Funtabulously Frivolous Friday Five 297

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.

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.

References:

• Battle WH. Three Lectures on Some Points Relating to Injuries to the Head. Br Med J. 1890; 2(1540): 4-10

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.

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.

Reference:

• The Western Journal of Emergency Medicine – Raccoon Eyes

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.

Greek lyrical poet, Archilochus (680-645BC)

The actual quote is:

We don’t rise to the level of our expectations, we 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.

Portugal

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.