Hua Tuo

Lore & Background

Hua Tuo lived during the 2nd century AD, with his life spanning approximately AD 145 to 220. The exact composition of his anesthetic powder, mafeisan, was lost when he burned his manuscripts just before his death. Neither the Records of Three Kingdoms nor the Book of the Later Han mentions the specific ingredients. Because Confucian teachings regarded the body as sacred and surgery was considered a form of body mutilation, surgery was strongly discouraged in ancient China. Despite Hua Tuo's reported success with general anesthesia, the practice of surgery in ancient China ended with his death. The name mafeisan combines ma (meaning 'cannabis, hemp, numbed or tingling'), fei (meaning 'boiling or bubbling'), and san (meaning 'to break up or scatter', or 'medicine in powder form'), probably meaning something like 'boiled cannabis powder'. Many sinologists and scholars of traditional Chinese medicine have guessed at the composition, but the exact components remain unclear. His formula is believed to have contained some combination of bai zhi (Angelica dahurica), cao wu (Aconitum kusnezoffii), chuān xiōng (Ligusticum wallichii), dong quai (Angelica sinensis), wu tou (Aconitum carmichaelii), yang jin hua (Datura stramonium), ya pu lu (Mandragora officinarum), rhododendron flower, and jasmine root. Others have suggested hashish, bhang, shang-luh, or opium. Victor H. Mair wrote that mafei 'appears to be a transcription of some Indo-European word related to "morphine."' Some authors believe Hua Tuo may have discovered surgical analgesia by acupuncture, and that mafeisan either had nothing to do with or was simply an adjunct to his strategy for anesthesia. Many physicians have attempted to re-create the same formulation but none have achieved the same clinical efficacy. In any event, Hua Tuo's formula did not appear to be effective for major operations.

Reader's Guide

Hua Tuo's significance rests on the historical accounts in the Records of Three Kingdoms (ca. AD 270) and the Book of the Later Han (ca. AD 430), which describe him as a surgeon who used general anesthesia. His mafeisan formula, a mixture of wine and herbal extracts, allowed him to perform procedures such as resection of gangrenous intestines. However, the exact ingredients were never recorded in those texts and were lost when he burned his manuscripts before his death. The cultural context of Confucian teachings, which discouraged surgery as body mutilation, meant that surgical practice in ancient China ended with his death. The name mafeisan likely means 'boiled cannabis powder,' but scholars have proposed many possible ingredients without reaching consensus. Some believe his true anesthetic technique was acupuncture, with mafeisan as a minor adjunct. Modern attempts to recreate the formula have not matched the reported clinical efficacy, and the source notes that his formula did not appear effective for major operations. His legacy influenced later figures such as Hanaoka Seishū, who, beginning around 1785, sought to recreate a similar compound, eventually developing tsūsensan.

Did You Know?

• Hua Tuo reportedly performed surgery under general anesthesia using a formula he developed by mixing wine with a mixture of herbal extracts he called mafeisan.
• The exact composition of mafeisan was lost when Hua Tuo burned his manuscripts just before his death, and it was not mentioned in either the Records of Three Kingdoms or the Book of the Later Han.
• Because Confucian teachings regarded the body as sacred and surgery as body mutilation, the practice of surgery in ancient China ended with Hua Tuo's death.
• Victor H. Mair wrote that the word 'mafei' appears to be a transcription of some Indo-European word related to 'morphine.'
• Hua Tuo's formula did not appear to be effective for major operations, according to the source.

Surgical Pioneering and the Anesthetic Breakthrough

Hua Tuo, a Chinese surgeon of the 2nd century AD, is recorded in the Records of Three Kingdoms (ca. AD 270) and the Book of the Later Han (ca. AD 430) as having performed surgery under general anesthesia. He developed a formula by mixing wine with a mixture of herbal extracts he called mafeisan (麻沸散). Before surgery, he administered an oral anesthetic potion, probably dissolved in wine, to induce a state of unconsciousness and partial neuromuscular blockade. He reportedly used mafeisan to perform even major operations such as resection of gangrenous intestines. However, the source notes that his formula did not appear to be effective for major operations, suggesting practical limits to its efficacy.

The Unsolved Puzzle of Mafeisan

The name mafeisan combines ma (meaning 'cannabis, hemp, numbed or tingling'), fei (meaning 'boiling or bubbling'), and san (meaning 'to break up or scatter', or 'medicine in powder form'), probably meaning something like 'boiled cannabis powder'. The exact composition of mafeisan, similar to all of Hua Tuo's clinical knowledge, was lost when he burned his manuscripts just before his death. The composition was not mentioned in either the Records of Three Kingdoms or the Book of the Later Han. Many sinologists and scholars of traditional Chinese medicine have guessed at the composition, but the exact components still remain unclear. His formula is believed to have contained some combination of: bai zhi (Angelica dahurica), cao wu (Aconitum kusnezoffii), chuān xiōng (Ligusticum wallichii), dong quai (Angelica sinensis), wu tou (Aconitum carmichaelii), yang jin hua (Datura stramonium), ya pu lu (Mandragora officinarum), rhododendron flower, and jasmine root. Others have suggested the potion may have also contained hashish, bhang, shang-luh, or opium. Victor H. Mair wrote that mafei 'appears to be a transcription of some Indo-European word related to "morphine."' Some authors believe that Hua Tuo may have discovered surgical analgesia by acupuncture, and that mafeisan either had nothing to do with or was simply an adjunct to his strategy for anesthesia. Many physicians have attempted to re-create the same formulation based on historical records but none have achieved the same clinical efficacy as Hua Tuo's.

A Culture That Turned Its Back on the Knife

Because Confucian teachings regarded the body as sacred and surgery was considered a form of body mutilation, surgery was strongly discouraged in ancient China. Because of this, despite Hua Tuo's reported success with general anesthesia, the practice of surgery in ancient China ended with his death. His clinical knowledge—every formula and procedural detail—was lost when he burned his manuscripts just before his death. What survives are only the secondhand accounts preserved in the Records of Three Kingdoms (ca. AD 270) and the Book of the Later Han (ca. AD 430), both of which postdate his life by a century or more and offer no ingredient lists or step-by-step methods.

Echoes Across Centuries: The Hanaoka Connection

Hua Tuo's legacy reached beyond China to Japan. The surgeon Hanaoka Seishū (1760–1835) was intrigued when he learned about Hua Tuo's mafeisan potion. Beginning in about 1785, Hanaoka embarked on a quest to re-create a compound with similar pharmacologic properties. His wife, who participated in his experiments as a volunteer, lost her sight due to adverse side effects. After years of research and experimentation, he developed a formula he named tsūsensan (also known as mafutsu-san), composed of extracts including yang jin hua (Datura stramonium), bai zhi (Angelica dahurica), cao wu (Aconitum sp.), chuān ban xia (Pinellia ternata), chuān xiōng (Ligusticum wallichii), dong quai (Angelica sinensis), and tian nan xing (Arisaema rhizomatum). The active ingredients were scopolamine, hyoscyamine, atropine, aconitine and angelicotoxin. When consumed in sufficient quantity, tsūsensan produced a state of general anesthesia and skeletal muscle paralysis. On 13 October 1804, Hanaoka performed a partial mastectomy for breast cancer on Kan Aiya using tsūsensan as a general anesthetic, regarded today as the first reliable documentation of an operation performed under general anesthesia.