A wonderful accumulation

This notable case report was published in the Medico-Chirurgical Transactions in 1852.  The author, John Marshall, was a young surgeon in private practice in London; it is not clear how ‘Mrs B.’ came to be his patient, given that she lived in Oxfordshire.  Marshall later became a well-known anatomist, a Fellow of the Royal Society and professor of surgery at University College Hospital. This case, from early in his career, was quite the oddity:

Mrs. B., aged 41, the wife of a corn dealer, residing at B–, in Oxfordshire, was a rather tall, well-formed woman, of fair complexion, good intelligence, and habitually benevolent to the poor. In the year 1844 I first attended her in childbirth. The labour was natural, and she soon recovered. My father had previously been her medical friend, and was with her at the birth of five children; a fortnight after the birth of the fifth child, in December 1842, she was affected with haematemesis, vomiting a wash-hand basinful of blood.

Not just unpleasant, but potentially serious: a basinful of blood is no trivial amount. (‘Haematemesis’ means simply ‘vomiting blood’)

During the succeeding forty-eight hours she lay in a state of total unconsciousness, pupils greatly dilated, and the pulse scarcely perceptible. The vomiting did not return, and she slowly recovered, but her countenance ever after was sallow.

The doctor next saw her in the autumn of 1845, when she complained of frequent sickness and abdominal pain. This time the physician found a possible cause of these symptoms:

On examining the abdomen, I discovered a hard tumour in the left iliac fossa, which moved freely across the abdomen, as she turned from side to side.

The left iliac fossa is one of the nine regions into which (for diagnostic convenience) physicians like to divide the abdomen. The major structure of the left iliac fossa is the colon – so the doctor must have been suspecting some kind of tumour inside the large intestine.

The size and shape of this tumour were very like an ordinary placenta, one edge much thicker than the other; the thickest edge much harder, and imparting to the fingers the feeling of its being very heavy. She stated that she had felt this substance for some months, and whenever she turned in bed it always moved, and caused nausea, but gave her no pain when she was quiet, nor was it tender to the touch.

The woman added that she suffered badly from flatulence and shooting pains in her shoulder-blades. She also believed that she was pregnant.

The nausea increased, and the stomach rejected everything; large quantities of a green ropy mucus, occasionally with blood, were thrown up, all of which was carefully examined, without detecting anything which would throw light on the case.

The doctor tried numerous remedies to alleviate the woman’s symptoms, but without success:

The emaciation and exhaustion became so great, that her death was daily expected. One teaspoonful of pale brandy was now given every hour, and not an atom, or drop of anything beside.

And then, to everybody’s surprise, she made a miraculous recovery. The vomiting ceased, she started to eat small meals, and four months later was able to walk two miles.

During this illness, Dr. Cowan, of Reading, visited my patient; he was greatly interested in her case, and expressed himself to be as much puzzled as I was respecting the nature of the tumour, which he compared to a cannon ball rolling across the abdomen.

The woman now enjoyed a period of almost five years in relatively good health. But then she suffered a major relapse.

On the 8th of October, 1850, I again saw her in consultation with Mr. Corsellis, of B–. From him I learned that she had been ill three weeks, that all her old symptoms had returned. Incessant vomiting, with pain between the shoulders, had reduced her to a state of great weakness and emaciation. A few hours after my visit, severe spasmodic pain came on in the bowels, and quickly terminated her sufferings.

The poor woman had died from a condition two doctors had been unable to diagnose. But, as they soon discovered, she had always known the cause of her illness. The following day they performed a post-mortem:

The thoracic viscera were healthy, and free from adhesions. On opening the abdomen the stomach was found drawn down to the pubes, and in its form resembled a champagne bottle.

Strange. The doctors decided to investigate further.

Having tied the oesophageal end of the stomach and the duodenum, I removed these organs. The stomach contained about a pint of semi-fluid matter, and felt very like the crop of a fowl; the duodenum resembled a large sausage stuffed with lead.

What on earth could have caused that?

On cutting into the stomach I found it partially filled with some gruel-like fluid, and in the lower half, which evidently constituted the tumour during life, an immense number of pins, of a purple black colour, not corroded, varied in size, all bent or broken, many very pointed.

The doctors also noted that the lower part of the stomach was ‘remarkably thickened’, and resembled that of an ox.

The weight of the pins contained in the stomach was nine ounces. An incision made into the duodenum displayed a mass of pins very tightly packed, of various shapes, similar to those found in the stomach, and wholly obstructing the tube. These weighed a pound, as nearly as I could ascertain without removing them. 

The woman’s digestive tract therefore contained 1 lb 9 oz (around 700g) of metal pins. At a rough estimate she had well over a thousand of them in her stomach and small intestine alone.

Her husband could scarcely believe the truth of what he saw, when we showed him the contents of the stomach, for he affirmed that he had never seen his wife put pins into her mouth. A son, 17 years of age, said that he had often observed his mother biting pins, and believed that she swallowed them. She took them out of her thimble with her tongue, having previously bent the head and point together. When his mother corrected him for any bad habit, he would say—Why do you eat pins? This reply always silenced her.

Typical teenager.

He stated that the servants when shaking the carpets frequently remarked on the number of bent pins they found. 

A strange habit – bending pins and then eating them. But when Mr Marshall looked into her history, a pattern started to emerge.

Mrs. B had a keen appetite, and would always partake of any food she fancied, however improper or indigestible.  A sister informs me that, when a child, she was fond of eating starch and slate pencil—and she remembers her biting pins.

This behaviour is characteristic of pica, a disorder which causes people to ingest inappropriate and non-nutritious substances.

When seventeen years of age she vomited blood, and remained for some months an invalid, until sent for change of air to Bath. 

Mr Marshall concludes his article by quoting a colleague, Dr Charles Cowan of Reading, who had also attended the woman during her illness. Dr Cowan believed that her compulsive eating was so ingrained a habit that she had ceased to be aware of it:

I do not think she had the slightest suspicion of the real cause of her illness, nor that she would have hesitated to have confessed her apprehensions, had they been experienced. She probably accidentally swallowed the pins from time to time, without noticing or disregarding the fact, and during a long series of years the wonderful accumulation took place.

It seems a bit of a stretch to suggest that more than a thousand pins were swallowed ‘accidentally’, but he may well be correct that she was barely aware of what she was doing.