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fluoride prophylaxis in building resistance to caries in boththe deciduous and permanent teeth. I)

RESULTS

705 children took part; 363 in a control and 342in a study group. At the age of three, children in thestudy group had a 57 % lower incidence of caries thanchildren in the control group, who received no sup-plemental fluoride. In five-year-olds the incidencewas decreased by 50% and in six-year-olds by 49%(table).MEAN NUMBER OF DECAYED TEETH SHOWING CUMULATIVE FREQUENCY

AT THE AGE OF 1 TO 6 YR.

* Control group -fluoride groupx 100.

Control group

The result of the effect of fluoride on the six-yearmolars is reflected by 70-80% lower caries incidenceat age seven or eight. A follow-up on a few childrenaged about ten showed that those in the fluoride

group had much better teeth.

DISCUSSION

Opinions differ regarding the best time for startingfluoride administration, either as tablets or drops.Some recommend two years of age, others suggestsix months or a year. All, it would seem, agree thatthe newborn is not harmed by drinking-water withfluoride, even with a high content (>1-2 p.p.m.).Hennon et al. and Margolis et al. in their trials ofvitamin A and D solutions with sodium fluoride

given from birth found no contraindications. 6, 7 Myown experience suggests that fluoride can be adminis-tered from birth without any disadvantage. In the

seven-year period, during which the children in thestudy group received 0-5 mg. of fluorine daily, noside-effects were observed. As regards development,these children differed in no respect from those inthe control group. The only difference detected wasthat the study group showed a statistically confirmedlower incidence of caries above the age of two years.My findings support similar trials where 0-5 mg.of fluorine in vitamin A and D solutions was administered to children daily from birth up to three years. 6,7 7The concentration of fluorine in the drinking-water

in the child’s home district is the factor that shoulddecide how much extra fluoride is to be administeredin vitamin preparations. The Council on Dental

Therapeutics recommends that extra fluoride shouldbe given where the fluorine concentration in thehome district is less than 0-7 p.p.m. For Swedishconditions I recommend that this limit should be setat 0-6 p.p.m.-i.e., children living in places where theconcentration is less than 0-6 p.p.m. would be offeredvitamins A and D plus 0-5 mg. fluorine daily, and

those living in places where the concentration is 0-6p.p.m. or more should be given vitamins A and Dalone. For children above the age of three one mightrecommend the use of fluoride tablets which wouldmix with the saliva when chewed, and have a directsurface effect on the dental enamel. Such a programmewould provide uniform standards.During their thirty years’ existence the child-

welfare centres have won such confidence from the

public that a built-in dental-health programmewould seem to be a welcome development. The workwould consist mainly of individual prophylacticmeasures in the form of dietary advice, with specialemphasis on dental diseases. Mothers and children,moreover, would be taught the importance of mouthhygiene. Extra fluoride would be administered wherethe fluorine concentration in water is low (<0-6p.p.m.) in the child’s place of residence. The adminis-tration of fluoride via vitamin solutions would be fullyexplained and its optional character emphasised.This is important-at least during a transitional

period-in order to relieve doubt and anxiety amongparents caused by inaccurate information abouteventual water fluoridation.The administration of fluoride through the child-

welfare centres makes it possible to reach all children,regardless of place of residence, where the adminis-tration of extra fluoride is indicated. Adequate dosagein combination with other preventive measures, as

well as the optional character of this method, seems torender it superior to all previous forms of fluoridation.

REFERENCES

1. Hamberg, L. Acta pharm. suec. 1967, 4, suppl. no. 1. 2. Statistisk Manadsskrift, 1969, no. 9, Stockholm.3. Hamberg, L. L&auml;kartidningen, 1970, 67, 751. Stockholm.4. Swedish National Board of Health, Stockholm, 1966.5. Reiss, L. Z. Science, 1961, 134, 1669.6. Hennon, D. K., Stookey, G. K., Muhler, J. C. J. Dent. Child.

1966, 33, 3.7. Margolis, F. J., Macauley, J., Freshman, E. Am. J. Dis. Child.

1967, 113, 672.

Hospital Practice

HOSPITAL BEDS

JAMES ANDREWSWest Middlesex Hospital, Isleworth, Middlesex

ALL consultants talk about hospital beds, but feware interested in them. Perhaps this is partly why theScottish Hospital Centre Report had to emphasise:" It is a matter of common knowledge that much bedarea furniture in hospitals is old, uncomfortable andbears little resemblance to the functional requirementsof modern hospital equipment." The report alsoremarked that, in one Scottish area, at the presentrate it would take a hundred years to replace theexisting beds.Those few consultants who do take an interest in

hospital beds and other ward equipment find thatmany of these items are not regarded as medical/surgical equipment but are obtained from a furniture/fitting vote which also controls the financial spendingon such items as general hospital office furniture andmaintenance and renewal of furniture in nurses’

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Basic positions of adjustable hospital springs.

homes. Senior nursing staff and hospital administra-tors are generally present at the committee meetingswhere the financial allocations are made but consul-tants rarely so.

KING’S FUND SPECIFICATION

In 1963 the King’s Fund set up a working-party toprovide a specification for a general-purpose bedstead.It produced a specification 2 for a relatively expensivebedstead which, it has been suggested, might besuitable for perhaps 60 % or more of hospital patients. 3

Perhaps it was unfortunate that the working-partythought in terms of a single general-purpose bedstead.Any one ward may need a variety of bedsteads; but,where there is frequent exchange of patients between acoronary-care unit and general medical wards, uni-formly rigid-based beds, with the same height-rangeand methods of adjustment, are an advantage.The King’s Fund flat-rigid design of bed base,

which four manufacturers are currently marketing,suits certain types of patients such as orthopaedic andcoronary-care patients and those undergoing proce-dures such as lumbar punctures. Official agreementhas now been reached for a specification of 24 in. (61cm.) fixed-height bedstead 4 similar in other respectsto the King’s Fund specification, and four manufac-turers are also already marketing such a bedstead.A fixed height is satisfactory for patients undergoingminor surgery or any patients needing inpatientinvestigation and treatment who have no serious loco-motor disability. However, the British Standard 24in. bedstead has proved too high for the care andrehabilitation of physically handicapped patients. 5,6It has now been suggested that elderly patientsshould have an extra thick mattress 5 in. (13 cm.)deep, thus bringing the total bed-height to about29 in. (84 cm.) and 2 or 3 in. higher if a patient isnursed on a large-celled ripple mattress. Experiencehas shown that a more suitable bed-height from thepatient’s angle is about 20 in. (51 cm.).

Should the bed height be that most suitable forthe nurses caring for the patient and making thebed, the doctor examining the patient, or the patientgetting in and out of bed ? In practice nurses oftendo not adjust the bed-height because this takestime. 8 In a recent random check 9 of high/low

beds of different models, carried out on a maleand female ward, 71 % of the beds were in the lowposition, 23% in an intermediate position, and 6% inthe high position, and rarely was the bed-heightchanged for bed-making without positive directionfrom a senior member of staff. This suggests, perhaps,that at least the nurses consider that the patient’sneeds are paramount and therefore the height of themattress-frame support, for any fixed-height bed,should be lower than the British Standard 24 in.

(61 cm.) and approximating to that of the Frenchstandard of 40 cm. (16 in.).

ELECTRICALLY OPERATED BEDS

Much more consideration should be given, in spiteof the financial implications, to adjustable-heightfully electrically operated beds, popular in NorthAmerica and elsewhere. Nurses might well adjust thebeds more often, according to need, when beds areof this easily controlled type. Another importantadvantage is that the beds can be adjusted by thepatients themselves, where suitable.

FOUR-SECTIONED HINGED BED

Perhaps because the King’s Fund working-party’sinvestigation was carried out on a female surgicalward, 10 it underestimated the value of the four-sectioned hinged bed, mechanically or electricallyoperated, for the care of patients. Nearly a quarterof non-psychiatric N.H.S. beds in England andWales are classified as geriatric or chronic sick, andmany patients in other departments are severely handi-capped from locomotor or neurological diseases. This

type of bed, with a knee-flexion position, has been ad-vocated by Gainsborough 11 and Andrew,’-2 and is

commonly used in Scandinavia, U.S.A., and Canada.The accompanying figure, from a current Americanmanufacturer’s catalogue, shows the uses this bedcan be put to-although British doctors may havereservations with regard to the value of some of thepositions.

Advantages of the four-sectioned type include: (1)enabling the patient to rest in a more or less physio-logical position, thereby adding to his comfort;(2) preventing the shearing strain on the buttocks andheels which so often contributes to the development

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of pressure-sores" (a situation produced by a con-ventional bed with a backrest); (3) its use in the treat-ment of incipient cardiac failure and pulmonarydistress; and (4) its use in giving support to handi-capped, often elderly, patients while practising gettingout of bed after serious illness or long-term locomotorincapacity. This type of bed should be comprehen-sively tested in this country.13 It could be arguedthat if patients can sit in the chair position in bedthey can just as well get up and sit in a chair. Manypatients are very frail at some time in their illnessand they are perhaps then better in bed, apart fromthe fact that the shortage of nurses may mean thatmany patients, contrary to medical advice, are keptin bed.

OTHER SPECIALISED BEDS

Beds with a lateral tilt are of particular use inintensive-care units for the treatment of patientsafter major chest operations, in postoperative chestcomplications and in the turning of those with pressuresores, and in changing the position of very heavypatients.

Further specialised beds would probably includean improved toilet bed in which a bedpan can beslipped under the patient in situ.Under some circumstances incorporation of X-ray

cassette-holders in the mattress-frame, so that chestfilms and possibly straight X-rays of the abdomen canbe taken in bed, is valuable, especially in intensive-careunits.

Specialised beds of any kind should have instruc-tions for assembly and use attached to them. Aconsiderable amount of tuition is needed before staffcan use sophisticated beds to full advantage. 14 Anotherproblem 15 is the danger caused to hospital structureand personnel by movable equipment, and some manu-facturers now produce bedsteads with such protectivedevices as rubber cushions and bumper bars.

Hospitals nowadays are transporting patients ontheir beds between wards and to other departmentssuch as the X-ray department and the operating-theatre suite. This procedure is made easier by theshort-wheel-based beds because of their manoeuvre-

bility. Fixed-height beds may call for vertical liftingof a patient who has to be moved from the bed to afixed X-ray table or theatre-trolley. Vertical lifting ofpatients by porters can be uncomfortable, painful, andeven hazardous.

Perhaps half the beds in many departments could beof the cheaper fixed-height variety, but their heightshould be lower than that now advocated. 4 The

money saved by retaining a proportion of fixed-height beds on many wards should be used to providemore specialised types of beds. 14 On many wards twoor more varieties may be needed, but of course thebed design should be such as to allow interchange-ability of accessories where possible. Sophisticatedbedsteads, including, of course, those electricallyoperated, although costly, would speedily find theirway into hospitals if the medical profession weremore interested and acknowledged that bedsteadsare the nurse’s work-bench.

ACCESSORIES

Backrests with the conventional bed are seldom com-fortable because the patient has to sit in an unphysiologicalposition with his back almost vertical and his thighs andlegs horizontal. On the whole, backrests formed bypulling forward the headboard are unsatisfactory as theyoperate at the wrong angle. Backrests which have a risingbase are more satisfactory, but these are sometimes difficultto manoeuvre with the patient in bed.

Head-ends of composition or wooden construction give amore informal impression; and boards of different colours,apart from the aesthetic angle, help the patient to orienthimself to his particular bed. If the head-end incorporatesa backrest, constructed of heavy material, adjustment is notalways easy. It has been found, however, that the need fora head-end, apart from its use as a backrest, can be over-emphasised and in the four-sectioned hinged bed it is

unnecessary. In nursing, especially intensive-care nursing,non-removable head-ends are usually a disadvantage,but occasionally they are useful in giving support to

handicapped patients training to get out of bed. Patients,surprisingly, do not appear to miss a head-end when one isnot supplied.

Foot-ends can be of use as: (1) bed-strippers, (2) if ofdifferent colours for patient orientation (which can also beachieved with locker tops and overbed tables), and (3) forsupport when giving bed-end exercises. Patients do notrequire a foot-end, but if this is omitted from a four-sectioned bed a suitable mechanism for keeping themattress in position is necessary.

Lifting-poles are particularly useful, but by custom havebeen placed in the centre of the head-end and are some-times fixed in position. Recently beds have been producedwith the bracket for the lifting-poles at each side of thehead-end. This side-placed lifting-pole is helpful whenteaching handicapped patients to get out of bed, especiallyif the lifting-pole swings out to a stop position at 45&deg; tothe side of the bed. The patient, when using a backrest, ispositioned farther down the bed and some lifting-poles arenot then within reach of the patient-a problem which canbe overcome by adjustable sling positions. In recentbedstead models, built-in brackets for lifting and drippoles have proved an asset, as they are less likely to damagehospital fabric.

Safety sides.-A small number of beds with safety sides(cot sides) are needed. They should be looked upon moreas protection than a means of constraining the patient.Safety sides which go "down and under" are oftensatisfactory. Another design folds down telescopically buthas the possible disadvantage of impeding bed-making, whileother models have detachable safety sides available indifferent lengths and heights which may be fitted to anybed; although useful, they take up storage space on theward.

Tilting mechanisms for the Trendelenburg position are ofgreat use, and the nursing is eased if the reversed Tren-delenburg position is always possible.

Bed-strippers are helpful, but on many beds they arelower than the height of the backs of two chairs placedtogether-the traditional means of folding back the bed-clothes. One bedstead model has a foot panel which hingesup rather than down, and thus a higher placed bed-stripperis achieved.

Pillow grips.-The difficulty of keeping pillows in placewhen a backrest is used is to some degree overcome by theuse of a pillow grip. It is more likely that pillows will slipwith composition and wooden backrests and backrests withvertical struts. Two models of pillow grip are manufac-

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tured-one for ordinary beds (awaiting modifications) andone for the King’s Fund bed-and have proved valuable.

Bed-cradles.-Some hospitals still keep a supply of thelarge-hooped ’ Crimea’ bed-cradles. Apart from the diffi-culty of storage the patients often complain of feeling cold.Many smaller bed-cradles are available and are functionallyadequate. One model placed in the foot of the bed is

particularly useful as it can be adjusted both horizontallyand vertically; it incorporates a footrest and is useful inhelping to control footdrop in patients, especially hemi-plegic patients, and acts as a fixture from which a patientcan push himself up the bed.

REFERENCES

1. Survey of Hospital Bedsteads, Cots, and Bedside Lockers. ScottishHospital Centre, December, 1966.

2. Design of Hospital Bedsteads. King Edward’s Fund for London,1967.

3. Br. Hosp. J. soc. Serv. Rev. Sept. 29, 1967, p. 1828.4. Department of Health and Social Security, Supplies Division.

General Purpose Hospital Bedstead: type B, 1969.5. Norton, D., McLaren, R., Exton-Smith, A. N. An Investigation of

Geriatric Nursing Problems in Hospital; p. 100. London, 1962.6. Norton, D. By Accident or Design; p. 7. Edinburgh, 1970.7. Specification Working Group on Mattresses and Related Items:

Interim Report. Department of Health and Social Security, 1968.8. Design of Hospital Bedsteads; p. 33, appendix P. London, 1967.9. Andrews, J. Unpublished.

10. Design of Hospital Bedsteads; p. 9. London, 1967.11. Gainsborough, H. Br. Hosp. J. soc. Serv. Rev. May 12, 1967.12. Andrews, J. Br. J. Hosp. Med. 1970, 3, Suppl. 1.13. Andrews, J. ibid. 1970, 3, 479.14. Harrison, S. E. Hospital Management. Planning and Equipment

supplement, May, 1967.15. Guest, J. Damage in Hospitals (report to the Ministry of Health).

Architect’s Department, Wessex Regional Hospital Board, 1968.16. White, G. Br. Hosp. J. soc. Serv. Rev. May 14, 1965, p. 874.

COGWHEEL COMMITTEES

M. E. MACGREGOR

Warwick Hospital, Lakin Road, Warwick

As a young consultant, totally inexperienced incommittee work, I can remember feeling astonish-ment and respect when an older colleague, well-known outside the board-room, assumed a new com-mittee personality. Unsuspected gifts of plain speech,of persistence in argument, of repartee, and of resource-fulness were revealed and exercised in the briskdebates of the committee-room. One quickly realisedthat in this sphere of professional life there was muchto learn, and that it had to be learnt if one’s professionalinterests were to be properly advanced.At that time our hospital group, a small one serving

200,000 people, conducted its medical business in anadvisory committee of some twenty-five people,which included the majority of consultants. Of course,there were the vocal and the mute, those whose onlycontribution was a rare hand raised to vote, and thosewho regularly led discussion and framed policy. Allmedical business came here, and the young consultantleft at the end of long meetings knowing a great dealabout administration, about shades of feeling, andabout what were the important medical issues, localand national, of the day. He had some years to watchsuccessive chairmen conducting business with greateror less skill, and to see how important decisions mightarise from the clash of opinion and interest, to realise

that there is no monopoly of wisdom, and that throughvigorous argument unperceived solutions to tangledproblems could be found. In summary, it was a

civilised, informative, and practical system of runningthe medical affairs of a small hospital group, giving asense of participation to the most recently appointed,and the opportunity, if so desired, of expressing anopinion on any issue. The chairmen of this com-mittee were medical members of the managementcommittee holding office for a limited number of

years, and decisions taken at the advisory committeewere respected and seldom revised elsewhere.

Two years ago the Cogwheel Committee recom-mended that the divisional system be introducedmore widely into the hospital service, and, not withoutmany expressed misgivings, it was adopted here too.This implied the abolition of the old medical advisorycommittee, and its replacement by medical, surgical,psychiatric, and pathological divisional committees,whose chairmen joined with the area medical officerof health and with a general practitioner to form anexecutive committee, itself chaired by a medicalmember of the management committee. One neednot enumerate the claimed advantages of this system:a smaller executive, wider representation of staff atdivisional level, elimination of discussion of irrelevantmatters of interest to only one professional group,and so on. These are commanding arguments,possibly, where large hospitals are concerned, butnot necessarily so with smaller hospital units. Infact the introduction of the Cogwheel system locallyseems to have had a number of undesirable effects,and the evils which it was supposed to counter werenot, in fact, very evident.

For what has happened ? Professional subsectionshave been created to which matters thought to con-cern them are referred. But who can tell what concernswhom ? Is it not probable that the psychiatrist willhave a constructive opinion upon the layout of casualtydepartments, the paediatrician on the staffing of anophthalmic ward, the physician about surgical waiting-lists ? The wise heads of the group have been cubi-clised into separate areas so that combined wisdom isno longer available. The chance of a balanced dis-cussion in a divisional committee, except upon themost parochial matters, is small. The medical staffare put into blinkers, shielded from the abrasiveinfluences of contending disciplines. Hospital doctorsmust function behind the obligatory mask of theirspecialty, and can express themselves only as anoes-thetist, or radiologist, with opinions invalid outsidestrict professional confines. Divisional discussioncan, therefore, be lustreless, the more so becausesuch meetings have no executive purpose. What issaid at divisions does not necessarily go, but is a moreor less agreed point of view which the chairman mustattempt to represent with all the force he can musterat the executive committee at another time. If thisview prevails, so much the better. If it does not, weshall not know the arguments by which it was van-quished. Inevitably a committee without any directpower must lose its vigour. This was apparent at thestart of the Health Service, when pre-existing medicalstaff committees at hospital level found their business