The Post Antibiotic Era will take your job away.

In 1934, The Los Angeles Milk Commission gave its employees devastating ultimatum- lose their tonsils or lose their jobs. When our antibiotics stop working, your employer may force you to make a similar choice; and they'd be right.

Infectious bacteria are developing resistances to our medicines at alarming rates, and we are entering a Post-Antibiotic Era. If you want to know how people will cope in this new era, the best place to look is in the past. In the era before antibiotics.

 In the early 1930's, scarlet fever and strep throat were much more common than they are today, and much more hazardous. In the worst case scenario, a sore throat could develop into full blown sepsis.

So when a report was published in 1931 describing 71 outbreaks of this disease that could be traced to one common factor, people paid attention. That common factor was milk contaminated with bacteria named Streptococcus epidemicus. These bacteria tended to infect the udders of cows, causing mastitis. Since the udders also happen to be where the milk was produced, bacteria inevitably spread to the milk.

Needless to say, these outbreaks needed to be brought under control.

That responsibility fell to the Los Angeles Milk Commission,  implemented a number of rules to prevent any more outbreaks occurring.

The first step was to find any dairy cows infected with the disease. Fortunately, there were already rules in place for this. Cows needed to be certified to be free of S. epidemicus, and any infected cows needed to be isolated from the rest of the herd.

Here is the problem. Both humans and cows could carry S.epidemicus. To control any outbreaks, the same restrictions that applied to cows had to apply to the humans who worked with them. Humans could carry S. epidemicus without any symptoms, and appearing perfectly healthy.

Out of a thousand employees tested, fifty were carriers. This was devastating. They could no longer be allowed to work, for the risk of them causing an outbreak was unacceptable. 

There were no available antibiotic treatments to allow these carriers to rid themselves of S.epidemicus, but that didn't mean there were no options. It was known at the time that S. epidemicus survived in human tonsils. If the tonsils were removed, then the bacteria would have nowhere to go, and die off.

In a quote from the Director of the milk commission:

"care is taken in each case to impress upon them that the procedure is not compulsory except that otherwise they must retire from employment at certified dairies"

Basically, the procedure was only compulsory if the workers wanted to keep their jobs.

Unsurprisingly, most of the workers chose to go through the operation.

But sixteen of the infected employees either refused to go through with it, or were refused on the basis of underlying health issues that could render such an operation life threatening. These people were forced out of their jobs, and any dairy in the area was given their details should they attempt to apply for another job in the milk industry. Essentially, they were blacklisted from the industry.

You can say it was cruel that employees were forced into this situation, and you're not wrong. But it was an awful dilemma, and one that is destined to repeat. In a world without antibiotics, people who become carriers of diseases may remain carriers for the rest of their lives. Through no fault of their own, these people will pose a threat to the rest of the population, and it will hurt their chances of working in certain jobs. Would you send your kid to a school where a teacher constantly infects their students with life threatening illness ? Or buy groceries from a man with chronic diarrhoea? Allow yourself to get treated by Typhoid Mary?

 None of those sixteen workers ever suffered any symptoms. They may spent their life working in the dairy industry, only to be cast aside. They at least had the option of getting surgery to prevent them from being carriers. Not all bacteria are polite enough to live solely within an easily removed organ. 

The Post-Antibiotic Era is coming, and it won't just affect "sick" people, it will have wider effects throughout society. If there is one lesson we can learn from this eighty year old paper, it is that you don't even have to be "sick" for bacteria to ruin your life.

*Streptococcus epidemicus is a defunct classification that tends to be refer to what would be called S. zooepidemicus these days, and S. pyogenes.

Bonynge C.W. (1934). Solution of the Streptococcus Carrier Problem *†, American Journal of Public Health and the Nations Health, 24 (10) 1031-1034. DOI: 10.2105/AJPH.24.10.1031

TMI Friday: When you've literrally had your Chips

The victim of this weeks TMI friday didn't really do anything wrong. In fact, this is less of a TMI Friday than a FML Friday, but it's an odd story that perhaps you'll find interesting, and perhaps learn from.
Our story begins with a 42-year old gym teacher who had hurt her foot. She didn't exactly know what could have caused the pain, but the point was that it was there. She had been enduring it  for four weeks, and her doctor had given her painkillers to help her get over the pain.
But it wasn't enough, but there are other things people can do to relieve pain, such as wrapping something very cold in a towel and applying it to the afflicted area. It usually works pretty well.
That was what this lady did. She wrapped a bag of frozen chips in a towel and rested it upon her aching feet. But then she fell asleep.
When she awoke forty minutes later, she found that the pain had subsided, but that her foot had now become swollen and red. The next day, the foot became discoloured, and her doctor prescribed her a course of antibiotics. The day after, she was in the emergency room with what was described in the paper as "third degree frostbite".
Frostbite causes blood vessels to constrict, which helps the body to retain heat, but reduces the blood flow to the extremities. Your extremities need blood, so not getting it can be pretty bad for them. When it gets cold enough for layers of skin to freeze, the real trouble begins, because this can cause the cells to die off, and can lead to blisters.  In this particular case, the cold compress froze the nerves and muscles below the skin, causing them to die off.
This is why physicians recommend that you always try to put some layers of fabric between you and the cold surface,and that you should never put on a cold compress for more than 30 minutes. Also, Chips are for eating.


Graham C.A. Frozen chips: an unusual cause of severe frostbite injury, British Journal of Sports Medicine, 34 (5) 382-383. DOI: 10.1136/bjsm.34.5.382

TMI Friday: Frippery Furrows Fanny

Jewellery, body piercing and other such frippery are usually harmless. A ring here, a piercing there. Humans have been using these accoutrements for millenia without problems. at least, problems they'll admit to.

In this weeks case, we look at a young lady who repeatedly suffered from vaginal bleeding after sex. There was nothing wrong with her menstrual cycles, and there were no signs of bleeding outside of sex. 

She had been suffering with this problem for seven months.

Further examination of the lady's delicate area revealed abrasions and lacerations. 

She then admitted that her boyfriend wore penile jewellery of the ‘Prince Albert’ type. This information shed light on the aetiology of the post-coital bleeding as well as the bizarre vaginal findings

With this revealed, the doctors furnished the woman with the rather obvious advice that she should get her boyfriend to remove his penile adornments before the engaged in copulation*.


Esen U.I. & Orife S. (2006). Penile jewellery: a cause of post-coital bleeding, Journal of Obstetrics & Gynaecology, 26 (5) 483-484. DOI: 10.1080/01443610600766884
*I got a thesaurus for Christmas.  Apologies.

TMI Friday: How long ?

This weeks victim/perpetrator showed up to Hirosaki hospital with blood in his urine. The doctors spotted that he had a foreign body that had wormed it's way up into his bladder, but they couldn't quite work out what it was. An x-ray revealed five cm diameter blob, but how could such a large object get up there in the first place ?
The patient revealed the answer. His suffering began when he inserted a long vinyl tube up his urethra.
How long had it been there ?
Two years. 
How long was it ?
One and a half metres.
I don't know if the Guinness book of world records recognises the accomplishments of people who stuff things up their own schlongs, but if they did, I suspect the gentleman in this study could be a world record holder.
Just don't try to break his record at home. Or in public.

 Imai A., Suzuki Y., Hashimoto Y., Sasaki A., Saitoh H. & Ohyama C. (2011). A Very Long Foreign Body in the Bladder, Advances in Urology, 2011 1-2. DOI: 10.1155/2011/323197

TMI Friday: The Grinch Syndrome

Last week, I blogged about the "Santa Claus" Syndrome. Taking inspiration from the "Worst ever Christmas story ever" from the "Gremlins" film, I clawed through the medical case literature to see whether there was any truth behind this story.
After much googling, I tracked down a paper entitled "The Santa Claus Syndrome", which appeared to answer all of my questions, but was locked behind a pay-wall. So I posted the awesome abstract of the paper and left it at that.
But I must have been a good little boy this year, because Santa* left me a present underneath my Christmas tree. A copy of the full paper !
So gather 'round children, you are in for a gruesome tale.

Our story begins with a 17 year old burglar who saw a tempting target of opportunity. It was in the early morning hours, the sun had not risen, and the store was empty. The doors were locked, but our enterprising thief noticed that the owners had left their chimney unguarded. I imagine a Grinch like smile crossing his face, and him rubbing his palms together. For he would not be going down that chimney to give presents, like Santa Claus. The plan was sheer elegance in its simplicity.

The paramedics found him fourteen hours later, jammed in the chimney, his hand caught in a heat vent.
You might be wondering what happens to someone when they get stuck in a chimney. I am here to give you the facts in all of their gory details.
They managed to get the burglar out of the chimney and he was immediately transported to a burns unit. His nostrils and tongue were coated with soot, and he had first and second degree burns all over his chest, abdomen and lower body. But it wasn't just the burns that were the problem for this young gentleman.
He was also covered in pressure sores. These occur at points on the body where bone is close to the surface of the skin (like your elbows, or your knees).  When you put pressure on these "bony prominences", the skin, the bone squeezes and tears at the body tissue it's pressing against.
 Effectively, the burglar's skin was been worn away, with the chimney acting as the pestle, and his very bones acting as the mortar.
The tissue around the burglars knee had already been severely damaged, and had become "Necrotic", and his hand had become infected and "gangrenous". But these weren't even his biggest problems.
His biggest problems was that there really wasn't much oxygen in that cramped chimney shaft. The oxygen levels in his blood were dangerously low. They intubated him, but his condition just kept getting worse.
He was soon suffering from "Acute respiratory distress", which happens to the cells of the lung that have suffered from so much injury that the immune system kicks into overdrive. In order to get as many immune cells as possible into the lungs, the blood vessels entering the lungs become "leaky". They leak fluid into the lungs as well as inflammatory cells, essentially flooding the lung. It's not unlike drowning.
The physicians prescribed steroids in the hope that they would bring this under control, as well as giving him antibiotics for his infection and intravenous fluid to keep him hydrated.
Yet it still got worse. The burns he had sustained, combined with the severe pressure sores and the gangrene had lead to his muscles breaking down. All muscles contain a compound known as myoglobin, which is like haemoglobin in that it stores oxygen, but only to be used for the muscles. Whilst it is useful, it is also very poisonous to the kidneys if a large amount of it enters the blood stream.
The burglars muscles had been damaged to the point that they were now leaking myoglobin into his blood, and his kidneys were now shutting down. The doctors put him on dialysis to take the pressure off the kidneys.
But his gangrene had now effectively "mummified" the patients hand, leaving it shrivelled, dried out and dead. The surgeons were forced to amputate his whole arm to prevent the spread of the gangrene.
Various parts of his "lower extremities" suffered from the burglar having been stuck so long in an upright position. The blood had flowed down to his legs under the pull of gravity, raising the pressure in his lower limbs, giving him "Compartment Syndrome".  The surgeons treated this by cutting the affected areas open so that the pressure can be relieved.
But all of this was for nought, because on the twelfth day after admission, the patient suffered from cardiac arrest and died.

The physicians who had attended this unfortunate ill fated burglar recognised that actually, people get stuck in chimneys more often than you would think. There were a number of cases reported in newspapers of people getting stuck in chimneys during burglaries, or in the process of performing pranks, many of them with fatal consequences. So the researchers devised the "Santa Claus Syndrome". These are series of specific symptoms for other physicians to watch out for if they need to treat someone who had been stuck in a chimney, so that they would have enough preparation to save their patient.
This paper was published in 1994 , and should have been a warning for us all. But housebreakers are still dying from getting stuck in chimneys.
It should be clear now that only Santa Claus is able to enter a chimney with his magic. The poor grinch is probably still stuck in some abandoned chimney in Whoville, legs swollen like melons,  skin crackling and popping from the heat, and desperately inhaling lungfuls of soot and ash.

HAPPY HOLIDAYS !

Boglioli L. & Taff M. (1995). The Santa Claus Syndrome' Entrapment in Chimneys, Journal of Forensic Sciences, 40 (3) 499-500. DOI:
*or an interested reader of the blog, who I'm assuming wishes to remain nameless, but I wasn't really very clear on that.

An Unpleasant Pheasant

Winter is open season for pheasant hunting. Families and friends come together to bond over the hunt. Dogs are released into the underbrush to scare up a few of the birds into the gunsights of the shooters.

But there are occasions when the prey can turn the tables on their predators, to spit their last breath at them in defiance. 

Our story regards a man, who was trying to impress his wife with his shooting. She was sat behind him, watching him as he shot at panicked pheasants. Her husband managed to hit one low flying pheasant as it was headed towards them. 

Although the pheasant had died, the laws of momentum allowed it to maintain it's trajectory. Had it been alive, it may have been able to manoeuvre out the obstacle that intersected with the aforementioned trajectory. Thus, it hit that object square on at full speed. That object was the man's wife with enough force to burst her spleen.

Enjoy your Christmas meal everybody !

Wilkinson M.C., Klein G., Cornell M. & Rainsbury R.M. (1987). The pheasant's revenge: an unusual zoonotic injury., BMJ, 295 (6613) 1659-1659. DOI: 10.1136/bmj.295.6613.1659

TMI Friday: The Santa Claus Syndrome

The Journal of Forensic Sciences has one article that I've been attempting to dig out with whatever resources I can muster, but all I could find was the abstract. Thus, I present it to you in it's full form now, until such time as I can find the full journal article and furnish you with the details.

In recent years, there have been sporadic reports in the lay press of individuals stuck in chimneys primarily during burglary attempts. Most of these individuals suffered from suffocation or soot inhalation. Because of the similarities between this form of breaking and entering and Santa Claus' traditional entrance into homes on Christmas Eve, we define the “Santa Claus Syndrome” as postural (positional) asphyxia, inhalational injuries and body burns, and/or complications related to compartment syndrome due to entrapment in chimneys. We report a case of a man who became trapped in a chimney during a burglary attempt and died a delayed death due to postural asphyxia associated with inhalational and burn injuries and anterior compartment syndrome. An analysis of this unusual case is presented. Exhaustional and postural asphyxia, compartment syndromes, and confined space-hypoxia syndrome are also discussed.

 Basically, if Santa Claus isn't dead already, he is probably some kind of horribly injured zombie.
 G'night kids !

Boglioli L. & Taff M. (1995). The Santa Claus Syndrome' Entrapment in Chimneys, Journal of Forensic Sciences, 40 (3) 499-500. DOI: