Chapter III - Diagnosis of urinary calculus

Now we shall discourse on the Nidana of Ashmari (urinary calculi). 1.

The disease admits of being divided into four several types, such as the Vataja, the Pittaja, the Kaphaja and the Shukraja (Seminal) concretions. An exuberance or preponderance of the deranged Kapha should be understood as the underlying cause of all invasions of this disease. 2.

General aetiology:—

The Kaphah of a man, who neglects to cleanse (Samshodhana) the internal channels of his organism, or is in the habit of taking unwholesome food, enraged and aggravated by its own exciting causes, is carried into the urinary bladder. Here it becomes saturated with the urine, and gives rise to the formation of concretions or gravels in its cavity. 3.

Premonitory Symptoms:—

An aching pain in the bladder, with a non-relish for food, difficulty in urination, an excruciating pain in the scrotum, penis, and the neck of the bladder, febrile symptoms, physical lassitude, and a goat-like smell in the urine are the symptoms, which indicate the formation of gravel in the bladder. 4.

Metrical Text:—

The deranged Doshas involved in a particular case respectively impart their specific colour to the urine, and determine the character of the accompanying pain. The urine becomes thick, turbid, and vitiated with the action of the aggravated Doshas, and micturition becomes extremely painful. 5.

Leading Indications:—

A sort of excruciating pain is experienced either about the umbilicus, or in the bladder, or at the median rape of the perineum, or about the penis, during micturition when gravel is forming in the bladder. The urine is stopped at intervals in its out-flow, or becomes charged with blood, or flows out twisted and scattered like spray, leaving a sediment of clear, sandy, red or yellow particles of stone, which resembles a Gomedha gem in colour. Moreover a pain is experienced in the bladder at the time of running or jumping or in swimming, or while riding on horseback, or after a long journey. 6.

The Shleshmashmari:—

Stone or gravel, originated through the action of the deranged Kapha, saturated with an excessive quantity of that Dosha by the constant ingestion of phlegm-generating (Shleshmala) substances, increases in size at the lower orifice of the bladder and ultimately obstructs the passage of the urine. The pressure and recoil of that incarcerated fluid on the walls of the urinary bladder gives rise to a kind of crushing, bursting, pricking pain in that organ, which becomes cold and heavy. A Kapha-origined stone or gravel is white and glossy, attains to a large size, to that of a hen’s egg, and has the colour of the Madhuka flower. This type is called Shleshmashmari. 7.

The Pittaja Ashmari:—

The Kapha charged (dried) with the deranged Pitta becomes hard (condensed) and large in the aforesaid way, and lying at the mouth of the bladder obstructs the passage of the urine. The bladder, on account of the flowing back of the obstructed urine into its cavity, seems as if it has been exposed to the heat of an adjacent fire, boiling with the energy of an alkaline solution. A kind of sucking, drawing and burning pain is experienced in the organ. This type of Ashmari is further marked by symptoms which characterise Ushna-vata (stricture). The concretion is found to be of a reddish, yellowish black colour like the stone of the Bhallataka fruit, or it is coloured like honey. This type is called Pittaja Ashmari. 8.

The Vatashmari:—

The deranged Kapha (mucus) inordinately saturated with the bodily Vayu, acquires hardness and gains in dimensions, and these lying at the mouth of the bladder obstructs the passage of the urine. The incarcerated fluid causes extreme pain in the organ. The patient constantly under severe pain gnashes his teeth or presses his umbilical region, or rubs his penis, or fingers his rectum (Payu) and loudly screams. A burning sensation is experienced in the penis, and urination, belching and defecation become difficult and painful.^[1] The concretions in this type of Ashmari are found to be of a dusky colour, rough, uneven in shape, hard, facetted and nodular like a Kadamva flower. This type is called Vatashmari. 9.

Infants are more susceptible to an attack of any of the three preceding types of Ashmari, inasmuch as they are fond of day sleep or of food composed of both wholesome and unwholesome ingredients, and are in the habit of eating before the digestion of a previous meal, or of taking heavy, sweet, emollient and demulcent food. In children the bladder is of diminished size and poor in muscular structure. These facts contribute to the easy possibility of the organ being grappled (with a surgical instrument) and of the stone being extracted with the greatest ease in cases of infantile Ashmari. 10.

The Shukrashmari:—

Shukrashmaris or seminal concretions are usually formed in adults owing to the germination of semen in their organisms. A sudden or abrupt stoppage of a sexual act, or excessive coition tends to dislodge the semen from its natural receptacle in the body. The fluid thus dislodged, but not emitted, finds a wrong passage. The Vayu gathers up the fluid (semen), thus led astray, and deposits it (in a round or oval shape) at a place lying about the junction of the penis and the scrotum and dries up the humidity with which it is charged. The matter, thus formed, condensed, and hardened, is called the seminal stone (Sukrashmari), which then obstructs the passage of the urine, giving rise to pain in the bladder, painful micturition, and swelling of the scrotum. The stone vanishes under pressure in its seat^[2]. 11—12.

Authoritative verses on the subject:—

Concretions, sands and sediments found to be deposited in the urine in a case of Bhashma-meha are but the modifications, or attendant symptoms of a case of stone in the bladder (Ashmari). The same group of symptoms and the same kind of pain are exhibited and experienced in a case of gravel (Sharkara) as in a case of stone (Ashmari) in the bladder. The local Vayu coursing in its natural direction helps the discharge of calculi (Ashmari) with the urine in the event of they being extremely attenuated in structure. Particles of a stone broken by the Vayu are called urinary calculi (Sharkara). A pain about the cardiac region, a sense of weakness and lassitude in the thighs, a griping pain in the regions of the spleen and liver (Kukshi-shula), a shivering sensation, thirst, hiccough or eructations, darkness or sallowness of complexion, weakness, emaciation with a non-relish for food and impaired digestion are the symptoms which are manifest in a gravel-patient. A gravel (Sharkara) obstructed at the mouth of the urinary channel is detected by the following indications:—vis., weakness, lassitude, emaciation, cachectic condition of the body, pain over the hepatic region (Kukshi-shula), a non-relish for food, sallowness of complexion, hot and high coloured urine, thirst, pressing pain at the cardiac region and vomiting. 13.

The bladder is situated in the pelvic cavity, surrounded on its different sides by the back, loin (Kati), umbilicus, scrotum, rectum (Guda), groins and penis. This organ is provided with a single aperture or opening and lies with its mouth downward, covered with nets of nerves (Shira) and ligaments (Snayu), in the shape of a gourd. The organ is extremely thin in structure; and thus situated within the pelvic cavity, it is connected, through its mouth or external orifice, with the rectum, the penis, and the testes. It is also known by the name of Maladhara (the receptacle of impure matter) and forms (one of) the primary seats of vital energy (Prana)^[3]. The urinary ducts (ureters) pass close by the large intestines (Pakvasaya) and constantly replenish the bladder and keep it moist with that waste product of the system in the same manner as rivers carry their contributions of water into the ocean. These passages or ducts (which are two) are found to take their origin from hundreds of branches (or mouths tubuli uriniferi), which are not visible to the naked eyes, on account of their extremely attenuated structures and carry, whether in a state of sleep or wakening, the urine from below the region of the stomach^[4] (Amashaya) into the bladder keeping it filled with this important fluid of the body, just as a new pitcher, immersed up to its neck in a vessel full of water, is filled by transudation through its lateral pores. 14.

In the same way the Vayu, Kapha and Pitta are carried into the bladder (through their respective ducts or channels), and in unison with the retained urine, give rise to the formation of stone, on account of the slimy character of the deposit produced. Stone is formed in the same way in the bladder as sediments are ultimately deposited from clear and transparent water at the bottom of a new pitcher which contains it. As the wind and lightning jointly condense the rainwater into hailstones, so the bodily Vayu and Pitta (heat) jointly contribute to the condensation of the Kapha in the bladder and transform it into stone.

The Vayu in the bladder, coursing in its natural downward direction, helps the full and complete emission of urine; while coursing in a contrary direction, it gives rise to various forms of maladies such as, Prameha, strangury, as well as seminal disorders; in short, it produces any urinary trouble to which the bladder may be subjected. 15.

 

Thus ends the third Chapter of the Nidana Sthana in the Sushruta Samhita which treats of the Nidana of urinary calculi.

Footnotes and references:

[1]:

Stool and urine can be voided only with the greatest straining.

[2]:

We can not but contemplate with admiration the fact that Sushruta was aware of the formation of seminal or spermatic concretions in the seminal vesicles through degenerative changes of spermatozoa and other secretions and their subsequent calcification as lately discovered by the savants of the West .—Translator

[3]:

The text has Pranayatana, which means that an injury to the urinary bladder may be attended with fatal result.

[4]:

From the kidneys.