Volume 171 Issue 11

Editorial Doctors and the "environment" A "call to arms" for medical practitioners in Australia MJA 1999; 171: 576-577

Editorial William Osler: a model for the 21st century? Osler's teachings are as relevant now as they were 100 years ago Whatever way my days decline, I felt and feel, tho' left alone, His being working in mine own, The footsteps of his life in mine. MJA 1999; 171: 577-579

Michael F O'Rourke

Editorial Humour in medical teaching The place of humour in medical teaching seems paradoxical MJA 1999; 171: 579-580

John B Ziegler

Editorial The burden of disease and injury in Australia: time for action Another report or the beginning of a new era? MJA 1999; 171: 581-582

Water Hazards Dead in the water: how safe are our water sports? We now have the Australian Water Safety Council and its National Water Safety Plan: the impact of these initiatives remains to be seen MJA 1999; 171: 584-586

Robyn M Walker

Water Hazards Patterns of drowning in Australia, 1992-1997 Ian J Mackie MJA 1999; 171: 587-590 For editorial comment, see Walker Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Public and environmental health Abstract Objective: To determine patterns of victims, circumstances and locations of drownings in Australia in 1992-1997, inclusive. Methods: Population figures and available details of all drownings were obtained from the Australian Bureau of Statistics. Accidental non-boating drownings (ICD E910), boating incidents (E830-832), homicide (E964), suicide (E954), and other deaths without a drowning E code but "flagged" because drowning was involved (although not the primary cause of death) were included. Results: The overall accidental non-boating drowning rate was 1.44/100 000 population/year. The commonest sites for non-boating drowning were ocean or estuary (22%), private swimming pools (17%), non-tidal lakes and lagoons (17%), surfing beach (10%) and bathtub (7%). 22% of victims were aged under 5 years; this group had a drowning rate of 4.6/100 000 population/year. Very few young children drowned in the ocean or in boating incidents. The rate of boating drownings was 0.29/100 000 population/year. Overseas tourists comprised 4.7% of all non-boating drownings, 18% of surf and ocean drownings, and 25% of all scuba drownings. Indigenous people had a much higher drowning rate than the general population. Conclusions: Drownings in children aged less than 5 years continue to be the greatest challenge for water safety organisations and legislators. Drownings in the Indigenous community and among tourists requires more detailed study and action. To assist in developing preventive strategies, the National Water Safety Council will need to clarify the categories described as "ocean/estuary" and " lake, lagoon, dam and waterhole". Introduction Accidental drowning is a largely preventable cause of death. Water safety organisations, the general public and legislators need adequate information about the circumstances of drowning to target preventive action effectively. While the 1993 National Drowning Study concluded that the risk of accidental drowning in Australia and other countries has steadily decreased since 1920,1 that study and a later report2 did not provide detailed national information on where drownings occurred. Although the Australian Bureau of Statistics (ABS) has provided figures on accidental drownings in Australia dating from 1920, it has only reported the locations of accidental drownings since 1992. Currently, drowning is classified under the International Classification of Diseases (ICD) Supplementary classification of external causes of injury and poisoning codes.3 The relevant "E" codes and brief descriptions are shown in Box 1. In addition to the E codes, in 1992 the ABS introduced a nationally consistent system of "flags" for all drownings and other conditions where drowning is cited as one of two or more causes of death, but not the primary cause. These flags form the basis of specialised drowning tables in which flags 1-36 are for non-boating drownings and flags 37-53 are for various boating deaths. In this study, I examined both the international E codes and the ABS flag system4 to present new data which may help target those most at risk in the different locations where drownings occur. Methods Figures on accidental drownings in Australia from 1992-1997, inclusive, were obtained from the ABS. Accidental non-boating drownings (ICD E910: "Accidental drowning and submersion") were divided into locations and activities, which were then examined separately for age and sex distribution. Boating incidents (E830-832), homicide (E964), suicide (E954), and other deaths without a drowning E code but with the drowning flag applied were also studied. Implementation issues in 1992 and 1993 resulted in very slight discrepancies in drowning figures between the "E" code and "flag" systems. Five groups were subjected to detailed analysis. These were children aged under five years, people aged over 65 years, Indigenous people, overseas tourists, and those who drowned in the bathtub. Results Overall, 2673 people drowned in Australia in 1992-1997. These included 1551 non-boating drownings (E910; see Box 2), 292 drownings in boating incidents (E830-832; see Box 3), 390 suicides in the water (E954), and 28 homicides (E964), as well as several accidental drownings that appeared under a "drowning flag" rather than an E code (46 people with epilepsy who drowned, 13 who drowned because they had a heart attack or stroke while in the water, and 86 who drowned in motor vehicles accidents in the water). The remaining 267 deaths were "incidental" drownings -- generally those for which the coroner could not decide on a classification. The distributions of locations of all Australian accidental non-boating drownings and for selected groups are shown in Box 4, as is a summary of features of drowning deaths for children aged under five years, people aged 65 or more years, Indigenous people and overseas tourists. The age and sex distribution and detailed findings for bathtub drownings are shown in Box 5. Discussion Overall, this study shows that children aged under five years are most vulnerable to drowning in Australia. It also shows, with data not previously presented, that a considerable number of overseas tourists drown in our waters, and that the frequency of drownings of Indigenous people is disproportionately high, with an unusual number of drownings in young men. Twenty-two per cent of all drowning victims are in the 0-4-years age group, although this group comprises only 7% of the population. The rate of drownings in this age group (4.6 per 100 000 population per year) for 1992-1997 has changed little from that for 1986-1990 (4.7 per 100 000 population per year).1 It is thus clear that the high frequency of drowning in very young children is not improving. The figures provide strong backing for the recommendations of Nixon and colleagues,2 which were compilation of better coronial information, better police investigation of toddler drownings to include information on fencing and other vital details, detailed study of adolescent drownings, investigation of surveillance methods, support for advocacy of fencing of swimming pools, community education on the dangers of mixing alcohol with aquatic activities, and making first aid training mandatory for all pool owners. In particular, legislation on fencing for private pools is inadequate -- it varies from State to State, and local government areas have their own rules which are not always enforced. There is a real need for uniform national legislation for pool fencing that complies with the recommendations of the Australian Standards Association to help arrest this high rate of drowning in very young children. Details of drownings involving overseas tourists have not previously been published, and this is clearly an area in which government must work through the Water Safety Council to reduce the risk. Tourists and new migrants must be provided with suitable information and perhaps increased supervision when near the ocean. The ocean and recreational snorkelling or scuba diving present the greatest risks for tourists. Drowning in Aboriginal and Torres Strait Islander people also requires urgent government action through the appropriate established organisations. Differences in drowning incidence in different racial groups have been previously documented.6-8 The pattern of drownings in the Australian Indigenous population (Box 4) is quite different from that of the population as a whole, with a very high incidence in children under five years and in the 25 to 34 years age group. Further, ABS advice indicates that "death data for indigenous persons is undernumerated. While indigenous status is now a question on all State and Territory death forms, the ABS only regards data for South Australia, Western Australia and Northern Territory as having sufficient coverage to be of publishable standard" (ABS, personal communication). Bathtub drownings are disturbingly common on a national basis and preventive approaches need to vary for different age groups. The frequency of infant and toddler bathtub deaths has been documented in State reports for two decades,1 but this is the first national survey. The bathtub is the only site where female deaths predominate. This has been reported in previous studies,1 but the reasons for this phenomenon are not apparent. Most bathtub deaths require much more careful forensic scrutiny than they have received to date in most countries. Carbon monoxide, epilepsy, drugs and alcohol, cardiac arrest, suicide, homicide and child abuse have all been implicated, and there is little doubt that death in the bathtub at any age should be investigated carefully to determine whether the cause was natural or deliberate. Confirmation of true accidental drowning in bathtubs may be less common with such an approach. The quality of the information available needs to be improved to help target preventive action. For example, as pointed out previously,4 reliance solely on E codes would result in many drownings remaining unidentified. There were 80 drownings in motor vehicle accidents and a large number of suicides (390, making suicide more common than drowning in boating accidents [292]), and others, such as deaths from myocardial infarction, stroke and spinal injuries, where the involvement of drowning was only obvious from the ABS flag system. Further, there is a lack of detailed information on drownings listed within the E codes. "Lake, lagoon, dam and waterhole" and ocean/estuary drownings cover many different locations requiring different preventive measures -- this needs further investigation by the recently formed National Water Safety Council in conjunction with coroners, police and the National Injury Surveillance Unit. The most comprehensive review of measures to prevent drowning in Australia was published in 1995 by the Commonwealth Department of Human Services and Health, and contains most of the references of importance up to that time.2 The data for 1992-1997 in this study will provide the new National Water Safety Council with added information to assist more informed targeting of individual risk groups in specific areas. Acknowledgements I received great assistance from the officers of the Australian Bureau of Statistics, the executive officers of the Royal Life Saving Society Australia and Dr George Stathers. Purchase of the statistical computer disk with relevant data was funded by the Royal Life Saving Society Australia. References Mackie I, Tebb N, Eady T. National drowning study, Parts 1 to 4. Sydney: Royal Lifesaving Society Australia, 1993. Nixon J, Pearn J, Oldenburg B, Pitt W. Review of countermeasures to reduce drowning, near drowning and spinal injuries fron diving into shallow water. Canberra: Commonwealth Department of Human Services and Health, 1995. Department of Health and Human Services. The international classification of diseases, 9th revision, clinical modification (ICD-9-CM). 5th ed. Vol. 1: Diseases tabular list, October 1994. Bethesda, Md: United States DHHS (Publication No. PHS 94-1260). Smith G, Langley J. Drowning surveillance: how well do E codes identify submersion fatalities. Injury Prevention 1998; 4: 135-139. Australian Bureau of Statistics. Population by age and sex. Canberra: ABS, 1997. (Catalogue no. 3201.0.) Dietz P, Baker S. Drowning: epidemiology and prevention. Am J Public Health 1974; 64: 303-312. Branche C. Who drowns in the United States? Proceedings of International Medical-Rescue Conference. San Diego: International Lifesaving Federation, 1997. Mael F. Staying afloat: within-group swimming proficiency for whites and blacks. J Appl Psychol 1995; 80: 479-490. (Received 5 May, accepted 28 Oct, 1999) Authors' details Royal Life Saving Society Australia, Sydney, NSW. Ian J Mackie, AM, FRACP, National Medical Adviser. Reprints: Dr I J Mackie, PO Box 280, Cronulla, NSW 2230. ianmackieATmsn.com.au 1: International Classification of Diseases (ICD) Supplementary classification of external causes of injury and poisoning codes relating to drowning*E830Accident to watercraft causing submersionE832Other accidental submersion or drowning in water transport accidentE910Accidental drowning and submersionE954Suicide and self-inflicted injury by submersion (drowning)E964Assault by submersion (drowning)E984Submersion (drowning) undetermined whether accidentally or purposefully inflicted.*Drowning is defined by the Medical Commission of the International Lifesaving Federation as death resulting from suffocation within 24 hours of submersion in a liquid medium. Back to text2: Accidental non-boating drownings in Australia in 1992-1997 (E910) Overall There were 1551 drownings, a national rate of 1.44 per 100000 population per year (based on 1996 population data5) 77% of victims were male. Of 1096 victims aged over 14 years, the presence of drugs including alcohol was recorded in 148 (14%); 117 of these were male. The highest prevalence was in the 0-4 years age group Males made up 64% of the 0-4 years age group and 62% of people aged over 64 years who drowned. Locations of drownings Most non-boating drownings (22%) occurred in ocean/estuary (tidal) sites. - 90% of the victims were male and very few were aged under 15 years. 17% of drownings occurred in private swimming pools. - 64% involved children aged under four years, two-thirds of whom were male. - Of all those aged over 34 years who drowned in private pools, 63% were female. - Only 3% of accidental drownings occurred in public and "other" pools (28 drownings in public pools [20 males] and 18 in "other" pools [11 males]). 17% of drownings occurred in non-tidal lagoons and lakes. - 82% of victims were male, and there was a high frequency of drownings in 0-4-year-olds. 10% of drownings (162) occurred at surfing beaches. - 144 victims (89%) were male. - No one aged less than 5 years and few aged 5-14 years drowned at a surfing beach. 5.8% of drownings occurred while victims were fishing. - They comprised 54 victims (one female), all aged over 15 years, who were washed from rocks, and another 36 people (35 male) who drowned in tidal water. - The only female was 10 years of age, one male was four years old; there were no drownings in males aged 5-14 years, then deaths were relatively evenly distributed for age, with the greatest number, eight, in the over 65 years age group. 3.6% of the 1551 people drowned while using scuba equipment. - 44 (79%) were male, 15 (27%) were overseas tourists. - 36% of scuba deaths occurred in Queensland, 21% in Western Australia and 18% in New South Wales. 15 people drowned while snorkelling (11 males, 3 overseas tourists). 36 people (34 males) drowned while attempting rescues; 12 in surf, one in a public pool and 23 at other sites. Back to text 3: Drowning in boating incidents in Australia in 1992-1997 (E830, E832) There were 292 boating drownings, an average of 52 per year and a rate of 0.29 per 100000 population per year 94% of victims were male. The presence of a drug was reported in 7% of victims, all aged between 35 and 54 years (alcohol in 19, and a different drug in two others). Back to text 4: Drownings in selected groups Children aged <5 years There were 353 drownings in this group (64% boys), a rate of 4.6 per 100000 population/year. - In addition to the locations shown, 6% of toddlers drowned in an object such as a bucket and 2% drowned in an irrigation canal. - 37 infants (22 boys) drowned in their first year of life, 26 in the bathtub, 4 in a private pool, 3 in an object such as a bucket, 2 in a lake, 1 in the ocean and 1 in an irrigation canal. People aged 65+ years 12% of all accidental drowning victims were in this group (38% were women), a rate of 1.5 per 100000 population/year. - More women than men drowned in pools (22 v.11) and bathtubs (18 v. 4). Indigenous people The 63 non-boating drownings of Aboriginals and Torres Strait Islanders represent 4.2% of the national total, while they constitute only 1.8% of the population. - 30% of all Indigenous drownings were in the 25-34 years age group (95% of these male). - Only 7 Indigenous people drowned in boating incidents. All victims except one were in motorised craft; all were male. Overseas tourists 88 tourists from 12 countries drowned in Australia during 1992-1997 (age range, 3-78 years; 16 female) - 73 drowned in non-boating incidents, 5 in boating incidents and 10 in unspecified circumstances. - 38 tourists came from Europe (15 from the United Kingdom, 10 from Germany), 35 from Asia (17 from Japan), 7 from the United States and 8 from other countries. - 89% of tourists drowned in the ocean and 11% drowned in fresh water. 61% drowned at surfing beaches or elsewhere in the "ocean" and a further 24% drowned while scuba diving or snorkelling. Tourist drownings comprised 4.7% of non-boating drownings, 18% of surf and ocean drownings, 25% of scuba and snorkelling drownings and 1.6% of boating drownings. Back to text 5: Bathtub drownings in Australia, 1992-1997 There were 112 bathtub drownings (64 female [57%]). Bathtub drownings comprise 7% of all drownings. 47% of victims were aged <5 years. 20% of victims were aged over 64 years. Alcohol was present in 14% of victims aged over 15 years. Of these, all except one were aged over 60 years. An unspecified drug (but no alcohol) was detected in three younger people who drowned in the bathtub. Back to text

Ian J Mackie

Water Hazards Snorkelling deaths in Australia, 1987-1996 Carl W Edmonds and Douglas G Walker MJA 1999; 171: 591-594 For editorial comment, see Walker Abstract - Introduction - Methods - Results - Discussion - Acknowledgments - References - Authors' details - - More articles on Travel, aviation and underwater medicine

Carl W Edmonds · Douglas G Walker

Water Hazards Scuba diving medical examinations in practice: a postal survey Graham Simpson and David Roomes MJA 1999; 171: 595-598 For editorial comment, see Walker Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - More articles on Travel, aviation and underwater medicine

Graham Simpson · David Roomes

The Weight Debate What should we do about overweight and obesity? The goals of treatment should not necessarily be to normalise weight, but to optimise health MJA 1999; 171: 599-600 Introduction - Why are we getting obese? - Why have we not been effective in treating obesity? - What should we do about obesity? - What has been ignored is our environment - - More articles on Nutrition

Ian D Caterson

The Weight Debate The sources of risk factor information for general practitioners: is physical activity under-recognised? Fiona Dupen, Adrian E Bauman and Rose Lin MJA 1999; 171: 601-603 For editorial comment, see Caterson Abstract - Introduction - Methods - Results - Discussion - Acknowledgement - References - Authors' details - - More articles on General practice and primary care

Fiona Dupen · Adrian E Bauman · Rose Lin

The Weight Debate The effectiveness of popular, non-prescription weight loss supplements Garry Egger, David Cameron-Smith and Rosemary Stanton MJA 1999; 171: 604-608 For editorial comment, see Caterson Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - More articles on Complementary medicine

Garry Egger · David Cameron-Smith · Rosemary Stanton

The Weight Debate Obesity and virtue. Is staying lean a matter of ethics? Self-control of one's own weight might be described as a form of bioethics John N Burry MJA 1999; 171: 609-610 Article - References - Authors' details - - More articles on Ethics

John N Burry

The Weight Debate Why staying lean is not a matter of ethics Joseph Proietto MJA 1999; 171: 611-613 Introduction - What is obesity? - Is obesity a risk to health? - Are obese people entirely responsible for their excess weight? - Are the obese abused in our society? - What should be the consequences of our new knowledge of the aetiology of obesity? - Acknowledgement - References - Authors' details - - More articles on Ethics

Joseph Proietto

Rural Healthcare Accessibility to general practitioners in rural South Australia A case study using geographic information system technology MJA 1999; 171: 614-616 Errol J Bamford, Lyle Dunne, Danielle S Taylor, Brian G Symon, Graeme J Hugo and David Wilkinson Abstract - Introduction - Methods - Results - Discussion - References - Authors' details - - - More articles on Administration and health services

Errol J Bamford · Lyle Dunne · Danielle S Taylor · Brian G Symon · Graeme J Hugo · David Wilkinson

Rural Health Mobile intensive care services in rural South Australia John E Gilligan, William M Griggs, Michael T Jelly, David G Morris, Ross R Haslam, Neil T Matthews, Evan R Everest, Robert L Bryce, Peter B Marshall and Ron A Peisach MJA 1999; 171: 617-620 Synopsis - Introduction - The service - Patient care - Discussion - Acknowledgement - References - Authors' details - - More articles on General practice and primary care Synopsis In the 12 years from 1984 to 1995, Adelaide-based mobile intensive care teams transported 4443 critically ill patients from rural areas in South Australia and adjacent States to tertiary-level hospitals in Adelaide. The SA Ambulance Service undertook communications, support staffing and deployment of transport. Average radial distances in 819 road missions were 71 km, in 808 helicopter missions 122 km, and in 2777 fixed-wing aircraft missions 398 km. The largest groups of patients were neonates (23%) and those with trauma (25%). Rural hospitals made 96% of the requests for intensive care transport; 4% came from ambulance or other emergency service crews at accident locations. Emergency surgical or operative obstetrical procedures were performed on 2.7% of patients before transport. One hundred and thirteen patients (2.5%) died during resuscitation or transport, with one death deemed to be preventable. Introduction South Australia has a rural population of 390 000 in an area of about 984 000 km2. Over 100 communities have populations of less than 5000, and the largest provincial cities have populations below 25 000. In these circumstances regional medical services cannot provide intensive care services locally to all patients. The solution has been to use specialised medical teams travelling by road, helicopter or fixed-wing aircraft to stabilise and transport critically ill patients to tertiary referral centres in the South Australian capital, Adelaide. This system was first reported in the Journal in 1977.1 This article describes the function and outcomes of the mobile intensive care service from 1984 to 1995. The service Intensive care teams and facilities were provided by the Royal Adelaide Hospital, the Women's and Children's Hospital, Flinders Medical Centre and the Queen Elizabeth Hospital. The Lyell McEwen Health Service and Modbury Hospital, two community hospitals on the outskirts of Adelaide, played a minor role in providing teams. Rural hospitals were connected to intensive care units at the tertiary centres by dedicated telephone lines so that rural medical officers could obtain emergency advice, contact other specialists and arrange transfer of patients. Mobile teams consisted of a consultant or senior trainee in intensive care, anaesthesia or emergency medicine and a critical care nurse, commonly assisted by a paramedic or Royal Flying Doctor Service (RFDS) nurse. Other specialists (eg, surgeon, obstetrician) travelled as required. The SA Ambulance Service Communications Centre co-ordinated transport and provided supporting staff. Very high frequency radio and mobile phones linked road ambulances, aircraft, tertiary centres and rural hospitals. A twin-engine, pressurised Super KingAir B200C fixed-wing aircraft of the RFDS, carrying a pilot and up to five cabin crew, two stretchers and a stretcher-loading device,2 was used for most long-distance transfers. Recently, Pilatus PC XII aircraft of similar performance have been used. The helicopter used was a twin-engine Bell 412 helicopter of the State Government Insurance Commission-State Rescue Helicopter Service, with 2-4-stretcher capability, pilot, crewperson and up to three medical crew as needed. The Department of Human Services, Royal Flying Doctor Service (Central Section) Medical Review Committee and the SGIC-State Rescue Helicopter Committee audited the operations of the mobile intensive care service. At times, the service was extended to remote areas in other States. Box 1 shows the range of operations. Patient care We did not attempt to classify all patients according to a universal pathological grouping or severity scoring system -- this would have been difficult with the diverse ages and conditions represented among the patients. Our empirical categorisation (Box 2) is similar to that in other reports of transporting the critically ill.3One hundred and thirteen patients died (2.5%) during resuscitation or in transit. One preventable death resulted from an endotracheal tube displacement in transit, which was managed unsuccessfully by emergency tracheostomy at a nearby hospital. Box 3 lists the procedures performed to stabilise patients before transport. A third of patients required endotracheal intubation. Major biochemical disturbances commonly involved potassium or glucose levels. Hypothermia and hyperthermia were corrected to the degree possible. Box 4 lists emergency surgical and obstetrical procedures undertaken before transporting patients. Discussion Rural general practitioners in Australia have a crucial role in recognition, triage and resuscitation of patients with critical illness, but they treat relatively few critically ill patients and lack resources for their care. Access to specialist assistance can reduce the professional isolation felt by rural doctors. Effective care for critically ill rural patients requires an integrated hierarchy of rural and city hospitals, ambulance services, the RFDS and mobile intensive care. Larger rural hospitals have specialist surgical and anaesthetic services, but may lack tertiary centre services such as neurosurgery, burns, spinal injuries, specialised organ imaging, extensive transfusion facilities and major (level III) intensive care.4,5 Because of the large distances involved, staff at tertiary intensive care units encouraged rural medical officers to start a dialogue early with the retrieval service whenever a patient might require retrieval. Intensive care units provided necessary advice while the team was in transit. After stabilising the patient, treatment in transit was commonly restricted to adjustment of sedation, infusion rates and ventilator settings. The transfer of patients immediately after emergency surgery or obstetric procedures was uneventful. Obstetric conditions requiring transfer included eclampsia and major blood loss. The number of obstetric patients declined from 1984 to 1995 as improved antenatal care identified at-risk pregnancies, with elective movement of mothers to a major centre. A surgeon did not usually accompany the mobile intensive care team, largely because the surgical facilities in small rural hospitals were limited. There were 30 patients with suspected extradural haematoma, for whom a local medical officer commenced burr holes, directed by telephone, pending arrival of the team (accompanied by a neurosurgeon in 16 cases) to complete the procedure and retrieve the patient. Data suggest that such emergency drainage of an extradural haemorrhage is a valid procedure if the patient is more than two hours from a trauma centre.6 Ambulance crews at rural accident sites with multiple victims or patients deteriorating during prolonged entrapment were encouraged to request support when needed from local medical officers and/or retrieval teams. While primary (site) retrieval was requested in 149 instances (13% of trauma cases), distance commonly decreed that teams would attend after patients had been transferred to the local hospital. This contrasts with some overseas services that perform mainly primary retrieval missions by helicopter over shorter distances.7-9 Paramedic services provide a high level of care, but retrieval teams have a different role, with a wider therapeutic armamentarium and the ability to undertake major procedures in rural hospitals. Advanced trainees or consultants in intensive care, anaesthesia or emergency medicine, and their nurse counterparts, provide requisite clinical experience and procedural skills. To be effective, they must also be able to work in unfamiliar hospitals, in vehicles and other restricted sites, and they must have insight into the problems of rural doctors and nurses and the concerns of patients and relatives. Fixed-wing aircraft and helicopter services are complementary. Fixed-wing aircraft mobilisation from Adelaide took 45-60 minutes, commonly for distances beyond 200 km. Executive or passenger jet aircraft complete extended trips (eg, Darwin, 2600 km) in half the time of turboprop aircraft. RAAF services assisted in five early cases. Pressurised aircraft were introduced in 1988, enabling smooth, rapid flight above adverse weather and allowing sea-level cabin pressure (eg, in decompression sickness). The helicopter's rapid mobilisation, ability to land close to an incident, and reduced need of supportive road transport offsets slower airspeed. Helicopter transit times, commonly 50 minutes shorter than road transport, were improved by helipads at tertiary centres. Sports fields, lit at night, proved acceptable helipads in country areas. While road transport was used for shorter trips or if aircraft were unavailable, road transfer by local medical officers or ambulance staff (often with inadequate supportive resources) was commonly less satisfactory than if local staff continued resuscitation in the hospital pending arrival of a team. Safe transport requires compact ventilators, infusion pumps and monitors with modest consumption of medical gases and battery power. Monitoring by the mobile teams included electrocardiography, pulse oximetry, core temperature, end-tidal carbon dioxide and (for neonates) transcutaneous measurement of respiratory gases. Intravascular blood pressure and central venous pressure measurements were especially useful, as pulse oximetry and non-invasive blood pressure measurements have limited reliability in hypothermia, shock10,11 and during transport. Neonatal transport incubators weigh about 100 kg, requiring a stretcher base, ventilator, monitors and heating for all phases of transport,12 as combating hypothermia remains the most necessary component. Early transfer of the critically ill has been associated with improved survival.13 Results of care in larger tertiary units are often better than in smaller, local hospitals, especially for severe trauma,14 neonatal15 and paediatric intensive care.16 See Box 5 for some case histories. For this series of 4443 patients, specialised transport was safe, with only one preventable death (a rate of preventable mortality of 0.02%). Two failed intubations occurred before the mobile intensive care team reached the patients. No other adverse effects of resuscitative procedures were reported. Comparable transport mortality rates of 1/2700 (0.04%) have been reported by retrieval organisations in the UK and Canada, usually over shorter distances.3,17 The 112 other deaths during resuscitation or transport were associated with overwhelming injury (eg, ruptured aortic aneurysm or massive trauma) or lack of local resources plus the effect of distance -- an unavoidable death rate of 2.5%. Acknowledgement We thank Ms Liesl Sawyer, computer slide artist, Medical Illustration Unit, Royal Adelaide Hospital, for production of graphics. References Gilligan JE, McCleave DJ, Nicholson B, et al. Retrieval of the critically ill in South Australia: a coordinated approach. Med J Aust 1977; 2: 849-855. Gilligan JE, Goon P, Maughan G, et al. An airborne intensive care facility (fixed wing). Anaesth Intens Care 1996; 24: 245-253. Runcie C. Principles of safe transport. Chapter 3. In: Morton NS, Pollack MM, Wallace P, editors. Stabilisation and transport of the critically ill. New York, London, Melbourne: Churchill Livingstone: 1997. Faculty of Intensive Care. Australian and New Zealand College of Anaesthetists. Minimum standards for intensive care units (IC-1, 1994). Melbourne: ANZCA, 1994. Report of the AHMAC (Australian Health Ministers Advisory Council) Aeromedical Services Working Party. Canberra: Commonwealth Department of Health, Housing, Local Government and Community Services, 1993: 47. Simpson DA, Heyworth JS, McLean AJ, et al. Extradural haemorrhage: strategies for management in remote places. Injury 1988; 19: 307-312. Grabosch A. Ten years experience in helicopter rescue in West Germany. Proceedings of the First International Assembly on Emergency Services. Washington DC: US Department of Transportation, 1982: 222-228. Poisot D. Presentation du SAMU 33. SAMU 33 1994. Paris: Societé Assistance Medicale d'Urgence, 1994: 5-13. Morley AP. Prehospital monitoring of trauma patients: experience of a helicopter emergency service. Br J Anaesth 1996; 76: 726-730. Clayton DG, Webb RK, Ralston AC, et al. A comparison of 20 pulse oximeters under conditions of poor perfusion. Anaesthesia 1991; 46: 3-10. Rutten AJ, Ilsley AH, Skowronski GA, Runciman WB. A comparative study of the measurement of mean arterial blood pressure using automatic oscillometers, arterial cannulation and auscultation. Anaesth Intens Care 1986; 14: 58-65. Duncan AW. The critically ill child. Chapter 101. In: Oh T, editor. Intensive care manual. 4th ed. London: Butterworth-Heinemann, 1997. Purdie JA, Ridley SA, Wallace PG. Effective use of regional intensive therapy units. BMJ 1990; 300: 79-81. West JG, Cales RH, Gazzaniga AB. Impact of regionalisation: the Orange County experience. Arch Surg 1983; 118: 740-744. Harris BA Jr, Wirtschafter DD, Huddleston JF, Perlis HW. In utero versus neonatal transportation of high risk perinates. A comparison. Obstet Gynecol 1981; 57: 496-499. Pollack MM, Alexander SR, Clarke N, et al. Improved outcomes from tertiary center pediatric intensive care: a statewide comparison of tertiary and non-tertiary care facilities. Crit Care Med 1991; 19: 150-159. Girotti MJ, Pagliarello G, Todd TR, et al. Physician-accompanied transport of surgical intensive care patients. Can J Anaesth 1988; 35: 303-308. (Received 31 Aug 1998, accepted 28 Sep 1999 Authors' details Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA. John E Gilligan, AO, FFICANZCA, FANZCA, Director of Retrieval and Resuscitation; William M Griggs, FFICANZCA, FANZCA, Director of Trauma Services. Department of Human Services, Adelaide, SA. Michael T Jelly, FRACMA, Chief Medical Officer. Women's and Children's Hospital, Adelaide, SA. David G Morris, FRANZCOG, Head of Obstetrics, Department of Perinatal Medicine; Ross R Haslam, FRACP, Head of Neonatal Medicine, Department of Perinatal Medicine; Neil T Matthews, FFICANZCA, FANZCA, Medical Unit Head, Paediatric Intensive Care. Flinders Medical Centre, Adelaide, SA. Evan R Everest, FRACP, Director, Trauma Services and Specialist, Intensive Care; Robert L Bryce, MSc, PhD, FRANZCOG, Director of Obstetrics, Department of Obstetrics and Gynaecology; Peter B Marshall, FRACP, Director, Neonatal Medicine. The Queen Elizabeth Hospital, Adelaide, SA. Ron A Peisach, FFICANZCA, Director, Intensive Care Unit. Reprints: Dr J E Gilligan, Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000. jgilligaATmedicine.adelaide.edu.au Make a comment 1: Mobile intensive care service missions, 1984-1995 In 12 years (1 January 1984 to 31 December 1995) there were 4443 rural and interstate mobile intensive care missions (three to provide standby services). Missions were conducted around the clock. They constituted 5% of all rural patient transfers (data from Annual Report of St John Ambulance, South Australia). Most missions were by air, comprising about 10% of medical flights to Adelaide (Ms G Malone, RFDS, personal communication). The other flights were mostly transfers by the RFDS of less critically ill patients. Map showing operational area of mobile intensive care services based in Adelaide, South Australia. Missions were flown throughout South Australia and the Northern Territory, to Broken Hill and Mildura, and to transfer neonates from Adelaide to Melbourne for cardiac surgery Mean duration of missions (hours)All missions*5.1Rural SA4.49Interstate8.51All neonatal missions6.08All trauma missions4.85Radius <300 km4.14Radius <200 km3.78Radius <100 km3.13Roadside accident response†1.84* Stabilisation time in hospitals sometimes exceeded one hour, especially for neonates. †Mostly by road or helicopter. Back to text 2: Condition categories of 4443 retrieved patientsMajor trauma. Includes 48 major surgical procedures before transport: craniotomy (30), laparotomy (15), thoracotomy (3). Tracheostomy performed in 12.1125 (25.3%)Neonatal. Commonly prematurity with respiratory distress.1025 (23.0%)Cardiovascular. (a) Aortic and other major vascular bleeding. (b) Myocardial: recurrent major dysrhythmias; heart block requiring pacing; ventilatory failure after cardiac arrest.561 (12.6%)Central nervous system. Profound coma or uncontrolled fits (eg, from cerebrovascular accident, meningitis; subarachnoid bleed). Tracheostomies performed in three.347 (7.8%)Obstetric emergencies (eg, severe bleeding, eclampsia, obstructed labour). Includes 45 operative interventions: caesarean section (26), forceps (8), breech delivery, removal of retained products (8).226 (5.0%)Postsurgical (non-trauma). Commonly multiple problems following surgery and anaesthesia, such as septic shock, ventilatory failure, renal failure, coagulation defects, inhaled gastric content. 137 (3.0%)Poisoning/envenomation/bites 137 (3.0%)Respiratory (eg, severe asthma, pneumonia; laryngotracheobronchitis and epiglottitis in children). Tracheostomies performed in 5.574 (12.9%)Gastrointestinal. Major haematemesis, melaena. Severe gastroenteritis in children.94 (2.1%)Paediatric (unspecified) 70 (1.6%)Severe burns44 (1.0%)Infection. Septic shock, no obvious cause.32 (0.7%)Diving mishaps. Severe decompression sickness, gas embolism.18 (0.4%)Diabetes. Uncontrolled acid-base disturbance.16 (0.3%)Near-drowning11 (0.2%)Allergy. Severe anaphylactic/anaphylactoid reactions.9 (0.2%)Renal/urinary tract7 (0.2%)Psychiatric3 (0.1%)Heat stroke3 (0.1%)Standby (sieges, bushfires) 3 (0.1%)Unclassified1Back to text 3: Stabilisation measures performed by local medical officers or mobile intensive care teamsInterventionAll patients (n=4443)Trauma (n=1125)Peripheral intravenous access4443 (100%)1125 (100%)Intubation,* controlled ventilation1505 (34%)544 (48%)Invasive arterial pressure monitoring786 (18%)276 (24%)Central venous cannulation518 (12%) 164 (15%)Blood transfusion274 (6%)165 (16%)Inotrope infusion†219 (5%)-Formal pleural drainage200 (4%)166 (15%)Needle thoracostomy4 (0.1%)4 (0.4%)Defibrillation20 (0.5%)-Transvenous pacing19 (0.5%)-Regional nerve block17 (0.4%)17 (1.5%)Military antishock trousers11 (0.2%)0*Usually intravenous anaesthesia-relaxant-narcotic sequence. †Other infusions included thrombolytics, sedatives, relaxants. Back to text 4: Emergency surgical and obstetrical procedures performed before transporting patientsProcedureCasesCraniotomy30Thoracotomy4Tracheostomy20Cricothyrotomy1Operative obstetrics:Caesarean section26Forceps delivery8Various procedures: breech delivery, removal of placenta, curettage11Laparotomy (trauma or other)22Oesophagoscopy, laryngoscopy2Fasciotomy1Reduction of dislocated limb2Total127Back to text 5: Resuscitation and recovery - some case histories Shotgun trauma; thoracotomy A man aged 54 with shotgun wounds of the chest and arm had a thoracotomy by a rural surgeon and anaesthetist to control cardiac tamponade and bleeding. A team then transported him, ventilated and with multiple chest drains, by helicopter 240km for further thoracic and abdominal exploration. Multiple outback casualties Ten people injured in a bus accident 900km from Adelaide were taken 80km to the nearest hospital. They were treated by medical staff in five Royal Flying Doctor Service aircraft, two mobile intensive care retrieval teams and two local medical officers, ambulance and nursing staff. After resuscitation, and in one case after fasciotomy for compartment syndrome, all patients were evacuated. Craniotomy pretransport A 20-year-old man was intubated, ventilated and had a burr hole for suspected extradural bleed performed by local medical officers following advice from an intensive care unit in Adelaide. The team neurosurgeon completed the procedure. The ventilated patient was airlifted 230km for postoperative care. Obstetric emergency A woman, 28 weeks pregnant, had an antepartum bleed 340km from Adelaide. She was given intravenous fluids and tocolytics while her partner drove 100km to collect blood. She developed pulmonary oedema requiring artificial ventilation. An obstetric team delivered the baby by caesarean section in the local hospital, then transported mother, baby and partner to a tertiary centre in a two-aircraft mission. Paediatric epiglottitis A four-year-old child developed progressive stridor and drooling from epiglottitis. The medical team intubated the patient under halothane anaesthesia and transported him to a paediatric intensive care unit in Adelaide. Back to text

John E Gilligan · William M Griggs · Michael T Jelly · David G Morris · Ross R Haslam · Neil T Matthews · Evan R Everest · Robert L Bryce · Peter B Marshall · Ron A Peisach

Rural Healthcare Rural doctors -- who are they? Three rural doctors tell their stories MJA 1999; 171: 621

The Research Enterprise Funding Australia's basic biomedical research of 1993 and 1994 The meshing of two databases of scientific publications -- the Wellcome Trust's Research Outputs Database, and the Research Evaluation and Policy Project's database of Australian publications -- allows a detailed analysis of the funding agencies providing external (as opposed to intramural) support for Australia's basic biomedical research. This analysis shows the success Australian researchers are having in attracting funding from overseas, and the high citation rates achieved by publications with external funding. Linda Butler MJA 1999; 171: 629-633 Introduction - Characteristics of basic biomedical research funding - Comparison of funded and unfunded publications - The impact of funded research - Conclusions - References - Authors' details - - More articles on Economics

Linda Butler

The Centenary Institute of Cancer Medicine and Cell Biology The institute with the long name, short history, and tall goalposts Antony Basten Introduction - The first decade: - The second decade: - The future: the next decade - References - Authors' details - - More articles on Immunology and allergy Introduction As the joint centenaries of the University of Sydney's Medical School and its campus teaching hospital, Royal Prince Alfred Hospital (RPAH), crept closer in the early 1980s, a small group of clinical academics from medical, surgical, and obstetric specialties could be seen huddled together in corridors. What were they meeting about? asked their colleagues, exuding, as always, the paranoia and suspicion so common in academia. The answer soon became clear. Having trained and then exported, to other States and overseas, some of Australia's most talented researchers and clinical department heads, the time was ripe for the medical school and the hospital to reverse the New South Wales brain drain. The proposed mechanism was to be the creation on campus of a centre of excellence in medical research, akin to the successful Victorian institutes (the Walter and Eliza Hall, Baker and Howard Florey institutes) and the Garvan Institute in Sydney. The first decade: 1981-1989 The idea of a centre of excellence in medical research was warmly endorsed, not just by the university and hospital, but by the then Federal Liberal Government and the New South Wales State Labor Government, which jointly funded a feasibility study for construction of a research building, to accommodate 300 staff, adjacent to the medical school and hospital campus. In recognition of the need for a single major centre specialising in all aspects of cancer research and cell biology, the proposed institute received the name it still bears under an Act of the NSW Parliament: the Centenary Institute of Cancer Medicine and Cell Biology.1 Although failing to fit on any conference registration form, the name was intended to cover "all bases" -- in particular, to embody the concept that, to understand the abnormalities responsible for disease, the biology of normal cells must be studied first. In 1984, an Australian Science and Technology Council (ASTEC) Working Party2 reviewed the proposal and concluded that it was far too ambitious. The Working Party's verdict was that it was better to start small and build up slowly around a competitive research group. As a result, the wind was taken out of the Centenary Institute's sails and the project was becalmed for four long years. In retrospect, it is clear that this delay worked to the Institute's disadvantage in the long term. Instead of being established before the value of the specialised research centre was fully appreciated in NSW, its creation as a functional entity coincided with the rush to institute status by multiple groups on our own campus and elsewhere, leading ultimately to the current situation, with too many "institutes" competing for limited resources. In 1989, I was invited to be the inaugural Director of the Centenary Institute. At the time, as head of the Clinical Immunology Research Centre, one of the original 10 Commonwealth Centres of Excellence, I was trying to juggle exciting new research based on transgenic technology with the task of advising the Federal Government on medical and scientific aspects of HIV/AIDS. Little did I suspect, back then, that I would be jumping out of the frying pan into the fire. The second decade: 1989-1999 Early days The challenge in 1989 was to create an independent institute at a time of dwindling resources, both in the tertiary education sector and in the healthcare system. The Clinical Immunology Research Centre, operating from its crowded quarters in the 1880 building shared with other hospital and university staff, became the core unit of the Institute. We were faced with three formidable tasks. The first was to cope with the loss of our Centre of Excellence grant from the Australian Research Council, as funding for medical research centres was now deemed to be the responsibility of the National Health and Medical Research Council (NHMRC). Despite negotiating an increase in our NHMRC program grant, we were faced with an immediate loss of around $250 000 in research funding -- not the most auspicious start for a new institute. The second task was to appoint a new Board and Chairperson. A vigorous search, itself an experience for a naive academic like me, enabled us to secure the former Chairman of the Stock Exchange, Jim Bain, to chair the new Board. Under his stewardship, the Institute was steered through the next three difficult years and the Board established a Foundation, chaired by Tim Besley (Chairman of the Commonwealth Bank). The "Kick a Goal for Life" fundraising campaign, the brainchild of Ken Cowley (Chief Executive of News Ltd), a Foundation Trustee, gave us, for the first time, a public profile and much-needed funds. The campaign was launched to coincide with the final of the Commonwealth Bank Cup, awarded to the winners of the schoolboy rugby league competition. Alas, the number of on-field brawls reached such a pitch that the Commonwealth Bank promptly withdrew its support and our initial foray into the community came to an abrupt halt! The third vital task in 1989 was to obtain funding for a new building. Two further feasibility studies and six years later, four and a half floors of the Institute's new six-storey research facility were completed and fitted out at a cost of $17.24 million. This was funded largely from Federal and State capital works grants, with additional assistance from the NSW State Cancer Council and our two parent organisations, the University of Sydney and the Central Sydney Area Health Service. The Institute building is strategically located in the grounds of RPAH, adjacent to the university medical school, and was officially opened by the Prime Minister in 1997. The new team As the new edifice took shape, it was time to begin assembling a team of researchers with the skills to create a "critical mass" in immunology. My group, with its interest in self-tolerance in the B cell lineage, and that of Warwick Britton, head of a research program in mycobacterial infection, were already in place. Jon Sedgwick, well known for his work on autoimmunity in the central nervous system, was the first recruit from overseas. Described by the late Alan Williams of Oxford University as the best "postdoc" he had ever had, Jon was instrumental in grafting "knockout" (gene ablation) technology onto the Institute's existing expertise in transgenesis. Jon was followed by four other immunologists. Barbara Fazekas de St Groth, who, as a medical undergraduate, had done a BSc(Med) under my supervision a decade earlier, was the first. Returning to Sydney from postdoctoral study with Mark Davis at Stanford Medical School, Barbara is now recognised internationally for her work on tolerance and autoimmunity in T cell receptor transgenic models. Together with Patrick Bertolino, who joined us from Lyons in France two years ago, they make a formidable CD4+/CD8+ T cell team. Roland Scollay, known at the time as one of Australia's two leading exponents on thymus biology, was recruited from the Walter and Eliza Hall Institute, along with Phil Hodgkin from the John Curtin School of Medical Research in Canberra. Phil's recent studies on immune regulation and the relationship between division number and lymphocyte behaviour are among the most original contributions to immunology in the past five years. The final member of the quintet was Alan Baxter, who joined us from Cambridge (UK). Alan is rapidly acquiring an excellent international reputation in the field of insulin-dependent diabetes and the genetics of autoimmune diseases, including systemic lupus erythematosus and autoimmune gastritis (see Box). Achievements: the upside During the past decade, the staff has risen from 20 to 95; two NHMRC program grants have been held by research group heads; and the Institute, by virtue of its independent status, has brought to the campus more than $30 million in capital works and infrastructure funds, in addition to over $20 million in peer-reviewed grants. We were particularly delighted that Nobel laureate and immunologist, Peter Doherty, saw fit on the occasion of the official opening of the new building in 1997 to designate us as "Australia's major immunology research centre". A significant amount of the credit for these achievements must go to the Board and to Ken Tribe, its Chairman from 1994 to 1999. Ken brought to the Institute a wealth of knowledge and experience and gave us stable governance during this crucial period in our development. At the same time the work of the research staff has been underpinned by a dedicated research support and management team who have become past masters at maintaining an effective enterprise on the very shortest of shoestrings. Their loyalty and strength of purpose have been most gratifying to me personally. It has also been encouraging to work closely with the other four established independent institutes in NSW (the Garvan, Children's Medical Research, Prince of Wales Medical Research and Heart Research institutes) when negotiating with government and other bodies over issues such as infrastructure funding. The downside If one is honest there is inevitably a downside to any enterprise during its formative years and this has certainly applied to the Centenary Institute. Due to the delay already alluded to in "getting out of the blocks", the Institute has found itself competing for a dwindling pool of resources in the era of what cynics describe as the "epidemic of institutes". Some of them strive to be "independent" like us, while others are "motels" for existing academic and clinical staff or simply single departments renamed for the purpose of raising their profile and respectability. The end-result has been ongoing confusion among funding bodies, government, and even the community at large about who is most deserving of support. The consequence for the well intentioned Director and staff of the Centenary Institute was that when the new building opened they faced a hostile reception on campus, particularly from colleagues who were short of funds and research space. They saw our hard-earned new building as the answer to their prayers, while failing to appreciate our statutory charter and independent status. If only the building had not resembled a casino! Like all of the fledgling independent research centres which have emerged during the recent "epidemic", the Centenary Institute has had to deal with three major issues: inadequate infrastructure, limited funds for developing new groups of merit, and insufficient job security (not to mention salaries) for our full-time career scientists. Perhaps of greatest concern is the fact that the days when one can offer "fame and poverty" to the very best researchers, as Fiona Stanley so aptly put it, are dwindling fast.3 This was driven home to me when two of our most senior group heads were lured to the United States by the offer, not just of much higher salaries, but of far better resources. "If only I did not have to write so many grants for such pathetic amounts of money I would actually have time to do some research", Jon Sedgwick said to me before his departure. The future: the next decade Medical research in Australia Do institutes, independent or otherwise, have a future, or are they likely to acquire the same mortality rate as the biotechnology companies of yesteryear? I believe that some institutes like ours must survive and flourish if Australian medicine is to retain its place at the international table. We have clearly moved into the era of specialisation, in which it is quite acceptable to be recognised as a superb teacher or clinician or researcher, but what is no longer feasible is to be good at every aspect of medicine. The role of institutes, with their critical mass of full-time research staff, is to serve as a focus for collaborative research on the campuses of teaching hospitals and universities with which they are usually affiliated. It is timely that the Wills Review4 has just been published, coinciding as it does with the Federal Government's most welcome commitment to doubling NHMRC funding over the next five to six years. Not only does the Review promote competitive research by extending the concept of partnerships to both Government itself and industry, but it contains a series of innovative recipes which acknowledge the value of the independent institute as a research entity in Australia and of the full-time career scientist. Its implementation is therefore eagerly awaited, particularly by the 30-odd members of the Association of Australian Medical Research Institutes, which between them employ over 2500 research staff. In response to the Wills Review, the challenge for all of us in the medical research community is to secure sufficient ongoing funds to ensure that its recommendations bear fruit. In the case of an institute like ours, this means adding to the existing infrastructural support from the NSW State Government and the Central Sydney Area Health Service by raising funds in the non-Government sector, including from industry and the corporate and wider communities. While creating a public profile and exploiting research are anathema to the purists of the research world, the reality is that the rest of society expects to know about us if they are going to provide the financial support we urgently need. Medical research at the Centenary Institute Having commissioned a new building and recruited high-quality staff, the Institute is now poised to complete the final stage of its 10-year strategic plan. The goal is to create a second critical mass of career researchers in molecular and cellular oncology. A major step forward occurred earlier this year when a $6 million funding package was approved by the Prime Minister. The package is designed to support a strategic alliance with the Sydney Cancer Centre, whereby the Institute would develop a basic cancer research program in the remaining one and a half floors of our building to dovetail with translational and clinical research studies at the Sydney Cancer Centre, located on the adjacent RPAH campus. The first move towards this collaboration has now been made, with the conjoint appointment of John Rasko, a haematologist, who has returned to his old alma mater from the Fred Hutchinson Cancer Research Center in Seattle to head up the Institute's gene therapy laboratory (see Box). The combination of our brand of cellular immunology (traditionally one of Australia's strongest disciplines) with molecular biology targeted at cancer is designed to give the Institute a discrete niche in the postgenomic era now upon us. Edward Jenner as the role model On reading an article recently about the famous country general practitioner, Edward Jenner,5 I rapidly perceived that he was the ideal role model for the institute director of the future. Jenner, famous for his discovery of smallpox vaccination, had other admirable but lesser-known attributes, including an entrepreneurial flair for raising funds, a fascination with diverse areas of science, and proficiency as a poet and musician. When the veracity of his findings on smallpox was being disputed by the inevitable envious colleagues in the United Kingdom and the United States, he raised funds from the public to extend his work (in the absence of any NHMRC equivalent). Later in his life he demanded and received special grants, the first of no less than £10 000, from the government of the day in Great Britain to compensate for the expenses incurred by his research and to set up free vaccination clinics for the public. In 1789 he was elected to the Royal Society, not for his work on vaccination, but rather for his authoritative studies on the habits of the cuckoo nestling. He also found time to classify the botanical specimens brought back by Joseph Banks from James Cook's second voyage to Australia. Despite working full-time on his research, Jenner managed to raise funds and remain a civilised human being. How wonderful it would be for those of us who are institute directors to aspire to just one or two of his many attributes. References Centenary Institute of Cancer Medicine and Cell Biology Act 1985 (NSW). Australian Science and Technology Council. Annual Report 1983-1984. Appendix C. Canberra: AGPS, 1984: 30-36. Stanley FJ. The TVW Telethon Institute for Child Health Research: the birth and growth of a research institute. Med J Aust 1998; 169: 630-633. Wills PJ (Chairman). Health and Medical Strategic Review. The virtuous cycle: working together for health and medical research. Canberra: Department of Health and Aged Care, 1999. Friedman M, Friedland GW. Edward Jenner and vaccination. In: Medicine's 10 greatest discoveries. New Haven: Yale University Press, 1998: 65-93. Authors' details Centenary Institute of Cancer Medicine and Cell Biology, Sydney, NSW. Antony Basten, AO, FAA, FTSE, Executive Director. Reprints: Professor A Basten, Centenary Institute of Cancer Medicine and Cell Biology, Locked Bag 6, Newtown, NSW 2042. a.bastenATcentenary.usyd.edu.au Prime Minister John Howard (center) with Professor Peter Doherty (right) and Professor Antony Basten (left) at the offical opening of the Institute's new building in 1997. The original headquarters of the Centenary Institute located in multipurpose building 94 at the Royal Prince Alfred Hospital. The new Institute building commissioned in 1994. The Centenary Institute of Cancer Medicine and Cell Biology at a glance YearCorporate milestonesResearch milestones 1985Established under an Act of the NSW Parliament as an independent institute with its own Board of Governors and affiliated with the University of Sydney and RPAH 1989Became a functional entity with appointment of Professor Tony Basten as Director and Mr Jim Bain as Chairman of the Board Staff of 20. Director's Clinical Immunology Research Centre became core unit of Institute, comprising his B cell Biology Group and Mycobacterial Research Group (Associate Professor Warwick Britton, University of Sydney) 1991Creation of Foundation with Mr Tim Besley (Chairman), Mr Ken Cowley and Mr Tony Berg as trustees Became a Member Institute of AMRAD Immunopathology Group (Dr Jon Sedgwick, Wellcome Trust SRF)† NHMRC Program Grant to Director renewed 1992Devolved from management of University Appointment of General Manager (Denyse Bartimote) Capital works funding of $17.24 million obtained for new building T cell Biology Group (Dr Barbara Fazekas de St Groth, Wellcome Trust SRF) Thymus Biology Group (Dr Roland Scollay, NHMRC SPRF)† 1994Mr Ken Tribe appointed Chairman of the Board 1995Four and a half floors of new six-storey building commissionedImmune Regulation Group (Dr Phil Hodgkin, Medical Foundation SRF) Liver Immunobiology Group (Professor Geoff McCaughan, RPAH) 1997New building officially opened by Prime Minister New research and development infrastructure funding scheme introduced by State Health Department, providing Institute with $800000 per annumAutoimmunity Research Group (Dr Alan Baxter, NHMRC R Douglas Wright Research Fellow) 1998NHMRC Program Grant in diabetes (Alan Baxter co-chief investigator) 1999$6 million package announced by Prime Minister for joint cancer research program with Sydney Cancer Centre, RPAH Mr Malcolm Noad appointed Chairman of the Board Total staff of 95 Gene Therapy Research Group (Dr John Rasko) Total funding brought to the campus by the Institute was in excess of $50 million *For further details on research programs refer to web site <http://www.centenary.usyd.edu.au> †Left Institute to take up position in United States NHMRC = National Health and Medical Research Council. RPAH = Royal Prince Alfred Hospital. SPRF = Senior Principal Research Fellow. SRF = Senior Research Fellow.

Antony Basten

The Research Enterprise Nature, nurture and my experience with smallpox eradication A career influenced by chance events Frank Fenner MJA 1999; 171: 638-641 Introduction - Family and education - Infectious diseases - Myxomatosis - The Intensified Smallpox Eradication Programme - References - Career outline - Why smallpox could be eradicated - Remaining problems with smallpox - Subsequent eradication programs - Authors' details - - More articles on Infectious diseases and parasitology

Frank Fenner

Medical Education The rise and rise of academic general practice in Australia The Heads of General Practice are excited about partnerships with GPs and the community Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden MJA 1999; 171: 643-648 Introduction - The struggle for identity - Standing as an academic discipline - Role of academic general practice - Divisions of General Practice - Evidence-based medicine - Improving GP morale - The way forward - Authors' details - - More articles on General practice and primary care

Kerrie A Lawson · Mabel Chew

Bites and Stings Stinging insect allergy Safe, effective immunotherapy is available MJA 1999; 171: 649-650

Robyn E O'Hehir · Jo A Douglass

Bites and Stings Funnel-web spider (Hadronyche infensa) envenomations in coastal south-east Queensland Five patients with confirmed funnel-web spider bites (Hadronyche infensa) presented to Nambour General Hospital, in south-east Queensland, between 1992 and 1998. Two patients required antivenom; low doses of antivenom were effective. Patients were bitten in spring and early summer. In areas such as this, where funnel-web spider bites are reported less frequently than in New South Wales, clinicians and the community should be aware of the risks and immediate management of these bites. Anthony P Harrington, Robert J Raven, Paul C Bowe, Gabrielle M Hawdon and Kenneth D Winkel MJA 1999; 171: 651-653 Introduction - Clinical record - Discussion - Acknowledgements - References - Authors' details - - More articles on Insects, bites and stings

Anthony P Harrington · Robert J Raven · Paul C Bowe · Gabrielle M Hawdon · Kenneth D Winkel

Bites and Sting Exotic myiasis with Lund's fly (Cordylobia rodhaini) After a four-week holiday in East Africa, a woman was diagnosed with furuncular myiasis: a third-instar larva of the fly Cordylobia rodhaini (Lund's fly) was found in a skin lesion. This is the first report of exotic myiasis and importation of this species of fly into Australia, and reflects the increasing risk of introducing exotic flies of public health and veterinary importance to Australia. Merilyn J Geary, Bernard J Hudson, Richard C Russell and Andrew Hardy MJA 1999; 171: 654-655 Introduction - Clinical record - Discussion - Acknowledgements - References - Authors' details - - More articles on Insects, bites and stings Introduction Myiasis is the invasion of living tissue by the larval stage (maggot) of flies.1 Australia has some species of flies that produce facultative and accidental myiasis in humans,2 but in other countries, particularly in Africa and South America, there are flies with zoonotic obligate myiasis that infest humans. With more frequent international travel, there is an increasing risk of infestations of these species being brought into Australia. Clinical record A 57-year-old woman presented to her general practitioner (A H) with a painful, discharging lesion on the outer aspect of her right thigh three days after returning to Australia from a safari vacation in East Africa. She was referred to a specialist (B J H), who diagnosed furuncular myiasis after seeing "something moving" at the base of the lesion. After occlusion with petroleum jelly, a fly larva protruded from the lesion and was removed with forceps (Figure 1a). The lesion healed uneventfully over the following two weeks. The patient had left Australia one month earlier and spent most of the safari trip camping. She travelled in four countries -- Kenya, Tanzania, Uganda and Zimbabwe (see Map). For the final 10 days she stayed at a private residence on a ranch between Bulawayo and Victoria Falls in Zimbabwe. She noticed the lesion two days after arriving at the ranch. It gradually developed over the next 10 days, becoming moderately painful and discharging. Although it was not possible to determine exactly where the infestation was acquired, from the species involved and the time required for its stage of development the contact probably occurred shortly before or shortly after arrival at the ranch in Zimbabwe. Discussion Genus Cordylobia The genus Cordylobia contains three species, C. anthropophaga, C. rodhaini and C. ruandae.1 Larvae of these flies are parasites of various mammals, particularly rodents. C. anthropophaga (the Tumbu fly of sub-Saharan Africa), and occasionally C. rodhaini, also parasitise humans.3,4Cordylobia is confined to the African continent, with C. rodhaini associated with tropical Africa, especially areas of rainforest from Senegal, through Central Africa, to Angola and Zimbabwe (see area marked on Map). The adult flies of C. rodhaini are large and robust, with a non-metallic red-brown to black abdomen and yellow coloration on the thorax and head. Adult flies feed on rotting fruits, vegetables and faeces, and are more abundant throughout the wet season, and most active in the early morning and evening. The life cycle of C. rodhaini is shown in Figure 2. Public health concerns Although importation of exotic myiasis-causing flies into Australia is not common, several species of obligatory fly parasites enter this country each year in the skin of overseas travellers (unpublished data).2,5-10 The most common exotic species of myiasis fly imported to Australia in humans is the human botfly (Dermatobia hominis) (Figure 1b), found in travellers returning from South and Central America (unpublished data). Others include the Tumbu fly (C. anthropophaga) (Africa), and the New World screw-worm fly (Cochliomyia hominivorax) (Central and South America). All are of medical and public health concern, and some, such as Chrysomya bezziana from Africa, South-East Asia and Papua New Guinea, and C. hominivorax, are of critical veterinary importance,8,11 and threaten local livestock industries. Travellers to the tropics and general practitioners in Australia should be aware of the potential for skin infestation by fly larvae, and local health professionals can assist quarantine, agriculture and other interested bodies to monitor the importation of these medically important insects. Acknowledgements The photographs were taken by Mr Stephen Doggett of the Department of Medical Entomology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital. References Zumpt F. Myiasis in man and animals in the old world. London: Butterworths, 1965: xi-xii, 75-77. Lee DJ. Human myiasis in Australia. Med J Aust 1968; 1: 170-173. Bertram DS. A note upon myiasis due to the larvae of Cordylobia Rodhaini Gedoelst. Ann Trop Med Parasitol 1938; 32: 431-435. Scholten ThH, Hicks RJ. Myiasis by Cordylobia rodhaini contracted in Africa and diagnosed in Canada. Can J Public Health 1973; 64: 488-489. Field AS. Myiasis in an Australian abroad. Med J Aust 1981; 1: 581-582. Moorehouse DE. Exotic parasitic infections in Australia [editorial]. Med J Aust 1983; 2: 592-593. Prociv P. The risk from exotic myiasis in Australia [letter]. Med J Aust 1989; 150: 722-723. Searson J, Sanders L, Davis G, et al. Screw-worm fly myiasis in an overseas traveller -- case report. Commun Dis Intell 1992; 16: 239-240. Rubel DM, Walder BR, Jopp-McKay A, Rosen R. Dermal myiasis in an Australian traveller. Australas J Dermatol 1993; 34: 45-47. Levot G. Interception of larvae of an exotic fly pest in skin lesions on Australian travellers. Commun Dis Intell 1994; 18: 229-230. Norris KR. Myiasis in humans. Med J Aust 1989; 150: 235-237. (Received 17 Jun, accepted 27 Oct, 1999) Authors' details Department of Medical Entomology, University of Sydney, and Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW. Merilyn J Geary, DipAppSc, Senior Technical Officer. Richard C Russell, MSc, PhD, Director. Microbiology Department, Royal North Shore Hospital, Sydney, NSW. Bernard J Hudson, FRACP, FRCPA, Staff Specialist. Manning Medical Practice, Woollahra, NSW. Andrew Hardy, MB BS, General Practitioner. Correspondence: Professor R C Russell, Department of Medical Entomology, Westmead Hospital, Westmead, NSW 2145. RichardRATicpmr.wsahs.nsw.gov.au Make a comment Back to text 1a 1b Back to textBack to textFigure 1a: A third-instar larva of Cordylobia rodhaini (size about 20mm, bar=1mm), infecting a woman just returned from East Africa. Myiasis caused by this species has not previously been recorded in a patient in Australia. The third instar of C. rodhaini is readily recognisable, with a scattered covering of spines, longer than those of the related fly larva C. anthropophaga and not organised in rows as in that species.1,3 Figure 1b: A third-instar larva of Dermatobia hominis (bar=1mm), which occurs in Central and South America, and is the myiasis fly species that most commonly infects travellers returning to Australia. Figure 2: Description of lesion: At the site of penetration, a red papule forms and gradually enlarges. At first the host may experience only intermittent, slight itching, but pain develops and increases in frequency and intensity as the lesion develops into a furuncle. The furuncle's aperture opens, permitting fluids containing blood and waste products of the maggot to drain. Back to text

Merilyn J Geary · Bernard J Hudson · Richard C Russell · Andrew Hardy

History The suicide of Thomas Wentworth Wills Thomas Wentworth Wills was the most important Australian sportsman of his time. He captained the Victorian colony at cricket and was the first hero of Australian Rules football. Although his picture now adorns the conservative Melbourne Cricket Club, he died in 1880, an isolated, destitute alcoholic, after stabbing himself in the heart. Wills embodied a tradition, as prevalent today as it was over 100 years ago, that weds sport with alcohol in Australian culture. Gregory M de Moore MJA 1999; 171: 656-658 Introduction - Alcohol abuse, delirium tremens and suicide - Acknowledgements - References - Authors' details - - More articles on History Illustration: an 1870 oil painting of Thomas Wills.

Sex, Science & Society Will sex survive to 2099? We stand on the threshold of a brave new world MJA 1999; 171: 659

Mabel Chew

Sex, Science & Society What if there is a "sunset clause" on the Y chromosome? A view on reproductive technologies in the future Alan O Trounson MJA 1999; 171: 660-662 Introduction - Identification of genetic disorders and their correction - Evolution towards a single-sex society - Conclusion - References - Authors' details - - More articles on Genetics Introduction A range of options exist within present IVF clinical services to assist couples with fertility problems (Figure), and new applications of these are evolving. There are also genetic determinants of infertility that can now be identified, their inheritance avoided and more appropriate treatment options provided. As a consequence, costs for the long term support of severely sick or handicapped patients will decrease because affected embryos produced through IVF and birth of affected babies who will express the genetic disorders known to be present in the parents and their families will be reduced. Genes which predispose individuals to diseases such as breast and prostate cancer are being identified. Disorders and handicaps that are controlled by multiple genes will be identified and their suitability for selection in pregnancy or in the early embryo will need to be discussed with the community. There is also a number of more futuristic possibilities related to IVF that may or may not be relevant, suitable or desirable (Figure). This essay explores the future of sex and technology in the new millennium. Identification of genetic disorders and their correction Preimplantation genetic diagnosis: Genetic disorders contribute to a wide range of genetic diseases that are present in the community at relatively low incidence, and treatment and support of patients with these conditions comes at some considerable cost. For diagnosis of serious genetic diseases that are known to be present in the family, it is likely that prospective parents will begin to choose IVF and preimplantation genetic diagnosis (PGD) of embryos in preference to other prenatal screening methods. Hence, there may be some shift from reproduction by intercourse to assisted reproductive techniques (eg, IVF). While this may be considered unnatural, IVF does not attract this stigma any more. The demand for technology will generally bring acceptance, unless there are dangers that can be identified with some certainty. IVF, including many associated procedures such as embryo cryopreservation, embryo donation and intracytoplasmic sperm injection (ICSI), are accepted. Even surrogacy is allowed in the Australian Capital Territory. While these techniques were widely condemned by particular interest groups, they are now well tolerated by the community. The presence of genetic mutations that are correlated to human infertility can be screened in men for deletions in the Y chromosome1 and mutations in the androgen receptor gene present on the X chromosome.2,3 These will be inherited by the sons or daughters, resulting in the same or even more serious infertility in the case of sons, or carriers of the infertility genes in the case of daughters. Presently, science does not have the capacity to correct these genomic errors. It is very likely that some aspects of female infertility will also be transmitted to sons and daughters because of the availability of IVF. Sex selection: It is perhaps of some concern that the more simple diagnostic techniques of fluorescent in situ hybridisation (FISH) can be used to identify sex of embryos, and in some States there is no barrier to the use of this for selection of the sex of children by IVF. The concern is that sex alone is considered a sufficient criterion for selection of embryos for transfer. Considering that 50% or more of all embryos are aneuploid,4 it would be scientifically sound that embryos should, at the very least, be selected for normal chromosomal numbers rather than simply sex. Since there are already good genetic screening processes for embryo genetic health,5 selection for sex alone6 is scientifically inadequate. It will be interesting to see if the selection for sex of children for social reasons (balancing family sex ratio) will be tolerated. This appears to be a major departure from the strictly medical reasons for assisted reproduction. Phenotype selection: Given the capacity to identify point mutations in single cells of human embryos,7 one might ask if there are more or less desired phenotypes, including intelligence,8 that might be selected for or against. It is difficult to believe that parents will seek IVF and PGD for other phenotypes, but the interest in balancing the sex of families for relatively high personal cost suggests that some parents will also seek to endow their children with phenotypic advantage. Given the emphasis for education of children and, on occasions, the specific selection of partners as parents, it is likely that genes controlling desired and undesired phenotypes might be identified and, where possible, requested for selection for or against. Since it is likely that much of the functional human genome will be identified within the next few years, issues of access to identification of genotype or germline gene alterations need to be explored seriously with the community. Selection against genetic disease is recognised as a parental right, but enhancement of phenotype by genetic selection or genetic engineering needs to be considered. There will certainly be strong condemnation of selection against behaviour (eg, sex preference, aggression), but, if parental desire is high enough, there may be jurisdictions of sufficient flexibility to allow an assessment and community reaction to phenotypic enhancement. Evolution towards a single-sex society Recent research has confirmed our worst fears, that the Y chromosome is under siege, with large numbers of gene deletions detected that appear to correlate with increasing male infertility.1 While the Y chromosome represents very little of the total haploid genomic DNA (2%-3%), it contains a lot of repeated sequences with few genes that are either degrading or are dispensable, but there are also genes crucial for male-specific function and gender. It has been hypothesised that the Y chromosome evolved from the X chromosome by progressive alteration or additions,9 an important inversion of the biblical view of Eve's creation. During meiosis it is only the tips of the short arms of the X and Y chromosome that pair to exchange euchromatic DNA, severely limiting the ability of the Y chromosome to repair the deletions that are appearing. The inescapable hypothesis that follows is the Y chromosome has a limited evolutionary lifetime that means the male is facing eventual extinction. If there is a "sunset clause" that has been inserted into the genomic blueprint of evolution, an alternative may need to be found for sexual reproduction. Perhaps the recent observation of inheritance of Y chromosome deletions by sons born of severely infertile men after the IVF technique known as ICSI10 will prolong the inevitable demise of the Y chromosome. Indeed, some interest groups will applaud the good sense of evolution in preprograming the decay of the Y chromosome. Conservative sectors of the community, on the other hand, will be very disappointed and may call for scientists to immediately address germ cell genetic engineering to halt increasing Y chromosome deletions as a serious research project. It is notable that serious scientists of one of the major Australian medical research institutes have embarked on the recreation of the extinct thylacine (Tasmanian tiger)11 and would probably tackle the resurrection of the decaying Y chromosome with relish. Prospects for asexual or non-sexual reproduction With the advent of nuclear transfer or cloning12,13 there is an obvious alternative to sexual reproduction. However, it is absolutely vital that basic scientists continue to work through the numerous developmental problems that are observed in cloning that include high rates of embryonic and fetal loss, birth problems and neonatal fitness.14 The artifacts of the failure to completely reprogram nuclei used for transfer for normal development are a major concern, and scientists need to improve cloning techniques to provide the necessary degree of safety for any application to asexual human reproduction and maintenance of populations. Reproduction by same-sex couples Given that cloning may remain anathema to many, it may be worth suggesting that some sort of recombination events are desirable to distance ourselves from ourselves (clones). Gametes (sperm and oocytes) may not be essential for development.5 If this is so, and proof is essential, nuclei of cells of two females could be combined in isolated ooplasm and induced to segregate into haploid nuclei that will recombine to form a female conceptus which may then develop to term in the uterus of a gestational mother. One has to overcome the obvious concerns and probable discrimination against same-sex conception. Reproduction in later or after life The option has existed for some time for women approaching menopause, or after menopause, to have children if oocytes (eggs) from younger women are available. The uterus remains receptive to an implanting embryo throughout life, provided hormone replacement therapy is given to women. Eggs from women over 40 years of age have increasing aneuploidy (incorrect chromosome numbers) and therefore oocytes generally need to be obtained from younger women. They may be donated by relatives or friends, or anonymously from IVF clinics. They may also be purchased at very high prices on the Internet from "models". This rather extraordinary example of commercialisation says something about the commodity mentality of the free-market world. Given the general disapproval of postmenopausal childbearing (although this does not apply to men, who have no age limit to their reproductive opportunities), it is unlikely that large numbers of older women will be in obstetric care in the near future. Perhaps this might eventually be challenged under discrimination against female age. It is probably more certain that posthumous conception will not be acceptable, despite the frequent requests to cryopreserve sperm of recently deceased male partners. While it may be understandable for a young wife or partner to desperately seek to retain a connection to a loved partner, the absence of consent from the deceased to have a child remains a major obstacle. It is much more difficult to cryopreserve eggs, so this has not been requested, to my knowledge, for a deceased partner. However, young women entering treatment for cancer have had some of their ovary cryopreserved in case of sterility after cancer therapy.15 Conclusion There is little reason to believe that sex will be less enjoyable or less important as an expression of intimacy and love for a partner. Some concern exists for the long term future of the Y chromosome, but this is unlikely to affect relationships by 2099. There will certainly be more knowledge of genes and phenotype, and it is likely that there will be a drift towards use of technology to diagnose mutations related to disease or disadvantage. In the longer-term, there may also be a trend to enhance desirable phenotypes for children. As sexual reproduction is a minor component of sexual activity, these trends will have little, if any, effect on sex per se. Thank goodness! References de Kretser DM, Mallidis C, Ma K, Bhasin S. Male infertility and the androgen receptor: molecular, clinical and therapeutic aspects. Reprod Med Rev 1997; 6: 113. Wang Q, Ghadessy FJ, Trounson A, et al. Azoospermia associated with mutation in the ligand-binding domain of the androgen receptor with normal ligand binding, but defective transactivation. J Clin Endocrin Metab 1998; 83: 4303-4309. Dowsing AT, Yong EL, Clark M, et al. Linkage between male infertility and trinucleotide repeat expansion in the androgen receptor gene. Lancet 1999; 354: 640-643. Gianaroli L, Magli MC, Ferraretti AP, et al. Preimplantation genetic diagnosis increases the implantation rate in human in vitro fertilization by avoiding the transfer of chromosomally abnormal embryos. Fertil Steril 1997; 68: 1128-1131. Trounson AO, Wood C. Future developments in IVF and related technologies. In: Trounson AO, Gardner DK, editors. Handbook of in vitro fertilization. 2nd ed. Boca Raton: CRC Press, 1999; 543-550. Smith D. $10,000 can buy parents 'designer babies'. The Age (Melbourne) 1999; 2 October: 1. Wells D, Sherlock JK. Strategies for preimplantation genetic diagnosis of single gene disorders by DNA amplification. Prenatal Diagn 1998; 18: 1389-1401. Tang YP, Shimizu E, Dube GR, et al. Genetic enhancement of learning and memory in mice. Nature 1999; 401: 63-69. Graves JA. The origin and function of the mammalian Y chromosome and Y-borne genes -- an evolving understanding. Bioessays 1995; 17: 311-320. Cram D, Ma K, de Kretser D, et al. Transmission of YQ deletions in men with spermatogenic disorders through the use of intracytoplasmic sperm injection. Proceedings of the 11th World Congress on IVF and Human Reproduction and Genetics. Sydney, 1999. Abstract S-008. That tiger again! New bid for a resurrection. The Age (Melbourne) 1999; 8 September: 6. Wilmut I, Schnieke AE, McWhir J, et al. Viable offspring derived from fetal and adult mammalian cells. Nature 1997; 385: 810-813. Wakayama T, Perry ACF, Zuccotti M, et al. Full-term development of mice from enucleated oocytes injected with cumulus cell nuclei. Nature 1998; 394: 369-374. Reprogramming cell fate -- transgenesis and cloning. Reprod Fertil Develop Special Issue 1999; 10(7,8). Wood EC, Shaw JM, Trounson AO. Cryopreservation of ovarian tissue: potential "reproductive insurance" for women at risk of early ovarian failure. Med J Aust 1997; 166: 366-369. Authors' details Monash University, Melbourne, VIC. Alan O Trounson, MSc, PhD, Professor, Centre for Early Human Development, Monash Institute of Reproduction and Development. Reprints will not be available from the authors. Correspondence: Professor A O Trounson, Monash Institute of Reproduction and Development, Monash Medical Centre, Clayton, VIC 3168. jillian.mcfadyeanATmed.monash.edu.au Make a comment For a larger version of figure click here Back to text

Alan O Trounson

Sex, Science & Society Future change in sexual behaviour? Virtual sex is not a substitute for normal sexual intercourse, lacking emotional interaction between couples and the intimacy and reinforcement of a loving relationship. Carl E Wood MJA 1999; 171: 662-664 Introduction - Chemical control of love, lust and attachment - Changes in sexual behaviour - Prediction - References - Authors' details - - More articles on Sexual health Introduction The female eunuch, by Germaine Greer,1 is an example of how one person helped change social attitudes by discarding current religious and cultural values. Sexual behaviour has been irrevocably changed by the insights provided by the work of Masters and Johnson on sexual physiology,2 Kinsey and others on sexual behaviour,3 and the general discarding of the sexual repression that dominated in the previous 100 years.1 In the past 30 years we have reintroduced a more liberal attitude to sexual behaviour, through a social revolution of young people who rejected war in the shadow of "the bomb"; they popularised free sex in the famous slogan "Make love, not war" in the 1960s and 1970s. Access to sexual information has proliferated in specialty sex shops, sex exhibitions, daily press, radio, television, and the Internet. Developments such as virtual sex and chemical agents that affect sexuality are likely to lead to further changes in sexual expression. There may be an assumption that more information leads to more sexual freedom, interest and satisfaction. Some of the information available is exaggerated and may do more harm than good by increasing performance anxiety. There is a need for realistic sex education. Chemical control of love, lust and attachment Advances in the neural, metabolic and hormonal physiology and biochemistry of sexual behaviour (Box) may enable control or cure of sexual problems adversely affecting society, marriage or health. Just as sildenafil has helped treat erectile dysfunction, so may future drugs enhance or inhibit sexual drive, romantic love, and bonding. This may seem "cold-hearted" compared with "natural" love or lust, but the misery experienced by those with excessive or too little sexual drive, or the inability to feel romance and bonding to another, would be aided by pharmacological modulation of these processes. Enduring attachment between spouses may be associated with high levels of vasopressin and oxytocin, and low levels of testosterone.12,13 The future may unveil a "love pill" or "family pill" to ensure marital harmony and encourage greater stability for child-rearing. Little imagination is required to conjure various circumstances when greater happiness would be achieved by changing sexual drive, romantic potential or bonding capacity. Lowering of testosterone levels may become acceptable to maintain a happy long term relationship, while increasing testosterone levels may assist single or divorced men with lower than average testosterone levels to find and satisfy new partners. The same may apply to women, particularly those who have ovarian failure and low testosterone levels. Changes in sexual behaviour Broader sexual repertoires: The contraceptive pill has assisted the development of recreational sex. Sex is now for fun, love and intimacy, thanks to the greatly reduced risk of unwanted pregnancy. In the late 1950s, only 12% of American couples reported practising cunnilingus; today about 75% practise this art.14 Foreplay has increased from 10 to 15-17 minutes in the United States.15 The sexual act may become more varied as sexual aids, devices, lotions and drugs are developed, with increased knowledge of sexual biochemistry and pharmacology. The female role in change: World attitudes about women's premarital sexuality are now becoming more permissive, although there are still marked differences between cultures.16,17 As standards of health rise, contraception and therapeutic abortion become more widely available, and people become more interested in sex. As women gain economic independence, they become less likely to exchange sexual freedom for protection and financial support. Women are experimenting with sex earlier in life, living with partners outside marriage, expecting a wider variety of sexual techniques, using contraception and planning families, marrying later, and divorcing when spouses do not satisfy their social and sexual needs.17 The pace of change may increase even further. Cybersex: A recent poll of 10 000 US households found 30% of individuals tuned in to "adult" sites on the Internet, talking about or having cybersex with strangers.18 Usually the participants write sexually explicit things to each other until one reaches orgasm. Pornography on the Internet is no different to pornography in many ancient cultures, but may be viewed at a younger age. This exposure may encourage men and women to expand their sexual repertoire, or it may increase sexual anxiety. Virtual sex: Sexual arousal and orgasm may be produced by virtual sex, which involves the projection of three-dimensional visual images in space so that sexual acts can be seen; viewers may become aroused and, if they wish, achieve orgasm. Virtual sex has numerous advantages: safety from sexually transmitted diseases, as an alternative to prostitution, and a sexual outlet for sexually shy or anxious persons. It may also enable people who have discontinued sexual intercourse as a result of a previous traumatic experience during coitus (eg, rape, violence or ridicule) to enjoy safe sexual arousal and orgasm. Conversely, adverse interpersonal experiences associated with natural intercourse may be avoided. Prostitution: The role of the prostitute may become more generally accepted, as in earlier centuries.19 Two-thirds of people in Melbourne believe it should not be against the law to sell sex from a brothel, and two-thirds of Victorians believe there is nothing wrong with paying for sex.20-22 The role of prostitutes could be enhanced by education in secondary and tertiary institutions so they can act effectively as sexual and social counsellors and sexual surrogates. Prostitutes may become more involved in sexual education, counselling, and training of couples having difficulty establishing effective sexual relationships, a problem generally ignored by the medical profession. Marriage: The importance of sexual intercourse in marriage, and marriage itself, may gradually change. Already there is a 40% divorce rate, and a high incidence of infidelity.23-25 Sexual problems are the third most common reason for failed relationships. The ignorance and failure of sexual enjoyment in so many couples is a blight on those responsible for general education. Perhaps in the future education will embrace the realities of cohabitation, the different sexual needs of men and women, sexual techniques, and perhaps the use of sexual surrogates to assist with sexual problems. Reproduction: Natural conception has the disadvantage that it is unpredictable, and it allows implantation of genetically abnormal embryos, sometimes resulting in therapeutic abortion if the defect is detected, or in birth of children with mental or physical disabilities (3% of births).26 In future, women may be able to store eggs by a simple surgical procedure soon after puberty.27 They will then be able to decide if and when they wish to conceive. In-vitro fertilisation (IVF) allows each embryo to be tested to avoid embryos with genetic abnormalities.28 Prediction We will move to a more collaborative society, a "global culture" in which the merits of both sexes are understood and valued. This will encompass a more understanding, liberal and satisfying time when both sexes practise and enjoy safe sex associated with a satisfactory emotional and intellectual experience. References Greer G. The female eunuch. London: MacGibbon and Kee, 1970. Masters WH, Johnson VE. Masters and Johnson on sex and human bonding. Boston: Little, Brown and Company, 1986. Kinsey AC, Pomercy WB, Machin CE. Sexual behaviour in the human male and female. Sanders, Philadelphia, 1948 and 1953. Fisher H. Lust, attraction and attachment in mammalian reproduction. Hum Nature 1998; 9: 23-52. Liebowitz MR. The chemistry of love. Boston: Little, Brown and Company, 1983. Wise RA. Psychomotor stimulant properties of addictive drugs. In: Kalivas PW, Nemeroff CB, editors. The mesocorticolimbic dopamine system, Ann N Y Acad Sci 1988; 537: 228-234. Sherwin BB, Gelfand MM, Brender W. Androgen enhances sexual motivation in females: a prospective cross-over study of sex steroid administration in the surgical menopause. Psychosom Med 1985; 7: 339-351. Sherwin BB, Gelfand MM. The role of androgen in the maintenance of sexual functioning in oophorectomized women. Psychosom Med 1987; 49: 397. Bancroft JD, Davidson DW, Warner P, Tyrer G. Androgens and sexual behaviour in women using oral contraceptives. J Clin Endocrin 1980; 12: 327-340. Sherwin BB. A comparative analysis of the role of androgen in human male and female sexual behaviour: behavioural specificity, critical thresholds, and sensitivity. Psychobiol 1988; 16: 416-425. Sherwin BB. Sex hormones and psychological functioning in postmenopausal women. Experim Geront 1994; 29: 423-430. Blum D. Sex on the brain: The biological differences between men and women. New York: Viking, 1997. Wingfield JC. Hormone-behaviour interactions and mating systems in male and female birds. In: Short RV, Balaban E, editors. The differences between the sexes. New York: Cambridge University Press, 1994. Blumstein R, Schwaitz P. American couples, New York: Morrow, 1983. Darling CA, Davidson JK, Cox RP. Female sexual response and the timing of partner orgasm. J Sex Marital Ther 1991; 17: 3-21. Posner R. Sex and reason. Cambridge, Mass: Harvard University Press, 1992. Laumann EO, Gagnon EH, Michael RT, Michaels S. The social organization of sexuality: sexual practices in the United States. Chicago: University of Chicago Press, 1994. Harmon A. For parents, a new and vexing burden. New York Times 1997; 27 June. Federico Andahagi. The anatomist. Sydney: Anchor, 1998. Queensland Criminal Justice Committee Report, 1992. Profile of Sex Workers in Victoria, Prostitutes Collective of Victoria Research Report. Melbourne: Prostitutes Collective of Victoria, 1998. Qualitative Study of the Victorian Sex Industry Research Report of Prostitutes Collective of Victoria. Melbourne: Prostitutes Collective of Victoria, 1998. Australian Bureau of Statistics. Marriages and divorces, Australia. ABS, 1997. (Catalogue no. 3310.0.) Statistical handbook on the American family. Phoenix, Arizona: Oryx Press, 1993. Baker RR, Bellis MA. Human sperm competition. Chapman & Hall, London, 1995. Lancaster P, Shafir E, Huang E. Assisted conception, Australia and New Zealand, 1992 and 1993. Canberra: Australian Institute of Health and Welfare, 1995; 18. Trounson A, Kuleshova L, Gianaroli L. What can we expect from thawing gametes? [abstract]. Congress on Controversies in Obstetrics and Gynaecology, Prague, Czech Republic, 8 September 1999. Trounson A, Wood C, Kausche A, et al. Oocyte maturation in vitro. The Fertility Society of Australia XIII Annual Meeting, Brisbane, October 1994. Authors' details Monash University, Melbourne, VIC. Carl E Wood, FRCS, FRACOG, Monash University, Emeritus Professor, Department of Obstetrics and Gynaecology. Reprints will not be available from the author. Correspondence: Professor C E Wood, 19 Simpson Street, East Melbourne, VIC 3002. PROFWOODATmalvern.starway.net.au Make a comment The chemistry of love, lust and attachment Lust, love and attachment are complex chemical interactions that ultimately determine our ability to achieve happiness, emotional stability, cohabitation and offspring. Perhaps in the future we will be able to assess and enhance, if necessary, our sexual drive and facility to experience romantic love and bonding. Romantic love is related to dopamines and norepinephrine,4,5 which produce euphoria, exhilaration, insomnia, anorexia, increased energy and hyperactivity.4,6 Dopamine stimulates a desire to see, talk with, and be with the loved one; the focused behaviour makes the loved one unique.4 High levels of dopamine cause anxiety and fear of loss of the loved one, and intensify the romance.4 Bonding: Norepinephrine causes bonding in other species and increased memory of new stimuli, which assists bonding.4 Obsessive thinking in love is similar to "obsessive compulsive" disorders, which are associated with low serotonin levels. Sex drive: The appetite for sex begins in the hypothalamus, which stimulates the gonads to produce testosterone and estrogen, assisted by the adrenal glands which produce smaller amounts of these hormones. Genes, social circumstances, and hormone levels all play a role in initiating sexual activity. In the absence of natural testosterone, injections of this hormone initiate sexual activity in 24-48 hours.7,8 Men and women with naturally high testosterone levels have more sexual thoughts, and more sexual activity (including more frequent masturbating), than men or women with lower testosterone levels.9-11Back to text

Carl E Wood

Sex, Science & Society Sex, reproduction and impregnation: by 2099 let's not confuse them Since prehistoric times humans have had sex for reasons other than reproduction Robert P S Jansen MJA 1999; 171: 666-667 Introduction - Impregnation's risks and benefits - Reproduction and choice - Sex and vulnerability - References - Authors' details - - More articles on Sexual health Introduction Impregnation -- the entry of sperm into the female body -- is a powerful biological, emotional and social event. Sex is also each of these things. So too is reproduction, or having children. It is important not to confuse the three. Impregnation's risks and benefits The human body is no zoological fortress, as the medical fields of virology, bacteriology and parasitology make clear.1,2 Spermatozoa introduced to the reproductive mucosa or elsewhere will sooner or later be phagocytosed by macrophages. Nonetheless, sperm are intrepid: sperm heads can persist in macrophages for seven days or more and, in mice, tritiated-thymidine-labelled DNA from sperm heads in the reproductive tract has been found not just in the uterus, but in the ovaries, the lymph nodes, the spleen, and even the heart.2,3 Through their display of polycationic binding sites, spermatozoa can act as vectors for foreign DNA.4 HIV is concentrated in seminal plasma.1The chasm that has opened between sex and reproduction needs a paradigm more understanding than abstinence or furtiveness. Given these risks, why accept impregnation? The one rational reason is for reproduction. Otherwise impregnation appears to be a non-essential side-effect of sex. However, whether fertilisation takes place internally or in vitro, there may be biological benefit to non-conceptional exposure of a woman's immune system to her mate's antigens before reproduction. An increased likelihood of subsequent embryonic survival5,6 and protection against eclampsia7,8 have both been suggested as possible biological benefits of impregnation for a time before conception occurs. Reproduction and choice Unless impregnation has been forced,9 a woman nowadays can more or less choose to whose sperm her eggs will be exposed. Ordinarily, she can choose who her mate will be, or she might choose a sperm donor from a commercial sperm bank, such as those that presently flourish in the United States.10 Either way, she is able to make some assessment of the safety of impregnation before attempting to conceive internally. Reproduction with the use of assisted (ie, non-sex-based or "artificial") insemination is safer if the process is supervised. Australia has strict regulations for medically assisted insemination that compel screening for infectious disease. Because of the possibility of viral contamination it is mandatory to store donated semen for a minimum six months before use, pending repeat testing of the donor. Semen from anonymous donors can already be bought on the Internet; although nominally for purchase by medical practitioners, advertisements are targeted to potential recipients. The chief hazard with modern, anonymous sperm donation, especially among women not in a heterosexual relationship, and irrespective of the material requirements for raising children, is the lack of a genetic father to identify to the inevitably inquisitive child or children who result.11 Children who have been adopted are winning the right to identify their biological parents in country after country, and it is likely that the same rights will be won by the children of donated sperm, eggs and embryos. Some practitioners in the field of infertility medicine, myself included,11 have chosen to medically facilitate conceptions with donated gametes only when the intending donor is willing to be made known, and preferably to take some part in the child's extended family. Among sexually reproducing species, the power of choice of mate for the purpose of having offspring of wanted or optimal phenotypic characteristics is probably as ancient as copulation.12 It remains the most potent force for "eugenic" reproduction and is as natural as sex itself, no doubt moving from the subconscious to the conscious in much human reproductive decision making. Yet the vagaries of Mendelian inheritance and homologous recombination mean that a couple's offspring will still manifest wide variation. "Wouldn't it be good if [she/he] had your [this] and my [that]!" we say. And then, as night follows day, we laugh, "But maybe not so good with your that and my this!". At least, within the context of the mate they have chosen, most couples, most of the time, are happy to leave the rolling of the recombining chromosomes to chance. Conception need not be internal for a woman to reproduce. Developed to overcome infertility caused by destruction of the normal site of conception (the fallopian tubes), by the mid-1980s the certainty conferred by in-vitro fertilisation (IVF) had become proper practice for overcoming many other causes of infertility.13 Through embryo biopsy and molecular DNA testing of an embryonic cell or cells, IVF is also used for the detection of genetic abnormalities before implantation.14 Designer babies? Not quite. Genetic selection for certain traits within a family is not a blank canvas upon which any gene can be placed. To extend the metaphor, the palette cannot for the foreseeable future be broader than the prospective parents' particular genes; assortment is the variable they might try to influence. Charles Darwin had 10 children to express the diversity of his and his chosen mate's genetic phenotypes -- a number considered impractical today by most modern Australian couples. If prospective parents have a strong enough conviction that their child would be better without the burden of a gene or genetic trait that could be stopped, they could choose for implantation only those fertilised eggs that do not bear the unwanted gene. It is hard to distil valid objections to exercising reproductive choice this way that are distinct from faith-based moral objections to IVF itself15 -- and objectors to IVF on moral grounds have long been in the minority in Australian society.16 Similarly, the use of IVF for sex selection -- a use anticipating genetic testing (with evidence to date in Western countries revealing that there is a slight excess in couples attempting to select a girl as their next baby17) -- comes down to the question of whether reproductive choices in pluralistic societies are to be made by politically compelled governments, by committees of paternalistic strangers, or by the people who will live with the consequences of their decision. Will IVF widely replace getting-pregnant-by-having-sex? IVF today accounts for more than 1% of all babies born in Australia.18 This number will increase. In real terms, the cost of IVF is falling. Nonetheless, there are reasons why its use will not rise inexorably. The community cannot be expected to subsidise all its personal uses19 and it will continue to be expensive compared with sex and impregnation; it will also continue to be inconvenient and uncomfortable. Sex and vulnerability Most animals copulate with the opposite sex only when the female is in oestrus and is susceptible to conception,20 but since prehistoric times humans, like dolphins and bonobo chimpanzees, have had sex for reasons other than reproduction. That this is in principle a natural and expected thing is evidenced by the moral sanction many communities and cultures confer upon sexual intercourse during pregnancy (when another pregnancy can hardly be the goal). Whatever the particular sexual act might be, morality in a sociobiological context will, it is to be hoped, centre more on the reasons for having sex with the particular other person involved (if there is such a person). When we have sex there is a moral distinction between sex for the expression of love, promotion of fidelity, and mutual sexual relief or fun, on the one side, and the less virtuous motives of domination, emotional entrapment or abuse,9,20 on the other. Sex is inseparable from personal vulnerability and will remain so, and it is in the sharing or exploitation of personal vulnerability that its perennial power for causing good or harm resides. In my opinion, the social challenge for sex in the new millennium is at once to clarify the separate harms and benefits of impregnation, of reproduction, and of having sex with someone. We need to acknowledge and appreciate the differences, and, when the good outweighs the harm, or when the harm remains imaginary rather than based on evidence, we need to grow comfortable with and to give credence and legitimacy to the unorthodox. In our modern society we have both an earlier age at puberty and a later age considered suitable for parenthood. Whether it is advice to be comfortable sharing a toothbrush before accepting impregnation, or to regard virginity as lost only when sex has been unprotected from impregnation, the chasm that has opened between sex and reproduction, and into which our blinking adolescents stumble, needs a paradigm more understanding than abstinence or furtiveness. The singular, responsible satisfaction to be had from mucosal intimacy when sex, impregnation and reproductive intent all come together might or might not be slightly rarer in 2099 than 1999, but it will have lost none of its power to bond a human relationship. References Forrest BD. Women, HIV, and mucosal immunity. Lancet 1991; 337: 835-836. Jansen RPS. Bioethics and the spermatozoon. In: Grudzinskas JG, Yovich JL, editors. Cambridge Reviews in Reproduction. Gametes -- the spermatozoon. Cambridge: Cambridge University Press, 1995: 282-306. Ball RY, Scott N, Mitchinson MJ. Further observations on spermiophagy by murine peritoneal macrophages in vitro. J Reprod Fertil 1984; 71: 221-226. Lavitrano M, French D, Zani M, et al. The interaction between exogenous DNA and sperm cells. Mol Reprod Dev 1992; 31: 161-169. Chaykin S, Watson JG. Reproduction in mice: spermatozoa as factors in the development and implantation of embryos. Gamete Res 1983; 7: 63-73. Bellinge BS, Copeland CM, Thomas TD, et al. The influence of patient insemination on the implantation rate in an in vitro fertilization and embryo transfer program. Fertil Steril 1986; 46: 252-256. Duenhoelter JH, Jimenez JM, Baumann G. Pregnancy performance in patients under fifteen years of age. Obstet Gynecol 1975; 46: 49. Serhal PF, Craft IL. Oocyte donation in 61 patients. Lancet 1989; I: 1185-1187. Greer G. Raped women in refugee camps. In: The madwoman's underclothes. Essays and occasional writings 1968-85. London: Pan Books, 1987: 108-110. Jansen R. IVF and reproductive genetics in 1999: biology, business, ethics and sociology. In: Jansen R, Mortimer D, editors. Towards reproductive certainty. Fertility and genetics beyond 1999. London: Parthenon, 1999: 5-7. Jansen RPS. Reproductive medicine and the social state of childlessness. Med J Aust 1997; 167: 321-323. Jansen RPS. Bioethics and the oocyte: reproductive choice. In: Grudzinskas JG, Yovich JL, editors. Cambridge reviews in reproduction. Gametes -- the oocyte. Cambridge: Cambridge University Press, 1995: 396-427. Jansen R. The clinical impact of in-vitro fertilization. Part 1. Results and limitations of conventional reproductive medicine. Med J Aust 1987; 146: 342-353. Jansen R. Getting pregnant. A compassionate resource for overcoming infertility. Sydney: Allen & Unwin, 1997; 302-308. Jansen RPS. Evidence-based ethics and the regulation of reproduction. Hum Reprod 1997; 12: 2068-2075. Brumby M. Australian community attitudes to in-vitro fertilization. Med J Aust 1983; ii: 650-653. Statham H, Green J, Snowdon C, France-Dawson M. Choice of baby's sex. Lancet 1993; 341: 564-565. Hurst T, Shafir E, Lancaster P. Assisted conception in Australia and New Zealand 1997. Sydney: AIHW National Perinatal Statistics Unit, 1999; 1. Jansen R. The clinical impact of in-vitro fertilization. Part 2. Regulation, money and research. Med J Aust 1987; 146: 362-366. Greer G. Seduction is a four-letter word. Playboy 1973; January: 80-228. Authors' details University of Sydney, Sydney, NSW. Robert P S Jansen, Clinical Professor, Department of Obstetrics and Gynaecology, and Medical Director, Sydney IVF. Reprints will not be available from the author. Correspondence: Professor R S Jansen, Sydney IVF, 4 O'Connell Street, Sydney, NSW 2000. Make a comment

Sex, Science & Society Reproductive technology, efficiency and equality Our challenge is to ensure everyone can share the benefits of reproductive technologies Julian Savulescu MJA 1999; 171: 668-670 Introduction - The radical possibility - Sex and reproduction - Should we fear the radical possibility? - Acknowledgements - References - Authors' details - - More articles on Ethics Introduction As epitomised by the Clinton sex scandal, "having sex" can be an elusive concept to define. For this article, I will define "having sex" broadly as any intentional physical touching between at least two persons which results in sexual feelings in at least one of them. What I will argue is that one possibility -- the Radical Possibility -- is that many people may not be having sex in 2099. The interesting question is not "Will we be having sex in the year 2099?" but "Who will be having sex in 2099?". Having sex has two primary purposes: pleasure and reproduction. Some would add intimacy and expression of love. There are also secondary purposes, such as providing employment, or to obtain physical protection. The radical possibility Sex for pleasure and Nozick's Experience Machine In 1974, the philosopher Robert Nozick asked us to imagine what life would be like in the "Experience Machine", a machine with electrodes that can be implanted into our brains to provide any set of experiences which we dial up, including "writing a great novel, or making a friend, or reading an interesting book. All the time you would be floating in a tank, with electrodes attached to your brain". Nozick is sceptical that we would plug in to such a machine. What does matter to us in addition to our experiences? First, we want to do certain things, it is only because we want to do the actions that we want the experiences of doing them or thinking that we've done them . . . A second reason for not plugging in is that we want to be a certain way, to be a certain sort of person. Someone floating in a tank is an indeterminate blob . . . Is he courageous, kind, intelligent, witty, loving? It's not merely that it's difficult to tell; there's no way he is . . . Thirdly, plugging into an experience machine limits us to a man-made world, to a world no deeper or more important than that which people can construct. There is no actual contact with any deeper reality, though the experience of it can be simulated.1 Nozick makes two claims. The first, that we should not connect to such a machine, I will address later. His second claim is that we would not connect. This has not been borne out by history. We have enthusiastically embraced various "experience machines". Television and other electronic fantasy worlds have replaced the real world of games and play for many children. Sometime next century, "sensual machines" will deliver a complete visual-auditory-tactile environment.2 "Virtual sex" may well become more pleasurable, more available, less risky, and cheaper than what some people find to be a rather ordinary, painful or disappointing physical alternative compared with the glamorous "reality" offered to them by the advertising and other industries. By 2099, Nozick's Experience Machine may be a reality. Moore's Law states computational power is roughly doubling every 18 months. Bill Gates has claimed that in 20 years a US$10 000 computer will have the same power as the human brain.2 If artificial intelligence replaces or supplants human intelligence, and human minds "upload" into machines3 or are replaced by them, "sex" between artificial minds may become a reality. The intimacy and love aspects of sex would presumably be as important to artificial persons as they are to us, and sex between artificial persons could mimic or improve all aspects of physical sex. Sex and reproduction Many will regard the possibility of virtual sex replacing physical sex for pleasure as unlikely. What is more likely is that many people in 2099 will no longer reproduce by sexual intercourse. Already 1.2% of births in Australia are the result of artificial reproduction (AR),4 defined as reproduction by any means not employing sexual intercourse. At present, AR is almost entirely confined to the treatment of infertility and prevention of genetic disease. The use of AR may expand considerably in the near future for two reasons: the introduction of preimplantation genetic diagnosis (PGD) and the identification of new genetic information. When the Human Genome Project is complete, the potential of PGD will be enormous. Couples may be able to select embryos less likely to develop heart disease, cancer, dementia, and so on. As genes for more complex characteristics like intelligence,5 personality and behaviour are identified, there will be pressure to select certain desired traits. PGD is now used for sex selection,6 and may in the future play a greater role in family planning. The next step might be to remove any genetic predisposition to disease. Still more controversially, we may modify non-medical characteristics (eg, creating darker-skinned children to protect against UV radiation as the ozone layer disappears). We may soon see the use of AR beyond treating infertility or preventing genetic disease. Postmenopausal women have produced children using AR with donor eggs, and men have "donated" sperm after death and fathered children.7,8 A 32-year-old investment banker recently had embryos frozen in England to allow her the option of having a child after she had established her career.9 Freezing eggs is more experimental and not readily available. However, the technology is rapidly advancing and births have been reported.10-13 Although freezing embryos is a well developed technique, is readily available, and has good success rates, it requires sperm -- freezing eggs does not. Freezing eggs and embryos has a number of attractions (Box 1). Reproduction may change more radically. Cloning in non-human animals is already a reality.14 In some States same-sex couples and single people can use AR to reproduce with donor gametes; in future, parthenogenesis (the production of an individual from an egg) and induced meiosis (causing a somatic cell to change to a sex cell) may enable them to have a child with genetic material from only themselves. Should we fear the radical possibility? I have raised the above as mere possibilities. I have not endorsed or rejected them. The radical possibility, then, is the possibility that many people will not have sex -- as physical touching -- either for pleasure or for reproduction. Nozick claimed that we should not connect to the Experience Machine. In part, his claims were based on the limits of artificiality and the man-made world. But it remains an open question what "pleasure machines" and artificial intelligence would be able to do, and what we would be able to do with them. Non-carbon-based life may be better, more productive and part of a "deeper reality". Ethical concerns Many concerns about the radical possibility will be raised. The most valid concern about any new technology is its safety, as the National Bioethics Advisory Commission concluded in its inquiry into cloning.15 Harm to others is also an important concern. For example, sex selection is alleged to have harmful effects on children of the opposite sex in the family and for the status of women in society. Another concern is that the use of technology to select children will place great expectations on the child. In the cloning debate, this is called the "living in the shadow" objection. It is argued that parents, in choosing a child with defined characteristics, may fail to love that child "unconditionally" and use (or commodify) it for their own ends. There are also worries that the use of these technologies will change the structure of families. For example, the offspring produced by cloning will have only one immediate genetic parent, and in AR, offspring may not know their genetic parents, and half- or full-siblings may not know of their relationship. Victoria and South Australia now require that details of gamete donors be kept and released to offspring. Concerns have been raised by UNESCO that cloning is an "affront to human dignity".16 However, there are over 5000 clones living in Australia today who have happy, normal existences. Indeed, one in every 300 births produces new clones (as identical twins). "Slippery slope" arguments claim that the expanded use of AR is the thin end of the wedge, the beginning of a return to Nazi eugenics and euthanasia.17,18All these objections have been critically addressed in the ethics literature.9,19-20 There are two major arguments for allowing access to these new technologies. The first is respect for "procreative autonomy", the liberty of couples to decide when and how to have children, and indeed which children to have, according to what they judge is best.10 Parents know best their own circumstances and ultimately it is parents who must live with and make sacrifices for their children. The second argument is that there can be good reasons in individual circumstances to choose certain characteristics in the children we bear. Consider the Ayala case (Box 2). In similar cases, AR has been used to produce children to serve as bone marrow donors.24 There was only a one-in-four chance that the child the Ayalas conceived would be compatible with Anissa. Use of AR (cloning Anissa or PGD and HLA typing of embryos) could have made it certain that the child would be compatible with Anissa. While Marissa's parents "used her" to save the life of Anissa, they also appear capable of loving her as a person in her own right. And her sister's life was saved. Should Marissa regret the fact that her parents decided to have her to provide bone marrow for her sister? She could, if her life has been so bad that she wishes she had never been brought into existence, but her life is not that bad. This raises a general point about reproductive technologies: if the intervention determines which unique sperm and egg unite, that particular child would not have existed without the technological intervention. Even if the child is disadvantaged psychologically, it is only wrong to employ the technology from the child's perspective if its life is so bad that it is not worth living. Efficiency and equality There is, however, at least one thing wrong with the radical possibility. There is already strong, justifiable pressure not to use scarce community resources to provide access to these new technologies. Thus, couples receiving IVF and PGD for sex selection in Sydney receive no Medicare rebate and fund the full cost themselves. Economic considerations will deny many people access to these interventions. Who will be having sex in 2099? It is possible that only the poor will be having sex, for either pleasure or reproduction. This would have at least one bad effect. The rich will enjoy the highest pleasures and select or create the babies they judge to be best. While some people are better off and no-one is worse off, this is potentially divisive and inegalitarian. There may be serious conflict between efficiency and equality. There may also not be a conflict. If genetic and reproductive technology is used to prevent genetic disease or correct genetic inequality, this may promote both equality and efficiency. Some have argued that genetic enhancement of those disadvantaged by the genetic lottery is required by justice.25 What if there is an irresolvable tension between equality and efficiency? There are several alternatives. One is to ban the use of technology in these ways and so to ensure that nobody has access to it. If the divisiveness that differential access to these technologies causes is great enough to threaten social stability, this may be the best option. Another option is to ensure that everyone has some access to AR, or a right to a "fair go". Consider a parallel: football. Everyone can go to the football. Some have better seats, some meet the players, some get to go to the Grand Final, some even have individual boxes, but everyone can go and watch and barrack and feel a part of the footy culture. When there is talk of building a new football stadium, no-one ever says (at least not publicly) that the resources would be better used to reduce hospital waiting lists or on improving health in other ways. Our challenge may be to find some way in which all the community can enjoy, to some level, the perceived benefits of technological advance, whether these be new forms of pleasure or different modes of reproduction, even if the benefits are not the prevention or treatment of disease. Even if we do not use community resources from the health budget to fund access to these new technologies (because they represent "personal preferences" and not "medical needs"), perhaps we can access other budgets -- sport and leisure for example -- to fund more equitable access. At any rate, what all of us have a legitimate claim to is a tolerably good life in a broad sense, and not the longest life, or even the healthiest possible life. Acknowledgements Thanks to Evan Hollonds and Ainsley Newson. References Nozick R. Anarchy, state and utopia. New York: Basic Books, 1974; 43-44. Kurzweil R. The age of spiritual machines. Sydney: Allen and Unwin, 1999; 146-149. Broderick D. The spike. Melbourne: Reed Books, 1997. Hurst T, Shafir E, Lancaster P. Assisted conception Australia and New Zealand 1997. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 1999; 1. Newson A, Williamson R. Should we undertake genetic research into intelligence? Bioethics 1999; 13: 327-342. Savulescu J. Sex selection: the case for. Med J Aust 1999; 171: 373-375. Harris J. Rights and reproductive choice. In: Harris J, Holm S, editors. The future of reproduction. Oxford: Clarendon Press, 1998. Robertson JA. Children of choice: freedom and the new reproductive technologies. Princeton: Princeton University Press, 1994. Brennan Z. Woman to freeze embryo for the sake of her career. The Sunday Times (London) 1998; 16 August. Porcu E, Fabbri R, Seracchioli R, et al. Birth of a healthy female after intracytoplasmic sperm injection of cryopreserved human oocytes. Fertil Steril 1997; 68: 724-726. Gook DA, Edgar DH. Cryopreservation of the human female gamete -- current and future issues. Hum Reprod. In press, 1999. Kolata G. Researchers report breakthrough using frozen eggs to create pregnancy. New York Times 1997; 17 October: 1. Tucker MJ, Wright G, Morton PC, Massey JB. Birth after cryopreservation of immature oocytes with subsequent in vitro maturation. Fertil Steril 1998; 70: 578-579. Wilmut I, Schnieke AE, McWhir J, et al. Viable offspring derived from fetal and adult mammalian cells. Nature 1997; 385: 810-813. National Bioethics Advisory Commission. Cloning human beings. Maryland: National Bioethics Advisory Commission, 1997. UNESCO. Declaration on the Human Genome and human rights, adopted on 11 November 1997 (13), Article 11. UNESCO, 1997. Lamb D. Down the slippery slope: arguing in applied ethics. New York: Croom Helm, 1988. Burgess JA. The great slippery slope argument. J Med Ethics 1993; 19: 169-174. Harris J. Goodbye Dolly? The ethics of human cloning. J Med Ethics 1997; 23: 353-360. Tooley M. The moral status of the cloning of humans. In: Humber JM, Almeder RF, editors. Human cloning. New Jersey: Humana Press, 1998; 65-101. Harris J, Holm S, editors. The future of reproduction. Oxford: Clarendon Press, 1998. Rachels J. When philosophers shoot from the hip. Bioethics 1991; 5: 66-71. Hastings Center Report 1994; May/June: 2. Lamperd R. Race for life. Sun Herald (Melbourne) 1998; 2 July: 1. Holtug N. Does justice require genetic enhancements? J Med Ethics 199; 25: 137-143. Authors' details Royal Children's Hospital, Melbourne, VIC. Julian Savulescu, MB BS, PhD, Director, Ethics Unit, Murdoch Institute, and Director, Ethics Program, Centre for the Study of Health and Society, University of Melbourne. Reprints will not be available from the authors. Correspondence: Associate Professor J Savulescu, Murdoch Institute, Royal Children's Hospital and Centre for the Study of Health and Society, University of Melbourne, Parkville, VIC 3052. savulesjATcryptic.rch.unimelb.edu.au Make a comment 1: Benefits of freezing eggs or embryos for non-medical reasons Promotes equal participation by women in employment Gives women time to find a partner May allow establishment of a family at a better time Allows women and couples to have another child if circumstances change An option for women and children at risk of premature ovarian failure May reduce risk of genetic abnormality Freezing gametes avoids some of the moral objections to freezing embryos Back to text 2: The Ayala case A 17-year-old girl, Anissa Ayala, had leukaemia. When no donor had been found after two years, her father had his vasectomy reversed with the intention of having another child to serve as a bone marrow donor. There was a one-in-four chance the child would be compatible with Anissa. The child who was born, Marissa, was a compatible donor, and a successful transplant was performed.22 A report later noted: "Marissa is now a healthy four-year-old, and, by all accounts, as loved and cherished a child as her parents said she would be. The marrow transplant was a success, and Anissa is now a married, leukaemia-free, bank clerk."23 Back to text

Julian Savulescu

Doctors' Tales CLINICam The world's first live general practice on the Internet MJA 1999; 171: 671

Michael R Kidd

Doctors' Tales Some thoughts while nymphing Being ruminations on the similarities of the esoteric arts of fly fishing and anaesthesia -- by a practitioner of both MJA 1999; 171: 673-674

Douglas N Gow

Doctors' Tales A new, occasional instrument for measuring marital quality The time required to make a cream cheese and salmon bagel following funnel-web spider bite . . . more succinctly termed "Sweating yet, honey?" Garry Walter MJA 1999; 171: 674-675

Garry Walter

True Story Breaking the rules: a thoracic impalement injury In the case of a patient with an impalement injury, the object should be removed in a controlled operating theatre environment. We report an 18-year-old man for whom this rule could not be followed. He was removed from a metal pipe transfixing his chest at the roadside. Carole L Foot and Pat Naidoo MJA 1999; 171: 676-677 Introduction - Clinical record - Discussion - References - Authors' details - - More articles on Emergency medicine

Carole L Foot · Pat Naidoo

True Story A riposte for a fencer The residency appointment of Alfred Edmund Finckh to Sydney Hospital in 1905. Was it just a matter of male chauvinism? Alfred Finckh gained a residency at Sydney Hospital in 1905 in preference to a more academically successful female medical graduate, amid some controversy over the place of female doctors in hospitals. Here, two of his descendants argue his cause: that he was an experienced scientist with qualities that merited his selection for the post. MJA 1999; 171: 679-680

Ernest S Finckh · Andrew S Finckh

True Story "Ute surfing": a novel cause of severe head injury Riding on the load tray of a moving utility vehicle, often after drinking alcohol, is a recognised pastime among young Australian men. The cases presented here show that associated accidents can result in serious head injuries and probable permanent neurological deficits. Rodney S Allan, Peter J Spittaler and John G Christie MJA 1999; 171: 681-682 Introduction - Clinical records - Discussion - References - Authors' details - - More articles on Neurology

Rodney S Allan · Peter J Spittaler · John G Christie

Snapshot! Happy Valentine's baby A 30-year-old man presented with abdominal pain. A computerised tomography scan of the abdomen and pelvis was performed. Contrast defines a heart in the anal canal. Perhaps this case should have been reserved for the MJA's February issue... John Rouse Radiology registrar St Vincent's Hospital, Darlinghurst, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

John Rouse

Snapshot! Bottom of my heart Have you ever wondered how to tell that special person in your life just how much you love them? Radiology can provide a unique way. This patient displayed her heart on her buttocks. Could this be where Stevie Wonder found the inspiration to write the song: "I just called to say I love you I just called to say how much I care I just called to say I love you And I mean it from the BOTTOM of my HEART"? Rodney Strahan Radiology Registrar Concord Hospital, Concord NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Rodney Strahan

Snapshot! Smiley face This computed tomography (CT) scan shows a "smiley face" on the first sacral vertebra of an 80-year-old man with sclerotic vertebrae resulting from extensive prostate metastases. The patient had his prostate cancer diagnosed in 1993, and was initially treated with zoladex and androcur. Bone metastases were detected in 1998 and palliative therapies over the past two years have included various analgesics, localised external beam radiotherapy to the lumbar spine and sacrum, and strontium (89Sr) treatment. When this CT scan was taken he was taking morphine (20 mg twice daily), and was free of pain most of the time. His bone scan showed extensive diffuse uptake throughout the skeleton, and his prostate-specific antigen level was 4400 micrograms/L (normal range, <4 micrograms/L). Malcolm Feigen Radiology Registrar The New Children's Hospital, Westmead, NSW Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Malcolm Feigen

Snapshot! "The fish will eat your eyes" A young Australian surfer visiting Bali did not heed the warning of local villagers who told him not to stay out on the lagoon at dusk or the "fish will eat your eyes". One evening, while paddling back to shore from a day's surfing, he was suddenly hit in the face by an unknown object. This produced instant and intense pain in the right orbit with subsequent periorbital cellulitis and cervical lymphadenopathy, although his vision was maintained. Oral antibiotics given by local doctors had no effect, so he flew back to Australia for medical consultation. A computed tomography scan showed a 6cm foreign body passing along the right inferoloateral orbital floor, missing the globe and the optic nerve, but penetrating the inferior orbital fissure to terminate approximately 5mm anterior to the internal carotid artery (Figures a and b). It was surgically removed and proved to be the broken-off snout of a "javelin" or "needle" fish (Figure c). It comprised the upper and lower jaws, complete with multiple small teeth. The patient made an excellent recovery. Christopher J O'Donnell Radiologist, Victorian Imaging Group Elsternwick, VIC Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Christopher J O'Donnell

Illustration: Multiple incisions of recent cupping procedure To the Editor: For six months a Bedouin patient had suffered from terrible headaches. Doctors at San'a' hospital performed blood tests and scans, but the tablets they prescribed did not stop the headaches, so he sought the help of a matowa, or holy man, from a nearby village. The matowa performed readings from the Holy Koran, but the headaches continued unabated, so the patient left San'a' to seek the help of a traditional healer in the desert. The healer recommended cautery and cupping. Cautery is used throughout the Arab world and parts of Africa in the treatment of pain, paralysis and a variety of other illnesses.1,2 The instrument of cauterisation is usually a metal rod, fashioned at one end into a disc. Small deep burns are inflicted close to the site of the pain or at distant points believed to influence the affected organ.3 Cupping, on the other hand, is usually used in the treatment of metaphysical conditions, such as the extraction of malicious spells, harmful medicines, and the effects of the evil eye,3 although in some parts of the world it is also used for treating physical ailments. For example, in less law-abiding parts of Africa, it is used in the treatment of shotgun wounds, and is popular among taxi drivers, who are occupationally predisposed to firearm attack.3 The skin is incised with a razor blade or knife in a series of parallel incisions about 5 mm apart and 5 cm long in an area about the size of a large coin. Then, the wide end of a goat horn is placed over the incisions and the healer sucks out the air through a hole in the tip to create a vacuum. A piece of beeswax is placed over the hole in the horn to maintain the pressure for up to half an hour.3 "The edge of the desert", wrote T E Lawrence, "is littered with the debris of great civilisations and thoughts".4 Lawrence was honouring the resistance of the desert Bedouin to cultural incursion, but in the last four decades even the Bedouin have succumbed to change from outside, and the role of the healer has also changed. In earlier times the healer functioned as a teacher, judge and religious leader, but, with the advent of schools, courts and hospitals, his traditional role has been curtailed. Today, against this trend of acculturation, the healer survives and continues to play an important role in treating difficult ailments for which Western medicine has no cure.1,5 This case is characteristic of the management of medical problems in the region. Western medicine is the treatment of first choice. This is followed by incantations from the Koran. Failing these methods, the treatments of last resort are the pre-Islamic practices of cupping and cautery. Although the specifics of management vary, the trend is always the same: towards earlier cultural modes of treatment and cure.1,3 Social policy planners around the world have long despaired at indigenous people resorting to traditional healers. There is no evidence for the efficacy of traditional cures, it is argued, and the treatments are at times harmful or disfiguring. But Western medicine fails to understand the role of the traditional healer as a familiar and trusted repository of culture in a time of uncertainty and change.3,6 The world over, traditional medicine persists in otherwise acculturated societies because it provides the sanction of an old and trusted belief system during times of crisis.3,6 The Bedouin, surrounded by ways of life they do not fully understand or even like, return to the healer who understands them, a person they know and trust, who will guide them back to health in a perplexing and unsettling world. The patient has returned for treatment of his hypertension. He nervously fingers his prayer beads as he gazes out the door of the outpatient clinic into the blazing sunshine. There is no contradiction in this. Hypertension is an invisible Western disease which requires a Western cure. But, even so, the Western diagnosis may not be accepted as complete. Should overt complications arise which are unresponsive to treatment, he may believe that there are metaphysical or other causes at work and seek the skills of the matowa or even the Bedouin healer. Chris Cooper Lecturer, Department of General Practice University of Sydney, Sydney, NSW (Dr Cooper worked for eight years as a general practitioner in Middle Eastern countries.) Ghazanfar SA. Wasm: a traditional method of healing by cauterization. J Ethnopharmacology 1995; 47: 125-128. Mohamed A, Neilson B, Hawash F, et al. Skin cauterisation marks on patients in Saudi Arabia. Lancet 1983; 1: 714. Reminick RA. The evil eye belief among the Amahra of Ethiopia. In: Landy D, editor. Culture, disease and healing. Studies in medical anthropology. New York: Macmillan, 1977: 218-225. Lawrence TE. The seven pillars of wisdom. London: Penguin, 1965. Rosenberg RA, Sagi A, Stahl N, et al. Maqua (therapeutic burn) as an indicator of underlying disease. Plast Reconstruct Surg 1988; 82: 277-280. Romanucci-Ross L. The hierarchy of resort in curative practices: the Admiralty Islands, Melanesia. In: Landy D, editor. Culture, disease and healing. Studies in medical anthropology. New York: Macmillan, 1977: 481-486.

Chris Cooper

To the Editor: My first reaction to reading "On dry land" (in In this Issue, in the 5 April issue of the Journal1) was to ask myself, "hang on, isn't the Australian Medical Association (AMA) based in Canberra now, and surely Canberra wouldn't be crowing about the superiority of its winters over Melbourne's?". Then, of course, a quick look at the first page of that issue revealed that the Journal is published in . . . surprise, surprise ... Sydney! It seems that The Medical Journal of Australia is as Sydneycentric as the ABC: "Most of us [my italics] have long suspected that Aussie Rules football should not be played outside of Melbourne". Most Sydneysiders, perhaps (although you may want to look at the number of people attending matches played by the Swans compared with those at rugby league games before you get too confident), but, in any case, Australian Rules has completely dominated football south and west of the Murray River. This is an area which contains nearly half of Australia's population, and, more importantly, nearly half of the members of the AMA. You then proffer the gratuitous insult that knee injuries could be reduced if "grounds were prepared with constant watering and little exposure to the sun -- simulating the conditions of a typical Melbourne winter!". I wonder if the same terms would have been used if the In this Issue item had been written more recently, in light of Sydney's weather in the last few months compared with Melbourne's glorious autumn and mild early winter. A David Grounds Physician Richmond, VIC 1. On dry land [In this Issue]. Med J Aust 1999; 170: 191. In reply: We stand castigated for our Sydneycentricity. Grounds' observations about the weather in the two cities during the 1999 football season aroused some curiosity in our editorial office, so we obtained the recent weather statistics (derived from Bureau of Meteorology data) from a very helpful Western Australian website.1 As the Figure shows, Sydney, although slightly warmer, had a much wetter six months in 1999. Further, the statistics for average rainfall between 1840 and 1989 show that Sydney's football season is always wetter than Melbourne's. So, it seems the answer to where we would rather spend winter, and which football code we would rather support, lies not in the weather... Whether the weather be fine, Or whether the weather be not, Whether the weather be cold, Or whether the weather be hot, We'll weather the weather, Whatever the weather, Whether we like it or not! Anon Comparison of (a) average temperatures (minimum/maximum) and (b) total monthly rainfall for Melbourne and Sydney in the 1999 football season. Ruth M Armstrong Assistant Editor The Medical Journal of Australia 1. Australian Weather Statistics. <http://cygnus.uwa.edu.au/~cloader/weather//>

To the Editor: Recent articles in the Journal on spider bites and skin ulceration1,2 made little of the importance of excluding microbial causes before diagnosing necrotising arachnidism. We report a case which illustrates this point. A 31-year-old woman was picking mandarins near Bindoon, Western Australia, when she felt something bite her wrist. When she looked, she saw a large hairy spider. A red lesion developed immediately and failed to resolve after a week, so she attended her general practitioner (A R N), who prescribed roxithromycin. After a further week she developed a 30 mm diameter, full-thickness ulcer on her wrist with some lymphangitis (Figure, above). At this point she attended an after-hours clinic, where wound care and an occlusive dressing were provided. After another three weeks she returned to her GP with no improvement, and nodular lymphangitis. Pus was aspirated from a fluctuant nodule and sent for culture. Therapy with doxycycline was started. The gram stain of the aspirate showed numerous pus cells, but no organisms. The culture showed no growth after two days, but was kept for extended incubation. The working diagnosis was necrotising arachnidism. After a further week the patient was referred to plastic surgeons at a public teaching hospital, where she was admitted and treated with intravenous clindamycin. She was discharged home with little improvement. Meanwhile, after 10 days' incubation, the aspirate culture plates grew a yeast-like organism, which was subcultured onto cornmeal agar for slide culture at 25°C. Microscopy showed a mould form of the organism, with clusters of ovoid, denticulate conidia produced sympodially on short conidiophores. With time at 25°C, the colony became blackened, glabrous and developed a wrinkled surface. This characteristic microscopy and thermal dimorphism confirmed the organism's identity as Sporothrix schenckii -- the agent of sporotrichosis. The patient has since been prescribed itraconazole and her condition is rapidly improving. Although our patient had lymphocutaneous sporotrichosis, there is also a fixed cutaneous form without lymphangitis.3 While there are reports of sporotrichosis associated with a variety of bites, including insects,4,5 we believe that this is the first report associated with a possible spider bite. We think it is important that in cases like this good quality specimens be sent for microbiological analysis and that they be specifically cultured for mycobacteria and fungi, or at least incubated for an extended period, before necrotising arachnidism -- the diagnosis of exclusion -- is diagnosed. Len D Moaven Clinical Microbiologist, St John of God Pathology Wembley, WA (moavenATbigpond.com.au) Shelley A Altman Senior Scientist, St John of God Pathology Wembley, WA A Richard Newnham General Practitioner Bindoon, WA Pincus SJ, Winkel KD, Hawdon GM, et al. Acute and recurrent skin ulceration after spider bite. Med J Aust 1999; 171: 99-102. White J. Necrotising arachnidism. Med J Aust 1999; 171: 98. Auld JC, Beardmore GL. Sporotrichosis in Queensland: a review of 137 cases at the Royal Brisbane Hospital. Aust J Dermatol 1979; 20: 14-22. Vismer HF, Hull PR. Prevalence, epidemiology and geographical distribution of Sporothrix schenckii infections in Gauteng, South Africa. Mycopathologia 1997; 137: 137-143. Lober C, Kaplan R, Herron C. Sporothrix schenckii inoculation on the abdomen. South Med J 1980; 73: 1637-1638.