FOUR    The Search for Therapies in the Far South

ZHANG AS MIASMA AND SOUTHERN DISORDERS

Zhang was one of the most frequently discussed families of far-southern disorders in imperial China, from the earliest written records that mention it in the fifth century to its treatment in the Song era.² Its Chinese character, understood as denoting epidemics occurring in the south, can be traced to the fifth century. Before then, this character appeared neither in excavated early manuscripts nor in The Inner Canon, which is the oldest of any medical texts considered canonical and contains materials dating to the Han era.³ The character for zhang appears, for example, in the biography of Ma Yuan (d. 49 CE), which Fan Ye wrote as part of a standard history, History of the Later Han (Hou Han shu), and presented it to the court in 445 CE. According to the biography, Emperor Guangwu (5 BCE–57 CE, r. 25–55 CE) commissioned Ma in 42 CE to suppress a rebellion on the far-southern border, in Jiaozhi (now the northern area of Vietnam). When he was there, Ma often consumed coix seeds (yiyishi) to overcome the “miasmatic atmosphere” (zhangqi).⁴ In the autumn of 44 CE, after Ma’s armies quashed the rebellion, approximately 40–50 percent of the soldiers involved died in zhang epidemics (zhangyi).⁵ The biography used the character for zhang to refer to the miasmatic atmosphere and fatal epidemics but introduced no explanations of what might have triggered them.

A report by Yang Zhong to Emperor Zhang (57–88 CE, r. 75–88) in 76 CE (another record in History of the Later Han) used the term zhang to denote obstacles, when referring to a debilitating issue arising from the southern environment. In the report, Yang said: “The south is ‘summer hot’ (shu) and damp; ‘obstacles’ (zhang) and ‘the toxic’ (du) give rise to each other.”⁶ Yang used this explanation to persuade Emperor Zhang not to exile political criminals to the remote southern areas of China. By extension, in his report, the character for zhang was used in reference to disorders that were specific to the south to discourage migration. Yang ascribed the southern-specific disorders to the “summer heat” (shu) and dampness in that region.⁷

After the Eastern Han dynasty (25 CE–220 CE), Lingnan became an area in which zhang was thought to be endemic. Existing studies formulate the development of the concept of zhang as follows: The ceaseless warfare occurring in northern China between the third and sixth centuries impelled a flow of northern immigrants to the south during this period. These immigrants suffered from various unfamiliar disorders in Lingnan, and they used the character for zhang as a portmanteau term to denote these.⁸

Along with the increasingly closer connection between Lingnan and the geographical origin of the rampant zhang from the third century onward, the early seventh century witnessed the appearance of the first medical treatise that introduced and categorized zhang-related disorders in independent sections, rather than discussing them side by side with other disorders. That was Treatise on the Origins and Symptoms of All Disorders (Zhubing yuanhou lun, hereafter Origins and Symptoms). It was the first such treatise on etiology in China, compiled by the Sui court in 610. In the late sixth century, the founding emperor of the Sui, Wendi (r. 581–604), had ended four hundred years of political division between areas that we now think of as parts of China. After bringing the country back under the control of a single central government, Wendi and the second (and also the last) emperor of the Sui, Yangdi (r. 608–618), extended their unifying efforts to economic and cultural projects, such as dredging the Grand Canal to improve the transportation of goods between northern and southern China. One outcome of these ambitious projects was the completion of Origins and Symptoms, whose grand title signals the government’s ambition to cover the etiologies of all disorders known at that time. In its section on “symptoms of zhangqi,” a wide variety of disorders were attributed to zhangqi in Lingnan, such as alternating chills and fever, headache, a feeling of fullness in the chest, and a feeling of expansion or bloating in the abdomen.⁹ Origins and Symptoms provided the foundation of the etiologies and symptoms of zhang disorders for all later medical texts.¹⁰

Given the wide range of phenomena that imperial authors attributed to and categorized under the term zhang, recent studies have refrained from translating the term as “malaria” or “miasma.”¹¹ This book likewise does not adopt a singular English translation but instead refers to a zhang atmosphere or zhang disorders, according to the context. Avoiding translating zhang as “malaria” makes sense not only because its meaning varied across narrative contexts but also because retrospectively diagnosing a given historical disorder as a modern disease might kindle a methodological controversy in the field of medical history. Such a retrospective diagnosis presumes that modern disease categories mirror the naturalness or ultimate identity of diseases, representing what medical historians call a “natural-realist approach.” Instead, this book applies what scholars call a “historicalist-conceptualist approach,” which analyzes concepts of a given disease as historical products shaped by surrounding sociocultural developments.¹²

THE FORMULARY FOR SAVING LIFE IN LINGNAN

Neither Li Qiu’s nor Wang Fei’s formularies survived as independent texts; instead, they were preserved in partial form in a Yuan-dynasty formulary. After obtaining his jinshi degree in 1112, Li traveled extensively during his career as a civil official. In the south, he was appointed to Ying Prefecture (in Guangdong) in 1121, thereafter residing in Cangwu in 1131 and Ji Prefecture (in Jiangxi) in 1134.¹³ The court then promoted Li to the rank of “imperial attendant” (daizhi) in 1139, and he became the magistrate of Chengdu Prefecture in 1143.¹⁴ With extensive travel experience but no formal training in medicine, Li wrote a formulary that was devoted to far-southern disorders, which came to be known in the Song and Yuan periods as Treatise on Zhang, or alternatively The Formulary for Saving Life in Lingnan (Lingnan weisheng fang).¹⁵ The fifteenth-century encyclopedia Great Compendium of the Yongle Era includes a formulary by Li Qiu but called it Treatise and Formulary for Preserving Life in Guangnan (Guangnan shesheng fang lun).¹⁶ Unfortunately, textual evidence regarding this title is too sparse to infer whether it was another name for Li’s Treatise on Zhang or if Li wrote two formularies on disorders in Lingnan.

Sometime between 1131 and 1139, Zhang Zhiyuan (1090–1147) expanded Li’s Treatise on Zhang. He obtained his jinshi degree in 1121 and served as the magistrate of Guang Prefecture (in Guangdong) between 1138 and 1140.¹⁷ Zhang left no words indicating how he obtained Li’s formulary, while describing at length how meticulously he examined Li’s medical opinions after receiving the text. He discussed the formulary with a “physician-scholar” (yishi), Wang Zijin of Hua Prefecture (in Henan), and tested the formulas collected therein. After confirming their therapeutic efficacy, Zhang composed his own formulary, in which he recorded the etiology of and prescription strategy for zhang disorders in Lingnan in a manner similar to what he saw in Li’s work. Zhang’s expanded version was also named variously, including Treatise on Zhang, Treatise on Zhang and Intermittent Fever, and The Formulary for Saving Life in Lingnan (Lingnan weisheng fang).

The short time period that passed between the completion of Li Qiu’s Treatise on Zhang and the completion of Zhang Zhiyuan’s work is noteworthy. In the extant Treatise on Zhang, Li mentions no plan to publish the formulary. No more than eight years after its completion, however, Zhang produced a follow-up formulary. Such a short interval suggests the considerable likelihood that Li had published or circulated his formulary, at least in manuscript form, among his acquaintances in Lingnan.

Later, Wang Fei, an official whose background is obscure, commented on both Li’s and Zhang’s versions and also wrote a follow-up formulary, Instructing the Lost, between 1139 and 1177. Unfortunately, none of the formularies written by Li, Zhang, or Wang has survived as an independent work. Only three lengthy essays drawn from each are preserved in a Yuan-dynasty formulary that bears the same title: The Formulary for Saving Life in Lingnan. Its author, a Buddhist cleric, Jihong, departed from Henan, traveled in Lingnan sometime between 1254 and 1264, moved to Jiangxi in 1265, and resided in Zhejiang between 1272 and 1274. He treated several people and wrote essays about medicine during his travels. He collected his essays on far-southern disorders and parts of other Song officials’ formularies into his Formulary for Saving Life in Lingnan, writing a preface to this work in 1283.

Drawing on multiple formularies, the Song officials’ medical essays that are preserved in the Yuan edition of The Formulary for Saving Life in Lingnan can by no means be simplified as northerners’ stereotypes of the far south. Some authors were northerners, whereas others actually came from the south. Li Qiu’s “place of origin” (jiguan) was Bian (at Kaifeng city in Henan), in the north of Song China. In contrast, Zhang Zhiyuan’s was Nanjian Prefecture (in Fujian), in the south of Song China. Wang came from Hui Prefecture (in Anhui). Bearing the authors’ diverse places of origin in mind, my analysis of the formularies of Li, Zhang, and Wang are based on the three lengthy essays collected in the Yuan edition of The Formulary for Saving Life in Lingnan.

FORMULARIES ON LINGNAN BEFORE THE TWELFTH CENTURY

Medical texts from early China had already associated a number of disorders with Lingnan before Li Qiu and Wang Fei wrote theirs. Nonetheless, it was in the Tang dynasty that a host of formularies devoted to treating disorders endemic to Lingnan first emerged. Those include Wang Fangqing’s Formulary for Lingnan (Lingnan fang), Zheng Jingxiu’s Treatise and Formulary for Preserving Life in Guangnan in Four Seasons (Guangnan sishi shesheng fang lun), Li Xuan’s Treatise on Foot Qi in Lingnan (Lingnan jiaoqi lun), and an anonymous author’s Essential Formulas for Urgent Conditions in Lingnan (Lingnan jiyao fang).¹⁸ (Wang Fangqing was the commander-in-chief of Guang Prefecture [in Guangdong] sometime between 690 and 694.)¹⁹ Unfortunately, those Tang-era formularies are either lost or remained only as fragments that were preserved in later literature.

While they did not write books, other Tang officials who were appointed to Lingnan recorded and distributed medical formulas for treating disorders there. For example, Liu Zongyuan, who was the regional inspector in Liu Prefecture (in Guangxi) in 815, documented three such formulas and sent them to his friend, Liu Yuxi, who was exiled to Lian Prefecture (in Guangdong) in 815. Liu Yuxi later collected the three formulas into his own formulary, Passing on Trustworthy Formulas, and distributed it to his friends. Historians attribute the surge in Lingnan-specific formularies and formulas in the Tang dynasty to the rising medical need created by the increasing number of northern officials and immigrants who shifted to the far south during this period.²⁰

The fall of the Tang dynasty in 907 introduced the nearly sixty-year political fragmentation of China known as Five Dynasties and Ten Kingdoms (907–960). Small local states were established and succeeded one another until the Song state conquered them and brought a considerable part of China back under the authority of a single government. After the conquest of Lingnan in 971, the Song emperors and local governments immediately conducted a series of campaigns against perceived unorthodox healing customs in Lingnan, customs that included a preference for “spirit mediums” (wu) over physicians, the abandonment of sick relatives, and the cultivation of “gu-poisoning” (gu).²¹ One major means the Song government used across the Lingnan region to promote physicians instead of spirit mediums was to distribute medical texts. This took place at least ten times between the 970s and the 1120s. In 971, Fan Min, the governor of Yong Prefecture (in Guangxi), engraved unspecified formularies on stone stelae on a wall of the government hall.²² Three years later, the court provided people in Qiong Prefecture (on Hainan Island) unspecified formularies and pharmacological collections.²³ Given that Lingnan was a newly conquered territory, these two policies were highly likely to have been designed to display the authority and presence of the Song state.

In 992, the court distributed a printed version of The Imperial Grace Formulary to all prefectures.²⁴ In the 990s, Chen Yaosou, the fiscal commissioner of the Guangnan West circuit, engraved A Collection of Effective Formulas (Jiyan fang) on stone stelae at postal stations in Gui Prefecture (in Guangxi).²⁵ In 998, the court accepted Chen’s suggestion to produce and disseminate “medical formulas and formularies that can preserve life” to prefectures in Lingnan.²⁶ The court also “gave” (ci) The Imperial Grace Formulary to Lingnan in 1006.²⁷ In 1018, the court gave to prefectural offices in Lingnan Zheng Jingxiu’s Treatises on Preserving Life in Guangnan in Four Seasons and medical formulas that Chen Yaosou collected.²⁸ An edict in 1051 ordered officials to select formulas for treating epidemics and “zhang pestilence” (zhangli) from The Imperial Grace Formulary to be transcribed on placards at places where epidemics and zhang pestilence had occurred.²⁹ The court in 1072 gave copies of Treatise on Preserving Life (Shesheng lun, presumably written by Zheng Jingxiu) and The Imperial Grace Formulary to every prefecture in Lingnan.³⁰

In addition to the abovementioned ten occasions on which medical texts were distributed in Lingnan, some Song officials stationed there disseminated such texts in their administrative regions without claiming that they wanted to transform local customs perceived as unorthodox. For example, when he was named magistrate of Yu Prefecture (in Guangxi) sometime between 1086 and 1093, He Yujuan wrote Summary of Preserving and Nurturing Life in Guangnan in Four Seasons (Guangnan sishi sheyang kuozi) and disseminated the printed edition to the “people” (ren) in the prefecture.³¹ Lü Wei, an official at the Guangnan West circuit, inscribed the formula for a decoction that could nurture qi on stone stelae that were erected in 1112 in Gui Prefecture (in Guangxi).³²

The Northern Song officials’ involvement in distributing or writing medical texts on far-southern disorders may have resulted from multiple motives, such as a desire to meet their own medical needs or an aspiration to transform and educate locals. Another motive might have involved the military need to prevent Song soldiers in the far-southern frontiers from contracting debilitating disorders. The legendary general and military official Di Qing (1008–1057), once suggested to Emperor Renzong that he order officials in Lingnan to search for elderly people who had been exiled there but remained healthy, learn how they maintained their healthy bodies, and then distribute descriptions of their practices in printed form to soldiers there.³³ Di’s suggestion came at a time when the Jiaozhi Ly Kingdom’s invasion of Guangxi and the Nong Zhigao rebellion there led the Song state to exert tighter administrative and military control over the area. Following that, Guangxi was considered an important southern frontier until the end of the Southern Song era.³⁴

In short, some Tang and Northern Song officials who were assigned to Lingnan wrote about local disorders and their treatments. These writers attributed their work to various purposes, such as meeting their own medical needs, transforming and educating commoners in Lingnan, and saving lives. They also distributed medical treatises in several ways, which included circulating hand-copied manuscripts, engraving remedies on stone steles, and disseminating printed editions. Like their Tang and Song predecessors, Li Qiu and Wang Fei wrote and distributed formularies to save lives in Lingnan.

THE PERCEIVED DEARTH OF RELIABLE MEDICAL TREATISES

Although multiple Tang formularies addressed far-southern disorders and the Song government disseminated many such works in Lingnan, Li Qiu and Wang Fei saw none of those as a reliable treatise for treating endemic disorders in the far south.³⁵ This perceived absence contrasts with the canonization of Zhang Ji’s Treatise on Cold Damage that took place in the context of cold damage medicine in Li’s day. As we will see, Li’s and Wang’s formularies and The Imperial Grace Formulary—an encyclopedic work that the Song court compiled and then distributed in Lingnan at least four times before Li completed Treatise on Zhang—differ in several significant ways with respect to the types of far-southern disorders under discussion, the role of poison or toxicity (du) in the etiology of those disorders, and the emphasis on tailoring prescription strategies to individuals’ symptomatic and bodily particularities. These differences help to explain why Li and Wang were reluctant to appeal to earlier medical authors as a persuasion strategy but instead proposed their own therapeutic recommendations with the support of the empirical strategy.

One obvious difference between Li’s and Wang’s formularies, on the one hand, and The Imperial Grace Formulary, on the other, concerns the types of far-southern disorders being discussed. The Imperial Grace Formulary records three types of disorders that were occurring in Lingnan: “zhang poison [bringing in] foot qi” (zhangdu jiaoqi), grass gu-poisoning (cao gu shu), and “mountain zhang–intermittent fever” (shan zhangnüe).³⁶ In contrast, Li’s and Wang’s formularies focused only on zhang-related disorders, one of which was “zhang and intermittent fever.” As their original formularies have survived only partially, it is no longer possible to determine whether the lost texts mentioned other types of far-southern disorders.

A second difference between the three formularies is that the concept of “poison or toxicity” (du) is less crucial to the etiology of southern disorders in Li’s and Wang’s formularies than that for the three types of far-southern disorders listed in The Imperial Grace Formulary.³⁷ The Imperial Grace Formulary offers only a brief description of grass gu-poisoning, saying that residents of Lingnan and Xiliang often administered it. Once the toxin of grass gu-poisoning entered a person’s throat, she would feel so much pain that she would rather die.³⁸

Gu (often translated as “gu-poisoning”) is a complex term that signifies either witchcraft or a range of disorders that were often ascribed to venom, insect bites (chong), or the practice of using magic to harm others.³⁹ During the Tang dynasty, gu-poisoning was associated with the lower Yangzi area, Fujian, and Lingnan.⁴⁰ An edict issued in 1040 reveals the long-standing perception of a connection between gu-poisoning and the south in the Song era. The edict prohibited commoners in the southern and western territories of Northern Song China, including Lingnan, from “cultivating” (or “storing,” xu) poison emitted by snakes or gu-poisoning medicines, as well as killing people to worship “bewitching deities” (yaoshen).⁴¹ Gu-poisoning had also been associated with non-Han ethnic minority groups, such as Miao groups in Lingnan and on the southwest frontier of China.

“Zhang poison foot qi” as a subtype of disease first appears in The Imperial Grace Formulary, whereas the term “foot qi” (jiaoqi) can be traced back to the fourth century. Ge Hong in his Formulary Kept in One’s Sleeve maintains that foot qi disorders originated in Lingnan and then spread northward to Jiangdong (literally, east of the river, referring to a region east of the lower Yangzi River).⁴² As existing scholarship indicates, among the seventy-three categories of disorders in The Formulary Kept in One’s Sleeve, foot qi is the only one whose region of origin is noted.⁴³ Ge said that the disease originated in Lingnan and then spread to Jiangdong but did not discuss its etiology. From the fourth century to the Song dynasty, a variety of symptoms were recorded in medical treatises under the disease category “foot qi.” They included weakness, swelling, painful feet, “an extended and taut chest and abdomen” (xinfu zhangji, or inflated abdomen and taut heart), and headaches.⁴⁴ These symptoms were all perceived as having originated in the feet and were subsumed by the name “foot qi” (which was occasionally called jiaoruo, literally, “foot weakness”).

Origins and Symptoms ascribed foot qi to the body’s “resonance” (gan) with “wind poison” (fengdu).⁴⁵ Given the low-lying topology of Jiangdong and Lingnan, “the qi of wind and dampness” that arose from the land would easily sicken people and trigger foot qi.⁴⁶ The etiology offered in Origins and Symptoms was adopted in The Imperial Grace Formulary.⁴⁷ The authors of the latter identified the low-lying land, dampness, and zhang poison as disorder-inducing environmental features of a harmful atmosphere in Jiangdong and Lingnan.

The introduction to “mountain zhang–intermittent fever” in The Imperial Grace Formulary is almost the same as that in Origins and Symptoms, which states that it occurred in Lingnan and the symptoms consisted primarily of alternating chills and fever. This disorder resulted from the “qi of damp poison” (shi du qi) in streams and mountain peaks.⁴⁸ Nüe (intermittent fevers) refers primarily to any type of intermittent chills and fever, which in imperial Chinese medical treatises could be either a systematic disorder or a symptom of such a disorder.⁴⁹ Nüe could be treated either by pharmacotherapy or religious healing.⁵⁰ Following the publication of Origins and Symptoms, medical texts discussed zhang with nüe more frequently.

The centrality of poison is evident in the abovementioned discussion of far-southern disorders in The Imperial Grace Formulary, namely, grass gu-poisoning practices, zhang poison triggering an outbreak of foot qi in Jiangdong and Lingnan, and the qi of damp poison causing mountain zhang–intermittent fever. Other examples can be seen in the entry on “zhangqi symptoms” in Origins and Symptoms, which associates the occurrence of blue-green grass zhang disorders and yellow floss grass zhang disorders in Lingnan with “miscellaneous types of poison” (zadu) resulting from the warmth there.⁵¹

In contrast, the concept of poison seldom appears in Li Qiu or Wang Fei’s explanations of the occurrence of zhang disorders; the two authors described the disorder-inducing environmental features of Lingnan in relatively neutral tones. Li proposed that Lingnan was a “terroir of flame” (yanfang) and the land was thin; these two characteristics caused the qi of yang-heat there constantly to “disperse” (xie) itself. The term “terroir of flame” served as a reference to the south in general, and sometimes Lingnan specifically, in both historiographical texts and literature.⁵² Lingnan occupied low-lying land near the sea; these two features rendered the qi of yin-dampness constantly abundant. The qi of yang-heat and the qi of yin-dampness constantly attacked each other, which gave rise to the syndrome of heat (in my reading, a burning sensation) in the upper body and coldness in the lower body—in Li’s views, this was a typical syndrome of “zhang disorders” (zhangji).⁵³ On this account, dampness and low-lying land remain relevant as disorder-inducing environmental features, while no reference to poison is made.

Like Li, Wang Fei concentrated on environmental features as disorder- inducing factors without mentioning poison. For instance, he attributed the occurrence of hot zhang (one of three types of zhang disorders he discussed) to reckless behavior, such as walking in the hot sun during warm seasons without drinking enough water and thus experiencing severe symptoms from the “summer heat.” Although the hot climate in Lingnan remained health-threatening, Wang did not employ the concept of poison. He even warned that, although “formularies” (Wang did not specify their titles, calling them only fangshu) posited that poison existing between heaven and earth, between water and spring water, and between grass and trees in Lingnan would affect people and caused their disorders, readers should not stick slavishly to this etiology. Wang’s warning calls for explicit reflection on the traditional etiology that highlighted poison as a chief cause of disorders in Lingnan. Diverging from the poison- centered explanation, Li and Wang understood disorders in Lingnan differently from the authors of earlier mainstream medical treatises.

The third difference between The Imperial Grace Formulary and Li’s and Wang’s work can be seen in Li’s emphasis on a prescription strategy that was tailored to individuals’ symptomatic and bodily particularities.⁵⁴ The Imperial Grace Formulary provides standardized remedies but rarely specifies how readers might modify its medical formulas according to the particular circumstances of the sick. In comparison, Li offered information about prescription strategies for treating a wider range of symptoms and progressions of zhang disorders.

These three differences help to explain why Li Qiu and Wang Fei neither recognized earlier formularies as reliable texts for treating zhang disorders nor cited them as a persuasion strategy. Instead of advocating for specific medical treatises, Li detailed his success in treating zhang disorders in Cangwu, and Wang Fei documented his daily practices that were designed for maintaining health in Lingnan.

DEVELOPING THERAPIES BY TRIAL AND ERROR

Li Qiu used an empirical strategy to prove the trustworthiness of treatments that he developed for addressing zhang disorders by delineating the process in which he applied them and attained successful results. His descriptions of his healing success began with his criticism of physicians in Lingnan for failing to notice the obvious connection between the pattern of the external qi there and the specific syndrome of zhang disorders (namely, heat in the upper body and coldness in the lower body), thereby prescribing ineffective medicines. According to Li, their ignorance of the true cause of the zhang disorders led physicians to mistakenly diagnose a patient’s symptoms—being “depleted” (xu), “upset” (fan), “compressed” (yu), or “oppressed” (men)—as manifestations of heat inside the body when they were actually symptoms of zhang disorders. When treating misdiagnosed heat, those physicians prescribed either medicine to “discharge the exterior condition” (fabiao), which in turn damaged the infirm yang qi in their patients’ bodies, or drugs that were intended to “disinhibit” (li) and “purge” (xia) the heat, which in turn exacerbated the coldness in the patient’s lower body. Li condemned the physicians because people were dying not from zhang pestilence but rather their ineptitude and mistaken prescriptions.⁵⁵

Following his criticism of incompetent physicians, Li described an outbreak of zhang pestilence that he witnessed in Cangwu, after which he developed medicinally effective treatments for zhang disorders that performed better than the so-called inept physicians’ prescriptions. In 1130, an outbreak of zhang pestilence was so severe that almost everyone in the families of prominent local officials Wang Jizhi, Zhang Ding, and Ge Tuan died. Li moved to Cangwu the next year and remained there, witnessing countless locals and northern visitors suffering from fatal zhang pestilence. Li asked which drugs “the unfortunate” individuals had consumed and discovered that they consisted mainly of ephedra (mahuang), bupleurum (chaihu), turtle shell (biejia), and White Tiger Decoction. Indeed, Li himself contracted the pestilence and became seriously ill in the same year. As shown in the quotation cited at the opening of this chapter, he applied a set of remedies to himself and recovered fully.⁵⁶

During this outbreak of zhang pestilence, Li’s two servants also fell ill. They experienced “focal distention” (pi) and felt stuffed, upset, and restless in their chests. One fainted and another asked for drugs with a cooling quality to refresh and disinhibit his diaphragm and stomach. Li discerned their disorders and then learned that both the servants were actually suffering from heat syndrome in their upper body parts and coldness in their lower ones. He prescribed Decoction of Fresh Ginger and Aconite (Shengjiang Fuzi Tang) rather than drugs with a cooling quality, as the servant requested. He let the decoction cool down first before allowing the servants to consume it. They regained consciousness the next day and said that their chests and diaphragms felt fresh and cool, a sensation associated with cooling drugs, without realizing that it was aconite, a drug thought in pharmacological manuals to be associated with extremely hot qualities, that had brought them relief. The next morning, Li asked them to consume pills of cinnabar when their stomachs were empty, followed by porridge. Next, he applied drugs that were therapeutically effective at “normalizing qi” (zhengqi) and “calming the stomach” (pingwei). As a result of this series of treatments, the servants recovered fully. After learning about the therapeutic efficacy of these treatments, Li applied the Decoction of Fresh Ginger and Aconite to ten of his acquaintances. All ten were saved.⁵⁷

The sequence in which Li used the set of remedies he prescribed to treat his servants first and then his acquaintances indicates that Li himself was not absolutely certain of the therapeutic efficacy of the remedies. This implies that this application of the decoction to treat zhang pestilence was not common in Lingnan, or at least not in Cangwu, in the early 1130s.

After detailing his healing success, Li devoted the second part of his long essay to explaining the mechanism through which the Decoction of Fresh Ginger and Aconite achieved efficacy, as well as giving instructions for prescription strategies for applying other drug remedies in accordance with particular symptoms. For instance, he indicated that if a sick individual’s chest was upset and oppressed, the ailing person could consume the cooled decoction; otherwise, in Li’s opinion, the efficacy of aconite could manifest too quickly. In addition, Li explained how to apply three other drug remedies to complement the decoction. Unfortunately, none of the specific ingredients in the three remedies collected in Treatise on Zhang remain available to us.

Li instructed that the priority for treating zhang should be to stabilize the root and normalize the qi of the body. The Decoction of Fresh Ginger and Aconite could achieve this desired therapeutic outcome for most cases of zhang disorders. Once the sick person’s primary qi was stabilized and restored to a normal condition, the patient could consume “the Ground Powder of the Seven Preciousnesses” (Qibao Cuo San). If physicians could not determine a patient’s symptoms or wondered whether the person was suffering from a heat symptom, Jiahe Powders (Jiahe San) provided a suitable alternative.⁵⁸ In contrast to the abovementioned prescription strategies, The Imperial Grace Formulary merely listed a number of medical formulas in an item-by-item format, explaining little to its readers regarding the sequence that should be followed in choosing and applying them in accordance with the progression of a disorder.

Instructing the Lost begins with an introduction to Wang Fei’s medical knowledge and training, which helps to establish the credibility and reliability of the medical opinions that follow. Wang had studied medicine, especially formulas and pulse diagnosis, before moving to Lingnan. He did not specify from whom he learned medicine, a fact that implies that he was self-taught, or at least did not receive training from a master on a regular basis. After arriving in Lingnan, he invited a “senior physician” (or, an elder physician, laoyi) in Guilin (in Guangxi) to discuss formularies he had read.

Instructing the Lost then turns to a comparison between Wang’s experiences in Lingnan with health environments and disorders recorded in other formularies, elaborating on discrepancies between his experiences and the records. In this comparison, he concurred with Li Qiu’s and Zhang Zhiyuan’s formularies but was disappointed by their failure to account for the “pulse patterns and breath” (maixi) in treating zhang disorders. In Wang’s view, this omission made it difficult for zhang sufferers to use Li’s and Zhang’s formularies to find formulas that fit their symptoms. It was this concern that moved him to compose Instructing the Lost.⁵⁹

In fact, the extant part of Li’s and Zhang’s Treatise on Zhang does briefly mention pulse diagnosis of zhang disorders. Li warned his readers that they could not apply decoctions containing aconite when a sick person’s eyes turned red and yellow or when their pulse pattern did not indicate the presence of heat syndrome in the upper body and coldness in the lower body. Li then presented his own witness as evidence: when he was in Cangwu, among some one hundred people suffering from zhang disorders, only the defense commissioner, Mr. Zheng, presented alternating chills and fever without sweating, and his pulse pattern was “surging and floating.” Mr. Zheng thereby took a Minor Bupleurum Decoction (Xiao Chaihu Tang) rather than ones containing aconite, and recovered.⁶⁰

The importance of pulse diagnosis in discerning types of zhang disorders in both Li’s and Wang’s formularies meant that the two authors assumed that their readers knew how to diagnose and distinguish between distinct pulse patterns. Intended for an audience with knowledge of pulse diagnosis, their formularies likely targeted readers who were familiar with medical treatises, not residents of Lingnan, who were often depicted as knowing little about classical medicine. The readership Wang had in mind might have included physicians, medical officials, and civil officials.

After comparing his direct local experience with what he had learned from texts, Wang also deployed an empirical strategy to advocate for maintaining a well-regulated lifestyle as a primary method of preventing disorders in Lingnan. As an official, Wang first resided in Cangwu and then in Liucheng (in Guangxi), Yiyang, and finally Rong Prefecture. Wang claimed that his experiences and observations in these southern regions proved that the local environment was not as lethal as the texts available to him had suggested; for example, mist (which many medical authors deemed a source of disorders in the south) did not actually occur every day but only once every two days. Administrative staff and soldiers suffered disorders caused more by their unregulated lifestyles than by the environment. Wang further shared his routine for maintaining health after his residency in Lingnan. This included the following steps: after arising, a person would consume Powder to Calm the Stomach (Pingwei San) and eat a small portion of porridge; eat breakfast between nine and eleven o’clock in the morning and dinner between three and five o’clock in the afternoon; and, when attending social events, consume alcohol moderately. Wang concluded his long medical essay by noting that “I straightforwardly stated what I heard and saw so as to benefit smart readers to a slight extent.”⁶¹ The phrase “heard and saw” (wenjian) appears frequently in Song notebooks. In Instructing the Lost, the term refers to Wang’s personal experience in Lingnan.

MEDICAL STATEMENTS AND THEIR SOCIAL IMPLICATIONS

In addition to writing formularies, scholar-officials used notebook-style texts to document their experience in Lingnan and to inform medical statements related to that experience. The practice had already spread through notebook-style writings beginning in the late ninth century: scholar-officials verified information pertaining to regional phenomena about which they had previously read and heard and documented their personal experiences in the places in question. The authors of those late ninth-century writings often wrote about Lingnan. In addition to Duan Gonglu’s Northward-Facing Doors, another work by an official who spent time in Lingnan and recorded his opinions of local disorders and medicinal substances is Liu Xun’s Recording the Extraordinary beyond the Ling Ranges. In that work, Liu proposes that zhang results from Lingnan’s mountainous landscape and waterways.⁶² The practice of verifying information about regional phenomena and documenting authors’ eyewitness experiences in a given region continued well into the twelfth century, extending from medical treatises to notebooks and from travel literature to local gazetteers.⁶³

Southern Song authors who wrote down their personal experiences of Lingnan in their notebook-style writings found that the less-structured style was more appropriate for presenting their relatively random thoughts on far- southern medicine, thoughts that were not systematic enough to be composed into a lengthy piece of medical writing or a medical monograph. The prominence of this practice among scholar-officials’ writings in the Southern Song era helps not only to justify Li Qiu’s and Wang Fei’s application of the empirical strategy but also to enhance the evidential value of this strategy.

Regarding the practice of documenting authors’ experiences in Lingnan and related medical opinions during the Southern Song era, one case in point is “Ten Talks about the Lingbiao area” (Lingbiao shishuo, hereafter “Ten Talks”), a long essay preserved by the Yuan edition of Formulary for Saving Life in Lingnan. The author of this essay, Zhang Jie, was the administrative assistant of the fiscal commission of the Guangnan East circuit between 1133 and 1134 and was promoted to vice fiscal commissioner of the same circuit between 1137 and 1139. “Ten Talks” consists of ten entries, each of which covers a topic related to maintaining health in Lingnan, including remarks on the local habit of eating betel nuts and consuming alcoholic drinks to avoid contracting zhang, descriptions of potentially debilitating environmental features, the etiology of zhang disorders, and advice on an appropriate lifestyle for living in Lingnan. In one of the ten talks, Zhang clearly uses a first-person pronoun that means “your humble servant” (pu). In addition, the vivid descriptions of various aspects of Lingnan and his comments on them reinforce the impression that he was drawing to some degree on his own experiences and observations there.

The entry of “Ten Talks” that best illustrates Zhang’s interest in arguing about healing affairs in Lingnan is one in which he argues against the notion that consuming alcohol could prevent zhang, saying that a pharmacological manual recorded the notion. Although he did not specify its title, Song authors, when disagreeing with the idea of consuming alcohol to prevent zhang, often referred to a story in Tao Hongjing’s Collected Annotations. The story reads as follows: Once upon a time, three people encountered mist when traveling in the morning. Later, one was fine, another became ill, and the third one died. Before setting off, the healthy one had consumed alcoholic drinks, the sick one had consumed porridge, and the dead one had eaten nothing. Tao Hongjing suggested that the healthy one was fine because of the “propensity” (shi) of alcohol to repel malicious substances.⁶⁴ Even though the story did not indicate whether the mist was a zhang atmosphere or not, the Song authors frequently mentioned this story when refuting the notion that drinking alcohol could prevent zhang.⁶⁵ Disagreeing with this notion, Zhang proposed that it was indulgence in drinking that actually caused people to suffer zhang, claiming that “the earth of the south is summer heat and dampness. If one indulges in drinking alcohol, then one usually is struck by the poison of summer heat.”⁶⁶ Zhang’s word of caution reminds us of Wang Fei’s abovementioned daily routine for maintaining health.

Fan Chengda was another avid participant in the scholarly trend whereby authors verified putative regional characteristics, documented their experiences, and registered their medical opinions regarding illnesses in Lingnan. Fan was a magistrate in Jingjiang Prefecture (in Guangxi) between 1172 and 1175, after which, in 1175, he was assigned to Chengdu (in Sichuan). On his way there, he recalled his times in Jingjiang Prefecture and composed Treatises of the Supervision and Guardian of the Cinnamon Sea (Guihai yuheng zhi, hereafter Cinnamon Sea). Cinnamon Sea comprises information that Fan collected about the Guangnan East circuit and his experience in this region. He divided it thematically into thirteen chapters, discussing relevant topics in an entry-by-entry format in each.⁶⁷ Fan’s chapters and entries cover a broad range of topics, such as precipice-grottoes, metals, stones, aromatics, alcoholic drinks, birds, flowers, fruits, and ethnic-minority groups living there.

In one entry on zhang in a chapter on miscellaneous items, Fan addressed its occurrence of and remedies for it. He noted that the south of Guilin (in Guangxi) was home to zhang, which resulted from mountain mists and watery poisons together with foul gas emitted by wild grasses and a steamy swelter from lush vegetation. Victims of the zhang atmosphere looked like they had contracted intermittent fever. Although there were many extant treatments, aconite was usually used in urgent cases while “Priceless Qi-Correcting Powder” (Buhuan Jin Zhengqi San) was used in less urgent cases.⁶⁸ Fan did not specify who used aconite or the powder, the ingredients the powder contained, or how to make it. That he mentioned only the powder’s name without providing any information about its composition or manufacture suggests that Fan either assumed that readers already knew about it or assumed that they would consult other sources when seeking to treat zhang-caused intermittent fever.

Apart from those who wrote entirely about Lingnan, other Southern Song authors recorded their experiences of and medical opinions about the area as a part of their notebooks on a wider range of topics, which is exemplified by Jade Dew in the Crane Forest (Helin yulu) by Luo Dajing (1196–1242?, jinshi 1226), who once was the judicial administrator of Rong Prefecture. In an entry on betel nuts, Luo first indicates that locals in Lingnan ate them as an alternative to drinking tea, believing that this could help them “resist zhang” (yuzhang), thus preventing adverse reactions to a zhang atmosphere or suffering from zhang disorders. He recalled that when he arrived in Lingnan, he could not bear to eat betel nuts. After staying a while, though, he learned to eat a small number of them. After a year there, he found that he could not live without them for a single day. Luo then proposed four benefits of betel nuts, including facilitating digestion.⁶⁹

Among the Southern Song notebooks that contained authors’ experiences of and medical opinions about Lingnan, Vicarious Replies from beyond the Ling Ranges (Lingwai daida, hereafter Vicarious Replies) is particularly noteworthy because its author, Zhou Qufei (ca. 1134–?), reproduced part of Wang Fei’s Instructing the Lost. Zhou, originally from Yongjia (in Zhejiang), lived more of his life as a northerner than as a resident of Lingnan. He earned his jinshi degree in 1163 but never rose into higher echelons of bureaucratic systems. He served as a low-ranking official in Qin Prefecture and Jingjiang Prefecture (both in Guangxi), from approximately 1172 to 1178.⁷⁰ He was also an acquaintance of Fan Chengda in Guilin. After moving northward from Lingnan, he compiled Vicarious Replies in 1178. Zhou notes in his preface that when writing Vicarious Replies, he drew from his experience and observations in Lingnan, entries in Cinnamon Sea, and other texts that he did not specify.⁷¹ In Vicarious Replies, Zhou neither mentions Wang Fei by name nor addresses his formulary by its title. In one entry on zhang, however, Zhou repeats Wang’s description of three types of zhang disorders in an identical manner.

To show the resemblance between Zhou Qufei’s entry on zhang and Wang Fei’s discussion of zhang disorders, I introduce Wang’s discussion first and compare it with Zhou’s entry. Wang began his discussion by noting the etiology of zhang disorders recorded in “statements of formularies that [he] now reads.” It ran as follows: the qi of heaven in the south was warm, and the qi of earth was compressed and steaming. The yin was constantly “closed” (bi), and the yang was emitted and dispersed. Grass, woods, and water in the south all received malicious qi. Living in such a debilitating environment, inhabitants gradually developed infirm primordial qi, which resonated with the malicious qi, and thus suffered from zhang disorders. Those who suffered only mildly would experience symptoms that included hot and cold flushes, which was similar to suffering intermittent fevers. This type of zhang disorder was called “cold zhang.” Those who suffered more seriously would experience heat (burning sensations) inside the body that felt like they were lying on burning charcoal. This type was called “hot zhang.” Those suffering from the most serious zhang disorders would become mute for unknown reasons, thereupon leading to its being known as “muteness-causing zhang” (yazhang). Immediately after describing the three types of zhang disorders, Wang commented that “this is what formularies say; however, in my shallow view, what is called muteness-causing zhang is voice-loss cold damage disorders. Isn’t it?”⁷² This comment refers to the analogy as Wang’s innovative notion. In comparison, in Vicarious Replies, Zhou Qufei repeated Wang’s summary of the etiology and three disorder types almost verbatim. More importantly, Zhou also proposed that treatments for voice-loss cold damage disorders could be applied to treat muteness-causing zhang, a therapeutic recommendation clearly inspired by Wang’s analogy.⁷³

Zhou’s use of Wang’s Instructing the Lost indicates the short time over which that medical treatise circulated among officials who were stationed in Guangxi. This is reminiscent of the short time it took for Zhang Zhiyuan to review Li Qiu’s Treatise on Zhang as well as for Wang to review Li’s and Zhang’s formularies. The rapid circulation of Li’s, Zhang’s, and Wang’s formularies among officials in Lingnan collectively attests to a case, that is, that other contemporaneous civil officials serving in Lingnan constituted an important readership of medical texts that Southern Song officials there wrote about the treatment of far-southern disorders. Those civil officials had not, for the most part, received expert medical training but were familiar with medicine through reading. They were likewise articulate in their views of healing affairs in Lingnan, either in their medical works or in their notebook-style writings.

By relocating the contents of Wang’s formulary to his own notebook, Zhou expanded the social implications of medical knowledge from treating the sick to demonstrating an author’s erudition. He lived at a time when the number of less politically established scholar-officials and the number of notebooks both rose precipitously. Those scholar-officials had either attempted but failed to pass the civil service examination or had passed but had struggled in low echelons of bureaucratic systems throughout their lives. They acquired knowledge on assorted topics through hands-on experience or through traveling as examinees or civil servants. The characteristic features of a notebook—its wide topical coverage and item-to-item presentation in a casual and less-structured organization—enabled those politically underachieving scholar-officials to share their knowledge on various subjects. By compiling such a wide array of knowledge in their notebooks, they were signaling their erudition and building up their sense of themselves as intellectual elites, despite their less than fully successful political careers.⁷⁴

Zhou Qufei’s Vicarious Replies epitomizes this Southern Song trend. In his preface, Zhou claims that he wrote it in part because “I am tired of [being asked about things in Lingnan] at social occasions. If someone asks me these questions again, I can use this text instead.”⁷⁵ The title also signals this purpose. The numerous questions that Zhou’s relatives and acquaintances asked, even if he exaggerated somewhat, indicates the high level of curiosity about Lingnan that was common among scholar-officials and laypersons. Such curiosity also suggests that having knowledge of this remote and exotic place had a positive impact on a scholar-official’s popularity at social occasions, which occupied a significant portion of their lives in the Song era. They frequently gathered with friends and colleagues, held banquets to welcome newly arrived officials, and attended farewell parties for those whom the court assigned to other locations. At such occasions, contributing novel conversational material was a critical means by which a scholar-official, especially a low-ranking one like Zhou, could display his erudition and enhance his social and cultural fame.⁷⁶

Displaying one’s erudition had more practical social implications for low-ranking officials, like Zhou, in the Southern Song era than it did in the Northern Song. We have seen in chapter 2 how Kou Zongshi extended the social functions of a medical treatise by submitting his Elucidating the Meaning to the throne in 1116 for possible bureaucratic promotion. Sixty years after Kou’s submission, in Zhou’s day, low-ranking officials encountered fewer opportunities to move upward through the echelons of bureaucratic systems. The increasingly higher number of candidates in the Southern Song period led to a highly competitive examination. Even though a fortunate few did pass and hence gained the qualifications for entering officialdom, they soon encountered new challenges along their career paths.

Often beginning as “low-level executory officials” (xuanren), when seeking promotion to the status of “high-level administrative official” (jingguan), applicants needed to assemble portfolios of recommendation letters from five sponsors whose bureaucratic rankings were higher than theirs. The number of letters that each sponsor could write in a given year was limited, depending on his bureaucratic rank.⁷⁷ In addition to this limit, a shortage of bureaucratic positions made career advancement more challenging.⁷⁸ It was thus crucial for low-level executory officials to maintain and extend their personal networks to acquire the coveted letters. Exhibiting their erudition, gaining popularity at social occasions, and enhancing their cultural and social fame would all help them build networks that could facilitate their advancement. In this regard, having knowledge of medicines as well as exotic Lingnan provided practical social advantages for those marginal officials.

COLD DAMAGE MEDICINE IN THE HOT SOUTH

In addition to employing the empirical strategy, Li Qiu’s and Wang Fei’s formularies both resemble Southern Song notebook-style writings in another important respect: their shared concern with the applicability of cold damage medicines to Lingnan. This indicates the tighter intertextual space that was emerging between medical literature and notebook-style writings in the Southern Song era.⁷⁹ It additionally offers us a glimpse into scholar-officials’ uncertainty when applying relatively northern classical medicines to the far south, which contrasts starkly with the assertiveness underlying the Song government’s campaign to promote medicine in this region. The contrast reveals practical difficulties in integrating the far south into the “civilized” Chinese empire.⁸⁰

The concern with the applicability of cold damage medicine in Lingnan had already appeared in the seventh century; however, since the Song dynasty came to power, particularly since the twelfth century, it became increasingly pronounced as more authors of nonmedical literature voiced the same concern. The rising urgency of this issue parallels the boost in cold damage medicine in the Song era. Existing scholarship reflects this interest in such medicine by examining predominantly medical texts that refer to cold damage disorders in their titles. In this section, by shifting attention to formularies on Lingnan and notebooks, I reveal the much wider scope of the influences of cold damage medicine on Song-dynasty medicine than existing scholarship has hitherto observed.

The textual evidence for the expansion of cold damage medicine to treatments of disorders in Lingnan can be traced to the early seventh-century Origins and Symptoms. This treatise suggests that cold damage medicine was extendable to zhang disorders in Lingnan, given that the transmission of zhang manifestations through the bodily “channels” (jing) and “links” (luo) in a patient’s body were almost the same as those posited for cold damage disorders north of the Ling ranges. Nevertheless, because of warm seasonal qi in Lingnan, when treating zhangqi there, physicians were expected to use drugs of a colder quality than those used to treat cold damage disorders north of the Ling ranges. In a similar vein, drugs with a hot quality that were applied to treat zhang disorders in Lingnan should have involved lower doses than those advised for treating cold damage disorders.⁸¹

The caution regarding regional styles expressed in Origins and Symptoms has ancient roots. At least as early as the Han dynasty, the notion already existed that regional differences in diet, climate, and the quality of the land caused inhabitants in separate regions to possess different bodily constitutions and required correspondingly tailored treatments. Although it was implicit, the ancient medical classic Basic Questions expressed this notion as well. It addressed regional therapeutic styles in a section entitled “On Different Methods Being Appropriate for Different Directions,” which declares that the varying skin patterns of inhabitants in five directions (i.e., east, west, north, south, and center) required matching treatments.⁸²

In the Song dynasty, one view that radically challenged the notion of applying cold damage medicine to treatments for zhang emerged in a privately compiled formulary, Discussions on Cold Damage and General Disorders. Its author, Pang Anshi, was a famous physician and friends with two leading literary figures, Su Shi and Huang Tingjian, in the late eleventh century. Both Su and Huang praised this formulary highly and planned to print it. Eventually, in 1113, an unknown publisher printed the formulary. The first section covers models for diagnosing and prescribing medicine for cold damage disorders, which laid out the theoretical foundation for the rest of his formulary. In that section, Pang claims that “the south is a place where there is no frost and snow, and people there are not being struck by cold qi. The qi of land is not stored. Types of insects emit poison. Mountain mist and zhang atmosphere occurred intermittently.”⁸³ Pang thereby notes that disorders endemic in the south require treatments different from those for cold qi–inducing disorders.⁸⁴ Although he did not specify the names of any of the southern places to which he referred in making this claim, their characteristics in the quotation all are reminiscent of Lingnan. Pang was registered as having come from Qi Prefecture (in Hubei), being active around this area, and leaving no textual evidence, which suggests that he had been to Lingnan in person.⁸⁵ If this were the case, his statement could be viewed as a northern physician’s imagining of the far south, where environmental features were very different from those in the center of China and required correspondingly different remedies.

Apart from Pang’s remarks, few Northern Song observations about the relationship between cold damage disorders and zhang in Lingnan have come down to us. However, Southern Song authors left us additional, more informative, sources of their views regarding the applicability of cold damage medicine to Lingnan. For instance, Chao Gongwu, the famous bibliographer, expressed a view that was similar to Pang’s. Chao obtained his jinshi degree in 1132, resided in Sichuan for many years, and never visited Lingnan. In his grand bibliographical text, Memoirs of Reading in the Jun Studio, he commented that Zhang Ji’s Treatise on Cold Damage “contains drugs only for healing disorders in the north but was missing treatments for southern disorders.”⁸⁶

Although the notion of regionally tailored therapies had already emerged in the Han dynasty, Chinese authors in the twelfth century took this idea a step further by describing how the application of specific drugs should be adapted to the perceived particularities of a given locality, as we shall see regarding Li Qiu’s formulary. While not explicitly denying the applicability of cold damage medicine to Lingnan, Li Qiu and Zhang Zhiyuan both adopted cautious attitudes toward the idea. Li criticized what he saw as inept physicians for applying ephedra, bupleurum, or a White Tiger Decoction, which were ingredients or drug therapies more typically used to treat cold damage disorders, as treatments for zhang disorders. Echoing Li’s criticism of these treatments, Zhang complained that they failed to discern any specific syndromes associated with zhang disorders that resulted from Lingnan’s environmental features. Consequently, they mistakenly applied “methods of treating wind damage and cold damage disorders in the north,” prescribing drugs that cause “sweating” (han) and “purging” (xia) of the sick, thus losing the lives of “five to six patients out of ten.”⁸⁷

Li’s and Zhang’s criticisms of incompetent physicians in Lingnan emerged during a period when warfare between the Song and Jin states raged continuously across the middle and lower reaches of the Yellow River and the area south of the Huai River in the early to mid-eleventh century. The warfare drove a stream of migrants southward to Lingnan. Some of the physicians Li and Zhang criticized may have recently immigrated from the north, as a result applying cold damage medicine that was prominent in the north to treat the sick in Lingnan. An account supporting this scenario comes from Zhang Jie’s “Ten Talks,” in which he described “northern physicians” (beiyi) arriving in Lingnan and applying a Major Bupleurum Decoction to treat hot zhang disorders. As Zhang Jie commented, only those whose fundamental qi was vigorous and replete could bear the effects of the decoction; locals who had consumed betel nuts over a long period of time had already depleted the qi of their organs and thus often could not tolerate drugs with cold quality (such as bupleurum). Zhang did not explain why such northern physicians traveled to Lingnan in the 1130s, a period when he lived in Lingnan, but it seems possible that they were war-weary immigrants.⁸⁸

After the 1130s, scholar-officials expressed a wider variety of views regarding the applicability of cold damage medicine to Lingnan. Wang Fei believed that whether such medicine was applicable varied across distinct types of zhang disorders. He claimed that muteness-causing zhang was actually a case of losing one’s voice as a result of cold damage disorders and being struck by wind. This explanation reflects Wang’s efforts to account for zhang disorders by drawing on intellectual sources associated with cold damage medicine.

Some Southern Song scholar-officials endeavored to understand zhang disorders through language drawn from cold damage medicine. This endeavor is best seen in their explanation of the “picking-grass-seeds” (tiao caozi) technique, a set of therapies that locals in Lingnan used to treat zhang disorders. Such an explanation appears in a lengthy essay of the Yuan edition of Formulary for Saving Life in Lingnan, which is entitled “Wang Nanrong’s Discussion on Remedies and Pulse Diagnosis of Cold and Hot Zhang Disorders.” Modern scholars have long suspected that the Wang Nanrong named as the author of the essay was actually Wang Fei, considering that the character expressing Wang Fei’s surname could easily be mistaken as the character that expresses Wang Nanrong’s surname and that Wang Fei was the magistrate of Nanrong (i.e., Rong Prefecture) when composing Instructing the Lost. In other words, the name “Wang Nanrong” is highly likely to be an admixture of Wang Fei’s surname (but with the wrong character) and the place name where Wang Fei completed his formulary. “Grass seeds” (caozi) was a local term used in Lingnan in reference to hot and cold epidemics.⁸⁹ “Picking grass seeds” then could mean combatting hot and cold epidemics via therapies that involve the use of needles.

Wang Nanrong (or Wang Fei) identified picking grass seeds as the only method for treating hot zhang disorders. This method went as follows: When a person suffered from hot zhang for more than one to two days, local healing practitioners used needles to prick the middle of the inside part of the sick person’s upper and lower lips, wiping the blood off their hands and tongue with leaves of chu trees, which belonged to the mulberry tree family. The sick person was then required to stand with his heels together. The practitioner would prick the standing patient’s blue vessels on the back of his heels, letting the blood out. After this procedure, the sick person would consume “blue-green wormwood herb” (qinghao) with water.⁹⁰

The picking-grass-seeds technique differed remarkably from therapies, such as drug remedies, moxibustion, and acupuncture, that scholarly elites often encountered in medical genres. Regardless, Wang endeavored to explain the therapeutic mechanism underlying this technique via the language of cold damage medicine. He declared that pricking a person suffering from hot zhang and letting his blood out actually complied with the therapeutic principle of inducing perspiration. In his view, hot zhang disorders were manifestations of “major yang” (taiyang) cold damage disorders. After the sick person’s major yang area became disordered for three days, his “yang brightness” (yangming) area became disordered as well. It was believed to be through the upper and lower lips that the stomach channel of yang brightness passes, while the backs of the heels was where the bladder channel of major yang passes. This was why pricking an ailing person’s upper and lower lips and heels could treat the disordered major yang and yang brightness areas. Wang commented that the needling of “southerners” (nanren) thus tacitly was consistent with the principle of treating the manifestation of major yang cold damage disorders.⁹¹

By interpreting a local healing technique using medical language drawn from cold damage medicine, Wang exhibited a relatively positive attitude toward the technique. One contrast to this is found in Fan Chengda’s comments on the picking-grass-seeds technique in Cinnamon Sea, where he remarked that it had no healing effects and the sick still needed to consume drugs. Wang’s interpretation demonstrates a more neutral, Sinocentric perspective on far-southern residents’ healing practices than earlier and contemporaneous scholar-officials had been accustomed to expressing.

Although Wang attempted to rationalize the picking-grass-seeds technique by extending cold damage medicine to zhang in Lingnan, he nevertheless admitted the limitations of this practice. For instance, for a dying man suffering from hot zhang that had penetrated deep into the interior of his body, one therapy suggested was to prick his penis. After describing this, Wang wrote that “I personally consider” (qieyi) that the penis was connected internally to the five visceral systems, and thus pricking it “perhaps” (huo) would remove the sick person’s interior heat.⁹² The phrases “I personally consider” and “perhaps” together suggest Wang’s uncertainty about the healing mechanism, which went beyond the scope of his knowledge but nonetheless he deemed worthy of recording as a local therapy.

Zhou Qufei in Vicarious Replies likewise talks about the applicability of cold damage medicine in Lingnan. Nevertheless, some of his accounts actually draw from others’ formularies. Zhou not only used Wang Fei’s equation of muteness-causing zhang and voice-loss cold damage disorders without crediting the source, but he also nearly copied the abovementioned description by Wang Nanrong and his explanation of the “picking-grass-seeds” technique. Here again we see how Zhou transformed medical knowledge that was written primarily for healing purposes into knowledge that he used to support his conversational skills and signal his erudition.

Apart from the uncredited use of Wang Fei’s and Wang Nanrong’s formularies, Zhou also wrote that, in the south, all disorders were called zhang; their “reality” (shi) was similar to that of cold damage disorders occurring in “central prefectures” (zhongzhou) of China. Without clarifying this statement, especially his reference to “reality” and “central prefectures,” Zhou explained the etiology of zhang and distinguished three types (i.e., Wang Fei’s opinions on cold zhang, hot zhang, and muteness-causing zhang). After proposing that treatments for cold damage disorders could be applied to treat hot zhang and muteness-causing zhang, Zhou reminded his readers that there were still differences between zhang and cold damage disorders: “For treating zhang, one cannot simply apply drugs used for cold damage disorders occurring in the central prefectures. If one merely sees the sick suffering from heat severely, he then applies the sort of drugs such as ‘the crude form of sodium surface’ [poxiao] and ‘rhubarb root’ to purge the heat. If the inherited bodily constitution is weak, the sick immediately falls into crisis.”⁹³ Zhou disagreed with a simplistic application of drugs that were used for cold damage disorders in “central prefectures” to treat zhang in Lingnan. He warned that physicians merely noticed heat as a symptom of zhang disorders and accordingly applied the crude form of sodium surface and rhubarb, two drugs with a cold quality. Overall, like Wang Fei’s stance on expanding cold damage medicine to zhang disorders, Zhou Qufei’s can be summarized as follows: because of the similar essentials associated with these two categories of disorders, the expansion was feasible but had to be conducted with caution and account for sick people’s individual bodily constitutions.

THE EMPIRICAL STRATEGY in Li Qiu’s and Wang Fei’s formularies was based largely on two factors. First, the two authors observed a dearth of reliable medical treatises pertaining to far-southern disorders. On the one hand, since the Tang dynasty, medical authors—including officials in Lingnan—had written multiple treatises devoted to treating these disorders. The Northern Song government actively disseminated medical texts to Lingnan, and local officials engraved formulas on stone stelae. On the other hand, despite the ample number of privately composed and state-disseminated medical treatises, Li and Wang did not find any of them canonical or exemplary for the treatment of zhang disorders. Their reluctance to endorse those treatises may reflect distinct understandings of far-southern disorders presented in their formularies and in the earlier works. In the absence of authoritative medical treatises and given a shortage of competent physicians in Lingnan, Li and Wang proposed their preventive and therapeutic recommendations for zhang disorders and maintaining health there. The two sought to render their opinions more authoritative by describing in detail their relevant practices and sharing their observations of the practice of medicine in Lingnan.

Another factor that encouraged Li and Wang to rely on the empirical strategy was scholar-officials’ long-standing practice of narrating their personal observations of putatively regional phenomena. Since the late ninth century, they had demonstrated a strong interest in verifying information regarding regional particularities about which they read and heard. This interest became more salient in the twelfth century, proliferating across medical texts, notebooks, travel literature, and local gazetteers. Among all the places that had been subjected to scholar-officials’ personal inspections, Lingnan, as a remote, untamed area that was dramatically different from the heartland of Chinese civilization, fascinated them. The proliferation of authors’ experiences of and medical opinions about Lingnan in the nonmedical literature helped to warrant Li’s and Wang’s extensive use of the empirical strategy in their formularies.

The twelfth century witnessed not only the greater prevalence of the practice of documenting authors’ local experiences but also the emergence of a tighter intertextual space between authors of formularies on Lingnan and notebook writers. This is evident in their shared concerns about the applicability of cold damage medicines in that area. In the early seventh century, medical authors voiced these concerns. Beginning in the twelfth century, notebook authors participated in discussions regarding them, which reflected a heightened awareness of the importance of treating zhang disorders in accordance with environmental features and the bodily particularities of sick people in Lingnan. The Song authors’ opinions varied considerably, as they disagreed about how and to what degree cold damage medicine could be applied to the etiology and treatment of zhang disorders. The variety of opinions regarding Lingnan contrasted starkly with the Northern Song government’s active and assertive policies that promoted the expansion of classical medicine to the region. This gap between the political realm, where officials assertively promoted classical medicine as a matter of policy, and local medical practices, where trial-and- error approaches and uncertainty governed the pursuit of effective treatments, reveals the tension between the standardized remedies that the government offered and individualized prescription strategies considered more regionally appropriate. This tension only intensified in subsequent centuries. In the sixteenth century, for example, tailoring prescriptions to individuals and specific circumstances became an essential skill among scholar-physicians as well as a staple narrative theme in the new “medical case statements” genre.