Funtabulously Frivolous Friday Five 297

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the  Funtabulously Frivolous Friday Five 297

Question 1

What sign is being described at the Royal College of Surgeons in 1890:

…a most important indication that the posterior fossa of the skull is the seat of the fracture” and concluded “that it appears, in the first place, in front of the apex of the mastoid process. That it often spreads upwards over the mastoid in a line, slightly curved, and with the convexity backwards, its direction being approximately that of the outline of the external ear, from which it is distant half to three-quarters of an inch”

[Lancet July 1890]

Reveal the funtabulous answer

Battle sign

These observations derived from approximately 17 clinical cases by William Henry Battle and were further explored in cadaveric studies where injection of fluid containing blue dye into the occipital musculature resulted in subsequent superficial migration to adjacent tissues. This supported Battle’s anatomical reasoning that extravasated blood would also move to more superficial tissues in the mastoid region along the course of the posterior auricular artery.

ICE 002 Battle sign

As acknowledged by Battle, earlier observations of this sign were made by fellow surgeon Sir Prescott Hewett (1812-1891). Hewett remarked:

Extravasation of blood, and consequent discolouration of the skin, appearing in the mastoid region some hours after a severe injury to the head, may lead to the suspicion of a fracture involving the posterior part of the base

Unlike the time course alluded to above, Battle described this sign as manifesting “from the third to the fourth day after the injury, but its appearance may be delayed until the twelfth or fourteenth day”. As such the clinical relevance and sensitivity in the acute setting may be limited.

Direct trauma to this area may also produce a similar appearance. As acknowledged by Hewett, “…all the more valuable will this sign become if the injury did not bear directly upon this region, and especially if it bore upon the opposite side of the head

It is unclear from Battle’s case series what proportion of patients with a presumptive diagnosis of skull fracture subsequently had confirmation of this at autopsy.


Question 2

What is the difference in distribution of bruising with ‘raccoon’ or ‘panda’ eyes versus a black eye?

Reveal the funtabulous answer

Sparing of the tarsal plate

Raccoon / panada eyes have sparing of the tarsal plate whereas a black eye secondary to direct trauma will have no sparing of the tarsal plate.

Tarsal plate sparing is due to an anatomic structure called the orbital septum, which limits extravasation of blood beyond the tarsal plate

Raccoon / panda eyes are suggestive of a basal skull fracture as opposed to direct trauma. There are also case reports of metastatic neuroblastomas in children presenting this way along with amyloidosis which weakens capillaries, any cranial or nasal surgery, rhabdomyosarcoma, leukaemia, aplastic anaemia, orbital myositis, pertussis, thrombocytopenia and light-chain deposition disease.

As an aide memoir you can think of raccoon / panda eyes of ‘smokey eye makeup’ gone bad.


Question 3

Hansen’s disease is one of the oldest diseases known to man. The earliest possible account of the disease appears in an Egyptian Papyrus document written around 1550 B.C. In Europe, Hansen’s disease first appeared in the records of ancient Greece after the army of a famous knot solver came back from Asia. What is Hansen’s disease more commonly know as and who is the famous knot solver?

Reveal the funtabulous answer

Leprosy and Alexander the Great.

In 1873 Dr. Gerhard Henrik Armauer Hansen of Norway was the first person to identify the bacteria that causes leprosy under a microscope. Hansen’s discovery of Mycobacterium leprae proved that leprosy was caused by bacteria, and was thus not hereditary, from a curse, or from a sin.

Alexander the Great cut the Gordian knot:

The Phrygians were without a king, but an oracle at Telmissus (the ancient capital of Lycia) decreed that the next man to enter the city driving an ox-cart should become their king. A peasant farmer named Gordias drove into town on an ox-cart and was immediately declared king. Out of gratitude, his son Midas dedicated the ox-cart to the Phrygian god Sabazios (whom the Greeks identified with Zeus) and tied it to a post with an intricate knot of cornel bark. The knot was later described by Roman historian Quintus Curtius Rufus as comprising “several knots all so tightly entangled that it was impossible to see how they were fastened”.

The ox-cart still stood in the palace of the former kings of Phrygia at Gordium in the fourth century BC when Alexander arrived, at which point Phrygia had been reduced to a satrapy, or province, of the Persian Empire. An oracle had declared that any man who could unravel its elaborate knots was destined to become ruler of all of Asia. Alexander wanted to untie the knot but struggled to do so without success. He then reasoned that it would make no difference how the knot was loosed, so he drew his sword and sliced it in half with a single stroke. In an alternative version of the story, Alexander loosed the knot by pulling the linchpin from the yoke.

Sources from antiquity agree that Alexander was confronted with the challenge of the knot, but his solution is disputed. Both Plutarch and Arrian relate that, according to Aristobulus, Alexander pulled the knot out of its pole pin, exposing the two ends of the cord and allowing him to untie the knot without having to cut through it. Some classical scholars regard this as more plausible than the popular account.

Alexander later went on to conquer Asia as far as the Indus and the Oxus, thus fulfilling the prophecy.

Question 4

What is the origin of the quote attributed to a Navy SEAL

Under pressure, you don’t rise to the occasion, you sink to the level of your training

Reveal the funtabulous answer

Greek lyrical poet, Archilochus (680-645BC)

The actual quote is:

We don’t rise to the level of our expectationswe fall to the level of our training.

Archilochus is credited with being among the earliest Greek writer of iambic, elegiac, and personal lyric poetry. His surviving partial works prove him to have been an exceptionally talented innovator of poetic meter. It is thought that Archilochus probably served as a soldier but exact accounts are sparse.

Question 5

In 2001, which country became the first (and only) to decriminalize drug possession?

Reveal the funtabulous answer


Portugal decided to abandon the usual practice of criminalising users and spent the money on harm reduction and social programs to rehabilitate users. The results have been dramatic:

  • Increased uptake of treatment (roughly 60% increase as of 2012.)
  • Reduction in new HIV diagnoses amongst drug users by 17% and a general drop of 90% in drug-related HIV infection
  • Reduction in drug related deaths, although this reduction has decreased in later years. The number of drug related deaths is now almost on the same level as before the drug strategy was implemented. However, this may be accounted for by improvement in measurement practices, which includes a doubling of toxicological autopsies now being performed, meaning that more drugs related deaths are likely to be recorded.
  • The number of drug related deaths has reduced from 131 in 2001 to 20 in 2008.

And Finally…

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Funtabulously Frivolous Friday Five

Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.

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