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«Stephen Boyanton Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Graduate School of Arts and ...»

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Although Li Gao in this passage attributes the deaths primarily to mistreatment, the remainder of this text, of which this is the opening section, reveals that the difficulty facing these physicians was formidable. The following sections of the text argue that both external damage— by which Li Gao primarily means cold damage—and internal damage can produce fever and chills, aversion to wind, heat in the hands, changes in the mouth or nose, alterations in the patient’s breathing, headache, difficulty getting up and moving about, and loss of appetite. We are even told that internal damage combined with the heat of summer can produce a condition similar to the yang-brightness disease described in the Treatise on Cold Damage, which produces high fevers, extreme sweating, and a large, surging pulse.412 Li explains in detail how to recognize whether these symptoms are caused by internal or external damage, but the distinctions are often subtle and were all based on Li’s personal experience and reasoning. No previous medical text had made these differentiations. Li Gao refashioned internal damage into a complement for cold damage, producing similar febrile illnesses but demanding very different treatment methods.

Li Gao wrote two books explaining his point of view on internal damage: Eliminating Doubt Regarding Internal and External Damage (Neiwaishang bianhuo lun 內外傷辨惑論,

1247) and the Treatise on the Spleen and Stomach (Piwei lun 脾胃論, 1249). In these books, Li Gao relied primarily on the Inner Classic to justify his doctrinal innovations, but also made occasional references to the Treatise on Cold Damage. Li’s preference for using sweet and warm (ganwen 甘溫) medicinals to treat internal damage, for example, was justified in part by

precedents from the Treatise:

Some may say, “How can sweet and warm [medicinals] generate blood? And these aren’t even medicinals for the blood!” [I] reply, “Zhongjing’s method is to use ginseng [which Neiwaishang bianhuo lun, juan shang, in ibid., 9–16.

is sweet and warm] to supplement the blood when it is vacuous. When the yang is flourishing, then it is able to generate yin-blood.”413 或曰:甘溫何能生血,又非血藥也。曰:仲景之法,血虛以人參補之,陽旺則能生 陰血也。 Moreover, in treating internal damage Li relied heavily on the Treatise. The Treatise’s formulae appear frequently in Li’s two books on internal damage, as do formulae from the Treatise’s sister text, Essentials of the Golden Coffer. Eliminating Doubts Regarding Internal and External Damage includes a list of four formulae for treating basic patterns of the spleen and stomach, two of which are taken from the Treatise.414 A similar list found in the Treatise on the Spleen and Stomach adds two more formulae from the Treatise while replacing one formula from the Treatise with a closely related formula from Essentials of the Golden Coffer.415 In addition to the use of the Treatise’s formulae, Li Gao incorporated another element of the Treatise into his own writing. As noted by the Song author Zhang Lei (quoted above), the Treatise on Cold Damage “describes the method of increasing or reducing [the quantity of medicinals] and adding or removing [medicinals].416 Several formulae in the Treatise are followed by explanations of how to modify the formula to deal with different clinical situations.

For example, following the instructions for preparing Four Reversals Decoction for Unblocking

the Pulse (tongmai sini tang 通脈四逆湯), we find the following advice:

If [the patient’s] face is red, add nine stalks of scallion. If his abdomen aches, remove the scallions and add two liang417 of peony root. If he vomits, add two liang of fresh ginger.

If his throat is sore, remove the peony root and add one liang of platycodon root. If the Piwei lun, juan zhong, changxia shire weikun youshen yong qingshu yiqi tang lun, in ibid., 92; An almost identical passage is found in Neiwaishang bianhuo lun, juan zhong, yinshi laojuan lun, in ibid., 19.

Neiwaishang bianhuo lun, juan zhong, sishi yongyao jiajian fa, in Li Gao, Dongyuan yiji, 21.

Piwei lun, juan xia, piwei sun zai tiao yinshi shi hanwen, in ibid., 124.

Postface, in Pang Anshi, Shanghan Zongbing Lun, 206. This postface is no longer this dissertation of any editions of the text, but is found in the Mount Ke Collection (Keshan ji 柯山集), juan 44.

The liang is the most common unit of weight mentioned in the Treatise on Cold Damage, its exact measure remains unclear, but estimates range from 13-16g. By the Song, the liang was taken to weigh approximately 40g, and medicinal formulae tended to use the qian 錢, one-tenth of a liang or approximately 4g, as the primary measure.

From the Song onwards, most authors used one qian of a medicinal for each liang specified in the Treatise.

diarrhea stops but the pulse is not palpable, remove the platycodon root and add two liang of ginseng root. When the illness is fully in accord with the formula, only then [should the patient] take it.418 其面色赤者,加蔥九莖。腹中痛者,去蔥,加芍藥二兩。嘔者,加生薑二兩。咽痛 者,去芍藥,加桔梗一兩。利止脈不出者,去桔梗,加人參二兩。病皆與方相應 者,乃服之。 The inclusion of modifications for formulas was not typical in either the pre-Song formulary literature or the miscellaneous disease sections of formularies from the Song and after. Li Gao, however, included extensive instructions for modifying the formulae he presented in his books.

For his most famous formula, Supplement the Middle and Increase the Qi Decoction, Li introduces no fewer than twenty-four modifications, written in a style very similar to those found in the Treatise and frequently recommending the same modifications: “If there is abdominal pain, add five fen419 of white peony root and three fen of licorice root 腹中痛者,加白芍藥(五 分)、甘草(三分).” While Li Gao’s formula-modifications were not always identical to those found in the Treatise, his sense of their necessity and the form in which he wrote them further reveal both his concern to adapt medicinal formulae to a specific instance of illness and the influence of the Treatise on Cold Damage on his methods of managing this concern.

Li Gao thus extended Zhang Yuansu’s use of formulae from the Treatise on Cold Damage to treat miscellaneous diseases. He frequently and unselfconsciously recommended the Treatise’s formulae for illnesses due to internal damage. Moreover, his doctrine of internal damage, though devoted to describing miscellaneous diseases, reshaped internal damage into a mirror image of cold damage. While the category of miscellaneous diseases had always been the complement of cold damage diseases in a quantitative sense—whatever was not cold damage was a miscellaneous disease—Li Gao’s formulation of internal damage was a complement of Shanghan lun, juan 6, pian11, p. 11b, line 317, in Zhang Ji, Zhongjing quanshu, 451.

One fen is one-tenth of a qian (see note 111 above). In Li Gao’s time it was approximately equal to 0.4g.

cold damage in a more qualitative sense. Their etiologies were parallel. Evils coming into the body from the outside caused cold damage; evils generated within the body itself caused internal damage. This fact was highlighted by Li’s preference for the previously rare term “external damage” as a synonym of cold damage. Most striking, however, are the ways in which Li Gao unified the treatment of cold damage and internal damage. He used cold damage formulae to treat internal damage, and followed the example of the Treatise by giving extensive guidance on how to modify his formulae to adapt to varying clinical situations. Finally, Li Gao’s interest in internal damage, like Northern Song author’s interest in cold damage, was strongly motivated by his experience of epidemic disease. Li Gao’s doctrine of internal damage blurred the distinction between miscellaneous diseases and cold damage, but did not collapse it. His student, Wang Haogu, would take up that task.

Wang Haogu Wang Haogu was born in Zhao Prefecture in what is now Hebei. He was a younger fellow student of Li Gao’s during Zhang Yuansu’s life. On Zhang’s passing, he took Li Gao as a teacher. Wang’s attachment to the Treatise on Cold Damage is well attested. Of the six texts that can be reliably attributed to him,420 three deal explicitly with some aspect of the Treatise as their primary topic. In his preface to These Things are Difficult to Know (Cishi nanzhi 此事難知, Wang’s first preface, dated 1238, to Materia Medica for Decoctions (Tangye bencao 湯液本草, 1248) mentions four texts he authored: Brief Precedents on Yin Patterns (Yinzheng lueli 陰證略例), Supreme Commander of the Bastion of Medicine (Yilei yuanrong 醫垒元戎, 1237), Gathering Heroes’ Discussions of Macules (Banlun cuiying 癍論萃英, date unclear), and Supplementing the Legacy of Qian Yi (Qian Yi buyi 錢乙補遺, lost). A sixth text, These Things are Difficult to Know (Cishi nanzhi 此事難知, 1264), is extant with a preface by Wang. Twelve other texts are attributed to Wang, but are only attested in late sources and are now lost.

1264), Wang explains that his decided to study with Li Gao because Li could explain the Treatise on Cold Damage correctly.421 Wang Haogu continued Li Gao’s use of the Treatise’s formulae for miscellaneous diseases, but he did so explicitly. In his 1238 preface to Materia Medica for Decoctions (Tangye bencao 湯液本草, 1248), Wang notes that he has at times “… used cold damage prescriptions to treat miscellaneous diseases ⋯⋯以傷寒之劑,改之雜病.” Moreover, he also applied the Treatise’s doctrines and nosological divisions to miscellaneous diseases. He particularly emphasized applying the six-channel nosology of the Treatise to all types of illness. In his short text on childhood macular rashes, Gathering Heroes’ Discussions of Macules (Banlun cuiying 癍 論萃英, date unclear), Wang opined, “On the whole, treating [macules] in the same way you treat cold damage is the most insightful opinion. Use medicinals in accord with the [six] channels. You cannot be remiss 大抵傷寒同治,最為高 論,隨經用藥,不可闕也.”422 In Supreme Commander of the Bastion of Medicine (Yilei yuanrong 醫壘元戎, 1237),423 Wang divided all illnesses among the six channels of the Treatise on Cold Damage—completely ignoring the distinction between cold damage and miscellaneous diseases. In the conclusion of the book, he made his point clear by repudiating the distinction between methods (fa Preface, in Wang Haogu, Wang Haogu yixue quanshu, 115. This preface is dated 1308, “至大改元;” however, this is inconsitent with the dates of Wang’s other works. It is generally believed to be an error for 1264 “至元.” Banlun cuiying, Haicang Laoren banlun, in ibid., 168.

Fabien Simonis translates this title as Medical Ramthis dissertations Against the Yuan Barbarians. This translation is possible--and the double entendre may have been intentional--but neither the preface nor the body of the book supports this reading. It is more likely that the term “supreme commander (yuanrong 元戎)” is a reference to Zhang Ji, whose ideas are the backbone and structure of the text. Simonis, “Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine,” 106.

法)—associated with the Treatise—and formulae (fang 方)—associated with

miscellaneous diseases:

Those in the world who treat cold damage have methods; those who treat miscellaneous diseases have formulae. Although this is so, it is still incorrect. I say that in treating miscellaneous diseases there are also methods; in treating cold damage there are also formulae. Methods are precisely formulae; formulae are precisely methods. Is there a difference [between them]?

世之治傷寒有法,療雜病有方,是則是矣,然猶未也。吾謂治雜病亦有法,療傷寒 亦有方,法即方也,方即法也。豈有異乎。 For Wang Haogu, all illnesses could be understood and treated using the methods and formulae of the Treatise on Cold Damage. Like Zhang Zihe of the Hejian current, Wang’s views anticipated ideas which would become widespread at the end of the Ming dynasty, almost four centuries later, but during his lifetime, they were by no means universally accepted.

The Danxi Current By far the most influential of the medical currents that developed in the 13th and 14th centuries, the Danxi current exerted tremendous influence on text-based medicine in the Ming dynasty, rivaling—though never eclipsing—the influence of the Treatise on Cold Damage and Zhang Ji.424 The founder and center of the Danxi current, Zhu Zhenheng is better known by the epithet Danxi 丹溪—the name of a creek near his home. A native of Wu Prefecture in what is now Zhejiang, Zhu studied Learning of the Way Confucianism and sat for—and failed—the civil service examinations twice before turning to medicine.

Zhu’s approach to medicine self-consciously synthesized the approaches of his 13thcentury predecessors. By selectively emphasizing different aspects of previous medical authors’ Ibid., 136–201.

work, he was able to forge a synthetic style of practice that he claimed combined the best of all medical ideas. Zhu also placed great stress upon the individualization of treatment. Recent scholarship has frequently presented this individualization as an innovation of Zhu’s, but, as this chapter has shown, the variability of illness and the consequent need to individualize treatment was a central concern of elite medical thought from the Song onwards. Zhu Zhenheng was certainly one of the most vocal champions of this method, but he was by no means the first.

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