‘The present state and statistical observation of mental patients under home custody’,by Kure Shūzō and Kashida Gorō (1918)

Abstract

This text, dealing with the private confinement of the mentally ill at home, or shitaku kanchi, has often been referred to as a ‘classic text’ in the history of Japanese psychiatry. Shitaku kanchi was one of the most prevalent methods of treating mental disorders in early twentieth-century Japan. Under the guidance of Kure Shūzō (1865–1932), Kure’s assistants at Tokyo University inspected a total of 364 rooms of shitaku kanchi across Japan between 1910 and 1916. This text was published as their final report in 1918. The text also refers to traditional healing practices for mental illnesses found throughout the country. Its abundant descriptions aroused the interest of experts of various disciplines.

Keywords

Kure Shūzō mental health law private confinement religious therapy 20th-century Japan

Introduction

This text, dealing with the private confinement of the mentally ill at home, or shitaku kanchi, has often been referred to as a ‘classic text’ in the history of Japanese psychiatry. Shitaku kanchi was one of the most prevalent methods of treating mental disorders in the first half of the twentieth century in Japan. According to statistics from the Japanese Ministry of Health and Welfare, at least until the 1920s the number of patients who were cared for in shitaku kanchi was larger than in mental hospitals. The number of such patients continued to increase, and in 1937 they reached a peak of about 7200 (Kōseishō, 1955).

Under the guidance of Kure Shūzō (1865–1932), professor of psychiatry at Tokyo University, Kure’s 12 assistants, including co-author Kashida Gorō, inspected a total of 364 rooms of shitaku kanchi across Japan between 1910 and 1916. Their final report, ‘Seishin byōsha shitaku kanchi no jikkyō oyobi sono tōkeiteki kansatsu’ (The present state and statistical observation of mental patients under home custody), was published in a Japanese journal in 1918. It reports on 105 patients of shitaku kanchi, with many photographs and illustrations. The text also refers to traditional healing practices for mental illness found throughout the country: bathing under waterfalls or in hot springs, prayers and spells in temples or shrines, and other folk therapies and beliefs. In recent years, some people have made use of the history of psychiatry in modern Japan, including shitaku kanchi, when teaching about the violation of human rights and the reform of psychiatry. They quote the text by Kure and Kashida, arguing that psychiatry in Japan is nowadays still in this backward state.¹ However, this view represents only one side of the text, and its detailed descriptions, which extend to religion and folklore, have aroused the interest of experts in various disciplines.

The text is written in old-style Japanese so it is not easy to read, even for most Japanese people today. Probably for this reason – and in spite of its importance as an academic text – it does not seem to have been well known, either within or outside Japan, apart from the title and some short quotations. Although the text that is translated here from Japanese into English consists of excerpts and rather lacks the tone of the original, the translation may interest a wider range of readers around the world who are interested not only psychiatry but also in history, religion and culture. The year 2018 marked 100 years since the text was first published; to commemorate this, a number of events and publications were planned in Japan.²

Shitaku kanchi and the law

The first author, Kure Shūzō, was the most influential figure in terms of the establishment of modern psychiatry in Japan. After returning from studying in Austria and Germany (1897–1901), he was engaged in the reform of the treatment of mental patients, and asserted that shitaku kanchi should be abolished (Okada, 1982). At the time, the number of mental hospitals was so restricted that the law (mentioned below) allowed the confinement of patients at home under the control of the police (Hashimoto, 2011: 25–34).

In the premodern period, shitaku kanchi as a form of confinement of mental patients had probably been used throughout the country (Hiruta, 1985). But after the Japanese government enacted the first law for mental patients – the Mental Patients’ Custody Act (Seishinbyōsha kango hō), on 1 July 1900 – these patients had to be firmly controlled by the central and local governments. The main purpose of this law was to prevent mental patients from illegal confinement and, at the same time, to assert public control of them through custody. The law depended greatly on the role of the patient’s family: to make responsibility for custody clear, a family member of the patient was assigned to be a kangogimusha (custodian) to take care of the patient. The kangogimusha had to file an application with the relevant government office to put the patient in an institution, whether a mental hospital or a shitaku kanchi room at home. The practice of shitaku kanchi under government oversight was a particular form of institutionalization invented in modern Japan. A compromise, made due to the restricted number of psychiatric beds, was to put shitaku kanchi under bureaucratic control. In other words, the places where mental patients were confined were private spaces where a patient, with their families, led their everyday lives, but at the same time they were public spaces whose structure and management were authorized by the government and regulated by law.

Under the Mental Patients’ Custody Act, the governments of all 47 prefectures, the highest local governments in Japan, regulated the custody details of mental patients. In order to build a room for confinement in or next to a house, kangogimusha had to apply to the prefectural governor through the police. The application was formulated in detail, and it had to contain a medical certificate by a doctor, the reason and place for shitaku kanchi, the method of care, and precise details of the construction of the room where the patient would be confined. Finally, shitaku kanchi was permitted by the prefectural governor. After a patient was confined to a room, the policemen in charge regularly inspected patients to see whether the family was taking proper care of them, and there was no fear that they would run away. If the patient ran away the police would search for them, and the search order would appear in the official report not only of their own prefecture but also of other prefectures all over the country.³

Criticism and evaluation of shitaku kanchi

In this text, Kure and Kashida strongly objected to shitaku kanchi and aimed to reveal the poor state of confined patients, based on detailed descriptions of these cases and statistical observations. It was natural for these enlightened psychiatrists to criticize shitaku kanchi and the Mental Patients’ Custody Act which stipulated it. For them, the modernization of psychiatry in Japan meant matching European standards, and they criticized shitaku kanchi as an unsatisfactory form of care that should be replaced by care in mental hospitals. They recognized, however, that the central issue lay rather in the shortage of psychiatric institutions. They reported that in Japan there was a lack of national and public (prefectural) mental hospitals, and that the capacity of private mental hospitals was also very low; of the estimated 140,000 to 150,000 mental patients in Japan, only about 5000 gained any benefits from the medicine they took. Comparing the public system and institutions for mental patients in Western countries with those in Japan, they asserted that the latter and the former were as different as night and day. Finally, they criticized the present state of psychiatry, stating that over 100,000 patients in Japan were unfortunate not only because they had become ill, but also because they had been born in Japan.

Their text played an effective role in the establishment of the law for building public (prefectural) mental hospitals, the Mental Hospital Act (Seishin byōin hō), in 1919. The construction of public mental hospitals, however, was slow. Just before the outbreak of the Pacific War in 1941, only 7 prefectural mental hospitals, with a total of less than 3000 beds, existed in all of Japan under this law. On the other hand, the number of private mental hospitals steadily increased, and in 1940 there were 154. Although they had about 20,000 beds altogether, the total number of psychiatric beds in Japan, including those of public mental hospitals and university hospitals, was still not enough for patients who needed to be hospitalized (Kōseishō, 1941). In this context, shitaku kanchi continued to be a realistic option, especially in rural areas, and the Mental Patients’ Custody Act remained in effect until 1950, when the new Mental Hygiene Act (Seishin eisei hō) came into effect.

It should be mentioned that from the 1930s onwards some medical doctors associated with the government defended shitaku kanchi. For example, Aoki Nobuharu, a medical doctor and government official of the Ministry of Home Affairs, pointed out – based on research into shitaku kanchi undertaken by the Ministry in 1930 – that most shitaku kanchi patients were treated well because of the strong traditional family system in Japan, and that even the poorest families made efforts to care for their family members day and night for years. Moreover, he asserted that shitaku kanchi corresponded to the trends in psychiatry abroad. Aoki tried to connect shitaku kanchi with the concept of foster family care, which was modelled on the village of Gheel in Belgium and was successfully practised from the late nineteenth century onwards in Western countries as an alternative to inhumane and expensive care in large, closed mental hospitals. According to Aoki, ‘shitaku kanchi is a kind of extramural care, and I believe strongly that, if its good points are improved and its bad ones are removed, shitaku kanchi will be superior to the family care practised in Europe and America’ (Aoki, 1937: 1089). Sasaki Tsuneichi, a medical doctor and local government official in Kyoto Prefecture, believed that the ‘beauty of family’ could improve the state of care of mental patients. While he pointed out that in Kyoto the mortality rate of shitaku kanchi patients was much higher than that of patients in mental hospitals, he was convinced that, provided some problems were solved, compassionate care at home – a type of care peculiar to Japan – would prove its merits and dramatically reduce the high mortality rate (Sasaki, 1938).

Religious and traditional healing

In addition to the poor state of shitaku kanchi, Kure and Kashida also deal with religious and traditional healing practised in non-medical institutions. According to their text, only a few wealthy people were able to receive medical treatment through house visits by doctors or hospitalization. As a result, shitaku kanchi and folk therapies were the representative treatments for mental patients in Japan at the time.

Sakaki Hajime, Kure’s teacher and the first Professor of Psychiatry at Tokyo University, wrote in his 1886 article on the history of psychiatry in Japan that treatment of the mentally ill had been left in the hands of priests, fortune-tellers or sometimes laymen, but some treatments remained the same after the modernization of medicine (Sakaki, 1886). The modern Japanese government, on the other hand, was interested in the state of non-medical institutions in which the mentally ill were staying for treatment, such as temples, shrines, waterfalls and hot springs. The Ministry of Home Affairs (from 1938 onwards the Ministry of Health and Welfare) published a list of non-medical institutions several times in the first half of the twentieth century. Probably reflecting the growing demand for the treatment of mental illness at the time, the number of such institutions seems to have increased year by year, regardless of modernization or the Westernization of medicine; for instance, 18 in 1917 (Naimushō, 1918), 29 in 1927 (Naimushō, 1928), 34 in 1937 (Naimushō, 1937) and 55 in 1940 (Kōseishō, 1941).

Kure and Kashida, in the Classic Text which follows, wrote about six institutions for the treatment of mental illness: (1) Takaosan Yakuōin (Tokyo), (2) Shōchūzan Hokekyōji (Chiba), (3) Barakisan Myōgyōji (Chiba), (4) Hozumi Jinja (Shizuoka), (5) Ōiwasan Nissekiji (Toyama) and (6) Jōgi Onsen (Miyagi). Numbers (1), (2), (3) and (5) are Buddhist temples, where the patients received incantations and prayers or bathed under waterfalls; (4) is a Shintō shrine, where they received hot water prayers (yukitō), and (6) is a hot spring inn, where they usually stayed for a long time for recovery. Kure and Kashida criticized bathing under waterfalls as having no effect, and even being harmful to the patients. In terms of incantations and prayers, however, the authors seem to evaluate a part of the practices as being a form of religious psychotherapy. Moreover, bathing in the hot springs at Jōgi was thought to be comparable to duration bathing (Dauerbad) used in the early twentieth century in Europe as physical therapy for mental patients. The Classic Text also refers to some folk medicine for mental illness: charred animals (kuroyaki), cow gallstones (goō) and herbs. Some of these seem to have their roots in traditional Chinese medicine (kanpō). Finally, Kure and Kashida describe the ways of transporting patients from their homes to mental hospitals, and criticize the fact that patients were often transported in an inhumane manner, which had a bad effect on people’s state of mind.

Shitaku kanchi after World War II

Shitaku kanchi was prohibited by the new Mental Hygiene Act in 1950, although it was allowed until 1951. During this one-year extension, people released patients from cages at home and hospitalized them. According to the new law, psychiatrists who were appointed by the Ministry of Health and Welfare as mental hygiene inspectors (seishin’eisi kantei i) roamed the countryside to examine shitaku kanchi patients, and in many cases had to transport them to mental hospitals by force (Hashimoto, 2011: 171–2).

According to one of the mental hygiene inspectors who was active in Wakayama Prefecture, at the beginning of the 1950s he often inspected the patients’ custody situation together with community health centre employees. He recalls that the home inspections were often dangerous; for example, one patient was waiting for them, holding a hatchet behind him, and another patient climbed to the top of a persimmon tree to escape. Some of the patients’ houses were in mountain valleys, which the inspectors could not reach by car, so they got out of their car midway and had to walk for hours to reach the houses.⁴

On the other hand, the mental hospitals which had to accept the shitaku kanchi patients were thrown into utter confusion all over the country. A psychiatrist at a private mental hospital in Ehime Prefecture recalls that every morning he never began his work in the hospital without seeing several patients, rolled up in futons and lying in the corridors, waiting to be examined. The hospital refused to hospitalize them, in spite of their families pleading that they could not take the patients home because the shitaku kanchi room had been destroyed by the public office (Nose, 1975).

However, shitaku kanchi in Japan did not end completely in 1951. Until the revision of the Mental Hygiene Act in 1965, it was allowed in exceptional cases if there were unavoidable circumstances: ‘A mental patient who should be hospitalized may be accommodated in places other than mental hospitals if that patient is not able to be hospitalized at once’ (Article 43). Moreover, illegal shitaku kanchi was seen after the 1950s (Okada, Yoshioka, Kaneko and Hasegawa, 1965).

In the southernmost parts of Japan, people depended on shitaku kanchi for longer than on the mainland because of the special conditions following World War II. In the Amami Islands, which were ruled by the US military government from 1946 to 1953, shitaku kanchi was legal until 1954. When the islands were returned to Japan in 1953, the Japanese government issued cabinet orders, including temporary measures, for the returned Amami Islands. With reference to the mental hygiene administration, it said that, regardless of the regulations in the Mental Hygiene Act, shitaku kanchi in Amami should be legalized for a year after the enforcement of the cabinet order. In 1954, when shitaku kanchi was still legal in Amami, Satō Kansei, a psychiatrist and professor at Kagoshima University, visited Amami to examine 33 shitaku kanchi patients. To his surprise, Satō saw six patients who could barely move because they were shackled. In his 1955 article he harshly criticized the state of care in Amami (Satō, 1955). On the other hand, the Okinawan islands were returned to Japan from the US military government in 1972. The Mental Patients’ Custody Act (1900) was in force until 1960, and in the same year the government of Okinawa (Ryūkyū seifu) established its own Mental Hygiene Act (of Ryūkyū), modelled on the Mental Hygiene Act (1950) of the Japanese mainland. Because of the lack of psychiatric institutions in Okinawa, the law stipulated confinement in places other than mental hospitals, which allowed mental patients to be put into shitaku kanchi rooms (Kitamura, 2014).

However, generally speaking, after World War II the number of psychiatric beds in Japan dramatically increased until the 1990s, while the deinstitutionalization of mental patients proceeded in Western developed countries: in 1950, when the Mental Hygiene Act was enacted, there were fewer than 18,000 psychiatric beds in the country, but in 1993 the number reached a maximum of c. 363,000 (2.9 beds per 1000 population). According to the Organisation for Economic Co-operation and Development (OECD, 2014), ‘Japan has lagged behind the deinstitutionalisation trend’ and ‘Japan’s mental health system stands out amongst OECD countries for all the wrong reasons’. In recent years the number of beds has gradually decreased, but about 300,000 patients are still hospitalized, and two-thirds of them are long-stay patients of more than one year (Kōseirōdōshō, 2014).

Bibliographic information, and chapters of the Classic Text

Kure and Kashida’s text was first published in 1918 in the Japanese medical journal Tokyo igakukai zasshi. In the same year it was also published as an offprint by the Ministry of Home Affairs. The two texts are almost the same except for some small differences in expression. The translation following is from the latter, because this reprinted version has been more widely available.⁵

The text consists of a short preface and eight chapters. Chapter 1 (Introduction) refers to the history and present state of psychiatry in Japan, compared with those of Western countries. Chapter 2 (The present state of shitaku kanchi patients) is the main part of the text. Kure’s 12 assistants visited a total of 364 shitaku kanchi rooms and, from these, 105 cases with illustrations and photographs were chosen for the text. Cases 1 to 92 are divided into 4 categories, according to the structure of the shitaku kanchi rooms and the treatment of patients by their families: ‘good’ (8 cases), ‘average’ (27), ‘bad’ (33), ‘very bad’ (24). Cases 93 to 105 concern poor patients supported by public assistance. Chapter 3 (The present state of mental patients at home who are not confined) deals with 10 cases (106 to 115) who are not confined but registered as ‘non-confined mental patient (mikanchi seishin byōsha)’ at the local government office. In Chapter 4 (Religious and traditional healing), six institutions for the treatment of mental illness are described as examples of religious and traditional healing (see earlier), with four cases receiving such healing (116 to 119). In the mentally ill cases described in Chapters 2, 3 and 4, names and addresses are obscured, probably on account of the patients’ privacy. Chapter 5 (Statistical observation of shitaku kanchi patients) summarizes all the inspection data of shitaku kanchi statistically. Based on these chapters, in Chapter 6 (Criticism) Kure and Kashida criticize the present state of Japanese psychiatry. Further, in Chapter 7 (Opinions) they assert that psychiatric institutions and legislation on mental illness should be improved, and that knowledge of treatment and the care of those with mental illnesses should be disseminated to everyone. Chapter 8 is the ‘Summary and conclusion’. The Classic Text is a translation of some excerpts from Chapters 1–7.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Notes

References

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