Newsletter January 2024: The Japanese surgeon who performed general anaesthesia decades before Morton

The prevailing view regarding the discovery of modern anaesthesia primarily focuses on the groundbreaking ether anaesthesia performed by William T.G. Morton (1819-1868) on October 16, 1846, in Boston. In honour of this event, the lecture hall at the Massachusetts General Hospital is also called the “Ether Dome,” where Morton’s memorable demonstration took place, turning it into something of a pilgrimage site for those interested in the history of medicine. However, the acclaim for the first successfully conducted anaesthesia is by no means uncontested. Two other pioneers laid claim to the laurels for the first successful modern anaesthesia: the dentist Horace G. Wells (1815-1848), who had performed nitrous oxide analgesia and sedations for teeth extractions already two years before Morton and Charles Th. Jackson (1805-1880) asserted the same success for himself because he had recommended using sulfuric ether to Morton as his mentor before the latter’s achievement. Jackson claimed to have successfully anaesthetised animals and humans years earlier but could not provide convincing evidence. Morton’s claim was primarily substantiated by two essential points: the successful demonstration in the Ether Dome with enthusiastic recognition from the surgeon Bigelow (“Gentlemen, this is no humbug!”), and the use of an apparatus created by himself that allowed reasonably controlled dosing of the ether-air mixture. The three protagonists, Morton, Wells, and Jackson, engaged in bitter legal disputes against each other, each claiming to have invented pharmacologically induced anaesthesia. Although Morton ultimately prevailed, the legal proceedings completely ruined him. The other two adversaries also suffered bitter fates. Wells, who had become addicted to drugs, was thrown into prison and committed suicide there, ironically under self-administered bloodletting while attempting to numb himself. Jackson also ended tragically in a closed psychiatric ward, where, with the clinic’s approval, he occasionally conducted anaesthesia experiments on his fellow patients. 

None of these three contenders were aware that a Japanese surgeon had preceded their claim to priority by around 40 years. We are talking about Hanaoka Seishū (1760-1835), who, starting from October 13, 1804, performed various surgical procedures, primarily mastectomies for breast cancer, under orally administered deep sedation or pharmacologically induced coma. The reason why this fact has been and still is largely ignored lies in Japan’s self-isolation at the time. Japanese medicine of that era was largely oriented towards Chinese traditions, but individual doctors sought and found access to Western literature. Combining these two sources of knowledge with their own, sometimes experimentally acquired experiences resulted in a very pragmatic and rationally oriented local medical science that largely went unnoticed outside of Japan. This self-isolation, known as “Sakoku” and decreed by the Tokugawa Shogunate, lasted from 1630 to 1853, serving as a form of self-protection against the aggressive colonial aspirations of the Western world. It was only with the forced opening of the country by the American Commodore Matthew C. Perry in 1853 and the Treaty of Kanagawa in March 1854, which he enforced, that the exchange of goods and ideas with the outside world began, almost a decade after the first successful anaesthesia in America. 

The elusive Japanese anaesthesia pioneer was Hanaoka Seishū, born in the mid-18th century in the small provincial town of Kii (Wakayama Prefecture). He was the son of a physician who reportedly acquired his medical knowledge from Spanish and Portuguese sources. Growing up under the influence of his cosmopolitan father, Hanaoka gained initial medical knowledge in Kyoto from a medical school that, unlike the prevalent esoteric-dominated Chinese medicine of the time, leaned towards observation and derived experiences. This atypical openness to rational thinking for the period provided him access to literature from Western sources received from his teacher, Yamato Kenryū. The surgical treatises of Leipzig court physician Caspar Schamberger (1623-1706) had a significant impact, particularly demonstrations of his techniques by a visit of a Dutch delegation in Nagasaki and Edo (modern-day Tokyo) in 1649, predating the Japanese isolation period. Since then, the Japanese referred to this type of surgery as “Caspar-Surgery.” 

Hanaoka incorporated much of this knowledge but increasingly focused on the treatment of breast cancer, which later became his explicit speciality. Upon returning from Kyoto to his hometown, he took over his father’s practice and began experimenting with mixtures of plant alkaloids such as scopolamine, hyoscyamine, atropine, aconitine, and angelicotoxin, known at the time for their psychotropic properties. He tried different ratios of extracts from the original plants, testing them on his cats. Most of those experiments ended fatally for the animals, prompting him to adjust the doses. Undeterred by the fatal outcome of his animal experiments, he involved his close relatives in further trials. Subsequently, he persuaded his wife and his own mother to taste his elixirs, a request likely accepted without protest in the context of the strict patriarchal society of that time. In the case of his wife, this resulted in a prolonged coma from which she awoke only the next day but remained blind after that. The effects on his mother are unknown, but apparently, he eventually succeeded in finding a tolerable yet effective dose. As a result, on October 13, 1804, his first anaesthesia for a surgical procedure was successfully conducted. It involved a mastectomy on a 60-year-old woman from a family with a high incidence of breast cancer. His refined alkaloid mixtures, which he called Tsūsensan and Mafutsusan, had to be taken two to four hours before the start of the operation and lasted several hours, sometimes even an entire day. This long-lasting effect partially addressed the immediate postoperative pain issue, too, thus becoming a very sought-after kind of treatment that was unique for that period. Overall, following this successful debut, Hanaoka is said to have performed a total of 153 mastectomies under orally administered anaesthesia. Unfortunately, nothing is known about the outcome of these surgical-anaesthetic achievements. 

In hindsight, one can observe that in anticipation of a development that took place in other parts of the world a full century later, Hanaoka Seishū had established himself as a skilled surgeon and anaesthetist at the same time and during the same interventions, not unlike the first generation of Western anaesthetists. Of course, there can be debate about whether orally administered intoxication leading to a reversible coma constitutes genuine anaesthesia. There is no talk of controlling the depth of unconsciousness in this context, and the pharmacological effects were merely the largely unpredictable interplay between the administered dose and its absorption, metabolism, and elimination. The inhalation anaesthesia performed almost half a century later in the United States offered the possibility of actively removing and exhaling the anaesthetics by exhalation, providing a certain degree of control, especially with Morton’s apparatus. Nevertheless, Hanaoka Seishū, largely unrecognised and scarcely mentioned in relevant medical historical literature, can be considered the true pioneer and inventor of general anaesthesia. 

At his workplace in Wakayama Prefecture, there is a park and a museum called Seishu-no-Sato, which was established in his house and cabinet in honour of Hanaoka. It is quite remote, about 100 km south of Kyoto, and attracts only a modest number of visitors interested in medical history. However, retrospectively, it may be no less significant than the much more well-known Ether Dome. 

References 

1. Izuo M (2004). “Medical history: Seishū Hanaoka and his success in breast cancer surgery under general anesthesia two hundred years ago”. Breast Cancer. 11 (4): 319–24. doi:10.1007/BF02968037 
2. Hyodo M (1992). Doctor S. Hanaoka, the world’s-first success in providing general anesthesia”. In Hyodo M, Oyama T, Swerdlow M (eds.). The Pain Clinic IV: proceedings of the fourth international symposium. Utrecht, Netherlands: VSP. pp. 3–12. ISBN 978-90-6764-147-0 

Authors

• Prof. Peter Biro (MD DESAIC) – Medical Faculty, University of Zurich, Switzerland