In 1874 The Lancet printed this cautionary tale by Thomas Whiteside Hime, who had discovered the hard way that things aren’t always what they seem. He began his article by reminding his colleagues of the ‘great importance of carefulness in diagnosing’ – particularly where a supposed pregnancy is concerned:
Early in July last, M. G., unmarried, aged seventeen, became a patient of mine at the Hospital for Women. She had ceased menstruating in the previous February, and had been dismissed from her situation in June on suspicion of being pregnant. She looked healthy; her abdomen was much more prominent than is usual in young virgins; her breasts were large and full, the nipples firm and projecting from a dark, well-defined areola, which was studded with enlarged follicles; the mammary glands were firm and large, but there was no milk. Since the cessation of menstruation she had suffered from temporary attacks of incontinence of urine, and has not passed more than a wineglassful at any time. Micturition was not painful. She had also had severe attacks of vomiting. Her urine had become very thick and offensive the last few weeks.
Dr Hime reports that a urine sample brought to him the next day ‘smelt abominably’. This led him to suspect an infection caused by a bladder stone, but she had never passed any ‘gravel’ – the tiny shards of mineral deposit which sometimes indicate the presence of a larger stone lodged inside the bladder.
The nature of many of the above signs and symptoms rendered a further examination necessary to decide as to whether the girl was pregnant or not, though there was strong and prima facie evidence that she was. I could detect no enlarged uterus through the abdominal walls, either by the aid of palpation or percussion, nor of that most instructive of all manoeuvres in such cases, simple pressure exerted with some vigour.
This led the doctor to consider the differential diagnosis – the range of other conditions which might present similar symptoms.
On passing a metallic catheter into the bladder I struck on a calculous mass of large size, which prevented the catheter penetrating more than about half an inch into the bladder. Having taken the patient into hospital, I next day, without the least difficulty, passed my first finger through the urethra and reached the calculus. The vesical walls were so firmly contracted about it that I could not extend my examination in any direction except on the side opposite the urethra. I scraped away a good deal of the mass, and injected water to wash it out, repeating this operation every couple of days for a week. The pain, however, became so severe that, as I dreaded lacerating the bladder, I determined to remove the body by lithotrity, if possible.
Lithotrity involves breaking down a stone in situ so that the fragments become small enough to be passed naturally. It is a less invasive procedure than the only alternative available at this date, lithotomy, which would have entailed cutting open the bladder.
Having chloroformed the patient, I again passed my finger into the bladder, and found the mass extending right and left from the internal orifice of the urethra as far as my finger could reach. I could not get above, below, or behind it, owing to the contraction of the bladder, which also prevented any quantity of fluid being injected. I succeeded in getting the lithotrite round the calculus, but, to my surprise, though the outside was so soft, I could make no impression on it.
The lithotrite was a long, thin surgical instrument with a pair of jaws at its end, which was inserted into the bladder and used to crush, drill or hammer the stone into pieces. The fragments were then grasped and extracted. This was all done blind, of course.
I now found, on examination, that beneath the calculous covering was a hard, smooth core. Following up the effect of the lithotrite, I denuded this of a considerable part of its coating, and reached a sharp extremity firmly embedded in a cul de sac, which apparently reached as far as the inner third of Poupart’s ligament on the left side.
Poupart’s ligament, generally known today as the inguinal ligament, runs from the spine to the pubic bone. Its function is to contain the soft tissues of the lower abdomen.
With great difficulty, and after much time had been spent, this end became loosened, and a successful turn brought it to the urethra, whence it was extracted. It turned out to be a toothbrush-handle, and presented the appearance shown in the annexed woodcut, which is of full size.A large part of the calculous covering had been detached while the mass was in the bladder. Even after this the girl denied all knowledge of the matter. Subsequently she admitted having several times used the implement to relieve stoppage of her urine. But on the last occasion she said it was “drawn into” her bladder.
She lost her job and her reputation – and all because of a toothbrush.
For a couple of days her urine was slightly red, and her bladder was washed out with a weak solution of carbolic acid. In a week she was discharged well, her water being perfectly normal. Twenty-five days afterwards she menstruated normally, the first time for seven months, and she has continued well since.
Let’s hope her former employer was persuaded to reconsider.