The woman who peed through her nose

paruria erraticaThis is the most extraordinary and perplexing case of all the many I’ve sifted through while finding material for this blog. It was printed in The American Journal of the Medical Sciences in 1827, and written by a Dr Salmon A. Arnold from Providence, Rhode Island.  Dr Arnold acknowledges in a footnote that a shorter account of the case had previously appeared in ‘a Journal of limited circulation’ – er, the New England Medical Journal, today one of the best known medical publications in the world.

Dr Arnold felt he had identified a new illness, which he named paruria erratica ­– ‘wandering disorder of urination’. When you read on, you’ll find out why.   

Maria Brenton, aged 27 years, of sound constitution, generally enjoyed good health until June, 1820, when she was afflicted with a suppression of the catamenia, accompanied with haemoptysis.

Translated into English: she had missed her period and was spitting blood.

The medical attendants, irregular practitioners, bled her profusely every other day, and after the system had become greatly debilitated, injudiciously administered emetics, the operation of which was succeeded by a prolapsus uteri, and a total inability to perform the function of urinary excretion. In this state she continued for nearly two years and a half without any alleviation of the disease, though for the most part of the time under the care of respectable physicians.

A prolapsed uterus occurs when the muscles and ligaments holding it in position in the abdomen weaken and stretch. The organ then slips down into the vagina. A common complication of this condition is a prolapsed bladder, which can cause inability to urinate, as in this case. 

The urine had been drawn off by the catheter, generally every twenty-four hours, but when this was neglected, she often perspired very profusely about the lumbar region.

This is where things started to turn very… weird.

In September, 1822, soon after I first saw her, the bladder not having been emptied by the catheter for seventy-two hours, the urine found an outlet by the right ear, oozing drop by drop, and continued for several hours after the bladder had been emptied. The next day, at five o’clock P. M. the discharge from the ear again commenced and continued about as long as on the preceding, but a larger quantity was poured out. The fluid was thrown on a heated shovel, and gave out the odour so peculiar to urine, indicating the presence of urea.

The ‘heated shovel test’ is inexplicably no longer a part of conventional diagnostic practice. The discharge of urine from the ears continued, becoming more frequent each day.  It was, reports Dr Arnold,

increasing gradually in quantity, and being discharged in less time, until a pint was discharged in fifteen minutes in a stream about the size of a crow quill; then becoming more irregular, being discharged every four hours, and increasing in quantity, until eighty ounces were discharged in twenty-four hours.

Four pints; more than the average person urinates in a day. New symptoms then appeared: she started to suffer from spasms and ‘swooning’, and sometimes remained catatonic for up to twelve hours. And worse was to come.

The sight of the right eye was soon destroyed, and frequently that of the left was so impaired that she could not distinguish any object across the room, but the latter is now entirely restored. The hearing of the right ear is much impaired, she cannot distinguish sounds with it, and there is a constant confused noise heard by her like the roaring of a distant water-fall.

Strangely, this soon turned into an actual waterfall:

The next outlet the urine found was by the left ear, a few moments previous to which discharge, a noise is heard similar to that noticed in the right ear: she cannot hear distinctly for ten or fifteen minutes before and after the urine passes out. Soon after the discharge from the left ear, the urine found another outlet by the left eye, which commenced weeping in the morning and continued for several hours, producing considerable inflammation.

Look, this is getting ridiculous now. But wait, there’s more.

On the 10th of March, 1823, urine began to be discharged in great quantities from the stomach, unmixed with its contents. On the 21st of April, the right breast became tense and swollen, with considerable pain, and evidently contained a fluid, a few drops of which oozed from the nipple. On the 29th, one ounce was caught in a nippleshell, which, by analysis, was found to contain urea. Urine has been discharged occasionally from the left breast. 

So far we have urine coming from both ears, both eyes, the stomach, and both breasts. There can’t be any more orifices left, surely? WRONG.

May 10th, 1823, the abdomen about the hypogastric and umbilical region became violently and spasmodically contracted into hard lumps, and a sharp pain was felt shooting up from the bladder to the umbilicus, around which there was a severe twisting pain; in a few days subsequently a loud noise was heard, similar to that produced by drawing a cork from a bottle, and immediately afterwards urine spirted out from the navel, as from a fountain.

The poor woman’s experience sounds pretty ghastly, but you have to admit that a fountain of urine gushing from the navel must have been quite a sight. But not even this spectacle was the piece de resistance:

Nature wearied in her irregularities made her last effort, which completed the phenomena of this case, and established a discharge of urine from the nose. This discharge commenced on the 30th of July, 1823, oozing in the morning guttatim [drop by drop] and increasing in quantity every day until it ran off in a considerable stream.

Was the liquid really urine? Dr Arnold sent several samples to a professor of chemistry, who analysed them and confirmed that they contained large quantities of urea, as one would expect. The next obvious question: was she faking it somehow?

To remove every doubt, I and my friend Dr. Webb, who at my request had occasionally attended her, remained with her four hours alternately, during twenty-four hours, and the quantity discharged during this time was as large as it had been for several days previous to, and after this period. There has never been any doubt that these fluids, which have been proved to be urine, were actually discharged from the ear and the other outlets, since the fact has been proved, day after day, by ocular demonstration.

So what happened to her? The story has a happy ending – of a sort:

This great disturbance in the system continued to increase for nearly six months, and it was the opinion of all who saw the patient that she could not survive from day to day; after which period it gradually abated, and she is now, when the urine is freely discharged, so much relieved that she is able to walk about her room, and during the summer of 1824, frequently rode out. The discharges from the right ear, the right breast and navel, continue daily, but they are not so great nor so frequent as they were a year since; from the bladder the quantity is as usual; from the stomach, nose, eye, there has for some months been no discharge.

Not ideal: a tendency to urinate spontaneously from the ear does not make one the perfect dinner-party guest.

Here’s the really amazing thing about this case: it might actually be true – in part, at least. Obstruction to the outflow of the bladder can result in a condition called uraemia, in which the blood contains an abnormally large volume of urea. Possible symptoms include fatigue, abnormal mental state and tremors, all of which were present in this case. But the most striking symptom, seen only in patients with serious kidney failure, is uraemic frost, in which urea passes through the skin and crystallises. When dissolved in sweat it produces a liquid which smells and looks like urine.

A gigantic caveat: while it’s quite plausible that a patient with kidney failure would ‘sweat’ urine in relatively large quantities, this is unlikely to explain the ‘fountain’ of urine which appeared from Maria Brenton’s navel or the copious streams from her nose and ears. If any urologists or renal specialists are reading this and have an opinion to offer, please leave it in the comments below.

Update: Here’s an opinion from a reader who is a nephrologist (kidney specialist) with considerable expertise in this area:

“The only possibility is an association of oedema [build-up of fluid in the tissues] and uraemia with sweat like urine. But it is difficult to imagine survival for more than 6 months with such severe uraemia. So a fake case remains the most plausible hypothesis.”

Thanks to @SBurtey for allowing me to share this assessment.

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