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Home , Book of Han, Book of Wei, Chen Shou, Guan Yu, Han Shizhong, Hua Tuo

Saving the God of War:

The Ancient Chinese Approach to Osteomyelitis

Yichi Zhang

Tulane University School of Medicine

War has been an inseparable part of human history ever since the inception of civilization. Many regions of the world worshipped diverse manifestations of gods of war. A western audience may be familiar with cruel Ares from Olympia, wise Odin of Valhalla, or the powerful Horus, ruler of upper and lower Egypt. It is legend that these lead armies into the fray time and time again, staring death in the eye until they achieve ultimate victory. While they often suffer injuries during their conquests, they always overcome the pain or setback with their divine powers. But sometimes the doctor is still needed. Among the many courageous generals in the long list of decorated Chinese military commanders, one named was struck by an enemy arrow during battle. The consequent medical treatment he received became one of the most well-known orthopedics cases in ancient . It elevated him to a legendary status and enlisted him in the ranks of the gods of war.

Guan Yu, or Guan Yunchang, as his contemporaries would have called him during the early 3rd Century AD, was a general that served under the famous warlord . A crumbling

Eastern Dynasty gave way to rebellious farmers in what was known as the “Yellow Turban

Rebellion.” Regional power struggles continued for years until the rule of China was split between three warlords: , and Liu Bei1. This era, known as the “Warring

Kingdoms” or the “” thus began amongst the belligerent chaos. As necessity is

1, Dubs, Homer. The History of the Former by Pan Ku. Vol. 3. Ithaca, NY: Spoken Languages Services, 1938. the mother of invention so too is war the mother of medical advancements. In addition to discovering and documenting new herbal remedies, Chinese doctors proliferated the use of and moxibustion2. Armed with more knowledge and experience in interventional therapies, Chinese doctors faced the challenges of treating war casualties with a greater arsenal of medicinal and surgical tools. This is where Guan Yu’s story enters the ancient Chinese medical records.

Guan had just served as vanguard in a campaign against the warlord Cao Cao. While besieging the city of , he was shot by an arrow that penetrated his proximal right arm. In the heat of the battle, Guan removed the arrowhead lodged in his arm and continued to command his forces until the siege was complete3. It is not known the exact techniques Guan employed to stem the bleeding in the immediate aftermath of his injury. What is recorded is that although the wound gradually healed in the following days, Guan continued to experience severe pain deep in the arm and suffered from a loss of some active range of motion, which greatly hindered his ability to command3. Consequently, many of Guan’s subordinates advised him to order a strategic retreat, to which Guan responded: “How can I let such an important national campaign be delayed by such an inconsequential flesh wound?”3. Unwilling to be stopped despite his injury, Guan finally decided to seek out medical help.

Messengers were sent far and wide in search of experienced doctors capable of delivering an effective intervention. Guan told the arriving doctor that the pain is exacerbated during cold and rainy days, which indicates that this interaction likely took place more than a couple days’

2, Bary, Theodore, and Irene Bloom. Sources of Chinese Tradition. 2nd ed. Vol. 1. New York City, NY: Columbia University Press, 1999. 3, , Shou. Records of the Three Kingdoms (SanGuoZhi), 3AD. 4, Chen, Shou. Records of the Three Kingdoms, , Tales of Guan Yu, Chapter 6 . Edited by Songzhi Pei. Accessed December 17, 2019. https://baike.baidu.com/reference/23502084/a3919Q- WTGzrwAUl9WBDUQmT2LHeWxHQC552ZTqk2EJwkANsBzAWNW- ura5hIupOzchSksBjglFn_Nuqn_c41nn533vnoSCq44WT--vp. time after the injury. The doctor examined Guan’s arm carefully and noted signs of swelling and severe inflammation4.

“Your Excellency, I’m afraid that your injury requires an immediate and radical intervention, or you may lose the arm soon,” the doctor explained, “But I am worried if you will let me perform the procedure.”4

“Why is that?” Guan asked4.

“I need to tie your arm down with rope, make an incision at the injury site deep to the bone and remove the inflamed bits of bone and tissue. Then I will apply some herbal remedies and stitch the wound back up.” The doctor elaborated further4.

“Say no more doctor.” Guan said with a laugh, “and spare the rope, I promise I will not flinch.”4 Indeed, the procedure performed was without anesthetics. The legendary Chinese doctor

Hua Tuo was credited with the invention of the earliest anesthetic just two decades prior to

Guan’s injury. The substance, called “Ma Fei San” or “Numbing Powder”, was made from a blend of various herbs including Datura, wolfsbane, rhododendron and more. It was to be dissolved in wine and then taken by patients undergoing surgical procedures5. Armed with this new tool, was believed to be the first Chinese surgeon to perform abdominal such as splenectomies and colostomies6. However, it was also evident that despite the initial success of Hua’s “Ma Fei San”, most other Chinese doctors living during this era had yet to

4, Chen, Shou. Record of the Three Kingdoms, Book of Han, Tales of Guan Yu, Chapter 6. 5, , NS. “Legendary Hwa Tuo's under General in the Second Century China.” Acta Neurologica Taiwanica, December 13, 2004. https://www.ncbi.nlm.nih.gov/pubmed/15666698. 6, Tubbs, R.S., Riech, S., Verma, K. et al. China’s first surgeon: Hua Tuo (c. 108–208 AD). Childs Nerv Syst 27, 1357 (2011) doi:10.1007/s00381-011-1423-z 7, Chen, Shou. Records of the Three Kingdoms, , Records of Medicinal Techniques. Edited by Songzhi Pei. Accessed December 17, 2019. https://baike.baidu.com/reference/23502084/a3919Q- WTGzrwAUl9WBDUQmT2LHeWxHQC552ZTqk2EJwkANsBzAWNW- ura5hIupOzchSksBjglFn_Nuqn_c41nn533vnoSCq44WT--vp. adopt effective anesthesia as part of their practices7. Instead, they relied on their swift and dexterous techniques, the patient’s pain tolerance, and of course, some rope. Such was the case for Guan Yu and his doctor.

To distract himself, Guan set up a traditional game of Go with one of his proteges and gulped down a cup of wine. The doctor then proceeded to make the incision, exposing inflamed tissue as deep as the humerus. After carefully removing the infected tissue, the doctor focused his attention on the bone itself. The records document the knife making crunching sounds as the doctor scraped the surface of the humerus to eliminate diseased bone4. Presumably, portions of the periosteum are being removed from the wound in order to expose and debride deeper layers of diseased bone. The periosteum is rich in nociceptive nerve endings. Because of this, Guan would have experienced excruciating pain during such a grueling ordeal. But despite all this suffering, Guan reportedly remained calm and collected, and continued to play Go and take sips of his wine4.

The same could not be said about Guan’s subordinates and attendants. Some of them were tasked with holding up the basin under his arm, but their faces “losing color entirely” when they realized how much blood had accumulated4.

There should be just as much praise for the doctor’s technique as there is for Guan Yu’s nerve. The physician quickly debrided the last bits of diseased tissue and applied some herbal extracts to the wound4. Although the exact formulation of the extract remains unknown, an abundance of herbs in Chinese medicine demonstrate antiseptic and anti-inflammatory properties. Some of the more commonly used herbs of his category include Flos lonicerae (or

4, Chen, Shou. Record of the Three Kingdoms, Book of Han, Tales of Guan Yu, Chapter 6. 7, Chen, Shou. Records of the Three Kingdoms, Book of Wei, Records of Medicinal Techniques. 8, Muluye, R. A., Bian, Y., & Alemu, P. N. (2014). Anti-inflammatory and Antimicrobial Effects of Heat-Clearing Chinese Herbs: A Current Review. Journal of traditional and complementary medicine, 4(2), 93–98. doi:10.4103/2225-4110.126635 “ Yin Hua”) and Scutellaria baicalensis (or “Huang “)8. After the doctor applied the herbal extract, the wound was subsequently closed with sutures.

The news of Guan’s nerves of steel soon spread into camp, throughout the army, and around many of his countrymen back home4. Guan was already a decorated general of the Shu

Han faction, but the story of his “unorthodox” surgery elevated him to a legendary national status. He gained a reputation for having absolutely no fear: certainly, one fitting for a god of war.

Guan Yu returned to assume command of the army promptly after treatment and even engaged in single handed combat with a famous enemy general Xu Huang4. It can be inferred from Guan’s actions that his wound was able to heal well post-surgery and that most of his active range of motion was restored. Although the operation was remarkably successful in saving

Guan’s arm, considering it was performed almost 1800 years ago, there are hints in historical record that potentially show its imperfections as well.

In an account of Guan Yu’s heroic last stand at Province several years later, it was reported that the general-turned-god complained of weakness in his right arm while trying to pick up his heavy blade4. It is not known if this weakness is due to residual damage from the infection, or perhaps a complication of the operation9. A good reason to champion the latter hypothesis is the fact that branches of the axillary nerve lie deep to the deltoid muscles, just superficial to the surgical neck of the humerus. Some branches of this nerve could have easily been damaged by the crude instruments employed at the time of the operation. An injury to these nerves results in dysfunction of the deltoid muscle to some degree, affecting abduction of the

4, Chen, Shou. Record of the Three Kingdoms, Book of Han, Tales of Guan Yu, Chapter 6. 8, Muluye, R. A., Bian, Y., & Alemu, P. N. (2014). Anti-inflammatory and Antimicrobial Effects of Heat-Clearing Chinese Herbs: A Current Review. 9, Zhang, Alex. “Review of Surgical Debridement of Guan Yu” ZhiHu. Zhihu. Accessed December 17, 2019. https://daily.zhihu.com/story/4868996. arm from 15 to 90 degrees. This is an important action that Guan would have had to perform to pick up and swing his blade in battle.

Taking perspective from the limited historical records and putting it into modern language, what had befallen the unflinching Chinese god of war was likely a case of osteomyelitis secondary to a penetrating open limb wound. It is consistent with Guan Yu’s etiology as well as his presenting signs and symptoms. The open, penetrating arrow wound could have resulted in the introduction of microorganisms to the bone and its surrounding tissues. The wound was not treated promptly, allowing infection to incubate and spread, causing pain, swelling and the loss of range of motion10.

Born more than a millennium too early to know about antibiotics, Guan Yu’s doctor nevertheless realized the importance of clearing the infection as soon as possible to save his patient’s arm, as well as his life. Surgical debridement is still used in the modern era for cases of recurrent, chronic osteomyelitis that have been resistant to antibiotic therapy10, but for Guan, this was the only option available. It is a pity that more details of the operation could not be found as there would have been many challenges that this ancient physician had to overcome with his limited tools. How did he control hemorrhage? How did he approach vascular reconstruction?

How did he manage the residual dead space11? Purely judging by Guan Yu’s relatively benign recovery process, the doctor must have come up with quite the ingenious solutions to some of these problems that continue to trouble modern surgeons today.

10, Rao, Nalini, Bruce H , and Benjamin A Lipsky. “Treating Osteomyelitis: Antibiotics and Surgery.” Plastic and reconstructive surgery. U.S. National Library of Medicine, January 2011. https://www.ncbi.nlm.nih.gov/pubmed/21200289. 11, Gage, Mark J, Richard S Yoon, Robert J Gaines, Robert P Dunbar, Kenneth A Egol, and Frank A Liporace. “Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls.” Journal of orthopaedic trauma. U.S. National Library of Medicine, February 2016. https://www.ncbi.nlm.nih.gov/pubmed/26429404. Guan’s case of osteomyelitis may have been the most famous, but his is only one of many cases treated using the debridement method throughout Chinese medical history. During the 6th century AD, a crown prince of the dynasty fell from a horse and fractured his arm12. An ensuing infection developed, causing his arm to swell up “several inches”.

Reportedly, his doctor performed debridement while the crown prince continued to chat with his court friends. People promptly started comparing the brave prince to Guan Yu, as a reincarnate of the god of war. Later, the crown prince did in fact enjoy victory in a series of conquests, though he would eventually die in middle age from an apparent re-infection/complication of his old injury12.

Another example lives in general Zhang Qiong, who blocked an arrow meant for the first of the with his body13. This heroic act resulted in a fractured femur, and the subsequent bone infection required debridement from the court doctors. According to the records, all general Zhang demanded was a large jar of wine prior to the procedure. Although several liters of blood drained during the operation, the general was saved13.

Later in the Song Dynasty, commanding general Han Shizhong was injured during a northern incursion against the Jin Kingdom14. A subsequent bone infection developed, and the field medic present did not have the appropriate metal instruments for cutting into bone.

Consequently, a was taken apart and its delicate metal parts were then used to perform the operation. Han Shizhong survived the ordeal, returned to his homeland from conquest and eventually died of old age14.

Looking back at these cases, ancient Chinese physicians chose the most appropriate approach that they could think of to treat bone infections. Obviously, the surgical debridement

12，, Yanshou. Northern History, Chapter 10. Vol. 22, 11AD. 13， Tuo, Tuo. History of the Song Dynasty, Chapter 1. Vol. 1, 14AD. 14，Tuo, Tuo. History of the Song Dynasty, Chapter 123. Vol. 364, 14AD. was imperfect. It could have resulted in further infections, or even nervous, muscular, and vascular damage of horrible sorts. Despite these success stories, in the hundreds and perhaps thousands of undocumented cases, many patients would have inevitably died. Even so, this imperfect intervention prevented immediate threats of gangrene, sepsis, and amputation in many cases. Without this operation, Guan Yu’s decorated military career would have ended abruptly, and he would have died a man, not a legend. Chinese families around the world would not adorn their doors with his image in hope for his protection and blessings. Temples and statues honoring his heroic life and career would not have been erected in nearly every Chinese city15.

But these Chinese physicians believed in Guan Yu’s potential and were determined to help him in his struggle for life and for greatness. They may not have had the fullest clinical picture possible, but they weighed the dangers and benefits from experience, risked their reputations to intervene, and did what they thought was best for their patient.

Perhaps without even realizing it, Guan’s doctor accomplished something incredible.

He treated a man, saved his life, and watched his patient become immortalized as legend.

15, Lou, Mary, and Shovava. “Monumental 1,320-Ton Sculpture of Chinese War God Watches Over the City.” My Modern Met, March 6, 2019. https://mymodernmet.com/guan-yu-1320-ton-war-god-sculpture- -china/.