Phytobezoar

CAN A SYMPTOM BE A CURE?

Study of a Phytobezoar as a recurring symptom of Impulse Control Disorders relating to the Obsessive-Compulsive Disorder spectrum in relation to the history of bezoars and the clinical bias associated with them as an antidote in ancient alexipharmic practice

Housed in the University of Cape Town Pathology Learning Centre, amongst many other human specimens is a Phytobezoar from 1970—catalogued anonymously with the number D5-m30-3335, alongside a QR code linking to the case detail of the specimen on the UCT Digital Pathology Online Catalogue (Fig. 1.1 & 1.2) (UCT Digital Pathology Catalogue, n.d.). Its caretaker is Dr Jane Yeats, both a pathologist and the curator of the Pathology Learning Centre. The identity of the ‘creator’ of the Phytobezoar is kept anonymous for ethical reasons relating to human remains and patient confidentiality, however, the clinical data provides a vague, seemingly objective medical profile (UCT Digital Pathology Catalogue, n.d.) (Fig. 2.3). It mentions the patient’s age of eleven years; their gender by use of the pronouns he and his; possible disability by mentioning that he was “mentally handicapped”; and his place of residence that is referred to “an institution”. By naming the boy an “inmate” it is suggested that he was not there by choice. The clinical data does not provide any insights into why the bezoar was formed; it only provides a vague reference of how. This is given in the mention that the boy “was known to be fond of eating grass” (UCT Digital Pathology Catalogue, n.d.).

This Phytobezoar is in simplified terms a grass ball: phyto meaning plant and bezoar referring to a composite clump of indigestible matter left behind in the stomach to form a congealed and obtrusive mass (Lee et al. 2009:2265). It is heavier than it looks, weighing in at 847 grams, nearly a kilogram, with the size of 18 x 19 x 8 cm that becomes variable if the bezoar is removed from its container. It could easily be mistaken for a fallen coconut if ever it escaped (Fig. 3) bearing distinct likeness in shape to the mystical coco de mer or double coconut (Fig. 4)—a giant seed from the Lodoicea Maldivica Palm (Dransfield, 2008), which was used in ancient alexipharmic practice (Barrosso, 2013:196). This is a medical practice relating to antidotes, directly translated from Ancient Greek as aléxō—to ward off and pharmakon—drug (Duckett, 2006).

This Phytobezoar came into the world on the 23^rd of March 1970, when it was surgically removed from the boy. It only came to the attention of the doctors when the boy began presenting physical symptoms which, according to the clinical data were “suggestive of an acute abdomen”, including, “abdominal pain, vomiting and on examination, tenderness and rigidity of the abdomen” (UCT Digital Pathology Catalogue, n.d.). The bezoar was discovered during an emergency laparotomy: a surgical incision into the abdominal cavity, and thereafter a further investigation via a gastrotomy, entailing the creation of an artificial external opening into the stomach. The most revealing part of the clinical data is the last sentence, which is as follows: “His convalescence was uneventful, but significantly about the 8th to 10th day he was noted to be attempting to eat his bandages.” (UCT Digital Pathology Catalogue, n.d.). This sentence of the report indicates a high chance of recurrence of a bezoar, further demonstrating that despite the removal of the bezoar, and hence the removal of the mechanical obstruction, the boy was not necessarily cured as the doctors had not investigated the cause, they had only removed an dangerous symptom for the time being. The cause was overlooked once the immediate threat to life had been dealt with.

THINGS LEFT UNSAID: Overlooking comorbid ICD

This begs the question, what is left unsaid? in the data surrounding this specimen, and how does this relate to bezoars today? The use of the word “fond” in the clinical data makes it seem like eating grass was one of the patient’s fun hobbies or favourite pastimes. But connotation of the term “fond” gives the idea of enjoyment which simplifies the cause of the bezoar. Simply put, why did nobody ask why would someone eat something that is not edible? This essay will look at the use of bezoars over the ages and examine their present-day relevance through the lens of anxiety and related disorders. It will examine how the bezoar has historically been a form of a cure, and possibly still is today: as a symptomatic result of a compulsion that temporarily cures the patient of their obsessive thoughts.

In many cases, bezoars present as a symptom of an Impulse Control Disorder (ICD)—the failure to resist an impulse—or relating to Obsessive Compulsive Spectrum Disorder (Prochwicz & Starowicz, 2012:197). Obsessive Compulsive Disorder is divided into two elements: the obsession and the compulsion. The obsession is the recurrent fear or anxiety that plagues the mind, and the compulsion is the repetitive actions or ritualised behaviours that are performed to distract from the obsession (Grohol, 2018). Impulse Control Disorders include Trichotillomania – hair pulling; Trichophagia – hair eating (often a symptom of the prior) and Dermatillomania – skin picking, amongst others. Trichobezoars (hairballs) and anxiety often accompany Trichophagia or Trichotillomania. They are a result of the long hair fibres that become “entangled in the gastric folds and resist peristalsis” (Sanders, 2004:38), blackened by gastric acid regardless of their original colour. This is also the case with the phytobezoar in this case study, except for the one or two white and red threads that have maintained their colouration (Fig. 5.1 & 5.2). Like Trichotillomania, “Pathological skin picking is associated with psychosocial impairments, social isolation, distress, and high levels of anxiety” (Prochwicz & Starowicz, 2012:197). These three Impulse Control Disorders are similar in their causes as are all known to have a high rate of psychiatric comorbidity—they are likely to occur alongside other psychiatric conditions such as depression, anxiety disorders and obsessive-compulsive disorder.

 RAPUNZEL SYNDROME: Don’t call me crazy

A medical case study done in 2016 looks into a patient with “Rapunzel syndrome”, involving a trichobezoar that was surgically removed from a fifteen year old girl, trailing from her stomach and extending into the intestine (Fig. 6). The article notes that the trichobezoar is a rare case, “usually seen in young females with age range 10 to 19 years” (Kumar Bn et al., 2016). Upon consultation with Dr Jane Yeats about this assertion, it became apparent that it was because most young girls have long hair due to gender norms, whereas young boys have shorter hair. This means that boys would be less likely to develop a Trichobezoar, even if they had Trichotillomania as their short hair would be unlikely to become tangled in the stomach. Dr Yeats concluded that this meant it was safe to say that there was likely not actually a gender bias in mental health, as suggested in the article, relating to this anxiety related ICD (Dr Yeats, personal interview, 2019 March 27). Perhaps the Phytobezoar in this object study is evidence of this, as the boy housed at the “mental institution” probably would have had short hair, possibly even shaven as a part of the institution’s protocol. Dr Yeats’s conclusion also highlights the unfairly gendered bias in the naming of this bezoar as “Rapunzel syndrome”, implying that it is a syndrome relating to women only. Although the name seems relevant due to Rapunzel being known for long hair resembling the form of the elongated bezoar, she was also a woman or “damsel in distress” who was isolated and trapped in a tower, eventually using her hair to escape. In this light the naming is somewhat reductionist, as it romanticises the distress. But to a certain extent the story rings true with the disorder: the hair is agent for escape, as with the case of the Phytobezoar where it is the grass. In effect, the compulsion that is acted out is because it is essentially calming. Perhaps it could mean that trichobezoars and phytobezoars, amongst other bezoars resulting from ICD related stress and anxiety are a quick fix—a cure to the anxiety, albeit temporarily and with other consequences, in a desperate attempt to distract the mind. Their formation comes as a meditation that is performed in the absence of treatment for the cause.

The naming of “Rapunzel syndrome” reveals the trivialising and almost comic approach of medical practitioners and doctors in the past to comorbid anxiety disorders, drawing historical ties back to women’s mental illness being overlooked and labelled as a condition called “Hysteria”.

“A common myth in the Victorian era was that women with symptoms ranging from loss of sexual appetite, fatigue and anxiety to mild depression were suffering from female hysteria, which could apparently be cured by pelvic massage leading to hysterical paroxysm (orgasm).” (Andrews, 2018: 31)

In this sense, the vibrator can be seen as an early cure for anxiety related disorders (Fig. 7). The notion of hysteria as an illness was supported by Dr Baker Brown’s 1860s definition of the symptoms of female insanity including: “epilepsy, masturbation, undertaking too much reading or expressing a desire to be a nurse.” (Andrews, 2018: 38). This definition demonstrates how women’s aspirations and their desire for creativity and learning were stifled, and how psychiatric conditions in women were overlooked. In terms of Rapunzel syndrome, it makes sense how a name that holds such insidious meaning could still be used today without anyone blinking an eye. It is likely that children’s mental illness was dealt with similarly, as children’s thoughts and emotions were often disregarded. Many cases of impulse control disorders go unreported due to the stigma attached to them, surrounding the fear of being called “crazy” which may not seem like a harmful word, yet it is flippantly used to brush off “emotional” or uncontrollable women, and bears an oppressive history. It could be speculated that this is how bezoars can become life-threatening, typically only discovered when physical symptoms occur (Sanders, 2004:41). The surrounding clinical data of the Phytobezoar under examination in this essay bears very little indication toward mental illness, besides for noting that the patient had a case of “mental retardation” (Saint Surgical Pathology Museum Catalogue, n.d.) (Fig. 2.3) which is problematic in itself. The Phytobezoar was previously classified as a “miscellaneous” specimen (Saint Surgical Pathology Museum Catalogue, n.d.) (Fig. 2.2) and has since been reclassified as a “mechanical” problem (Dr Yeats, personal interview, 2019 March 27) (Fig. 8). Both classifications bear witness to the perception of the bezoar as an obstruction to the body in alienation of the mind, reiterating that its causality is unto the body and once it is removed, the patient is “cured”.

 BEZOAR AS ANTIDOTE IN ANCIENT ALEXIPHARMICS

 The term “Bezoar” has its origins in ancient alexipharmic practice and is derived from the ancient Persian term padzahr: pad—expelling and zahr—poison (Barrosso, 2013:193) and the Arabic term badzehr both translating to counter poison or antidote (Sanders, 2004:38). Both humans and animals create bezoars, but their purpose differs slightly. Animal bezoars were typically used in history as an antidote or a cure to poison, initially found in the stomach of goats in the mountains of Western Persia (Sanders, 2004:38), whereas bezoars occurring in humans in psychiatric cases, are both a symptom and a cure relating to a compulsion. In ancient alexipharmics, animal bezoars were used “to treat poisons such as arsenic, venomous bites, epilepsy, dysentery and the plague” (Sanders, 2004:38). According to another source “the calcium and phosphates they contain appear to make them antidotes to arsenic” (Barrosso, 2013:193). Brushvite & struvite in goat and deer bezoar stones act as chelating agents and neutralise the poison. Chelating agents are used in present day medicine, injected into the bloodstream to remove heavy metals and minerals from the body (Barrosso, 2013:193).

In ancient alexipharmic practice, bezoars were used in similar ways to “unicorn horn” (rhino horn), another alexipharmic. Both were “scraped, reduced to powder and then suspended in liquids, usually wine, where their healing agents were diluted.” (Barrosso, 2013:194). Some bezoars were attached to “unicorn horn” bowls and used for dipping into foods, a technique that was believed to eliminate potential poisons. (Barrosso, 2013:199). Some bezoars are still used in the Malayan Peninsula, in Sarawak, in the Penan and Iban tribes. In this case, the healing power is attributed to the diet of the porcupine who produces them, which is toxic to humans, and is used by the tribes to stun fish in rivers. (Barrosso, 2013:196). Fake bezoars are sold today in some Asiatic markets, made from bitter substances and hair (Barrosso, 2013:196). Due to bezoars being an effective cure for some poisons, they became known as a universal antidote to a wide range of symptoms, even when they did not work in some cases. Over time, their value as an antidote became mostly symbolic so their monetary value did not decrease.

Historically, bezoars were worth ten times their weight in gold, deeming their weight an important factor in discerning value. There is one sixteenth century Spanish Oriental bezoar that has its weight inscribed on a golden ring surrounding it (Fig. 9) (Barrosso, 2013:199). Further evidence of their high value was in their decorative and symbolic use. Queen Elizabeth I (1535-1603) had a bezoar inlayed in her crown and the Kunsthistorisches Museum of Vienna, Austria houses a similar example, a bezoar embedded in golden filigree from seventeenth century (Fig. 10) (Barrosso, 2013:198). This is also the case in the collection at the Museu da Farmácia de Lisboa, in Lisbon, Portugal (Fig. 11) (Barrosso, 2013:199), where another similar example is held. In 1609, a Flemish mineralogist and physician, Anselm Boetis de Boodt (1550-1632) described a range of supposed therapeutic uses of bezoars, ranging from antidotes for various kinds of poisons; to improving depressive disorders; and also mentioning in his study that they “cured skin diseases” (Barrosso, 2013:202). Assertions like these would have been largely biased due to the value of bezoars at the time, putting physicians were under pressure to prescribe them, due to their popularity (Barrosso, 2013:204). These cases all support the underlying notion of the bezoar as a cure, both symbolically and medicinally.

CONCLUSION: SYMPTOM AS A CURE

The Bezoar’s historic use as a cure, brings to light the framing of it today, more specifically the reason why UCT has kept this Phytobezoar in its collection. Upon questioning Dr Yeats about this, she described the doctors who initially decided to keep the specimen as strictly “medical men” who would not have kept it because of its historical values, but rather as a case of interest to be studied. The term “medical men” does not sit well in establishing the absence of a bias. It has implications that these particular men were looking at the specimen “scientifically” which is supposedly objectively. Objective is a term that means an opinion comes from a non-biased perspective, but how it is non-biased to ignore all of the biased scientific history surrounding the object? In terms of what this essay has investigated, “medical men” have proven to have had many scientific theories that were highly biased, particularly surrounding mental illness and generalised anxiety disorders.

In other fields of scientific study “facts” are changing all the time with the rise of technologies, such as DNA barcoding, providing objective information that discredits past categorisations. But why is no one taking note of how easily and often “facts” change? The Phytobezoar and its surrounding data act as a testament to how medical and scientific “facts” need to be deeply examined in terms of how current day medical practices are influenced by biased groundwork. This takes us back to the notion of the bezoar as a cure as an important part of its history that should not be omitted. It brings to light that the bezoar could be a form of a cure in present day cases, in that the compulsion soothes the mind, distilling the obsessive thoughts. It is essentially a dangerous coping mechanism, in the absence of proper medical treatment, due to the cause being overlooked. It is a desperate attempt to cure what cannot be seen, by performing a meditation on the body that can be felt. Perhaps the patient is attempting to clean the body, because they do not know how to clean the mind. This Phytobezoar is as important as any other human tissue sample in the UCT Pathology collection in that it is a physical manifestation of a mental illness and should be reclassified as such. Its presence in the collection is pertinent, because often people do not believe things they cannot see.

Acknowledgements