World Journal of Surgery

, Volume 29, Issue 1, pp 10–17

Dutch Surgery in Japan

Authors

    • Department of SurgeryAcademic Medical Center, University of Amsterdam
    • Division of Surgical Oncology Nagoya University Graduate School of Medicine
  • Yuji Nimura
    • Division of Surgical Oncology Nagoya University Graduate School of Medicine
Surgical History: The Global View

DOI: 10.1007/s00268-004-7549-3

Cite this article as:
van Gulik, T.M. & Nimura, Y. World J. Surg. (2005) 29: 10. doi:10.1007/s00268-004-7549-3

Abstract

An isolation policy was adopted in feudal Japan from 1639 to 1853 owing to the fear of foreign influence. During those 200 years of isolation, all foreigners were withheld from the country with the exception of the Dutch, who were permitted to establish a trading post on a small island in the Bay of Nagasaki, called Decima. Western culture and science reached the Japanese exclusively through the Dutch on Decima. Health care on Decima was provided by Dutch barber-surgeons, who introduced Western surgical practice in Japan. Official interpreters were the only Japanese allowed on Decima. It was from among these interpreters that the first Japanese surgeons arose who, having mastered the Dutch language, translated several Dutch anatomic and surgical texts. Genpaku Sugita translated a Dutch anatomy textbook into Japanese, which was completed in 1774. This book, entitled Kaitai Shinsho [New Book on Anatomy], was the first Western scientific monograph to be translated entirely into Japanese. Several Dutch surgical schools were founded through which Dutch surgery, known in Japan as “surgery of the red-haired” was propagated. According to the custom of the surgical guilds in Holland, certificates were granted to Japanese apprentices who had completed their training in Dutch surgery. About 60 Dutch surgeons had served on Decima up to 1850, providing the basis for surgery to develop in Japan. Among them, Philipp Franz von Siebold was an exceptional scholar who also had a great impact in making Japanese culture known to the Western world.

Surgeons from Europe who are visiting a surgical department in Japan might be surprised by their Japanese colleagues asking for a “mes” when starting with an operation. The Japanese word for the surgeon’s scalpel is mesu, which is similar to the Dutch word mes, meaning knife. Other Japanese medical terms that find their origin in the Dutch language are kateteru, which is derived from the Dutch word catheter, and supoito, a syringe, which comes from the Dutch word spuit.

These Dutch words in “kimono” have their roots in the early seventeeth century, when, along with the ships of the Dutch East India Company sailing on the Japanese-coasts, “Dutch surgery” was introduced in Japan[1] (Fig. 1). Dutch surgery, known in Japan as komo-ryu geka, or “surgery of the red-haired,” was instrumental in introducing Western surgery in Japan and heralded a close collaboration between Dutch and Japanese surgeons that would continue for more than 400 years (Fig. 2).
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Figure 1

Dutch ship chartered by the Dutch East India Company as depicted by a Japanese artist (seventeeth century). Note that the engram of the Dutch East India Company (i.e., VOC) has been put up-side-down in the flag. (From the Collection of The Netherlands Economic History Archive, Amsterdam, The Netherlands.)

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Figure 2

Japanese print entitled “Dutch surgery” showing the surgeon Jan Feilke amputating a forearm (end of the eighteenth century). (From the Collection of Kobe City Museum, Kobe, Japan.)

The year 2002 was the memorial year of the foundation of the V.O.C., the Dutch East India Trading Company, which left an important legacy all over the world. During the following year, many exhibitions and festivities were organized to commemorate this event, both in The Netherlands and Japan. This article was written to highlight the impact of the Dutch barber-surgeons on teaching Western surgery in feudal Japan.

Dutch Factory in Nagasaki, the Gate to Dutch Surgery

The Portuguese were the first Europeans to set foot in Japan, around the year 1530. Bungo-Funai, where the Portuguese set up a small hospital, became the center of Portuguese medicine, the Namban Igaku. The Jesuit priest Ferreira, who later changed his name to the Japanese Savano Chuan, wrote a book on Portuguese surgery entitled Namban-Geka-Hidensho [The Secret Tradition of Namban Surgery]. The book basically conveyed the humoral theories of Hippocrates and Galen [2].

The increasing influence of the Christian church as propagated by the Portuguese priests aroused the suspicion of the Japanese authorities and eventually led to all foreigners being expelled from Japan. This event, enacted by Shogun Tokugawa Ieyasu in 1639, marked a period of isolation in which Japan kept its ports closed to all foreign ships. An exception was made for the Dutch because they kept far away from any religious involvement and limited themselves to trading with the Japanese. As a matter of fact, the Dutch in those days were at war with the Spanish, as they opposed compulsory Roman Catholicism, which tempted the Shogun to gather the Dutch on his side.

The Dutch had established a trading post, the Dutch “factory,” in Hirado on the north west coast of Kyushu. After the isolation decree of the Shogun, the Dutch were forced to move the factory to the island of Decima, where the Portuguese formerly resided [3]. Decima was a small artificial island in the Bay of Nagasaki, which was built by the Portuguese in 1635. Walled on all sides and attached to the main land by a narrow bridge, it was more or less a prison. The island was shaped like a fan measuring 300 meters on the south side, 160 meters on the north side, and 70 meters across in the middle (Fig. 3). On the shore side, the connecting bridge was fenced off by Japanese officials, and nobody could leave or enter the island without their permission. In the wall facing the sea, two slips were constructed to harbor the ships, which were allowed to anchor only after the crew was searched for forbidden articles. At first the ship’s rudder, cannons, and gunpowder were taken in consignment by the Japanese officials. Later, only the ammunition and the bibles of the crew were collected.
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Figure 3

Dutch trading post, or “factory,” on Decima, a small artificial island in Nagasaki Bay. During Japan’s isolation, which lasted more than 200 years (1639-1853), Japan’s only contact with the Western world was via the Dutch on this island. (From the Collection of the Maritime Museum “Prins Hendrik,” Rotterdam, The Netherlands.)

Japan’s isolation would last until 1853, comprising two centuries in which the only contact with the Western world consisted of the Dutch factory on Decima. Hence, Western culture and science, including medicine, reached the Japanese exclusively via the Dutch [4]. The usual inhabitants of the Dutch factory were, first, the chief (opperhoofd), who was in charge of the trade affairs and maintained contacts with the Shogun (Fig. 4). In addition, there were the warehouse keeper, the bookkeeper, several clerks, and a number of servants brought from Java in the East Indies [5]. The Japanese were not allowed on the island, with the exception of a few official interpreters. Apart from directing the trade negotiations, these interpreters were instructed to spy on the Dutch on Decima and report on their activities. Another, obviously more welcome group permitted to visit the island were the Japanese geishas who took care of the entertainment of the Dutch community on Decima. Among the permanent residents of the factory was the barber-surgeon (Fig. 5). He was responsible for health care on Decima and before long was also treating Japanese patients from Nagasaki.
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Figure 4

Dutchman through the eyes of a Japanese artist (eighteenth century). (From the Collection of the National Museum of Ethnology, Leiden, The Netherlands.)

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Figure 5

Map of the Dutch factory on Decima (1785) showing the house of the chief surgeon (30) and his apprentice (31). (From the Collection of the National Museum of Ethnology, Leiden, The Netherlands.)

First Japanese Treatise on Anatomy Translated from a Dutch Anatomy Textbook

During a period in which the Dutch were the only representatives of a Western nation in Japan, knowledge of the Dutch language was the only way to learn about Western science. The Nagasaki interpreters were able to communicate in Dutch on a practical level but lacked sufficient knowledge of the language to read Dutch scientific texts. Shogun Yoshimune in 1740 recognized this handicap and gave instructions for the systematic study of Dutch, giving rise to a group of rangaku scholars who studied the Dutch language in great detail [6]. One of these Dutch language specialists, the physician Genpaku Sugita, once examined a Dutch anatomy textbook and was struck by the similarity of the plates displayed in the book with the anatomic structures he had recently seen during the autopsy of an executed criminal. He then decided to translate the book into Japanese. The textbook was a Dutch version of a popular German manual on anatomy by the anatomist Johann Adam Kulmus, which was translated into Dutch in 1734 by Gerardus Dicten, a surgeon from the city of Leyden (Fig. 6). It took 4 years of painstaking work before the translation was completed in 1774 [7]. This book, entitled Kaitai Shinsho [New Book on Anatomy] was the first Western scientific monograph to be translated entirely into Japanese (Fig. 7, 8). Before that time, the Japanese lacked anatomic knowledge because postmortem dissections had long been prohibited. Thus, publication of Kaitai Shinsho was a major step forward in the evolution of Dutch surgery in Japan.
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Figure 6

Frontispiece of the anatomy textbook Ontleedkundige Tafelen, a Dutch translation (1734) of the German manual on anatomy by Johann Adam Kulmus. This textbook was translated into Japanese by Genpaku Sugita in 1774, who gave it the name Kaitai Shinsho [New Book on anatomy]. (From the Collection of the University Library, Amsterdam, The Netherlands.)

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Figure 7

Frontispiece of Kaitai Shinsho [New Book of Anatomy], the Japanese translation of the OntleedkundigeTafelen. (From the Collection of the National Museum of Ethnology, Leiden, The Netherlands.)

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Figure 8

Illustration from Kaitai Shinsho [New Book on Anatomy] with Japanese annotation. (From the Collection of the National Museum of Ethnology, Leiden, The Netherlands.)

Importance of Dutch Surgery on Decima

The surgeons of the Dutch factory on Decima played a significant role in the advancement of Western medicine in Japan. Particularly surgery, as practiced by the Dutch, was regarded with great interest. Operations had, on a limited scale, been performed by the Portuguese; and one wonders why the Japanese regarded surgery carried out by the Dutch as so sensational. It might have been because the Dutch surgeons of Decima offered a surgical system, which was in keeping with the development of surgery in Europe. The introduction of vessel ligation for hemostasis by the French surgeon Ambroise Paré at the end of the sixteennth century, marked a new era in surgery. With increasing knowledge of anatomy thanks to the work of, among others, Vesalius, Eustachius, Fallopius, and Van den Spiegel, surgery eventually achieved the status of a science. The Japanese translation of the Dutch handbook on anatomy opened the door to practice surgery.

During the seventeeth century, the barber-surgeons in the Dutch cities were organized in guilds, which also conducted competence examinations. Having passed the examinations, surgical apprentices were admitted to the guild, which granted them a surgeon’s certificate. The first surgeons to arrive at the Dutch factory on Decima, however, were ship’s surgeons, who clearly formed a separate category within the profession. The Dutch East India Company assigned to each of her major ships one or more surgeons, who were in charge of the health care of the crew during the long voyage to the East. During the first quarter of the seventeeth century, the Company’s Chamber at Middelburg, for example, engaged 114 surgeons and 3 physicians for its ships and stations in the Dutch East Indies [8].

To become a ship’s surgeon took only 1 year of apprenticeship; and because he was authorized to work only on board ship or overseas, the ship’s surgeon had, in general, a less favorable image than his mainland colleagues. Up to the year 1850, some 60 surgeons had been appointed to the Dutch factory on Decima for a period varying from 1 to 4 years [9]. Although salaries were low and life on Decima lacked the conveniences of the homeland, most of the factory surgeons obviously found some reason for wanting to visit Decima. For the adventurous, there was the journey to Japan, past remote coasts and exotic ports. The scholar could study the Japanese culture, which at that time was unknown to the Europeans. Thus, the quality of the Decima surgeons varied greatly, from a mere “horse doctor” to a scientist of great importance.

Nagasaki Interpreters, the First Students of Dutch Surgery

Communication between the Dutch and the Japanese took place by means of interpreters; consequently, the first Japanese physicians of Western medicine emerged from the group of interpreters, rather than from the residing Japanese physicians [10]. The interpreter Dembei Inomata became one of the pupils of Caspar Schambergen; and together with six other interpreters he wrote the Kaspar-Ryu-Isho, or The Medical Book of the Caspar School, which was later succeeded by Oranda Geka-Sho [The Book of Dutch Surgery]. Hoan Arashiyama (1633-1692), was the first Japanese person to undergo complete surgical training from the Dutch on Decima. His main instructors were Daniel Busch and Hermanus Katz, who were serving as the surgeons to the Dutch factory around 1650. As was customary with the surgical guilds in Holland, Hoan Arashiyama received a surgeon’s certificate after he had passed a proficiency test. The certificate is dated January 21, 1665 and is signed by the head of the factory, Jacob Gruijs, and surgeons Nicolaes de Roy and Daniel Busch. The fact that a certificate was issued proves that the Japanese apprentices were trained in surgery according to the standards in Holland and hence were fully qualified. The surgeon’s certificate granted to the interpreter Nids Kitzibeoye has also been preserved. This certificate, issued on Decima on February 20, 1668, bears the signatures of factory chief Constantin Ranst and surgeon Arnold Dircksz. A passage from this certificate as translated from the Dutch, is as follows [11].

Constantin Ranst, born in Amsterdam, chief on behalf of the chartered Dutch East India Company in the empire of Japan, hail, attests that the chief-interpreter Kichibei Nishi, having witnessed the practice of surgery for many years under the Dutch as well as under the Portuguese priests, generally has distinguished himself through his keeness of observation in such manner that he not only largely must surpass the knowledge of all other Japanese physicians but is to be considered a European surgeon.

Dutch Surgical Schools in Japan

The first Dutch surgeon on Decima whose name occurs in the literature, is Caspar Schambergen, who was attached to the Dutch factory from 1649 to 1651. He gave lessons in surgery to the Japanese and introduced a surgical system, which after a century and a half was still acknowledged as the Kaspar-ryu-geka [the Caspar school of surgery].

Caspar Schambergen was also one of the first factory surgeons to visit Edo, the residence of the Shogun. Once a year, the head of the Dutch factory was obliged to wait upon the Shogun in Edo (nowadays Tokyo), as was the duty of all feudal lords. The annual journey to Edo took several months, and the head of the factory with a delegation from Decima traveled through the country by sedan [12]. During one of the first court visits in 1649, the surgeon Caspar Schambergen was in the Dutch party. The court at Edo was so much impressed by his skills and his knowledge of surgery, that, when the Dutch delegation departed for Nagasaki, he was invited to stay. For 6 months he was the guest of the Shogun, which is considered quite an achievement so shortly after the proclamation of isolation. In the presence of the court physicians, Caspar Schambergen lectured on Dutch surgery and demonstrated operations. This was referred to as Komo-ryu geka.

The Caspar school was the first school of Dutch surgery, but more schools were to follow. In his Dawn of Western Science in Japan, Genpaku Sugita mentioned several surgical schools [7]. Although the surgical schools were all more or less alike, each school had its own rules and philosophy as laid down in the Densho, the instructions of the school. In addition to the Caspar school, the Nishi school of surgery, founded by the interpreter Kichibei Nishi (1666), the Kurisaki school, and the Katsuragawa school were all reknown surgical schools in Japan.

Japanese Surgical Textbooks

Hoan Arashiyama, the founder of the Katsuragawa school, wrote a textbook on Western medicine entitled Bankoku-Chiho-Ruishu-Tekiden [An Explanation of the Medical Practices of Foreign Countries]. He mainly recorded what he had learned from his instructor Daniel Busch and limited himself for the greater part to the treatment of wounds. Occasionally, he mentioned operations and operative techniques but scrupulously omitted many of the details because they were considered confidential. In this respect, he also followed his Dutch masters, as it was common practice with competing surgeons in Holland not to reveal to one another their specific skills.

More communicative about operative techniques was Chinzan Narabayashi, who lived from 1648 to 1711. As an interpreter on Decima, his contacts with the Dutch surgeons aroused his interest in surgery to such an extent that he gave up his job as an interpreter and committed himself entirely to surgery. He was a pupil of Willem Hoffmann, who served as factory surgeon from 1671 to 1675. Chinzan Narabayashi published what he had learned from Hoffmann in a book entitled Koi-Geka-Soden [An Explanation of Dutch Surgery] [13]. He discussed certain surgical techniques in some detail (e.g., the technique of trepanation) also by means of illustrations and descriptions of the surgical instruments used. The illustrations in Koi-Geka-Soden seem to be similar to the plates found in the works of Ambroise Paré, the famous sixteenth century French surgeon [14] (Figs. 9, 10). It is likely that Narabayashi had based his text on a Dutch translation of Paré’s works, which he combined with the teaching of his Dutch instructors.
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Figure 9

“Dry suture” of a face wound from the Dutch translation of Ambroise Paré’s (1510-1590) book Des Playes en Partculier. From Rogge [14].)

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Figure 10

“Dry suture” from Kinso Tetsuboku Ryoji No Sho (1735) by Nishi Gentetsu. Note the similarity to Paré’s illustration in Figure 9. (From Huard P et al. [13].)

In the year 1768, Jan Crans, chief of the Dutch factory, and surgeon Rudolf Bauer set out from Decima for the annual visit to the Shogun’s court at Edo. Bauer was reknowned for his surgical skills, and it was under his tutorship that the interpreter Kozaemon Yoshio was trained in Dutch surgery. Yoshio, who meanwhile had built up a reputation of his own as a surgeon, accompanied the Dutch party to act as interpreter. In Edo, the Dutch surgeon and his Japanese apprentice aroused great interest. Bauer cured a patient with gangrene of the tongue and performed a venesection. Genpaku Sugita attended the venesection surgery and described how skillfully Bauer, who had estimated beforehand the distance the blood would spurt, caught the jet of blood in a vessel. Highly impressed, Genpaku Sugita accompanied the two surgeons during the rest of their visit. On one occasion, Yoshio showed him a Dutch surgical textbook he had recently acquired for the price of 20 barrels of the best sake (rice wine). The textbook, which Sugita was eager to borrow from Yoshio, was a copy of the Heelkundige Onderwijzingen [Lessons in Surgery] by Laurens Heister; it was a highly acclaimed surgical textbook published in Dutch in 1741 [7].

Laurens Heister was a citizen of Frankfurt (Germany), who had been trained in surgery in Leiden and Amsterdam and was eventually appointed chief surgeon of the Dutch army [15]. His work Heelkundige Onderwijzingen constituted one of the first systematic treatises on the subject of surgery (Fig. 11). The Japanese translation of this book was accomplished in 1790 by Genpaku Sugita and his pupil Gentaku Otsuki. The translation was an important contribution to the study of surgery in Japan (Fig. 12).
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Figure 11

Frontispiece of the Dutch version of Laurens Heister’s surgical textbook Heelkundige Onderwijzingen (1741). This was one of the first systematic treatises on the subject of surgery and was translated into Japanese in 1790. (From the Collection of the University Library, Amsterdam, The Netherlands.)

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Figure 12

Laurens Heister (1638-1758) portrayed by Kangan Kitayama (1767-1801) after an engraving on the frontispiece of his surgical manual Heelkundige Onderwijzingen (Fig. 11). (From the Collection of the Kobe City Museum, Kobe, Japan.)

Von Siebold: Surgeon of Great Versatility

The last in the lineup of factory surgeons to be mentioned is Philipp Franz von Siebold, possibly the most reputable of all [16, 17]. He was sent as a surgeon to the Dutch factory in 1823 (Fig. 13), and 3 months after his arrival he was already lecturing on various medical subjects to an audience of Japanese physicians and interpreters. The factory chief at that time, Cock Blomhoff, by courtesy of the Japanese authorities in Nagasaki had arranged for Von Siebold to give his lectures in one of the factory buildings on Decima, for which purpose a room was set up. Von Siebold soon became widely known, and patients from all parts of Japan came to Nagasaki to consult him. As a guest lecturer, he was frequently invited by the surgical schools, in particular by the Narabayashi school. Most sensational for the Japanese were the cataract operations Von Siebold performed, as well as his breast surgery and plastic surgery for a harelip.
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Figure 13

Surgeon-major Philipp Franz von Siebold (1769-1866) was assigned to Decima from 1823 to 1830. His contributions to the knowledge of Japanese culture in the Western world were numerous. (From the Collection of the Municipal Archives of Leiden, Leiden, The Netherlands.)

Von Siebold was more than just surgeon; he was also a biologist, a geographer, and an ethnologist. His pupils, to whom he granted a diploma modeled on the surgeon’s certificate of Daniel Busch, were required to write a dissertation in the Dutch language about various subjects relating to Japanese culture. In this way, he gathered material from which he composed his Nippon, an impressive seven-volume publication dealing with Japanese culture. The name of Von Siebold was to live on in his pupils, some of whom, such as Gensho Honma (1804-1872) and Seikai Totsuki (1799-1876), became renowned surgeons in Japan.

Epilogue

It would take until 1853 before Japan was forced to give up its isolation policy and open its ports to Western nations. Thereafter, Western medical knowledge, which had reached the Japanese only through the Dutch factory on Decima, continued to develop. By 1870, the evolution of Western medicine in Japan had become strongly influenced by German medicine [2]. This reorientation from Dutch to German medicine resulted from the fact that in Europe the German medical system had attained a leading position. Then ofter World War II, it was the American visiting professors who greatly contributed to modern Japanese medical practice [18]. Today, surgery in Japan has its own identity and has made major contributions to the various fields of surgery.

Interestingly, the religious reasons that some 400 years ago prohibited the performance of autopsies and hampered anatomic knowledge in feudal Japan have directed the way transplantation surgery developed in modern Japan. The belief that human integrity should be preserved after death, has proven to be a major obstacle to retrieving donor organs for transplantation. Whereas many thousands of cadeveric liver transplantations have been performed in Europe, perhaps only a dozen cadaveric liver transplants have been undertaken in Japan. The Japanese solution to this problem was the concept of using partial liver grafts from living donors. Japanese surgeons have pioneered this technique and have provided the basis for living (un)related liver transplantation, as is now practiced in a number of centers throughout the world. This surgical achievement in the end may be seen as a credit to Caspar Schambergen and his red-haired colleagues, who, three and a half centuries ago, laid the foundation for surgery in Japan.

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© Societe Internationale de Chirurgie 2004