Cutting for stone in the seventeenth century
Stones in the urinary tract have been a part of life for
humans for all of recorded history. The earliest treatments for the condition
originated in India when Susrutha, the undisputed father of Plastic Surgery
described a method of lithotomy of cutting for stone. There is some dispute about
when exactly Susrutha lived. There are some over patriotic Indian authors who
believe that he lived around 3000 B C. Colonial historians who were reluctant
to believe that everything did not originate in the West or near about placed
him at the end of the first millennium in the Common Era. However most sober
scholars place him at about 600 BC which makes him roughly contemporaneous (give
or take a century of two), with the Buddha and Mahavira.
Susrutha described perineal lithotomy. This method was
described in Ashmari Chikitsa (roughly translated as Management of vesical
stones). The method has been described as follows:
“First, the patient should be cleansed of the vitiated
dosas. Then the patient, who is strong enough and is not nervous, should be
laid flat with upper part of his body resting on the lap of another person
sitting on a knee-high plank facing east; the patients’ waist should be raised
by cushions and his knees and ankles flexed and tied together by straps
(lithotomy position). After massaging the left side of the well oiled umbilical
region, pressure should be applied first below the navel until the stone comes
down. Introduce the lubricated index and middle fingers into the rectum below
the perineal raphe. Thereafter, with manipulation and force bring the stone
down between the rectum and the penis. Keeping the bladder tense and distended
so as to obliterate the folds, the stone is pressed hard by fingers so that it
becomes prominent like a tumor An incision of about the size of the stone is
then made just a few millimeters away from the perineal raphe on the left side.
Some surgeons prefer the incision on the right side for the sake of technical
convenience. Precautions should be taken so that the stone does not get broken
or crushed. Even a small particle left behind can increase in size. The stone
is then removed with an agravaktra instrument (small-tipped forceps, like
mosquito forceps).”
The operation,
perineal cystolithotomy which Susrutha described was performed in ancient times
in Arabian countries as well as Europe and was known as ‘cutting for stone.’ In
later times it travelled to Britain and in the seventeenth century it was a
standard, though feared practice. No patient of Susrutha time has left any
account of the procedure, but we do have a vivid description from much later
and 7,000 kilometers away.
Samuel Pepys : a Portrait
Samuel Pepys, the well-known diarist who has left very vivid
descriptions of his times (the turbulent second
half of the seventeenth century) in England, underwent the surgery probably in
1658. His vivid description of the procedure did not find place in the
diary which he did not start till later, but one of his biographers has given
us an account pieced together from various sources, including his own
description which found place in a later letter to one of his friends.
The operation, during the seventeenth century was the same
as described by Susrutha, more than 2000 years earlier. The results were also
still very debatable. One treatise for surgeons written during this time warned
“in this great and dangerous Operation, life and death doe so wrestle together,
that no man can tell which will have victory”. However Pepys was in such pain
that he saw no alternative but to submit himself to the surgery.
His surgeon was Thomas Hollier of St Thomas and Bart’s
hospital. He had a more than 30 years’ experience in surgery and was considered
to be one of the most experienced surgeons in London of that that time. He was assisted by a brilliant young surgeon
Joyliffe, The surgery took place on March 26th. Pepys was operated in the house
of his cousin Jane. Previous to the surgery, it has been recorded his father
went about mobilizing as many of his friends, relatives and neighbors as he
could to pray for his son.
In those days, in England, patients were advised to have the
surgery in the spring. Both cold and heat were considered to be unsuitable for
good healing, and the bright sunlight that one might hope for would, it was
thought, make the surgeon’s job easier. The preoperative preparation was
extensive. Patients were advised to cultivate a calm frame of mind and were
asked to avoid anger or sadness. Wine was prohibited during the weeks prior to
surgery and patients were advised a diet of fresh meat, chicken, butter, barley
and gruel. They were allowed to drink only sweet drinks made from almond,
cucumber and melon. The patient was often advised warm baths and on the day of
surgery, given a good meal (perhaps in the unconscious imitation of a condemned
man’s last meal)
The day started with a visit form the priest and the patient
was then asked to swallow a drink made of liquorice, marshmallow, cinnamon,
milk, rosewater and the whites of sixteen eggs. He was then positioned on the
table. The patient was then tied up with long linen strips which prevented them
from moving during a painful procedure which, of course, was without anesthesia.
The surgeon, meanwhile, lubricated his instruments with warm
water and milk of almonds. The procedure started with the passage of a
catheter. In Susrutha’s time, there was a choice of silver, gold and several other
materials, but Pepys’s surgeon used a silver one. The stone was then pushed
down from the abdominal side, so that it protruded into the perineum. The incision
was then made just lateral to the perineal raphe, the line running from the
base of the penis to the anus. The stone was then removed, making sure that all
the bits were removed and the wound dressed. No attempt was made to repair the
wound which healed by secondary intention. In Pepys’s time, a plaster of egg yolk,
rose vinegar and anointing oils were used to plaster the wound.
The patient was nursed with his legs tied together to keep
the wound tightly closed, and he stayed in bed for a week. Recovery took
between 30 to 40 days; Pepys took 35. Two years later, he recorded in his diary
that he had a perfect cure.
His surgeon operated on more than 30 patients that year with
a perfect record. However, he had a horrendous next year (1659) when four
patients in a row died. Pepys, it is recorded attended the funeral of one of
them.
The stone was recorded to be as large as a tennis ball and
Pepys later had a special stone case made for it, costing all of 25 shillings. He
used to proudly demonstrate it to his friends.
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