28 APRIL 1967, Page 9

Bed to worse?

MEDICINE JOHN ROWAN WILSON

For a long time the bed has held an almost mystical significance in the practice of medi- cine. When I was a boy, if you were ill you were sent to bed, and if you weren't in bed it was assumed that there wasn't much wrong with you. The public schools, a stronghold in those days of dangerous and reactionary medi- cine, held fast to this simple-hearted view. Boys with heavy head colds were sent sniffing on to rugger fields or round cross-country courses. But as soon as they developed a temperature they were slapped into the sanatorium and fed on milk and boiled fish, as if they were chronic invalids. It was one thing or the other.

Of recent years this policy has been ques- tioned. The healthy practice has grown up of asking what confinement to bed is really doing for the patient. In many cases, of course, the answer is obvious. If a patient is seriously ill, one wishes to put as little strain as possible on his vital processes. If he is recumbent, he is burning up less energy; his heart, in par- ticular, has a great deal less work to do. A person with a high temperature feels weak and miserable and is simply not up to the effort of getting about. Bed is cosy and reassuring and gives him a feeling of being looked after. When restriction of activity is important, bed may be the most efficient solution.

In hospital, bed rest may be required for a variety of other reasons, such as the giving of special treatments, transfusion and so on. It also has certain advantages from a purely ad- ministrative point of view. A ward is much easier to manage if the patients are confined to bed instead of wandering all over the place • in hideous pyjamas and tattered Jaeger dressing- gowns. They are more in a ordance with sister's idea of good order pd tkliness.

However, it is now recognised that hospitals are there to get patients well and not simply to keep them in order, and most ward sisters are happy to accept a certain amount of ad- ministrative confusion in the interests of good therapy. Confinement to bed can be exasperat- ing to younger patients, if they do not feel ill; but to older patients it can actually be dangerous. There are a number of serious con- ditions which are now known to be either caused or made worse by inactivity. Perhaps the most serious of these is thrombosis. When we lie flat we do not ordinarily use the muscles of our legs, and it is the contraction of these muscles which drives the blood from the leg veins to the heart. The blood consequently tends to stagnate in the leg veins and this may cause clot formation. If the clot is large, it may lead to a swollen leg. If it is small, it can easily go unnoticed and this may be even more dangerous, since the clot may become dis- lodged, pass along the circulation, and lodge in the lung. This is known as a pulmonary embolism, a potentially fatal condition.

There are other dangers. The shallow breath- ing which is common to most patients after operation predisposes towards infection and waterlogging of the lungs. With prolonged bed rest, joints stiffen up and muscles become weak. A consequence of this is that when the patient does finally get up, he or she will have diffi- culty in walking and is a candidate for sprains, dangerous falls and even fractures of the bones. Finally, patients confined to bed for months, as is sometimes necessary for the treatment of chronic diseases, may become overweight through overeating and inactivity. And obesity causes a multitude of problems of its own.

For all these reasons the present policy is: get them up whenever you can, as soon as you can. The old, tidy, spotless spick-and-span ward has turned into something reminiscent of a doss-house. Old men sit crouched in front of the stove, sucking pipes and reading the Daily Mirror. At one end of the ward a boy is learning to walk again after a leg operation, at the other there is a noisy game of penny nap. Physiotherapists are everywhere, demon- strating breathing exercises and forcing patients to use abdominal muscles which have been under the knife only forty-eight hours before.

It would be a mistake to imagine that all this activity is welcomed by the patients. The old ones in particular tend to complain that nowadays they get no peace when they are ilL I myself was working in a large provincial hospital when the vogue for increased move- ment first took hold. We had one ward of chronic sick where the new policy was par- ticularly unpopular. Old people who had been lying happily inert for years, gorging them- selves on enormous meals washed down by bottles of stout provided by fond relatives, found themselves turned out of bed, put on low-calorie diets, and chivvied about merci- lessly in the name of rehabilitation. Most of them took the view that the increased expecta- tion of life they were promised was hardly worth what they were asked to undergo. One unfortunate man was put back on his feet, in- duced to lose twenty pounds in weight, and then sent home as cured. He fell down dead the next day. I asked the ward sister what he had died of. 'Sheer aggravation, if you ask me,' she said.