Category Archives: Medical Practitioners

Canine Cures or Our Best Friend…

By Marc Bruck

To paraphrase the old adage: dogs are humanity’s best friend. Loving, loyal and protective, they are often considered members of the family. They are symbols of wealth and power, love and affection. Recent accounts in the popular press, such as the Guardian’s piece from July “Hot dogs: What soaring puppy thefts tell us about Britain today”, have shown that they are also valuable accessories to modern life. However, in Early Modern Europe, the qualities of the canine were much more varied than that of a cherished companion. In particular, until the end of the Eighteenth Century, folk healers identified dogs as treasure troves for medical remedies and treatments. While an affront to many modern sensibilities, dogs were not simply pets, but were themselves useful sources of materia medica that cured a variety of ailments.  This essay puts the focus on an aspect of dogs that is ubiquitous with the ownership of the animal, dog feces, which was known in medicinal terms as album graecum

The use of  dog feces in medicine can be traced back to ancient Egypt and classical Greece and Rome. Known by a variety of medicalized names in the premodern period, including album graecum, tercus canis, cynocoprus,zibethum caninum, and flores melampi, the medical feces comes from dogs that are fed limited diets of bones alone.  Album graecum, therefore, is white dung produced by a dog (preferably a white one) that is free of color and obnoxious smells (Fig. 1).

Figure 1 – Album graecum

At the chemical level, album graecum contained significant amounts of calcium phosphate, mineral that figures prominently in many modern drugs and remedies.  Today, for human consumption, the mineral is largely extracted from the mineral Apatite, while in veterinary practice it is derived from animal calcium and bone meal.

In early modern European recipe books, album graecum was used as a dried and friable element in medicines for everyday ailments.  For instance,  one can find the white powder incorporated in the records of the seventeenth century German doctors von Mynsicht (1588-1638) and Ettmüller (1644-1683).  In the eighteenth century, album graecum appeared in pharmacopoeias across Europe. The Cyclopaedia of Chambers of 1728 designates its usage “with honey, to clean and deterge, chiefly in Inflammations of the Throat; and that principally outwardly, as a Plaister.”

The medicinal uses of the materia medica of dogs figures prominently in a fascinating mid-eighteenth century medical manuscript written by a healer called Sébastien-François de Blanchart.  Penned largely in French, de Blanchart’s work is known as the “Vieux recueil de remèdes” and commonly called “Blanchart’s Remedies.” It is currently housed in the National Archives of Luxembourg, where it has been scanned for digital access for the public.  While little is known of Blanchart, his remedies featured everyday materials of unsanctioned healers of Early Modern France.  In particular, dog feces, or album graecum as it was known in Latin, figured prominently in remedies for moderate internal inflammation. 

The seventeenth century healer de Blanchart considered album graecum essential to the treatment of common maladies affecting the throat, though not for those where the inflammation obstructs breathing and swallowing (Fig. 2). His records show that white powder could be administered directly to the uvula by means of a feather or combined into a serum. In one recipe, he records its combination with a mixture of everyday items, including beer and honey. 

Figure 2 – Sébastien-François de Blanchart, Vieux recueil de remèdes, fs 200. National Archives of Luxembourg.

De Brouchart’s recipe for throat ailments calls for the following: 

1 pint of beer of the strongest and oldest available

6 pieces of Album graecum

2 spoons of mel rosatum (honey)

The preparation involved cooking the ingredients over a gentle fire until the liquid reduced to half its volume. The liquid was to be strained and sieved, before being administered to the patient either consumed by the spoonful or by rinsing the mouth.  

Materials derived from dogs figure prominently in numerous recipes from de Brouchart and other early modern European medical texts, which we will pick up in a subsequent post called “Puppy Love.” For more on the use of dogs in remedies, please see: Lisa Smith’s “The Puppy Water and Other Early Modern Canine Recipes” from October 23, 2018. 

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I am most grateful to Mme Zeien curator and librarian at the Archives nationales for making the digitised document available; it was originally classified as item 423 of the 15th department of the historic section of the Institut grand-ducal in Luxembourg.

Ovid’s Toothpaste: Literary Allusion in One Medieval Cosmetic Recipe

By Chelsea Rae Silva

Women, declares the sixteenth-century physician Donatus Antonius de Altomare, “think nothing more unseemly… then when they laugh, to show their foule rusty & spotted teeth.” In order to remedy this issue, his text promises to “first shew how we may make [teeth] that are blacke as white as the shining pearles, & then how we may cover with flesh them that are weake & naked in their gums & how we may make them strong” (London, British Library MS Harley 4349, f. 258v). As Seth LeJacq noted on this blog back in 2013, the use of remedies would have been preferable for late medieval readers wishing to avoid painful surgical procedures like the one pictured below.

A dentist with silver forceps and a string of large teeth, extracting the tooth of a seated man (from London, British Library, MS Royal 6 E VI, f. 503v). Image credit: Wikimedia Commons.

Altomare’s pronouncement, and the remedies that follow, attest to the indistinct boundary between cosmetic and medical arts, and between literary and medical discourse. I first encountered Altomare’s manuscript collection in the British Library last summer and have been fascinated by its contents for the better part of a year. Much of that fascination stems from Altomare’s use of literary techniques like allusion, personification, and narrative in his discussion of medical and cosmetic care.

The cosmetic recipes are grouped together and, unlike the other recipes in the manuscript, read as a continuous passage rather than a sequence of distinct texts. Altomare apparently anticipated the possibility of a reader who might crack open this portion of his medical collection to read—linearly, continuously—rather than to learn piecemeal. Perhaps the most interesting of these recipes are two deceptively simple ones for dentifricia, or tooth-paste or -powder:

“Also of the pumis stone the best & most profitable dentifricia weare prepared as Pliny saith. And the teeth rubbed with the poulder of yvory the teeth were made like yvory as Ovid.” (f. 259)

The allusion is explained at the top of the following folio, which bears the sentence “what if I command you to wash your mouth in the morning with water, that your teeth looke not blacke.” This is an admittedly poor translation of a question from the Ars amatoria—“Quid, si præcipiam, ne fuscet inertia dentes, / Oraque suscepta mane laventur aqua?”one that elides the original attention to handwashing in favor of emphasizing dental hygiene.[1]The textual evidence suggests that the scribe himself may have found this confusing, and the presence of the quotation on the top of the next page, without any clear connection to its original author’s name on the bottom of the previous folio, likely contributes to this uncertainty. But in its awkward placement, the reference to Ovid also invites a kind of literary thinking enabled by the text as it appears to read on first glance: the equation of some work by Ovid with the kind of transformation described by Pliny.

Ovid is better-known for his storytelling than his medical expertise (although his Art of Beauty, does include a number of cosmetic recipes, all are for facial cleansers or masks and none make use of ivory or claim to remedy dental issues). But the parallel implied between Ovid and Pliny is not necessarily medical in nature; instead, that two-word reference—“as Ovid”—suggests a literary resonance in the form of the story of Pygmalion. In doing so, it evinces the entanglement of literary and medical textual traditions, and the slippage that might occur between them.

Ovid’s version of Pygmalion properly begins with the Propoetides, women who became the first sex workers after denying Venus’s divinity. “Losing all sense of shame,” the story goes, “they lost the power to blush, as the blood hardened in their cheeks, and only a small change turned them into hard flints.” A skilled sculptor living in Amanthus, Pygmalion is disgusted by the Propoetides and, by extension, all mortal women. Rather than seek out a partner or a wife, he instead carves a beautifully lifelike statue out of ivory. The statue is so realistic that even Pygmalion himself is half-convinced that it’s a flesh-and-blood woman, and the craftsman falls in love with her. After he prays to Venus, the sculpture is transformed into a living being, and the two are married soonafter.

Pygmalion working on his sculpture (from Jean de Meun’s Roman de la Rose; MS NLW 5016D f. 130r). Image credit: Wikimedia Commons.

What I’m most interested in is just how that transformation is effected. Returning home from Venus’s temple, Pygmalion repeatedly kisses and strokes the statue’s body, and the ivory begins to soften like wax under his fingers. He continues to kiss and touch her, “reaffirm[ing] the fulfilment of his wishes, with his hand, again, and again,” until the transformation is complete. In other words, it is the repetitive press and rub of flesh against the statue’s ivory which changes it into flesh itself.

That’s a surprisingly rich allusion to find in a recipe for tooth powder, but as recent discoveries have shown, we can learn a lot from medieval teeth. The touch of Pygmalion’s hand transforms ivory into flesh; so too, the dentifricia recipe suggests, might the application of ivory to teeth transform those teeth into ivory themselves. That two-word note, “as Ovid,” may allude to the events of the Pygmalion story, popular throughout the medieval West because of its presence in texts like Jeun de Meun’s Roman de la Rose. But it may also work as a promise of efficacy, suggesting to the reader that her teeth will be as beautiful as the ivory maiden’s skin. The latter possibility makes this two-word addition an interesting twist on the regimens falsely attributed to various noble ladies, like the dietary of Queen Isabella, in circulation at the time. This tooth-whitening recipe suggest that the power of celebrity to sell things like skin care regimens might have extended to literary and mythological characters as well.

Correction: This post has been updated to attribute the Ovid quote to the Ars amatoria.


[1] Ovid: The Art of Love and Other Poems, trans. J. H. Mozley and revised by G. P. Goold, Loeb Classical Library 232 (Cambridge: Harvard University Press, 1929), ll. 197-98.

Pigeon slippers

By Robert Ralley and Lauren Kassell

The Casebooks Project, a team of scholars at the University of Cambridge, has spent a decade studying 80,000 consultations recorded by the seventeenth-century astrologer-physicians Simon Forman and Richard Napier. To mark the completion of our work, we selected 500 cases for full transcription. When the launch was announced on 16 May 2019, it received considerable media attention. Headlines included ‘Prescribing deer dung and pigeon slippers’ (BBC news), ‘Purges, angels and “pigeon slippers”’ (The Guardian), and ‘“Kisse myne arse”: Doctor’s notes reveal bizarre medical notes from 400 years ago’ (c/net).


Fig. 1: Richard Napier’s CASE51060, MS Ashmole 414, f. 76r. Bodleian Library, University of Oxford.

When Mrs Elizabeth Chester, suffering from hot, red eyes, consulted Richard Napier, the Anglican rector and astrologer, in June 1620, his remedy included ‘a pigon slitt & applyed to the sole of each foote’ (see Fig. 1). Applying freshly killed pigeons to the feet or other parts was not one of Napier’s standard treatments, but we have spotted references to it in around 30 cases. More instances await discovery amidst the 70,000 consultations that Napier recorded between 1597 and 1634. Roughly half record treatments. Often unhelpfully shortened to ‘pig’ – whence remarks such as the cryptic-looking ‘pig to the feete’ – this remedy appears often enough for Joanne Edge, one of the Casebooks Project’s editors, to dub it ‘pigeon slippers’.

We don’t know whether Napier read about the use of pigeons in a medical book or learned it from another healer. It’s not amongst the treatments, as far as we can tell, that he learned from his mentor, Simon Forman. Napier first recommended slit pigeons, twice, in March 1607 (see here and Fig. 2; and here), and occasionally thereafter for the rest of his career.

Fig. 2: Richard Napier’s CASE30882, MS Ashmole 193, f. 113r. Bodleian Library, University of Oxford.

Pigeons were common in early modern Europe. People kept and ate them, their broths were fortifying, and distillations made from them were good for the skin. English medical texts, typically translated from earlier Latin and vernacular editions, regularly referred to blood drawn from under their wings to help with eye troubles. From antiquity, pigeon dung featured in plasters and drinks for numerous remedies. Galen, the great second-century physician, had recommended the application of freshly-killed pigeons, puppies and ram lungs to the head. Medieval medical treatises and recipe collections perpetuated the practice, especially for cases of frenzy. Physicians trained at Montpellier applied pigeons to the chest to comfort the heart. Sixteenth-century books of secrets recommended pigeons—either freshly killed or live with their tail feathers plucked—to draw foul matter out of plague buboes. Napier duly noted, ‘apply halfe a pigeon new slitte to the outsyde of the sore’.

Medieval texts often recommended rubbing the feet, and other extremities, with salt, vinegar and wine, but so far the earliest reference we’ve found to ‘A quick Pidgeon cut in two, and bound to the soles of the feet’ is by Felix Platter, the distinguished Basel physician, in his extensive 1614 medical book.[1] Used with other remedies, pigeons to the feet helped ensure a speedy recovery. By 1638, the Hull physician James Primerose noted that ancient and modern writers advised applying pigeons to the head in diseases of the brain, but, to his knowledge, this was rarely done in practice. Rather, ‘the common people’ and ‘very many physicians’ instead applied pigeons to the feet.[2] Napier’s casebooks attest to this. He usually recommended slit pigeons to the feet for problems of the head or throat, whether a swollen face (see Fig. 3), hot, running or sore eyes (see Fig. 4), or even a bad cough. A handful of cases concern the mind, from what Napier called ‘lightheadedness’ (not dizziness), via melancholy, up to frenzy. Occasionally he chose the neck instead or both neck and feet. He always combined pigeons with other therapeutics (various internal medicines, ointments, clysters, blisters and bloodletting, for instance). When in 1632 the vicar of Westmill, Hertfordshire reported to him that a parishioner had been treated for frenzy with pigeons to her feet and a slit cock all over her head, Napier replied suggesting a sigil and a list of medicines.

Fig. 3: Richard Napier’s CASE23369, MS Ashmole 238, f. 212v. Bodleian Library, University of Oxford.

In seventeenth-century England, pigeon slippers seem to have become standard in the medical repertoire. John Hall, the physician from Stratford-upon-Avon who married Shakespeare’s daughter, recorded that when he suffered from a ‘light Delirium’ caused by a dangerous fever in 1632, the cure included ‘a Pigeon cut open alive, and applied to my feet to draw down the Vapours’.[3] Theodore de Mayerne and fellow royal physicians applied a pigeon to the head of the ailing Prince Henry in 1612, and a slit cock to his feet, without success.[4] Samuel Pepys, in his famous diary, recorded the treatment’s use when patients’ lives were in danger: in October 1663 he noted that Catherine of Braganza ‘was so ill as to be shaved and pidgeons put to her feet, and to have the extreme unction given her by the priests’; in January 1667/8 he visited the house of a man whose ‘breath rattled in his throate, and they did lay pigeons to his feete while I was in the house, and all despair of him, and with good reason’. There is no sign that Napier regarded the treatment as a last resort.

Fig. 4: Richard Napier’s CASE23227, MS Ashmole 238, f. 190r. Bodleian Library, University of Oxford.

For learned physicians and laypeople alike, pigeon slippers worked through attraction. Just as Hall explained that they had ‘draw[n] down the Vapours’, so in 1604, Napier noted that William Godfrey, who suffered from bloodshot eyes and a hot rheum, had ‘applyed a pigeon slitte to his necke which drew the rheume thither & eased’. In May 1600 Napier recorded that Mother Gale had decided that a boy’s burning shoulders, aching back and swollen knees were because he was forspoken (bewitched), and treated him by putting ‘a cock pigion slit to his … face’ and throwing his nail parings in a fire. Perhaps her rationale was to remove some sort of poison, as when slit pigeons were applied to plague sores. Primerose considered and dismissed the possibility that the pigeons’ gentle heat on a patient’s feet could affect the head and its humours at all. ‘Nevertheless’, he wrote, ‘I doe not absolutely speake against the applying them to the soles of the feet, because it may doe a little good, and cannot doe hurt.’[5]


[1] Platerus golden practice of physick fully and plainly discovering, trans. Nicholas Culpeper, 1664, Bk 2, Ch. 2, Of fevers.

[2] James Primerose, Popular Errours, trans. Robert Wittie (London, 1651), p. 397.

[3] John Hall, Select observations on English bodies of eminent persons in desperate diseases (transl. James Cook, 1679), OBSERV. LX.

[4] Hugh Trevor-Roper, Europe’s Physician (2006), p. 172.

[5] James Primerose, Popular Errours, transl. Robert Wittie (London, 1651), p. 400.

How Best to Treat the Heat in 1793 Beijing

By Marta Hanson

Translating traditional Chinese medical terms into modern English forces one to consider dramatic changes in medicine over the past two centuries. Take, for example, the modern Chinese phrase fa re for “fever,” which literally means “to produce (fa) heat (re).” Although today it refers to elevated body temperature, traditionally it referred to the preternatural heat that patients experienced dispersed throughout their bodies and only sometimes referred to elevated skin temperature.[1] In fact, before the late 19th-century, the English term “fever” also contained multivalent meanings and multifarious patterns of excessive heat.[2] Fever in the sense of having a temperature above the 97.3 to 99.5 °F human range was not even defined in western medicine, nor a convenient clinical thermometer invented to measure it, until the late 1860s.[3] Although many of the febrile-related symptoms that fall under the Chinese disease concept “Hot diseases” (rebing) could fit under the biomedical umbrella of acute-infectious diseases, in classical Chinese medicine they were originally conceptualized as caused by climatic configurations of qi (i.e., vital energy/matter).[4]

The Yellow Emperor’s Inner Canon: Basic Questions (ca. 1st c. BCE) originally distinguished two types of Hot diseases related to different types of climatic qi. The first included an acute-onset febrile disorders caused by external pathogenic qi related to changing seasons or local weather. The second was a type of “Cold Damage” (shanghan) acquired in the winter but which went dormant until the heat of the spring or summer manifested it as excessive heat and internally impairing dryness. The first Inner-Canon definition that Hot diseases could be due to other types of pathogenic climatic qi also facilitated conceptualizing epidemics as due to pathogenic environmental qi unrelated to the winter cold or local climate.[5] Nonetheless, no matter the original cause when excessive heat was the result, it had to be expelled.

An interesting case of disagreement on how best to “treat the heat” occurred in Beijing during a febrile epidemic (wenyi) in the spring and summer of 1793. The Qing official, Ji Yun (1724–1805) unusually responded to this epidemic by comparing the success rate of three therapeutic drug strategies. The first, associated with Zhang Jiebin (1563-1640), resulted in 80–90% mortality. The second, promoted by Wu Youxing (1582?-1652), was no more effective. But a third formula created by the living doctor, Yu Lin (ca. late 18th cent.), had successfully cured the concubine of the Chief Minister of the Court of State Ceremonies, Feng Yingliu (1741–1801) with a strong gypsum-based formula.[6] Ji noted that those who witnessed this were shocked but those who followed his method ended up saving countless lives.[7]

The three competing cures in Ji’s short anecdote illustrate well how Cold and Heat were the main metaphors used to understand the cause of epidemics and legitimate drug choices for treating them. Zhang’s “warming and tonifying” (wenbu) tonics were based on what the Cold Damage Treatise (Shanghan lun, ca. 220 CE) recommended for treating Hot diseases (believed to have their origin in winter Cold manifested in the summer). These included warming herbs such as Cassia twig (guizhi) and Ephedra (mahuang) to release cold via the exterior and Aconite (fuzi) to warm the exterior and expel cold.  [See rebing entry to far left in Figure 1]

Medication chart from the Gold-Dusted Cold Damage [Treatise] (Shanghan diandian jin, completed 1341, date of this printing unknown). Image credit: Wellcome Collection.
 Wu’s “purgative” (gongxia) formulas contained Rhubarb root and rhizome (dahuang) to purge downward, and even Betel Nut (binglang) to expel pathogenic qi.  Wu termed this anomalous qi (yiqi), deviant qi (liqi), or pestilential qi (liqi) in his Treatise on Febrile Epidemics (Wenyi lun, 1642). [See figure 2] As He Bian has written on this blog, Chinese rhubarb had its heyday in the eighteenth century, yet not all physicians were in accord with its suitability during epidemics.

 

Rhubarb from Li Shizhen’s Systematic Materia Medica (Bencao Gangmu) printed in 1596.

The third author named in this story, Yu Lin, later became famous for his recipe titled: “Epidemic-Clearing and Toxin-Dispersing Beverage” (Qing wen bai du yin). [8]  The fourteen-ingredient recipe was based on a combination of the White Tiger Decoction (baihu tang) that cleared out heat on the exterior with two other formulas.[9]  Yu’s recipe, however, featured crude gypsum (i.e., the “White Tiger”) in quantities at least three times the other main ingredients (raw foxglove root, rhinoceros horn, and coptis root). This made it an extremely Cold formula, and potentially life-threatening for those who thought Cold was the underlying cause and so used Zhang’s formulas. For Yu, however, Gypsum’s cold-cooling quality cleared excessive heat accumulated in the stomach system. [Figure 3 depicts this heat-clearing function of gypsum at the center of the man’s chest).

Depiction for White Tiger Decoction in Illustrations and Explanation of the Major Formulas of the Cold Damage Treatise (Shanghan lun dafang tu jie, 1833). Image credit: Wellcome Collection.

Expelling pathogenic Cold qi and warming the interior with aconite and cassia twigs, purging pestilential qi through the bowls with rhubarb, and clearing out the pathogenic Heat from the stomach with gypsum were thus all therapeutic strategies at play during the 1793 epidemic in the capital. The first framed the cause of the epidemic in latent winter cold that had to be dispersed. The second saw it as externally contracted pestilential qi that needed to be purged. Finally, the third considered it excessive heat that had to be cleared. Despite these major differences all three approaches nonetheless treated the febrile symptoms subsumed under fa re or, in the modern term, “fevers” as something that drugs could manage by adjusting the internal balance of Hot and Cold.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Translations for Figures 1 and 3

Figure 1: From right to left are listed three disease concepts – Cold Damage, Wind Damage, and Hot Diseases. Their commonly used formulas are written below. The six formulas listed under rebing are from right going down and then to left going down: With sweat cassia twig decoction (han guizhi tang), Cassia twig and gypsum decoction (guizhi jia shigao), Cassia twig decoction together with gypsum, anemarrhena, cohosh, and ephedra (guizhi jia shigao zhimu sheng[ma] ma[huang], Without sweat ephedra decoction (wuhan mahuang tang), Evening produced (i.e., heat) gardenia, cohosh, and ephedra decoction (wan fa zhizi sheng[ma] ma[huang]), and Cassia twig decoction with ephedra and gypsum (guizhitang jia mahuang shigao).

Figure 3: From the right to left across the top is written. 1) “The assistant [drug] Amemarrhena (zhima) disperses dryness [and] produces jin [fluids].” 2) the space below the chin reads “protects the lungs.” 3) and to the left is written “licorice (gancao) harmonizes the stomach and rice (gengmi) assists the stomach qi.” 4) The 5-character phrases on either side of the oblong circle together state the therapeutic strategy “[When] the pathogenic [qi] has already changed into Fire, then clear, cool, and make it disperse.5)  In the long oval at the center of the body, the phrase instructs: “When it [i.e., the Fire} enters the stomach, use gypsum.”

[1] Nathan Sivin, Traditional Medicine in Contemporary China, Science, Medicine, & Technology in East Asia 2 (Ann Arbor: The University of Michigan Center for Chinese Studies, 1987), xxiv-xxv, 86, 108.

[2] Christopher Hamlin, More Than Hot: A Short History of Fever, Johns Hopkins Biographies of Disease (Baltimore: John Hopkins University Press, 2014).

[3] J.M.S. Pearce, “A brief history of the clinical thermometer,” QJM: An International Journal of Medicine 95.4 (1 April 2002): 251-52. Thomas Clifford Allbutt (1836-1925) invented the 6-inch thermometer that was first able to record a temperature in 5 minutes in 1866 and in 1868 Carl Wunderlich, using a foot-long thermometer put in the axilla (i.e., armpit), established the normal range from 36.3 to 37.5 °C or 97.3 to 99.5 °F.

[4] Shigehisa Kuriyama, “Epidemics, Weather, and Contagion in Traditional Chinese Medicine,” in Lawrence I. Conrad and Dominik Wujastyk, eds., Contagion: Perspectives from Pre-Modern Societies, (Aldershot, Hampshire: Ashgate Publishing Limited, 2000), 3-22.

[5] Marta Hanson, Speaking of Epidemics in Chinese Medicine: Disease and the geographic imagination in late imperial China (London: Routledge, 2011), 16-17.

[6] Gypsum is monoclinic calcium sulfate. See discussion of this episode in Hanson, Speaking of Epidemics, 2011, 126-27.

[7] Ji Yun 紀昀, Yuewei caotang biji 閱微草堂筆記(Jottings from Yuewei Hall), printed 1800. Repr. Shanghai: Shanghai guji chubanshe, 1980. Passage in juan 18, jotting #24, 458-9. Online access https://ctext.org/library.pl?if=gb&file=36038&page=45&remap=gb

[8] Jian Min Wen and Garry Seifert, translators, Warm Disease Theory, Wēn bing xúe (Brookline, Mass.: Paradigm Publications, 2000), 141.

[9] White Tiger Decoction is used to treat an illness pattern with great heat, thirst, and sweating and a surging and large pulse. For analysis of the logic of the formula see Craig Mitchel, Feng Ye, Nigel Wiseman, Shang Han Lun: On Cold Damage: Translations & Commentaries (Brookline, Mass.: Paradigm Publications, 1999), 316-24