The stone bullet

In 1829 a surgeon from Wolverhampton, William Lewis, contributed this unusual surgical tale to The Lancet:

Stone bullet shot into the bladder

John Roden, a boy about 11 years of age, (of the Deanery-row,) of a spare habit and pale complexion, received a shot wound on the 5th of November last, while passing a door from behind which a pistol was discharged, loaded with a stone bullet.

A ‘spare habit’ means that he was slim. A stone bullet may sound an odd idea, but at this period pistols did not use ready-made cartridges but had to be loaded by hand. First the gunpowder was tipped into the muzzle of the weapon, then a small piece of paper or cloth known as wadding, and finally the projectile, usually a lead ball. Pebbles or other small hard objects were sometimes used as a cheaper alternative.

The shot, after penetrating the door, entered the upper part of the left thigh, and afterwards passed into the bladder.

An unlucky accident – particularly as the stone had already passed through a door.

On my first visit, I found a contused wound of a circular shape. I extracted several small pieces of wadding, but was not able, by the most minute examination, to detect the presence of any other foreign body. Syncope supervened, although the haemorrhage was slight, and no urine passed through the wound at that time.

‘Syncope’ is fainting.

On the following day, there was great external inflammation about the region of the bladder, with excruciating pain whenever an attempt was made to pass the urine; great tenderness upon pressure of the abdomen; pulse quick, hard, and full; tongue dry; great thirst, and many other symptoms of excessive inflammatory action.

The doctor decided to bleed the patient, both by opening a vein in his arm and by applying leeches to the affected area. Then he administered laxatives, enemas and a warm poultice, which apparently alleviated the symptoms.

On the third day the urine passed freely through the orifice in the thigh, and continued so to do for many weeks; during this time, bloody urine was occasionally passed by the urethra, and frequently a considerable quantity of mucus; there was also a great sympathetic swelling of the glands in the groin.

The boy had developed a fistula, an abnormal connection between the bladder and the surface of the body.

The wound at length became partially healed, and the symptoms of stone in the bladder were very much aggravated. I was particularly anxious at this time to introduce a sound; but neither the parents nor the patient would consent, and at length the wound entirely healed, and the swelling in the groin gradually disappeared. I then succeeded in introducing the sound, and immediately detected some foreign body in the bladder.

Evidently the final resting place of the stone projectile. An unusual accident, but in some ways a happy one, since the net result was that the boy was now suffering from a bladder stone, a condition well known to surgeons. The surgical removal of these objects was a fairly routine operation by the 1820s – albeit a dangerous one. Mr Lewis decided to employ a procedure developed a century earlier by the London surgeon William Cheselden:

Soon afterwards I determined upon performing the lateral operation of lithotomy, which I did on the 23rd of June, in the usual manner, with the gorget…

The gorget was a sharp knife with a groove along the blunt side of the blade. In Cheselden’s ‘lateral operation’ this was inserted through the urethra and used to made an incision in the neck of the bladder. Forceps or other instruments could then be passed along the groove to extract or crush the bladder stone. (See illustration below).

… and extracted the marble without difficulty, considerably increased in size, from a deposition of calculous matter adhering firmly to it. Not a single unfavourable symptom resulted from the operation, and in a fortnight the boy was enabled to get about. He now enjoys perfect health.

Young bodies heal quickly, and the patient’s youth undoubtedly improved his chances of recovery – but even taking this into account, it was a remarkable outcome after a serious injury.

Gorget illustration

Gorget used for the lateral operation of lithotomy, from John Dorsey’s Elements of Surgery (1813) 

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