A SHORT HISTORICAL REVIEW OF THE DEVELOPMENT OF SURGERY IN CHINA

B*
F. I. TSEUNG, M.B., B.S. (H.K.)., J.P.

The oldest classic of Chinese medicine "Internal Classic" (Nei Ching (*)$), supposed to be written by Huang Ti recorded that Huang Ti invented the nine needles for acupuncture and wrote a treatise on medicine and surgery. The Internal Classic dealt with Anatomy and Physiology in a very crude manner and also dealt with the theory of disease, pulse indications, health conservation, principles of treatment and acupuncture, etc. According to Historical Records the first Chinese surgeon during 2698-2598 B.C. was Yu Fu (jjIfWt)- It was recorded that he cut open the skin, dissected the muscles, severed the blood vessels, tied the tendons, washed the stomach and cleansed the intestines. This description revealed that abdominal surgery was practised in China as early as this period. Another famous surgeon who lived about 255 B.C. was Pien Ch'iao also named Ch'in Yueh-jen ( ^X-^^^A ). It is said that he obtained his medical knowledge from Chang Sang-chun (-jt^i^) who gave him a book and a package of herbs and asked him to take the herbs for a period of one month. He followed his directions and eventually was able to see through the human body revealing all the diseases of the internal organs. This seemed to be an anticipation of the modern X rays. In Lieh Tzu Tang Wen Pien (#!]-? ft J&), the following passage is of interest: Kung Hu of Lu and Ch'i Ying of Chao fell ill and both asked Pien Ch'iao for treatment. Pien Ch'iao addressed Kung Hu:

"Your will is strong, but your animus weak, hence you are strong in one respect but weak in another. The will of Ch'i Ying is weak but his animus is strong, hence he is weak in thought and dangerous in his designs. If your hearts were exchanged there would be an equilibrium and the result would be good. He gave the two persons narcotic wine to drink which made them insensible for three days. He cut their chests open, removed the hearts, exchanged them and put them in again. The two persons made an eventual recovery. About four hundred years later, i.e 190 A.D China produced the best known surgeon ever recorded in history by the name of Hua To (JJif'S). His fame rests mainly on his discovery of the use of anaesthetics and his outstanding skill of surgical technique. According to the Annals of the Later Han Dynasty, he gave a patient an effervescent powder in wine which produced numbness and insensibility. He opened the abdomen or back, as the case might be, washed, cut, or removed the diseased portion. He then sutured the parts together and applied a salve to the wound which healed up in four or five days, completely returning to normal within a month. In his biography there was an account of a case of splenectomy performed by him under anaesthetics. One man suffered from sharp cutting pains in the abdomen. Within ten days the whiskers and eyebrows dropped out. Hua To diagnosed the case as gangrene of the spleen and advised the patient to have an operation. After giving the patient a dose of medicine, he put him in a recumbent position and opened his abdomen. The spleen was found to be half gangrenous.

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This was excised, the wound smeared with an ointment, and another dose of medicine was given. The patient made a complete recovery after one hundred days. In the Wei and Han Annals, Chronicles of the Three Kingdoms, were described all sorts of operations performed by Hua To ranging from venesection and acupuncture to laparotomy, splenectomy. excision of intestines and liver. Sometimes he operated without an anaesthetic as in the case of Kuan Kung, a famous general of the Three Kingdoms whom he operated on for necrosis of arm as the result of a poisoned arrow. Another story was that Tsao Tsao, King of Wei was suffering from persistent headache. Being his personal physician, Hua To was summoned to treat him. He offered to open the skull of Tsao Tsao but his offer was declined. The king suspected him that he wanted to murder him and thereupon put him in prison where he died. Just before his death, he gave his manuscripts to the warder, who however, dared not accept them. So he burnt all his papers leaving behind only the description of the art of castration which is still practised by the Chinese on cocks and boars. The death of Hua To unfortunately marks the end of Chinese surgery, for since then history does not record any further use of the effervescent powder for anaesthetics nor any attempt for major operations by Chinese surgeons. It should be noted that in China surgeons were classified on an inferior plane than physicians and only lower grade doctors were put in charge of the surgical department of Government in the old days. The first and most important treatise on gynaecology is the Fu Jen Ta Ch'uan Liang Fang ( $?A^^-JJt^ ) by Chen Tzu-ming of the Sung dynasty in which menstruation, conception, pre-natal care, hygiene during pregnancy,

preparations for delivery, difficult labour, the puerperium and various diseases of women were described. The first reliable source on ophthalmology was the Tzu Wu Ching ( JJ"Jf-#3L) or "the Importance of Needling" published in the Han dynasty in 250 B.C. The Yen K3 Ta Ch'uan (a.>ft*-) or "Most Complete Eye Book" was written, at the end of Ming dynasty, 1628 A.D in which it is noteworthy to mention the procedure for excision of pterygium and the golden needle for removing cataract, which are most probably the only surgical methods which have been used for treating eye diseases up to the present time.
In 1821 A.D. in Yen Ke Liu Yao ( or "The Six Essential Features of Eye Diseases'' by Chen Hou-hsi, the method of clamping the lids with the aid of forceps made of bamboo in cases of entropion is discussed.

The decline of Chinese surgery is mainly due to two reasons: (1) the Confucian doctrine which holds the body to be sacred and not to be mutilated in any way and (2) the degradation of the medical profession which is classified amongst the four artisans, the others being fortune-telling, astrology and physiognomy. Whatever remains of Chinese surgery now since the last thousand years is acupuncture, bone-setting, incision of abscesses, removal of tumours, perineal lithotomy and a very crude form of entropion operation. The introduction of Western medicine in the 19th century at first met with tremendous difficulties in overcoming the Chinese prejudices and the Chinese then only looked to surgery as a very last resort. It is interesting to record that the first operation for bladder stone was performed by

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HISORICAL REVIEW OF THE DEVELOPMENT OF SURGERY IN CHINA

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Dr. Parkes in 1844 who in 1846 published a book on "Surgical Practice amongst the Chinese." In 1847 ether anaesthesia was first adopted in Canton followed by chloroform narcosis a year later. In 1857 Hobson published a book 'First Lines of the Practice of Surgery." It was in 1874 that the first female stone operation was performed in Canton and a year later the first ovariotomy was attempted. In 1876 operations were performed under antiseptic precautions in Shanghai and about a year later the Lister's method was perfected.

The establishment of missionary medical schools and hospitals and Government institutions and the training of Chinese doctors during the last decade or two have considerably changed the attitude of the Chinese people towards operations and in recent years more and more Chinese doctors gradually took up surgery as their post-graduate specialty. Certainly the majority of the Chinese. people have more confidence in surgery now than hithertofore and there is a great future in the advancement of surgery in China.

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