While almost everyone practising surgery in India and indeed around the world recognises the pioneering contributions of Sushruta towards establishing surgery as an invaluable modality of treatment and often refer to him as the ‘Father of surgery’, his earliest contributions in the field of anatomy have not attracted similar attention. The fact that in his ‘Sushruta Samhita’, there is an exclusive section dedicated to the study of human anatomy by the name of ‘Sarira Stahna’ is not so well known. In the days, 600 years before the birth of Christ, when the human body after death was considered sacred by the prevailing religious texts or ‘Shastras’, not to be desecrated by knife but respectfully cremated on a pyre, how Sushruta performed the dissections and documented the anatomy of not only the adult human but also the foetus in various stages of development is an amazing example of the earliest scientific research ever conducted in the field of anatomy. This paper attempts to briefly trace the history of anatomy and Sushruta’s contribution to this field. It also dwells in the lesser-known arena of an indigenous simulation laboratory devised for surgical training by Sushruta way back in 600 B.C.

Introduction

Ancient civilisations of India, Greece, Mesopotamia, Egypt, and China have shaped the study of medicine and human anatomy, but the Indian sages, with their Vedic philosophies and Ayurvedic tradition, offered the world the oldest known systems of medicine, preceding the rest of the world by more than four centuries. Varanasi, or Kashi, as it was called in ancient times, is the oldest living city in the world, where humans have existed uninterrupted since 1500 B.C. It is little wonder that Sushruta, the disciple of Dievodasa, from the school (Gurukul) of Dhanwantri, the Lord Deity of Ayurveda, the ancient Indian art and science of healing, practised and taught his skills in Kashi, on the banks of river Ganga, way back in 600 B.C. Medicine was taught in ancient India through a hereditary model—‘Guru-Shishya parampara’, with the knowledge being passed from ‘Guru’, or teacher, to ‘Shishya’, or student, in the form of shruti, or spoken verses. These ancient Indian texts were written solely in Sanskrit and were available only to a direct disciple of that Guru or descendant of that particular school or Gurukul [1].

Though the post-Upanishad era was the ‘Golden Age of Indian Medicine’, the earliest pieces of evidence of surface anatomy were seen in the archaeological excavations of cave paintings of the Indus Valley Civilisation dating from 1500 B.C. to 200 B.C [2]. These rock art depicting pictures of animals on which those critical areas are marked, which when hit would have killed the animals, may have been an effort to teach hunting skills, but they leave no doubt in also being the clear evidence of the first lessons in surface anatomy. Then again, the Vedas referred to the heart as ‘Lotus with nine gates’, which is surprisingly an accurate description of the heart as we know it today. If the heart is held with its apex upwards, there are nine openings—3 in the right atrium, 4 in the left atrium, and one each in the right and left ventricles, it indeed looks like a lotus bud.

The post-Upanishad era commenced roughly around 600 B.C. Ayurveda, the science of life (Ayur = long life; Veda = science), evolved during this period by two great proponents—Sushruta and Charaka. Sushruta was a proponent of human dissection [3]; Sushruta was of the opinion that for one to be a skilful and erudite surgeon, one must first be an anatomist. He introduced a systemic way of dissecting a human cadaver, and in his landmark Sanskrit work ‘Sushruta Samhita,’ he dedicated a complete section on anatomy, the Sarira Sthana. This section has 10 chapters on the study of human anatomy, including gross anatomy, embryology, and histology [4]. The Sarira-Sthana also discusses the technique of dissection of the human body, and this undoubtedly is Sushruta’s pioneering contribution. Through these dissections, he described the number of bones and muscles of the body, various blood vessels, 4 pairs of cranial nerves, lungs, stomach, intestines, bladder, uterus, and rectum. He also described the joints and the effects of their injuries—fractures and dislocations. Sushruta is aptly called ‘The father of surgery’ [5] and can easily be also named ‘The father of applied anatomy’.

Dissection of Human Cadaver

Sushruta was a strong upholder of the dissection of the human cadaver as a prerequisite to the knowledge of medicine and surgery. Through his documentation in Sarira Sthana, it becomes obvious that he had given considerable thought to anatomical structure and function [6]. His documentation nowhere gives an indication that the knowledge of anatomy was acquired from animal dissection. They were mastered from extensive human dissection, which they skilled despite religious restrictions. According to Hindu tenets, the human body is sacred in death. Hindu law (Shastras) states that a dead person’s body cannot be violated by a knife, and if the deceased is older than 2 years of age, he/she must be cremated in their present state at death, unscarred and unblemished [7]. How was Sushruta able to bypass this decree is however not very clear.

Preparation of the Human Body for Dissection

Sushruta was the first person who established the method of preservation of a dead body and preparation before cadaver dissection in a scientific manner [8]. To quote the appropriate translation from Sarira-Sthana ‘Anyone, who wishes to acquire a thorough knowledge of anatomy must prepare a dead body and carefully observe and examine all its parts’. The method of study was to submerge the body in flowing water and allow it to decompose. An examination of the decomposing body was carried out at intervals to study structures, layer by layer, as they got exposed following decomposition [9]. Sarira-Sthana further mentions ‘For dissecting purposes, a cadaver should be selected which has all parts of the body present.’ The body should be of a person who had not died due to poisoning, was not suffering from a chronic disease, and had not attained 100 years of age. From such a body the faecal contents of the intestines should be removed before preservation. Such a cadaver was wrapped by any one of ‘munja’ (bush or grass), bark, ‘kusa’, flax, etc., and kept inside a cage, and suspended in a slowly flowing river, allowing it to decompose in a dark area.

Dissection

After proper decomposition for seven nights, the cadaver was removed from the cage and then dissected slowly by rubbing it with brushes made out of any of usira (fragrant roots of a plant), hair, bamboo, or ‘balvaja’ (coarse grass). The human body could thus be visually examined in detail, layer by layer [10]. Skin, muscles, vessels, nerves, body cavities, solid organs, hollow organs, ligaments, bones, and joints got exposed for observation successively.

Embryology and Genetic Diseases

Sushruta, in his Samhita, proposed a thorough understanding of human embryology before going on to understand the anatomy of the human body. He felt that the adult body was an extension of the embryo. He dealt with the rudiments of embryology and anatomy of the human body together with obstetrics to interpret their clinical relevance [11]. The Samhita describes the sequential development of the structures of the foetus.

Evidence from Sushruta Samhita indicates that surgeons of ancient India not only had enough knowledge about various congenital diseases, but they were also aware of their treatment [12]. In one of the chapters of Sarira-Sthana, Sushruta mentioned that the foetus develops from seven layers of skin. He then named each layer and the specific diseases which may affect that layer in adult life. He was also aware of diseases by genetic inheritance and many congenital defects acquired from parents that were a result of avoidable carelessness on part of the mother during pregnancy. So he advised her to avoid exertion for the perfect development of the foetus [13]. Even neuro-embryology finds a mention in one of the sections of Sarira-Sthana [8]. So, by merely observing the aborted foetuses, the proficiency which Sushruta had acquired is simply astonishing and rivals the present-day knowledge acquired by advanced prenatal investigations.

Gross and Applied Anatomy

Sushruta in his Samhita describes surgical procedures that can be categorised today as general surgery, ENT, urology, orthopaedics, paediatric surgery, plastic surgery, orodental surgery, obstetrics, and gynaecology. None of them was possible without a thorough knowledge of the gross anatomy of that region.

Sushruta had a profound knowledge of facial anatomy, and no wonder he succeeded in reconstructing cut noses and torn ear lobules by using flaps from the cheek. Regarding rhinoplasty, there is often a misunderstanding and it is the forehead flap rhinoplasty that is attributed to him. In the Samhita, however, the donor site mentioned is kapol (cheek) and not kapal (forehead). The fact that blood was a vital fluid for life and it flowed through the body in ‘channels’ was known to Sushruta [14], and for a tissue to survive, blood had to flow through it, hence the discovery of flaps!

Sushruta delineated five anatomical divisions (Madalas) of the eye: eyelashes, eyelid, sclera, choroid, and pupil [15]. He described 101 marmas (vital spots) in the body, which causes fatal result on injury, either sudden death or subsequent deformity. The detailed anatomical landmark of each and every marma was described by Sushruta [8]. The in-depth knowledge of the anatomy of the eye is evident in the section of the Samhita, in which Sushruta describes the preoperative preparations, the position of the patient and the surgeon, intra-operative steps, and postoperative care of cataract surgery [15]. The operation of the couching is described in great detail, with care being taken to do the surgery bloodlessly.

The anatomy of the urinary bladder, its location and relations, and the occurrence of various types of stones in it are documented in a chapter on urinary stones in the Samhita [11]. The Acharya (teacher) did not fail to admonish that “The surgeon who is not well cognizant of the nature and position of the vulnerable parts in the 8 srotas (ducts), namely the perineal raphe, spermatic cords, ducts of the testes, Yoni (vagina), the rectum, the urethra, urine-carrying ducts or ureters, and the urinary bladder and is not practised in the art of surgery, brings about the death of many innocent victims” [16]. In a section on urethral ailments in his Samhita, Sushruta mentions about stricture of the urethra or Niruddhaprakasha, thus ‘a tube open at both ends made out of iron, wood, or shellac should be lubricated with clarified butter and gently introduced into the urethra. Thicker and thicker tubes should be made to dilate the urethra successively in this manner and emollient food should be given to the patient. As an alternative option, an incision should be made into the lower part of the penis, avoiding the sevani(raphe), and it should be treated as an incidental ulcer’ [17]. Undoubtedly, such clarity of the urethral stricture disease would not have been possible without appreciating the anatomy of both the normal urethra and the diseased urethra!

In Sarira Stana, Sushruta describes over 300 bones, various types of joints, ligaments, and muscles from different parts of the body [18]. He may have overestimated the number of bones contained in the human body because of the large number of child cadavers with individual parts of bones that had not yet fused. Sushruta classified bones of the human body based on the keen observation of his anatomical dissections as flat bones, small cubical bones, cartilages, thin curved bones, and long bones. This in turn gave him a thorough knowledge of types of fractures (kanda-bhanga), dislocation (sandhi-mukta), sprain, and their healing process. He also devised various devices to assist in the proper healing of fractured bones and sprained joints [19].

Sushruta was of the opinion that the head was the centre of all functions. Through exquisite dissections, he described the cranial nerves in great detail and even offered their physiologic importance. The Samhita mentions that “Ten nerves maintain the functions of the body by carrying impulses of sound, touch, vision, taste, smell, respiration, sighing, yawning, hunger, laughing, speech, and crying. A pair of nerves each responds to sound, touch, vision, taste, and smell.” “Two nerves lower down at the back of the ear (vidhura) which if cut produces deafness; a pair of nerves inside the two nostrils which if cut cause anosmia; a pair of nerves below the end of the eyebrow which if cut causes blindness.” Sushruta Samhita has references to various neurological diseases like hemiplegia, epilepsy, fainting, stiff neck, and blindness [20].

Teaching of Anatomy

Susruta Samhita emphasises the importance of dissection of the human body for an aspiring medical student: ‘A pupil, otherwise well-read, but uninitiated, in the practise (of medicine or surgery) is not competent to take in hand the medical and surgical treatment of disease’ [21]. There is compelling evidence of the fact that the knowledge of human anatomy, which was revealed by both inspections of the surface of the human body and through human dissection by Sushruta, was taught practically to students aspiring to be surgeons as a first step towards acquiring proficiency in Ayurveda [18, 21]. In Sushruta Samhita, we find a mention of this verse.

Tasmat nihsamsayam jnanam harta salyasya vanchata

Sodhayitva mrtam samyag drastavyah anga-vinisccayah

Pratyaksatah hi yat drstam sastra-drstam ca yat bhavet

Samasatah tat ubhayam bhuayh jnana-vivardhanam

Roughly translated, this means, “The different parts or members of the body, as mentioned before, including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, anyone desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully observe it by dissecting it and examining its different parts” [21].

Simulation Lab for Surgical Training

The ability to acquire surgical skills requires consistent practise, and many of these technical skills can be learnt away from the operating theatre. Surgical simulation offers the opportunity for trainees to practice their surgical skills prior to entering the operating theatre, allowing detailed feedback and objective assessment of their performance by a technical mentor. This enables better patient safety and improves standards of care. Simulation of surgical procedures, perfected in skill laboratories for mastering cognitive, clinical, and technical skills to improve patient safety, is a rather recently acquired concept. It is not surprising when we find that way back in 600 B.C., to obtain proficiency, skill, and speed in various surgical procedures, Sushruta had devised various experimental modules. He felt that incision and excision were to be practised on vegetables and leather bags filled with the mud of different densities; scraping on hairy skin of animals; puncturing on the veins of dead animals and lotus stalks; probing on moth-eaten wood or bamboo; scarification on wooden planks smeared with beeswax, etc. Susruta Samhita mentions that medical students should be taught the art of making cuts in the bodies of a puspaphala (a kind of gourd), alavu (bottle-gourd), or ervaruka (cucumber) prior to dissection of human cadavers [22]. This only goes to suggest that Sushruta was well ahead of his time in teaching techniques.

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