The Development of the Japanese Nursing Profession

Adopting and Adapting Western Influences

Aya Takahashi

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134403448
• Edition: 1
• Topic: History
• Subtopic: Japanese History
• Index: History

In the years after 1868, when Japan's long period of self-imposed isolation ended, in nursing, as in every other aspect of life, the Japanese looked to the west. This book tells the story of 'Florence Nightingale-ism' in Japan, showing how Japanese nursing developed from 1868 to the present. It discusses how Japanese nursing adopted western models, implementing 'Nightingale-ism' in a conscious, caricature way, and implemented it more fully, at least on the surface, than in Britain. At the same time Japanese nurses had to cope, with great difficulty, with traditional Japanese attitudes, which were strongly opposed to women being involved in professions of any kind, and, as the book shows, western models did not in fact penetrate very deeply.

Part I
An imported profession

1
The emergence of the female profession of nursing

The modern nursing profession emerged in the course of medical westernization. However, there have been western influences on medicine in Japan since the early modern period. In popular Japanese medical historiography, the modernization of medicine begins with schooling native doctors in western medicine, their pursuit of western medico-scientific knowledge, and doctor-centred institutional as well as intellectual medical development. The westernization of healthcare work, other than medical treatment, is often described as secondary to the introduction of western medicine, supplementary and peripheral. The nursing profession falls into the periphery. The modern nurse usually appears as a sub-character in the doctor-centred history of medico-scientific advance, though this is not unusual in histories of medicine in other countries.¹ The task of this chapter is to introduce the historical context enabling us to place the ‘secondary history’ on the centre stage. Introducing the general historiography from existing studies, first, I shall briefly depict the medical setting that gave birth to the Japanese nursing profession and describe some early professional initiatives, then, I will look more widely at the situation of women in Japan, 1868 to c. 1900.

Medicine from the West

European medical knowledge is believed to have been first introduced in the mid-sixteenth century by Catholic missionaries—Jesuits and Franciscans—who came to evangelize Christianity in the Orient. The missionaries often provided some kind of medical care to the indigenous objects of their evangelizing efforts, which included the foundation of small-scale voluntary clinics and hospitals and the organization of voluntary care groups, as seen on the European continent.² After the Tokugawas united the war-torn country in 1600, the Tokugawa government increasingly regarded Christianity as an ‘evil religion’, which might well undermine its authority. By 1639, the government had persecuted converted Japanese Christians to extinction; exiled the foreign missionaries; prohibited Japanese contact with foreigners; and put an end to all missionary-related activities, including their provision of medical care. However, some methods of treatments of wounds and herbal medicines that the western missionaries had introduced remained, and were, subsequently, taken into traditional medical practice, which prepared Japanese doctors to absorb further medical knowledge from the West.

During the period between 1639 and the 1850s, the Tokugawa Shogunate prohibited its subjects from contacting foreign countries and foreigners, except through very restricted trade with Holland and China. Through the government-controlled Japanese—Dutch trade at the island-port, Dejima, western medical knowledge was again brought in. Although the government was extremely cautious about its subjects’ contact with foreigners, it was interested in novel and curious western imports, including clocks, telescopes and other mechanical innovations³ as well as medical knowledge. The Tokugawa authority permitted privileged Japanese doctors to attend lectures, or ‘question time’, held by Dejima-based Dutch doctors, who served local Dutch residents, and also permitted the importation of medical books, instruments and medicines, through the Dutch East India Company. Some western practice and anatomical knowledge gradually spread among Japanese doctors through these contacts.⁴ Throughout the Tokugawa period, ‘Dutch medicine’ attracted a number of physicians, intellectuals, and often progressive government officials, although the Tokugawa Shogunate always feared that the importation of western ideas would be harmful for maintaining its social equilibrium.

Toward the end of the Tokugawa period, an increasing number of medical books were brought into the country through both official and unofficial channels. Many Japanese had already known that western medicine, particularly surgery and ophthalmology, was superior to traditional Kanpō medicine, which emphasized holistic treatment based on Chinese anatomical knowledge and using a variety of herbal medicines. The 1858 cholera epidemic, Japan’s second, was the turning point in popular medicine in Japan: traditional doctors trained in Kanpō medicine failed to offer any effective treatment to the deadly disease. However, Dutch doctors and Japanese trained in ‘Dutch medicine’ succeeded both in diagnosing and curing a number of cases and in offering effective preventive methods. Smallpox had also played a part in this westernizing process. In 1849 vaccination was successfully brought from Europe via Batavia and rapidly spread across the country. As a result, respect for traditional consultants who had treated smallpox with herbal medicine and other superstitious methods without success declined.

Stormy political and social reforms followed the end of the rule of the Tokugawas in 1868. The new democratic government set up modern social systems and institutions, appropriate to what western powers expected of a ‘civilized’ state. Medicine was one of the new state’s main objectives in its modernization programme. In 1868, the first year of the Meiji period, the government announced that it would adopt ‘western medicine’ as official medicine, with which it would develop Japan’s healthcare infrastructure. As a result, traditional medicine rapidly declined through various legislative measures in favour of western medicine. Growing academic interests in western medical research also contributed to the decline, causing conflicts between champions of the old and the new.⁵

The government needed an example for official western medicine to follow. Britain seemed to be the most likely candidate, because of its close diplomatic relation with the Meiji government. In fact, William Willis, the British medical officer attached to the British Consul, had already been influential in Japanese political circles since he displayed brilliant surgical skills in the fierce civil war of 1868. However, ‘German medicine’ turned out to be the preference in 1870. The reason for the government’s choice was apparently because the authority judged that ‘German medicine’ was superior to its British counterpart in academic terms. There were also underlying political and linguistic concerns: some people were concerned about Willis’s ever-growing political power; and the number of intellectuals who read Dutch, which was linguistically similar to German, was then much greater than the English-reading population in Japan.⁶

The adoption of ‘German medicine’ meant for the Japanese, first of all, learning western medicine, including anatomical knowledge, surgical techniques, and pharmaceutical developments, from German doctors. To initiate medical modernization, the government employed two doctors from Prussia, Army surgeon Benjamin L.Müller, and Naval physician Theodor E.Hoffmann, to establish a model centre for medical education. They began to teach at the forerunner of the medical school of the Imperial University of Tokyo in 1871. The two Prussian doctors differentiated themselves from other foreign doctors already practising in Japan in that they were so-called ‘government-employed foreigners’, who were given authority, under the Minister of Education, to design and control medical training at the model medical school, almost as they wished.⁷ Japanese officials and doctors, who had little knowledge of advanced medicine in Europe and were also almost ignorant of western-style education, could not help relying entirely on their leadership.

The strong leadership of the Prussian doctors was, indeed, necessary. The medical school, supposedly one of the leading educational institutions, still used the traditional way of teaching, based on learning by heart. Müller and Hoffmann immediately set up a three-year preliminary course followed by a five-year medical course, which seemed to the Japanese incredibly long. Their drastic reform aroused the opposition of many Japanese associates, who insisted on the urgent need for as many doctors as possible to be trained in western medicine, regardless of their quality. In 1875, just before the Prussian doctors left the country, the school set up another three-year course to produce ‘instant’ doctors, who were allowed to practice alongside those who had finished the proper, longer training.

The government promulgated the Medical Regulation, Isei , in 1874. This established the fundamental system of medicine, under chief of the medical section of the Ministry of Domestic Affairs, Nagayo Sensai, who contributed to drafting the Regulation after studying the healthcare systems of the US, France, Germany, Britain and Holland. The main aims of the Isei , based on a mixture of western examples, were to establish the system to license medical practice; to set up systematic medical education based on western medicine; and to separate medical practice from selling medicines. The legislation that standardized western-style medicine intended almost to extinguish the traditional form of healthcare provided by local Kanpōdoctors.⁸ The forced westernization of medicine, which began with the Isei followed by other legislation on medical education and practice, was a child of Japanese modernization ‘from the top’, which centred on the ‘doctor’. While the ‘midwife’ was mentioned in the sei , there was no definition of the ‘nurse’ in this crucial legislation in the development of medicine.

The introduction of medicine from the West during the Tokugawa period featured the partial importation of printed sources of medical science and the lectures by Dutch doctors. However, because Christianity was prohibited, organizational nursing, which centred on religious institutions in Europe, played very little part in this process of medical importation. From the end of this era to the early Meiji period, the acceptance and development of western medicine was motivated by successful treatment with immediate effect, and the introduction of western medicine concentrated on medical knowledge rather than a western mode of medical care in a wider sense. In fact, the initial medical development was promoted by the Ministry of Education and centred on the forerunner of the Imperial University of Tokyo—the ivory tower of Japan’s academic development. This preliminary process paved the way to doctor-training-centred modernization in medicine. The development of hospitals supported this process.

As the number of doctors trained in western medicine increased, the number of hospitals grew. In the 1860s and 1870s there were both private- and public-funded, mainly three types of hospitals in Japan: general hospitals, military hospitals, and other specialized hospitals including asylums. Hospitals funded either by the central or local government were usually attached to medical schools or established them as annexes. These hospitals proposed to provide reasonable medical services for local communities. The number of hospitals rapidly increased to more than 500 by the early 1880s, of which public hospitals comprised more than half of the total. As inflation attacked the country, 1887 legislation forbade local government funding for public medical schools, which inevitably led to the bankruptcies of the schools and the hospitals run in tandem with them. Although the number of public hospitals declined toward the end of the century for financial reasons, the total number of hospitals continued to increase, reaching almost 800, thanks to the foundation of numerous private institutions.⁹

Many of the general hospitals, particularly public-funded ones, considered the training of medical students their primary purpose. These hospitals often intended the treatment of patients to provide training for medical students and academic research opportunities for doctors. Such hospitals could provide reasonable or free medical services to the poor, who were in turn treated as so-called ‘patients for academic use’. Therefore, in the 1880s, after the local-government-funded medical schools lost public subsidies, hospitals increasingly served the people in the middle- and upper-income levels, while the remaining public-funded hospitals often continued to see patients almost as human guinea pigs for medical training and research.

The dawn of modern nursing

It was not until the 1880s that Japanese doctors who studied medicine in Britain and the US and some foreign missionaries active in Japan recognized and acted on the need to train nurses along western lines. A concept of ‘nursing’ was, however, not unfamiliar in traditional society. The Japanese word, ‘kanbyō’, curing and taking care of the sick, had been used from ancient times. From the eighth century ‘kanbyō-sō or -ni’, male or female monks who treated and nursed the sick alongside doctors and shamans, were often summoned to sick beds by nobles. There was no clear boundary between diagnosing illness and giving treatment, nursing and praying for the patient. As time went by, ‘kanbyō’ was distinguished from treatment and became a word simply signifying taking care of the sick. The ‘kanbyō-nin’ (or -fu for female) worked for patients in the capacity of domestic servants in the benevolent hospital founded in the early-eighteenth century by the feudal government for the poor in the capital. The ‘kanbyō-nin (or -fu)’ was not yet established as a specific profession, and patients’ kin and friends, or under-maids, played the role of the ‘kanbyō-nin’, although women began to be used as ‘kanbyō-nin’ during the civil conflict around the time of the Meiji Restoration.¹⁰

Even in modern hospitals founded by doctors trained in western medicine, the ‘kanbyō-nin and -fu’ were still seen as domestic servants. In the civil war of 1868, a station hospital in Yokohama, which was then under the British doctor, Willis, first employed old women to care for the wounded. After the hospital moved to Tokyo and was named Daibyōin, it became one of the top hospitals in the country. The Daibyōin employed married and widowed women aged thirty to fifty. But they were still seen as under-maids rather than expert carers. Other modern hospitals increasingly employed women as ‘kanbyō-fu’. However, their ‘caring’ work still consisted of cleaning rooms, doing washing, feeding invalid patients, and then minor caring work. They sometimes cooked for patients, but as another British doctor, Siddall, reported in 1868, they were careless about feeding and the quality of food given.¹¹ Even in the Daibyōin, ‘kanbyō-nin and -fu’ were not yet organized as expert medical staff: the hospital recruited low-grade workers mainly for domestic chores.

There were, at that time, few women who had social and political influence, or financial independence empowering them to do anything revolutionary for hospitals and medical care. There was, however, one woman who showed marked ability in this arena. The emergence of such a woman seems to parallel British and American experiences in nursing developments. The movement to improve the quality of nursing came almost universally from outside the medical profession and indeed outside male society. One episode is particularly well known. Sugimoto Kane worked in the Daibyōin from 1868 and was appreciated by doctors for her skill in bandaging and caring for surgical cases and also for her respectable personality. When an enlightened doctor, Satō Nahonaka, founded the forerunner of the Juntendō Hospital in 1872, Sugimoto Kane was offered a position as Chief Nurse. She was from the former samurai class, which had been a ruling class and was seen as respectable; but she was divorced and had to maintain herself when women of her social position were not expected to work to earn a living. It is said that her respectable behaviour and efficiency in work later encouraged Satō to recruit nurses from her class.

The eminent figure of Sugimoto Kane might suggest some similarities with those Victorian ladies, such as Florence Nightingale, who attempted to improve hospital arrangements, showed their ability to organize domestic affairs, and finally gained a measure of power in hospitals. This was, however, not the case in Japan. In nursing literature Sugimoto is introduced as an exceptional and distinctive woman, and her glory tends to be in her personal achievement alone; and such historiography reflects the reality.¹² It is possible to say that she contributed to making ‘kanbyō-fu’ an occupation for women and encouraged some doctors to recognize the need for a group of efficient ‘kanbyō’ staff in hospitals. Yet there is no evidence that Sugimoto or any other woman gained a voice or attempted a revolution in hospital hygiene and organization. As shown later in this chapter, some aristocratic and upper-class women supported the development of nursing from the mid-1880s onward by fundraising for nursing education and presenting nursing as benevolent women’s mode of contribution to the state. However, they rarely called for drastic and comprehensive improvement in hospital arrangements as Nightingale did because they could exercise little independent political or financial power for change in male-dominated society and could only assist hospitals as they found them.

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Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures
• Acknowledgements
• Conventions and Abbreviations
• Introduction
• Part I: An Imported Profession
• Part II: The Development of a Japanese Model
• Part III: ‘Re-Encounter’ With Western Nursing Professionalism
• Conclusion
• Notes
• Bibliography