The Origins and Legacy of Ancient Chinese Surgery

Surgery in ancient China began to develop long before the common era. The period during which the work of surgeons was not merely permitted but, to some degree, even encouraged in China lasted a considerable time. That early tolerance allowed anatomical curiosity, anaesthetic experimentation, and manual technique to flourish before later cultural forces pushed the discipline into decline.

The history of surgery in ancient China

The history of surgery in ancient China stretches back to legendary antiquity, when investigation of the human body was framed as an imperial and philosophical pursuit. Chinese medicine treated the body as a system of vessels and organs to be observed, and the earliest surgical thinking grew out of that observational tradition rather than from routine dissection.

The beginning of ancient Chinese surgery

According to legend, ancient Chinese surgery was set in motion by Shi Huangdi, the Yellow Emperor, who ordered his dignitaries Yu-Wu, Qi-Bo and Lei-Gong to "look and investigate" — the phrase attributed to him in the Huangdi Neijing — the human viscera and "vessels," as well as "the large and small blood vessels." This mythic charge to examine the interior of the body established, in Chinese cultural memory, the idea that the physician's authority rested on direct inspection of anatomy.

Early surgical practices in Chinese medicine

Early surgical practices in Chinese medicine combined manual manipulation, herbal preparations and simple cutting instruments applied by physicians who trained through apprenticeship and observation. Practitioners relied on palpation, pulse reading and the careful handling of soft tissue rather than on a formal science of dissection, so the surgical repertoire developed alongside — and often within the constraints of — a medical culture that prized the intact body. Even so, Chinese physicians accumulated genuine competence in draining, excising and suturing wounds long before comparable techniques were systematized elsewhere.

The flourishing of Chinese surgery

Chinese surgery reached its high point in the second century AD, after which a marked decline set in. In the centuries surrounding that peak, chronicles record both anatomical measurement authorized by the state and the celebrated operations of individual masters, showing how far the discipline had advanced during its permitted phase.

Chronicled evidence of dissections (16 AD)

A striking entry appears in the chronicle for the year 16 AD, describing dissection carried out under imperial authority to determine the cause of a mass death:

About half of the army perished from an epidemic of an unknown disease. By order of the emperor, corpses were dissected to establish the cause of death. During this, the organs were measured and the blood vessels traced.

This documented dissection marked the beginning of the flourishing of Chinese surgery, demonstrating that at least occasionally the state sanctioned direct study of human anatomy for a practical medical purpose.

The Chinese physician Hua Tuo and his operations

The Chinese physician Hua Tuo, a genuine historical figure whose reputation has rightly endured through the ages, worked before the discipline's decline and became the emblem of Chinese surgical skill. The accounts of Hua Tuo come from chronicles written both during his lifetime and shortly after his death at the start of the third century AD.

A man suffered severe abdominal pain for ten days in a row. During this time all the hair on his head and beard fell out. At last the patient turned to Hua Tuo. The physician examined his pulse and said: "Half of your spleen has gone bad. The abdomen must be cut open and the rotted part removed." When the patient gave his consent, the surgeon offered him ma-yao (an anaesthetic), told him to lie down and to keep completely calm.

Then Hua Tuo took a knife and opened the patient's abdomen, and the patient felt no pain. When the abdomen was cut open, everyone present saw that indeed half of the spleen had darkened and shrivelled. Hua Tuo washed it with medicine, then cut off the shrivelled part and applied a healing plaster to the wound. Then he took a silk thread, dipped it in medicinal liquid and sewed up the wound. After some time the patient recovered.

Abdominal operations and tumour removal

Abdominal operations — and, if the testimony of Hua Tuo's biographers is to be believed, even the removal of brain tumours — were performed under anaesthesia in the second century AD, an extraordinary claim for that era. The narrative of the spleen operation illustrates a surgical sequence that is recognizable in principle: pain control, incision, excision of diseased tissue, wound dressing and suturing with treated silk. Whether or not every biographical detail is literal, the accounts show that Chinese surgery of Hua Tuo's time embraced cavity operations and the deliberate resection of morbid tissue.

Anaesthesia in third-century Chinese surgery

Anaesthesia was central to third-century Chinese surgery, and the use of pain-deadening drugs during operations can be considered well documented from roughly the third century AD. Both general and, according to some sources, local anaesthesia were known in China from very early times, which is what made ambitious cavity surgery conceivable in the first place.

Agents for general anaesthesia (cannabis, opium, aconite)

For general anaesthesia, Chinese practitioners used preparations of Indian cannabis, hashish, opium, aconite and other substances, applied to render the patient insensible during surgery. These agents made possible the kind of abdominal operation attributed to Hua Tuo, in which the patient reportedly felt no pain while the abdomen was opened. The reliance on plant-derived narcotics places early Chinese anaesthesia among the oldest documented traditions of surgical pain control.

Agents for local anaesthesia

For local anaesthesia, Chinese medicine used ointments compounded from plants such as Atropa belladonna and Datura alba, among others, applied to numb a limited area of the body. Such topical preparations allowed procedures on the eye and surface tissues to proceed with reduced sensation, complementing the general narcotics used for deeper operations.

Waking the patient from anaesthesia

To rouse the patient from anaesthesia, salt water was poured into the mouth. This simple reversal measure closed the surgical sequence — sedation, operation, revival — and shows that Chinese surgeons managed both the induction and the ending of the anaesthetized state.

Orthopaedic practices in ancient China

Orthopaedics in ancient China developed within the same manual tradition that shaped Chinese surgery, emphasizing the setting of fractures, the reduction of dislocations and the immobilization of injured limbs. Because bone-setting could be accomplished without opening the body or shedding much blood, it sat comfortably within the cultural limits that restricted deeper surgery, and it became one of the most durable branches of Chinese practical medicine. Chinese orthopaedic technique relied on skilled palpation, traction and splinting rather than on internal exposure, so it survived even as invasive surgery fell out of favour.

Decline and stagnation of Chinese surgery

Chinese surgery, having reached its zenith in the second century AD, entered a long decline driven mainly by cultural and philosophical forces rather than by any failure of technique. The very hands-on, material character of surgery placed it in conflict with an intellectual climate that increasingly distrusted empirical investigation of the body.

Persecution of surgery by Confucianism

What heights Chinese surgery might have reached had Confucianism, from that time onward, not shed its early progressive elements and turned into a fierce persecutor of any knowledge grounded in a materialist understanding of the world. In place of experience — the most important method for investigating nature — the Confucians of the Dong Zhongshu school (late second to early first century BC) set the immutable primordial will of Heaven, and of the emperor as holder of the "heavenly mandate" over all earthly affairs. Because surgery is precisely the branch of medicine most rooted in materialism, it found itself in an especially unfavourable position.

Factors responsible for the decline of surgery

Several reinforcing factors were responsible for the decline of Chinese surgery, and together they explain why a discipline that had produced Hua Tuo could stagnate for centuries:

• the Confucian rejection of empirical investigation in favour of received authority;
• the religious insistence that the body remain whole for the afterlife, which discouraged both dissection and invasive operation;
• filial obligations that treated the body as an inheritance not to be cut;
• a cultural aversion to blood and to the handling of corpses;
• a broadly conservative outlook that valued preserving tradition over experimental progress.

None of these factors reflected a loss of manual skill; rather, they steadily removed the social permission that surgery needs in order to advance.

Barriers to anatomical knowledge in China

Barriers to anatomical knowledge in China arose because dissection of the human body was, with rare exceptions, culturally and religiously forbidden. Since the corpse was expected to remain intact for the afterlife, physicians could rarely observe internal structures directly, and understanding of human anatomy therefore depended heavily on inference, analogy and the occasional state-sanctioned examination such as the dissections recorded in 16 AD. Without regular access to bodies, Chinese medicine could not build the cumulative, corrected picture of human anatomy that surgery ultimately requires.

Limitations of physiological understanding

Limitations in the understanding of human physiology followed directly from the restrictions on dissection, since function is hard to map without a reliable grasp of structure. Chinese medicine described the body largely through channels, vessels and correspondences rather than through observed organ function, so its model of human physiology remained conceptual rather than dissection-based. This gap constrained how far surgical reasoning could develop, because operators could not fully anticipate what they would encounter beneath the skin.

Cultural and religious obstacles

Cultural and religious obstacles, more than any technical limit, shaped the fate of surgery in China. Reverence for the intact body, obligations to ancestors, and a distaste for bloodshed combined to make invasive operation morally suspect, even where the skill to perform it existed.

Reverence for the dead and the integrity of the body

Reverence for the dead in Chinese culture required that the body be preserved whole, and this belief directly limited surgery. According to Confucian teaching, a person had to appear before their creator after death undamaged and complete, so any cutting of the living or dead body carried a heavy cultural penalty. This reverence for the integrity of the body made both dissection and elective surgery difficult to justify, no matter their medical merit.

Filial piety and medical practice

Filial piety powerfully constrained medical practice, because the body was regarded as a gift received from one's parents and ancestors that one was duty-bound to keep unharmed. To cut into the body — one's own or another's — could be seen as a violation of that inherited trust, so filial obligation lent moral weight to the taboo against invasive surgery. In this way a core Confucian virtue worked against the very branch of medicine that most depended on breaching the body's surface.

Aversion to blood in the development of surgery

An aversion to blood further hindered the development of Chinese surgery, since procedures that shed blood or exposed the interior of the body were culturally distasteful and ritually troubling. Bloodless techniques — bone-setting, manipulation, external medicines and needling — were far more socially acceptable than open operation, which pushed Chinese medicine toward non-invasive methods. Surgery, which cannot avoid blood, was left with little room to grow.

Conservative attitudes and the braking of medical progress

Conservative attitudes braked medical progress in China by elevating the authority of established texts and inherited doctrine above fresh observation. When tradition is treated as complete and correct, experimental deviation looks like error rather than discovery, and surgery — an inherently experimental, hands-on craft — suffers most under such a mindset. This conservatism helps explain why the striking achievements of the second and third centuries were not built upon but instead gradually forgotten.

Eunuchs at the imperial court

Eunuchs at the imperial court illustrate how a single surgical operation could survive even in a culture hostile to surgery. Castration had long been practised in China, as in other countries of the East, and each imperial court numbered some two to three hundred eunuchs; various dignitaries also kept them to serve their numerous harems.

Castration as a permitted surgical intervention

Castration was one of the very few serious surgical interventions that religion in China permitted, which is why it persisted while other operations withered. Yet even this exception bowed to the demand for bodily wholeness: because Confucian teaching held that a person must appear before their creator intact and complete, the testicles removed during castration were kept for the whole of the eunuch's life and then placed in the coffin at death, so that the man could depart for Heaven in his "original" form. Despite such extraordinary constraints, surgery continued to exist in China, and Chinese medicine achieved real successes in the field.

By the definition handed down from Hua Tuo, the Chinese surgeon had three resources at their disposal: the hand, the instruments and the local remedies. The most perfect of the three was the hand — it was no accident that the highest title the people bestowed on Hua Tuo was "the hand of the nation." For surgical operations, instruments were created for incising, removing, enucleating and amputating.

The cataract operation shows how these three resources — hand, instrument and local remedy — worked together in a refined procedure. Just before the cataract operation, the patient is bent over a basin of the freshest spring water. Sitting on the side of the affected eye, the physician washes both the eyeball itself and the eyelids and the surrounding area. This rinsing continues for a long time, until the eye grows cold "as ice." It was believed that

the blood in the eye congeals, so that during the operation the patient will not feel severe pain, while at the same time the very substance of the cataract hardens.

Having finished the washing, the physician gives the patient a rolled cylinder of paper in each hand, which they must grip firmly. The patient must now sit not leaning forward but reclined against the back of the chair. Two assistants help the physician, standing behind and holding the patient's head so that it cannot move during the manipulations that follow.

With two fingers of the left hand — thumb and middle finger — the operator parts the eyelids, while pressing the "black of the eye" (meaning the iris) with the index finger to deprive the eye of mobility. Taking the needle in the right hand, the physician sets it parallel to the transverse diameter of the eye. The puncture itself is made outside the transverse axis of the cornea, at the boundary between the first and second thirds of the line drawn from the edge of the cornea to the outer corner of the eye. The needle is then very carefully and slowly advanced to the affected area where the body obstructing vision lies; this is first lowered, then raised, then lowered again by means of the needle. Leaving the needle inside the eye, the physician asks the patient whether they can see. If the patient distinguishes the colours shown to them accurately, the final part of the operation begins: the needle is withdrawn with even greater care so that the obstructing body follows it out.

Post-operative care

Post-operative care after the cataract operation consisted mainly of various compresses, most often made from a special kind of leaf of the fu-jung tree. Only leaves in which one half had already yellowed while the other was still green were considered suitable; they were dried in the sun and ground into a powder, which was mixed with water to a dough-like consistency. This paste was placed over the closed operated eye, from the eyebrows to the cheekbone, with a disc of stiff paper on top, then another layer of paste and again paper. This four-layer dressing had to be kept moist at all times, the drying paper being wetted day and night with a brush, and the dressing was changed once every twenty-four hours.

The patient was allowed to sleep only face-up, and a series of measures was recommended to avoid complications. While awake, patients were to sit as much as possible and to rise very slowly, doing everything carefully and avoiding significant exertion. For the first three days only rice broth was permitted. After that, meat and some other foods could be eaten, but always thoroughly cooked so that the food need not be chewed. On the fifth or sixth day the dressing was removed and the diet lifted. Tonic, general-strengthening medicines were widely used during the recovery period, and if the patient felt pain in the operated eye, poultices were applied to the temple on the corresponding side three to five times.

There was a rule not to wash the face for about a month. Eating fish, spicy and heating dishes, and drinking spirits were forbidden for a whole year. The operation was contraindicated for women after childbirth and for pregnant women, and it could not be performed in inclement weather.

Comparing early Chinese surgery with other traditions

Compared with other early surgical traditions, ancient Chinese surgery was remarkable for its early mastery of anaesthesia yet distinctive for how sharply culture limited its later growth. Indian surgery, associated with practitioners such as Sushruta, developed an extensive catalogue of instruments and reconstructive operations, and Greco-Roman surgery advanced through military medicine and anatomical study; both benefited from more permissive attitudes toward examining and cutting the body. Chinese surgery matched these traditions in inventiveness — as the operations of Hua Tuo and the detailed cataract procedure show — but, unlike them, it was steadily narrowed by taboos on dissection, reverence for the intact body and Confucian conservatism, so its anatomical and physiological foundations never expanded to keep pace with its early manual skill.

Ancient Chinese surgery rested on the knowledge of the physicians of Chinese medicine, on their intuition, the sensitivity of their hands and their command of surgical intervention, on the use of anaesthetic agents and simple instruments, and on an individual approach to each patient (see more: Treatment with Chinese medicine).