252 the

laboratory.3.5 The first important finding is that vir-

obtained from different individuals tend to have different fingerprints-in other words, a great variety of herpes viruses circulate in the human population. Since mutation seems uncommon, the differences ’have presumably developed over a long time in human history. This fits in with our idea that herpes simplex virus infects an individual early in life and is then carried to the grave. Roizman’s group2-4 have studied viruses from patients and staff in a special-care baby unit-for instance, from a baby with encephalitis, nurses with herpetic whitlow, and a spouse with pharyngitis-and they found that, in contrast to the situation in the general population, the viruses from all the people concerned were indistinguishable. Thus the test can be used, as phage typing is in bacteriology, to refine the process of epidemiological investigation, and similar techniques may in the future be applied to related viruses such as cytomegalovirus or herpes zoster/varicella virus. Viral fingerprinting has also been used to study the biology of the latent carriage of herpes simplex virus. Lonsdale and others5 have described the "rescue" of herpes viruses from cultures of human ganglia which apparently contained none, by cocultivation with susceptible cells or by addition to the cultures of temperature-sensitive mutants of herpes simplex virus in order to supply genetic functions which, it was guessed, might have been lost by a latent virus. The experiment apparently worked, and virus grew out even though the temperature of incubation was too high for the rescuing virus itself to multiply. The restriction enzymes were used in two ways. One was to prove very convincingly that the rescued virus D.N.A. was indeed quite different from the D.N.A. of the rescuing virus; the other revealed that the viruses isolated from different ganglia of the same individual were indistinguishable from each other, though again, they were different from the viruses obtained from other individuals. It is a healthy sign that clinical practice has provided valuable material for the molecular virologist and that the molecular virologist in turn has so quickly used his new techniques to illuminate some interesting but obscure corners of the biology of herpes virus infection of man. Doubtless these methods will be used on viruses of other groups; for example, it might distinguish between white-pox viruses and variola-a thorny and topical matter. By related techniques the R.N.A. of the new H1N1 or "red" influenza viruses has been mapped to show which previously epidemic viruses it resembles,6 and in the D.N.A. of some adenoviruses evidence has been found of genetically distinct subtypes with different degrees of virulence.7 uses

SIGN HERE FOR TREATMENT

patients having to sign a contract before receiving treatment is likely to lead to ribald remarks about the advance of bureaucracy. But although for THE idea of

Roizman, B., Adams, G., Stover, B. H. J. infect. Dis. 1978, 138, 488. 4. Linnemann, C. C., Jr, Buchman, T. G., Light, I. J., Ballard, J. L., Roizman, B. Lancet, 1978, i, 964. 5. Lonsdale, D. M., Brown, S. M., Subak-Sharpe, J. H., Warren, K., Koprowski, H. Abstr. IV int. Congr. Virol. no. 230, 1978. 6. Nakajima, K., Desselberger, U., Palese, P. Nature, 1978, 274, 334. 7. Wadell, G., Varsanyi, T. M. Infect. Immun. 1978, 21, 238.

forms of medicine such a contract would be laughable, in psychiatry it has been taken more seriously. Whilst it is appropriate for a patient with an organic condition to present himself for treatment and to play little active part in the management of his disease, such an approach is not suitable for many psychiatric conditions, particularly neurotic and personality disorders. Some psychiatrists go even further; they believe that repeated exposure to passive treatment is actually harmmost

ful. The term "learned helplessness"! has been coined to describe this disease. The introduction of a treatment contract places the relationship between doctor and patient on a different setting. Treatment contracts are not new in psychiatry and their .use has been encouraged by the advance of behaviour therapy in many disorders. Although the contract between patient and doctor in behaviour therapy is often implied, in several studies it has been formalised with apparent benefit.2-5 Treatment contracts have lately been introduced at a psychiatric unit in a London teaching hospital.6 Inpatients have their problems assessed by the psychiatric team and a treatment contract is drawn up. This is a written document framed in a legalistic manner in an attempt to emphasise its contractual component. The contract selects the goals of treatment, sets a time-limit for attaining them, and gives details of the techniques of therapy, the personnel concerned, and the patient’s role in treatment. The contract is signed by the patient and all the personnel involved in his treatment. The patient is at liberty to renegotiate parts of the contract and may delay for several days a decision on whether to sign. The results of this radical departure from the conventional approach cannot be assessed at this stage as the report is only a preliminary one. What is not clear is how patients are selected for the contract, or indeed whether all patients have to sign one. It would be quite inappropriate for a severely depressed, suicidal patient or an acutely psychotic, schizophrenic one to be asked to sign the contract, but there is no indication how patients are excluded. The consequences of failing to agree on the contract or defaulting during treatment are also unclear and many questions remain unanswered by Rosen’s paper. If the patient refuses to sign the contract are all forms of treatment refused? If the doctors, nurses, or the patient fail to keep their part of the contract what sanctions are imposed? Have patients any right of appeal if they feel that the contract is not being followed appropriately ? Is there any form of independent arbitration? It is all very well framing a contract in legal language but unless all possible consequences of failing to keep the contract are similarly phrased and defined the contract has little meaning. Until answers to these questions are forthcoming, treatment contracts should be regarded as experimental or restricted to certain treatment approaches. In the future evaluation of such contracts it also seems fair that the opinions of the patients should have as much weight as those of their therapists.

3. Buchman, T. G.,

1.

M. E. P. Helplessness: On Depression, Development and Death. Francisco, 1975. Stuart, R. B. J. consult. clin. Psychol. 1969, 33, 675. Liberman, R. Am. J. Orthopsychiat. 1970, 40, 106. Cooklin, A. I. Br. J. med. Psychol. 1973, 46, 279. Stern, R. S., Marks, I. M. Br. J. Psychiat. 1973, 123, 681. Rosen, B. ibid. 1978, 133, 410.

Seligman, San

2. 3. 4. 5. 6.

Sign here for treatment.

252 the laboratory.3.5 The first important finding is that vir- obtained from different individuals tend to have different fingerprints-in other wor...
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