urgical Anesthesia in Ancient China
The earliest known painless surgical operation in China was ascribed to Pien Ch’iao in 255 B.C. It was recorded that he gave narcotic wine to two patients who were rendered unconscious for three days, opened their chests, removed their hearts, exchanged them and put them in again. The two patients reportedly recovered.¹ Modern sinologists-historians considered such recording anecdotal, and at best described a composite of the experiences of Chinese physicians spanning this period in ancient history. Thus instead of referring to an individual, Pien Ch’iao became a term used to represent all ancient Chinese physicians over the course of several centuries.²

The first Chinese physician who applied surgical anesthesia was Hua T’uo, 190-265. Hua was known to dissolve a drug in wine for anesthetic purposes. The drug known as ma-fei-san, or ma-yao, is believed to have been morphine or opium. Unfortunately, for political reasons, Dr. Hua T’uo was executed in a turbulent era of Chinese history. While imprisoned he intended to entrust his jail guard with his writings, but the latter feared its dangerous consequence. Hua T’uo instead burned his medical writings before he died.

Acupuncture, Diagnostics and Therapeutics in Chinese Medicine
Chinese medicine traces its origins back some 4,000 years. It is based upon a philosophical principle of tao, which manifests the great harmony in life transcended from natural phenomena in the universe. Most Westerners are by now familiar with the two forces interacting in nature, yin and yang, which are broadly interpreted as negative and positive elements. A healthy body is one that maintains the great harmony of the tao, attained by a balance of yin and yang. Such bodily equilibrium indicates the presence of an abstract vital pneuma called chi, which is contained in tracts or meridians deeply imbedded within muscles. There are 365 acu-points on these tracks (one for each day), which emerge to the surface of the body and present themselves for needling for therapeutic purposes. The ancient Chinese believed that an excellent physician would control disease before any illness is manifested by a careful monitoring of the chi in the meridians embedded in the body.³ Thus prevention is the foundation of Chinese medicine [Figure 1].

Figure 1: Symbols of internal organs associated with the five elements in nature. From Teachings of acupuncture with the copper doll, 1715.

The Yellow Emperor (Huangti) ruled the Chinese Kingdom around 4,000 years ago at the dawn of Chinese history. His Nei Ching (Cannon of Internal Medicine) is the earliest medical treatise and forms the foundation for medicine in China. It is written in the style of a dialogue between the emperor Huangti and his minister Chi-Puo on matters both medical and philosophical. These writings included two volumes: the Su-Wen, or “Simple Dialogues,” and the Ling-Hsu, “On Acupuncture.” Through history the volume on acupuncture has intermittently appeared and disappeared.

As this oldest medical treatise was incomplete, Chinese medical scholars made it their tasks to research, study and elaborate the principles and wisdom emanated from Huangti and his minister. Huangfu Mi became the first authority to take up this task in 256 A.D., to discuss the principles and practice of acupuncture in a comprehensive treatise called chen-chiu chia i ching. His book dealt systematically with physiology, pathology, diagnosis and therapy. It also discussed the prophylactic functions of acupuncture, described accurate acu-points, and instructed needling techniques in terms of degrees of penetration and duration for cure of diseases and pain relief. It became the most influential book on Chinese medicine in Japan.

In the 6th century, the spread of Buddhism was accompanied by the spread of acupuncture. Buddhist monks well-versed in medical matters traveled to Korea. From Korea, religion and medicine further spread to Japan. In China at the dawn of the first millennium (1027), Wang Wei-I cast the first life-size bronze statue with small holes on its metal wall indicating the acu-points, accompanied by a manual of instruction to aid students and practitioners of acupuncture.⁴ Subsequent studies of acupuncture would make reference to the bronze statue as Chinese medicine spread to other Asian cultures in Korea and Japan.

Soon Japanese students were dispatched to China on learning missions, which included the popular transcription of Chinese medical classics into Japanese. These rare volumes include important 14th century treatises in which text in traditional Chinese style calligraphy was transcribed in black ink by hand on volumes of stitch-bound rice paper. Two such in this tradition were recently acquired by the Wood Library-Museum of Anesthesiology (WLM). Written in 1341 by the prominent Chinese physician Hua Shou, these volumes are hand-transcribed from the Chinese text by Japanese scholar physicians. They are titled shih ssu ching fa hui (“The elucidation of the fourteen acu-tracts”) and do ren hsing chen ku ji nan sho (“Transcribed guides to acupuncture on a bronze figure”) and represent the earliest Chinese-Japanese work on acupuncture in the WLM [Figure 2].

Figure 2: Acupuncture in Chinese-Japanese literature, with annotations in both languages. From Hua Shou’s The elucidation of the fourteen acu-tracts, 1341.

Hua Shou was an academic physician from a prominent scholarly family whose writings on acupuncture were considered the last great landmark on the subject in the Yuan (Mongolian) Period. Hua’s brother, Liu Chi, was a brilliant military strategist who helped the founding emperor of the Ming Dynasty overthrow the Mongolian regime in the 14th century. For political reasons, our scholar-physician took the pseudonym “Hua Shou” to disassociate himself from his influential brother and allow him to continue the practice of medicine.

Hua Shou was the first to define the acu-points as openings or cavities along the meridians, and not simply as points of pneumo energy. He considered these openings as valves for the flow of pneumatic energy, which regulate the wellness of internal organs for good health. Hua Shou emphasized the importance of the two auxiliary meridians running anterior and posterior of the body, the jen-mo and the tu-mo, for maintaining the proper flow of chi. These treatises in the WLM collection bibliographically have dual significance of both Chinese and Japanese origins, reflecting the characteristics of the medical traditions in two East Asian cultures.

Acupuncture and Chinese medical therapeutics found their way to Europe in the second half of the 17th century. One important aspect involved therapeutics based upon the theory of the circulation of blood in the system and the effects of pneuma energy (as indicated by the pulse) on the 14 meridians. Monitoring the pulse allowed Chinese physicians to determine the sources of illness due to abnormalities of the internal organs. Andreas Cleyer’s Specimen Medicinae Sinicae, Frankfurt, 1682, is a Latin translation of the Chinese theory of the pulse based on two Chinese classics on sphygmology from the 3rd and 9th centuries.⁵

Figure 3: Western anatomical interpretation of the posterior acu-tract, tu-mo, as illustrated in Willem ten Rhijne’s Dissertatio de Arthritide, …De Acupunctura, 1683.

Curiously, Cleyer did not claim to write this book, but rather listed himself as editor and ascribed authorship to Polish Jesuit Michael Boym. A religious evangelist, Fr. Boym had devoted his life to aiding a converted Ming royal in his futile efforts to reclaim the throne from the new Ching ruler of the Chinese Empire. Fr. Boym did not live to see the publication of his own translation of the 10th century classic on sphygmology, published several years after Cleyer’s. Nevertheless medical scholars have found little similarity between Cleyer’s version and Boym’s, other than their agreement on the relationship between pulse diagnosis and the 14 acu-tracts of the body⁶ [Figure 4].

Figure 4: Manual pulse monitoring for therapeutic diagnosis in Chinese sphygmology. From Andreas Cleyer’s Specimen Medicinae Sinica…1682.

Cleyer’s book significantly influenced the work of English physician Sir John Floyer, who wrote Physician’s Pulse-Watch, or an Essay to explain the Old Art of Feeling the Pulse, and to Improve it by the help of a Pulse Watch, 2 volumes, 1707, 1710 (also a part of the WLM collection). Floyer paraphrased Cleyer’s work and was credited for his effort to accommodate Chinese and European observations about the pulse into his two-volume work on sphygmology. He also introduced the use of a stopwatch in the study of pulse rate in many diseases, a precursor of patient monitoring.

Perhaps the surgeons of the Dutch East India Company were even more important to the spread of Chinese medicine. Willem ten Rhijne, 1647-1700, joined the Dutch service in 1673. He was assigned to Deshima, Japan, although Japan was closed to foreign contacts at that time. Ten Rhijne met and conferred with Japanese physicians for almost two years and wrote the first treatise on acupuncture in the western world, titled Dissertatio de Arthritide, Mantissa Schematica; De Acupunctura; et Orationes Tres, circa 1683 (title abstracted).

Ten Rhijne’s volume copiously illustrated the acupuncture points and observed that acupuncture and cautery were the primary techniques employed by both the Chinese and Japanese for the relief of every pain derived from illness. Ten Rhijne also pointed out that Chinese medicine emphasized the circulation of blood but opposed phlebotomy, fearing that venesection would remove both healthy and diseased blood and thus shorten life. Instead the Chinese used acupuncture to expel blood’s bad elements.⁷ Ten Rhijne’s volume was simultaneously published in London, the Hague and Leipzig. WLM recently acquired a copy of the London imprint.

The theories and efficacy of the acu-tract and acu-point system in acupuncture continued to influence medicine in continental Europe and England into the 19th century. Other important and seminal literature from this era also is represented in the WLM collection, such as works by Chevalier Salandié, who employed electric current in acupuncture, and Jules Cloquet, who adopted acupuncture in hospital clinics. In England, also in the 19th century, J. M. Churchill published two books on acupuncture in 1821, A Treatise on Acupuncturation …1821 and another 1828. His achievements included cure of rheumatic conditions, sciatica, back pain, trismus, achieving immediate numbness and eventual cure, and are also chronicled in the collection of the WLM.⁸

Figure 5: 18th century Chinese anatomical drawing of internal organs and their pathological functions. From Teachings of acupuncture with the copper doll, 1715.

Acupuncture and Therapeutics From the WLM Collection
Most of the cited classics in Chinese medical literature on acupuncture and therapeutics have been collected in the WLM. It is hoped that this attempt to understand the evolution of this ancient medical art with reference to key literature on the subject would provide a relevant identity for each of our titles related to the subject. Despite the antiquarian nature of such literature, it is intended to acquaint the reader with an ancient philosophical wisdom on the matter of health and healing.⁹

Sadly, religious stigma and reverence for the physical body in Chinese society put the practice of surgery in a lowly social position and thus stifled its development through the ages. However, with this short article, perhaps one humble librarian can put to rest the anesthesia controversy regarding “Who Was First?” Who was really first? The Chinese!

References:
1. Wang CM. China’s contribution to medicine in the past. Ann Hist Med. 1926; 8(2):192-201.
2. Veith Ilza. Huang ti nei ching su wen (The Yellow Emperor’s Classic of Internal Medicine), new edition. Berkeley: University of California Press; 1949:3.
3. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:121.
4. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:119, 130-131.
5. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:276-277.
6. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:284-285.
7. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:271.
8. Lu Gwei-djen, Needham J. Celestial Lancets. Cambridge: Cambridge University Press; 1980:296-298.
9. Veith Ilza. The Yellow Emperor’s Classic of Internal Medicine, new edition. Berkeley: University of California Press; 1973:76.

Lydia A. Conlay, M.D., Ph.D., is Professor of Anesthesiology, Baylor College of Medicine, Houston, Texas.

Patrick Sim, M.L.S., Paul M. Wood Distinguished Librarian, has served the WLM and ASA since 1971.