Xiao-Yang Gu explores the tension between two different diagnosis methods of diabetes in 1920s China and the consequent changes in the power dynamics in the clinical context.
In the early 1900s, diabetes was defined by excretion of sugar into the urine and symptoms such as thirst, hunger, and excessive secretion of urine. Diabetes was arguably similar to the concept of dispersion-thirst disease (xiao ke bing, 消渴病) in Traditional Chinese medicine (TCM). Throughout history, Chinese medical practitioners have treated dispersion-thirst disease with diet regimens and herbal medicine.
With the progress of endocrinology in the first twenty years of the twentieth century, Chinese biomedical professionals started emphasising the hidden pathologic process in the pancreas. The discovery of insulin in1921 strengthened this cognitive change. Laboratory results of such tests as blood sugar and urine test, instead of symptoms, became the “objective criteria” for diagnosis. Therefore, the diagnostic model of diabetes gradually shifted from a patient-centred, symptom-based approach to a quantitative, pathology-based one.
The patients’ narratives and symptoms were marginalised as a result. This biomedical practice also took away the diagnostic power from TCM doctors, who emphasise paying attention to patients’ narratives and symptoms via inspection, listening and smelling, inquiry, and palpation (望闻问切). Therefore, we are witnessing not only the changes in the power dynamics in doctor-patient relationships but also that between Traditional Chinese medicine and biomedicine (Western medicine). In this article, I introduce two cases of diabetes from the 1920s in the archive of Peking Union Medical College Hospital. I hope to use these two historical cases to exemplify the tension between the diagnostic criteria created by biomedicine and the patient’s subjective feelings and bodily messages.
A “detective story” of diabetes diagnosis
The hospital archive records a case of possibly the first Chinese to receive insulin injection as a treatment of diabetes (Li 2012: 56–57). In July 1923, a 41-year-old businessman went to the hospital because the infection on his right foot had impaired his ability to walk. Developed around seventy days ago, the infection affected one toe, part of the front palm of his right foot, and the thumb of his left hand.
After hearing the patient’s narrative, the doctor at the surgery department did not arrange an operation on the infection immediately. Instead, he asked the patient to recall the frequency and volume of his daily drinking and urination. He found that the patient had suffered from excess thirst and fatigue in the last four years. Consequently, he drank lots of fluids every day and urinated a lot. On the admission record, the doctor wrote down “thirst and polyuria for about four years” as the patient’s chief complaint. A blood sugar test then confirmed his suspicion of the patient having diabetes (Li 2012).
This was not an isolated case. In the 1920s and 1930s, doctors at this modern hospital in China observantly found the “truth” hidden under the symptom of infection and diagnosed many diabetes cases (Mills 1927: 914–921; Wang 1937: 159-178). When looking deeper into those patients’ admission records, we will find that under the section of “chief complaint”, it reads the doctor’s interpretation of those uncomfortable feelings and symptoms described by the patient. In other words, the so-called “chief complaint” is a rendered version of the patient’s self-statement. Even though the 41-year-old patient narrated a story of infection, the doctor chose to record another story of diabetes that the patient was not aware of. As Rita Charon put it in Narrative Medicine: Honoring the Stories of Illness, the body keeps secrets from the person who lives in it and “colludes with the doctor to negate what the patient says” (Charon 2006: 91-95). The doctor seems to have more insights into the patient’s body than the patient himself, which further chips away at the patient’s authority and control over his own body.
From one perspective, we can read this historical case as a detective story in the context of biomedicine. The intelligent doctor, much like Sherlock Holmes, was not deceived by such superficial symptoms as infections. Instead, he dug deeper and secured the truth because of his profound knowledge of the pathological changes of diabetes. However, from another perspective, this is also a story about the power hierarchy in doctor-patient relationship. As the one holding the secret and sacred knowledge of biomedicine, the diabetes specialist dismissed the patient’s narrative. The discourse power of the patient was deconstructed.
A contested diabetes case of a celebrity
The second patient, Hu Shih (胡适), was a well-known Chinese philosopher and essayist in Republican China. In November 1922, this “celebrity” was admitted to Peking Union Medical College Hospital due to suspected symptoms of diabetes, including swollen and painful legs, dry mouth, and frequent micturition. Soon after the admission, there were rumours in the press that he had diabetes. Therefore, he announced his diagnosis process in the newspaper immediately after hospital discharge:
On detection of glucosuria, […] I was admitted to the most well-equipped hospital in Asia. I have taken thirty times of urinalysis and stool examinations, three times of blood tests, and undergone strict dietary restriction for seven days. […] The doctor confirmed that I did not have diabetes.
我因发现糖尿，……来住在亚洲第一个设备最完全的医院，受了三十次的便尿分验，三次的血的分验，七日的严格的食料限制 […] 此次诊察的结果, 已断定不是糖尿病。
However, this public statement did not clear the air. There were rumours of his diabetes afloat in newspapers from time to time. The origin of this public conjecture can be traced back to Hu’s own record. In 1920, Hu visited Zhong’an Lu (陆仲安), a famous TCM doctor, and his symptoms of swollen and painful legs were relieved after the consultation. The following year, to express his gratitude, Hu agreed to write an inscription for the painting Studying Classics in the Chamber in Autumn (《秋室研经图》) collected by Lu. He commented on Lu’s treatment in the inscription, saying that the treatments from his friends studying biomedicine had some therapeutic effects but failed to solve his problem completely. After taking Mr. Lu’s herbal medicine, he fully recovered (Hu 1933: 21-22).
Hu’s self-statement was regarded as evidence that a TCM doctor cured his diabetes. This story has been frequently discussed by TCM doctors since then and is widely known in China today (Zhang 1985: 78-80; Meng 2006: 32-33). Moreover, some TCM doctors believe that Hu Shih lied about his disease. As the vanguard in the New Culture Movement, Hu strongly advocated modernisation and biomedicine. Therefore, some suspect that he lied to hide the fact that TCM cured his disease. Since academic debates about TCM and biomedicine were part of modern China’s long-lasting ideological and cultural debate, we can easily understand why such suspicion exists.
Charles Rosenberg once used the phrase “tyranny of diagnosis” to describe how biomedicine has increasingly separated disease from the individual in the late 19th and 20th centuries (Rosenberg 2002: 237-260). In Hu’s case, TCM doctors ignored his blood glucose test results and his statement about the diagnosis process. They continued to discuss his illness based on the symptoms Hu had once described in his diary. The unadjusted version of Hu’s narrative before hospital admission became a “weapon” used by TCM doctors to fight against the tyranny of the diagnostic power of biomedicine.
Let us look back at the modern era. Chinese diabetologists today have repeatedly stressed that many Chinese diabetics have no symptoms. They highlight the importance of screening tests and call for doctors to educate patients and make them better informed about the disease. However, the history of diabetes taught us that the problem is far more complicated than the lack of patient education. Diabetes treatment was and still is filled with struggles for power between different parties.
Whatever diagnostic criteria biomedical doctors hold for the disease, the patient’s feelings and symptoms are still the most direct “conversation with the body” and something bothering the patient consistently. We should be aware that there is a constant tension between the doctor’s belief in hidden pathological processes and laboratory tests and the patient’s subjective feelings and bodily messages. It is also important for doctors to realise that it is not enough to persuade the patient to accept that he or she is “asymptomatic yet diabetic”. A broader range of perspectives to perceive the illness, such as complementary and alternative medicine, psychology, history of medicine, and narrative medicine, will help doctors better understand the patient’s statement and perception of his/her bodily conditions. After all, doctors and patients are supposed to be collaborators in the process of coping with illness.
This work is funded by Fund for Young Scholars in Humanities and Social Sciences Research of the Ministry of Education (19YJCZH040).
About the author
Xiao-Yang Gu is an Associate Professor in the School of Medical Humanities at Capital Medical University, China. Her research interest is in the history of medicine and medical humanities education. Currently, she is completing a monograph on the history of insulin in China.
Charon, Rita. (2006). Narrative Medicine: Honoring the Stories of Illness. 1st ed. NY: Oxford University Press: 91-95.
Hu, Shih. Cao, Boyan(ed). (2001). The Complete Diary of Hu Shih 3 (1919-1922). 1st ed. Hefei: Anhui Education Press.
Hu, Shih. (1923). Scattered Feelings: “What Is the Case with Mr. Hu Shih?”. Effort Weekly, no. 36: 3.
Hu, Shih. (1933). Inscription for “Studying Classics in the Chamber in Autumn”. Shenzhou Guoyi Medical Journal 1(5): 21-22.
Li, Naishi. (2015). The First Case of Diabetes Mellitus Treated with Insulin at Peking Union Medical College Hospital in 1923. Chinese Journal of Diabetes 4 (1): 56–57.
Meng, Qingyun. (2006). The Inscription of “Studying Buddhist Scriptures in the Chamber in Autumn” – the Case of Lu Zhongan Cures Hu Shi’s “Diabetes”. Chinese Medicine Culture, no. 3: 32–33.
Mills, Clarence. (1927). Diabetes Among the Chinese: Danger of Insulin Usage. The China Medical Journal 41(11): 914–921.
Rosenberg, Charles. (2002). The tyranny of diagnosis: specific entities and individual experience. Milbank Q. 80(2):237-60.
Wang, Shu-Hsien. (1937). Diabetes Mellitus An Analysis of 347 Cases (Chinese Inpatients), PartⅡ.Treatment and Prognosis. Chinese Medical Journal 51 (2): 159–178.
Zhang, Xichun. Wang,Yun-kai et al.(eds). (1985). ZiCuiYin. Shijiazhuang: Hebei Science and Technology Press: 78-80.
World Health Day and Disease Day Column
This essay is published as part of the “World Health Day and Disease Day” column and coincides with World Diabetes Day, which runs on 14th November each year. This column publishes articles on monthly basis to bring insights into healthcare and societal wellbeing in China and East Asia.