From the Netherlands to Japan: communicating psychiatric practice in the 1830s

Introduction

In a recent article, James Secord (2004: 661) called for historians to consider the study of science as ‘communicative action’, with attention not only to how it is produced in local contexts, but also to how knowledge is communicated, received and transmitted from one place to another. Such an approach, he suggested, might be considered an alternative both to grand narratives of scientific modernization and to more fragmentary microhistories, in which science is studied in specific times and places in the context of everyday life. This article attempts to contribute to such an endeavour by exploring the communication of Dutch psychiatric knowledge in an unlikely local context: the city of Edo (now Tokyo) prior to its ‘opening’ to the West in the mid-nineteenth century.

Thanks largely to the work of Japanese historian Hiruta Genshirō, it is now well established that Japanese doctors were interested in psychiatric medicine prior to the introduction of Western influence (Hiruta and Beveridge, 2002). From the middle of the Edo period (1600–1868), Japanese society experienced economic and social developments that led to an increasingly commercialized economy and a remarkably literate population. An increase in the number of doctors and increasing levels of specialization among medical practitioners accompanied these developments.

During the Edo period, Japanese doctors approached mental illness from a variety of theoretical perspectives. Chinese medical theory dominated, but Japanese doctors adopted different schools of thought, some of which diverged considerably from an original emphasis on metaphysical theories. Koihō (lit. ‘old way’) medicine, represented by Gotō Konzan (1659–1733), emphasized clinical observation and experimentation. ¹ His student Kagawa Shūtoku (1683–1755) is known for his particular contribution to the study and treatment of mental illness. Some doctors, such as Wada Tōkaku (1744–1803) and Imaizumi Genryū (1797–1874), developed methods of cognitive therapy, called isei henki no hō (移精変気の法), in which they talked to their patients and persuaded them to change their beliefs and behaviour (Hiruta and Beveridge, 2002: 137). Still others combined their medical treatments with religious practices such as bathing under a waterfall, or the saying of prayers (Yagi and Tanabe, 2002: 34–9). Tsuchida Ken (dates unknown) published what is considered to be Japan’s first specialist book on mental illness in 1806. This book outlined Tsuchida’s theoretical approach to the diagnosis and treatment of mental illness and described many of his own clinical case studies (Hiruta and Beveridge, 2002: 138; Okada, 2002: 71–3; Yagi and Tanabe, 2002: 40).

Against the background of a flourishing interest in medicine and psychiatric problems, some Japanese doctors began to explore Western approaches to the topic by reading and making translations of Western medical writings (Hiruta, 2001; Kitanaka, 2012; Okada, 2002). The present article builds upon previous work in Japanese, which has not yet been discussed widely by historians working in English. In particular, I introduce a previously unidentified Japanese translation published in 1837 by Mitsukuri Genpo (1799–1863). The original paper, entitled ‘Observation of a case of insanity, which followed from an ear inflammation, with an elucidation of the delusional ideas given by the patient after her recovery’, was originally written by Dutch neuro-anatomist Jacobus Schroeder van der Kolk (1797–1862) in 1826. Mitsukuri was Schroeder van der Kolk’s contemporary, and the rendition of this article into Japanese a mere 11 years after its original publication offers opportunities to reflect on the communication of psychiatric knowledge, both globally across linguistic and cultural borders, and locally among Japanese physicians in the nineteenth century.

Mitsukuri Genpo and Japan’s first journal of Western medicine

Between 1836 and 1842, the Dutch-learning (rangaku) scholar, Mitsukuri Genpo published what is considered to be Japan’s first journal of Western medicine, Taisei mei-i ikō (A Compendium of Articles by Renowned Western Doctors) comprising eight volumes published in three series. With the exception of the prefaces, it consisted entirely of articles translated from Dutch medical journals and books, originally published between 1771 and 1837. Until recently, Mitsukuri’s journal has been remarkably little studied, partly, perhaps, because the orthography that was used to transcribe the European authors’ names made them very difficult to identify in Roman form. It had been assumed that the translations came from one well-known Dutch journal, the Practisch tijdschrift voor de geneeskunde al haren omvang (A Practical Journal for All Aspects of Medicine). A closer study of the contents by Jannetta and Nakamura (2012), however, has revealed that the bibliographic material used was far more diverse.

A total of 40 Dutch medical writings were translated into Japanese and published in Taisei mei-i ikō’s eight volumes. While the quality of the writings was variable, a number of the articles could be considered at the ‘cutting edge’ of contemporary medical scholarship. Of particular interest in this respect is the translation of Schroeder van der Kolk’s psychiatric case study that appeared in volume six of the journal. Before examining the article in more detail, it will be helpful to begin with a brief introduction to Mitsukuri and how he came to create and edit the journal.

Mitsukuri Genpo was born as the third son of a well-established medical family which had already served as official doctors to Tsuyama domain (Okayama prefecture) for three generations. ² His early teachers included a Confucian scholar called Nagata Tōin, and Takenaka Bunsuke (1767–1836), a prominent and somewhat controversial Kyoto doctor whose approach to medicine was an eclectic mix of surgery and koihō style Chinese medicine. His unorthodox approach may have helped to fire Mitsukuri’s interest in Western medicine. Nevertheless, it should be remembered that Mitsukuri was well versed in Chinese scholarship. He wrote Chinese poetry for pleasure and published many of his works and translations in Chinese.

In 1823 Mitsukuri was provided with an opportunity to travel to Edo on duty, and this gave him his first chance to study Dutch. He promptly enrolled with Udagawa Genshin (also known as Chinsai, 1769–1834), one of the most successful rangaku scholars of his time. Mitsukuri’s encounter with Western learning profoundly changed his way of thinking, as he later recalled:

I loved Chinese poetry from a young age. Before I travelled to the Eastern capital [Edo], I was always serene of mind. When I saw a famous mountain or special river, I always composed a poem. After I came to the capital and buried myself in Western books, I abandoned my poetic writings but did not ridicule the poetic landscape. When I saw the stars or moon, I wondered how far away they were, and when I heard thunder, I thought of electricity. I was always searching for the truth, and later gave up poetry. (quoted in Fujikawa, 1978: 303)

Mitsukuri appears to have progressed rapidly in his study of Dutch. He made a brief foray into private medical practice, but after his house burned down in 1834, he retreated to the domain residence to focus his life’s work on scholarship and translation rather than active medical practice. He was later appointed to the Shogunate’s official translation bureau, the bansho wage goyō, and he continued his translation work in the service of the Shogunate in Edo for the remainder of his life. Thus, Mitsukuri’s work on Taisei mei-i ikō came at something of a turning point in his life: from physician to translator, to official government translator.

The journals began with a number of prefaces, written by Mitsukuri’s colleagues Udagawa Yōan (1798–1846) and Tsuboi Shindō (1795–1848), who added their endorsements to the publication, and by Mitsukuri himself. He was at some pains to explain why he chose to adopt the format of a journal. He clearly recognized its innovative nature and appeared to justify it to his audience, borrowing terminology familiar from Chinese scholarship. He compared medical masterpieces such as those by de Gorter, Plenck, Consbruch and Bischoff to the Chinese Classics. These works, he suggested, were the foundational canon of basic medical principles and rules. Journal articles, such as case studies and short essays, on the other hand, were like ‘histories’, which noted the immediate situation of the illness and methods used at the time to fit the patients’ needs. ³ Mitsukuri argued that there was a need for both of these complementary kinds of writing in everyday medical practice.

In describing the process by which Taisei mei-i ikō came into being, Mitsukuri wrote of the large number of journals which were brought into the country and even translated, but left unpublished because they were too short to form a complete volume. He saw his journal as providing a forum for these publications and for the discussion of everyday medicine, with an emphasis on practical rather than theoretical content. Mitsukuri did many of the translations himself, but he also engaged the skills of a number of his associates and students. The other translators included his student Maki Bokuchū (1809–63); Ogata Kōsai (1810–63), who later became famous as Ogata Kōan, founder of the Tekijuku school; Minato Chōan (1786–1838); Horiuchi Sodō (1801–54); Tawara Genshū; and Kawamoto Kōmin (1810–71). Mitsukuri clearly acknowledged his fellow translators at the beginning of their essays, and even invited his readers to submit their own translations for publication. It appears that, as editor, he understood the potential of the journal for creating a community of practitioners, who openly shared their ideas and experiences.

What kind of topics, then, did Mitsukuri consider to be important for everyday medicine in the Japan of the 1830s? The translations reveal a wide range of topics overall, but many of them were related to surgery. For example, there were essays on an arterial wound on the elbow, the use of tampons for uterine haemorrhage, cancer, and the creation of an artificial anus through surgery. Many of the writings in volumes seven and eight were related to the new drugs morphine and strychnine. There were also articles on women’s health, syphilis, epilepsy, and the article on mental illness mentioned, which I will now discuss.

‘Observation of a case of insanity’ (Schroeder van der Kolk, 1826/1837)

It is significant that Mitsukuri considered an observation of a case of mental illness to be suitable for publication in a journal devoted to ‘everyday medicine’. This point reflects the increasing attention to mental illnesses in medical publications of the time, and adds weight to the assertion that the mentally ill were coming to be seen as patients with physical illnesses, rather than as people possessed or otherwise in need of religious care. ⁴ The original psychiatric case study on which the translation was based was published in the Netherlands by Dutch neuro-anatomist Jacobus Schroeder van der Kolk in 1826. It appeared in the first volume of a new Dutch journal, Geneeskundige Bijdragen (Medical Contributions), and it was the only article that Mitsukuri selected from this particular journal. The Japanese translation was made by Maki Bokuchū (1809–63), a student of Mitsukuri. Maki, who was in his late twenties at the time, trained in medicine but eventually became what we might term a professional translator. He was one of several promising young men who made translations for the journal.

In the Netherlands, Schroeder van der Kolk is regarded as the ‘Dutch Pinel’ for his humane approach to the treatment of the mentally ill. ⁵ He had graduated in medicine from Groningen University in 1820, and shortly afterwards was appointed medical director of an institution known as the ‘Outer Hospital’ in Amsterdam, which housed the insane, as well as those with sexually transmitted diseases and other medical conditions considered to be socially unacceptable. Schroeder van der Kolk was charged with the task of reforming the hospital and, influenced by French neurologist Claude Francois Lallemand (1790–1853), he came to believe that mental illness was a physical disease, not a problem of the patients’ morality (de Waardt, 2005: 49–50).

In 1826, the year in which the case study in question was published, Schroeder van der Kolk was appointed Professor of Anatomy and Physiology at Utrecht University. He was invited to join the Board of Directors of the local mental asylum, and pushed for reforms there on humane grounds. He does not appear to have taught psychiatry formally, although he used a private seminar to do so after 1831 (de Waardt, 2005: 51). International fame came with a speech he made in 1837, at the end of his appointment as Rector of Utrecht University. This speech, entitled ‘An address on the neglect of care required for the assuagement of the fate of the insane, and of the cure of the same in our country’, was published in English the following year (Schroeder van der Kolk, 1838). It was the first of several of his works to be published in other European languages. Notable was On the Minute Structure and Functions of the Spinal Cord and Medulla Oblongata and on the Proximate Cause and Rational Treatment of Epilepsy, published in Dutch in 1858 and in English and German in 1859, in which he argued that the overstimulation of the medulla oblongata was the cause of epilepsy. ⁶ This research grew out of Schroeder van der Kolk’s observations on the many epileptic patients who were housed in the mental asylums that he oversaw. As Paul Eling (1998: 310–13) suggests, Schroeder van der Kolk was therefore not a psychiatrist as such, but he is considered to be the ‘father of Dutch psychiatry and neurology’ for his pioneering work in the study of the brain.

It is highly doubtful that the Japanese doctors knew of Schroeder van der Kolk’s growing fame when they chose to translate his early essay in 1837, for it was only then that he was beginning to achieve an international profile. This suggests that Mitsukuri specifically selected the essay for its intrinsic interest to Japanese doctors. What kind of meaning, then, might it have held for them? The discussion below will present first a brief summary of the translation. Following this, I will turn to a contextualization of the ideas it contained, focusing on three main areas: how the vocabulary used reflected contemporary theoretical understandings of mental illness in Japan; how the suggested treatments compared with Japanese treatments of the mentally ill, and how the translation might be situated within the existing historiography of writings on mental illness, both then and now.

In Taisei mei-i ikō the translated title of the article is rendered in Chinese, and it reads: ‘A case study of a patient who developed mania after an ear inflammation, and who talked about her own delusions after her recovery’. Schroeder van der Kolk’s name, the name of the editor, and the book in which it appears are all given in Chinese characters with a Japanese katakana gloss. On the whole, the Japanese translation of the text appears to be a fair rendition of the original. Some sections, notably the introduction, have been abbreviated slightly, a point to which I will return later. In the discussion below, all quotations are my translations from the Japanese version. ⁷

Schroeder van der Kolk begins the essay by expressing his regret that there are not many doctors who try to research treatments for the mentally ill. He mentions Philippe Pinel’s (1745–1826) pioneering work at the beginning of the nineteenth century and suggests that this helped to establish a field of research into mental illnesses. However, most doctors had been very cautious and stuck to old methods. He explains that it is still not well understood what happens in cases when the illness has a physical cause which affects the brain, and what happens in cases when the illness does not have a physical cause. Moreover, since it is difficult to determine for each patient whether the problem lies in the brain itself, or from a related illness, or a problem such as a blockage in the stomach, whether it is caused by the nerves, or in the bowels, the treatments are often very arbitrary. He notes that although Dutch doctors have a good reputation in other areas of medicine, in the area of mental illness, there is still much to learn. He finishes his introductory section with the following statement:

This case study has been published in the hope of stimulating interest among other doctors to conduct research in this area. It has value because it was particularly difficult to treat, and because the patient herself explained the nature of her condition after her recovery. It also demonstrates the way in which psychiatric treatments should be paired with internal medicines. (Mitsukuri, 1837: 2)

He then moves on to describe the symptoms and treatment of a 21-year-old woman who had a curious habit of sticking sharp objects into her ear in order to clean them. She developed an ear infection from this habit, and while in a feverish state she had dreamed that she had tried to murder members of her family and hide them under the bed. Following this, she fell into a delusional state. Before being treated by Schroeder van der Kolk, she had been seen by other doctors who had forcibly drugged her with opium and large quantities of alcohol.

Schroeder van der Kolk took a much gentler approach, which involved the use of emetic syrups and tartar emetic to relieve her constipation, the use of an ointment on her forehead and gentle footbaths. He also spent time quietly talking to the woman until he gained her confidence. He convinced her family to let him hospitalize her in the asylum, as he felt that her delusions about them were hindering her recovery. She made one unsuccessful suicide attempt in the hospital, but he was eventually able to gently reacquaint her with her family members and convince her that she had not killed them. He ends the case study with the following comment:

… although doctors in our country can heal a hundred sicknesses, when it comes to this one, there are so few who can cure it. There are even some who think it is not an illness at all, and lock the patient up for the rest of his life … However, as we have seen above, there are people, who, despite suffering anxiety and intestinal fevers, can be completely restored to health. (Mitsukuri, 1837: 15)

The final section of the essay consists of a further 10 points about the treatment of mental illnesses. Since they give a good idea of Schroeder van der Kolk’s approach, these are outlined in abbreviated form here.

The historical context

It is often stated that the major contribution made by the introduction of Western medical texts to Japan was the idea that consciousness was situated in the brain, and that the cause of mental illness was therefore to be found there. This understanding of the function of brain and nerves is usually traced back to Sugita Genpaku and Maeno Ryōtaku’s landmark translation of an anatomical text, Kaitai shinsho in 1774. ¹⁰ As seen in the summary above, this way of thinking is present in both in Schroeder van der Kolk’s case study and the Japanese interpretation of it, in particular the idea that the mental illness could be traced to an ear infection that went on to affect the brain and cause delusional symptoms. However, equally clear is that Schroeder van der Kolk is ambivalent about the connection between intestinal disorders and mental illnesses. There is a sustained tension between his conception of the significance of the brain and the observation that many of his psychiatric patients were constipated. He argued that mental illness could not be treated successfully without first treating the underlying constipation, and in the case study the treatment described was largely based on a combination of laxative medicines and cognitive therapy. In this respect, Schroeder van der Kolk appears to typify the tensions between psychological and somatic approaches that were characteristic of his period, as well as a deep-seated vitalism (Brown, 1997: 443; cf. Eling, 1998: 334). De Waardt has also further explained that Schroeder van der Kolk espoused two different kinds of insanity: first, idiopathic, in which the brain suffered some kind of direct injury, either external or hereditary; and second, sympathetic, in which some other kind of illness caused damage to the brain that in turn brought on insanity. He placed particular importance on diseases of the digestive system and sexual organs as being responsible for mental conditions (de Waardt, 2005: 55). Schroeder van der Kolk uses the terms ‘ideopathic’ and ‘sympathetic’ in the introduction to his ‘Observation’ essay, but these are conspicuously missing from the Japanese. A rather simplified discussion replaces them, but the thrust of the Dutch author’s meaning has clearly been understood.

In the Japanese context, a similar approach is apparent in a slightly earlier translation of Johannes de Gorter’s Gezuiverde geneeskonst (Pure Medicine) which is well known for its description of mental illness. ¹¹ It included an accurate description of melancholia (depression), and several other mental conditions (Hiruta, 2001: 178). The publication was first translated into Japanese from 1793–1810, and was republished in expanded form by Mitsukuri’s teacher Udagawa Genshin in 1822 (Miyashita, 1975: 33). This work was very influential in Japan and was used widely as a medical textbook in the late Edo period (Yagi and Tanabe, 2002: 43). Although it described mental illness as a disease of the brain, the cause was seen to be black bile that had accumulated there, and the treatment recommended was to excrete it through faecal movements (Kitanaka, 2012: 34).

As Kitanaka and others have noted, such explanations resonated with Japanese doctors who were accustomed to thinking about mental illness (or depression specifically, in Kitanaka’s analysis) in terms of a stagnation of ki, or vital energy (Kitanaka, 2012: 24). Normally in Chinese medicine, thoughts and feelings were associated with the stomach and chest, but because ki was thought to circulate around the body and indeed the world and entire cosmos, it was not difficult to imagine that the ki was also circulating to the brain and could become blocked. Udagawa explained that it was easy for black bile to be absorbed into the bloodstream from the intestines and travel to the brain (Hiruta, 2001: 180). Maki, as we have seen, suggested that a blockage of blood to the brain could cause the nerves to tremble, as in a fit (see Note 9). Moreover, the word he used to describe the rising of blood to the brain was jōshō, a word borrowed from the Chinese medical vocabulary. The introduction to Japan of a Western anatomical model in which the mind was located in the brain has been described as revolutionary (Hiruta, 2001: 176), but at least as far as mid-nineteenth-century medical practice was concerned the Japanese and Western models were remarkably compatible.

This compatibility, or willingness to find equivalencies between foreign and native ideas, extended to the pharmaceuticals that were described in Western books. The Japanese doctors were particularly interested in the prescriptions used and translated them in detail, including doses as well as the names of drugs. The translator Maki also added his own notes and commentary to the text, trying to make it easier to understand. For example, when Schroeder van der Kolk described his use of Authenrieth’s salve (an ointment made from tartar emetic), Maki transcribed it phonetically using Chinese characters and wrote: ‘this prescription is not very clear’. He then cited another author who had suggested that it probably had similar effects to white precipitate ointment. Other treatments were more familiar to the Japanese doctors. In the case study, Schroeder van der Kolk prescribed tartar emetic mixed into the patients’ food, and a medicine made from croton oil and syrup of maidenhair fern (Adiantum capillus-veneris). The Japanese had already equated this plant with their own native version of the maidenhair fern Adiantum monochlamys, which they knew by the common name of hakonegusa (lit. grass from Hakone) but they adopted a Chinese name for it as well. In a separate pharmaceutical work, Udagawa Genshin described how to make the syrup, and noted that it was good for opening up the chest and relieving constriction and thick phlegm, and making it easier to vomit, and that it was also good for coughs, asthma, chills, cold damage and various other ailments (Sōda, 1993: 75–8). Thus, Schroeder van der Kolk’s prescriptions would have been understood against the background of these other works, which were no doubt familiar to Mitukuri and Maki and which gave them meaning and context in a broadly Sino-Japanese framework. Whether they were actually used or not is a different question. Hiruta (2001: 190) has suggested that Japanese knowledge of Western psychiatric medicine remained at the level of introduction and translation, and was not used in clinical practice. Unfortunately, little is known about the readership of Mitsukuri’s journal, and it is difficult to know how the essay might have been received.

I now turn to an examination of the vocabulary used in the translation. In the Dutch original, the main words used to describe the patient’s condition are krankzinnig and waanzinnig (mad/insane), denkbeelden and voorstellingen (imaginings/delusions). In Japanese, these words are translated using a wide variety of terms borrowed from the existing Sino-Japanese medical vocabulary, including tenkyō (insanity), seishin sakuran (mental confusion), kyōshitsu/kyōbyō (madness), kyōka (lunatic), and mōshū/mōnen (delusions). The translator Maki does not use the modern term for mental illness (seishinbyō). This word was first used by Ogata Kōan (interestingly also a contributor to Mitsukuri’s journal) in his translation of Hufeland’s Enchiridion Medicum, published 20 years later in 1857 (Hiruta, 2001: 185). Maki does, however, use the terms seishin, shinshiki and shinki, words reflective of ‘the mind’ or ‘mental awareness’ as well as the term ryōshinshiki hōhō for what Schroeder van der Kolk calls psychische behandeling, or psychiatric treatment. These terms are similar to but also slightly different from the vocabularies used in other contemporary Japanese medical works (Hiruta, 2001: 176–7). The abundance of Maki’s vocabulary suggests the well-developed context into which he was introducing Schroeder van der Kolk’s ideas. As Sugimoto Tsutomu has suggested with regard to Sugita and Maeno’s translation of Kaitai shinsho, Japanese Dutch-learning scholars were not translating into a vacuum. Even apparently revolutionary ideas such as ‘nerves’ and ‘brain’ and the idea that the mind might be seated there were adopted into Japanese using a pre-existing Sino-Japanese vocabulary and context (Sugimoto, 1997: 242–6). This made them simultaneously innovative and familiar.

Practical care for the mentally ill

In the final part of this paper, I will consider what Schroeder van der Kolk’s psychiatric treatments might have meant for contemporary Japanese, by discussing the social as well as medical means of caring for the mentally ill in the Edo period. A number of excellent studies have been published in Japanese in recent years to which I cannot do adequate justice here (Hashimoto, 2010a, 2011; Itahara and Kuwahara, 1998; Kanekawa and Hori, 2009; Yagi and Tanabe, 2002). They are helpful, however, in providing a general picture of the context into which Schroeder van der Kolk’s work was being introduced.

As discussed earlier, Schroeder van der Kolk had considerable experience as medical superintendent and advisor to lunatic asylums in Amsterdam and Utrecht. While he was highly critical of the conditions he saw there and was instrumental in introducing more humane treatment of the mentally ill – including facilities such as bathing, fresh air, exercise and labour, and the use of restraint only when absolutely necessary – he saw distinct benefits for the mental patients in institutionalization (de Waardt, 2005: 49–51). This way of thinking is apparent in the case study under consideration here, through his hospitalization of the patient in the asylum and through his advocacy of the general benefits of temporarily disconnecting patients from their families and everyday circumstances. Interestingly, Maki translates the asylum (Schroeder van der Kolk’s Gasthuis) as byōin, the modern Japanese word for ‘hospital’.

In Edo period Japan, mental hospitals were virtually unknown. The lack of psychiatric hospitals and appropriate medical care was bemoaned by psychiatrists in the early twentieth century who were pushing for the medicalization and institutionalization of psychiatric care, and historiographically, too, the situation was often seen by historians as a sign of Japan’s ‘backwardness’ (Suzuki, 2003: 194). More recently, however, historians have been examining and even celebrating with a certain sense of nostalgia the ways in which some of the mentally ill were cared for in this pre-modern period (Nakamura, 2010). I will present a brief overview here.

Up to and including the Edo period, and to some extent beyond, family members were held responsible for dealing with the day-to-day care of the mentally ill. The sick were not usually confined unless they were socially disruptive, but if they were, or if the family chose to seek treatment, there were a number of options available. The most common approach to treating the mentally ill was religious, and families of the mentally ill could take the sufferer to a temple or shrine so that prayers might be offered, either to atone for past sins or to attempt to relieve the person from possession by an evil spirit. A number of temples offered services for the care of the mentally ill, either through Chinese-style herbal medication or through the reading of sutras. Some of them even specialized in this treatment, such as the Iwakura Daiunji in Kyoto, where patients received ‘water therapy’ which involved pouring cold water over their bodies (often under a waterfall, which might be considered sacred). By the Edo period, there were as many as 30 temples which offered this kind of care for the mentally ill (Yagi and Tanabe, 2002: 29–34). Unfortunately, however, such treatment was expensive, so not everyone could afford it. At temples or thermal springs, a three-week stay was usually expected, and patients needed to be accompanied by a family member who would also require food and lodgings. This was beyond the means of many families (Nakamura, 2010: 202). At Iwakara, people could even leave their sick relatives with local families, who made a useful extra income by providing carers and lodgings for the mentally ill (Hashimoto, 2010b; Nakamura, 2010: 204). The patients might be occupied doing work on the land with local families, or be asked to babysit; even if they tried to run away, they were almost always discovered as the village was sufficiently isolated (Nakamura, 2010: 198). While we might draw a comparison here between this peaceful picture and the idyllic version of the asylum envisaged by Schroeder van der Kolk (minus the medical care), there were also far less appealing solutions to dealing with the mentally ill.

When patients were more disruptive, various forms of confinement were socially and legally condoned. Because the law made families responsible for any crimes committed by their mentally-ill relatives, people of Edo-period Japan often chose to be cautious and keep the sick person out of harm’s way. The responsibility for making decisions about the sick person lay with the family, but authorities also played a role in granting permissions and making inspections. The availability of different forms of confinement depended on the person’s position within the family, as well as the geographical location in which the family lived. There were three basic forms of confinement: prison, the tameazuke (a sort of hostel), and home confinement (Hashimoto, 2010a: 17).

In the cities, people who were considered dangerous or likely to commit a crime could be housed in prison. The application was made to the local authorities, and the procedure required the consent of the household head, important family members and, for reasons of collective responsibility, the local neighbourhood group (goningumi). In documents explored by Itahara and Kuwahara, a family applied to have a sick relative imprisoned because he often drank and caused trouble in the neighbourhood, was in danger of setting something alight, was ‘disturbed’ and could no longer be controlled by family members (Itahara and Kuwahara, 1998: 48–51). Prisons in Edo Japan were not intended for the long-term incarceration of criminals, who after sentencing were usually punished in other ways, but as a way of confining the uncontrollable mentally ill, prisons seem to have been commonly used.

Another institution that was used for housing the mentally ill was called the tameazuke (lit. ‘the dump’), an institution designed to house sick prisoners, underage prisoners too young to be banished, and sick and homeless vagrants. This institution was run by members of an outcaste group, the hinin, who had specific duties related to looking after prisoners and vagrants. The two tameazuke in Edo both had special areas that were devoted to housing the mentally ill, according to Itahara and Kuwahara (1998: 56). Because the tameazuke housed sick prisoners, local doctors made daily rounds, but the level of medical care provided was limited (Ishii, 1964: 179–80).

A third way of confining the mentally ill in the Edo period was to restrain family members at home, often inside a bamboo cage, or an enclosure. This method was usually reserved for elders within the family who could not easily be put in prison, and the conditions under which permission was granted were strict. Because the confinement of a family member, particularly a household head, might be made on false pretences in order to secure an inheritance, it was necessary to obtain the signatures of family members, neighbourhood group or household head, and to supply supporting evidence from a doctor to certify that the person was indeed mentally ill. The doctor’s report was expected to contain a description of the symptoms and the medicines that had been used. Sometimes a picture of the location of the cage within the house was also appended. A doctor might also provide continuing treatment for the confined person, and issue another report should the person recover and require release (Itahara and Kuwahara, 1998: 56–8; 1999: 99). Thus, these cases provide evidence that doctors in the second half of the Edo period were contributing to the medicalization of mental care through their social roles as well as through their medical writings.

While doctors in the late Edo period increasingly saw a role for themselves as providers of psychiatric care, and to some extent there was a developing social expectation that they play a role in providing justification for confinement, it was not until the early twentieth century that Japanese doctors made their push for the establishment of asylums in Japan. They were motivated by a desire to medicalize and monopolize mental health care and so exclude all other forms of treatment, but they found themselves faced with a complex situation that required negotiation with families, communities and authorities rather than the simple adoption of a Western model (Suzuki, 2003). Moreover, as Burns (2012) has also recently suggested, localized and lay understandings of mental illnesses and how to heal them were remarkably persistent, despite the efforts of the newly professionalized psychiatrists.

Conclusion

What does the selection of Schroeder van der Kolk’s case study for translation and publication in Japanese in 1837 reveal about the ‘communicative practice’ of psychiatric medicine in this period? (Secord 2004: 670). When Schroeder van der Kolk published his essay ‘in the hope of encouraging research into the healing of [mental] illness’, he hardly could have foreseen that his audience would include an enthusiastic group of Japanese contemporaries. It is significant that ordinary Japanese doctors – in a country which is often (somewhat erroneously) described as ‘closed’– were reading a vernacular Japanese translation of a Dutch psychiatric case study a mere 11 years after its original publication. This point alone is revealing of the ability of scientific information to cross even the most unlikely cultural and geographic borders.

For political reasons surrounding Japan’s foreign policy in this period, Dutch was a privileged language in Japan, so naturally the very accessibility of this essay to Japanese scholars must have influenced the decision to translate it. In choosing to translate this essay for his journal, Mitsukuri was offering his readers the best that recent Dutch scholarship had to offer. There is little doubt that Schroeder van der Kolk was at the forefront of its thinking on mental health. I suggest, however, that (despite the title of his journal) Mitsukuri did not select the essay on the basis of the author’s reputation. The intrinsic appeal of the case study was probably the reason behind its inclusion. Of particular interest to the Japanese physicians was perhaps Schroeder van der Kolk’s overview of the situation in the Netherlands and his call for more research. Moreover, being a case study, it was presented in relatively simple language and the content was practical, thus fitting in with Mitsukuri’s understanding of ‘histories’ and their value for the study of medicine.

In contrast to the common assumption that Western psychiatric approaches were somehow more advanced, and therefore deserving of transportation around the globe, in many ways Schroeder van der Kolk’s approaches resonated with the ways in which Japanese physicians already conceived of mental illnesses. His gentle approach to therapies and rejection of strong drugs like opium, and his belief that constipation or similar disorders of the stomach could be associated with mental illness were similar to the approach of many Chinese-style physicians, who believed that blockages in ki or vital energy could be responsible. His attention to the emotional needs of the patient through quiet discussion was also similar to what some Japanese physicians had been attempting. Even as he warned of the delicate connections between the ear and brain, Schroeder van der Kolk was reluctant to disregard the importance of clean bowels and abdomen in treating the mentally ill. For the readers of Taisei, the treatments that Schroeder van der Kolk described were probably not so very different from those they already knew and used.

The fact that this psychiatric case study was included in a collection of practical medical essays is reflective of an increasing interest among Japanese physicians in the treatment of mental illness. Japanese doctors from a variety of theoretical schools were already engaging in clinical research and publishing their theories and case studies concerning mental illness. In trying to understand and interpret the essay, the Japanese were able to draw upon a pre-existing body of related literature in Japanese which included a sophisticated vocabulary to describe mental illness and knowledge of many of the drugs used in Western medical practice. Despite their foreignness, Schroeder van der Kolk’s ideas could be transported relatively easily into a Japanese context.

It is therefore clear that a number of Japanese doctors and medical scholars were interested in Western approaches to psychiatric care in the mid-nineteenth century. This translation sits alongside other previously known examples of Western works concerning mental illness, such as those by Johannes de Gorter (Japanese translation published in 1822) and Hufeland (Japanese translation published in 1857). ¹² A growing interest in Western psychiatric medicine was one aspect of a developing medicalization of mental health care in Japan. While Schroeder van der Kolk’s therapies probably offered little that was new to Japanese readers, of note was his call for a more humane approach to the treatment of the mentally ill. Above all, he saw the mentally ill as patients with a physical disease. He was in favour of hospitalization, or at least of removing patients from their regular environments – a medicalization of their care that would eventually also become established in Japan. But just as the translators of this essay interpreted the Dutch author’s writing within the context of their existing vocabulary and framework of medical knowledge, the social context of mental care was also necessarily localized. Thus, by the mid-nineteenth century it was surprisingly easy to communicate psychiatric practice around the world, but it was in the local contextualization of these ideas that both the real challenges and innovation lay.