Reinvented Places: ‘Tradition’, ‘Family Care’ and Psychiatric Institutions in Japan

Reinvented Places: ‘Tradition’, ‘Family Care’ and Psychiatric Institutions in Japan Abstract This article explores the history of the care of the mentally ill at Iwakura, a site in northeast Kyoto in Japan where two large psychiatric hospitals now stand. Long a topic of research in Japan, Iwakura reflects a peculiar spatial arrangement common in Japan in which psychiatric hospitals came to be established near religious sites associated with care of the mentally ill in the pre-modern period. In the early twentieth century, Japan’s first generation of psychiatrists began to celebrate Iwakura as offering an indigenous form of ‘family care’, then the object of considerable discussion among psychiatrists and others in Europe and North America. I argue that the valorisation of Iwakura as offering a mode of care that was simultaneously ‘traditional’ and ‘progressive’ reflects the struggle to establish psychiatric institutions that involved local economic interests, public policy, and members of the new psychiatric discipline. psychiatry, family care, Japan, psychiatric hospitals Today the area known as Iwakura in northeast Kyoto, Japan’s seventh largest city by population, appears to be a typical post-war suburb. An agricultural village, Iwakura was linked by only two narrow roads to the city of Kyoto until 1925 when the Eizan Railway opened. But after the village was incorporated into the city’s Sakyō Ward in 1949, new roads were constructed, new bus lines established, and in the late 1990s the Karasuma subway line was extended, connecting Iwakura with Kyoto station, a major transportation terminal.1 As large public apartment complexes were built, young families flowed into Iwakura, increasing the population five-fold over 30 years. Now only a few scattered rice fields are to be found among the jumble of houses and apartment buildings, while large chain supermarkets, convenience stores, and family-style restaurants line the main throughways. But the streets in the centre of ‘old’ Iwakura, near the temple complex known as Jissōin, reveal another aspect of Iwakura’s history, one that predates but has come to intersect with the post-war medical system. Here one finds a surprising number of private psychiatric hospitals and clinics, among them Kitayama Hospital (795 beds) and Iwakura Hospital (533 beds).2 These institutions are the traces of Iwakura’s long association with the care of the mentally ill, a connection that some claim dates back to antiquity. Writing in the 1930s, Tsuchiya Eikichi, the director of a psychiatric hospital in Iwakura, summed up the village’s reputation among Kyoto residents of that period, when he stated ‘if one hears the word “madness” (kichigai), one thinks of Iwakura, and if one hears “Iwakura,” one thinks of madness’.3 In this essay, I explore the history of Iwakura as a point of access into the evolving debates, struggles and negotiations that surrounded what has been cast simultaneously as both ‘traditional’ and ‘progressive’ modes of care for the mentally ill in Japan in the first half of the twentieth century. Iwakura is the best known example of a phenomenon that has been well documented by Japanese historians and ethnographers: a significant number of modern psychiatric facilities were established outside urban areas near temples and shrines that had longstanding associations with care of the mentally ill.4 Within this body of work, Iwakura has been singled out for particular attention: from the 1890s until the present, it has been celebrated as providing an alternative to confinement in a psychiatric hospital. Only recently have some scholars begun to question the idealised view of Iwakura as a benevolent therapeutic community with deep historical roots.5 My interest in Iwakura, as both a social and a discursive site, is two-fold. First, the case of Iwakura suggests that the establishment of psychiatric hospitals near religious sites does not simply reflect the persistence of traditional beliefs or modes of care, as some have argued. Rather, the apparent continuity was the result of the intersection of multiple interests, including not only the state and the new psychiatric discipline, but also local residents, whose involvement has been largely ignored. Secondly, the intense interest in Iwakura on the part of the psychiatric community compels us to think more carefully about the transnational flow of psychiatric discourse and practice in the late nineteenth and early twentieth centuries. Akira Hashimoto, whose work on Iwakura informs my own, has argued that the celebration of Iwakura reflects the ‘Orientalism’ of Japanese psychiatrists, who felt a ‘reactionary pride’ at the comparison of Japanese practices with progressive developments in Europe.6 In contrast, I argue that the discourse on Iwakura reflects the participation of Japanese psychiatrists in an international debate on the ethics, economics and therapeutic value of the institutionalisation of the mentally ill. Iwakura and the ‘Tradition’ of Care Today the modern psychiatric institutions located in Iwakura are clustered around the area where a temple known as Daiunji, part of the temple complex called Jissōin, once stood. Founded in 971, Daiunji was for centuries a temple of considerable prestige, one to which members of the imperial family who had taken Buddhist orders retired.7 There is some evidence that Daiunji’s association with the cure of madness dates back to the century or so after its founding. According to one source, an imperial prince who was possessed by some kind of spirit (mono no ke) prayed for relief at Daiunji and was cured.8 Even more widely cited is the story of an imperial princess, the daughter of the emperor Go-Sanjō 1034 CE to 1073 CE, who was taken to Iwakura after she showed signs of madness and recovered there.9 However, while members of the Kyoto elite did indeed seek relief at Daiunji upon occasion, there is little evidence to support the claim that the temple had a popular reputation for the treatment of the mentally ill in the long pre-modern period or that there was an unbroken tradition of care from antiquity forward. What is clear is that sometime in the late seventeenth century, Daiunji gained a reputation for healing. The timing is significant. Although Daiunji continued to be a temple of considerable wealth and power into the medieval period—according to one source it had an income of 100,000 koku (approximately 500,000 bushels) of rice and supported a thousand monks—its fortunes declined dramatically in the sixteenth century as the political and economic power of the Kyoto-based nobility that had supported it and other Buddhist institutions shifted to the warrior class. Compelled to seek out other sources of support, the temple put its ‘hidden Buddha’ (hibutsu) on display for the first time in 1690.10 This was an image of the Bodhisattva Kannon, a deity associated with compassion towards those in distress. This attempt to attract commoner support paid off, and the image subsequently became the object of popular devotion as people from Kyoto, Osaka, and elsewhere in Japan travelled to Iwakura to view it. This was also the time when rumours began to circulate that the sick were being cured at Daiunji. In this period, temples around Japan were becoming involved in medical matters, part of a new and booming economy of care.11 They not only sold amulets and charms to prevent and cure illness but also manufactured medicinal compounds and performed healing rituals. The medical historian Tatsukawa Shōji has noted that ‘guidebooks’ designed to attract visitors to temples and shrines in a particular region or city often took note of their efficacy for curing one illness or another, with the result that ‘tourism and treatment became intertwined’.12 Initially, accounts of miraculous healing at Daiunji apparently focused on ailments of the eye. According to a temple record, in 1706, a man who had been blinded in a childhood accident had his sight restored after praying before the temple’s statue of Kannon. A guidebook published 50 years later also makes mention of the temple’s efficacy in treating eye disease, although in this case, it is standing under the waterfall, a practice associated with purification (misogi), that is said to have effected a cure.13 It was only in the second half of the eighteenth-century that Daiunji came to be associated primarily with the treatment of the mentally ill. According to the records of city leaders in Kyoto, in 1765 a 33-year-old man suffering from ‘a disordered heart’ (ranshin), one of several terms used to describe mental illness, was dispatched to Iwakura so that he could pray before the Kannon and stand under the waterfall.14 Writing 30 years later, the well-known Kyoto physician Nakagami Kinkei implied that this practice was relatively recent. In 1796, he stated, ‘these days among commoners in Kyoto, whenever someone goes mad, they take him to a place like Iwakura’.15 How the transfer from eye disease to mental illness took place is unclear, although Tatsukawa’s research suggests that religious sites were often associated with multiple ailments and even with specific parts of the body with some claiming efficacy for ‘the lower half’ or ‘above the neck’.16 Of course, it may also have been that mental illness was more responsive to the treatments offered at the temple and therefore more profitable. Late eighteenth-century sources reveal the contours of the new and lucrative ‘trade’ in the mentally ill that benefited both the temple and villagers. An illustration of Daiunji in Miyako meisho zukai (1780, ‘Famous Sites in the Capital’) depicts not only the main temple buildings but also five simple structures that are labelled komoriya (‘retreats’).17 Temple records reveal that these were constructed to house those who came seeking a cure at Daiunji. The temple not only charged a fee to lodge in these shelters but also required payment for performing rituals of exorcism, for access to a spring rumoured to have curative properties and for the privilege of standing in its waterfall.18 All three of these activities were believed to be useful in expelling possessing spirits, animal and other, that were widely regarded as responsible for producing the symptoms of madness. As Daiunji gained fame, some Iwakura villagers began to operate so-called tea shops (chaya) that provided food and drink to temple visitors. Initially, such businesses were forbidden by the temple from housing those who came for healing, but they performed other important and apparently profitable functions. For one, the temple required that an attendant (kaihōnin) accompany an afflicted visitor during his stay. For families who had journeyed from afar to deposit their relatives at Daiunji, this rule was no doubt burdensome, and the tea houses began to offer the services of paid attendants who were known as ‘strong men’ (gōriki), a term that suggests their management of the afflicted relied a good deal on physical strength. In his remarks on Iwakura, the physician Nakagami Kinkei wrote scathingly of these attendants: Many family members say they cannot watch the sick person and so they leave him in the care of those they have hired. But [the attendants] fear the patient will runaway and so they tie him up day and night, so that they can eat and sleep in peace. As a result, the sick ones become agitated, and in many cases their madness becomes more extreme.19 Temple authorities were aware of the reputation of the ‘strong men’ for abuse. In a 1799 record, Jissōin, which, as the main temple, had ultimate authority over Daiunji, described the treatment visitors had received at their hands: some were denied food, beaten, or restrained ‘like criminals’, others were enticed into gambling or other vices, and some women were subjected to sexual abuse.20 Several times temple authorities threatened to forbid the presence of these paid attendants within their grounds, but the operators of the tea houses protested, stating that without their help it would be impossible to care for the large number of afflicted visitors.21 A decline in the number of long-term ‘patients’ would have had financial implications not only for the tea houses, but also for the temple as well, and in the end, the authorities of Jissōin settled for a series of half measures: they required the attendants to seek permission before using restraints and ordered that female visitors be cared for by female attendants.22 The symbiotic nature of the temple and the tea houses’ economic relationship is perhaps best revealed by the temple’s decision in the early nineteenth century to relax its restrictions on the boarding of visitors outside temple grounds, allowing tea houses to provide lodging to those who came for a cure, a decision apparently driven by the need to accommodate the overflow of visitors. By the 1870s, the term ‘tea shop’ was no longer used to refer to the establishments. Instead, they had come to be termed yadoya (‘inns’).23 Discovering the Asylum Of course, only a tiny fraction of those regarded as ‘mad’ in early modern Japan ever made their way to Daiunji. The temple represented only one of an array of strategies for dealing with the mentally ill before modernity. In many areas, families would confine members who posed a danger to themselves or others or who interfered with the work of agricultural production to a room within the home or in an adjacent structure. This typically required the consent not only of immediate family members, but also of neighbours, village officials, often a doctor as well as the samurai official under whose authority the village fell.24 In Edo (later renamed Tokyo) and other urban areas, a mentally ill person found on the streets was often turned over to the status group known as hinin (a term often translated as ‘outcasts’), who were authorised to beg on temple grounds and city streets and who were also charged with caring for those with no means of support, such as abandoned children and elderly people.25 As this set of heterogeneous policies suggest, there was nothing like the ‘asylum’ in Japan before modernity. Knowledge of the possibility of such an institution came only in the mid-nineteenth century when Japanese first travelled to Europe and the USA in the 1860s and 1870s. An early description of the asylum came from Fukuzawa Yukichi who visited the USA and Western Europe in the 1860s as a member of two shogunal missions. The best-selling work he later compiled on Western culture and institutions called Conditions in the West (Seiyō jijō) included a discussion of what Fukuzawa termed ten’in, a neologism he coined as a translation for ‘asylum’. According to Fukuzawa, the asylum he visited was a ‘quiet and serene’ place where patients whose symptoms were not severe read books, painted, danced and took walks.26 In marked contrast to Fukuzawa’s impressions were those of Kume Kunitake, a member of the Iwakura mission, dispatched by the new Meiji government in 1873. He visited the Insane Asylum of California located in Stockton. Describing this institution, Kume wrote, There were more 1500 patients there, both men and women. They were divided into different rooms depending on the severity of their sickness. Those who were very sick were locked in their rooms with restraints on their arms and legs, and were soiled with excrement and urine. There was a male or female attendant in each room, and the restraints were made of iron.27 Kido Takayoshi, another member of the same mission, was more favourably impressed by the Stockton asylum and recorded in his journal that ‘its administration and cleanliness left nothing to be desired’. He obtained a copy of its rules and regulations in order to pass them on the Nagayo Sensai, the official charged with creating a medical policy for the new government.28 The ‘discovery’ of the asylum was to have a profound impact on the system of care that had taken form at Iwakura. After the political revolution of 1868, the new government rapidly began a process of top-down social and political reform aimed at transforming Japan into a modern nation state, efforts that included medical modernisation. But not all reforms originated with the government in Tokyo. In 1875, the local government of Kyoto ordered the establishment of a public asylum. This institution, the short-lived Kyoto Prefectural Asylum, has long been celebrated as the ‘first’ modern public facility for the mentally ill to be established in Japan, although it predates its rival, the Tokyo Prefectural Asylum, by only four years. The later institution had its origins in the ‘madman’s ward’ (kyōshitsu) of the Tokyo Poorhouse, which was created in 1875 to house the poor, the sick and the disabled who wandered the streets of Japan’s new capital, an unintended result of the destruction of the early modern status system within which their care had been embedded. The real significance of the Kyoto Asylum lies not in its chronological advantage, but rather in the circumstances of its establishment. Unlike the Poorhouse and the Tokyo Asylum, the Kyoto institution was not created by directive from the central government in Tokyo but rather through the efforts of local civic activists responding to a perceived local crisis. And unlike the Poorhouse and the Tokyo Asylum, which were devices for social control rather than treatment or care, the Kyoto Asylum was envisioned as a facility that would provide treatment.29 It thus represented the intersection between a new medical paradigm of mental illness and a new conception of social welfare. The initiative for the establishment of the Kyoto Asylum came from two Kyoto commoners, Kan Masasuke and Akashi Hiroakira (1838–1910), both of whom submitted petitions to Nagatani Nobutane, the governor of Kyoto prefecture, in April 1875. Little is known about Kan other than that he was a commoner and resident of the city, but his compatriot Akashi was a prominent physician of Western medicine and a successful entrepreneur. In 1871, he joined the local government as a ‘medical official’ (ikan) and was instrumental in the founding of a public hospital and medical school.30 The petitions submitted by Kan and Akashi to the governor laid out similar arguments. In Kan’s words, Since the common people are ignorant in the extreme, they think that this illness is because of a divine curse or spell, or that it results because of the actions of foxes and badgers, and because they believe these ridiculous theories that rest upon baseless speculation, there is the bad custom of not seeking medical treatment. And so in your jurisdiction, in places like Daiunji in Iwakura … rough huts are constructed and the sick are housed in them and they are just entrusted to Buddha. [Those who house them] profit by charging for room and board, but although much money is paid, not only is their illness not cured, in fact it becomes more severe.31 Here and in Akashi’s petition as well, Iwakura is described in explicitly critical terms: its popularity reflected ignorance and superstition, it allowed for the abuse and neglect of the afflicted, and it encouraged desperate families to squander their limited resources. According to Akashi’s petition, these concerns prompted him to confer with Ferdinand Edelbert Junker, an Austrian physician who had been hired in 1872 to work in the new hospital and medical school. Junker recommended the establishment of a public asylum, and Akashi described the institution he envisioned in terms strikingly similar to those used by Fukuzawa Yukichi: it should have a garden where the patients could walk and rest, make available musical instruments they could play to ‘calm their senses’, and aid the patients in developing skills through handicrafts and other work. It was not to be operated for profit but rather would provide free medical care to those in need.32 Kyoto authorities took the charge that the mad were being mistreated at Daiunji seriously. A week after the submission of the petitions, the governor ordered an investigation into the conditions at Iwakura and another religious site where the mentally ill of Kyoto congregated. The report submitted by the investigator revealed that around 20 people were housed in four inns near the temple and that treatment consisted of standing under the waterfall.33 In the aftermath of this report, the prefectural government announced the establishment of the new public asylum. The resolution it promulgated in July 1875 explained the need for such an institution by attacking the mistaken beliefs that led families to entrust their kin to places such as Daiunji where they were subjected to ‘cruel’ treatment. It explicitly valorised a new medical explanation of mental disorders, stating, ‘as for the cause of insanity, at first something causes sadness, despair, fear, or anger, and this upsets the spirit (seishin), and for some this leads eventually to brain disease (nōbyō). … This is a disease, and for diseases, there is medicine, that is, drugs and other treatments.’34 Embracing this new understanding of madness as ‘disease’, the prefectural government also sought to disestablish what were now viewed as ‘backward’ practices. In 1878 it issued a new law that made it illegal for temples, shrines and inns to engage in the business of housing the mentally ill. Ironically given the critique of temple-based care, the new asylum was established on the grounds of the Nanzenji temple in central Kyoto, utilising a building belonging to a subtemple called Eikandō. The seemingly odd choice came in the midst of a wave of anti-Buddhist sentiment. In the late 1860s, the new government had called for the separation of Buddhist institutions and those devoted to indigenous deities, an order designed to shore up the new imperial ideology but one that was interpreted by some as authorising the disestablishment of Buddhism itself. In Kyoto, where the priesthood had long been under attack for its love of luxury and loose adherence to the vow of celibacy, the priests of the city’s temples came under considerable pressure. Whether willingly or under duress, they made hefty donations to support the establishment of the new public hospital in 1872, and when the city needed a site to house its planned asylum, Higashiyama Tenka, the head priest of Eikandō, offered up one of its structures.35 Thus, while the idea of the ‘asylum’ was new, the actual facilities neatly meshed with longstanding practice. There is no evidence that anyone involved in the founding of the asylum was concerned about the possible mixed message that resulted from housing the asylum in a temple, but this choice may have unintentionally contributed to the remarkable popularity of the new institution. During its first year of operation, 82 patients were admitted, including those who had been removed from Iwakura. That number grew with each passing year until in 1882 the asylum housed 332 people. The setting aside, the new asylum had little in common with either Daiunji or the inns at Iwakura. The care of its patients was entrusted to the staff of the prefectural hospital and medical school, who kept careful records on their patients. ‘Psychiatry’, if it can be termed that, was still in its infancy, but the staff created a new diagnostic lexicon that seems loosely based on that of pioneering British psychiatrist Henry Maudsley. In 1876, Kanbe Bunsai, a doctor on the staff of the public hospital and the asylum, had translated one of Maudsley’s works under the title An Outline of Mental Illness (Seishinbyō yakusetsu).36 According to the Journal of the Prefectural Hospital (Ryōbyōin zasshi), one of the earliest medical serials to be published in Japan, between 1880 and 1882 the asylum admitted a total of 571 patients, with the most common diagnoses listed as ‘acute insanity with seizures’ (105 patients), ‘chronic insanity with seizures’ (177) and ‘melancholia with night wandering’ (56).37 Case records published in the Journal suggest that the treatment offered at the asylum reflected an effort to put into practice the principles of Maudsley’s so-called ‘moral treatment’. A case in point was that of a 27-year-old man who was admitted in 1874 after multiple suicide attempts. He was diagnosed with melancholia, a condition asylum staff attributed to worry over family finances. His treatment consisted first of massages, hot baths, nourishing drinks of milk, eggs and brandy as well as doses of what were described as ‘Japanese medicines’ (wasai), herbal compounds based on Sino-Japanese pharmaceutical principles. As his condition improved, he was encouraged to take walks in the asylum grounds. Sometime later, he was prompted to speak about his ‘feelings and ideas’ (jōi). In response the patient voiced his concerns about various family matters, including his fear that his wife and older brother might be having some kind of illicit relationship and his sense that this brother thought he was malingering. The staff tried to aid him in ‘correcting his mistaken thoughts and distinguishing between the true and the false’ and believed he was making progress. After a year and half of treatment, he was judged to be much improved and released to his family. The patient committed suicide weeks later.38 This tragic case, recorded in considerable detail, sheds critical light on the large numbers of ‘complete cures’ recorded by the asylum. In 1879, for example, the asylum reported that 210 patients were released as ‘cured’, another 186 required further treatment, and that 27 (7 per cent of the total) had died while in care.39 The release of patients who showed some improvement may have been prompted by the increasingly strained finances of the institution. Although patients of means paid some fees, this revenue—even when supplemented by contributions from the city’s elite and local Buddhist temples—was simply not enough to support an institution of such a scale. In October 1882 the prefectural government announced the closure of the asylum, a decision that prompted an inquiry to the Home Ministry in Tokyo about what should happen to its patients. The Ministry responded: ‘those who are violent and therefore difficult to abandon should be placed in a separate room within the jail, those who are not [in such a condition] should be returned to their household heads who should provide appropriate care.’40 This advice reflected the policy deployed in the capital. In 1872, the government of the city of Tokyo, in a declaration addressed to ‘family heads’ charged that ‘wandering madmen’ were committing random acts of arson and violence. It instructed the populace to confine their mad (kyōbyō) family members or risk being held responsible for their acts. In 1878, the Tokyo government moved to regularise this policy when it issued Police ordinance no. 38, which required families that wanted to confine their members, whether unruly children or mad adults, to register with their local police station—a procedure that gave police, not doctors, authority over the mentally ill.41 The demise of the asylum created an opportunity for the proprietors of Iwakura’s inns to revive their former businesses and they acted almost immediately. By this time, Daiunji had been closed for several years, one of thousands of temples around Japan that had fallen victim to the anti-Buddhist campaigns of the 1870s. As villagers worked to revive their inns, the idea of the ‘asylum’ newly informed their efforts. According to Tsuchiya Eikichi, who authored a history of the psychiatric hospital he headed, in 1884 a group of powerful figures in the village joined forces to establish the Private Iwakura Asylum, hiring a physician named Ōshima Kōshirō to serve as its titular head.42 At the time Ōshima, an obstetrician by training, was also involved in teaching at a new midwifery school in central Kyoto, so it seems unlikely that he participated in the day-to-day operation of the new ‘asylum’.43 Fujikawa Tatsuaki and Higashimura Teruhiko, who carried out research on Iwakura in the 1970s, discovered a sign stating ‘Agents for Iwakura Asylum’ in the home of the family of a villager who had operated an inn for the mentally ill.44 It seems that the ‘asylum’ at Iwakura had a peculiar form from the outset. While unruly patients were confined within the dedicated structure, more docile ones were housed in the inns. At some point, these began to be termed ‘rest homes’ (hoyōshitsu), a term that would be widely employed until the post-war period. The fact that the Kyoto authorities approved this arrangement seems inexplicable given the criticism of the care provided at Iwakura voiced only a decade before. Perhaps the claim to be establishing an ‘asylum’, even with only minimal medical oversight, was enough to assuage concern. However, it seems likely that the pressing need for a place to house the mentally ill after the collapse of the prefectural asylum was also involved. Certainly, the ‘Iwakura Psychiatric Hospital’, as it was renamed in 1892, was successful. According to Tsuchiya, by that year, the hospital itself had two wards for psychiatric patients and a third for general medicine, with a total capacity of 78 patients.45 The establishment of the Iwakura Psychiatric Hospital marked an important development in the history of psychiatric care in Japan. The idea of the ‘asylum’ inspired the local reformers, Akashi and Kan, who proposed a new and innovative solution to a perceived local problem. By the mid-1880s the concept of medicalised treatment of the mentally ill in institutions had taken hold even among the villagers of Iwakura who embraced it to transform the old economy of care that had been organised around Daiunji. The result of the intersection of new political, social and economic interests was the creation of a hybrid solution that served local interests, reduced the need for public expenditure and provided for the care and control of the mentally ill. Kure Shūzō, Iwakura and Family Care The hybrid arrangement of inns with some medical oversight that took shape at Iwakura would likely have remained an interesting but purely local project but for the intervention of Kure Shūzō, considered by many to be the ‘father’ of psychiatry in Japan. The centre of modern medical education at the time was the Tokyo University Faculty of Medicine. In 1882, Erwin Bälz, a German physician employed as an instructor at the school, gave the first lectures on psychiatry. Bälz had no particular training in psychiatry, but he apparently based his lectures on Wilhelm Griesinger’s textbook The Pathology and Therapy of Mental Illness (1861).46 He also attempted to give his students clinical experience by having them work with those confined in the Tokyo Prefectural Asylum, bringing the patients under medical scrutiny for the first time. Among Bälz’s students was Sakaki Hajime, who was dispatched at government expense to study psychiatry at the University of Berlin, a well-established centre of psychiatric research, for four years. Sakaki returned to Japan in 1886 and soon after was appointed the first Professor of Psychiatry of Tokyo University’s medical school and Director of the Sugamo Hospital, as the Tokyo Asylum had been renamed.47 Although Sakaki died prematurely in 1897 at the age of 39, he was responsible for training the first generation of Japanese psychiatrists. Among his students, no one would be more influential than Kure Shūzō, who graduated from the new Department of Psychiatry in 1890. In the decade that followed his graduation Kure quickly became a leading figure in the new field of psychiatry in Japan. He embraced the notion that mental illness was often hereditary in nature, an idea that was one of the defining constructs of biological psychiatry, and this made him an early and passionate advocate of the national need for psychiatric institutions. In an 1893 article entitled ‘On Asylums’ (Tenkyōin ni tsuite), for example, he argued that while madness was just as common in Japan as in Europe, Japan lacked asylums where patients could be confined and treated. As a result, while almost all of the madmen in Britain were safely confined within an asylum, only a tiny fraction of what Kure estimated to be Japan’s 70,000 madmen were, with the result that they were free to wander the streets and commit crimes and—even worse—to procreate and create another generation of madmen.48 It is unclear when Kure himself visited Iwakura, a curious fact, given both his initial enthusiasm for this site and the fame it was soon to acquire, but between 1895 and 1914, in a series of articles addressed to both popular and professional audiences, he repeatedly discussed what he described as the ‘Iwakura colony’, a phrase that he seems to have coined. Kure’s first mention of Iwakura came in his Outlines of Psychiatry (Seishinbyōgaku shūyō). Published in 1895, it provided a systematic and lucid summary of contemporary European psychiatric theory, and its publication solidified Kure’s growing reputation. He was selected for further study in Europe and in 1897, he began a four-year period of study in Vienna, Paris and Heidelberg. In 1901 after his return, Kure was appointed Professor of Psychiatry at Tokyo University medical school and head physician of Sugamo Hospital. In Outlines of Psychiatry, Kure took up Iwakura in the midst of a discussion of contemporary European psychiatric care in relation to what he termed ‘private home care’ (shitaku kango): ‘Private home care’ refers to [the practice] of having those who are mentally ill live for a long time with an appropriate family other than their own. This is one method of treatment. This method began in the village of Geel in Belgium long ago for religious reasons. Recently, in Germany, in Ilten in Hanover, it has been emulated and it is said that it has had very good results. A necessary requirement for this method is the existence of an asylum nearby. In this system, there is a close relationship with the doctors of the asylum and experienced doctors oversee it. … When the number of patients is appropriate, the care is attentive and compassionate. … In the northern part of Kyoto in the village of Iwakura, there is a temple called Daiunji. There is a Kannon there and it was said that it has efficacy [for madness]. … Patients came from every direction to seek healing there, and many village families took them in and lodged them. And it is said that they gathered firewood and helped with the farming. Now because the prefectural government has forbade it, this [practice] has been abandoned, although there are still a few families who lodge the sick, care for them, and live with them intimately. If we extend medical care, provide treatment, and offered guidance, this would become private home care. That is, if we use this custom from long ago, we can approximate the colony method that is so praised in the West these days.49 These remarks suggest that Kure was not particularly well informed about the situation at Iwakura: he makes no mention of the Iwakura Psychiatric Hospital nor of the practice of housing the mentally ill, not in family homes, but in family-run inns. Nonetheless, this passage marks the beginning of the deployment of Iwakura within an intense and evolving international debate over the best system of care for the mentally ill, asylums versus arrangements identified by terms such as ‘family care’, ‘free air treatment’, ‘boarding-out’, ‘the colony or cottage system’ and later as ‘open care’, ‘extra-mural care’ and ‘therapeutic communities’.50 Discussions of non-asylum-based care proliferated in Europe and North America over the second half of nineteenth century. Like Kure, most participants, both critics and advocates alike, referenced the Belgium village Geel (rendered Gheel until the mid-twentieth century). Geel is associated with the sixth-century martyr St Dymphna, an Irish princess said to have been murdered by her father either because of her Christian faith, or because of her rejection of his incestuous advances. From medieval times, her grave was believed to have miraculous healing powers for the insane, with the result that a growing number of patients were brought there in the hope that they might be cured. While pilgrims seemed initially to have been housed in facilities controlled by the Church, at some point they began to lodge in ordinary homes. In the nineteenth century, the state instituted a set of system oversight: physician-officials were made responsible for supervising the households that were allowed to house one or two patients and rules were established to regulate room size, ventilation, quality of meals and other matters of daily life. Beginning in the 1860s, Geel—where approximately 10 per cent of the eleven thousand residents was classified as insane—became a mecca for reform minded doctors, social welfare activists and the merely curious.51 Although interest in ‘family care’ was an international phenomenon, attempts to implement it differed greatly. Thomas Mueller, who has compared the French and German efforts, argues that enthusiasm for family care reflected an ‘anti-psychiatric impulse’ within French civil society but was also a response to a set of immediate issues, including overcrowding in urban hospitals and lack of facilities elsewhere. Beginning in the 1890s, financially stressed villages such as Dun-sur-Auron and Ainay-le-château, where no psychiatric hospitals were in existence, became the sites of new ‘colonies’ in which the mentally ill were placed with families.52 In contrast, in Germany ‘family care’ took shape not against but as an adjunct to established psychiatric hospitals. According to Mueller, ‘family care patients often stayed in nearby huts, sometimes on the grounds of the mental hospital itself where they had access to no other ‘family’ than a nursing couple’. The family care system established in Berlin differed even more from the Geel model: the Dalldorf Hospital placed its chronic cases in group homes that housed as many as 18 people over which psychiatrists exercised tight control.53 In the USA attempts to implement family care varied from state to state. While Massachusetts paid to board patients with families and required only that a doctor check on them every three months, Michigan’s Kalamazoo Psychiatric Hospital founded a ‘colony’ called Brooks Farm in a nearby location. The farm housed psychiatric patients who carried out agricultural labour under the close supervision of attendants.54 Kure himself would visit Geel during his stay in Europe, but as the passage from the Outlines of Psychiatry I quoted above reveals, even before he left Japan, he was already well aware of its place in the contemporary debate over care.55 After his return, he enlarged upon his advocacy of the ‘colony method’, although he revised his translation of the term. He had originally rendered ‘colony method’ as shokuminhō but subsequently began to transcribe ‘colony’ phonetically in the Japanese syllabary as koronī, perhaps because term shokuminchi was now associated with Japan’s new colonies of Taiwan and Korea, and he was uneasy about applying it to communities of Japanese citizens. This change of nomenclature aside, Kure continued to assert the multiple benefits of ‘colonies’ like Iwakura. In therapeutic terms, he argued, the opportunity for social contact, activity and productive labour would have a good effect upon patients in contrast to the isolation and idleness that characterised life within asylum walls. But there were economic advantages as well: the colony could become a self-supporting community where residents farmed, raised livestock and even made their own shoes and clothing. According to Kure, ‘[The colony model] has benefits as therapy, has benefits for the finances of hospital, and has benefits for the patients after they leave the asylum.’56 The terms of Kure’s endorsement of family care were by no means original, but his insistence that something akin to it had once existed in Japan was. The situation at Iwakura, which only two decades before, had been viewed by modernising activists in Kyoto as backward and abusive, was now recast as an indigenous form of family care that, with some tweaking, would mesh with progressive developments in Europe and transform Japan’s mentally ill into productive citizens. In explaining this enthusiasm for Iwakura, Hashimoto Akira has described Kure and his fellow psychiatrists as ‘“Japanese Orientalists”, who felt it was their duty to translate Japanese traditional concepts of madness and remedies into western vocabularies. … The belief that the tradition at Iwakura was comparable to Geel was a typical translation at the time based on “Japanese Orientalists” way of thinking. To put it another way, it was a product to subordinate Japanese practice to western thinking.’57 Hashimoto is certainly correct that Japanese intellectuals were quick to suggest parallels between pre-modern Japanese practices and modern Western ones. In this same period, advocates for the creation of institutions to house sufferers of leprosy were drawing comparisons between longstanding practices of social exclusion in Japan and the modern leprosaria and ‘leper colonies’ established elsewhere in the world.58 Although the identification of analogues with Western practices reflected a nationalist impulse to celebrate Japanese prescience, it was also strategic. Reformers who wanted the government to take greater responsibility for those who were both vulnerable and dangerous advocated for public funding of institutions such as leprosaria and psychiatric hospitals by characterising them as ‘modern’ solutions that also had deep historical roots, a powerful claim in an era when the enthusiasm for ‘Westernisation’ in the 1870s and 1880s was under attack. Kure’s advocacy for the ‘colony method’ reflected his critical posture towards state policy on the mentally ill. In 1900, the Japanese government passed the Law for the Protection of the Mentally Ill (Seishinbyōsha kangohō). This law took the strategy that had been deployed in the city of Tokyo since the 1870s and made it into national policy, authorising what became known as ‘confinement within private residences’ (shitaku kanchi); that is, forcible confinement within the home and by their families of those deemed mentally incompetent. While the 1900 law required physician involvement to confirm that confinement was necessary, it made no provisions for treatment or even periodic re-examination by a doctor.59 Private confinement placed the mentally ill under the authority of their families and the local police, with the result that psychiatry, a crucial part of what Kure liked to call ‘the medicine of the imperial age’ (sedai igaku), was made largely irrelevant for most Japanese.60 Kure’s disdain for ‘confinement within private residences’ and enthusiasm for ‘family care’ was of course fraught with irony. He advocated for the removal of the mentally ill from their own families in order to place them within other families. Like other advocates of family care, Kure argued that it was not just an alternative form of confinement: family care was also a form of ‘treatment’. Separation from a family riddled with pathology and immersion in a healthy household would, it was argued, promote the resocialisation of the patient. But while Kure’s interest in ‘family care’ reflected his professional interest in the extension of psychiatric oversight, it also had an undeniably humanistic dimension. In the aftermath of the passage of the 1900 law, Kure, an ardent nationalist, became an outspoken critic of government policy. In 1918, he wrote, ‘for the tens of thousands of mentally ill of our country, their misfortune is not only to have fallen victim to this disease; they have had the additional misfortune to have been born in this country’.61 Reportage and the Iwakura ‘Colony’ Kure’s characterisation of Iwakura as a ‘colony’ oriented around the ‘family care’ of the mentally ill was but one of many descriptions of the village that made their way into print in the early decades of the twentieth century. Contemporary observers offered very different assessments of the kind of care on offer in the village and its relationship to both ‘traditional’ and psychiatric practices. Local officials writing with a popular readership in mind tended to emphasise continuity with premodern practices. The turn of the century saw the publication of a new genre of modern gazetteers that were compiled at the village and county levels. Their production was prompted initially by a failed governmental project of compiling an ‘imperial geography’ (kōkoku chishi), but the gazetteer as a genre was detached from the national project and became a means both of expressing local pride and of promoting tourism and commerce. Significantly, two such texts produced on Iwakura celebrated its long tradition of caring for the mentally ill. The first, published in 1906, contained a section on ‘the origins of the care of the mentally ill’ that was authored by Iwakura’s mayor Hyōgo Teikichi. Hyōgo referenced the practices associated with Daiunji in the early modern period and asserted that the recent establishment of the psychiatric hospital had ‘added’ medical treatment to such activities as drinking the spring water, praying before Kannon, and wandering among the fields, with the result that Iwakura offered patients ‘the best [care] of all’.62 A second gazetteer on Otagi County, where Iwakura was located, was published six years later. In this iteration, the story of Go-Sanjō’s daughter was incorporated to explain the tradition of care at Iwakura, which was described as suspended ‘for a brief period’ in the 1880s. Like Hyōgo’s work, this one too states that Iwakura Hospital functioned merely to ‘add’ medical care to traditional practices.63 In contrast to the authors of the gazetteers, the psychiatric professionals who wrote on Iwakura emphasised the medicalisation of care and its affinities with European ‘family care’. A decade after its establishment, Iwakura Hospital hired a trained psychiatrist to head its staff. Tsuchiya Eikichi, who became Director of Iwakura Hospital in 1904, was educated at the Kyoto Prefectural Medical School, where he had studied under Shimamura Shun’ichi who, like Kure, was one of the first generation of psychiatrists trained by Sakaki at Tokyo University Faculty of Medicine. No early writings by Tsuchiya, who spent his entire career at Iwakura Hospital, are available, but in his published essays from the 1930s and 1940s, he strongly emphasised the authority of Iwakura Hospital vis-à-vis the rest homes. Writing in a Kyoto journal of public health, Tsuchiya stated that while the rest homes and the hospital were administratively completely distinct entities, in point of fact they ‘maintained an intimate relationship like a main family and a branch family’, a reference to Japan’s patriarchal family structure in which the eldest son had certain rights and privileges in relation to his siblings. According to Tsuchiya, the hospital was the ‘main family’ with the result that those in charge of the rest homes ‘submitted to his control’, allowing Tsuchiya to decide in which rest home a patient should be placed and to oversee the treatment, nursing and hygiene they provided.64 In his unpublished history of Iwakura Hospital, Tsuchiya went even further, describing those who were housed in the rest homes as ‘unconfined’ patients of the hospital. But even as Tsuchiya asserted the authority of the hospital, he also praised the ‘familial’ environment of the rest homes. In his words, ‘the daily life of each patient is in fact as if they were a member of the family’.65 Imamura Shinkichi, another student of Sakaki and a classmate of Kure, offered another perspective on Iwakura. In 1903 Imamura, who had just returned from four years of study in Germany, was appointed the first professor of psychiatry at Kyoto University’s medical school. In 1907 he returned to Europe to attend the First International Congress on Psychiatry, Neurology, Psychology and the Treatment of the Insane in Amsterdam. There he presented a paper entitled ‘Iwakura Village’, which he authored with two collaborators, perhaps his students. This choice of topic itself is an indication of the significance of the village for this first generation of Japanese psychiatrists.66 Although Imamura et al. related in some detail the origin story involving the imperial princess, their main focus was on the early modern and contemporary situation and their discussion called into question easy analogies with Geel. According to the essay, a few patients, those who were ‘half cured’, lived with ordinary families, but most were housed in commercial establishments, the largest of which provided care for between 15 and 45 patients. In these, five or six patients lived in a single room under the supervision of a paid attendant. During his presentation, Imamura apparently displayed photographs of the various kinds of restraints that were used on patients, including not only leg and neck irons, but also what was described as a ‘mouth basket’ to prevent biting. He noted that when these methods did not suffice, patients could be confined to small isolation cells. Imamura made no explicit mention of religious practices, although he offered a description of what he described as the ‘water therapy’ practised at Iwakura: 90 minutes standing in the waterfall was, he suggested, capable of ‘calming’ even violent patients. Notably, the origin of this practice as a purification ritual went unmentioned. This disturbing depiction of early modern care at Iwakura meshes quite well with that offered by early modern sources, evidence that Imamura had done some research. Curiously, however, his tone is distinctly uncritical. Indeed, Imamura chastised Kyoto officials for their intervention and argued that ‘through natural evolution, [Iwakura] has assumed a form that contemporary psychiatrists take as ideal’. That modern ‘form’ included the existence of Iwakura Hospital ‘half of which is in the European style’, as well as the modern commercial establishments that had reorganised ‘about twenty years ago’. Imamura used several different terms to refer to the rest homes, terming them ‘institutions’ (anstalten), ‘guesthouses’ (gasthäuser) and ‘sanitaria’ (Heilenstalten). However, beyond a bucolic description of life in the village, where patients ‘pass the days … comfortably without boredom’, he offered little information about the care of patients within the modern rest homes. It was during the period that Imamura was conducting research on Iwakura that the village received its first international visitor, the German-Latvian psychiatrist Wilhelm Stieda, who toured Japan in 1906. Stieda travelled to Iwakura at the suggestion of Kure and with Imamura as his guide. His account of his tour of Japanese psychiatric facilities, later published in both German and Japanese, offered a mixed review of psychiatric care in Japan.67 Echoing the views of his Japanese hosts, Stieda was critical of the government’s failure to fund psychiatric care, noting that Japan lacked a single national psychiatric hospital and that Tokyo’s Sugamo Hospital (the renamed public asylum) was the only public facility in the country. On the other hand, Stieda praised the three hospitals he visited (Sugamo Hospital, Iwakura Hospital and another private hospital in Kyoto) as clean and serene. He offered particular praise for the fact that the hospitals were built as wooden structures that reflected the norms of domestic architecture, with tatami rooms, verandas (engawa), and gardens. These were architectural features, he argued, that Europe would do well to emulate. Stieda offered a lengthy description of Iwakura, dutifully describing the village as ‘something like a Japanese Geel’. But while he made the obligatory mention of the legend of the princess, he emphasised the break with traditional practices. In his words, ‘the age of appealing to the deities for a cure has ended at Iwakura, although the tradition of family care remains’. Unlike Imamura, who had declared to his audience in Amsterdam that ‘the ideal form’ of family care was already in place, Stieda portrayed a situation in flux: although Japanese psychiatrists were endeavouring to ‘renovate’ (isshin) the system of family care in place by pressuring the state to require medical oversight, more than 100 patients, most of whom appeared to be catatonic, were already residing in family homes. His use of the term ‘family care’, notwithstanding, Stieda was well aware of the scale of care in the commercial rest homes. He mentioned that one ‘family’ was caring for more than 50 patients. If Stieda’s numbers are correct, the largest rest homes were substantially larger than Iwakura Hospital, which he stated housed only about 40 patients. However, Stieda offers no comment on this arrangement. Instead, he praised the hospital at some length, describing it as a ‘grand structure’ that was bright and clean, with wards that were ‘completely Japanese’ and laboratories and treatment rooms that were ‘European-style’. Another international visitor offered a very different description of Iwakura. Frederick Peterson, Professor of Psychiatry at Columbia, former head of the New York Commission on Lunacy, and the co-author of a widely used textbook, arrived in Japan in the summer of 1911.68 Peterson was one of the pioneers of the ‘colony’ model of care in the USA: in the 1880s he was involved in the founding of the Craig Colony in upstate New York, an institution devoted to the care of sufferers of epilepsy and in 1895 he became its first director. Like Stieda, he too visited several psychiatric institutions during his time in Japan. In Tokyo, he toured Sugamo Hospital and was favourably impressed, praising it as ‘airy, neat, and clean’ with a well-equipped laboratory and attentive staff.69 However, Peterson saved his highest praise for Iwakura, where he too travelled at the suggestion of Kure and in the company of Imamura. Peterson later published an enthusiastic account of his visit to the village, complete with photographs, in the journal The Survey, then one of the most important American publications on progressive social policy.70 Peterson’s description of Iwakura shares little with that of Stieda: he made no mention of either Iwakura Hospital or of the large commercial rest homes. Instead, he describes the village as a pastoral paradise where ‘one or two patients were received into each family to share in the occupations of the household which were chiefly out-of-door employments … and some of the arts and crafts of the ordinary Japanese household’. The ‘gentleness, kindness, patience, and assiduousness’ offered by the villagers was contrasted with that provided within ‘the vast, complicated, and unwieldy’ public asylums that had been established in the USA, institutions in which ‘the individual is lost sight of in an immense aggregations of patients’. Reflecting the nostalgic and anti-modernist sentiments that shaped many accounts of Japan at the time, Peterson criticised the Japanese government for being ‘misled by a false impression of the value of our Western methods of caring for the insane’, which had led them to conclude that ‘their colony system which had grown up so naturally was too far removed from American and European standards’. There is no suggestion that the situation at Iwakura required reform to fit the model of ‘family care’. Instead, the village is presented as a model of care that ‘the West’ should emulate: ‘This system, [which] evolved over a period of nearly a thousand years, is the best of all methods for caring of the insane. … No doubt we in the West will one day be glad to copy this Japanese model when we finally awaken to how far we have drifted from an ideal of care and treatment of the insane, with our immense, expensive and complicated machinery of mere support and custody’.71 These conflicting accounts of Iwakura in both domestic and international sources suggest that interest in Iwakura was more complicated than Hashimoto’s conception of ‘translation’ as a reflection of ‘Japanese Orientalism’ suggests. For one, it is clear that varied economic, political and cultural motives were in play. The gazetteers, for example, make no mention of ‘family care’, the term that looms so large in the psychiatric literature. Rather, they suggest that Iwakura is a place where one can access both traditional and medical treatments, an appealing prospect perhaps to patients and their families who may not have understood or embraced psychiatric explanations of mental illness. In contrast, the psychiatrists had their own diverse set of aims. While Kure and his colleagues cast Iwakura as ‘family care’ to argue for the authority of the psychiatric discipline, Peterson—writing for an American audience—made it a potent means to criticise the reliance on large public institutions. Stieda seems to have had an agenda as well—he was interested in the possibility of less-institutional institutions. So while Kure and his Japanese compatriots reconceptualised Iwakura in relation to their understanding of family care in Europe, Peterson and Stieda made it an emblem of a uniquely ‘Japanese’ system of care, one that did not rely upon an institutional structure, one that was more intimate, familial and humane. Also important is the circulation—not the unidirectional translation as Hashimoto implies—of accounts of Iwakura. The reports of Stieda and Peterson were informed by opinions of their Japanese counterparts, but they appeared not only in English or German but also in Japanese. The result was a complicated pattern of references and cross-references that renders the real situation at Iwakura opaque. The Rise of the Rest Homes The professional advocacy of Japanese psychiatrists for ‘family care’ and the local embrace of the business of housing the mentally ill led to a rapid increase in the number of rest homes in Iwakura in the 1920s and 1930s. By 1935 there were fourteen such facilities in Iwakura, nine of which had been founded after 1930. Only two of these facilities were operated by families associated with the ‘tea shops’ of the eighteenth century.72 And rest homes were no longer a solution limited to the Kyoto area. According to a survey of facilities for the mentally ill undertaken by Kan Osamu, a doctor on the staff of Matsuzawa Hospital (the name of the Tokyo prefectural psychiatric hospital after 1919), there were 45 rest homes for the mentally ill in operation in Japan in 1935, 14 in Ishikawa prefecture alone. To be sure, the designation of what was a ‘rest home’ was arbitrary. Although some rest homes housed only a small number of patients suggesting that they may well have offered a family-like atmosphere, others accommodated significant numbers of patients. In the 1930s, the two largest rest homes in Iwakura each housed between 50 to 60 people, while the largest facility in the country, located in Miyagi prefecture in northern Honshu, had a capacity of 100.73 It is noteworthy as well that many of the larger rest homes were established at sites that had associations with the healing of madness in the premodern period, suggesting that, as at Iwakura, their proprietors had grasped the economic potential of traditional sites. Needless to say, institutions that housed 20 or more people in no way reflected the model of family care that had originally oriented the psychiatric profession’s valorisation of Iwakura. These were businesses, the operation of which was enabled by a set of competing but ultimately reconcilable interests, including those of the state, the psychiatric profession, patients and their families, and local entrepreneurs. The rest homes were always of dubious legality. The 1900 Law explicitly forbade the lodging of the mentally ill in inns and boarding houses on a fee for services basis, and they were never recognised as bona fide hospitals. Speaking at a national congress of the directors of psychiatric hospitals in 1932, Tsuchiya Eikichi openly acknowledged the extra-legal status of the rest homes in Iwakura: ‘there isn’t any kind of law [regulating the rest homes]. They do it because they have a long history.’ He also acknowledged that both medical and administrative oversight was limited: ‘they don’t have a direct relationship with the hospital, but I oversee them. They are just allowed to lodge the mentally ill who are not privately confined. The only thing that is reported is some diagnosis, and the police do come around.’74 This situation did not seem to have overly concerned Tsuchiya’s colleagues at the congress, one of whom proclaimed ‘Japan’s Iwakura Hospital is something to be proud of before the whole world.’75 This enthusiasm for the rest home model was, however, not universal. By 1916, Kure Shuzō, who had done so much to popularise the Geel analogy, had lost interest in Iwakura. The revised edition of his Outlines of Psychiatry published in that year discusses family care in Europe at some length but without mentioning Iwakura.76 Kure was not the only one who seems to have reconsidered Iwakura’s value as a model therapeutic community. In 1930, Miyake Kōichi, professor of psychiatry at Tokyo Imperial University, attended the first International Congress of Mental Hygiene held in Washington, DC. He presented a paper on the state of the psychiatric discipline and the mentally ill in Japan that made no mention of Iwakura, ’family care’ or colonies, although he noted that a large number of patients were housed outside public institutions, in ‘private mental hospitals, sanatoriums [i.e. “rest homes”], and other places (temples, mountain resorts, or similar religious institutions).’77 Also in attendance at the Congress was Frederick Sano, then medical director of Geel. In his discussion of the Geel system, Sano took note of the many attempts to emulate it around the world, most of which in his estimation had failed. He attributed Geel’s the success to specific conditions that were lacking elsewhere, including the religious influence of the cult, the familiarity and tolerance of the local people towards the mentally ill, and state support for this system. Neither Miyake nor the other two Japanese delegates participated in the discussion that followed.78 A report issued by the Social Affairs Office of the Kyoto City government provides some insight into why Kure and his colleagues may have rethought their advocacy of Iwakura. It reveals that the rest homes had multiple grades of care, with the cost ranging from 36 to 66 yen per month—this, at a time when the average income of a farmer in Kyoto was about 38 yen a month. And this basic charge covered only room and board: there were also stiff additional fees for nursing and medical care.79 In contrast, a month’s stay in one of Kyoto’s private psychiatric hospitals could cost as little as 30 yen per month.80 Kure had advocated for ‘family care’ as a cost effective means to extend the influence of psychiatry over the mentally ill and resocialise patients, but it had devolved into the housing of the mentally ill in unregulated pseudo-institutions for hefty fees. Conclusion Ultimately, the divergence between the reality of Iwakura and the rhetoric that surrounded it is not surprising, given that all of those involved in producing the latter had a stake in presenting Iwakura as something other than what it was. As a result, in the 1920s and 1930s the commercial rest homes of Iwakura and elsewhere flourished, becoming an important part of the landscape of psychiatric care. Although the Japanese government took some steps to increase the availability of facilities for the mentally ill—by funding the placement of patients in private hospitals at public expense, for example—the 1900 law that authorised private confinement was not repealed until 1950. Two decades after Kure had denounced the failure of the government to act on behalf of its mentally ill citizens, many continued to languish in home confinement, or even worse, in what came to be known as ‘detention centres’ (shūyōjo), gaol-like facilities established by local authorities to house those deemed dangerous. In this context, care in a rest home, at Iwakura or elsewhere, may have seemed preferable, at least for those who could afford it. The fanfare that surrounded the Iwakura rest homes notwithstanding, they quickly disappeared in the immediate post-war era. In 1950, the Japanese government passed a new Mental Health act that made private confinement illegal and provided funds for the construction of public psychiatric hospitals and subsidies for private facilities. In the wake of this law, the rest home concept was quickly abandoned—even by its most fervent supporters. At Iwakura, two of the most successful proprietors of rest homes before 1945 quickly regrouped to create the large private hospitals in operation today. After the establishment of the National Health Insurance system in 1962, the number of those in psychiatric hospitals increased dramatically. Japan’s ‘great confinement’, it can be said, occurred in the post-war era. But the vision of Iwakura as a community in which the mentally ill lived happy and productive lives among sympathetic and caring villagers continues to be both powerful and flexible. In the 1960s and 70s, activist psychiatrists would evoke it to argue for the de-institutionalisation of the mentally ill, ironically echoing Peterson’s use of the village 60 years before.81 The administrators of the post-war hospitals continue to evoke the ‘tradition’ of care at Iwakura to promote their institutions. Today the websites of both Kitayama Hospital and Iwakura Hospital relate the legend of Go-Sanjō’s daughter, with the former declaring that Iwakura is ‘a place blessed with a healing environment’.82 To be sure, this claim is not entirely unjustified. Its incorporation into Kyoto notwithstanding, the neighbourhoods of ‘old’ Iwakura remain pleasantly village-like, and many local residents express pride in their community’s reputation for tolerance towards the mentally ill. Recently, the Daiunji temple has re-emerged and it too has attempted to capitalise on Iwakura’s reputation. In 1985 a temple bearing the name Daiunji was re-established in Iwakura, albeit with none of the grandeur of its predecessor. Now detached from Jissōin, it has operated in a ramshackle building for three decades. In the late 2000s, someone associated with Daiunji created a website to advertise its effectiveness in curing all ‘brain disease’, including stress, neuroses, alcoholism and depression, as well as disorders of the eyes, ears, nose and throat. It noted as well that ‘the temple is always mentioned in the books and articles produced by psychiatric associations’.83 And so the complex set of relationships this paper has explored—involving the medical profession, commerce, social policy, and that thing we like to call ‘tradition’—continues to unfold. Footnotes 1 On the history of Iwakura, see Nakamura Osamu, ed., Rakuhoku Iwakura (Kyoto: Iwakura Kita Shogakkō Sōritsu Nijūshūnen Iinkai, 1995). Transportation developments are discussed at 153–60, housing construction at 149–50, population growth at 152. 2 As a point of reference, Tokyo Metropolitan Matsuzawa Hospital, Japan’s largest public mental health facility, has 1,005 beds. 3 Tsuchiya Eikichi, ‘Kyōtofu-ka Iwakuramura ni okeru seishinbyōsha ryōyō no gaikyō’, Kyōto iji eisei shi, 1930, 6. 4 On the relationship between pre-modern religious sites and modern psychiatric hospitals, see Omata Waichirō, Seishinbyōin no kigen (Tokyo: Ōta Shuppan, 1998), Hyōdō Akiko, ‘Futatsu no Awai Jinja no rekishi kara: Minkan ryōhō shisetsu to seishin byōin no kindai’, Chiryō no koe, 2006, 7, 41–4. 5 Important interventions in the celebration of Iwakura, include Kobayashi Takehiro, ‘Kindaiteki seishin iryō no keisei to tenkai: Iwakura no chiiki iryō wo megutte’, in Sekai jinken mondai kenkyū sentā kiyō,1998, 195–216 and Hashimoto Akira’s perceptive analysis of the repeated claim that Iwakura was ‘Japan’s Geel’ in Hashimoto Akira, ‘Kyokō toshite no Iwakura mura’, Aichi Kenritsu Daigaku bungakubu ronshū (Shakai fukushi gakka hen), 2002, 51, 29–44. A revised version of the latter essay is Akira Hashimoto, ‘Invention of a “Japanese Geel”: Psychiatric Family Care from a Historical and Transnational Perspective’, in Waltraud Ernst and Thomas Mueller, eds, Transnational Psychiatries: Social and Cultural Histories of Psychiatry in Comparative Perspective, 1900–2000 (Newcastle upon Tyne: Cambridge Scholars, 2010), 142–71. For a critical treatment of the care provided by Daiunji in the early modern period, see Atobe Makoto, Iwasaki Naoko, and Yoshioka Shinji, ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, Seishin igaku, 1995, 37, 1221–8 and ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 2, Seishin igaku, 1995, 37, 1335–9. 6 Hashimoto, ‘Invention of a “Japanese Geel”, 164–5. 7 For the history of Daiunji and Jissōin, see Fujikawa Tatsuhiko and Higashimura Teruhiko, ‘Rakuhoku no chi “Iwakura” ni okeru seishin shōgaisha ni taisuru shogū no rekishi ni tsuite’, part 1, Aino Byōin igaku zasshi, 1982, 4, 49–60 and Sugitatsu Yoshikazu, Kyō no ishiseki tanbō (Kyoto: Shibunkaku, 1984), 96–7. 8 Fujimoto Bunrō, ‘Iwakura mura to shōgaisha’, Shōgaisha mondai kenkyū, 1986, 44, 51. 9 The story of Go-Sanjo’s daughter is widely cited in the scholarship on Iwakura. See, for example, Tatsukawa Shōji, Edo yamai no sōshi (Tokyo: Chikuma Shobō, 1998), 343–4 and Sugitatsu, Kyō no ishiseki tanbō, 96–7. 10 Sugitatsu, Kyō no ishiseki tanbō, 97. 11 On the medical ‘marketplace’ in early modern Japan, see Susan L. Burns, ‘Nanayama Jundō at Work: A Village Doctor and Medical Knowledge in Early Modern Japan’, East Asian Science, Technology, and Medicine, 2008, 29, 61–82. For a careful look at an early modern temple’s involvement in healing, see Duncan Ryūken Williams, Another Side of Zen: A Social History of Sōtō Zen Buddhism in Tokugawa Japan (Princeton: Princeton University Press, 2009). 12 Tatsukawa Shōji, Byōki wo iyasu chiisana kamigami (Tokyo: Heibonsha, 1993), 14–15. Tatsukawa identifies more than 500 religious sites associated with healing in this work. 13 Gutei, Miyako meisho tebiki annai (Kyoto: Shirokiya Hanemon et al., 1763). 14 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1123. 15 Nakagami Ryōta, Seiseidō idan: Ijin Nakagami Kinkei no shisō to chiken (n.p.: Kinkei Ōkina Hyakusanjūkaiki Kinen Shuppan, 1963), 16. 16 Tatsukawa, Byōki wo iyasu chiisana kamigami, 330–1. 17 This illustration is reproduced in Fujikawa and Higashiyama, ‘Rakuhoku no chi “Iwakura”’, 56–7. 18 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1224. 19 Nakagami, Seiseidō idan, 17. 20 Quoted in Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 2, 1337. 21 Ibid. 22 Ibid., 1337–8. 23 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1227. 24 Tomita Mikio, Seishinbyōin no teiryū (Tokyo: Seikyūsha, 1992), 162. 25 On the care of the mentally ill in Edo, see Omata, Seishinbyōin no kigen, 174–92. 26 Fukuzawa Yukichi, ‘Seiyō jijō’, in Fukuzawa Yukichi zenshū, vol. 1 (Tokyo: Iwanami Shoten, 1958), 309. 27 Kume Kunitake, Beiei kairan jikki, vol. 1 (Tokyo: Iwanami Shoten, 1977), 115. 28 Sydney DeVere Brown and Akiko Hirota, trans., The Diary of Kido Takayoshi, volume 2: 1871–1873 (Tokyo: University of Tokyo Press, 1985), 121. 29 In characterising the Yōikuin in these terms, I am following Kitahara Itoko, ‘Toshi ni okeru hinkon to kyōki’, in Tsuda Hideo, ed., Kinsei kokka no kaitai to kindai (Tokyo: Hanawa Shobō, 1979), 422–43. 30 On Akashi, see Sugita Hiroshi, Kindai Kyōto in ikita hitobito: Meiji Jinbunshi (Kyoto: Kyoto Shoin, 1987), 195–211. 31 Kyōto furitsu shiryōkan, ed., Kyōto-fu hyakunen no shiryō, vol. 4: Shakai (Kyōto Furitsu Sōgō Shiryōkan, 1982), 490–1. 32 Ibid. 33 Ono Naoka, ‘Kyōto Furitsu Tenkyōin no setsuritsu to sono keii’, Nihon ishigaku zasshi, 1994, 39, 479. 34 Kyōto Furitsu Sōgō Shiryōkan, ed., Kyōto-fu hyakunen no shiryō, 494. 35 On the involvement of Buddhist priests in the establishment of the hospital, see Kawabata Shin’ichi, Kyō no igaku: Jijin no keifu to Furitsu Idai no sōsō (Kyōto: Jinbun Shoin, 2003); on the role of Higashiyama Tenka, see Kyōto-fu Ishikai, eds, Kyōto no igakushi (Kyōto: Shinbunkaku, 1980), 825–6. 36 Kanbe Bunsai and Henry Maudsley, Seishinbyō yakusetsu (1876; repr., Chōfu: Seishin Igaku Shinkeigaku Koten Kankōkai, 1973.) 37 ‘Meiji 10-nen yori Meiji 12-nen ni itarau nyūin kanja nenpyō’, Ryōbyōin zasshi, 1880, 14,9–11. 38 ‘Kyōjō chiken’, Ryōbyōin zasshi, 1880, 14, 15–22. 39 ‘Tenkyō Byōin nyūinsha nenpyō’, Ryōbyōin zasshi, 1880, 14, 103. 40 Kyōto Furitsu Sōgō Shiryōkan, ed., Kyōto-fu hyakunen no shiryō, 499. 41 Nishikawa Kaoru, Nihon seishin shōgaisha no seisakushi (Niigata: Kōkodō, 2010), 26. 42 The discussion that follows is based on Tsuchiya Eikichi’s unpublished work, Iwakura Byōinshi sōan. Tsuchiya was Director of the Iwakura Hospital from 1904 until 1945 when the hospital was closed. Uotani Takashi, then director of Kitayama Byōin, kindly allowed me to copy the manuscript when I initially carried out fieldwork in Iwakura in the mid-1990s. 43 Matsuoka Tomoko and Iwawaki Yoko, ‘Kyōto Furitsu Ika Daigaku ni okeru sanba kyōiku no reimeiki: Meiji jidai no Kyōto ni okeru sanba kyōiku no hensen wo fumaete’, Kyōto Furitsu Ika Daigaku zasshi, 2010, 119, 78. 44 Fujikawa and Higashiyama, ‘Rakuhoku no chi “Iwakura” ni okeru seishin shōgaisha ni taisuru shogū no rekishi ni tsuite’, part 1, 5, 44. 45 Tsuchiya, Iwakura Byōinshi sōn, unpaginated. 46 Kure Shūzō, Wagakuni ni okeru seishinbyō ni kansuru saikin no shisetsu (Tokyo: Igakkai Jimusho, 1912), 28. 47 ‘Ko Ika Daigkau kyōju igaku hakusei Sakai Hajime no den’, Tōkyō igakkai zasshi, 1897, 11, 34–41. 48 Kure Shūzō, ‘Tenkyōin ni tsuite’, Chūgai Iji Shinpō, 1893, 324, 1063–6; 1893, 325, 1134–7; 1893, 326, 1212–15. 49 Kure Shūzō, Seishinbyōgaku shūyō, vol. 2 (Tokyo: Kure Shūzō, 1895 ), 549–51. 50 On the debates on Geel among British doctors, see William L. Parry-Jones, ‘The Model of the Geel Lunatic Colony and Its Influence on the Nineteenth-Century Asylum System in Britain’, in Andrew Scull, ed., Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era (Philadelphia: University of Pennsylvania Press, 1981), 201–17. On the debates in the USA, see Nana Tuntiya, ‘Free-Air Treatment for Mental Patients: The Deinstitutionalization Debate of the Nineteenth Century’, Sociological Perspectives, 2007, 50, 469–88. On Europe, see Andreas Pernice, ‘Family Care and Asylum Psychiatry in the Nineteenth Century: The Controversy in the Allgemeine Zeitschrift für Psychiatrie between 1844 and 1902’, History of Psychiatry, 1995, 6, 55–68 and Thomas Mueller, ‘Reopening the Closed File of the History of Psychiatry: Open Care and its Historiography in Belgium, France, and Germany, c. 1880–1980’, in Ernst and Mueller, Transnational Psychiatries, 1900–2000 (Newcastle upon Tyne: Cambridge Scholars, 2010), 172–199. 51 On Geel, see Parry-Jones, ‘The Model of the Geel Lunatic Colony’, 204–5 and Matthew P. Dumon and C. Knight Aldrich, ‘Family Care after a Thousand Years—A Crisis in the Tradition of St. Dymphna’, American Journal of Psychiatry, 1962, 119, 116–21. 52 Mueller, ‘Reopening the Closed File’, 187–8. 53 Ibid., 193. 54 On Massachusetts, see Owen Copp, ‘Some Results and Possibilities in Family Care of the Insane in Massachusetts’, The American Journal of Insanity, 1902, 59, 299–313; on Michigan’s approach, see Report of the Board of Trustees of the Michigan Asylum of the Insane (Lansing: State Printers, 1887–1896). 55 Hashimoto, ‘Invention of a Japanese Geel’, 161. 56 Kure Shūzō, ‘Tenkyōmura (Seishinbyōsha no sagyōhō) ni tsuite’, in Kure Shūzō chosakushū, vol. 2, (Kyoto: Shibunkaku Shuppan, 1982), 43. 57 Hashimoto, ‘The Invention of a “Japanese Gheel”’, 150. 58 Susan L. Burns, ‘From “Leper Villages” to Leprosaria: Public Health, Medicine, and the Culture of Exclusions in Modern Japan’, in Alison Bashford and Carolyn Strange, eds, Isolation: Policies and Practices of Exclusion (London: Routledge, 2003), 104–18. 59 On the formulation of the law, see Nishikawa, Nihon seishin shōgaisha no seisakushi, 50–64. 60 Kure, Seishinbyōsha shitaku kanchi no jikkyō (1918; repr. Chōfu: Seishin Igaku Shinkeigaku Koten Kankōkai, 1973), 138. 61 Ibid. 62 Quoted in Nakamura Osamu, ‘Seishin iryō no nagare to Rakuhoku Iwakura: Dainiji sekai sensō made’, Osaka Furitsu Daigaku kiyō, 2005, 53, 28. 63 Kyoto-fu Otagi-gun shi (Otagi, Kyoto: Kyoto Otagi-gun, 1906). 64 Tsuchiya, ‘Kyōtofu-ka Iwakuramura ni okeru seishinbyōsha ryōyō no gaikyō’, 7. 65 Tsuchiya, Iwakura Byōinshi sōan, 36. 66 Imamura Shinkichi, Osawa Hiroshi and Higuchi Tatsusuke, ‘Dorf Iwakura’, in G. A. M. Wayenberg, ed., Compte rendu des travaux (Amsterdam: J. H. de Bussy, 1908), 881–5. 67 Wilhelm Stieda, ‘Ueber die Psychiatrie in Japan’, Nervenheilkunde und Psychiatrie, 1906, 216; ‘Nihon no seishinbyōgaku’, Shinkeigaku zasshi, 1906, 5, 337–50. 68 The textbook was Nervous and Mental Disorders (Philadelphia: W. B. Saunders), co-authored with Archibald Church. Nine editions were published between 1899–1915. 69 Frederick Peterson, ‘The Insane in Japan’, in Psychiatric Society of New York, (ed.), Studies in Psychiatry (New York: The Journal of Nervous and Mental Disease Publishing Company, 1912), 3. 70 Frederick Peterson, ‘From Vanves to Iwakura’, The Survey, 5 October 1912, 29–1, 25–33; Iwakura figures as well in Peterson’s ‘The Insane in Japan’. The latter was excerpted and reprinted elsewhere in the medical press. 71 Peterson, ‘From Vanves to Iwakura’, 32–3. 72 ‘Kyoto-shi ni okeru seishinbyōsha oyobi sono shūyō shisetsu ni kansuru chōsa’, Kyōto-shi shakaika chōsa hōkoku, 1935 ,34, 51–4. 73 Kan Osamu, ‘Honpō ni okeru seishinbyōsha narabini kore ni kinsetsuseru seishin ijōsha ni kansuru chōsa’, Seishin shinkeigaku zasshi, 1937, 41, 875–6. 74 ‘Dai-ikkai zenkoku kōritsu oyobi daiyō seishinbyōin shūinchō kaigi’, Seishin eisei, 1933, 5, 10–11. 75 Ibid. 76 Kure Shūzō, Seishinbyōgaku shūyō, vol. 2 (2nd edition; Tokyo: Tohōdo, 1916–1918), 974–8. 77 Miyake Kōichi, ‘The Mental-Hygiene Movement in Japan’, in Frankwood Earl Williams, (ed.), Proceedings of the First International Congress of Mental Hygiene Held at Washington D.C., USA, May 5th–10th 1930 (New York: International Congress of Mental Hygiene, 1932), 109. 78 Frederick Sano, ‘The Care of the Insane Outside of Institutions’, in Williams, (ed.), Proceedings of the First International Congress of Mental Hygiene, 391–402. 79 ‘Kyoto-shi ni okeru seishinbyōsha oyobi sono shūyō shisetsu ni kansuru chōsa’, 52–3. 80 Ibid., 41–51. 81 The appeal to an international readership continued as well. See, for example, Y. Kumasaka, ‘Iwakura: Community Care of the Mentally Ill in Japan’, American Journal of Psychotherapy, 1967, 21, 673–5. 82 See http://www.sankokai.jp/history.html and http://www.toumonkai.net/co_navi/article/khI20150521110701–12.html. Both accessed 5 June 2016. 83 Accessed (and screen-shot) on 21 September 2009. The current webpage (http://daiunji.net/) is far more elaborate and includes considerable information about the temple’s history in relation to mental illness. It also declares that the temple is ‘world famous for healing brain disease and other difficult illnesses’. Accessed 4 June 2016. © The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social History of Medicine Oxford University Press

Reinvented Places: ‘Tradition’, ‘Family Care’ and Psychiatric Institutions in Japan

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
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0951-631X
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Abstract

Abstract This article explores the history of the care of the mentally ill at Iwakura, a site in northeast Kyoto in Japan where two large psychiatric hospitals now stand. Long a topic of research in Japan, Iwakura reflects a peculiar spatial arrangement common in Japan in which psychiatric hospitals came to be established near religious sites associated with care of the mentally ill in the pre-modern period. In the early twentieth century, Japan’s first generation of psychiatrists began to celebrate Iwakura as offering an indigenous form of ‘family care’, then the object of considerable discussion among psychiatrists and others in Europe and North America. I argue that the valorisation of Iwakura as offering a mode of care that was simultaneously ‘traditional’ and ‘progressive’ reflects the struggle to establish psychiatric institutions that involved local economic interests, public policy, and members of the new psychiatric discipline. psychiatry, family care, Japan, psychiatric hospitals Today the area known as Iwakura in northeast Kyoto, Japan’s seventh largest city by population, appears to be a typical post-war suburb. An agricultural village, Iwakura was linked by only two narrow roads to the city of Kyoto until 1925 when the Eizan Railway opened. But after the village was incorporated into the city’s Sakyō Ward in 1949, new roads were constructed, new bus lines established, and in the late 1990s the Karasuma subway line was extended, connecting Iwakura with Kyoto station, a major transportation terminal.1 As large public apartment complexes were built, young families flowed into Iwakura, increasing the population five-fold over 30 years. Now only a few scattered rice fields are to be found among the jumble of houses and apartment buildings, while large chain supermarkets, convenience stores, and family-style restaurants line the main throughways. But the streets in the centre of ‘old’ Iwakura, near the temple complex known as Jissōin, reveal another aspect of Iwakura’s history, one that predates but has come to intersect with the post-war medical system. Here one finds a surprising number of private psychiatric hospitals and clinics, among them Kitayama Hospital (795 beds) and Iwakura Hospital (533 beds).2 These institutions are the traces of Iwakura’s long association with the care of the mentally ill, a connection that some claim dates back to antiquity. Writing in the 1930s, Tsuchiya Eikichi, the director of a psychiatric hospital in Iwakura, summed up the village’s reputation among Kyoto residents of that period, when he stated ‘if one hears the word “madness” (kichigai), one thinks of Iwakura, and if one hears “Iwakura,” one thinks of madness’.3 In this essay, I explore the history of Iwakura as a point of access into the evolving debates, struggles and negotiations that surrounded what has been cast simultaneously as both ‘traditional’ and ‘progressive’ modes of care for the mentally ill in Japan in the first half of the twentieth century. Iwakura is the best known example of a phenomenon that has been well documented by Japanese historians and ethnographers: a significant number of modern psychiatric facilities were established outside urban areas near temples and shrines that had longstanding associations with care of the mentally ill.4 Within this body of work, Iwakura has been singled out for particular attention: from the 1890s until the present, it has been celebrated as providing an alternative to confinement in a psychiatric hospital. Only recently have some scholars begun to question the idealised view of Iwakura as a benevolent therapeutic community with deep historical roots.5 My interest in Iwakura, as both a social and a discursive site, is two-fold. First, the case of Iwakura suggests that the establishment of psychiatric hospitals near religious sites does not simply reflect the persistence of traditional beliefs or modes of care, as some have argued. Rather, the apparent continuity was the result of the intersection of multiple interests, including not only the state and the new psychiatric discipline, but also local residents, whose involvement has been largely ignored. Secondly, the intense interest in Iwakura on the part of the psychiatric community compels us to think more carefully about the transnational flow of psychiatric discourse and practice in the late nineteenth and early twentieth centuries. Akira Hashimoto, whose work on Iwakura informs my own, has argued that the celebration of Iwakura reflects the ‘Orientalism’ of Japanese psychiatrists, who felt a ‘reactionary pride’ at the comparison of Japanese practices with progressive developments in Europe.6 In contrast, I argue that the discourse on Iwakura reflects the participation of Japanese psychiatrists in an international debate on the ethics, economics and therapeutic value of the institutionalisation of the mentally ill. Iwakura and the ‘Tradition’ of Care Today the modern psychiatric institutions located in Iwakura are clustered around the area where a temple known as Daiunji, part of the temple complex called Jissōin, once stood. Founded in 971, Daiunji was for centuries a temple of considerable prestige, one to which members of the imperial family who had taken Buddhist orders retired.7 There is some evidence that Daiunji’s association with the cure of madness dates back to the century or so after its founding. According to one source, an imperial prince who was possessed by some kind of spirit (mono no ke) prayed for relief at Daiunji and was cured.8 Even more widely cited is the story of an imperial princess, the daughter of the emperor Go-Sanjō 1034 CE to 1073 CE, who was taken to Iwakura after she showed signs of madness and recovered there.9 However, while members of the Kyoto elite did indeed seek relief at Daiunji upon occasion, there is little evidence to support the claim that the temple had a popular reputation for the treatment of the mentally ill in the long pre-modern period or that there was an unbroken tradition of care from antiquity forward. What is clear is that sometime in the late seventeenth century, Daiunji gained a reputation for healing. The timing is significant. Although Daiunji continued to be a temple of considerable wealth and power into the medieval period—according to one source it had an income of 100,000 koku (approximately 500,000 bushels) of rice and supported a thousand monks—its fortunes declined dramatically in the sixteenth century as the political and economic power of the Kyoto-based nobility that had supported it and other Buddhist institutions shifted to the warrior class. Compelled to seek out other sources of support, the temple put its ‘hidden Buddha’ (hibutsu) on display for the first time in 1690.10 This was an image of the Bodhisattva Kannon, a deity associated with compassion towards those in distress. This attempt to attract commoner support paid off, and the image subsequently became the object of popular devotion as people from Kyoto, Osaka, and elsewhere in Japan travelled to Iwakura to view it. This was also the time when rumours began to circulate that the sick were being cured at Daiunji. In this period, temples around Japan were becoming involved in medical matters, part of a new and booming economy of care.11 They not only sold amulets and charms to prevent and cure illness but also manufactured medicinal compounds and performed healing rituals. The medical historian Tatsukawa Shōji has noted that ‘guidebooks’ designed to attract visitors to temples and shrines in a particular region or city often took note of their efficacy for curing one illness or another, with the result that ‘tourism and treatment became intertwined’.12 Initially, accounts of miraculous healing at Daiunji apparently focused on ailments of the eye. According to a temple record, in 1706, a man who had been blinded in a childhood accident had his sight restored after praying before the temple’s statue of Kannon. A guidebook published 50 years later also makes mention of the temple’s efficacy in treating eye disease, although in this case, it is standing under the waterfall, a practice associated with purification (misogi), that is said to have effected a cure.13 It was only in the second half of the eighteenth-century that Daiunji came to be associated primarily with the treatment of the mentally ill. According to the records of city leaders in Kyoto, in 1765 a 33-year-old man suffering from ‘a disordered heart’ (ranshin), one of several terms used to describe mental illness, was dispatched to Iwakura so that he could pray before the Kannon and stand under the waterfall.14 Writing 30 years later, the well-known Kyoto physician Nakagami Kinkei implied that this practice was relatively recent. In 1796, he stated, ‘these days among commoners in Kyoto, whenever someone goes mad, they take him to a place like Iwakura’.15 How the transfer from eye disease to mental illness took place is unclear, although Tatsukawa’s research suggests that religious sites were often associated with multiple ailments and even with specific parts of the body with some claiming efficacy for ‘the lower half’ or ‘above the neck’.16 Of course, it may also have been that mental illness was more responsive to the treatments offered at the temple and therefore more profitable. Late eighteenth-century sources reveal the contours of the new and lucrative ‘trade’ in the mentally ill that benefited both the temple and villagers. An illustration of Daiunji in Miyako meisho zukai (1780, ‘Famous Sites in the Capital’) depicts not only the main temple buildings but also five simple structures that are labelled komoriya (‘retreats’).17 Temple records reveal that these were constructed to house those who came seeking a cure at Daiunji. The temple not only charged a fee to lodge in these shelters but also required payment for performing rituals of exorcism, for access to a spring rumoured to have curative properties and for the privilege of standing in its waterfall.18 All three of these activities were believed to be useful in expelling possessing spirits, animal and other, that were widely regarded as responsible for producing the symptoms of madness. As Daiunji gained fame, some Iwakura villagers began to operate so-called tea shops (chaya) that provided food and drink to temple visitors. Initially, such businesses were forbidden by the temple from housing those who came for healing, but they performed other important and apparently profitable functions. For one, the temple required that an attendant (kaihōnin) accompany an afflicted visitor during his stay. For families who had journeyed from afar to deposit their relatives at Daiunji, this rule was no doubt burdensome, and the tea houses began to offer the services of paid attendants who were known as ‘strong men’ (gōriki), a term that suggests their management of the afflicted relied a good deal on physical strength. In his remarks on Iwakura, the physician Nakagami Kinkei wrote scathingly of these attendants: Many family members say they cannot watch the sick person and so they leave him in the care of those they have hired. But [the attendants] fear the patient will runaway and so they tie him up day and night, so that they can eat and sleep in peace. As a result, the sick ones become agitated, and in many cases their madness becomes more extreme.19 Temple authorities were aware of the reputation of the ‘strong men’ for abuse. In a 1799 record, Jissōin, which, as the main temple, had ultimate authority over Daiunji, described the treatment visitors had received at their hands: some were denied food, beaten, or restrained ‘like criminals’, others were enticed into gambling or other vices, and some women were subjected to sexual abuse.20 Several times temple authorities threatened to forbid the presence of these paid attendants within their grounds, but the operators of the tea houses protested, stating that without their help it would be impossible to care for the large number of afflicted visitors.21 A decline in the number of long-term ‘patients’ would have had financial implications not only for the tea houses, but also for the temple as well, and in the end, the authorities of Jissōin settled for a series of half measures: they required the attendants to seek permission before using restraints and ordered that female visitors be cared for by female attendants.22 The symbiotic nature of the temple and the tea houses’ economic relationship is perhaps best revealed by the temple’s decision in the early nineteenth century to relax its restrictions on the boarding of visitors outside temple grounds, allowing tea houses to provide lodging to those who came for a cure, a decision apparently driven by the need to accommodate the overflow of visitors. By the 1870s, the term ‘tea shop’ was no longer used to refer to the establishments. Instead, they had come to be termed yadoya (‘inns’).23 Discovering the Asylum Of course, only a tiny fraction of those regarded as ‘mad’ in early modern Japan ever made their way to Daiunji. The temple represented only one of an array of strategies for dealing with the mentally ill before modernity. In many areas, families would confine members who posed a danger to themselves or others or who interfered with the work of agricultural production to a room within the home or in an adjacent structure. This typically required the consent not only of immediate family members, but also of neighbours, village officials, often a doctor as well as the samurai official under whose authority the village fell.24 In Edo (later renamed Tokyo) and other urban areas, a mentally ill person found on the streets was often turned over to the status group known as hinin (a term often translated as ‘outcasts’), who were authorised to beg on temple grounds and city streets and who were also charged with caring for those with no means of support, such as abandoned children and elderly people.25 As this set of heterogeneous policies suggest, there was nothing like the ‘asylum’ in Japan before modernity. Knowledge of the possibility of such an institution came only in the mid-nineteenth century when Japanese first travelled to Europe and the USA in the 1860s and 1870s. An early description of the asylum came from Fukuzawa Yukichi who visited the USA and Western Europe in the 1860s as a member of two shogunal missions. The best-selling work he later compiled on Western culture and institutions called Conditions in the West (Seiyō jijō) included a discussion of what Fukuzawa termed ten’in, a neologism he coined as a translation for ‘asylum’. According to Fukuzawa, the asylum he visited was a ‘quiet and serene’ place where patients whose symptoms were not severe read books, painted, danced and took walks.26 In marked contrast to Fukuzawa’s impressions were those of Kume Kunitake, a member of the Iwakura mission, dispatched by the new Meiji government in 1873. He visited the Insane Asylum of California located in Stockton. Describing this institution, Kume wrote, There were more 1500 patients there, both men and women. They were divided into different rooms depending on the severity of their sickness. Those who were very sick were locked in their rooms with restraints on their arms and legs, and were soiled with excrement and urine. There was a male or female attendant in each room, and the restraints were made of iron.27 Kido Takayoshi, another member of the same mission, was more favourably impressed by the Stockton asylum and recorded in his journal that ‘its administration and cleanliness left nothing to be desired’. He obtained a copy of its rules and regulations in order to pass them on the Nagayo Sensai, the official charged with creating a medical policy for the new government.28 The ‘discovery’ of the asylum was to have a profound impact on the system of care that had taken form at Iwakura. After the political revolution of 1868, the new government rapidly began a process of top-down social and political reform aimed at transforming Japan into a modern nation state, efforts that included medical modernisation. But not all reforms originated with the government in Tokyo. In 1875, the local government of Kyoto ordered the establishment of a public asylum. This institution, the short-lived Kyoto Prefectural Asylum, has long been celebrated as the ‘first’ modern public facility for the mentally ill to be established in Japan, although it predates its rival, the Tokyo Prefectural Asylum, by only four years. The later institution had its origins in the ‘madman’s ward’ (kyōshitsu) of the Tokyo Poorhouse, which was created in 1875 to house the poor, the sick and the disabled who wandered the streets of Japan’s new capital, an unintended result of the destruction of the early modern status system within which their care had been embedded. The real significance of the Kyoto Asylum lies not in its chronological advantage, but rather in the circumstances of its establishment. Unlike the Poorhouse and the Tokyo Asylum, the Kyoto institution was not created by directive from the central government in Tokyo but rather through the efforts of local civic activists responding to a perceived local crisis. And unlike the Poorhouse and the Tokyo Asylum, which were devices for social control rather than treatment or care, the Kyoto Asylum was envisioned as a facility that would provide treatment.29 It thus represented the intersection between a new medical paradigm of mental illness and a new conception of social welfare. The initiative for the establishment of the Kyoto Asylum came from two Kyoto commoners, Kan Masasuke and Akashi Hiroakira (1838–1910), both of whom submitted petitions to Nagatani Nobutane, the governor of Kyoto prefecture, in April 1875. Little is known about Kan other than that he was a commoner and resident of the city, but his compatriot Akashi was a prominent physician of Western medicine and a successful entrepreneur. In 1871, he joined the local government as a ‘medical official’ (ikan) and was instrumental in the founding of a public hospital and medical school.30 The petitions submitted by Kan and Akashi to the governor laid out similar arguments. In Kan’s words, Since the common people are ignorant in the extreme, they think that this illness is because of a divine curse or spell, or that it results because of the actions of foxes and badgers, and because they believe these ridiculous theories that rest upon baseless speculation, there is the bad custom of not seeking medical treatment. And so in your jurisdiction, in places like Daiunji in Iwakura … rough huts are constructed and the sick are housed in them and they are just entrusted to Buddha. [Those who house them] profit by charging for room and board, but although much money is paid, not only is their illness not cured, in fact it becomes more severe.31 Here and in Akashi’s petition as well, Iwakura is described in explicitly critical terms: its popularity reflected ignorance and superstition, it allowed for the abuse and neglect of the afflicted, and it encouraged desperate families to squander their limited resources. According to Akashi’s petition, these concerns prompted him to confer with Ferdinand Edelbert Junker, an Austrian physician who had been hired in 1872 to work in the new hospital and medical school. Junker recommended the establishment of a public asylum, and Akashi described the institution he envisioned in terms strikingly similar to those used by Fukuzawa Yukichi: it should have a garden where the patients could walk and rest, make available musical instruments they could play to ‘calm their senses’, and aid the patients in developing skills through handicrafts and other work. It was not to be operated for profit but rather would provide free medical care to those in need.32 Kyoto authorities took the charge that the mad were being mistreated at Daiunji seriously. A week after the submission of the petitions, the governor ordered an investigation into the conditions at Iwakura and another religious site where the mentally ill of Kyoto congregated. The report submitted by the investigator revealed that around 20 people were housed in four inns near the temple and that treatment consisted of standing under the waterfall.33 In the aftermath of this report, the prefectural government announced the establishment of the new public asylum. The resolution it promulgated in July 1875 explained the need for such an institution by attacking the mistaken beliefs that led families to entrust their kin to places such as Daiunji where they were subjected to ‘cruel’ treatment. It explicitly valorised a new medical explanation of mental disorders, stating, ‘as for the cause of insanity, at first something causes sadness, despair, fear, or anger, and this upsets the spirit (seishin), and for some this leads eventually to brain disease (nōbyō). … This is a disease, and for diseases, there is medicine, that is, drugs and other treatments.’34 Embracing this new understanding of madness as ‘disease’, the prefectural government also sought to disestablish what were now viewed as ‘backward’ practices. In 1878 it issued a new law that made it illegal for temples, shrines and inns to engage in the business of housing the mentally ill. Ironically given the critique of temple-based care, the new asylum was established on the grounds of the Nanzenji temple in central Kyoto, utilising a building belonging to a subtemple called Eikandō. The seemingly odd choice came in the midst of a wave of anti-Buddhist sentiment. In the late 1860s, the new government had called for the separation of Buddhist institutions and those devoted to indigenous deities, an order designed to shore up the new imperial ideology but one that was interpreted by some as authorising the disestablishment of Buddhism itself. In Kyoto, where the priesthood had long been under attack for its love of luxury and loose adherence to the vow of celibacy, the priests of the city’s temples came under considerable pressure. Whether willingly or under duress, they made hefty donations to support the establishment of the new public hospital in 1872, and when the city needed a site to house its planned asylum, Higashiyama Tenka, the head priest of Eikandō, offered up one of its structures.35 Thus, while the idea of the ‘asylum’ was new, the actual facilities neatly meshed with longstanding practice. There is no evidence that anyone involved in the founding of the asylum was concerned about the possible mixed message that resulted from housing the asylum in a temple, but this choice may have unintentionally contributed to the remarkable popularity of the new institution. During its first year of operation, 82 patients were admitted, including those who had been removed from Iwakura. That number grew with each passing year until in 1882 the asylum housed 332 people. The setting aside, the new asylum had little in common with either Daiunji or the inns at Iwakura. The care of its patients was entrusted to the staff of the prefectural hospital and medical school, who kept careful records on their patients. ‘Psychiatry’, if it can be termed that, was still in its infancy, but the staff created a new diagnostic lexicon that seems loosely based on that of pioneering British psychiatrist Henry Maudsley. In 1876, Kanbe Bunsai, a doctor on the staff of the public hospital and the asylum, had translated one of Maudsley’s works under the title An Outline of Mental Illness (Seishinbyō yakusetsu).36 According to the Journal of the Prefectural Hospital (Ryōbyōin zasshi), one of the earliest medical serials to be published in Japan, between 1880 and 1882 the asylum admitted a total of 571 patients, with the most common diagnoses listed as ‘acute insanity with seizures’ (105 patients), ‘chronic insanity with seizures’ (177) and ‘melancholia with night wandering’ (56).37 Case records published in the Journal suggest that the treatment offered at the asylum reflected an effort to put into practice the principles of Maudsley’s so-called ‘moral treatment’. A case in point was that of a 27-year-old man who was admitted in 1874 after multiple suicide attempts. He was diagnosed with melancholia, a condition asylum staff attributed to worry over family finances. His treatment consisted first of massages, hot baths, nourishing drinks of milk, eggs and brandy as well as doses of what were described as ‘Japanese medicines’ (wasai), herbal compounds based on Sino-Japanese pharmaceutical principles. As his condition improved, he was encouraged to take walks in the asylum grounds. Sometime later, he was prompted to speak about his ‘feelings and ideas’ (jōi). In response the patient voiced his concerns about various family matters, including his fear that his wife and older brother might be having some kind of illicit relationship and his sense that this brother thought he was malingering. The staff tried to aid him in ‘correcting his mistaken thoughts and distinguishing between the true and the false’ and believed he was making progress. After a year and half of treatment, he was judged to be much improved and released to his family. The patient committed suicide weeks later.38 This tragic case, recorded in considerable detail, sheds critical light on the large numbers of ‘complete cures’ recorded by the asylum. In 1879, for example, the asylum reported that 210 patients were released as ‘cured’, another 186 required further treatment, and that 27 (7 per cent of the total) had died while in care.39 The release of patients who showed some improvement may have been prompted by the increasingly strained finances of the institution. Although patients of means paid some fees, this revenue—even when supplemented by contributions from the city’s elite and local Buddhist temples—was simply not enough to support an institution of such a scale. In October 1882 the prefectural government announced the closure of the asylum, a decision that prompted an inquiry to the Home Ministry in Tokyo about what should happen to its patients. The Ministry responded: ‘those who are violent and therefore difficult to abandon should be placed in a separate room within the jail, those who are not [in such a condition] should be returned to their household heads who should provide appropriate care.’40 This advice reflected the policy deployed in the capital. In 1872, the government of the city of Tokyo, in a declaration addressed to ‘family heads’ charged that ‘wandering madmen’ were committing random acts of arson and violence. It instructed the populace to confine their mad (kyōbyō) family members or risk being held responsible for their acts. In 1878, the Tokyo government moved to regularise this policy when it issued Police ordinance no. 38, which required families that wanted to confine their members, whether unruly children or mad adults, to register with their local police station—a procedure that gave police, not doctors, authority over the mentally ill.41 The demise of the asylum created an opportunity for the proprietors of Iwakura’s inns to revive their former businesses and they acted almost immediately. By this time, Daiunji had been closed for several years, one of thousands of temples around Japan that had fallen victim to the anti-Buddhist campaigns of the 1870s. As villagers worked to revive their inns, the idea of the ‘asylum’ newly informed their efforts. According to Tsuchiya Eikichi, who authored a history of the psychiatric hospital he headed, in 1884 a group of powerful figures in the village joined forces to establish the Private Iwakura Asylum, hiring a physician named Ōshima Kōshirō to serve as its titular head.42 At the time Ōshima, an obstetrician by training, was also involved in teaching at a new midwifery school in central Kyoto, so it seems unlikely that he participated in the day-to-day operation of the new ‘asylum’.43 Fujikawa Tatsuaki and Higashimura Teruhiko, who carried out research on Iwakura in the 1970s, discovered a sign stating ‘Agents for Iwakura Asylum’ in the home of the family of a villager who had operated an inn for the mentally ill.44 It seems that the ‘asylum’ at Iwakura had a peculiar form from the outset. While unruly patients were confined within the dedicated structure, more docile ones were housed in the inns. At some point, these began to be termed ‘rest homes’ (hoyōshitsu), a term that would be widely employed until the post-war period. The fact that the Kyoto authorities approved this arrangement seems inexplicable given the criticism of the care provided at Iwakura voiced only a decade before. Perhaps the claim to be establishing an ‘asylum’, even with only minimal medical oversight, was enough to assuage concern. However, it seems likely that the pressing need for a place to house the mentally ill after the collapse of the prefectural asylum was also involved. Certainly, the ‘Iwakura Psychiatric Hospital’, as it was renamed in 1892, was successful. According to Tsuchiya, by that year, the hospital itself had two wards for psychiatric patients and a third for general medicine, with a total capacity of 78 patients.45 The establishment of the Iwakura Psychiatric Hospital marked an important development in the history of psychiatric care in Japan. The idea of the ‘asylum’ inspired the local reformers, Akashi and Kan, who proposed a new and innovative solution to a perceived local problem. By the mid-1880s the concept of medicalised treatment of the mentally ill in institutions had taken hold even among the villagers of Iwakura who embraced it to transform the old economy of care that had been organised around Daiunji. The result of the intersection of new political, social and economic interests was the creation of a hybrid solution that served local interests, reduced the need for public expenditure and provided for the care and control of the mentally ill. Kure Shūzō, Iwakura and Family Care The hybrid arrangement of inns with some medical oversight that took shape at Iwakura would likely have remained an interesting but purely local project but for the intervention of Kure Shūzō, considered by many to be the ‘father’ of psychiatry in Japan. The centre of modern medical education at the time was the Tokyo University Faculty of Medicine. In 1882, Erwin Bälz, a German physician employed as an instructor at the school, gave the first lectures on psychiatry. Bälz had no particular training in psychiatry, but he apparently based his lectures on Wilhelm Griesinger’s textbook The Pathology and Therapy of Mental Illness (1861).46 He also attempted to give his students clinical experience by having them work with those confined in the Tokyo Prefectural Asylum, bringing the patients under medical scrutiny for the first time. Among Bälz’s students was Sakaki Hajime, who was dispatched at government expense to study psychiatry at the University of Berlin, a well-established centre of psychiatric research, for four years. Sakaki returned to Japan in 1886 and soon after was appointed the first Professor of Psychiatry of Tokyo University’s medical school and Director of the Sugamo Hospital, as the Tokyo Asylum had been renamed.47 Although Sakaki died prematurely in 1897 at the age of 39, he was responsible for training the first generation of Japanese psychiatrists. Among his students, no one would be more influential than Kure Shūzō, who graduated from the new Department of Psychiatry in 1890. In the decade that followed his graduation Kure quickly became a leading figure in the new field of psychiatry in Japan. He embraced the notion that mental illness was often hereditary in nature, an idea that was one of the defining constructs of biological psychiatry, and this made him an early and passionate advocate of the national need for psychiatric institutions. In an 1893 article entitled ‘On Asylums’ (Tenkyōin ni tsuite), for example, he argued that while madness was just as common in Japan as in Europe, Japan lacked asylums where patients could be confined and treated. As a result, while almost all of the madmen in Britain were safely confined within an asylum, only a tiny fraction of what Kure estimated to be Japan’s 70,000 madmen were, with the result that they were free to wander the streets and commit crimes and—even worse—to procreate and create another generation of madmen.48 It is unclear when Kure himself visited Iwakura, a curious fact, given both his initial enthusiasm for this site and the fame it was soon to acquire, but between 1895 and 1914, in a series of articles addressed to both popular and professional audiences, he repeatedly discussed what he described as the ‘Iwakura colony’, a phrase that he seems to have coined. Kure’s first mention of Iwakura came in his Outlines of Psychiatry (Seishinbyōgaku shūyō). Published in 1895, it provided a systematic and lucid summary of contemporary European psychiatric theory, and its publication solidified Kure’s growing reputation. He was selected for further study in Europe and in 1897, he began a four-year period of study in Vienna, Paris and Heidelberg. In 1901 after his return, Kure was appointed Professor of Psychiatry at Tokyo University medical school and head physician of Sugamo Hospital. In Outlines of Psychiatry, Kure took up Iwakura in the midst of a discussion of contemporary European psychiatric care in relation to what he termed ‘private home care’ (shitaku kango): ‘Private home care’ refers to [the practice] of having those who are mentally ill live for a long time with an appropriate family other than their own. This is one method of treatment. This method began in the village of Geel in Belgium long ago for religious reasons. Recently, in Germany, in Ilten in Hanover, it has been emulated and it is said that it has had very good results. A necessary requirement for this method is the existence of an asylum nearby. In this system, there is a close relationship with the doctors of the asylum and experienced doctors oversee it. … When the number of patients is appropriate, the care is attentive and compassionate. … In the northern part of Kyoto in the village of Iwakura, there is a temple called Daiunji. There is a Kannon there and it was said that it has efficacy [for madness]. … Patients came from every direction to seek healing there, and many village families took them in and lodged them. And it is said that they gathered firewood and helped with the farming. Now because the prefectural government has forbade it, this [practice] has been abandoned, although there are still a few families who lodge the sick, care for them, and live with them intimately. If we extend medical care, provide treatment, and offered guidance, this would become private home care. That is, if we use this custom from long ago, we can approximate the colony method that is so praised in the West these days.49 These remarks suggest that Kure was not particularly well informed about the situation at Iwakura: he makes no mention of the Iwakura Psychiatric Hospital nor of the practice of housing the mentally ill, not in family homes, but in family-run inns. Nonetheless, this passage marks the beginning of the deployment of Iwakura within an intense and evolving international debate over the best system of care for the mentally ill, asylums versus arrangements identified by terms such as ‘family care’, ‘free air treatment’, ‘boarding-out’, ‘the colony or cottage system’ and later as ‘open care’, ‘extra-mural care’ and ‘therapeutic communities’.50 Discussions of non-asylum-based care proliferated in Europe and North America over the second half of nineteenth century. Like Kure, most participants, both critics and advocates alike, referenced the Belgium village Geel (rendered Gheel until the mid-twentieth century). Geel is associated with the sixth-century martyr St Dymphna, an Irish princess said to have been murdered by her father either because of her Christian faith, or because of her rejection of his incestuous advances. From medieval times, her grave was believed to have miraculous healing powers for the insane, with the result that a growing number of patients were brought there in the hope that they might be cured. While pilgrims seemed initially to have been housed in facilities controlled by the Church, at some point they began to lodge in ordinary homes. In the nineteenth century, the state instituted a set of system oversight: physician-officials were made responsible for supervising the households that were allowed to house one or two patients and rules were established to regulate room size, ventilation, quality of meals and other matters of daily life. Beginning in the 1860s, Geel—where approximately 10 per cent of the eleven thousand residents was classified as insane—became a mecca for reform minded doctors, social welfare activists and the merely curious.51 Although interest in ‘family care’ was an international phenomenon, attempts to implement it differed greatly. Thomas Mueller, who has compared the French and German efforts, argues that enthusiasm for family care reflected an ‘anti-psychiatric impulse’ within French civil society but was also a response to a set of immediate issues, including overcrowding in urban hospitals and lack of facilities elsewhere. Beginning in the 1890s, financially stressed villages such as Dun-sur-Auron and Ainay-le-château, where no psychiatric hospitals were in existence, became the sites of new ‘colonies’ in which the mentally ill were placed with families.52 In contrast, in Germany ‘family care’ took shape not against but as an adjunct to established psychiatric hospitals. According to Mueller, ‘family care patients often stayed in nearby huts, sometimes on the grounds of the mental hospital itself where they had access to no other ‘family’ than a nursing couple’. The family care system established in Berlin differed even more from the Geel model: the Dalldorf Hospital placed its chronic cases in group homes that housed as many as 18 people over which psychiatrists exercised tight control.53 In the USA attempts to implement family care varied from state to state. While Massachusetts paid to board patients with families and required only that a doctor check on them every three months, Michigan’s Kalamazoo Psychiatric Hospital founded a ‘colony’ called Brooks Farm in a nearby location. The farm housed psychiatric patients who carried out agricultural labour under the close supervision of attendants.54 Kure himself would visit Geel during his stay in Europe, but as the passage from the Outlines of Psychiatry I quoted above reveals, even before he left Japan, he was already well aware of its place in the contemporary debate over care.55 After his return, he enlarged upon his advocacy of the ‘colony method’, although he revised his translation of the term. He had originally rendered ‘colony method’ as shokuminhō but subsequently began to transcribe ‘colony’ phonetically in the Japanese syllabary as koronī, perhaps because term shokuminchi was now associated with Japan’s new colonies of Taiwan and Korea, and he was uneasy about applying it to communities of Japanese citizens. This change of nomenclature aside, Kure continued to assert the multiple benefits of ‘colonies’ like Iwakura. In therapeutic terms, he argued, the opportunity for social contact, activity and productive labour would have a good effect upon patients in contrast to the isolation and idleness that characterised life within asylum walls. But there were economic advantages as well: the colony could become a self-supporting community where residents farmed, raised livestock and even made their own shoes and clothing. According to Kure, ‘[The colony model] has benefits as therapy, has benefits for the finances of hospital, and has benefits for the patients after they leave the asylum.’56 The terms of Kure’s endorsement of family care were by no means original, but his insistence that something akin to it had once existed in Japan was. The situation at Iwakura, which only two decades before, had been viewed by modernising activists in Kyoto as backward and abusive, was now recast as an indigenous form of family care that, with some tweaking, would mesh with progressive developments in Europe and transform Japan’s mentally ill into productive citizens. In explaining this enthusiasm for Iwakura, Hashimoto Akira has described Kure and his fellow psychiatrists as ‘“Japanese Orientalists”, who felt it was their duty to translate Japanese traditional concepts of madness and remedies into western vocabularies. … The belief that the tradition at Iwakura was comparable to Geel was a typical translation at the time based on “Japanese Orientalists” way of thinking. To put it another way, it was a product to subordinate Japanese practice to western thinking.’57 Hashimoto is certainly correct that Japanese intellectuals were quick to suggest parallels between pre-modern Japanese practices and modern Western ones. In this same period, advocates for the creation of institutions to house sufferers of leprosy were drawing comparisons between longstanding practices of social exclusion in Japan and the modern leprosaria and ‘leper colonies’ established elsewhere in the world.58 Although the identification of analogues with Western practices reflected a nationalist impulse to celebrate Japanese prescience, it was also strategic. Reformers who wanted the government to take greater responsibility for those who were both vulnerable and dangerous advocated for public funding of institutions such as leprosaria and psychiatric hospitals by characterising them as ‘modern’ solutions that also had deep historical roots, a powerful claim in an era when the enthusiasm for ‘Westernisation’ in the 1870s and 1880s was under attack. Kure’s advocacy for the ‘colony method’ reflected his critical posture towards state policy on the mentally ill. In 1900, the Japanese government passed the Law for the Protection of the Mentally Ill (Seishinbyōsha kangohō). This law took the strategy that had been deployed in the city of Tokyo since the 1870s and made it into national policy, authorising what became known as ‘confinement within private residences’ (shitaku kanchi); that is, forcible confinement within the home and by their families of those deemed mentally incompetent. While the 1900 law required physician involvement to confirm that confinement was necessary, it made no provisions for treatment or even periodic re-examination by a doctor.59 Private confinement placed the mentally ill under the authority of their families and the local police, with the result that psychiatry, a crucial part of what Kure liked to call ‘the medicine of the imperial age’ (sedai igaku), was made largely irrelevant for most Japanese.60 Kure’s disdain for ‘confinement within private residences’ and enthusiasm for ‘family care’ was of course fraught with irony. He advocated for the removal of the mentally ill from their own families in order to place them within other families. Like other advocates of family care, Kure argued that it was not just an alternative form of confinement: family care was also a form of ‘treatment’. Separation from a family riddled with pathology and immersion in a healthy household would, it was argued, promote the resocialisation of the patient. But while Kure’s interest in ‘family care’ reflected his professional interest in the extension of psychiatric oversight, it also had an undeniably humanistic dimension. In the aftermath of the passage of the 1900 law, Kure, an ardent nationalist, became an outspoken critic of government policy. In 1918, he wrote, ‘for the tens of thousands of mentally ill of our country, their misfortune is not only to have fallen victim to this disease; they have had the additional misfortune to have been born in this country’.61 Reportage and the Iwakura ‘Colony’ Kure’s characterisation of Iwakura as a ‘colony’ oriented around the ‘family care’ of the mentally ill was but one of many descriptions of the village that made their way into print in the early decades of the twentieth century. Contemporary observers offered very different assessments of the kind of care on offer in the village and its relationship to both ‘traditional’ and psychiatric practices. Local officials writing with a popular readership in mind tended to emphasise continuity with premodern practices. The turn of the century saw the publication of a new genre of modern gazetteers that were compiled at the village and county levels. Their production was prompted initially by a failed governmental project of compiling an ‘imperial geography’ (kōkoku chishi), but the gazetteer as a genre was detached from the national project and became a means both of expressing local pride and of promoting tourism and commerce. Significantly, two such texts produced on Iwakura celebrated its long tradition of caring for the mentally ill. The first, published in 1906, contained a section on ‘the origins of the care of the mentally ill’ that was authored by Iwakura’s mayor Hyōgo Teikichi. Hyōgo referenced the practices associated with Daiunji in the early modern period and asserted that the recent establishment of the psychiatric hospital had ‘added’ medical treatment to such activities as drinking the spring water, praying before Kannon, and wandering among the fields, with the result that Iwakura offered patients ‘the best [care] of all’.62 A second gazetteer on Otagi County, where Iwakura was located, was published six years later. In this iteration, the story of Go-Sanjō’s daughter was incorporated to explain the tradition of care at Iwakura, which was described as suspended ‘for a brief period’ in the 1880s. Like Hyōgo’s work, this one too states that Iwakura Hospital functioned merely to ‘add’ medical care to traditional practices.63 In contrast to the authors of the gazetteers, the psychiatric professionals who wrote on Iwakura emphasised the medicalisation of care and its affinities with European ‘family care’. A decade after its establishment, Iwakura Hospital hired a trained psychiatrist to head its staff. Tsuchiya Eikichi, who became Director of Iwakura Hospital in 1904, was educated at the Kyoto Prefectural Medical School, where he had studied under Shimamura Shun’ichi who, like Kure, was one of the first generation of psychiatrists trained by Sakaki at Tokyo University Faculty of Medicine. No early writings by Tsuchiya, who spent his entire career at Iwakura Hospital, are available, but in his published essays from the 1930s and 1940s, he strongly emphasised the authority of Iwakura Hospital vis-à-vis the rest homes. Writing in a Kyoto journal of public health, Tsuchiya stated that while the rest homes and the hospital were administratively completely distinct entities, in point of fact they ‘maintained an intimate relationship like a main family and a branch family’, a reference to Japan’s patriarchal family structure in which the eldest son had certain rights and privileges in relation to his siblings. According to Tsuchiya, the hospital was the ‘main family’ with the result that those in charge of the rest homes ‘submitted to his control’, allowing Tsuchiya to decide in which rest home a patient should be placed and to oversee the treatment, nursing and hygiene they provided.64 In his unpublished history of Iwakura Hospital, Tsuchiya went even further, describing those who were housed in the rest homes as ‘unconfined’ patients of the hospital. But even as Tsuchiya asserted the authority of the hospital, he also praised the ‘familial’ environment of the rest homes. In his words, ‘the daily life of each patient is in fact as if they were a member of the family’.65 Imamura Shinkichi, another student of Sakaki and a classmate of Kure, offered another perspective on Iwakura. In 1903 Imamura, who had just returned from four years of study in Germany, was appointed the first professor of psychiatry at Kyoto University’s medical school. In 1907 he returned to Europe to attend the First International Congress on Psychiatry, Neurology, Psychology and the Treatment of the Insane in Amsterdam. There he presented a paper entitled ‘Iwakura Village’, which he authored with two collaborators, perhaps his students. This choice of topic itself is an indication of the significance of the village for this first generation of Japanese psychiatrists.66 Although Imamura et al. related in some detail the origin story involving the imperial princess, their main focus was on the early modern and contemporary situation and their discussion called into question easy analogies with Geel. According to the essay, a few patients, those who were ‘half cured’, lived with ordinary families, but most were housed in commercial establishments, the largest of which provided care for between 15 and 45 patients. In these, five or six patients lived in a single room under the supervision of a paid attendant. During his presentation, Imamura apparently displayed photographs of the various kinds of restraints that were used on patients, including not only leg and neck irons, but also what was described as a ‘mouth basket’ to prevent biting. He noted that when these methods did not suffice, patients could be confined to small isolation cells. Imamura made no explicit mention of religious practices, although he offered a description of what he described as the ‘water therapy’ practised at Iwakura: 90 minutes standing in the waterfall was, he suggested, capable of ‘calming’ even violent patients. Notably, the origin of this practice as a purification ritual went unmentioned. This disturbing depiction of early modern care at Iwakura meshes quite well with that offered by early modern sources, evidence that Imamura had done some research. Curiously, however, his tone is distinctly uncritical. Indeed, Imamura chastised Kyoto officials for their intervention and argued that ‘through natural evolution, [Iwakura] has assumed a form that contemporary psychiatrists take as ideal’. That modern ‘form’ included the existence of Iwakura Hospital ‘half of which is in the European style’, as well as the modern commercial establishments that had reorganised ‘about twenty years ago’. Imamura used several different terms to refer to the rest homes, terming them ‘institutions’ (anstalten), ‘guesthouses’ (gasthäuser) and ‘sanitaria’ (Heilenstalten). However, beyond a bucolic description of life in the village, where patients ‘pass the days … comfortably without boredom’, he offered little information about the care of patients within the modern rest homes. It was during the period that Imamura was conducting research on Iwakura that the village received its first international visitor, the German-Latvian psychiatrist Wilhelm Stieda, who toured Japan in 1906. Stieda travelled to Iwakura at the suggestion of Kure and with Imamura as his guide. His account of his tour of Japanese psychiatric facilities, later published in both German and Japanese, offered a mixed review of psychiatric care in Japan.67 Echoing the views of his Japanese hosts, Stieda was critical of the government’s failure to fund psychiatric care, noting that Japan lacked a single national psychiatric hospital and that Tokyo’s Sugamo Hospital (the renamed public asylum) was the only public facility in the country. On the other hand, Stieda praised the three hospitals he visited (Sugamo Hospital, Iwakura Hospital and another private hospital in Kyoto) as clean and serene. He offered particular praise for the fact that the hospitals were built as wooden structures that reflected the norms of domestic architecture, with tatami rooms, verandas (engawa), and gardens. These were architectural features, he argued, that Europe would do well to emulate. Stieda offered a lengthy description of Iwakura, dutifully describing the village as ‘something like a Japanese Geel’. But while he made the obligatory mention of the legend of the princess, he emphasised the break with traditional practices. In his words, ‘the age of appealing to the deities for a cure has ended at Iwakura, although the tradition of family care remains’. Unlike Imamura, who had declared to his audience in Amsterdam that ‘the ideal form’ of family care was already in place, Stieda portrayed a situation in flux: although Japanese psychiatrists were endeavouring to ‘renovate’ (isshin) the system of family care in place by pressuring the state to require medical oversight, more than 100 patients, most of whom appeared to be catatonic, were already residing in family homes. His use of the term ‘family care’, notwithstanding, Stieda was well aware of the scale of care in the commercial rest homes. He mentioned that one ‘family’ was caring for more than 50 patients. If Stieda’s numbers are correct, the largest rest homes were substantially larger than Iwakura Hospital, which he stated housed only about 40 patients. However, Stieda offers no comment on this arrangement. Instead, he praised the hospital at some length, describing it as a ‘grand structure’ that was bright and clean, with wards that were ‘completely Japanese’ and laboratories and treatment rooms that were ‘European-style’. Another international visitor offered a very different description of Iwakura. Frederick Peterson, Professor of Psychiatry at Columbia, former head of the New York Commission on Lunacy, and the co-author of a widely used textbook, arrived in Japan in the summer of 1911.68 Peterson was one of the pioneers of the ‘colony’ model of care in the USA: in the 1880s he was involved in the founding of the Craig Colony in upstate New York, an institution devoted to the care of sufferers of epilepsy and in 1895 he became its first director. Like Stieda, he too visited several psychiatric institutions during his time in Japan. In Tokyo, he toured Sugamo Hospital and was favourably impressed, praising it as ‘airy, neat, and clean’ with a well-equipped laboratory and attentive staff.69 However, Peterson saved his highest praise for Iwakura, where he too travelled at the suggestion of Kure and in the company of Imamura. Peterson later published an enthusiastic account of his visit to the village, complete with photographs, in the journal The Survey, then one of the most important American publications on progressive social policy.70 Peterson’s description of Iwakura shares little with that of Stieda: he made no mention of either Iwakura Hospital or of the large commercial rest homes. Instead, he describes the village as a pastoral paradise where ‘one or two patients were received into each family to share in the occupations of the household which were chiefly out-of-door employments … and some of the arts and crafts of the ordinary Japanese household’. The ‘gentleness, kindness, patience, and assiduousness’ offered by the villagers was contrasted with that provided within ‘the vast, complicated, and unwieldy’ public asylums that had been established in the USA, institutions in which ‘the individual is lost sight of in an immense aggregations of patients’. Reflecting the nostalgic and anti-modernist sentiments that shaped many accounts of Japan at the time, Peterson criticised the Japanese government for being ‘misled by a false impression of the value of our Western methods of caring for the insane’, which had led them to conclude that ‘their colony system which had grown up so naturally was too far removed from American and European standards’. There is no suggestion that the situation at Iwakura required reform to fit the model of ‘family care’. Instead, the village is presented as a model of care that ‘the West’ should emulate: ‘This system, [which] evolved over a period of nearly a thousand years, is the best of all methods for caring of the insane. … No doubt we in the West will one day be glad to copy this Japanese model when we finally awaken to how far we have drifted from an ideal of care and treatment of the insane, with our immense, expensive and complicated machinery of mere support and custody’.71 These conflicting accounts of Iwakura in both domestic and international sources suggest that interest in Iwakura was more complicated than Hashimoto’s conception of ‘translation’ as a reflection of ‘Japanese Orientalism’ suggests. For one, it is clear that varied economic, political and cultural motives were in play. The gazetteers, for example, make no mention of ‘family care’, the term that looms so large in the psychiatric literature. Rather, they suggest that Iwakura is a place where one can access both traditional and medical treatments, an appealing prospect perhaps to patients and their families who may not have understood or embraced psychiatric explanations of mental illness. In contrast, the psychiatrists had their own diverse set of aims. While Kure and his colleagues cast Iwakura as ‘family care’ to argue for the authority of the psychiatric discipline, Peterson—writing for an American audience—made it a potent means to criticise the reliance on large public institutions. Stieda seems to have had an agenda as well—he was interested in the possibility of less-institutional institutions. So while Kure and his Japanese compatriots reconceptualised Iwakura in relation to their understanding of family care in Europe, Peterson and Stieda made it an emblem of a uniquely ‘Japanese’ system of care, one that did not rely upon an institutional structure, one that was more intimate, familial and humane. Also important is the circulation—not the unidirectional translation as Hashimoto implies—of accounts of Iwakura. The reports of Stieda and Peterson were informed by opinions of their Japanese counterparts, but they appeared not only in English or German but also in Japanese. The result was a complicated pattern of references and cross-references that renders the real situation at Iwakura opaque. The Rise of the Rest Homes The professional advocacy of Japanese psychiatrists for ‘family care’ and the local embrace of the business of housing the mentally ill led to a rapid increase in the number of rest homes in Iwakura in the 1920s and 1930s. By 1935 there were fourteen such facilities in Iwakura, nine of which had been founded after 1930. Only two of these facilities were operated by families associated with the ‘tea shops’ of the eighteenth century.72 And rest homes were no longer a solution limited to the Kyoto area. According to a survey of facilities for the mentally ill undertaken by Kan Osamu, a doctor on the staff of Matsuzawa Hospital (the name of the Tokyo prefectural psychiatric hospital after 1919), there were 45 rest homes for the mentally ill in operation in Japan in 1935, 14 in Ishikawa prefecture alone. To be sure, the designation of what was a ‘rest home’ was arbitrary. Although some rest homes housed only a small number of patients suggesting that they may well have offered a family-like atmosphere, others accommodated significant numbers of patients. In the 1930s, the two largest rest homes in Iwakura each housed between 50 to 60 people, while the largest facility in the country, located in Miyagi prefecture in northern Honshu, had a capacity of 100.73 It is noteworthy as well that many of the larger rest homes were established at sites that had associations with the healing of madness in the premodern period, suggesting that, as at Iwakura, their proprietors had grasped the economic potential of traditional sites. Needless to say, institutions that housed 20 or more people in no way reflected the model of family care that had originally oriented the psychiatric profession’s valorisation of Iwakura. These were businesses, the operation of which was enabled by a set of competing but ultimately reconcilable interests, including those of the state, the psychiatric profession, patients and their families, and local entrepreneurs. The rest homes were always of dubious legality. The 1900 Law explicitly forbade the lodging of the mentally ill in inns and boarding houses on a fee for services basis, and they were never recognised as bona fide hospitals. Speaking at a national congress of the directors of psychiatric hospitals in 1932, Tsuchiya Eikichi openly acknowledged the extra-legal status of the rest homes in Iwakura: ‘there isn’t any kind of law [regulating the rest homes]. They do it because they have a long history.’ He also acknowledged that both medical and administrative oversight was limited: ‘they don’t have a direct relationship with the hospital, but I oversee them. They are just allowed to lodge the mentally ill who are not privately confined. The only thing that is reported is some diagnosis, and the police do come around.’74 This situation did not seem to have overly concerned Tsuchiya’s colleagues at the congress, one of whom proclaimed ‘Japan’s Iwakura Hospital is something to be proud of before the whole world.’75 This enthusiasm for the rest home model was, however, not universal. By 1916, Kure Shuzō, who had done so much to popularise the Geel analogy, had lost interest in Iwakura. The revised edition of his Outlines of Psychiatry published in that year discusses family care in Europe at some length but without mentioning Iwakura.76 Kure was not the only one who seems to have reconsidered Iwakura’s value as a model therapeutic community. In 1930, Miyake Kōichi, professor of psychiatry at Tokyo Imperial University, attended the first International Congress of Mental Hygiene held in Washington, DC. He presented a paper on the state of the psychiatric discipline and the mentally ill in Japan that made no mention of Iwakura, ’family care’ or colonies, although he noted that a large number of patients were housed outside public institutions, in ‘private mental hospitals, sanatoriums [i.e. “rest homes”], and other places (temples, mountain resorts, or similar religious institutions).’77 Also in attendance at the Congress was Frederick Sano, then medical director of Geel. In his discussion of the Geel system, Sano took note of the many attempts to emulate it around the world, most of which in his estimation had failed. He attributed Geel’s the success to specific conditions that were lacking elsewhere, including the religious influence of the cult, the familiarity and tolerance of the local people towards the mentally ill, and state support for this system. Neither Miyake nor the other two Japanese delegates participated in the discussion that followed.78 A report issued by the Social Affairs Office of the Kyoto City government provides some insight into why Kure and his colleagues may have rethought their advocacy of Iwakura. It reveals that the rest homes had multiple grades of care, with the cost ranging from 36 to 66 yen per month—this, at a time when the average income of a farmer in Kyoto was about 38 yen a month. And this basic charge covered only room and board: there were also stiff additional fees for nursing and medical care.79 In contrast, a month’s stay in one of Kyoto’s private psychiatric hospitals could cost as little as 30 yen per month.80 Kure had advocated for ‘family care’ as a cost effective means to extend the influence of psychiatry over the mentally ill and resocialise patients, but it had devolved into the housing of the mentally ill in unregulated pseudo-institutions for hefty fees. Conclusion Ultimately, the divergence between the reality of Iwakura and the rhetoric that surrounded it is not surprising, given that all of those involved in producing the latter had a stake in presenting Iwakura as something other than what it was. As a result, in the 1920s and 1930s the commercial rest homes of Iwakura and elsewhere flourished, becoming an important part of the landscape of psychiatric care. Although the Japanese government took some steps to increase the availability of facilities for the mentally ill—by funding the placement of patients in private hospitals at public expense, for example—the 1900 law that authorised private confinement was not repealed until 1950. Two decades after Kure had denounced the failure of the government to act on behalf of its mentally ill citizens, many continued to languish in home confinement, or even worse, in what came to be known as ‘detention centres’ (shūyōjo), gaol-like facilities established by local authorities to house those deemed dangerous. In this context, care in a rest home, at Iwakura or elsewhere, may have seemed preferable, at least for those who could afford it. The fanfare that surrounded the Iwakura rest homes notwithstanding, they quickly disappeared in the immediate post-war era. In 1950, the Japanese government passed a new Mental Health act that made private confinement illegal and provided funds for the construction of public psychiatric hospitals and subsidies for private facilities. In the wake of this law, the rest home concept was quickly abandoned—even by its most fervent supporters. At Iwakura, two of the most successful proprietors of rest homes before 1945 quickly regrouped to create the large private hospitals in operation today. After the establishment of the National Health Insurance system in 1962, the number of those in psychiatric hospitals increased dramatically. Japan’s ‘great confinement’, it can be said, occurred in the post-war era. But the vision of Iwakura as a community in which the mentally ill lived happy and productive lives among sympathetic and caring villagers continues to be both powerful and flexible. In the 1960s and 70s, activist psychiatrists would evoke it to argue for the de-institutionalisation of the mentally ill, ironically echoing Peterson’s use of the village 60 years before.81 The administrators of the post-war hospitals continue to evoke the ‘tradition’ of care at Iwakura to promote their institutions. Today the websites of both Kitayama Hospital and Iwakura Hospital relate the legend of Go-Sanjō’s daughter, with the former declaring that Iwakura is ‘a place blessed with a healing environment’.82 To be sure, this claim is not entirely unjustified. Its incorporation into Kyoto notwithstanding, the neighbourhoods of ‘old’ Iwakura remain pleasantly village-like, and many local residents express pride in their community’s reputation for tolerance towards the mentally ill. Recently, the Daiunji temple has re-emerged and it too has attempted to capitalise on Iwakura’s reputation. In 1985 a temple bearing the name Daiunji was re-established in Iwakura, albeit with none of the grandeur of its predecessor. Now detached from Jissōin, it has operated in a ramshackle building for three decades. In the late 2000s, someone associated with Daiunji created a website to advertise its effectiveness in curing all ‘brain disease’, including stress, neuroses, alcoholism and depression, as well as disorders of the eyes, ears, nose and throat. It noted as well that ‘the temple is always mentioned in the books and articles produced by psychiatric associations’.83 And so the complex set of relationships this paper has explored—involving the medical profession, commerce, social policy, and that thing we like to call ‘tradition’—continues to unfold. Footnotes 1 On the history of Iwakura, see Nakamura Osamu, ed., Rakuhoku Iwakura (Kyoto: Iwakura Kita Shogakkō Sōritsu Nijūshūnen Iinkai, 1995). Transportation developments are discussed at 153–60, housing construction at 149–50, population growth at 152. 2 As a point of reference, Tokyo Metropolitan Matsuzawa Hospital, Japan’s largest public mental health facility, has 1,005 beds. 3 Tsuchiya Eikichi, ‘Kyōtofu-ka Iwakuramura ni okeru seishinbyōsha ryōyō no gaikyō’, Kyōto iji eisei shi, 1930, 6. 4 On the relationship between pre-modern religious sites and modern psychiatric hospitals, see Omata Waichirō, Seishinbyōin no kigen (Tokyo: Ōta Shuppan, 1998), Hyōdō Akiko, ‘Futatsu no Awai Jinja no rekishi kara: Minkan ryōhō shisetsu to seishin byōin no kindai’, Chiryō no koe, 2006, 7, 41–4. 5 Important interventions in the celebration of Iwakura, include Kobayashi Takehiro, ‘Kindaiteki seishin iryō no keisei to tenkai: Iwakura no chiiki iryō wo megutte’, in Sekai jinken mondai kenkyū sentā kiyō,1998, 195–216 and Hashimoto Akira’s perceptive analysis of the repeated claim that Iwakura was ‘Japan’s Geel’ in Hashimoto Akira, ‘Kyokō toshite no Iwakura mura’, Aichi Kenritsu Daigaku bungakubu ronshū (Shakai fukushi gakka hen), 2002, 51, 29–44. A revised version of the latter essay is Akira Hashimoto, ‘Invention of a “Japanese Geel”: Psychiatric Family Care from a Historical and Transnational Perspective’, in Waltraud Ernst and Thomas Mueller, eds, Transnational Psychiatries: Social and Cultural Histories of Psychiatry in Comparative Perspective, 1900–2000 (Newcastle upon Tyne: Cambridge Scholars, 2010), 142–71. For a critical treatment of the care provided by Daiunji in the early modern period, see Atobe Makoto, Iwasaki Naoko, and Yoshioka Shinji, ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, Seishin igaku, 1995, 37, 1221–8 and ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 2, Seishin igaku, 1995, 37, 1335–9. 6 Hashimoto, ‘Invention of a “Japanese Geel”, 164–5. 7 For the history of Daiunji and Jissōin, see Fujikawa Tatsuhiko and Higashimura Teruhiko, ‘Rakuhoku no chi “Iwakura” ni okeru seishin shōgaisha ni taisuru shogū no rekishi ni tsuite’, part 1, Aino Byōin igaku zasshi, 1982, 4, 49–60 and Sugitatsu Yoshikazu, Kyō no ishiseki tanbō (Kyoto: Shibunkaku, 1984), 96–7. 8 Fujimoto Bunrō, ‘Iwakura mura to shōgaisha’, Shōgaisha mondai kenkyū, 1986, 44, 51. 9 The story of Go-Sanjo’s daughter is widely cited in the scholarship on Iwakura. See, for example, Tatsukawa Shōji, Edo yamai no sōshi (Tokyo: Chikuma Shobō, 1998), 343–4 and Sugitatsu, Kyō no ishiseki tanbō, 96–7. 10 Sugitatsu, Kyō no ishiseki tanbō, 97. 11 On the medical ‘marketplace’ in early modern Japan, see Susan L. Burns, ‘Nanayama Jundō at Work: A Village Doctor and Medical Knowledge in Early Modern Japan’, East Asian Science, Technology, and Medicine, 2008, 29, 61–82. For a careful look at an early modern temple’s involvement in healing, see Duncan Ryūken Williams, Another Side of Zen: A Social History of Sōtō Zen Buddhism in Tokugawa Japan (Princeton: Princeton University Press, 2009). 12 Tatsukawa Shōji, Byōki wo iyasu chiisana kamigami (Tokyo: Heibonsha, 1993), 14–15. Tatsukawa identifies more than 500 religious sites associated with healing in this work. 13 Gutei, Miyako meisho tebiki annai (Kyoto: Shirokiya Hanemon et al., 1763). 14 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1123. 15 Nakagami Ryōta, Seiseidō idan: Ijin Nakagami Kinkei no shisō to chiken (n.p.: Kinkei Ōkina Hyakusanjūkaiki Kinen Shuppan, 1963), 16. 16 Tatsukawa, Byōki wo iyasu chiisana kamigami, 330–1. 17 This illustration is reproduced in Fujikawa and Higashiyama, ‘Rakuhoku no chi “Iwakura”’, 56–7. 18 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1224. 19 Nakagami, Seiseidō idan, 17. 20 Quoted in Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 2, 1337. 21 Ibid. 22 Ibid., 1337–8. 23 Atobe et al., ‘Kinsei Kyōto Iwakura-mura ni okeru “katei kango”’, part 1, 1227. 24 Tomita Mikio, Seishinbyōin no teiryū (Tokyo: Seikyūsha, 1992), 162. 25 On the care of the mentally ill in Edo, see Omata, Seishinbyōin no kigen, 174–92. 26 Fukuzawa Yukichi, ‘Seiyō jijō’, in Fukuzawa Yukichi zenshū, vol. 1 (Tokyo: Iwanami Shoten, 1958), 309. 27 Kume Kunitake, Beiei kairan jikki, vol. 1 (Tokyo: Iwanami Shoten, 1977), 115. 28 Sydney DeVere Brown and Akiko Hirota, trans., The Diary of Kido Takayoshi, volume 2: 1871–1873 (Tokyo: University of Tokyo Press, 1985), 121. 29 In characterising the Yōikuin in these terms, I am following Kitahara Itoko, ‘Toshi ni okeru hinkon to kyōki’, in Tsuda Hideo, ed., Kinsei kokka no kaitai to kindai (Tokyo: Hanawa Shobō, 1979), 422–43. 30 On Akashi, see Sugita Hiroshi, Kindai Kyōto in ikita hitobito: Meiji Jinbunshi (Kyoto: Kyoto Shoin, 1987), 195–211. 31 Kyōto furitsu shiryōkan, ed., Kyōto-fu hyakunen no shiryō, vol. 4: Shakai (Kyōto Furitsu Sōgō Shiryōkan, 1982), 490–1. 32 Ibid. 33 Ono Naoka, ‘Kyōto Furitsu Tenkyōin no setsuritsu to sono keii’, Nihon ishigaku zasshi, 1994, 39, 479. 34 Kyōto Furitsu Sōgō Shiryōkan, ed., Kyōto-fu hyakunen no shiryō, 494. 35 On the involvement of Buddhist priests in the establishment of the hospital, see Kawabata Shin’ichi, Kyō no igaku: Jijin no keifu to Furitsu Idai no sōsō (Kyōto: Jinbun Shoin, 2003); on the role of Higashiyama Tenka, see Kyōto-fu Ishikai, eds, Kyōto no igakushi (Kyōto: Shinbunkaku, 1980), 825–6. 36 Kanbe Bunsai and Henry Maudsley, Seishinbyō yakusetsu (1876; repr., Chōfu: Seishin Igaku Shinkeigaku Koten Kankōkai, 1973.) 37 ‘Meiji 10-nen yori Meiji 12-nen ni itarau nyūin kanja nenpyō’, Ryōbyōin zasshi, 1880, 14,9–11. 38 ‘Kyōjō chiken’, Ryōbyōin zasshi, 1880, 14, 15–22. 39 ‘Tenkyō Byōin nyūinsha nenpyō’, Ryōbyōin zasshi, 1880, 14, 103. 40 Kyōto Furitsu Sōgō Shiryōkan, ed., Kyōto-fu hyakunen no shiryō, 499. 41 Nishikawa Kaoru, Nihon seishin shōgaisha no seisakushi (Niigata: Kōkodō, 2010), 26. 42 The discussion that follows is based on Tsuchiya Eikichi’s unpublished work, Iwakura Byōinshi sōan. Tsuchiya was Director of the Iwakura Hospital from 1904 until 1945 when the hospital was closed. Uotani Takashi, then director of Kitayama Byōin, kindly allowed me to copy the manuscript when I initially carried out fieldwork in Iwakura in the mid-1990s. 43 Matsuoka Tomoko and Iwawaki Yoko, ‘Kyōto Furitsu Ika Daigaku ni okeru sanba kyōiku no reimeiki: Meiji jidai no Kyōto ni okeru sanba kyōiku no hensen wo fumaete’, Kyōto Furitsu Ika Daigaku zasshi, 2010, 119, 78. 44 Fujikawa and Higashiyama, ‘Rakuhoku no chi “Iwakura” ni okeru seishin shōgaisha ni taisuru shogū no rekishi ni tsuite’, part 1, 5, 44. 45 Tsuchiya, Iwakura Byōinshi sōn, unpaginated. 46 Kure Shūzō, Wagakuni ni okeru seishinbyō ni kansuru saikin no shisetsu (Tokyo: Igakkai Jimusho, 1912), 28. 47 ‘Ko Ika Daigkau kyōju igaku hakusei Sakai Hajime no den’, Tōkyō igakkai zasshi, 1897, 11, 34–41. 48 Kure Shūzō, ‘Tenkyōin ni tsuite’, Chūgai Iji Shinpō, 1893, 324, 1063–6; 1893, 325, 1134–7; 1893, 326, 1212–15. 49 Kure Shūzō, Seishinbyōgaku shūyō, vol. 2 (Tokyo: Kure Shūzō, 1895 ), 549–51. 50 On the debates on Geel among British doctors, see William L. Parry-Jones, ‘The Model of the Geel Lunatic Colony and Its Influence on the Nineteenth-Century Asylum System in Britain’, in Andrew Scull, ed., Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian Era (Philadelphia: University of Pennsylvania Press, 1981), 201–17. On the debates in the USA, see Nana Tuntiya, ‘Free-Air Treatment for Mental Patients: The Deinstitutionalization Debate of the Nineteenth Century’, Sociological Perspectives, 2007, 50, 469–88. On Europe, see Andreas Pernice, ‘Family Care and Asylum Psychiatry in the Nineteenth Century: The Controversy in the Allgemeine Zeitschrift für Psychiatrie between 1844 and 1902’, History of Psychiatry, 1995, 6, 55–68 and Thomas Mueller, ‘Reopening the Closed File of the History of Psychiatry: Open Care and its Historiography in Belgium, France, and Germany, c. 1880–1980’, in Ernst and Mueller, Transnational Psychiatries, 1900–2000 (Newcastle upon Tyne: Cambridge Scholars, 2010), 172–199. 51 On Geel, see Parry-Jones, ‘The Model of the Geel Lunatic Colony’, 204–5 and Matthew P. Dumon and C. Knight Aldrich, ‘Family Care after a Thousand Years—A Crisis in the Tradition of St. Dymphna’, American Journal of Psychiatry, 1962, 119, 116–21. 52 Mueller, ‘Reopening the Closed File’, 187–8. 53 Ibid., 193. 54 On Massachusetts, see Owen Copp, ‘Some Results and Possibilities in Family Care of the Insane in Massachusetts’, The American Journal of Insanity, 1902, 59, 299–313; on Michigan’s approach, see Report of the Board of Trustees of the Michigan Asylum of the Insane (Lansing: State Printers, 1887–1896). 55 Hashimoto, ‘Invention of a Japanese Geel’, 161. 56 Kure Shūzō, ‘Tenkyōmura (Seishinbyōsha no sagyōhō) ni tsuite’, in Kure Shūzō chosakushū, vol. 2, (Kyoto: Shibunkaku Shuppan, 1982), 43. 57 Hashimoto, ‘The Invention of a “Japanese Gheel”’, 150. 58 Susan L. Burns, ‘From “Leper Villages” to Leprosaria: Public Health, Medicine, and the Culture of Exclusions in Modern Japan’, in Alison Bashford and Carolyn Strange, eds, Isolation: Policies and Practices of Exclusion (London: Routledge, 2003), 104–18. 59 On the formulation of the law, see Nishikawa, Nihon seishin shōgaisha no seisakushi, 50–64. 60 Kure, Seishinbyōsha shitaku kanchi no jikkyō (1918; repr. Chōfu: Seishin Igaku Shinkeigaku Koten Kankōkai, 1973), 138. 61 Ibid. 62 Quoted in Nakamura Osamu, ‘Seishin iryō no nagare to Rakuhoku Iwakura: Dainiji sekai sensō made’, Osaka Furitsu Daigaku kiyō, 2005, 53, 28. 63 Kyoto-fu Otagi-gun shi (Otagi, Kyoto: Kyoto Otagi-gun, 1906). 64 Tsuchiya, ‘Kyōtofu-ka Iwakuramura ni okeru seishinbyōsha ryōyō no gaikyō’, 7. 65 Tsuchiya, Iwakura Byōinshi sōan, 36. 66 Imamura Shinkichi, Osawa Hiroshi and Higuchi Tatsusuke, ‘Dorf Iwakura’, in G. A. M. Wayenberg, ed., Compte rendu des travaux (Amsterdam: J. H. de Bussy, 1908), 881–5. 67 Wilhelm Stieda, ‘Ueber die Psychiatrie in Japan’, Nervenheilkunde und Psychiatrie, 1906, 216; ‘Nihon no seishinbyōgaku’, Shinkeigaku zasshi, 1906, 5, 337–50. 68 The textbook was Nervous and Mental Disorders (Philadelphia: W. B. Saunders), co-authored with Archibald Church. Nine editions were published between 1899–1915. 69 Frederick Peterson, ‘The Insane in Japan’, in Psychiatric Society of New York, (ed.), Studies in Psychiatry (New York: The Journal of Nervous and Mental Disease Publishing Company, 1912), 3. 70 Frederick Peterson, ‘From Vanves to Iwakura’, The Survey, 5 October 1912, 29–1, 25–33; Iwakura figures as well in Peterson’s ‘The Insane in Japan’. The latter was excerpted and reprinted elsewhere in the medical press. 71 Peterson, ‘From Vanves to Iwakura’, 32–3. 72 ‘Kyoto-shi ni okeru seishinbyōsha oyobi sono shūyō shisetsu ni kansuru chōsa’, Kyōto-shi shakaika chōsa hōkoku, 1935 ,34, 51–4. 73 Kan Osamu, ‘Honpō ni okeru seishinbyōsha narabini kore ni kinsetsuseru seishin ijōsha ni kansuru chōsa’, Seishin shinkeigaku zasshi, 1937, 41, 875–6. 74 ‘Dai-ikkai zenkoku kōritsu oyobi daiyō seishinbyōin shūinchō kaigi’, Seishin eisei, 1933, 5, 10–11. 75 Ibid. 76 Kure Shūzō, Seishinbyōgaku shūyō, vol. 2 (2nd edition; Tokyo: Tohōdo, 1916–1918), 974–8. 77 Miyake Kōichi, ‘The Mental-Hygiene Movement in Japan’, in Frankwood Earl Williams, (ed.), Proceedings of the First International Congress of Mental Hygiene Held at Washington D.C., USA, May 5th–10th 1930 (New York: International Congress of Mental Hygiene, 1932), 109. 78 Frederick Sano, ‘The Care of the Insane Outside of Institutions’, in Williams, (ed.), Proceedings of the First International Congress of Mental Hygiene, 391–402. 79 ‘Kyoto-shi ni okeru seishinbyōsha oyobi sono shūyō shisetsu ni kansuru chōsa’, 52–3. 80 Ibid., 41–51. 81 The appeal to an international readership continued as well. See, for example, Y. Kumasaka, ‘Iwakura: Community Care of the Mentally Ill in Japan’, American Journal of Psychotherapy, 1967, 21, 673–5. 82 See http://www.sankokai.jp/history.html and http://www.toumonkai.net/co_navi/article/khI20150521110701–12.html. Both accessed 5 June 2016. 83 Accessed (and screen-shot) on 21 September 2009. The current webpage (http://daiunji.net/) is far more elaborate and includes considerable information about the temple’s history in relation to mental illness. It also declares that the temple is ‘world famous for healing brain disease and other difficult illnesses’. Accessed 4 June 2016. © The Author 2017. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.

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Social History of MedicineOxford University Press

Published: Sep 25, 2017

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