Last week, we did an eyeball case. Let’s do more this week.

Exophthalmos is a condition where the eyeballs bulge out of the eye sockets abnormally.* It is frequently associated with hyperthyroidism.

One night, I saw a woman who had such severe exophthalmos that the eyelids caught behind one of her eyeballs. This caused the eye to protrude even farther. As a result, she was not able to close or move the eye. I had to gently press her eyeball back into its socket and work the eyelids back over the front of her eye.

*

This is an image from the Internet, not my patient.

The other eyeball patient was a one-hundred-year-old lady who fell out of bed in the middle of the night. She hit her face on something and ruptured her globe, which is the medical term for the eyeball. Her eye was so bulged out and had so much chemosis** (swelling of the surface of the eye) that, like the first patient, the lid was caught behind the eye so she couldn’t close or move it. The entire front portion of the eye was full of blood.

She was admitted to the hospital to have the eye removed.

**

Again, not my patient.

These are easy to make and come out rich and moist but firm. With all of the kinds of M&Ms available, you could make then with any you like and they would be different and interesting. When I fist saw this recipe in the newspaper, it was at Christmas time and they were supposed to be made with Holiday M&Ms.

Recipe By: Family Circle

Yield: 5 to 6 dozen

Ingredients:

2 ½ cups all-purpose flour

¾ cup unsweetened cocoa powder

1 teaspoon baking powder

¼ teaspoon salt

1 cup unsalted butter, at room temperature

¾ cup packed light brown sugar

¾ cup granulated sugar

2 large eggs

2 teaspoons vanilla

¼ cup hot coffee or water

1 ½ cups M&Ms

Directions:

1. Heat oven to 375 degrees.

2. Sift together flour, cocoa, baking powder and salt. Set aside.

3. Using an electric mixer, beat butter until smooth and creamy.

4. Add both sugars. Beat until light and fluffy.

5. Beat in eggs one at a time. Mix in vanilla.

6. With mixer on low speed, mix in flour mixture.

7. Stir in coffee.

8. Fold in M&M’s.

9. Drop batter by heaping tablespoonfuls onto ungreased baking sheets. Press a couple of M&M’s into the top of each little mound of dough.

10. Bake for 8 to 11 minutes or until set. Cool briefly on baking sheets. Transfer cookies to wire racks to cool completely.

Notes:

For Christmas cookies, use red and green M&Ms.

I walked into the Accident Room of Charity Hospital in New Orleans. A young man sat in one of the old, wooden, high-backed wheelchairs they used at that time*. He was thin and pale. His shoulder length hair was greasy and unkempt.

He sat still and showed no emotion. His left eye was covered with a large paper cup, which had been taped in place by emergency staff. Under the cup was the wooden handle of an old ice pick, the point of which had been thrust into his eye. The cup had been placed over the handle to prevent it being bumped, possibly making his obviously serious injury worse.

I asked him what had happened. In very flat and unemotional words he told me he suffered from psychotic depression and had wanted to die for a very long time. He recounted how he had seen a show on public TV that showed cross-sectional images of the brain. This made him realize his brain sat immediately behind his eyes. He reasoned that poking an ice pick into his brain would clearly kill him. So, he planned to drive an ice pick through his eye and into his brain, in order to die.

He denied being in any pain unless he moved the eye, which he found difficult to do. He said, as far as he could tell, his vision was OK.

When I gently lifted the eyelid open, I could see an old, dirty, rusty ice pick entering the lower part of his eye. The rest of the eye, above the ice pick, seemed to be working fine.

I had three problems. The most immediately life-threatening was brain injury. He was right in recognizing the brain does sit behind the eyes. The bones of the orbit, which surround the eyes, are thin and could easily be pierced by even an old, dull ice pick. From the looks of how far the ice pick seemed to have entered his head, it looked like he probably had stabbed himself in the brain.

My next worry was his eye. Though his vision seemed to have been unaffected so far, I was concerned that trauma and potential infection might threaten his vision.

The third problem, very real but not so acute, was his depression and suicidal ideation.

There was no good way to fully evaluate either his brain or his eye with the ice pick in place. I was afraid to pull it out without addressing the possible brain injury, so I called the neurosurgeon who went with me to the CT scanner. The neurosurgeon placed one hand on the patient’s forehead, grabbed the ice pick handle with his opposite hand and gently pulled, twisting slightly to get it to let go.

After the ice pick was removed, the CT scan was done which showed no bleeding or other problem in the brain that required neurosurgery.

I then made arrangements for ophthalmologists, the eye doctors, to see the patient. They took him to the operating room where they cleaned out the wound. They found only a small nick in the lower part of the globe, which they cleaned and repaired. The patient was then admitted to the hospital for a few days to make sure no complications arose. Afterwards, he was transferred to the psychiatric ward.

This poor man must have been at the end of his rope to get the nerve to do such a horrible thing. He really wanted to die and, by all rights, he very well could have.

However, when he stabbed himself, he hit just low enough that, rather than puncturing the eyeball, it was displaced upwards. The ice pick passed under the globe, missing the vital parts of the eye, so his vision was not affected.

A small hole in the bone of the orbit would heal with no treatment. Ironically, the part of the brain he punctured, the frontal lobe, is probably the most forgiving part of the brain to damage. So, rather than dying, he ended up fine with no permanent damage done at all.

I certainly hope his psychiatric care ended with the same good results as his medical care did. I think that was not too likely, as this sort of depression is very hard to treat.

*

I found this in Google images. It is exactly like the wheelchair my patient was sitting in that sad  day.

When Philip was watching Elizabeth sew her bag, he came up with the idea for polka-dots. Pretty soon, he had worked out and put into action his plan for yellow on black.

Here he is sewing at the dining room table.

Here he is, justifiably proud of his creation.

A great bag, especially for a beginner!

I made these cookies with Lucky Charms left over after Christmas. Our son-in-law, Austin, loves them and we bought them for him for a Christmas treat. I think they are disgusting.  I can’t even imagine putting them in a bowl, pouring milk over them and eating them. But they were fun in the cookies.

Here is a nice round ball scooped out with a cookie scoop and a tasty red “marshmallow” showing.

Here one is flattened. The recipe calls for using a fork but I just flattened them with my fingers.

Here is a cooked one showing all of the wonderful, artificial colors that make Lucky Charms so magically delicious!

Recipe By:

Mercury News

Yield:

24

Ingredients:

½ cup butter, softened

½ cup granulated sugar

½ cup brown sugar

1 large egg

1 teaspoon vanilla

1 cup flour

1 teaspoon baking powder

¼ teaspoon baking soda

¼ teaspoon salt

¾ cup oats

1 ½ cups dry cereal such as cornflakes, Product 19 or Special K

 Directions:

1. Heat oven to 350 degrees.

2. Sift together flour, baking powder, baking soda and salt. Set aside.

3. Cream together butter and sugars. Beat in egg and vanilla.

4. Add flour mixture. Stir until combined.

5. Add oats and dry cereal to the dough. Mix well.

6. Drop by two tablespoonfuls onto parchment-covered cookie sheet, pressing down with a fork.

7. Bake 9 to 12 minutes until just browning around the edges.

8. Cool on a cookie rack.

 Notes:

Submitted to Mercury News by Carolyn Gutierrez. I am sure she would not approve of using Lucky Charms!

Pseudocyesis is the medical term for a mental disorder that causes a woman to believe she is pregnant when she is not. I am not sure how common this is but I have seen it several times in my practice.

I have cared for several women who were so disabled by Pseudocyesis that they are in the hospital all the time. They are well known to staff in both the Emergency Department as well as Labor and Delivery where they go insisting they are in labor.

Here are a couple of specific cases I have recorded:

Pseudocyesis Case 1

A 27-year-old woman presented at triage saying that her water broke, she was in labor and was about to deliver. She was rushed right up to Labor and Delivery where an examination, pregnancy test and ultrasound proved she was not pregnant. She then admitted she had been seen at another hospital earlier that same day where they told her she was not pregnant. The Labor and Delivery staff sent her back down to the emergency department to evaluate her abdominal pain.

My examination and laboratory tests failed to uncover a reason for her abdominal pain. This didn’t bother her because she didn’t care at all about her abdominal pain. She continued to insist, in the face of all the evidence, that she was pregnant and in labor.

I did my best to convince her, which was not possible. I then tried to reassure her, which was also impossible. I finally resorted to the speech I use in the rare situation where someone cannot be convinced after all I can do. I said something like, “I know you are not pregnant and there is nothing you can do to convince me that you are. You know you are pregnant and there is no way I can convince you that you are not. We are just going to have to agree to disagree.”

After giving my speech, as sympathetically as possible, I turned to walk out of the examination room. She then started to scream, saying the baby’s head was pushing out.

Though frustrated, I stopped, went back in with the nurse and examined her down there again. When I found nothing, she finally left, continuing to complain of feeling the baby coming out and saying that we had done nothing to help her.

Pseudocyesis Case 2

A 51-year-old woman came in by ambulance complaining that her water broke. She claimed to be one month pregnant, which was making her nauseous. She admitted to having had a negative pregnancy test at her doctor’s office earlier that day.

She insisted to me that she was pregnant and demanded to know how far along she was. She said she had seen the fetus and the umbilical cord “with my eyes closed.”

I told her it would be very unlikely for her to be pregnant being 51 years old and having a negative pregnancy test. Upon hearing that, she got irate and started to swear and yell at me, refusing to let me examine her. As she walked out she threatened that if she lost the baby because I didn’t provide her with needed care, she was going to sue me.

Source:

Capitol Cookies, Munch Your Way Across the USA. From Lambuth Memorial Methodist Jewel Circle, Midwest City, Oklahoma

Ingredients:

4 cups flour, 18 ounces

5 cups oatmeal, blended into fine flour after measuring

1 teaspoon salt

2 teaspoons baking powder

2 teaspoons baking soda

2 cups butter at room temperature

2 cups sugar

2 cups brown sugar

4 large eggs

1 tablespoon vanilla

18 ounces milk chocolate, grated

24 ounces semisweet chocolate chips

3 cups pecans, chopped (optional)

Directions:

Heat oven to 375 degrees.

Combine flour, oats, salt, baking powder and baking soda. Set aside

Cream butter and sugars. Stir in eggs and vanilla.

Stir in flour mixture.

Stir in chocolates and nuts.

Form into balls with 2 tablespoon cookie scooper.

Bake 8 to 10 minutes.

 Notes:

The cookbook has this note: As its name suggests, $250.00 Cookies are very, very rich. About 15 years ago, Kathy Blalock said her boss brought a tin of very expensive cookies back to the office from a business trip. Later, one of her co-workers found the recipe and they jokingly started calling them “the $250.oo cookies” every time a batch was made and brought to the office. The name stuck and so did everyone’s taste for these exquisite cookies.

Over the holidays, Elizabeth wanted to make  a yellow and blue bag for a Swedish friend.* She had never sewn before and was a bit apprehensive but did a great job.

Here she is, starting out putting the first row on the bottom.

Here, I give her a pointer.

Here she is with the final bag.

The final bag looked so great, she may not be able to part with it!

* The Swedish flag

A 35-year-old man came in saying his shoulder became dislocated when he passed out from his sugar going too low. Besides diabetes, he had Ehlers-Danlos Syndrome, which causes very loose joints, among other things. He said he had suffered from dislocations like this many times in the past and told us exactly the dose of narcotics it would take to relieve his pain in order to get his shoulder back into joint.

We gave him the amount of pain medicine he asked for but were then not able to get the joint back in place, even after multiple tries by me and by the orthopedist I called to help me when I had been unsuccessful.

We gave him more and more medicine until he finally fell sound asleep at which time, the shoulder slid right into place. It was noted while he was unconscious that his shoulder was so loose, it could just slide in and out of place with minimal pressure. We put it in place and applied a shoulder immobilizer.

When he woke and called for more pain medicine, the shoulder was out again and it became clear he could move it in and out of socket at will. He had been holding his joint out of socket and feigning his pain in order to get narcotics.