When did Western Medicine expand into Japan?

Deshima island in Nagasaki Bay in 1825

Western medicine slowly filtered into Japan during the Tokugawa period (1600-1858). While Japanese variants of Chinese medicine dominated Japanese medical practice, western medicine made significant inroads and penetrated Japan. Historian John Bowers claims that Western medicine ultimately triumphed over Chinese medicine due to the perseverance of Japanese students, scholars and European physicians stationed at Deshima. Over this time period, Japan experienced a gradual expansion of western medicine throughout Japan due to the concerted and dedicated efforts of some of the most important Japanese medical practitioners and advocates.

Medicine during the Edo period became increasingly Balkanized as five separate schools of medicine were practiced in Japan. Each of these schools was based on the Chinese medical tradition. In the sixth century, Chinese medicine, kanpō, was brought to Japan by Buddhist priests.[1] Kanpō utilized Chinese herbs, acupuncture, moxibistion and massage. Chinese medicine was based on the principle that the body, like the universe, can potentially achieve “a state of dynamic equilibrium if no strain is imposed on the system.”[2] Unfortunately, the body was constantly disturbed by internal and external influences which manifest themselves as either deficiencies (ying) or excesses (yang) of energy. Because patients were seen as part of nature, illness was caused by these continual environmental forces acting on their bodies.[3] Physicians working in the Chinese system focused on categorizing illness under a complex set of groupings that demonstrated the relationships between man and the universe. The Chinese medical system did not bother portraying the body in an anatomically accurate way because it was far more concerned with the “functional interrelationships between the parts of the body.”[4] While Japanese physicians in the five separate sects adopted and modified the Chinese medicine, the theoretical foundations for kanpō remained tied to Chinese medicine.

The goseiha or rich school (founded in during the late 1500s) was highly theoretical, but doctors from this school were not necessarily tied blindly to theory and trusted their own experience.[5] The goseiha sect was eventually overshadowed by the koihō sect. The koihō school sought to return to Confucian scholarship and was essentially as a reactionary movement against the goseiha school. But this sect would later emphasize clinical experimentation and an understanding of anatomy.[6] By the mid-seventeen hundreds, a reform school called the kōshōgaku led by the powerful Taki family altered Japanese medicine’s course and relied on the Shōkanron, a Chinese medical text from 200 A.D.[7] By 1791, the kōshōgaku sect’s medical school became the official school of the Bakufu (the Shogunate).[8]

The wahō sect differed from its competitors because it sought to emphasize its Japanese roots. Instead of relying on Chinese texts, wahō physicians “emphasized observation based on the five senses and experience.”[9] Physicians of the wahō sect studied classic Japanese texts. On the other hand, the kanransetchu or Chinese-Dutch eclectic school focused on outside influences and combined some elements of Western and Chinese medicine. Physicians from the </i>karansetchu</i> school incorporated some Westerner surgical, bloodletting and obstetrics techniques. A karansetchu physician, Hanoako Seishu (1760-1835), developed anesthesia forty years before Europeans.[10] While karansetchu physicians incorporated Western elements into their practices, they were not true ranpō or Western doctors. These systems of medicine dominated throughout the Edo period, but Western medicine began to slowly filter into Japan and challenge their dominance.

Western medicine was introduced to Japan by the Portuguese and Spaniards, but they made few contributions to medicine in Japan. The true cultural exchange between Japanese and European physicians occurred with the introduction of Dutch traders into Japan during Tokugawa Iemitsu’s rein. [11] By 1641, the Dutch had relocated their trading post to the island Deshima in Nagasaki Bay. The staff of the trading post on Deshima almost always included a European physician. These physicians played a vital role in the dissemination of Western medical knowledge to Japanese physicians and scholars throughout the Edo period. While this transference was hindered by the Bakufu’s severing of ties with the rest of Europe, Western medical knowledge slowly spread. By 1630, Tokugawa Iemitsu had effectively banned most Western books from Japan.

Due to Japan’s isolation from the Europe, the translation and study of Dutch books became synonymous with Western studies. While the term rangaku literally translates to “Dutch learning,” rangaku scholars studied other European works as well.[12] In practice, ranguku scholars were essentially limited to the Dutch works for two reasons: first, the Tokugawa ban prevented the translation of most other works, and second, the Dutch possessed a foothold in Nagasaki which ensured the inflow of some Dutch texts. In order to subvert the Tokugawa book ban, ranguku scholars were primarily limited to translating European texts which were considered practical by the Bakufu. It was not unusual for rangaku scholars to focus their attention on medical works.

According to John Bowers, the first Japanese to learn about Western medicine were the Orandatsuji or Dutch interpreters. The Dutch were required to provide the Orandatsuji with formal training in reading and writing Dutch. Increasingly, the Dutch began to teach Western medicine to the Japanese who were sent by their daimyos to Nagasaki.[13] Often these interpreters learned Western medicine from European physicians stationed in Deshima. In the seventeenth century, two physicians stationed on Deshima, Daniel Busch and Engelbert Kaempfer played important roles in the early dissemination of Western medicine in Japan. Daniel Busch worked at the Deshima station from 1662 to 1666. Not only did Nagasaki officials allow Busch to treat Japanese citizens, but they allowed him to teach Western medicine to a number of Japanese physicians, including the first Japanese ranpō practitioners.[14]

Engelbert Kaempfer was not just an educator; he was a physician, a world traveler and a true scholar. The posthumous publication of his History of Japan provided Europeans with a window to Japan. Kaempfer was a German physician employed by the Dutch East India Company. He was stationed in Japan for two years starting in 1690. Kaempfer also served as an instructor in Western medicine and surgery and Dutch to an interpreter who faithfully served and studied with him during his two year stay. Kaempfer stated that he taught the “learned young man” about Dutch, mathematics, medicine. His loyal student provided Kaempfer with information about “the country, the government, the court, their religion and history of past ages.”[15] While Kaempfer may not have been free to teach Japanese physicians about Western medicine, he contributed to its dissemination. Kaempfer communicated his knowledge of Western medicine the interpreters and some interested Japanese physicians. John Bowers maintains that after Kaempfer left Japan, “there was a vacuum in scholarship at Deshima for more than eighty years.” [16] Therefore, it is unsurprising that next major event in the proliferation of Western medicine can be credited to a Japanese physician.

The key event in the expansion of Western medicine in Japan during the eighteenth century was the publication of Sugita Gempaku’s Kaitai Shinsho (New Treatise on Dissection) in 1774. Shigehisa Kuriyama described the publication of this book as “a major turning point in Japanese cultural history.”[17] The Kaitai Shinsho challenged Chinese medicine’s understanding of anatomy and started the radical transformation of Japanese medicine. All five sects of Japanese medicine were forced to face the new understanding of human anatomy advocated by Gempaku. The Kaitai Shinsho was a translation of the Johann Adam Kulman’s Tafel anatomia (1731). Kulman’s book was an extremely accurate Dutch book on anatomy. The book contained numerous lithographs of human anatomy. While Katai Shinsho did not become the standard for Japanese medicine until the Meiji era, it would eventually play a vital role in transforming Japanese medicine. Gempaku demonstrated that Japanese and Chinese physicians had failed to perceive anatomy correctly “because of long-standing delusions, owing to certain dispositions o the mind. They had looked, but they had not seen.”[18]

Gempaku’s book allowed Japanese physicians, for the first time, to see the body as it existed. Gempaku decided to translate the Dutch text after attending a dissection of a female criminal. During the dissection, Gempaku realized by comparing the body depicted in Tafel anatomy and the actual cadaver that “they were in perfect agreement.”[19] Perhaps even more important, the cadaver did not resemble those described in the Chinese or Japanese texts. Japanese and Chinese scholars had unintentionally missed the form of the body; because they were predisposed to believe that there interpretation of the human body was correct. Gempaku’s book was a call for reform in Japanese medicine. Gempaku’s books essentially lead to the creation of ranpō or “Dutch style” medicine.[20]

While Gempaku was publishing his treatise on anatomy, another physician scholar, Carl Pieter Thunberg, arrived at Deshima. Thunberg was a Swedish physician and botanist. He arrived in Deshima in 1775.[21] By the time Thunberg arrived, the frosty relations of interpreters and Dutch physicians are a thing of the past. Thunberg, unlike Kaempfer, did not have to resort to plying the interpreters with liquor and information to win them over. [22] By 1775, the interpreters had been able to convert their lessons on Western medicine into profitable medical practices. The interpreters were more willing to listen to and request consultations with Thunberg regarding their patients.

While Thunberg stated that the impact of Western medicine in Japan had been minimal, his experiences with students during the hofreis demonstrated that Western science was becoming more widely known.[23] Perhaps even more important was the emphasis placed on Western knowledge by the Shogun. Bowers even highlights an instance where the shogun was incapable of hiding his interest in the foreigners. The Shogun even saw fit to disguise himself as a prince in order to take part on a low-level discussion of the Dutch East India Company’s annual report to the Bakufu.[24]

Even after Thunberg left Japan in 1776, he continued long distance communications with two of his Japanese students in Edo. Not only did the three men ignore the bans against foreign communications they provided each other with books and seeds. Thunberg sent both books and botanicals to Japan for his students. In a letter from one of his students, the student acknowledged the receipt of three books from Thunberg and agreed to send 100 seeds and dried leaves. Japanese physicians were beginning to network with Western style physicians to further their own medical knowledge.[25]

While Gempaku’s impact on Japanese medicine may not have been immediate, his book hastened the desire of scholars to study more Western texts rangaku and ranpō. Between 1786 and 1846, twelve private schools of Western medicine opened their doors. The school of Western medicine was opened in Edo by a Japanese physician named Ōtsuki Gentaku. Gentaku was trained as ranpō physicians from the age of nine and he was a disciple of Gempaku. He was both a ranpō and rangaku scholar. Soon after learning Dutch he began translating it. Not only did he translate, but he published a book for anyone who wished to study Dutch called Rangaku Kaitei (Ladder to Dutch Study). In order to reach as broad an audience as possible, Gentaku published the book in katakana.[26]

Phillp Franz Balthasar von Siebold was one of the last physicians stationed at Deshima to have a major impact on the expansion of Western medicine in Japan. The Siebold family in Germany had produced a number of prominent physicians before Philip Franz Siebold. When Siebold attended medical school in Germany, he went when Germany was leading the world in medical education. The medical curriculum took five and years to complete and included numerous prerequisites including botany, chemistry, physics, comparative anatomy, and geology.[27] By comparison, medical education in the United States was not analogous. Most American medical schools only prerequisites were that the student needed to be reasonably proficient in the English students. Students were often required only to complete one or two semesters of lectures.

Aside from serving as a physician for Deshima, Siebold was sent to Japan by the Dutch to help convince the Japanese that they deserved special consideration, when and if Japan was opened up to foreign trade. The Dutch hoped to preserve the fiction in the eyes of the Japanese that the Netherlands was repository of Western learning.[28] Therefore, Siebold was chosen because he was considered to be an outstanding emissary. Initially, Siebold was an outstanding emissary. He was popular with the city officials from Nagasaki and he attracted students from throughout Japan. He began to build a reputation as an outstanding physician. Japanese physicians even began to take their problem cases to Nagasaki in order to have a consultation with Siebold. These physicians would often stay and join Siebold’s students in the lecture room.[29]

Siebold ultimately attracted so many students that he established a free medical school in Nagasaki, the Narutakijuki. A student even provided Siebold with a building in Nagasaki to conduct lectures and surgeries. Siebold’s school taught exclusively Western medical practice and surgery. Not only did Siebold lecture to his students, but there is evidence which suggests that he “taught by demonstration” which was unheard of Japanese medical schools. Siebold may have conducted as many as six operations in front of his students to demonstrate Western surgical techniques.[30] Siebold diagnostic techniques also differed dramatically from the pulse diagnosis, tongue examination and patient observation common in Japanese medicine.[31]

While the Dutch had hoped to that Siebold would strengthen their hand with the Japanese, ultimately he sparked an anti-Western reaction from the Bakufu. Instead of focusing only on medicine, Siebold was gathering as much information about Japan as possible. He secured maps of Sakhalin Islands and the Japanese coastlines, conducted linguistic studies of Korean and Ainu, visited a coal mine, studied marine biology and engaged in a number of extracurricular activities. These divergent interests and his conduct on the pilgrimage to Edo ultimately undermined his credibility with the Bakufu.

After three years in Japan, Siebold was finally allowed to travel to Edo as part of the hofries. In 1738, the hofries became a quadrennial event and it was eventually limited to just three Dutch representatives. While the Dutch retinue was limited to three representatives, despite these restrictions Siebold was able to bring four of his students on the mission.[32] During the hofries, Siebold took endless notes about the journey. In Edo, Siebold met with physicians, court officials, and the Bakufu’s court astronomer, Takahashi Sakuzemon. Through Takahashi, Siebold was able to secure a copy of a highly accurate map of the Japanese coastlines. The map was a state secret and strategically vital to Japan’s national security.[33] Over a year after his trip to Edo, Siebold was arrested for the map. After a year of exile on Deshima, he was expelled. John Bowers argues that Sielbold was doomed by his own ego and unwillingness to acknowledge that he subject to Japanese.[34]

Even after Siebold was exiled, his students continued to spread Western medicine throughout Japan. Takano Chōei (1804-1850), a Siebold disciple, became one the most influential and prominent rangaku scholars and ranpō physicians. Chōei has been described as “probably the most accomplished Dutch scholar of his day in Japan.” [35] Despite Chōei’s reputation as a medical scholar, he has been primarily studied by historians because he wrote The Tale for the Dream (1838) which criticized the Bakufu’s hostile policy towards foreign ships. Like Siebold, the Bakufu punished Chōei for his work. Chōei was imprisoned for writing The Tale of the Dream. While Chōei later escaped from prison and lived several years in hiding, he eventually committed suicide to avoid capture. This tragic story has often overshadowed his role as a leading rankagu scholar in Japan.[36]

Chōei was born into a middle ranking samurai family, but he ultimately rejected his samurai heritage to focus on his rangaku scholarship and medical practice. Chōei began his medical studies in Edo when he was sixteen years old. While in Edo, Chōei studied with Gempaku as a day student. After five years of intermittently studying medicine and working as a masseur to support himself; Chōei moved to Nagasaki to study Dutch and medicine with Siebold. [37]

Chōei raved about his studies with Siebold. Chōei describes treating “townspeople” and collecting medicinal plants.[38] Chōei lived at Siebold’s school because he could not afford alternative accomendations. Chōei’s education at the Siebold School came to end after Siebold’s arrest. Immediately after Siebold’s arrest, Chōei went into hiding because he feared that some of his translations would potentially implicate him in the Siebold scandal.[39] Instead of going home, Chōei fled to Kumanmoto. By this time, Chōei had essentially severed ties with his family and he was on his own.

After Chōei studied with Siebold he began to try and focus more on scholarship than a practicing medicine.[40] Due to his poor economic circumstances, Chōei was often forced to work a physician. After hiding in Kumanmoto, he eventually made his to Kyoto where practiced medicine and networked with ranpō doctors. After his stay in Kyoto, Chōei finally made his way back to Edo. By this time, Chōei was forced to work a local doctor. As a ranpō physician, Chōei practiced a more Western style of medicine, but in general, ranpō doctors practiced an amalgamation of Western and Chinese methods. Despite Chōei’s reliance on practicing medicine to make ends meet, he began to slowly shift his energies back to rangaku scholarship. It was through his career as a scholar that Chōei began to network with other physicians in Japan to spread Western medicine and thought.

Chōei’s translation work interested Fukuda Sōtei, a prominent Kōzuke physician.[41] Chōei adapted Dutch medical texts to help Japanese physicians develop solutions for local problems. Chōei did not provide literal translations of the Dutch source materials; he interpreted the work to best serve the social needs of his physician audience. Sōtei was learning Dutch and he sought out Chōei for additional guidance because he saw the potential for practical applications of Western medicine.[42] Sōtei and Chōei began a relationship that allowed Chōei to network with a number of rural physicians from Kōzuke. Nakamura believes that this interchange of ideas between urban and rural intellectuals created an impetus for social change in Japan that extended beyond the Tokugawa period.

Ranguku scholars developed extensive networks in Japan to spread medicine to rural or local physicians. Nakamura’s work is part of a growing field of Japanese scholarship called zaison no rangaku or “study of Western learning in the countryside.”[43] By changing perspectives and examining Western learning for the practical reasons it was taken up with by Japanese scholars, Nakamura demonstrates that physicians sought to employ Western techniques to solve Japanese medical problems in rural Japan. While the spread of this information was haphazard and unsystematic, it reached remote areas such as Kōzuke. Physicians throughout Japan actively networked and studied with ranpō physicians and rangaku scholars because they believed that Western medical knowledge could be put to some practical use. Like their western colleagues, Japanese physicians were becoming concerned that their methods were less effective at treating people than they would like.

Three of these physicians, Sōtei, Yanagida Teizō, and Takahashi Keisaku (1799-1875) developed long-term relationships with Chōei. They would be his students, patrons and collaborators on future works. Unlike American or European physicians, the Japanese doctors were limited by any codes which provided limitations on physicians consulting with members from other sects or traditions. This permitted physicians to employ various methods to serve their patients. Chōei’s book Fundamentals of Western Medicine was funded by Sōtei, while Treatise on Two Things for the Relief of Famine and Methods of Avoiding Epidemic Diseases was a collaboration with these rural physicians.[44] It is unsurprising that these physicians would collaborate on books dealing with public health problems. Rural physicians were interested in famine and epidemic diseases because they often oversaw public health in their small communities. Treatise on Two Things for the Relief of Famine and Methods of Avoiding Epidemic Diseases were essentially public health tracts. While famine may appear to be a primarily economic or agricultural issue, rural physicians ultimately had the responsibility for treating the victims of famine. These physicians also knew that it was not uncommon for epidemics and famines to spread together. Chōei emphasized this symbiotic relationship in Methods of Avoiding Epidemic Diseases.[45] Not surprisingly, Japanese physicians viewed famine as a medical problem.

Chōei believed that Western texts included helpful solutions for fighting famine in Japan, because it was often the result of cold weather which reduced rice crops. Chōei believed that Europe had a far more inhospitable and colder climate than Japan. In order to survive he assumed that the Europeans must have possessed crops that could withstand cold summers and harsh winters.[46] In his work on famine, Chōei focused on the potential usefulness of such crops as buckwheat and potatoes for limiting the effects of famine.[47] The Kōzuke physicians had introduced potatoes and buckwheat to Chōei. The rural physicians understood that these crops could potentially limit the effects of famine. Unlike rice, buckwheat allowed Japanese farmers to have two or three harvests even in cold summers. Chōei advocated planting potatoes because they were incredibly hardy and could withstand cold, wet summers. While these efforts did not necessarily swell the production of buckwheat and potatoes, their efforts set the stage for the eventual expansion of these crops after the Meiji Restoration.

By 1847, Otto Mohnike (1814-1887), another German physician, was stationed at Deshima describes how Bakufu physicians were using Western medical practices. But unlike Kaempfer and Siebold, he was not a virtual prisoner to the island.[48] He was allowed to roam more freely and treat patients. Even though Mohnike described knowledge in Western medicine as “limited, superficial and aphoristic,” he believed that Japanese physicians were interested in learning more.[49] In 1849, a viable smallpox finally arrived in Japan over forty years later than to most counties. Mohnike provided the small-pox vaccine to Japanese physicians who sought distribute it throughout Japan.

After the 1849 arrival of a viable smallpox vaccine, rural physicians developed networks to deliver the smallpox vaccinations to local villages. Nakamura argues that the efforts by ranpō physicians to bring small pox vaccinations to Japan encouraged “the wider acceptance of Western medicine, not only among private physicians but eventually the shogunate itself.”[50] For the most part these networks were local networks, organized by ranpō physicians to both deliver and preserve the smallpox vaccinations. Because these networks were somewhat informal, the smallpox vaccines were not distributed throughout the country at the same time. In fact, Keisaku, an advocate of Western medicine, had difficulty securing a smallpox vaccination for his village.

Western medicine slowly penetrated Japan during the Edo period. Initially, the Japanese interpreters at Deshima first learned about Western medicine from European physicians such Kaempfer. Ultimately, the key event in the spread of Western medicine was the publication of Genpaku’s Kaitai shinsho. Before Kaitai shinsho, advocates of Western medicine had failed to demonstrate why it is was either practical or necessary for Japanese physicians to adopt it. While the book did not instantly create a sea-change in Japanese medicine; Japanese physicians began to gravitate towards Western medicine because they realized it could potential helpful in their medical practices. After its publication, networks began to slowly develop which communicated some of practical benefits. Siebold’s students began to further spread western medical practice. By the early to mid-1800s, rangaku scholars such as Choei were even making contact with physicians in rural Japan. Rangaku scholars dispersed Western medicine throughout Japan via social networks of Japanese physicians who believed that the practical benefits of Western medicine could improve the quality of their patients’ lives. Western medicine was spread by extensive social networks to physicians throughout the country. Practicing physicians learned Western medical methods and spread those practices throughout Japan even as the Bakufu increasingly limited the flow of Western ideas into Japan. Social networks between physicians and scholars allowed for the “exchange of ideas between urban and rural intellectuals, and, eventually, for social change in the late Tokugawa period and beyond.”[51]

Still the progress of Western medicine was exceedingly slow. But by 1849, Western medicine was able to successfully procure a smallpox vaccination for Japan. By utilizing the developing rural ranpo medical networks, Japanese physicians were able vaccinate Japanese citizens. Even if the knowledge of Western medicine among Japanese physicians in 1849 was rudimentary and unsystematic, the networks developed to spread Western thought contributed to controlling smallpox, a disease that Japanese medicine was defenseless against.


  1. Lock, East Asian Medicine in Urban Japan, 27.
  2. Lock, East Asian Medicine in Urban Japan, 32.
  3. Lock, East Asian Medicine in Urban Japan, 32-33.
  4. Lock, East Asian Medicine in Urban Japan, 34.
  5. Lock, East Asian Medicine in Urban Japan, 54.
  6. Nakumura, Practical Pursuits, 12.
  7. Lock, East Asian Medicine in Urban Japan, 54.
  8. Nakumura, Practical Pursuits, 12.
  9. Nakumura, Practical Pursuits, 12
  10. Nakumura, Practical Pursuits, 13
  11. Bowers, When the Twain Meet, 4.
  12. Nakumura, Practical Pursuits, 6
  13. Bowers, Western Medical Pioneers in Feudal Japan, 29.
  14. Bowers, Western Medical Pioneers in Feudal Japan, 80-81,83.
  15. Kaempfer, Kaempfer’s Japan: Tokugawa Culture Observed, p. 28.
  16. Bowers, Western Medical Pioneers in Feudal Japan, 60.
  17. Kuriyama, “Between Mind and Eye: Japanese Anatomy in the Eighteenth Century,” Paths to Asian Medical Knowledge, p. 21.
  18. Kuriyama, Paths to Asian Medical Knowledge, 24.
  19. Kuriyama, Paths to Asian Medical Knowledge, 29.
  20. Kuriyama, Paths to Asian Medical Knowledge, p. 28-30.
  21. Bowers, Western Medical Pioneers in Feudal Japan, 78.
  22. Kaempfer, Kaempfer’s Japan, p. 28.
  23. Bowers, Western Medical Pioneers in Feudal Japan, 80-81, 83.
  24. Bowers, Western Medical Pioneers in Feudal Japan, 80-81,83.
  25. Bowers, Western Medical Pioneers in Feudal Japan, 86-87.
  26. Bowers, Western Medical Pioneers in Feudal Japan, 94-95.
  27. Bowers, Western Medical Pioneers in Feudal Japan, 105.
  28. Bowers, Western Medical Pioneers in Feudal Japan, 108.
  29. Bowers, Western Medical Pioneers in Feudal Japan, 112.
  30. Nakamura, Practical Pursuits, 32-33.
  31. Bowers, Western Medical Pioneers in Feudal Japan, 112.
  32. Bowers, Western Medical Pioneers in Feudal Japan, 116.
  33. Bowers, Western Medical Pioneers in Feudal Japan, 120.
  34. Bowers, Western Medical Pioneers in Feudal Japan, 124.
  35. Bowers, Western Medical Pioneers in Feudal Japan, 126 (Bowers is citing from George B. Sansom’s 1962 work, The Western World and Japan (1962), 260.
  36. Nakamura, Practical Pursuits, 39.
  37. Nakamura, Practical Pursuits, 47-49.
  38. Nakamura, Practical Pursuits, 50.
  39. Bowers, Western Medical Pioneers in Feudal Japan, 126-127.
  40. Nakamura, Practical Pursuits, 50.
  41. Nakamura, Practical Pursuits, 85.
  42. Nakamura, Practical Pursuits, 85-87.
  43. Nakamura, Practical Pursuits, 2.
  44. Nakamura, Practical Pursuits, 85.
  45. Nakamura, Practical Pursuits, 105-109.
  46. Nakamura, Practical Pursuits, 124.
  47. Nakamura, Practical Pursuits, 118-124.
  48. Bowers, When the Twain Meet: The Rise of Western Medicine in Japan, 11.
  49. Bowers, When the Twain Meet: The Rise of Western Medicine in Japan, 13.
  50. Nakumura, Practical Pursuits, 151.
  51. Nakamura, Practical Pursuits, 181.