Hyperglycaemia, Automatism, and Insanity

912 SERUM LEVELS OF LIPOPROTEIN A AND TOTAL CHOLESTEROL IN FOURTH

(LAST) WEEK OF PLACEBO PHASE AND DURING ADMINISTRATION OF LOVASTATIN

Results as Lp(a); total cholesterol (both m mg/dl). Patients A, B, F, and H *On bezafibrate before treatment with lovastatin.

were

female.

month or so during treatment with lovastatin, serum Lp(a) and total cholesterol levels were measured. 6,7 Total cholesterol levels fell in all eight patients. However, serum Lp(a) concentrations rose from medium to high levels in five (A, C, E, F, H) and from low temporarily to medium levels in three (B, D, G), probably due to a drug-induced disturbance in lipid metabolism in the liver (table). Since Lp(a) levels of more than 20-30 mg/ml must be considered as a risk for atherosclerosis we would recommend the measurement of serum Lp(a) before and during lovastatin therapy. Institute of Medical Biochemistry, Karl-Franzens Universtat, A-8010 Graz, Austria

GUNTHER JURGENS AHMED ASHY

herniated into the site of multiple comminuted fractures. It seemed that, on sudden deceleration, this man had moved forwards and to the left, the movement being directed by the restraint of the passenger seat belt (left shoulder held); and he had struck the right side of his face and head on the windscreen and other internal parts of the car. A 25-year-old woman driver of a car in a head-on collision with a lorry had severe injuries to her left face, left orbit, and left frontal region of the brain. She remained in coma for 12 days until artificial respiration was discontinued. Necropsy revealed a head injury localised to the left face and orbit, and left frontal region of the brain, which was herniating into frontal comminuted fractures. This driver (right shoulder held) had been thrown forwards and to the right, striking the left side of her head on the windscreen and other internal parts of the car. I support the Oxford Road Accident Groups who have recommended the introduction of symmetrical restraint systems that would prevent forward rotary movement to left or right. Department of Neuropathology, Radcliffe Infirmary,

J. T. HUGHES

Oxford OX3 6HE

1 Editorial. Seat belts reviewed. Lancet 1986; i: 75-76. 2. Seat belt regulations retained. Br Med J 1986; 292: 286. 3. Gallup BM. The assessment of facial injury to fully restrained drivers through full-scale car crash testing. J Trauma 1987; 27: 711-18. 4. Campbell BJ Safety belt injury reduction related to crash severity and front seated position. J Trauma 1987; 27: 733-39 5. McCoy GF, Johnstone RA, Nelson IW, Duthie RB. Facial injuries to restrained drivers caused by steering wheels Lancet 1988; ii: 456.

Department of Internal Medicine II, Landeskrankenhaus Graz

GERALD ZENKER

Medicine and the Law Widhalm K, Senser D. Increased lipoprotein (a) levels in children with familial hypercholesterolaemia. Lancet 1988; ii: 1262. 2. Grundy SM HMG-CoA reductase inhibitors for the treatment of hypercholesterolemia. N Engl J Med 1988, 319: 24-33. 3. Dahlen GH, Guyton JR, Attar M, Farmer JA, Kautz JA, Gotto AM Association of levels of lipoprotein Lp(a), plasma lipids, and other lipoproteins with coronary artery disease documented by angiography Circulation 1986; 74: 758-65. 4. Rhoads GG, Dahlen G, Berg K, Morton NE, Dannenberg AL. Lp(a) lipoprotein as a risk factor for myocardial infarction. JAMA 1986; 256: 2540-44. 5. Murai A, Miyahara T, Fujimoto N, Matsuda M, Kameyama M. Lp(a) lipoprotein as a risk factor for coronary heart disease and cerebral infarction. Atherosclerosis 1986; 1.

59: 199-204. 6 Zenker G, Költringer P, Bone G, Niederkom K, Pfeiffer KP, Jurgens G. Lipoprotein(a) as a strong indicator for cerebro-vascular disease. Stroke 1986; 17: 942-45. 7. Költringer P, Jurgens G. A dominant role of lipoprotein(a) in the investigation and evaluation of parameters indicating the development of cervical atherosclerosis. Atherosclerosis 1985; 58: 187-98. 8. Hoff HF, Beck GJ, Skibinski CI, et al. Serum Lp(a) level as a predictor of vein graft stenosis after coronary bypass surgery in patients. Circulation 1988, 77: 1238-44

RESTRAINING THE OTHER SHOULDER

SiR,—The introduction of seat belts for drivers and passengers of vehicles has brought a welcome improvement in the mortality and injury from road accidents in the UK. Over the three years from January, 1983, when seat belt wearing became compulsory, the measure is thought to have saved more than 200 lives and more than 7000 serious injuries every year.2 Much research has been done on the efficacy of seat belts.3,4 Today, most seat belts in cars in Britain are of the same design-namely, a transverse strap across the lower abdomen plus a diagonal belt which on right-hand drive cars, passes from above the motor

right shoulder downwards and to the left for the driver and from left to right for the front seat passenger. Two recent necropsies suggest that this design should be changed. A 19-year-old man, the front seat passenger in a car involved in a head-on collision, suffered head injuries and a fractured right femur and died 24 hours after the accident. Necropsy showed that the head injury comprised lacerations and fractures of the right side of the face, fractures of the right orbit, and of the right frontal bone with severe damage to the right frontal lobe of the brain, which had

Hyperglycaemia, Automatism, and Insanity DIABETIC patients who commit crimes while hypoglycaemic may be able to plead (non-insane) automatism so that in law they are not responsible for their acts. However, crimes committed during hyperglycaemia are different. If the patient claims that his mental processes were so seriously disturbed by his hyperglycaemic condition that he did not know what he was doing, any defence of automatism will be of the insane variety under the M’Naghten rules. The same holds for crimes committed unknowingly during an epileptic seizure,’ as ruled in a much-criticised House of Lords decision in 1983.’ The case of R v Hennessy ([1989] 1 WLR 287), decided in January of this year, concerned a man with insulin-dependent diabetes who had not taken insulin or eaten for several days. He was anxious and depressed. He was charged with taking a car without authority and with driving while disqualified. He argued that the offence was committed while he had hyperglycaemia caused by or contributed to by the stress, anxiety, and depression brought on by marriage and employment difficulties, and he sought to raise the defence of (non-insane) automatism. At the time of his arrest he had appeared to be in full possession of his faculties and quite cheerful and intelligent. However, after being at the police station for some time, he was taken to hospital. He arrived dazed and confused and told a nurse that he had failed to take his insulin for several days, and his blood sugar was over 22 mmol/l. After an injection of insulin he was discharged. His evidence was that he had been diabetic for 10 years and was dependent on insulin injections morning and afternoon. The dose would depend on factors such as stress and eating habits. He was on a strict carbohydrate diet. His general practitioner testified to his medical condition. The judge ruled that any impairment of the mind, if it existed, could not have been caused by anything other than the diabetes, from which the defendant was a long-term sufferer. (Automatism produced by malfunctioning of the mind and caused by an 1. Brahams D.

Epilepsy is mental illness

Lancet 1983;

ii:

116.

913

underlying disease suffered by the defendant may, however, qualify for an insanity plea. However, that opportunity was not seized by the defendant, who immediately changed his plea to guilty.) He was given two suspended prison sentences and disqualified from driving for 2 years. On appeal he claimed that he did not know what he was doing when the offence was committed because of hyperglycaemia and that he should have been entitled to raise the defence of (non-insane) automatism. Lord Lane C?’, presiding in the Court of Appeal, said that the trial judge had been right to take the view that the preliminary question for him to decide was whether this was truly a case of (non-insane) automatism or legal insanity within the M’Naghten rules. "If the defendant did not know the nature and quality of his act because of something which did not amount to defect of reason from disease of the mind, then he will probably be entitled to be acquitted on the basis that the necessary criminal intent which the prosecution has to prove is not proved. But if, on the other hand, his failure to realise the nature and quality of his act was due to a defect of reason from disease of the mind, then in the eyes of the law he is suffering from insanity." What had to be decided, therefore, was whether the defendant’s condition was a disease of the mind. That means not just any disease of the brain but a condition that affects the proper functioning of the mind. It is important to differentiate between the Hennessy case (hyperglycaemia) and the claim of hypoglycaemia made in R v Quick ([1973] QB 910). The accused, a nurse at a mental hospital, was charged with assaulting a patient. Quick, who had diabetes, relied on the defence of automatism, claiming that he had taken insulin on the morning of the assault, had drunk spirits, and eaten little food thereafter. He said he had no recollection of the assault. He called medical evidence that his condition was consistent with hypoglycaemia but the judge ruled that such evidence could support a defence of insanity, not automatism. Quick then pleaded guilty. On appeal the conviction was quashed, and the trial judge was held to have been wrong in that the alleged mental condition was not caused by diabetes but by insulin prescribed by the defendant’s doctor. He was therefore entitled to have his defence of automatism left to the jury. Lord Justice Lawton said that the fact that Quick’s condition may have been due to the injections of insulin meant that the malfunction was due to an external factor and not to the disease. It was the drug that caused the hypoglycaemia, not the low blood sugar. However, hyperglycaemia is caused by an inherent defect. At appeal in Hennessy it was submitted that the defendant’s depression and marital troubles were sufficiently potent external factors to be capable in law of constituting a state of (non-insane) automatism but this argument was rejected. Lord Lane said: " ... stress, anxiety and depression can no doubt be the result of the operation of external factors, but they are not... external factors of the kind capable in law of causing or contributing to a state of automatism. They constitute a state of mind which is prone to recur. They lack the feature of novelty or accident, which is the basis of the distinction drawn up by Lord Diplock in R v Sullivan."l The purpose of the legislation relating to the defence of insanity, since its origin in 1800, has been to protect society against recurrence of dangerous conduct. Lord Lane also cited with approval the reasoning of Mr Justice Devlin in Hillv Baxter ([ 1958]1 QB 277): "For the purposes of the criminal law there are two categories of mental irresponsibility, one where the disorder is due to disease and the other where it is not. The distinction is not an arbitrary one. If disease is not the cause, if there is some temporary loss of consciousness arising accidentally, it is reasonable to hope that it will not be repeated and that it is safe to let an acquitted man to go entirely free. But if disease is present, the same thing may happen again, and therefore, since 1800, the law has provided that persons acquitted on this ground should be subject to restraint". A verdict of not guilty by reason of insanity requires the defendant to be detained for an indefinite period and is such an unpopular option that most defendants faced with it will change their not guilty plea to one of guilty. DIANA BRAHAMS, Barrister-at-law

Obituary FREDERICK

KRAUPL TAYLOR

MD

Prague, FRC Psych Dr Kraupl Taylor, known to his colleagues as KT and to his friends as Peter, died last month aged 83. consultant at the Maudsley Hospital from 1948 to 1971 he important contributor to its great days during the ’50s and ’60s. This was an odd position for a Czech who, after qualifying in Prague in 1929, practised general medicine in Berlin and Vienna and the Sudetenland. Harrassed by the Nazis, he was befriended by the Quakers, who brought him to England just before the war. Until 1941 he had no permit to practise medicine and worked in the laboratory of the York Retreat. His interest in psychiatry was quickened there, and when he was allowed, he trained first at the Crichton Royal, taking the DPM in 1942, and then at Netherne Hospital. His interest lay in the neuroses. Freudianism attracted but never seduced him. He offered to Maudsley registrars who shared his scepticism the only possibility of practising psychodynamically oriented psychotherapy without abandoning their critical faculties. His was the firm that the discerning chose to be on. The new element that he introduced into therapy was that once the patient’s transference had developed (and never until then) he exploited his or her resistance rather than just trying to overcome it. He aimed, by means of "prokaletic therapy" (his term for the challenging technique), to change the patient’s life situation. Since he accepted, from all over the country, patients with severely disturbed personalities, who often injured or poisoned themselves, this was necessary. The technique required him sometimes to utter As

a

was an

disturbing prophylactic challenges-"you may very well go on and take

an

overdose after this interview"-but the intention

was to

bring about the opposite by making use of the resistance; and this happened. Prokaletic therapy, widely practised first by his students and now by their students, worked even when the patient had tumbled to what was going on. Some would say he promoted the technique too exclusively, but he certainly used it to good effect. His reputation was based on his eclecticism as well as his scholarship and powerful intelligence. He wrote an important textbook on psychopathology. He was the first to study, using mathematical analysis, what went on in psychotherapeutic groups, of which he was a pioneer. He created a long-term social club for patients, many of whom were seriously incapacitated. During his productive retirement, in which he went on treating patients, he wrote a profound treatise on concepts of disease. His second wife Natalie, who survives stimulate his interest in people and ideas.

him, did

a

great deal

to

N. K.

International Diary 1989

A lecture on Autoimmunity and the Thyroid: London, UK, June 6 (Dr D. R. J. Singer, European Medical Research Group, c/o Fellowship of Postgraduate Medicine, 6 St Andrew’s Place, London NWI4LB). 19th meeting of the Federation of European Biochemical Societies:

Rome, Italy, July 2-7 (Organising Secretariat, Studio EGA srl, Viale Tiziano 19, 00196 Rome). Care An international conference on Emergency Health Development: Washington DC, USA, Aug 15-18 (Conference Organiser, Medical Care Development International, 1742 R Street NW, Washington, DC 20009). 14th European symposium on Hormones and Cell Regulation: Ste-Odile (near Strasbourg), France, Sept 25-29 (Organiser, Prof J. E. Dumont, Institute of Interdisciplinary Research, Universite Libre de Bruxelles, Faculty of Medicine, 808 route de Lennik, 1070 Brussels,

Belgium).