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LIGHTENING THE LOADIN January national health insurance will beextended to half a million people with incomes -up toE420, and whether or not doctors approve of the

extension a number of them will find it brings anadditional burden to what, was already becoming aharassed life. The addition may not sound numeric-ally large-in 1938 the 16,840,000 insured personswere shared on 16,200 doctors’ lists-but there arenow fewer doctors in panel practice and the new-comers will not be evenly distributed on the lists.Moreover they are drawn from the income group whichhave hitherto found the doctor’s bill particularlyhard to meet and have therefore stinted themselves ofmedical attendance even beyond the limits of safety.They will now come to the doctor for many ailmentswhich they would previously have treated themselvesor left untreated, and some of them, from ignoranceof the rules and customs of insurance practice, maygive the doctor more trouble than they need and notget as good attention as they might. The insuredperson, like his doctor, is bound by a code of rules ;but, whereas the doctor who breaks his may well findhis quarterly cheque reduced by way of fine, thepatient’s shortcomings are overlooked unless theyaffect his relations with the approved society. Theseven rules which should govern his relations with thedoctor are printed on the back of his medical card intype so inconspicuous that few patients read themeven if their eyesight allows them to do so, The rulesare sound, and if strictly kept would bring ease to thebusy practitioner. " He shall," says rule e, " wheneverhis condition permits, attend at the surgery or placeof residence of the practitioner attending him on.suchdays and at such hours as may be appointed by,thepractitioner." "He shall not," says, " summon thepractitioner to visit him between the hours of 6 P.M.and 9 A.M. except in cases of serious emergency."" He shall," ends g, " when his condition requires ahome visit, give notice to the practitioner, if thecircumstances of the case permit, before 10 A.M. onthe day in which the visit is required." On the wholeinsured patients are reasonably good about attendingthe surgery once they have found their way to it andovercome their initial shyness, but the new class ofpatient may not appreciate the charms of a chat in thewaiting-room. Rules f and g, too, are more oftenbroken by newcomers than by the old hands who havebeen well trained by the doctor and know his ways.The unnecessary messages at odd hours which leadto double journeys and make the day’s visiting-listunending often arise from misapplied kindness ofheart in the patient (" I .left it as long as I could;Doctor "), though there is a playful East End habitin an emergency of broadcasting appeals to everydoctor within reach, so that three have been known tomeet on the doorstep. A nice judgment of whatconstitutes a " serious emergency " may require morelevelheadedness and clinical acumen than the generalrun of patients or their relatives possess, and while thelate evening call may appeal to the dramatic sense itis more likely to originate from panic or a faulty

diagnosis than from reckless disregard of the doctor’sconvenience.What are the remedies ? 1 For the very few who

treat the doctor as they do all public servants anddemand their rights with no thought for the servants’convenience the doctor can in theory seek redress fromthe insurance committee, but he rarely does. Nearlyall will make as little trouble as they can if theyare shown the doctor’s point of view. The familiarmethods of propaganda could here be effectivelyapplied. The extension of insurance seems a fittingoccasion for a " Help your Doctor to help You "campaign, the B.B.C. providing a series of five-minuteconversations between doctor and patient, and theMinistry of Health supporting them with advertise-ments in the press. This might, in fact, be made partof the large "Health Front " advocated by Dr.BARBER on another page. The doctor should speakhis mind on occasion and he can appeal to the patient’sbetter nature by handbills or posters exhibited in hiswaiting-room, as suggested in these columns last year.!IF YOU WANT TO HELP YOUR DOCTOR IN WAR-TIME

Send messages before 10 A.M. if you want him to visityou. Remember that his petrol is rationed and that histravelling expenses have risen, so he doesn’t want tocover the ground twice or more on one day, especiallyduring the blackout.Avoid night calls and Sunday visits whenever possible.Come to the surgery if you can, rather than ask for a

visit, and come during surgery hours, the earlier thebetter. "

In a message state as clearly as you can what is. wrongand how long the patient has been ill. Don’t exaggerateor the doctor may have to neglect somebody more seri-ously ill in order to hurry to you.

Before the war the London insurance committeeand some others enclosed in each new medical card alist of Don’ts-e.g.,

" Don’t forget your medical cardwhen you want the doctor." Shortage of paper hassuspended this custom, but it might well be revived forthe January freshmen, who will respond more heartilyto the medical Do-this than to the administrativeDon’t-do-that. The universal consideration for thedoctor which such a campaign might bring would domuch this winter to offset the trials of blackout andblitz and the tribulations of a changing populationand shorthandedness.

PROBLEMS IN HÆMAGGLUTINATIONTwo aspects of agglutination phenomena in blood

are receiving current attention ; the first is the

question of autoagglutination. Few experiences axemore disturbing than to be asked to provide blood forthe urgent transfusion of a gravely anaemic patientand to find that the patient’s serum agglutinates thered cells of all available blood ; the patient’s serumtested against his own cells will be found to agglutinatethese as well-hence the phenomenon is called " auto-agglutination." It is due to the presence in theserum of a non-specific, cold-sensitive agglutinin ;this affects red blood-cells of all blood groups and ismost active below 5° C., still active at room teinpera-ture, but as a rule inactive at 37° C. The term"

autoagglutination "

is now applied only when theeffect is seen at room temperature- or above. Auto-

agglutination is often associated with/severe anaemiaand with disease of the liver. - It has not been cer-tainly shown to cause any disease but Mr. BENIANS

1. Lancet, 1940, 2, 409.

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and Captain FEASBY, who report in this issue thecombination of Raynaud’s syndrome and autoagglu-tination, regard them both as caused by chilling in acold-sensitive patient. The blood of outwardly normalpeople may also show it; an example is provided onanother page by Dr. PARISH and Dr. MACFARLANE’Sreport of an unusual case in which ionised calciumplayed a part, and it is noteworthy that, though theirpatient was an allergic subject with angioneuroticoedema, the autoagglutination was not connected withany allergic attacks. Autoagglutination is not com-mon, but among the large numbers of people nowbeing grouped by the transfusion services some arebound to show it, and- since the ordinary groupingtests will not detect them the effects of possible mis-grouping are worth examination.

0

When blood is taken for the grouping test sufficientplasma is carried over to agglutinate the red cellseven in the presence of test sera ; the autoagglutinatorwill therefore be recorded as group AB when in facthe might be any of the other groups. If his blood istaken for transfusing a group AB patient unexpectedagglutination will take place when his cells are testedagainst the patient’s serum. The next step is usuallyto try another specimen of blood, so that as long ascross-matching is possible no harm will be done, andin emergencies when time does not permit cross-

matching group 0 blood-never group AB-is used.If the autoagglutinator’s blood is turned into serumor plasma the results are again unlikely to be serious

I since the abnormal agglutinin is usually inactive at37° C., and with the large batches of pooled plasmanow used the abnormal agglutinin will be muchdiluted. The true group of an autoagglutinator canusually be determined by repeating the tests at 37° C.or by washing the red cells in saline before testing. Ifthe incorrectly grouped autoagglutinator is himself toreceive blood he will be safe so long as cross-matchingis properly done, when unexpected agglutinationshould indicate the necessity for repeating the group-ing test at 37° C. The drip method is undoubtedlythe safest way of giving blood to such a patient.The mass-production tactics of the transfusion servicesmake it difficult for every group AB donor to be

regrouped using precautions to detect autoagglutina-tors, and such regrouping is not vital. On the otherhand, when patients in need of transfusion for severeanaemia are found to be group AB, it is worth whileto exclude autoagglutination.The second problem, involving group-specific iso-

agglutinins, arises in connexion with the use of serumfor transfusion. Just as the blood-banks store group0 blood for emergency use because its red cells containno agglutinogens, so from a theoretical standpoint

, group AB serum is the ideal since it contains no

agglutinins. But only 3-7% of donors are groupAB ; much of the plasma and serum comes necessarilyfrom the 40-46% of donors who are group 0 andtherefore contains both anti-A and anti-B agglutinins.BRYCE and JAKOBOWICZ/ who made a quantitativeexamination of a large number of group 0 sera, foundthat 3l’2% had an anti-A titre and 10-1% an anti-Btitre of over 1 in 100. It is generally thought desir-able that plasma or serum, especially concentratedserum, should be freed from these isoagglutinins, andthe fact that it is more difficult for serum to be so

1. Bryce, L. M. and Jakobowicz, R. Med. J. Aust. 1941, 1, 290.

freed has been made a point against its use. Mixingof group A and group B blood before separating theplasma, so that the A cells absorb the anti-A iso-agglutinins of group B blood and vice versa, has beenone method, but this again limits the donors to about50% of those available. DELLA VIDA and DYKE 2

utilised the fact that agglutinogens are not limited tothe red blood-cells but also occur in body fluids includ-ing plasma and serum, so that group A serum can beused to absorb the anti-A isoagglutinins of group Bserum and vice versa. They showed how with group0 serum the agglutinin titre could be considerablyreduced, even if not completely absorbed, by mixingin suitable proportions with group A and B sera, sothat the blood of all groups could be used. A thirdmethod is suggested by WITEBSKY, KLENDSHOJ andSWANSON.3 They point out that the group-specificsubstances (agglutinogens) are complex carbohydrate-like bodies resembling the capsular substance ofpneumococci. Group A substance can be preparedfrom commercial pepsin, mucin or peptone, butgroup B substance has so far only been isolated fromthe gastric juice of group B persons. By adding thesetwo group-specific substances to group 0 blood theyare able to reduce the titre of the anti-A and anti-Bagglutinins in the plasma to a safe level. This methodis an interesting application of our increasing know-legdge of the nature of the blood groups but is hardlysuitable as yet for large-scale work. Clinical reportsof reactions after the transfusion of group 0 seruminto patients of other groups are scanty, and it is notyet clear how far the presence of anti-A and anti-Bisoagglutinins is really detrimental. The definitionof safe limits for the titres of these agglutinins inpooled serum should not be too difficult and wouldprovide the transfusion services with a useful standard.

PERTUSSIS PROPHYLAXISTHE present prevalence of whooping-cough reminds

us how little has been attempted in this countrytowards the prevention of this preventable disease.Too many of us still regard pertussis and measles asthe inescapable and not very serious afflictions ofchildhood. But in London these two rank fourth andfifth among the causes of death in children under five

years, and in hospital practice the case-fatality frompertussis exceeds that of both measles and diphtheria(L.C.C. Annual Report, 1935). Moreover, about atenth of the cases and two-fifths of the deaths from

pertussis occur in the first year of life 4 while STOCKSestimated that 44% of London children developed thedisease before their fifth birthday. Prophylaxisof so prevalent a respiratory infection could only bepossible by specific vaccination, and this method ofprevention has been shown, particularly in America,to be a practical possibility. Unfortunately, four orfive weekly injections of large doses (10-30 thousandmillion organisms) of a carefully prepared smooth-phase vaccine are apparently necessary to secure aneffective immunity, which for large-scale immunisa.tion introduces serious problems in production andadministration. The possibility of protecting thechild by fewer doses of the vaccine spaced at longerintervals, as has been proved effective with diphtheria2. Della Vida, B. L. and Dyke, S. C. Lancet, 1941, 1, 564.3. Witebsky, E., Klendshoj, N. C. and Swanson, P. J. Amer. med.

Ass. 1941, 116, 2654.4. Zamkin, H. O. Amer. J. publ. Hlth, 1940, 30, 394.