Impact of Chinese Medical Model on Japan

Sec. Sci. Med. Vol. 21, No. 8, pp. 945-950. 1985 0277-9536/X5 $3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright c 19X5 Pergamon Press Ltd

THE IMPACT OF THE CHINESE MEDICAL MODEL ON JAPAN OR, HOW THE YOUNGER

BROTHER COMES OF AGE

MARGARET LOCK McGill University, 845 Sherbrooke Street West, Montreal, P.Q. H3A 2T5. Canada

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.

Japanese responses to the contemporary Chinese medical model can only be understood through an historical examination of the relationship between these two societies; a relationship constantly tinged with ambivalence, particularly on the part of the Japanese and about which there has been a pro- tracted debate lasting at least 1500 years. Further- more. the response is modified by Japans relationship with the Western world, both historical and contemporary, and this dimension must also be taken into consideration.

An historical examination of the Japanese medical model is an interesting exercise since there have been two major paradigmatic shifts both initiated from within Japan itself and involving a radical change in the mode of production of medical knowledge, to use Youngs terminology [l]. The first was the introduction of the traditional Chinese medical system to Japan in the 6th century A.D. via Korea. Not only was the technological inventory of Chinese medicine, including acupuncture and complex herbal medication promoted. but this was done simultaneously with the introduction of the Chinese writing system, the Chinese organization of political, legal and medical institutions. and the philosophical theories of Tao- ism. Buddhism and Confucianism. The use of Chi- nese medicine was thus officially adopted and legiti- mized as part of a much larger process of radical change among the upper echelons of Japanese society.

Twelve hundred years later a second major institutional transformation took place at the Meiji Resto- ration in 1867. Once again a new medical model was officially adopted. this time that of biomedicine and based upon the German system. Once again the process of legitimation was facilitated by the simulta- neous acceptance of other organizational patterns developed in the West and a promotion of European- style arts. literature and culture including, to a limited extent. a serious analysis of the merits of Christianity

With each paradigmatic shift there has been a consciously articulated attempt to transform not only the organization, delivery and technology of the. medical system but also actual medical discourse, that is, the generative rules that govern the content of medical knowledge [I, p. 1 IO]. The first of these during the 6th century involved the classification systems of yin and yang, the Five Phase Theory and the Numerical Emblems [2] which were officially adopted as the basis for medical practice, and the concept of supernatural agents as active in disease causation was officially rejected. This major shift in medical discourse produced repercussions in every aspect of the medical system, from organizational and licensing procedures to diagnostic and therapeutic techniques to doctor/patient relationships, and acted as a rein- forcement for the implementation of institutional changes.

The second change, in the last quarter of the nineteenth century, brought about the official rejec- tion of the traditional East Asian medical concepts which tend to promote inductive thinking and an emphasis on the inter-relationship of all the parts of the human body, and in their place a reductionistic approach was encouraged in which the emphasis was upon the dissection and understanding of body or- gans in relative isolation. This major shift in medical discourse was once again integrated with and reinforced by the concurrent institutional changes. During both transformations the respective groups who held power in the medical domain, Shinto priests in the 6th century and East Asian medical practitioners in the 19th century, were relegated to less dominant positions, and a place was made for the creation of a politically powerful medical pro- fession educated in the new medical system. No attempt was made, however, to legislate either Shinto priests or East Asian medical practitioners completely out of the medical realm but rather to reduce their access to political power [3]. A hierarchically

946 MARGARET LOCK

organized, pluralistic medical system has, therefore. been the norm in Japanese society and still exists today.

Despite the careful organization and execution of these major changes, a gradual process has taken place in the ensuing years after each transformation in which there has been a systematic modification of medical practice into something which is regarded as uniquely Japanese. This process is self-consciously termed Nihonka or Japanization and is recognized by Japanese scholars as being a characteristic attri- bute of the process of social change in their culture whether it be in the realm of medicine or any other domain.

In this paper I will examine some of the modifications which took place in the traditional Chinese medical system as it was practised in Japan, and then at the impact of the contemporary Chinese medical system on both East Asian medicine and biomedicine as practiced in Japan today. It will be shown that even though an alien medical model is officially adopted in conjunction with major institutional transformations, in actual medical practice certain modifications have been made in order to adjust to some specific and relatively unchanging conditions in the Japanese ecological niche and in the organization of Japanese social relations.

Secondly, it will be demonstrated that the contemporary Chinese medical model has, to date, made a relatively small impact on the practice of medicine in Japan. It will also be shown that the traditional Chinese model continues to be influential in its modified, Japanized form.

THE CHINESE WAY IN FEUDAL JAPAN

In order to examine the modification of traditional Chinese medicine (known, in Japan, as kanp6 or the Chinese Way), I will focus on the rise of one of the three most influential schools of medical thought in the 17th century. The school is known as the kohGha, the classical school. and is still important in contemporary East Asian medical circles.

The kohGhu was founded as part of a larger change in political and philosophical attitudes in which an influential segment of the intelligentsia began to react against the Neo-Confucian doctrines upheld by the feudalistic Tokugawa government. Comments voiced against the Neo-Confucian inspired medical texts stated that they were too abstract, too philosophical and too speculative [4, p. 3281. Members of the ko- h&u called for a return to a single classical medical text. the .shtikunron (Chinese: shang bun lun) tirst compiled around 200 A.D. The stated purpose was to strip away all the centuries of accumulated speculation in medical thinking and to develop a rational approach to medical practice. What this meant, in fact, was a reductionistic approach, very characteristic of Japanese thinking and exemplified by the remark of a young /~npcT physician practicing in Kyoto today: The Chinese are very philosophical but we Japanese are above all a practical people.

In the .sh6kanron various diseases are named, their physical symptoms are described in minute detail and 113 prescriptions are included with which to treat the diseases. There is no theory of disease causation, no

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 thin- ekers 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 text- books produced from the 17th century onwards in Japan reflect a uniformly pragmatic, reductionistic approach limited largely to diagnostics and thera- peutics. 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. Never- theless, 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

Impact of the Chinese medical model on Japan 947

had already been totally abandoned by the 10th century and by the 17th century among the koh&z, the dominant medical faction centered in Edo (now Tokyo), only the most genera1 theoretical ideas from the original Chinese model remained intact. Even traditional therapeutic techniques had been seriously modified due to the ecological constraints of the Japanese environment. The enormous variety of plant material required to practice herbal medicine in the Chinese style was never available in Japan and the Japanese were, therefore, always dependent upon imported material in order to mix the required complex prescriptions. the result was that with the exception of a few wealthy doctors residing near the major ports, the majority of kanpij doctors were forced towards a reduced form of medical practice due to the constraints imposed by their environment, a situation very similar to that in many developing countries today.

IMPACT OF THE CHINESE MODEL ON THE PRACTICE OF EAST ASIAN MEDICINE

IN CONTEMPORARY JAPAN 151

Until the end of the last century relationships between China and Japan had always been character- ized by them in Confucian terms, with China playing the role of the elder brother and Japan in the role of the younger, submissive brother. The Sino-Japanese war of 1894 brought about a fundamental questioning of the traditional subservient relationship of Japan. a questioning which accelerated as Japans level of economic development forged ahead rapidly. In the years since World War II this attitude has persisted and many Japanese currently believe that there is, at the moment, relatively little the Chinese can teach them in the field of science and technology or in the organization of social institutions.

In the world of traditional East Asian medicine several Japanese practitioners have been asked to China and an exchange of ideas is taking place enhanced by the closeness of the written languages.

There are two types of traditional medical practitioner in Japan today, licensed practitioners who use combinations of acupuncture, moxibustion and massage in their practice, and secondly, M.D.s who have chosen to specialize in traditional medicine after completing medical school and who make herbalism central in their therapeutic procedures. They form a professional body with limited political power whose medical practice is subject to legal restrictions imposed by the government and indirectly by the Japanese Medical Association.

Since 1978 the licensed practitioners have had some contact with China and several groups have gone for short professional observation trips. The teaching director of the Meiji College of Oriental Medicine has this to say on the subject: It is impossible to assess everything that is happening in East Asian medical practice in China from one or two short visits, but I think that both countries should gradually try to establish closer mutual co-operation as far as the study of acupuncture and moxibustion is concerned. However. he adds. even though the Japanese and Chinese probably have the same origins, nevertheless, Japanese customs. history and modernization are

very different from China and I think that there is a limit to the usefulness of mutual exchange (personal communication).

The licensed practitioners state that they have very little in common with paramedicals such as barefoot doctors. So far, most of their exchange of ideas is with Taiwan and Korea, with their equivalent professional body, the licensed practitioners in these countries.

In contrast to licensed practitioners, M.D.s who are kanp5 practitioners have been asked to China officially several times and once there associate with hospital-based doctors of both traditional and biomedicine, many of whom are learning Japanese as their second language in order to facilitate com- unication. About a dozen Japanese medical students and one doctor are at present studying the clinical application of East Asian medicine in China and several Chinese doctors and pharmacists are engaged in basic research related to East Asian medicine in Japan. Contact between the two countries has led the Japanese to several conclusions. Firstly, they believe that Japan has much to offer Chinese scientists as far as research facilities, technology and scientific ex- pertise is concerned, nevertheless it is agreed that some good, but limited research is being done in China.

Secondly, Japanese practitioners come away from China feeling somewhat envious of the large variety of clinical experience available to Chinese doctors of traditional medicine. In Japan the patient population is. for the most part, self-selected and limited largely to patients suffering from chronic diseases. More- over, the practice of traditional medicine is usually performed in separate facilities from those of biomedicine. In China there is a much closer association between specialists of all kinds, and practitioners of traditional medicine are exposed to a wide variety of diseases and patients. Japanese doctors therefore believe that they could profit greatly from some clinical experience in China.

Lastly, it has become clear from the recent exchange of ideas between the two countries that the practice of traditional medicine in China today is very -different from the form it takes in Japan. Chinese practitioners refer most frequently to Ching medical texts (1616-1911) which, until recently, were not translated and were virtually unknown in Japan. Chinese practitioners state that they continue to use the theories of yin and yang and the five phase theory albeit in a modified form, which the pragmatic Japanese find surprising but interesting. This recent contact has reinforced in the minds of the Japanese that they have a distinct medical system adapted to the Japanese environment and specific patient needs. One doctor comments that obviously Chinese and Japanese medical practice will be different since the epidemiology of disease is different. He also states that the dosage for medication is about five times as strong in China as in Japan. Japanese practitioners have always stressed that one should give as light a treatment as possible both for herbal medication and acupuncture, for which purpose they developed es- pecially fine needles. They emphasize that the body should be stimulated simply in order to promote the natural healing process and that the Chinese have

948 MARGARET LOCK

possibly lost sight of one of the basic premises of East Asian medicine. In relation to this point, many Japanese doctors are against the production and use of concentrated extracts of herbal medicine for injec- tions. They believe this is contraindicated and is opposed to the basic principles of herbal pharma- cognosy.

An important result of contact with modern China has been the stimulation both of self-criticism and of promotional activity among kanp5 practitioners in Japan. Certain practitioners believe that their col- leagues have relied too heavily on the sh&anron and have throughout history rejected new innovations while clinging to an outmoded classical text. Others believe that Japanese practitioners, despite their ex- cellent technical skills and innovative techniques in, for example, acupuncture therapy, have not applied enough scientific and logical analysis to the theory used in traditional medicine. Several research groups have been formed where such issues are discussed. Some clinicians want to see the system derived largely from the Ching texts that is used in China today promoted in Japan. They have translated several texts with this end in view but so far its actual application is minimal. The majority of kunp5 practitioners subscribe to the philosphy that the traditional medicine practiced in Japan today is, de fucto, the most suitable for Japanese patients.

In summary, the contemporary Chinese medical model has made some impact on East Asian medical practitioners in Japan. They are interested in what is happening in China and pleased that traditional medicine is part of the official Chinese medical system because this has helped indirectly, largely through the mass media, to boost interest in traditional medicine in Japan. It has also acted directly to enhance research and discussion among Japanese practitioners in an atmosphere of confidence and excitement over possible future developments.

IMPACT OF THE CONTEMPORARY CHINFSE MODEL ON BIOMEDICINE AND HEALTH

CARE DELIVERY IN JAPAN

It has been demonstrated elsewhere that there is considerable informal interaction between the biomedical and traditional medical systems in Japan (61, and a practitioner of biomedicine in Japan who wishes to learn the techniques of acupuncture or about herbal medicine would usually undertake training in a medical setting in Japan. The only exception to this would be in the case of acupuncture anesthesia and many Japanese doctors have been to the P.R.C. to observe this technique which has been selectively applied for the past IO years in several of the leading Japanese hospitals. Its use is limited exclusively in Japan to certain dental procedures, to ton- sillectomies. to minor gynecological procedures and to some difficult cases of child-birth. At a symposium for anasthesiologists which I attended in 1974 in Tokyo there was unanimous agreement that acupuncture anesthesia is very elfective in reducing post- operative bleeding and nausea but that it was not always a satisfactory analgesic for procedures other than those listed above.

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 pro- fession 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 disease from predominantly acute to chronic prob- lems, and fear of long-term ingestion of synthetic drugs on the part of patients, among other factors. The mass media has also been influential in this matter and numerous TV programs on traditional medicine, traditional practitioners and acupuncture anesthesia have been produced, some of these programs are filmed in China but most are made in Japan. The interest of the West in the Chinese model has also played a role in that it has inspired traditional Japanese practitioners with more confidence even if Westerners do not flock to look at their clinics the way they do to Chinese ones. Recently there has been more private and government money invested in scientific research into traditional medicine. Another governmental response to the revival of interest in traditional medicine has been to incorporate some of its practice into the health insurance system. But this process could, in fact, aid in the demise of traditional medicine as a distinct medical system [9]. Senior members of the Japanese Medical Association, including the current president, have recently visited China and so too have government officials involved in departments concerned with health care. The

impact of the Chinese medical model on Japan 949

changes cited above have perhaps been in part pro- induce psychological well-being. Social and environ- moted because of direct observation of the Chinese mental stress should be dealt with in the social and situation. political realms [6, p. 1371.

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 TRENDS IN JAPANESE MEDICINE

Contemporary trends in both traditional and biomedicine in Japan indicate that a distinct Japanese medical discourse prevails and that it can be remark- ably consistent, whether applied in the biomedical or traditional medical system.

Dr Yasuo Otsuka, an M.D. and a leading spokes- man 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 Ja- panese 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.

These same assumptions are made in the biomedical system by the currently very active research- ers in psychosomatic medicine in Japan. Models of biofeedback, autogenic training. transcendental me- ditation, controlled fasting and other techniques de- signed 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.

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 un- acceptable 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.

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 expla- nation 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].

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,

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 eth- nomedical variables must all be included in the examination and analysis of any medical system.

REFERENCES

1.

2.

3.

4.

5.

Young A. A. Mode of production of medical knowledge. Med. Anthrop. 2, 97. 1978. Porkert M. The Theoretical Foundations qf Chinese Medicine. MIT Press, Cambridge, 1974. Fujikawa Yu. Nihon Igakushi KG_vO. Vol. I. Heibonsha. Tokyo, 1974. Otsuka Y. Chinese traditional medicine in Japan. In Asian Medical Systems (Edited by Leslie C.). University of California Press, Berkeley, 1976. 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

6. Lock M. East Asian Medicine in Urban Japan: Varieties qf Medical Experience University of California Press. Berkeley, 1980.

7. Reich M. R. and Kao J. J. (Eds) A Compararice Vietc, of Healrh and Medicine in Japan and America. Japan Society, New York. 1978.

8. An exception to this is Saku hospital in Nagano pre- fecture which for over 30 years under the leadership of Dr Wakatsuki has been using paramedicals and citizen participation in the delivery of health care in rural communities.

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 CM- temporat-! Japan. CambrIdge University Press. 1984 for a fuller analysis of this point.

Documents

Impact of Chinese Medical Model on Japan