active rather than to intensify efforts designed to rnaintain safer sexual practices among those who have already modified their behaviour. Where information on the age distribution of subjects is available we suggest that its inclusion in communications would facilitate the interpretation of trends in numbers of reported diagnoses. ADRIAN RENTON LUKE WHITAKER Academic Departmicit of P'ublic Health, St Mary's Hospital Medical School, London WV2 I PG I French PD, Mercey DE Tomlinson DR, Harris JRW. Preventing the spread of HI\V infection. BM] 1991;302:962. (20
April.) 2 Singaratnam AE, Boag F, Barton SE, Hawkins DA, Lawrence AG. Preventing the spread of HIV' infection. BAIj 1991;302:
349. (23 February.) 3 van den Hoek JAR, vanlGriensven GJIP, Coutinho RA. Inicrease in unisafe homosexual behaviour. I.ancet 1990;336:180. 4 Waugh MIA. Resurgent gonorrhoea itt homosexual men. Lancet
1991;337:375. 5 Riley V'C. Resurgent gonorrhoea in homosexual mcn. Lanet
1991;337:183. 6 Tomlinson DR, French P1), Harris JRW, Mercev DE. Does rectal gonorrhoea reflect unsafe sex? Lancet 1991;337:501.
orbital volume replacement at the time of enucleation. Primary orbital implantation would avoid the post-enucleation socket syndrome in most of these patients. Secondary implantation is possible in patients who are disfigured by the syndrome, but results are usually inferior to those of primary implantation.2 We disagree with the authors that ptosis of the upper eyelid is a common physical sign in anophthalmic patients. In our experience of 27 patients with the post-enucleation socket syndrome who had reconstructive surgery at our hospital between April 1990 and March 1991 only one patient had ptosis of the upper eyelid. The ptosis had been present before enucleation. Retraction of the upper eyelid was a more common feature. This is supported by the results of recent study into the cause of the post-enucleation socket syndrome.' It is our experience that orbital volume replacement alone is usually sufficient to correct the malpositions of the eyelid and that the use of fascial slings is rarely indicated. BRIAN LEATHERBARROW JEFFREY KWARTZ Manchester Royal Eye Hospital, Manchester M13 9WH
Self induced automatism SIR,-It was refreshing to read Dr P B C Fenwick's succinct exposition of the distinction between sane and insane automatism according to the current law in England. His suggestions for reform seem eminently reasonable. They would benefit the accused as well as save lawyers the headaches of running a defence of automatism as if the accused puts his or her state of mind in issue by pleading non-insane automatism it is open to the prosecution to prove insanity. Even if it is established that the automatism was non-insane an absolute acquittal, though likely, does not necessarily result if the automatism was self induced. If the automatism was self inducedas, for example, if a diabetic patient became an automaton as a result of taking insulin and failing to eat properly-the accused cannot be convicted of any crime in relation to the time when he was an automaton unless he is proved to have been subjectively reckless-that is, before he became an automaton he appreciated the risk that taking insulin and not eating would be likely to make him aggressive or uncontrollable with the result that he might endanger others.2 If the accused was proved to have been subjectively reckless he would be liable to be convicted of a crime of "basic" but not "specific" intent. Broadly speaking, crimes of basic intent are those in which recklessness suffices as to the mental element, whereas in those of specific intent, intention and nothing less is required.3 In the above circumstances, if the accused is proved to have been subjectively reckless as to the risk of aggression or uncontrollability he can be convicted even though at the time of the offence he lacked the mental element of the crime charged. M J SWORN Department of Histopathology, Royal Hampshire County Hospital, WXiinchester S022 5DG Fenwick PBC. Brain, mind, insanity, and the law. BMJ 1991;302:979-80. (27 April.) 2 Bailey [1983] 2 ALL ER 503, [1983] 1 WLR 760, CA. 3 DPI v Atajewski [1977j AC 443, [1976] 2 ALL ER 142, HL.
I Bailey CS, Buckley RJ. Ocular prostheses and contact lenses. ICosmetic devices. BMA 1991;302:1010-2. (27 April.) 2 Smit TJ, Koornneef L, Mourits MP, Groet E, Otto AJ. Primary versus secondary intraorbital implants. Ophthalmic Plastic and Reconstructive Surgery 1990;6: 115-8. 3 Smit TJ, Koornneef L, Zonneveld FW, Groet E, Otto AJ. Computed tomography in the assessment of the postenuncleation socket syndrome. Ophthalmology 1990;97: 1347-51.
Diagnosing maternofetal toxoplasmosis SIR,-The author who described her appalling experience during pregnancy, which culminated in the unnecessary loss of her baby, will have touched the hearts of all who read her account. ' Her conclusion that this episode could have been prevented if there was a routine national prenatal screening programme for toxoplasmosis in this country is, however, controversial. Of course all doctors who care for pregnant women should be properly informed about the best ways to diagnose and manage this infection, but introducing a screening programme would be an unnecessarily cumbersome approach and unlikely to achieve this goal. Moreover, the practice of fetal diagnosis would become more widespread and the complication that the author experienced, which is even more likely to occur outside the few centres of excellence currently undertaking cordocentesis, would sadden yet further lives. The clinical costs of a screening programme for toxoplasmosis (which would include not only some unnecessary fetal deaths from both therapeutic terminations2 and diagnostic intervention,' but also adverse drug reactions,' and social and psychological sequelae') would almost certainly outweigh any gains achieved through medical education. What is needed is improved undergraduate and postgraduate teaching about toxoplasmosis and better (sensitive, specific, and non-invasive) diagnostic tests to detect maternofetal infection. SUSAN M HALL Public Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ
Ocular prostheses SIR,-We congratulate Messrs C Steven Bailey and Roger J Buckley on their article on ocular prostheses and contact lenses.' It should be possible to obtain an excellent cosmetic result in most patients who have undergone an enucleation. Unfortunately, many patients do not undergo
1208
1 Attonymous. Controversy breeds ignorance. BMJ 1991;302: 973-4. (20 April.) 2 Desmonts G, Daffos F, Forester F, Capella-Pavlovisky M, rhulliez PH, Chartier M. Prenatal diagnosis of congenital
toxoplasmosis. Iancet 1985;i:500-4. 3 Royal College of Physicians. Prenatal diagnosis and genetic screening: community and service implications. London: Royal College of Physicians, 1989. 4 Ostlere LS, Langtrv JAA, Staughton RCD. Allergy to spiramycin
during prophylactic treatment of fetal toxoplasmosis. BMt7 1991;302:970. (20 April. 5 Richards MPM. Social and ethical problems ot fetal diagnosis and screening. journtal of Reproducttive and Intfantt Psychology 1989;7: 171-85.
Physiotherapy for stress urinary incontinence SIR,-We agree with Ms Jill Mantle and Mr Eboo Versi's conclusion that there is a need for research data on the efficacy of physiotherapists' treatments for stress incontinence of urine.' We believe that these treatments should be subjected to the same scrutiny as drug treatment to show their effectiveness and their lack of adverse affects and to justify continued or increased investment in resources. We were alarmed to read that many districts possess and still use machines to stimulate the pelvic floor muscles electrically to improve muscle strength when they may produce the opposite effect. Faradic stimulation (50 Hz) is not classed as low frequency when referring to rehabilitation of skeletal muscle. There is no evidence showing that faradic stimulation is useful in incontinence of urine. Indeed, it may be potentially harmful. High frequency stimulation often results in a decrease in maximum tetanic force.2 In addition, this paper suggests that many physiotherapists believe interferential stimulation to be effective, but good evidence to support this is lacking. Force is believed to be maintained in mixed frequency stimulation regimens.'4 These patterns of stimulation are currently being developed to stimulate muscle but are not yet ready for clinical use. In view of the current uncertainty about the safety of these techniques we question their use until more evidence is available from well conducted studies. JAMES A BARRETT Clatterbridge Hospital, Wirral L63 4JY JACQUELINE A OLDHAM
Liverpool University, Liverpool 1 Mantle J, Versi E. Physiotherapy for stress urinary incontinence: a national survey. BMJ 1991;302:753-5. (30 March.) 2 Kernell D, Eerbeek 0, Verhey BA, Donselaar D. Effects of physiological amounts of high and low rate chronic stimulation on fast twitch muscle of the cat hind limb. I. Speed and force related properties.] Neurophysiol 1987;58:598-613. 3 Rutherford OM, Jones DA. Contractile properties and fatiguability of the human adductor pollicis and first dorsal interosseus: a comparison of the effects of two chronic stimulation patterns. ] Neurol Sci 1988;85:319-3 1. 4 Oldham JA, Stanley JE. Rehabilitation of atrophied muscle in the rheumatoid arthritic hand: a comparison of two methods of electrical stimulation. ] Hand Surg[Br] 1989;14:294-7.
Childhood immunisation: uptake of pertussis vaccine in Grampian SIR,-Drs I Abu Arafeh and J A Carmichael discuss some of the difficulties in improving the uptake of whooping cough vaccine. ' They rightly point out that inaccurate computerised records contribute to an underestimate of immunisation uptake. In Grampian this has been vigorously addressed in several ways. Firstly,, computerised lists of patients who default on immunisation are fed back to individual general practitioners on a quarterly basis; they are then updated and returned to the primary care department. Initially many discrepancies were uncovered, but these have diminished with time. Secondly, the computer software used to record immunisations has been revised to improve the validation of data entered. Implausible ages (dates) at immunisation are
BMJ
VOLUME
302
-18 MAY 1991
April.) 2 Singaratnam AE, Boag F, Barton SE, Hawkins DA, Lawrence AG. Preventing the spread of HIV' infection. BAIj 1991;302:
349. (23 February.) 3 van den Hoek JAR, vanlGriensven GJIP, Coutinho RA. Inicrease in unisafe homosexual behaviour. I.ancet 1990;336:180. 4 Waugh MIA. Resurgent gonorrhoea itt homosexual men. Lancet
1991;337:375. 5 Riley V'C. Resurgent gonorrhoea in homosexual mcn. Lanet
1991;337:183. 6 Tomlinson DR, French P1), Harris JRW, Mercev DE. Does rectal gonorrhoea reflect unsafe sex? Lancet 1991;337:501.
orbital volume replacement at the time of enucleation. Primary orbital implantation would avoid the post-enucleation socket syndrome in most of these patients. Secondary implantation is possible in patients who are disfigured by the syndrome, but results are usually inferior to those of primary implantation.2 We disagree with the authors that ptosis of the upper eyelid is a common physical sign in anophthalmic patients. In our experience of 27 patients with the post-enucleation socket syndrome who had reconstructive surgery at our hospital between April 1990 and March 1991 only one patient had ptosis of the upper eyelid. The ptosis had been present before enucleation. Retraction of the upper eyelid was a more common feature. This is supported by the results of recent study into the cause of the post-enucleation socket syndrome.' It is our experience that orbital volume replacement alone is usually sufficient to correct the malpositions of the eyelid and that the use of fascial slings is rarely indicated. BRIAN LEATHERBARROW JEFFREY KWARTZ Manchester Royal Eye Hospital, Manchester M13 9WH
Self induced automatism SIR,-It was refreshing to read Dr P B C Fenwick's succinct exposition of the distinction between sane and insane automatism according to the current law in England. His suggestions for reform seem eminently reasonable. They would benefit the accused as well as save lawyers the headaches of running a defence of automatism as if the accused puts his or her state of mind in issue by pleading non-insane automatism it is open to the prosecution to prove insanity. Even if it is established that the automatism was non-insane an absolute acquittal, though likely, does not necessarily result if the automatism was self induced. If the automatism was self inducedas, for example, if a diabetic patient became an automaton as a result of taking insulin and failing to eat properly-the accused cannot be convicted of any crime in relation to the time when he was an automaton unless he is proved to have been subjectively reckless-that is, before he became an automaton he appreciated the risk that taking insulin and not eating would be likely to make him aggressive or uncontrollable with the result that he might endanger others.2 If the accused was proved to have been subjectively reckless he would be liable to be convicted of a crime of "basic" but not "specific" intent. Broadly speaking, crimes of basic intent are those in which recklessness suffices as to the mental element, whereas in those of specific intent, intention and nothing less is required.3 In the above circumstances, if the accused is proved to have been subjectively reckless as to the risk of aggression or uncontrollability he can be convicted even though at the time of the offence he lacked the mental element of the crime charged. M J SWORN Department of Histopathology, Royal Hampshire County Hospital, WXiinchester S022 5DG Fenwick PBC. Brain, mind, insanity, and the law. BMJ 1991;302:979-80. (27 April.) 2 Bailey [1983] 2 ALL ER 503, [1983] 1 WLR 760, CA. 3 DPI v Atajewski [1977j AC 443, [1976] 2 ALL ER 142, HL.
I Bailey CS, Buckley RJ. Ocular prostheses and contact lenses. ICosmetic devices. BMA 1991;302:1010-2. (27 April.) 2 Smit TJ, Koornneef L, Mourits MP, Groet E, Otto AJ. Primary versus secondary intraorbital implants. Ophthalmic Plastic and Reconstructive Surgery 1990;6: 115-8. 3 Smit TJ, Koornneef L, Zonneveld FW, Groet E, Otto AJ. Computed tomography in the assessment of the postenuncleation socket syndrome. Ophthalmology 1990;97: 1347-51.
Diagnosing maternofetal toxoplasmosis SIR,-The author who described her appalling experience during pregnancy, which culminated in the unnecessary loss of her baby, will have touched the hearts of all who read her account. ' Her conclusion that this episode could have been prevented if there was a routine national prenatal screening programme for toxoplasmosis in this country is, however, controversial. Of course all doctors who care for pregnant women should be properly informed about the best ways to diagnose and manage this infection, but introducing a screening programme would be an unnecessarily cumbersome approach and unlikely to achieve this goal. Moreover, the practice of fetal diagnosis would become more widespread and the complication that the author experienced, which is even more likely to occur outside the few centres of excellence currently undertaking cordocentesis, would sadden yet further lives. The clinical costs of a screening programme for toxoplasmosis (which would include not only some unnecessary fetal deaths from both therapeutic terminations2 and diagnostic intervention,' but also adverse drug reactions,' and social and psychological sequelae') would almost certainly outweigh any gains achieved through medical education. What is needed is improved undergraduate and postgraduate teaching about toxoplasmosis and better (sensitive, specific, and non-invasive) diagnostic tests to detect maternofetal infection. SUSAN M HALL Public Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ
Ocular prostheses SIR,-We congratulate Messrs C Steven Bailey and Roger J Buckley on their article on ocular prostheses and contact lenses.' It should be possible to obtain an excellent cosmetic result in most patients who have undergone an enucleation. Unfortunately, many patients do not undergo
1208
1 Attonymous. Controversy breeds ignorance. BMJ 1991;302: 973-4. (20 April.) 2 Desmonts G, Daffos F, Forester F, Capella-Pavlovisky M, rhulliez PH, Chartier M. Prenatal diagnosis of congenital
toxoplasmosis. Iancet 1985;i:500-4. 3 Royal College of Physicians. Prenatal diagnosis and genetic screening: community and service implications. London: Royal College of Physicians, 1989. 4 Ostlere LS, Langtrv JAA, Staughton RCD. Allergy to spiramycin
during prophylactic treatment of fetal toxoplasmosis. BMt7 1991;302:970. (20 April. 5 Richards MPM. Social and ethical problems ot fetal diagnosis and screening. journtal of Reproducttive and Intfantt Psychology 1989;7: 171-85.
Physiotherapy for stress urinary incontinence SIR,-We agree with Ms Jill Mantle and Mr Eboo Versi's conclusion that there is a need for research data on the efficacy of physiotherapists' treatments for stress incontinence of urine.' We believe that these treatments should be subjected to the same scrutiny as drug treatment to show their effectiveness and their lack of adverse affects and to justify continued or increased investment in resources. We were alarmed to read that many districts possess and still use machines to stimulate the pelvic floor muscles electrically to improve muscle strength when they may produce the opposite effect. Faradic stimulation (50 Hz) is not classed as low frequency when referring to rehabilitation of skeletal muscle. There is no evidence showing that faradic stimulation is useful in incontinence of urine. Indeed, it may be potentially harmful. High frequency stimulation often results in a decrease in maximum tetanic force.2 In addition, this paper suggests that many physiotherapists believe interferential stimulation to be effective, but good evidence to support this is lacking. Force is believed to be maintained in mixed frequency stimulation regimens.'4 These patterns of stimulation are currently being developed to stimulate muscle but are not yet ready for clinical use. In view of the current uncertainty about the safety of these techniques we question their use until more evidence is available from well conducted studies. JAMES A BARRETT Clatterbridge Hospital, Wirral L63 4JY JACQUELINE A OLDHAM
Liverpool University, Liverpool 1 Mantle J, Versi E. Physiotherapy for stress urinary incontinence: a national survey. BMJ 1991;302:753-5. (30 March.) 2 Kernell D, Eerbeek 0, Verhey BA, Donselaar D. Effects of physiological amounts of high and low rate chronic stimulation on fast twitch muscle of the cat hind limb. I. Speed and force related properties.] Neurophysiol 1987;58:598-613. 3 Rutherford OM, Jones DA. Contractile properties and fatiguability of the human adductor pollicis and first dorsal interosseus: a comparison of the effects of two chronic stimulation patterns. ] Neurol Sci 1988;85:319-3 1. 4 Oldham JA, Stanley JE. Rehabilitation of atrophied muscle in the rheumatoid arthritic hand: a comparison of two methods of electrical stimulation. ] Hand Surg[Br] 1989;14:294-7.
Childhood immunisation: uptake of pertussis vaccine in Grampian SIR,-Drs I Abu Arafeh and J A Carmichael discuss some of the difficulties in improving the uptake of whooping cough vaccine. ' They rightly point out that inaccurate computerised records contribute to an underestimate of immunisation uptake. In Grampian this has been vigorously addressed in several ways. Firstly,, computerised lists of patients who default on immunisation are fed back to individual general practitioners on a quarterly basis; they are then updated and returned to the primary care department. Initially many discrepancies were uncovered, but these have diminished with time. Secondly, the computer software used to record immunisations has been revised to improve the validation of data entered. Implausible ages (dates) at immunisation are
BMJ
VOLUME
302
-18 MAY 1991
