288 4 February 1967
NEW APPLIANCES
New Turning-tilting Bed and Head-traction UnitSir LUDWIG GUTTMANN, of the NationalSpinal Injuries Centre, Stoke MandevilleHospital, Aylesbury, Bucks, writes: Thecare and management of any seriously illpatient after injury or disease places heavydemands on both nursing and medical staffif complications from recumbency, such aspressure sores, lung complications, and stasisin the urinary tract leading to ascending infec-tion and stone formation, are to be avoided.People paralysed as a result of fractures orfracture-dislocations of the spine have alwaysbeen particularly prone to these complica-tions on account of their bladder paralysisand the initial loss of vasomotor control andtone of all tissues in the paralysed area,resulting in the lowering of tissue resistanceto pressure. It is true that these complica-tions can be avoided by the employment ofpillows or sorbo-rubber packs, combined withregular two-hourly turning day and nightfrom the supine to the lateral position. How-ever, four persons are necessary, especiallyin the early stages after paraplegia or tetra-plegia, to carry this out properly, and thestrain on the nursing staff is only too obvious.Because of the high survival rate of traumaticparaplegics and tetraplegics, even those asso-ciated with severe injuries to the chest andother parts of the body, on the one hand,and the increasing difficulty in obtainingadequate nursing staff on the other, turning-beds have been introduced. The best knownis the Stryker frame and its modifications.However, this type of turning-frame has itsdisadvantages in the management of fracture-dislocations, especially those of the thoracicand lumbar vertebrae. While in such aframe, with rolls placed underneath thefracture to reduce the fracture-dislocation,hyperextension by posture can be achieved inthe supine position, this cannot be main-tained when turning the patient on to theabdominal position, which is the only alterna-tive in this type of turning-bed. Thus theobject of maintaining hyperextension tosecure realignment and promote stability ofthe broken spine is defeated. Moreover, intraumatic paraplegics with associated frac-tures of the ribs, pelvis, or long bones, andin particular patients with haemothorax orpneumothorax (let alone those who are un-
conscious), turning on to the abdominalposition is clearly too hazardous and usuallycontraindicated. If such patients have tomaintain their recumbency in the supineposition day and night, owing to lack of
regular turning from the supine to the lateralposition, early development of pressure soresis inevitable.
For some time I have been engaged in thedevelopment of an electrically operatedturning-bed on which hyperextension oftraumatic paraplegics could be maintainedwhile the patients were turned from thesupine to the lateral position in the sameway as it is done manually. This aim hasnow been achieved since Egerton EngineeringLimited succeeded in designing such a bed(A. C. Egerton Engineering Ltd., Tower Hill,Horsham, Sussex).Two types of bed have been constructed:
one which allows turning only from thesupine to the lateral position; the otherwhich, in addition to this turning, can alsobe tilted up and down. Both types have hadextensive trials in this centre, and it has beenproved that postural reduction of fracture-dislocations of even the most severe type canbe maintained safely during the turning pro-cedure. Moreover, permanent recumbencyin the supine position is avoided, and thusstagnation in the urinary tract as well asthe development of pressure sores can beprevented.The following details of the construction
of the Egerton/Stoke Mandeville turning-and-tilting bed demonstrate the managementof a traumatic tetraplegic patient. The bedis constructed in mild steel tubing, and thetubes are electrically welded. The height ofthe bed (to top of mattress) is 30* in.(77 cm.), the length of the bed-frame is92i in. (235 cm.), and the width is 451 in.(116 cm.). The bed is mounted on 7-in.(18-cm.) castors, which have brakes, and thehead and foot rails are detachable, givingeasy access to the patient. The bed is con-structed in such a way that it can easily bebroken down for shipping quantities of beds,and at its destination easily reassembled.The bed is provided with a three-sectional
polyester mattress of G14 density. Themattress platform is divided longitudinallyinto two parts, each part two-thirds of thebed's width, bothparts being hingedat the top. Thisallows movementof the patient to --take place without -----
compressing thesurface of the mat-
tress, and thus avoids creases on the patient'sbody. Symmetry is retained on the bed bya low tubular rail, which makes it impossiblefor the three sectional parts of the mattressto overlap at any point.The turning of the bed is accomplished
by the action of two small single-phaseelectric motors fixed on either side of thebed and connected with a threaded shaft.Each motor has its own switch-box, whichoperates the motor facing the attendant. Bypushing the button, each side of the bed islifted, and thus the patient can be turnedfrom the supine position to a 70 degreeslateral position in a few seconds (Figs. 1
and 2). Adjustments to the switch-box arepossible to allow patients in later stages ofparaplegia or tetraplegia, especially those whohave been provided with a turning-bed athome, to carry out the turning of the bedthemselves by operating a switch from thebed, either by hand or, as in the case ofhigh cervical lesions with paralysis of allmuscles of the upper limbs, by mouth withthe aid of a tube. As the motors areindependent it is possible, during turning,to raise slightly the side of the bed on whichthe patient rests. This eliminates any possi-bility of slipping, and gives the patient anadded feeling of security. Furthermore, thepatient can be tilted manually by a handle,head and feet up or down, to a maximumangle of 14 degrees (Fig. 3). No matter towhat angle or how often patients are turned,they always return to the centre of the bed.The tilting mechanism can, of course, if sodesired, be operated electrically instead ofmanually.
GUTTMANN HEAD-TRACTION UNIT
For the treatment of traumatic tetraplegicsafter fracture-dislocation of the cervical spine,both the turning and turning-tilting bed canbe provided, as can any other hospital bed,with any type of skull calliper described byCrutchfield, Blackburn, Cone, and others.However, it must be remembered that, what-
FIG. 1
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4 February 1967 New Appliances
FIG. 3
ever the type of bed used for skull tractionin the treatment of the broken cervical spine,it is necessary to disconnect the traction cordof the pulley and weights when turning thepatient from the supine to the lateral position.Consequently, the person who has the taskof holding the skull calliper in extension andtraction has at the same time to support thehead during the turning procedure. There-fore greatest care has to be exercised tokeep the head in line with the axis throughthe length of the body in order to preventany torsion of the neck which could resultin redislocation of the broken spine. Further-more, the person who is holding the headmust delay reconnexion of the traction cordto the weight until all arrangements havebeen made to secure the proper lateralpositioning of the head on special pillowsupports, in line with the axis of the body.All this can now be avoided by the employ-ment of a special head-traction unit which hasbeen designed to my instructions primarilyfor use with either of the Egerton/StokeMandeville beds. The head-traction unitwill allow the patient to be turned from sideto side at frequent intervals without anydiscontinuation of the skull-traction cord; thehead will remain in line with the axis throughthe length of the body, and correct tractionwill be maintained during the process ofturning.
The new device con-
sists of: (1) a traywhich is placed under
the central section ofthe three-sectionalmattress (2) two long
square pillars to which@ -Iare attached the stems
that carry the facepads; (3) the centralpulley set, which canbe raised or lowered;
..._ and (4) the containerfor the weights. Fig.
4 shows these details.
This equipment has
been designed tosimplify the procedureof turning these
patients and at the same time ensure effici-ency so that the turning can be done quicklyby the nursing staff or ward orderlies. Toprepare the head-traction unit for use thetray is placed underneath the central sectionof the three-sectional mattress and the longsquare pillars to which are attached thestems which carry the face pads. The patientis then placed in position, and the centralpulley is raised or lowered by means of theknurled wheel directly beneath it to bringit into direct line with the traction cord ofthe calliper, which is then passed over thepulley and wound round and through thespiral attachment below the knurled wheel.The container for the weights is then attachedto the cord, and the appropriate weights are
inserted.The height of the arms which carry the
face-pads attachment can be adjusted to suiteach individual patient. When this is com-
pleted the patient's head is held firmly butnot harshly in position, and he can be turnedfrom the supine to the lateral position lyingcontinuously with his head on the underlyingface-pad. The correct traction can be main-tained, no matter what degree, from 0 to
70 degrees. Fig. 5 shows the head-tractionunit in action with the patient turnedlaterally. For attending the patient's backfor washing, etc., the head-traction cord andweight can be disconnected from the centralpulley and connected with a hook fixed on a
detachable metal rod. The turning as wellas the turning-tilting bed can, of course, alsobe used for the management of patients withother forms of severe disability or disease,such as high polio cases, rheumatoid arthritis,strokes, and other cerebral lesions.
SUMMARY
Two versions of a new turning-bed calledthe Egerton/Stoke Mandeville turning-bedhave been devised: one allows only turningfrom the supine to a 70-degree lateralposition; the other allows both turning as
well as head-up and head-down tilting to14 degrees. The beds are electrically operatedby motors fixed to either side of the bed.thus facilitating greatly the management ofseverely ill patients, in particular those withparalysis occurring after spinal-cord injuryor disease. Postural reduction of severe
fracture-dislocations can be successfully main-tained during turning and the developmentof pressure sores prevented. The turning-bedcan also be usefully employed in the manage-
ment of other severe disabilities.A new head-traction unit has been devised
for the treatment of traumatic tetraplegicsresulting from fracture-dislocation of thecervical spine. This device allows turningof the patient from side to side withoutdiscontinuation of the skull-traction cord;the head will remain in line with the axisthrough the length of the body, and correcttraction be maintained during the process ofturning.
REFERENCESGuttmann, L. (1956). Practitioner, 176, 157.
(1965). Paraplegia, 3, 193.
TRACTION CORD CENTRE PULLEY
FIG. 4.-Guttmann head-traction unit.
BRMUrsHMEDICAL JOURNAL 289
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