Introduction

Sushruta was the first surgeon in the world to describe the surgical instruments and other related subjects in the detailed treatise called Sushruta Samhita. He performed surgeries in the era when no diagnostic facilities were available. The exhaustive knowledge of basic sciences has made him a versatile surgeon. The progress made from that ancient time period till the present day seems to be astonishing. Major operations like Amputations, Lithotomy (or extraction of stone) and even Trephining of the skull were well-known to our old sages.1 For the attainment of surgical insight, it is ethical for the aspiring surgeon, to have a rigorous practice on the non-living representatives of the living body. The initial training on the human beings is considered to be unethical as the trainee may endanger the life of the patient at risk. Learning anatomy through the dissection is viewed as the uniquely defining features of medical courses. Explosion of knowledge in the field of medicine was feasible due to exploration of the human body through human cadaver dissection which was performed by Acharya Sushruta in those periods when no preservative chemicals were available.

Surgical Instruments used in Ancient Period

Acharya Sushruta have mentioned more than 100 instruments (yantra) and 20 Sharp instruments (sastras).Out of them, Acharya emphasizes on the most important instrument as hand because any of the instruments will be of no use without the hand. To be successful in surgery, the surgeon should be exceptionally competent with the instruments. He should practice the handling of the instruments before using them on patients. The surgical training has been described in the context of Yogyasutreeyam in Sushruta Samhita which is an excellent example of the ethical considerations which have been given utmost importance in this holistic system of medicine. The substances utilized for the surgical training are analogous with the part of the body which is the site of a surgical procedure.

The instruments mentioned in Sushruta Samhita are categorized as Blunt instruments (yantras) and Sharp instruments (sastras). The Ayurveda surgery describes these sharp and blunt surgical tools on the basis of their similarity with the commonly known animals, birds or the shapes. The six types of the blunt instruments described in the Sushruta Samhita are named on the basis of their shapes analogous with the commonly known shapes.

 The Yantras or the Blunt instruments were categorised as follows:

• Cruciform instruments (Svastika yantras)
• The Swastika yantras which can be correlated to forceps in the contemporary surgical era was divided into twenty-four subclasses. They resemble the mouths of beasts or birds. They were mainly used for extracting thorns or foreign bodies embedded in bones.
• Dissecting forceps or tongs (Sandamsha yantras)
• The Sandansha yantras which are the dissecting forceps in modern era are divided into two classes as with or without locks. The one with locks (forceps which bite/hold) has the capability to bite or hold tightly due to the presence of teeth. They were used for extracting foreign bodies from skin, muscles, blood vessels and ligaments.
• Spoon shaped instruments (Tala yantras)
•  Tala yantras which are spoon shaped instruments similar to tweezers with one or two surfaces resembled the scale of a fish. They were used for extracting foreign bodies from the ear, nose or a sinus.
• Tubular instruments (Nadi yantras)

Nadi yantras, as the name suggests are in shape of a nadi (tubular), which are of various types, were used for removing foreign bodies, as well as inspection and treatment of disease spots of external orifices like ear, nose, mouth, vagina and rectum. They were of different diameters and lengths depending on the dimensions of the passage. They have a hollow interior with an opening at one or both ends. Some have one or two openings on the sides as well. Those with openings at both ends are used for inspection of the throat and extraction of foreign bodies from it. They were also used for aspiration and facilitating surgical operations on external orifices.

 Endoscopes which are extensively used these days come under the category of tubular instruments. They were used in piles, fistula in ano, anal stenosis etc. The arsho yantra (rectal speculum for piles), bhagandara yantra (rectal speculum for fistula in ano) and yoni vranekshanam (vaginal speculum) are some of the examples of endoscopes for examination of external body orifices.

Throat speculum

Sushruta describes the method of extraction of a foreign body, for example a substance made of lac, from the throat. A heated iron probe should be introduced through a tube of copper and made to touch the foreign body. The foreign body will melt and stick to the probe. This is then cooled by sprinkling cold water through the speculum and then the foreign body is extracted.

Rod like instruments (Shalaka yantras)

 Shalaka yantras which look like rods were of several types and were used for different purposes according to their lengths and circumferences depending on the site of application. Under this category, there were eight instruments which were again divided into four groups. Each group of two have mouths resembling earthworm, serpent hood, feathered end of an arrow or a hook and were used for probing, retraction, separation and extraction. Two have mouths like a half lentil grain(masuradala) and slightly bent at the top, which was used for extracting foreign bodies from passages. Six were capped with cotton(karpasakruta ushneesa) and were used for cleaning. Three were ladle shaped(darvi) and mortar mouthed(khalla mukha) for applying caustic drugs. Three others had Jambu fruit (Jamun - Syzygium cumini) like mouths and three had hook shaped mouths(ankushavat) – all the six were meant for cauterization. One had the mouth like half of the nut of kola fruit (a kind of berry) with sharp lips like a mortar and was used for removing nasal polyps. One has the circumference of a black chickpeas(kalaya parimandala) and both ends are shaped like flower buds(mukulaagra) and was used for applying collyrium. One was meant for cleaning urethra - having length and thickness comparable to the tip of the petiole of malati (a kind of jasmine) flower.

Accessory instruments (Upa yantras)

 These were the supporting accessories which help in the procedure like rope, intertwined thread, bandages, leather straps, bark, creeper, linen cloth, round pebble, stone, hammer, palm and sole, fingers, tongue, teeth, nail, mouth, hair, ring of a horse’s bridle, twig of a tree, spittoon, evacuating, exhilaration, magnetic stone, caustic, fire cautery, drugs etc

The Sastras or the sharp instruments mentioned by Acharya Sushruta were twenty in number namely:

Acharya Sushruta have categorised the surgical operations into eight different subtypes, viz. 1. Bhedya (Excision) 2. Chhedya (Incision) 3. Lekhya (Scarification) 4. Vedhya (Puncture) 5. Eshya (Probing) 6. Aharya (Extraction) 7. Visravya (Drainage) 8. Sivya (Suturing). The Shastras or the sharp instruments and their usage in different types of surgical operations have also been elaborately mentioned in Ayurveda literature which are as follows:

• Circular knife (Mandalagra) and Bone saw (Karapatra) which were used for excision and Scrapping.
• Scalpel (Vrddhipatra), Nail parer (Nakhasastra), Ring knife (Mudrika), Lancet (Utpalapatra) and Single edged knife (Ardhadhara) were used for incision and Excision.
• Bistoury (Kusapatra), Hawk bill scissors (Atimukha), Scissors (Sararimukha), Curved Bistoury (Antarmukha) and Three-edged knife (Trikurcaka) were used for drainage.
• Chisel (Kutharika), Trocar (Vrihimukha), Awl (Ara) and Scalpel of different type (Vetasapatraka) were used for puncturing.
• Sharp hook (Badisa) and Tooth scaler (Dantasanku) were used for extraction of foreign bodies.
• Sharp probe (Eshani) was used for probing and as a director.
• Suturing needle (Suci) was used for drainage, puncturing and suturing.

Acharya Sushruta have given a detailed note on how the surgical training has to be attained on non-living matters to enhance the practise of 8 shastra karmas like

• Chhedana (Excision) to be practised in Cucumber, Watermelon
• Bhedana (Incision) in Urinary bladder of animals, leather sac filled with water.
• Lekhana (Scrapping) in Leather piece with hair
• Vedhana (Puncturing)in the blood vessels of the dead animals and stalk of the Lily plant, Bamboo and Pitcher gourd.
• Eshana (Probing) on Wood having pores created by the moths, various sticks like the hollow reed, Bamboo, Dry pitcher gourd.
• Aharana (Extraction) of fleshy tissue of the fruits of Bilwa, Panasa, Bimbi and the teeth of dead animals.
• Visravana (Drainage of the fluids) of Shalmali plank covered with bee wax.
• Seevana (Suturing) of thin and thick cloth or soft hides like the leather.
• Bandhana (Bandage) of dummies of human body as used for display in the garment stores.
• Agni, Kshara karma (Cautery & Caustic) on the soft fleshy tissue
• Netra Pranidhana Vasti, Vrana basti, Vasti peedana (Application of various enema & related procedures) with Pot/pitcher having a beak/spout by its side.

These training procedures help the scholars to practise well with the instruments and get better expertise when handling with patients.

Significance of Dissection using Cadaver

Sushruta, a practitioner of ancient Indian medicine has made significant contribution to various branches of medicine especially in surgical techniques. Learning anatomy through the dissection is viewed as the uniquely defining features of medical courses. Lack of knowledge about the anatomy and physiology of body makes it very difficult to diagnose the medical conditions affecting various tissues and organs in the body. Acharya Sushruta have given a very detailed note on how to preserve, decompose and dissect a body to understand their position, route, layers etc.

The description starts with dealing with the aspects to be verified while securing a dead body like the cause of death should be non-poisoning, the person not dead being suffered from any prolonged illness, not a very old aged person etc. The procedure for preservation has also been mentioned where the intestine and fecal matter are removed after which body is wrapped with Kusha, flax or made of similar material for which the recent researches confirm that these materials act as preservatives²

 and later immersed in cold running water source with slow currents which doesn’t interfere with local people or wildlings. After 7 days of decomposition, body gets loose, is taken out and examination starts from there. Each layer of skin and every organ is observed after peeling with a brush of bamboo bark or similar materials which are not too blunt. Dissection of Skin is done within the first 7 days by full separation of all the seven layers of skin after which deep fascia and muscles are separated in the next 7 days or so and in the remaining fortnight, the ligaments of various joints also get separated. Various organs in the body are examined after removing all other attachments using available instruments. A remarkable fact which is very notable is that even though Acharya Sushruta have mentioned numerous instruments for different surgical procedure, he has only preferred naturally available soft brush like bamboo, kusha etc for the cadaveric dissection and studies. This may be because during those time, the preservative chemicals were not present and being immersed in water will make all the tissues soft and decomposed making the dissection with blunt or sharp instruments impossible. Even though the modern techniques used for dissection from cadaver selection to its embalming techniques and dissection process have much changed with usage of preservative chemicals like ethanol, glycerine, thymol which prevents decomposition and all the tissue, organs, muscle etc remain intact which makes it easily manageable with instruments.

 Acharya Sushruta proposed cadaveric dissection mainly to attain three purposes which are Shariravichaya, Sharirashodana and Sharira upakarartha which implies dissecting the body, understanding the anatomical structures inside the body for proper research and apply the knowledge obtained for the treatment of ailments. Only after attaining proper clarity of the anatomy of body, a physician can easily diagnose and treat the ailments.

Conclusion

All the above description regarding instruments used in that period and how they have been modified through the present era clearly depicts the surgical practise in Ayurveda which used to be flourished during those time. The techniques used for cadaveric dissection is also very remarkable as they were practised in a time period when there were no other preservative techniques available for dissecting the body for research purpose. The Ayurveda literature has always been filled with its magnificent history which is well sceptical for some and astonishing for others.

References

1. Shah, Niranjan. (2017). Historical Note: Some Thoughts on Hindu Medicine-An Address by Kaviraj Mahamahanandhya Gananath Sen. Indian Journal of History of Science. 52. 10.16943/ijhs/2017/v52i4/49266.
2. Minakshi S. Patil. Preservation techniques for dead bodies in Ayurveda. J Ayurveda Integr Med Sci 2022;1:325-328