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management committees shall not have the statutoryrights appropriate to the responsibilities he intendsthem to bear. " Responsibility without rights

" doesnot sound like a hopeful basis for the individual effortwhich hospitals will still have to make if they are toavoid uniformity and stagnation. In these mattersmuch can be learnt, both by way of example and byway of warning, from the experience of the LondonCounty Council, who in 1930, under the distinguishedleadership of Sir FREDERICK MENZIES, took over thehospitals of the Metropolitan Asylums Board and 26boards of guardians and welded them into an

integrated service of higher standard. The assimi-lation of 75 general and special hospitals with40,000 beds and 26,000 staff was a task of the firstmagnitude, taking several years to complete, and itis clearly comparable to the job facing regional boards,who may not have to handle larger total resourcesbut will have to deal with those resources scatteredover smaller and more numerous units-on the averageprobably about 200 units each-and over much widerareas. The mental hospitals, moreover, will have tobe taken over and made part of the general systemimmediately, whereas the L.C.C. postponed fusing theadministration of the mental-hospital service withthat of the other hospitals for several years. Centralpurchasing and accounting, planned adaptations andextensions, central control of budgets and finance,and central staff-appointment systems are bound tomake the individual hospital feel that its individualityis diminished and its initiative fettered. Much consciouseffort and ingenuity at the centre will be needed tocombine local freedom with the necessary degree ofcontrol. Departmental committees on which individualmembers of hospital staffs are strongly represented atall levels, to make appointments and deal with commonproblems, frequent visits of central staffs to individualhospitals, sports associations, and above all the con-stant recognition that each hospital is part of a vitalmachine serving the sick of the area, will help. Inter-

hospital visiting, medical and nursing societies, andstaff committees covering all branches of personnelshould receive the active support of regional boardsand management committees.The hospital surveys have sadly proved the need

for change and integration, but a great opportunityas well as a great responsibility now lies before

hospital staffs and hospital administrators. Themain defects of the present can be summarised asinadequate accommodation, shortage and maldis-tribution of consultants, lack of coordination, and theabsence of any real system to deal with the chronicsick. In the proper combination of team-work andof individual responsibility and initiative lies the keyto future improvement.

Hydraulics of the Peritoneal CavityIN 1900 FowLER recommended the adoption of

an ’’ elevated head and trunk posture " in the post-operative treatment of " diffuse septic peritonitis."Since then most abdominal surgeons have adoptedthe Fowler position (with or without modifications) asa routine, but lately SPALDING 2 has questioned its

advisability. Experience will show whether his views1. Fowler, G. R. Med. Rec. 1900, 57, 617.2. Spalding, J. E. Lancet, May 4, 1946, p. 643.

are correct, but his arguments in their favour havedrawn attention to the complex problem of absorptionfrom the peritoneum.

"

Two channels of absorption exist-the blood-capillaries and the lymphatics. For water and simplecrystalloids the subserous blood-capillaries are morethan adequate, and considerable amounts of normalsaline can be absorbed from the peritoneal cavityby that route in a few hours. Toxins of low molecularweight may possibly also be absorbed through theblood-vessels. But large protein molecules and parti-culate matter such as red cells and bacteria are

removed through the lymphatics, as in other partsof the body. From the point of view of lymphaticabsorption, the subphrenic peritoneum is the most

important and the pelvic the least, the omentumand mesenteries occupying an intermediate position.RUBIN 3 believed that the omentum plays a prominentpart in peritoneal absorption, and though manyworkers have disputed the existence of omental

lymphatics SIMER 4 seems to have established thatthey are present in man. Eighty years ago VONRECKLINGHAUSEN 5 thought he had found a structuralbasis for the absorptive efficiency of the subphrenicperitoneum in the form of

" stomata " between the

peritoneal cells, and his views gave rise to one of theclassical controversies of both normal and patho-logical histology. MACCALLUM’S 6 conclusion that thestomata do not exist was generally accepted for manyyears, though ALLEN has more recently revertedto VON RECKLINGHAusEN’s original view. But the

presence or absence of stomata does not make anypractical difference, for, as MACCALLUM pointed out," it seems necessary to suppose that the connexionsof the endothelial " (i.e., peritoneal)

" cells are so laxthat the violent pumping action of the respiratorymovement is enough to force material between themwhen they come to form the only obstruction to itsentrance." Later papers by CUNNINGHAM 8 and others,introducing the concept of passage through the cellsrather than between them, again make no practicaldifference to the final result.

If the subphrenic peritoneum is the area of mostactive absorption for particulate matter, how much canit absorb and at what rate ? There is experimentalevidence on these points. As to the speed, if a suspen-sion of carbon particles is injected into the peritonealcavity some of them may be found in lymph-nodesabove the diaphragm within a few minutes 9 providedthat respiratory movements are taking place, evenif they are effected by artificial respiration. Paralysisof one half of the diaphragm results in slower absorp-tion on the paralysed side.10 There may be speciesdifferences in the amount which can be absorbed.The rabbit 11 can absorb from the peritoneal cavity infour hours a quantity of whole blood equal to a fifthof its blood-volume, whereas when blood was injectedintraperitoneally into the dog 12 only a sixteenth of

3. Rubin, I. C. Surg. Gynec. Obstet. 1911, 12, 117.4. Simer, P. H. Anat. Rec. 1935, 63, 253.5. von Recklinghausen, F. Die Lymphgefässe und ihre Beziehung

zum Bindegewebe, Berlin, 1862.6. MacCallum, W. G. Bull. Johns Hopk. Hosp. 1903, 14, 105.7. Allen, L. Anat. Rec. 1936, 67, 87.8. Cunningham, R. S. Amer. J. Physiol. 1922, 62, 298.9. Higgins, G. M., Graham, A. S. Arch. Surg., Chicago, 1929, 19,

453.10. Higgins, G. M., Beaver, M. G., Lemon, W. S. Amer. J. Anat.

1930, 45, 137.11. Siperstein, D. M., Sansby, J. M. Amer. J. Dis. Child. 1923, 25, 107.

12. Florey, H., Witts, L. J. Lancet, 1928, i, 1323.

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the corpuscles were absorbed in six hours. Animal

experiments by HAHN et al., 13 using red cells containingradio-active iron, showed that a few hours aftertheir intraperitoneal injection these cells could bedetected in the blood-stream, and after twenty-fourhours about 40% of the cells had been absorbed.The course taken by the cells was perfectly clear, andtheir lymphatic pathway in the thorax was markedby red lymph-nodes which do not seem to have offeredany serious obstruction to their passage. The processin man may be much the same, and there have beenadvocates 11 of the intraperitoneal route for blood-transfusion under certain conditions. Apart fromtheir practical application, these experiments on theabsorption of blood strikingly emphasise- the sizeof the particles which can pass through. the

diaphragm, for not only mammalian but - also

amphibian red cells can pass, and it seems a reason-able inference that smaller particles such as bacteriawould traverse the diaphragm at least as rapidly, ifnot more so.

,

Another fundamental factor in diaphragmaticabsorption is the relation between the pressures aboveand below the diaphragm. One might suppose thatduring expiration, when the diaphragm is relaxed,it would offer no resistance to the upward pull of theintrapleural negative pressure and the elastic recoilof the lungs, and that the intraperitoneal pressureimmediately below the diaphragm would then alsobe negative (i.e., less than atmospheric). In inspiration,on the other hand, when the diaphragm is contracting,one would expect an increasingly negative pressurein the pleural cavity above the diaphragm, associatedwith a positive intraperitoneal pressure below it.There would thus be a pressure gradient between thepotential cavities above and below the diaphragmmaking for the rapid upward passage of particulatematter. But the position is not quite so simple. Thatthere are respiratory variations in subphrenic pressureFLOREY 14 demonstrated in the rabbit by insertingbetween the liver and the diaphragm a small balloonat the end of a rubber catheter. OVERHOLT 15 found indogs that " the pressure within the peritoneal cavitydecreased simultaneously with the decrease in intra-pleural pressure during inspiration." He furtherfound that the intraperitoneal pressure was greater inthe lower part of the abdomen than in the upper,the difference being more with the animal in thehead-up (8-20 cm. of water) than in the horizontal(C’5-4’4 cm. of water) position. Would such a pressuredifference be sufficient to ensure, with a patient inFowler’s position, a steady upward flow of fluid fromthe pelvis to the subphrenic region ? 1 SpALDINGmaintains that it would, though the conditions inOvEBHOLT’s experiments, with the animal anaesthetisedand the abdominal muscles more or less atonic, arenot comparable to those in patients. Such an upwardmovement of fluid would be against gravity ; how-ever, it would not be the movement of a simple fluidcolumn, but of a film between many coils of intestine,obeying the laws of capillary attraction rather thanthose of gravity, and influenced by movements of theviscera and of the trunk. The air which is alwayspresent in the peritoneal cavity after laparotomy will13. Hahn, P. F., Miller, L. L., Robscheit-Robbins, F. S., Bale, W. F.,

Whipple, G. H. J. exp. Med. 1944, 80, 77.14. Florey, H. Brit. J. exp. Path. 1927, 8, 497.15. Overholt, R. H. Arch. Surg., Chicago, 1931, 22, 691.

interrupt the continuity of the fluid film, and, in theelevated position of the trunk, will reduce the effectof suction from above. In the recumbent position,on the other hand, fluid will pass freely into thesubphrenic area, whether or not a pneumoperitoneumis present ; whether this is a good thing or a badthing will depend on whether the normal channels oflymphatic absorption can deal with this large amountof infected fluid, or whether they are overcome,

leading to subphrenic abscess. -

The teachings of experimental inquiry can then beused to support as well as to attack Fowler’s position,and the final answer will come only from clinicalresearch and observation at the bedside. Surgeons,among -the most conservative of mankind, will nodoubt closely follow the results obtained by those whopropose to defy one of their most cherished traditions.

Filariasis in the PacificTHE prospect of service on those islands in the

Pacific where bancroftian filariasis is common amongthe native populations caused some apprehensionamong the American armed forces.and their friendsat home when it was found that Europeans were justas susceptible to infection as their coloured brethren.Study of the standard medical textbooks, with theirillustrations of cases of gross elephantiasis, did nothingto allay this anxiety. Indeed one American writerrecords that " the end results on morale are terrific." 1

The U.S. Army Medical Corps took steps to investigatethe matter, and the most important and unanimousconclusion drawn from their extensive inquiries isthat the gross disfiguring deformities commonlyencountered in natives in some of the filarial endemicareas of the world are a sequel to often-repeated heavyinfections with Wuchereria bancrofti over many years,and that brief exposure to infection does not producethem. Prompt removal from the endemic area of mensuspected to be infected leads to regression of theearly manifestations of the disease, and forestallsthe development of the grosser changes classicallyassociated with it. Fears of impotence and of sterilityas a sequel to the infection under such circumstanceshave proved groundless.The diagnosis of early bancroftian filariasis in the

field is difficult, and is largely made on a history ofexposure to the risk of infestation and on symptomsand signs. Search of the blood for micronlariae or adiagnostic eosinophilia is of little help, and the skinreaction to a filarial antigen is not much more valu-able.2 Of the clinical manifestations, attacks of

lymphangitis and lymphadenitis, often remote fromthe areas usually associated with these in the latecondition, and tending to progress in the directionopposite to the normal lymph flow, are highly sugges-tive of filariasis. These episodes are ephemeral andcommonly recur in association with slight fever.One or more such attacks of " mumu," with swellinglasting at least one day, in a filarial endemic area areregarded as evidence of infection and an indicationfor the speedy removal of the Service patient to atemperate climate. Where removal is prompt thesymptoms and signs diminish with the passage oftime, and in most cases have vanished completely1. Buchans, R. A. J. Urol. 1945, 54, 59.2. Behm, A. W., Hayman, J. M. jun. Amer. J. med. Sci. 1946,

211, 385.