Impact of Chinese Medical Model on Japan
Content
Sec. Sci. Med. Vol. 21, No. 8, pp. 945-950.
0277-9536/X5 $3.00 + 0.00
Copyright ‘c 19X5 Pergamon Press Ltd
1985
Printed in Great Britain. All rights reserved
THE IMPACT OF THE CHINESE MEDICAL MODEL ON
JAPAN OR, HOW THE YOUNGER
BROTHER COMES OF AGE
MARGARET
McGill
University,
845 Sherbrooke
Street
LOCK
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 protracted debate lasting at least 1500 years. Furthermore. the response is modified by Japan’s 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 Young’s 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 Taoism. Buddhism and Confucianism. The use of Chinese medicine was thus officially adopted and legitimized 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 Restoration 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 simultaneous acceptance of other organizational
patterns
developed in the West and a promotion of Europeanstyle 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. 1IO]. 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 reinforcement for the implementation
of institutional
changes.
The second change, in the last quarter of the
nineteenth century, brought about the official rejection 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 organs 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 profession 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
MARGARET
946
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
attribute 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 koh&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
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 body’s 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
Impact of the Chinese medical model on Japan
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 characterized 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 Japan’s
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
947
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 comunication. 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 expertise 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. Moreover, 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 Ch’ing 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 especially 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
MARGARETLOCK
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 injections. They believe this is contraindicated
and is
opposed to the basic principles of herbal pharmacognosy.
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 colleagues 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 excellent 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 Ch’ing 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.
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
93.5”h 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
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 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, extremely’well
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
1. Young A. A. Mode of production of medical knowledge. Med. Anthrop. 2, 97. 1978.
2. Porkert M. The Theoretical Foundations qf Chinese
Medicine. MIT Press, Cambridge, 1974.
3. Fujikawa Yu. Nihon Igakushi KG_vO.Vol. I. Heibonsha.
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
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 prefecture 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.
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.
0277-9536/X5 $3.00 + 0.00
Copyright ‘c 19X5 Pergamon Press Ltd
1985
Printed in Great Britain. All rights reserved
THE IMPACT OF THE CHINESE MEDICAL MODEL ON
JAPAN OR, HOW THE YOUNGER
BROTHER COMES OF AGE
MARGARET
McGill
University,
845 Sherbrooke
Street
LOCK
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 protracted debate lasting at least 1500 years. Furthermore. the response is modified by Japan’s 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 Young’s 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 Taoism. Buddhism and Confucianism. The use of Chinese medicine was thus officially adopted and legitimized 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 Restoration 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 simultaneous acceptance of other organizational
patterns
developed in the West and a promotion of Europeanstyle 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. 1IO]. 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 reinforcement for the implementation
of institutional
changes.
The second change, in the last quarter of the
nineteenth century, brought about the official rejection 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 organs 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 profession 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
MARGARET
946
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
attribute 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 koh&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
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 body’s 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
Impact of the Chinese medical model on Japan
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 characterized 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 Japan’s
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
947
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 comunication. 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 expertise 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. Moreover, 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 Ch’ing 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 especially 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
MARGARETLOCK
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 injections. They believe this is contraindicated
and is
opposed to the basic principles of herbal pharmacognosy.
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 colleagues 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 excellent 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 Ch’ing 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.
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
93.5”h 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
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 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, extremely’well
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
1. Young A. A. Mode of production of medical knowledge. Med. Anthrop. 2, 97. 1978.
2. Porkert M. The Theoretical Foundations qf Chinese
Medicine. MIT Press, Cambridge, 1974.
3. Fujikawa Yu. Nihon Igakushi KG_vO.Vol. I. Heibonsha.
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
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 prefecture 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.
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.
