Happy New 2019


Some reflections on Dr. Shuzou Kure

   Happy 2019! The forerunner of Matsuzawa Hospital, Tokyo Tenkyo-in, opened its doors 140 years ago, and in 1919, moved its operations from the city center to what was then known as Matsuzawa Village in Ebara County where it was re-christened Matsuzawa Hospital. This year is thus our centenary year.

   Now if those familiar with the history of Matsuzawa Hospital were asked to name its most famous director, I think they would be unanimous in naming Shuzou Kure, the fifth director. Shuzou Kure graduated in 1890 from Tokyo Imperial University, then spent the years from 1897 to 1901 in Austria and Germany to study under Obersteiner, Krafft-Ebing, Kraepelin, and other luminaries who were to leave their indelible imprint on the history of psychiatry.

   Upon his return to Japan in 1901, Kure became professor in the medical department of Tokyo Imperial University and assumed the medical directorship (later, simply “directorship”) of Tokyo Sugamo Hospital, one of the early forerunners of Matsuzawa Hospital. Kure was 36 years old at the time, a remarkably young age even in the Meiji Period for one to acquire a professorial seat at Tokyo Imperial University as well as the directorship of Sugamo Hospital although his accession to the latter post was due to the untimely death of the previous director, Hajime Sakaki. Kure continued to serve as the director of Sugamo Hospital for some 20 years after assuming the mantle of directorship in 1925.

   The most famous of Kure’s achievements is his work, The Status and Statistical Observations on the Home Custody of Psychiatric Patients, published in 1918, which compiled the results of a 16-year, nation-wide study begun in 1910 of the home custody of psychiatric patients. “Home custody” refers to the practice of isolating psychiatric patients in private residences pursuant to the Act for the Custody and Care of Persons with Mental Disorders, which was promulgated in 1900.
The act allowed homeowners, with the aid of the relevant public offices, to build a cell-like room on their property to house patients deemed to have an intractable mental illness. This law was enacted at a time when psychiatric wards were yet unknown, and it was thought preferable to place patients under some form of government custody than to allow them free reign, but its effect was to give the government imprimatur to a practice which compelled these patients to live under inhumane conditions.

   Kure investigated in detail the manner in which this policy was implemented and published the results of his research in a bid to improve the treatment of persons with mental disorders. Kure writes in his book, “The tens of thousands of psychiatric patients in Japan must endure not only the misery caused by their illness, but also the misfortune of having been born in this nation. The rescue and protection of these patients, which confront us now, is a matter of pressing humanitarian concern.” These words are well-known among Japanese psychiatrists even today, where they serve at times as an admonishment, at times as a source of inspiration.

   Last year, a documentary examining Kure’s achievements, entitled, “Before Dawn: Kure and a Century of the Anonymous Mentally Ill,” was aired to great public acclaim. A century ago, in a time when psychotropic drugs and mECT were unknown, Kure banished the tools used to restrain patients from Matsuzawa Hospital and decreased the use of so-called “protection rooms.” In the same year, NHK’s “Close-up Gendai Plus” broadcast a documentary dealing with the recent, drastic reduction in the use of restraints at Matsuzawa Hospital. Thus, in the 21st century, Matsuzawa Hospital once has once again found itself in the limelight for having dramatically reduced the use of restraints, which had allegedly been removed entirely by Kure a century ago. I confess that as I was being interviewed for both of these documentaries, I had rather mixed feelings about the matter.

   In 2012, the restraint rate was approaching 20% at Matsuzawa Hospital. It is currently at 2-3%. How was this dramatic decrease effected? It was made possible by a simple determination by all the staff that psychiatric treatments could not be administered while the patients were in restraints. No changes in the hospital’s infrastructure or deployment of the staff were necessary to put this determination into practice. In fact, the number of newly hospitalized patients rose from 2,400 in 2012 to 3,800 in 2018, such that each member of the care staff is now responsible for 1.5 patients. In other words, the reduction of patient restraints was not motivated by the lack of care personnel or a scarcity of protection rooms.

   The policy of so-called “emergency measure hospitalization” was formulated to deal with patients reported by the police during the hospital’s non-operational hours and holidays. Unlike patients in other types of emergency, such as those who visit the hospital for regular treatments or those who come with a letter of referral, most patients qualifying for emergency measure hospitalization do not have detailed medical records or a clear history of their life and family circumstances. Indeed, even their identity may be unknown. The only thing that is clear in such cases is that the patient was taken into custody by a police officer who deemed the individual to present a danger to his or her own life or that of others. As these patients are admitted in accordance with policy during the night time hours and holidays when the hospital operates with a skeleton staff, about 70% of them were place in restraints in 2012. That figure, as I have said, is now 2%.

   While the restraint rate was decreasing, the use of intravenous sedatives to calm emergency outpatients was also showing a statistically significant reduction. On learning of this fact, I was able to set aside my worry that reducing the restraint rate would necessitate the use of large quantities of sedative drugs. Meanwhile, the proportion of patients who voluntarily take their medications from the day after their admission has increased (Egoshi, Imai, 2018).

   We were able to achieve this drastic reduction in the use of restraints at Matsuzawa Hospital thanks to the efforts of our staff to persuade patients to comply with their hospitalization through treating them in person and as persons, making the painstaking effort to obtain their compliance, and showing empathy with them in their suffering.

   Things quickly achieved may quickly be undone. The current, humane hospital culture must be allowed to take root firmly in our institution so that we are not faced with the need, 100 years hence, once again to find ways of eliminating the use of restraints.

   On this note, I would like to ask all the members of our community for their support and encouragement again this year.