The unusual case histories posted on this blog often defy easy explanation. Indeed, I have an entire category of posts entitled ‘mysterious illnesses’. But however exotic the symptoms it is usually possible to suggest some arcane diagnosis to explain them.
Not this time.
This case from 1825 has me utterly stumped. It is, by the standards of two hundred years ago, unusually well documented. Several doctors examined the patient and wrote accounts of her symptoms independently. Another hundred or more individuals are said to have witnessed them at first hand. And yet the case report describes something so extraordinary that I can find nothing else in the literature like it. But, after all, I’m not a medic. So I’m crowdsourcing this diagnosis – if you think you know what this illness could be, please leave a comment at the bottom of this page.
This report was published in the Philadelphia Journal of the Physical and Medical Sciences in 1825. The author was Charles Fullerton, a physician in Gibson County, Indiana:
In the sixteenth number of your Journal you express a wish to have an authentic account of the extraordinary case of a girl in this neighbourhood, thirteen years old, “from whose face and under the eye clots of blood would occasionally ooze.”
Who could resist?
The girl is small of her age, but well made, of a good disposition, and of a poor but honest and industrious family. In the spring and summer of 1823, a little blood would occasionally appear about her eye and face, which neither excited alarm nor curiosity. In the November following, however, the quantity became suddenly very large. The family in which she lived think a pound was found some mornings about her face and pillow in clots.
There are several potential explanations for a little blood oozing from the eyes or face – but a pound is a huge amount, close to a pint (~430 ml, to be more accurate).
When this oozing of blood had continued about five days, a physician being called in applied, without knowing for what reason, a plaster to the place from whence the haemorrhage came. But the blood soon pushed it off.
Blood is one thing. But this case was about to become even more weird.
About this time, fimbriated substances, resembling moss or spiders, and pieces of bone were discovered among the clots.
‘Fimbriated’ means ‘having a fringe’. It is little used today but was often employed by Victorian biologists to describe structures such as tentacles. But let’s not let an exotic bit of vocabulary to distract us from the fact that this unfortunate young woman was now shedding pieces of bone through her skin.
Henceforward things changed. Generally a single clot of blood would appear first in the morning, and be followed by lumps of fleshy substance and pieces of bone alternately all day. The bones were of every size under the weight of two drachms, of various and irregular shapes, generally having one or two smooth sides without any periosteum, while the other sides appeared much like fractured surfaces.
A drachm, in the old apothecaries’ system of weights and measures, is a sixteenth of an ounce or ~1.7g. Periosteum is the hard outer covering of bone.
An earlier edition of the journal contained an extract from a letter by Dr Shuler, a doctor who had taken away some of these fragments for analysis.
Enclosed are specimens of bone and cartilage, with a clot, that were taken from the girl’s face. I regret I have no more to send to you… The specimens I found are smaller than most that made their appearance. The largest of them owes its whiteness, externally, to having been brushed, and is smoother than most of those which I saw. All the bones had some parts of their surface smooth— but this smoothness was generally on one side. The cartilaginous substances appear when dry, to be of two kinds — the one pale and transparent, and the other yellowish, and more opaque, as you will find by examination. It is probable, I think, if the cartilage and bone were properly analysed, they would be found to contain a larger proportion of gelatine than the regular bone of the human body — and the yellow places especially, to be composed principally of gelatine.
Alas, we do not know whether any chemical analysis was performed, or the results.
They continued to come for about six weeks with an intermission of three or four days. At first they came as often as once in every ten or fifteen minutes, and were very hard. At last they came much more seldom, and gradually assumed a cartilaginous appearance. They generally adhered to the cheek slightly, by a kind of glutinous substance, till pulled off.
So for six weeks this unfortunate girl endured pieces of bone (under 4g, so quite small) emerging through the skin of her face – and later pieces of cartilage. But how?
Their first appearance was astonishing. While the bystanders would be gazing at the place from whence they came, they would be suddenly surprised with their appearance without being able to tell how they came, for the girl would feel no pain, and not the least sign of an opening or a scratch could ever be discovered. All agreed in thinking they must come through the skin. The lumps of flesh that alternated with the bones, were about the size of the end of a finger, and had much the appearance of the soft kind of polypus.
A polypus or polyp is a small abnormal tissue growth.
All these things appeared about the left eye, and mostly upon the cheek under the eye. Two pieces of cartilage made their appearance between the eyelid and eye. The last of all that appeared, was a cartilage nearly as large as the nose, which came through the left nostril, causing in its passage considerable irritation.
Why on earth was a piece of cartilage that size emerging from her nose? I have no answers.
During this extraordinary case, I visited the girl several times, and once in company with several other physicians. Not the least sign of swelling, discolouration, soreness, or anything else indicating disease could ever be discovered about the girl, except she acknowledged that she had occasionally a slight pain about her hips and loins.
Was this ‘slight pain’ clinically significant? Somebody more expert than me might know.
I have been told, that soon after the last cartilage made its appearance, she commenced menstruating regularly, and nothing strange has ever appeared about her since.
Again, another tantalising possible clue, and yet one I can make nothing of. Was the onset of menstruation in any way relevant?
During the time the bones were coming, the girl was subject to eructating, after eating, a kind of gas of a very strong smell, which the family compared to that of whiskey.
This might be indicative of ketosis (when the body is short of carbohydrates), which results in a distinctive type of bad breath. Or indeed some kind of digestive problem – for instance, an obstruction to the small gut or pylorus can cause fermentation to occur in the stomach, resulting in foul-smelling gas belches. But neither of these conditions is even vaguely related to the other symptoms documented in the case report.
So what was going on here? My only theory – and an imperfect one – is that the patient may have been suffering from a condition called hematidrosis, in which blood seeps through intact skin, as if it were sweat. It’s extremely rare but well documented, and is thought to be the explanation for many occurrences of stigmata.
One factor in favour of this theory is that the condition often affects prepubescent girls. But there are also major objections, such as the apparent expulsion of bone, cartilage and polyp-like tissue fragments.
Of course it is always possible that the whole thing was a fraud, or the description exaggerated or misleading. But if we credit it with any degree of accuracy, I really don’t know how to explain it.
So what do you think? If you have any ideas, please do leave a comment below. I’d love to see what your combined expertise will come up with.