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emphasis has been on joint staff consultative com-mittees’,.which may be valuable for improving morale.but as means of ensuring economy are far less effectivethan is personal responsibility.. The concept- ofdepartmental costing also has particularly importantrepercussions on the hospital’s annual budget-a point made’very clearly in the King’s Fund report :

" The’- budget of a hospital or group is at present’regarded as. a sum of money to cover the - estimatedexpenditure to be incurred during the next financialyear ; as a document laying down limits which mustnot be exceeded. This, in our opinion, is not a budget ;it is an appropriation of funds. We regard a budgetas a constructive plan of action, which has, in its severalparts, been agreed by the heads of all departments.concerned and approved by the management. It is’an expression, in accounting terms, of the plan andfuture policy of the hospital and a pre-requisite to sound’management. This view of a budget places emphasison the financing of the cost of care rendered to patientsrather than on that of financing the hospital as aninstitution. Within a hospital or group it must beflexible to meet changing conditions in the volume andincidence of service rendered, and to allow of justcomparisons." .

There are certain technical differences betweenthe two reports, the chief of which concerns themethod of distributing the cost of general services.The Nuffield Provincial Hospitals Trust -prefers to

express the departmental figures in terms of "

primecost "-i.e., , expenditure on salary and wages ofstaff working in a department and on the materialsactually used in the department. Thus a medical

department would include only medical salaries andsalaries-of nurses and ward orderlies and the cost ofall materials used in the wards, such as dressings,linen, and crockery. This system means that eachresponsible member of the staff is made aware of theexpenditure incurred by him for his department andof variations in the expenditure that can be controlledby him : costs over which he has no control are

excluded. This simple system does indeed seem

preferable to the technique advocated by the King’sFund, whereby a proportion of general service charges(e.g., heating, laundry, and catering), is allocatedto each department according to its claims on theseservices. Allocations that might be based on semi-arbitrary decisions would tend to undermine a senseof individual responsibility and also reduce confidencein comparative figures. The King’s Fund reportsuggests- a greater number of departmental units tobe costed-an arrangement not favoured by theTrust. Certainly it seems undesirable to cost eachward separately, because a position might arise inwhich ward sisters sought to avoid patients whomade expensive demands on. their stock. Thereare in fact too many variables to allow a useful

comparison between individual wards.The proposed costing system would be a further

step away. from the method of Treasury control

formerly exercised, which could hardly have beenbetter designed to inhibit economy. The, essence ofthe Treasury system was control of payments (notexpenditure) by reference to detailed yearly estimateswhich were broken down into many inelastic groups.As the Fund clearly points out, this system left theway open for waste and inemciency ; for, in a’last-minute scramble to spend balances in hand, moneywas frittered away on short-term palliative main-tenance work, pieces of equipment, furniture, and

so on-orders small enough to be completed withinthe financial year. It was also especially stultifyingto long-term planning and to the careful husbandingof resources towards this end, since there was anabsolute prohibition against carrying forward unspentbalances. Working and budgeting in terms of depart-mental medical services to the community is a

sensible and logical approach, and would go far torelease hospital services from the sterilising Treasurysystem.One essential test to apply to any proposed change

in the N.H.S. is whether-or not it will facilitate thegrowth of the dangerous virus of national uniformity.There is, in fact, a risk that the proposed system ofcosting might facilitate this growth ; but the advan-tages of the system seem to outweigh its dangers,though these must be kept constantly in mind. We

may add that it would have been a virtual impossibilityfor any Government department to have undertakenthe surveys worked out by the Nuffield ProvincialHospitals Trust and the King’s Fund, and theirefforts afford yet another example of the value of theindependent observer. The reports of the twofoundations will provide medical historians withfurther evidence of the valuable contribution theyare making to the British hospitals services. Atribute should also be paid to the Ministry of Healthfor its perspicacity in seeking independent assistancein a difficult and contentious field.

1. Medawar, P. B. J. Anat., Lond. 1944, 78, 176; Ibid, 1945,79, 517.

2. Dempster, W. J., Lennox, B., Boag, J. W. Brit. J. exp. Path1950, 31, 670.

TransplantationTHOUGH the human body is often beset with

autonomous new growths of great vigour, it is seldomable to transgress the rules and to support life fromthe tissues of another individual. Only quite limitedgrafts of highly specialised tissues have so far been a .success-for example, blood-transfusion, corneal graft-ing, and the transplantation of homologous cartilage,bone, and blood-vessels, which are now an acceptedpart of surgical practice. The career of most of these

implants as distinct pieces of tissue is short; indeed it is

questionable whether they need be alive at the momentof grafting. Most of our knowledge of transplantationis based upon experiments in animals; but these, itseems, differ as much from man in their response to-

homografting as in the diseases from which theysuffer. The only explanation of these phenomenathat is based upon observed facts, rather than onabstractions, is that of MEDAWAR.l He has shownthat skin homografting evokes an immune responsein the host. If this response has already been pro-’,duced by a preliminary exposure to skin or whiteblood-cells from the same donor, the survival-time of a,second graft is much shorter. There is also evidencethat if the reticulo-endothelial system of the recipientis inactive at the time of grafting, the survival periodis significantly prolo ’ngqd. 2 , Total body radiation orthe administration of nitrogen mustard’ will depressthe activity of the reticulo.-endothelial ’system, butas a result the body also loses its resistance to bacterialinfection during the phase of marrow aplasia. Underthese circumstances ’ antibiotics alone are seldomsufficient to control.a massive infection’; but when they ,

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were used in the treatment of people irradiated by theexplosion of the atomic bomb at Hiroshima 3 theydid, in borderline cases, allow time for the reticulo-endothelial system to recover. JACOBSON et awl. 4

found that the recovery-rate in irradiated pure-strainmice was greatly increased by the intraperitonealinsertion, after exposure, of splenic homografts fromone-week-old mice of the same strain, and haemopoiesisin the marrow and spleen returned to normal muchsooner than in the few control mice that survived. Itremains to be seen whether animals of mixed strainwill respond in the same way. Homologous ratovaries have been implanted in the spleen, where theydeveloped into tumours, which in some cases metasta-sised to the liver. 5 More limited " takes " were obtainedby FAWCETT, 6 who placed fertilised ova under therenal capsule of adult mice. The cheek pouch of thegolden hamster (a highly inbred species) has also beendescribed 7 as a favourable site for homografts andeven heterografts, though no explanation has beensuggested. In general it seems that fcetal tissues havea better chance of surviving as homografts, but aretheir antigenic properties necessarily less than thoseof adult tissues ? Some evidence to suggest that theyare was provided by KEMP 8 who observed that red-cell agglutinogens could be demonstrated in thehuman foetus at 37 days, and that the sensitivity ofthese cells to immune sera increased progressivelythereafter.

Organ transplantation occupied CARREL in his mostactive years ; using a precise technique, as he didin tissue-culture work and in vascular surgery, headvanced the subject far ahead of his time. Endocrine

transplants interested HALSTED ; he believed that

they would " take " more readily if the recipient wasin physiological need of them. The endocrine basisfor this law is now quite familiar ; for example,A.C.T.H. is found to be present in excess in Addison’sdisease. BROSTER’s case 9 of adult-adrenal trans-plantation and other instances in which foetal adrenalshave been used are later examples of this possibility.Kidney homografts function only for a short time,even though their vascular pedicle may remain intactfor very much longer. DEMPSTER has developed thetechnique of this operation in dogs, using autogenouskidneys ; but the disposal of the ureter is a difficultpoint, even with autografts, and hydronephrosis is acommon cause of late failure. Homotransplantedkidneys usually fail after only a few days, duringwhich they produce a urine of fixed specific gravity.DEMPSTER describes a " toxic hypertensive state "which develops in dogs at this stage if they lack theirown kidneys. Extensive degenerative changes are

found in the transplant, and the tubules are damagedmuch earlier than the glomeruli. In the fewexamples 10 11 of human kidney homotransplants thathave been recorded, the graft has survived very much3. Hersey, J. Hiroshima. London, 1946; p. 104.4. Jacobson, L. O., Simmons, E. L., Marks, E. K., Gaston, E. O.,

Robson, M. J., Eldredge, J. H. J. Lab. clin. Med. 1951, 37, 683.5. Biskind, M. S., Biskind, G. R. Proc. Soc. exp. Biol., N.Y. 1944,

55, 176; Ibid, 1945, 59, 4; Cancer Res. 1950, 9, 35.6. Fawcett, D. Anat. Rec. 1950. 108. 83.7. Lemon, H. M., Lutz, B. R , Pope, R., Parsons, L., Handler, A. H.,

Patt, D. I. Science, 1952, 115, 461.8. Kemp, T. Acta path. microbiol. scand. 1930, 7, 146.9. Broster, L. R., Gardiner-Hill, H. Brit. med. J. 1946, ii, 570.

10. Lawler, R. H., West, J. W., McNulty, P. H., Clancy, E. J.,Murphy, R. P. J. Amer. med. Ass. 1950, 144, 845.

11. Hume, D. M., Merrill, J. P., Miller, B. F. Clinical Congress of theAmerican College of Surgeons. 1952.

longer than in the dog ; but these kidneys did notfunction normally, and it is uncertain -whether theyserved to clear away the products of previous renalfailure during their period of activity, or whetherresolution was due to recovery of the patient’s ownkidneys. Skin homografts in man also survive longerthan in animals-for periods of from three to sixweeks. Under favourable circumstances therefore,skin donors can be a great help in providing skincover for extensive burns, particularly in children.WOODRUFF 12 made the interesting observation thatthe areas of homologous skin were not affected inan intercurrent attack of chickenpox, while the

autogenous strips were. He agrees with most otherauthorities that ABO blood-groups apparently playno part in the compatibility of other tissues. He adds,however, that, as in MEDAWAR’s experiments, blood-transfusion in humans may produce immunity to thatparticular donor at least. An exception to these

general rules is provided by grafts inserted into the’anterior chamber of the eye. Homologous skin 13 andthyroid 14 can survive indefinitely here, though, in thecase of the skin, vascularisation of the transplant is aprelude to its destruction., Moreover, a survivingpiece of homologous thyroid in the eye is also destroyedsoon after another piece from the same donor isinserted subcutaneously. It seems that antibodies,once formed; can reach the anterior chamber, thougha homograft inside the chamber need not evoke animmune response. WOODRUFF, however, has alsofound that long-established anterior chamber trans-plants are no longer affected by a subcutaneous graftfrom the same donor, though this itself is destroyed inthe usual way. He therefore believes. that there is acritical period during which recent homografts in theeye, and perhaps in other sites, are most readilydestroyed by the antibodies of the host. Theremay thus be some way of maintaining conditionswhich are favourable to the graft until the critical

period is over, after which it should have a betterchance of permanent survival.

Should homografting fulfil its promise to surgery,the collecting and storing of donor tissues will becomeof the greatest importance. The Corneal GraftingAct, 1952, allows eye banks to be operated much moreeasily than before, and comparable legislation maysoon be needed for other tissues to be collected insimilar circumstances. Storage difficulties have

already set a limit to the scope of arterial grafting,for fresh grafts, like stored blood, should not be usedafter three to four weeks. PEIRCE,15 in a year’s work,collected 50 grafts, but only 3 of these were actuallyused in patients. The most practical method ofhusbanding these scarce commodities has so far beento freeze them to --70°C, and to keep them at thattemperature by means of solid carbon dioxide. Inthis way storage may be prolonged indefinitely.Various tissues are known to survive this kind oftreatment : arteries,16 spermatozoa,17 red blood-

cells,18 and skin 19-can all function successfully when12. Woodruff, M. F. A. Ann. R. Coll. Surg. 1952, 11, 173.13. Medawar, P. B. Brit. J. exp. Path. 1948, 29, 58.14. Woodruff, M. F. A., Woodruff, H. G. Phil. Trans. B. 1950,

234. 559.15. Peirce, E. C. Ann. Surg. 1952, 136, 228.16. Hufnagel, C. A., Eastcott, H. H. G. Lancet, 1952, i, 531.17. Polge, C., Rowson, L. E. A. Nature, Lond. 1952, 169, 626.18. Mollison, P. L., Sloviter, H. A., Clapham, H. Lancet, Sept. 13,

1952, p. 501.19. Billingham, R. E., Medawar, P. B. J. exp. Biol. 1952, 29, 454.

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thawed. Techniques for frozen storage of livingtissues are complicated, and homograft survival islimited and uncertain, but enough has already beenaccomplished to illustrate the abundant surgicalapplications that may finally prove possible.

1. Williams, C. D. Annual Report for 1932, Medical Department,Gold Coast; Arch. Dis. Childh. 1933, 8, 423; Lancet, 1935,ii, 1151.

2. Lancet, 1950, ii, 580.3. Kwashiorkor in Africa. F.A.O. Nutritional Studies no. 8 and

W.H.O. Monograph Series no. 8. Rome and Geneva, 1952.Pp. 78. 5s.

KwashiorkorIN 1933 CICELY WILLIAMS 1 drew attention to a

nutritional disease common among the children of theGold Coast, where it was known by the vernacularname of kwashiorkor. Since then there have beennumerous reports from all parts of Africa, and alsofrom Asian, American, and even European countries,describing clinical syndromes which resemble kwashi-orkor in greater or less degree. Some authors have

emphasised similarities to the condition originallyobserved in the Gold Coast : others have laid stresson differences. Unfortunately, most of them havebeen able to speak from experience of only one area,and their accounts of varying setiological factors andclinical features have made it hard to know whetherthe disorders they are describing are essentially thesame disease. But whether they are the same or not,they are certainly very important as causes of miseryand loss. The time is more than ripe, therefore, foran attempt to correlate the items of knowledge gainedin the past twenty years, and we hope for useful resultsfrom the conference on kwashiorkor now in progressat Fajara in the Gambia, at which delegates frommore than twenty African territories are meetingunder the presidency of Prof. B. S. PLATT, directorof the Medical Research Council’s field research stationin that place.

It may be recalled that in 1950 a joint expertcommittee of the World Health Organisation and theFood and Agricultural Organisation recommended thesubject for study by the United Nations 2 ; and fromthis initiative comes a report 3 by Dr. J. F. BROCK,professor of medicine at Cape Town, and Dr. M.AUTRET, of F.A.O. Having made an extensive Africantour, they define kwashiorkor as a nutritional syn-drome, common among the natives of many parts ofAfrica, in which characteristically there occurs :

"(a) retarded growth in the late breast-feeding,weaning, and post-weaning ages with (b) alterationsin skin and hair pigmentation, (c) oedema, (d) fattyinfiltration, cellular necrosis, or fibrosis of the liver,(e) a heavy mortality in the absence of proper dietarytreatment and (,f) the frequent association of a varietyof dermatoses." Perhaps it is this variety of thedermatoses, determined partly by local vitamindeficiencies and partly by environmental trauma, thathas chiefly delayed agreement on the nature of thedisease. Clearly there are local variations, relatedboth to local dietary deficiencies (notably the variedintake of the B group of vitamins) and to local preva-lence of tropical infections ; but BROCK and AuTBETshowed that behind these variations there is a clinicalentity at least as distinct as beriberi or pellagra.Pragmatically anyhow, the use of the word kwashi-orkor has been justified, for it has led to the recog-

nition and treatment of individual cases and to thedevising of means of prevention. Physicians whohave used it in the same sense as BROCK and AUTRETinclude such authorities as CLARK and TROWELL 5

in East Africa, PIERAERTS 6 and DRICoT et al. in theBelgian Congo, and BERGERET 8 and BERO0UNI0Uand TRÉMOLIÈRES 9 in French West Africa. Never-theless there are dissidents, represented by KAHN,10of Johannesburg, who recently asked in this journalwhether we are justified in

"

bundling together caseswith and without oedema, with and without mucousmembrane changes, with and without dermatosis, andso on ? " He would restrict the term kwashiorkor tothe pigmentary changes in the hair, which in someareas turns from black to russet ; but he seems tobe in error (with CICELY WILLIAMS) in believing thaton the Gold Coast kwashiorkor means " red boy

"

and is solely descriptive of these changes. MAc-PHERSON11 says that in fact it means " possessed byred devils " and is a sinister word knit with GoldCoast magic.The first task before BROCK and AuTRET was to

establish whether or not kwashiorkor was a real medical

problem, affecting large numbers of children in manyparts of Africa. To this question their answer was anemphatic " yes." They went on to produce muchevidence that a widespread lack of protein (particu-larly animal protein) in the diet during the early yearsof life is the all-important aetiological factor : as theGovernor of the Gambia said in opening the Fajaraconference,12 the general opinion is that the main

contributory cause is a deficiency in protein foods,especially at the time of weaning. The relation ofdeficiency in the diet to the deficiency in pancreaticfunction which was observed some years ago inchildren with kwashiorkor 13 and is now being furtherinvestigated 14 15 still needs to be worked out.; butso far as treatment is concerned, the efficacy of

proteins (particularly milk proteins) is almost beyonddispute. The problem of prevention, however, hasno equally simple solution. We know that, apartfrom the heavy mortality, vast numbers of Africanchildren are retarded and stunted, both- physicallyand psychologically, by this form of malnutrition:indeed it is no exaggeration to say that the Africanpeoples will never be able to take their proper placein a free world so long as they are thus handicapped.The recent work of DEAN 16 encourages the hope thatproteins from vegetable sources will suffice for preven-tion ; but before the African child of the future canreceive a sufficiency of these there will have tobe a revolution in African standards of mother-craft, and several revolutions in African agriculture.This is the kind of fact that we hope the conference,like the W.H.O.-F.A.O. report, will help to drivehome.

4. Clark, M. E. Afr. med. J. 1951, 28, 229.5. Trowell, H. C. Trans. R. Soc. trop. Med. Hyg. 1949, 42, 417.6. Pieraerts, G. Bull. Soc. Path. exot. 1950, 43, 120.7. Dricot, C., Beheyt, P., Charles, P. Ann. Soc. beige Méd. trop.

1951, 31, 581.8. Bergeret, C. Bull méd. Afr. occid. franç. 1948, 5, 257.9. Bergouniou, J. L., Trémolières, J. Bull. Soc. Path. exot. 1952,

45, 113.10. Kahn, E. Lancet, Sept. 20, 1952, p. 588.11. MacPherson, A. Ibid, 1951, i, 53.12. See Times, Nov. 20, 1952.13. Davies, J. N. P. Lancet, 1948, i, 317.14. Thompson, M. D., Trowell, H. C. Ibid, 1952, i, 1031.15. Srinivasan, P. R., Patwardhan, V. N. Ibid, Nov. 1, 1952,

p. 864.16. Dean, R. F. A. Brit. med. J. Oct. 11, 1952, p. 791.