Tianyuan Huang //
—The Observer Became the Subject (of Medical History)—
My first ambulance ride happened somewhat in slow motion.
In celebration of the conclusion of April, I treated myself to ice-cream after a late dinner of green beans. By midnight I was restless. Nothing hurt or itched, but something felt wrong. I walked into the bathroom and stared into the toilet bowl gingerly. Nothing. I went back to sit on the edge of the bed, in silence and stillness, only to realize I was still on the edge. I returned to the bathroom. This time, I kneeled down, and then it all began.
Emerging from the third round of barfing my guts out, I caught a glimpse of my reflection in the mirror before collapsing slowly onto the bathroom floor in exhaustion. What my bloodshot eyes picked up were teeny-tiny blood spots emerging all over my face, something I had never experienced before. Drenched in sweat and shivering in waves of chills, I double-checked that ambulance was free of charge in Japan, and dialed the number.
It was a bit of a blur and a lot of confusion after that. In between more vomiting and feeling only half-conscious, I tried describing what happened to the paramedics, to the emergency room staff, and then to my attending physician after I was admitted for hospitalization. Japanese was my research language, and I only rushed to Tokyo alone amid an ongoing pandemic for my dissertation field work. Never did I expect to use the language not only to understand another society’s history but also to recount my immediate own. At first, I could not even recall the type of green beans I ate, the primary suspect for my alleged allergic reaction. “They were on sale, and I never had an allergy to anything” was all I got.
—Where There Is a Need, There Is a Guide—
It is no secret that doctor-patient communication affects health outcomes (Stewart 1995; Ha and Longnecker 2010). In practice, though, the knowledge gap between the expert and the layperson, varying priorities of the healer and the sick, and the different stakes physicians and patients each have—all these factors shape what and how communication takes place. I was adequately lucid during my own interaction with healthcare providers, but this recent experience—I still got one bloodshot eye—helped me see a specific type of historical records in new light: popular guides on how to talk to a doctor.
The guides that piqued my interest appeared in some of the 1911 issues of Fujin eisei zasshi (Journal of women’s hygiene). Committed to promoting knowledge about health and hygiene among Japanese women, the journal’s contents were characteristically tailored to a female audience and often penned by physicians, nurses, or at least written from a specialist’s point of view. Although over a century old, a pair of recommendations from such guides stood out to me not only for their contemporary relevance but also for the historical moment they were both capturing and caught in.
#1. Talk to one doctor a day, keep other doctors away
The first recommendation caught me off guard, as it discouraged patients from requesting to see multiple doctors simultaneously. As a recent and recovering sick person and a firm believer in peer-review systems, I’d rather be, and was in fact, seen by multiple doctors than by one. However, according to one guide on how to see a doctor, when patients themselves initiated a consultation, the primary care physician would likely make compromises due to the consulting physician’s presence, with the latter also exercising restraint, all to avoid “hurting one another’s feelings” (Fujin eisei zasshi 1911a, 50). The guide therefore asserted that “although it is said that four eyes see more than two, that is often not the case. When aiming with a bow or a gun, one would even close an eye, and there is often no particular benefit for three or four physicians to gather together…” (ibid).
In a critical tone, the guide’s anonymous author even contended that the reasons for patients, especially “the rich and the distinguished,” to consult multiple physicians at the same time included “distrust towards the primary care physician,” “display of vanity,” and “being urged by families and relatives” (Fujin eisei zasshi 1911a, 49). Curiously, having observed that consultation was a ubiquitous phenomenon, the guide did not disapprove consultation when the attending physician, rather than the patient, was behind its initiation.
#2. Speak about everything, but not everything
The second recommendation left an impression on me mostly because of its seemingly self-conflicting thesis. On the one hand, it argued that patients must be as exhaustive as they can when describing their medical history. According to one guide, when physicians asked about a patient’s medical history, they expected to know her past illnesses “from the moment you were born, nay, from when you were still in the womb, or even since the time of your ancestors” (Fujin eisei zasshi 1911b, 41). Be it the timing of menarche, tuberculosis within the family, or one’s dietary habits of consuming Chinese or Western cuisine, in order to receive an accurate diagnosis, the patient must confess it all (Fujin eisei zasshi 1911b, 42).
On the other hand, however, the same guide mocked at the “matchlessly chatty women patients” and warned against discussing anything unrelated to one’s illness (Fujin eisei zasshi 1911b, 45). It is worth noting, though, that the ultimate judge of relevance was implied to be the physician rather than the patient herself. Neither should patients make any attempt of labelling their condition. This included “talking about the name of their own illness, or using the nomenclature of medicine that they picked up by ear” (Fujin eisei zasshi 1911b, 45). Nothing seemed to annoy physicians more than when a patient “brings out the pathology of ancient times and says things like ‘I think I’ve got inner heat’ or ‘it is the way of blood,’” as such behaviors of self-diagnosing constituted implicit criticism against the attending physician’s judgement (Fujin eisei zasshi 1911a, 51).
—Asymmetry in Power and a Health Culture in Transition—
In retrospect, I had perhaps committed both offenses the 1911 guides had vigorously cautioned about. The difference is, when I suggested that the blood spots on my face might have resulted from vomiting rather than allergy, my attending physician, who was also patient enough to listen to me talk about my research (about none other than the so-called “pathology of ancient times”) and what not, harbored no grudge. Instead, the kind doctor encouraged me to see specialists in search for a more conclusive answer, rather than taking the diagnosis of his or his emergency room counterpart’s for granted.
This is not to say that the pair of recommendations that greeted Japanese women over a century ago was “wrong.” If anything, my own and recent experience actually invited me to appreciate more of why such recommendations regarding patient-physician communication and interaction made sense in their own historical context. As historian W. Evan Young (2015) has pointed out, even during the last century of the Edo-period (1600–1868), there was little political management over doctoring. Nearly anyone could practice as and claim to be a physician so long as they fulfill their other and more primary sociopolitical obligations. Moreover, being sick was also a family and social bonding matter, as close and distant families, relatives, and even neighbors and acquaintances would travel to visit and/or help the sick recover. It was not uncommon for those who could afford it to summon multiple doctors, or to change doctors in the middle of a treatment plan, at their will.
My own experience of examining the diary of Rai Baishi (1760–1844), the female poet and mother of renowned Confucian scholar Rai San’yō, also confirms that the Rai family, under Baishi’s management, regularly summoned multiple doctors to treat all kinds of ailments (Kizaki and Rai 1931). In this context, consultation initiated by the patient’s side was less about vanity and more about having options and being discreet. Changing doctors or inviting additional ones upon a relative’s suggestion was nothing inappropriate. The popularity of folk medicine and kanpō, the Japanese adaptation of Chinese herbal medicine, also meant that concepts such as “heat” or the female-specific health condition “way of blood” represented a way of communication understood and used by both the healer and the sick.
The health culture of the Edo period would give way to an institutionalized medical system. Since the late nineteenth century, legislation and political regulation regarding formal medical education, licensure, and public health measures had begun to take shape in Japanese society. This effectively created a community of professional and professionalized healthcare providers who had both an interest in gatekeeping knowledge and a stake in establishing an asymmetry between their authority vis-a-vis the layperson patient’s power in deciding what happened to the latter’s body. As indicated in the 1911 guides, by the 1910s, disease concepts used by kanpō or in folk medicine had already fallen into the category of the “pathology of ancient times” as biomedicine received state sponsorship to develop and as the idea that modern medicine ought to be scientific took root. In this context, it was by no surprise that the 1911 guides disapproved consultations initiated on the patient’s side and frowned upon the use of both (bio)medical terms and folk and kanpō medical terms in the patient’s speech, while Japanese women and ordinary people in general still retained the healthcare habits of a past era.
Having said all that, this “matchlessly chatty woman patient” would just like to say that she hopes that she will never have to visit the emergency room or ride an ambulance ever again.
Utagawa, Kuniyoshi. Medical and surgical treatments for a lame princess and others. 1849/1852. Woodcut, triptych printed in colors, 35.5 x 74.5 cm. Wellcome Collection.
Fujin eisei zasshi. 1911a. “Ishi wo manegu kokoroe” [Instructions on how to summon doctors], April 20, 1911.
———. 1911b. “Yōtai no nobekata” [Ways to describe one’s health condition], October 20, 1911.
Ha, Jennifer Fong, and Nancy Longnecker. 2010. “Doctor-Patient Communication: A Review.” Ochsner Journal 10 (1): 38–43.
Kizaki Aikichi, and Rai Seiichi, eds. 1931. Rai Sanʾyō zensho. Vol. 8. Hiroshima-shi: Rai Sanʾyō Sensei Iseki Kenshōkai.
Stewart, M A. 1995. “Effective Physician-Patient Communication and Health Outcomes: A Review.” CMAJ: Canadian Medical Association Journal 152 (9): 1423–1433.
Young, William Evan. 2015. “Family Matters: Managing Illness in Late Tokugawa Japan, 1750–1868.” PhD diss., Princeton University.