1 part tian nan xing (Arisaema rhizomatum or cobra lily). Some sources claim that Angelica archangelica (often referred to as garden angelica, holy ghost, or wild celery) was also an ingredient. Reportedly the mixture was ground to a paste, boiled in water, and administered as a drink. After 2 to 4 hours the patient would become insensitive to pain and then lapse into unconsciousness. Depending on the dosage, they might remain unconscious for 6–24 hours. The active ingredients in tsūsensan were scopolamine, hyoscyamine, atropine, aconitine and angelicotoxin. When consumed in sufficient quantity, tsūsensan produced a state of general anesthesia and skeletal muscle paralysis. Shutei Nakagawa (1773–1850), a close friend of Hanaoka, wrote a small pamphlet entitled "Mayaku-ko" ("narcotic powder") in 1796. Although the original manuscript was lost in a fire in 1867, this brochure described the current state of Hanaoka's research on general anesthesia. Use of tsūsensan as a general anesthetic Once perfected, Hanaoka began to administer his new sedative drink to induce a state of consciousness equivalent to or approximating that of modern general anesthesia to his patients. Kan Aiya (藍屋勘) was a 60-year-old woman whose family was beset by breast cancer - Kan being the last of her kin alive. On 13 October 1804, Hanaoka performed a partial mastectomy for breast cancer on Kan Aiya, using tsūsensan as a general anesthetic. This is regarded today by some as the first reliable documentation of an operation to be performed under general anesthesia. Nearly forty years would pass before Crawford Long used general anesthesia in Jefferson, Georgia. Hanaoka's success in performing this painless operation soon became widely known, and patients began to arrive from all parts of Japan. Hanaoka went on to perform many operations using tsūsensan, including resection of malignant tumors, extraction of bladder stones, and extremity amputations. Before his death in 1835, Hanaoka performed more than 150 operations for breast cancer. He also devised and modified surgical instruments, and trained and educated many students, using his own philosophy for medical management. Hanaoka attracted many students, and his surgical techniques became known as the Hanaoka method. Publications Hanaoka wrote the following works. None of these were printed books. Rather (as was the custom in Japan at that time), they were all handwritten manuscripts which were later reproduced by his students for their personal use. 1805: Nyuigan chiken-roku, a one-volume book that provides a detailed description of Hanaoka's first operation