Professional Documents
Culture Documents
1985
University,
845 Sherbrooke
Street
LOCK
West,
Montreal,
Abstract-There
have been two major paradigmatic
shifts in the history of Japanese medicine, one in the
6th century with the introduction
of Chinese medicine, a second in the late 19th century when European
medicine was adopted as the official medical model. The impact of the Chinese model on historical Japan,
the contemporary
practice of traditional
medicine, and the contemporary
practice of biomedicine
is
examined.
Despite constant
contact.
use of Chinese medical texts, and considerable
imitation
of the
Chinese model at certain historical periods. the Japanese have retained a unique medical system adapted
to core cultural values and to their ecological niche. Public health is government
controlled
in Japan. but
clinical medicine is largely administered
by the private sector, which severely limits any simple adoption
of the Chinese model. The practice of contemporary
biomedicine
and traditional
medicine in Japan share
common features and, despite numerous exchanges with China, influence from China at the level of policy
IS minimal. and in regard to clinical practice and research relatively small.
MARGARET
946
LOCK
mention
of preventive
medicine
or of a possible
relationship
between social and psychological
systems and the physical system anywhere in the text,
What the book does focus on is the dynamic nature
of the human body and the change of symptoms with
time as a disease is modified by the bodys natural
defences and by pharmacotherapeutics.
It also focuses on the inter-relationship
of the bodily parts one
with another and the impact of both illness and the
then known therapies on all the body systems. There
is, therefore, an emphasis on the unified nature of the
human body but no1 on the relationship
of the body
with external events; in this respect the sh5kanron is
unusual as a Chinese medical text and has never been
regarded with as much favor by the Chinese as by the
Japanese.
Two of the major thinkers of the kohaha. GotiS
Gonzan
(1659-1733)
and
TiidB
Yoshimasu
(1702-1773),
deal specifically with the question
of
etiology. GotB focuses completely on factors internal
to the body and consciously
tries to reduce the
multi-causal explanations
of the current Chinese thinekers to one dominant causal factor as the origin of
all diseases. Todd goes even farther and states for
me.
it is nonsense
to discuss the etiology of a
disease since etiology is more or less a product of
speculation . . . . We should depend on what we have
really seen and examined
and nothing else [4, p.
3301.
Diagnosis
and the actual treatment
of disease
symptoms, therefore, form the core of medical practice for the kohGha whose most practical contribution
to medicine was to develop a refined and sensitive
abdominal
palpation
technique
still used in Japan
today and unknown in China. How much this reductionistic thinking is a product of European influence
then beginning to make itself evident in Japan and
how much it is locally generated remains a matter for
further investigation.
Whatever
its origins, it was
congnitively
acceptable
to a large body of medical
practitioners
and the majority of the medical textbooks produced
from the 17th century onwards in
Japan reflect a uniformly
pragmatic,
reductionistic
approach
limited largely to diagnostics
and therapeutics. This approach was reinforced at the end of
the 19th century when the Western medical model
became dominant and is one which is still prevalent
in the practice of East Asian medicine today. Nevertheless, the approach
to diagnosis and treatment
of
physical symptoms remains quite different from that
used in Western medicine in that a holistic approach
to the actual body systems is emphasized.
Diagnosis
of a particular disease and specific treatment
of the
major symptoms
only is regarded
as inadequate;
diagnosis should consist of eliciting groups of symptoms, major and minor, which are thought to be
inter-connected
and then to treat them all using a
variety of therapeutic techniques which are applied at
the physical level.
Despite eleven centuries.
therefore,
in which the
Chinese and Japanese theoretically
shared the same
major philosophical
and religious idioms, gradually a
characteristic
Japanese world view re-emerged
as a
dominant
force and a uniquely Japanese system of
medicine was firmly established.
The Chinese organizational system for licensing and medical practice
947
948
MARGARETLOCK
In Japan, although there is a social health insurance system, the actual practice of medicine and the
control of most of the hospitals and clinics (76.6 and
93.5h respectively [7. p. 71) are in the hands of private
practitioners. This division has reinforced an official
dichotomy present in Japanese health care for the
past 100 years: that responsibility for public health is
in the hands of government
agencies while responsibility for medical care lies with private practitioners. What this means in contemporary medical
practice, both of biomedicine and traditional medicine, is that while the majority of practitioners are
willing to acknowledge that environmental and social
factors may be extremely relevant in the etiology of
disease, they also believe that it is not within their
realm to manipulate these variables: medical practitioners should deal with and manipulate internal.
physical causes and manifestations of illness while
environmental
and stress-related factors should be
dealt with by the government, the educational system,
the work place and at home.
If any changes are to be made in Japan modelled
on the broader dimensions of the Chinese model,
such as changes in the organization of health care
delivery, public education, use of paramedicals (as
opposed to traditional practitioners) or in preventive
medicine, then this would be implemented primarily
through governmental agencies and the medical profession would not be expected to play a large role in
such changes [8]. So far there is no clear indication
that the conservative Japanese government has been
influenced by the Chinese model. In recent years there
has been less centralization of health care in Japan
and more emphasis on community health planning
with citizen participation at local government levels
[7, p. 21 but this is probably in response to incidents
such as the Minamata disaster and is typical of
ongoing political process within Japan itself.
Recently there has, however, been a marked revival
of interest in and use of the traditional East Asian
system in Japan. Many factors play a part in this
revival including changes in the epidemiology of
IMPACT OF THE CONTEMPORARY CHINFSE
disease from predominantly acute to chronic probMODEL ON BIOMEDICINE AND HEALTH
lems, and fear of long-term ingestion of synthetic
CARE DELIVERY IN JAPAN
drugs on the part of patients, among other factors.
It has been demonstrated
elsewhere that there is The mass media has also been influential in this
considerable informal interaction between the bio- matter and numerous TV programs on traditional
medical and traditional medical systems in Japan (61, medicine, traditional practitioners and acupuncture
and a practitioner of biomedicine in Japan who anesthesia have been produced, some of these prowishes to learn the techniques of acupuncture or grams are filmed in China but most are made in
Japan. The interest of the West in the Chinese model
about herbal medicine would usually undertake trainhas also played a role in that it has inspired tradiing in a medical setting in Japan. The only exception
tional Japanese practitioners with more confidence
to this would be in the case of acupuncture anesthesia
even if Westerners do not flock to look at their clinics
and many Japanese doctors have been to the P.R.C.
to observe this technique which has been selectively
the way they do to Chinese ones. Recently there has
applied for the past IO years in several of the leading
been more private and government money invested in
Japanese hospitals. Its use is limited exclusively in scientific research into traditional medicine. Another
Japan
to certain
dental
procedures,
to tongovernmental response to the revival of interest in
sillectomies. to minor gynecological procedures and
traditional medicine has been to incorporate some of
to some difficult cases of child-birth. At a symposium
its practice into the health insurance system. But this
for anasthesiologists
which I attended in 1974 in process could, in fact, aid in the demise of traditional
Tokyo there was unanimous agreement that acumedicine as a distinct medical system [9]. Senior
puncture anesthesia is very elfective in reducing postmembers of the Japanese Medical Association, inoperative bleeding and nausea but that it was not
cluding the current president, have recently visited
always a satisfactory analgesic for procedures other
China and so too have government officials involved
than those listed above.
in departments concerned with health care. The
impact
of the Chinese
changes cited above have perhaps been in part promoted because of direct observation
of the Chinese
situation.
The Chinese model therefore has served a role as
an agent for the promotion
of East Asian medicine
in Japan but it has made virtually no impact on the
actual organization
of health care in general.
CONTEMPORARY
Contemporary
trends in both traditional
and biomedicine in Japan indicate that a distinct Japanese
medical discourse prevails and that it can be remarkably consistent,
whether applied in the biomedical or
traditional
medical system.
Dr Yasuo Otsuka, an M.D. and a leading spokesman in the kanpo world, sums up the reasons as he
sees them from his perspective as a clinician, for the
boom in traditional medicine as it is called in Japan
[4, p. 3221. Firstly. he points out difficulties that have
arisen due to the over-use of synthetic medicine in
biomedicine.
This is a major problem
known as
yakugai or drug pollution and its occurrence
has been
associated
with the right of private practitioners
to
sell their own drugs. I have demonstrated
elsewhere
that it has also arisen in part because modern Japanese doctors still think extremely holistically about
internal
body systems
and consistently
prescribe
groups of drugs in order to counter-act
possible
side-effects from the specific drug that is indicated
for the disease in question [IO]. In contrast,
herbal
medication,
although the prescription
often contains
between 15 and 20 crude drugs, is regarded by both
practitioners
and patients as natural and without
side-reactions.
The second reason that Dr Otsuka cites is the
analytic nature of modern medicine and with it the
tendency
towards
more and more specialization
which, while it is necessary
for research,
is unacceptable
in clinical practice
since it leads to a
fragmented
approach
in patient care. Dr Otsuka
states that one of the advantages
of kanp6 is that the
patient is always examined and treated as a whole
body.
The
last
point
is in connection
with
the
presentation
of complaints
by patients.
A further
advantage of kunp6, according to Dr Otsuka, is that
patients complaints
are considered
important
and
made active use of in the process of diagnosis,
whereas in biomedicine
they tend to be ignored.
These three points all reinforce the idea that in
kunp6 a holistic
model of the human body is of
central importance.
One makes use of all of the
complaints of the patient in order to make a diagnosis
based on collections
of symptoms,
and therapy is
then prescribed which will act on the whole body. Dr
Otsuka then goes on to make a further statement
which clearly indicates his ties with the physicians of
the 17th century: In kunpo . . the cause . . of the
disease is rather unimportant.
While he and other
kunp6 practitioners
acknowledge
that environmental,
social and psychological
factors can be very important factors in disease causation, they believe that
these extrinsic factors should not be dealt with in the
medical system and they focus instead on the relief of
somatic symptoms which will in turn, it is assumed,
medical
model
on Japan
949
induce psychological
well-being. Social and environmental stress should be dealt with in the social and
political realms [6, p. 1371.
These same assumptions
are made in the biomedical system by the currently very active researchers in psychosomatic
medicine in Japan. Models of
biofeedback,
autogenic training. transcendental
meditation, controlled
fasting and other techniques designed to induce psychological
well-being
through
somatic changes are being refined in all the major
universities today, whereas more traditional
types of
verbally-oriented
psychotherapies
continue
to be
poorly developed. The philosophies
and medical discourse of the kartp6 doctors
and of specialists
in
psychosomatic
medicine
are extremely
close and
heavily influenced by Buddhist values even though
there is little exchange of ideas between these two
groups. Both these sets of clinicians believe that they
are synthesizing
a unique type of medicine which
combines
the precision
of science with a holistic.
somto-psychic
approach to the human body and that
this is the best type of medicine for contemporary
- Japan. Dominant
17th century thinkers such as Todo
Yoshimasu
apparently
held very similar ideas and
were also heavily influenced
by Buddhism and the
science of their times.
This approach
to medical care has, of course,
evolved through the centuries as an adaptive response
to the Japanese environment
and to cultural values.
Patients
are socialized,
as are their physicians,
to
think holistically
about their bodies, to focus on
somatic rather than psychological
levels of explanation and to expect the family, place of work, and
other social units to participate actively in health care
except for the actual diagnosis and specialized treatment of diseases [6, p. 2171. The Japanese public is
also, for the most part, extremelywell
versed in a
scientific approach
to the body. Pluralism
in the
organization
of medical care and in medical practice
is the norm in Japan but despite the great diversity
apparent
in hospitals
and clinics, there are, nevertheless, certain striking and dominant features which
can be discerned in a variety of clinical settings and
which form the basis for a uniquely Japanese
approach to health care [l I].
In summary,
the Japanese case furnishes an example of how medical models become adapted
to
core cultural values; the data indicate that an imported medical model could only be applied at a very
abstract level and that historical, political and ethnomedical
variables
must all be included
in the
examination
and analysis of any medical system.
REFERENCES
Tokyo, 1974.
4. Otsuka Y. Chinese traditional medicine in Japan. In
Asian Medical Systems (Edited by Leslie C.). University
of California Press, Berkeley, 1976.
5. The data presented in this section were obtained by
interviewing three M:D.s and two licensed practitioners. all of whom specialize in the clinical application of traditional medicine.
950
MARGARET
LocK
9. Lock M. The organization
and practice of East Asian
medicine in Japan: continuity
and change. Sot. Sci.
Med. 148, 245. 1980.
10. Lock M. An examination
of the influence of traditional
thcrdpeutic
systems on the practice of cosmopolitan
medicine in contemporary
Japan. J. c,hrrt. .Mrd. 1980.
I I See Ohnuki.
Tierney E. //lttc~c (//I(/ Cul/uw
ift CMtemporat-! Japan. CambrIdge
University Press. 1984 for
a fuller analysis of this point.