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INTRODUCTIONForeign body ingestion rarely causes complications, though it can pose a significant diagnostic challenge. Perforation, particularly of more muscular viscera, can present insidiously with a wide range of differential diagnoses.PRESENTATION OF CASEHere we present a case of 75 year-old woman presenting with chest and epigastric pain. Initial imaging suggested a pancreatic lesion. Despite appropriate treatment she deteriorated clinically, and following urgent laparotomy a duck bone fragment was found to have perforated the lesser curvature of the stomach and embedded within the liver causing subhepatic abscess formation and associated inflammation.DISCUSSIONThere are a number of examples of insidious presentations of gastrointestinal perforation. However, we have found only one other case of a perforation presenting as a pancreatic pseudotumour, and ours is the first to have been successfully managed by removal of the foreign body and drainage of the abscess alone.CONCLUSIONA high level of suspicion is required to make the correct diagnosis in cases such as these where the symptoms are not clear-cut. Thorough review and discussion of imaging prior to surgical treatment is essential to prevent unnecessary intervention.

LAURENCE STERNE AND THE EIGHTEENTH-CENTURY BOOK CHAPTER 4: THE MARBLED PAGE I A NATURAL PHILOSOPHY OF NOSES (Broken) noses cast a long shadow in Tristram Shandy, especially in the second instalment (vols. 3 and 4) of Tristram Shandy, which carries the marbled page. It opens with Elizabeth's prolonged labour and Tristram's eventual arrival into the Shandy family, when his nose is crushed during a bungled forceps delivery. Walter is left reeling, and throws himself prostrate on the bed in an exasperated fury, as Tristram explains:No doubt, the breaking down of the bridge of a child's nose, by the edge of a pair of forceps,however scientifically applied,-would vex any man in the world, who was at so much pains in begetting a child, as my father was,-yet it will not account for the extravagance of his affliction, nor will it justify the unchristian manner he abandoned and surrender'd himself up to.To explain this, I must leave him upon the bed for half an hour,-and my uncle Toby in his old fringed chair sitting beside him. (3.30.144-5)Tristram goes on to account for Walter's vexation by explaining that his father had dedicated much of his life to collecting books on the history and natural philosophy of noses. He departs from this scene of woe to explain that many generations of Shandys have suffered from anxieties around noses. Tristram begins with his great-grandmother, who had insisted upon a marriage article which allowed her a large jointure due to her fiancé having little or no nose. This long-running family concern with the facial member goes some way toward explaining Walter's staying in bed for the rest of the volume, and his peculiar bibliographical bent.Walter's book collecting is passionate but it has been a challenge: despite the 'many millions of books in all languages, and in all possible types and bindings' which have been 'fabricated upon points not half so much tending to the unity and peacemaking of the world' (3.34.161), he can find very few written on the subject of noses. Those he finds are contradictory, like the works of Prignitz and Scroderus, the first of which argues that the size of one's nose reflects the capacity of one's fancy, and the other vice versa. 1 It 1 W.G. Day has shown that Sterne drew his references to Bouchet, Panocrates and Grangousier from John Ozell's footnotes to the nose passage in Rabelais's Gargantua and Pantagrel. 'Sterne and Ozell', English Studies, 53 (1972), 434-436.

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