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essentially alike to streptokinase and will be broken down;therefore one excluding factor is an injury or surgicaloperation within the previous ten days. For vascular, neuro-surgical, or ophthalmic procedures this interval must beextended to two months. An open wound or ulcer, a cerebro-vascular accident within the previous six months, hyper-tension, pregnancy, menstruation, or a known bleedingdiathesis are also absolute exclusions because of the risk of

haemorrhage. In addition high levels of antibody to strepto-kinase, whether from a previous course of treatment or from arecent streptococcal infection, will make treatment difficultor impossible. In those few patients who remain the clinicaldiagnosis must have been confirmed by venography andthrombolytic treatment should be considered only for thosepatients with thrombosis in the thigh or pelvic veins. Strepto-kinase should be given in a standard dose for three days andthis will be sufficient to produce maximal lysis in mostpatients. 12 All invasive procedures must be eliminated duringtreatment so that laboratory control is precluded. If

haemorrhage nevertheless develops, treatment must cease.Shortly after the end of the streptokinase infusion the patientshould be anticoagulated with heparin and then later trans-ferred to oral anticoagulants. If such a policy is followed all wecan hope at present is that the detailed study in a small groupof Swedish patients has obscured the overall benefits that wecan expect from similar treatment in a larger group of people.Meanwhile with an estimated half a million varicose ulcers inthe United States of America alone15 we must continue topreach prevention.

COPING WITH GRIEF

PSYCHIATRY is still in the stage of development at whichdifferent treatments are viewed in a spirit of rivalry ratherthan collaboration. The rapid strides made by thebehavioural approach in psychiatry over the past twentyyears have therefore led to much debate about the relativemerits of behaviour therapy and psychotherapy. Much of thedebate is theoretical and sterile, centering on the status ofpsychiatric symptoms. Are such symptoms synonymous withillnessi or are they the tip of the iceberg of unconsciousconflict.2 Does it really matter? What is relevant is theevidence that behaviour therapy and psychotherapy are ofapproximately equal efficacy in neurotic disorders3 and sothere might be merit in combining the two approaches.Marks insists that behaviour therapy is a form of psycho-therapy4 but terms such as "behavioural psychotherapy"have not caught on. It is unfortunately viewed as an

oxymoron by those who see behaviourists as insensitive

philistines who treat their patients like laboratory rats andpigeons, and by others who see psychotherapists as pedlars offairy tales about the naughty unconscious.One subject ripe for collaboration is grief. Any form of loss

requires readjustment and this can be painful and difficult.Grief is a normal process in that readjustment, but ifunresolved can lead to depressive illness. The variationbetween normal grief and pathological depression has longbeen recognised as a consequence of loss. In 1777, Johnson

15. Coon WW, Willis PW, Keller JB Venous thromboembolism and other venous diseasein the Tecumseh Community Health Study. Circulation 1973; 48: 839-46.

1. Eysenck HJ, Rackman S. Causes and cures of neurosis. London: Routledge and KeganPaul, 1965.

2. Femchel O. The psychoanalytic theory of neurosis. London: Routledge and KeganPaul, 1945.

3. Sloane RB, Staples FR, Cristol AH, Yorkston NJ, Whipple K Psychotherapy versusbehaviour therapy. Cambridge, Massachusetts: Harvard University Press, 1975.

4. Marks I. The future of the psychotherapies. Br Psychiatry 1971, 118: 69-73.

dogmatically remarked to Boswell that "all unnecessary griefis unwise" and "never continued for very long unless wherethere is madness". Unnecessary grief is unresolved grief, inwhich the symptoms of resentment, guilt, hopelessness, anddenial that the loss has actually taken place, persist long afterthe event. There is good evidence that, if grief is first

expressed openly and thoroughly, healthy readjustment ismore likely than if the feelings are partly suppressed ordenied.5,6 The bereaved window at whom everyone marvelsfor controlling her feelings so well is often more at risk thanher weeping sister who bemoans her loss to all within earshot.It is also possible for unresolved loss to incubate morbidly formany years before surfacing again as a severe depressiveillness.’Psychotherapists have long recognised that "grief work" is

necessary to achieve a healthy readjustment after loss. Thecircumstances of the loss and the patient’s ambivalent

feelings afterwards are explored sensitively and the emotionsassociated with grief allowed full expression. The sameprocess has also been examined from the behavioural stand-

point, with encouraging initial results.B,9 This has beenextended in a comparative study by Mawson and his

colleagues in which the treatment strategy called "guidedmourning" was compared with a control procedure. 10Although this bears many similarities to the psychothera-peutic approach it is considerably more formalised. Thegroup that received "guided mourning" was exposed toideas, memories, or situations associated with the loss whichtend to be avoided or are particularly painful. In addition thesubject is given special tasks such as looking at a photographof the dead person or of saying "goodbye" audibly at thecemetery where the burial took place. In the control group theopposite procedure was adopted with the subject encouragedto avoid thinking of the loss and to concentrate on day-to-dayliving. "Guided mourning" led to a better outcome than thecontrol procedure in several important areas of adjustment.This type of approach deserves further study, not least todetermine the type of grief reaction for which it is particularlyhelpful.This work shows that grief and more complex forms of

behaviour have come into the realms of behaviour therapy,Its implications should not be lost on the purists who sitbehind ideological barriers proclaiming that the twain shallnever meet.

RABIES: A LITTLE ANTIBODY A DANGEROUSTHING?

SPECIFIC antibody has been regarded as a major factor inthe prevention of rabies since Babes and Lepp showed itsprotective effect in 1889.1 Numerous subsequent reportssupport the view that antibody protects if it is present beforeexposure and that vaccine administered after exposureinduces resistance associated with antibody production.=

5. Freud S. Mourning and melancholia. In: Jones E, ed. Collected papers, vol 4. LondonHogarth Press, 1917.

6. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry1944; 101: 141-48.

7 Brown GW, Harris T. Social origins of depression a study of psychiatric disorder inwomen. London: Tavistock, 1978.

8. Ramsay RW. Behavioural approaches to bereavement Behav Res Ther 1977. 15:131-35.

9. Lieberman S. Nineteen cases of morbid grief. Br J Psychiatry 1978; 132: 159-o310. Mawson D, Marks IM, Raum L, Stern RS. Guided mourning for morbid grief: in

controlled study. Br J Psychiatry 1981; 138: 185-93.1. Babes V, Lepp V. Recherches sur la vaccination antirabique Ann Inst Pasteur 1889, 3:

384-90.2. Plotkin SA, Wiktor TJ. Rabies vaccination Annu Rev Med 1978; 29: 384-90