Chronic Kidney Disease (CKD) of unknown aetiology is the most common kidney disease prevalent in the North-Central Province of Sri Lanka today and so it is in Polonnaruwa as well. However, in the 1980’s when I worked there as the Surgeon this condition was unheard of and by far the most common form of kidney disease that I encountered in the surgical ward was Kidney Stones.
What are kidney stones, where do they form? What is their chemical composition?
A kidney stone is a hard crystalline mineral material formed within the kidney and the urinary bladder. These stones may remain at the site of formation or migrate elsewhere. Thus a stone formed in the kidney may pass along the urinary tract into the urinary bladder, and if small enough, may pass out of the urethra at the time of urination.
There are four main types of stones depending on the chemical composition – calcium oxalate, struvite (triple phosphate – ammonium magnesium phosphate) uric acid and cystine stones. The most common is the calcium oxalate stone. Calcium oxalate forms hard, whitish stones, which may become darkened by continual staining with blood. Curious spiky stones variously called “mulberry”, “hedgehog”, “jackstone”, “sea urchin” are forms of oxalate calculus. Phosphatic stones associated with urine infection are generally white and crumbly. They may adjust their shape according to their position such as in the kidney and form a “stag horn” calculus.
The majority of stones are seen on an X-ray of the abdomen because of the high content of calcium.
What are the symptoms due to Kidney Stones?
There are many people who have kidney stones, but have no symptoms. These are called “silent stones” and are diagnosed on an X-ray or Ultrasound Scan of the abdomen. Pain is the leading symptom and is referred to as a renal colic. This pain usually originates in the loin and moves towards the groin and on occasions can be very severe. Stones may be associated with urine infection, and the passage of blood during urination.
Problems in managing Kidney Stones at the Polonnaruwa Hospital in the 1980’s
Kidney stones were a common problem in Polonnaruwa. Patients were admitted as an emergency with acute pain or renal colic. Most of the patients were males. There were children too. Since this was a common condition we suspected that the pain could possibly be due to stones in the kidney or urinary tract. Patients with stones in the bladder were admitted with pain on passing urine, blood in urine or sometimes the inability to pass urine due to the outlet being blocked. The Polonnaruwa Hospital at that time had only basic facilities for any investigation. Therefore we had to make a diagnosis based on the clinical features. The only investigation that was available was a plain X-ray of the abdomen done by the radiographer. There was no radiologist to report on the X-ray. Therefore, I had to look at the X-ray and come to a conclusion of the presence of a stone by the appearance of an opaque mass. I related the site of the stone based on the anatomical position of the kidney, urinary tract and bladder as revealed in the plain X-ray. Luckily, the radio-opaque nature of the stones helped in the diagnosis. I was able to diagnose stones in the kidney, ureter, urinary bladder and sometimes in the urethra.3
Once I diagnosed that the patient had a stone, in most cases the stone had to be removed to relieve the pain and prevent complications. These operations are usually done by surgical specialists in that field called Urologists. But none were available in Polonnaruwa and at that time there were only three Urologists in the entire country, two in Colombo and one at the Kandy Hospital. I could have referred them to these hospitals for specialised care, but it was a tough task for these poor farmers to travel such a distance (150- 240km), be on waiting lists for years to have their operation, suffer in pain in the mean time due to the stones and finally develop complications and die.
Back to the Operative Surgery Book /Perform Surgery use the “Healing Knife”
I decide to perform surgery on these patients to remove the stones. I had no special equipment but only the “Healing Knife. In fact I had seen and assisted at some of these operations during my internship period in the 1970’s at the General Hospital, Colombo where the General Surgeon under whom I worked did these operations and removed the stones. I had no hesitation in proceeding with the job. To make sure that I perform the operation well and successfully, I had to go back and read the chapter on Renal Surgery in my operative surgery book titled:
General Surgical Operations by R M Kirk MS, FRCS.
With God’s grace I performed the surgery successfully. I learnt and re-learnt with every operation to remove stones from the kidneys and various sites of the urinary tract, thus relieving the patient’s symptoms to their utmost satisfaction. It is true that the operations were performed by so called ‘open technique’ where I had to cut the muscles of the wall of the abdomen. The site of the incision in the loin or abdomen depended on the location of the stone. Thereafter for stones in the kidney, the kidney had to be cut to remove the stone and the tissues stitched back in place. Removal of stones in the urinary tract entailed the opening of the tract / bladder and stitching the opening with catgut stitches (that was the only suture material available). No doubt there were a few complications that had to be managed in the postoperative period. This open technique is rarely practiced today as there are many non-invasive and minimally invasive techniques practiced by specialist urological surgeons to remove such stones. But for me at that time, there was no other method available to remove the stones. My aim was to relieve the suffering and nothing more, with whatever instrument that was available in that primitive set-up. Thus, it was that “Healing Knife” that I had to use again and again.
What about the stones?
I removed hundreds of stones of different sizes, shapes, colour and consistency. What did I do with these stones? Once a substantial collection was reached, I decided to make a nice rectangular box somewhat similar to those found in jewellery shops. A velvet cloth was pasted to the back of the box and the stones were fixed to this to give it a somewhat luxurious appearance. A light to illuminate the inside of the box made it brighter and more attractive.
This “Kidney Stone Box” of mine is the one and only one in Sri Lanka. It is my treasure. It has done the rounds visiting various medical exhibitions not only in Colombo including the ones held at the Bandaranaike International Conference Hall, The Auditorium of the College of Surgeons of Sri Lanka and also in Polonnaruwa where it all originated. This Kidney stone box has attracted many a visitor to the medical exhibitions. Many were surprised and did not want to believe that these were stones removed from the Kidney and Urinary tracts of people living in Polonnaruwa. They were shocked! Some people have asked me whether these stones were from the Gem City of Ratnapura!
Yes, they came to the surgical ward at the Polonnaruwa Hospital with moans and groans and went back home relieved, leaving their stones with me which today is my treasure. I thank all those poor people who trusted me at the time of their distress and gave me the choice of removing their stones using the Healing Knife without batting their eye lids.
“I Did the Operations, God Healed Them”
Dear Reader, You might be interested to read about the next story whom I met as a passer by, was a bit curious because he was walking with the help of two stools, after hearing his story I decided to help him : ‘PREMASIRI (MR BANKU)* WALKS AGAIN!’