(1) The Medicine of the Southern Barbarians in Japan

After a brief contact in 1543, direct cultural exchange between Europe and Japan began exactly 450 years ago, in 1549, with the landing of the eminent Spanish Jesuit Francisco Xavier. In the 90 years that followed, it was chiefly Portuguese and Spanish missionaries and merchants that brought European culture to the Far East and Japanese culture to the West. Although the Japanese called them by a less-than-flattering name "southern barbarians" (nanban-jin), they certainly respected their weapons, their skills in astronomy, navigation, surgery and art. On their imposing galleons sealed with pitch, which were dubbed "black ships" by the Japanese, the strangers brought not only European wares, but also important goods such as silk, tropical wood and medicinal drugs from all over Southeast Asia and even from Central and South America.

Actually, the Jesuits took little interest in surgical activities. For the Church had eschewed blood ever since the famous Council of Tours in the year 1163: "Ecclesia abhorret a sanguine". But it just so happened that Luis d'Almeida, a licensed surgeon who had made it rich as a merchant, joined the Society of Jesus in Japan. In Funai (eastern Kyûshû) he founded a hospital with one hundred beds, where, as one missionary wrote, "the body was treated with medicines and the soul with prayers." In a country wracked by civil wars, there was no dearth of patients. The enthusiastic letters and annual reports from the mission testify to the popularity of the "southern barbarians' hospital".[1]

These years are regarded as the beginning of European medicine in Japan. But the innovations were not as revolutionary as might appear. Some authors point out the new type of gunshot wound, the hitherto unknown washing of wounds with alcohol and the use of porkfat [p. 4] and olive oil. But injuries caused by firearms had not been known in Europe for very long either, and there was still some controversy over their nature and treatment in the 16th century. Furthermore, the missionaries were wise enough to appreciate Japanese traditions. In the hospital at Funai, the "internal medicine" was left entirely to Japanese physicians, some of whom were praised by name

The approach to pharmaceuticals was likewise pragmatic. The bulk of the drugs came from the surrounding mountains and from Macao, Malacca and Cochinchina. Documents show that Chinese remedies and instruments were to be found in d'Almeida's dispensary. The missionaries had Chinese texts explained to them. In the mission's letters and dictionaries we find a number of indications that they delved into acupuncture and moxibustion. Luis Frois, a layman in the field of medicine, wrote that he knew how to take someone's pulse in the Japanese way. And when they fell ill, many of the European priests sought out Japanese doctors, including the famous Manase Dôsan in Kyôto.[p. 5]

In a comparison of European and Japanese cultures in 1585, on the other hand, that same Luis Frois regretted that the Japanese would not accept urine diagnosis, phlebotomy, enema, cautery and other traditional methods highly esteemed in the West. Nor did Japanese field surgeons follow the example of many of their Occidental colleagues when it came to pouring boiling/hot oil into wounds.

So the interchange of medical know-how was fairly balanced and the conditions relatively favourable for a new symbiosis between the East and West. But this enterprise aborted as early as 1587 when the hospital in Funai fell victim to the strife between Japanese war lords.

From the 1580s on, the mission ran into trouble everywhere. The decades that followed until the Iberians were ultimately driven out of the country were marked by destruction, expulsion, exhaustion, illness, death. No one knows how to venesect, complained father Coelho in 1589, and three of the members of the order who fell ill from the strain of persecution have already died. When in 1591 João Rodriguez was taken ill in Kyôto, he had to travel 700 kilometresto Nagasaki for treatment. The last Christian nursing homes run by the Japanese there disappeared around 1620. To make matters worse, criticism of such medical endeavours was mounting within the Society of Jesus itself. In the end, everything relating to medicine disappeared from the writings of the Jesuits under the categorical ban (obediencia) imposed by Francisco Pasio in 1612. Nothing remained of what had been built up under the Europeans.

 (2) Japanese "Southern-Barbarian-Style Medicine"

Today there are no known Japanese sources from which to glean how Western medicine was perceived during this second half of the 16th century. Most likely, exposure to Western concepts and methods of healing was confined to a very small group of people in a few places and during certain brief periods of time. There was no chance of any continuity due to the changeable and increasingly difficult situation of foreign and native Christians. In the wake of the destruction of the hospital, it is hardly conceivable that a group of Japanese doctors could have existed along the lines of Thomas Kuhn's concept of the paradigm, in[p. 6] other words a group that underwent similar technical training and possessed and handed down a common canon of problem-solving approaches.

And it is certainly not by chance that traces of the "southern barbarians" did not appear in Japanese medical texts until the early 17th century. The "Anthology of Everything for the Outside" (Mangai shûyô), which dates from 1619, is considered the oldest work of "southern barbarian style medicine" (nanbanryû geka). But the mention of five plasters, washing wounds with spirits, and some instruments like scissors and scalpel goes to show that, even after seven decades of East-West contact, there were still some writers who knew almost nothing about Western surgery.[2]

Standard Japanese works on the history of medicine name Kurisaki Dôki (1582-1665) as an exponent of "surgery in the style of the southern barbarians".[3] He is said to have gone to the Philippines as a child and undergone training there. From 1617 on he worked as a physician in Nagasaki, where some Portuguese were still living until 1638 and where two years later the Dutch East India Company was to set up a trading post. The teachings compiled by his pupils, however, reveal a blend of Japanese, Chinese, Iberian and Dutch elements. If he really received training in Western methods, one ought to find more European elements. What's missing is anatomy, for instance, to which great importance was attached at European universities as well as in the surgeons' guilds. The presentation of furuncles, a focal point of Kurisaki's teachings, shows no trace of the systematic arrangement you find in Western works on the subject. Either Kurisaki's pupils only set down what they understood, or he had merely acquired some practical skills and rudimentary knowledge in the Philippines. Anyway, though he clearly became a successful physician in Nagasaki, he can hardly be regarded as a representative figure of "southern-barbarian-style surgery." It is not impossible that some new[p. 7] material will be found, however, it is not purely by chance that to this day not a single reference to any Western work on medicine, surgery, anatomy, pharmacy is known in any manuscript dating from the long period between the advent of the Iberians' in 1549 and their final expulsion in 1638.

And that is in spite of the fact that the language barriers were not all that high then, certainly much lower than in the following two centuries. Some of the Europeans spoke excellent Japanese and many Japanese spoke Portuguese just as well, some even Latin.

What's more, the social and intellectual conditions were quite favourable for the reception of new knowledge and thought. For one thing, many scholars parted with Buddhism. For another, the efforts of the regional rulers to bolster their domains through overseas trade with East and Southeast Asia led to the adoption of a number of foreign innovations, many of which stemmed from China. To name just a few: improvements in smelting and forging methods, in papermaking, silk-weaving, book-printing, and some in ship-building and navigation as well. Most of this know-how was disseminated not by Buddhist monks or scholars as in the past, but by merchants and artisans; hence it was predominantly of a practical nature.[4]

Consequently it was not due to a lack of intellectual receptiveness that the Iberians' medicine did not take root firmly in Japan. Given the destruction of the mission hospital in Funai, the mounting persecution of Christians and also resistance within the Society of Jesus, there was no stable basis anymore for an effective interchange. So, to take issue with the standard literature on the subject to date, I do not believe the Japanese ever came to practice "southern-barbarian-style surgery" in the sense of a paradigm that could be passed on or handed down to succeeding generations. [p. 8]

 (3) The Surgery of the "Redheads" and Japanese "Redhead-Style Surgery"

The Dutch, dubbed 'redheads' (komôjin) by the locals, probably because most had blonde hair with a reddish tinge, reached Japan at the beginning of the seventeenth century. In 1609, they established a trading post on the western island of Hirado, but in 1641 were forced to move to the small man-made island of Deshima in the Bay of Nagasaki. Because they displayed tactical acumen and did not proselytise, they were the only Europeans allowed continued access to Japan.

Interest in the Western art of healing was rekindled in Edo and Nagasaki in the mid-seventeenth century when a German surgeon, Caspar Schamberger, who is credited with the birth of 'Caspar-style surgery' (kasuparu-ryû geka), the first Japanese school of 'redhead-style surgery', sparked a lasting interest in Western medicine, herbal lore and pharmaceutics.[5] His successors at the trading post on Deshima continued to pass on surgical knowledge, which gradually merged with other disciplines to form the so-called 'Dutch studies' (rangaku).[6]

As is always the case, events were influenced by a variety of factors. Schamberger, who received his professional education in the guild of Leipzig and gained professional experience during the Thirty Years War,[p. 9] must have been an extremely competent surgeon. Considering the formality of the court at Edo, he must also have displayed a greater mastery of etiquette than the average barber-surgeon of his time. For example, in the days of the 'good old Hirado trading post' the notorious alcoholic Pieter Stamper, who went to Kyôto to care for a Japanese official, had to be recalled after bouts of heavy drinking and accusations of theft.[7] Thus, Schamberger's personal qualities must be recognised as a significant factor in the introduction of Western surgery into Japan.

Chance, too, played a part. When the shôgun Ietsuna became seriously ill in 1650, the Dutch legation in Edo, led by special envoy Andries Frisius, had to wait months for an audience. During the long wait, some high-level officials suffering from diseases of old age sought out the foreign surgeon Schamberger, giving credibility to the medicine of the 'redheads'. Subsequently, Schamberger and three other Europeans were asked to stay in Edo for another six months following the departure of the Dutch legation. Without this interest and approval, the name of 'Master Caspar' would never have been handed down to later generations, despite his professional skills and lengthy stay in Edo.

Political and economic factors were also significant. By limiting its external relations to only a few partners, Japan became heavily dependent on these few countries for certain goods. Talks held in 1639 by the Dutch opperhoofd, François Caron, with the inspector general, Inoue Masashige, and the imperial councillor, Sakai Tadakatsu, show the government's concern for an uninterrupted supply of raw silk, textiles, and Chinese herbal drugs and medicaments. The adoption of new Western medical knowledge was seen as beneficial, not only to their own health but also to the further development of Japan, and thus the consolidation of the Tokugawa regime. In addition to medicine and pharmacy, armaments, astronomy and cartography were of special interest and the supply of goods in these branches of knowledge was never threatened, even after the introduction of the Japanese seclusion policy.

Acceptance of aspects of Western technology was due largely to the foresight and influence of particular individuals. Many events and decisions during the decades before and after Schamberger's stay in Japan cannot be adequately explained without taking into account the influence of the imperial inspector general Inoue Masashige, Chikugo-no-kami.[8] As well, the governors of Nagasaki and some of the feudal lords and imperial councillors played important roles during the second half of the century. Therefore, socially and institutionally, conditions for the introduction of Western surgery were favourable.

Although the new knowledge was initially kept secret and was handed down only from teacher to pupil and from father to son, it spread widely with amazing speed. One single Japanese doctor, Kawaguchi Ryôan, the most outstanding adherent of Schamberger's surgery, carried 'Master Caspar's teaching' from Nagasaki to Kyôto, to northern Honshû and even to Shikoku within less than twenty years.[9]

The apparently positive response to the new methods in the regions very soon led to an increasing demand for more knowledge of the 'secrets'. The first printed books on surgery in the style of the 'redheads' appeared only two decades after Schamberger left Japan.[10] Schamberger's[p. 11] influence significantly changed the life of his successors at Deshima, who were constantly bothered by curious visitors trying to learn the new methods. Because the usually short stay of the opperhoofd and his few companions in Edo during their annual journey to the court allowed no time for any systematic instruction, during the late 1650s the feudal lords began to send their personal physicians to Nagasaki.[11] Once even the twelve-year-old son of a physician was to spent ten years being educated at Deshima.[12] Such prolonged visits were difficult, considering the working and living conditions of the European surgeons and the reluctant attitude of the VOC. Nevertheless, a number of Japanese received some instruction for several months, while others with good connections were allowed sporadic visits to the trading post, even for periods as long as one or two years.

Because most of the Western plasters and ointments required ingredients that were not available in Japan, drugs, herbs and medicaments had to be ordered at high prices from the VOC. This encouraged the search for identical or similar local herbs, as well as imports of young plants and seeds for the famous herb garden at Nagasaki. When, once or twice a year, the Dutch left their tiny island for a day trip to the mountains surrounding Nagasaki Bay, their expertise on Japanese herbs was tested. Because of this, and after repeated requests, in 1670 and 1672 the Company sent a specialist in herbs to Japan. The orders for Dodonaeus' Herbal, the famous Kruid boek, become understandable in the light of these efforts to find out more on the local flora.[13] [p. 12]

The pressures of cost and scarcity led to the importation of a still with instructions on how to produce medicinal oils, and in 1672, a distillery was set up on Deshima.[14] Six Japanese interpreters translated the instructions given by the German pharmacist Frans Braun, and sketched the equipment. The resulting report was eventually leaked and was copied so frequently it must have become known throughout the country.[15]

Medical textbooks were also considered necessary. Soon after Schamberger's departure in 1651, inspector general Inoue ordered works on anatomy in Portuguese and a book on herbs.[16] Other books on medicine, pharmacy, and natural sciences followed at irregular intervals throughout the second half of the century, despite an official ban on importing Western books.[17]

Confronted with the language barrier, the interpreters at Deshima used to transliterate unknown terms using the Katakana syllabary. Because it was extremely difficult to translate such language monstrosities as unguentodearuteiya, it is not coincidental that the rise of interest in Western surgery was accompanied by the appearance of Japanese glossaries, which were used to clarify the various reports.[18]

A strong indication of the final breakthrough of 'redhead-style surgery' came in the late 1650s, when Hatano Gentô who was leaving for Edo, asked for a certificate to prove that he had been educated by a Dutch surgeon.[19] Several such certificates were issued until late in the century, some of which survive. In 1673, the central government appointed Nishi Genpo, a Deshima interpreter who had received his surgical certificate in 1668, as Portuguese interpreter and Western-style surgeon in Edo.[20] By this time, doctors in all regions had set up their own 'redhead-style' schools, and granted certificates to qualified pupils in their own right.

During these first decades, it was always the Japanese who took the initiative, requested information, placed orders, and selected, accepted or rejected what the rather reluctant Europeans had to offer. Thus, it is surprising that the developments that characterised the nineteenth century did not occur in the seventeenth century. However, closer scrutiny shows that the Japanese still had a number of reservations about Western medicine.

 (4) The Limits of 'Redhead-Style Surgery'

Japanese surgery in the style of the 'redheads' did not go beyond low-level or minor surgery (chirurgica minora). This is not surprising in view of the limited professional training of the East India Company surgeons; although, even in this small field, the Japanese confined themselves to specific tasks.

The same subjects are dealt with repeatedly in the manuscripts from the period: plasters, ointments and the treatment of wounds and fractures. There are no references to cataract operations, extraction of bladder[p. 14] stones, bone surgery, or amputations – operations that were routine for any ambitious surgeon in the West. Cauterisation and phlebotomy, still practised in the West in the early nineteenth century, were abhorred by the Japanese. In addition, there is not a word about human anatomy, which was considered very important not only at European universities but also in the training of apprentices by the guilds. Indeed, the manuscripts contain only a few names of bones and a couple of minor remarks on arteries and veins on a 'thin skin around the brain', and the 'skin between the chest and abdomen'.[21]

In a stimulating study on popular imagery in later Edo Japan, Timon Screech demonstrated that exposure to Western optical equipment, such as lenses, mirrors, and glass, had a profound impact on Japanese notions regarding the faculty of sight.[22] The invoices of Dutch ships leaving Batavia for Japan show that Japanese imports of this kind were already quite common during the second half of the seventeenth century; mirrors, magnifying glasses, spectacles, telescopes, zograscopes, and probably even microscopes came into the country[23], and should have had some influence on doctors in their examinations of the human body. Nonetheless, there is nothing in the mass of old manuscripts that indicates a changed attitude.

Despite the great flexibility and openness of the Japanese mind, the impact of Western surgery and related disciplines remained limited[p. 15] for many reasons.

Euro-Japanese communication had deteriorated dramatically since the days of the Christian missions, and the Japanese disapproved of the Dutch becoming proficient in Japanese. However, to the end of the seventeenth century the language skills of Japanese interpreters were adequate only for business negotiations and everyday conversation, not for reading scientific books. This meant that everything had to be explained and demonstrated by the surgeons at the trading post, and such instructions were a nightmare for everyone involved.[24] Since the Japanese understood only a few of the Latin and Portuguese medical terms, they merely noted the pronunciation in Katakana syllabary; the meanings of the names of medicines, herbs and other specialist terms had to be explored later.

In an isolated instance, a single brief abstract was written in the seventeenth century on the subject of humoral theory[25] which probably no Japanese reader understood. The philosophical and scientific bases of Western medicine remained inaccessible, and no notice was taken of the dynamic advances in medicine in Europe. Ultimately, its reception was limited to specific subjects, and it failed to diminish the importance of Sino-Japanese medicine.

Since educated Japanese could read the literature from China, and Japanese thought had evolved throughout centuries of interaction with China, Chinese ideas could be more readily assimilated. Moreover, in the seventeenth century, for perhaps the first time in their relationship, the Japanese understood and accepted Chinese science and Confucianism as comprehensive systems. To consolidate its own power, the new Tokugawa regime actively promoted the adoption of Confucianism, as interpreted [p. 16] by the twelfth-century Chinese scholar Zhuzi or Zhuxi (Shushi), which strongly emphasised submission to authority. The establishment and expansion of libraries and a number of private and feudal clan schools, which created a kind of academic infrastructure, fostered the acceptance of this philosophy.[26] This enhanced the prestige of Chinese medicine, particularly as many Confucian scholars earned their living as physicians.

The theoretical basis of Sino-Japanese medicine was accepted even by those open to Western therapies. However, as mentioned above, Sino-Japanese medicine attached great importance to cosmic harmony and freedom from bodily harm, leaving little room for invasive surgical measures. Presumably, Japanese doctors in the seventeenth century had the opportunity to examine the internal organs of the seriously injured, but they still ignored such things as the form, colour, composition and position of the stomach, liver or heart.

It is not surprising, therefore, that they took little interest in the European surgeons' explanations of human anatomy, which held only a minor place in the theory and day-to-day practice of Japanese physicians. In the second half of the century, the Deshima interpreter, Motoki Shôdayu, drew pictures taken from Pinax Microcosmographicus by Johannes Remmelin and provided a simple summary in Japanese, and Hara Sanshin, physician to the feudal lord in Fukuoka, made copies of it.[27] Nevertheless, this work had no impact during this period. It would be another hundred years before a Japanese doctor opened up a human cadaver to take a closer look at its 'inner landscapes'.[28] [p. 17]