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Reference as: May, B., Tomoda, T. and Wang, M. (2000). The life and medical practice of Hua Tuo.

Pacific Journal of Oriental Medicine, 14: 40-54.

The Life and Medical Practice of Hua Tuo

Brian May, Takako Tomoda and Michael Wang

Both Hua Tuo 華佗 and Zhang Zhong-Jing lived at the end of the Later or Eastern Han Dynasty (25 - 220

AD). While the life of Zhang remains obscure we have received his writings in the form of the Shang Han

Lun. In the case of Hua Tuo, we have numerous stories of his life but his writings appear to have all been

lost. Despite the paucity of information on Zhang few dispute his historical existence, however some

scholars view Hua Tuo as a mythical figure based on legends imported from India concerning the ancient

Indian doctor Jivaka (see Unschuld 1985 p 151). Certainly Hua Tuo is surrounded by a mass of stories

some of which appear to be of an apocryphal or allegorical nature. However, other stories concerning his

life and medical exploits do not appear to be of this type. The purpose of this article is to examine the

stories that surround Hua Tuo and to evaluate them in terms of what they tell us about Hua Tuo and about

ancient medicine in China.

The Historical Period

The story of Hua Tuo is closely linked to the events that surrounded the fall of the Han Dynasty.

Consequently, prior to examining Hua Tuo's story a brief summary of these events is warranted. From

about 100 AD the central authority of the Han Dynasty was in decline. The roles of advising the emperor

and of administering the state that had been the preserve of scholars educated in the Confucian tradition

were undermined as emperors withdrew into the confines of the palace in Luo-yang where they relied

upon the advice of the eunuchs who served in the imperial household. Since scholars were excluded from

the palace, their political power declined allowing ambitious eunuchs to stage coups and placed the

administration in their hands. Such takeovers were regarded as illegitimate and were resisted with

counter-coups some of which ended in considerable slaughter. Problems in succession brought the

opportunity for palace cliques to install child emperors and rule in their stead. The increasing control by

the resident eunuchs and the influence of the families of the emperor's favourite wives alienated many

scholars to the extent that it even became fashionable to refuse public office and remain in one's home

region to engage in literary and other private pursuits or even foment dissent. With corruption so evident

at the centre, regional loyalties grew and local officials, generals and landed gentry consolidated their

power bases. From the 160s scholar factions openly criticized the corruption at court and this sparked a

series of repressions that only exacerbated dissent.

Official corruption had resulted in the gradual erosion of the dynasty's tax base as fewer peasants were

enrolled on the registers and influential landowners obtained tax exempt status. This meant that social

conditions in the countryside deteriorated, particularly in northern China where the bulk of the tax

revenue and corvee labour duties were extracted. These factors provided the right conditions for

grass-roots protest as well. From about 170 AD a Daoist religious movement grew in north eastern China

which came to be known as the 'Yellow Headbands' (Huang Jin Zei 黄巾賊). It was started by Zhang Jue 張角 and his brothers and taught that, according to a scripture received by Zhang Jue, a new millennium

was nigh and following a period of upheaval a new age of great peace (Tai Ping 太平) would be

established. In 184 a rebellion erupted which threatened to overthrow the dynasty. Despite their

differences, the elites rallied around the dynasty to suppress the revolt. Since the court was so weak the

effect of this move was to legitimize regional military leaders as the protectors of the Han. Following the

suppression of the main Yellow Headband armies and the killing of their leaders, the country entered a

period of civil war. The last Han emperor Xian Di became the pawn of military strong-men all claiming to

be restoring the power of the Han whilst eliminating rival supporters of the Han. Out of this turmoil a

three way division of power emerged with Cao Cao emerging victorious in the northern heartland as the

ruler of the state of Wei 魏. In the regions below the Yangtze river Sun Quan 孫權 held sway over the

2

state of Wu 呉 while a distant relative of the Han house Liu Bei 劉備 controlled the region of Shu 蜀

(modern Sichuan) in the west.

Following Cao Cao's death in 220 AD, his son Cao Pei no longer found it necessary to continue the

pretence of supporting the Han and had Xian Di abdicate in his favour. The rulers of the other regions

soon followed suit and the subsequent period of formal division is known as the Three Kingdoms (San

Guo 三國). Its dates are generally given as 220 to 265 AD even though real power had been seized well

before 220. Warfare continued between the kingdoms with Wei taking Shu in 263. Wei itself, succumbed

to an internal takeover by the Si Ma clan who ousted the Cao clan and established the Jin dynasty in 265.

In 280 the southern kingdom of Wu was also overrun thereby unifying China again, if only for a brief

period (Fairbank & Reichauer 1989, Twitchett & Fairbank 1986).

Sources of information on Hua Tuo

Most of the information we have on Hua Tuo derives from written sources that have been passed down

through the hands of many copyists. Such received sources can suffer from problems such as copyist's

errors, interpolations, the inadvertent conflation of history and fiction and deliberate forgery.

Consequently, the reliability and antiquity of these sources needs to be considered when trying to separate

history from legend and fiction. The oldest biography of Hua Tuo is found in the Wei Zhi 魏志 section of

the San Guo Zhi 三國志 (History of the Three Kingdoms) written at the end of the 3rd century by Chen

Shou 陳壽 (233-297). Chen was a minor courtier from the kingdom of Shu who then obtained a post

under the conquering Jin Dynasty that reunified China in 280. His work was extensively edited by the

scholar Pei Song-Zhi 裴松之 (372-451) in the early 5th century and it was not until the completion of this

commentary in 429 that it achieved recognition as an official history. Another biography of Hua Tuo is

found in the Hou Han Shu 後漢書 (History of the Later Han Dynasty) compiled by Fan Ye 范曄

(398-445 AD) in the mid 5th century (De Woskin 1983, Gardiner 1973). Both the San Guo Zhi and Hou

Han Shu biographies contain extracts from a lost work of unknown authorship called the 'Separate

Biography of Hua Tuo' (Hua Tuo Bie Zhuan 華佗別傳). De Woskin (1983) states that the Hou Han Shu

biography is shorter and considerably different to that in the San Guo Zhi. However, the Hou Han Shu

version appears to be an abridged version of the San Guo Zhi biography that contains essentially the same

information. Most sections use identical language to the San Guo Zhi but this biography is much shorter

and, since the order of the sections is different, it gives the impression of having different content. It

contains fewer cases overall and fewer extracts from the Hua Tuo Bie Zhuan but the cases that it does

contain are the same as in the San Guo Zhi. Wong and Wu (1936) source much of their information to the

Wei Zhi (Annals of the Wei Dynasty) but we have not been able to locate this information in the Wei Zhi

section of the San Guo Zhi, so we suspect that they are actually referring to the Wei Shu 魏書. This book

was compiled by the court official Wei Shou and a team of historians during the Northern Qi Dynasty and

was presented to the throne in 554 AD but the controversy that it generated led to a number of revisions

(Gardiner 1973). Unfortunately, we have not been able to locate any references to Hua Tuo in the Wei Shu

but it is a long work and the passages that Wong and Wu quote may well be contained therein.

A number of early medical writers make mention of Hua Tuo. A brief reference to Hua Tuo is found in the

preface to the Zhen Jiu Jia Yi Jing (Yang & Chace 1993). This book was written by Huang Fu-Mi in the

years up to 282 but since no ancient editions still exist, the actual date of the preface is difficult to

determine. The Mai Jing which was written about 280 by Wang Shu-He 王叔和 also contains brief

references to Hua Tuo in both the preface and the body of the text (Yang 1997). Ge Hong in his Bao Pu Zi,

written around 230 AD, makes a few references to Hua Tuo (Ware 1966). Tao Hong-Jing (456-536) makes

mention of Hua Tuo in his preface to the Shen Nong Ben Cao Jing Ji Zhu where he says that he thought

the remaining four chapters of the Ben Cao Jing had been written by either Zhang Zhong Jing or Yuan

Hua 元化 (i.e. Hua Tuo) (Unschuld 1986). The Chao Shi Zhu Bing Yuan Hou Lun 巣氏諸病源候論

(Chao's Pathology) was written by Chao Yuan-Fang 巣元方 about 610 AD and contains a number of

references to Yuan Hua.

Probably the best known source for Hua Tuo's story is the historical novel San Guo Yan Yi 三國演義

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'Romance of the Three Kingdoms' (hereafter referred to as the Romance) which is attributed to Luo

Guan-zhong. Little is known about Luo but he appears to have been a poet and recluse who lived during

the last years of the Yuan dynasty. He was probably born between 1315 and 1318 and was still alive in

1364. One source suggests that he was involved in anti-Yuan rebellions in south China but retired to write

an unofficial history (Roberts 1995). Although Luo is given as the author, he could not have written the

version of the Romance that we have today. The earliest extant version of the Romance is prefaced 1494

and the earliest edition is dated 1522. However, modern versions are based on the Mao edition that

appeared in the mid 1660s (Roberts 1995). Consequently, the Romance must be considered a product of

the Ming Dynasty that is based on earlier historical and popular works that may include one by Luo. Even

though the Romance is the least reliable source for the Hua Tuo story, the popularity of this novel makes it

the most influential.

The Life of Hua Tuo

Both the San Guo Zhi and Hou Han Shu concur in saying that Hua Tuo was also called Hua Fu, and his

style name (zi 字) was Yuan Hua 元化. He was a native of Qiao in the state of Pei 沛 (SGZ 1975, HHS

1973). This places him in Bo-xian County in An-hui province to the north and west of modern Nanjing

(Zhen 1995, Zhen 1994). The dates of his birth and death are not known for sure. Huang-Fu Mi simply

says that he lived during the Han dynasty (Yang & Chace 1993). Neither the San Guo Zhi nor Hou Han

Shu specify any dates but the San Guo Zhi includes a quote from the Separate Biography of Hua Tuo

which says that Liu Jing-Zong 劉景宗 the grand protector of Shan-yang reported seeing Hua Tuo several

times during the Zhong Ping 中平 era (184-189). According to Zhen (1994), another section of the San

Guo Zhi places the death of Cao Cao's son in the 13th year of Jian An 建安. Since Hua Tuo was killed

earlier, this indicates that Hua Tuo died prior to 208 AD (Zhen 1994, De Woskin 1983). However, the

Romance has him die in the same year as Cao Cao (220 AD). While the various sources do not agree on

the exact date of his death, they all agree that he was killed by Cao Cao sometime in during the first two

decades of the third century. Both the San Guo Zhi and Hou Han Shu say that people in his time thought

he was approaching 100 years of age (SGZ 1975, HHS 1975). The Hou Han Shu adds that following his

death he became an immortal (xian) (HHS 1975). However, the preface to the Zhong Zang Jing says Tuo

was killed by the Wei ruler before he was 60 years old (Yang 1993). Based on information in the Wei Zhi,

Hsu and Peacher (1977) and Chuang (1982) say he was killed in the 12th year of Jian An when he was 97

years old thereby establishing his dates as 110-207 AD.

If we accept the indirect evidence from the San Guo Zhi and Hou Han Shu we can conclude that Tuo was

killed in or before 207. Even though the histories say that people thought he was approaching 100 years of

age, there is nothing in the details of his life to suggest he was an old man. He seems to have been young

enough for Cao Cao to want to take him on as a physician and young enough to have a wife and family to

return to. Even though the Zhong Zang Jing story has an apocryphal character, its conservative estimate of

his age way well be true. If so, he was born in the 140s around the same time as Zhang Zhong-Jing. His

tomb is in Xu Zhou 徐州 and is marked by a bronze statue (Hsu & Peacher 1977).

Of his parents we know nothing but it is said that when he was young he was interested in books and read

on many subjects. Many of his townspeople were dying of war, famine and epidemics and this stimulated

him to study medicine. According to the San Guo Zhi, he went to Xu Tu 徐土, the capital of the state of

Pei 沛 (now Xu Zhou 徐州 in Jiangsu province), where he studied the classics. He seems to have

obtained a degree and was offered an official post by the Minister of Pei state Chen Gui 陳珪 and was

also offered a post by the defence minister Huang Wan. However, he appears to have refused official

positions to study medicine (De Woskin 1983, SGZ 1975, HHS 1973).

How he learned his medical skills is not recorded but the Wei Annals and the preface to the Zhong Zang

Jing 中臓經 contain the following story. When Hua Tuo was young he was fond of travel and roamed in

the mountains. One day he was resting in front of a cave when he heard voices within discussing medicine

so he moved closer to hear. One of them said. 'Hua is here, we can give him our secret' but the other

replied, 'That lad is greedy and cruel, how can we give it to him?' Excited, Hua Tuo rushed into the cave

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and found two old men dressed in bark with grass headgear. Tuo said that he had overheard them

discussing medicine and was unable to restrain himself since he was very interested in such life-saving

work. Unfortunately, he had not yet acquired any effective methods and would be forever grateful if they

could enlighten him. One of the old men said that they hesitated to share their secrets with him not

because they were stingy but because these secrets may give Tuo trouble in the future. The old man told

Tuo that if he did not discriminate between high and low, rich and poor, noble and common; refused

bribery; was not afraid of hardships; and was kind to the old as well as to the young, he would get out of

the calamity eventually. Tuo bowed and said that he would faithfully remember these words. The old men

smiled, pointed to the east cave and told him he would find a book on a stone couch. He was to take it and

not show it to anyone. Tuo went to get the manuscript and when he turned around the old men were gone.

Feeling frightened he quickly left the cave and once outside a sudden rain storm hit and the cave collapsed.

He read through the book and in it found many strange ideas which when put into practice proved

marvellously effective (Wong & Wu 1936, Yang 1993).

In this story the old men are clearly the kind of immortals that impart knowledge to true seekers in many

Daoist inspired stories. The Romance opens with a very similar story of how the leader of the Daoist

inspired Yellow Headband rebel movement, Zhang Jue 張角, received the revelatory scripture the Tai

Ping Jing 太平經 (Great Peace Classic) (Roberts 1995).

It is said that Hua Tuo travelled and practiced medicine in the provinces of Jiangsu, Shandong, Henan and

Anhui (Zhen 1995). He became famous in his time and the reports of his cases indicate that he treated

many officials as well as common people. In the end it was his fame that proved his undoing. The Prime

Minister under the last Han emperor Xian Di (190-220) and military leader of northern China, Cao Cao,

heard about Tuo. According to both the San Guo Zhi and Hou Han Shu, Cao summoned Hua Tuo and Tuo

was always at his side. Cao suffered from bad headaches (tou feng 頭風), each time he had one he also

had mental disturbance (xin luan 心亂) and eye dizziness (mu xuan 目眩). Hua Tuo treated him with

acupuncture at a place called li 膈 and his condition improved. De Woskin (1983) says the acupuncture

was done at the diaphragm but Lu & Needham (1980) make a convincing argument that the character

used refers to the sole of the foot, thereby making it Kidney 1.

In a later section the San Guo Zhi continues this story. It says that Tuo had originally been a scholar. He

had taken up medicine but often regretted having done so. Later, Cao Cao took a particular interest in Tuo

and being severely ill he had Tuo take care of him. Tuo said, 'Your disease cannot be fixed in the short

term. It requires attacking treatment (gong zhi 攻治) over some months'. It seems that Cao wished to

retain Tuo as his physician but Tuo does not appear to have been keen on this idea. The story continues as

follows. Tuo was far from home and wanted to return. He requested permission to return for a short time

to collect some books saying that he would come back soon. However, after he was home he did not

return but extended his time away saying that his wife was sick. He was sent orders to return and offered

an official post but he did not reply. Cao became angry and sent officials to investigate. They were told to

check whether his wife was really sick and if so, to give Tuo an extension of leave and 200 sheng of beans

(xiao dou 小豆). However, if she were not sick they were to arrest Tuo. Since Tuo had only been making

excuses, his crime was uncovered and he was arrested, brought back to the capital and thrown in gaol

under Warden Xu where he was tortured and forced to confess. The military official Xun Yu tried to

dissuade Cao by saying 'Tuo is an honest technician. People's lives depend on him. It would be

appropriate to be lenient'. However, Cao Cao would not relent and said, 'Don't worry about him. Wouldn't

the world be better off without rats like Tuo?'

Tuo was tortured to death in prison and before he died he offered a work on medicine in one scroll (juan 巻) to the gaoler saying, 'This can save lives'. However, the gaoler was too frightened of the law to accept

the book. Tuo did not insist. He found a fire and burned it. After Tuo's death Cao Cao's headaches returned.

Cao said, 'Tuo could have cured me. That inferior person (xiao ren 小人) treated my illness but he was

only interested in himself. Even if I hadn't killed him he would never have gotten rid of the cause of my

illness'. Later, Cao's beloved son Cang Shu 倉舒 got sick and died. Cao sighed, 'I regret killing Hua Tuo,

it has resulted in the death of my son'. The Hou Han Shu contains an abbreviated form of the same story

5

(De Woskin 1983, Zhen 1995, Yang & Chace 1993, Wong & Wu 1936, SGZ 1975, HHS 1973).

The Romance of the Three Kingdoms contains a different version of this story as follows. Cao Cao was

being disturbed by mental images of the recently murdered Lord Guan (Guan Yu 關羽) and wished to

build a new palace which he hoped would not be haunted by ghosts of the past. To provide timber for

building Cao ordered his workmen to cut down a huge pear tree. Local elders opposed the cutting of the

tree saying that it was hundreds of years old and contained a spirit. Cao Cao declared that no one dared

oppose him and that included spirits. He struck the tree with his sword and blood gushed out splashing

over Cao. This shocked Cao and he rode back to his palace in distress and that night had a bad dream. In

the dream the spirit of the pear tree dressed in a black robe appeared and threatened to kill him. The spirit

swung a sword at him and he awoke with a severe headache. Doctors were called but they could not bring

him any relief.

The official Hua Xin suggested that Hua Tuo be called and told Cao about Tuo's cases including his

treatment of Guan Yu. Since Tuo was at Jin-cheng not far from Luo-yang he was soon summoned to treat

Cao. Tuo examined Cao and informed him that his headaches were due to air and fluid building up inside

his skull. He said that medicine would be of no use and that he needed to give Cao an anaesthetic, open

his skull and remove the accumulation. Cao Cao did not believe that such an operation could be

performed and suspected Tuo of being a friend of Lord Guan out to kill him. He had Tuo imprisoned and

despite Jia Xiu's protests ordered that he be killed. One of the gaolers, called Wu, brought Hua Tuo wine

and food. Realising he was going to die, Tuo said that his main regret was that his 'Book of the Black Bag'

would be lost to posterity. In return for his kindness he offered to give Wu this book. He sent a letter to his

wife requesting the book be given to Wu. Wu took the letter to Jin-cheng, got the book and brought it back

to Tuo. After reading it Tuo gave the book to Wu who was very pleased that he would be able to give up

his job as a gaoler to cure the sick and pass on Tuo's methods. Wu took the book home. Ten days later Tuo

died and Wu provided the coffin and had his body prepared for burial. Wu then resigned his office and

went home to study the book. On arriving home he was horrified to find his wife burning the book. He

tried to recover it but could only retrieve a couple of pages from the flames. He was very angry with his

wife over the book. She said that even if he could become as great a doctor as Hua Tuo, he would only

end up dead in gaol like Tuo. So what was the use of having the book? The Romance then bemoans the

loss of Tuo's book and says that the only writings that survived were on castrating eunuchs and pigs.

Following Tuo's death Cao Cao's condition worsened, he had bad dreams and began to have visions of

people he had murdered. According to this account both Cao and Tuo died in the 25th year of Jian An

(220 AD)(Roberts 1995).

Cao's reaction to Tuo's proposed treatment may seem excessive. However, an earlier event related in the

Romance gave Cao good reason to be suspicious of medicos. According to the Romance, in the 5th year

of Jian An (200 AD) Cao was ill with headaches. Also, a relative of the empress called Dong Cheng was

sick and the emperor sent a famous court physician called Ji Ping to treat him. Dong Cheng was

conspiring with other disaffected nobles and scholars to get rid of Cao before he completely usurped the

power of the Han. One night Ji Ping was attending Dong Cheng and overheard him talking in his sleep

about killing Cao. He offered to join the conspiracy and said he would poison Cao when he went to treat

him. To show his devotion to the cause, Ji Ping bit of the tip of his finger. Unfortunately for the

conspirators, a servant overheard them and informed Cao. So Cao pretended to have a headache and

called Ji Ping. Ping prepared the poison but Cao insisted that Ping try the medicine first. Realising that he

had been discovered, Ping tried to force the medicine down Cao's throat but it spilled on the floor. Cao

had Ping seized and tortured. Although Ji Ping did not confess before he died, Cao had sufficient evidence

from the servant to identify the conspirators and have them and their entire families executed (Roberts

1995).

Hua Tuo's medicine

According to the San Guo Zhi and Hou Han Shu, he knew the techniques of nourishing the nature (養性

yang xing) and the people of that time generally believed him to be almost 100 years of age even though

6

he had a youthful appearance. The Hou Han Shu also says that people thought he was an immortal (仙

xian) (De Woskin 1983, HHS 1973, SGZ 1975). They then go on to outline his use of medicine,

acupuncture, moxa and surgery (see later sections). Besides these general descriptions, there are many

stories about the medical exploits of Hua Tuo deriving from various sources. In order to examine the

medical techniques of Hua Tuo these stories have been numbered and grouped under the categories of

surgery; diagnosis and prognosis; medicine, acupuncture and moxa; other therapeutic methods; worm

diseases; and strange cases.

Surgery

Both the San Guo Zhi and Hou Han Shu contain a description of Hua Tuo's use of anaesthesia and surgery.

They say that when there was an accumulation inside (jie ji zai nei 結積在内) that neither needles nor

medicine could reach, Tuo would cut the body open. First he made the patient drink a medicine called Ma

Fei San 麻沸散 and they would become instantly comatose and insensible as if dead. Then he cut into

either the patient's abdomen or back. If the disease was in the abdomen (chang zhong 腸中 in SGZ,

chang wei 腸胃 in HHS) he could cut the intestines, wash them and remove sections of the affected parts,

sew the abdomen back up and apply a salve/plaster (gao ma 膏摩 in SGZ, shen gao 神膏 in HHS). In

four or five days the sickness would get better and the pain would disappear without the patient ever

awakening. If the patient stayed in bed for a month he would recover his health (De Woskin 1983, Chuang

1982, Zhen 1995, Wong & Wu 1936, Zhen 1994, SGZ 1975, HHS 1973). The following cases are also

cited regarding Tuo's surgical prowess.

Case 1. Both the San Guo Zhi and the Hou Han Shu cite the same story from the Separate Biography of

Hua Tuo as follows. A man had severe cutting pain on one side of his abdomen. Over 10 days his beard

and eyebrows fell out. Tuo said, 'Your spleen is half rotten (pi ban fu 脾半腐) but I can cure your

condition.' He gave the man some medicine to make him sleep and cut into the abdomen. The spleen was

indeed half rotten and Tuo removed the bad flesh (e rou 悪肉). He put salve on the wound, gave him

some medicine and in 100 days the man had recovered (Wong & Wu 1936, De Woskin 1983, Zhen 1994,

SGZ 1975, HHS 1973).

Case 2. The Romance of the Three Kingdoms provides the best known story. Lord Guan (Guan Yu), the

general from the state of Shu 蜀, was hit in the right arm by an arrow while leading an assault on the city

of Fan. The wound would not heal and had ulcerated to the bone. His arm had become greenish, stiff and

swollen and Lord Guan's officers were worried. They were looking everywhere for a good doctor when

Hua Tuo arrived unexpectedly by boat from Wu. He was wearing a square hat, loose fitting clothes and

carried a black bag. When they heard Hua Tuo's name the officers were pleased since they knew his

reputation. Lord Guan was playing chess with the general Ma Liang to distract himself from the pain and

from the poor military position. Hua Tuo examined the wound and said that the arrow had been poisoned

with aconite and the poison was entering the bone. He said that if it were not treated soon the arm would

become useless. Tuo was concerned that Lord Guan would not be able stand the treatment but he said he

needed a post with a loop nailed to the top. He would put the arm through the loop, tie it and put a blanket

over Lord Guan's head while he cut open the wound. Lord Guan said he was not afraid of pain and needed

no such preparation. He ordered food and wine and continued playing chess while Tuo cut down to the

bone and scraped away the greenish part. The dish that was held under the wound filled with blood as Tuo

cut and those watching went pale when they heard the sound of the knife scraping the bone. Lord Guan

continued eating and drinking showing no signs of pain. Tuo applied medicine to the wound and sewed it

up. Tuo was amazed at Lord Guan's tolerance for pain and soon afterward Lord Guan's arm was able to

move again. Tuo warned that the wound was better but it had to be protected from the shock of anger and

it would be 100 days before it was normal. Lord Guan held a banquet to thank Tuo and offered him 100

taels of gold. Hua refused the money saying that he had come because of Lord Guan's good reputation and

sense of honour. After providing a prescription for medicine to put on the wound Tuo left. Lord Guan

continued his military campaigns and was able to use his arm but it was still weak. Sometime later he was

defeated due to a betrayal and became furious causing the wound to split open. He recovered again but his

military situation continued to deteriorate. Further betrayals soon led to he and his son being surrounded

7

and killed, in 220AD at the age of 58, by forces from the southern kingdom of Wu (Roberts 1995).

The story of Lord Guan has long been a popular and he has become the god Guan Di pacifier of demons.

His statue can often be seen in shrines where he is depicted with a fierce red face and long black beard

dressed in military garb holding a long halberd (Maspero 1981). The incident with Hua Tuo has been a

popular topic for artistic depictions and a good example can be found in Huard and Wong (1968) on page

17.

Case 3. Both the San Guo Zhi and Hou Han Shu record that a grand minister (shi da fu 士大夫) was

feeling bad. Tuo said, 'Your disease is deep, I can open your abdomen and take out (the cause of the pain).

However, your natural lifespan is not more than ten years. The disease will not kill you whether have the

operation or not, so there is no need for the operation'. However, the official could not stand the pain and

requested Tuo to operate. After the operation the pain was gone but he died ten years later as Tuo had

predicted (De Woskin 1983, SGZ 1975, HHS 1973).

Tuo has long been famous as the 'Father of Surgery' in China but doubts have been raised about the use of

surgery in ancient China and it has been suggested that the Hua Tuo story was the result of cultural

diffusion from India where surgery had an established tradition (Unschuld 1985).

There are actually three questions to be resolved regarding Hua Tuo and surgery: 1. Was Hua Tuo the first

surgeon in China?; 2. Was surgery practiced in ancient China?; and 3. Are accounts of surgery in ancient

China a result of Indian influence? Regarding the first question, in his biography of Bian Que and Cang

Gong, the historian Si Ma Qian says that an ancient doctor called Yu Fu 兪附 did not use decoctions to

treat disease but cut open the skin, dissected the muscles, severed the blood vessels, tied the tendons,

washed the stomach and cleansed the intestines (Wong & Wu 1936, Lu & Needham 1980). Since Si Ma

Qian completed his Shi Ji (Historical Records) by 90 BC, and he places the story of Yu Fu in the mouth of

Bian Que during the Warring States Period, the concept of surgery in the treatment of disease must have

been present in China in the Former Han. Therefore, even by Chinese accounts Hua Tuo was not the first

surgeon in China but the heir to a tradition that was at least 500 years old by his time. It is very unlikely

that the Yu Fu surgical account is the result of diffusion from India since the first mention of Buddhism

dates to 65 AD (Twitchett & Fairbank 1986). Even though contact with India must have preceded

Buddhism there seems to be no evidence of such contact during the Former Han (202 BC - 9 AD), so such

contact is unlikely to have preceded Buddhism by long period. Since Si Ma Qian is known for his

thorough research it is unlikely that he would not have been able to distinguish a recently imported story

from an ancient one. Therefore, we can only conclude that the Yu Fu story is not of Indian origin.

Regarding the second question, the similarity in the Yu Fu and Hua Tuo accounts of surgery suggests the

possibility of conflation. Neither Wang Shu-He nor Huang Fu-Mi mention Hua Tuo's surgery and only

two surgical cases are mentioned in the San Guo Zhi and Hou Han Shu. However, Wang Shu-He and

Huang Fu-Mi provide few details of any kind and another Jin Dynasty writer Ge Hong in the Bao Pu Zi

says that Chun Yu Yi could open the skull and rearrange the brain and that Hua Tuo could open the

abdomen and drain the stomach (Ware 1966). Therefore the idea that Hua Tuo did abdominal surgery was

extant by around 320 AD, only 100 or so years after his death.

Considering the number of early references to a doctor called Hua Tuo there seems to be no reason to

doubt his existence. This leaves the question of the surgical cases. There has long been scepticism about

whether such surgery was possible. The doctor Xu Chun Fu wrote in the Gu Jin Yi Tong Da Quan

'Complete book of ancient and modern medicine' in 1556 that it was impossible for Hua Tuo to have

opened the abdomen and for the person to have survived (Unschuld 1988). However, the details provided

in the cases certainly suggest first-hand experience. So even if the surgical cases are the result of the Yu

Fu story being retold, this does not discount the use of surgery in ancient China. Also, other accounts are

extant. Around 255 AD there is a report in the Annals of the State of Wei (Wei Zhi or perhaps the Wei Shu)

of a caesarean on the wife of a Tartar prince. She was 12 months pregnant and the baby was delivered

through her right side. The baby survived, the mother did not suffer much pain and the wound healed.

8

According to the History of the Jin Dynasty (Jin Shu 晉書), Wei Yang-chi had a hare lip and went to a

surgeon who was a pupil of Yin Chung-K'an. He was given the operation and after 100 days of liquid diet

and abstinence from laughter he was cured (Wong & Wu 1936). Therefore, the evidence does not support

the frequent claim that with the loss of Hua Tuo's book surgery came to an end in China.

Taken in totality, the evidence suggests that abdominal and possibly cranial surgery was practiced in

China from the end of the Warring States period and continued to be practiced beyond Hua Tuo's time.

Such surgical techniques were probably the preserve of a narrow, and perhaps secretive, tradition which

was not incorporated into the mainstream of court medicine and this accounts for the scanty references. It

is probable that Indian surgical techniques had an influence with the advent of Buddhism but the use of

more risky surgical procedures seems to have declined rather than proliferated as Buddhism spread. Why

this should be so is difficult to determine. It is possible that the wars and disordered social conditions that

prevailed in the long period following Wang Mang's attempted overthrow of the Han in 9 AD till the Sui

reunification in 618 AD were not conducive to the preservation of medical techniques that could not be

learned from books and required direct training over a long period. In such circumstances the death of a

master practitioner could well mean the end of a line of transmission. It is notable that neither of Tuo's

well-known students is recorded as having practiced surgery. The rise of scholarly medicine and hence the

status of doctors may also have worked against the preservation of messy manual skills such as surgery.

The nature of Hua Tuo's anaesthetic formula Ma Fei San has long been a subject of interest. Huard and

Wong (1968) appear to take the character ma 麻 at face value when they assert it to be based on Indian

hemp. However, it seems unlikely that hemp alone would have the strong effects ascribed to this medicine.

More likely contenders as ingredients in ancient Chinese anaesthetics are aconite and, following contact

with India, white datura (Man Tuo Lo Hua 曼陀羅花). The use of such preparations appears to have a

long history in Chinese bone setting and military medicine. Although there is not a great deal of surviving

literature on these rather lowly forms of medicine, the Shi Yi De Xiao Fang 世医得效方 by Wei Yi-Lin 危亦林 (1277-1347) contains detailed instructions on the preparation of anaesthetics (ma yao 麻薬) in the

context of the surgical treatment of compound fractures and the removal of arrows from the bone. Wei

gives the formula for Cao Wu San 草烏散 as follows: Zhu Ya Zao Jiao 猪牙皀角, Mu Bie Zi 木鼈子, Zi

Jin Pi 紫金皮, Bai Zhi 白芷, Ban Xia 半夏, Wu Yao 鳥薬, Chuan Xiong 川芎, Du Dang Gui 杜当帰, and

Chuan Wu 川鳥 each 5 liang 両, Bo Shang Hui Xiang 舶上茴香, Zuo Na 坐拏 and Shu Cao Wu 熟艸鳥

each 1 liang, and Mu Xiang 木香 3 qian 銭. Later, the Japanese surgeon Hanaoka Seishu 華岡青洲

(1760-1835) researched old Chinese texts and used a similar anaesthetic formula to perform the first

modern style operation under general anaesthesia in 1805 (Miyasita 1973).

Diagnosis and Prognosis

As in case 3 above, many of Hua Tuo's cases stress his extraordinary diagnostic and prognostic abilities.

These powers are reminiscent of those attributed to Bian Que and like Bian Que, Tuo is known for his

skill in pulse diagnosis. In fact, Wang Shu-He in his discussion on Bian Que's approach to pulse diagnosis

states that Hua Tuo emulated his methods (Yang 1997).

Case 4. In the preface to the Zhen Jiu Jia Yi Jing, Huang-fu Mi says that Huo Tuo worked wonders in

curing countless difficult cases and that no one has been able to give a comprehensive account of his

achievements. Once Hua Tuo was asked to treat a royal wine taster named Liu Ji-Yan who was suffering

from apprehension and malice and whom he treated and cured. He predicted, 'In 9 years Ji-Yan will suffer

a relapse and the root of this will be apprehension and malice. If this illness comes to pass he will die.' In

the end it was as Hua Tuo said (Yang & Chace 1993).

Case 5. According to the San Guo Zhi, a military official called Mei Ping 梅平 fell ill and resigned his

commission to return to his home in Guang-ling 廣陵 (in Jiangsu province). After traveling only 200 li 里 he stopped at a relative's house. It so happened that Tuo arrived at the house at the same time. The host

asked Tuo to examine Ping. After examining him Tuo told Ping, 'If you had seen me earlier the disease

could have been cured but now the disease has set in (become knotted). If you travel quickly you can see

9

your family, you have five days left.' He travelled home quickly and died five days later as Tuo had

predicted (De Woskin 1983, SGZ 1975).

Case 6. The San Guo Zhi said that Yan Xin 嚴 from Yan Du 監 (a prefecture in Jiangsu province) was

waiting with his men to see Hua Tuo. As soon as Tuo arrived he asked Xin, 'Is your body well inside?' Xin

replied, 'It is the same as always.' Tuo said, 'You have an acute disease and I can see it in your face, you

should not drink too much wine.' After this, Xin began his trip home but after going a few li he became

dizzy and fell from the cart. His men propped him up and tried to get him home but he died during the

night (De Woskin 1983, SGZ 1975).

Case 7. The San Guo Zhi and the Hou Han Shu (in a quote from the Wei Zhi) say that a prefectural clerk

called Yin Shi 伊世 had severe discomfort in the four limbs, dry mouth, could not bear the sounds from

people around him, and difficulty urinating. Tuo said, 'Make and give him hot foods (re shi 熱食), if the

patient sweats he will be cured but if not he will die after three days.' So, hot food was made but after

eating it no sweat appeared. Tuo said, 'The zang qi 蔵氣 is blocked inside, he will die sobbing.' It was as

Tuo said (De Woskin 1983, SGZ 1975, HHS 1973).

Case 8. The San Guo Zhi records the case of a circuit inspector called Dun Zi-Xian 頓子獻 had been sick

and was recovering. Hua Tuo was passing through and examined his pulse. Tuo told him, 'You are still

depleted (xu 虚) and not fully recovered, you must not exert yourself or you will die. On the verge of

death your tongue will protrude several cun.' Zi-Xian's wife had heard of his recovery and had travelled

almost 100 li to see him. She stayed that night and they had sex. Within three days Zi-Xian became sick

again and died as Tuo had predicted (De Woskin 1983, SGZ 1975).

Case 9. In the San Guo Zhi it says that shortly before Hua Tuo's death a military official called Li Cheng 李成 had a bad cough, could not sleep night or day, and often spat up pus and blood (nong xue 膿血). Tuo

told him, 'You have an abscess in the intestines (chang yong 腸痈), what you are coughing up does not

come from the lungs. Here is two fen of powder for you, you will cough up two more cups of pus and

blood. After that, if you take good care of yourself in a month you will be able to get around a little, and in

a year you will be strong again. However, in 18 years the disease will recur slightly, so take the remains of

the powder and you will recover. If you do not take the medicine you will die.' Tuo gave him another two

fen of powder, Cheng got the medicine and left. Five or six years later one of his relatives got the same

disorder as Cheng had had. The relative pleaded with Cheng, 'Now you are strong and healthy and I am

about to die, how can you not immediately give me the medicine and avoid having my death on your

hands? Give me the medicine now and when I am better I will get some more from Hua Tuo.' Cheng have

him the medicine and he recovered. Afterwards, the relative went to see Tuo but this was about the time

that Tuo was arrested and the relative was too frightened to see him. Eighteen years later Cheng had a

relapse and died since he did not have any of the medicine to take (De Woskin 1983, SGZ 1975).

Case 10. The San Guo Zhi says that the circuit inspector Xu Yi 徐毅 became sick and Tuo went to

examine him. Yi told Tuo, 'Yesterday an assistant in the medical offices called Liu Zu 劉租 did

acupuncture on Wei Guan 胃管. Afterwards, I began to cough violently. I wanted to go to sleep but could

get no peace.' Tuo explained, 'When he inserted the needle he did not hit Wei Guan but hit your liver by

mistake. Each day you will eat less and less and in five days there will be no hope for you.' It turned out

just as Tuo had said (De Woskin 1983, SGZ 1975).

In modern acupuncture Wei Guan is CV 13 but there is no point called Zhong Gan 中肝 so we have taken

this to mean that he hit the liver organ rather than needled the wrong point.

Medicine, acupuncture and moxibustion

According to the San Guo Zhi, Hua Tuo was skilled in the use of medicines but used only a few

decoctions. He could estimate the amounts so well that he did not bother to weigh the ingredients. Once

the decoctions were cooked he would administer them and explain whatever abstinences were required

10

and then leave. Recovery was inevitable. When using moxa he never used it at more than one or two

locations and he used only seven or eight cones (zhuang 壯) on each spot. He also used acupuncture at

only one or two points. In needling he would insert the needle and tell the patient that he was guiding the

qi to here and there and ask the patient to tell him when they felt sensation at the spot. Once they felt the

sensation he would withdraw the needle and the disorder would be eliminated (De Woskin 1983, Lu &

Needham 1980, SGZ 1975).

Case 11. The San Guo Zhi and the Hou Han Shu (in a quote from the Wei Zhi) say that two district clerks,

Er Xun 兒尋 and Li Yan 李延 were both suffering from headaches and hot body. They went together to

see Tuo. Even though their symptoms were identical Tuo said, 'I will use purging for Xun and inducing

perspiration for Yan.' When questioned, Huo explained, 'Xun has exterior fullness (wai shi 外實) whereas

Yan has interior fullness (nei shi 内實), so the treatment must be different.' He gave medicine to them and

they were both better the next day (De Woskin 1983, SGZ 1975, HHS 1973).

This case seems to have been incorrectly recorded since the treatment used is exactly opposite to what we

would expect. Purging is used for interior fullness and sweating is used for exterior fullness. Once the

treatments are reversed the case makes sense and demonstrates that the principle of 'same symptoms,

different treatment' was in use during this period.

Case 12. The following story is found in the San Guo Zhi and a section in the Hou Han Shu attributed to

the Wei Zhi (this probably means the Wei Zhi section of the San Guo Zhi). A woman from the Xiang 相 family of Gan-ling 甘陵 (a prefecture in Shandong province) was six months pregnant and had

abdominal pain that could not be relieved. Tuo took her pulse and said, 'The foetus has already died.' He

had someone feel for the location of the foetus saying that if it was located on the left it was a boy and if

on the right it was a girl. The person said, 'It is on the left.' Tuo gave her a decoction, she expelled a dead

male foetus and was relieved of the pain (De Woskin 1983, SGZ 1975, HHS 1973).

Case 13. Both the San Guo Zhi and the Hou Han Shu record the case of general Li's wife. She was very

sick, Tuo was called and after taking her pulse he said, 'She has been injured in pregnancy and the foetus

has not been expelled.' The general said, 'I heard that she was injured but she has already given birth.' Tuo

insisted, 'The pulse indicates that the foetus has not arrived.' The general would not accept this diagnosis

so Tuo gave up and left. His wife improved a little but about 100 days later the problem recurred and Tuo

was called again. Tuo said, The pulse indicates there had been a foetus. Before, she was going to have

twins. The first was born but during the birth she lost a lot of blood and the second child could not be

expelled. The mother was not aware (of there being twins) and the other people did not realise it either.

Since the foetus was not delivered it could not survive. Now the foetus is dead and the pulse cannot return

(to how it was before). Perverse dryness is affecting the mother's spine and this is causing the severe pain.

I will now give her a decoction and do acupuncture at one point to expel the foetus.' The medicine and the

acupuncture were given and the woman experienced acute pain like giving birth. Tuo said, 'The dead

foetus has dried up and can not come out itself, someone needs to probe for it.' Eventually, a dead boy was

delivered. He had fully formed hands and feet, was black and was a few chi 尺 in length (De Woskin

1983, Huard & Wong 1968, Hoizey & Hoizey 1993, SGZ 1975, HHS 1973).

Both these obstetric cases are well known and both involve the use of pulse diagnosis in pregnancy. Case

13 is rather complex and the San Guo Zhi is not easy to follow. It appears that on the first consultation the

second twin was still alive and this is what confused Hua Tuo. On the second visit the pulse that had

indicated pregnancy on the first visit now indicated that the pregnancy was no more and since there had

been no birth in between the only possibility was the one that Tuo concluded. The details provided in this

case make it probably the most convincing example of Tuo's skill because Tuo is not simply presented as

a physician of miraculous skill but as one who has worked out a difficult case on the second attempt.

Case 14. The San Guo Zhi says that Chen Shu-shan 陳叔山 of Dong-yang 東陽 had an infant son of two

years old who was sick, he had diarrhoea, cried constantly and was getting more emaciated day by day.

He asked Tuo and Tuo explained, 'The mother is pregnant again, her yang qi is inside to nourish the foetus.

11

Her milk is deficient cold and consequently the child had received the cold pathogen from his mother, but

the child can soon be cured.' Tuo prescribed the mother Si Wu Nu Wan Wan 四物女宛丸. The child was

better after ten days (De Woskin 1983, SGZ 1975).

This case is a good example of treating the mother to treat the child. However, we are left to wonder what

the four ingredients of the formula were since, as far as we can tell, it is not mentioned in the Zhong Zang

Jing, the Mai Jing, the Jin Gui Yao Lue, or the gynaecology and paediatric sections of the Qian Jin Yao

Fang (Sun Si-Miao 1997, Yang 1997, Yang 1993).

Case 15. Both the San Guo Zhi and the Hou Han Shu quote the following story from the Separate

Biography of Hua Tuo. The Hou Han Shu version is slightly less detailed, so the following is the San Guo

Zhi version. A man had a disease of both his feet and could not walk. He was carried to see Tuo on a sedan

chair. Tuo looked at him and said, 'You have had a lot of acupuncture and moxa, and consumed a lot of

medicine, there is no need to take your pulse yet again' (the Hou Han Shu just says that Tuo took his

pulse). He had the man remove his clothes. Tuo then made more than ten dots (or pointed out ten spots)

along his back, some spaced at one cun 寸 apart and others at five, which would be no match for the

aligned pathogen (zong xie 縦邪). He told people to burn ten cones of moxa on each spot (the HHS says 7

cones) and when the moxa scars had healed the man would walk again. After the moxa treatment the scars

were one cun close to the spine on either side (jia ji yi cun 夾脊一寸) and evenly balanced up and down

the length of the man's spine. The man's back was just like a guide rope had been stretched along it (De

Woskin 1983, SGZ 1975, HHS 1973).

The details of this case are somewhat difficult to understand. We have taken the clause beginning with

zong xie to mean that the pathogen that caused the man's disease was in lines along the man's spine like

ranks of troops, and that the points chosen by Tuo were the ones that the pathogen would not be able to

resist in the coming battle. Both the use of the words jia ji 夾脊 and the location of the points that he used

for moxa suggest that these are the points that came to be known as Hua Tuo Jia Ji 華佗夾脊 points.

According to Deadman, Al-Khafaji and Baker (1998) these points were first mentioned in the Hou Zhou

Ge (Poem to Keep up Your Sleeve) but we cannot find them in the version of this poem given in the Zhen

Jiu Da Cheng (see Yang Ji Zhou 1997).

Case 16. The first appearance of Hua Tuo in the Romance of the Three Kingdoms follows an incident in

which Zhou Tai, a general of the state of Wu, is severely wounded following a fight with bandits and the

rescue of the Sun Quan 孫權. Zhou Tai had received more than twelve major wounds which had become

infected and he was in a serious condition. The future Wu king Sun Ce was worried. Dong Xi told him

that he had once received many spear wounds and had been cured by a surgeon who had been

recommended by the scholar Yu Fan (Zhong Xiang). Sun Ce decided to employ Yu Fan and had him

summoned and given a post. When asked about the physician, Yu Fan said that Hua Tuo from Qiao

district was the most marvellous physician of the time. Tuo was sent for and soon arrived. He is described

as 'young of face with hair like the feathers of a crane. He had the light and easy manner of one who no

longer belongs to this world.' Having seen the patient Tuo pronounced it 'not a difficult case' and applied

medicines. The wounds healed in a month (Roberts 1995 p 193-4). Some years later, in the 4th year of

Jian An (199 AD) Sun Ce had become the ruler of Wu and was severely wounded in an assassination

attempt. He tried to see Hua Tuo but Tuo had gone to the north. Instead a student of Tuo treated him. The

student examined the wound caused by a poisoned arrow, gave him some medicine and told him to rest

for 100 days and not get angry. However, Sun Ce had an irascible nature and was frustrated that he could

not be cured that day. After 20 days he began official business again despite the protests of his supporters.

Sun Ce did not believe in the supernatural and became annoyed when a Daoist priest called Yu Ji appeared

in the town and drew large crowds. Sun Ce accused the priest of 'fanning the flames of men's ignorance'

and had him thrown in prison and later executed despite the protests of his wife and ministers. Soon after

the ghost of Yu Ji began to haunt him and Sun Ce became distraught, his wounds reopened and he died.

His brother Sun Quan succeeded him and it was Sun Quan who later caused the death of Lord Guan

(Roberts 1995).

12

Case 17. The San Guo Zhi says that a woman from Peng-cheng 彭城 (a small kingdom in modern Anhui

province) was stung on the hand by a scorpion while going to the toilet one night. She groaned and cried,

unable to bear the pain. Tuo ordered an infusion (wen tang 温湯) to be made. It was boiled and she

soaked her hand in it. In a short while she was able to sleep again. The servants changed the infusion

repeatedly to keep the hand well heated. By the next morning she was cured (De Woskin 1983, SGZ

1975).

Other therapeutic methods

Tuo used numerous methods in the treatment of disease and he often used them in combination. Those

listed above include acupuncture, moxa, decoctions, external washes and ointments as well as surgery. All

these are standard methods used in Chinese medicine. However, he also used more unusual techniques as

the following cases illustrate.

Case 18. The San Guo Zhi and the Hou Han Shu quote the following case from the Separate Biography of

Hua Tuo. A man was suffering from dizziness and could not raise his head or see anything. He had had

this problem for many years. Tuo ordered that his clothes be stripped off and that he be hung upside down

with his head one or two cun from the ground. Tuo wet a cloth and scrubbed the man's body, he ordered

that a cloth be wrapped around (his body), and that (his students) examine the pulses (mai 脈), which

showed the five colours to the extreme. Tuo told several of the man's brothers to lance a vessel (vessels)

with a sword needle (pi dao 鈹刀), it was full of five colour blood, and was drained till red blood

appeared. He rubbed on an ointment and covered him with a quilt. When the sweat began to pour through

the wrapping cloth he had him take Ting Li Quan Xue San 亭歴犬血散. The man was cured (De Woskin

1983, SGZ 1975, HHS 1973).

This case is difficult to interpret. It is not always clear when mai refers to the pulse and when it refers to a

vessel. A number of pulses or vessels seem to have been examined but the location of the vessel or vessels

that were cut is not clear. It also seems that Tuo is telling other people what to do and it is not clear

whether these are students of Tuo or brothers of the man. We have assumed that pi dao 鈹刀 refers to one

of the nine needles called the pi zhen 鈹鍼 which according to the Ling Shu is used to let out pus

(Unschuld 1988). The powder Ting Li Quan Xue San is not mentioned in the Zhong Zang Jing but Ting Li

(Lepidium seeds) is mentioned in the Shen Nong Ben Cao Jing as a herb for treating conglomerations and

accumulations (Yang 1998). If the reference to the five colours is taken as indicating the presence of

multi-coloured purulent fluid, the use of sword needle and a bitter heat-clearing descending herb makes

sense. What the dog's blood does is unclear but it may just be part of the name of the powder.

Case 19. Another case from the Separate Biography of Hua Tuo, recorded in both the San Guo Zhi and

Hou Han Shu, says that a woman had been sick for many years. Everyone said the disease was due to

(pathogenic) cold and heat. In the eleventh month in the depth of winter Tuo had her sit in a stone trough.

When she was still, he had her showered with chilly water. He ordered this be done a hundred times. After

seven or eight showerings, she began struggling and wished to die, the person pouring the water became

afraid and wanted to stop the treatment. But Tuo insisted that the full number be done. When she was

showered for the eightieth time the heat qi began to rise from her body like steam, hissing two or three chi

into the air. When the one hundredth showering had been finished Tuo had her warm her body with a

blazing fire and covered her with a quilt, after a long time sweat appeared and he applied a powder. The

sweat dried and she was cured (De Woskin 1983, Wong & Wu 1936, SGZ 1975, HHS 1973).

Case 20. Both the San Guo Zhi and the Hou Han Shu record the following case. A commandery prefect

was ill and Tuo thought that if the man became fiercely angry he might be cured. Tuo accepted many gifts

from the man. He then simply left the area without making any attempt to cure him and left all the gifts

behind. On top of that he left a note reviling the prefect. The prefect became very angry and ordered men

to pursue Tuo and catch and kill him. But the prefect's son knew about the treatment and ordered the

retainers not to pursue Tuo. The prefect's eyes glared his disgust, then he vomited up several cups of black

13

blood and was cured (De Woskin 1983, SGZ 1975, HHS 1973).

This case is reminiscent of the story of the ancient doctor Wen Zhi (see May & Tomoda 1999). It may

derive from this story but the details are somewhat different. Also, the notion of anger as a cause of

disease is a fairly common one in Chinese medical cases.

Worm disorders

Case 21. The San Guo Zhi and Hou Han Shu record that Chen Deng 陳登, grand protector of Guang-ling 廣陵 had feelings of vexation and oppression (fan men 煩懣) in his chest. His face was red and he could

not eat. Tuo took his pulse and said 'There are several sheng of worms in your stomach and that will soon

result in internal ulceration (nei ju 内疽). You ate some uncooked food and that was the cause of the

disease. 'Tuo made up two sheng 升 of decoction and gave him one followed by another. After the patient

drank the medicine he spat up more than three sheng of worms. They all had red heads, wriggled about,

and had bodies half of which looked like raw minced fish. Deng's pain was relieved but Tuo told him that

the illness would recur in three months. Tuo said 'If you see a good doctor he will treat you.' However,

when the disease recurred Hua Tuo was not around and the grand protector died (De Woskin 1883, SGZ

1975, HHS 1973).

Case 22. Another case appears in both the San Guo Zhi and the Hou Han Shu. When Tuo was traveling he

came upon a man who was sick. The man's throat was blocked and although he craved food he was unable

to swallow. His family had loaded him into a cart intending to consult a doctor. Tuo overheard the man's

groans and stopped the cart to examine him. Tuo told him, 'A way up the road you will come across a shop

that sells flap jacks (bing 餅) and a very sour garlic puree (SGZ says suan ji 蒜韲, HHS says ping ji 萍韲). Drink three sheng (3 cups) and your disease will be better.' Things happened just as Tuo had said. The

man drank three cups and immediately vomited up one snake (she 蛇) that hung over the side of the cart.

Later the man went to Tuo's house to thank him but Tuo had not yet returned. He met a child who was

playing outside the gate and the child said, 'It appears you have already met my master. Hanging over the

side of your cart is the cause of your illness.' When the man went inside to sit down he saw the same kind

of snakes hanging all along the northern wall. There were so many of them that they could be counted in

tens (De Woskin 1983, Hsu and Peacher 1977, SGZ 1975, HHS 1973).

The 'snake' referred to in this case must be a long parasitic worm which Hsu and Peacher (1977) suggest

is Dracuncalua medinensis. What the man drank must have been a sour condiment the ingredients of

which are somewhat unclear. A note in the Hou Han Shu suggests that Fu Ping 浮萍, a kind of cress,

could be the herb referred to but this is for clearing oedema whereas garlic is well-known for expelling

worms. Even so, a condiment made from garlic, vinegar and cress could well prove too much for a worm.

The last part of the story is typically Daoist since it features the young, but wise, boy who meets the guest

instead of his master. The Romance makes good use of such a situation when it has Liu Bei call upon the

Daoist Kong Ming (Zhuge Liang) for help only to be turned away by a boy time after time.

Case 25. Both the San Guo Zhi and Hou Han Shu quote the Separate Biography of Hua Tuo regarding the

following case. Liu Xun 劉勳 was the grand protector of the city of He-nei 河内 that was located

between the Wei and Yellow rivers. He had a daughter of twenty years of age. She had a sore (chuang 瘡)

on her left leg above the knee that itched but was not painful. It would heal for about ten days and then

reappear. This had been happening for seven of eight years. The prefect took her to Tuo who examined her

and said, 'This is easily cured. I need one rice-straw-coloured yellow dog and two good horses.' He tied a

rope around the dog's neck and made one horse pull the dog along. When the horse got tired he used the

other horse. He kept track of the distance and had them walk over 30 li until the dog was no longer able to

walk. Then he had men on foot drag the dog some more till the total distance was 50 li. After this he gave

the girl some medicine so she became unconscious. He cut into the dog's belly with a big knife directly in

front of its rear leg and placed the incision two or three cun from the girl's sore. Immediately a thing like a

snake began to crawl out of the sore. Tuo smashed its head with a metal mallet and it wriggled for a while

inside her skin before stopping. He then pulled the rest out. It was over three chi long. It was a snake. It

14

had eye sockets but no pupils and had reverse scale ears (ni lin er 逆鱗耳). Tuo put an ointment on the

wound and it healed in seven days (De Woskin 1983, SGZ 1975, HHS 1973).

Some of the details of this case suggest that the worm entered via the skin causing the sore and it had

hooking appendages at one end. We can assume that the dragging of the dog was to render it comatose so

it could be cut and presented as bait for the worm.

Strange cases

Cases 23 and 24. In the Romance of the Three Kingdoms Hua Xin describes a case of Hua Tou's in which

a man had a tumour next to his eyebrow that itched intolerably. Hua Tuo was summoned and after

studying the growth declared that something winged was inside. Everyone laughed but when Tuo cut it

open a small sparrow flew out and the man was cured. He also cited the case of a man who had been

bitten on the toes by a dog. Afterwards two lumps of flesh grew there and one hurt and the other itched

severely. Tuo said that there were ten needles inside the one that hurt and two chess pieces, one black and

one white, inside the one that itched. No one thought this diagnosis credible but when he cut the lumps

open it was exactly as he said (Roberts 1995).

Since all the cases are presented as examples of Hua Tuo's skill these stories could be considered purely

hagiographic. However, the inclusion of cases that he could not cure coupled with the variety of

conditions and treatments make it unlikely that this is simply a collection of medical marvel stories.

Except for the last two cases, they all describe recognisable conditions and some provide details that

suggest actual observation. The presence of errors of a medical nature suggests that the recorders of these

stories were not medical people and this probably accounts for some of the confusing sections.

Hua Tuo's Legacy

Tuo is credited with inventing the Five Animals Exercises / Play / Pattern (Wu Jin Zhi Hui 五禽之戲). It is

said that on his travels he watched the movements of the tiger leaping, the deer running, the bear climbing

uphill, the monkey hanging from a tree and the crane spreading its wings to fly (Zhen 1995 ). Both the

San Guo Zhi and the Hou Han Shu record the same basic story as follows. Hua Tuo told Wu Pu 呉普 'The

body needs to be exercised but this should not be done to the extreme. Movement makes the gu qi

disperse and moves the blood through the vessels so that the body will be free from diseases just as a door

hinge is never worm-eaten. Therefore, the immortals of ancient times practiced dao yin 導引, moving the

head like a bear and twisting the neck like an owl, stretching the waist and moving the joints, to prevent

the problems of aging. I have a technique called the Wu Jin Zhi Hui, one is the tiger, two is the deer, three

is the bear, four is the monkey and five is the bird. These serve as a dao yin and can expel disease and

benefit the feet. When you feel not well, do an exercise till the sweat pours out, then dust yourself with

powder. Your body will become light and your appetite will improve.' Pu followed these instructions and

when he was 90 years of age his ears and eyes were still sensitive and bright and his teeth were still

complete and firm (Zhu 1995, Hsu & Peacher 1977, De Woskin 1983, SGZ 1975, HHS 1973, Huard &

Wong 1968, Despeaux 1996).

The notion that Hua Tuo invented this system of dao yin is often found in the secondary literature (see

Huard & Wong 1968 and Zhen 1995 State). However, there is nothing in the San Guo Zhi or Hou Han Shu

to indicate that he was the inventor, they only say that he knew the exercises and taught them to his

student Wu Pu. Moreover, Hua Tuo himself is quoted as saying that such exercises were done by ancient

immortals. The antiquity of exercises modelled on the movements of the bear and bird is evidenced by a

reference in the Zhuang Zi 莊子 to such exercises being done by adepts intent on longevity. This

indicates that this type of dao yin was popular by 300 BC in the Warring States period (Despeaux 1996).

Moreover, a sheet of silk that was copied between 205 and 196 BC was found in a tomb from the Former

Han dynasty. Dubbed the Dao Yin Tu 導引圖, this set of remarkably well preserved drawings depicts 44

sketches of movements, some of which have legible names. Amongst these names are some that indicate

that the exercise is for treating disease while others have animal names such as 'crane', 'dragon ascending',

15

'bear ramble', 'gibbon shouting', 'monkey bawling to pull internal hotness' and some fragmentary names

that refer to birds (Harper 1998). These early references to animal imitating styles of dao yin are the most

substantial but a number of brief references can be found in other ancient literature such as the Lu Shi

Chun Qiu 呂氏春秋 and the Huai Nan Zi 淮南子 (Despeaux 1996, Harper 1998). Neither Huang-Fu Mi

nor Wang Shu-He mention his set of exercises but in Ge Hong's Bao Pu Zi, written around 320, there is a

brief summary of the same story as found in the San Guo Zhi (Despeaux 1996, Ware 1966). The first

detailed accounts of the Five Animals Play appear in the Yang Xing Yan Ming Lu 養性延命録 and the Tai

Shang Lao Jun Yang Sheng Jue 太上老君養生訣 (also called the Lao Jun Jue 老君訣) together with other

sets of exercises. The Lao Jun Jue is attributed to Hua Tuo but it is a work of the Tang dynasty or later.

The Yang Xing Yan Ming Lu is attributed to Tao Hong-Jing or Sun Si-Miao and has been dated to the

mid-Tang Dynasty although it probably incorporates much earlier material. Both works can be found in

the Daoist Canon (Dao Zang) (Despeaux 1996). Although Tuo could not have originated health-giving

exercises based on the movements of animals, we know that he was famous as a practitioner of health

enhancement so it is possible that he practiced a specific set of five exercises that he passed on to his

students who then popularised them.

The book the Hua Shi Zhong Zang Jing 華氏中臓經 (Classic of the Central Viscera) is attributed to Hua

Tuo. The preface is by Deng Chu-Zhong 處中 and dated 234 AD. In it he tells us that he is the son of

Tuo's daughter and having paid his respects to the master in his room he had a dream. In it Tuo ushered

him into a room, had him sit down and told him, and said, 'The Zhong Zang Jing contains miraculous

methods to save lives. You can take it but do not give it to anyone unworthy.' Deng was surprised and

frightened when he awoke but went to search amongst the master's things where he found a stone box

containing the book (Yang 1993, Zhu 1994). This story is rather typical of Daoist stories of the discovery

of revelatory manuscripts and must be viewed with scepticism. Consequently, the book has sometimes

been described as a forgery but it this is also unlikely since it contains nothing that links it to Hua Tuo

beyond the preface. It seems strange that someone intent on forging a book by Hua Tuo would fail to

include the formulas recorded in the San Guo Zhi or sections on surgery, expelling worms and other likely

methods. Moreover, Tuo is described as using simple decoctions but the book mainly contains

multi-ingredient pills. Therefore, while the book cannot be attributed to Hua Tuo it is nevertheless an early

book on a strand of Chinese medicine that has a clear Daoist influence. The current book is the result of a

compilation of old manuscripts by Sun Xing Yan (1753-1818) who believed the book dated to the Six

Dynasties Period (265-581 AD) (Yang 1993). Other books attributed to Tuo include the Nei Cao Tu 内照圖, Hua Tuo Shen Yi Mi Zhuan 華佗神医秘傳 and Hua Tuo Shen Fang 華佗神方 (Wong & Wu 1936,

Zhen 1994).

Tuo's Disciples

The San Guo Zhi and Hou Han Shu mention that Tuo had two famous disciples. Wu Pu 呉普 (Chuang

1982 says Wu Jin) was from Guang-ling 廣陵. He followed the art of Hua Tuo precisely and his patients

generally recovered (De Woskin 1983, SGZ 1975). Besides using Tuo's exercises and living to over 90,

Wu is known for his knowledge of materia medica. Tao Hong-Jing said that during the Wei and Jin

Dynasties Wu Pu and Li Dang-Zhi 李當 had abridged and supplemented the Ben Jing so that different

versions contained 595, 431 or 319 drugs (Unschuld 1986). Wu is also credited with the Wu Pu Ben Cao 呉普本草 (also called Wu Shi Ben Cao 呉氏本草) (Hoizey & Hoizey 1993, Wong & Wu 1936). A short

work of this name is often appended to the Shen Nong Ben Cao Jing but its origin is unclear (Yang 1993).

Li Dang-Zhi is said to have died in 250 AD. He wrote a materia medica called the Li Shi Yao Lu 李氏藥錄

in 3 volumes which has been lost (Wong & Wu 1936). Hoizey and Hoizey (1993) list him as another of

Tuo's students but there is no mention of him as such in the San Guo Zhi or Hou Han Shu.

The other student mentioned in the San Guo Zhi and Hou Han Shu and is Fan A 樊阿 of Peng-zheng. The

San Guo Zhi says, 'He was skilled in acupuncture. Other doctors said that when needling in the area of the

back and chest cavity you must not be careless and needling should not be more than 4 fen (in depth). But

Fan A inserted needles one or two cun on the back, and on the point Ju Que 巨闕 (CV 14) on the chest

cavity he needled to a depth of five to six cun. The disorders would always be cured. Like Tuo, Fan A was

16

always looking for things that could be consumed to benefit health and Tuo gave him the prescription Qi

Ye Qing Nian San 漆葉青粘散 as follows: crushed (xie) Qi Ye 漆葉 1 sheng and crushed Qing Nian 青粘 14 liang in these proportions. Tuo said this medicine could expel the three worms (san chong 三蟲),

regulate the five zang organs, lighten the body and keep the hair from turning white. Fan A followed Tuo's

advice and lived to be over one hundred. Qi Ye is commonly found everywhere and Qing Nian is said to

grow in Feng 豐, Pei 沛, Peng-cheng 彭城, and Chao-ke 朝歌.' The San Guo Zhi goes on to quote the

Separate biography of Hua Tuo, 'The herb Qing Nian is also called Di Jie 地節 and Huang Zhi 黄芝. It

principally benefits the five zang and nourishes the jing qi. It was first found by a man who was lost in the

mountains, he saw an immortal consuming it and told Tuo about it. Tuo found it to be very good and

passed the information to Fan A who kept it a secret. Recently, some people were amazed at Fan A's

longevity, vigour and strength and asked him what he consumed, but they drank and had disordered lives

and did not use it the proper way. Once some people took it and found it to be effective (De Woskin 1983,

SGZ 1975).

There is no mention of the formula Qi Ye Qing Nian San in the Zhong Zang Jing. Qi Ye appears to be the

leaves of the lacquer tree but there is no mention of this herb in the Shen Nong Ben Cao Jing.

Nevertheless, it does appear in the Ben Cao Gang Mu (Li Shi-jen 1995) where it is indicated for expelling

worms. It is also possible that this herb refers to Ze Qi 澤漆 (Euphorbia heliopscopia L.) which does

appear in the Ben Jing (Yang 1998). We cannot identify Qing Nian although there is a reference to a

Huang Zhi in the Ben Jing that Yang (1998) cites as a ganoderma fungus. It is probable that the reference

to the three worms is not intended to indicate that the medicine is a vermifuge but that it promotes

longevity. According to a Daoist theory that seems to have developed by Hua Tuo's time, the body was

host to three worms that conspired to shorten a person's life. These worms could be eliminated by a

variety of practices including religious rites, the abstention from grains, consumption of certain foods and

the administration of medicines including manufactured mineral elixirs. This doctrine is closely linked to

the doctrine of the Three Corpses (san shi 三尸) and was greatly elaborated over the centuries but its

origins probably lie in practical experience with parasites that lead to death such as the Schistosoma

japonicum, Ascaris lumbricordei (round worm), Ancylostoma duodenale (hookworm) and Taenia saginata

(tapeworm) all of which have been prevalent in China since ancient times (Miyakawa 1995).

Conclusion

Given the number of references to Hua Tuo and his students that are found from early times in a variety of

sources, it difficult to accept him as anything other than an historical figure. It is probable that some of the

stories concerning his life are the result of misidentification and mythologizing but the general details of

his life are consistent. Almost all his cases take place in the same region and the combination of the detail

provided regarding the specifics of some cases and the identity of the people involved makes it likely that

some at least are authentic. He had at least two disciples and it is possible that he had many more since

some cases are written with Tuo ordering others to perform the treatment. His therapeutic methods were

many and varied. Besides complex techniques such as surgery he also used very simple treatments, often

making use of local materials. This is consistent with him being a traveling doctor who presumably was

unable to carry a great variety of medicines. Of his background we know little beyond his being educated

and having a family. His education would no doubt have given him access to the local elites and his cases

were probably recorded by local officials and scribes. Had he only ministered to the common people it is

unlikely that any records would remain.

It is difficult to determine whether the aspects of his story that contain a Daoist flavour reflect his own

leanings or are purely the result of his later adoption as a medical saint. Refusing political posts was

certainly in keeping with Daoist behaviour but in the late second century numerous scholars of all

persuasions were dropping out of the system in disgust. His reputation for engaging in longevity practices

such as dao yin make him a candidate for the Daoist stamp but the absence of alchemical references or

any involvement in the Yellow Headbands places him in neither the esoteric lineage nor the populist one.

None of the cases cast him in the role of anything but a skilled and well-known physician, so it seems

reasonable to discount references to his great age or his becoming and immortal as the preferences of his

17

biographers. It is telling that the San Guo Zhi only says that people thought he was approaching 100,

rather than saying that he himself made such claims.

The above cases do throw some light on the practice of medicine at the end of the Han but they contain

omissions, unclear passages and unidentifiable terms. This is probably partly due to the cases being

recorded by people who were not well versed in medicine but it is also likely that these cases contain

many references not apparent to the modern reader. Since these are the only set of cases that have

survived from the Eastern Han period they warrant careful scrutiny so we would appreciate any feedback

that can throw further light on these cases.

18

References

Chen Shou and Pei Song-Zhi (3rd C, 1975) San Guo Zhi (History of the Three Kingdoms). Beijing:

Zhong Hua Shu Ju. (referenced as SGZ)

Chuang Yu-min (1982) The Historical Development of Acupuncture. Bulletin of the Oriental Healing Arts

Institute of U.S.A., Vol 7 No. 8, pp 1-83.

Gardiner K.H.J. (1973) Standard Histories, Han to Sui. In Leslie, Donald D., Mackerras, Colin and Wang

Gungwu (eds) Essays on the Sources for Chinese History. Canberra: Australian National University.

Deadman, Peter, Al-Khafaji, Mazin and Baker, Kevin (1998) A Manual of Acupuncture. East Esssex:

Journal of Chinese medicine Publications.

Despeux, Catherine (1969) Gymnastics: The Ancient Tradition. In Kohn, Livia (ed) Taoist meditation and

longevity techniques, pp 225-261. Ann Arbor: Uni of Michigan Press.

De Woskin, Kenneth (1983) Doctors, diviners and Magicians of Ancient China: Biographies of Fang Shi.

New York: Columbia University Press.

Fairbank, John K. and Reichauer, Edwin O. (1989) China: Tradition and Transformation. Sydney: Allen &

Unwin.

Fan Ye (5th C, 1973) Hou Han Shu (History of the Later Han Dynasty). Beijing: Zhong Hua Shu Ju.

(referenced as HHS)

Harper, Donald J. (1998) Early Chinese Medical Literature: The Mawangdui Manuscripts. London: Kegan

Paul International.

Hoizey, Dominique and Hoizey, Marie-Joseph (1993). A History of Chinese medicine. Edinburgh:

University Press.

Hsu Hong-Yen and Peacher, William G. (trans) (1977) Chen's History of Chinese Medical Science.

Bulletin of the Oriental Healing Arts Institute of U.S.A., Vol 2 No. 6, pp 1-148.

Huard, Pierre and Wong Ming (1968) Chinese Medicine. London: World University Press.

Li Shi-jen (Ming, 1995) Ben Cao Gang Mu. Zhong Qing: Zhong Qing Da Xue Chu Ban Shi.

Lu Gwei-Djen and Needham, Joseph (1980) Celestial Lancets: A History and Rationale of Acupuncture

and Moxa. Cambridge: Cambridge University Press.

Maspero, Henri (Kierman, Frank Jr. trans) (1981) Taoism and Chinese Religion. Amherst: University of

Massachusetts Press.

May, Brian and Tomoda Takako (1999) The Origins of the Wu Xing. Journal of ACMERC, 4(2), pp

14-23.

Miyakawa Hisayuki (1995) Medical aspects of the Daoist doctrine of the three cadavers. In Hashimoto K,

Jami, C. and Skar, L. eds East Asian Science: Tradition and Beyond. Osaka: Kansai University Press, pp

345-349.

Miyasita Saburo (1973) A neglected source for the early history of anesthesia in China and Japan. In

Nakayama S. & Sivin, N. eds Chinese Science. Cambridge Mass.: MIT Press, pp 273-278.

19

Roberts, Moss (1995) Three Kingdoms: A Historical Novel. Beijing: Foreign Languages Press.

Sun Si-Miao (Tang, 1997) Bei Ji Qian Jin Yao Fang. Shang-yang: Liao Ning Science and Technology

Press.

Twitchett, Denis and Fairbank, John K. (1986) The Cambridge History of China, Volume 1: The Ch'in and

Han Empires 221 BC- AD 220. Cambridge: Cambridge University Press.

Unschuld, Paul, U. (1985) Medicine in China: A History of Ideas. Berkeley: Uni. of California Press.

Unschuld, Paul, U. (1986) Medicine in China: A History of Pharmaceutics. Berkeley: Uni. of California

Press.

Unschuld, Paul U. (1988) Introductory Readings in Classical Chinese Medicine. Dordecht: Kluwer

Academic Publishers.

Ware, James R. (1966) Alchemy, medicine and religion in the China of AD 320: The Nei P'ien of Ko

Hung. New York: Dover Publications.

Wong, K. Chimin and Wu Lien-Teh (1936) History of Chinese Medicine, second edition. Shanghai:

National Quarantine Service.

Yang Ji-Zhou (Ming, 1997) Zhen Jiu Da Cheng. Shang-yang: Liao Ning Science and Technology Press.

Yang Shou-Zhong trans. (1993) Master Huo's Classic of the Central Viscera: A translation of Hua Tuo's

Zhong Zang Jing. Boulder: Blue Poppy Press.

Yang Shou-Zhong trans. (1997) The Pulse Classic: A translation of the Mai Jing by Wang Shu-he.

Boulder: Blue Poppy Press.

Yang Shou-Zhong trans. (1998) The Divine Farmer's Materia Medica: A translation of the Shen Nong Ben

Cao Jing. Boulder: Blue Poppy Press.

Yang Shou-Zhong and Chace, Charles trans. (1993) The Systematic Classic of Acupuncture / Moxibustion

by Huang-Fu Mi. Boulder: Blue Poppy Press.

Zhen Zhi-Ya (1995) History of Traditional Chinese Medicine. In Advanced Textbook on Traditional

Chinese Medicine and Pharmacology, vol 1. Beijing: State Administration of TCM.

Zhen Zhi-Ya (1994) Zhong Guo Yi Xue Shi (Chinese Medical History). Taipei: Zhi Yin Chu Ban Shi.