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Friday, May 8, 2015

Abscess of the auricle gets drained


A while ago, I published a post with an assortment of videos showing yucky abscesses being lanced. Today, I've found yet another cool educational clip on YouTube where a painful, pus-filled problem is being tackled with a scalpel.





Some poor person has an infection of the auricle (that's the external part of your ear - also called the pinna), or more precisely - of that little hanging fleshy part where earrings are inserted, the lobe. The earlobe is very red, swollen and it looks like the condition must be agonizing to say the least. You can watch as the surgeon carefully injects some local anesthetic around the abscess, then makes an incision with a scalpel and a stream of whitish pus flows out. Afterwards, the surgeon packs the bleeding abscess cavity with gauze. Unfortunately, the text of the video is all in Spanish. The original video was posted on YouTube by one DrCarbonell.


Saturday, May 2, 2015

Early pharmacies at a glance


In ancient Greece and Rome, pharmacies were unknown - physicians prepared medical concoctions themselves, using herbs, vegetables, honey and animal parts. In the Middle Ages, both monasteries and castles had herbal gardens; medicinal herbs were carefully cultivated, dried and stored. (Even among the poor folk, a certain amount of herbal lore was common knowledge: every peasant's wife gathered wild herbs during spring and summer - mint and chamomile for stomach ailments, linden flowers for colds and fever, and so on). However, pharmacies as such were another matter. In German-speaking countries, they began to appear in cities from the 13th century onwards. The first pharmacy was founded in 1262 in Rostock. The next cities to follow were Hamburg (1265), Münster (1267), Wismar (1270), Augsburg and Magdeburg (1285). Apothecaries quickly became recognized as a separate class of medical professional; according to a law established in 1240 by Frederick II, Holy Roman Emperor, no physician could run a pharmacy or work in one.

Medieval illustrations depicting the interior of a pharmacy show a single room with many shelves containing jars full of various ingredients. A helper is frequently pictured, busily pounding something in a mortar. Apart from herbs and mineral salts, a number of fanciful and disgusting substances were used to prepare medications: insects, dried frogs and snakes, the fur, blood, entrails and other body parts of various animals (snake flesh was thought to cure leprosy, while patients suffering from kidney stones were treated with ashes from a burnt hare's corpse), as well as animal and human feces. Yes, certain ailments were actually treated with potions containing feces. Yum.

Apothecaries were forbidden to give medical advice to patients; their job was to prepare medications according to a doctor's instructions. Certain preparations were also available without a prescription; these were so-called confections, made from sugar, fruits and spices. They were very popular, but usually possessed little medicinal activity. Such spice- or fruit-based conserves, candies or lozenges could soothe a sore throat, alleviate a cough, help with bad breath (a common complaint before toothbrushes came into use) or - in the case of confections containing caraway seeds - relieve flatulence. As late as the 19th century, conserve of rose petals (along with asses' milk) was recommended as a treatment for tuberculosis of the lungs.

Before written prescriptions came into use, physicians would personally go to the pharmacy and issue instructions to the apothecary, using a long staff to indicate the - often richly decorated - jars that contained the required ingredients. If the patient was severely ill, the medicine had to be prepared at once; the doctor would return with the freshly made potion, electuary or ointment and oversee its administration.



A 15th century French apothecary. (Source: Wikipedia)




Wednesday, April 29, 2015

Almost 500 years ago: boiling oil for bullet wounds


In the sixteenth century, helping wounded soldiers on the battlefield became increasingly difficult and daunting. A new, deadly kind of weapon - firearms - had come into wide use, and military surgeons had to treat wounds of a kind not seen before. Since deep bullet wounds often led to gangrene, the belief arose (mostly in Italy and France) that the residue of burnt gunpowder on a bullet "poisons" the victim's entire body. To combat the supposed poison, boiling elderberry oil was poured into fresh wounds. Soldiers treated in this brutal fashion complained of terrible pain, but only rarely survived.

The man who put an end to this barbaric practice was Ambroisé Paré (1510-1590; pictured below), a French army surgeon. The son of a poor craftsman, he was apprenticed to a barber surgeon. In those times, a barber was a medical practitioner of a lower rank as compared to a physician. With no university education, possessing only sharp blades and dexterous fingers, barbers not only cut clients' hair and shaved their beards, but also performed a range of minor surgical procedures: bloodletting, tooth extraction, abscess drainage, stitching wounds, setting fractures and dislocated joints. They routinely accompanied armies, treating all sorts of injuries sustained on the battlefield. After Paré had learned this craft, he worked for three years as an assistant at the renowned Paris hospital, the Hôtel-Dieu.

In 1536 he became a military surgeon. During a campaign in the Duchy of Savoy, injured French soldiers were, of course, treated by scalding their wounds with smoking-hot oil - and, doubtless, rarely recovered. By a fortunate accident, Paré managed to discover just how useless and harmful this practice was. After a great battle, he had to attend to such a large number of wounded men that his supply of oil ran out. Dismayed, he treated the remainder by anointing their wounds with a salve prepared from egg yolks, rose oil and turpentine. On the next day, he found that - contrary to his expectations - the soldiers treated with boiling oil were all feverish and suffered terrible pain, while those treated with the improvised ointment were quite comfortable, and their wounds subsequently healed without complications. From that day on, Paré became an opponent of the "poisoning" theory, and the barbaric practice of scalding bullet wounds with oil eventually died out.

Paré is also credited - among other things - with crafting prostheses for men who had lost their upper or lower limbs (a not uncommon fate for a soldier in those days, since the only "cure" for a severely wounded arm or leg was amputation). Those prosthetic limbs were fashioned from articulated metal plates, like armor, and could be bent or moved, incorporating such cunning elements as mechanical knees, gears, catches and springs. Clearly, he was far ahead of his times in his thinking. However, it's a common but completely false stereotype that medical practitioners 500 years ago had few means at their disposal except bloodletting and prayers!



Saturday, April 4, 2015

Earwig in the ear



Does the mere possibility of an earwig entering your ear make your flesh creep? Or are you firmly convinced that rumors about ear-dwelling earwigs are nothing but urban legends?

Earwigs make up an insect order containing about 2,000 species in 12 families. Their characteristic feature is a pair of pincers on the abdomen. These insects are found throughout both Americas, Africa, Eurasia, Australia and New Zealand. They lead a mostly nocturnal life, hiding in small crevices during the day and coming out at night to feed on a wide variety of insects and plants. The scientific name for the order, Dermaptera, is Greek in origin, stemming from the words derma, meaning "skin", and ptera, "wings". The common term, earwig, is derived from the Old English ēare, which means "ear", and wicga, "insect". The name may be related to the legend that earwigs burrowed into the brains of humans through the ear to lay eggs inside.





A female common earwig (Forficula auricularia). 
Photo taken by fir0002 | flagstaffotos.com.au



Earwigs are not known to climb into external ear canals on purpose, but there have been anecdotal reports of earwigs being found in people's ears. Although these insects are relatively harmless and, in all likelihood, enter the ear only by chance, such an unwanted "guest" scrabbling about in the ear canal can cause a fair amount of pain and distress. Thus, there is a grain of truth in the ancient myth. A letter to the editor containing the following short report about an adventurous earwig was published in the Western Journal of Medicine in 1986.

"Earwigs are nocturnal, drab-colored insects of the order Dermaptera that are attracted to light and occasionally creep into homes. Their chewing mouthparts and forceps-like abdominal appendages give them a foreboding appearance.

The common name for these arthropods in at least six European languages incorporates a word for ear. The extended hindwing of some species resembles the shape of a human ear and [...] there is an ancient Anglo-Saxon legend that they crawl into the ears of sleeping persons. Entomologists, however, insist that this belief is without foundation. The following is the second report from Arizona - and also only the second in English literature - to document the veracity of the legend.

At 3 AM, my 8-year-old daughter awoke me from a sound sleep. She was extremely upset. For the preceding few minutes she had attempted to remove a creature crawling about in her left external ear canal. A light sleeper, she had been aroused by "the sound of little feet". Otoscopic examination revealed a dark brown mass near the tympanic membrane. My brief discussion with her on the importance of proper hygiene was interrupted when I saw the form move. Then, bathed in brilliant illumination from the otoscope, a female earwig (family, Carcinophoridae) cautiously emerged, to the relief of insect, child and father.

Earwigs do not, as once believed, enter the brain to cause insanity but they can enter the external ear canal while we sleep. Some species pinch sharply and forcibly eject a highly irritating fluid from abdominal glands. In the previous report a male earwig (Forficula auricularia) punctured and lacerated the tympanic membrane of a sleeping graduate student in Flagstaff, Arizona."


Source:

Fisher JR. (1986) Earwig in the ear. West J Med. 145(2): 245.


Wikipedia: Earwig.

Thursday, April 2, 2015

The truly desperate smoker


Cigarette smoking is notoriously addictive. Even though the negative consequences of this smelly habit (lung cancer, oral cancer, laryngeal cancer, chronic bronchitis, emphysema and cardiovascular disease, among other things) have been known for a long time - and mandatory health warnings are now placed on cigarette packets in many countries - smokers still find it very hard to quit. However, one nicotine-addicted cancer survivor really took things to the extreme. Despite having had his larynx removed four years earlier because of a malignant tumor, this 48-year-old man managed to continue with his cigarette habit, using the tracheal stoma to inhale smoke. Telltale yellow staining under his chin (right) alerted his doctors.

Sticking cigarettes into a post-laryngectomy hole in one's neck in order to get that daily nicotine fix sounds so drastic it's almost bizarre. However, this is typical behavior for someone whose cravings are totally out of control, like eating French fries while being 150 pounds overweight, or sinking deeper and deeper into debt because of compulsive shopping, or drinking a bottle of vodka a day when you already have alcoholic liver disease. Addiction - any addiction - is a beast. Seek professional help before it's too late.


Source:
BMJ. 2004 Oct 9; 329(7470): 866.  

 

Saturday, March 21, 2015

Neurofibromatosis type 1 presenting as a large growth on the buttock


A huge unsightly tumor growing on the back and buttock would be embarrassing for anyone, but doubly so for a teenager. I really feel sorry for the young man described in today's blog post - the victim of a fairly common genetic condition.

Neurofibromatosis type 1, also known as von Recklinghausen's disease, is an autosomal dominant disorder characterized by changes in skin pigmentation and the growth of tumors along nerves in the skin, brain, and other parts of the body. It affects approximately 1 in 3,000 individuals. Neurofibromatosis type 1 is caused by a mutation in the NF1 gene, located on chromosome 17q. The product of this gene - a protein called neurofibromin - acts as a tumor suppressor, which means that it keeps cells from growing and dividing too rapidly or in an uncontrolled way. Mutations in the NF1 gene lead to the production of a nonfunctional version of neurofibromin that cannot regulate cell growth and division.

The signs and symptoms of this condition vary widely among affected people. Since early childhood, almost all people with neurofibromatosis type 1 have multiple café-au-lait spots, which are flat darkened patches on the skin. These spots increase in size and number as the individual grows older. Most adults with neurofibromatosis type 1 develop neurofibromas - benign tumors that are usually located on or just under the skin. These tumors may also occur in nerves near the spinal cord or along nerves elsewhere in the body. Some people with neurofibromatosis type 1 develop cancerous tumors that grow along nerves, known as malignant peripheral nerve sheath tumors. People with this condition also have an increased risk of developing other cancers, including brain tumors and leukemia.

Neurofibromas, while benign, can grow to a large size and significantly impair a patient's quality of life, as the following case shows. A 19-year-old Pacific Islander suffered from a large growth involving the back and buttock. The mass, present since birth, had been growing slowly over the past several years. Not surprisingly, the resulting disfigurement was a source of substantial embarrassment for the patient.


 A case of neurofibromatosis type 1: a large growth involving the lower back and buttock.

Physical examination revealed a soft tissue mass of the back that extended from the tenth thoracic vertebra to the inferior gluteal clefts. The growth was hyperpigmented and corrugated. No additional neurofibromas or café-au-lait spots were noted. Neurological examination was normal. CT scan images demonstrated the mass to be confined to the subcutaneous tissues, without extension into the underlying musculature.

The patient underwent a radical resection of the mass down to the paravertebral fascia. The wound was initially managed with negative pressure wound therapy, and once a bed of healthy granulation tissue was created, autogenous skin was harvested from the upper back and grafted to the granulation bed. Two weeks later, excellent graft take was noted and the patient returned home.


The final result after surgery. Images from: Washington et al. (2010)


Source:

Washington EN, Placket TP, Gagliano RA, Kavolius J, Person DA. (2010) Diffuse Plexiform Neurofibroma of the Back: Report of a Case. Hawaii Med J. 69(8): 191–193.

Wednesday, March 11, 2015

Huge abdominal tumor in a 43-year-old man


Solitary fibrous tumors are rare neoplasms that usually affect the pleura. On occasion, they can also occur in extrapleural tissues, such as the peritoneum, pericardium, anus, and paranasal sinuses. The benign form of this tumor is 3 to 4 times more common than the malignant form. The clinical manifestations depend on the size and location of the lesion. The mean age of patients at presentation is 54 years.

Solitary fibrous tumors of the peritoneum are extremely rare. Preoperative diagnosis is difficult, since several other neoplasms can give similar symptoms. A 43-year-old man in Tunisia had the misfortune to suffer from a very large abdominal tumor of this type. He sought medical help because of chronic stomach pain, abdominal fullness, and vomiting episodes, especially after heavy meals. His family and medical history were unremarkable. He had no history of previous abdominal surgery. On physical examination, a hard mass was palpated deeply in the abdomen. It was not tender, and bowel sounds were normal.



CT scan image showing a huge abdominal mass.


Laparotomy was performed and a huge, encapsulated tumor was found. It did not adhere to the wall of the stomach, liver parenchyma or adjacent structures. The surgeon was able to carefully remove the entire mass without having to resect the intestines. After removal, the tumor was found to measure 40 × 14× 20 cm. Its cut surface showed lobulated white and yellowish-brown areas.

Histologic features indicated that the mass, despite its size, was a benign solitary fibrous tumor of the peritoneum. After surgery, the patient recovered with no complications. The story ends on a positive note: no evidence of recurrence or metastasis was observed after 36 months.





Huge peritoneal tumor after resection: a 40 × 14× 20 cm mass with lobulated white and yellowish-brown areas. Images from: Bouassida et al. (2012)
 


Source:


Bouassida M, Mighri MM, Becha D, Hamzaoui L, Sassi S, Azzouz MM, Touinsi H, Sassi S. (2012) Huge Abdominal Tumor: Peritoneal Solitary Fibrous Tumor. Gastrointest Cancer Res. 5(5): 179–180.