A N ANCIENT URINARY VESICAL CALCULUS by

Raymond Williamson*

In the Museum of the Department of Pathology in the University of Cambridge there is a large vesical calculus weiglung 34 ounces the history of which seems worth recording. It has been described twice; the first time in 1750 by William Heberdenl the elder, before anythmg was known about the chemical composition of calculi and the second time in 1821 by James Cumming2 Professor of Chemistry at Cambridge, shortly after the chemical composition of calculi had been determined.

During the reign of Charles II this stone was removed after death from the bladder of the wife of Thomas Raisin, a locksmith in Bury St. Ed- munds, by Mr. Gutteridge, a Norwich Surgeon. It came into the hands of Mr. Samuel Battely Member of Parliament for Bury who presented it to Trinity College Library about the middle of Queen Anne’s reign. It aroused the interest of William Heberden who was in practice for some years in Cambridge and it is due to his curiosity that we know its history which he pieced together from accounts obtained from the Right Rever- end Dr. Glaggett, Bishop of Exeter (who was librarian at the time the stone was presented to the library), from the Reverend Dr. Baker (who was a Fellow of the College and entertained the man who brought the stone), and from a son-in-law of the woman from whom the stone was taken. He says :

“She had felt much less Pain than might have been expected from so large a stone; and might probably have liv’d much longer with it, if she had not thought herself well enough to attempt a journey on Horse-back; for while she was riding, she was suddenly seized with violent Pains, that

M. A., 3. Sc., M. D., Reader in Morbid Histology in the University of Cambridge. From the Department of Pathology.

Centaurm 1956: voI. 4: no. 4: pp. 319-324

320 RAYMOND WILLIAMSON

obliged her to be taken off the Horse immediately; After which she could never make Water, unless the Stone was fkst moved, and she continued in great Agonies till she died”.3

Soon after Mrs. Raisin’s death Charles I1 was in Newmarket and hearing of the stone he had it brought to him. Portions were chipped from one end of it to demonstrate to the King that like most animal stones it was formed in layers.

The stone aroused interest because of its size. Heberden says: “This monstrous Stone weighs 33 ounces 3 Drachms and 36 Grains,

Troy Weight. There appears to have been at least half an ounce broken off, on the occasion before related; not to mention what it must have lost by mere wear in fourscore year^",^ and he thinks it must be one of the heaviest anywhere recorded with the exception of one referred to by Dr. Lister in his Journey to Paris.

Martin Lister’s reference to the Paris stone is as follows: “Another popular Disease here is the Stone; and there are Men well

practised in the Cutting for it. There are also two Hospitals, where great numbers are cut yearly, as La Charite, and Hotel-Dieu; in both these are Wired Chests full of Stones cut from Human Bodies; and in the Chest of La Charite is one, which exceeds all belief; it was cut from a Monk, who died in the very Operation; it is as big as a Childs Head. It is but the Model or Patern of the Stone which is kept in the Chest; which has this Inscrip- tion on it

‘Figure et grosseur de la Pierre, pesant 51 ounces, qui sont trois livres trois ounces, qui a estP tire6 dans cet Hospital au mois de Juin 1690, et que I’on conserve dans le Couvent de la Charite’”.5

Lister goes on to give an account of Frere Jacques the famous lithoto- mist whom he saw operate.

A larger stone was described by Sir James Earle in the Philosophical Transactions for 1809.s This weighed 44 ounces troy and measured sixteen inches round its long axis, and fourteen inches round its short axis. It was preserved in the Museum of the Royal College of Surgeons but was destroyed, with the entire calculus collection, in the fire caused by enemy action in May, 1941. A very detailed history, a description of Mr. Clive’s attempt to remove the stone, and a full description of the post- mortem appearances is recorded in the Catalogue of Ca l~u l i .~

Very little was known about the chemical composition of calculi in Heberden’s day and his own interest in them was entirely clinical. Paracel- sus had speculated on their composition and formation comparing them

Description of the Plate.

Fig. 1 . Exterior of the Calculus; the size of the Original. A . B. The line of section.

Fig. 2. Section of the Calculus. n. Lithic nucleus. b. Oxalate of lime. c. Ditto, mixed with sparkling triple crystals. J . Triple crystals with a little lithic. e. Lithic, with minute layers of fusible Calculus. f. Triple crystals, (four thin layers). g . Lithic. h. Fusible.

Inches.

Largest circumference ...................... 15. Circumference of the section . . . . . . . . . . . . . . . . 13.1 Least circumference ........................ 1 I .7 Weight after being sawn, (exclusive of the dust) . . . . . . . 32 oz. 7 dr. Specific gravity ............................ 1.756

1.768 Ditto, after being two days in water . . . . . . . . . .

Photographs of the coloured plate in Professor Cumming’s Notice of cr large Hirmon Ccd- culrrs in the Library of Trinity College.

Photographs of the calculus now in the Museum of the Department of Pathology in the University o f Cambridge. The upper one shows a different view from that illustrated by Professor Cumming, the lower one shows the chips in the cut surface made by him when

he undertook its analysis in 1821.

AN ANCENT URINARY VESlCAL CAL CUtUS 32 1

with the tartar on the side of wine casks and giving them the name tartar because they burn the patient like hell-fire. Van Helmont believed that they differed from mineral stones and were formed by the precipitation of the natural salt of urine. Stephen Hales appears to have been the first to attempt to determine the nature of vesical and biliary calcufi. In Vegetable Sraticksa he describes how he distilled various calculi in an iron retort and measured the amount of air given off. He compared his results with those obtained by the distillation of Renish Tartar and concluded “we may well look upon the calculus and the Stone in the Gall BZadder, as true animal Tartar, and doubtless Gouty concretions are the same”.D AIthough not a physician he was intensely interested in the possibility of finding an internal medicine which wodd dissolve calculi in the body and he thought the results of his experiments “should rather encourage than discourage us, in reaching after some proper dissolvent of the Stone in the Bladder”.1o Later he made a number of unsuccessful attempts to find a suitable sol- vent.’l It was unfortunate that one of the first applications of the infant science of cheSnistry to practical medicine was to a problem which has proved insoluble.

Dr. Robert Whytt in 1743 first suggested the use of lime-water as a soIvent for the Stone.lz He was stimulated to try to find such a remedy by the reward of f5,OO made by Parliament in 1739 to Mrs. Joanna Stephens for publishing her medicines against the stone and by “the ingenious experiments published (1741) by the Reverend and learned Dr. Hales, upon Mrs. Stephen’s medicines”,13 and also by the fact that those medi- cines were so bulky and nauseous that some patients prefered to be cut for the stone rather than to continue with them.

Heberden was familiar with these experiments for in Conimentaries on rke History and Cure of Diseasest4 he says, “Lime water’ has in many cases appeared to communicate a solvent power to the urine” and he refers to a patient of his who took it regularly and whose “urine in a few days dissolved a fragment of a calculus immersed in it, which had before been steeped in the urine of two other persons for some months without losing any of its weight”.15

Real knowledge of the chemical constitution of calculi dates from the work of Scheele in 1776. lo All the calculi he examined were of the same kind. He found that they consisted for the most part, of a peculiar acid to which the name bezoardic acid was applied and that this acid was contained in all human urine and was the principal constituent of the sediment in febrile disorders. French chemists later changed the term

322 RAYMOM) WILLIAMSON

bezoardic acid to lithic acid and then to uric acid after which the terms ljthic acid and uric acid were used synonymously.

Very little of importance was added to knowledge of the nature of calculi until 1797 when William Hyde W o l l a ~ t o n ~ ~ described three new species of calculi of diflerent chemical composition from the uric acid calculi described by Scheele. They were fusible calculus, mulberry cal- culus and bone-earth calculus. Fusible calculus was so c d e d because on being heated with a blow-pipe

a portion was left which fused into an opaque &ass. This had been first noticed by Sdthson Tennant who thought this kind of stone was com- posed of phosphate of lime mixed with other phosphoric salts from the urine. Wollaston showed that it consisted of crystals of triple phosphate together with phosphate of‘ time and a little uric acid. He also showed that the mulberry calculus was mainly composed of oxalate of Iime and the bone-earth calculus mainly of neutral phosphate of lime.

Many communications by workers in different countries now appeared on the chemical composition of calculi and all their constituents soon became known; but an erroneous view of the formation and composition of certain calculi composed of alternating layers of different constitutents was at first obtained because many chemists had only examined the surface of calculi witbout sawing them through, while others who had cut through calculi had only analysed the sawdust or material obtained by filing the cut surface. Because of‘ this much work had to be repeated at a later date. John YeIlolyl* had many calculi previously described by Marcet cut in two and the successive layers re-examined.

James Cumming appears to have been the first to publish an account of the detailed analysis of an alternating calculus. Il’his was an important step towards the proper understanding of the formation of calculi. He obtained permission from the Fellows of‘ Trinity College to have the large calculus described by Heberden sawn assunder and he analysed it layer by layer.

Cumming’s description of‘ the Cambridge Calculus is as follows: “Its structure is such as, taken conjointly with its magnitude, to make

it, perhaps the most curious and instructive calculus in this kingdom; since it presents the characters of not less than four distinct species. The nucleus is lithic, to this succeeds a considerable portion of the oxalate of lime variety, this is followed by layers of the triple crystals, covered by a thick coating of fithic, which is occasionally broken by a layer of triple cxystats, and the external surface is principally composed of the fusible

AN ANCIENT URMARY VESfCAL CA.L.CULUS 323

calculus.-Its present weight, after being sawn is 32 02. 7 dr; the specific gravity 1.756, which after being two days in water became 1.768. I t measures 15 inches in circumference in one direction, and 133 inches in the ~ t h e r ' ~ . l ~

Cumming then discusses the large calculus described by Sir J. Earle pointing our that it is composed entirely of phosphates thus affording confirmation of Fourcroy's statement that all large calculi are phosphatic, and that its structure suggest that it really consists of a number of calculi cemented together. He then says that the Cambridge calculus which he has examined is formed round a single nucleus and is a remarkable exception to the general rule, as nine-tenths of it at least are lithic.

The late Dr. DonneUy of Addenbrooke's Hospital, Cambridge, reported as follows on an X-ray of the Cambridge calcuIus.

8th August, 1955. "The stone is of a size never seen in radiological practice in modem

times. It is slightly oval, measuring almost exactly 11 crn. in the longest diameter and approximately 8 cm. in breadth. The very dense, rather spiky, nucleus roughly 2.5 em. in diameter contains a relatively less dense centre. This small centre could have resulted from a ureteric calculus which passed into the bladder a very long time before the calculus was eventually removed. The calculus is beautifully laminated around the nucleus, resembling fairIy closely in appearance the cross section of a tree trunk".

The calculus described in this paper is of a size never met with in clinical practice to-day ; even when large calculi were more commonly seen than now it was regarded as an object of curiosity, but from being an object of curiosity it became an object of research, since it was one of the first calculi to be chemically examined layer by layer,

REFERENCES

I . William Heberden, An uccounr ofu very large hirmun CuIcufus. Phil. Trans., 1750: 46:

2. 3, Cumming, Notice of u Iarge Human Calculus in the Librury of Trinity College< Camb. PhiIosA Trans., 1821: 1 : 347-348, 1 plate coloured.

3. Heberden. op- cit., p. 597.

596-598.

324 RAYMOND WILLIAMSON

4. Ibidem, pp 597-598. 5. Martin Lister, A Journey to Paris in the year 1698 London 1699, p. 2 3 2 6 Sir Jamcs Earle, An Account of a Calculus from rhe Human Bladder of uncammon

Magnitude. Phit Trans., 1809, pp. 303-312, 2 piater, 7. Catalogue of the Calculi and other animal concretiom contained in the Museum of the

Royal College of Surgeons in London. London 1842, pp. 116-1 19 8. Stephen Hales, Vegeioble Stnticks. London 1727 9. fbidem, p. 192.

10. Ibidem, p. 193. 1 I . Stephen Hales, An account of some Experiments on Stones in the Xihies ond Bladder

with an inquiry into the Nature of those anomolous Concretions, StaticnlEssays. London

Robert Whytt, An Essay on rite Yirfues of Lime-Water and Soap in the Cure of the Stone. First published in the Edin. Med. Essays 1743, 5: Pt. 2. Published separately Edin. 1752, 54 and 61 and in Tlie Works of Robert Whytt, by his son, Edin. 1768.

13. The Works ofRobert W f p f , by his son. Edin 1768, p. 338. 14. William Heberden, Commentaries on the History and Cure of Diseases. London 1802. f 5 I bidem, p. 89. 16. Carl Wilhelrn Scheele. Kongl Vetenskaps-Aend. Handl., 1776: 37 : 327-332 17. William Hydc Wollaston, On Gouty and Urinary Concretions. Phil. Trans.. 1797: 87:

38 6-400. 18. John YeUoly, Remarks on the tendency ro Cnlulur Discnsez; with observations on the

nature of urinary concretions, and an analysis of a largepart of the collection belonging to the Norfolk and Norwich Hospital PhiI. Trans. 1829: 55-81.

19. J. Curnming, op cit., pp 347-348

1733, 2: 187-252. 12