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Tuesday, September 30, 2014

Water Safety at the Jersey Shore

As the summer season winds down, we’re heading away from the many beaches, and toward drier fall activities. Although we’re heading away from the water, we shouldn’t lose sight of the dangers that can lurk on the many beaches along the Jersey Shore. New Jersey has roughly 130 miles of coastline that offer everything from boardwalks and fishing to swimming and surfing, and with all those activities come the risk of drowning. This is not to say that the beaches are dangerous, but safety should always be a concern whenever you get near the water.

The CDC reports that ten people die each day from unintentional drowning, and roughly two in ten are children aged 14 and younger. Additionally, drowning is the fifth leading cause of unintentional injury and death in the US. Roughly 81 percent of water incidents are attributed to riptides – strong, narrow currents that form as waves and travel from deep to shallow water. Riptides move away from the shore and anyone getting caught in one could be easily pulled into deep water. Although many beaches have lifeguards on duty, it is important for you to understand what to do if you, or someone you know, are caught in a riptide, as well as how to administer CPR in the event of drowning.

Responding to a Riptide

For many people, the first response is to fight against the tide to remain close to shore. While this might seem like a reasonable reaction, doing so can actually make the situation worse. Riptides are so strong that even a Michael Phelps-level swimmer can be easily overcome. Fighting against the current will actually tire you out, making you unable to return to shore once you are out of the current’s grip. That exhaustion will make you more prone to drowning. The following steps can actually increase your chances of escaping the riptide safely:

1.  Remain as calm as possible. Panic can lead to poor decision making;

2.  Riptides are shaped like a funnel with a wide base at the shore that tapers to a narrow neck, then widens to a head at the deep end. Swim along the coastline, which will take you across the current instead of against it, and eventually out of the riptide. Keep your eye on the coastline to make sure you are swimming in the right direction;

3.  When you are out of the riptide, swim toward the shore.

If you are unable to swim across the riptide, remain calm and float on your back or tread water and let the tide carry you out until you either exit the tide naturally, or are able to start swimming across. Always keep your eyes on the coastline.

If you are unable to escape the tide at all, draw attention to yourself by waving your arms and yelling to shore.

If you see someone else stuck in a riptide, do not attempt to enter the water to help. Call 911 or find a lifeguard.

It’s also a good idea to be aware of the conditions that could cause riptides, such as offshore storms.

Finally, you should always take care never to swim on a beach that is deserted or does not have a lifeguard on duty.

Learning CPR

CPR, or Cardio-Pulmonary Resuscitation, is not only handy in drowning situations, but in any situation where someone might stop breathing. You can find several online CPR references for adults and children, but they won’t give you all the information you need. CPR is a delicate procedure that you can only really learn through practice and there are several CPR classes in NJ that can teach you the correct way to administer adult, child, and even infant CPR.

The great thing about these classes is that they are offered year-round, which means you can earn your CPR certification during the off-season and be prepared when you head back to the beaches in the summer.

If you do choose to get CPR certification, you will need to keep it up to date by taking refresher courses every year or so. This is because the America Red Cross is constantly updating the procedure to make it safer, more efficient, and save more lives

This is a blog post by Nancy Evans.

Thursday, September 11, 2014

The Woman Who Claimed She Urinated a Bullet

While urinating a worm is physically possible as described in a recent blog post, there is an early medical report from 1668 of a woman urinating something even more incredible…a bullet. The story goes like this.

A large, pale, woman by the name of G. Eliot in Suffolk, England was tormented with intestinal problems for many years. She was persuaded by a neighbor who had similar problems to swallow two bullets.  It is not stated what the logic was behind how swallowing bullets would supposedly help. The woman claimed that she felt better initially after swallowing the bullets but that the pains returned and increased.

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After 15 years of continued symptoms, she presented to Dr. Nathan Fairfax’s pharmacy.  He prescribed her something called Lady Hollands powder that was mixed into a hot drink. She vomited over night.  When using the bathroom the next morning (which was referred to as the chamber pot), she urinated when a thwang was heard on the side of the vessel.  This reportedly surprised her and led her to wonder what it could be. So she poured the urine and saw a heavy gravelly stone that was yellow-red in color and as big as the end of a thumb. However, this is based solely on self-report.  She reportedly took a hammer, knocked off the outer crust, and found a bullet enclosed in it. She then reportedly cut it a little with a knife and found lead within it.

Dr. Fairfax asked her if she had ever urinated bullets before and she said no, including the other bullet. Recollecting back to when she swallowed the two bullets, she stated that she checked her feces slightly for days afterwards and never found the bullets and so she gave up. She stated that the bullet was smaller compared to when she originally swallowed it.  Before and since that time, she stated that she urinated an abundance of red gravel.

Ms. Eliot stated that when she voided the bullet that it felt like a kidney stone but that it lasted longer (i.e., weeks),  caused her to bow forwards, and led to vomiting.  She claimed to feel it move lower from the kidney to the bladder.  Dr. Fairfax asked her if she was sure that the bullet came from the urine and she assured him that it was and that she was not mistaken. Dr. Fairfax stated that the bullet did have a gravelly coat. Since she passed the bullet, she stated that she still had kidney stone pains but not as bad as before.

Dr. Fairfax stated the tale strengthened his belief that there must have been a passage from the stomach to the bladder but in reality, there is no such passage.  He believed that nature had found a way to finally rid the body of something it found offensive. Basically, his argument was that the body works in mysterious ways.

This story is a good lesson that highlights the problem that arises when health care professionals rely on self-report , despite claims that the self-report is definitely not mistaken. What this woman described is actually anatomically impossible. There is no known mechanism by which someone can swallow a bullet or any other foreign object and have it passed from the stomach to the kidneys. When solid objects and liquid enters the stomach from the esophagus it goes directly to the small intestines. The blood picks up excess fluid and is filtered by the kidneys but there is no way for the blood to transfer a solid object from the small intestine to the blood and into the kidneys.

Thus, either Ms. Eliot made the story up and showed the doctor a bullet that was not the one she swallowed or she or Dr. Fairfax misperceived the middle of a kidney stone as a bullet. Incidentally, there is no report in the modern medical literature of a foreign object being passed out of the body through the urine.

Fairfax, N. (1668). An Extract of a Letter, Written by Dr. Nathan. Fairfax to the Publisher, about a Bullet Voided by Urine, Philosophical Transactions, 40, 803-805.

How a Flower Can Kill a Rattlesnake: The Medical Dangers of Pennyroyal Oil

While doing some historical medical research from the 1600s, I recently came across a fascinating account of how people in Virginia used a common flower to kill rattlesnakes. The story was relayed by Captain Silas Taylor to members of the Royal Society in England, who were always interested in hearing new discoveries from places overseas.

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Captain Taylor spoke about how colonists in Virginia used a plant known as pennyroyal (pictured below) to kill rattle snakes. He noted that the leaves of this plant produced a very hot sensation when placed on the tongue.  So the colonists took some of the pennyroyal leaves, tied them to the end of a long stick, and held them by the nose of the rattlesnake.


When exposed to the pennyroyal leaves, the rattlesnakes would turn and wiggle and do whatever they could to avoid it. But the colonists were persistent and eventually the rattlesnake died in less than 30 minutes from the scent of these leaves.

How is this possible? Medical science has the answer. As it turns out, the essential oil in pennyroyal is very high (up to 90%) in pulegone. This oil is highly toxic, particularly to the liver, even at very low levels. (e.g., one ounce). The rest of the oil is made up of similar toxins. Human consumption of just a half a teaspoon of the oil can result in death.

The high toxicity of pulegone is mainly due to methofuran, an organic chemical that the body converts the oil into. Pennyroyal oil can cause seizures, fainting, failure of multiple organs, acute (sudden) kidney and/or liver failure, brain damage, hallucinations, paralysis of respiratory muscles, failure of the heart and lungs, coma, and as mentioned, death. In humans, the toxicity usually occurs a few hours after ingestion, but if one held the flower over the rattlesnake for 30 minutes, the constant exposure to the oils in the flower could explain why death occurred during that time frame.

Pennyroyal oil causes damage to organs by depleting levels of glutathione, a natural chemical in the body that prevents damage to cells. Thus, when not enough glutathione is present, cellular damage occurs quickly.
Humans need to make sure not to ingest pennyroyal oil. For example, in 1996, two infants died because they drank a tea that was made with pennyroyal.  Dogs have died after licking this oil off of their fur. A college student who drank two teaspoons of pennyroyal oil in teas died two days later in 1994. Thousands of years ago, pennyroyal oil was actually used to terminate unwanted pregnancies. It is also used as a powerful insect repellent.

Reference: 1665 (author unknown). Of A Way of Killing Rattle-Snakes. Philosophical Transactions, 3, 43.

Tuesday, September 09, 2014

Worms in the Urine: Strange Facts

Many people have heard of parasitic worm infections in their animals and even in humans. In those cases, people generally are familiar with worms being found in the fecal matter. However, many people are unaware that people can actually urinate worms. The reason is because some types of worms can infect the urinary tract.

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One type of worm infection is trichomoniasis, but these worms are microscopic. Another worm infection is schistosomiasis, which is caused by a worm called a fluke. This can cause severe kidney failure, blood in the urine, blockage of urine flow, and can eventually result in bladder cancer. In cases of fluke infection, worm eggs are released in the urine from the worms that live in blood vessels around the urinary bladder.

 Another parasitic worm infection is filariasis, which is threadworm infection. This can cause lymph fluid to enter the urine and a severe enlargement of tissues (elephantitis).  Yet another parasitic worm infection that can rarely present in the urine is strongyloidiasis which is caused by a type of roundworm.  Sometimes, the worms are living and swimming freely in the urine.  Identification of worms such as these in urine samples can sometimes prevent fatal health outcomes as these conditions are often treatable and reversible with medication.

Another type of roundworm infection that can rarely present in the urine is Ascaris lumbricoides (see picture above, image copyrighted by the Journal of Postgraduate Medicine).  These worms can live in the body for 12 to 18 months and can produce 240,000 eggs.

One of the earliest accounts of a worm present in the urine occurred in 1677 by a man named Matthew Milford. Mr. Milford noted that worm he passed was snake-headed and alive. He noted that it was small at the tail. He noted being very ill before hand and that since that time he had blood in the urine. He reportedly probably had urinary retention for some time. The worm presented on the second urine, leading the writer of the article to hypothesize that it descended from the kidney to the bladder initially and then out into the urine stream. The worm was then noted to be dead, dry, and a dull red color, with a thickness of 1/12th of an inch. It is unclear exactly what type of worm this was.

Reference : Ent and Milford (1677). A Relation of a Worm Voided by Urine; Communicated by Mr. Ent: to Whom It Was Sent by Mr. Matthew Milford. Philosophical Transactions, 140, 1009.

Monday, September 08, 2014

Babies that Turn to Stone: Meet the Lithopedions

Stone Baby from 1897

Earlier this year, an 84-year old woman in Brazil was found to have a 44-year-old fetus inside her (of 22 to 28 weeks gestation). The fetus had become calcified to protect the mother from the fetus’s dead tissue and possible infection. The calcified fetus is known as a Lithopedion, which is Greek for “stone child.” Lithopedions are commonly referred to as Stone Babies. They occur when a fetus develops outside of the womb, dies, is too large to be absorbed by the body, and calcifies inside the abdomen when medically undetected.

Stone Babies are extremely rare, occurring in 0.0054% of all pregnancies.One is pictured above from 1897 (copyright Bulletin of the Johns Hopkins Hospital).

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Women who carry a calcified fetus for decades generally do so unknowingly, as incredible as this may sound. See the case from 1677 discussed at the end of this article, for an exception. Although a Stone Baby can develop from any time between 14 weeks and full-term, the larger it is the more likely it is to be discovered. Age of diagnosis in the mother of a Stone Baby can vary across the life span, from 20 to 100 years.

Women can have additional future uncomplicated pregnancies while the Stone Baby is present because the uncomplicated pregnancy develops inside the womb unlike the presence of the Stone Baby outside of the womb.  However, the presence of a Stone Baby has been known to interfere with fertility by distorting the structure of the pelvis, impairing the pick-up of the egg cell.

While such women can have stomach pains from the calcified fetus, the pains usually go away at some point or are intermittent and can improve with pain medication. If the woman seeks medical care and an imaging study (e.g., x-ray) is not performed, then the real source of the problem goes undetected. If imaging is performed, a Stone Baby or a tumor may be suspected. Stone Babies are more common in counties where there is limited access to healthcare and in settings where health care providers are unaware of their existence. 

Various features of Stone Babies, including the face, can still be recognized even 44 years later. A 40-year-old Stone Baby was discovered in 2013. The oldest Stone Baby known was 60-years-old, found inside a Chinese woman in 2009. The youngest was less than 18 months in 2014. Ultimately, surgery is needed to remove it.

Fewer than 300 cases of Stone Babies have been reported in the past 400 years of medical literature, although the Arabic physician, Albucasis, described one for the first time in the 10th century. The earliest known Lithopedion dates to 1100BC. The first “modern” reported case dates back to 1582 when a 68-year-old French woman named Madame Colombe Chatri was found to have had a 28-year-old Stone Baby. Early physicians used to think that the cause of Stone Babies was a mystical force as they had not yet developed the scientific knowledge to explain their development.

In 1880, the German physician, Friedreich Kuchenmeister, published a review of 47 cases of Lithopedions, beginning in 1582. However, he missed a case from 1677, which is now summarized and referenced below. The case involved a Lithopedion that remained in the mother (Margaret Mathew) for 26 years. She was in the 9th month of her pregnancy and her water broke, but the baby did not come forth. Over the next 20 years, she had the perception that the child was still inside of her along with unspecified “troublesome symptoms.” She desired a surgeon to open her abdomen and relive her of the problem. However, over the next six years, she did not perceive the child to move.

The woman eventually passed away at age 64 and the surgeon then opened her abdomen. At this point, the Stone Baby was discovered, weighed 8 pounds, was 11 inches long, and was not joined to the mother. The head was downward and the skull was broken into several pieces. The brain and the flesh was red or yellow. The tongue was pink. The heart was red but contained no blood. The inner organs were blackish, The back part of the child was covered with a membrane that could only be separated with a knife. When this was done, barely any blood came forth. The forehead, eyes, ear, and nose were covered with a callous substance. The teeth were like those of an adult. Three days after it was removed, no bad smell was noted.

Reference: Bayle, M. (1677). A Relation of a Child which Remained Twenty Six Years in the Mothers Belly. Taken out of the Journal Des Scavans; Being the Extract of a Letter Written from Tolouse 22. June to the Author of That Journal, by Monsieur Bayle, M.D. Philosophical Transactions, 139, 979-980.

What Was It? The "Monstrous Birth" from 1677

Conjoined twins are identical twins who are joined together in the uterus. They have the appearance of one body with two heads.  If the faces are pointed in opposite directions, they are referred to as janiceps, although those can rarely survive due to severe brain abnormalities. Conjoined twins are rare, occurring between 1 in 49,000 to 189,000 births.  Most are stillborn (deceased at birth) and a smaller percentage dies soon thereafter.

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Conjoined twins are three times more likely to be female than male. Some are successfully separated through surgeries. Other live connected together throughout their lives. Some hypothesize the condition is caused by a fertilized egg not completely separating. Others believe the fertilized egg completely separates but that stem cells from one twin find similar cells on the other twin, fusing them together.  Most conjoined twins are fused from the upper chest to the lower chest although some are joined via other body parts.

The earliest known depiction of conjoined twins dates back to ceramics from the Moche culture in Peru from around the year 300 AD. St. Augustine of Hippo also wrote about conjoined twins in 450 AD in his book, City of God. It is unclear, however, if these descriptions and depictions were fictional or not. The earliest known documented case of conjoined twins dates to 942 AD when a pair was brought from Armenia for medical evaluation in Constantinople. 

Some other early descriptions of conjoined twins exist, such as from Arabia and England but the vast majority of case have been documented in the 20th century and beyond. This includes Chang and Eng Bunker (1811-1874) who were born in Siam (now Thailand) and thus became known as “Siamese twins.”

The Famous Siamese Twins
Because early documented descriptions of conjoined twins are hard to come by, I wanted to present how a London doctor in the late 1600s described a pair of conjoined twins he delivered (on 12/20/1667) when writing in a medical journal.

One of the most interesting descriptions is the title, “A Relation of a Monstrous Birth.” Such a description, while likely apt to the doctor who delivered the baby, would never be allowed in medical journals today because it would be considered offensive and pejorative.  Because English was written and spelled differently back in the 1600s, I will offer a modern translation of some parts of the article.

The first thing the author noted is that “It had two heads,” which sounds more like a sci-fi movie title to describe a monster (e.g., “It Came From Beneath the Sea”) rather than the opening line of a medical article. Modern journals would stick to using the gender, which in this case was female. Also interesting is that the name of the mother (Joan Peto) is listed, which would never be allowed today due to confidentiality protections.  She is also described as the wife of a butcher.

Both of the heads were described as very well-shaped, which is not unusual if this was a full-term delivery.  The left face looked swarthy (dark-skinned) and did not breath. The right head was perceived to breathe but not cry. Thus, one side appeared to be a stillbirth with the other side surviving to birth. The left head was bigger. This type of discordance between the left and the right is not uncommon in conjoined twins, likely due to genetic, environmental, and abnormalities in the placenta and/or in the circulation of the fetus.

The author says that between the heads was a protruberance, like another shoulder. The clavicles and breast were very large, about seven inches wide. The conjoined twins were of the parapagus variety, meaning they were fused side by side with a shared pelvis. There were two hands and two feet, although other conjoined twins are known to be born with four hands and feet.  The brain in each head was described as very large, indicating that the heads must have also been quite large, perhaps macrocephaly (abnormally large head), which is a known malformation in some conjoined twins. There were also two spinal cords, two pairs of lungs, and two hearts (on each side of the chest, the left heart being bigger). The lungs on the left were blackish and the other lungs looked well. 

The esophagus was divided into two branches, with one branch projecting to each throat. There was one aorta (the main artery in the human body) and vena cava (two large veins that bring blood to the heart).  The aorta and vena cava were divided into two parts, bringing blood to both hearts in the shape of a Y.

There were also two stomachs. One was shaped naturally but the other was shaped like a “great bag,” resembling what would be found in a cow or sheep.  The intestines contained a substance like meconium (early feces), similar to newborns.  The intestines were also large, as was the liver, spleen, uterus, and left kidney. Overall birth weight was 8 pounds. It is unknown what happened to the conjoined twin who was breathing.

Reference:  Morris, S. (1677). A Relation of a Monstrous Birth, Made by Dr. S. Morris of Petworth in Suffex, from His Own Observation: And by Him Sent to Dr. Charles Goodall of London; Both of the Colledge of Physicians, London, Philosophical Transactions, 138, 961-62.