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most remarkable difference consisted in the virtuallycomplete elimination of generalised side-effects.This work was supported by the Swedish Medical Research

Council and the Astra Company.

N. WIQVISTM. BYGDEMAN.

Department of Women’s Diseases,Karolinska Sjukhuset,

Stockholm 60,Sweden.

EMERGENCY CALL SERVICE

H. E. G. REES.

SIR,-Dr. Pinsent (Sept. 19, p. 604) states that on" over 80% of occasions on which the call service was con-

tacted no medical emergency was found." If he denies the

patient the opportunity to telephone his doctor for advice,the patient will do the only thing he can-ask for a visit. Iestimate that at least half of all out-of-hours telephone callscan be dealt with by telephone or the matter left until" routine working hours ".

I also disagree with Dr. Pinsent’s classification: a childwho develops otitis media on Saturday afternoon should notwait until " routine working hours " for treatment. Thereare many causes of a crying child, among the commonerbeing earache and abdominal pain: it can be very difficultfor an experienced doctor to diagnose the cause of crying;to expect an emotionally involved parent to make a correctdiagnosis is less than fair.A two-tier system of doctors and nurses in radio contact

may be one way of providing off-duty for doctors. I sub-

mit, Sir, that one doctor (on call for his colleagues) who canadvise by telephone or arrange to see the patient at a

convenient time gives a more economical and more satis-factory service.

SOCIAL WORK IN GENERAL PRACTICE

SiR,—The paper by Dr. Harwin and his colleagues(Sept. 12, p. 559) is an important contribution to the re-construction of medical care in Britain. In an era when the

range of domiciliary care has enormously increased andmorbidity moved towards a preponderance of degenerativeand psychosocial conditions, it is astonishing that thetrained social caseworker has as yet found little place in oursystem of personal medical care. Potentially, she stands ina similar practising relationship to the behavioural sciencesas does the doctor to internal medicine. In practice, how-ever, she remains incarcerated largely within the institu-tional setting. Some of the reasons for this are historical.In the pre-N.H.S. days of fee-paying general practice andof " voluntary " and " municipal " hospitals, the hospitalrepresented concentration points of maximum need. Inthese the social caseworker was strategically placed. Butthat it remains so after 22 years of the N.H.S. is a measureof the medical profession’s aversion to change.That favourable attitudes to medicosocial teamwork

were, in this survey, associated with younger practitioners,is perhaps a sign of hope for the future: but that 50% ofpractitioners in practice for less than 10 years were " neu-tral " or " unfavourable " to such developments surelytempers any optimism. And that even " a few " doctorsare still under the happy illusion of welcoming such team-work " chiefly because it offered them the hope of freedomfrom an unwanted burden " tempers it still further.The immediate need is for the provision of much wider

experimental attachment of social caseworkers to selectedgeneral practices; and the critical assessment, from experi-ence, of how social caseworker and general practitionerwork best together.Dr. Harwin remarks " that few doctors had any clear

idea of the function of the social worker or of the types of

problems with which her help might be usefully invoked ".Is this surprising ? Our own experience, in a departmentstaffed with a social caseworker of many years’ experience incommunity work, is that we are only now beginning tolearn.We propose that 15-20 such attachments be set up in

selected practices, each for a period of, say, three years.This would provide a wealth of basic experience. But itcan be achieved only with the support of the Department ofHealth and Social Security in funding and coordination,and with the cooperation of the Royal College of GeneralPractitioners and the Institute of Medical Social Workers.It is immaterial from which of these three the initiativecomes. But if the Department is willing to undertake sucha role, there should be no insuperable difficulty in findingsuitable practices.The second need is for changes in the educational pattern

of physicians and, perhaps, of social workers also. Uni-

versity departments of general practice will have to accept(as has Manchester) that they have certain responsibilitiesto cooperate, when requested, in the training of socialcase-workers and health visitors as well as student

physicians. The undergraduate (as well as graduate)physician needs to be introduced not only to the theoreticalconcepts but also to the practice of social science. Wherebetter to illustrate these than in a group general practice inwhich a social caseworker is an integral part of the team ?

E. M. INESONH. J. WRIGHT.

Darbishire House Health Centre,University of Manchester,Manchester M13 OF P.

S.H. ANTIGEN AND CHRONIC LIVERDISEASE

SiR,The continued presence of the serum-hepatitis(s.H.) antigen in some patients with a history of serumhepatitis and in some patients with progressive liver diseaseraises the possibility of an association between some formsof chronic liver disease and chronic s.H. virus infection.1,2A survey of thirteen published reports 13-14 reveals that

S.H. antigen has been detected, albeit with varying fre-quency in individual series, in serum in 47/374 cases ofchronic active hepatitis, 49/417 cases of cirrhosis (of varioustypes), and in 9/130 cases of carcinoma of the liver. Theagar-gel diffusion technique was used to test sera for thepresence of s.H. antigen in all but one of these series.8 8To evaluate a possible relationship between chronic

liver disease and chronic s.H. antigenvemia, we have testedsera from cases of chronic liver disease for the presence ofS.H. antigen in a variety of populations. Sera were tested

by both agar-gel diffusion 15 and high-voltage immuno-electroosmophoresis (I.E.O.P.).16 The I.E.O.P. method isten times as sensitive as agar-gel diffusion.

1. Wright, R., McCollum, R. W., Klatskin, G. Lancet, 1969, ii, 117.2. Prince, A. M., Hargrove, R. L., Jeffries, G. H. Trans. Am. Ass.

Physns, 1969, 82, 265.3. Okochi, K., Murakami, S. Vox Sang. 1968, 15, 374.4. Gitnick, G. L., Gleich, G. J., Schoenfield, L. J., Baggenstoss, A. H.,

Sutnick, A. I., Blumberg, B. S., London, W. T., Summerskill,W. H. J. Lancet, 1969, ii, 285.

5. Fox, R. A., Niazi, S. P., Sherlock, S. ibid. p. 609.6. Mathews, J. D., Mackay, I. R. Br. med. J. 1970, i, 259.7. Velasco, M., Katz, R. Lancet, 1970, i, 779.8. Krassnitzky, O., Pesendorfer, F., Wewalka, F. Dt. med. Wschr.

1970, 95, 249.9. Hadziyannis, S. J., Merikas, G. E., Afroudakis, A. P. Lancet, July

11, 1970, p. 100.10. Blumberg, B. S., Sutnick, A. I., London, W. T. Bull. N.Y. Acad.

Med. 1968, 44, 1566.11. Chandra, R. K. Lancet, 1970, i, 537.12. Reinicke, V., Nordenfelt, E. ibid. p. 141.13. Guardia, J., Bacardi, R., Gras, J. ibid. p. 1007.14. Smith, I. B., Blumberg, B. S. ibid. 1969, ii, 953.15. Prince, A. M. Proc. natn Acad. Sci. 1968, 60, 814.16. Prince, A. M., Burke, K. Science, 1970, 169, 593.