Figure 1. The woman is Kan Aiya, 60 years old and the mother of Rihei, a dyer of indigo cloth in Kii Province. On October 13, 1804, she was the first patient on whom Hanaoka used mafutsusan to successfully excise a tumor from her left breast. This operation is recognized as the world's first surgical procedure conducted under general anesthesia. "A Surgical Casebook" is a manuscript of hand-painted pictures commissioned by Hanaoka Seishu. The colorful, often charming, pictures in this casebook capture the likenesses of the men and women who came to Hanaoka for treatment, and they depict graphically the medical and surgical problem to be treated. Hanaoka Seishu (October 23, 1760 - November 21, 1835) was a Japanese surgeon with a knowledge of Chinese herbal medicine, as well as Western surgical techniques. He successfully operated for hydrocele, anal fistula, and even performed certain kinds of plastic surgery. He was the first surgeon in the world who used the general anesthesia in surgery and who dared to operate on cancers of the breast and oropharynx, to remove necrotic bone, and to perform amputations of the extremities in Japan. He also devised and modified surgical instruments, and trained and educated many students, using his own philosophy for medical management. He died in 1835 at the age of 75.