Understanding Cancer (2): The Pain Beneath the Scalpel — Notes on Zhou Zhiyuan's TCM Anti-Cancer Studies (6)

1

The bamboo hut is bare, the birds chatter; content with the view, I lie in the cold village.

Only the art of raising the dying back to life is in mind; how could I seek the gates of fur coats and fat horses.

The author of this poem was Hanaoka Seishu, one of Japan's earliest integrative Chinese-Western physicians—in Japan called the Kampo-Dutch eclectics, meaning compromisers between Chinese (Kampo) medicine and Dutch (Western) medicine. The Japanese called Chinese medicine "Kampo" and Western medicine "Dutch medicine," because Western medicine was introduced to Japan by the Dutch.

Hanaoka Seishu was a physician obsessed with medicine. His given name was Seishu, courtesy name Baikō, common name Zuiken; born in 1760 (Hōreki 10) into a medical family. At 23 he traveled to Kyoto to study ancient formulas under Yoshimasu Nangai.

After three years, Hanaoka had an awakening: "Knowing that the physicians of the age were confined to old formulas, bound by the classics, unable to apply them flexibly, dividing internal medicine into specialties without understanding unity—this is why their treatments failed," he resolved to return home. In his later work, Lectures on the Shanghan Lun, he offered outspoken criticism of his own school—the Yoshimasu current of Japan's Ancient Formula school.

Hanaoka later studied in Nagasaki under Yamawaki KentŎtsu's heir, the Dutch-school physician Oana Tateru, learning Western surgery. Japan's Irako Mitsutaka, introducing his predecessors, called Hanaoka the Japanese Kampo-Dutch eclectic surgeon—a second-generation descendant of the anesthetics-obsessed Irako Dogyu.

Hanaoka studied both Chinese and Western medicine, absorbing them while retaining a critical, innovative spirit. He became famous for pioneering breast-cancer resection. The Lord of Kishu repeatedly invited him, granting samurai status and free attendance, but Hanaoka preferred to remain a free, unpracticed doctor treating common people.

Hanaoka performed 156 breast-cancer operations in his lifetime, and also created medicine's first informed-consent waiver: before surgery, he required the patient and family to sign an agreement reading, "Whatever misfortune occurs during treatment, no word of complaint shall be made at the time."

Of the 156 breast-cancer patients he operated on, apart from a few who did not survive, most recovered well and lived happily. Some married and had children, daily enshrining Hanaoka's image in gratitude for saving their lives.

The main anesthetic Hanaoka used was datura (man-tuo-luo). Datura entered China along the Silk Road during the Yuan dynasty and became a Chinese herb. The "Caowu Powder" used in TCM orthopedic bone-setting (first recorded in Shiyi Dexiao Fang, written in 1337 by Wei Yilin) already contained datura flower. Japan's Nanban-style wound therapy (a 1671 manuscript) used datura stems and leaves as anesthetic for "cutting flesh" and "suturing."

In his work Qing Nang Mi Lu, Hanaoka named his surgical anesthetic "Mafei Tang," honoring the ancient Chinese physician Hua Tuo as the originator of anesthesia—Mafei San first appears in Hua Tuo.

Hanaoka's Waike Suyan follows the disease names listed in Chen Shigong's Waike Zhengzong (Orthodox External Medicine) of the Ming dynasty, describing symptoms, diagnosis, and treatment.

Hanaoka was a remarkably learned physician; his surviving works show he was in every sense a general practitioner.

He left a complete breast-cancer case record, Nyugan Chikenroku, preserving the names, addresses, and ages of the women he treated. It may be medical history's earliest research record dedicated to breast-cancer patients. From his first case in 1804 until his death in 1835, over 31 years, Hanaoka performed mastectomy on 156 patients.

Hanaoka emphasized combining internal and external treatment. He was an outstanding surgeon but also skilled in internal medicine, his foundation in Kampo, absorbing Western surgical technique. In his lifetime his clinic was so crowded that nearby houses filled with patients come from afar.

As the opening poem says, Hanaoka was indifferent to fame and wealth, spending his life on healing, writing, and training successors.

2

Hanaoka's breast-cancer patients were lucky to meet an innovative doctor. Human knowledge of tumors began with surface tumors such as breast cancer. Lacking anatomy, early physicians' most direct encounter with tumors was women's breast cancer.

The image above shows a breast-cancer ulceration. Ancient Chinese physicians called such an ulcerated breast cancer—where internal organs might even be exposed—ruayan (rock breast): "rock" because the tumor was as hard as rock and fixed. Successive TCM surgical texts note: "Once ruayan ulcerates, it is untreatable."

Hanaoka was not the first to operate on breast cancer; Chinese and Western medical texts both record many such operations. But early surgery was, for the patient, simply torture.

Hippocrates, the father of Western medicine, even pessimistically said that for tumor patients the best treatment was no treatment at all, because under the conditions of the time, untreated patients lived longer.

Another Western pioneer, the ancient Greek Claudius Galen, strongly opposed operating on tumor patients, because most operated patients died within a very short time, and quite a few died on the table.

In the mid-14th century, John of Arderne wrote: "Surgery only brings you disgrace... those who pretend to cure cancer by cutting, scooping, and excising merely convert a non-ulcerating cancer into an ulcerating one... In my career I have never seen a cancer cured by excision, nor heard that anyone did."

Because most operations then proceeded without anesthetics or antibiotics, the patients' screams on the table were harrowing. Postoperatively there were no anti-infection measures, and many died of sepsis.

Most European surgery then took place in a dark room of a clinic (sometimes in the back room of a barber shop). The patient was tied down with leather straps; the scalpel was rusty, and if it fell to the floor, surgeons would pick it up, wipe it on their coats, and plunge it back in.

The pus and blood drained from patients were collected in buckets; staff carrying buckets out of the operating room spilled them on the floor. Such conditions are beyond comparison with modern sterile operating theaters.

The 18th-century German surgeon Lorenz Heister described mastectomy in his clinic: "Many women summon enormous courage and do not even groan. But others scream incessantly, and the bravest surgeon is unnerved, hindering the operation. To perform it, the surgeon must have a steadfast character, undisturbed by the patient's cries."

By comparison, Hanaoka Seishu, trained in both Chinese and Western medicine, drew on TCM anesthesia to greatly reduce suffering. Postoperative care also drew on TCM internal formulas, lowering infection risk and shortening recovery—a major advance.

From these records, the agony humans endured to survive is truly chilling. We who live today, though still tormented by malignancy, are far better off than our forebears of two or three hundred years ago, at least in the suffering we must endure for treatment.

3

Born over a century before Hanaoka, the Qing physician Chen Shiduo (c.1627–c.1707) wrote in the preface to his Dongtian Aozhi:

"In the winter of the Guihai year I traveled again to Yan (now Beijing); all I encountered were festering, hopeless sores. I applied formulas, but families doubted and rejected them, trusting instead the worldly surgeons' knife and needle, from which extraordinary disasters followed; then they sought rescue with trivial, mild medicines, and died still unawakened. Grieved long, I wrote this book, titled Dongtian Aozhi."

From Chen Shiduo's account, Beijing in the Kangxi era already had many patients with surface tumors, and Chinese surgeons were already operating. Even earlier, Chen Shigong, the Ming surgical master and author of Waike Zhengzong, was skilled in the "knife technique" and performed many operations.

Chen Shiduo, courtesy name Jingzhi, art name Yuangong, also Zhuhuazi and Liangong, self-styled master of the Daya Hall, was from Shaoxing, Zhejiang. A famous TCM surgeon who favored internal herbal treatment of external diseases, he liked large doses of raw Huangqi and Jinyinhua.

Chen Shiduo was a successor of Fu Qingzhu. Fu Qingzhu (Fu Shan) was an important figure of the late Ming/early Qing, influential in many fields. He mastered the healing arts and practiced medicine to save people, while as a scholar with patriotic feeling he secretly carried out anti-Qing, pro-Ming political activity. Many wuxia novels include him.

Like his master, Chen Shiduo also secretly worked for Ming restoration. He wandered widely, learning medicine from various itinerant masters including Fu Qingzhu. On a journey in Sichuan he is said to have met Daoist priests on Mount Emei, from whom he learned several highly effective secret formulas, which he wrote into Dongtian Aozhi—a classic of TCM external medicine.

By Chen Shiduo's account, 17th-century Chinese surgeons already commonly operated on tumors, and patients preferred surgery to internal medicine—perhaps because internal results disappointed them.

But surgical results were obviously poor too, with major aftereffects, so many TCM surgical experts, including Wang Hongxu, Chen Shiduo's contemporary, strongly opposed surgery.

Wang Hongxu wrote in his Waike Zhengzhi Quansheng Ji:

"Medicine is entrusted with life and death. Reading the printed external-medicine texts that boast of being orthodox, they say that when the seven evils appear the patient dies. They also describe heating a red-hot needle in tung oil, inserting it half an inch into a phlegm nodule, inserting a lowered-medicine strip, and after seven days the mass splits open; insert the strip another seven days and the nodule falls off. They also say poison between skin and flesh requires cutting an inch deep to drain it. They do not know that when poison is between skin and membrane, even if an incision is indicated, it must not go deeper than three fen, lest it injure the inner membrane. If it goes an inch deep and pierces the inner organs, how can the patient endure this extreme punishment? The seven evils appear in an instant. Those in the world who follow this method are all executioners."

From Wang Hongxu we see that many surgeons then did operate, and results were poor.

Most admirably, Wang Hongxu held a view still remarkably accurate today: early cancer may be operated on, but the surgery must not injure the body. "Poison between skin and membrane, if an incision is indicated, still must not exceed three fen, lest it injure the inner membrane." For mid- and late-stage cancer with metastasis, surgery is out: "if it goes an inch deep and pierces the inner organs, how can the patient endure it?" Such patients have lost the surgical option.

Though ancient Chinese did not study cancer at the cellular or genetic level, their clinical observation was careful. A movable breast mass is early-to-mid stage; "fixed, immovable" is mid-to-late, because the tumor has adhered to surrounding tissue. Surgeons like Wang Hongxu decided whether to operate on just this basis.

Even prognosis in late cancer was soberly understood.

Another Qing surgical master, Gao Bingjun, wrote in his Yangyi Xinde Ji: "In internal medicine there are four incurable patterns: wind-consumption, taxation, distension, and blockage. In external medicine there are likewise four: shirong, tongue gan, ruayan, and shenyan-fanhua. Other patterns, once their yin-yang, cold-heat, qi-blood, root-branch are discerned, can all be treated."

The "distension" he mentions is today's ascites of late cancer; "blockage" is the dysphagia of late esophageal and cardia cancer; "shirong" is late lymphoma or lymph-node metastasis; "tongue gan" is late tongue cancer; "ruayan" is late breast cancer; "shenyan-fanhua" is late penile cancer.

From TCM classics across dynasties we see that most TCM physicians were helpless against late cancer. Almost no surgical master advocated operating on late cancer patients—not even Chen Shigong, who left procedures including nasal-polyp removal, sequestrectomy, toe amputation, and tracheal/esophageal suturing.

Introducing his internal formula Herong Sanjian Wan and external plaster Feilong Awei Huapi Gao for late surface tumors, Chen Shigong fairly assessed his own results: "I have treated several; though not fully cured, they did not die prematurely. This is truly a life-lengthening medicine."

Lengthening life and letting late cancer patients survive with cancer is also a central question of modern cancer care. We see that even today, our overall principles have not surpassed the ancients by much.

4

In 1703, the London anatomist Matthew Baillie published The Morbid Anatomy of Some of the Most Important Parts of the Human Body, describing lung, stomach, and testicular cancer with rich, vivid engravings.

This was medicine's earliest anatomical textbook on tumors, opening a new era in European tumor surgery.

Baillie's uncle, the Scottish surgeon John Hunter, had been removing tumors in a London clinic since the 1760s. Hunter could not only resect tumors but observed that if they were movable they could be removed (how similar to ancient Chinese surgeons!) without harming the fragile tissue beneath.

He wrote: "If a tumor is not only movable but can be naturally separated, it can be safely removed, but with great caution to determine whether these secondary tumors are within the scalpel's reach, for we are easily deceived."

For immovable tumors, Hunter frankly advised—only to sympathize with the patient, nothing more.

On the morning of October 16, 1846, around 10 o'clock, Boston dentist William Morton demonstrated a new technique to assembled doctors in a crowded operating theater at Massachusetts General Hospital.

He brought a small glass distiller with an inhaler containing about a quart of ether. He opened the valve and let the patient Edward inhale a few breaths of vapor. Edward soon became unconscious; a surgeon then made a small cut in his neck and tied off a swollen, deformed blood vessel. Minutes later the patient woke, saying he had felt no pain throughout, though he knew the operation was happening.

Western medicine entered the age of anesthesia, overcoming a huge barrier to surgery.

In 1865, the Scottish surgeon Joseph Lister noticed that postoperative wounds left open to air easily turned gangrenous, while closed wounds often stayed clean and infection-free.

He further found that dressing wounds could prevent decay. Inspired by a neighboring sewage plant using carbolic acid to treat sewage, he began applying carbolic acid paste to postoperative wounds to prevent infection.

Lister's attempt succeeded. When his sister Isabella developed breast cancer, he used this simple antiseptic for her postoperative care; she developed no infection. She survived three and a half years before dying of liver metastasis. He then operated on another sarcoma patient, again dressing with carbolic acid; no infection occurred.

By then European and American medicine had overcome the three great obstacles to tumor surgery. A new generation of surgeons finally broke the bottleneck Hippocrates and Galen could not. Surgical treatment of tumors advanced greatly, operative mortality fell sharply, and patients' survival lengthened. Surgeons grew optimistic, believing surgery was the best cure.

True modern surgery was thus built step by step. Surgeons no longer listened, hearts in mouths, to patients' hideous screams; patients no longer risked death as their ancestors had. Though modern surgeons still, like Hanaoka, require patients and families to sign informed consent for anesthesia and surgery, the proportion dying on the table has grown ever smaller.

Surgery for tumors brought immense hope and lifted surgeons' spirits. The radical school, led by William Stewart Halsted (born 1852 in New York), proposed the concept of "radical surgery."

Halsted strongly advocated extensive surgery on tumor patients. The breast-cancer patients he operated on had not only lymph nodes cleared but even chest tissues and clavicle removed.

Halsted was a hardworking, excellent surgeon who almost wished he need not sleep to study technique; to reduce sleep he even became addicted to drugs, and his personality was somewhat extreme. His "radical surgery" embodied all his hopes: to cure tumor patients completely. Sadly, most of his radical-surgery patients recurred one after another.

In later life Halsted was reluctant to face this embarrassing reality. His term "radical surgery" became widely used in tumor surgery—terms like "distal gastrectomy radical (D2)" all originate from this surgeon-founder.

But many of Halsted's own disciples abandoned his radical approach, choosing smaller operations and preserving tissue that need not be removed.

Of course, whether to perform extensive surgery remains a hotly debated question. Terms like "radical surgery" please surgeons and hearten patients. But for most patients the hope is hard to realize; most who undergo radical surgery eventually recur.

Now surgical robots have entered hospitals and surgery grows ever more precise, yet tumors truly curable by surgery remain few. Some early tumors can indeed be cured surgically, but in clinic most are hard to detect early.

Mid- and late-stage patients often cannot be operated on, or only palliated. Even palliative surgery's meaning and value remain widely debated.

The road ahead is long. Today's surgeons, though far advanced over the past, still have far to go if surgery is to give cancer patients the greatest hope of survival.