The foot-long bladder stone

This short article appeared in a Norfolk local newspaper, the Norwich Gazette, on June 7th 1746:

On Sunday last was cut for the stone by Mr. John Harmer, John Howse, gardener, from Porland, aged 49, from whom he extracted a stone of a prodigious magnitude, measuring 12 inches one way and 8 the other, and weighed upwards of 14 ounces and a half, and is said to be the largest ever extracted from any one person who recovered the operation, as this man is likely to do, he not having yet had one bad symptom. In my next I shall insert a further account of this operation, in which the Publick shall be informed whether the patient be living or dead.

‘Cutting for the stone’ is an old term for the surgical removal of bladder stones, or lithotomy.  A bladder stone a foot long and weighing close to a pound is a truly exceptional specimen. As promised, the following week’s newspaper included an update:

John Howse, the gardener who, as mentioned in my last, had the large stone (which weighed upwards of 14½ ounces) extracted from him is in a fair way of recovery and judged to be out of danger. The above Mr. Harmer has cut for the stone upwards of 170 persons, and that with as much success as any man living, but never extracted one so large before.

The last sentence is something of a giveaway: these news articles were in fact advertisements, written and paid for by Mr Harmer himself to publicise his surgical practice.

Many such advertisements were placed by quacks, but John Harmer was nothing of the sort; he was, in fact, one of the most eminent practitioners of lithotomy in Norfolk, if not the whole of England.  During the 18th and 19th centuries the county had by far the highest incidence of bladder stones in Great Britain – a fact possibly attributable to the largely grain-based diet of its inhabitants. It’s no coincidence that Norfolk surgeons and doctors became particularly expert in the condition.  (You can read an interesting essay on this ‘Norwich School’ here). The Norfolk and Norwich Hospital, founded in 1771, was widely regarded as a European centre of excellence for the treatment of bladder stones.

Norwich Hospital, founded 1771

One of the founders of the hospital was Benjamin Gooch, a celebrated figure (and friend of the eccentric Messenger Monsey, recently featured on this blog) who wrote several important books about the practice of surgery.

In one of them, Cases and Practical Remarks in Surgery (1758), Gooch gives his own account of John Howse’s mammoth bladder stone. It confirms that John Harmer had not exaggerated the details in any way.

singular case of the stone

J.H. of P., aged 48, had been subject to the stone from his infancy; was searched, and should have been cut at eight years of age.

It is strange that small children (mainly boys) were particularly prone to bladder stones in Norfolk. ‘Searched’ in this case means that a doctor looked for and found a stone while he was still a child.

His constitution was naturally robust, but he had much impaired it by drinking, and living a very intemperate life.

Heavy drinkers are often dehydrated, a state which tends to promote the growth of bladder stones, since it increases the concentration of minerals in the urine.

The operation was performed, on June the 8th, 1746, after Marianus’s method, by Mr Harmer, late of Norwich, an experienced lithotomist.

Marianus’s method’ was a lithotomy technique devised around 1520 by the Italian Giovanni de Romanis, but first recorded by his pupil Mariano Santo a couple of years later. It entailed making an incision in the perineum, the area between the genitals and anus, and through the urethra.  Dilators were used to widen the urethra to allow the operator to pass forceps into the bladder and remove the stone. It was a standard method across much of Europe for more than two centuries – and in 1746, of course, the patient would have to endure this excruciating process without any anaesthetic.

It was found impracticable to extract the stone through a wound of the common size, which the operator had made, or to break it by the force of the forceps; therefore, at his desire, I divided the parts occasionally, as he continued a gentle extraction.

By which Gooch means that he widened the incision to make room for the stone to be removed.

The stone weighed near 15 ounces, and I believe is the largest we have upon record, taken from a living subject.  I have it now in my possession. It is of a hard texture, and has a substance like spar, to a considerable thickness, upon many parts of its surface.

‘Spar’ is an old mining term for a crystalline substance. In 1896, when the Lancet alluded to this case, it was still believed to be the largest bladder stone ever removed from a live patient.

There was no reason to expect the wound would ever be perfectly healed, after the extraction of a stone of that enormous size; but he had no symptoms that threatened his life in consequence of the operation. He died in April 1751, and constantly walked abroad till a few days before his death.

After Marianus-type lithotomy the wound was generally left open to heal of its own accord. Though the patient was able to resume something like a normal life, the enormous incision continued to torment him for a long time afterwards. Gooch adds this painful postscript:

The wound remained in a foul and bad condition, and was made worse by being constantly wetted with the urine, which prevented all applications from having their proper effect.

The incision went directly into the urethra, which made healing extremely difficult (and painful).

These circumstances induced this poor, unhappy sufferer, to endeavour to tempt a little favourite dog to lick the parts; and in a short time he was so well instructed in his business, that whenever his master laid down and uncovered them, he immediately went to work with his tongue, which afforded a pleasing sensation.

This sounds as if it ought to be illegal.

Then the application of soft, dry linen cloths, gave him more ease than any applications his surgeon furnished him with. As long as he lived his dog was his surgeon, and kept the wound tolerably clean and easy, to his great comfort and satisfaction, as he often told me.

Not recommended. Today we know that dogs’ mouths – like our own – are teeming with bacteria. One recent study of the microbiology of the canine mouth identified well over 300 species of bacteria, many of them capable of causing human disease.  Gooch does not indicate what killed Mr Howse the gardener, but if his wound remained in a ‘foul and bad condition’ it may well have been the cause of death.

But what happened to the stone? In 1846 the Norwich and Norfolk Hospital set up a pathological museum, which included the largest collection of bladder stones in the world: this gigantic specimen was on display, but alas I don’t know whether it still exists. Thankfully we do have a visual record, however. Robert Gooch commissioned an engraving for his book, which I reproduce below.

bladder stone
John Howse’s 12-inch bladder stone. Illustration from Robert Gooch, Cases and Practical Remarks in Surgery (1758)

One thought on “The foot-long bladder stone”

  1. The dog! I was not expecting the dog!

    I’m surprised the patient lived so long after his lithotomy. I would’ve thought that a stone of that size and the state of surgery in 1747 would mean that Howse’s bladder was toast.

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