (see figure) from an inverted hammock of webbing, supported between two arched iron rods. In the foot-down tilt the patient reclines on the bed and sits on the donkey, which also supports his legs. If his thighs are short, two lateral straps are slackened and the whole hammock lowers to fit him. His heels touch neither bed nor donkey, thus avoiding heel-pain or bedsores. If his legs are extra long, a pillow under his buttocks makes him fit the donkey. The Fowler or cardiac posture is thus attained (see figure) with much of his weight transferred from his buttocks to his thighs. This avoids bedsores and the On an wearisome pains in the bent lower back. ordinary bed the Fowler position usually entails a bent spine and hence a bulging abdomen, conducive to flatus and stretched stitches. Moreover a helpless patient slips, and needs that exhausting and repeated hoisting which is such a reproach to the clinician. This is prevented absolutely by two cords or straps that secure the donkey to the bed-frame. The hot bottle (coverless) is housed under the arch of the donkey, where it cannot touch the patient’s skin, but the warmth rises. An arched rod takes off the weight of the bedclothes. Foot-drop is prevented by a pillow or board (15 x 11 in.) tied to the arches of the donkey by four strings. In swollen legs or phlebitis the donkey is reversed to provide an effective slope, quickly emptying a " white leg." In the tropics this donkey would be much cooler for the legs than is the usual " Dutch wife " bolster. In the afternoon rest of tired ladies the donkey, on bed or couch, produces a restful relaxation of every muscle. This I confirmed by that the stimulus to produce a kneeneeded finding jerk is, in anxious patients, a half or a third of that needed in the crossed-knee sitting posture. This perfect relaxation should help patients during psychoanalysis or for hypnosis. SOME MEDICAL USES
-
The feet-doum tilt secures without cardiac posture needed in bad hearts,
slipping the asthma, and
569 In a case of renal with ascites, under Dr.
pneumonia. anasarca
D. C. in the
Muir, multiple punctures legs-with a mackintosh
at the bedand 6 pints of fluid on the first, second, and third days respectively. The tilt also caused the ascites to empty. Sir Arthur Hurst tells me that he has never seen sepsis occur in these incisions ; neither have I. For bed-weary patients, perhaps
leading to a bucket foot-yielded 10, 8,
with backache or congested lungs, the mere change of tilt is useful ; all the pressure-points and directions of pull and sag are altered. I have observed distended patients belching abundantly when shifted from the horizontal to the Fowler
posture. In the head-down position the bed opens up new possibilities. In abscess of the lung, bronchiectasis, or difficult expectoration postural drainage is secured. After certain poison gases the excessive and suffocating bronchial secretion should drain mouthwards. In diphtheria with
tilting
of Fowler position. Patient reclines on bed with flat abdomen without fear of slipping. General muscular relaxation saves energy and encourages sleep which does
Composite photograph straight spine and not alter
posture.
pharyngeal paralysis head-down tilt may save life by draining away mucus. Bedblocks are often inadequate. The " death rattle" is produced by thin mucus surging up and down the trachea, which the patient is powerless to expel. This need not be assumed to be fatal, for a head-down tilt soon stops the horrible noise, and complete recovery may follow-as I have seen in diphtheritic paralysis of the diaphragm and in severe meningitis. Deglutition pneumonia may be avoided by a steep head-down tilt (blocks being useless) because I have found that the patient can easily swallow uphill, but the fluid food cannot flow into the trachea uphill. A desperate meningitis case, needing 15 cisternal punctures in the first month, was saved by this uphill feeding (Eve 1937). Artificial respiration can be performed with the tiltable bed by my rocking method (Killick and The bed is merely rocked about 30 Eve 1933). degrees up and down a dozen times a minute by relations or other volunteers. The weight of the abdominal contents pushes and pulls at the inert diaphragm, securing a pulmonary ventilation equal to or exceeding Schaefer’s method. After a few days of this, recovery is quite likely to occur-in two days after my first diphtheritic diaphragm case (Eve 1932) and after eight days’ rocking in Dr. Kerr’s recent severe poliomyelitis case at Grimsby a
(Kerr 1939). Thus a tilting bed can meet these tragic emergencies with the necessary promptitude, and the rare long cases can later be put into an iron lung " if preferred. But this demands so much storage and such very expert nursing (Gauvain 1938) that I believe a rocking bed will prove the cheapest and simplest solution of this problem. The bed fits any patient and allows access to any nurse anywhere. Enterprising Grimsby has already authorised one driven by a small electric "
motor. The rocking method of artificial respiration has been criticised as likely to produce sea-sickness. I
have not seen it occur, and Mr. W. Riley tells me that in his extensive experience of the rocking stretcher with trainees and resuscitations at the Wakefield Central Rescue Station he has met with only one case -that of carbon-monoxide poisoning in a youth who recently had a heavy meal (treatment successful). I can only surmise that this curious immunity may be due to hyperventilation-similar to the 75 per cent. cure of sea-sickness by oxygen inhalation recently reported by Boothby (1938) of the Mayo Clinic. Hence, if sea-sickness did occur with rocking, the addition of oxygen by mask or nasal catheter should alleviate. To sum up, the tiltable bed and donkey have been designed to convert gravity-that ancient enemy of the nurse and of her helpless patient in bed-into a friend. Clinicians can conduct their postural therapy in three dimensions rather than in two. A new field, which might be called gravitational nursing, needs
developing. I wish I could here thank individually all those doctors and nurses at the Hull Royal Infirmary and at our Isolation and Children’s Hospitals who have helped so much-besides the manufacturers-to worry out these mechanical, medical, and nursing
problems. REFERENCES
Eve, F. C. (1932) Lancet, 2, 995. (1937) Clin. J. 66, 426. Gauvain, H. (1938) Lancet, 2, 1327. Kerr, J. A. (1939) Ibid, Jan. 7, p. 24. Killick, E. M., and Eve, F. C. (1933) Ibid, 2, 740. -
THE Rockefeller Foundation have announced that
during the next seven years they will grant a sum not exceeding :tl2,OOO to the Imperial College of Science and Technology, South Kensington, for research on vitamins, sterols, and related compounds. The work will be carried out under the direction of the professor of organic chemistry, Prof. 1. M. Heilbron, F.R.S.
manifestations.
Summary A method is described by which the sensitivity of a microbe to M. & B. 693 can be tested in vitro. By this method pneumococci have been found to vary enormously in their sensitivity to the drug and this variation is not associated with the type of pneumococcus but with the individual strain. Experiments in mice confirm the results obtained in vitro. It is suggested that wherever possible such a test should be carried out and according to the result obtained forecasts can be made as to the result likely to be obtained with 693 treatment. If the infecting organism is very sensitive simple treatment with the drug will probably be effective ; if it is only moderately sensitive it is very likely that some increase in immunity will be necessary in addition to 693 treatment ; but if the organism is insensitive to 693 in concentrations which can be attained in the human body there is no justification for embarking on a course of 693 treatment, which cannot do good and may have serious toxic effects. In the second part of the paper it is shown that a single dose of pneumococcus vaccine given to mice or rabbits profoundly affects the course of an experimental infection in these animals when treated with M. & B. 693, and a strong case is made out for the combined use of vaccines and M. & B. 693 in all cases of pneumonia in man. In the concluding part experiments are cited which prove that pneumococci can, in an infected animal treated with 693, readily establish a tolerance or fastness to the drug. This makes it essential that the initial doses should be large, and also-as M. & B. 693 merely interferes with the growth of the bacteria and the body has to do the actual killing-it is essential that the immunity should be raised to as high a degree as possible by any means, active or passive, specific or non-specific, so that the destruction of the bacteria may be complete before they have established tolerance to the drug. REFERENCES
Barach, A. L. (1931) J. exp. Med. 53, 567. Cokkinis, A. J., and McElligott, G. L. M. (1938) Lancet, 2, 355. De, S. P., and Basu, V. P. (1938) Brit. med. J. 2, 564. Fleming, A. (1938a) Lancet, 2, 74. (1938b) Ibid, p. 564. Loewenthal, H. (1939) Ibid, Jan. 28, p. 197. de Smidt, F. P. G. (1938) Brit. med. J. 2, 1140. Whitby, L. E. H. (1938a) Lancet, 1, 1210. (1938b) Ibid, 2, 1095. Willcox, W. H., and Morgan, W. P. (1909) Ibid, 2, 471. Wynn, W. H. (1936) Brit. med. J. 1, 45. -
A NEW TILTABLE BED: ITS MEDICAL USES
BY F. C.
EVE, M.D. Camb., F.R.C.P.
SENIOR CONSULTING PHYSICIAN TO THE ROYAL INFIRMARY, AND SENIOR PHYSICIAN TO THE VICTORIA HOSPITAL FOR
CHILDREN, HULL
WE
ourselves clinicians-from the Greek bed-but do we not forget that the bed is xÀv1J, It has remained our chief clinical implement ? unaltered during the twenty-five centuries since Tutankhamen ; hence we are apt to take the all. important bed for granted and to leave it too much to the nurses. True, we now have the excellent cardiac beds which lift the knees and back; but these are costly, complicated, and liable to rust, and wrongly assume a constant length of thigh. Moreover they do not provide the invaluable head-down tilt. Bed-blocks give the very ineffective tilt of 1 in 6 (10 degrees). Hence I have designed a cheap and simple tiltable bed, now manufactured to clinical requirements by Messrs. Siddall and Hilton, of Sowerby Bridge, Yorkshire. The figure shows how it can be tilted and clamped at any desired angle, headA check-cord is an additional, if up or feet-up. call
a
redundant, precaution. I found that such a bed was useless without an efficient and adaptable bed-donkey, which did not exist. This was contrived (see figure) from an inverted hammock of webbing, supported between two arched iron rods. In the foot-down tilt the patient reclines on the bed and sits on the donkey, which also supports his legs. If his thighs are short, two lateral straps are slackened and the whole hammock lowers to fit him. His heels touch neither bed nor donkey, thus avoiding heel-pain or bedsores. If his legs are extra long, a pillow under his buttocks makes him fit the donkey. The Fowler or cardiac posture is thus attained (see figure) with much of his weight transferred from his buttocks to his thighs. This avoids bedsores and the On an wearisome pains in the bent lower back. ordinary bed the Fowler position usually entails a bent spine and hence a bulging abdomen, conducive to flatus and stretched stitches. Moreover a helpless patient slips, and needs that exhausting and repeated hoisting which is such a reproach to the clinician. This is prevented absolutely by two cords or straps that secure the donkey to the bed-frame. The hot bottle (coverless) is housed under the arch of the donkey, where it cannot touch the patient’s skin, but the warmth rises. An arched rod takes off the weight of the bedclothes. Foot-drop is prevented by a pillow or board (15 x 11 in.) tied to the arches of the donkey by four strings. In swollen legs or phlebitis the donkey is reversed to provide an effective slope, quickly emptying a " white leg." In the tropics this donkey would be much cooler for the legs than is the usual " Dutch wife " bolster. In the afternoon rest of tired ladies the donkey, on bed or couch, produces a restful relaxation of every muscle. This I confirmed by that the stimulus to produce a kneeneeded finding jerk is, in anxious patients, a half or a third of that needed in the crossed-knee sitting posture. This perfect relaxation should help patients during psychoanalysis or for hypnosis. SOME MEDICAL USES
-
The feet-doum tilt secures without cardiac posture needed in bad hearts,
slipping the asthma, and
569 In a case of renal with ascites, under Dr.
pneumonia. anasarca
D. C. in the
Muir, multiple punctures legs-with a mackintosh
at the bedand 6 pints of fluid on the first, second, and third days respectively. The tilt also caused the ascites to empty. Sir Arthur Hurst tells me that he has never seen sepsis occur in these incisions ; neither have I. For bed-weary patients, perhaps
leading to a bucket foot-yielded 10, 8,
with backache or congested lungs, the mere change of tilt is useful ; all the pressure-points and directions of pull and sag are altered. I have observed distended patients belching abundantly when shifted from the horizontal to the Fowler
posture. In the head-down position the bed opens up new possibilities. In abscess of the lung, bronchiectasis, or difficult expectoration postural drainage is secured. After certain poison gases the excessive and suffocating bronchial secretion should drain mouthwards. In diphtheria with
tilting
of Fowler position. Patient reclines on bed with flat abdomen without fear of slipping. General muscular relaxation saves energy and encourages sleep which does
Composite photograph straight spine and not alter
posture.
pharyngeal paralysis head-down tilt may save life by draining away mucus. Bedblocks are often inadequate. The " death rattle" is produced by thin mucus surging up and down the trachea, which the patient is powerless to expel. This need not be assumed to be fatal, for a head-down tilt soon stops the horrible noise, and complete recovery may follow-as I have seen in diphtheritic paralysis of the diaphragm and in severe meningitis. Deglutition pneumonia may be avoided by a steep head-down tilt (blocks being useless) because I have found that the patient can easily swallow uphill, but the fluid food cannot flow into the trachea uphill. A desperate meningitis case, needing 15 cisternal punctures in the first month, was saved by this uphill feeding (Eve 1937). Artificial respiration can be performed with the tiltable bed by my rocking method (Killick and The bed is merely rocked about 30 Eve 1933). degrees up and down a dozen times a minute by relations or other volunteers. The weight of the abdominal contents pushes and pulls at the inert diaphragm, securing a pulmonary ventilation equal to or exceeding Schaefer’s method. After a few days of this, recovery is quite likely to occur-in two days after my first diphtheritic diaphragm case (Eve 1932) and after eight days’ rocking in Dr. Kerr’s recent severe poliomyelitis case at Grimsby a
(Kerr 1939). Thus a tilting bed can meet these tragic emergencies with the necessary promptitude, and the rare long cases can later be put into an iron lung " if preferred. But this demands so much storage and such very expert nursing (Gauvain 1938) that I believe a rocking bed will prove the cheapest and simplest solution of this problem. The bed fits any patient and allows access to any nurse anywhere. Enterprising Grimsby has already authorised one driven by a small electric "
motor. The rocking method of artificial respiration has been criticised as likely to produce sea-sickness. I
have not seen it occur, and Mr. W. Riley tells me that in his extensive experience of the rocking stretcher with trainees and resuscitations at the Wakefield Central Rescue Station he has met with only one case -that of carbon-monoxide poisoning in a youth who recently had a heavy meal (treatment successful). I can only surmise that this curious immunity may be due to hyperventilation-similar to the 75 per cent. cure of sea-sickness by oxygen inhalation recently reported by Boothby (1938) of the Mayo Clinic. Hence, if sea-sickness did occur with rocking, the addition of oxygen by mask or nasal catheter should alleviate. To sum up, the tiltable bed and donkey have been designed to convert gravity-that ancient enemy of the nurse and of her helpless patient in bed-into a friend. Clinicians can conduct their postural therapy in three dimensions rather than in two. A new field, which might be called gravitational nursing, needs
developing. I wish I could here thank individually all those doctors and nurses at the Hull Royal Infirmary and at our Isolation and Children’s Hospitals who have helped so much-besides the manufacturers-to worry out these mechanical, medical, and nursing
problems. REFERENCES
Eve, F. C. (1932) Lancet, 2, 995. (1937) Clin. J. 66, 426. Gauvain, H. (1938) Lancet, 2, 1327. Kerr, J. A. (1939) Ibid, Jan. 7, p. 24. Killick, E. M., and Eve, F. C. (1933) Ibid, 2, 740. -
THE Rockefeller Foundation have announced that
during the next seven years they will grant a sum not exceeding :tl2,OOO to the Imperial College of Science and Technology, South Kensington, for research on vitamins, sterols, and related compounds. The work will be carried out under the direction of the professor of organic chemistry, Prof. 1. M. Heilbron, F.R.S.