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A 1,500-Year-Old Bladder Stone
0022-5347 /81/1264-0452$02.00/0 Vol. 126, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
A 1,500-YEAR-OLD BLADDER STONE JOHN M. STREITZ, ARTHUR C. AUFDERHEIDE, MAHMOUD EL NAJJAR AND DONALD ORTNER From the Research Laboratory, St. Luke's Hospital, Duluth, Minnesota, Department of Anthropology, State University of New Mexico, Las Cruces, New Mexico, and Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, D. C.
ABSTRACT
A calcium oxalate calculus was found in the anatomically normal bladder of a 1,500-year-old native American male mummy from the Northeastern Arizona Basketmaker cultural group. Results of analysis by chemical, optical, spectrographic and x-ray diffraction methods are listed and compared to several other reported prehistoric uroliths. Recently, we had the opportunity to study a solitary bladder calculus from a 1,500-year-old Southwestern American mummy. Since only a few such calculi have been studied by modern analytical methods we thought that it would be of interest to document our findings. The mummy. The body was removed from Vandal Cave in Northeastern Arizona by an archaeological team in 1928. Associated artifacts suggested the "Late Basketmaker Culture" (circa 500 to 750 A.D.). The body was stored at the University of Colorado until 1979, when it was removed and studied in detail at The Smithsonian Institution. Part of this study included dissection and histologic examination of the viscera. This adult male body (estimated age 30+) had been wrapped in a cloth garment embellished with fur and feathers and placed in the cave in a flexed position (without interment). Mummification occurred by natural dehydration without any embalming or other preservative methods. When dissected the body was well preserved. The skin was intact as were facial features. Internal examination of the chest and abdomen demonstrated good preservation of most organs, although the spleen could not be recognized and the liver was reduced to a handful of sand-like material. The heart and both lungs were recognized. The left kidney could not be found but the right kidney was represented by a 3 X 1.5 X 0.1 cm. brown membrane. Histology revealed recognizable tubular but not glomerular structure. No pathology was noted. No ureters were identified and no renal calculi were present. The penis was recognizable but the prostate, scrotum and testes could not be identified. The bladder was normal anatomically. It was contracted snugly around a single calculus within its lumen. Histologic examination of the bladder wall revealed a fibromuscular wall without evidence of inflammation. Nuclei were absent. Postmortem degenerative changes had resulted in loss not only of bladder mucosa but the mucosa! and epithelial lining of all other organs except the skin. The calculus. The calculus measured 3.0 x 2. 7 x 2.5 cm. and weighed 17.5 gm. Its light brown surface contained many blunt protrusions, 2 to 3 mm. in diameter (see figure). Optical microscopic analysis showed a predominance of monoclinic crystals with moderate birefringence and an extinction angle of 31 degrees, characteristic of calcium oxalate monohydrate. In addition, small amounts of orthorhombic crystals were present, the optical properties of which were those of magnesium ammonium phosphate hexahydrate, uric acid and ammonium hydrogen urate. Infrared spectrography revealed the calculus to be composed predominantly of calcium ox.alate monohydrate, with absorption maxima noted also for magnesium oxalate, magnesium ammonium phosphate hexahydrate, calcium phosphate (carbonate apatite) and ammonium hydrogen urate.
X-ray diffraction pattern revealed only 2-degree angle peaks for calcium oxalate monohydrate, other components recognizable by this technique being present in amounts insufficient for detection. The cleaved surface revealed calcium and magnesium as the major elements, while minor elements detected included iron, sodium, copper, silicon, phosphorus, strontium, potassium and aluminum, with trace quantities of lead, manganese and antimony. Human urinary calculi usually do not exhibit detectable spectral lines for iron, copper or silicon. In summary, the percentage composition of the calculus is calcium oxalate monohydrate-75, magnesium oxalate-9, magnesium ammonium phosphate hexahydrate-6, carbonate apatite-4, uric acid-3, ammonium hydrogen urate-2 and silicon dioxide- I.
Accepted for publication November 7, 1980. Supported by St. Luke's Hospital Foundation and Minnesota Medical Foundation. 452
DISCUSSION
Vesical lithiasis is an ancient malady. The well known British Egyptologist, G. Elliot Smith, found such a calculus in a 16year-old boy who died nearly 7,000 years ago. 1 A few other prehistoric uroliths have been reported. 2 ' 3 Bladder calculi became so common in the European medieval period that lithotomy became a subspecialty. Indeed, the evolution of modern surgery has been associated with this practice. 4 Boys were especially susceptible. Neither infection nor tumor seems to have caused the condition and, once removed, the stone seldom recurred. It persists today only in certain rural parts of the world. 5 As a nation industrializes and develops its research resources the problem disappears, resulting in a paucity of detailed biochemical studies. 5 Several authors have reported bladder stones of prehistoric origin but only a few used the modern physical and chemical analytical methods reported herein. 3• 5 ' 6 Most analyses of such ancient stones have identified them to be composed of calcium oxalate, uric acid or ammonium acid urate. 5• 6 Calculi from 2 native American burials from the late Archaic period in Indiana studied by x-ray diffraction recently were apatite stones3 but archaeological data were insufficient to determine their renal or vesical position. In 1926 chemical and spectrographic analysis results were reported on a bladder stone from the skeleton of a member of the same Basketmaker culture as that of our mummy. Those tests suggested the presence of calcium carbonate, phosphate and uric acid.2 A stone composed primarily of calcium oxalate is not normally found in a bladder afflicted with infection or tumor. Deposition of magnesium ammonium phosphate usually follows infection by urea-splitting organisms and, once such deposition is initiated, it is rare for other substances to be represented in the further crystal growth. 7 The predominance of calcium oxalate in our mummy stone and the minor component of magnesium ammonium phosphate suggest that infection was a significant factor only shortly before death. The etiology of solitary calculi in bladders without apparent local pathology usually is not obvious. Experimentally, defi-
4fi3
1,500-YEAR-OLD BLADDER STONE
Bisected vesical calculus from 1,500-year-old mummified adult male member of Northeastern Arizona JSasketmaker cultural group, One external and one sectioned surface is demonstrated, Calculus weighed 17,5 gm, and measured 3,0 cm, in maximal diameter,
of magnesium, vitamins A, Bl, B6, orthophosphate and all have been found to be lithogenic. 8 In humans a hot and predominantly vegetarian diet with low intake of animal protein have been suggested as contributing factors in modern patients. 9 The evidence from the Vandal Cave mummy suggests that these factors also were in North America. There are, however, many local in such associations and it is probably best to view the cause of this bladder stone as unexplained. The calculus seems to be an incidental finding since the cause of death was found in the lungs: massive aspiration of soil possibly a severe dust stormo Nmman Oldroyd, Louis C. Herring and Co., Orlando, Florida, did the laboratory analysis on this calculus. Dr. Birdwell Finlayson, University of Florida School of Medicine, departmental instruments for the analysis. REFERENCES l,
2. 3. 4. 5.
Shattock, So G.: A prehistoric or predynastic Egyptian calculus. Trans. Path. Soc, Lond., 56: 275, 1905. Williams, G.D.: An ancient bladder stone. J.A.M.A., §7: 941, 1926, Co W. and Mulvaney, W, P.: Apatitic urinary calculi from American Indians. J.A.M.A., 195: 1044, 1966. Ellis, , A History of Bladder Stone, Oxford: Blackwell Scientific Publications, p. 71, 1969. Lonsdale, K.: Human stones. Science, 159: 1199, 1968.
6. Sutor, D. J., Wooley, S. E. and Illingworth, J,
· A ""''°"'~nlhirol and historical survey of the composition of minary stoneso J. Urol., 46: 393, 1974. 7. Prien, E. L.: Crystallographic analysis of urinary calculi: a 23-year survey study. J. U:rol., 89: 917, 1963. 8. Halstead, S. B.: Studies on the epidemiology of u 11 ,~ns,rn, bladder stone disease. In: Idiopathic Urinary Bladder Diseaseo Edited by R. Van Reen. Fogarty International Center Proceedings No. 37, Washington, D. C.: Department of Health, Educa· tion, and Welfare Publication, National Institutes of Health No. 77-1063, p. 1977. 9. Anderson, D. · Historical and geographical differences in the pattern and incidence of urinary stones considered in relation to possible aetiological factors. In: Renal Stone Research sium Edited by A, Hodgkinson and B. E. C. Nordin. Churchill Livingstone Publishers, p, 7, 1968,
EDITORIAL COMMENT
In modem Western societies bladder stones unassociated with either bladder neck obstruction, foreign bodies or neurogenic disorders are uncommon, What has led to the apparent disappearance of "''"~n,,rni bladder stones remains unknown, Although our knowledge stone disease has increased greatly during the last few decades our 1.mderoo standing of its etiology continues to remain limited. Martin Department of Bowman Gray Winston-Salem, North
THE JOURNAL OF UROLOGY
Copyright© 1981 by The Williams & Wilkins Co.
A 1,500-YEAR-OLD BLADDER STONE JOHN M. STREITZ, ARTHUR C. AUFDERHEIDE, MAHMOUD EL NAJJAR AND DONALD ORTNER From the Research Laboratory, St. Luke's Hospital, Duluth, Minnesota, Department of Anthropology, State University of New Mexico, Las Cruces, New Mexico, and Department of Anthropology, National Museum of Natural History, Smithsonian Institution, Washington, D. C.
ABSTRACT
A calcium oxalate calculus was found in the anatomically normal bladder of a 1,500-year-old native American male mummy from the Northeastern Arizona Basketmaker cultural group. Results of analysis by chemical, optical, spectrographic and x-ray diffraction methods are listed and compared to several other reported prehistoric uroliths. Recently, we had the opportunity to study a solitary bladder calculus from a 1,500-year-old Southwestern American mummy. Since only a few such calculi have been studied by modern analytical methods we thought that it would be of interest to document our findings. The mummy. The body was removed from Vandal Cave in Northeastern Arizona by an archaeological team in 1928. Associated artifacts suggested the "Late Basketmaker Culture" (circa 500 to 750 A.D.). The body was stored at the University of Colorado until 1979, when it was removed and studied in detail at The Smithsonian Institution. Part of this study included dissection and histologic examination of the viscera. This adult male body (estimated age 30+) had been wrapped in a cloth garment embellished with fur and feathers and placed in the cave in a flexed position (without interment). Mummification occurred by natural dehydration without any embalming or other preservative methods. When dissected the body was well preserved. The skin was intact as were facial features. Internal examination of the chest and abdomen demonstrated good preservation of most organs, although the spleen could not be recognized and the liver was reduced to a handful of sand-like material. The heart and both lungs were recognized. The left kidney could not be found but the right kidney was represented by a 3 X 1.5 X 0.1 cm. brown membrane. Histology revealed recognizable tubular but not glomerular structure. No pathology was noted. No ureters were identified and no renal calculi were present. The penis was recognizable but the prostate, scrotum and testes could not be identified. The bladder was normal anatomically. It was contracted snugly around a single calculus within its lumen. Histologic examination of the bladder wall revealed a fibromuscular wall without evidence of inflammation. Nuclei were absent. Postmortem degenerative changes had resulted in loss not only of bladder mucosa but the mucosa! and epithelial lining of all other organs except the skin. The calculus. The calculus measured 3.0 x 2. 7 x 2.5 cm. and weighed 17.5 gm. Its light brown surface contained many blunt protrusions, 2 to 3 mm. in diameter (see figure). Optical microscopic analysis showed a predominance of monoclinic crystals with moderate birefringence and an extinction angle of 31 degrees, characteristic of calcium oxalate monohydrate. In addition, small amounts of orthorhombic crystals were present, the optical properties of which were those of magnesium ammonium phosphate hexahydrate, uric acid and ammonium hydrogen urate. Infrared spectrography revealed the calculus to be composed predominantly of calcium ox.alate monohydrate, with absorption maxima noted also for magnesium oxalate, magnesium ammonium phosphate hexahydrate, calcium phosphate (carbonate apatite) and ammonium hydrogen urate.
X-ray diffraction pattern revealed only 2-degree angle peaks for calcium oxalate monohydrate, other components recognizable by this technique being present in amounts insufficient for detection. The cleaved surface revealed calcium and magnesium as the major elements, while minor elements detected included iron, sodium, copper, silicon, phosphorus, strontium, potassium and aluminum, with trace quantities of lead, manganese and antimony. Human urinary calculi usually do not exhibit detectable spectral lines for iron, copper or silicon. In summary, the percentage composition of the calculus is calcium oxalate monohydrate-75, magnesium oxalate-9, magnesium ammonium phosphate hexahydrate-6, carbonate apatite-4, uric acid-3, ammonium hydrogen urate-2 and silicon dioxide- I.
Accepted for publication November 7, 1980. Supported by St. Luke's Hospital Foundation and Minnesota Medical Foundation. 452
DISCUSSION
Vesical lithiasis is an ancient malady. The well known British Egyptologist, G. Elliot Smith, found such a calculus in a 16year-old boy who died nearly 7,000 years ago. 1 A few other prehistoric uroliths have been reported. 2 ' 3 Bladder calculi became so common in the European medieval period that lithotomy became a subspecialty. Indeed, the evolution of modern surgery has been associated with this practice. 4 Boys were especially susceptible. Neither infection nor tumor seems to have caused the condition and, once removed, the stone seldom recurred. It persists today only in certain rural parts of the world. 5 As a nation industrializes and develops its research resources the problem disappears, resulting in a paucity of detailed biochemical studies. 5 Several authors have reported bladder stones of prehistoric origin but only a few used the modern physical and chemical analytical methods reported herein. 3• 5 ' 6 Most analyses of such ancient stones have identified them to be composed of calcium oxalate, uric acid or ammonium acid urate. 5• 6 Calculi from 2 native American burials from the late Archaic period in Indiana studied by x-ray diffraction recently were apatite stones3 but archaeological data were insufficient to determine their renal or vesical position. In 1926 chemical and spectrographic analysis results were reported on a bladder stone from the skeleton of a member of the same Basketmaker culture as that of our mummy. Those tests suggested the presence of calcium carbonate, phosphate and uric acid.2 A stone composed primarily of calcium oxalate is not normally found in a bladder afflicted with infection or tumor. Deposition of magnesium ammonium phosphate usually follows infection by urea-splitting organisms and, once such deposition is initiated, it is rare for other substances to be represented in the further crystal growth. 7 The predominance of calcium oxalate in our mummy stone and the minor component of magnesium ammonium phosphate suggest that infection was a significant factor only shortly before death. The etiology of solitary calculi in bladders without apparent local pathology usually is not obvious. Experimentally, defi-
4fi3
1,500-YEAR-OLD BLADDER STONE
Bisected vesical calculus from 1,500-year-old mummified adult male member of Northeastern Arizona JSasketmaker cultural group, One external and one sectioned surface is demonstrated, Calculus weighed 17,5 gm, and measured 3,0 cm, in maximal diameter,
of magnesium, vitamins A, Bl, B6, orthophosphate and all have been found to be lithogenic. 8 In humans a hot and predominantly vegetarian diet with low intake of animal protein have been suggested as contributing factors in modern patients. 9 The evidence from the Vandal Cave mummy suggests that these factors also were in North America. There are, however, many local in such associations and it is probably best to view the cause of this bladder stone as unexplained. The calculus seems to be an incidental finding since the cause of death was found in the lungs: massive aspiration of soil possibly a severe dust stormo Nmman Oldroyd, Louis C. Herring and Co., Orlando, Florida, did the laboratory analysis on this calculus. Dr. Birdwell Finlayson, University of Florida School of Medicine, departmental instruments for the analysis. REFERENCES l,
2. 3. 4. 5.
Shattock, So G.: A prehistoric or predynastic Egyptian calculus. Trans. Path. Soc, Lond., 56: 275, 1905. Williams, G.D.: An ancient bladder stone. J.A.M.A., §7: 941, 1926, Co W. and Mulvaney, W, P.: Apatitic urinary calculi from American Indians. J.A.M.A., 195: 1044, 1966. Ellis, , A History of Bladder Stone, Oxford: Blackwell Scientific Publications, p. 71, 1969. Lonsdale, K.: Human stones. Science, 159: 1199, 1968.
6. Sutor, D. J., Wooley, S. E. and Illingworth, J,
· A ""''°"'~nlhirol and historical survey of the composition of minary stoneso J. Urol., 46: 393, 1974. 7. Prien, E. L.: Crystallographic analysis of urinary calculi: a 23-year survey study. J. U:rol., 89: 917, 1963. 8. Halstead, S. B.: Studies on the epidemiology of u 11 ,~ns,rn, bladder stone disease. In: Idiopathic Urinary Bladder Diseaseo Edited by R. Van Reen. Fogarty International Center Proceedings No. 37, Washington, D. C.: Department of Health, Educa· tion, and Welfare Publication, National Institutes of Health No. 77-1063, p. 1977. 9. Anderson, D. · Historical and geographical differences in the pattern and incidence of urinary stones considered in relation to possible aetiological factors. In: Renal Stone Research sium Edited by A, Hodgkinson and B. E. C. Nordin. Churchill Livingstone Publishers, p, 7, 1968,
EDITORIAL COMMENT
In modem Western societies bladder stones unassociated with either bladder neck obstruction, foreign bodies or neurogenic disorders are uncommon, What has led to the apparent disappearance of "''"~n,,rni bladder stones remains unknown, Although our knowledge stone disease has increased greatly during the last few decades our 1.mderoo standing of its etiology continues to remain limited. Martin Department of Bowman Gray Winston-Salem, North