Tuesday, January 3, 2017

Rupture of the heart without external wound (a case from 1880)

A strange case was described in the British Medical Journal in 1880. A man had been run over and killed by an empty cart. One of the wheels had passed over his chest, but there was no external wound and no ribs had been broken. A postmortem examination showed that his heart had ruptured under pressure! Apparently, since he had suffered from a long-standing syphilis infection, the tissues of his heart were weakened, which greatly facilitated the rupture.

Henry Handford, Assistant House-Surgeon to the General Hospital in Nottingham, relates the incident thus:

"On Saturday, November 1st, a man, A. B., aged about 35, was brought to the General Hospital, Nottingham. A wheel of a light cart (empty) had passed over his chest. According to the statements of the men who witnessed the accident, he never spoke or moved after the receipt of the injury, but continued to make a moaning noise for a few minutes. When he was brought to the hospital, about ten minutes later, he was quite dead."

The postmortem examination showed the following:

"The body was well nourished; height about 5 feet 8 inches; muscular. Rigor mortis was very strongly marked. There was an incised wound about an inch long on the back of the head, and numerous syphilitic sores and scars on the penis, scrotum, and thichs. (He had been an in-patient of the hospital some mnonths previously for syphilis.) There was no trace of any wound or contusion on the chest, nor were any of the ribs broken. On examination of the thorax, the pericardium was found much distended; and on opening it, about eight or ten ounces of serum and imperfectlv coagulated blood escaped. While examining the heart in situ, a rupture about three-fourths of an inch long was discovered on the posterior wall of the left auricle. The aorta was distinctly atheromatous; and there was thickening of the mitral, and less so of the aortic and tricuspid valves. The endocardium lining the left auricle was markedly thickened in irregular patches, and of an opaque yellowish colour. The muscular fibres of the left auricle, taken from the immediate neighbourhood of the rupture, showed, under the microscope, well-marked pigmentary degeneration; i.e., an accumulation of pigment granules arranged more or less in rows in the region of the nucleus; but no distinct trace of fatty degeneration, though the fibres were not well striated. " 

The heart had given way at the weakest spot: the left auricle (a flap of heart wall on the anterior surface of the left atrium of the heart), which has the least support from surrounding structures. Dr Handford concludes:

"Death probably took place from compression of the heart by the blood effused into the pericardial sac; and the extreme rapidity of the death may, perhaps, account for the absence of marks of bruising on the skin of the chest."


Handford H. (1880) Case of Rupture of the Heart from External Violence without Penetrating Wound. Br Med J. 1(1012): 768.

Image: Wikipedia.

Friday, September 18, 2015

Asian child's jaw becomes necrotic, falls off (a case from 1938)

Imagine suffering for months from a purulent, festering infection in your mouth; imagine it going deeper and deeper into the tissues, eating away at your lower jaw as you burn with fever, until the entire mandible breaks off from the skull, a hunk of blackened, dead bone...

Sounds like something from a Stephen King novel, right? Well, this horrid scenario unfortunately occurred in real life, nearly 80 years ago, and the hapless victim was a 6-year-old male child from the island of Formosa (known today as Taiwan). The boy came from a family of poor villagers, and his dental troubles started with a simple toothache. The case was recounted in detail in the Canadian Medical Association Journal in 1939 by one J. L. Little, M. D.

"G.B.P., a Formosan child, aged 6, was presented at the clinic with a complaint of a swollen face and a foul, necrotic piece of bone lying in the floor of the mouth. Four months previously the child had suffered from toothache and a small "gum-boil" at the site of the second right lower molar tooth. After an extraction of this tooth inflammation advanced rapidly until the mouth could scarcely be opened and the right eye was closed. After three days of suffering the swelling began to invade the left jaw as well and it was decided to move him from his home village into the nearest municipal hospital. There an external incision over the right ramus was made to provide drainage, and a quantity of foul pus was evacuated. The father reported that during the ensuing weeks the mouth was very putrid, the gums swollen and spongy, while the teeth seemed to rise up out of the festering tissue. The child ran a high fever, became waxen in colour, and was delirious every evening. He removed many of his loose teeth with his fingers. After a month's treatment with daily irrigation the patient was sent back to the village herbalist in despair of recovery. Slowly the alveolar sockets emerged from the soft tissues, while the upper teeth became disfigured with a dense black film but were otherwise unaffected. 

The child was admitted on September 27, 1938, with the tongue pushed up against the palate by a black, jagged, bony mass which moved slightly on pressure, but scarcely any pain was elicited. On the prominent right cheek was a sinus which was discharging thin, serous matter, and through which dead bone could be felt with a probe. At this time the child was afebrile and in quite good health. [...] It was decided that the best course of action would be to divide the mandible in the midline and extract the two halves through the mouth.

Under ether-chloroform anaesthesia it was found that the heads of both wings of the mandible could be moved quite readily and it became evident that the mouth would deliver the entire sequestrum without injury to the adjacent tissues. Under gentle pressure and with practically no bleeding the jaw was detached and withdrawn intact."

The boy was able to enjoy a soft diet immediately after the operation, and began to play about the ward three days later. He was discharged from hospital on October 7, 1938. The author blithely concludes:

"It is unlikely that this particular child will ever receive any further attention to his dental needs because of his poverty, but he will undoubtedly be able to handle the rice diet of the Formosan farmer without great inconvenience."

One can't help wondering how long this child lived afterwards, what quality of life he had, and whether he survived World War II.


Little JL. (1939) Sequestration of the entire mandible. Can Med Assoc J. 40(5): 481–482.

Tuesday, September 8, 2015

Congenital penile sinus (a case from the 1960s)

A ventral mid-line sinus of the penis is an unusual congenital defect. The following case report was published in the Postgraduate Medical Journal in 1964.

"A 43-yr old circumcised man sought advice about two superficial sore lesions on the under surface of his penis and scrotum. These had been present for two weeks and had discharged a small quantity of pus. Seven years previously he had noticed a pore on his penis from which it was possible to express a chalky material. At this time his doctor had incised a superficial infective lesion close by this orifice. On examining the penis and scrotum there were two mid-line infected lesions, one being at the peno-scrotal junction and the other 5 cm posterior to it. In addition there were two sinuses, one, 2 cm in length, extended along the proximal third of the shaft of the penis from an orifice situated in the mid-line just proximal to the peno-scrotal junction. The other, 12 cm in length, extended from a similar pore in the central part of the scrotum to just in front of the anus. Probing revealed that both sinuses terminated blingly and had no communication with the urethra, each other, or the superficial infective lesions. 

Each sinus was palpable [...] as a firm, non-tender cord. On general clinical examination there was no evidence of other congenital anomalies. There was no history of veneral [sic] disease [...] Culture of pus from the infective lesions grew only Staphylococcus albus.

Under general anaesthetic the sinuses were laid open with scissors and their deep aspects were seen to consist of pink mucous membrane. The slit thus produced healed rapidly during the next seven days with no treatment other than dressings." (Wastell 1964)

The case report contains two black-and-white photos, shown below. The left-hand one shows the sinus at the peno-scrotal junction, while the right-hand one depicts the more posterior of the two sinuses with a probe passed along its entire length. The tip of the probe is just anterior to the anus. 


Wastell C. (1964) Congenital Penile Sinus. Postgrad Med J. 40(460): 95–97.


Saturday, September 5, 2015

Death from a ruptured varicose vein

Lots of people worldwide suffer from varicose veins - twisted, enlarged veins, usually on the legs and ankles. Although this unsightly condition is usually benign, occasionally it can prove life-threatening. Massive hemorrhage caused by vein rupture is an unusual complication of this common venous pathology. Such bleeding demands immediate medical intervention, otherwise the patient can actually bleed to death!

In one slightly gruesome case, a neighbor found a 66-year-old woman dead in her house, surrounded by a large quantity of blood. Multiple bloodsoaked tissues were found around her body, as shown in the photo below, showing that she had frantically tried to stop the bleeding. The examination of the rest of the house revealed smears and smaller blood pools. The lady had lived alone and her medical history was unknown.

Medical mystery? Not quite. Autopsy soon solved the puzzle. It revealed a 7 mm ulcer on the internal surface of the left lower leg communicating with a varicose vein. Signs of pulmonary edema and liver cirrhosis were also discovered. Toxicological analysis was negative.

Death from fatal hemorrhage due to varicose vein rupture is a well-described clinical entity; 23 cases were reported during a single year in England and Wales. The phenomenon was described for the first time in 1973. The youngest person dying of fatal varicose vein rupture has been reported to be a 29-year-old man who was found deceased in his store lying in a pool of blood.

Characteristic features of deaths due to massive bleeding from a ruptured varicose vein include old age, social isolation, underlying medical conditions (e.g. restricted mobility, dementia), hemorrhage related to minor trauma and certain associated features such as alcohol consumption or anticoagulant medications. Another important risk factor is sclerotic changes of the vessel walls that may lead to spontaneous hemorrhage. A coexisting disease, such as ischemic heart disease, also increases the risk of a fatal outcome. Interestingly, in the case described here, the presence of liver cirrhosis seems to have contributed to the lady's death, since a diseased liver has a reduced capacity to produce coagulation factors. The impaired ability of the blood to clot undoubtedly made the bleeding more intense and longer.


Fragkouli K, Mitselou A, Boumba VA, Siozios G, Vougioklakis GT, Vougiouklakis T. (2012) Unusual death due to a bleeding from a varicose vein: a case report. BMC Res Notes 5: 488.

Wednesday, June 24, 2015

Zip injury to the penis: it happens more often than you think!

Zip! And it's done up. The modern zipper provides an easy and convenient means for fastening clothes. An engineer named Gideon Sundback is credited with inventing this ingenious device in 1913. On garments, it was first marketed as a fastener for children’s clothes because of its ease of use. Since then, it has become especially popular for fastening trousers.

Amusingly (or perhaps not), the zipper is not without its dangers. It's not at all uncommon for a boy (or a grown man, for that matter) to have an embarrassing accident while zipping up his fly: a bit of loose skin from the genitals, usually the foreskin, becomes caught between the zipper's teeth.

Between 2002 and 2010, an estimated 17 616 patients presented to US Emergency Departments with trouser zip injuries to the genitals. The penis was almost always the only genital organ involved. Zipper injuries represented nearly one-fifth of all penile injuries. Quite surprisingly, amongst adults, zips were the most frequent cause of penile injuries. In another study, thirty boys, aged 2-12 years, presented with penile zip entrapment to one Pediatric Accident and Emergency Department over a 7 year period. The rate of presentation was one zip entrapment per 4068 new patient attendances. In contrast to previous reports, injuries occurred most commonly whilst the zip was being done up and whilst underpants were being worn.

Luckily, releasing a zip-entrapped prepuce is usually a fairly easy and straightforward procedure. Several nonsurgical techniques have been developed to help patients in this predicament. One of these methods involves inserting the thin blade of a small screwdriver between the outer and inner faceplates of the zip fastener, and then twisting it toward the median bar. This will widen the gap between faceplates, disengaging the foreskin. This simple technique was used in 12 children and was found to be safe, effective and painless. It can be performed by an attending pediatrician even in nonhospital settings. Another quick and nontraumatic approach involves instantly releasing the prepuce by lateral compression of the zipper with pliers. Other reported interventions have ranged from dismantling the zipper with bone or wire cutters (after opening the zipper teeth, the zipper falls apart and can be removed from the foreskin) to circumcision.

So... guys, best watch what you're doing when you're doing up your fly!

Image courtesy of foto76 at


Wyatt JP, Scobie WG. (1994) The management of penile zip entrapment in children. Injury. 25(1):59-60.

Bagga HS, Tasian GE, McGeady J, Blaschko SD, McCulloch CE, McAninch JW, Breyer BN. (2013) Zip-related genital injury. BJU Int. 112(2): E191-4. 

Mishra SC.(2006) Safe and painless manipulation of penile zipper entrapment. Indian Pediatr. 43(3): 252-4

Raveenthiran V. (2007) Releasing of zipper-entrapped foreskin: a novel nonsurgical technique. Pediatr Emerg Care. 23(7):463-4.

Monday, June 15, 2015

Bifid penis: an old case from Estonia

Bifid means, basically, "split into two equal parts". A bifid penis sounds scary, doesn't it? Yet in the animal world, it's not always an anomaly. Many male marsupials (for example, koalas) naturally have a bifid penis, with two prongs which are simultaneously inserted into the female's two vaginal canals. 

In humans, a bifid penis is a (mercifully) rare congenital defect. It is often present together with hypospadias, a condition where the urinary opening is not located where it should be, on the head of the penis. In the past, boys born with a bifid penis often underwent sex reassignment surgery and were raised as girls, because penile reconstruction was deemed too difficult. They received hormone replacement therapy and developed female characteristics.

In 1924, a case of bifid penis was briefly described in the Journal of Anatomy. The photos were taken at the Surgical Clinic of the University of Dorpat (today - Tartu, the second largest city of Estonia). The author, Alexander Lipschutz, writes:

"In this case the body and glans show complete separation into two parts, giving the appearance of a double penis. The body and glans of each half appear of usual length, but together are slightly wider than normal. The scrotum and testicles are normal in size and position, and this taken in conjunction with the secondary male character of the triangular-shaped distribution of the pubic hair, would indicate that the patient was sexually normal.

It is to be regretted that no other details of this case are available, as the hospital archives were lost during the war and revolution."

And here are the grainy old photos of the anomaly:

If the patient was, as reported, "sexually normal", one can't help wondering - was he capable of achieving an erection and having intercourse? While an erection does seem anatomically possible (so long as the corpora cavernosa, smooth muscles and so on were normally developed and there was no impairment in blood supply), I'm not so sure about the intercourse part - but then, I suppose stranger things have happened!


Lipschutz A (1924) A Note on a Case of Bifid Penis. J Anat. 58: 254–255.
Wikipedia: Bifid penis

Thursday, June 11, 2015

Reconstructing a destroyed ear almost 90 years ago

Reconstructing the intricate anatomy of the auricle, with its folds and bends of thin cartilage, isn't easy even today. (Many patients decide to opt for an ear prosthesis rather than a reconstructed ear, which can look chunky, unnatural and just plain ugly.) I was surprised to learn that back in the 1920s, when plastic and reconstructive surgery was still in its infancy, some adventurous surgeons were attempting ear reconstruction procedures. One such case is documented in California and Western Medicine - the official journal of the California Medical Association. The case report was published in 1927. The patient, a young man, had been injured in a railway accident, losing all but a small portion of his ear. 

The procedure was largely carried out on a trial-and-error basis. The surgeon, one Harrington B. Graham, writes:

"The tissues on the scalp were undamaged so that I could use the non-hairy parts for the reconstructed portion. My first step was to transplant a piece of septal cartilage the shape of the sole of a shoe to the subcuticular tissues posterior to the defect. I placed this directly behind the defect instead of above and behind, so that when I brought my tissues forward I did not have enough support to keep them high enough. Any cartilage either from the nose of rib, used to keep the soft tissues up and away from the head, should lie, by preference, in the one-third of the completed ear. It is difficult to get enough nasal septal cartilage to fill the demand, so that the lower portion of the lobe may have to be disregarded."

Despite the difficulties with obtaining enough cartilage from the nose, the author is not convinced that rib cartilage would work better. He also stresses the importance of the final cosmetic effect of the surgery, which depends largely on the operator's skill and on the technique used.

"[obtaining rib cartilage] is a difficult task and the shaping might increase the tendency to absorption. It is hard to get a piece of rib cartilage as thin as septal cartilage, and this is a very important factor, as far as the cosmetic appearance of the ear is concerned.

The thinness of the new tissue will depend to a great extent upon the position subcutaneously of the transplant. If it is buried deeply in the tissues, the result must be a thick ear. A superficial position is a difficult one to obtain, but will pay the operator for his pains. Any tissue taken from the arm or chest must be thick, looking like a piece of putty when transplanted. However, time modifies its appearance so that under certain circumstances it may be permissible to use it."

The reconstruction was carried out painstakingly in stages and involved skin grafting from the leg:

"After leaving the cartilage in place for a month, I made a circular incision to the hair line, starting at the upper anterior part of the old ear. This incision was carried to the periosteum and the skin thus outlined, including the cartilage, was raised and folded in such a way as to have the upper border of the ear covered by a continuous layer of skin. The anterior portion was now sewed down to the tragus, and the defect on the scalp remedied by the customary undermining, reduction in size of the opening, and a skin graft taken from the leg [...] Were I to do another I should not fold the upper edge back, as in this case, but would use it entire, placing a graft over the whole posterior surface. This flap, if the cartilage were properly placed, would be quite sufficient to form a new ear without any further addition.

After another month the lower part was incised, carried forward and sewed to the freshened lobule, another graft being placed posteriorly. A few minor operations were done to smooth things out, and an attempt made to stiffen the upper border somewhat by the introduction of celluloid."

Here is a picture from the initial stages of surgical work:

And the final result looked like this:

All images from: Graham (1927)

The author self-critically admits:

"The ear that I constructed is considerably smaller than the normal ear, due to the fact that I did not carry my incision high enough on the head, that I folded too much tissue back in order to get a smooth border, and that my cartilage was not placed high enough. All of these errors should be avoided in future work."

However, the final result of the reconstruction still looks quite impressive, given the times!


Graham HB. (1927) The reconstruction of a completely destroyed auricle. Case report. Cal West Med. 27(4): 518–519.