Hua Tuo
Hua Tuo (c. 140–208), courtesy name Yuanhua, was an ancient Chinese physician who lived in the late Eastern Han Dynasty. The historical texts Records of the Three Kingdoms and Book of the Later Han record Hua as the first person in China to use anaesthesia during surgery. He used a general anaesthetic combining wine with a herbal concoction called máfèisàn (麻沸散, lit. "cannabis boil powder"). Besides being respected for expertise in surgery and anaesthesia, Hua Tuo was famous for his abilities in acupuncture, moxibustion, herbal medicine, and medical Daoyin exercises. He developed the Wuqinxi (Wade–Giles: Wu-chin-hsi; 五禽戲; lit. "Exercise of the Five Animals") from studying movements of the tiger, deer, bear, ape, and crane.
Historical accounts
The oldest extant biographies of Hua Tuo (tr. DeWoskin 1983:140-153 and Mair 1994:688-696) are found in the official Chinese histories for the Eastern Han Dynasty (25-220) and Three Kingdoms period (220-280). The 3rd-century Records of Three Kingdoms (Sanguozhi) and 5th-century Book of the Later Han (Houhanshu) record that Hua was from the district of Qiao (譙) in the state of Pei (沛, i.e., modern Bozhou, Anhui), and studied Chinese classics throughout Xu Province (covering parts of modern Jiangsu and Shandong). Hua refused employment offers from high-ranking officials (e.g., Chen Gui 陳圭) and chose to practise medicine.
The dates of Hua's life are uncertain. Estimations range from 110-207 (Li 1974:296, Mair 1994:227) to 190-265 (Veith 1996:3); Lu and Needham (2002:117) conclude that the "best estimate" is circa 145-208. Hua Tuo was an older contemporary of the physician Zhang Zhongjing (150-219).
The name Hua Tuo combines the Chinese surname Hua (華, lit. "magnificent; China") with the uncommon Chinese given name Tuo (Wade–Giles: To; 佗 ["hunchback"] or 陀 ["steep hill"]). He was also known as Hua Fu (尃, "apply [powder/ointment/etc.]"), and his courtesy name was Yuanhua (元化, "Primal Transformation").
Some scholars (e.g., Chen Yinke 1977:36-40, Chen Jinhua 2007:293) believe Hua Tuo's name was probably of Indian origin, and he learned Ayurveda medical techniques from early Buddhist missionaries in China. Victor H. Mair (1994:227) describes him as "many hundreds of years ahead of his time in medical knowledge and practice", and suggests his name Hua Tuo, which was roughly pronounced *ghwa-thā in ancient Chinese, could derive from Sanskrit agada "medicine; toxicology". Several stories in Hua's biography "have a suspiciously Ayurvedic character to them" (see Salguero 2009), and he was active "in the areas where the first Buddhist communities were established in China."
Hua Tuo's Sanguozhi biography describes him as resembling a Daoist xian (Wade–Giles: hsien; 仙, "immortal") and details his medical techniques.
Hua-t'o had mastered the technique for nourishing one's nature. Although his contemporaries thought that he must have been a hundred years old, he still looked hale and hardy. Hua-t'o was also highly skilled in prescribing medicines. In curing illnesses, the decoctions that he prepared required only a few ingredients. His mind was so adept at dividing up and compounding according to the right proportions that he did not have to weigh the different components of his medicines with a balance. Once the decoction was boiled thoroughly it could be drunk. Hua-t'o would tell the patient how to take the medicine and then would go away, after which the patient's condition would promptly improve.
If Hua-t'o employed moxibustion, he would only burn punk in one or two places and in each place he only made seven or eight separate cauterizations, to which the disease would rapidly respond during the course of its elimination. If he employed acupuncture, it was also only in one or two places. As he instated the needle, he would instruct the patient, "I am going to guide the point to such-and-such a spot. When you feel it reach there, tell me." As soon as the patient told him that the point had already reached the designated spot, he would withdraw the needle and the sickness would likewise be virtually alleviated.If a sickness were concentrated internally where the effect of acupuncture needles and medicines could not reach it, Hua-t'o would recognize that it was necessary to operate. In such cases, he would have his patients drink a solution of morphean powder whereupon they would immediately become intoxicated as though dead and completely insensate. Then he could make an incision and remove the diseased tissues. If the disease were in the intestines, he would sever them and wash them out, after which he would stitch the abdomen together and rub on an ointment. After a period of about four or five days, there would be no more pain. The patient would gradually regain full consciousness and within a month he would return to normal. (tr. Mair 1994:688-689)
Hua Tuo's corresponding Houhanshu biography explains this mafeisan "cannabis boiling powder" decoction was dissolved in jiu (Wade–Giles: chiu; 酒, "alcoholic beverage; wine"). Hua's prescription for mafeisan anaesthetic liquor was lost or destroyed, along with all of his writings. The (c. 636) Book of Sui lists five medical books attributed to Hua Tuo and his disciples, but none are extant (Fan 2004:316).
The subsequent portion of Hua Tuo’s biography in the Sanguozhi (Mair 1994:689-694) lists sixteen medical cases: ten internal medicine, three surgical, two gynaecological, and one paediatric case. Thus, writes Fan (2004:314), "Hua Tuo’s treatment of diseases was centered on internal medicine, but also included surgery, gynaecology and paediatrics. He removed parasites, performed abortions and treated ulcers, sores and analgesia." For example:
The governor of Kuang-ling, Li Teng, had an illness which caused him to be distressed by a feeling of stuffiness in his chest. He also had a red face and no desire for food. Hua-t'o took his pulse and said, "Your honor, there are several pints of parasitic bugs in your stomach and you are on the verge of developing an ulcer. This was caused by eating raw fish." Whereupon he prepared two pints of a decoction for the governor, Hua-t'o had him drink one pint first and then after a little while had him finish the remainder. In the space of time that it takes to eat a meal, the governor vomited up three pints or so of parasites. They had red heads and were all wriggling; half of their bodies looked like sashimi. The discomfort that he had experienced was immediately relieved. "This sickness will erupt after three years. If you are attended by a good doctor, he will be able to save you." The sickness did indeed erupt after the specified period. At the time, Hua-t'o was not in the area and the governor died as Hua-t'o had said he would if he did not have a good doctor. (tr. Mair 1994:692-693)
Cao Cao (155-220), who laid the foundation of the Cao Wei state in the Three Kingdoms period, was Hua Tuo's best-known patient, and suffered from chronic headaches (possibly caused by a brain tumour).
Ts'ao Ts'ao heard about Hua-t'o and summoned him to court where he henceforth was often in attendance. Ts'ao Ts'ao suffered from blustery headaches. Whenever an attack came on, he would become dizzy and confused. Hua-t'o would employ acupuncture treatment at the diaphragmatic transport insertion point and the condition would be alleviated as soon as the procedure was carried out. (tr. Mair 1994:693)
Lu and Sir Joseph Needham (2002:118) translate Cao's condition as "migraine headaches accompanied by mental disturbance and dizziness", and identify this acupuncture point on the sole as Yongquan (Wade–Giles: Yung-chuan;涌泉, "bubbling fountain").
Cao ordered Hua to work as his personal physician, which Hua resented.
Examples of Hua-t'o's superlative skills are in general of this sort. However, since he was originally a scholar, he often regretted that he was looked upon as a physician by profession. Later, when Ta'ao Ta'ao took personal control of the affairs of state, his sickness intensified and he had Hua-t'o attend him exclusively. "It will be difficult to heal you in the near term but if we maintain a program of treatment over a longer period, it will be possible to extend your life-span." (tr. Mair 1994:694)
In order to avoid treating Cao, Hua repeatedly made excuses that his wife was ill, but Cao discovered the deception and ordered Hua's execution. Xun Yu, an advisor of Cao Cao, petitioned on behalf of the physician.
Hua-t'o had been far away from home for a long time and wished to return, so he said, "I just received a letter from home and would like to go back temporarily." After he reached home, excusing himself on the grounds of his wife's illness, he requested several extension of his leave and did not come back. Ts'ao Ts'ao repeatedly wrote letters to Hua-t'o calling him back, and he issued imperial orders to the commandery and district authorities to send Hua-t'o back. Proud of his ability and finding it distasteful to wait upon others for a living, Hua-t'o continued to procrastinate in setting off on the journey. Ts'ao Ts'ao became very angry and dispatched men to go and investigate. If Hua-t'o's wife were really sick, Ts'ao Ts'ao would present him with forth bushels of lentils and be lenient in setting a date when his leave would expire. But if Hua-t'o were prevaricating, then he would be apprehended and escorted back. Consequently, Hua-t'o was handed over to the prison at Hsü where after interrogation, he confessed his guilt. Interceding on behalf of Hua-t'o, Hsün Yü said, "Hua-t'o's techniques are truly effective and people's lives are dependent upon them. It is fitting that you be clement toward him." "Don’t worry," said Ts'ao Ts'ao. "Do you think there aren't any other rats like him under heaven?" (tr. Mair 1994:694)
Hua Tuo wrote down his medical techniques while awaiting execution, but destroyed his Qingnang Shu (Wade–Giles: Ching-nang Shu;青囊書, lit. "green bag book," which became a Classical Chinese term for "medical practices text").
Whereupon the investigation against Hua-t'o was concluded with the announcement of the death penalty. When Hua-t'o was about to be executed he brought out a scroll with writing on it and handed it over to the jailer, saying, "This can preserve people's lives." Fearful of the law, the prison subaltern would not accept it, nor did Hua-t'o force it upon him. Instead, he asked for a fire in which he burned the scroll. (tr. Mair 1994:694)
This loss to traditional Chinese medicine was irreplaceable. Veith (1966:3) notes that, "Unfortunately, Hua T'o's works were destroyed; his surgical practices fell into disuse, with the exception of his method of castration, which continued to be practised. Due to the religious stigma attached to the practice of surgery, the social position accorded to the surgeon became increasingly lower and thus made a revival of Chinese surgery impossible." A Liezi legend (tr. Giles 1912:81-83) claims the renowned physician Bian Que (ca. 500 BCE) used anaesthesia to perform a double heart transplantation, but that (ca. 4th century CE) text was compiled after Hua Tuo used mafeisan.
Cao Cao later regretted executing Hua when his son Cao Chong (196-208), a child prodigy who discovered Archimedes' principle, died from illness.
After Hua-t'o's death, Ts'ao Ts'ao's blustery headaches did not go away. "Hua-t'o could have cured me," said Ts'ao Ts'ao, "but the scoundrel prolonged my illness, wishing thereby to enhance his own position. Thus, even if I hadn't put the knave to death, he never would have eradicated the source of my sickness." Later on, when his beloved son Ts'ang-shu was critically ill, Ts'ao Ts'ao said with a sigh, "I regret having put Hua-t'o to death and causing my son to die in vain." (tr. Mair 1994:695)
The Sanguozhi does not specify Hua Tuo's exact date of death, but since Cao Chong died in 208, Hua Tuo could not have lived past that year.
Hua's biography ends with accounts of his disciples Wu Pu 吳普 and Fan A 樊阿.
Wu P'u of Kuang-ling and Fan Ah of P'eng-ch'eng both studied with Hua-t'o. Using Hua-t'o's methods of treatment, many people were completely cured by Wu P'u. "The human body needs exertion." Hua-t'o told Wu P'u, "but it shouldn't be pushed to the limit. Movement of the limbs facilitates the absorption of nutrients in food and enable the blood in the arteries to flow freely, preventing sickness from occurring. It's like a door-pivot that never decays from bugs or worms because of the constant opening and closing. That's why, when the ancient transcendent practiced duction, they strode like a bear and turned their head backward like an owl. They elongated their waist and limbs and moved all of their joints, seeking to stave off old age. I have a technique called 'the exercise of the five animals'. The first is the tiger, the second is the deer, the third is the bear, the fourth is the ape, the fifth is the bird. They may also be used to get rid of illness and are beneficial for the legs and feet because they are a type of duction. If there is discomfort somewhere in your body, get up and do one of my animal exercises until you're soaking with sweat, then sprinkle powder on yourself. Your body will feel relaxed and you'll have a good appetite." (tr. Mair 695-696)
Fan A was skilled at acupuncture and inserted the needles to extraordinary depths. Mair (1994:695) notes this unusual name may indicate Fan A was a foreigner, and this area was around modern Tongshan County, Jiangsu, "location of the first known Buddhist community in China".
Fan Ah requested from Hua-t'o the recipe for an orally ingested medicine that would be beneficial to one's health, and Hua-t'o instructed him how to make a powder of varish tree leaves and herbe de flacq. The proportions are fourteen ounces of shredded herbe de flacq for each pint of shredded varnish tree leaves. Hua-t'o said that if one takes a long course of this medicine, it will get rid of the three worms [types of parasites], benefit the five viscera, make the body feel nimble, and prevent you hair from turning white. (tr. Mair 1994:696)
These herbs are qiye (Wade–Giles: chi-yeh; 漆叶, "Toxicodendron vernicifluum leaves") and qingdian (Wade–Giles: ching-tien;青黏, "Sigesbeckia orientalis").
The Song Dynasty Confucianist scholar Ye Mengde (1077–1148) criticised the Sanguozhi and Houhanshu biographies of Hua Tuo as being mythological. Ye's "Physicians Cannot Raise the Dead" essay repeated the descriptions of Hua using anaesthesia to perform internal surgery, and reasoned,
There is absolutely no principle whereby to account for this. That which makes a human being a human being is his physical form, and that which enlivens the physical form is the vital breath. I have no way of knowing whether Hua-t'o's medicine could make a person intoxicated to the point of unconsciousness so that he could endure being cut open and could fully recuperate, causing the damaged portions to grow back together again. However, once the abdomen, back, intestines, or stomach have been cut open and dissected, how can they again be infused with vital breath? Being in such a condition, how could they be brought back to life again? If Hua-t'o could do this, then whoever was subjected to the punishment of dismemberment could be brought back to life again and there would no longer be any reason for carrying out royal punishments [involving physical mutilation]. (tr. Mair 1994:697)
In later times, a set of 34 paravertebral acupuncture points was named the "Hua Tuo Jiaji" (Wade–Giles: Hua To Chia-chi; 華佗夹脊) in his honour. Hua is considered a shenyi (Wade–Giles: shen-i; 神醫, "divine doctor") and is worshipped as a medicinal god or immortal in Daoist temples. "Hua Tuo zaishi" (Wade–Giles: Hua To Tsai-shih; 華佗再世, "Hua Tuo reincarnated") is a term of respect for a highly skilled doctor.
Fictional accounts
In Luo Guanzhong's historical novel Romance of the Three Kingdoms, Hua Tuo supposedly healed the general Guan Yu, who had been struck with a poisoned arrow during the Battle of Fancheng in 219. Hua Tuo offered to anaesthetise Guan Yu, but he simply laughed that he was not afraid of pain. Hua Tuo used a knife to cut the flesh from Guan Yu's arm and scrape the poison from the bone, and the sounds chilled all those who heard them. During this excruciating treatment, Guan Yu continued to play a game of weiqi with Ma Liang without flinching from pain. When later asked by Ma Liang, Guan Yu said that he feigned being unhurt to keep the morale of the army high. After Hua Tuo's successful operation, Guan Yu allegedly rewarded him with a sumptuous banquet, and offered a present of 100 ounces of gold, but he refused, saying that a doctor's duty was curing patients, not making profits. Despite the historical fact that Hua Tuo died in 208, a decade before Guan Yu fought the Battle of Fancheng, this storied operation is a popular artistic theme.
Hua Tuo was later called upon to cure a chronic excruciating pain in Cao Cao's head, which turned out to be a brain tumour. Hua Tuo told Cao Cao that in order to remove the tumour, it would be necessary to open up his skull. However, Cao Cao suspected the doctor intended murder, and ordered that Hua Tuo be jailed and executed. This was because Ji Ben, a former imperial physician, had participated in Dong Cheng's assassination plot on Cao Cao.
The novel Romance of the Three Kingdoms has it that Hua Tuo gave his Qing Nang Shu, which recorded techniques for treating patients, to a prison officer before his execution so that his medical profession would survive. The officer's wife burnt the book to avoid implication. Alarmed, the officer immediately seized the burning scrolls from her, but the only parts he obtained were those dealing with how to emasculate hen and ducks and the other medical methods of Hua Tuo were lost forever.
Mafeisan
Hua Tuo's innovative anaesthetic mafeisan "cannabis boiling powder" is a long-standing mystery.
The name mafeisan combines ma (麻 "cannabis; hemp; numbed"), fei (沸 "boiling; bubbling"), and san (散 "break up; scatter; medicine in powder form"). Ma can mean "cannabis; hemp" and "numbed; tingling" (e.g., mazui 麻醉 "anesthetic; narcotic"), which Li (1974:297) believes semantically "derived from the properties of the fruits and leaves, which were used as infusions for medicinal purposes".
Modern Standard Chinese mafei is reconstructed as Old Chinese *mrâipəts, Late Han Chinese maipus (during Hua's life), and Middle Chinese mapjwəi (Schuessler 2007:233, 373).
Many sinologists and scholars of Traditional Chinese Medicine have guessed at the anaesthetic components of mafei powder. Smith (1871:61) contends that Hua Tuo, "the Machaon of Chinese historical romance", used yabulu (押不蘆 "Mandragora officinarum") rather than huoma (火麻 "cannabis") and mantoulo (曼佗羅 "Datura stramonium", n.b., Hua's name Tuo) "infused in wine, and drunk as a stupefying medicine". Herbert Giles (1897:323) translates mafeisan as "hashish"; his son Lionel Giles (1948:72) identifies "hemp-bubble-powder" as "something akin to hashish or bhang". Veith (1966:3) quotes the sinologist Erich Hauer's "opinion that ma-fei (麻沸) means opium." Victor H. Mair (1994:689) notes that mafei "appears to be a transcription of some Indo-European word related to "morphine"." Although Friedrich Sertürner first isolated morphine from opium in 1804, Mair suggests, "It is conceivable that some such name as morphine was already in use before as a designation for the anaesthetic properties of this opium derivative or some other naturally occurring substance." Wang and Ping (1999:91) find consensus among "scientists of later generations" that mafei contained yangjinhua (洋金花 "Datura stramonium") and wutou (烏頭 "rhizome of Aconitum, Chinese monkshood") or caowu (草烏 "Aconitum kusnezofflin; Kusnezoff monkshood").
Lu and Needham (2002:118) suggest Hua Tuo may have discovered surgical analgesia by acupuncture, "quite apart from the stupefying potions for which he became so famous – if so he kept it to himself and his immediate disciples so that the secret did not survive".
