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ADAPTATION IN PHYSIOLOGICAL PROCESSES
705 The stomach was still nearly full after 27 hours, but a little barium had reached the descending colon by that time. Very little left the stomach in the next two days, and the stomach was still more than half full after six days (b in figure), by which time the head of the meal had reached the pelvic colon. After ten days the stomach was a third full, and after fifteen days it was still about a quarter full. On the twentyfifth day there was still an appreciable amount of the original barium meal left in the stomach (c in figure), and on the thirtieth day part of the stomach wall could still be seen outlined with flecks of barium.
The amazing thing about this patient is that he had good appetite all the time, ate three good meals every day, and worked fairly hard as a printer. Every fortnight or so he vomited a large quantity of food, after which he felt more comfortable and went back to his three big a
meals
a
day!
London, W.1.
I. EBAN.
ADAPTATION IN PHYSIOLOGICAL PROCESSES SIR,-In discussing the valuable contributions of Professor Selye a distinction must, I think, be made between the facts he presents and the interpretations he offers. I shall deal here with his experiments on " exercise, one of the main categories of stress " which he has studied.1 The physiological responses to exercise, he finds, are complexly patterned-i.e., they appear as a multiform syndrome. Exercising animals to a point of exhaustion led within 48
hours to involution of endocrine glands, the great parenchymatous organs, different parts of the hsemopoietio system, and lymph-nodes and lymphatic vessels. With the same experimental method Selye produced ovarian atrophy and oestrous disturbances, regression of acinar tissue of the pancreas, a shift of fat from subcutaneous deposits into the liver, and various biochemical reactions. Among the other effects of exercise to which he refers are increased excretion of corticoids (previously observed only in race-horses), recorded by Venning and Kazmin ; temporary inhibition of urine secretion, a phenomenon originally discovered by Hellebrandt ; and changes in capillary permeability, a subject studied for many years by Eppinger. All these reactions are non-specific and can be elicited not only through exhaustive exercise but also through transection of the spinal cord, starvation, histamine, bacterial toxins, hormones, certain pharmacological substances, anoxia, asphyxia, solar radiation, electrical injury, cold, X-irradiation burns, and trauma.
Selye has proved that basically the animal" organism reacts in a constant manner to a variety of alarming stimuli" of which exercise is one. He clearly differentiates between specific forms of reaction to stress-i.e., reactions which depend upon the nature of the stimulusand the uniform pattern of the " alarm reaction " and of the " syndrome of adaptation." Thus, it is not justifiable to say that Selye proposes a monistic concept of pathology. In so far. as he deals with the synonymity of certain aspects of the physiological reaction to stress, he follows the precedent set by Walter Cannon, whose theories have for many years formed a fruitful basis for experimental research in physiology of exercise.2 A different attitude must, I submit, be taken in respect of the criticism levelled against Selye’s views as set out in his chapter on Clinical Applications of the General Adaptation Syndrome Concept. A categorical distinction must be made between adaptations in physiological as against adaptations in pathological processes. This concept, which was first formulated about 1890 by Cohnheim, of Breslau, was admirably presented by his pupil, William Henry Welch. " One fails to see in pathological conditions," Welch wrote, " that coordinate and special fitness which we are accustomed to find in physiological adaptations."3 Pathological 1. 2. 3.
Selye, H. Stress. Montreal, 1950. Jokl, E. Z. Neurol. Psychiat. 1930, 129, 460. Welch, W. H. Adaptation in Pathological Processes. Baltimore, 1937.
reactions, he maintained, may or may not be of theraand they may even aggravate the His thesis was that in pathological processes adaptation is of the kind used in physiological processes for the distinct purpose of bringing about an adjustment of a given function to changed environmental conditions. " We have no reason to suppose," he once remarked, " that the animal body is endowed with
peutic significance, disorder.
properties designed
to meet
pathological emergencies.
Indeed, its sole weapons of defence, often lamentably imperfect for morbid states, are adapted primarily for
physiological use." If they do meet certain pathological conditions, the explanation is simply coincidence. Conversely, there is no evidence that in normal subjects physical exercise can be conducive to any of the clinical conditions which, according to Selye, react in some way other to A.C.T.H. or’Cortisone.’ Elsewhere4have dealt with a variety of pathological conditions encountered in athletes, with special reference to apparently healthy persons breaking down during effort. Some of these conditions are specifically produced by exercise, among them being " indisposition after running " or athlete’s sickness " (a syndrome characterised by vomiting, profuse sweating, and headache, commonly observed after quarter-mile sprints) ; hypoglycaemia after marathon races ; muscle-cramp in gymnasts; or fainting due to gravitatory displacement of blood after exertion. But in a greater number of the pathological states I described, the exercise, though often the last contributory cause, did not actually produce them. Examples are with occlusion associated effort, rupture of coronary arteries, paroxysmal anomalies of intracardiac conduction, and haemorrhagic pancreatitis after muscular exhaustion. All general autonomic adjustments elicited by muscular effort involve endocrine and nervous functions of the kind studied by Selye. This is important since he believes that adaptation energy represents an unspecific pool of physiological driving force that may become exhausted if the organism is exposed to stress, irrespective of its nature. Exercise may aggravate pre-existing illness : for example, a girl hockey-player with myasthenia gravis had to double her daily dose of neostigmine when she resumed training. On the other hand, many diabetics and other chronically ill people do better and need less insulin when they are physically active 5 : two of the greatest tennis-players in the world today are afflicted with diabetes. Normal humoral or tissue immunity, however, is not increased through training. Normal immunological reactions are by-products of physiological cell metabolism -a concept first expounded by Paul Ehrlich 6-and contrary to popular belief there is no evidence that a high standard of physical" fitness (i.e., a state of adaptation to one of Selye’s stresses ") is associated with, or conducive to, heightened resistance towards infectious diseases. Universal protection against infectious diseases is certainly not afforded by physical training. Physical of the training does not even lead to a general increase 7 scope of normal immunological mechanisms. Selye’s material illustrates the correctness of Cohnheim’s original thesis by showing that many autonomic adaptations are basically the same whether they are elicited by exercise or-to choose one of Selye’s or
"
standard experiments-by transection of the spinal cord. His findings corroborate the conclusion that in pathological situations the body is unable to mobilise weapons other than physiological ones. Only in physiological situations do these reactions serve a purpose. They achieve nothing in the way of repairing a severed Jokl, E. Syncope in Athletes. Pretoria, 1947. Jokl, E. Brit. J. phys. Med. 1948, ii, 2. Ehrlich, P. Beitrage zur experimentellen Pathologie und Chemotherapie. Leipzig, 1909. 7. Jokl, E. Z. ges. exp. Med. 1931, 77, 769.
4. 5. 6.
706
spinal cord ; nor do they help the organism to resist The fact an attack by the lipmolytic streptococcus. that in controlled experiments physiological substances, given in large quantities, may exert a therapeutic influence upon pathological conditions-the recent discovery of the apparent efficacy of A.C.T.H. and cortisone on malignant tumours is an impressive example 8-fits into this concept. Professor Selye deserves the admiration and thanks of the medical profession for presenting so much new experimental evidence. The most effective answer to his critics he has given himself by stating : " Our facts must be correct. Our theories need not be if they help us to discover important new facts." Union Education Department, Pretoria.
ERNST JOKL.
STREPTOMYCIN AND TUBERCULIN
SiR,-I have already reported in your columns certain observations on the effect of streptomycin on the tuberculin reaction in tuberculous meningitis.Further experience has shown that in this respect cases fall into three groups as follows : 1.Moderate cases, in which the reaction increases at the commencement of streptomycin treatment and then falls away as recovery sets in. When the stage of apparent cure is reached, the test again becomes strongly positive and remains so during convalescence. 2. Severe cases, in which the reaction is negative or weakly positive in the early stages and becomes stronger as treatment proceeds. Its subsequent behaviour depends on the course of the disease. 3. Very severe cases with a positive reaction in which the outcome is fatal despite treatment. In these cases, the reaction remains positive throughout.
In the light of the above observations, I have now used subcutaneous or intravenous tuberculin in conjunction with streptomycin for some time, varying the dose according to the strength of the reaction. In three cases I have administered tuberculin intrathecally, but I have now abandoned this route because of the violent reactions which followed. CASE L-Aged 10 years. Admitted April 6, 1947. On Oct. 2, 1947, tuberculin 0-01 ;jLg. was given intrathecally, in view of the persistence of a high level of protein in the cerebrospinal fluid. The reaction was severe. The temperature rose above 39°C, there was violent headache, and the c.s.F. pressure increased. Two days later 0’1 g. was given, and the same reaction was observed, but subsided within 24 hours. The patient was discharged on Dec. 16, 1947, and has remained well since. CASE 2.-Aged 8. Admitted April 11, 1947. One dose of tuberculin 1 g. was given intrathecally on April 20, 1947, but was not repeated in view of the violence of the reaction. Tuberculin was subsequently given subcutaneously. The patient was discharged on Oct. 5, 1947, and has remained well since. CASE 3.-Aged 6. Admitted Dec. 27, 1947. Owing to the prolonged course of the disease, one intrathecal injection of tuberculin 0-01 tg. was given on April 16, 1948. This the temperature was followed by a very severe reaction : rose to over 40"C, the pulse-rate to 150, and the c.s.F. pressure so high as to cause exophthalmos. For two weeks symptoms had to be relieved by drawing off c.s.F. After that time it was found that protein had increased from 1’6 to 4 g. per 100 ml., and cells (mainly lymphocytes) from 30 to 750 per ml. The patient recovered and was discharged on Sept. 20, 1948.
Though
we
cannot
yet draw any conclusions
as
to the
usefulness of tuberculin in
conjunction with streptomycin, it is the general opinion in our clinic that tolerance to tuberculin increases during St. Sophia’s Children’s Hospital, Athens.
streptomycin treatment. K. CHOREMIS.
Spies, T. D., Stone, R. E., Lopez, G. G., Milanes, F., Toca, R. L., Reboredo, A. Lancet, Aug. 12, 1950, p. 241. 9. Choremis, K., Zervos, N., Constantinides, V., Pantazis, S. 8.
Ibid, 1948, ii, 595.
BACTERIAL SYNTHESIS OF VITAMIN B12 SiR,-I have read with great interest the article by Dr. Dyke and his colleagues, in your issue of March 18 ; and I should like to add some comments.
In a bacteriological investigation of the mucosa of fresh pig stomach and of three commercial preparations from different factories of pig stomach against pernicious anaemia, I have constantly found considerable numbers of only two types of bacteria-Bacillus subtilis and one I therefore of the non-pathogenic corynebacteria. presume that one of these bacteria may be identical Later investigations with the " intrinsic factor."1 have shown that both these bacteria synthesise vitamin BIZ in amounts that may be supposed to be important for the concentration of B12 in intestinal mucosa. Clinical investigations with strains of these bacteria in cases of pernicious anaemia have hitherto not given convincing results, but the provisional results indicate that these bacteria, besides producing vitamin BÌ2 by their synthesis of antibiotics, are able to control unwanted bacterial growth in the intestinal mucosa in these cases. This has led to the following working hypothesis of the aetiology of pernicious ansemia: if vitamin B12 is to be absorbed it must be present in intestinal mucosa in a concentration higher than that in the tissues. This is the case in the normal organism, where the intestinal mucosa. is infected with B12-producing strains. In the diseased organism these strains are expelled from the mucosa and replaced by B12-consuming Bact. coli and lactobacilli, and this mucosa forms a barrier to the absorption of B12 from the intestinal contents. Further investigations are being made on the basis of Ibis working- bvnotbesis.
Microbiological Laboratory, Ferrosan Ltd., Copenhagen.
B. NOER Chief Microbiologist.
HOSPITAL ADMINISTRATION
SIR,-It would be difficult to overrate the importance of your correspondent’s article of Sept. 30 under the title Preface to Hospital Administration. It is stimulating chiefly because it insists that hospital administration is one thing, and that the services and crafts which go to meet a hospital’s physical problems are another. These functions are all too frequently confused ; and the confusion has increased because there has been limited experience in procedures for meeting the growing needs of the Ministry of Health for standardised practices and tabulated information. Dr. MacWilliam’s thoughtful letter (Nov. 11) is an evidence that in the present transition in the health services this distinction is likely to be smothered in a welter of administrative conveniences and methods. Readers of the principles set out by Dr. MacWilliam are likely to accept them without, perhaps, realising their far-reaching implications. The questions posed by him focus our attention on some of the difficulties and dangers of the present attempt to weld together two different conceptions of hospital practice and control. But the distinctions between the voluntary hospital and local-authority hospital lay not in accountancy techniques, budgetary controls, and other tools of administration. The distinction was rather in responsibility. On the one hand this responsibility was carried entirely by the hospital board and its administration, and was immediately affected by public reactions to its policies. On the other hand there was an administration responsible in an auditing sense to a financial authority outside the hospital, elected for other than hospital tasks, and having no special sanction or experience in the field of economy consistent with the requirements of the sick. Dr. MacWilliam’s analysis demonstrates some important 1. Nocr, B.
Dansk. Tidsskr. Farm. 1949,
23,
111.
The amazing thing about this patient is that he had good appetite all the time, ate three good meals every day, and worked fairly hard as a printer. Every fortnight or so he vomited a large quantity of food, after which he felt more comfortable and went back to his three big a
meals
a
day!
London, W.1.
I. EBAN.
ADAPTATION IN PHYSIOLOGICAL PROCESSES SIR,-In discussing the valuable contributions of Professor Selye a distinction must, I think, be made between the facts he presents and the interpretations he offers. I shall deal here with his experiments on " exercise, one of the main categories of stress " which he has studied.1 The physiological responses to exercise, he finds, are complexly patterned-i.e., they appear as a multiform syndrome. Exercising animals to a point of exhaustion led within 48
hours to involution of endocrine glands, the great parenchymatous organs, different parts of the hsemopoietio system, and lymph-nodes and lymphatic vessels. With the same experimental method Selye produced ovarian atrophy and oestrous disturbances, regression of acinar tissue of the pancreas, a shift of fat from subcutaneous deposits into the liver, and various biochemical reactions. Among the other effects of exercise to which he refers are increased excretion of corticoids (previously observed only in race-horses), recorded by Venning and Kazmin ; temporary inhibition of urine secretion, a phenomenon originally discovered by Hellebrandt ; and changes in capillary permeability, a subject studied for many years by Eppinger. All these reactions are non-specific and can be elicited not only through exhaustive exercise but also through transection of the spinal cord, starvation, histamine, bacterial toxins, hormones, certain pharmacological substances, anoxia, asphyxia, solar radiation, electrical injury, cold, X-irradiation burns, and trauma.
Selye has proved that basically the animal" organism reacts in a constant manner to a variety of alarming stimuli" of which exercise is one. He clearly differentiates between specific forms of reaction to stress-i.e., reactions which depend upon the nature of the stimulusand the uniform pattern of the " alarm reaction " and of the " syndrome of adaptation." Thus, it is not justifiable to say that Selye proposes a monistic concept of pathology. In so far. as he deals with the synonymity of certain aspects of the physiological reaction to stress, he follows the precedent set by Walter Cannon, whose theories have for many years formed a fruitful basis for experimental research in physiology of exercise.2 A different attitude must, I submit, be taken in respect of the criticism levelled against Selye’s views as set out in his chapter on Clinical Applications of the General Adaptation Syndrome Concept. A categorical distinction must be made between adaptations in physiological as against adaptations in pathological processes. This concept, which was first formulated about 1890 by Cohnheim, of Breslau, was admirably presented by his pupil, William Henry Welch. " One fails to see in pathological conditions," Welch wrote, " that coordinate and special fitness which we are accustomed to find in physiological adaptations."3 Pathological 1. 2. 3.
Selye, H. Stress. Montreal, 1950. Jokl, E. Z. Neurol. Psychiat. 1930, 129, 460. Welch, W. H. Adaptation in Pathological Processes. Baltimore, 1937.
reactions, he maintained, may or may not be of theraand they may even aggravate the His thesis was that in pathological processes adaptation is of the kind used in physiological processes for the distinct purpose of bringing about an adjustment of a given function to changed environmental conditions. " We have no reason to suppose," he once remarked, " that the animal body is endowed with
peutic significance, disorder.
properties designed
to meet
pathological emergencies.
Indeed, its sole weapons of defence, often lamentably imperfect for morbid states, are adapted primarily for
physiological use." If they do meet certain pathological conditions, the explanation is simply coincidence. Conversely, there is no evidence that in normal subjects physical exercise can be conducive to any of the clinical conditions which, according to Selye, react in some way other to A.C.T.H. or’Cortisone.’ Elsewhere4have dealt with a variety of pathological conditions encountered in athletes, with special reference to apparently healthy persons breaking down during effort. Some of these conditions are specifically produced by exercise, among them being " indisposition after running " or athlete’s sickness " (a syndrome characterised by vomiting, profuse sweating, and headache, commonly observed after quarter-mile sprints) ; hypoglycaemia after marathon races ; muscle-cramp in gymnasts; or fainting due to gravitatory displacement of blood after exertion. But in a greater number of the pathological states I described, the exercise, though often the last contributory cause, did not actually produce them. Examples are with occlusion associated effort, rupture of coronary arteries, paroxysmal anomalies of intracardiac conduction, and haemorrhagic pancreatitis after muscular exhaustion. All general autonomic adjustments elicited by muscular effort involve endocrine and nervous functions of the kind studied by Selye. This is important since he believes that adaptation energy represents an unspecific pool of physiological driving force that may become exhausted if the organism is exposed to stress, irrespective of its nature. Exercise may aggravate pre-existing illness : for example, a girl hockey-player with myasthenia gravis had to double her daily dose of neostigmine when she resumed training. On the other hand, many diabetics and other chronically ill people do better and need less insulin when they are physically active 5 : two of the greatest tennis-players in the world today are afflicted with diabetes. Normal humoral or tissue immunity, however, is not increased through training. Normal immunological reactions are by-products of physiological cell metabolism -a concept first expounded by Paul Ehrlich 6-and contrary to popular belief there is no evidence that a high standard of physical" fitness (i.e., a state of adaptation to one of Selye’s stresses ") is associated with, or conducive to, heightened resistance towards infectious diseases. Universal protection against infectious diseases is certainly not afforded by physical training. Physical of the training does not even lead to a general increase 7 scope of normal immunological mechanisms. Selye’s material illustrates the correctness of Cohnheim’s original thesis by showing that many autonomic adaptations are basically the same whether they are elicited by exercise or-to choose one of Selye’s or
"
standard experiments-by transection of the spinal cord. His findings corroborate the conclusion that in pathological situations the body is unable to mobilise weapons other than physiological ones. Only in physiological situations do these reactions serve a purpose. They achieve nothing in the way of repairing a severed Jokl, E. Syncope in Athletes. Pretoria, 1947. Jokl, E. Brit. J. phys. Med. 1948, ii, 2. Ehrlich, P. Beitrage zur experimentellen Pathologie und Chemotherapie. Leipzig, 1909. 7. Jokl, E. Z. ges. exp. Med. 1931, 77, 769.
4. 5. 6.
706
spinal cord ; nor do they help the organism to resist The fact an attack by the lipmolytic streptococcus. that in controlled experiments physiological substances, given in large quantities, may exert a therapeutic influence upon pathological conditions-the recent discovery of the apparent efficacy of A.C.T.H. and cortisone on malignant tumours is an impressive example 8-fits into this concept. Professor Selye deserves the admiration and thanks of the medical profession for presenting so much new experimental evidence. The most effective answer to his critics he has given himself by stating : " Our facts must be correct. Our theories need not be if they help us to discover important new facts." Union Education Department, Pretoria.
ERNST JOKL.
STREPTOMYCIN AND TUBERCULIN
SiR,-I have already reported in your columns certain observations on the effect of streptomycin on the tuberculin reaction in tuberculous meningitis.Further experience has shown that in this respect cases fall into three groups as follows : 1.Moderate cases, in which the reaction increases at the commencement of streptomycin treatment and then falls away as recovery sets in. When the stage of apparent cure is reached, the test again becomes strongly positive and remains so during convalescence. 2. Severe cases, in which the reaction is negative or weakly positive in the early stages and becomes stronger as treatment proceeds. Its subsequent behaviour depends on the course of the disease. 3. Very severe cases with a positive reaction in which the outcome is fatal despite treatment. In these cases, the reaction remains positive throughout.
In the light of the above observations, I have now used subcutaneous or intravenous tuberculin in conjunction with streptomycin for some time, varying the dose according to the strength of the reaction. In three cases I have administered tuberculin intrathecally, but I have now abandoned this route because of the violent reactions which followed. CASE L-Aged 10 years. Admitted April 6, 1947. On Oct. 2, 1947, tuberculin 0-01 ;jLg. was given intrathecally, in view of the persistence of a high level of protein in the cerebrospinal fluid. The reaction was severe. The temperature rose above 39°C, there was violent headache, and the c.s.F. pressure increased. Two days later 0’1 g. was given, and the same reaction was observed, but subsided within 24 hours. The patient was discharged on Dec. 16, 1947, and has remained well since. CASE 2.-Aged 8. Admitted April 11, 1947. One dose of tuberculin 1 g. was given intrathecally on April 20, 1947, but was not repeated in view of the violence of the reaction. Tuberculin was subsequently given subcutaneously. The patient was discharged on Oct. 5, 1947, and has remained well since. CASE 3.-Aged 6. Admitted Dec. 27, 1947. Owing to the prolonged course of the disease, one intrathecal injection of tuberculin 0-01 tg. was given on April 16, 1948. This the temperature was followed by a very severe reaction : rose to over 40"C, the pulse-rate to 150, and the c.s.F. pressure so high as to cause exophthalmos. For two weeks symptoms had to be relieved by drawing off c.s.F. After that time it was found that protein had increased from 1’6 to 4 g. per 100 ml., and cells (mainly lymphocytes) from 30 to 750 per ml. The patient recovered and was discharged on Sept. 20, 1948.
Though
we
cannot
yet draw any conclusions
as
to the
usefulness of tuberculin in
conjunction with streptomycin, it is the general opinion in our clinic that tolerance to tuberculin increases during St. Sophia’s Children’s Hospital, Athens.
streptomycin treatment. K. CHOREMIS.
Spies, T. D., Stone, R. E., Lopez, G. G., Milanes, F., Toca, R. L., Reboredo, A. Lancet, Aug. 12, 1950, p. 241. 9. Choremis, K., Zervos, N., Constantinides, V., Pantazis, S. 8.
Ibid, 1948, ii, 595.
BACTERIAL SYNTHESIS OF VITAMIN B12 SiR,-I have read with great interest the article by Dr. Dyke and his colleagues, in your issue of March 18 ; and I should like to add some comments.
In a bacteriological investigation of the mucosa of fresh pig stomach and of three commercial preparations from different factories of pig stomach against pernicious anaemia, I have constantly found considerable numbers of only two types of bacteria-Bacillus subtilis and one I therefore of the non-pathogenic corynebacteria. presume that one of these bacteria may be identical Later investigations with the " intrinsic factor."1 have shown that both these bacteria synthesise vitamin BIZ in amounts that may be supposed to be important for the concentration of B12 in intestinal mucosa. Clinical investigations with strains of these bacteria in cases of pernicious anaemia have hitherto not given convincing results, but the provisional results indicate that these bacteria, besides producing vitamin BÌ2 by their synthesis of antibiotics, are able to control unwanted bacterial growth in the intestinal mucosa in these cases. This has led to the following working hypothesis of the aetiology of pernicious ansemia: if vitamin B12 is to be absorbed it must be present in intestinal mucosa in a concentration higher than that in the tissues. This is the case in the normal organism, where the intestinal mucosa. is infected with B12-producing strains. In the diseased organism these strains are expelled from the mucosa and replaced by B12-consuming Bact. coli and lactobacilli, and this mucosa forms a barrier to the absorption of B12 from the intestinal contents. Further investigations are being made on the basis of Ibis working- bvnotbesis.
Microbiological Laboratory, Ferrosan Ltd., Copenhagen.
B. NOER Chief Microbiologist.
HOSPITAL ADMINISTRATION
SIR,-It would be difficult to overrate the importance of your correspondent’s article of Sept. 30 under the title Preface to Hospital Administration. It is stimulating chiefly because it insists that hospital administration is one thing, and that the services and crafts which go to meet a hospital’s physical problems are another. These functions are all too frequently confused ; and the confusion has increased because there has been limited experience in procedures for meeting the growing needs of the Ministry of Health for standardised practices and tabulated information. Dr. MacWilliam’s thoughtful letter (Nov. 11) is an evidence that in the present transition in the health services this distinction is likely to be smothered in a welter of administrative conveniences and methods. Readers of the principles set out by Dr. MacWilliam are likely to accept them without, perhaps, realising their far-reaching implications. The questions posed by him focus our attention on some of the difficulties and dangers of the present attempt to weld together two different conceptions of hospital practice and control. But the distinctions between the voluntary hospital and local-authority hospital lay not in accountancy techniques, budgetary controls, and other tools of administration. The distinction was rather in responsibility. On the one hand this responsibility was carried entirely by the hospital board and its administration, and was immediately affected by public reactions to its policies. On the other hand there was an administration responsible in an auditing sense to a financial authority outside the hospital, elected for other than hospital tasks, and having no special sanction or experience in the field of economy consistent with the requirements of the sick. Dr. MacWilliam’s analysis demonstrates some important 1. Nocr, B.
Dansk. Tidsskr. Farm. 1949,
23,
111.