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Japanese folk medicine;
Katsu; resuscitation, Katsu

Katsu: Traditional Japanese Resuscitation Methods

Twelve traditional Japanese resuscitation methods, called Katsu, are de- scribed, and their history and medical aspects are compared with those of traditional Western methods of manual resuscitation. Five katsu, developed parallel to but independently of traditional Western methods, are inferior to CPR and are of historical interest, only. Seven katsu not evaluated by West- ern researchers could be valuable if proven effective because they can be applied where CPR cannot. [Lang TA: Katsu: Traditional Japanese resuscita- tion methods. Ann Emerg Med January 1984;13:40-44.]

INTRODUCTION

Katsu (pronounced "kot-soo") are traditional Japanese resuscitation meth- ods. In the strictest sense, they are methods of restoring life or conscious- ness; in the broadest sense, they are first-aid procedures for treating a variety of conditions, including trauma to the head, kidneys, or testicles; anxiety; choking; muscle spasms; and nausea. Twelve katsu are described and their similarities to traditional Western methods of manual resuscitation are ex- amined.

DESCRIPTION

The katsu described here are classified either as mechanical methods, which involve manipulating the body to provide respiration, or as stimula- tion methods, which involve striking the body. Thus the mechanical meth- ods closely resemble several Western methods of artificial respiration, and the stimulation methods are reminiscent of the precordial thump.

Mechanical Methods

In Deguchi Katsu, the rescuer straddles the supine victim, pushes down on the victim's lower ribs to force expiration, then relaxes his push to allow inspiration (Figure i). The method is similar to the Howard method 1 of 1871 and to the LeRoy method of 1829, in which the rescuer kneels at the victim's side.1

In Hon Katsu, the rescuer straddles the supine victim, lifts the victim's hips to force inspiration, and lowers them to allow expiration (Figure 2). The hips are lifted until the shoulders leave the ground. Francis, in 1886, de- scribed a similar method, the only difference being that the supine victim was laid across a plank that was then lifted by two rescuers. 1

In So Katsu, the rescuer kneels by the supine victim and sharply com- presses the victim's epigastrium with the heel of his hand to force expiration. Inspiration follows passively (Figure 3). The method is identical to the ap- plication, but not the purpose, of the Heimlich maneuver for a supine vic- tim.2 The method also resembles the Osterreich pole-top method developed in 1931 to treat workers on electric power poles. 1

In LiraKatsu, the rescuer straddles the prone victim, lifts the victim's hips to force inspiration, and lowers them to allow expiration. The weight of the upper body counteracts the lift and stretches the chest for inspiration (Figure 4). Ura Katsu and the Emerson method 1 of 1948 are identical. Thompson evidently described a similar method in 1935.3

In Eri Katsu, the rescuer supports a sitting victim from behind and grips the victim's lapels from under his arms. Expiration is forced by compressing

Thomas A Lang
Loma Linda, California

From the Department of Respiratory Care, Loma Linda University Medical Center, Loma Linda, California.

Received for publication April 6, 1983. Accepted for publication June 20, 1983.

Address for reprints: Thomas A Lang, Medical Writer, Department of Respiratory Care, Loma Linda University Medical Center, Loma Linda, California 92354.

13:1 January 1984 Annals of Emergency Medicine

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KATSU

Lang

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the victim's thorax forward and down, inspiration by arch- ing the victim's back and raising his arms with the elbows (Figure 5). The method is not described in Western medical literature.

Stimulation Methods

Traditionally the stimulation katsu were to be applied in the order given until the victim revived or was considered dead. Each katsu was believed to be more potent than the preceding one.

In Se Katsu, the rescuer supports a sitting victim from behind and strikes a glancing blow with a cupped hand over the spinous processes of the fifth and sixth thoracic ver- tebrae (Figure 6). At the same time, the rescuer delivers a focused shout to the base of the victim's skull. This method is used today to revive quickly judo players who have been "choked out."

In Ashi Katsu, the rescuer sharply slaps the bottom of the victim's left foot (Figure 7). The slap is focused on the mid- line, below the ball of the foot.

In Nuki Katsu, the rescuer supports the supine victim on his thighs and drives his middle fingers into the cavity above the collar bones and toward the lower sternum (Fig-

ure 8). On each hand, the index finger is crossed over the middle finger to reinforce it during the motion.

In Tsume Katsu, the rescuer bites one of the victim's fin- gemails or toenails just above the quick of the nail. The finger may be wrapped with several layers of cloth to pre- vent the teeth from cutting it.

In Futo Koro Katsu, the rescuer stimulates the areola of the breast (not the nipple)with a pin or an ember.

Hiza Katsu is similar to Se Katsu. The rescuer stands be- hind a sitting victim and drives his knee into the fifth or sixth thoracic vertebra.

In Shiri Katsu, the rescuer removes the victirfi's clothes from below the waist and turns him to a face-down posi- tion. The rescuer lifts the victim's buttocks up and back until the victim's thighs are vertical. Supporting the victim in this position, and from the side, the rescuer drives the middle three fingers of one hand into the victim's rectum with a corkscrew motion.

HISTORY

Katsu come from seifukujutsu (say-fu-ku-joot-su), Japan's folk medicine tradition. In medieval times, they began to be incorporated into the military traditions, and many are pre-

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served today in Japan's classical martial arts, particularly in jujitsu, a traditional form of unarmed combat that gave rise to the modem sport of judo.

Most of japan's martial traditions, including katsu, were closely guarded secrets until the early 1900s. Techniques were kept within the clan and transmitted orally and by demonstration. Some techniques were recorded or illus- trated on scrolls, but they were described metaphorically to confuse the uninitiated. Katsu were considered kuden or "most-secret" techniques and may never have been re- corded. Thus their origins and development are difficult to trace.

In the late 1800s, the secrecy surrounding many martial traditions was dropped, and katsu were taught more openly. Today more than 100 katsu have been identified. 4 Many of these are described in martial arts texts,s-lo

The methods described here are from a group collected by Henry Seishiro Okazaki, a physical therapist and jujitsu master.lO In the early 1900s, Okazaki toured Japan to study jujitsu and seifukujutsu, including katsu. He included kat- su and other seifukujutsu techniques in Kodenkan Jujutsu, a comprehensive system of martial traditions that he found- ed and taught in Hawaii from 1929 until his death in 1951.

Fig. 1. Deguchi Katsu, expiration phase. The method is easi- ly performed, even by a small person on a larger one. The supine position increases the difficulty of keeping the air- way open, and the pressure on the lower ribs during forced expiration may aggravate or cause trauma to the chest.

Fig. 2. Hon Katsu, respiration phase. The method requires considerable strength; rescuers fatigue quickly The method is not suitable for small rescuers and large victims. Hyper- extension of the victim's lumbar spine may.present prob- lems, especially if the victim is lifted by his belt or at the waistdine rather than by his hips. Thesupine position pres- ents the expected airway problems, and the head may slide on the ground as the hips are lifted and lowered.

Fig. 3. So Katsu, expiration phase. The force needed to pro- duce expiration is considerable and increases the danger of aggravating or causing trauma to the chest and abdomen. It is also fatiguing. The palm and the thrusts must be posi- tioned and directed accurately.

Fig. 4. lira Katsu, inspiration phase. The method requires considerable strength. The extension of the spine aids m inspiration, and the prone position favors an open airway The victim's head may •ag on the ground as the hips are lifted and lowered.

Fig. 5. Eri Katsu, (a) expiration and (b) inspiration. The method is reasonably easy to perform, although the rescu- er's arms may fatigue from splaying to lift the victim's arms. The sitting position precludes the method in cases of back or chest injuries, and it is not ideal for airway mainte- nance, Gripping the lapels is helpful in performing the method, although not necessary.

Fig. 6. Se Katsu. Traditionally, the cupped-hand strike to the spine at T5 or T6 was believed to force air into the nerves at the area of the strike. The focused shout, or kiai (pronounced key-eye, literally "'harmonizing energy") was thought tostimulate nerves in the brain stem.

MEDICAL ASPECTS

Information on katsu in Western medical literature is limited. Norton 11 described several different katsu and the- orized on their effectiveness but reported no clinical trials. He recommended that katsu be evaluated clinically. De

13:1January1984 Annals of Emergency Medicine 42/75

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KATSU

Lang

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Fig. 7. Ashi Katsu. The strike is a sharp slap that continues past the foot after impact. The rescuer traps the victim's right leg under his shin to avoid injury should the victim convulse.

Fig. 8. Nuki Katsu. The finger jab should push the victim off the thighs.

Winter12 maintained that katsu provide reflexogenic stim- ulation of skin sites, respiratory effects, and cardiac effects. He did not detail his assertions, however.

Hyodo4 stated that katsu are based on artificial respira- tion, cardiac massage, stimulation of the nervous system, and "renewed circulation of stagnant blood to the heart." He also reported that "strict psychic concentration" is required on the part of the rescuer. He described a variation of So Katsu in which the rescuer "... uses the heels of both hands to shove sharply and upward the victim's lower abdo- men toward the chest . . . . Continuous recordings of ven- tilationand arterial and venous pressures showed the induc- tion of maximum breathing and increased endotracheal pressure up to 40 mm H20. Blood pressure at the femoral artery reached 20 mm Hg and over."

He claimed that the effects of closed-chest cardiac mas- sage on respiration and circulation are "inferior" [sic] to those produced by katsu, and that katsu are less likely to cause such complications as fractures or organ rupture. On the basis of clinical experience, he concluded that while katsu are not necessarily always the resuscitative methods of choice, they are reasonably effective, especially in treat- ing "so-called reflex collapse by mechanical trauma or men- tal shock." His research indicated to him that "katsu meth- ods are based on rational factors even from the viewpoint of modem medicine. ''4

DISCUSSION

The similarities between traditional Japanese mechanical katsu methods and traditional Western methods of artificial respiration raise the question of independent origin. There have been Japanese translations of European medical litera- ture since 1706;13 whether this literature included the re- suscitation methods of LeRoy (1829), Howard (1871), or Fran- cis (1886) is unknown, although it probably included the

later methods of Thompson (1935)and Emerson (1948). If, as a group, these katsu methods were adopted from Europe, then conspicuous by their absence are the Silvester Method (1861), the Holger-Neilson Method {i932), and the Schafer- Emerson Methods (1948). These three methods were the methods of choice in Western medicine until the introduc- tion in the 1960s of mouth-to-mouth respiration and closed- chest cardiac massage (CPR).1Considering these omissions and the secrecy with which katsu were treated, it is most likely that katsu developed independently of Western influ- ences.

If the development of these methods was independent, it was also parallel. Early practitioners in each culture devised methods of artificial respiration based on the following premises:

1)Inspiration can be assisted or induced by lifting the arms, arching the back or otherwise raising the rib cage;

2) Expiration can be induced by compressing the chest; and

3) If one half of the respiratory cycle is forced, the other half will follow passively as a result of the elasticity of the thorax. Thus these methods may involve forced inspiration and passive expiration, passive inspiration and forced ex- piration, or forced inspiration and forced expiration (Table}.

Gordon et al,14in comparing Western manual methods of artificial respiration, discovered that only those methods in- volving both forced inspiration and forced expiration pro- vided tidal volumes greater than normal resting tidal vol- umes. Thus Eri Katsu (the lapel method)is probably the only katsu capable of providing a sufficient tidal volume. However, the sitting position of the victim, the necessary flexion and extension of his spine, and the strength needed to apply Eri Katsu seriously limit its application as a first- aid procedure.

The stimulation methods appear to be unique to Japan. Anecdotal evidence (P Browne, Professor, Danzan Ryu Jujut- su, personal communication, Chicago, June 1980)indicates that Se Katsu, Nuki Katsu, and Ashi Katsu occasionally have restored a pulse, but none of the stimulation methods has been evaluated clinically. Because they can be applied in situations in which CPR cannot, as in the case of victims trapped in automobiles or with serious chest or facial wounds, the stimulation methods could be useful if proven effective.

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TABLE. Summary of traditional Japanese and Western methods of manual resuscitation

Japanese Method

Deguchi Katsu

Rescuer straddles and rhythmically compresses victim's chest with hands

Hon Katsu

Rescuer rhythmically lifts and Iowers victim's hips

So Katsu

Rescuer rhythmically pushes victim's epigastrum down and forward with his phtm

Ura Katsu

Rescuer straddles and rhythmicalfy lifts victim's hips

Eri Katsu

Rescuer rhythmically flexes and extends victim's back from behind

Western Method Howard (1871)1

Position of Victim Supine

Supine Supine

Prone Sitting

Supine

Prone

Prone

Inspiration/Expiration Passive/forced

Forced/passive Passive/forced

Forced/passive Forced/forced

Forced/forced

Forced/forced

Forced/forced

SUMMARY

The mechanical katsu methods probably developed inde- pendently of the Western methods of artificial respiration they so closely resemble. Because mechanical katsu meth- ods provide inadequate tidal volumes, involve awkward positions for the victim, and/or require excessive strength to perform, they are not to be preferred to standard CPR; they are of historical interest only. The stimulation meth- ods have not been evaluated by Western researchers. Be- cause they can be applied in situations in which CPR can- not, they could be useful if proven effective.

REFERENCES

1. Gordon A {ed): History and Evolution of Modern Resuscitation Techniques. Cardiopulmonary Resuscitation Conference Proceed- ings, National Research Council. NRC Publication No 1494, 1966.

2. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA i980;244:453-509.

3. Gordon A, Sadove M, Raymon F, eta]: Critical survey of man- ual artificial respiration. JAMA 1951;147:1444-1453.

4. Hyodo M: A study of judo resuscitation. Proceedings, 2nd Asi- an and Australasian Congress of Anesthesiology. Tokyo, 1966, p

138-139.

(LeRoy, 1829 not identicaf)~

Francis (I886)1 Osterreich (t 931 )

Emerson (1948)1 (Thompson, 1935 - - but not identical)3

Sylvester (1861)~
Rescuer rhythmically compresses victim's chest and extends victim's arms

Hotger-Neifson (t932) ~ Rescuer compresses victim's upper back and lifts victim's elbows forward

Schafer-Emerson (1948)1 Rescuer straddJes and rhythmically compresses victim's thorax and lifts victim's hips

similar but

simiPar

13:1 January 1984 Annals of Emergency Medicine 44/77

5. Hancock I, Higashi K: The Complete Kano Jujitsu. London, Putnam, 1907, p 503-507.

6. Mifune K: The Cannon of ]udo. Tokyo, Seibundo-Shinkosa Publishing Co, 1956, p 242-245.

7. Koizumi G: My Study of Judo. New York, Sterling Publishing Co, 1960, p 155-i56.

8. Untranslated Japanese manuscript. Library of Congress catalog No GV475 J98, vol 5.

9. Matsunosuke I: An illustrated introduction to kenpo. 1898 {Untranslated Japanese manuscript in author's collection).

10. Lang T: The Kata Manual of the American Judo and Jujitsu Federation, ed 2. Chico, CA, American Judo and Jujitsu Federa- tion, 1980, p 67-78.

11. Norton M: Kappo -- An oriental form of resuscitation. Med Sci Sports 1969;1:99-105.

12. De Winter E: Kuatsu. Abbottempo 1963;1:12-15.
13. Veith I (trans}:
The Yellow Emperor's Classic of Internal Medi-

cine. Berkeley, University of California Press, 1966, p 73.

I4. Gordon A, Rayman F, Sadove M: Manual artificial respiration; comparison of effectiveness of various methods in apneic adults. JAMA 1950;i44:1447-1452.

 

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