Sleepwalking, "disease of the mind"?

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health system and "topping up" the government shortfall themselves, while the poor will be trapped in RHAs that provide only the most basic of care. Helen Clark calls it "the demolition of the public health system". "No one has to look after the service needs of the whole population", she says. She believes the fragmentation of the health system is being promoted to create a market so that "competing players fight it out to attract the funds of consumers". The magnitude of change, she says, "is unknown anywhere else in the world". Indeed, the rest of the world will be able to watch the outcome of the New Zealand experiment to create a health market out of a public health system with interest, if with a degree of disbelief.

public

Sandra

Coney

1. Simon

Upton, Minister of Health. Your Health and the Public Health. Wellington. 1991.

USA: Return of measles In pre-vaccine days, measles

cases in the USA used to After mass vaccinations started in year. the sixties, the number dropped, to a low of about 1500 by 1983. However, the goal of eradicating measles has now faded from view. In 1989 and 1990, epidemics broke out sporadically, particularly among black and Hispanic children of pre-school age, in the poverty-ridden inner cities of such metropolitan areas as Los Angeles, Houston, Chicago, Philadelphia, and New York. In New York alone there have been 15 measles deaths. The epidemics have subsided in recent weeks, but the Centers for Disease Control expects them back. Continuing importation of measles through Hispanic persons who are recent immigrants is a factor contributing to the outbreaks. Inevitably, the rising cost of paying for the vaccine to cope with these measles flare-ups has become an issue in Washington. The Public Health Service had asked President Bush to budget for an emergency fund for this purpose, but he demurred. He explained to a gathering in the White House rose garden in June that he was sending a team to six cities, instead, to "learn why kids aren’t getting immunised". Nevertheless, he has requested an increase in vaccine money, and the legislation to provide it is being debated in Congress. Maintaining supplies of vaccines for the municipal health programmes is not the only factor to be tackled. Identifying and vaccinating toddlers in poor families is another. "The principal cause of the measles epidemic is failure to deliver vaccine to children at the recommended age", says a report by the Government’s National Vaccine Advisory Committee that was published in January. "Although immunization levels are 97-98 per cent at the time of school entry, they are reported to be as low as 50 per cent among two-year-olds in some inner city populations." Persuading some of the parents of children even to allow vaccination can be frustrating in itself. In Philadelphia, the First Century Gospel and Faith Tabernacle Churches teach faith healing and forbid members to accept medical care. Nearly 500 measles patients-close to half the totalbelonged to this faith. 6 of the children died, and it took a court order to vaccinate 8 schoolmates of the same denomination. Parental resistance, however, is just part of the problem. The National Vaccine Advisory Committee says personnel in emergency rooms and public acute care units should be routinely vaccinating the children of welfare families and often do not.

average 500 000

a

Donald Henderson, associate director for life sciences at the White House and a former leader in the World Health Organisation campaign to eradicate smallpox, believes that many changes in the child vaccination programme are in order. He told Susan Okie of the Washington Post that the US record for vaccinating children aged two and under is probably worse than that in any country in the western hemisphere except Bolivia and Haiti. The resurgence of measles as well as whooping cough, he said, means that preventable infections, including poliomyelitis, may be making a comeback. J. B. Sibbison

Germany: HIV tests for health workers The Federal Health Minister Gerde Hasselfeldt enraged the medical profession by her response in an interview published recently in a glossy weekly magazine. When asked whether she could imagine the introduction of obligatory HIV-test for doctors, she replied that if doctors did not undergo tests voluntarily the Government would have to think about stricter regulations. The question had been prompted by reports from the United States of several patients having been thought to have acquired their HIV infection from a dentist, and where a new law had been introduced to make it obligatory for health workers who do invasive procedures to undergo HIV tests. Furthermore, there was at the time a bill going through the US Congress to imprison and fine health workers who undertook invasive procedures while knowingly infected. Dr Karsten Vilmar, head of the General Medical Council (Bundesaerztekammer) in Cologne, issued a press statement expressing strong opposition to obligatory HIV-tests for doctors and other health personnel and pointing out that a single negative test was of no value. Writing in a daily medical newspaper the president of the Surgeons Society, Dr Karl Hempel, similarly expressed his anger about the health minister’s remarks. He saw no reason why doctors should have to undergo an HIV-test if patients did not. Many people were thus surprised when the General Medical Council and the Federal Health Ministry in Bonn published a common statement on HIV-tests for doctors. It states that those doctors and dentists who might sustain bleeding injuries during their work should undergo HIVtests voluntarily. Those negative should be retested regularly, whereas those positive should not continue to do invasive procedures and that they should possibly switch to another field of medical practice. There should be accurate support for infected surgeons and dentists by the employers and the doctor’s organisations. Annette Tuffs

Medicine and the Law Sleepwalking, "disease of the mind"? Under English law, for a person to be guilty of a crime he must be found not only to have committed the act but also to

guilty intent (mens rea). Where the act was involuntary (ie, without will) he may be able to plead automatism. In ordinary (or sane) automatism the direction

have had

for the act comes from an outside force or cause such as the effects of a drug; in insane automatism the lack of intent is

376

due to "a disease of the mind", and this has been held to include injuries caused during a fleeting epileptic seizure1 or while a person was delirious. The difficulties with this, on occasion fine, distinction have lately been considered by the Court of Appeal in a case involving acts of violence while sleepwalking. The defendant had been tried before a jury in July, 1989, on charges arising out of an attack on a woman.2 The defence admitted the acts of violence but submitted that the defendant had been sleepwalking and suffering from non-insane automatism. Medical evidence was called by the Crown (Dr P. B. C. Fenwick) and by the defence (Dr P. T. d’Orban, Dr Michael Nicholas, and Dr Peter Eames). The judge, Sir Ian Lewis, ruled that this defence could not be raised without involving the issue of insanity. The jury found the defendant not guilty by reason of insanity and he was ordered to be detained in hospital under the Criminal Procedure (Insanity) Act 1964. His appeal was dismissed on March 27,1991. Dismissing the appeal, Lord Lane, C, said that where a defence of automatism is raised the judge has two questions to decide before the defence can be left to a jury. Was there a proper evidential foundation for the defence of automatism and did that evidence show insane automatism (ie, a case falling within the M’Naghten rules on not guilty verdicts by virtue of insanity) or non-insane automatism? The sole ground of the appeal was that the judge’s ruling was wrong on whether the automatism was "insane". The woman assaulted occupied a flat immediately above that of the defendant. The two were friendly. The woman realised that he was probably in love with her but she did not wish anything beyond friendship. The defendant, then 32, was sexually inexperienced and of a solitary disposition. He had always behaved impeccably towards her. On the evening of the assault, he visited her flat. They had one glass of vermouth each. Having watched a videotape, she fell asleep. The next thing she knew was that something hard had hit her on the head. She woke, dazed, to find the appellant with the video recorder held up high, clearly intending to bring it down on her head, which he did. He must have unplugged the video recorder, detaching various leads before carrying it to where the woman lay asleep on the sofa. He was speaking loudly. He seemed vicious and angry--quite out of character. When she fell to the floor, he put a hand round her throat. With great presence of mind, she managed to say "I love you", whereupon he appeared to come to his senses and to show great anxiety. He telephoned for an ambulance. At the trial the man had testified that he too had fallen asleep. He remembered waking up and feeling confused. It then dawned on him that he was holding the woman down on the floor. He had no memory of hitting her. He had run away after the incident and had driven round the countryside. He wrote three letters to her, stating that he did not know what he was doing when he attacked her and that he must have had a blackout. The Trial of Lunatics Act 1883 (amended by the 1964 Act) a verdict of not guilty by reason of insanity in circumstances where evidence shows that the defendant was insane and not responsible for his actions at the time of the offence. Under the M’Naghten rules the presumption is that everyone possesses a sufficient degree of reason to be responsible for their crimes, until the contrary is proved to the satisfaction of a jury. Lord Lane said the reason for this special verdict is the absence of intent. However, "What the law regards as insanity for the purposes of these enactments may be far removed from what would be regarded as insanity by a psychiatrist". There was no doubt that the defendant was labouring under such a defect of reason as not to know what he was doing. The question for the Appeal Court was whether that was from "disease of the mind". Lord Lane stressed that the phrase was "disease of the mind" and not "disease of the brain".

provides for

The psychiatrist called by the prosecution took the view that this was not a sleepwalking episode. The most likely explanation, he

said, was that the man was in "an hysterical dissociative state"-a state in which, for psychological reasons, such as being overwhelmed by his emotions, a person’s brain works differently. Violent acts in sleepwalking were common but serious violence was rare. When asked whether a person should be detained if he was potentially in sleep Dr Fenwick said that "There is a lot which can be done for the sleepwalker, so sending him to hospital after a violent act to have his sleepwalking sorted out makes good sense". He thought that in certain circumstances hysterical dissociative states can be treated too. The Court of Appeal accepted that, on the medical evidence, the judge had been right to conclude that this was an abnormality or disorder, albeit transitory, due to an internal factor, which had manifested itself in violence. It was a disorder of abnormality that

might recur. The Court of Appeal (and indeed the trial judge) were alive to the apparent incongruity of labelling this sort of disability as insanity. They drew attention to a 1984 speech of Lord Diplock in R v Sullivan1 where he had said it was natural to feel reluctant to attach the label of insanity to someone with psychomotor epilepsy of the kind suffered by the defendant in the case before him. However, the label was contained in the current statute and only Parliament could alter it. R v Burgess [1991] WLR C7, Roch and Morland]].

1206

(CA) decided March 27,1991: Lord Lane

Diana Brahams 1. R v Sullivan (1984). AC 156 at 173; See Brahams D. Epilepsy and the law. Lancet 1984; i: 1481. 2. Fenwick P. Automatism and the law. Lancet 1989; ii: 753-54.

Conference Headlines for hormones What is the link between over 5000 of the world’s foremost endocrinologists, the president of Brazil, and Boris Yeltsin? They were all doing business in Washington, DC, the week of June 19. For once the politicians had to share the headlines; at times they were even relegated into second place by reports in the lay press of the 73rd annual meeting of the American Endocrine Society. The programme’s mix of ground-breaking basic research and state-of-the-art clinical management captured the popular imagination. The increasingly complex methods of molecular analysis are having a huge impact in all areas of endocrinology, breathing new life into long established and traditionally well-characterised areas of research. The many sessions on the latest aspects of regulation of the gonadotropic axis bore witness to this point. Much attention was focused on the presentation by Dr Laurie Tom (Harbor-UCLA Medical Center) on male contraception. Gonadotropin releasing hormone (GnRH) analogues stimulate the pituitary gland to secrete luteinising hormone (LH) and follicle stimulating hormone (FSH); in turn these hormones stimulate testosterone and sperm production in the testes. Agonistic and antagonistic analogues of GnRH inhibit endogenous GnRH and ultimately suppress sperm production; a concomitant decline in serum testosterone concentrations necessitates testosterone replacement to maintain sexual libido and function. Although GnRH agonists produced some suppression of sperm production in normal men, the antagonists have proved to be the best inhibitors of