History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21.s4.t4: Management of the urinary calculi
History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21.s4.t4
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Management of the urinary calculi
v1.c21.s4.t4.1
If the urinary calculi are not amenable to the medicinal treatment as described by Suśruta, surgery has to be the ultimate goal. The success is even uncertain in the hands of the expert surgeons, operation should be considered last of all in these cases and it should be carried out by a skilled surgeon, after taking the consent of the authorities concerned.
v1.c21.s4.t4.2
Pre-operative preparation
v1.c21.s4.t4.3
The patient should be oleated, his system should be cleansed with emetics and purgatives and be slightly reduced thereby. He should be massaged with oil, sudated, and be made to partake of a meal. Prayers, offerings and prophylactic charms should be offered and the instruments as well as surgical accessories, needed in the case should be arranged in proper order according to the instructions mentioned in the Sūtra-sthānam of Suśruta Saṃhitā Chapter V and he should be reassured.
v1.c21.s4.t4.4
Position of the patient
v1.c21.s4.t4.5
The patient of strong physique and unagitated mind should then be made to lie on his back on the table placing the upper part of his body in the attendant's lap, with his waist resting on an elevated cloth cushion and his knees as well as ankles fixed and tied together by straps.
v1.c21.s4.t4.6
Manipulation of the Stone
v1.c21.s4.t4.7
The umbilical region (abdomen) of the patient should be well rubbed with oil or with clarified butter (ghṛta), pressure should be applied by a fist below the navel until the stone comes down within the reach of the operator. The surgeon should then introduce into the rectum, the second and third fingers of his left hand duly anointed and with the nails well pared. Then the fingers should be carried upward towards the perineal raphe i.e. in the middle line, so as to bring the stone between the rectum and the penis, when it should be so firmly and strongly pressed as to look like an elevated tumour, keeping the bladder tense and distended so as to obliterate the folds.
v1.c21.s4.t4.8
Contra-indications to surgery
v1.c21.s4.t4.9
An operation should not be proceeded with, nor an attempt be made to extract the stone in a case where the patient would be found to drop down motionless (faint), with his head bent down, and eyes fixed in a vacant stare like that of a dead man, as an extraction in such a case is sure to be followed by death.
v1.c21.s4.t4.10
The operation should only be continued in the absence of such an occurence.
v1.c21.s4.t4.11
Operative Procedure and Technique (Perineal cysto-lithotomy)
v1.c21.s4.t4.12
An incision should then be made on the left side of the perineal raphe at the distance of a barley-corn and of a sufficient width to allow the free egress of the stone. Several authorities recommend the incision to be on the right side of the raphe of the perineum for the convenience of the operation. Precautions should be taken so that the stone does not get broken, or crushed. Even if a small particle is left behind it again increases in size: hence, all of it should be removed by the curved forcep.
v1.c21.s4.t4.13
In females, the uterus is adjacent to the urinary bladder, the incision should be directed oblique and upwards; otherwise a urinary fistula might result from the deep incision in that locality. Any hurt to the urethra during the operation would be attended with the same result even in a male patient.
v1.c21.s4.t4.14
Post-operative management
v1.c21.s4.t4.15
After removal of the stone the patient should be put in a tub of warm water and sudated. Thus the bladder does not get filled with blood, however, if it does get filled up, it should be irrigated through a catheter using the decoction of the latex trees.
v1.c21.s4.t4.16
For the clearance of the urinary passage after operation, a treacle solution should be given to the patient; and after taking him out of the tub, the incidental ulcer should be lubricated with honey and clarified butter (ghṛta), the patient should be given warm gruel processed with urine purifying substances and mixed with ghṛta twice daily for three days. After three days, milk and treacle and small quantities of well cooked rice should be given for ten consecutive days. Thereafter, citrous fruits and juices prepared from wild animal's meat should be given. After that, for ten days he should carefully be given sudation therapy either by oils or by liquids. Then his wound should be washed by the decoction of latex trees. The medicated pastes of some indigenous drugs should be applied to the wound. A medicated oil or ghṛta cooked with turmeric and other indigenous drugs should be applied to the ulcer.
v1.c21.s4.t4.17
Treatment of Impacted Urethral Stones
v1.c21.s4.t4.18
It seminal concretions or gravels spontaneously coming into the urinary passage get impacted there, they should be removed through the natural passage. If this does not seem possible, the passage should be laid open and the concretions should be extracted by budish instrument (a hook).
v1.c21.s4.t4.19
After the wound has healed, the patient should neither indulge in sexual intercourse, nor ride on a horse, an elephant, a chariot, or climb a mountain or a tree, for the period of one year; neither should he swim in water nor take heavy meals.
v1.c21.s4.t4.20
Precautions
v1.c21.s4.t4.21
The urinary passages, seminal passages, testicular-channels, trigone of the bladder (*Mūtrapraśeka*), perineal raphe, vagina, rectum and urinary bladder should be avoided from injury. If urinary passages are injured death occurs due to the bladder becoming full of urine. If seminal passages are injured death or impotency occurs. If testicular channels are injured loss of erection takes place. Injury to the vagina and the perineal raphe gives rise to severe pain. The features of injury to the urinary bladder as well as the rectum have been mentioned earlier.
v1.c21.s4.t4.22
Suśruta should also be credited to be the first who described the removal of the stone from the bladder through the perineal route, a method which was still in extensive practice, till the last century. Celsus in 3rd century A.D. described it, but Indians have been practising this method for centuries earlier and it is possible. Celsus may have borrowed it from Indian sources although he has not mentioned it. Suśruta is precise and explicit in describing the operative procedure, the precautions to be taken, complications encountered and the post-operative instructions, etc. which indicate his thoroughness with the technique.
Cites (1)
- Suśrutasaṃhitā — Suśruta & Nāgārjuna (siddha/alchemist), Sanskrit