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Katsubutsu Kyuri: The Unity of the Inside and the Outside

The CSA Committee on the History of Anesthesia congratulates the winner of the 2025 CSA History of Anesthesia Essay Contest: Elena N. Dansky, MD, author of “Katsubutsu Kyuri: The Unity of the Inside and the Outside.” 

Dr. Dansky, a CA-2 resident at the University of Southern California, is originally from San Diego. She completed her undergraduate studies at Northwestern University and earned her medical degree from the Larner College of Medicine of the University of Vermont.

By Elena N. Dansky, MD

On an October day before the invention of the steam engine or the light bulb, before the American Civil War or the end of Japanese isolationism, a breast tumor was excised. Remarkedly, the patient did not move! More than forty years later, William T.G. Morton demonstrated ether anesthesia in Boston, Massachusetts.

On October 13, 1804, Hanaoka Seishu, a Japanese physician, delivered the first successful anesthetic on record during his surgery in Kii Province (now Wakayama Prefecture). The patient was Kan Aiya, a sixty-year-old female patient undergoing a mastectomy.1

Born in 1760, Hanaoka grew up during the Edo period (1603-1868), a time of isolationism in Japan. Trade—and thus, information—was limited to China and Holland. Most physicians practiced herbal medicine, known as kanpo. But through the trading relationship with the Dutch, there was also a contingent of physicians practicing surgery in the Western style—rangaku (translated to “Dutch learning”).2-3

Hanaoka grew up in a physician household in the small village of Hirayama.2 Paintings of him as a young man depict a receding hairline and a kind smile.1 His father, Hanaoka Chakudo, was a surgeon and Seishu’s first teacher. But at the age of twenty-two, he moved to Kyoto to further his studies—first under Yoshimasu Nangai to study kanpo, followed by Yamato Kensui for rangaku.2

When Hanaoka returned home a few years later, he took over his father’s practice. And in between clinical duties, over the next twenty years, he would create a cocktail to anesthetize patients safely. Based on his foundational knowledge of herbal medicine, he began conducting experiments—first on dogs,1 and then on his mother and his wife Kae. Tragically, during these experiments, Kae became irreversibly blind, a phenomenon now attributed to the anticholinergic properties in the herbs.1 While we do not know if Kae had a mild case of narrow angle glaucoma, it is now known that extreme pupillary dilation in patients with glaucoma can result in dangerous elevations in intraocular pressure and blindness.

Through the course of these experiments, Hanaoka developed the concoction that he named Mafutsuto. It contained six medicinal herbs, with the primary ingredients being Datura and Aconitum.4 He would go on to perform operations using Mafutsuto for a variety of pathologies including tumors, cleft palates, kidney stones, and anovaginal fistulas.1

When Hanaoka successfully anesthetized Kan Aiya, it would be the first of over 150 breast tumor excisions that he would perform with Mafutsuto.1 She met with Hanaoka, at this point a man in his mid-forties, perhaps sterner, definitely more bald, and now with a goatee stubble.1 He evaluated her candidacy for surgery and prescribed an herb to take five days before surgery to prevent vomiting.5

On the morning of surgery, Hanaoka performed the first three required evaluations to ensure that it would be safe to administer Mafutsuto. These evaluations assessed for a variety of symptoms that pointed to comorbidities such as anemia, heart failure, respiratory illness, and gastroesophageal reflux disease (GERD).5 Had she not passed this preoperative screening, the surgery would have been cancelled. Three hours after taking the medicine, Kan Aiya was unconscious.

One hour after induction, Hanaoka donned his glasses for surgery and performed the last three mandatory examinations to confirm adequate anesthesia.6 These included flushing and pupillary dilation, a “floating” (easily compressible) pulse and tachycardia, and a stronger apex beat.5 She was monitored throughout the case, either by an assistant or Hanaoka himself. And after five hours, Kan Aiya woke up in recovery.5

Hanaoka became known as not only a skilled clinician, but also a great educator.He founded a private medical school named Shunrinken, where he would eventually train hundreds of future physicians.4 Two of these students, Kamada Gendai and Honma Gencho, are responsible for writing down his teachings. Much of what we know today about Hanaoka and Mafutsuto is from their documentation.4

In Kamada’s book Mafutsuto-Ron, there were specific instructions for the appropriate perioperative management of a patient undergoing anesthesia, with many of the same concerns that we have today. He emphasized appropriate candidates for surgery. And patients who did not pass the preoperative evaluation, such as those with a respiratory illness or those prone to vomiting, needed to be optimized before proceeding. He emphasized appropriate monitoring of patients under Mafutsuto. And he condemned those physicians who did not follow the standard of care.5

Hanaoka’s motto was Katsubutsu Kyuri—often misstated after a student wrote the epitaph Naigai-Goitsu Katsubutsu-Kyuri—7 which translates to“the unity of the inside and the outside.” The essence of his philosophy is that before performing surgery, physicians must fully understand the patient, because each patient is unique. Thus, it is our job as physicians to treat the patient, not the disease.2 It evokes an appreciation for the art and science of medicine, the intersection between a patient’s surgical and medical needs, and the specialty yet to be created: anesthesiology.

Hanaoka Seishu—groundbreaking researcher, educator, and clinician—died at the age of 75 in 1835, almost ten years before the widely publicized demonstration of general anesthesia on what is now known as Ether Day.4 While his work was widely disseminated in Japan by his contemporaries, information did not leave the archipelago in his lifetime due to the isolationism policies in place. And in 1855, Sugita Seikei used ether for the first time in Japan,8 ushering in the beginning of a new era in anesthesiology.

References:

  1. Kotler DL, Hirose H, Yeo CJ, Cowan SW. Dr. Seishi Hanaoka (1760-1835): surgeon, pharmacist, and anesthesiologist. Am Surg. 2014;80(1):E7-9. doi:10.1177/000313481408000106
  • Matsuki A. Seishu Hanaoka, a Japanese Pioneer in Anesthesia. Anesthesiology. 1970;32(5):446-449. doi:10.1097/00000542-197005000-00016
  • Saito S, Kikuchi H, Matsuki A. The history of Japanese anesthesiology. J Anesth Hist. 2017;3(3):103-106. doi:10.1016/j.janh.2017.07.002
  • Dote K, Ikemune K, Desaki Y, et al. Two Japanese pioneers in anesthesiology: Seishū Hanaoka and Gendai Kamada. J Anesth Hist. 2017;3(1):19-23. doi:10.1016/j.janh.2016.12.002
  • Dote K, Ikemune K, Desaki Y, et al. Mafusuto-Ron: The first anesthesia textbook in the world. Biographic review and English translation. J Anesth Hist. 2015;1(4):102-110. doi:10.1016/j.janh.2015.10.005
  • Eger EI II, Saidman LJ, Westhorpe RN, eds. The Wondrous Story of Anesthesia. Springer; 2014. doi:10.1007/978-1-4614-8441-7_31
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