During the late Eastern Han dynasty, a brilliant Chinese physician named Hua Tuo—renowned for his pioneering medical techniques, surgical skill, and knowledge of herbal medicine—is said to have perfected a powerful form of anaesthesia centuries before similar developments in the West. Known as mafeisan, this herbal concoction was made entirely from plant extracts and was so potent that it could render a patient unconscious for more than 24 hours—long enough for Hua Tuo to perform highly invasive surgical procedures, such as the removal of diseased intestines.
A fictional depiction of Hua Tuo performing surgery on general Guan Yu, while the latter plays Go to distract him from the pain.
Most of what we know about Hua Tuo comes from later historical sources, such as the third-century Records of the Three Kingdoms and the fifth-century Book of the Later Han. According to these texts, Hua Tuo was born in Qiao County around 140 CE and studied the Chinese classics throughout the Xu Province. He rejected court appointments multiple times, choosing instead to live as an itinerant physician.
Hua Tuo possessed extensive knowledge of herbal medicine. In the Records of the Three Kingdoms, the third-century historian Chen Shou wrote, “Hua Tuo’s mind was so adept at dividing and compounding according to the right proportions that he did not need to weigh the different components of his medicines with a balance.”
He also employed traditional Chinese healing methods such as moxibustion—the burning of dried mugwort on specific points of the body—and acupuncture, which involves inserting fine needles into targeted areas to stimulate energy flow and alleviate illness. However, when a disease was located deep within the body, beyond the reach of needles or herbal remedies, Hua Tuo recognized that surgery was necessary.
Chen Shou describes that:
in such cases, he would have his patients drink a solution of morphean powder whereupon they would immediately become intoxicated as though dead and completely insensate. Then he could make an incision and remove the diseased tissues. If the disease were in the intestines, he would sever them and wash them out, after which he would stitch the abdomen together and rub on an ointment. After a period of about four or five days, there would be no more pain. The patient would gradually regain full consciousness and within a month he would return to normal.
The drink that Chen Shou refers to is mafeisan, a mysterious concoction of plant extracts described as having a powerful anaesthetic effect. Mafeisan remains a longstanding mystery. Both the Records of the Three Kingdoms and the Book of the Later Han credit Hua Tuo with creating this anaesthetic, yet no written formula or list of ingredients has survived. The exact composition of mafeisan, along with much of Hua Tuo’s clinical knowledge, was lost when he burned his manuscripts shortly before his death.
The name mafeisan combines ma (麻), meaning “cannabis,” “hemp,” or “numbed/tingling”; fei (沸), meaning “boiling” or “bubbling”; and san (æ•£), meaning “to scatter” or “medicine in powder form.” The term likely translates to something like “boiled cannabis powder.”
Hua Tuo
Herbal anaesthetics were described in various medical texts throughout Chinese history. For example, Zheng Gu Yao during the Tang dynasty, Shui Sheng San during the Song dynasty (960–1279), and Cao Wu San during the Yuan dynasty (1279–1368) all contain references to anaesthetic formulas. Although their compositions likely differed from that of mafeisan, these herbal decoctions were reportedly used with success in surgical procedures long before the advent of modern anaesthesia.
Dou Cai (1076 – 1146), a Chinese doctor in Song Dynasty wrote in his medical book Bian Que Xin Shu:
For people who could not tolerate the pain during moxibustion. They went to deep slumber after taking Shui-sheng-san without feeling pain……the dose was 3 Qian (15 grams) for adults and 1 Qian (5 grams) for children. For open reduction and internal fixation of fractured bones, Cao-wu-san was used. If the patient was not in sleep after taking Cao-wu-san, he could have a little bit good wine with 5 qian (25 grams) each of Datura flowers and Aconitum in it to get anesthetized. Then you could start. If the patient was like comatose drunk (after taking Cao-wu-san), no more medicine was allowed. There were old and young, weak and bleeding patients, give medicine according to patient’s condition, do not overdose.
These records indicate that traditional Chinese physicians not only performed surgery under herbal general anaesthesia but also understood the varying effects of these herbs on different patients. They were capable of adjusting dosages or combining additional substances to achieve safer and more effective anaesthesia.
Many sinologists and scholars of traditional Chinese medicine have attempted to reconstruct the composition of Hua Tuo’s mafeisan, but its exact ingredients remain unknown. The formula is believed to have primarily included four main herbs: Datura, Aconitum, Radix Angelica acutiloba, and Ligusticum. Other supplementary ingredients may have included Angelica dahurica, Arisaema, Radix ligustici, and Cannabis sativa.
Modern pharmacological research shows that these herbs exhibit anticholinergic, anaesthetic, analgesic, and neuroprotective properties—effects consistent with those required for surgical sedation. Additionally, they possess anti-inflammatory, antimicrobial, antifungal, and antipyretic qualities, further supporting their potential use in premodern surgical care.
The only other physician known to have achieved success with a herbal general anaesthetic was Hanaoka Seishū, a Japanese surgeon of the Edo period.
Hanaoka Seishū
Hanaoka became fascinated by historical accounts of Hua Tuo’s mafeisan and, beginning around 1785, embarked on a quest to recreate a compound with similar pharmacological properties. His experiments were extensive and, at times, personally costly—his wife volunteered to assist in the trials and tragically lost her sight due to the adverse effects of one of the test formulations. After many years of research and experimentation, Hanaoka eventually developed a formula which he named tsÅ«sensan.
The recipe for tsūsensan was as follows:
- 8 parts Datura stramonium (A toxic alkaloid and hallucinogen)
- 2 parts Angelica dahurica (It contains a toxin called angelicotoxin which affects the respiratory system, central nervous system, and the vasculomotor system of the body causing convulsions and paralysis.)
- 2 parts Aconitum (A potent neuro toxin that causes respiratory paralysis or heart failure)
- 2 parts Pinellia ternata (It contains ephedrine, a central nervous system stimulant and sympathomimetic agent that is often used to prevent low blood pressure during anaesthesia.)
- 2 parts Ligusticum wallichii (This plant as analgesic, anti-inflammatory and sedative effect.)
- 2 parts Angelica sinensis
- 1 part Arisaema rhizomatum
These ingredients were ground into a paste, boiled in water, and administered as a drink. After two to four hours, the patient would become insensitive to pain and eventually lapse into unconsciousness. Depending on the dosage, the anaesthetic effect could last anywhere from 6 to 24 hours.
The active compounds in this preparation included scopolamine, hyoscyamine/atropine, aconitine, and angelicotoxin. In combination, these substances produced anaesthesia, sedation, and paralysis. The most significant among them are the tropane alkaloids, particularly atropine—derived from Atropa belladonna and still used today in ophthalmology to dilate pupils—and scopolamine, a potent compound that inhibits the transmission of nerve impulses between neurons.
The first successful use of tsÅ«sensan took place on 13 October 1804, on a 60-year-old woman named Kan Aiya, who was suffering from cancer in her left breast. In stark contrast to Fanny Burney’s agonizingly painful mastectomy seven years later, Kan Aiya’s surgery was notably calm. Hanaoka successfully anesthetized her using tsÅ«sensan, then removed the diseased tissue while she remained unconscious.
Hanaoka would go on to perform over 150 mastectomies before his death in 1835. He also used tsÅ«sensan in a wide range of surgical procedures, including the resection of malignant tumours, bladder stone extractions, and amputations of limbs—all at a time when surgery without anaesthesia was still the norm in most of the world.
Despite the clear benefits of Hanaoka’s work, it had little to no impact on the global development of general anaesthesia. Japan's national isolation policy under the Tokugawa shogunate prevented news of his medical innovations from spreading abroad. It wasn’t until 1854, when Japan reopened to the outside world, that his achievements became known internationally. By then, however, several British and American surgeons had already demonstrated the anaesthetic effects of diethyl ether, nitrous oxide, and chloroform, marking the beginning of modern anaesthesia in the West.
Hua Tuo’s medical abilities were not limited to surgery and anaesthesia. He is also credited with treating a wide range of conditions: he removed parasites, performed abortions, and treated ulcers, sores, and various types of pain using herbal remedies, acupuncture, and other traditional techniques. His treatments as described in the Records of the Three Kingdoms were legendary:
The governor of [Guangling], Chen Deng, had an illness which caused him to be distressed by a feeling of stuffiness in his chest. He also had a red face and no desire for food. [Hua Tuo] took his pulse and said, "Your honour, there are several pints of parasitic bugs in your stomach and you are on the verge of developing an ulcer. This was caused by eating raw fish." Whereupon he prepared two pints of a decoction for the governor, [Hua Tuo] had him drink one pint first and then after a little while had him finish the remainder. In the space of time that it takes to eat a meal, the governor vomited up three pints or so of parasites. They had red heads and were all wriggling; half of their bodies looked like sashimi (raw fish slices). The discomfort that he had experienced was immediately relieved. "This sickness will erupt after three years. If you are attended by a good doctor, he will be able to save you." The sickness did indeed erupt after the specified period. At the time, [Hua Tuo] was not in the area and the governor died as [Hua Tuo] had said he would if he did not have a good doctor.
Cao Cao (155–220 CE), the warlord who rose to power during the final years of the Han dynasty and later established the foundation for the Cao Wei state in the Three Kingdoms period, was likely Hua Tuo’s most well-known patient. Cao Cao suffered from chronic headaches that, during acute episodes, left him dizzy and disoriented. Hua Tuo initially treated the condition with acupuncture, which reportedly alleviated the symptoms whenever it was administered.
Impressed by the results, Cao Cao ordered Hua Tuo to become his personal physician—a position Hua Tuo found burdensome and restrictive. Unwilling to serve at court, Hua Tuo repeatedly requested leave under the false pretence that his wife was ill. When Cao Cao eventually discovered the deception, he was enraged and ordered the physician's imprisonment and execution, despite pleas for clemency from his adviser, Xun Yu.
While awaiting execution in prison, Hua Tuo recorded his medical techniques on a scroll and offered it to the jailer, saying, “This can preserve people's lives.” However, the jailer, fearful of disobeying the law, refused to accept it—and Hua Tuo, rather than insist, asked for a fire and burned the manuscript himself.
The loss of Hua Tuo’s writings was a devastating blow to traditional Chinese medicine. Historian Ilza Veith wrote:
Unfortunately, Hua T’o's works were destroyed; his surgical practices fell into disuse, with the exception of his method of castration, which continued to be practised. Due to the religious stigma attached to the practice of surgery, the social position accorded to the surgeon became increasingly lower and thus made a revival of Chinese surgery impossible.
Cao Cao reportedly regretted the execution of Hua Tuo deeply—especially after the death of his son, Cao Chong, who succumbed to illness that Hua Tuo might have been able to treat.
Hua Tuo's reputation continued to grow in later dynasties, and he became a revered figure in literature, folklore, and popular culture. He appears prominently in the 14th-century historical novel Romance of the Three Kingdoms, where his skills are dramatized and celebrated, further cementing his legendary status.
While Hua Tuo’s use of anaesthesia is widely revered, modern historians question whether mafeisan truly induced full surgical unconsciousness or merely produced a state of deep sedation. As early as the 11th century, the Song dynasty Confucian scholar Ye Mengde expressed scepticism about the more dramatic surgical claims. In his essay “Physicians Cannot Raise the Dead,” Ye Mengde wrote:
I have no way of knowing whether [Hua Tuo]'s medicine could make a person intoxicated to the point of unconsciousness so that he could endure being cut open and could fully recuperate, causing the damaged portions to grow back together again. However, once the abdomen, back, intestines, or stomach have been cut open and dissected, how can they again be infused with vital breath?
Such doubts highlight the difficulty of separating historical fact from later embellishment, especially in traditions passed down through a blend of historical documentation and oral storytelling.
Nevertheless, despite the uncertainty surrounding some of the more miraculous elements of his legend, Hua Tuo’s legacy remains foundational in the history of Chinese medicine. His pioneering use of herbal anaesthesia and surgical intervention was centuries ahead of its time. Whether or not mafeisan functioned exactly as described, it remains among the earliest recorded attempts at anaesthesia anywhere in the world.
References:
# Hua Tuo, Wikipedia
# Peishan Zhao, Xuejiao Yu, Yoko Kagemoto. “Was there Mafeisan, an anesthetic in ancient China?”, Journal of Anesthesia History
# Masaru Izuo. “Medical History: Seishu Hanaoka and His Success in Breast Cancer Surgery Under General Anesthesia Two Hundred Years Ago”. Breast Cancer
# Tomio Ogata. “Seishu Hanaoka and his anaesthesiology and surgery”. Anaesthesia
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