Chapter VII - The medical treatment of urinary conditions

Now we shall discourse on the medical treatment of urinary calculus, etc. (Ashmari). 1.

Metrical Texts:—

Ashmari (urinary calculus, etc) is a dangerous disease and is as fatal as death itself. A case of recent origin (acute) proves amenable to medicines, while an enlarged or chronic one requires surgical operations. The remedial measures, in the order of anointing, etc., should be employed in the first or incipient stage of the disease, whereby the entire defects with their causes (i.e., roots of the disease) would be radically cured. 2.

Treatment of Vataja Ashmari:—

Clarified butter cooked with a decoction of Pashanabheda, Vasuka, Vashira, Ashmantaka, Shatavari, Shvadamstra, Vrihati, Kantakarika, Kapotavamka, Artagala, Kakubha^[1], Ushira, Kubjaka, Vrikshadani, Bhalluka, Varuna, Shaka-phala, barley, Kulattha, Kola and Kataka fruits and with the Kalka of the drugs constituting the group of Ushakadi, speedily brings about the disintergration of Ashmari (urinary calculi, etc.) due to the action of the deranged Vayu. Milk, Yavagu (gruel), a decoction, soup, or an alkali, properly prepared with the above Vayu-subduing drugs should also be administered as food and drink in the above cases. 3.

Treatment of Pittaja Ashmari:—

Similarly a medicated clarified butter cooked with the decoction of Kusha, Kasha, Shara, Gundra, Itkata, Morata, Ashmabhid, Shatavari, Vidari, Varahi, Shali-mula, Trikantaka, Bhalluka, Patala, Patha, Pattura, Kuruntika, Punarnava^[2], Shirisha, with the paste (Kalka) consisting of Shilajatu, Madhuka (flower) and the seeds of Indivara^[3], Trapusha and Ervaruka, would speedily bring about the disintegration of Pittaja Ashmari (calculi, etc.). An alkali, Yavagu (gruel), soup, a decoction, or milk, properly prepared with the above Pitta-subduing drugs, should also be prescribed as food and drink in these cases. 4.

Treatment of Kaphaja Ashmari:—

The use of medicated clarified butter prepared from the milk of a she-goat† and cooked with the paste (Kalka) of the drugs constituting the Varunadi group^[4], Guggulu, Ela, Harenu, Kushtha, the Bhadradi group, Marica, Citraka, Surahva and the Ushakadi group, leads to the speedy disintegration and expulsion of the Ashmari (stone, etc.) due to the action of the deranged Kapha. So also the use of an alkali, Yavagu (gruel), soup, milk, or a decoction, properly prepared with the above Kapha-subduing drugs, is recommended as food and drink in such cases. 5.

A potion consisting of the powdered fruit of the Pichuka, Amkola, Kataka, Shaka and Indivara mixed with treacle^[5] and water proves beneficial in cases of Gravel (Sarkara). The bones of the Krauncha, camel and ass, as well as the drugs known as Shvadamshtra,^[6] Talamuli, Ajamoda, Kadamba- roots and Nagara pounded together and administered through the vehicle of wine (Sura) or hot water, leads to the disintegration of Sharkara (gravel). The milk of an ewe mixed with powdered Trikantaka- seeds and honey should be used for seven days for the disintegration and separation of an Ashmari. 6–7.

Alkaline Treatments:—

An alkali should be prepared from the ashes of the drugs used in the preparation of the aforesaid medicated clarified butters, by dissolving and filtering them in ewe’s urine The alkali should then be slowly boiled with an alkali similarly prepared from the dung of domestic animals, with the powders of Trikatu and the drugs of the Ushakadi group thrown into them as an after-throw. It proves curative in cases of stone, Gulma, and gravel. Alkalies^[7] from burnt bark of sesamum, Apamarga, plantain, Palasha and barley taken with the urine of an ewe destroy the gravel (Sharkara). As an alternative, the alkalies of Patala and Karavira should be used in the preceding manner. 8–9.

Two Tola (Aksha) weights of the pastes of Shvadamstra, Yashti-madhu and Brahmi (mixed with ewe’s urine) should be given to the patient; or the expressed juice of the Edaka, Shobhanjana and Markava (with the said urine) should be given, or a potion consisting of the pasted roots of the Kapotavamka with Kanjika, or Sura, etc., should be administered. Milk boiled with the aforesaid drug (Kapotavamka) should be taken by a patient in case there is pain (in urinating). Milk boiled with Triphala or Varshabhu should be administered as a drink and a decoction of the drugs of the Vira-taradi group should be employed in all these cases.^[8] 10.

A physician should have recourse to the following measures (surgical operations) in cases where the above-mentioned decoctions, medicated milk, alkalies, clarified butter and Uttara-vasti (urethral syringe) of the aforesaid drugs, etc., would prove ineffective. Surgical operations in these cases do not prove successful even in the hands of a skilful and experienced surgeon; so a surgical (Lithotomic) operation should be considered a remedy that has little to recommend itself. The death of the patient is almost certain without a surgical operation and the result to be derived from it is also uncertain. Hence a skilled surgeon should perform such operations only with the permission of the king. 11–12.

Modes of Surgical Operations:—

The patient should be soothed (Snigdha) by the application of oleaginous substances, his system should be cleansed with emetics and purgatives and be slightly reduced thereby; he should then be fomented after being anointed with oily unguents; and be made to pertake of a meal. Prayers, offerings and prophylactic charms should be offered and the instruments and surgical accessories required in the case should be arranged in the order laid down in the Agropaharaniya chapter of the present work (Sutra-sthana, ch. V.). The surgeon should use his best endeavours to encourage the patient and infuse hope and confidence in the patient’s mind. A person of strong physique and unagitated mind should be first made to sit on a level board or table as high as the knee-joint. The patient 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. Then the elbows and knee-joints (of the patient) should be contracted and bound up with fastenings (Shataka) or with linen. After that the umbelical region (abdomen) of the patient should be well rubbed with oil or with clarified butter and the left side of the umbelical region should be pressed down with a closed fist so that the stone comes 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 rope of the perineum 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 Granthi (tumour), taking care that the bladder remains contracted but at the same time even.

Prognosis-M. Text:—

An operation should not be proceeded with nor an attempt made to extract the stone (Salya) in a case where, the stone on being handled, the patient would be found to drop down motionless (i.e., 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. The operation should only be continued in the absence of such an occurrence.

An incision should then be made on the left side of the raphe of the perineum at the distance of a barleycorn and of a sufficient width to allow the free egress of the stone. Several authorities recommend the opening to be on the right side of the raphe of the perineum for the convenience of the operation. Special care should be taken in extracting the stone from its cavity so that it may not break into pieces nor leave any broken particles behind (i.e., inside the bladder), however small, as they would, in such a case, be sure to grow larger again. Hence the entire stone should be extracted with the help of an Agravaktra Yantra (a kind of forceps the points of which are not too sharp). 13.

Lithotomic Operation in a female:—

In a woman, the uterus (Garbhashaya) is adjacent to the urinary bladder, hence the stone should be removed by making an oblique and upward incision, otherwise a urine-exuding ulcer 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. An incision made only on one side of the organ in a disease other than that of stone, baffles all attempts at healing; while an ulcer incidental to an incision made on both its sides, should be deemed incurable An ulcer incidental to an incision made on either side of the bladder in extracting a stone might be healed up, inasmuch as medicinal potions and fomentations, etc., employed for the healing of a surgical wound, lead to the healing of the wound in the bladder; secondly because the surgical opening is only made large enough for the extraction of the stone as recommended in the authoritative books; and thirdly because an increase in the quantity of urine contributes to an increase in the size of the stone and hence a slight secretion of that fluid or employment of diuretic Peyas, etc., are not attended with any injurious effects.

Post-Surgical Measures:—

After the extraction of a stone, the patient should be made to sit in a Droni (cauldron) full of warm water and be fomented thereby. In doing so the possibility of an accumulation of blood in the bladder will be prevented; however if blood be accumulated therein, a decoction of the Kshira-trees should be injected into the bladder with the help of a Pushpa-netra (urethral Syringe). 14–15

Memorable Verse:—

Stones and the accumulated blood in the bladder would be speedily expelled by means of injecting a decoction of the Kshira-trees into it with the help of a Pushpa-netra (urethral Syringe). 16.

For the clearance of the urinary passage, a treacle solution should be given to the patient; and after taking him out of the Droni, the incidental ulcer should be lubricated with honey and clarified butter. A Yavagu, boiled with the drugs^[9] possessed of the virtue of cleansing or purifying the urine, and mixed with clarified butter, should be given to the patient in a warm state every morning and evening for three consecutive days.

After that period a diet (meal) of rice well boiled and mixed with milk and a large quantity of treacle, should be given (to the patient) in small quantities for ten days for the purification of the blood and the secretion of urine as well as for the purpose of establishing secretion in the ulcer. The patient should be made to partake of a diet (of rice) with the soup of the flesh of Jangala animals and the expressed juice of acid fruits after the lapse of these ten days. 17.

After that period, the body of the patient should be carefully fomented for ten successive days by applying any warm oleaginous substance or with any warm medicinal fluid (Drava-Sveda). As an alternative, the ulcer should be washed with the decoction of (the bark of) the Kshira-Vrikshas. A paste of Rodhra, Madhuka, Manjishtha and Prapaundarika (pounded together), should be applied then to the ulcer. A medicated oil or Ghrita cooked with turmeric and the preceding drugs should be applied to the ulcer. The accumulated blood in the affected part should be removed with the help of a Uttara-vasti (urethral Syringe). The ulcer should be cauterized with fire in the manner described before in the event of the urine not flowing through its natural passage after the lapse of seven days. After the urine takes its natural course, Uttara-vasti, asthapana and Anuvasana measures should be employed with the decoction of the drugs belonging to the Madhura-Varga.

A seminial stone or gravel (Sharkara) spontaneously brought down into the urinary passage should be removed through the same passage. The urethra should be cut open and the stone should be extracted with a hook (Vadisha) or any other instrument in the case of its not being expelled out by the passage. The patient should refrain from sexual intercourse, riding on horse back or on the back of an elephant, swimming, climbing on trees and up mountains and partaking of indigestible substances for a year even after the healing of the ulcer. 18.

Parts to be guarded in Lithotomic Operations:—

The Mutra-vaha (urine-carrying, and the Shúkra-vaha (semen-carrying) ducts or channels, the Mushka-srotas (cords of the testes), the Mutra-praseka (urinary) channels, the Sevani (the raphe of the perineum), the Yoni (uterus, vagina, etc.), the Guda (rectum,)and the Vasti (bladder) should be carefully guarded at the time of performing a lithotomic operation. Death results in the event of the urine-carrying channels being in any way hurt during the operation owing to an accumulation of urine in the bladder. Similarly, any hurt or injury to the semen-carrying ducts at the time, results in death or in impotency of the patient; a hurt to the cords of the testes begets an incapacity of fecundation; a hurt to the urinary ducts leads to a frequent dribbling of urine; while a hurt to the Yoni (uterus, vagina, etc.), or to the raphe of the perineum gives rise to extreme pain. The symptoms which characterise a hurt to the rectum or to the bladder have been described before. 19.

Memorable Verses:—

The surgeon who is not well cognisant of the nature and positions of the Marmas or vulnerable parts seated in the eight Srotas (ducts) of the body such as, the raphe of the perineum, the spermatic cords, the cords of the testes and the corresponding ones in females (Yoni), the anal region, the urinary ducts, the urine-carrying ducts, and the urinary bladder and is not practiced in the art of surgery brings about the death of many an innocent victim. 20.

 

Thus ends the seventh Chapter of the Chikitsita Sthana in the Sushruta Samhita which deals with the treatment of Urinary calculus.

Footnotes and references:

[1]:

Chakradatta reads “Kopotavaktra” in place of “Kapotavamka” “Kancana” in place of “Kakubha”; and “Gulmaka” in place of “Kubjaka From an examination of Dallana it appears that “Kacchaka” is also a reading of “Kakubha.”

[2]:

Chakradatta reads “Punarnave” i.e., both the kinds of Punarnava.

[3]:

Jejjata explains “Indivara” as ‘Nilotpala.’ But Gayadasa does not support this.

[4]:

Same say that “Aja-sarpih” is superfluous. Chakradatta reads “gaṇe varuṇakadau guggulvelahareṇubhiḥ” in place of “gaṇo varuṇakadistu guggulvelahareṇavaḥ” meaning thereby that the decoction of the Varunadi-gana is to be used. Chakradatta’s reading seems to be the correct one and is observed in practice with good results.—Ed.

[5]:

The quantity of treacle, to be taken, should be equal to the entire quantity of the powders; and hot water should be used—Pallana.

[6]:

Some explain it as “Gokshura-seeds” and others as “Markataka- seeds.”

[7]:

Four or six Tola weight of an alkali should be dissolved and filtered for a number of times before use.

[8]:

Dallana recommends the use of Triphala boiled with milk in cases of pain accompanying Pittaja Ashmari, while that boiled with Varshabhu is advised to be given for the alleviation of pain in a case of Vataja or Kaphaja Ashmari. The drugs of Vira-taradi group should be used with milk, clarified butter, a decoction, Yavagu (gruel), food, etc., and also for bath, immersion, etc.

[9]:

The urine-purifying drugs are the Trina-Pancamulas, Gokshura, Kasamarda, Pashanabheda, etc.