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dtsjppeared and no new lesions have since been detected.The improvement had persisted for more than three months- the longest lesion-free period observed in this patientB’I’e: the past six years.Because treatment with levodopa combined with a peri-

pheral dopa-carboxylase inhibitor is easy to manage andhas few side-effects, we feel that this approach may offerpossibilities in severe uncomplicated psoriasis. We havenow started a controlled trial of levodopa plus Ro 4-4602in non-parkinsonian patients with severe longstandingpsoriasis.The theoretical implications of this finding on the role

of the central nervous system in the pathophysiology of thisillness have not escaped us, nor have we neglected to lookinto the possible synergistic actions of levodopa and fusidicacid, These studies will be reported elsewhere.Clinical Research Institute of Montreal, . —.’T). ..Hotd-Dieu Hospital and ANDRE BARBBAU

University of Montreal. JEAN-MARIO GIROUX.ANDRÉ BARBEAU

JEAN-MARIO GIROUX.

Clinical Research Institute of MontrealHôtel-Dieu Hospital andUniversity of Montreal.

SPONTANEOUS AGGREGATION OF PLATELETS

JACQUES P. CAEN.

Hôpital Lariboisière,2 Rue A. Paré,

Paris.

SIR,-Professor Vreeken and Dr. van Aken (Dec. 25,p. 1394) present a very interesting case in which idio-pathic thrombosis associated with recurrent painful toesand fingers seems to be related to a spontaneous aggre-gation of blood-platelets.Some years ago we recorded, in a case of congenital

hypoiibrinogensemia, such recurrent painful toes, but,contrary to your contributors’ findings, we noticed somebenefit after heparin therapy. From the fact that thrombingeneration was accelerated in our patient, we postulatedthat this acceleration could be relevant to recurrent

thrombosis. As in the Dutch case, the platelet-count wasoften high. Did Professor Vreeken and Dr. van Akenlook at the different antithrombins and at the formation ofthrombin in their patient ? ? Was it also a spontaneousaggregation in hypercitrated or sequestrened platelet-richplasma (P.R.P.) ? We also confirm that spontaneousaggregation is uncommon in normal individuals (around!-2%) in normal citrated P.R.P.Hopital Lariboisiere,

2 Rue A. Park,Paris. JACQUES P. CAEN.

REHABILITATION AFTER MYOCARDIALINFARCTION

A. U. MACKINNON.

Sn—The letter from Dr. Bethell and Dr. Nixon’Jan, 1, p. 49) is timely in drawing attention to the import-ance of the coronary patient’s " way of life " and the needfor most of them to change to a less lethal pattern.The dramatic experience of a myocardial infarction will

usually cause intelligent patients to look at their past livescritically, and to decide to live less stressfully in future.If combined with rehabilitation on the Charing Crossmodel, much may be gained. General practitioners whoreceive coronary patients from hospital at increasingly earlystages, and those who treat their own patients at home,have an important and difficult duty here. Their first task,if it has not already been done, is to sit down and listen tothe patient’s personal and emotional histories. It is sur-prising how many of the younger patients present a pecu-distinctive personality complex, which has been4aignated behaviour pattern A,2 and have lived arrhythmicand aggressive lives. Smouldering resentment againstsome person or institution is quite common, and the whole

1 Caen, J., Faur, Y., Inceman, S., Chassigneux, J., Seligmann, M.,Anagnostopoules, T., Bernard, J. Nouv. Revue fr. Hémat.

1964, 4, 321. Fnedman, M. Geriatrics, 1967, 19, 562.

life picture is often one of a distortion of the aggressiveinstinct.The difficult patients are those who deny the reality ol

their illness (a common coronary characteristic), and thosewho are excessively afraid of the future. Progressivelygraduated exercise is a great morale builder in the firstfew weeks and months. A pedometer is very helpful tcboth patient and family doctor. Semantics-the exact

words hospital doctors and general practitioners use-are very important. An optimistic outlook is essentialThe patient’s future will depend no less, if not more.on his attitude to life than on the drugs he takes.

305 Harrogate Road,Leeds LS17 6PA. A. U. MACKINNON.

H.A.A. IN DRUG ADDICTS

MUNTHER AL-HUJAJHERMANN SCHÖNTHAL.

SIR,-The report by Dr. Szmuness and Dr. Prince 1

prompts us to describe our findings in drug addicts.From January to April, 1971, we had the opportunity to

test sera from 40 addicts, who had injected drugs intra-venously, for the presence of Au/s.H. antigen, using amodified cross-over-electrophoresis technique.2 More-over, S.G.P.T., S.G.O.T., alkaline phosphatase, bilirubin, andelectrophoresis were performed. The group comprised34 males and 6 females, aged 15-23 years; 31 were out-patients and 9 inpatients of our neurological department.The history of intravenous drug injection was 2-18 monthsin duration. 29 of the 40 had had hepatitis, and 35 personalcontact with jaundiced friends. On admission there wereno clinical signs of acute hepatitis. We found slightlyelevated transaminases (under 40 units) in 15, and abnormaly-globulins (1 -5-1-7 g. per 100 ml.) in 2. Only 3 of the 40were carriers of Au/s.H. This relatively low prevalence ofAu/S.H. in drug addicts accords with other reports.3-b

Ev. Johannes-Krankenhaus, MUNTHER AL-HUJAJ

Bielefeld, West Germany. HERMANN SCHONTHAL.

BEHAVIOURAL SCIENCES IN THE MEDICALCURRICULUM

SIR Professor Black (Dec. 18, p. 1366) suggests thathuman psychology should be taught by academic psycholo-gists in the preclinical course and by psychiatrists andclinical psychologists in the clinical course.The teaching of psychology in the preclinical period is

fraught with difficulties and even dangers. The studentmust be made aware of the relevance of what is being taughtto his future career. This is not easy to achieve withoutbringing the student into personal contact with patients,and attempts to do so, as at Western Reserve, can lead tomajor problems, because the student is often too immatureand does not have the necessary medical knowledge whichenables him to adopt a physician’s role. If the necessaryrelevance to the subject is not brought home to the student,then there is the danger that he or she may actively rejectthe teaching.

I think it would be wrong, during the clinical years,to leave the teaching of psychological assessment of indi-vidual patients entirely to psychiatrists and clinical psy-chologists. The former are becoming more and moreinvolved solely with the complicated problems of humanbehaviour. All clinicians should make a positive assess-ment of their patients as human individuals with uniquepsychosocial characteristics. Unless the clinician makes

1. Szmuness, W., Prince, A. M. Lancet, 1971, ii, 433.2. Al-Hujaj, M., Schönthal, H. Diagnostik, 1971, 4, 530.3. Cherubin, C. E., Hargrove, R. L., Prince, A. M. Am. J. Epidem.

1970, 91, 510.4. Nordenfelt, E., Kai, K., Ursing, B. Vox sang. 1970, 91, 371.5. Ziegler, F. D., Miller, J., Kelly, J. Lancet, 1971, ii, 1034.