Bathtub drownings: report of seven cases.

The domestic bathtub is an important site for infant drownings. A total population study of drowning and near-drowning accidents involving Honolulu infants has enabled the risks to be specified with greater detail. A series of seven consecutive bathtub immersion accidents is presented. The "at risk" profile comprises highly mobile families of lower socioeconomic status; usually younger siblings in larger families are involved and often the father had immediate care of the infant at the time of the accident. Another case of bathtub immersion as a form of nonaccidental injury is described. In five of the other six cases reported, the drowned child was left attended by an older sibling. Preventive strategies are discussed.

A clinical study of chronic childhood spinal muscular atrophy. A review of 141 cases.

The case histories and clinical details of 141 children (67 males and 74 females) with chronic childhood spinal muscular atrophy (SMA) have been reviewed. Hundred of these children were alive at the time of the study. The cases comprise a consecutive unselected series of all with this disease who presented to two large English neurological centres over a 10-year tracing period. Chronic childhood SMA is defined here as a progressive disease of anterior horn cells with initial proximal selectivity, which does not of itself cause death before 18 months of age. Clinical signs are first manifest between birth and 8 years of age, but in 95% before 3 years. Cumulative frequency tables for motor skills are presented; 46% of children never walked, even with orthopaedic aids; 37.6% were able to walk unaided at some stage. No child was able to run after 12 years of age. Late-presenting sporadic cases retain motor skills longer than do familial cases. A sex influence on the clinical course of the disease has been demonstrated, males being more severely affected. Cumulative frequency curves for age-at-onset and age-at-presentation have been compiled. A sib of an affected index case, still clinically normal at 2 years of age, has passed 90 percent of his risk period; the use of such cumulative frequency curves for studies of carrier-frequency and incidence is discussed. The median age at death for this disease exceeds 10 years. The range encompassed by the clinical spectrum is discussed.

The mass of venom injected by two elapidae: the taipan (Oxyuranus scutellatus) and the Australian tiger snake (Notechis scutatus).

Using an enzyme immunoassay technique, a new method for measuring, in vivo, the mass of venom injected during snake bite, is presented. The venom injected into mice (as prey) and the venom left on the skin surface during bites by the two Australian Elapidae, the Taipan (Oxyuranus scutellatus) and the Tiger Snake (Notechus scutatus) has been measured. Venom delivery patterns vary significantly between these two species. In the case of the Tiger Snake (a total of 45 bites studied) the mean mass of venom injected in a first bite was 12.7 mg (S.E. 3.4 mg, median 8.1 mg); an average mass of 0.8 mg (S.E. 0.4 mg, median 0.17 mg) was left on the skin surface. A second bite delivered by the same snake yielded a mean venom mass only 27% of the first. In the case of the Taipan (a total of 24 bites) the mean venom mass injected in the first bite was 20.8 mg (S.E. 6.4 mg); with an average of 0.9 mg (S.E. 0.5 mg) left on the skin surface. In contrast to the situation observed with Tiger Snakes, second and third bites delivered in a rapid sequence yielded increasing masses of venom. The mean delivered in the third of a sequence of three bites was 48.8 mg (S.E. 23.8 mg). The ranges of venom mass, by species and by the sequence number of the bite, are also presented. In 66 of the 69 experimental bites studied in this report, venom could be easily detected, the species identified, and the absolute mass of venom measured.

Further studies on the mass of venom injected by Elapid snakes.

Further experimental studies to determine the mass of venom injected by medically-significant Australian elapids are reported. The use of a modified enzyme immunoassay technique to measure venom injected during snake bite is presented. The feeding biting pattern of the Australian eastern brown snake (Pseudonaja textilis) is described. Using data from ten different snakes of this species, it is established that the mass of venom delivered in a first-bite is 4.69 +/- 0.85 mg (mean +/- S.E.) and a mean of 91% of the delivered venom is injected s.c. or into deeper tissues in a first-bite. For this species, the mass of venom delivered sequentially in a bite sequence falls to 1.32 +/- 0.94 mg in the third bite in such a sequence. For the Australian rough-scaled snake (Tropidechis carinatus), the mass of venom delivered in a first feeding bite is 6.15 +/- 2.23 mg, falling to a minimum of 1.92 +/- 0.61 mg in the third bite of a sequence. for the Australian death adder (Acanthophis antarcticus) the mass of venom delivered in a feeding bite is 41.95 +/- 16.13 mg for a first bite. Biting data is also presented for three species of the genus Pseudechis (the Australian mulga (king brown) and black snakes.

Venom of the Australian rough-scaled snake, Tropidechis carinatus: lethal potency and electrophysiological actions.

A series of experiments to define the lethal potency (LD50) and electrophysiological properties of the venom of the Australian Rough-scaled Snake (Tropidechis carinatus) are described. Crude pooled venom contains at least five fractions which were separated using liquid chromatography and high pressure liquid chromatography techniques (Fractions I-V). LD50 studies are reported using each of these fractions, with data for both adult and neonatal mice. Fraction I (mol. wt greater than 100,000) was essentially non-toxic. Fraction IV (mol. wt less than or equal to 10,000) and Fraction V (mol. wt less than 1,000) were potent toxic components with LD50'S (s.c. injection; fraction in 0.1% bovine serum albumin and 0.85% saline; neonatal mice) of 0.04 mg/kg and 0.06 mg/kg respectively. LD50'S for the whole crude venom were similar in both adult and neonatal mice. Electrophysiological studies using a Bulbring preparation (rat isolated phrenic nerve-hemidiaphragm) indicated that Fractions I, IIa and IIb were inactive. Fraction IV (mol. wt less than or equal to 10,000) caused rapid neuromuscular blockade which appeared to be irreversible. Neurophysiological experiments with a rat isolated extensor digitorum longus muscle preparation suggested that the major toxic activity of the whole venom resides in Fractions III and IV, and that both of these fractions have presynaptic and postsynaptic action.

A corneal abnormality associated with trisomy 8 mosaicism syndrome.

Eye abnormalities are a significant feature of trisomy 8 mosaicism syndrome. This paper gives the first account of the specific histopathology of a corneal opacity which is characteristic of this syndrome. The importance of early recognition is stressed because of potential therapeutic visual improvement. The necessity of including mosaic trisomy 8 in the differential diagnosis of such corneal opacities is illustrated by this case.

Erythroblastosis fetalis--the discovery and partial elimination of rhesus incompatibility--the origins of exchange transfusion in Australia.

The first 2 exchange transfusions in Australia for Rhesus-induced erythroblastosis (hemolytic disease of the newborn) were conducted in the 9 mth period from December 1945 to August 1946. These pioneering endeavours in medical research were undertaken by 3 transfusionists who were, or had been, directors of the Red Cross Blood Transfusion Service in Australia. Called "substitution transfusion" or "exsanguination transfusion" they were conducted prior to the international publication of the first case series of exchange transfusions for "Rhesus Disease". The first successful exchange transfusion in Australia, and one of the first in the world, was performed by Dr George Kelsall at the King Edward Memorial Hospital for Women, in Perth. Dr Kelsall had monitored pregnancies with serum raised himself from blood from a Rhesus monkey in the Perth Zoo. The second exchange transfusion, and the first with volume-monitoring, was successfully undertaken in Brisbane by Dr Eric Shaw, pathologist and Director of the Queensland Red Cross Blood Transfusion Service, and Dr Noel Gutteridge, a former Director and senior pathologist of Brisbane. Dr Kelsall's pioneering transfusion in Perth was a direct non-anticoagulated transfusion which was undertaken within minutes of birth and was completed within 5 min. The first volume-controlled exchange transfusion, in which the input-discard volumes were matched, used a plastic tube obtained from the Telephone Branch of the Postmaster General's Department, and employed citrated blood. These heroic exchanges (heroic for the infants and families concerned as well as for the operators) form a significant milestone in the history of blood transfusion, serology and preventive medicine in Australia.

Ciguatera poisoning: an example of a public health challenge.

Ciguatera is a common form of fish poisoning, endemic in all nations of the Pacific region. Several thousand cases have been notified to Queensland authorities over a 10-year period. However, many cases remain undiagnosed and most go unreported. The public health implications include raising awareness of the condition, ensuring that ciguatera is considered in differential diagnosis and promoting better documentation and reporting.

Dr William Wilson Ingram (1888-1982): doctor-soldier, physician and Antarctic expeditioner.

Dr William Wilson Ingram (1888-1982), a Scottish-born physician, contributed significantly to the health and heritage of Australia, his adopted land. Born on Speyside and educated in Aberdeen, he was a doctor-soldier in two World Wars and decorated with the Military Cross. Ingram was a Foundation Fellow (1938) of the Royal Australasian College of Physicians and established one of the first specialist diabetic clinics in Australia, in Sydney in 1928. As an arachnologist, he published clinical descriptions of both surviving and fatal cases of envenomation by the Sydney funnel web spider, Atrax robustus. He founded the Kolling Institute of Medical Research at the Royal North Shore Hospital in Sydney where for two generations he was a leader in both undergraduate and postgraduate medical education. The international significance of his life's work relates to his service as the medical officer and biologist on the two British, Australian and New Zealand Antarctic Research Expeditions (BANZARE) of 1929-1931, for which service he was awarded the Polar Medal and subsequent Clasp. Those expeditions secured, for the British Crown, what was to become the Australian Antarctic Territory, ceded to Australia by a British Order in Council of 24 August 1936. Sir Douglas Mawson, polar expeditioner and the leader of BANZARE, described Ingram as 'an ideal medical officer', one who in addition to his clinical skills and judgement, manifested courage and 'physical endurance and a full measure of camaraderie'. Ingram has no published obituary or biography. This précis records some details of his extraordinary life.

Idiopathic necrotizing dermatitis: current management.

OBJECTIVES: To identify and demonstrate necrotizing dermatitis in infancy; an uncommon, puzzling syndrome, in which anecdotal reporting and personal experience indicates that one third of cases may require skin grafting. Much informed discussion about the pathogenesis of this distressing syndrome centres on the role of spider envenomation; and in particular on the speculative role of the Australian White-tailed spider, Lampona cylindrata. METHODS: We present here six cases of necrotizing dermatitis treated surgically at the Royal Children's Hospital and Mater Children's Hospital in Brisbane over the period from 1991 to 1999. Clinical history, surgical details and pathological investigations were reviewed in each case. Microbiological investigation of necrotic ulcers included standard aerobic and anaerobic culture. RESULT: Nocardia and Staphylococcus were cultured in two cases, but no positive bites were witnessed and no spiders were identified by either the children or their parents. All cases were treated with silver sulphadiazine creme. Two of the infants required general anaesthesia, excision debridement and split skin grafting. The White-tailed spider, Lampona cylindrata, does not occur in Queensland, but Lampona murina does; neither species has necrotizing components in its venom. Circumstantial evidence is consistent with this syndrome being due to invertebrate envenomation, possibly following arachnid bites. CONCLUSION: In our experience there is insufficient evidence to impute a specific genus as the cause, at this stage of scientific knowledge. If the offending creature is a spider, we calculate that the syndrome of necrotizing dermatitis occurs in less than 1 in 5000 spider bites.

Survival in subzero temperatures: two field experiments on temperature estimation and "snowhole" (survival hole) temperatures.

Two field experiments in a subarctic environment are described. Individuals consistently underestimated the degree of cold, because visual cues dominated sensory skin receptors in the subjective estimation of temperature. In snowholes (survival holes) temperatures rose 20 degrees C within 30 minutes of occupancy, but stabilized at freezing point. Implications for travel and survival in a subzero environment are described.

The pivot: the First Australian Casualty Clearing Hospital at the Gallipoli beachhead--the first seven days.

In October 1914, a new type of medical unit was added to the order of battle of the Australian Army's casualty evacuation chain. Designated the casualty clearing hospital, it was called a Casualty Clearing Station on the beach at Anzac Cove in the Gallipoli campaign. This unit was established as the most forward unit to provide emergency surgery, freeing the forward field ambulances from the necessity of holding wounded soldiers, a task which compromised their mobility and prevented them from moving with the brigades they supported. The Casualty Clearing Station was to be the most forward unit where specialist surgeons, anaesthetists, nurses, radiologists and a dentist were to be found. The 1st Australian Casualty Clearing Station (1ACCS) was raised in Hobart and consisted of 93 men including 7 doctors. After some seven weeks of training in camp, the new unit embarked for Egypt and the Gallipoli offensive. They landed on the beach at Anzac Cove at 11 a.m. on 25th April 1915, and remained on a 20 metre stretch of beach through eight months of the Gallipoli campaign. This paper reviews the first seven days of the Station's role at Anzac Cove, during which time this essentially inexperienced medical unit treated and evacuated an estimated 2700 wounded Australian and New Zealand soldiers. This paper also reviews the Commanding Officer's hitherto unpublished war diary and other archival and family records which add to the medical story of Anzac. This frightful baptism of mass casualty evacuation, undergone by the Australian Army Medical Corps, brings a perspective to the problems of mass disasters today.

Herbicides and congenital malformations: a review for the paediatrician.

The herbicides 2, 4, 5-T and 2, 4-D are relatively non-toxic to primates, in acute exposure. Dioxins, which have occurred as impurities in these two herbicides, manifest universal biological toxicity. The best understood dioxin TCDD, has, in susceptible strains of mice, a very low teratogenic minimal effective dose of 1-10 micrograms/kg. This fact has engendered an era of uncertainty about the potential teratogenic effects of herbicides, in the context of potential human exposure. This paper reviews current knowledge concerning herbicide teratogenesis following maternal exposure. Because of species specificity of teratogenic agents, it is not possible to extrapolate from effects in lower animals to potential effects in humans. It remains a fact however that all proven human teratogens have parallel animal models. Following maternal exposure to herbicides and to dioxins, it has not been possible to produce teratogenic effects in primates, although fertility may be affected. Epidemiological reports from Hungary, Italy (the ICMESA accident), New Zealand, the United States, Europe and Australia have not revealed any positive evidence to indicate that a human herbicide teratogenic syndrome exists.