An Edo Period Clinical Framework?
An Edo period doctor would not have any of the materials I've applied to Okada Izo in the Anachronisms section of this tumblr: he would lack the trauma and attachment theories, the DSM-V diagnostic criteria, and the ICD-10 codes for billing. He wouldn't know about Myers-Briggs types, boundaries, and social-cognitive learning theory. He wouldn't do a biopsychosocial assessment.
But, within the framework of his own time, the Edo doctor of traditional kampo (Japanese / Chinese medicine) would have a coherent medical system that would consider the relationship between emotional experience and physical illness, as well as a philosophical tradition drawn from Buddhism, Confucianism, and Taoist-influenced Chinese medicine, that takes the suffering of the heart-mind seriously as a medical problem.
The seven emotions framework would be an Edo doctor's primary diagnostic lens: fright, grief, anger, worry, pensiveness, joy, and fear are each associated with organ system, specific presentations, and recognized treatment approaches. Therefore, the Edo doctor looking at Izo would not think about post-traumatic stress disorder, but he might think about
é© (kyÅ), fright that has damaged the kidney and disturbed the heart-spirit, which cannot settle at night and cannot find its proper orientation during the day,
ę°é¬± (ki utsu), the stagnation of vital energy, which is concentrated in the liver and presents as the particular flatness of a man who has stopped allowing himself to feel, and
č (kyo), a general deficiency that is spreading across multiple organ systems as the stagnation and fright drain what is stored: heart blood insufficient to nourish the spirit, kidney essence depleted by fright, and ki weakened by grief, which is the lung's specific emotional domain.
The Edo doctor would diagnose using the pulse, face, and quality of the patient's voice and movement. He wouldn't understand the relational architecture, the attachment trauma, or the long history of Izo's delf being damaged by criticism, but he could articulate that Izo's ki is not moving freely and his shen is not properly housed and that the cause has not been removed.
That last observation is the most significant because the Edo period framework doesn't assume treatment will work while the cause of the illness is still in place. To the Edo doctor, treating fright while the patient continues to be frightened is a bit like trying to bail out water from a boat that still has a massive hole in its hull. Our Edo doctor would consider the continuing exposure to violence (being asked to commit more murders) as a fundamental obstacle to treatment even without the modern concept of ongoing trauma.
Treatment: Herbs, Acupuncture, Moxibustion, Diet
Medical interventions for Izo's condition would most likely take the form of herbal preparations in the Edo period and many classical formulas exist that map onto specific parts of Izo's presentation.
Suan zao ren tang nourishes heart-blood and calms the spirit. Its primary indications are insomnia, palpitations, and night sweats in a patient who is deficient, the thin, restless, undernourished quality of someone running on empty. (Modern day use is still treatment of insomnia.)
Chai hu shu gan san moves liver ki stagnation and relieves constraint. For a man carrying suppressed anger, rigid with the effort of managing what he cannot express, this addresses the mechanism rather than just the symptom. (Modern day use is for anxiety and depression.)
Ba zhen tang, the eight-treasure decoction, replenishes both ki and blood following significant depletion. After Izo's injury and fever and certainly after his time in jail, this is the formula for a body that has spent everything it had and needs the most fundamental kind of rebuilding.
The Edo doctor would also consider acupuncture and moxibustion to treat the physical injury and the body following Izo's time in jail. The management of chronic pain through acupuncture has a reasonably strong modern evidence base, and a skilled period practitioner would be working with the same points and principles that evidence base has validated.
Diet would be taken seriously as treatment rather than adjunct. Specific foods for specific deficiencies. The instruction to eat, which the physician gives repeatedly, is not merely common sense but grounded in a detailed theory of how particular foods nourish particular organ systems and how the depletion of those systems manifests in precisely the symptoms Izo presents with.
What's Helpful about the Period Framework?
In an Edo period setting, the mind-body integration would be a fundamental premise of the entire system while modern approaches open still divide the psychological from the physical in practice, even when holistic approaches are considered. The trauma specialist, pain management physician, and addiction counselor are three different people with different notes in different charts, while the Edo doctor would be all three simultaneously and his integrating framework is arguably more appropriate for Izo's treatment than the fragmented modern approach would be.
Another benefit of the Edo period approach would be that the doctor's consultation is not an hour followed by a bill, regardless of how much or little progress has been made. An Edo physician who is genuinely attending a patient with a disorder of the heart-mind would be less bound by billing requirements and clincial structures and therefore more responsive to the patient. If Izo stopped talking, the Edo doctor would not consider therapeutic silence and countertransference. He would just wait because that's what a doctor sitting with a patient would do. This absence of structure could actually create a lot more space for the kind of gradual, unhurried opening that Izo's treatment would need.
The Buddhist philosophical framework, which is available to the Edo doctor as cultural context even if not as clinical tool, offers something the modern framework struggles to provide: a way of thinking about suffering that does not require its elimination as the treatment goal. Modern therapy is fundamentally oriented toward symptom reduction, toward the construction of a life that hurts less, toward functional improvement. These are not wrong goals, but can create the message that the suffering itself is the problem, that the patient will be fixed when the suffering is reduced, which can generate shame about the pace of recovery and the persistence of pain.
The Buddhist framework that saturates the period says something different: suffering is the fundamental condition of existence and arises from attachment. The task is not to eliminate suffering but to change one's relationship to it. That's potentially a much more realistic and compassionate frame than the modern therapeutic promise of recovery. The Edo physician who has absorbed this framework does not need to promise that the pain will go away. He only needs to be present with it, to treat what the body offers for treatment, and demonstrate through his own continued presence that suffering can be witnessed without the one witnessing it being destroyed by it.
The architecture of Izo's relationship with Takechi Hanpeita would not be seen as a medical problem by our Edo doctor. He might observe that his patient seems distressed in connection with his teacher and could note the particular quality of the pulse when the teacher is mentioned. He might even realize, through clinical experience, that his patient's suffering is organized around this relationship in some unusual way, but he would have no framework to understand what the relationship is doing to the patient's sense of self, no concept of attachment trauma, and no theory of how early relational experiences have shaped adult Izo's capacity for self-regard.
The Edo doctor would also absolutely miss the difficulties Izo has with reading and writing as dyslexia or some other learning difference. He would consider it to either be insufficient effort or insufficient intelligence, which is exactly what has been doing damage to Izo for years.
Izo's drinking would be understood as a problem but not as a strategy for self-soothing. The Edo period framework would consider alcohol as something that generates damp-heat in the body, harms the liver and stomach, and clouds the spirit. Which is all correct in its way. But it does not capture the drinking having become the patient's primary tool to regulate his nervous system enough to sleep, and therefore lacks any specific approaches to reducing alcohol use.
The (passive) suicidal ideation is probably the most serious gap between the Edo doctor and our modern framework. He might recognize that the patient seems to not be trying to live, but he would have no systematic way to assess or address it.
Izo's visit with a skilled kampo doctor might look something like this:
The doctor would take his pulse at each visit and adjust the herbal prescriptions accordingly, which means each visit involves laying hands on the patient, which is both medical and relational. Physical contact, in a person who has had his body treated as a tool and an obstacle, as something to be used and punished and sent back out regardless of its condition, is not a neutral clinical act. The doctor taking his pulse carefully, attending to it, adjusting treatment based on what the body is reporting, communicates something about the value of the body that the patient has not been receiving.
The doctor would give concrete, practical instructions: eat this, avoid that, take this decoction at this time, rest when possible, reduce the sake. The concreteness is important for Izo specifically: he functions best when he has something to do, something to follow, or a structure to orient within. The herbal prescription is not just medicine but a daily practice that encodes the physician's continued attention and gives the patient a tangible action that constitutes taking care of himself.
The doctor would also be a consistent, predictable presence who returns when he says he will return and treats the patient the same way each time regardless of whether the patient has improved or worsened or relapsed or failed to follow instructions. Consistency of this kind is treatment for a nervous system that has been shaped by inconsistency.
The doctor likely would find ways to talk with the patient about his teacher. Not as a therapeutic intervention consciously designed to address the attachment trauma, but because a doctor who is paying attention will notice that when the teacher is mentioned, something happens in the pulse and something happens in the face, and because a physician who cares about his patient will eventually, gently, find ways to sit with him in that particular pain.
He would, in the context of Buddhism available to him, be able to say something true about attachment and suffering that is not equivalent to the modern therapeutic frame but would be helpful regardless. That the suffering of losing a person one has loved (even a person who proved unworthy of that love) is real suffering, and that real suffering is not something to be ashamed of or managed away, but something to be sat with until it changes shape.
What is Lost in the Period Treatment
+ Passive suicidal ideation would go unrecognized as a specific clinical risk. The doctor might sense that the patient seems not to be trying to live, might increase specific herbs,or might spend more time with him. But he would not have a systematic assessment tool and he would not have language for the specific risk.
+ The mechanism of the adrenaline response would never be explained to the patient. Izo would carry the belief that the involuntary laughter is something wrong with him indefinitely, because the period framework has no account of adrenal flooding that would constitute a corrective explanation. The shame around it would persist.
+ The dyslexia would never be named. He would remain, in his own accounting, a man who is stupid, because no one in his period had the framework to tell him otherwise.
+ The schema-level self-concept damage would be addressed only incidentally, through the accumulation of corrective relational experience with the physician rather than through targeted intervention. This is slower and less complete than schema therapy but would likely produce some change over time.
Special thanks to my friend A, who asked not to be identified but who put his Master's of Science degree in Oriental Medicine and NCCAOM (Nationally Certified Diplomat of Oriental Medicine) Chinese Herbalist certifications to good use prescribing Izo the specific decoctions in this post.
