Ping Yu, MD, PhD
National Institutes of Health, Bethesda, Maryland, United States
Chi Lu, PhD
University of Kentucky, Lexington, United States
The Chou Dynasty, 11th-9th Centuries B.C.
Since the dawn of history, traditional medicine has been an integral part of the Chinese civilization.1-5 Of particular interest is a publicly funded health care system that might have existed during the reign of the Zhou Dynasty (11th to 3rd century BC). Information about it is derived primarily from the classical book Rites of Zhou (Chinese: Zhou Li), written no later than the middle of the 2nd century BC and translated into French in late 19th century.6 Although several academic studies have been devoted to the Rites of Zhou,7-11 the health care system and government management of medicine recorded in that book seem to be understated.
A physician or medical professional was a common career in ancient China, frequently mentioned in Chinese classic books. Confucius said, “the Southerners have a saying: ‘If a man is not constant in his self-cultivation, he cannot be a shaman or a healer.’ It is a good proverb.”12 Once Kangzi sent Confucius some medicine as a present; respectfully receiving it, Confucius said, “I don't know about this medicine, so I don't dare to take it.”13 Both sayings may indicate the reservations early Chinese intellectuals had about healing and drugs, as well as the underlying complexity of medicine at that time. Possibly even before or not much later than Confucius there was a comprehensive and well-functioning publicly funded health care system, described in the first chapter of the Rites of Zhou.6
According to that chapter, there were five types of medical professionals in the Zhou Kingdom, licensed by the government and receiving wages and benefits. The chief division, superior to the other four, was that of the "Principal Physicians." It included two ranked officials of the first class, four ranked officials of the third class, two wardens, two writers, and twenty followers. "Physicians for Food" consisted of two ranked officials of the second class. "Physicians for Simple Ailments" were made up of eight ranked officials of the second class, and "Physicians for Ulcers or Surgeons" were eight ranked officials of the third class. Four ranked officials of the third class assembled "Physicians for Animals," or Veterinarians.6-14 Another a division of officials, the Si Jiu, included two ranked officials of the second class, two writers, and twenty followers; it helped fight epidemics and defended the ethics and morality of society.15
An issue of interest is that shamanism, while quite common in early cultures and always mixed with medicine (as shown here in the Southerners’ proverb quoted by Confucius), was never part of the medical system described in the Rites of Zhou. In fact, there were several sentences in another part of the book talking about the official shamans,16 perhaps indicating that medicine had already been somewhat separated from shamanism during the Zhou Dynasty.
As the supreme officials of medicine, the Principal Physicians’ main duties were issuing orders and managing collected drugs and herbs. They were assigned work places where they could be easily visited by the people. Because of its importance, the service of Principal Physicians had thirty employees, more so than the sum of the other four divisions. Also, Principal Physicians was the only division of medical professionals that included the first-class physicians. The Principal Physician in charge made a preliminary diagnosis then sent the patient to a Physician for Simple Ailments or one for Ulcers, who were expected to keep records of the cases seen and the outcome of their treatment. At the end of each year, the Principal Physicians analyzed the documents and decided the next year’s wage and benefits for these physicians according to their performance. If their patients were virtually all healed, they would be assigned to the “upper level” and probably have their benefits increased. But if many of their patients were not cured, those physicians would be placed in the lower levels, with less income and benefits for the next year.14,17
Physicians for Simple Ailments and the Physicians for Ulcers received their patients from the Principal Physicians, a relationship somewhat analogous to that between general practitioners and medical specialists in modern times. However, they were somewhat subordinate to Principal Physicians, being evaluated annually by the Principal Physicians and responsible to report their results to them. Preventing seasonal diseases was a major duty of Physicians for Simple Ailments. Physicians for Ulcers treated ulcers and trauma, and also performed surgeries, therefore were translated as “surgeons”.6
The Physician for Food served the monarch and the royal family only, while the Physicians for Animals did not treat humans. Therefore these two services should not be included in the health care system. Nonetheless, as stipulated by the Rites of Zhou, the income of a Physician for Animals was decided by the number of animals dying right after the medical treatment, a somewhat similar annual assessment as for the Physicians for Simple Ailments and the Physicians for Ulcers.
From the above descriptions we may conclude that the government of Zhou was the health care provider for its people and that the system was publicly funded. Since the size of early population of the crown land of Zhou was quite small, there were only twenty two official doctors (six Principal, eight for Simple Ailments, and eight surgeons), while not exclusively, serving the common people. The medical service was hierarchical and rudimentarily specialized. Two physicians in the first class (Principal Physicians) administered twenty physicians and surgeons of the second and third class. Both simple ailments and surgeries were handled by specialties. Perhaps because surgery was underdeveloped, doctors for simple ailments had a higher rank than surgeons. Moreover, the Physicians for Simple Ailments and the Physicians for Ulcers were regulated by their bosses, the Principal Physicians, and their income was strictly dependent on their performance. Medical cases were well documented, and preventive care was included in the duties of the medical professionals.
Many issues, such as the training of professionals or the fees for their services, are not mentioned in the Rites of Zhou, which describes this health system in less than 400 words. Furthermore, the current version of the book was not uncovered to the public late until the Western Han Dynasty (1st century BC), and the credibility has been questioned ever since. Its true author is unknown. Its exact date of publication remains uncertain, assigned by some scholars to the unstable Warring States period (5th to 3rd century BC),18 but perhaps covering the spring and autumn period (770 BC) or even earlier, before the Kings of Zhou lost controls over the vassal states that encompassed the vast majority of the land and population of their kingdom.
- Ilza Veit, The Yellow Emperor's Classic of Internal Medicine, (Berkeley: University of California Press, 2002).
- Yang Shou-Zhong, The Divine Farmer's Materia Medica: A Translation of the Shen Nong Ben Cao Jing (Boulder: Blue Poppy Enterprises, Inc., 2007).
- Greta Young, Robin Marchment, Shang Han Lun explained: a guided tour of an ancient classic text written by Zhang Zhong Jing in 200 AD and its modern clinical applications, (Philadelphia: Churchill Livingstone/Elsevier, 2008).
- Ci Song, Brian E. McKnight, The Washing Away of Wrongs: Forensic Medicine in Thirteenth-Century China (Ann Arbor: University of Michigan, 1981).
- Ancient Chinese Physicians: Hua Tuo, Ji Ben, Bian Que, Zhang Zhongjing (Memphis: General Books LLC, 2010).
- Edouard Biot, Rites des Tcheou (Paris: Imprimerie nationale, 1851). Partially translated into English by Ulrich Theobald, according to the French translation.
- Bernhard Karlgren, “The Early History of the Chou Li and Tso Chuan Texts” in: Bulletin of the Museum of Far Eastern Antiquites, Issue 3 (Stockholm: A. B. Hasse, 1932).
- Dore J. Levy, Constructing sequences: another look at the principle of Fu "Enumeration", Harvard Journal of Asiatic Studies, Vol. 46, No. 2, 1986, pp. 471-493.
- William G. Boltz, “Chou li”, in Early Chinese Texts: A Biliographical Guide (ed. Michael Loewe, Berkeley: Society for the Study of Early China, 1993).
- Maxwell Aiken, Wei Lu, Historical instances of innovative accounting practices in the Chinese dynasties and beyond, The Accounting Historians Journal, Vol. 20, No. 2, 1993, pp. 163-186.
- Michael Nylan, The Five “Confucian” Classics (New Haven: Yale University Press, 2001).
- The Analects, Ch. 13, verse 22, translated into English by A. Charles Muller, http://www.acmuller.net/con-dao/analects.html
- ibid, Ch. 10, verse 11.
- Rites of Zhou, Ch. 1.
- ibid, Ch. 2.
- ibid, Ch. 3.
- Zheng Xuan, Jia Gongyan, Peng Lin, Zhou Li Zhu Shu (Shanghai: Shanghai Ancient Books Publishing House, 2010). Original written in 2nd century AD by Zheng Xuan; complemented by Jia Gongyan in 7th century AD.
- Shen Changyun, Li Jing, Compared to bureaucracy within the Spring and Autumn period: a further investigation on the date of Zhou Li, Historical Research (China) Issue6, 2004, pp. 3-26. Witten in Chinese.