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get adequate consideration of the epidemiological conditions,but the problem is of major importance for pigeon-fanciers.This is not only because of their own health, but because some35% of fanciers are tenants on local-authority estates; per-mission to keep pigeons is therefore subject to the opinions andprejudices of housing committees-and they, like so manyothers, can be misinformed.

C. A. E. OSMANEditor, The Racing Pigeon.

19, Doughty Street,London, W.C.1.

RENAL AUTOTRANSPLANTATION

E. BENGOECHEA GONZALEZ.

General Hospital,Warrington,Lancashire.

SIR,-Dr. Serrallach-Mila and his colleagues must surelybe given the credit for first describing the treatment of renal-artery stenosis by autotransplantation of the kidney to theiliac fossa. They were the first who actually did it, even ifMr. Dempster (Jan. 1) had suggested it before. This procedureseems to me a logical answer in certain cases where revas-cularisation of the kidney in its normal position is technicallydifficult. I have the impression that we shall be hearing moreabout this approach in the future.As Mr. Dempster points out, this form of autotransplanta-

tion of the kidney is also a solution to the problem of re-establishing ureteral continuity after injury or disease of a longsegment of ureter. Hardy has reported a clinical case success-fully treated by this method.2 The alternative of using intestineto bridge the gap may be more appealing to a greater numberof surgeons with a different training, but this has the draw-backs of producing reflux, metabolic acidosis, and sometimesmassive dilatation of the intestinal segment.

ENZYMES IN DOWN’S SYNDROME

LING-YU SHIHDAVID YI-YUNG HSIA.

Children’s Memorial Hospital, andDepartment of Pediatrics, North-western University Medical School,

Chicago.

SiR,-An increase of leucocyte alkaline phosphatase 3 andleucocyte glucose-6-phosphate dehydrogenase (G.-6-P.D.) 4 5has been reported in patients with Down’s syndrome. We

report here the activity of these two enzymes in the plateletsof such patients.The platelets were prepared as described by Wurzel et al. B

except that they were washed with 0-2% saline solution once tocomplete the destruction of erythrocytes, and lysis was carriedout using saponin. G.-6-P.D. was assayed by the procedure ofKornberg and Horecker,’ and alkaline phosphatase by themethod of Bessey et al. using p-nitrophenol phosphate assubstrate at pH 9-3. There was no difference between the

patients with Down’s syndrome and controls in G.-6-P.D.

activity (expressed as platelet-count, or as protein content ofnicotinamide-adenine dinucleotide phosphate [N.A.D.P.]) andalkaline-phosphatase activity, as follows (all values are expressedas mean standard error, and the numbers of subjects studiedare given in parentheses):

1. Serrallach-Mila, N., Paravisini, J., Mayol-Valls, P., Alberti, J., Casellas,A., Nolla-Panadés, J. Lancet, 1965, ii, 1130.

2. Hardy, J. J. Am. med. Ass. 1963, 184, 97.3. Trubowitz, S., Kirman, D., Masek, B. Lancet, 1962, ii, 486.4. Mellman, W. J., Oski, F. A., Tedesco, T. A., Maciera-Coelho, A.

Harris, H. ibid. 1964, ii, 674.5. Shih, L. Y., Wong, P., Inouye, T., Makler, M., Hsia, D. Y. Y. ibid.

1965, ii, 746.6. Wurzel, H., McCreary, T., Baker, L., Gumerman, L. Blood, 1961,

17, 314.7. Kornberg, A., Horecker, B. L. Meth. Enzym. 1955, 1, 323.8. Bessey, O. A., Lowry, O. H., Brock, M. J. J. biol. Chem. 1946, 164, 321.9. Ramot, B., Fisher, S., Szeinberg, A., Adam, A., Chaim, S., Gafni, D.

J. clin. Invest. 1959, 38, 2234.10. Ramot, B., Szeinberg, A., Adam, A., Sheba, C., Gafni, D. ibid. p. 1659.11. Gartler, S. M. Int. Congr. hum. Genet. 1961, 2, 622.

quine-sensitive type of G.-6-P.D. deficiency, no abnormality inenzyme activity has been found in leucocytes 12 or fibroblasts 13corresponding to the decrease seen in erythrocytes. Cox 14

reported that an extra chromosome 21 does not affect eitherthe alkaline-phosphatase concentration or its mode of regula-tion in skin cultures derived from trisomic patients with Down’ssyndrome. The failure to find an increase of either plateletalkaline phosphatase or platelet G.-6-P.D. in Down’s syndromesuggests that the increase in leucocyte alkaline phosphatase andleucocyte G.-6-P.D. probably represents not the direct action ofa structural gene locus, but a more localised reaction. Thiswould also provide further confirmation for the concept thatplatelets have a different origin from leucocytes and

erythrocytes .15We wish to thank Dr. N. Shahidi for his suggestions. These

studies were supported by grants from the Illinois Mental HealthFund and the United States Public Health Service (TI-AM-5186).

NO CHARGE

GEORGE L. HINDSON.

Sir,-I was very surprised to read your annotation 16 aboutprescriptions issued by general practitioners.The implication of overprescribing by disillusioned doctors

leaves a bitter taste in the mouth and must be far from the

truth-except perhaps in some instances. At a time whencritical negotiations are in progress to improve the NationalHealth Service it is unwise to make damaging statements whichcould be detrimental to the profession.Let us face the facts-the public are conditioned to using

free services, and, human nature being what it is, some peoplewill quite naturally get all they can for nothing. This appliesparticularly to inadequate hypochondriacal personalities whoconstitute about 2% of every practice and are content to usetheir family doctor in the same way as they would a drug store.This 2% from each practice throughout the country, viewedcollectively, represents a formidable destructive force withinthe N.H.S., and in the context of all the other social amenitiesand benefits which they astutely manoeuvre to their own

advantage. This factor should be considered when planningfuture welfare schemes.

HELPING YOUR DOCTOR/PATIENTSIR,-It seems reasonable that, with so much recent publicity

given to abuses of the National Health Service by patients,some efforts should be made to redress the balance.Two telephone calls from the daughter of a 66-year-old

patient, a chronic and severe case of Parkinson’s disease, in theweek before Christmas failed to produce a visit from thedoctor. On Christmas Eve the patient fell, and a third phone-call finally brought the G.P. He left, leaving a Helping YourDoctor leaflet published by the Ministry of Health. Paragraphs3 and 4 were marked, and the second half of the sentence inparagraph 3, pointing out that " Doctors are not under anobligation to see a patient just whenever and wherever thepatient thinks fit ", was underlined. A final gesture was a noteon the back of the leaflet: " Please get your mother changed toanother doctor."From this incident it appears that the Ministry have in-

advertently provided general practitioners with a form, similarto that of a driving-test examiner, on which the appropriatepresumed faults in attitude of patients and their relatives can12. Marks, P. A., Gross, R. T., Hurwitz, R. E. Nature, Lond. 1959, 183,

1266.13. Gartler, S. M. 4th Macy Conference on Genetics; p. 194. Ann Arbor,

Michigan, 1964.14. Cox, R. P. Expl Cell Res. 1965, 37, 690.15. Saltzman, G. F. Acta med. scand. 1949, 132, suppl. 221.16. Lancet, 1965, ii, 1172.