TMI Friday: Taking it to third base ..literally

The variety of foreign bodies in the rectum tests a surgeon's ingenuity to solve a myriad of geometric puzzles

So begins Major PT Mcdonald's  1976 paper, in which he has to deal with a  patient with a somewhat unique problem.
The patient, a 49 year old baseball fan, who had serious trouble with his bowels ever since the Oakland A's won the world series in 1974. The doctors examined him, and noticed

 " a firm, fixed, round object barely palpable which was lodged high in the rectum"

It was a baseball. To celebrate the Oakland A's victory, he had his sexual partner force the hardball up his rectum, where it got lodged. Unable to get any purchase on the surface of the ball, retrieval seemed impossible.
Thus it was left to the surgeon to figure out how to get the ball out. They drained the man's bladder using a catheter to take some of the pressure off the baseball. They tried to hook the ball, and drag it out as you would a particularly large fish. But this anal fishing expedition was for naught, as they only managed to rip some of the skin from the baseball.
They then decided that perhaps a better way of extracting the ball was through using obstetrics forceps. For those of you who don't know, these are generally used to deliver babies. So they pumped a little bit of air around the baseball, and tried to use the forceps to grab the ball.
It didn't work. They realised what the problem was. The baseball had travelled up through the pelvic arches, and after it had done so, it had become swollen with fluid, and become lodged in the pelvis.
It was a dire situation. The surgeon decided to cut into the man's abdomen to get access to the baseball. It was still stuck fast, and he needed to get some grip on the surface. So he skewered the baseball with a corkscrew, and tried to use it to pull it out. It still wasn't enough.  So he got an assistant to stick their fingers up the patients arse from the other end whilst also pulling on the corkscrew, and with " a force enough to lift the patient off the table", popped the baseball out.

McDonald M.P.T. & Rosenthal C.D. (1977). An unusual foreign body in the rectum—A baseball report of a case, Diseases of the Colon & Rectum, 20 (1) 56-57. DOI: 10.1007/BF02587455

TMI Friday: Using a Bottle for a Throttle

Today we once again must again take a look at men who take incredible risks in order to find new and grotesque methods of masturbation. You have been warned.

This week, the object of their fascination is.. the plastic bottle. 

In the grand scheme of things, at least the plastic bottles don't have spinning blades inside them, so in theory, these individuals are better off than those who turn on the vacuum cleaner for stimulation.

The first case we shall be examining comes from 2004, when a 27 year old man in India was admitted to hospital with a peculiar problem. His penis was stuck in a hard plastic bottle. There apparently were no attempts at an excuse, just the simple explanation that he had attempted to use it for masturbation. They called in the hospital carpenter to cut away the bottle *very* carefully using an Iron cutting saw. After 15 minutes of struggle, the bottle was removed.

In 2009, a 77 year old man in Singapore was admitted into hospital with complaints of blood in his urine, and difficulty urinating. Initially he wasn't forthcoming about his case history, for reasons that will soon become clear. You see, one week previously he had pushed a 1.5 litre bottle over his genitals, and got stuck. Over the next 3 days, he managed to cut away most of the bottle. But he still couldn't remove the neck of the bottle, despite attempts at lubricating it with soap. The surgeons managed to pry off the bottle neck with scissors, and they managed to repair some of the damage, but he died 3 days after admission.

The third case we will look at came from 2010 , and also occurred in India. A 47 year old man came in 14 hours after attempting to masturbate himself with a plastic bottle. That in itself is not the hair raising part of this case. We are told that the bottle neck was placed in such a position that it was impossible to access with a normal cutting device. So what did they use ? A soldering iron. Think about that. They mitigated the heat somewhat through adding cold saline in order to regulate the temperature. Still, it's not exactly a pleasant thought.

The final case I'll be talking about involves a 58 year old man. His flatmate called an ambulance for him after recognising that he was behaving oddly. But he sent them away, claiming that he didn't have anything wrong with him. Two days later his flatmate found him dead. The autopsy revealed that his genitals had been constricted with a plastic bottleneck. This bottleneck had cut off the circulation to this region, and allowing parts of his genitals to begin decaying. This lead to bacteria entering the bloodstream, and eventually caused multiple organ failure.

So how could these people stick their members into such small openings, and then get stuck. In order to answer this, we must examine how the penis works. Essentially it is a balloon filled with blood.  To become erect, arteries dilate in order to increase blood flow. However, if the veins that take the blood out of the penis are constricted, by say, a plastic bottleneck, then blood takes longer to escape, and so it swells up and gets stuck. This can actually be very dangerous. when the circulation is cut off, it can become gangrenous and in severe cases of penile strangulation, the only option is amputation. this is not even the worst case scenario, as we have seen, if this is not dealt with as soon as possible, then there is a risk of death.

 Penile strangulation appears to have a higher body count than men who stick their appendages into the whirling blades of a vacuum cleaner !

References

Jain S., Gupta A., Singh T., Aggarwal N., Sharma S. & Jain S. (2004). Penile strangulation by a hard plastic bottle : A case report, Indian Journal of Surgery, 66 (3) 

Ooi C.K., Goh H.K., Chong K.T. & Lim G.H. Penile strangulation: report of two unusual cases., Singapore medical journal, PMID: 19296009

Shamrao Kumbhar U., Dasharathimurumu & Bhargavpak (2011). Acute penile incarceration injury caused by a plastic bottle neck., International Journal of Biological & Medical Research, 2 (4) 

Morentin B., Biritxinaga B. & Crespo L. (2011). Penile strangulation: report of a fatal case., The American journal of forensic medicine and pathology, PMID: 22101437

TMI Friday: An Unusual Rectal Injury

The year was 1953, it was the fifth of November and a 24 year old man stumbled into Beckett Hospital complaining of abdominal pains. He told the doctors that it was a regular occurrence, that he had been plagued by abdominal pain for the past ten years. He told them that the evening before, he had noticed blood issuing from his bowels, and that he had vomited that morning.

As the doctor noting his horribly swollen and tender belly, he fainted.  This made finding the source of the problem more difficult. The doctor checked for tumours, and ended up trying to perform a proctoscopy. This involved the insertion of an instrument known as a proctoscope up the anus in order to get a look at the inside of the rectum. However, the copious amount of blood and faecal matter belching from the anus made it impossible to see anything.

This called for more drastic measures. The patient was anaesthetised, and the abdomen was opened up to get some idea what was going on. The abdominal cavity was full of blood, that was likely caused by some form of internal bruising. In the absence of an obvious injury, the abdomen was closed up. The doctor took another examination of the rectum, which was easier now that the patient was sedated, and found the source of the bleeding, a three cm rip in the rectum. With this established, surgery was performed to heal the wound, and to reverse the damage. But an important question still remained.

How did this injury occur ? Clearly, the patient had not told the whole story about what had happened to him. The three centimetre rip was clearly caused by a traumatic injury. The patient admitted this, and then gave them another explanation for what happened.

It was the fifth of November, Bonfire night, where the English stage fireworks displays to celebrate the foiling of the gunpowder plot. The man said that he had bent over at the wrong moment, and a carefully aimed firework had shot up his anus.

But this story didn't make sense. There would be damage to the anal sphincter and the butt cheeks had this been the case. When confronted with this evidence, the man told them a third story. I shall now quote directly from the article.

For domestic reasons he had become unhappy and morose, and on the evening of November 4 he decided to explode a firework up his seat. He accordingly fashioned a narrow tube, using cartridge paper, and with the aid of a pencil introduced one end of this tube, approximately 6 inches (15cm.) in length, into his rectum. He then placed a lighted firework into the end of the tube projecting out of his anus...

This story still left the question as to where the firework went, as no fragments were found. and there was a distinct lack of singeing. It is possible that the sheer volume of effluence issuing from the anus could have washed out the bits of firework. The patient maintained their story under psychiatric evaluation, so we must assume that this was the true story.There is no escaping the image of a man not only lighting a firework up his own anus, but then hitching up his pants and waiting until the next day to actually go to hospital.
The frustrating thing about this tale is that the patient went to some length to deceive the doctors with a fake medical history. Had he told the doctors the truth, he would have been put under anaesthesia, and have been treated more rapidly. That is one of the lessons we can draw from this study, aside from the obvious one.


Butters A.G. (1955). Unusual Rectal Injury, The British Medical Journal, 2 (4939) 602-603. DOI: 10.1136/bmj.2.4939.602

TMI Friday: Vacuum Cleaners Suck

When you look at a vacuum cleaner, what do you see ? A tool perhaps, to help you deal with the crisps trodden into the carpet from a party the night before. A way to keep armies of dust from taking over your house and to frighten your pet dog. 

But there are some people (Who am I kidding, It's men.) who look at vacuum cleaners in a different way. Who observe the coquettish expression on a Henry vacuum cleaner and contemplate a universe of intimacy. Not much is known about these people. Are they a real sub-culture ? Do they compare notes on Rule 34 ?

What we do know is that these individuals tend to end up in an emergency room, crossing their legs out of embarrassment and to stem the flow of blood.

Dr Ralph Benson, in his article "Vacuum Cleaner Injury: A Common Urologic Problem ?", he examines  five cases where men had attempted intimacy with these household implements... and suffered the consequences.  All of these cases occurred when  men attempted to use vacuum cleaners as masturbatory aids. I don't want to get into the details of the injuries, but the words "laceration" and "penis" should give you an idea of what happened. If you don't know what the terms "avulsion" and "degloving" mean, then don't worry, the paper comes with helpful photographs. Why not download the paper and look at them ?

Dr Benson notes in the paper that the cases he describes are not isolated incidents. Reports of vacuum cleaner injury go right back to the 1960's. But the interesting thing that Dr Benson notes is that even though he lived in a relatively small town,  he encountered a cluster of these vacuum cleaner cases. In the absence of a tangible connection between these people, he came to a somewhat incredible conclusion. 

His conclusion was that this was not an isolated cluster of vacuum abusers. Instead , he suggests that vacuum cleaner abuse may be far more common than is generally recognised. He notes that often, people will lie about the causes for the injury, and will only reveal the truth if the doctor subjects them to more intense questioning. He proposes that in busier emergency rooms, medics don't have the time or the inclination to probe into these lies, and just get on with repairing the injury.

Nevertheless, there is an important lesson in here, that I never would have thought needed to be iterated, but nonetheless here it is- Do not stick any part of your body into a hole that contains whirling blades.

C. Benson R. (1985). Vacuum cleaner injury to penis: A common urologic problem?, Urology, 25 (1) 41-44. DOI: 10.1016/0090-4295(85)90561-8

TMI Friday: A Vexacious Consequence of a Vasectomy

It was an emergency. The patient was 51 years of age, running a high fever, and pain and swelling in a particularly sensitive area, in which an operation had been performed a week previous. Gentlemen of delicate dispositions may wish to avoid reading further, for that operation was a vasectomy.

The purpose of a vasectomy is contraception, to make sure that a man cannot impregnate a woman with his sperm. A vasectomy works through preventing sperm from escaping from your testicles, where they are manufactured. It does this by cutting the vas deferens, the tube through which the sperm travel out of the testicles. This procedure has become relatively advanced in recent years.

The gentleman in question had a "No scalpel" incision vasectomy. This has a number of benefits , not least that it doesn't involve a scalpel being wielded near to a "gentleman's dangling region". It its quicker, leaves a tiny operation scar, which means less bleeding pain and infection, and more importantly, a quicker return to sexual activity. 

The 51 year old gentleman however had clearly acquired some form of infection after the operation. Infection after a vasectomy is generally uncommon. They then found the identity of the bacterium causing this infection. It was Streptococcus pyogenes, the bacterium that commonly causes sore throats. Long time readers of this blog probably have some idea of where this is going...

His wife had been looking after their children who were suffering from sore throats. And unbeknownst to anyone, the Streptococcus pyogenes had been passed to her, and was settling on her tonsils. The night before the fateful emergency visit, she and her husband had an intimate moment. During this process, the bacteria on the wife's tonsils somehow ended up on the husbands genitals. The paper describing this clinical case describes the infectious process that followed:

It is reasonable to assume that the vasectomy incision was only superficially healed, and therefore, violated and impregnated during the “trauma” of oral intercourse.

This is one of those cases where a series of events coincide, which results in a bizarre disease complication.

That was my TMI Friday, I hope you endured it as well as I did.

Ramaswamy K. &; Kaminetsky J. (2011). Unique Infective Complication after Routine Vasectomy: A Case Report, The Journal of Sexual Medicine, 8 (9) 2655-2658. DOI: 10.1111/j.1743-6109.2011.02345.x

TMI Friday: Taking a Bite out of Love

Love isn't commonly encountered within the medical literature. The romantic lives of two people in love is a subject that rarely requires the attention of a doctor.

But occasionally in the violent throes of a passionate embrace, there is an emphasis on the violence. With this in mind, let us consider the Hickey.

Once when I was in school, I met up with my friend and the first thing I said to him was "What the f**k happened to your neck ? Did you get attacked ?" at which point I realised the girl next to him started to giggle.
I later learned that during the violent throes of passion, that occasional nibble may occur, leaving a bruise, or just a red mark. But on occasion, some couples go a little bit too far. This is where medical professionals get involved.
In a set of case reports published by the British Journal of Surgery in 1990, 7 cases of what are described as "Traumatic" love bites are reported. I shall summarise them below

1. Patient 1, a 35 year old man, came into hospital complaining of a hard lump in his shoulder that had been bothering him for long time. It was a worrying lump, and the doctors initially suggested that it was some sort of cyst. When they removed the cyst, they were dismayed to find... a plastic tooth. It turned out that he had engaged in intimate relations with a lady who was not only dressed as a vampire, but possessed an incredible commitment to the lifestyle.
2. Patient 2 arrived at the hospital with an abscess in his neck that was swollen with bacteria, caused by a particularly violent love bite that had happened 3 weeks previously
3. Patient 3 arrived at the emergency room, bleeding from the jugular vein that was caused by deep bite marks that had been inflicted 2 hours earlier under undisclosed circumstances.
4. Patient 4, a 26 year old woman had been suffering from cellulitis in the neck for about 3 days before she went to hospital, and later confessed it was due to "ferocious love biting" by her boyfriend, and in response, the surgeons gave her a course of antibiotics and also a tetanus shot.
5. Patient 5 appeared to accept some form of responsibility for the infected wound on his neck, as the wounds were inflicted after he had returned from a long holiday by his "frustrated" girlfriend.
6. I feel sorry for Patient 6, who had to cut off her honeymoon early after her drunken husband accidentally bit off her left nipple. The doctors don't mention the fate of this relationship, but I would be very surprised if "Divorce" was not a key feature of it.
7. Patient 7 suggested that the primary reason for the infected injury in the left breast was due to the short stature of her paramour.

Only in two of these cases is the injury in itself severe enough to merit an immediate visit to hospital. The majority of the problems caused by these human bites come from infection. The human mouth is generally full to the brim with bacteria, that could potentially become hazardous if introduced into a wound.

When one attempts a lovebite, always remember to take a sensible nibble, if you end up with a mouthful of blood then you are probably doing it wrong. Unless you are a vampire, in which case, check that you still have all of your teeth at the end of it.

Al Fallouji M. (1990). Traumatic love bites, British Journal of Surgery, 77 (1) 100-101. DOI: 10.1002/bjs.1800770134

The Early Emergence of Antibiotic Resistance

The development of resistance to the antibiotics is a phenomenon of great theoretic interest to a bacteriologist, and it may some day become a matter of major concern to the clinician.

This is the opening line in C. Phillip Miller's paper on the development of resistance to antibiotics, which he published in 1947. Penicillin had only just been in production for five years. It was saving countless lives. It was emerging as a miracle drug. But even in this relatively optimistic era, a number of scientists were getting a taste of things to come.