plausibility of points of view other than our own, we are likely to run into a head-on collision which will probably leave us all as losers. It seems that much of the controversy concerns the concept of a " total commitment allowance ". It is difficult to see how an offer could be more carefully designed to anger part-time consultants and embarrass whole-time consultants. What are its implications ? Either that payment will be given for undefined functions that a fulltimer performs or for his geographical reliability as there is nowhere else for him to be during his working day. Alternatively this payment is made for not performing private practice, which sounds like something out of Catch 22. I would like to be paid for not smoking, but it doesn’t make any sense and there are other better reasons, and I do smoke anyway. How much could it be worth not treating ansemia or Liberals or street musicians ? It is entirely out of order for the Government to intrude in matters of this kind, which are none of its business. Perhaps I have missed the point, which is probably just as well, because I understand it is imperceptibly changing into something unrecognisable, but why not negotiate for an open contract for full-time employees which, with a sensible salary of E15-20.000, can be divided for part-time employees according to the number of sessions they contract to work? Furthermore, let us work to guarantee that sessions paid for by the N.H.S. are worked, and that those which are missed are not paid for. A consultant paid to be in one place doing his job from 9 A.M. to 1 P.M. must be there, not for five minutes to make sure his registrars can handle it. He is there and acknowledges a professional and ethical obligation to be there, with sanctions defined by statute in the event of his failure. If this is asking too much of a professional man’s integrity, how about a new whole-time contract ? Just that, with no part-time option at all. And those who wish to practise private medicine can do so, full-time and uncompromised. St.

George’s Hospital

Medical School, Department of Hæmatology, Blackshaw Road, London SW17 OQT.



SiR,—At a meeting of the junior medical staff of the University of Wales Group, held to discuss the new junior contract, a number of doctors expressed concern that the consequences of the introduction of a 40-hour standard working week had not been fully worked out by those negotiating on our behalf. The representatives of the Hospital Junior Staffs Group Council and Junior Hospital Doctors Association present at the meeting offered no real solution to the problems raised. A separate meeting of the junior pathologists was then called to discuss the effect of the 40-hour week on pathology and other shortage specialties and a number of points were agreed. The prime income of a junior hospital doctor should be his basic salary, and the payment of substantial extra-duty allowances after 40 hours will widen the salary gap between those specialties where on-call duties are worked and those in which on-call duty is infrequent or non-existent. This will have a severe effect on recruitment into these specialties and in turn lead to a reduction of the standard of medical care. Emigration would become increasingly attractive, since other countries are often equally short of doctors in these specialties. The proposal that " shortage specialty allowances " should be paid was felt to be one possible means of overcoming the problem, but the meeting felt that no doctor should have to earn extra-duty or other

allowances in order to achieve a standard of living similar to that of his contemporaries at a similar point in training. It was also felt that the introduction of a 40-hour week could be impossible without introducing an unacceptable level of surveillance by employing authorities, and coupled with this are the real problems of what constitutes extra duty and the difference between being on-call and actually

working. For the N.H.S. to work successfully all medical services be adequately staffed. It would be a pity that some shortage specialties already unattractive for various reasons should be made even more so because of large differences in salary. We invite other pathologists, radiologists, and members of other shortage specialties to ensure that their views and interests are heard in the current review of salary.




University Hospital of Wales, Park, Cardiff CF4 4XW.



SIR,-Because they found

no difference in the presence between strains of Escherichia coli from upper and lower urinary-tract infections in women, Kalmanson et al. conclude that host factors determine the localisation of infection. No-one would question that host factors have a part to play, but the role of the bacteria themselves should not be too readily dismissed. Kalmanson et al. give their results as " K antigen present " or " absent ". Yet the crucial feature of the method of measurement used,2 as shown by Glynn and Howard,3 is that it determines the amount of biological activity of the K antigen present. The activity which depends on both the weight and degree of polymerisation of the K antigen is measured as inhibition of red cell agglutination (A.I.A.). We presume that the term " K present " as used by Kalmanson et al. does in fact refer to a significant level of activity, but the point is too important to be left uncertain. Localisation of the site of infection in Kalmanson et al.’s work was by ureteric catheterisation. Glynn et al.2 found a clear excess of K-rich strains of E. coli from patients in whom the diagnosis of renal involvement was based on a high titre of 0 antibody. It is interesting that the preponderance of K-rich strains was less when renal involvement was assessed by the neomycin bladder washout method. They suggested that the latter might include cases of ureteric bacteriuria not always accompanied by renal invasion. Kaijser4 found K antigens more frequently and in greater amounts in urinary E. coli from girls with pyelonephritis than from those with cystitis. The diagnosis of pyelonephritis was based on clinical grounds plus impairment of renal concentrating ability. We have also examined the ability of E. coli strains to produce ascending infections in mice. Known doses of organisms were injected into the bladder made susceptible by the presence of 2 small cotton sutures through the

of K


Kalmanson, G. M., Harwick, H. J., Turck, M., Guze, L. B. Lancet, Jan. 18, 1975, p. 134. 2. Glynn, A. A., Brumfitt, W., Howard, C. J. ibid. 1971, i, 514. 3. Glynn, A. A., Howard, C. J. Immunology, 1970, 18, 331. 4. Kaijser, B. J. infect. Dis. 1973, 127, 670. 1.

271 anterior wall. The number of kidney infections produced was very dose dependent, but the 50% infectious doses (I.D.so) for the strains tested were inversely proportional to the activity of their K antigens. Mary’s Hospital Medical School Department of Bacteriology, A. A. GLYNN Wright-Fleming Institute, Paddington, London W2 1PG. ANDREA M. NICHOLSON.



SIR,-Might I be permitted to point out a minor, but not unimportant, terminological inexactitude in your excellent leading "article on vagotomy (Jan. 18, p. 149) ? You mentioned the advent of highly selective vagotomy without drainage (H.s.v.) alias parietal-cell vagotomy, selective proximal vagotomy..." and quoted Holle and Hart’s paper of 1967. This is not strictly correct, because Holle and Hart insisted, as indeed they still insist, on the need for a

complementary drainage procedure (pyloroplasty)


limited form of antrectomy in conjunction with " s.p.v.11. Thus the " beautifully coordinated antro-pyloro-duodenal mechanism " described in the article is still sacrificed in the course of s.p.v. Vagotomy confined to the parietal-cell mass, with preservation of an intact antral mill and pyloric sphincter (H.s.v. or P.c.v.) was first used in 1969, in Leeds and Copenhagen. 1-4 University Department of Surgery, The General Infirmary, Leeds 1.



SIR,-The comments of Dr Kjellstrand and his colleagues (Jan. 25, p. 219) are interesting. The first, though incidental,

point to strike us is that their incidence of delayed onset of function is less than half our figure for all cadaver kidneys. It would be interesting to know if this is related to different circumstances surrounding the harvesting of kidneys. The experience of Kjellstrand et al. of kidneys with delayed onset of function is very different from ours, and they suggest that this is due to our small sample size and to the loss of kidneys or recipients in the delayed-function group as a result of " invasive diagnostic procedures " and dialysis problems. Since our sample was very much smaller than theirs we cannot refute their first criticism. Only 1 kidney was lost as a result of an invasive diagnostic procedure-i.e., a needle biopsy. 3 patients died whilst being dialysed. This was one of the main points of our paper-that dialysis in the postoperative immune-suppressed patient is a hazardous undertaking and the transplantation of kidneys which do not function at once exposes more patients to these hazards. The rejection rate of 6 of 16 kidneys with delayed function, against 1 of 12 with immediate function, is striking, in spite of the small sample size, and illustrates another main point: that the diagnosis of rejection in an oliguric patient is difficult to make and may be made too late, so that the transplantation of kidneys with delayed function may result in a higher incidence of irreversible rejection. The use of daily scanning with the gamma-camera may alter this situation, and it would be interesting to know if Kjellstrand and" his colleagues use this device or other " non-invasive methods of diagnosing rejection. Department of Surgery, University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon Tyne NB1 4LP. 1. 2.


Johnston, D., Wilkinson, A. R. Br. J. Surg. 1969, 56, 626. Amdrup, E., Jensen, H.-E., Pedersen, G. Danish Surgical Society,

1969. 3. Johnston, D., Wilkinson, A. R. Br. J. Surg. 1970, 57, 289. 4. Amdrup, E., Jensen, H.-E. Gastroenterology, 1970, 59, 522.

LYMPHOKINES AND NEPHROTIC SYNDROME SIR,-We support Shalhoub’s1 hypothesis on the

pathogenesis of lipoid nephrosis and have studied the biological activity of supernatants from short-term human lymphocyte-cultures. 2-4 In patients with nephrotic syndrome (N.s.), the suggested role of increased capillary permeability accords with the prompt recurrence of proteinuria after kidney transplantation in some cases.5 Lymphokines may enhance capillary permeability. 6,7 We cultured lymphocytes from patients with N.s. and tested the supernatants for a skin reactive factor. After glass-wool separation, peripheral lymphocytes were cultured at a concentration of 1 x 106 per ml. in medium 199 containing 20% of normal human serum AB or in minimum essential medium without serum. Nonspecific stimulation was carried out using concanavallin A (5 g. per ml.). Supernatants were collected on the 2nd day and 0-1 ml. of each supernatant was injected intradermally into Hartley guineapigs. Vascular permeability was measured by the Evans-blue technique (surface determination after 30 minutes). Any delayed reaction was estimated after 24 hours by clinical examination for erythema and induration and histology. The supernatants from control cultures (without cells) did not have any immediate effect on vascular permeability. Supernatants from cultures of lymphocytes from twenty-three controls gave weakly positive immediate results in four cases only, with a mean reaction area of 50 sq. mm. Forty supernatants from lymphocyte-cultures of fortysix patients with N.S. induced strong positive results. The intensity of the reaction was not dependent on the histological pattern of N.s. However, the results for each group of patients differed significantly from those of the control group (p < 0-0005). As with the immediate effects, only supernatants of cell-cultures from N.S. patients had positive delayed effects. Erythema appeared after 2 hours and maximum induration after 12 hours (20 to 50 sq. mm.). Both signs disappeared after 24 hours. Histologically we found mixed infiltration with polymorphonuclear and mononuclear cells. Although the skin reactive factor was released by lymphocytes cultured without serum, the addition of normal human serum at the start of culture enhanced its production. The immediate reaction was not influenced by antihistamines, antiserotonins, indomethacin, and salicylate. Meclofenamic acid and pyridinolcarbamate inhibited the reaction, and diethyldithiocarmabate and the addition of normal human serum before injection enhanced it. These results suggest a possible relation with the kinin system. The factor was dialysable. Its activity was reduced by heating for 30 minutes at 56 °C. It was destroyed by digestion with pepsin but was resistant to D.N.ase. The molecular weight of this skin reactive factor was estimated as being between 30,000 and 60,000 by gelfiltration chromatography. The factor had the electrophoretic mobility of an aI-globulin. We conclude that cultured peripheral lymphocytes from patients with N.s. release a lymphokine-type factor which has an inflammatory effect and enhances vascular permeability. Its properties are very similar to those of the skin reactive factor described by Maillard et al. and Pick et al. 1. 2.

3. 4.

5. 6.


Shalhoub, R. J. Lancet, 1974, ii, 556. Lagrue, G., Xheneumont, S., Branellec, A. Nouv. Presse Méd. 1973, 25, 1719. Lagrue, G., Xheneumont, S., Branellec, A., Hirbec, G., Weil, B. Biomédecine (in the press). Lagrue, G., Branellec, A., Blanc, C., Xheneumont, S., Weil, B. ibid. (in the press). Hoyer, J. R., Simmons, R. L., Vernier, R. L., Raij, L., Najarian, J. S., Michael, A. F. Lancet, 1972, ii, 343. Maillard, J. L., Pick, E., Turk, J. L. Int. Archs Allergy app. Immun. 1972, 42, 50. Pick, E., Turk, J. L. Clin. exp. Immun. 1972, 10, 1.

Letter: Urinary-tract infection: localisation and virulence of Escherichia coli.

270 plausibility of points of view other than our own, we are likely to run into a head-on collision which will probably leave us all as losers. It s...
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