HUA TUO

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Biographical information about Hua Tuo has been summarized and presented in English in three works: an article in the Journal of Traditional Chinese Medicine (1), a monograph in Chen's History of Chinese Medical Science (2), and an extensive report in the Advanced Textbook on Traditional Chinese Medicine and Pharmacology (3). The following has been derived primarily from those sources, except as noted.

Hua Tuo is a famous physician of the Han Dynasty who is so widely respected that his name and image adorn numerous products (e.g., as a brand name for acupuncture needles and for medicated plasters) and a set of frequently used acupuncture points (called Hua Tuo Jiaji, see Appendix). He is known for the early qi gong exercise set known as the frolics of the five animals, in which one imitates the actions of tigers, deer, bears, apes, and birds; these practices were later incorporated into various health promoting martial arts practices, such as taijiquan. His name is always mentioned in relation to surgery, as he was considered the first surgeon of China, and one of the last famous surgeons of ancient China. He has been compared, in this regard, to Jivaka of India, who lived at the time of Buddha (about 500 B.C.) and was renowned for surgery, but had no significant successors until the modern era when surgery was reintroduced by Western doctors (4).

Legends of Hua Tuo's work are mentioned in historical novels, such as Romance of the Three Kingdoms and Taiping's Comprehensive Anthology of Stories. It was a tradition in the past that when a patient had recovered due to the efforts of a competent physician, the family would present a congratulatory board to the doctor inscribed with the words: A Second Hua Tuo.

Hua Tuo was born around 110 A.D., in Qiao of Peiguo (today called Haoxian or Bo) county, in what is now Anhui Province, one of the four major herb distribution centers of modern China. He lived for about 100 years, having died around 207 A.D. He was an older contemporary of China's famous herbalist Zhang Zhongjing, who died around 220 A.D. In the Chronicles of the Later Han Dynasty, it is said that: "Knowing well the way to keep one in good health, Hua Tuo still appeared in the prime of his life when he was almost 100, and so was regarded as immortal." It is said that Cao Cao, ruler of the state of Wei, had Hua Tuo put to death for reasons that are unclear. Cao Cao summoned him to serve as his personal physician, and either became enraged with Hua Tuo's hesitancy to return again later to provide more treatments or suspected an assassination attempt when Hua Tuo suggested brain surgery as a treatment for his severe headaches. According to the Records of the Wei Dynasty (Wei Zhi), Cao Cao had Hua Tuo killed in 207 A.D. at age 97. Cao Cao's second son, Cao Pi (187-226 A.D.), became Emperor of the Wei Dynasty, taking over China upon the forced abdication of Emperor Xian; China then collapsed into chaos, and Cao Pi was left only a few years rule of Wei, the northern kingdom of the "three kingdoms" that resulted from the breakdown.

According to the limited existing reports of his life, it is said that Hua Tuo studied and mastered various classics, especially those related to medical and health measures, but also astronomy, geography, literature, history, and agriculture, when he was young. He was stimulated to pursue a career in medicine after seeing so many people die of epidemics, famines, and injuries from wars (Zhang Zhongjing also mentioned the epidemics as leading him to undertake medicine as a career). His father had died when Hua Tuo was seven. His family lived in poverty and his mother wanted him to pursue a career. So, he walked hundreds of kilometers to Xuzhou to access all the medical classics retained there and learned from a famous physician named Cai. He studied tirelessly while practicing medicine, and became expert in several fields, including acupuncture, gynecology, pediatrics, and surgery. For the latter, he invented various herbal anesthetics. One, known as numbing powder (Mafai San), was taken with alcohol before surgery. His ancient prescriptions are lost, but the ingredients are thought to include cannabis and datura, which had been recorded later, during the Song Dynasty, as an anesthetic.

Two specific cases of abdominal operations were relayed in Hua Tuo's official biography:

• A patient who went to Hua Tuo was told: 'Your disease has been chronic, and you should receive an abdominal operation, but even that could lengthen your life by not more than ten years.' The patient, being in great pain, consented to the surgery and was cured immediately, but he died exactly ten years later.
• A patient who suffered from abdominal pain for more than 10 days and had depilation of his beard and eyebrows asked Hua Tuo for treatment. The doctor diagnosed him as having a deterioration in the abdomen, asked him to drink the anesthesia, then explored his abdomen and removed the deteriorated part, sutured and plastered the abdomen, and administered some herbs. The patient recovered after 100 days.

The latter story is believed to be a treatment of acute appendicitis. In the Wei Zhi (5), it was reported that for intestinal diseases Hua Tuo "would cut them out, wash them, sew up the abdomen, and rub on an ointment; the illness would remit if four to five days." There is also the story of general Guan Yu, whose arm was pierced by a poisoned arrow during a battle; General Guan calmly sat playing a board game as he allowed Hua Tuo to clean his flesh down to the bone to remove necrosis, with no anesthetic. This event is a popular historical subject in Chinese art.

Hua Tuo has been called the "miracle working doctor" (also translated as divine physician; shenyi) because of his emphasis on using a small number of acupuncture points or small number of herbs in a prescription to attain good results. Some sayings have been attributed to him; for example, in advocating that people exercise to stay healthy, he said: "The body needs exercise, but it should not be excessive. Motion consumes energy produced by food and promotes blood circulation so that the body will be free of diseases just as a door hinge is never worm eaten." Being an accomplished Taoist (Anhui was the birthplace also of the legendary Taoist founders Laozi and Zhuangzi) and following its principles, he did not seek fame or fortune, though much praise was heaped upon him. He served as a physician in what are now Jiangsu and Shandong Provinces adjacent to his home Province of Anhui, and turned down offers for government service.

It is said that Hua Tuo wrote several books, but none of them has been handed down, so his teachings remain largely unknown. One story is that while in prison awaiting his death, Hua Tuo handed over his works, collectively referred to as the Book of the Black Bag, to the prison ward and asked him to help save people's lives with his medical books, but the warden dared not accept it, and Hua Tuo burned it. Another story is that the warden took the volume home, but that his wife, afraid of the trouble it might bring them, burned it. Either way, the lasting story is that his written teachings went up in smoke. It is thought that some of Hua Tuo's teachings have been preserved within other books that came out in subsequent centuries, such as the Pulse Classic, Prescriptions Worth a Thousand Gold, and Medical Secrets of an Official. An existent book was ascribed to him, but it has been determined to be from a much later writer; it was translated to English under the title Master Hua's Classic of the Central Viscera (Zhong Zang Jing), with the unsubstantiated claim that only one of Hua's scrolls was burned and this came through unscathed (6). Similarly, a book called Prescriptions of Surgery was attributed to Hua Tuo, but is believed to have been compiled at least a century or two after his death (7).

Despite Hua Tuo's reputation in the field, the loss of his works resulted in the first monographs on surgery being erroneously attributed to others. There were many short documents produced during the time from the end of the Han Dynasty through the 5th century, of which one survives, called Liu Junzi's Mysterious Remedies. Like the other documents of this time, it mainly focused on lancing of carbuncles and cleaning out deep ulcers, as well as some other superficial surgeries, not the abdominal surgery that Hua Tuo is said to have done.

Hua Tuo had several disciples, including Wu Pu, Fan E, and Li Dangzhi, all of whom were excellent physicians. They also practiced qi gong, acupuncture, herbal medicine, and other things learned from Hua Tuo. It is said that Wu Pu wrote an herb guide and that Fan lived to be over 100, thanks to the exercises he practiced regularly.

REFERENCES

1. Zheng Bocheng, The miracle-working doctor, Journal of Traditional Chinese Medicine, 1985; 5 (4): 311-312.
2. Hong-yen Hsu and William G. Peacher, Chen's History of Chinese Medical Science, 1977 Oriental Healing Arts Institute, Long Beach, CA.
3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, volume 1, 1995 New World Press, Beijing, China.
4. Unschuld PU, Medicine in China: A History of Ideas, 1985 University of California Press, Berkeley, Ca.
5. Sivin N, Chinese Alchemy: Preliminary Studies, 1968 Harvard University Press, Cambridge, MA
6. Yang Shouzhong (translator), Master Hua's Classic of the Central Viscera, 1993 Blue Poppy Press, Boulder, Co.
7. Wang Jaixiu, The first monograph on surgery, Journal of Traditional Chinese Medicine, 1986; 6(2): 136.
8. O'Connor J and Bensky D (translators), Acupuncture: A Comprehensive Text, 1981, Eastland Press, Seattle, WA.
9. Yu Huichan and Han Furu, Golden Needle Wang Leting, 1996 Blue Poppy Press, Boulder, CO.
10. Shen Xueyong, Xu Xingsheng, and Zhuang Wei, 23 cases of summer fever treated by needling huatuojiaji points, Journal of Traditional Chinese Medicine 1995; 15(3): 192-194.
11. He Shuhuai, Huatuo jiaji ponts for migraine: 70 cases, Journal of Traditional Chinese Medicine 1983; 3(3): 231-232.

APPENDIX: HUA TUO ACUPUNCTURE POINTS.

The Hua Tuo acupuncture points, known as Hua Tuo Jiaji (jia = lining; ji = spine), are located in a row along side the spine, bilaterally. The points are attributed to Huo Tuo because it is said that he preferred treating certain conditions with these points. For example, there is a story that a patient having problems with his feet couldn't walk, so he went to Hua Tuo, who applied moxibustion to points on his back along the spine. Soon, the patient was able to walk again. Historical records of these points are few. The Zhenjiu Jicheng (Comprehensive Collection of Acupuncture-Moxibustion; published in 1847) says:

The jiaji treat sudden chaos twisted sinews. Order the patient to lie in prone position and extend their two hands to touch the body. Then use a string to connect the tips of the two elbows. The points are located 1.5 cun bilateral to the spine below the point where the string crosses the spine. Moxa 100 cones and nothing will fall short. This is Hua Tuo's method.

The "twisted sinews" may refer to tendons and muscles that have become stiff or paralyzed, causing one to be unable to walk, and this statement may simply be a reflection of the original story linking these points to Hua Tuo. The initial descriptions refer to use of moxibustion, but needling is emphasized in modern texts.

The general use of points near the spine was eventually organized into a set of 17 specific points in a row (see figure) with specific relation to the vertebrae, but these have been increased to 24 bilateral points by extending the set upward on the neck and downward on the sacrum (8). The points are located between the single row of Governing Vessel points that run directly along the spinal column and the inner set of bilateral Bladder meridian points. The Bladder meridian runs in two lines parallel to the spine; the inner row being 1.5 cun lateral to the spine. The Huo Tuo Jiaji are usually said to be located 0.5 cun lateral to the lower border of each spinous process; some authors locate the points slightly closer to the spine, and others as far as 1 cun from the spine.

The points lie along the interspinous transverse ligaments and muscles. Each point has its related posterior branch of the spinal nerve starting from below the vertebra and the accompanying artery and vein. It is understood that the stimulation of these points will treat problems of the organs and body parts that are located in the same general region. Their functions correspond, roughly, to those of the Bladder-associated shu points. Hence, the points in the upper portion of the thorax are used to treat diseases of the throat, heart, lung, and upper extremities; the points in the lower portion of the thorax are used to treat diseases of the liver, gallbladder, spleen, and stomach; points in the lumbar region are used to treat diseases of the urogenital system, the intestinal tract, lumbosacral region, and lower extremities. From the modern viewpoint, needling the nerves extending from the spinal column to the associated regions could explain these recommendations.

Location of the points, in terms of distance from the spine, has been an issue of some contention. The physician Wang Leting (1894-1990) preferred needling the points slightly closer to the spine (9). He moved the location inward so that the points were just 0.3 cun lateral to the spinous processes. Wang cited the satisfactory needle response as one basis for selecting this location and expressed the view that treating the jiaji would have the effect of simultaneously improving the flow of qi in both the Governing Vessel and Bladder meridian. Such treatment would be of particular benefit for many cases of paralysis; Wang also recommended these points for relieving pain syndromes, including lumbar pain, gastrointestinal disease with pain, herpes zoster, and intercostal neuralgia.

In an article on using the Hua Tuo jiaji points for treatment of summer fever (with weakness in the lower extremities, fatigue, and stiffness in the back), the authors indicate that these points are used to regulate the functions of the internal organs and relieve the stiffness (10). As to location, the authors stated:

Originally, all the points along both sides of the spinal column were designated jiaji, without fixed location. Later, three main ways for location of jiaji points were used according to the clinicians' experiences. The first and most popular way is 0.5 cun; the second way is 1.0 cun, and the third way, 0.8 cun bilateral to the midpoint between each two vertebral spinous processes. From our experience, it is dangerous to apply acupuncture at 1.0 cun bilateral to the spinal column, 0.5 cun is safe but the needling sensation would not be strong enough. Perpendicular insertion of the needles in the third way [0.8 cun] is not only safe, but also more effective because needling sensation would be elicited easily. In regard to the depth, it is common to insert the needle perpendicularly 0.3-0.5 cun deep at the point 0.5 cun lateral to the midpoint between each two spinous processes. But we consider that this depth is not enough, so that no promising needling response could be elicited. Therefore, no good effect could be expected by shallow needling. For this reason we have adopted deep needling [0.5-1.0 cun for upper thoracic points; 1.0-1.5 cun for lower thoracic and lumbar points] to treat summer fever for a better result.

Wang also relied on deep insertion, which was easier to perform and safely done closer to the spine, with 1.5 cun depth except for thin people, who he would needle at 1.0-1.5 cun. He recommended perpendicular needle insertion. In an article on treatment of migraine with Hua Tuo jiaji plus fengchi (GB-20), He Shuhai indicated that needles should be inserted into the points to a depth of 1 cun or a little more or less depending on the fatness or thinness of the patient, using a slight oblique angle of 75 degrees to the skin toward the spine (12).

Thus, it appears that one of the considerations for treatment of this region is to needle close enough to the spine to avoid the danger of puncturing the internal organs (specifically to avoid pneumothorax), while puncturing deeply enough to attain an adequate qi response and therapeutic effect. Yet, the points need to be far enough from established points (those of the Governing Vessel and inner Bladder meridian line) to be considered a separate treatment method. Thus, points are selected at a distance from 0.3-0.8 cun lateral to the spinous processes, with a needling depth of 0.5-1.5 cun, using perpendicular or slight oblique needling angle. Needle retention time is 20-30 minutes, with stimulation by reducing or tonifying method as appropriate to the point (e.g., reducing therapy for liver, tonifying for spleen). The points are mainly used to regulate the internal organs and alleviate stiffness, paralysis, and pain syndromes.

August 2002

Location of the Hua Tuo Jiaji. This illustration shows the 17 basic points, which can be expanded to 24 points by extending along the spine upward and downward. The Hua Tuo points are bilateral, that is, on both sides of the spine, even though only one row is displayed here.

20th century painting of Hua Tuo at Academy of Traditional Chinese Medicine in Beijing.

Painting of Hua Tuo, published in Medicine in China: Historical Artifacts and Images by Paul Unschuld. The text on the painting suggests that this is a copy of an image that was constructed on the river Jialing during the Three Kingdoms period, a few years after Hua Tuo's death.

19th century Japanese painting showing Hua Tuo operating on the wounded arm of general Guan Yu, who is busy playing a board game.