74

To gain some idea of the amount of geriatric accom-modation needed, the working-party discovered forselected areas the total number of beds at presentoccupied by all patients aged 65 or over in bothpsychiatric and geriatric units. The figures revealedthat the proportion of geriatric and psychiatric bedsdiffered considerably from area to area; and a deficiencyof the one was generally made up by more of the other.One conclusion to be drawn from this information isthat the practice of counting only geriatric beds whenassessing hospital provision for the elderly is mis-leading. The working-party also point out that manyof the mentally impaired elderly must at present besent arbitrarily to geriatric or psychiatric units, depend-ing on the availability of beds and not on any clinicaldifferentiation. They believe, however, that, althoughsome patients are misplaced, there is a large group ofpatients who can equally well receive the care theyneed in either type of bed. The need for psycho-geriatric assessment units, both now and in the future,is questioned by the working-party. When adequateopportunities for discharge do not exist, such a unitbecomes blocked; but once they do, both geriatricphysicians and,psychiatrists will probably be willing toadmit borderline patients for assessment. The working-party conclude that the overall need is in the region of20-23 beds per 1000 aged 65 or over in all types ofaccommodation (excluding part-in hostels); this num-ber might be broken down as 3-5 beds in specialresidential hostels, 10-15 beds in geriatric units, and5-8 beds in psychiatric accommodation. New psy-chiatric wings in district general hospitals may provetotally inadequate to meet psychogeriatric demands.Therefore, the psychiatric hospital will still have animportant contribution to make, provided that itworks as part of a comprehensive psychiatric service,with responsibility for other areas of psychiatry aswell as psychogeriatrics.

HOW SAFE IS SURGICAL-GLOVE POWDER?

CONTAMINATION of the peritoneal cavity by surgical-glove powder leading to starch peritonitis has beenincreasingly recognised as a clinical entity over thepast few years. 1-4 It is an acute illness characterisedby cramping abdominal pain, fever, and signs of

peritoneal irritation, and it appears between 10 and 40days after an apparently trouble-free abdominal

operation. Although the white-blood-cell count maybe raised with or without an eosinophilia, the erythro-cyte-sedimentation rate is disproportionately high.5.sReoperation usually reveals ascites, 3. an omental mass,and many cream-coloured peritoneal implants resem-bling tumour spread or tuberculosis. The diagnosis isconfirmed by the finding of intracellular starch

particles showing as doubly refractile " maltesecrosses " when a biopsy specimen is examined under

1. McNaught, G. H. D. Br. J. Surg. 1964, 51, 845.2. Neely, J., Davies, J. D. Br. med. J. 1971, iii, 625.3. Perper, J. A., Pidlaon, A., Fisher, R. S. Am. J. Surg. 1971, 122,

812.4. Ignatius, J. A., Hartmann, W. M. Ann. Surg. 1972, 175, 388.5. Macpherson, G. H., Barrie, W. W. Br. med. J. 1971, iv, 747.6. Nichols, J. ibid. p. 426.

polarised light. 5 The diagnosis can be made withoutreoperation, from the clinical picture and the finding ofintracellular starch particles in ascitic fluid obtainedby paracentesis.

Well over fifty such cases have been reported, andsome of the patients were critically ill; but this hazardmust be seen against the background of the manythousands of abdominal operations performed eachyear. Indeed, we may speculate why the condition isso rare when starch powder is so widely used. Threefurther questions may be asked. Why is it only recentlythat starch peritonitis has been recognised as a clinicalentity, when starch has been used since the early 1950s ?What is the mechanism of the peritoneal reaction ?And what can be done to prevent the condition ?

Many years elapsed before the damaging effect oftalc was appreciated, but the mechanism of starchperitonitis may be different. Although most peopleregard it as a foreign-body reaction, Bates suggestsit is partly due to delayed hypersensitivity. If this isso, there are many ways in which patients could besensitised to starch, including previous operation.Another possibility is that there has been a recentchange in the manufacturing process. In the U.S.A.the sudden appearance of cases was attributed to achange from corn-starch to rice-starch powder, butrice starch has not been used in the manufacture ofglove powder in Britain. Experimental work hasproduced starch granulomas and adhesions in ani-mals 8,4 and this effect is enhanced by peritonealtrauma,9 but in some experiments relatively very largequantities of powder have been used; the mechanismby which adhesions are produced experimentally maybe different from that of the acute generalised febrileillness in man. The animal work must be interpretedwith caution, and the part played by starch powder inthe formation of the common postoperative adhesionsin patients remains uncertain.When considering prevention, it is surprising to

learn that conventional preoperative washing of glovesmay make matters worse,9 by producing clumping,so delaying absorption. A very thorough washingand wiping of the gloves is needed to remove all thepowder. But the most important question is this:Is there now any need for the gloves to have powderon the outside if they are sterilised by gamma-irradia-tion instead of being autoclaved ?Once a definite diagnosis has been made, reopera-

tion should be avoided, since it increases the morbidity. 4Steroids appear to speed recovery.10This interesting syndrome has been given various

names, but is probably best called simply " starchperitonitis " to stress the generalised nature of thereaction. Surgeons and glove manufacturers shouldnot be complacent, but there is a danger of the riskbeing over-emphasised and of many late postoperativeabdominal complications being wrongly attributed tostarch peritonitis: subphrenic and pelvic abscessesremain more common.

7. Bates, B. Ann. intern. Med. 1965, 62, 335.8. Taft, D. A., Lasersohn, J. T., Hill, L. D. Am. J. Surg. 1970, 120,

231.9. Ellis, H. E. Abstracts, Association of Surgeons of Great Britain and

Ireland, annual meeting, 1972, p. 32.10. Maggs, R. L., Reinus, F. Z. Am. J. Surg. 1959, 98, 111.