Epidemics and Mortality in Early Modern Japan [Course Book ed.] 9781400858378

Citation preview

Epidemics and Mortality in Early Modern Japan

Epidemics and Mortality in Early ModernJapan

ANN BOWMAN JANNETTA

PRINCETON UNIVERSITY PRESS PRINCETON, NEW JERSEY

Copyright © 1987 by Princeton University Press Pubhshed by Princeton University Press, 41 Wilham Street, Princeton, New Jersey 08540 In the United Kingdom Princeton University Press, Guildford, Surrey All Rights Reserved Library of Congress Cataloging in Pubhcation Data will be found on the last printed page of this book ISBN 0-691-05484-3 Publication of this book has been aided by a grant from TheJapan Foundation This book has been composed m Monophoto Bembo Clothbound editions of Princeton University Press books are printed on acid-free paper, and binding materials are chosen for strength and durability Printed in the United States of America by Princeton University Press, Princeton, NewJersey Frontispiece Woman and Child with Measles Courtesy of Clements C Fry Collection, Yale Medical Library

TO MY P A R E N T S

Edna Cowgill and Raymond Tomlinson Bowman

CONTENTS

LIST OF TABLES

ix

LIST OF ILLUSTRATIONS

Xl

PREFACE

L II.

Introduction

16

Disease Characteristics

16

Community Disease Patterns

19

The Early History of Epidemic Diseases

25 27

The Japanese Sources The Descriptive Accounts The Kakocho

IV.

Smallpox: The Most Terrible Minister of Death

SmaDpox in the Tokugawa Period Smallpox in Isolated Communities

100

The Early History of Smallpox in Japan

VI.

Measles: An Epidemiological Puzzle

108

DiseaseCharacteristics

110

The Early History of Measles in Japan

114

The Tokugawa Measles Epidemics

117

Measles Mortahty in Other Societies

141

Dysentery and Cholera: Early and Late Arrivals

145 146 147 155

Disease Characteristics Dysentery Epidemics in PremodernJapan Cholera Epidemics in TokugawaJapan

VII.

Epidemics and Famine The Hida Records

173 176 178

Conclusions

188

GLOSSARY

209

BIBLIOGRAPHY

211

INDEX

219

TheDescriptiveSources

VIII.

33 36 50 61 62 65 70

Disease Characteristics

V.

3

Epidemic Diseases and Human Populations

TheJapaneseExperience

III.

Xvil

LIST OF TABLES

3.1 3.2 3.3 3.4 4.1 4.2 4.3 4.4 5.1 5.2 5.3 5.4 5.5 5.6 5.7 6.1 6.2 7.1

Epidemics per Century: Japan to 1868' ChronologyofEpidemicsintheTokugawaPeriod Distribution of Deaths from Epidemic Diseases by Age Group, Hida Villages: 1771—1852 Distribution of Deaths by Cause by Age Group, Hida Villages: 1771-1852 Years of Recorded Smallpox Epidemics and Intervals Between Epidemics: Japan to 1868 Smallpox Epidemics, Hida Villages: 1771—1852 Distribution of Smallpox Deaths by Age, Hida Villages: 1771-1852 Ages of 25 Children for Whom Sasuyu for Smallpox Were Held in Edo Castle: 1812-1840 Years of Recorded Measles Epidemics and Intervals Between Epidemics: Japan to 1868 Chronology of Measles Epidemics in the Tokugawa Period Distribution of Measles Deaths by Age and Epidemic Year, Hida Villages Distribution of Measles Cases by Age, Edo Castle: 1824 Measles Mortality in the Hida Villages: 1771—1852 Distribution of Measles Deaths by Age, Hida Villages: 1771-1852 Measles Mortality in the Faeroe Islands: 1846 Years and Seasons of Dysentery Epidemics: Japan to 1868 Distribution of Dysentery Deaths by Age Group, Hida Villages: 1771-1852 Deaths Attributed to Starvation and Jieki, Hida Villages

44 49 59 60 68 79 90 99 117 119 130 131 140 141 143 148 153 182

LIST OF ILLUSTRATIONS

MAPS

Maps drawn by Jon Coulter. 1. Japanese Islands 2. Hida Villages

xiv χν FIGURES

Figures drawn by William R. Filer. Original data source: Suda Keizo, Hida "O" jiin kakocho no kenkyii, unless otherwise indicated. 3.1

Distribution of Deaths by Year, Hida Villages: 1771-1852 3.2 Distribution of Deaths by Year, Excluding Those Due to Epidemic Diseases, Hida Villages: 1771—1852 4.1 Distribution of Smallpox Deaths by Year, Hida Villages: 1771-1852 4.2 Distribution of Smallpox Deaths by Month, Hida Villages: 1771-1852 4.3 Distribution of All Deaths by Month, Hida Villages: 1771-1852 4.4 Correlation of Intervals Between Smallpox Periods with Numbers of Smallpox Deaths, Hida Villages: 1771-1852 4.5 SmallpoxPeriod 1: 1771-1773 4.6 Smallpox Period 2: 1778-1779 4.7 Smallpox Period 3: 1783-1785 4.8 Smallpox Period 4: 1789—1791 4.9 Smallpox Period 5: 1796-1798 4.10 Smallpox Period 6: 1804—1805 4.11 Smallpox Period 7: 1810-1812 4.12 Smallpox Period 8: 1816—1817 4.13 Smallpox Period 9: 1823-1824 4.14 Smallpox Period 10: 1827 4.15 Smallpox Period 11: 1829 4.16 SmaHpox Period 12: 1831-1832 4.17 Smallpox Period 13: 1835-1837 4.18 Smallpox Period 14:1839—1840

57 58 78 78 79

80 80 81 81 81 82 82 82 83 83 83 84 84 84 85

ILLUSTRATIONS

Xll

4.19 4.20 4.21 4.22 4.23

4.24 4.25

5.1

5.2

5.3 6.1 6.2 7.1 7.2 7.3

Smallpox Period 15: 1842-1843 Smallpox Period 16: 1845—1847 Smallpox Period 17: 1851—1852 Age Distribution of Smallpox Deaths of Children to Age 10, Hida Villages: 1771-1852 Distributions of Smallpox Deaths and Deaths from All Other Causes by Year, Children to Age 5, Hida Villages: 1771-1852 Distributions of Estimated Births and Deaths by Year, Hida Villages: 1771-1852 Distributions of Estimated Births and Deaths by Year, with Smallpox Deaths Removed, Hida Villages: 1771-1852 Proportion of Measles Cases by Age Group (Japanese Age), Izumi Province, 1862 Data from Matsuda Takeshi, "Edo jidai no mashin ryuko." Proportion of Measles Cases, 21 to 30 sai, Izumi Province, 1862 Data from Matsuda Takeshi, "Edo jidai no mashin ryuko." Distribution of Measles Deaths by Year, Hida Villages: 1771-1852 Distribution of Dysentery Deaths by Year, Hida Villages: 1771-1852 Distribution of Dysentery Deaths by Month, Hida Villages: 1771-1852 Distribution of Deaths Attributed to Starvation by Year, Hida Villages: 1771-1852 Differential Mortality Curves Distribution of Starvation and Jieki Deaths by Month, Hida Villages, 1837-1838

85 85

86 92

93 96

96

132

133 139 151 152 179

180 183

ILLUSTRATIONS

1. 2. 3. 4.

Child with Smallpox. Courtesy of Samuel X. Radbill, M.D. Sasuyu Ceremony for Recovery from Smallpox. Courtesy of the National Library of Medicine. Washington, D.C. Subduing the Measles Demon. Courtesy of the National Library of Medicine, Washington, D.C. Samurai and Measles Demons. Courtesy of the National Library of Medicine, Washington, D.C.

72 98 135 136

ILLUSTRATIONS

5. 6.

Magical Treatment of Child with Measles. Courtesy of Clements C. Fry Collection, Yale Medical Library Incineration of Corpses During the Cholera Epidemic of 1858. Courtesy of Les Editions Roger Dacosta

xiii

137 167

1. Japanese Islands

2. Hida Villages

PREFACE

The genesis of this book was the desire to learn whether the epidemics of bubonic plague that periodically devastated the populations of Europe between the fourteenth and seventeenth centuries caused similar havoc in Japan. The first epidemics of bubonic plague to strike Europe in the latter half of the fourteenth century became known as the Black Death. The name reflects both the symptoms of the disease and the high mortality that it caused. The consequences of the plague—the reduction of much of the world's population between India and Europe by one-third to one-half within half a century— have fired the imaginations of historians ever since. Indeed, the im­ pact of this one disease on the political, social, and economic insti­ tutions of medieval Europe is regarded as a watershed in European history that separates the Middle Ages from the modern era. The importance of bubonic plague in European historiography has meant that the histories of other epidemic diseases have also been carefully scrutinized, and studies of changing causes of mortality have come to occupy a central place in the history of the West. I was therefore surprised to learn that epidemics are not regarded as an important topic in Japanese history, and I became curious to learn why this was so. It is well known that Japan is afflicted with more than her share of natural disasters: earthquakes, volcanic eruptions, tidal waves, and typhoons are relatively common occurrences, and fire has been an unusually destructive force. It seemed possible that the pro­ minence of these catastrophes had made epidemic diseases seem, by comparison, much less significant. Well aware that infectious diseases are common in all societies, particularly so before the twentieth cen­ tury, I began to search for Japanese source materials that described epidemics of the past. It soon became evident that the history of epidemics is not con­ sidered by the Japanese to be in the mainstream of historical explana­ tion. Japanese bibliographers politely suggested that I would do well to study something else. Fire, flood, and famine were important causes of disaster and topics worthy of research, they said, but epidemics were not. My search for source materials seemed to confirm their opinion. I found no studies pertaining to Japanese epidemics in West­ ern historical literature; and, in consultations with epidemiologists and historians of medicine, I learned that virtually nothing was known in the West about the history of epidemic diseases in Japan. A review of

xviii

PREFACE

the Japanese secondary literature revealed that Japanese historians have had little interest in the history of disease, and even Japanese histories devoted exclusively to disasters rarely include information about dis­ asters caused by epidemics. Was it possible that epidemics were unimportant in premodern Japan, as I had been warned? If so, it seemed to me that this was an im­ portant revelation that merited investigation. It was difficult to ima­ gine a preindustrial society in which epidemics were not important. I eventually learned that in Japan the history of disease is a small subcategory of the history of medicine. Japanese historians of medi­ cine are usually physicians who publish their work in a few select journals supported by schools of medicine. Japanese guides to period­ ical literature are divided into two main categories—social science and natural science—and the history of medicine falls into neither category. For this reason, it is difficult for scholars to gain access to Japanese literature on the history of disease. My first breakthrough occurred at the National Library of Medi­ cine, in Washington, D.C. A search through the card catalogue for the name of a Japanese journal devoted to the history of medicine eventually turned up Nihon ishigaku zasshi (A journal of the history of medicine in Japan). Most of the articles in this journal are devoted to the influence of Western medicine on Japanese medicine; however, several articles concerned with the history of epidemic diseases in Japan opened the door to a small but excellent Japanese literature on this subject. It is a major objective of this book to bring this literature out of obscurity and into the mainstream of both Japanese and West­ ern historical analysis. The epidemic diseases of the early modern, or Tokugawa period (1600—1868), are the focus of this study. Epidemic diseases are studied from different vantage points by social historians, historians of medi­ cine, epidemiologists, and demographers. However, these diverse groups share a common interest. All are concerned with measure­ ments of social progress or decline, or with comparisons of conditions in different societies. There is a consensus that before the advent of modern medicine, acute infectious diseases were a major cause of premature death in all preindustrial societies. But the studies from which this argument is derived are based almost exclusively on the historical experience of Western, primarily western European, coun­ tries. The excellent source materials of premodern Japan provide an opportunity to determine whether this maxim also applies to a nonWestern society. Especially appropriate for research on epidemics of the past are descriptive accounts written by contemporary observers and registers

PREFACE

xix

of deaths. Contemporary accounts provide a chronology of epidemics and document their severity in general terms, but they provide little indication of the changing impact of epidemics on mortality. Death records, when they are well kept, give a much closer look at changing mortality patterns. In Japan, descriptive accounts of major epidemics date from the late seventh century, and by the Tokugawa period death records are available for many localities and regions. This study uses contemporary descriptive accounts and Buddhist temple death registers to reconstruct the history of important epidemic diseases in early modern Japan. The use of temple death registers, or kakocho, to study mortality is a notable departure from the earlier work of Tokugawa scholars interested in historical demography. It was my good fortune to hear of an unusually fine temple register after my research on Japanese descriptive accounts was well under way. An obscure footnote in an article on life expectancy in TokugawaJapan led me to the death registers of Ogen-ji, a Buddhist temple near Takayama in the Hida region of Gifu prefecture. Suda Keizo, a phy­ sician who lives in Takayama, generously provided me with data that he had hand-copied from the Ogen-ji register. This particular register is an unbroken series of death records that spans two centuries (1771 — 1970). These records added a new dimension to this study: it was possible to combine the very detailed information contained in the Ogen-ji register with the general, impressionistic evidence provided by contemporary accounts. In the end, my search for epidemics of bubonic plague in premodern Japan went unrewarded. Although the question of whether the early pandemics of bubonic plague reached Japan merits further study, the Japanese sources reviewed here reveal no evidence of plague in Japan before the late nineteenth century. Finding the ab­ sence of plague puzzling, I turned my attention to discovering what were the important epidemic diseases of premodern Japan. This book is a history of those diseases and an attempt to assess their impact on mortality in Japan before the coming of the Western powers in the mid-nineteenth century. Many people have contributed to the research effort that produced this book, and it is a pleasure to thank them. I owe a special debt of gratitude to many members of the faculty of the Department of History at the University of Pittsburgh. In particular, I am beholden to JuHus Rubin, who first stimulated my interest in comparative economic development history and the fascinating field of historical demography. I am also deeply grateful to Evelyn S. Rawski and Richard J. Smethurst, who guided this study through its dissertation phase and made significant contributions at every stage of the re-

XX

PREFACE

search. Their enthusiasm for this project encouraged me to begin it, and their suggestions, criticisms, and continuing support made it pos­ sible to carry the project to completion. Other faculty members of the University of Pittsburgh who made important contributions to this research are L. Keith Brown and Richard Scaglion of the Depart­ ment of Anthropology, and Philip S. Sidel, Director of the Social Science Computer Research Institute. In Japan generous assistance was rendered by Hayami Akira, Pro­ fessor of Economics at Keio University, and by Suda Keizo, of Takayama, Gifu-ken. Professor Hayami directed my research efforts in Japan, and his many kindnesses on my behalf made my work there both productive and memorable. Dr. Suda generously sent his data to a graduate student whom he had never met, and after a year of consultation by mail he and his family welcomed me to Takayama and assisted my research efforts there. Miwa Makiko introduced me to libraries and librarians in Tokyo, and her translation of Hara Nanyo's Sokei Guki made an important contribution to this study. I am also grateful to Goto Keiji, Assistant to the Director at the Medical Library and Information Center of Keio University; Koide Izumi, Assistant Librarian at The International House of Japan, in Tokyo; and Miya­ moto Mami of Kyoto, who served admirably as companion and interpreter in Takayama. Although my purpose in studying the history of epidemics in Japan was to gain a better understanding of Japan's social and demographic history, it quickly became apparent that any useful analysis of acute infectious diseases based on Japanese sources must be able to withstand the scrutiny of epidemiologists and historians of medicine. I was, therefore, especially fortunate to gain the assistance of Philip S. Brachman, M.D., Director, Global Epidemic Intelhgence Service, at the Centers for Disease Control, who read all of the chapters on disease and offered critical advice on the discussion of infectious disease in Chapter II. Dr. Brachman also directed the chapters on smallpox, measles, and diarrheal diseases to specialists for comment. Donald R. Hopkins, M.D., Deputy Director, Centers for Disease Control, who is a world authority on smallpox, became a true collaborator. His per­ sonal knowledge and experience with smallpox made a significant contribution to the discussion of this disease in Chapter IV. I am further indebted to the late John Durand, Professor of Economics and Sociology at the University of Pennsylvania, who served as a consultant during the planning stages of this study, and to Laurel L. Cornell, Susan B. Hanley, William B. Hauser, Ronald P. Toby, Etienne van de Walle, Rubie Watson, and Susan Zimiki, who read and commented on all or part of the manuscript. Invaluable

PREFACE

xxi

assistance in locating Japanese woodblock prints to illustrate the text was rendered by Jonathon Erlen, Curator, History of Medicine, Uni­ versity of Pittsburgh; Susan Wheeler, Curator of the Clements C. Fry Collection, Yale University Medical Library; Samuel X. Radbill, M.D., private collector; and librarians at the History of Medicine Division, National Library of Medicine, Washington, D.C. An indispensable service was rendered by Cleat Szczepaniak and Donna Visciarelli, who typed the manuscript and never lost interest in it. Retsuko Sims expertly translated numerous articles, and Joan Meanor and Karen Muslovski, both of the Social Science Computer Research Institute, key-punched the death data and were always on hand to solve knotty computer problems. Very special thanks are due my husband, Peter, and my children, for their support and encouragement of a project that, at times, must have seemed endless. My youngest daughter, Binney, merits special recognition for her editorial assistance and her diligence in preparing the bibliography. Friends and colleagues whose support has taken many forms over many years are James A. Bryan, Janelle Greenberg, Maurine Greenwald, Carolyn Schumacher, Diana Wood, Elizabeth Noroian, Margareta and Aage Moller, and Barbara and John Opie. Finally, I wish to express my appreciation to the Mellon Founda­ tion for two years of support as a predoctoral fellow, and to the Japan Council of the University of Pittsburgh for a postdoctoral fellowship to revise my dissertation for publication as a book. A generous grant from the Japan Iron and Steel Federation and Mitsubishi Endowment Funds, University of Pittsburgh, has helped to cover the cost of illustrations and preparation of the final typescript. The customary Japanese form for Japanese names—surname followed by given name with no comma—is used in text, notes, and biblio­ graphy. When a surname applies to more than one person, the given name will be used to distinguish between them. Macrons are omitted in the spelling of well-known Japanese cities and islands (Tokyo, Kyoto, Honshu, Kyushu), except in translations from the Japanese. The term sai is used to designate Japanese age in quotations translated from Japanese and in other special circumstances. Japanese calendar years before 1872 were of unequal length; there­ fore, two calendar systems—the Japanese lunar-solar calendar and the Western Gregorian calendar—are used to refer to dates. Japanese dates are used when Japanese descriptive sources are discussed or translated; e.g., "the sixth day of the ninth month." Gregorian dates are used whenever seasons of the year or comparisons between years were considered to be important. When Western month names are used, in

XXIl

PREFACE

table captions, and within tables and figures (unless otherwise speci­ fied), dates are according to the Gregorian calendar. All tables and figures pertaining to the Hida villages are based on data copied from the death registers of Ogen-ji and published by Suda Keizo in Hida "O" jiin kakocho no kenkyu. Chapter III provides a detailed explanation of the adjustments that were made in the data. A list ofJapanese terms for disease names can be found in the Glossary, and translations of titles of Japanese references are given in the Bibliography.

Epidemics and Mortality in Early Modern Japan

CHAPTER I

INTRODUCTION Malthus suggested that epidemic diseases played an important role in limiting population growth in preindustrial societies.1 Modern-day microbiologists agree with Malthus: "From the beginnings of agricul­ ture and urbanization till well into the present century infectious disease was the major overall cause of human mortality and the most important stabilizer of population levels."2 Malthus believed that a population would grow until it reached the limit of its resources. A society that had reached "Malthusian" limits would experience periods of population growth interrupted by sharp increases in mortality. "Positive" checks in the form of epidemics, famine, and war would intervene and reduce the size of the popu­ lation to former levels. Recurring mortality crises were the mecha­ nisms by which people and the resources that sustain them were brought into equilibrium. The mortality crises of preindustrial Europe have been well studied, and the historical evidence supports Malthus's pessimistic view. There are innumerable accounts of regional or local famines, of severe epidemics, and of seemingly endless warfare that caused periodic waves of high mortality. Analyses of parish records confirm the de­ scriptive accounts. They show that death rates were high and widely fluctuating in early modern Europe. M. W. Flinn has observed that "right through to the nineteenth century what was most normal about western European mortality was its instability." 3 Recently the dominant role of the positive check in constraining population growth in preindustrial times has been questioned. Some scholars have argued that in the long run, preventive checks that limited fertility were more important than mortality crises in check­ ing population growth. Recent research has shown that, in some parts of Europe, social controls that permanently or temporarily de­ layed marriage were especially important. A study by E. A. Wrigley and R. S. Schofield of the secular changes in births, deaths, and 1 Thomas Robert Malthus, Population: The First Essay (Ann Arbor: University of Michigan Press, 1959), p. 39. 2MacFarlane Burnet and David O. White, Natural History of Infectious Disease, 4th ed. (Cambridge: Cambridge University Press, 1972), p. 1. 3M. W. Flinn, "The Stabilization of Mortality in Pre-Industrial Western Europe," Journal of European Economic History 3 (1974) :317.

CHAPTER I

4

marriages in England over a period of three centuries concludes that changes in social behavior that affected fertility were the most im­ portant determinants of long-term demographic trends.4 In England, relatively late marriage ages kept fertility rates low and Umited popu­ lation growth.5 Those who consider fertility rates to be the most important determinant of population growth attribute the spurt in growth rates after 1740 to an increase in the birth rate, not a decrease in the death rate. H. J. Habbakuk, for example, argues that Europe's population increased in the eighteenth century even though con­ ditions that foster all manner of diseases were growing worse as cities became overcrowded centers for an expanding industrial work force.6 But the importance of the positive check in the history of early modern Europe—approximately 1500 to 1800—cannot be denied. Death rates were high in the best of times, especially among infants, young children, and adolescents;7 and periodic mortality crises—war, famine, and pestilence—killed people of all ages. Certainly in the short run, the positive check was effective in controlling population growth in Europe well into the eighteenth century. Scholars who stress the importance of mortality patterns as an explanation of low population growth rates in preindustrial societies argue that the sus­ tained population growth that began in parts of Europe during the eighteenth century was due to a decline in mortality. Flinn notes that mortality crises gradually became less severe, and that the intervals between them grew longer during the eighteenth century.8 And Thomas McKeown attributes the dramatic rise in population in nineteenth-century Europe to a decline in mortality that followed improvement in nutrition and an increase in the standard of living.9 Most studies of the mortality and fertility patterns in the prein­ dustrial world are based on the experience of western Europe, but it is not at all clear that the demographic regime of preindustrial Europe was typical of other societies. The history of Europe in the early modern period—a time of global expansion—was, in fact, markedly different 4E. A. Wrigley and R. S. Schofield, The Population of England, 1540—1981: A Re­ construction (Cambridge, Mass.: Harvard University Press, 1981), p. 158. 5Ibid.,

p. 459. Habbakuk, "English Population in the Eighteenth Century," in Population in History, ed. D. V. Glass and D. E. C. Eversley (Chicago, 111.: Aldine, 1965), pp. 274— 84. 7Lawrence Stone, The Family, Sex and Marriage in England 1500—1800 (New York: Harper and Row, 1977), pp. 66—70. 8M. W. Flinn, The European Demographic System, 1500-1820 (Baltimore, Md.: Johns Hopkins University Press, 1981), p. 95. 9Thomas McKeown, The Modem Rise of Population (New York: Academic Press, 1976), pp. 134-36. 6H. J.

INTRODUCTION

5

from the history of any other world region. It seems highly possible, therefore, that the demographic history of non-European countries was different as well. Regardless of whether a rise in the birth rate or a fall in the death rate initiated modern population growth in western Europe, mortal­ ity and fertility are inextricably linked. Mortality lowers fertility when a significant part of the population does not live to the age of repro­ duction; societies with high fertility rates typically have high mortality rates; and both mortality and fertility are influenced by nutrition and disease. Hence, it is clear that an understanding of the population dynamics of any preindustrial society requires an understanding of both mortality and fertility patterns. This book is concerned with epidemics and mortality in early mod­ ern Japan—the period from 1600 to 1868, which in Japan is called the Tokugawa, or Edo, period. It will argue that epidemic diseases were much less important as a cause of death and a stabilizer of population in preindustrial Japan than they were in preindustrial Europe. The reason for this difference, it will be suggested, is that Japan's geo­ graphy and her isolation from the major world trade routes provided a cordon sanitaire that prevented major diseases from penetrating Japan until the mid-nineteenth century. There is no question that epidemic diseases were a prominent cause of high death rates and sharp fluctuations in mortality in premodern and early modern Europe. Epidemics are caused by acute infectious diseases. In the popular sense of the word, an epidemic is "a preva­ lence of a particular type of infection which appears to be unusually concentrated in time and space."10 Bubonic plague, typhus, small­ pox, measles, and diarrheal infections are examples of diseases that frequently caused epidemics in preindustrial Europe.11 These are all communicable, or contagious, diseases that are associated historically with large, densely settled populations.12 Japan presents a particularly interesting comparative case. In 1600, Japan had one of the world's most densely settled populations. Esti­ mates at the beginning of the seventeenth century range from 10 to 18 million people, and during the first century of rule by the Tokugawa shogunate, Japan's population doubled, reaching approximately 30 million people by 1725.13 An especially prominent feature of Toku10Burnet

and White, Natural History, p. 127. pp. 1-2. 12 Richard N. T-W-Fiennes, Zoonoses and the Origins and Ecology of Human Disease (London: Academic Press, 1978), pp. 16-45, 75-83. 13Hayami Akira, "The Population at the Beginning of the Tokugawa Period," Keio Economic Studies 4 (1966—67): 19. 11 Ibid.,

6

CHAPTER I

gawa Japan, as of early modern Europe, was the growth of large urban centers. The most remarkable example was the city of Edo, which is believed to have been the largest city in the world, with approximately one million inhabitants by the early eighteenth cen­ tury.14 Studies of preindustrial European cities have shown that death rates were very high. These high mortality rates are attributed to the spread of infectious diseases through unsanitary, crowded urban areas. Since acute infectious diseases are dependent upon large, dense popu­ lations, one would expect to find that Japan and European countries suffered equally from epidemics. There were also important differences betweenJapan and Europe in the seventeenth and eighteenth centuries. From the early seventeenth to the mid-nineteenth centuries, demographic trends in Europe and Japan were reversed. In early modern Europe, population growth was slow and irregular, and it is doubtful whether Europe's population at the beginning of the eighteenth century had regained the losses sus­ tained during the plague epidemics of the fourteenth century.15 How­ ever, around 1740, western Europe entered a period of unprecedented and sustained population growth. In Japan, after more than a century of growth, national population growth ceased in the eighteenth and early nineteenth centuries. This period is known in Japanese history as the period of population "stability" or "stagnation," depending upon one's interpretation of economic development during the Tokugawa period. Perhaps the most important difference between the early modern societies of western Europe and Japan was the extent of their contact with other world regions. Europe's contact with African and Middle Eastern populations was considerable after A.D. 1000, and with the New World and Asia after 1500. Japan, on the other hand, remained relatively isolated geographically, and her people had little association with population centers outside East Asia. Even contact with East Asian populations was relatively limited before the mid-nineteenth century. Why did Japan's national population stop growing during the sec­ ond half of the Tokugawa period? This cessation of growth, at just the time when population growth rates accelerated in many parts of the world, has attracted much interest. Scholars who advocate a Marxist interpretation of Japanese premodern history have blamed Malthus's positive checks and have looked for evidence of disasters that caused mortality crises. 14Giibert Rozman, Urban Networks m Ch'ing China and Tokugawa Japan (Prince­ ton, N.J.: Princeton University Press, 1973), p. 77. 15Flinn, The European Demographic System, p. 26.

INTRODUCTION

7

Twenty-five years ago, a Malthusian interpretation of Japanese premodern population trends dominated both Japanese and Western scholarship. Irene Taeuber, a prominent demographer, sets forth this viewpoint in The Population of Japan. Although Taeuber focuses on post-Meiji demography, she begins with the assumption that the sta­ bility of Japan's population after 1725 indicates that Malthusian population limits within the traditional system of agriculture had been reached. She claims that mortality was high and fluctuating because famine and epidemics exerted the classic controls on population, and she speculates that Japanese cultural practices of abortion and infan­ ticide may have been responsible for a pattern of low fertility as well.16 But early modern Japan does not fit the European model very well. War, for example, must be eliminated at the outset. In 1600, Tokugawa Ieyasu achieved a political settlement that ushered in two and one-half centuries of peace known as the Pax Tokugawa. Since the failure of the population to grow in the second half of the Tokugawa period cannot be attributed to the effects of war, it has been assumed the other disasters, such as earthquakes, floods, famines, and epidemics, caused mortality crises that kept the Japanese population in check. Taeuber places Japanese population stagnation within a context of general economic stagnation, inadequate agricultural yields, and a falling standard of living, which in turn were the result of flaws inherent in the political economy established under the Tokugawa shogunate. This represents the orthodox Malthusian view in Japanese historiography, which Honjo Eijiro1 an eminent Japanese economic historian, states clearly: famines, epidemics and other visitations were frequently re­ ported from several quarters of the country. A great many lives were lost by these calamities These so-called preventive and positive checks interrupted the increase of the population, and these are the reasons why the population did not increase in the latter half of the [Tokugawa] period.17 Taeuber concurs: "Famines, epidemics, and other calamities caused gyrations in the numbers of the people." 18 These scholars who attri­ bute a stable population size to high death rates assume that epidemic diseases were an important cause of death in Tokugawa Japan. 16Irene Taeuber, The Population of Japan (Princeton, N.J.: Princeton University Press, 1958), pp. 20-34. 17Honjo Eijiro, The Social and Economic History of Japan (New York: Russell and Russell, 1965), p. 164. 18 Taeuber, The Population of Japan, p. 24.

8

CHAPTER I

One other interpretation of Japan's low population growth rates should be mentioned. Carl Mosk, an economist who has studied fer­ tility trends in premodern and modern Japan, interprets the low birth rates of the Tokugawa period differently. He claims that the popula­ tion failed to increase in the late Tokugawa period because female fecundity was low due to poor nutrition.19 This is a Neo-Malthusian interpretation: population was kept in check not by periodic mor­ tality crises, but by chronic malnutrition that was sufficiently severe to affect fecundity on a long-term basis. But one would expect to find high death rates and a declining population if nutrition were so inadequate, and neither was typical of the Tokugawa period. There is, however, an alternative interpretation of Tokugawa popu­ lation history, one that will be referred to here as the "early modern development" model. Thomas Smith, William Hauser, Hayami Akira, Susan Hanley, and Kozo Yamamura challenge the view that TokugawaJapan was characterized by low agricultural productivity and that population was kept in check by shortage or poor distribu­ tion of food. Thomas C. Smith analyzes Tokugawa agriculture in The Agrarian Origins of Modern Japan, and he concludes that per capita yields and labor productivity did not decline but rather increased between 1600 and 1850. This increase was most notable in the more economically advanced parts of the country, regions in which population had de­ clined. He credits higher productivity to a highly developed system of family farming, and to technological changes that reduced labor needs at key points in the agricultural cycle. These technical innovations led to further specialization and commercialization of agriculture, and to the development of an extensive network of interregional trade.20 In other studies, Smith shows that by-employments in the countryside grew in importance in this period,21 and that the peasant class made significant long-term gains in its standard of living as the yield per unit of land rose while the rate of taxation remained stationary.22 Smith's work demonstrates the strength and flexibility of Tokugawa 19Carl Mosk, "Fertility Transitions in Japan and Korea. A Comparison" (paper delivered at a Regional Conference sponsored by the Committee for the Chmese Economy of the Social Science Research Councd, held at the Hoover Institution, Stanford Umversity, January 1979), p. 32. 20Thomas C. Smith, The Agrarian Origins of Modern Japan (Stanford, Calif.: Stan­ ford University Press, 1959). 21Thomas C. Smith, "Farm Family By-Employments in Preindustrial Japan," Journal of Economic History 29, 4 (December 1969) :397-423. 22Thomas C. Smith, "The Land Tax in the Tokugawa Period," The Journal of Asian Studies 18, 1 (November 1958):3-19.

INTRODUCTION

9

agriculture, and the picture that emerges does not fit the Malthusian model of cyclical economic distress brought on by an inadequate supply of food. Other studies have also demonstrated the vitality of the Tokugawa economy. William Hauser's work on the growth of the cotton trade after 1600 shows that this highly differentiated and profitable trade required that large amounts of land be planted in cotton and that cotton-growing regions import their rice from other areas.23 This type of regional specialization became highly developed during the Tokugawa period and drew much of the country into a national network of trade. Once again, the picture is one of flexibility in adapting to changing economic conditions, not one of increasing economic distress. These studies, which look at the changing relationships between various parts of the economy, are complemented by studies that con­ centrate on specific Tokugawa villages. Following the trend toward study of small segments of society, scholars interested in the social and economic history of preindustnal Japan have done important research on village demography. These studies are based on village population records, the shiimon aratame cho, and they shed considerable light on population structure and growth rates m Japanese villages of the Tokugawa period Hayami Akira's research demonstrates the importance of preven­ tive checks on population growth in Japan He believes that a change in marriage patterns was responsible for population growth in the first century of Tokugawa rule. In a study of three early seventeenthcentury Japanese villages, Hayami found that a large enough pro­ portion of the population remained celibate to exercise a significant control on population through low fertility 20 to 30 percent of fe­ males from ages 16 to 50 who lived in these villages were unmarried.24 Hayami reasons that the availability of more land for cultivation during the seventeenth century allowed social constraints against mar­ riage to be relaxed Servants and younger siblings in large extended families who previously would have remained single could now marry, migrate, and establish new households The result was an increase in the number of households, and a decrease in household size. 23William B Hauser, Economic Institutional Change in Tokugawa Japan Osaka and the Kinai Cotton Trade (Cambridge Cambridge University Press, 1974) 24Hayami Akira and Nobuko Uchida, "Size of Household in a Japanese County throughout the Tokugawa Era," in Household and Family in Past Time, ed Peter Laslett with Richard Wall (Cambridge Cambridge University Press, 1972) 413—455

10

CHAPTER I

By late in the Tokugawa period, the extended family was rare except in remote areas, and an average household size of four to five members had been established as the norm. The net result was an increase in population in the century before 1725. Hayami believes that the stability in population size after 1725 was due to constraints on fertility within marriage. Plot size and household size decreased and the age of marriage rose in the late Tokugawa period. The open­ ing of new lands for cultivation ceased, reducing opportunities to establish new households except by further division of land.25 Essenti­ ally, Hayami seems to believe that the population had filled the avail­ able niches and subsequently limited its own growth by controlling marital fertility after 1725. Susan Hanley and Kozo Yamamura argue that both birth rates and death rates were low in Japan in the seventeenth and eighteenth cen­ turies.26 This is an unexpected finding for a preindustrial society. Their analysis of village population registers in Okayama indicates that death rates were usually just below or insignificantly above birth rates, which would account for Japan's stable, or very slowly grow­ ing, population. Hanley and Yamamura believe that the numbers of deaths attributed to the major famines of the period have been grossly exaggerated, and that famines were not the basic cause of the slow rates of population growth that were noted even in regions and periods of economic prosperity. They estimate that Hfe expectancy in the late Tokugawa period was in the early 40s and thus was compar­ able to the life expectancy in western Europe for the first half of the nineteenth century.27 The implications of these findings for comparative study of Japa­ nese and European mortality are great. By the mid-eighteenth cen­ tury, western Europe was no longer experiencing the terrible plague epidemics and frequent famines that had beset her for centuries. The waning of these afflictions in Europe is credited to increases in the standard of living brought about by a transformation in agricultural technology and the benefits of world trade. But in Japan there was no fundamental alteration in the traditional agricultural system, nor did Japan rely on external trade for any basic commodities. Thus, if Hanley and Yamamura's estimates are reliable, mortality levels in Tokugawa Japan were comparable to levels that were achieved in Europe only after a fundamental change in economic organization. 25 Ibid.,

p. 507. Susan B. Hanley and Kozo Yamamura, Economic and Demographic Change in Pre­ industrial Japan, 1600—1868 (Princeton, N.J.: Princeton University Press, 1977). 27 Ibid., p. 317. 26

INTRODUCTION

11

Thomas C. Smith also found low birth and death rates in another Tokugawa period village 28 By comparing fertility and mortality in the village of Nakahara between 1717 and 1830 with the birth and death rates of other premodern societies, mainly those of western Europe, he was able to construct an age-specific life table. The most outstanding feature of this table was "the generally moderate level of mortality." 29 Fertihty in Nakahara, though remarkably low in com­ parison with that estimated for eighteenth-century European parishes, was somewhat higher than mortality 30 There were slight fluctuations in the crude death rate in Nakahara between 1717 and 1830. deaths per thousand numbered 20.1 for 1717—1749, 17 6 for 1750—1774, 20.3 for 1775—1799, and 16.0 for 1800—1830. All of these death rates are quite low for a premodern society, and the average is 18 2 per thousand for the period as a whole. Smith found that life expectancy at birth, which he estimates at 43.2 years, was about the same m Nakahara as in Colyton, England during a particularly favorable period between 1528 and 1624. And life expectancy was considerably higher in Japan than in French rural parishes in the eighteenth cen­ tury, where life expectancy ranged between 25.0 and 33 1 years.31 Smith speculates that Nakahara's "surprisingly low mortality lies in its fertility," 32 and he attributes low fertility mainly to a widespread system of infanticide. This practice contributed to lower mortality by selectively eliminating visibly weak or deformed infants, by limiting the population to numbers that the village had the capacity to sup­ port, by matching family size to family resources, by exercising strong constraints on fertility in bad times, and by reducing the risk of infection with smaller families. Smith concludes that the population was practicing sex-selective infanticide as a form of family planning. He suggests that "infanticide was not wholly a function either of poverty or of momentary desperation but in part a method of planning the sex composition and ultimate size of the family." 33 Smith's view that fertility was low because abortion and infanticide played a large role in reducing the number of children born (or registered as born) is not new. Such means have long been cited as 28 Thomas C Smith, Robert Y Eng, and Robert T Lundy, Nakahara Family Farming and Population in a Japanese Village, 1717—1830 (Stanford, Calif Stanford University Press, 1977) 29 Ibid,p 48 30 Ibid,pp 13-14 31 Ibid,p 57 32 Ibid 3 3 Ibid , ρ 14

CHAPTER I

12

prominent methods of population control in Japan. What is new is the idea that these practices were a routine method of family planning that was not related to poverty or periodic distress. In summary, those who adhere to the "early modern development model" of Japanese history focus on the importance of preventive checks to population growth. And there is a growing literature that argues that low mortality and fertility in the Tokugawa period were important preconditions of Japan's subsequent rapid growth. But was mortality really low? Low fertility and equally low mortality may explain the population stability of the late Tokugawa period, and infanticide and abortion may account for artificially low fertility rates, but how do we explain low mortality in a preindustrial society? As Smith concedes, "We are almost wholly in the dark about the causes of low mortality "34 Neither the "Malthusian models" nor the "early modern develop­ ment model" fully explain the population dynamics of the Tokugawa period. Conspicuously missing from Japanese historiography are studies that examine mortality patterns and causes of death—serious omissions if we are to understand the social and economic develop­ ment ofJapan. Samuel Preston writes as follows about the importance of mortality in a society: The circumstances under which men die are closely related to the conditions under which they live Not only do mortality conditions mirror those in the general society, but they also have their own important social implications. A population in which death is almost always deferred until the older ages is one that grows faster, is more willing to train individuals for the "longrun," can rely more heavily on the nuclear family for emotional gratification, and can dispense more readily with fatalistic or supernatural philosophies.35 It has been assumed that epidemic diseases were as important a cause of death in Japan as they were in Europe. However, this assump­ tion has not been tested. There is essentially no Western literature on the epidemic diseases of premodern Japan, and Japanese scholars have shown little interest in the subject. For the most part, Japanese economic historians accept the Malthusian interpretation of Tokugawa history articulated by Honjo Eijiro, which views epidemics as an important check on population growth. However, several Japanese 34 Ibid.,

p. 147. H. Preston, Mortality Patterns in National Populations: With Special Re­ ference to Recorded Causes of Death (New York: Academic Press, 1976), p. 1. 35 Samuel

INTRODUCTION

13

medical historians have done extensive research on the history of epidemic diseases in Japan. Foremost among these scholars is Fujikawa Yu (1865—1942), who searched premodern Japanese sources for materials that pertain to epidemics.36 His work is central to the analy­ sis that will be pursued here, and his background and expertise are discussed at length in Chapter III. Yamazaki Tasuku continued Fujikawa's work on the history of epidemic diseases in Japan, and extended his research to include an examination of the methods that were used to prevent or contain epidemics.37 Fujikawa and Yamazaki were both well acquainted with the germ theory of disease, and their greatest contributions to the history of medicine in Japan are their efforts to identify specific infectious diseases in the Japanese literature. However, neither of these men attempted to assess the impact of epidemic diseases on mortality or to evaluate the significance of their findings in comparative terms. More recently, Tatsukawa Shoji has reviewed the contemporary literature of the Edo period, studies of temple death registers, and the work of Fujikawa and others in order to learn which diseases were important in premodern Japan.38 He argues that the history of epidemic diseases in Japan was different from the European experience because different diseases were important in the two regions. Tatsukawa sees the history of infectious diseases in Japan as one of gradual penetration by new infections from the outside world, capped by a great upsurge in the frequency of epidemics in the second half of the nineteenth century—a consequence, he believes, of new patterns of foreign trade.39 This book analyzes the Japanese source materials that pertain to epidemics in premodern Japan. "Premodern" is used as a general term to refer to pre-Meiji Japan, or the period before 1868. Although the primary focus is on the epidemics of the Tokugawa period (1600— 1868), the histories of the most important epidemic diseases were traced from the earliest Japanese accounts of their occurrence. The writings of contemporary Westerners in Japan were also examined, although these are few m number and cover only short periods at the very beginning and end of the Tokugawa period. The first task was to identify which acute infectious diseases were causing epidemics in Japan before the opening of the country to Western trade in the mid-nineteenth century. The second was to assess the effects of these diseases on mortality and population growth The 36 Fujikawa

Yu, Nihon shippet sht, 3rd ed (Tokyo Heibonsha, 1969) Tasuku, Nthon ekishi oyohi bdekt shi (Tokyo Kokuseido, 1931) 38 Tatsukawa Shoii, Nihonnn no byoreki (Tokyo Chuko shinsho, 1976) 39 Ibid, pp 256-61

37 Yamazaki

14

CHAPTER I

discussion that follows will be limited to those acute infectious diseases that can be most easily recognized in historical sources It will not be concerned with chronic, long-term infections or with nutritiondeficiency diseases that were also shortening the span of life in preindustnal societies. Chapter II examines the basic relationships that exist between disease-causing microorganisms and human populations, and the characteristics of the physical and social environments that encourage or inhibit disease. It describes the distinguishing characteristics and epidemiological patterns that help the researcher to identify epidemic diseases in historical sources. Chapter III discusses the general problems associated with using historical sources to study epidemics of the past, and it describes the Japanese source materials that were used in this study These sources include descriptive accounts of epidemics, contemporary observations about particular epidemic diseases, and temple death registers and local histories from two regions of Japan—Sendai, on the northeast­ ern coast of Japan, and Hida, in the mountainous interior. Japanese descriptive sources were used to establish the chronology and period­ icity of recorded epidemics, and to identify the important epidemic diseases of premodern Japan. Local histories and temple death registers from the Hida region and Sendai domain supplement the national accounts- they were used to establish the regional periodicity of the diseases being studied, to determine the degree to which these diseases were endemic in Japan, and to estimate the effects of these diseases on mortality m Sendai and Hida. The kakocho of Ogen-ji, an unusual series of death registers, were analyzed in depth to establish the epidemiological patterns of important acute infectious diseases in Japan during the late Tokugawa period. Chapters IV through VI trace the histories of four different diseases, smallpox, measles, cholera, and dysentery. These diseases were chosen because, according to Japanese sources—both the descriptive sources and the death records, which are entirely independent of one another— they were the most prominent infectious diseases in early modern Japan. They account for a high proportion of the epidemics that were recorded m the Tokugawa period 40 Moreover, there is an excellent 40 Influenza has been omitted because, although it was an important epidemic dis­ ease in Japan as in the rest of the premodern world, it is not usually a cause of high mortality "The classic features of influenza are its occurrence in epidemics which arise abruptly and spread rapidly but irregularly over a region In an area the peak may be reached in three weeks, and the course essentially completed m another three to four weeks There is a high morbidity and low mortality In the majority of epi­ demics case fatality scarcely exceeds 1 per 10,000 " Thomas Francis1Jr , "Influenza," in Viral and Rickettsial Infections of Man, ed T M Rivers and F L Horsfall, Jr , 3rd ed (Philadelphia, Pa J B Lippmcott Co , 1959), pp 652—53

INTRODUCTION

15

international literature about these diseases, and each disease has clearly defined symptoms and a history that is well established. A discussion of the particular characteristics of each disease precedes an analysis of the Japanese source materials. TheJapanese accounts and death records are then analyzed in order to estimate the antiquity of these diseases, their periodicity, the age groups they affected, the routes they fol­ lowed, and the regions they struck. The choice of diseases that were common throughout the preindustrial world permits comparison with disease patterns in the West and provides an opportunity to test the credibility of the Japanese sources. Chapter VII reviews Japanese descriptive accounts and temple death records in order to distinguish between mortality caused by starvation and mortality caused by acute infectious disease. This problem is encountered regardless of the country under study. The Japanese sources often reveal whether the fundamental cause of a crisis was an acute infectious disease or a famine that caused severe malnutrition. They indicate that mortality due to famine usually remained high for several years, whereas typical epidemic crises seem to have been of short duration. By the Tokugawa period, the Japanese records are unusually good, and it is relatively easy to pinpoint the primary cause of a local crisis by studying temple death records and local histories. The evidence suggests that, in Japan, epidemics and famine were usually independent of one another. The following chapters will argue that the Japanese experience with epidemic diseases was different from that of Europe. The most significant epidemic diseases in early modern Europe were bubonic plague, typhus, smallpox, measles, influenza, and diarrheal infections. The last four diseases were also the most frequent causes of epidemics in early modern Japan, but bubonic plague seems to have been un­ known in Japan before the late nineteenth century, and epidemic typhus was not an important disease in Japan before the arrival of Western ships in the 1850s. In spite of Japan's unusually large, dense population, the fact that Japan was isolated geographically from the established trade routes meant that some of the worst epidemic dis­ eases of the early modern world were not important causes of mor­ tality there. The diseases that were present in both Japan and Europe were not unusually severe in Japan, and there is no evidence that they had a greater impact on mortality in the late Tokugawa period than in earlier periods. The conclusions of this study suggest that pestilence was not responsible for the population stability of the late Tokugawa period, and they offer a possible explanation of the relatively low and stable death rates found for Japanese villages during the eighteenth and nineteenth centuries.

CHAPTER II

EPIDEMIC DISEASES AND HUMAN POPULATIONS Historians who study epidemics are primarily concerned with ques­ tions of cause and effect, of change over time, and of regional and cultural variation An investigation of these concerns requires an un­ derstanding of the characteristics of disease-causing organisms, the transmission of these organisms, the response of human populations, and the influence of environmental factors on the incidence of disease m human societies Therefore, before examining the effects of epi­ demic disease on mortality in early modern Japan, it is necessary to consider the dynamic relationships that exist between disease-causing organisms and human populations In this chapter, the characteristics of disease-causing organisms and the mechanisms they employ for survival are discussed first Epidemi­ ology is treated next, followed by a review of the characteristics of human populations that encourage or inhibit the transmission of disease-causing organisms Finally, the environmental characteristics, both physical and social, that influence the interaction between diseasecausing organisms and human populations will be considered 1 The chapter concludes with a brief and somewhat speculative consider­ ation of the specific population and environmental characteristics that have influenced the history of epidemics in the world at large, and in early modern Japan in particular DISEASE CHARACTERISTICS

Diseases in man and other living species are caused by microorgan­ isms These microorganisms are parasites that have their own life 1 The author is indebted to Philip S Brachman, M D , Assistant to the Director, Centers for Disease Control, for his comments and criticisms of this chapter The fol­ lowing sources were used in its preparation Philip S Brachman, "Epidemiology of Infectious Disease," in Principles and Practice of Infectious Diseases, 2 vols, ed G L Mandell, R G Douglas, Jr , and J G Bennett (New York John Wiley and Sons, 1979) 1 109—20, Burnet and White, Natural History, Aiden Cockburn, The Evolution and Eradication of Infectious Diseases (Baltimore, Md Johns Hopkins University Press, 1963), Fiennes, Zoonoses, and G Melvyn Howe, "The Environment, Its Influences and Hazards to Health," in A World Geography of Human Diseases, ed G Melvyn Howe (London Academic Press, 1977) 3—31

EPIDEMIC DISEASES AND POPULATIONS

17

cycles and quite specific requirements for sustaining and perpetuating them. Burnet and White define a parasite as "an organism smaller and less highly differentiated than its host, which lives on the skin or within the tissues or body cavities and gains its nourishment at the expense of the host's living substance."2 Parasites that cause disease are often called pathogens, pathogenic agents, or simply agents, and most can live in only one host species or a small number of related species. The host is the environment of the disease organism. If the parasite causes the host to die, the parasite will also die unless it is able to transfer to another living host. Man and the organisms that cause human diseases can be viewed as competitors, but a kind of mutual accommodation normally takes place: For the parasite to affect the host fatally is not usually the most successful result, as the infecting agent may perish with the host. Long continued association of parasite with a host population results in the evolution of a biological balance, satisfactory to the parasite and generally tolerable to the host.3 Subsequent chapters will deal with specific acute infectious diseases that have unique personalities. The characteristics of a disease include its virulence, its transmissibility, the length of the period during which it can be communicated, its longevity outside the human host, and its ability to produce immunity in man. These characteristics make it possible to identify diseases in historical descriptions written many centuries ago, and to compare the effects of these diseases on different populations separated in space and time. The virulence of a disease is a measure of its ability to injure its host. Two aspects of virulence are 1) pathogenicity, which refers to the severity of a disease as measured by morbidity and mortality; and 2) invasiveness, which refers to the ability of the parasite to invade tissues. Smallpox, for example, was a highly virulent disease because it caused high morbidity and mortality in its host population. However, the virulence of a disease can vary greatly from one host to the next, and the virulence of many important diseases has changed over time. Virulence is also influenced by environmental conditions. Crowding, for example, can increase the virulence of some diseases, and the increased pathogenicity is most likely due to the larger dose of infect­ ing organisms that can be produced in a densely settled population. The transmissibility of a disease affects human mortality because it dictates whether large or small numbers of people become infected. 2

Burnet and White, Natural History, p. 7. E. Burton and Hugh H. Smith, Public Health and Community Medicine (Bal­ timore, Md.: Williams and Wilkins, 1975), p. 178. 3Lloyd

18

CHAPTER II

Transmissibility refers to the capacity of the microorganism to trans­ fer to a new host. It varies greatly depending upon the disease because the modes of transfer of pathogenic agents are quite different. There are four general means by which infectious diseases can be trans­ mitted: 1) contact transmission, which includes direct and indirect contact; 2) common vehicle transmission, which includes vehicles such as food and water; 3) airborne transmission, by droplet nuclei or dust; and 4) vector transmission, usually by means of insect vectors that transmit a pathogenic agent from one host to another of the same or different species.4 The length of time during which a disease can be transferred to another host also contributes to the transmissibility of a disease. This interval is known as the period of communicability. A disease is spread when the host sheds disease organisms into the environment. In the case of most acute infectious diseases, an incubation period follows the transmission of disease organisms to a new host. During this period the new host is often asymptomatic and cannot transmit the disease to others. The incubation period is followed by a period of communica­ bility, during which the new host experiences the effects of the infec­ tion (the morbid state) and sheds organisms into the environment. As disease symptoms subside, the host enters a period of recovery, after which transfer is no longer possible. Although most hosts experience symptoms of disease during the period of disease communicability, some hosts may be carriers (i.e., they have subclinical infections and are not aware that they are sick, although they shed disease organisms that infect others). In addition, many infectious diseases have long incuba­ tion periods, and the period of communicability may begin sometime before the disease is clinically evident. For instance, the period of communicability for smallpox and measles begins before the symp­ toms of these diseases are unmistakable. This means that smallpox and measles can be spread great distances in a relatively short period of time. The transmissibility of a disease pathogen is increased by the organism's ability to live outside its host. Given the opportunity, a parasite will quickly transfer to another host. However, many para­ sites have adapted to conditions in which opportunities for contact between hosts are few by developing the ability to survive outside the host. The length of time that pathogenic organisms can remain alive in droplet nuclei or in fecal material and retain their capacity to infect a new host varies considerably with different diseases and with environmental circumstances. 4Philip

S. Brachman, personal communication, August 1982.

EPIDEMIC DISEASES AND POPULATIONS

19

An important aspect of adaptation between disease organisms and human populations has been the development over time of human defense systems that produce varying degrees of immunity. Immunity is a state of lessened liability to injury by a microorganism. It is often perceived as a property of a particular disease, but in reality it is a defensive response of the human host. Immunity is conferred by the development of antibodies in the host. These antibodies form in re­ sponse to an attack on the host by a particular parasite. A person who recovers from an immunity-producing disease is usually immune at the time of recovery. The microorganism that has invaded the body may not have been completely destroyed, but for a time it is incapable of doing further harm. Some diseases produce immunity that lasts for a lifetime, and these diseases will not occur twice in the same indi­ vidual. Obviously, the ability of the host to produce antibodies radi­ cally affects the life cycle of the parasite, and immunity represents, as do all of the disease characteristics just discussed, a long process of adaptation between disease-causing organisms and man. This study is concerned with communicable, or contagious, diseases that infect man, more accurately referred to as acute infectious dis­ eases. A contagious disease is one that is transmissible from a source, or reservoir, to a host by one of the several means of transmission just discussed. Acute infectious diseases that are transmitted by person-toperson contact or through the air are usually highly contagious, but they typically have a short period of communicability, and usually the infecting organism can survive for only a brief period of time outside the host. These diseases are commonly host-specific to man, and they normally produce a sustained period of immunity. Because epidemic diseases require a continuous reservoir of infection, they can only survive in large, densely settled populations. Epidemics caused by acute infectious diseases are highly visible and have a sudden and dramatic impact on entire communities; consequently, epidemics have been noted in the historical records of every age. COMMUNITY DISEASE PATTERNS

The preceding discussion has sought to identify some of the basic mechanisms that contending species employ to ensure their survival. These mechanisms operate, at the simplest level, between a single host and a single parasite and are visible only as we perceive their effects on the host. These effects may be barely noticeable or exceedingly severe, and may lead in a precipitous fashion to death. They may be of short duration, or may persist in the form of chronic disease that produces an increasing disability in the host. Experience tells us that the effects

20

CHAPTER II

of disease vary enormously from one person to the next, even when the infecting organism is the same. But in spite of these individual variations, acute infectious diseases follow fairly predictable commu­ nity patterns of prevalence. The idea of categorizing diseases according to patterns of preva­ lence is very old. Hippocrates observed that different diseases affected a community in different ways: certain diseases were always present in the population, whereas others occurred only in certain years or dur­ ing particular seasons of the year. These differences in pattern were attributed to environmental factors.5 The term "epidemic" comes from the Greek "epidemios." It means simply "upon the people," sug­ gesting an external source, or an exceptional occurrence. "Endemic" means "native" or "indigenous," indicating a common state of affairs. A disease is said to have become endemic in a population—a city or national population, for example—when it can be sustained in that population without new importations from the outside. However, the terms "endemic" and "epidemic" are not mutually exclusive: acute infectious diseases that are endemic in a population may also occur in an epidemic, or cyclical, pattern. The confusion is one of terminology and results from the fact that the terminology predates an understanding of the mechanisms involved. In the case of epidemic diseases, group immunity determines com­ munity disease patterns. In a previously unexposed community, an acute infectious disease can infect the entire population. If the disease confers life immunity, for a time there will be few susceptibles in the population. As children are born, as unexposed persons migrate to the community, and as persons who have acquired immunity die, the proportion of susceptibles in the community rises. A recurrence of the disease will affect only susceptibles, and these will be mainly children, primarily those born since the previous epidemic. It is in this way that a disease that confers life immunity becomes a disease of children in communities that are frequently exposed to an infecting organism. Most communities are made up of individuals who vary in terms of their exposure to specific disease organisms. Some individuals are immune, some have a partial immunity, and some have no immunity. The proportion of a population that has little or no immunity deter­ mines the group susceptibility to a particular disease. This proportion is constantly changing as individuals who are susceptible are infected, acquire immunity, recover, and, in the case of some diseases, lose immunity again. An epidemic, by definition, requires a large number of potential 5Major

Greenwood, Epidemics and Crowd Diseases: An Introduction to the Study of Epidemiology (New York: Arno Press, 1977), pp. 21—23.

EPIDEMIC DISEASES AND POPULATIONS

21

hosts. When an epidemic has subsided, the number of susceptibles will have been significantly reduced. A reintroduction of the pathogen at this time will not result in a new epidemic, because parasites cannot subsist in a population with so few hosts. The host population as a whole has become immune to the disease, a phenomenon that is referred to as group or herd immunity. The interval between epi­ demic peaks is determined by the rate of increase of susceptibles. This rate varies in populations of different size, and it is dependent upon birth, death, and migration rates. Even after an acute infectious disease becomes endemic, it will continue to recur in epidemic form in fairly regular cycles because of changing herd immunity. An endemic disease is always smoldering somewhere because it has established a permanent reservoir of infec­ tion in human or nonhuman hosts. Without such a reservoir, acute infectious diseases die out and must be reintroduced from the outside before a new epidemic can occur. Population Characteristics

Because of the dependency of disease-causing parasites on their hosts, population characteristics are especially important to the history of epidemic diseases. In the case of most infectious diseases, large, dense populations will promote the propagation and transfer of disease organisms, whereas small, scattered populations will inhibit the pro­ cess. Large populations provide a greater number of hosts than small ones, and dense populations offer the optimal conditions for disease parasites to transfer from one host to another. When immunity is a factor, a large population will produce new susceptibles more rapidly than a small one, even if the birth rate is the same in both populations. In the case of some diseases, like bubonic plague or epidemic typhus, it is the size and density of animal or vector populations that determine the incidence of human disease. The relationship between density and disease has been recognized since antiquity. Writing in 1793, Noah Webster noted that in Bibhcal accounts, "it is ... remarkable that pestilence is every where men­ tioned as the peculiar scourge of cities," and he observed that in the time of the prophets "it was considered as a well known fact, that pestilential diseases are the effect of crouded [population], raging peculiarly in cities, forts and other confined places."6 The concept is the same whether one is concerned with large population units such as 6 N o a h W e b s t e r , A Brief History of Epidemic and Pestilential Diseases; With the Prin­ cipal Phenomena of the Physical World, Which Precede and Accompany Them, and Obser­ vations Deduced From the Facts Stated, 2 vols. (Hartford, Conn.: Hudson and Goodwin, 1799), 1:25.

22

CHAPTER II

national or city populations, or with small social units like the family. In either case, the crowding of susceptibles promotes disease. The spatial distribution of a population and its pattern of settlement are also important because they affect the transmission of infectious disease. Disease organisms are carried by infected human or animal hosts moving from place to place. The usual pattern is for a disease to flare up as an epidemic in cities or other densely settled areas and to diffuse outward into settlements of lower density. The rate of diffu­ sion will depend upon the rate of contact between population centers and outlying areas. The extent to which epidemics are concurrent in centers of density and more sparsely settled hinterlands usually indi­ cates the extent of contact between the two. Human populations in remote regions of the world may be reached infrequently or not at all. Because frequent exposure encourages adaptation between host and parasite, there is an inverse relationship between the frequency of epidemics and their severity. It is paradox­ ical that large, dense populations, in which epidemic diseases recur frequently because of the large number of susceptible hosts, generally suffer less in terms of morbidity and mortality than do smaller, scat­ tered populations, which experience epidemics less frequently. The latter often suffer very high mortality and great social disruption. Historically, the populations of small, isolated islands experienced major epidemic crises, as did the large, but isolated, New World populations in the sixteenth century. Environmental Influences

Characteristics of the physical environment also have a direct effect on disease processes. Many diseases have a characteristic seasonal distri­ bution of cases that follows a more or less regular pattern with max­ imal incidence at about the same time each year. It is common knowledge that acute respiratory infections are more frequent in the cold months and enteric diseases in the hot months. Disease patterns may also be specific to a distinctive climatic region. For example, the peak period for smallpox was different in the tropics than in temper­ ate climates. Presumably these differences reflect the environmental requirements of the parasite, although the resistance of the host popu­ lation may also be a factor. Other aspects of the physical environment influence the ability of disease organisms to establish themselves permanently or temporarily. The great river deltas with their slow-moving and meandering waters have been associated throughout recorded history with diseases that we now know are waterborne. High-velocity rivers, which are deter-

EPIDEMIC DISEASES AND POPULATIONS

23

mined by the amount of rainfall and the slope or gradient of the terrain, inhibit the propagation of disease organisms that live in water. And water quality is also an important factor, with acid water nega­ tively and alkaline water positively correlated with enteric diseases such as cholera. Such physical features can prohibit the indigenous development of certain microorganisms. They can also deter the transfer of disease pathogens to new regions. The social environment of man has also had an enormous influence on the history of human disease. Epidemics rarely fall within the jurisdiction of individual control, but rather occur as mass phenomena in human society. As a result, macro-community characteristics— modes of production, the extent of trade, political boundaries, the inclination of rulers to keep or disrupt the peace, the size of cities and their relationships with outlying areas—all affect the disease charac­ teristics of a community. At the micro-level, family size, dietary habits, type of housing, standards of personal sanitation, and com­ munity sanitation levels (quality of water supply and methods of waste disposal) affect disease dissemination and control. All variables are not equally significant for all diseases, but they constantly interact, and in combination they exercise great influence on community dis­ ease patterns. Historically, agricultural practices have had a great influence on the propagation and transmission of density-dependent diseases. At one end of the spectrum is slash-and-burn agriculture, which supports relatively small, migrating human populations, which in turn pre­ vents the build-up of human parasites in any one place. At the other end is irrigated wet-rice agriculture, which encourages large, highdensity, permanently settled human populations and a natural environ­ ment highly conducive to the propagation of disease organisms. In the latter situation there is an opportunity for long-term adaptation be­ tween host and parasite that is lacking in the former. Both populations would be vulnerable to new parasites entering the community, but morbidity and mortality would be much more striking, because of numbers alone, in the densely settled community. The growth of trade, so important in relieving regional shortages of food, has been largely responsible for transferring goods, people, and parasites to the farthest parts of the earth. Ships and caravans carrying surplus agricultural goods and an additional, if unwelcome, cargo of rats, fleas, and other vermin have spread disease between world regions. The velocity, volume, and speed of trade is also im­ portant. As these have increased over time, the pace of disease ex­ change has quickened also. War, long recognized as an important check on population growth,

24

CHAPTER II

has often claimed more victims through disease than in battle. This is because warfare disturbs community disease patterns, radically alter­ ing both environmental conditions and the population characteristics of hosts and parasites. Whatever balance has been achieved between hosts and parasites is tipped in favor of the latter: the proportion and density of parasites and of susceptibles in the population increase, as does the rate of contact between the carriers of disease (which may be humans, rodents, or insect vectors) and susceptibles. The research of R. J. G. Concannon on the Thirty Years' War in seventeenth-century Europe indicates that endemic and epidemic dis­ ease patterns in temporary communities of soldiers were similiar to those in permanent communities, but that morbidity and mortality were much higher in the military camps. Living conditions account for some of the difference, as troops lived in crowded quarters and sanitation was poor. Estimated sickness rates in the Thirty Years' War suggest that the soldiers served as a constant reservoir of infection. Infectious diseases were always present and caused steady attrition among the troops, but serious epidemic outbreaks were most likely to occur when troops were massed for an offensive.7 Although the shift from a low to a high incidence of cases is typical of acute infectious diseases, the reason for the shift was different from that in permanently settled populations. Disease pathogens did not have to wait for a new generation of susceptibles to be born. A dense group of new hosts, composed of soldiers from many different localities, became available whenever armies assembled in preparation for battle. This meant that the intervals between epidemics were dramatically shortend. Diseases that were particularly noteworthy in the Thirty Years' War were bubonic plague and typhus: diseases associated with rats, fleas, and lice, and especially in the case of typhus, with filth. Ab­ normally high migration rates meant that these and other diseases were efficiently disseminated over great distances. New recruits from all over central Europe brought a continuous supply of new suscep­ tibles to centers where diseases flourished. And desertion rates were high. As deserters trickled back to their villages they carried infection to areas that were not directly affected by the war.8 The civilian population also suffered abnormally high disease rates because of more frequent exposure as armies advanced and retreated, and because of a general decline in the standard of living. It was not uncommon for soldiers to be housed in the homes of noncombatants, or for the local food supply to be destroyed or confiscated by hungry 7 R. J. G. Concannon, "The Third Enemy: The Role of Epidemics in the Thirty Years' War," Cahiers d'histoire mondiale 10 (1967): 500—511. 8Ibid., p. 506.

EPIDEMIC DISEASES AND POPULATIONS

25

armies. Concannon argues that during the Thirty Years' War infec­ tious disease caused a crisis of great magnitude 9 He concludes that the number of estimated battlefield deaths—43,000 in four engagements— was insignificant compared with the uncountable number of deaths due to the combined effects of famine and disease. "Disease ... was pandemic, that is, infection was maintained throughout the country, flaring up wherever overcrowding or undernourishment weakened specific areas "10 To summarize, interaction between host and parasite rarely occurs as a single event Disease organisms must be constantly in search of new hosts, consequently, the infections they cause involve the entire community. At the community as well as the individual level, quali­ tative differences influence disease patterns These differences have been described in broad terms as environmental; that is, the incidence and severity of epidemic disease will depend upon whether a com­ munity is large or small, densely or sparsely settled, in the mainstream of regional or world intercourse or isolated from it, engaged in seden­ tary agriculture or pursuing a nomadic way of life, frequently dis­ rupted by war or politically stable. These community characteristics have changed radically during the course of human history, and the nature of interaction between host and parasite has changed as well. THE EARLY HISTORY OP EPIDEMIC DISEASES

Acute infectious diseases that cause catastrophic epidemics are beheved to be relative newcomers to human history. These "new" diseases are called "density-dependent diseases" because of their reliance on sizable populations, and because their very existence is the result of environ­ mental conditions produced by increasing human populations Frank Fenner, a noted microbiologist, argues that such diseases could not have existed in their present forms before human communities in at least one region of the world had reached a certain critical size. the background against which infectious diseases of man must be viewed is a transition in a few generations from small and scat­ tered groups of hunter-gatherers, through the neolithic revo­ lution to man the farmer, living in small villages but with a few large towns and cities, and only yesterday, as it were the increas­ ing aggregation of much larger numbers of human beings in large 9 Domemco Sella argues similarly concerning high rates of disease mortality during wartime in early modern Italy See Domemco Sella, Cnsts and Continuity The Eco­ nomy of Spanish Lombardy in the Seventeenth Century (Cambridge, Mass Harvard Uni­ versity Press, 1979), pp 49-51 10Concannon "The Third Enemy," ρ 509 1

26

CHAPTER II

and very large cities. The most important single parameter, from the point of infectious diseases, is the alteration in the size of the aggregates of men and the communications within and between these aggregates; for infectious diseases by necessity must be trans­ mitted from one host to another of the same or different species.11 Hence, the beginnings of agriculture in the late neolithic period are seen as a turning point in history when a combination of technical innovations permitted human populations to increase their numbers. One of the most important of these innovations—the use of animal fertilizer to restore soil fertility and increase yields—brought about a fundamental change in man's relationship with animals. Animals that formerly were wild were domesticated and brought to live within the confines of permanent human settlements. These changes in man's social and economic organization created an entirely new environ­ ment for existing parasites. Opportunities that encouraged the adapta­ tion and transfer of parasites between different species were greatly increased. Both human and animal populations increased and became more dense under this new arrangement, and the stage was set for the proliferation and specialization of microparasites. The densitydependent diseases that would later produce the major epidemics of human history were either unimportant or nonexistent before man assembled in permanent communities.12 These important changes in the social environment of man are believed to have taken place first in "the cradle of civilization," the Indus Valley, where the earliest known centers of population density developed. Other regions subsequently developed in a similar fashion, and it is thought that density-dependent diseases evolved in these regional centers. Human populations that remained sparsely settled or that were constantly on the move continued to have a much lower incidence of infection. Before the advent of modern modes of transportation, formidable natural barriers—oceans, deserts, and mountain ranges-—permitted the growth of discrete population centers that were isolated from one another. Some parasites developed in a particular region and became dependent upon the climate and fauna of that region for survival. As a result, human diseases that were dependent on an animal host or an insect carrier peculiar to a specific geographic area might flourish in that region but be totally absent in others. Consequently, societies that were separated by great distances or by natural barriers frequently had very different disease histories. 11Frank Fenner, "Infectious Disease and Social Change," part 1, Medical Journal of Australia 1, 20 (May 15, 1971):1043. 12 Fiennes, Zoonoses, p. 76.

EPIDEMIC DISEASES AND POPULATIONS

27

On the other hand, many parasites joined the waves of human migration and were able to adapt and survive in their new environ­ ment.13 Parasites such as the louse, the pinworm, and the typhoid bacillus had little difficulty adapting, because such parasites are closely attached to man. And some animal hosts migrated successfully, taking their parasites and the diseases they cause with them into new regions. Rodents that served as host to the plague bacillus, for example, are believed to have formed an initial focus of infection somewhere in east Africa or central Asia. Rattus rattus, the black rat that was impor­ tant in the transmission of bubonic plague, made its habitat within human settlements and migrated along with man. These rats eventu­ ally made their way to European cities, and as these cities grew in size, rat populations flourished and established new foci of infection for bubonic plague. The European cities that suffered the ravages of bubonic plague were far from the initial foci of infection Epidemics of plague, typhus, smallpox, and measles—all densitydependent diseases—were relatively unimportant in Europe before the Middle Ages, because the population was not sufficiently large or dense to support them. However, after A.D. 1000, the number and the size of European cities increased, and renewed contact during the Crusades established a disease link between population centers of Eu­ rope and the Middle East. Density-dependent diseases became impor­ tant in western Europe for the first time. From the eleventh century to the twentieth, Europeans served as the vectors of infectious disease: they carried new diseases to their own countries from the populous centers of the East, and they spread them around the world during this period of transoceanic expansion. The Europeans who discovered the New World m the late fifteenth cen­ tury carried Old World diseases to the large, dense, and previously unexposed populations of Central and South America, and these dis­ eases caused massive depopulation on an unprecedented scale. William H. McNeill calls this regional exchange of disease organisms, which he claims took place in Eurasia between 500 B.c and A.D. 1200, "the confluence of civilized disease pools "14 By the twentieth century, this disease exchange had been extended to virtually every part of the world. THE JAPANESE EXPERIENCE

How did this confluence of civilized disease pools affect Japan? Was premodern Japan exposed to the same diseases as European countries The Evolution and Eradication, ρ 32 Wilham H McNeill, Plagues and Peoples (Garden City, N Y 1977), Chapter 3 13Cockbum,

14

Anchor Press,

28

CHAPTER II

at the other end of the Eurasian continent? Did Japan also suffer massive depopulation as a result of contact with new epidemic dis­ eases? And if so, when did this depopulation occur? The evidence presented in the following chapters suggests that Japan's geographic position and limited contact with major disease centers protected her from some of the most important diseases of the premodern world. As a result, Japan's demographic and epidemiolog­ ical history was quite different from that of western Europe. Since the concept of geographic isolation is central to this argument, a brief description of Japan's geography, her early development, and the nature of her contacts with the outside world is in order. The Japanese islands form an arc lying to the east of the Eurasian continent, with the two ends of the arc being the points closest to the continent.15 The distance across the Tsushima-Korean Strait, which separates the southern Japanese island of Kyushu from the Korean peninsula, is approximately 200 kilometers. The northern tip of Hok­ kaido is about 300 kilometers across the Sea ofjapan from the adjacent mainland, and about 40 kilometers from Sakhalin Island, which is separated from the mainland by about 10 kilometers. During early Pleistocene times, both ends of the Japanese island arc were connected to the continent, and early migrants were able to cross over these land bridges to Japan. Approximately 18,000 to 20,000 years ago, both of these land bridges disappeared, and Japan became the fully insular land it is today.16 Despite the ocean barriers, there was more or less continuous migra­ tion from the Asian mainland to Japan over many thousands of years. TheJapanese islands were the final destination of a number of nomadic groups. The nomadic peoples who migrated to Japan settled along the narrow coastal plains and became sedentary, wet-rice farmers. The paddy field system characteristic of East Asian societies is known to have been firmly established in Japan by the fifth century A.D.—and probably well before.17 Little attention was paid to animal husbandry, perhaps because the land was unsuitable for grazing, and rice became the staple crop. Rice not only provided the means for supporting a large, dense population, but such a population became necessary in order to supply the great amounts of labor needed to build and maintain the complex irrigation systems and to perform the laborintensive operations of wet-rice farming. These operations included the preparation of dyked fields and the planting and transplanting of 15C. M. Aikens and T. Higuchi, Prehistory ofjapan (New York: Academic Press, 1982), pp. 25-27. 16Ibid., p. 27. 17John W. Hall, Government and Local Power in Japan, 500 to 1700: A Study Based on Bizen Province (Princeton, N.J.: Princeton University Press, 1973), pp. 41—42.

EPIDEMIC DISEASES AND POPULATIONS

29

rice seedlings, operations in which draught animals are of little use. The labor-intensive agriculture adopted by the Japanese ensured the high-density pattern of settlement that became an early feature of Japanese society. The population of Japan has always been concentrated on a small fraction of the total land area, because a high proportion of land is mountainous and not conducive to cultivation. The earliest regions of settlement were the narrow plains of southwestern Japan, the coastal areas bordering the Inland Sea, and the Kansai Plain, where the capital cities of Heij5 and Heian (modern-day Nara and Kyoto) were es­ tablished in the eighth century. Typically, the Japanese settled in small villages of clustered dwellings to facilitate cooperative farming. As the Japanese population grew, it expanded in a northeasterly direc­ tion, and by the Tokugawa period most inhabited parts of the main islands, and many small offshore islands as well, were being cultivated intensively. What is perhaps most distinctive about Japan's history is that this highly sophisticated island civilization developed with little inter­ ference from the outside world. Migration into Japan took place over many thousands of years, and it appears for the most part to have been a remarkably peaceful affair. In stark contrast to China and the civilizations on the western side of the Eurasian continent, Japan was spared repeated devastation by hordes of mounted or seaborne in­ vaders.18 Little is known about early contact between Japan and the outside world; however, it seems to have been fairly sporadic and on a relatively small scale. It was usually initiated by the Japanese. As late as the twelfth century, the Chinese knew little more about the Japa­ nese islands than that they existed somewhere to the east of China. As John Hall has observed, "The Japanese have literally lived on the farthest fringe of the civilized world." 19 As mentioned earlier, by the beginning of the Tokugawa period in 1600, Japan's population was unusually large and densely settled. Be­ tween 1600 and 1725 it grew from between 10 and 18 million people to more than 30 million.20 Japanese cities, although unknown to the rest of the world before the mid-sixteenth century, ranked among the world's largest, and during the first century of Tokugawa rule, Edo became the world's largest city, growing from a tiny settlement to a city of about 1 million inhabitants.21 18See Gari Ledyard, "Galloping Along With the Horseriders: Looking for the Founders of Japan," The Journal ofJapanese Studies 1, 2 (Spring 1975) :217-54, for a theory that argues for at least one invasion of Japan in protohistoric times. 19 Hall, Government and Local Power, p. 3. 20 Rozman, Urban Networks, p. 77. 21Ibid., pp. 286-88.

30

CHAPTER II

Thus, when the first Europeans arrived in Japan in 1543, there is no doubt that the population ofJapan was of sufficient size and density to support any of the density-dependent diseases that one would have encountered in Europe at that time. Moreover, the brisk trade between the various regions of Japan would have promoted the dissemination of disease-causing organisms throughout the islands. Kaempfer's con­ temporary and oft-quoted remarks paint a picture of a populous and highly mobile society: It is scarce credible, what numbers of people daily travel on the roads in the country, and I can assure the reader from my own experience, having pass'd it four times, that Tokaido, which is one of the chief, and indeed the most frequented of the seven great roads in Japan, is upon some days more crowded, than the publick streets in any the most populous town in Europe. This is owing partly to the Country's being extreamly populous, partly to the frequent journies, which the natives undertake, oftner than perhaps any other nation, either willingly and out of their own free choice, or because they are necessitated to it.22 During the late sixteenth and early seventeenth centuries all manner of European adventurers descended upon Japan. A number of them lived there for many years, and the letters and accounts that these men wrote described what seemed most remarkable to them about the country and people of Japan. Their observations reveal the amaze­ ment with which they viewed Japan's highly developed civilization— an atypical European reaction to foreign, "heathen" peoples. And with a certain fervor characteristic of the newly converted, these newcomers attempted to record the many small particulars of Japa­ nese life that struck them either as peculiar to Japan or as similar to their own ways. The first Europeans to arrive in Japan were surprised to find that severe epidemics were uncommon there. In their eyes, Japan seemed unusually free of many maladies to which they were accustomed. Among the writings of European observers are numerous statements having to do with disease in Japan. A particularly keen observer was Joao Rodrigues, who came to Japan in 1575 as a boy of 15. He remained in Japan until 1612, eventually becoming a member of the Society of Jesus. During his time in Japan, he wrote: 22Engelbert Kaempfer, The History of Japan Together With a Description of the King­ dom of Siam 1690—1692, trans. J. G. Scheuzer, 3 vols. (Glasgow: James MacLehose and

Sons, 1906), 2:330. Kaempfer was a German surgeon with the Dutch East India Co. in Japan between 1690 and 1692 who traveled to the major cities. His history of Japan was first published in English in 1727.

EPIDEMIC DISEASES AND POPULATIONS

31

The air is extremely wholesome and temperate and thus there are no prevailing maladies, such as the plague, in the kingdom. As a result the common people, who are not given to luxuries, usually lead a sober life, and the old folk are well disposed, strong and healthy. The nobles and rich people, however, given over to pleasures as they are, fall sick and do not live so long.23 And Arthur Hatch, who reached Hirado aboard the ship Palsgrave in 1620, wrote in a similarly complimentary fashion about Japan upon his return to England in 1623: "The Climate is temperate and healthie not much pestred with infectious or obnoxious ayres. ..."24 Such observations are noteworthy because European observers were famil­ iar with epidemics of acute infectious diseases that claimed many lives in their own countries. Epidemics of bubonic plague were particularly common in sixteenth- and seventeenth-century Europe, and other dis­ eases circulated as well. They were commenting, therefore, on the absence of diseases that to them were commonplace. Other Westerners noted the presence of diseases with which they were familiar. For example, Richard Cocks, who lived in Japan from 1613 to 1624, wrote in his diary of a smallpox epidemic: June 18, 1615.—I receved a letter from Jorge Durois, dated in Nagasaki, Ie 22nd of June, new stile.... He wrot me that above 2,600 persons are dead in Nagasaki this yeare of the smallpox, amongst whome his boy Domingo and a woman slave are two, since he writ me his last letter.25 The reactions of these outsiders are worth noting, for they provide a comparative dimension that cannot be found in Japanese accounts. Their comments tell us that certain density-dependent diseases with which they were familiar were causing epidemics in Japan at the beginning of the seventeenth century, while others were not. This suggests that some microparasites that caused severe epidemics in Europe during this and earlier periods had not yet reached Japan, or had found unfavorable conditions and failed to establish themselves. The European statements convey very general impressions based on personal observations. However, they were written by people of dif­ ferent nationalities and backgrounds who visited different parts of Japan at different times. This variety of experience can only add weight 23Michael Cooper, ed., They Came to Japan: An Anthology of European Reports on Japan, 1543—1640 (Berkeley and Los Angeles: University of California Press, 1965),

pp. 10-11. 24Ibid., p. 7. 25Ibid., p. 242.

32

CHAPTER II

to their credibility, because the accounts not only support one another in general impression, but also often coincide in small particulars. The diverse group of Europeans that arrived in Japan in the midsixteenth century wore out their welcome fairly quickly, and with the consolidation of power under the Tokugawa shogunate, virtually all Europeans were expelled from Japan by 1639. Only a small contin­ gent of Dutch traders were permitted to stay, and they were confined to the tiny island of Deshima in Nagasaki Bay. The official policy of the Tokugawa government Hmited foreign trade to the port of Nagasaki in Kyushu and the island of Tsushima, but although trade between Japan and other parts of East Asia continued, Tokugawa trade policies reinforced Japan's natural geographic isolation, and ef­ fectively reduced her contact with people of the outside world. Japan's isolation meant that before the opening of Japan by United States gunboats in 1853—1854, few accounts of events in Japan were written in Western languages. Therefore, the history of epidemics in Japan during the Tokugawa period must be constructed almost en­ tirely from Japanese records. These sources will be described in the following chapter.

CHAPTER III

THE JAPANESE SOURCES The quality of source materials is perhaps the most important factor in any investigation of past events. The limitations of premodern sources are especially great, and they become greater as one goes back in time. The quality of source materials varies in different periods, not only because the capacity to keep records and the motivation for keeping them differ from time to time, but also because many records have simply not survived. Gaps in the records cause special problems when one tries to trace the history of epidemic diseases because of the significance of the intervals between epidemics. The severity of an epidemic and its impact upon a population depend upon whether that particular disease has ever occurred in that place before, how recently it has occurred, and the extent to which it has infected and immunized the population. Without complete records, the historian must try to determine from the content of contemporary accounts whether the epidemic in question was regarded as a hew disease at the time, whether its severity seemed unusual, and the extent to which different age groups in the population were affected. Identifying specific epidemic diseases of the past from descriptions in the historical records is also a major problem. In the past, diseases were usually named according to the symptoms that were manifested, as names like "smallpox," "red measles," and "infantile paralysis" illustrate. These are common English examples, but Latin and ver­ nacular European terms were chosen in much the same way. Over time, names were often qualified to distinguish one disease from another with similar symptoms. For example, the term "smallpox," the common name for both Variola major and Variola minor, came into use only after syphilis, which was called the "great pox," became a virulent epidemic disease in Europe in the late fifteenth and early sixteenth centuries. Sometimes a distinction between diseases was made on the basis of the duration of certain symptoms. The term "three-day measles" distinguishes rubella from the more severe viral illness "six-day measles," or morbilli, which in *arn was coined to distinguish measles from an even more severe disease, il morbo, or bubonic plague.1 1 A. B. Christie, Infectious Diseases: Epidemiology and Clinical Practice, 2nd ed. (Edin­ burgh: Churchill Livingstone, 1974), pp. 204, 374.

CHAPTER III

34

Thus, disease names have their own histories, and historians of medi­ cine have been able to learn a great deal about the history of specific diseases by paying close attention to the evolution of the terminology used to describe them. When past epidemics are described clearly in the records, either by reference to well-known disease names or by detailed descriptions of disease characteristics, they can often be identi­ fied today. Although such methods are considerably less accurate than modern methods of identification by microscopic examination, they are an important source of information about epidemics of the past. On the other hand, many severe epidemics of the past cannot be identified at all, because the records used generic terms such as "pes­ tilence" or "plague" and gave no further details to enlighten future generations. Most epidemic diseases that occurred in Europe before the fourteenth century cannot be identified, due to the vague terms used to describe them, and for several centuries after the pandemic of bubonic plague known as the Black Death, accounts of epidemics used the term "plague" indiscriminately. Until recently, many periods of high mortality in Europe were thought to have been as­ sociated with bubonic plague; however, more recent analyses of grain prices and death records indicate that some of these crises were closely tied to famine conditions or were caused by typhus or other epidemic diseases.2 The ability to identify specific epidemic diseases in historical re­ cords usually improves over time. As density-dependent diseases caused epidemics more frequently in the growing cities of medieval Europe, certain diseases became well known to those who wrote of them. But disease terminology continued to be imprecise until the late nineteenth century, when the discovery of specific disease pathogens permitted diseases with similar symptoms to be classified according to the agents that cause them. The common names of diseases, however, usually remained the same as before, and the history of the most important of these can be traced backwards in time—in some cases, for many centuries. None of these uncertainties has prevented intensive study and analy­ sis of past epidemics or speculation about their effects on human society. This is especially true in the field of European history, where interpretations of the effect of epidemics on society range from the reason for victory in a particular battle to explanations of broad demographic and economic trends. Such interest has not been mani2See

Andrew Appleby, Famine in Tudor and Stuart England (Stanford, Calif.: Stan­ ford University Press, 1978), Chapter 7.

THE JAPANESE SOURCES

35

fested to the same extent elsewhere. As noted earlier, the history of epidemic diseases in non-Western civilizations, such as those of East Asia, has been largely ignored. In the case ofJapan, this neglect has been due to lack of interest, not the absence of adequate source materials. In fact, the Japanese source materials for studying the epidemics of the premodern period are excellent. This study uses two very different types of sources to trace the history of important epidemic diseases in Japan: contemporary descriptive accounts and temple death registers. Contemporary Japa­ nese accounts of epidemics begin in the late seventh century, and many of these accounts are sufficiently detailed to allow specific dis­ eases to be identified. These accounts reveal the evolution of the Japanese terminology for major world diseases, and they can be used to estimate the antiquity and periodicity of certain acute infectious diseases in Japan. In addition to these qualitative sources, Japan has some of the best population records of the preindustrial world.3 Hayami Akira lists four types of sources that are useful for demographic analysis of the Tokugawa period: shiimon aratame cho (records of the investigation of religious sects); ntnbetsu cho (registers of residents); shigo aratame (na­ tionwide population statistics); and private records, which include family genealogies and temple records.4 Of these, the shiimon aratame chd have been the most important for historical research. They are village census records, and they have been used extensively by scholars of the Tokugawa period to do village reconstitution studies, which have illuminated many aspects of village life.5 Susan Hanley cites some of the important ways in which the shiimon aratame cho can be used for research in demographic history. Only from the shiimon aratame cho can statistics be compiled on average age at marriage, average number of children raised, average age at first and last childbirth (of children who lived past early infancy), average family size, the age composition of the population, the incidence of migration, and other kinds of de­ 6 mographic behavior 3John

Durand, "Historical Estimates of World Population An Evaluation," Popu­

lation and Development Review 3 (September 1977) 277 4Hayami Akira, "Thank You Francisco Xavier An Essay in the Use of Micro-Data for Historical Demography of Japan," Keto Economic Studies 16, 1—2 (1979) 65—66 5 Hayami Akira, Laurel L Cornell, Susan B Hanley, and Thomas C Smith have done extensive research on Japanese historical demography using the village popu­ lation registers of the Tokugawa period 6Susan B Hanley, "Toward an Analysis of Demographic and Economic Change in TokugawaJapan A Village Study ,"Journal of Asian Studies 31, 3 (May 1972) 516

CHAPTER III

36

The shiimon aratame chd are the backbone of historical demography in Japan. These censuses were compiled annually in each village. In 1721 and every six years between 1726 and 1846, they were reported to the domains, then to the shogunate, and were compiled to form national statistics (shigo aratame). Thus, the shiimon aratame cho are the basis for village, provincial, and national level data, and they have been used, almost exclusively, to estimate birth rates, death rates, population size, and population growth rates for the late Tokugawa period. These records have made a major contribution to our understand­ ing of family and village life m premdustnal Japan. But in spite of the unusually high quality of Japanese population registers, they are not the best records to use for research on epidemics and mortality. Not only is it difficult to detect short-term changes in mortality that marked the passage of an epidemic, but it is also impossible to analyze changes m seasonal or age patterns of mortality that provide clues to the kinds of epidemics that caused a rise in mortality. The shiimon aratame cho have another defect that makes them in­ appropriate for mortality studies. Infants who were born and died in the interval between yearly registrations were not counted in the annual village census. The omission of this group leads to a serious underestimation of both fertility and mortality, because infant mor­ tality, which is always highest in the first few months of life, was especially so in premdustnal times. In addition, good series of shiimon aratame cho that span many years are rare. Even some of the best population registers have missing years, and no registers survive for many regions of Japan.7 Fortunately, there are other Japanese records that can be used to study epidemics and mortality during the Tokugawa period. Bud­ dhist temple death registers, or kakocho, are private records that are quite similar to European parish registers. Kakocho have been used very little for academic research, but they are excellent records for studying crises that influenced mortality. Since the quality of the Japanese source materials is of paramount importance to the argument that will be made here, the remainder of this chapter will be devoted to a detailed description of the qualitative and quantitative sources used in this study. THE DESCRIPTIVE ACCOUNTS

In many respects early Japanese descriptive records are superior to European sources on epidemics The Japanese are noted for their 7Laurel L Cornell, "Peasant Family and Inheritance in a Japanese Community 1671-1980" (Ph D diss ,Johns Hopkins University, 1981), pp 39-40

THE JAPANESE SOURCES

37

meticulous record-keeping, and records of many kinds have been treasured and protected throughout Japan's long history The sys­ tematic recording of important events m Japan began in earnest at the end of the seventh century with the Shoku mhongi,8 a chronicle that begins in A D 697 Other sources, such as the Kojiki 9 and the Nihongt,10 deal with earlier periods, but since these records were written much later, they are not contemporary accounts The early official histories were chronologies, a tradition of historical writing borrowed from the Chinese They consist of short accounts of events compiled in the order in which they occurred This style of record-keeping, which is especially useful when studying epidemics of the past, has continued in Japan to the present time The result is a wealth of source materials with remarkable continuity of form Not only is the form consistent, but also few major gaps exist in the Japanese records—certainly nothing to correspond to the paucity of primary sources and the gaps of several centuries that exist between accounts of European epidemics before the fifteenth century Unques­ tionably, many Japanese accounts of epidemics have been lost because Japan has been especially prone to disasters such as flood and fire, calamities that are notorious destroyers of written records However, there is nothing in Japanese history to parallel the repeated invasions and plunderings that devastated much of Europe before the eleventh century, and fortunately the long span of time covered by the Japa­ nese descriptive records serves to offset the loss of individual accounts Another advantage of the Japanese records is that, in contrast to European records, they are written in a single language Although recorders used various written forms, including classical Japanese and Japanese versions of Chinese, basically only one written language has been used m Japan The Chinese writing system, which the Japanese borrowed and adapted to their own very different language in the seventh century, is an asset when it comes to identifying epidemic diseases Diseases were labeled with Chinese characters that stood for the major symptoms of the disease, usually with two and sometimes with three or four characters used to refer to a single disease As was 8The Shoku mhongi covers the years 697-791 For a translation, see J B Snellen, trans , 'Shoku mhongi" (Books 1-6), Transactions of the Asiatic Society of Japan, 2nd ser , 11 (1934) 151-239, 14 (1937) 209-78 9The Kojtki incorporates legendary and protohistoncal material It was completed in A D 712 and covers Japanese history to 592 For a translation, see Basil Hall Chamberlain, trans , Translation of'Koji ki" or "Records of Ancient Matters" (Kobe, 1932) 10The Nihongi, also called the Nihonshoki, was completed in A D 720 and covers Japan's history to 697 For a translation, see W G Aston, trans , Nthongi Chronicles of Japan from the Earliest Times to A D 697, reprint (2 vols in 1) (London George Allen and Unwin, Ltd , 1956)

38

CHAPTER III

the case in Europe, disease names became more refined as characteris­ tics that differentiated similar diseases were noted The use of Chinese characters has helped to preserve the names of many diseases and their symptoms, and although there have been changes over the centuries in the characters used, two characters were seldom changed at the same time In many cases, the early Japanese terminology for a disease is still being used today Such linguistic continuity is unusual and of great value to the historian who attempts to identify past epidemics by name or type Of course, in many accounts it is not possible to identify an epi­ demic by name or even by type As in European records, a general term equivalent to "plague" or "pestilence" or simply "epidemic" was often used However, as in Europe, the Japanese records improve over time, and by the Tokugawa period a high proportion of epi­ demics can be attributed to well-known diseases The sources also improve with respect to regional representation, and they reflect the growth of the Japanese population and its expan­ sion northward The writers of the earliest accounts were often of­ ficial scribes who lived in the capital They commented on what was happening in the capital and on reports from the provinces They were mainly concerned with events in the more populous, settled regions of southwestern Japan Later, as Japanese political centers were established in the central and northeastern regions of the Japanese islands, and as population increased m those regions, accounts from central and northeastern Japan became more numerous In order to assess the impact of acute infectious disease on mor­ tality in the Tokugawa period, a review of Japanese descriptive ac­ counts of epidemics from the earhest accounts to the mid-nineteenth century is necessary Far from merely providing historical back­ ground, important though that may be, the identification of epidemic diseases in earher centuries is a first step in establishing the epidemi­ ological patterns of acute infectious diseases in the early modern period An understanding of such patterns is essential for determining which diseases were likely to be major causes of death from the seventeenth to the mid-nineteenth centuries For example, diseases that were endemic for many centuries in Japan may still have been an important cause of death in the Tokugawa period, but they could not have caused a "great dying" like that experienced by New World populations m the early sixteenth century 11 On the other hand, if certain diseases caused epidemics infrequently, or if new diseases en11 For a concise description of the causes of high mortality and the regions affected in the New World in the early sixteenth century, see Erie R Wolf, Europe and the People Without History (Berkeley University of California Press, 1982), pp 133-34

THE JAPANESE SOURCES

39

tered the country, their effect on morbidity and mortality in all age groups would presumably have been severe. In order to understand how epidemics affected mortality in the Tokugawa period, as much as possible must be learned about the history of the epidemic diseases that occurred earlier. A search through twelve centuries of records for references pertain­ ing to Japanese epidemics is obviously an undertaking of monumental proportions. Fortunately, such a search has already been made, and a compilation of such references was published early in the twentieth century. Nihon shippei shi (A history of Japanese epidemics) represents the lifework of Fujikawa Yu, and it remains to the present time the only source of its kind.12 It is the standard reference on Japanese epidemics, and it is systematically referred to by modern Japanese scholars. This work provides an annotated chronology of references to epidemics in Japan from the earliest known reference in A.D. 93 to the end of the Tokugawa period in 1867. Citations from the Japanese texts are given, the original source is identified, and the references are compiled in order by year. In addition, Fujikawa devotes a chapter to each of the most important epidemic diseases and analyzes the evo­ lution of the terminology used to record them. Fujikawa was uniquely qualified for this task. He was born in 1865 into an established family of physicians, and since medicine was a hereditary occupation in Japan, Fujikawa was trained in traditional Japanese medicine. However, his primary interest, apparently formed at a very young age, was history, and he began to seek out historical references to disease and treatment in Japan. Born a little more than a decade after the Western powers had forced the opening of Japan to foreign trade, Fujikawa was exposed to the influx of Western ideas, and he developed a keen interest in Western medicine and its history. In 1897, at the age of 32, Fujikawa, like many of his countrymen, went to Europe to study. He studied medicine and the history of Western medicine in Germany for approximately ten years, receiving a degree in medicine as well as a Doctor of Letters from Jena Univer­ sity. His sojourn in Europe coincided with an unprecedented series of breakthroughs in medicine: the improved methods of bacteriological 12 Fujikawa, Nihon shippei shi, first published in 1912, will hereafter be referred to as NSS Fujikawa is best known for his much longer history ofjapanese medicine, Nihon igaku shi, which was published in 1904. This earlier book deals with the history of medical practice and therapy. Fujikawa spent large sums of money buying the old medical and historical sources that were used in his research for these two publications. He donated his personal library to Kyoto University, where it is preserved as the Fujikawa Bunko For further details, see Matsuda Michio, "Kaisetsu," m Fujikawa, NSS, pp. 321-25

40

CHAPTER III

investigation developed by Louis Pasteur (1822—1895) and Robert Koch (1843—1910) had ushered in a new era in the history of infec­ tious diseases. Fujikawa's writings m the early twentieth century indi­ cate that he was well informed about the germ theory of disease. Fujikawa returned to Japan convinced of the need for a compre­ hensive history of infectious diseases in Japan At the time there was no Japanese parallel to the substantial European literature on epi­ demics, although references to epidemics were scattered throughout the voluminous source materials of premodern Japan.13 Fujikawa spent the rest of his long life collecting these primary source materials, and Nihon shippei sht is a major contribution to the history of disease: a compendium of a great variety of old records and medical documents that are specifically concerned with diseases that occur as epidemics. Fujikawa's Nihon shippei sht was the principal source used in this study for qualitative, descriptive accounts of epidemics in premodern Japan.14 His expertise as a medical historian, his acquaintance with all the permutations that took place over time in the use of Japanese and Chinese terminology, and his knowledge of the reliability of the sources make him the expert in this matter Further, his approach to the identification of specific acute infectious diseases was cautious and critical. When he believed a source to be unreliable or the termi­ nology unclear, he was hesitant to identify an epidemic disease by name, preferring that the specific disease remain in doubt.15 No other author of comparable authority has challenged his findings The very earliest Japanese records contain accounts of epidemics These accounts, which began to be kept regularly just before the turn of the eighth century, tell us that an epidemic occurred in every year be­ tween A.D. 698 and 713, and epidemics were recorded at frequent intervals thereafter. This does not mean that epidemics were un­ known in Japan before the late seventh century, but rather that they 13 The lack of interest m Japanese epidemics contrasts sharply with the great interest shown by the Japanese in other disasters Floods, famines, earthquakes, and volcanic eruptions are topics of great importance in Japanese history, and there exist many studies and compilations of records on these topics, however, few disaster histories include information on epidemics 14References to contemporary accounts of epidemics can be found in Fujikawa, NSS, on the pages cited, where excerpts from the original documents and the names of those documents are found 15For example, Fujikawa believed that the Nthongt was an unreliable source because it chronicled events that occurred long before it was written The Nihongt tells of an epidemic in A D 585 and uses one of the written characters for smallpox, but Fujikawa considered this account to be either hearsay or fabrication He felt that the first reliable written evidence of smallpox in Japan was the account of 735 in the Shoku nthongi For a discussion of problems associated with the early sources, see George Sansom, A History of Japan to 1334 (Stanford, Cahf Stanford University Press, 1958), pp 29-30, 55

THE JAPANESE SOURCES

41

were a common occurrence when the earliest accounts were written, and that they were among those events considered worthy of recording. The fact that accounts of epidemics can be found in the very earliest Japanese records also means that, by the seventh century, Japan either was importing diseases on a fairly regular basis, or had a population that was sufficiently large and dense to support endemic diseases that occur as epidemics.16 In terms of content, Japanese accounts of epidemics are similar to those in Europe. A typical account begins with the year and month in which an epidemic began.17 It may be even more specific and men­ tion the part of the month or even the day when an outbreak was first noticed. And the approximate duration of the epidemic was often recorded. For example, it was common for contemporary accounts to note that an epidemic lasted from the first to the fourth month, or from the tenth month of one year to the third month of the following year. Reference to season was also common, and the seasonality of certain epidemic diseases in Japan can be determined from contem­ porary accounts.18 An example of seasonal information can be seen in records from the year 1819. One account simply states that influenza was widespread in the second month; another mentions that dysen­ tery was prevalent in Edo from the end of the fifth month to the eighth month, and that an uncountable number of people died.19 Both of these epidemics exhibited the expected seasonality for in­ fluenza and dysentery. Regions that were affected by a serious outbreak are commonly mentioned, and the names of major cities are frequently found in accounts of epidemics. Some accounts indicate the routes along which 16The population of Japan, about 3 to 5.5 million people in A.D 645, was much larger than European populations at that time. See Wilham Wayne Farns, Population, Disease, and Land in Early Japan, 645—900 (Cambridge, Mass. Harvard University Press, 1985), p. 8. Accounts of epidemics do not show up in European records with any regularity before the High Middle Ages. Problems of record-keeping and pre­ servation in Europe between A.D. 300 and 1000 may mean that the importance and frequency of epidemics during this period have been underestimated, however, re­ ports of epidemics in Europe coincide with increases in population size and centers of density after the year 1000, supporting the theory that they were not important earlier Also, the interruption in trade between Europe and the Middle East for most of the first millenium A.D. was undoubtedly important in reducing the importation of infectious diseases A marked increase in accounts of epidemics followed the resump­ tion of this trade 17Japanese nengo or era names were used to designate year; however, Fujikawa's chronology includes the equivalent Gregorian year as well. 18Because of peculiarities of the Japanese solar-lunar calendar, when season and month are both mentioned in an account, they sometimes seem to be contradictory Problems of seasonality and the Japanese calendar are explained later in this chapter 19Fujikawa, NSS, pp. 60—61.

42

CHAPTER III

an epidemic spread, and how long the disease took to travel from one part of the country to another. This kind of reporting is illustrated in a 1684 account that describes an epidemic that was probably rubella or German measles: An epidemic was prevalent in Nagasaki in the fourth and fifth month. More than 7,000 people died from the disease. It is said that the epidemic was prevalent throughout Kyushu and Chugoku and that many people died. It reached Naniwa and Kyoto in the sixth and seventh month, and more than a thousand mer­ chants died from the disease in Sakai. In Kyoto people made dolls and went out beating drums m the evening in order to ward off the epidemic. This has never happened before. The same thing is going on in Kanto. In Nagoya, where I am living, many people were stricken during the middle of July. People lay prostrate from the disease but often recovered after three to five days. Goshu, Sesshu, Noshu, Sanshu and T5to were all affected by the same kind of epidemic. This must be the so-called "threeday disease."20 Many accounts include information on particular individuals or groups that were affected, as can be seen in the following accounts of an unidentified epidemic in 994—995, a smallpox epidemic in 1243, and a measles epidemic in 1708. 994—995

From before the [Kamo] festival of that year the country had been greatly upset, and in the following year [conditions] became increasingly bad indeed. To begin with, Great Ministers and High Court Noble­ men died in great numbers. On top of this, the num­ ber of those [who died] of the Fourth or Fifth Ranks was [so large as to be] unknown... [Such a thing] is not likely to happen again. Even in ancient times, for seven or eight Great Ministers and High Court Noblemen to be thus swept away in a period of two or three months was a rare occurrence.21

20Ibid , pp 53—54 Goshu, Sesshu, Noshu, Sanshu and Toto refer to Omi, Settsu, Mino, Mikawa, and Edo respectively These include some of the regions around and between Osaka, Kyoto, and Edo 21Joseph K Yamagiwa, trans , The Okagami A Japanese Historical Tale (Rutland, Vt Charles E Tuttle, 1966) pp 176—77 Fujikawa did not identify the epidemic of 994—995, but other scholars believe it was smallpox See William H and Helen Craig McCullough, trans, A Tale of Flowering Fortunes Annals of Japanese Aristocratic Life in the Heian Period, 2 vols (Stanford, Calif Stanford University Press, 1980), 1 168 η 41, 1 413-14, supp η 57

THE JAPANESE SOURCES

1243

1708

43

Fifth month, 29th day. Within a few days smallpox has spread more and more. It is said that this time it is affecting very young children.22 Measles invaded all of the provinces ofJapan. It started in the fall and lasted until spring of the following year. Everyone—man, woman, young and old, rich and poor-—was affected. Many died.23

Each of these epidemics had a different impact on society. The account of 994 tells of an epidemic so severe that it eliminated much of the ruling class, and no doubt much of the rest of the population as well. The account of 1243 says that smallpox was primarily a disease of young children in this particular year, and we can assume that smallpox was either endemic by that time or had been prevalent in the locality a short time before. And the account of 1708 tells us that this epidemic of measles was very severe. Old people were stricken and died of the disease; thus, it seems likely that measles had not been seen for many years. A dilemma that one encounters when analyzing accounts of early epidemics is how to separate accounts that describe crises caused by acute infectious diseases from those that describe the effects of severe malnutrition in times of famine. Fujikawa's compiled sources include both, and crises tend to fall into three major categories: epidemic crises, which seem to have been entirely unrelated to famine; sub­ sistence crises, in which famine and nonspecific epidemics occurred together; and "mixed crises," in which clearly identifiable epidemic diseases occurred in famine years.24 In a "mixed crisis" the causes of the famine and epidemic are different. Their concurrence may be coincidental, but each reinforces and magnifies the other to heighten the general crisis and increase mortality. In addition, many accounts provide insufficient evidence to determine the specific nature of a crisis. The major concern in Chapters III through VI will be epidemics of acute infectious diseases that seem not to have been associated with famine. Epidemics that appear to have been strongly linked with famine and "mixed crises" are considered in Chapter VII. Accounts of epidemics that do not mention famine can be divided into two categories: 1) those that identify a particular disease by name 22Fujikawa,

NSS, p. 38. pp. 182-83. 24Similar criteria have been used to categorize mortality crises in other societies. Paul Slack discusses the nature of the evidence used to distinguish between different types of crises in "Mortality Crises and Epidemic Disease in England, 1485-1610," in Health, Medicine, and Mortality in the Sixteenth Century, ed. Charles Webster (Cam­ bridge: Cambridge University Press, 1979), pp. 9—27. 23Ibid.,

44

CHAPTER III

Table 3 1

Epidemics per Century Japan to 1868 Epidemics (N)a 8 9 10 Identified diseases'5 5 5 8 Unidentified diseases 21 10 17 Total 26 15 25 % identified 19 33 32 diseases

Century 11 12 13 14 15 16 17 18 19 9 10 13 12 11

9

9 23 30

11 6 8 12 9 10 7 8 2 20 16 21 24 20 19 16 31 32 45 62 61 50 55 47 56 74 93

Source Fujikawa Yu, NSS Recorded epidemics not associated with famine b Disease identification by Fujikawa Yΰ

a

or note symptoms that allow a general classification of the epidemic by type, and 2) those that are too vague to permit identification of any particular disease As mentioned earlier, the impact of an epidemic disease on mortality depends, on the one hand, upon such biological factors as virulence, mode of transmission, communicabihty, and im­ munity, and, on the other hand, upon historical factors such as previ­ ous exposure of a population to the microorganism that causes the disease Only if we have some sense of the kinds of diseases that caused epidemics in the Tokugawa period can a judgment be made about their impact on mortality Therefore, our first concern will be to identify the important epidemic diseases of premodern Japan Table 3 1 shows the number of epidemics recorded in Japan by century In the early centuries there were many epidemics that cannot be identified, however, by the twelfth century, Fujikawa was able to identify specific epidemic diseases m more than half of the accounts In accounts written during the Tokugawa period, the proportion of epidemics that can be identified by name is high, reflecting the abun­ dance of excellent Japanese source materials on epidemics after 1600 Table 3 1 exhibits a sharp rise during the eighteenth and nineteenth centuries in the number of accounts of epidemics not associated with famine Does this mean that epidemics became more frequent and perhaps more important in checking population growth in the second half of the Tokugawa period7 This increase in epidemic frequency is subject to several interpreta-

THE JAPANESE SOURCES

45

tions. A rise in the number of the accounts may not reflect a rise in epidemics at all. It may simply represent more systematic record­ keeping under the politically stable Tokugawa regime, or better sur­ vival of records from more recent times. But even if the increase in the number of accounts does represent a real increase in the number of epidemics afflicting the Japanese people, conflicting interpretations must still be weighed. If we interpret this rise in the frequency of epidemics to mean that the population of Japan was more vulnerable to epidemic diseases than in former times, it is important to look at possible reasons for this increased vulnerability. For the number of epidemics to increase re­ quires an increase in the frequency of contact between disease-causing organisms and human hosts. In the case of indigenous diseases, such an increase would automatically follow an increase in the population, and since we know that Japan had a marked population increase in the sixteenth century, shorter intervals between epidemics are to be expected. An increase in epidemic frequency will also occur when there is greater contact with sources of infection. During the Tokugawa period, economic development brought remote parts of the island into more frequent contact with Japan's large and growing cities. With the extension of the market network, disease organisms were disseminated more thoroughly throughout Japan, causing increased epidemic outbreaks in regions previously protected by isolation. It is doubtful that there was greater contact with sources of infection outside Japan. Because of more stringent restrictions against trade and other types of contact with the outside world during the Tokugawa period, it is unlikely that epidemic diseases were imported more frequently than they were in earlier times. The best way to determine what increasing epidemic frequency means in terms of mortality is to identify the diseases that were causing epidemics in early modern Japan. Since the names of impor­ tant diseases have changed very Httle over time, and since many diseases are known by the same names today as were used in accounts written more than ten centuries ago, this is not too difficult a task.25 For example, the Japanese account that describes an epidemic of small­ pox in A.D. 735 uses the same Chinese character that is used for small­ pox today. This is the character so (¾), the ideograph that signifies "pustule," "boil," or "pox." This character in combination with ίο (&) forms to so (¾¾), the present Japanese word for smallpox. 25 Fujikawa, N S S , pp. 98-99. An excellent analysis of the evolution of terminology for disease names can be found on pp. 93—99.

46

CHAPTER III

The evolution of terminology for disease names in the Japanese sources is fairly clear. A review of contemporary accounts shows that disease names became more refined over time in order to distinguish between diseases with similar symptoms. The process was quite similar to that which took place in Europe; the same problems arose and similar modifications took place. For example, in medieval Europe, smallpox and measles were believed to be different manifestations of the same disease, and only in the seventeenth century were they established as separate entities.26 Before that time, they were often recorded as epidemics of "smallpox and measles." In Japan the terminology for smallpox was established in written records before measles appeared on the scene. Although the measles virus probably reached Japan earlier than existing accounts indicate, the first description of an epidemic that seems clearly to have been measles was written in A.D. 998. Accounts describing this epidemic simply modified the term for smallpox to fit the disease of measles. The result is a term that means "red rash pox" or "red smallpox."27 Although this adaptation of existing terminology suggests that, as in Europe, smallpox and measles may have been regarded as different varieties of the same disease, the confusion was resolved much sooner in Japan. By the early fifteenth century, the Japanese terminology for smallpox and measles retained no common Chinese characters, and only rarely were smallpox and measles epidemics said to have oc­ curred in the same year. As we shall see, in Japan differences in the epidemiological patterns of smallpox and measles were more obvious, and this may have helped the Japanese to distinguish between these two diseases more easily. Today the common name for measles is hashika, a term that first appears in an account written in 1405.28 Hashika is sometimes written with Chinese characters (0¾), and it also may be written in katakana, a Japanese phonetic writing system.29 This long continuity in termi­ nology means that measles epidemics can be clearly identified in Japa­ nese records that were written more than five centuries ago. TheJapanese term for measles was later adapted to describe rubella, or the "three-day measles." This may be the epidemic disease de­ scribed as the "three-day sickness" in an account written during the Muromachi period in 1244.30 The "three-day sickness" appears in a 26

Christie, Infectious Diseases , p. 374. Fujikawa, NSS, p. 178. 28Ibid., p. 180-81. 29The earliest known account in which these Chinese characters were used to describe an epidemic of measles was written in 1506. Fujikawa, NSS, p. 181. 30Fujikawa, NSS, p. 210-12. 27

THE JAPANESE SOURCES

47

number of subsequent accounts, and it is described as a disease of children that is like measles. By the Edo period, the accounts are telling of epidemics of mikkahashika, an exact translation of which is "three-day measles," andfiishin (JSS), for which a translation might be "measles that blows through quickly, like the wind." These terms followed a logical evolution. Although we cannot be certain that an epidemic in the past was caused by a specific micro­ organism, Japanese contemporary accounts do tell us that by the Tokugawa period, smallpox, measles, and rubella were commonly recognized diseases in Japan. Two other important epidemic diseases mentioned in early Japanese accounts are influenza and dysentery. Records from the Heian period (794—1160) describe epidemics of a coughing sickness that was char­ acterized by its rapid spread. Fujikawa identified twenty-one of these influenza-type epidemics in pre-Tokugawa accounts, the earliest epidemic appearing in records of A.D. 862 and 863.31 Twenty-seven influenza epidemics are described in contemporary accounts of the Tokugawa period.32 It is not surprising that influenza epidemics reached Japan fairly often, because the influenza virus mutates and can be carried by people of all ages. Moreover, influenza is highly conta­ gious, and it is noted for its ability to sweep very rapidly over vast areas. What is unusual is the number of existing accounts from such early periods and the clarity of the descriptions that permits influenza to be identified. Enteric infections, such as dysentery, were an important cause of death in most premodern societies, and Japan was no exception. Epidemics of diarrheal diseases may be widely or locally distributed, and their virulence can vary greatly. The generic term "dysentery" will be used to refer to diarrheal diseases, although today "dysentery" is used to describe a particular type of enteric infection. Fujikawa found accounts of eighteen epidemics of dysentery, the earliest known account written in A.D. 861. Many Chinese character combinations have been used to describe diarrheal diseases, but almost all combina­ tions include the character ή (¾), which means "diarrhea." 33 Chol­ era, a dysentery-type epidemic that first became important as a world disease in the nineteenth century, does not appear in the Japanese records until 1822.34 Two different terms were used in the earliest accounts of cholera, korori and korera. The first was a native term used to depict any sudden, catastrophic illness; the second was the Japanese 31 Ibid.,

pp. 250-53. pp. 253-62. 33 Ibid., pp. 294-98. 34 Ibid., p. 215. 32 Ibid.,

CHAPTER III

48

Table 3.2

Chronology of Epidemics in the Tokugawa Period

Japanese year 1601 1607 1614 1616 1619 1631 1640 1642 1649 1654 1671 1674 1679 1680 1682 1684 1690-1691 1693 1699 1702 1707 1708

1709 1711 1712 1714 1716 1720 1723 1730 1732 1733

Disease Unidentified Measles Influenza Measles Smallpox Unidentified Unidentified Unidentified Measles Smallpox Chicken pox Unidentified3 Smallpox Unidentified3 Smallpox3 Rubella Measles Unidentified Unidentified Smallpox Influenza Measles Dysentery Smallpox Smallpoxb Smallpox Smallpoxb Unidentified Unidentified Smallpox Smallpox Measles Unidentified Unidentified3 Influenza

Japanese year 1734 1735 1744 1746 1747 1748 1753 1763 1769 1770 1772 1773 1776 1779 1781 1784 1788 1795 1799 1801 1802 1803 1807 1811 1816 1817 1819 1821 1822 1824 1825

Disease Unidentified Unidentified Influenza Smallpox Dysentery Influenza Smallpox Measles Unidentified Influenza Unidentified Unidentified Smallpox Influenza Measles Rubella Influenza Influenza Unidentified Influenza Dysentery Influenza Influenzab Measles Influenza Influenza Unidentified Dysentery Influenza Dysentery Influenza Cholera Influenza Measles Smallpox

THE JAPANESE SOURCES

49

Table 3.2 (cont.)

Japanese year 1827 1829 1830 1831 1832 1835 1836 1837 1838 1841 1850 1851

Disease Influenza Dysentery Unidentified Influenza Influenzab Rubella Measles Unidentified3 Smallpox Dysentery Influenza Unidentified

Japanese year 1852 1854 1857 1858 1859 1860 1861 1862

1863 1867

Disease Unidentified Influenza Influenza Cholera Cholerab Influenza Unidentified Measles Cholera Cholera Influenza

Source: Fujikawa Yu, NSS. or starvation deaths were mentioned in the account. b Epidemic began in preceding year.

a Famme

rendition of the English word "cholera." "Cholera" was first written in katakana, the usual form for foreign loan words. Later, cholera was given a more formal written form using Chinese characters (,¾ ?!)$!)), but the pronounciation korera was retained. The epidemic diseases that appear in the pre-Tokugawa accounts, in order of their appearance in the records, are smallpox, measles, dysentery, influenza, mumps, rubella, and syphilis. Chicken pox and cholera do not appear in the records until after 1600. Table 3.2 is a chronological list of the Tokugawa epidemics documented in the sources compiled by Fujikawa. Most epidemics of the Tokugawa period can be attributed to specific acute infectious diseases. Those that occurred most frequently were smallpox, measles, dysentery, cholera, and influenza. According to contemporary sources, these diseases were the most important epidemic diseases of the Edo period. With the exception of influenza, which is not normally fatal, each of these diseases will be reviewed in turn. The major difference between the history of these diseases in West­ ern and Japanese sources is that they are well documented much earlier in Japan. Accounts exist for forty-six smallpox epidemics and

CHAPTER III

50

twenty-four measles epidemics between A D 735 and 1600 It is not surprising that these particular epidemic diseases reached Japan Living close to the China mainland, and possessing one of the world's largest and most densely settled populations, the Japanese must have been exposed to many of the diseases of East Asia quite early in their history, even if contact with China was infrequent When the first Japanese accounts were written, the two necessary conditions for epidemics to develop were present a population of sufficient size and density to permit density-dependent diseases to occur as epidemics, and exposure to microorganisms that were host-specific to man THE KAKOCHO

The analysis of mortality m this study will be based on Buddhist temple death registers, or kakocho, which are local or regional sources During the Tokugawa period, everyone was required to be affiliated with a Buddhist temple, and deaths of members were registered at the temple Many temple registers go back several centuries and are still being compiled today When a member of the temple died, a memo­ rial service was held, and his death was registered to assist his passage into the next world and to protect his descendants from misfortune There was every reason to register the death of a household member, and no reason not to Presumably it was popular to do so, since even stillborn children were registered The content of the kakocho varies from temple to temple The chief priest normally compiles the kakocho because they constitute an im­ portant record of the temple's past, and there is often a change in the style of the registers when a priest dies and is replaced by a new recorder The registers routinely give the posthumous name of the deceased (kaimyo) and the date of death The posthumous name indi­ cates whether the deceased was male or female, adult or child (under Japanese age 15) Some kakochd give the place of residence and the age of the deceased, and some even relate the specific circumstances of an individual's death and provide information about major disasters 35 Although temple death registers have been used very little by de­ mographers and historians, they are excellent sources for research 35The author is indebted to Arne Kalland, who has used kakocho from three fishing villages in Fukuoka prefecture to study mortality during the Kyoho famine, 1732—1733 See Arne Kalland and Jon Pedersen, "Famine and Population in Fukuoka Domain During the Tokugawa Period," The Journal of Japanese Studies 10, 1 (Winter 1984) 31-72 SeealsoRobertJ Smith, Ancestor Worship in Contemporary Japan (Stan­ ford, Calif Stanford University Press, 1984), pp 80-82 for additional mformation on posthumous names

THE JAPANESE SOURCES

51

because they show changes in mortality over time.36 Kakocho exist for most regions of Japan, and unlike the population registers, which supplied the regional and bakufu governments with information about the population under their control, the kakocho were private, not political, documents. Moreover, kakocho represent a virtually univer­ sal record of the Japanese population during the Tokugawa period, because as part of the Tokugawa government's effort to stamp out Christianity in Japan, every household was required to register with a Buddhist temple. The major problem with using temple records is that death rates cannot be calculated, because the sizes of temple populations in past years are seldom known. A temple's membership often came from several different villages; sometimes only part of the population of a village was affiliated with a temple. However, since epidemics and famines are usually regional occurrences, this is not a serious defect, and kakocho are exceptionally good records for research on changing mortality patterns. When death data recorded in temple registers are used to construct a mortality curve, periods of high mortality show up clearly. Because epidemics are highly concentrated in time and space, deaths caused by epidemic diseases create sharp peaks on the mortality curve. Of course, mortality peaks were also caused by other disasters, but when descriptive accounts in local histories are used in conjunction with temple death records, it is usually quite clear when an epidemic was the cause of a crisis. In addition, kakocho can be used to determine whether an epidemic noted in one locality affected other regions or villages. And in some instances, kakocho from different parts of Japan can be used to reconstruct the path and the timing of an epidemic as it spread through the Japanese islands. In particular, this analysis relies heavily on data from death registers in two regions of Japan: Sendai, in northeastern Japan, and Hida, in central Honshu. The registers were analyzed to estimate the effect of epidemic diseases on mortality in these two regions during the Tokugawa period. Two kakocho studies that contain information on epidemic diseases were used extensively: a study by Aoki Daisuke, 36A

group of Japanese medical historians have recently begun to collect and study

kakocho in order to learn about the health conditions and lifespans of people in

preindustrial Japan. In 1968, they formed a research group using the name Nihon Minzoku Eisei KySkai (Association to Study Race Hygiene), and under the leadership of Abe Koki formed a committee to organize research on the kakocho. Many of the members are associated with university schools of medicine. Abe Koki, "Rekishi jinko no minzoku eisei gakuteki kenkyu," Nihon minzoku eisei 36 (January 1970):1-12.

52

CHAPTER III

who used kakocho from temples in old Sendai domain to study Tokugawa epidemics in that region;37 and data from a study by Suda Keiz5 of the kakocho of Ogen-ji, a temple in the Hida region of Gifu prefecture.38 During the Tokugawa period, Sendai domain included all of present-day Miyagi prefecture and the southern part of Iwate prefec­ ture. This region has a long coastline facing the Pacific Ocean in northeastern Honshu, and it is known as the Tohoku region of Japan. The western section of Sendai domain is part of the Ou Mountains, which descend gradually to a coastal plain in the east. The northern coastline is heavily indented, and the southern coast around Sendai Bay is composed of sandy beaches. The climate in this region is cool, with clear dry winters, and along the coast winters are mild. During the Tokugawa period, Sendai was one of the larger do­ mains. The region flourished under the rule of the Date family, and the city of Sendai became the principal cultural and economic center of northeastern Honshu. Sendai developed as a major port during the Edo period, and her merchants engaged in trade with Osaka, Edo, and other regions of Japan. Because of its strategic location, Sendai is an excellent region for a study of epidemics, which reached the port of Sendai fairly quickly. Epidemics spread from there to villages along the coast, and then inland, along rivers, to villages in the mountainous parts of the domain. The Hida region of Japan, situated in an extremely mountainous part of central Honshu, is quite different from Sendai (see maps, pp. xiv, xv). It is drained by two rivers: the Hida River, which flows southeastward to the Pacific Ocean, and the Miya River, which empties into the Sea ofjapan. Takayama, a former castle town and the only city in Hida, lies approximately 120 kilometers north of Nagoya in a small river valley near thejapan Alps. Today, ajourney through the narrow valley cut by the Hida River can be made by train in less than four hours. However, in Tokugawa times, the trip was made on foot or horseback, and in winter deep snows made the trip a difficult one. Unhke Sendai domain, the Hida region is considered to have been one of the most inaccessible and isolated regions ofjapan. The temple of Ogen-ji is located in Miyamura, a village that is situated near the headwaters of the Miya River, about seven kilo­ meters south of Takayama City. In Tokugawa times, the temple membership came from Miyamura and a number of small villages that are now part of Kuguno-cho, which lies another four kilometers to 37 Aoki Daisuke, "Ekirei shi," in Saigai hen, vol. 22 of Miyagi-ken ski (Sendai; Miyagi-ken shi hensan iinkai, 1962), pp. 331-449. 38Suda Keizo, Hida "O" jiin kakocho no kenkyu (Takayama: Private edition, 1973).

THE JAPANESE SOURCES

53

the southeast of Miyamura. The Kuguno villages extend southward along the banks of the Hida River. Kuraiyama, the mountain that lies between Miyamura and Kuguno, is now traversed by a railroad tun­ nel, but in former times it must have been a formidable barrier be­ tween villages affiliated with the temple. Ogen-ji was established in Miyamura in the fifteenth century. It is a prestigious temple of the Shinshu, Otani sect, and a branch temple of Higashihongan-ji in Kyoto.39 The kakocho have been recorded by a succession of chief priests from 1528 to the present, and they now fill eighteen handwritten volumes, which are stored at Ogen-ji. During the eighty-two-year period between 1771 and 1852, chief priests of the temple systematically recorded many details about members who died. In almost all cases the sex and age of the deceased, the date of death, and the village of residence were recorded. In more than half of the cases, the priest entered a cause of death. There are no years missing from the series, and the sample of over 7,900 deaths is a large one. There have been seventeen chief priests at Ogen-ji since 1534, but only three of these men were in charge of the death registers between 1771 and 1852, the period that will concern us here.40 The first of these was Shinkyu, and it was he who began to regularly record causes of death in the registers. Shinkyu must have begun his tenure as a relatively young man, because he served as chief priest from 1762 to 1813, a period of fifty-one years. Priests of temples as prestigious as Ogen-ji were well educated, and it was not uncommon for them to have studied the practice of medicine. The Ogen-ji records suggest that Shinkyu became interested in following infectious disease cycles. Smallpox was occasionally mentioned in the kakocho before Shinkyu took over in 1762, but the regular recording of smallpox as a cause of death began with the smallpox epidemic of 1764—1766. From then until 1853, deaths attributed to smallpox, measles, and dysentery were meticulously documented in the death records, thus establishing the epidemic patterns of these diseases in the Hida villages that were affiliated with Ogen-ji. Later, Shinkyu began to note other causes of death as well. In many cases the causes given were vague—"long illness" and "sudden death" were frequently cited—but other explanations, such as "death by drowning" or "suicide by hanging," were quite precise. The chief priest who succeeded Shinkyu served for only ten years, and he ap­ parently had little interest in causes of death. Although he continued to note deaths from important epidemic diseases such as smallpox, 39 Ibid., 40

pp. 4—6.

Miyamura shi (Miyamura: Kyoiku iinkai, 1968), p. 232.

CHAPTER III

54

measles, and dysentery, he mentions other causes only infrequently. In 1823 Taigi became chief priest, and the kakocho reflect a renewed interest in causes of death. Taigi's tenure lasted until 1857, and he recorded not only epidemic diseases, but also many other causes of death until 1853. The recording of causes of death ceased abruptly in 1853, and from that time it is much more difficult to gauge the effect of epidemic diseases on mortality. It is not known why such a sudden change occurred, although it has been suggested that certain temple members raised objections to the practice of recording causes of death.41 One of the most remarkable features of the Ogen-ji records is the completeness of the data. The total number of deaths recorded during the eighty-two-year period between 1771 and 1852 was 7,962. The month of death was recorded in 98.7 percent of the cases, the day of the month in 98.3 percent, the sex of the deceased in 99.7 percent, the age of the deceased in 91.0 percent, and a cause of death in 79.8 percent of all cases. Data from the Ogen-ji records covering the period from 1688 to 1970 were hand-copied and published under the title Hida "O" jiin kakocho no kenkyii (A study of the death records of "O" Temple in Hida Province) by Suda Keizo, a physician who lives in nearby Takayama.42 Deaths were entered in the kakocho in chronological order, and the dates of death for those recorded before 1872 follow the old Japanese lunar calendar. As mentioned earlier, a problem with using kakocho is that yearly death rates cannot be calculated because the size of the temple popu­ lation is not known. The population of Ogen-ji was drawn from many villages, but not all families in each village were affiliated with this temple. Suda has estimated the size of the temple population for each year after 1771 by using a temple census taken in 1970 and calculating backward. His estimates indicate a population of about 2,677 in 1771, and of 3,142 in 1852. These population estimates follow expected demographic trends;43 however, since they were derived from the data itself, they were not used in this study to calculate death 41 Personal

communication. This explanation was suggested by the chief priest of

Ogen-ji, October 1981. 42Suda, Hida "O" Jiin. The names of the villages of the deceased persons recorded in the kakocho have been coded by Suda so as to protect the privacy of living descendants. 43 When the estimated population figures are plotted by year, the population curve shows a gradual increase over time and the increase is interrupted by known disasters that caused high mortality.

THE JAPANESE SOURCES

55

rates. Changes in numbers of deaths rather than death rates were used here to estimate the effects of different epidemic diseases on mortality. A second problem is that there are no independent data on births. Unlike European parish churches, Buddhist temples do not record births. Suda has calculated yearly estimates of births by subtracting ages at death from years of death. His estimates assume that everyone whose death was registered in the kakocho was bom into a household affiliated with the temple; however, it is likely that some of the deaths registered in these records are those of persons who were born else­ where and married into temple households. It is also possible that when temple members left the area their deaths were not recorded at Ogen-ji; however, according to the present chief priest, considerable effort was made to record the deaths of family members who moved away. And in fact, the deaths of many adults who died in other provinces were entered in the kakocho. For purposes of analysis here, we have assumed that deaths of household members were recorded at 0gen-ji, even if they had moved to other areas or married into households at other locations. Despite these problems, Suda's esti­ mates of births and population size are extremely useful, and they were used in a few instances in this study when it seemed important to try to assess the relationship between births and deaths. The death registers of Ogen-ji are also excellent sources for study­ ing infant mortality in the Tokugawa period. The deaths of infants and even stillbirths appear to have been faithfully recorded. This is important because deaths of children under age 1 represent a high proportion of all deaths recorded. Moreover, a consistent recording of deaths of infants and young children has particular significance for studies of epidemics, because children are more likely than adults to be susceptible to many acute infectious diseases. Two other problems that arise when using data based on the kako­ cho have to do with the form of the data in the original records. The first problem concerns the system used by the Japanese to calculate age; the second has to do with the Japanese calendar before 1873. In both cases, adjustments were made in the Japanese data in order to facilitate comparison with research findings on mortality in other preindustrial societies. The principle used to calculate age is entirely different in Japan from that in Western countries. In Japan, a person's age is equal to the number of calendar years in which he has lived. An infant is con­ sidered to be age 1 at birth, and if he dies on the day of birth, his age at death is recorded as age 1. On the first day of a new calendar year, each person's age increases by one year. Therefore, a child born on the

56

CHAPTER III

last day of the year who dies the following day will have his age at death recorded as age 2.44 This means that, in Western terms, all ages at death recorded in the kakochd are overstated by at least one year and in some cases by almost two years. If we assume that births are evenly distributed throughout the year, ages at death are overstated on the average by eighteen months. In this study, the recorded ages at death in the kakocho have been adjusted by subtracting only one year, even though this leaves the average Japanese six months older than his Western counterpart.45 The term "adjusted age" will be used to indicate this one-year change in the recorded ages at death. Japanese dates of death in the kakochd have also been changed to their Western equivalents to permit an analysis of the seasonality of mortality. The length of the old Japanese calendar year was irregular: some years had 354 or 355 days, while other years had as many as 383 or 384 days. Short years had twelve months; in long years an extra month was intercalated to make a thirteen-month year Months in the civil calendar were based on the phases of the moon and had either twenty-nine or thirty days An extra, or intercalary, month was added at approximately thirty-month intervals, and this extra month might fall at any time of the year For example, if an extra month was placed between the third and fourth month, it was designated as the intercalary third month. The end result was a lunar-solar calendar that frequently did not correspond to the seasons of the year, because seasons recur regularly each year according to the position of the sun. Unlike the adjusted ages at death, which are approximate, the adjusted dates of death have been converted very precisely to their Western equivalents in the Gregorian calendar. All references to dates of death from the kakochd of Ogen-ji, unless otherwise specified, are dates that have been converted to the Gregorian calendar.46 The Ogen-ji death registers are records of unusually high quality for a preindustnal society. It is rare to find deaths from specific 44In a small proportion of cases no age is given in the Ogen-ji registers For instance, no age was given in the case of stillbirths (which follows the logic of the system because a stillborn infant did not live in any calendar year) These cases have been removed from the sample All other cases in which no age of death was recorded have been treated as missing data 45The author is grateful to Hayami Akira for suggestmg this simple method to adjust the data The term "sat" will be used when there has been no adjustment of Japanese age 46 The author is mdebted to Phihp Sidel, Director of the Social Science Computer Research Institute at the Umversity of Pittsburgh, for designing a computer program to convert Japanese death dates to their equivalent in the Gregorian calendar The computer calendar conversion was based on the conversion tables m Uchida Masao, comp , Nihon rektjitsu genten (Tokyo Yusankaku Shuppan, 1975), pp 456-83

THE JAPANESE SOURCES

57

400 350-

Tempo f w

300-

JZ

O SCU 250O O ο

200-

Temmei famine

r/mean

0 1771

1781

1791

1801

1811

1821

1831

1841

1851

Gregorian Year 3.1

Distribution of Deaths by Year, Hida Villages: 1771-1852

epidemic diseases such as smallpox, measles, and dysentery-type ill­ nesses recorded consistently for many years. Not only is it possible to observe fluctuations in mortality at the time of an epidemic, but it is also possible to determine seasonal disease patterns and the age groups in the population that were affected by these diseases. Figure 3.1 shows a mortality curve that illustrates yearly fluctua­ tions in mortality between 1771 and 1852. Mortality fluctuated in a cyclical pattern with peaks occurring at fairly regular four-year inter­ vals. With the exception of 1837, when the average number of deaths in per year increased by approximately four times, fluctuations mortality are not extreme for a premodern society. The unusually high mortality peak in 1837 marks the height of the Tempo famine in the Hida villages. This subsistence crisis in the 1830s will be discussed separately in Chapter VII, which deals with famine and epidemics. The kakochd of Ogen-ji provide us with a rare glimpse at causes of death in a rural preindustrial society. Well-known diseases of the period were recorded very specifically by name, making it possible to determine which epidemic diseases were important causes of death and how they influenced mortality patterns. The kakocho recorded the following epidemic diseases as causes of death: toso (is fit) or hdsd (fSif), smallpox; hashika (M'S), also pronounced mashin, measles; ribyo (¾?¾), a diarrheal sickness; and fubyo an influenza type

58

C H A P T E R III

Gregorian Year

3.2 Distribution of Deaths by Year, Excluding Those Due to Epidemic Diseases, Hida Villages: 1771-1852 of illness. As w e have seen, these diseases had been known in Japan for centuries, and it is noteworthy that the terminology used in the death records of this temple in one of the most isolated regions ofJapan was the same as was used in the descriptive accounts of epidemics discussed previously. As in the descriptive accounts, some epidemics were recorded with nonspecific terminology. For example, ekibyo (B#S) and jieki (® 'M) are two general terms that were given as causes of death. The literal meaning of ekibyo is "epidemic sickness," whereas jieki can be translated as "current epidemic," "prevailing epidemic," or the "epidemic of the time." In the Hida region, both of these terms appear only during a severe famine. Figure 3.2 shows a mortality curve that has been altered dramatically by the removal of deaths attributed to epidemic-type diseases: smallpox, measles, dysentery, ekibyo, and jieki. Virtually all mortality peaks disappear, and those that remain coincide with the Temmei famine of 1784 and the Tempo famine, the worst years of which in the Hida region were 1834 and 1837. Both of these famines are well documented in the local records. The Hida temple registers also tell us that these epidemic diseases had a differential effect on adults and children. Table 3.3 shows the effects of different epidemic-type diseases on mortality in two age

THE JAPANESE SOURCES

59

Table 3.3

Distribution of Deaths from Epidemic Diseases by Age Group, Hida Villages: 1771-1852 N of deaths

% of epidemic deaths

% of all deaths

Under 10

10 and over

Under 10

10 and over

Under 10

Ekibyo Jieki

735 217 29 10 0 5

38 41 6 198 19 111

95.1 84.1 82.9 4.8 0.0 4.3

4.9 15.9 17.1 95.2 100.0 95.7

19.7 5.8 0.8 0.3 0.0 0.1

1.1 1.2 0.2 5.6 0.5 3.3

Totala

996

413

70.7

29.3

26.7

11.8

Disease Smallpox Dysentery Measles Influenza

10 and over

Original Data Source: Suda, Hida "O" jiin. a

Includes all cases for which age at death was given.

groups: 1) children under age 10, and 2) the remainder of the popula­ tion. Diseases that caused high mortality among children were differ­ ent from those that killed adults. Mortality from smallpox and measles was limited almost exclusively to children, but adults were more likely to die of influenza and the epidemics designated jieki and ekibyo. Since children are indeed more likely to die of measles and smallpox, and adults of influenza, the distribution of diseases by age inspires considerable confidence in the reliability of the kakocho of Ogen-ji. Table 3.4 shows that a small percentage of all deaths— children and adults—were due to epidemics. Very few adults died of epidemic diseases, but most adults did have some cause of death recorded under their name. Most of the deaths for which no cause was given were for children under age 10. The next three chapters review and analyze the epidemic patterns of smallpox, measles, dysentery, and cholera in Japan. These diseases were selected because they emerge as the most important epidemic diseases in both the qualitative, descriptive accounts and in the kako­ cho. Moreover, they caused a high proportion of the recorded epi­ demics of the Tokugawa period, and they were responsible for most of the mortality peaks in the Hida villages and in Sendai domain. The

60

CHAPTER III

Table 3.4

Distribution of Deaths by Cause by Age Group, Hida Villages: 1771-1852 Under age 10

Age 10 and over

Cause

N of deaths

% of deaths

% of all deaths

N of deaths

% of deaths

% of all deaths

Epidemic Other Unknown

996 1,770 967

70.7 39.4 71.9

26.7 47.4 25.9

413 2,772 377

29.3 60.6 28.1

11.8 77.5 10.7

Totala

3,733

51.6

100.0

3,562

48.4

100.0

Original Data Source: Suda, Hida "O" jiin. all cases for which age at death was given.

a Includes

purpose of the analysis is to trace the history of these diseases in Japan before the country was opened to international trade, to test the source materials against the known characteristics of each disease, and to assess the effects of these diseases on mortality during a period of national population stability.

CHAPTER IV

SMALLPOX: THE MOST TERRIBLE MINISTER OF DEATH For much of human history smallpox has devastated populations throughout the world.1 The origins of smallpox remain obscure, but the evidence is convincing that this disease afflicted all of the ancient civilizations: Egyptian mummies three thousand years old bear pockmarks that strongly resemble the scars left by smallpox, and the best written evidence today suggests smallpox reached India well before A.D. 400, China around 250 B.C·, and Greece around 430 B.C.2 Galen's account of the Antonine plague, which devastated Rome in the second half of the second century A.D., is regarded as "the earliest substantive evidence of smallpox in Europe " 3 By at least the be­ ginning of the Christian era, smallpox had reached most of the popu­ lation centers of the Old World,4 although epidemics undoubtedly occurred before there were records to document them. Even though it is impossible to pinpoint exactly when smallpox first reached specific populations, we do know that the disease wreaked havoc upon all societies with which it came in contact. Until the twentieth century, smallpox was an important cause of death everywhere in the world. Its introduction into the virgin popu­ lations of the New World by Europeans in the early sixteenth century led to the massive depopulation of American natives, and smallpox checked population growth in all populations sufficiently large to support it as an endemic disease. Donald R. Hopkins, a world author­ ity on smallpox, writes as follows about the potential for smallpox endemicity in the ancient world: By Roman times the Nile valley already had a population of about 7 million, China some 58 million, and India had more than 1 This chapter has benefited greatly from the generous assistance of Donald R. Hopkins, M.D., Assistant Director of International Health at the Centers for Disease Control. Dr. Hopkins, a world authority on the epidemiology and history of small­ pox, read early and late drafts of this chapter, and offered many suggestions for improvement. 2Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago, IU.: Uni­ versity of Chicago Press, 1983), pp. 14-19. 3Ibid., p. 22. 4Ibid., p. 21.

CHAPTER IV

62

25 million—all populations large enough to sustain smallpox once it was introduced. Long before the birth of Christ, these ancient civilizations were in contact frequently enough to have allowed smallpox to be disseminated to each other, no matter where it arose.... During the last milennium B.C. as in later times, wars, the establishment and collapse of empires, and trade caravans probably all helped spread smallpox via infected people and their contaminated clothing Buddha, Christ, and Moh­ ammed stimulated other movements that also spread smallpox. But by the beginning of the Christian era, smallpox appears to have been already endemic in northeast Africa, India, and prob­ ably China. It probably was not yet permanently established in thinly populated Europe.5 With smallpox established in China before the birth of Christ, it is no surprise to learn that the earliest Japanese records contain accounts of smallpox epidemics. Although human migration between China and Japan in premodern times was relatively small in scale, it was more than sufficient to carry the smallpox virus from the Chinese mainland to the Japanese islands. In this chapter, selected Japanese sources are used to trace the his­ tory of smallpox in Japan and to estimate the impact of smallpox on mortality and population growth during the Tokugawa period. Since this analysis and interpretation of the Japanese sources relies heavily on what is known about the history of smallpox elsewhere, some general information about the characteristics and epidemiology of smallpox is presented first. Next, a discussion of smallpox in Japan in the preTokugawa period lays the groundwork for an understanding of how this particular disease influenced mortality in Japan between 1600 and 1867. We are fortunate to be able to discuss smallpox in the past tense, because international public health programs successfully eradicated this disease from its last endemic focus in Bangladesh in 1977. DISEASE CHARACTERISTICS

Smallpox was caused by a virus that is host-specific to man. The smallpox virus belongs to a group of related pox viruses that cause Variola major and Variola minor in man, and cowpox, monkeypox, and white pox in other species; it is thought to have shared an ancestor common to the other pox viruses.6 However, because the smallpox 5Ibid.,

pp. 20—21.

6Fiennes

1

Zoonoses, pp. 28—29.

SMALLPOX: MINISTER OF DEATH

63

virus itself has never had a natural reservoir in other species, in order for smallpox to become endemic in a population, that population had to be large enough to provide a permanent reservoir of susceptible human hosts. This has been a key point in the epidemiological history of this disease. Variola means "pustule" or "pox," and the term "smallpox" was coined in England to distinguish this disease from the "great pox," which in the late fifteenth and early sixteenth centuries was the com­ mon name for syphilis.7 Variola major and Variola minor were the most important forms of smallpox, and although either could cause severe or mild disease, the tendency was for V. major to cause severe and V. minor to cause mild illness. As V. major was the only known form of the disease until the late nineteenth century, we will not be con­ cerned here with V. minor except to speculate on whether this form of the disease was ever important in Japan. The smallpox virus entered a human host by way of the mucous membranes of the upper respiratory tract and found its way to the cells of many organs. During the incubation period, which lasted for twelve days, the virus multiplied without visibly affecting its host in any way. Hopkins describes the onset of the illness and the clinical course of a typical case of smallpox: Around the ninth day, the first signs and symptoms appeared: headache, fever, chills, nausea, and backache, sometimes with convulsions or delirium. Some victims experienced terrifying dreams during this prodromal stage, which lasted up to three or four days At the end of the prodrome, the fever subsided and the victim temporarily felt better, just as the virus declared its presence by producing the characteristic rash. Typically, the flat reddish spots appeared first on the face, then spread rapidly over the arms, chest, back, and finally the legs.... Over the next several days the miserable, aching victim was transformed into a hideous, swollen monster as the flat spots of the rash became raised pimples, then blisters, and then pustules, after which the pustules dried up and turned into crusts or scabs.... At its height ... a dense rash sometimes made the victim's skin appear yellow Many died in the first few days of the rash, others soon after the first week of the rash, and some were carried to their graves even before the rash appeared. Once a person was infected, there was no effective treatment.8 7 Hopkins, 8 Ibid.,

Princes and Peasants,

p. 4.

p. 29.

64

CHAPTER IV

Those who were carried to their graves even before the rash appeared were suffering from hemorrhagic or fulminating smallpox. This form of the disease was almost always fatal, but as there was no sign of the vesicles that were the most common diagnostic feature of the disease, such a presentation was not always recognized as small­ pox.9 Occasionally smallpox produced only one or two eruptions, and in these cases too the diagnosis was often missed. Most cases of smallpox were easy to diagnose, but since a certain proportion of atypical cases occurred in any severe epidemic of this disease, the actual numbers of cases and fatalities due to smallpox are likely to be understated in historical records. The primary means by which smallpox was transmitted from per­ son to person was by airborne droplets, or occasionally by droplet nuclei shed from the respiratory tract. However, secretions from skin lesions and scabs could also contaminate the environment, and bed­ clothes and floor dust were potential, although less important, sources of infection. Under certain conditions, the smallpox virus could sur­ vive and retain its infectivity long after its host had died. The virus was able to survive longest when the humidity was low and the tem­ perature cool. The conditions of room temperature and humidity found in Great Britain are known to have supported smallpox viruses living outside a human host for well over a year.10 In moist tropical heat the virus is less able to survive for long periods. These character­ istics affected the seasonality of smallpox: in temperate climates small­ pox spread more rapidly and was more severe in the cold months; in the tropics the disease flourished in the dry season.11 Although at times smallpox epidemics were known to sweep rapidly through communities, the ability of the smallpox virus to retain its infectivity outside its host meant that smallpox could be sustained in a community for long periods of time. The chances were only fifty-fifty that a susceptible would get the disease from an in­ fected member of the same household,12 but if smallpox returned frequently, almost all members of a community would eventually contract the disease. Smallpox was often spread by migratory populations such as pil­ grims, merchants, and soldiers. It could travel long distances in either an active or inactive form, and this resilient virus was known to have precipitated epidemics even after lengthy sea voyages. Persons stricken 9 A. B. Christie, "Smallpox," in A World Geography of Human Diseases, ed. G. Melvyn Howe (London: Academic Press, 1977), p. 257. 10Christie Infectious Diseases, p. 212. 1 11 Hopkins, Princes and Peasants, p. 8. 12Ibid., p. 3.

SMALLPOX: MINISTER OF DEATH

65

with the disease might sicken and die or recover during a long voyage, but the virus could persist in clothes and bedding. Smallpox has been known to break out in ports where ships that no longer had infectious persons on board docked and sent laundry ashore to be washed. THE EARLY HISTORY OF SMALLPOX IN JAPAN The antiquity of smallpox in Japan is well established. EarlyJapanese accounts tell of severe epidemics of a disease that resembled smallpox, but since smallpox was known in China much earlier, it is likely that the virus made its way to Japan even before the earliest Japanese records were written in the late seventh century. There is general agreement that an unusually severe epidemic of smallpox spread through Japan between A.D. 735 and 737, but there is some question as to whether earlier accounts of unidentified epidemics were describing smallpox or some other disease. Scholars disagree about whether an epidemic in A.D. 585 was smallpox. Fujikawa chose not to identify this epidemic because he did not consider the Nihongi, which was written much later than the events it describes, to be reliable. Other scholars disagree and consider accounts of events in the Nihongi to be fairly trustworthy after A.D. 500.13 In Hopkin's opinion, the symptoms of the disease described in the Nihongi for 585—the fourteenth year of the reign of Bidatsu Tenno—sound very much Hke those caused by smallpox:14 A.D. 585

14th year, Spring, 2nd month ... 24th day At this time there was a pestilence rife in the land, and many of the people died. 3rd month ... 30th day Just at this time the Emperor and the Ohomuraji were sud­ denly afflicted with sores Again the Land was filled with those who were attacked with sores and died thereof. The persons thus afflicted with sores said:— "Our bodies are as if they were burnt, as if they were beaten, as if they were broken," and so lamenting, they died.15

The earliest terminology for smallpox was established in written accounts of the epidemic of 735—737. The common Japanese word for smallpox was mogasa, which could be written in several different ways. Three different combinations of Chinese characters used the character so (St), which means "pustule," "boil," or "pox," and one 13

Aston, Nihongi, p. xvi.

14Hopkins, 15Aston,

Princes and Peasants, p. Nihongi, 2:102-4.

106.

66

CHAPTER IV

combination used en (®j), and to (M), the characters for "pea" and "bean," as a prefix to "pox." A literal translation would be "bean-pea pox," and the term was obviously intended to convey the appearance of the skin eruption. Hdsd (¾¾) was also an early combination that has endured to the present time as a term for smallpox. The character ho (M) means "blister." The character so has continued to be used to designate smallpox to the present time; the character to was later modified by adding the sickness radical (f) to make g. These two characters have been used together to mean smallpox since the twelfth century, and although as many as twenty-eight different character combinations have been used to designate smallpox throughout its long history in Japan, to and so have predominated, and one or the other has been present in almost every combination.16 Even though the epidemic of 735—737 was probably not the first smallpox epidemic in Japan, contemporary descriptions of that epidemic indicate that it was a new disease in the experience of people living at the time.17 The epidemic began in the eighth month in Kyushu. William Farris's recent study of epidemics in Japan between A.D. 645 and 900 provides an excellent, detailed description and analy­ sis of this smallpox epidemic. He gives evidence of smallpox in 736 to show that accounts of735 and 737 were describing one great smallpox epidemic. The accounts of 735 are from Kyushu, the southwestern region of Japan where the epidemic began, and the accounts of 737 describe the epidemic at its peak in the area around the capital.18 The Shoku nihongi tells us that, in the eighth month of A.D. 735, 16 Fujikawa, NSS, pp. 98-99. A detailed and complex explanation of the evolution of the terminology used for smallpox can be found on pages 93-99. So was used from the first accounts in 745 The modified to was first used to describe an epidemic in the year 1143. Fujikawa, NSS, p. 36. 17Hara Nanyo, Sokei Guki, 1800. (The author is indebted to Miwa Makiko for translating this treatise.) Nanyo contends that the smallpox epidemic of 735—737 was the first to reach the capital (miyako), which at that time was Heijδ, the present-day Nara. He believed that smallpox had reached southwestern Japan earlier. This is a reasonable assumption since there was considerable contact between Korea and Japan in earher centuries. See Sansom, A History of Japan to 1334, pp. 17, 59. l8 Farns, Population, Disease, and Land, pp. 53—69. Farris reviews the controversy over whether the epidemic of 735-737 was smallpox or measles and concludes that it was smallpox. The controversy is based on a Chinese character in some of the contemporary documents that was later used for measles. Farris's translations of contemporary descriptions of this well-documented epidemic help to confirm that the disease was mdeed smallpox. According to Donald Hopkins, the severity and type of prodrome and the frequent references to "swellings" or "red swellings" imply a more raised, prominent rash than seen in any kind of measles. And he considers the ref­ erences to "scars," most likely meaning "pockmarks," to be conclusive. Personal correspondence, Donald R. Hopkins, M.D , 12 July 1985

SMALLPOX: MINISTER OF DEATH

67

many people suffered and died from an epidemic in Dazaifu.19 A disease producing large blisters like peas spread throughout the region. Everyone was affected. Farmers asked to be relieved of their taxes, and the government accepted their petition. The epidemic was still raging in the eleventh month, and an amnesty was given to prisoners. An account written in the twelfth month says that smallpox spread over the entire region from summer to winter. Accounts written in 737 continue to describe the ravages of small­ pox. In the fifth month, the Shoku nihongi states, farmers stricken with smallpox were too sick to tend to the young rice plants; in the sixth month, it says, many government officials were suffering from the disease. The government sent food and medicine to people in Yamato, Izu, Wakasa, Iga, and Suruga, who were suffering from disease and famine. In the eighth month, it was said that many farmers and members of the nobility had died of the disease. A summary, written at the end of the year, states that smallpox broke out in the spring, that it came from western Japan and prevailed all through the summer and autumn, that people from every class died of this disease, and that such a calamity had not been known for many years.20 These accounts provide a classic description of an epidemic disease coming into contact with a population that has no immunity to it. People of all social ranks were infected, and the functions of agricul­ ture and government were seriously disrupted. Moreover, the records suggest an unusual sequence of events. It appears that the famine was at least partly a result of the epidemic, and not merely a coincidence. According to the scribe, the epidemic was so debilitating that farmers were too sick to transplant the rice saplings in the spring, causing a widespread famine. Disruption of this magnitude is rare and occurs only when a high proportion of the population—young and old—is stricken within a short period of time. Even if the epidemic of 735—737 was not the first epidemic of smallpox in Japan, the effect of the disease on the population of Japan was as devastating as if it were. Over the next eleven centuries, smallpox epidemics were recorded with increasing frequency. In the early centuries the intervals between epidemics were relatively long, and the smallpox virus probably died out between epidemics. In later centuries epidemics became more and more frequent, and at some point fairly early in Japanese history, smallpox became an endemic disease. The pattern and frequency of smallpox epidemics recorded in Japan 19The Dazaifu was a regional government established by the Taiho codes for the administration of a special area comprising the provinces of Kyushu and the islands of Tsushima and Iki. Sansom, A History of Japan to 1334, p. 443. 20Fujikawa, N S S , pp. 15—16.

68

CHAPTER IV

Table 4.1

Years of Recorded Smallpox Epidemics and Intervals Between Epidemics: Japan to 1868

Japanese year 735-737 763 790 853 915 925 947 974 993 998 1001 1020 1025 1036 1072 1093-1094 1113 1126

Interval (Japanese years)

26 27 63 62 10 22 27 19 5 3 19 5 11 36 21 19 13

Japanese year

Interval (Japanese years)

Japanese year

Interval (Japanese years)

1143 1161 1175 1177 1192 1206-1207 1225 1235 1243 1262 1302 1314 1342 1361 1365 1374 1381 1452-1453 1477

17 18 14 2 15 14 18 10 8 19 40 12 28 19 4 9 7 71 24

1481 1523 1531 1537 1550 1619 1654 1679 1682 1702 1708-1709 1711-1712 1720 1723 1746 1748 1773 1825 1838

4 42 8 6 13 69 35 25 3 20 6 2 8 3 23 2 25 52 13

Source: Fujikawa Yu, NSS.

before 1868, according to Fujikawa Yu1 is shown in Table 4.1. Just when smallpox became an endemic disease is not clear. However, examination of the pattern of recorded smallpox epidemics and the content of individual accounts provides some helpful clues. The frequency of smallpox epidemics and the ages of those infected sug­ gest that smallpox had become an endemic disease in Japan by the twelfth century. Following a smallpox epidemic in 1113, the next nine epidemics were eighteen or fewer years apart. This means that in many areas the age of susceptibles must have been 18 years or less. An account of a smallpox epidemic in 1243 was the first to make special mention of smallpox as a disease of children. The Hyakurensho notes, "From the fifth month, nineteenth day, smallpox spread more

SMALLPOX: MINISTER OF DEATH

69

and more. This time it is afflicting young children."21 Earlier records show (Table 4.1) that an outbreak had last occurred eight years be­ fore, in 1235. If we assume that much of the susceptible population had been exposed and infected in 1235, the majority of those who got smallpox in 1243 would have been below the age of 8. Accounts of smallpox in 1452, 1523, 1531, 1537, and 1550 also mention high morbidity and mortality among children, suggesting that the disease was endemic by that time.22 The content of earlier records suggests that there are missing rec­ ords in the fourteenth century and that smallpox epidemics occurred more frequently than the number of existing accounts indicates. In the fourteenth century there were seven known epidemics of small­ pox. The intervals between recorded epidemics range from seven to forty years, and no groups were singled out for special mention. The longest interval—a period of seventy-one years between 1381 and 1452—is not realistic, because two different accounts emphasize that the 1452—1453 epidemic was a children's epidemic: 1452

Smallpox is seen everywhere. Many young children have died. (Bunsei nendaiki)23

1453

In Kyoto, young children suffered from smallpox. Many died. (Ryiisen-ji nendaiki)24

The emphasis on young children in 1452 suggests that the previous epidemic had occurred less than ten years before. If there had been seventy-one years after 1381 without an epidemic of smallpox, the entire population under 71 years of age would have been at risk. We can assume that at least one and probably several epidemics of small­ pox occurred between 1381 and 1452, and that either those epidemics were not recorded or accounts failed to survive. Although Japanese contemporary accounts provide rather firm evidence that smallpox had become an endemic disease in Japan by the twelfth century, a strong case can be made on the basis of popu­ lation size alone that smallpox was endemic even before the twelfth century. Japan's population was approximately six million people in the early eighth century, and population density was high.25 Although the smallpox virus seems to have died out after the early epidemics, Japan's population was large enough to support endemic 21 Ibid.,

p. 38. pp. 47-50. 23 Ibid., p. 47.

22 Ibid.,

24 Ibid. 25

Aoki Kazuo, Wara no miyako, Nihon no rekishi, vol. 3 (Tokyo: Chu6 Koronsha,

1965), p. 12.

70

CHAPTER IV

smallpox before the twelfth century. Even after the disease became endemic, the smallpox virus would have continued to cross the sea barrier between the Eurasian continent and the Japanese archipelago. However, both contemporary accounts and demographic evidence suggest that very early in Japan's history smallpox became an indige­ nous disease that did not need to be imported from the outside. This brief survey of the historical record leaves little doubt that, by the Tokugawa period, smallpox had been an endemic disease in Japan for several centuries. And by 1700 smallpox must also have been endemic in the large cities of Japan. This means that in cities like Kyoto and Osaka, smallpox was always present, even though epi­ demics would have continued to occur periodically as herd immunity to smallpox rose and fell. The sources compiled by Fujikawa tell us, for the most part, about epidemics in the important cities of Japan. It is interesting to note that by the mid-eighteenth century smallpox epidemics are rarely mentioned in the official records of important events. Or perhaps Fujikawa chose not to include them in his chro­ nology. It would be wrong, however, to conclude that smallpox was less important than before. Smallpox was, in fact, so common that it was no longer considered an event worthy of notice. But as we shall see, smallpox remained an important cause of death in Japan until the very end of the Tokugawa period. SMALLPOX IN THE TOKUGAWA PERIOD

If the importance of a disease can be judged from the attention it received in contemporary literature, smallpox seems to have been the most important acute infectious disease in early modern Japan. Even though smallpox epidemics were no longer regarded as unusual events, smallpox was the foremost topic of discussion in the medical books of the Tokugawa period. As Yamazaki Tasuku, a medical historian and student of Fujikawa Yu, wrote in the 1930s, "Smallpox is one of the old epidemics in our country. We have more medical books about this disease than almost any other particular disease."26 Smallpox was also a major topic of interest in the popular literature of the period. Tatsukawa Shoji, a prominent Japanese medical his­ torian, has examined popular Edo period literature in order to deter­ mine the most important diseases of the period.27 His review of contemporary accounts, of handbooks on popular treatment of com­ mon ailments, and of collections of popular short stories and comic 26 Yamazaki, 27 Tatsukawa

Nihon ekishi oyobi, p. 196.

Shoji, "Shomin shiry5 ni miru Edojidai no shippei," Nihon ishigaku

zasshi 20 (1974):313-35.

SMALLPOX: MINISTER OF DEATH

71

poetry is not restricted to acute infectious diseases, but his survey of popular literature does identify epidemic diseases that seemed impor­ tant to people at the time.28 Hejudged the importance of a disease by the number of times it was mentioned in popular stories and poems. Ordinary illnesses like eye disease, toothache, colic, venereal disease, and food poisoning were complained about most often; smallpox was the epidemic disease mentioned most frequently. Smallpox clearly falls into the category of everyday ailments with which everyone was familiar. Popular literature may best reflect life in the cities, but local and regional sources indicate that by the mid-eighteenth century, small­ pox was a common, endemic disease in remote as well as central areas. An examination of local sources from Sendai domain in the north­ eastern part of Honshu, and from Hida, an isolated region in central Honshu, shows how smallpox affected outlying communities. These sources show that smallpox was a regular and frequent caller, and that even in the rural countryside most people were infected before the age of 5. Smallpox in Sendai

Aoki Daisuke's research on epidemics in Sendai domain illustrates the endemic nature of smallpox in northeastern Japan during the Tokugawa period.29 Aoki was interested in major disasters that affected the Sendai region, and he was one of the few Japanese researchers to look at how different diseases affected mortality in Japan. He attempted to trace national epidemics to see if major smallpox epidemics in central and western Japan were also important in Sendai. He examined local histories of the domain and Buddhist temple registers to see if he could determine the impact of smallpox on mortality in the region. Aoki found that the smallpox epidemics identified by Fujikawa in the more populous regions of Japan had little effect on the Sendai region. Few of these epidemics were mentioned in the local histories of Sendai, nor was there evidence of them in the temple death records of the region. Occasionally an increase in child mor28The literature reviewed by Tatsukawa includes Tsumura Soan's Dankai, which contains discussions of medical practices in volumes 2 and 15; Mimibukuro, a collection of writings by Negishi Yasumori, a writer who served as a government official in Sado and Edo during the late Tokugawa period; Miyao Shigeo's Edo kobanashi shu, two volumes of short stories about life in Edo; and Yamamoto Narinosuke's Senryii iryo

Juzokushi, 29Aoki Daisuke, "Toso," in Saigai hen, vol. 22 of Miyagi-ken shi (Sendai: Miyagiken shi hensan iinkai, 1962), pp. 459-75.

72

C H A P T E R IV

1

Child with Smallpox (Courtesy of Samuel X Radbill, M D )

SMALLPOX

MINISTER OF DEATH

73

tality coincided with a smallpox epidemic in the major cities. How­ ever, fluctuations in infant and child mortality were common in preindustnal societies, and the local histories suggest that smallpox was epidemic in Sendai and in Edo and other cities at different times. Aoki found not only that the timing of smallpox epidemics in Sendai was different from that in the major population centers, but also that within the domain, smallpox was epidemic in different vil­ lages and towns at different times. In any given year, smallpox seems to have affected only a hmited area. Major regional epidemics were uncommon, suggesting that the smallpox virus circulated continuous­ ly, preventing herd immunity from droppmg throughout the region at any one time. Although poor reporting may be part of the answer here, the evidence from Sendai suggests that smallpox was either regionally endemic or imported frequently from more densely popu­ lated areas. Wherever smallpox was an endemic disease it always claimed the lives of many young children; however, it is more difficult to deter­ mine how important smallpox was relative to other causes of death. In order to attribute an increase in child mortality to smallpox, it is necessary to know when smallpox was circulating in a village or region. The following examples demonstrate how information from different sources can be used to determine the periodicity of smallpox epidemics m a given area and the likelihood that an increase in mor­ tality was due to smallpox. According to Fujikawa, a smallpox epidemic occurred in Japan in 1746, and Aoki found a sharp rise in child mortality during the first and second months of 1747 in the kakocho of H5J5-JI.30 This sudden increase in child mortality during the winter months may well have been due to smallpox, but there was no mention of smallpox in local histories of the region, nor do the kakocho of nearby temples show any rise in mortality. Thus, Aoki concluded that there was insufficient evidence to attribute the peak m mortality at HOJO-JI to the smallpox epidemic mentioned in Fujikawa's sources.31 A local history of Tome-gun in Sendai domain mentions that a smallpox epidemic broke out in 1775, and three other temples in the area show a rise in child mortality between the tenth month of 1774 and the third month of 1775.32 The likehhood that these deaths were caused by smallpox is greater than in the former case. Smallpox is specifically mentioned in the same area where an increase m child 30 Ibid,

p p 4 6 0 — 6 1 HOJO-JI is a temple in Iwanami, Natori-gun 461 32Ryugen-JI in Tome shows a peak in October 1774, T5y6-JI in Kometani in January 1775, and RySkoku-ji in Wakayanagi in March 1775 Ibid , ρ 464 31Ibid,p

74

CHAPTER IV

mortality was documented in the kakochd. Moreover, the increase in mortality occurred in the winter months, when smallpox epidemics are most likely. However, the evidence is far from conclusive, because the local history mentions neither the specific months nor specific places in which smallpox was prevalent. Another smallpox epidemic of great scale was documented in 1788, but Sendai local histories make no mention of smallpox in this year, or in 1787 or 1789.33 However, Aoki believed that evidence of this epidemic can be found in the kakocho of several Sendai temples. This conclusion seems unwarranted. In Aoki's sample of eight temples, there was only one temple in which the rise in adult mortality was not as marked as the rise in child mortality. Furthermore, peak mortality occurred in the eighth and ninth months, months when mortality from smallpox was normally lowest. A sharp rise in the number of deaths of both adults and children in the summer months is more typical of diarrheal diseases than of smallpox. In October of 1800, according to a local history of the area, there was a smallpox epidemic in Miyagi-gun.34 The kakocho of Hosen-ji, one of the temples in the area, show a distinct increase in child mor­ tality. The number of deaths rose abruptly in the tenth month and child mortality remained high through the end of the year. An ex­ tended period of high child mortality in the winter months is charac­ teristic of smallpox, and since a local history also mentions an out­ break of smallpox, the probability increases that smallpox was the cause of this increase in child mortality. The kakocho of two other temples in the area show no rise at all, suggesting that smallpox was confined to one small part of one of the regions of Sendai domain. In 1819, the kakocho of Seian-ji in Tosei-gun mention that many children died of smallpox in that year. And death records from two other temples in the area also show a marked increase in deaths of children from the end of 1818 through the fourth month of 1819. The increase in child mortality lasted for several months, and this time smallpox is mentioned in the death records themselves.35 It seems almost certain that smallpox contributed to the increase in child mor­ tality in the winter of 1819. However, even in this case, the reason for an increase in mortality is obscured by the fact that influenza—a disease that travels widely and rapidly and takes its highest toll among young children and old people—was also epidemic in the second month of 1819. As a result, the extent to which smallpox can be blamed for this increase in child mortality must remain uncertain. 33Ibid.,

p. 461. p. 464. 35Ibid., p. 465. 34Ibid.,

SMALLPOX: MINISTER OF DEATH

75

Other years in which smallpox is specifically mentioned in the local histories and kakocho of different parts of Sendai domain are 1823, 1830, 1841, 1851, 1854, 1858, and 1866. Almost all accounts describe smallpox as a disease of children, as would be expected given the frequency of epidemics. But it is difficult to determine from local historical accounts and kakocho just how many deaths in a region were due to smallpox, because the histories are not sufficiently specific about the place and time of epidemics. Moreover, local histories usu­ ally cover the gun or district level, whereas kakochd most often record deaths in only a small area of a district. The best evidence of mortality due to smallpox comes from evidence found in the death records themselves. The kakocho of K5mei-ji in Shikamoto, Tosei-gun, provide an example of this kind of evidence. In these records, the posthumous names of persons who died were listed chronologically by date of death. The character ho (¾), the first character of hosd (smallpox), was used in the posthu­ mous names chosen for four children who died during the first month and early in the second month of 1851. Although we do not know how many others were victims of smallpox or what percentage of children in Komei-ji these four represented, it is obvious that small­ pox was circulating in the region in the early months of 1851. A major problem with Aoki's analysis of Sendai kakocho is that the populations of the temples he studied were very small. A peak in child mortality may be represented by as few as twelve deaths, whereas one or two deaths are seen as a trough. With such small numbers, small fluctuations are greatly exaggerated. But when deaths from different temples of the same region are combined, mortality peaks in specific areas are usually lost. The results of Aoki's studies of Sendai domain leave many ques­ tions about mortality from smallpox unanswered. They do, however, confirm the endemicity of the disease, and thus its importance as a cause of death in that region during the eighteenth and nineteenth centuries. Moreover, the fact that smallpox epidemics recurred fre­ quently in Sendai means that smallpox mortality was, for the most part, limited to children. It is not possible to trace the movements of smallpox through the Sendai region or to discover how it spread to other regions. To do so would require a system of record-keeping such as was developed only in recent years in the most scientifically advanced and centrally organ­ ized societies. The meanderings of the smallpox virus were difficult to follow even in modern times because of its capacity to retain its infectivity outside the human host. But we can guess, based on what is known about the virus and its interaction with host populations of

CHAPTER IV

76

different sizes, that smallpox spread from the more populous areas around the city of Sendai to small outlying villages. Although the information gleaned from the Sendai records tells us little about how smallpox affected mortality in that region, it does tell us something about life in the domain. Smallpox is spread by human beings traveling from place to place; consequently, if smallpox was a disease of children in the many small villages of the domain, there must have been fairly frequent, perhaps regular, contact between the coastal and mountainous areas. It is not surprising to find that small­ pox was a child's disease in the port city of Sendai, where the virus would have been regularly reintroduced from other parts of Japan. But to find the disease so well disseminated throughout the domain is less expected. It suggests a high level of economic and social integra­ tion within Sendai, a domain that has been considered one of the less economically advanced regions of Japan in the early modern period. Smallpox in Hida

The temple death registers of Ogen-ji in the isolated, mountainous Hida region of central Japan provide much better data for estimating the effects of smallpox on mortality. The Hida records represent a much larger temple population than do those studied by Aoki, and they were kept continuously for more than two centuries. These death records specifically list smallpox as a cause of death, and they confirm that smallpox was the most important epidemic disease in the Hida villages and a major cause of premature death. The kakochd list smallpox as a cause of death in 799 cases in the eighty-two-year period from 1771 to 1852. Because the year, month, and day of death were registered in a high percentage of cases, it is possible to establish periods of smallpox prevalence in the Hida vil­ lages. When the Japanese dates of death are adjusted to the Gregorian calendar, the seasonal distribution of deaths from smallpox can also be calculated. In addition, the designation of age and sex in most cases permits an analysis of age- and sex-specific mortality from smallpox. Finally, when Suda's estimates of births and population size for this area are used, it is possible to estimate how smallpox mortality af­ fected population growth in this region.36 How the kakochd of Ogenji were used to establish the periodicity and seasonality of smallpox, the mortality it caused, and its effects on population growth will be discussed in detail in the following sections. 36 See Chapter III for a discussion of the problems associated with birth and popu­ lation estimates.

SMALLPOX· MINISTER OF DEATH

77

PERIODICITY AND SEASONALITY

A yearly distribution of deaths attributed to smallpox establishes the periodicity of smallpox epidemics from 1771 to 1852 in the Hida villages. The 799 deaths from smallpox were concentrated in about half, or thirty-nine, of the eighty-two calendar years,37 and they represented approximately 10 to 12 percent of all deaths during this period.38 The cyclical, or epidemic, pattern of smallpox can easily be seen in Figure 4.1.39 Smallpox deaths were clustered into seventeen periods, each of which spanned at most two or three calendar years. In be­ tween smallpox epidemics were intervals in which no deaths from smallpox were recorded. This suggests that the virus died out between epidemics, most Hkely because the populations of these small moun­ tain villages were not large enough to sustain the virus indefinitely. Smallpox cycles were somewhat closer together at the end of the period than at the beginning, but the most marked feature of Figure 4.1 is the regularity with which smallpox epidemics struck the Hida villages. Figure 4.2 illustrates the seasonal pattern of smallpox epidemics: the greatest numbers of deaths occurred in the winter and spring months and the fewest in the summer and autumn months. This conforms to the expected increase in the virulence of the smallpox virus in the cooler months of the year m temperate climates. The distinctive sea­ sonal pattern of smallpox mortality in the Hida villages is even more striking when it is contrasted with the seasonal pattern of deaths from 37Japanese

calendar years The total number of deaths registered for the period was 7,962; however, not all deaths were attributed to a specific cause. The higher figure, 12 percent, represents the percentage of deaths attributed to smallpox of all deaths for which a cause was given Ten percent is more realistic, however, because smallpox was one of the most easily identified of all causes of death, and it is unlikely that a large number of deaths for which no cause was given were due to smallpox However, some cases of smallpox were undoubtedly atypical and thus not recognized, so the proportion of deaths caused by smallpox is probably somewhat above 10 percent. 39The distribution of smallpox deaths is according to the Gregorian equivalent of the Japanese year. Dates of death in the kakocho conform to the Japanese premodern civil calendar Because the length of the Japanese year was irregular, some years had twelve months and others thirteen months. The dates of death as recorded m the kakocho have therefore been adjusted to the Gregorian or Western equivalent of the Japanese date. Although there are only small differences between the two calendars when deaths are distributed by year, the differences increase when deaths are dis­ tributed by month In order to be consistent, the adjusted dates of death (those converted to Gregorian calendar dates) were used in all analyses of the yearly and monthly distributions of deaths TheJapanese dates can be found m Suda, Hida "O" pin, pp. 22-185. 38

C H A P T E R IV

78

Gregorian Year

4 1 Distribution of Smallpox Deaths by Year, Hida Villages 1771-1852

4 2 Distribution of Smallpox Deaths by Month, Hida Villages 1771-1852 all causes shown in Figure 4 3. 4 0 Overall mortality rose in the summer months, whereas smallpox mortality fell sharply. Table 4.2 shows the periodicity of smallpox epidemics The duration of smallpox epidemics and the intervals between them are calculated in Gregorian months. There was a change in the established smallpox pattern after the smallpox epidemic of 1823—1824 the number of deaths due to smallpox, the duration of epidemics, and the intervals between epidemics all decreased. Table 4.2 also shows the expected correlation between the number of deaths from smallpox and the length of time between epidemics. The highest number of deaths, in the epidemic of 1804—1805, followed the longest interval

The absence of a seasonal mortality pattern for deaths from causes other than smallpox is an unexpected finding Other preindustnal societies have shown two strong seasonal mortality peaks one m the winter and one in the summer Frederick Sargent, Foreword to Seasonality in Human Mortality, by Sakamoto-Momoyama Masako (Tokyo University of Tokyo Press, 1977), p. xiv 4 0

SMALLPOX: MINISTER OF DEATH

79

20 § *_ 10 0) CL

0 4.3

Distribution of All Deaths by Month, Hida Villages: 1771-1852

Table 4.2

Smallpox Epidemics, Hida Villages: 1771—1852 Epidemic period 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Total

Years 1771-1773 1778-1779 1783-1785 1789-1791 1796-1798 1804-1805 1810-1812 1816-1817 1823-1824 1827 1829 1831-1832 1835-1837 1839-1840 1842-1843 1845-1847 1851-1852

Deaths (N)

Duration (months)

Interval (months)

69 38 28 70 97 102 63 22 85 2 16 15 48 2 22 73 47 799

23 18 22 19 22 10 19 20 11 1 8 13 31 2 19 32 13 283

20 56 50 52 59 75 67 55 68 39 20 17 35 24 23 21 41 722

Original Data Source: Suda, Hida "O" jiin.

(seventy-five months) without a death from smallpox; smallpox mortality was much lower in the epidemic of 1831—1832, which followed closest upon the preceding epidemic (an interval of seven­ teen months). Figure 4.4 illustrates this positive correlation between intervals and numbers of smallpox deaths graphically. Although the relationship is not perfect—the curves move in opposite directions in

C H A P T E R IV

80

Periods of Smallpox Prevalence

4.4 Correlation of Intervals Between Smallpox Periods with Numbers of Smallpox Deaths, Hida Villages: 1771-1852

4.5 Smallpox Period : 1771-1773 periods 1 and 17—periods 2 through 16 show the curves moving together and in the same direction. The statistics presented in Table 4.2 suggest that, in spite of the regularity of smallpox epidemics, their duration and severity varied

SMALLPOX: MINISTER OF DEATH

81

4.6 Smallpox Period 2: 1778-1779

4.7 Smallpox Period 3: 1783-1785

4.8 Smallpox Period 4: 1789-1791 considerably. Figures 4.5 through 4.21 illustrate the nature of these differences more clearly. In some epidemics smallpox deaths were tightly clustered; in others they were distributed over many months. In both kinds of epidemics there were sometimes gaps of many

82

C H A P T E R IV

4 9 Smallpox Period 5 1796-1798

410 Smallpox Period 6 1804-1805

411 Smallpox Period 7 1810-1812

SMALLPOX: MINISTER OF DEATH

4.12 Smallpox Period 8: 1816-1817

4.13 Smallpox Period 9: 1823-1824

4.14 Smallpox Period 10: 1827

83

84

C H A P T E R IV

4.15 Smallpox Period 11: 1829

4.16 Smallpox Period 12: 1831-1832

4.17 Smallpox Period 13: 1835-1837

SMALLPOX: MINISTER OF DEATH

4.18 Smallpox Period 14: 1839-1840

4.19 Smallpox Period 15: 1842-1843

4.20 Smallpox Period 16: 1845-1847

85

CHAPTER IV

86 I Ν. DEATHS" 47 ! 2Q_ Duration. 13 Mojnths interval 41 Months

24

16-

!

I 2 8 -

4O MJJ ASONDJFMAMJJ 1852 1851 4 21

Smallpox Period 17 1851-1852

months between deaths.41 These gaps are not surprising in view of the fact that the data come from villages that are separated by several miles. It is entirely consistent with the epidemiology of the disease for smallpox to turn up in nearby villages after a considerable lapse of time. The most outstanding characteristic of smallpox epidemics in Hida is the absence of any typical pattern. A smallpox epidemic might last for two months or for more than two years. Although most smallpox deaths occurred in the cooler months, an epidemic might begin in any month of the year. In some epidemics the disease peaked and died out quickly; in others smallpox continued to claim lives for many months. The number of deaths attributed to smallpox seems to have been totally unrelated to the duration of the epidemics: Figures 4.10 and 4.13 show that the smallpox epidemics of 1804—1805 and 1823—1824 caused many deaths within a short period of time. Figures 4.7 and 4.9 show epidemics that were of the same duration, but in 1783—1785 only twenty-eight smallpox deaths were recorded, whereas in 1796— 1798, ninety-seven deaths were attributed to smallpox. At this point it is necessary to digress momentarily to consider what appear to be inconsistencies in the data. But the digression will serve more than the purpose of explaining inconsistencies. It will also un­ derscore a sense of confidence in the sources being examined here. 41 Period 8 is especially unusual After one smallpox death in January of 1816, there were no further deaths until March of 1817—a gap of thirteen months This gap appears to be due to a lapse in the recording of causes of death The thirteen-month gap corresponds to the Japanese year Bunka 12 No specific causes of death were entered in the kakocho for the entire year of Bunka 12 During this year there was an increase in the number of deaths in the young age group susceptible to smallpox This suggests that children did die of smallpox in Bunka 12 (February 1816—March 1817), but that the recorder failed to note smallpox as the cause of death

SMALLPOX: MINISTER OF DEATH

87

Moreover, it will help to place the smallpox epidemics in the Hida villages in a broader historical context, and it will explain more fully some of the population dynamics at work in this region. The very small number of deaths in 1827 (Figure 4.14) and 1839—1840 (Figure 4.18) requires explanation. Only two smallpox deaths were registered in each of these periods, hardly qualifying either period as an epi­ demic. Perhaps these deaths were caused by isolated cases of smallpox, but the intervals between smallpox periods—thirty-nine months be­ fore 1827 and twenty-four months before 1839—were as long or longer than those that preceded other epidemics in which mortality was much higher. The number of smallpox deaths in each of these years seems unusually low if the smallpox virus returned to the vicinity after an absence of two to three years. Was smallpox erroneously recorded as the cause of death—perhaps as a result of a faulty diagnosis—or were there many more deaths from smallpox that were not recorded as such? The latter is a fairly strong possibility because, for any number of reasons, smallpox deaths may have gone unrecorded. But it is much less likely that a death that was said to have been caused by smallpox would have been caused by anything else. As we have seen, smallpox was well known in the region. Epidemics recurred every three to four years, and deaths that were attributed to smallpox undoubtedly followed typical, highly recognizable cases of smallpox. Those cases that led to death probably occurred along with many other cases that were not fatal. In 1827, two smallpox deaths were reported to the temple from two different, geographically separated villages. The first death, on July 16, 1827, was reported from Village K, the southernmost of the Ogen-ji villages, situated on the Hida River (see map, p. xvii). Village N, much farther north, located on a tributary that flows into the Hida River, reported the second smallpox death on August 31.42 Two independent observers, living in villages that were a considerable distance apart, each determined that a child died of smallpox, and each reported a death to the priest at Ogen-ji. The separation of these two events by time and place strongly suggests that these were indeed cases of smallpox. But if smallpox was circulating in the region in 1827, what can account for the unusually small number of deaths from smallpox in that year other than a failure of the recorder to enter smallpox as a cause of death in many other cases? A careful reading of the kakocho suggests that the sharp decline in smallpox mortality in 1827 was due to a significant decrease in the 42 Suda, Hida "O" jiin , p. 134. Gregorian dates were used to determine the intervals between reported deaths. In the Japanese calendar, the first date of death was 6/21/Bunsei 10; the second was Intercalary 6/6/Bunsei 10.

88

CHAPTER IV

number of smallpox susceptibles in 1826. As mentioned earlier, any event that intervenes to reduce or increase the number of susceptibles will affect the number of cases of smallpox and, in turn, the number of smallpox deaths. In 1827, the population susceptible to smallpox would have been composed, for the most part, of children born in the thirty-nine months following the smallpox epidemic of 1823—1824. However, the kakocho indicate that in 1826 many children under 4 years of age died of dysentery.43 Normally, smallpox would have attacked children in this age group, but a dysentery epidemic the year before had drastically reduced the population under age 4. When the smallpox virus returned to the region on schedule in 1827, the number of potential hosts was much smaller than usual. This undoubtedly ac­ counts for the unusually low smallpox mortality in that year. A similar reduction of smallpox susceptibles occurred for a different reason a decade later. The Tempo famine, a major famine in Japan during the 1830s, had its greatest impact on the Hida villages in 1837 and 1838. When smallpox returned to the area in 1839 it had been absent for only a short period of twenty-four months. In 1839 the majority of smallpox susceptibles would have been children under age 2. This group was unusually small for two reasons: a higher-thannormal death rate and a probable decline in the number of births during the Temp5 famine. The latter phenomenon is frequently ob­ served in times of famine because women suffering from severe mal­ nutrition commonly fail to ovulate, and the number of conceptions falls below normal. A combination of higher death rates, lower birth rates, and the short interval between epidemics would have meant that, in 1839 as in 1827, the number of smallpox susceptibles in the population was very small. The death records of Ogen-ji may not reveal the full story, but low smallpox mortality in 1827 and in 1839—1840 does seem appropriate to circumstances in the villages in those years. Apparent inconsis­ tencies that, at first glance, appear to signal possible omissions in the records, instead confirm their reliability as a tool for observing the effects of disease on the people of the Hida villages during the late Tokugawa period. What the Ogen-ji records show most clearly is that smallpox epi­ demics recurred regionally in a very regular pattern. When deaths are distributed by year, smallpox epidemics appear as distinct entities that are clearly separated in time; however, a monthly distribution of deaths shows that smallpox periods were not so sharply defined. And 43 Ibid. p. 132. The dysentery epidemic of 1826 was identified in the death records as ribyo.

SMALLPOX

MINISTER OF DEATH

89

the problem of separating smallpox cycles becomes more difficult after 1824 as scattered smallpox deaths between epidemics became more frequent. This suggests that there was a change between 1771 and 1852 in the pattern of smallpox prevalence. Some indication of change in smallpox periodicity can be seen by analyzing the intervals between smallpox periods (Table 4.2). A chisquare one-sample test44 shows that the intervals are not randomly distributed (chi-square = 139 76, probability less than 001) and that an analysis of trend is appropriate. When smallpox periods are divided into two groups (periods 1—9 in the first group and periods 10—17 in the second), the average interval between periods in the first group is 55.7 months and m the second is 27 5 months Similarly, when the eighty-two-year sample is divided in half, there are 7 smallpox periods in the first forty-one years and 10 periods during the second forty-one years In short, smallpox epidemics became more frequent in the second half of the period under study. What are the conditions under which this change could have taken place7 Two factors that would account for an increase in the fre­ quency of smallpox epidemics are a more frequent exposure to the virus, and a more rapid drop in herd immunity The fact that small­ pox epidemics occurred more often after 1825 suggests that the Hida villages had more frequent contact with outside populations in later years than in earher years. And herd immunity would also have dropped more quickly in the second half of the period if there was an increase in the number of births. Suda's estimated birth statistics indi­ cate that between 1771 and 1812 the mean number of births per year was 86.5; between 1813 and 1852 the mean rose to 100.45 It is reason­ able to speculate that smallpox epidemics occurred more often for both reasons because of more frequent exposure to the smallpox virus, and because a rise in the number of births produced new susceptibles and lowered herd immunity more quickly than in earlier years. MORTALITY

.Smallpox was responsible for between 10 and 12 percent of all deaths in the Hida villages between 1771 and 1852. Although the frequency of epidemics in this region tells us that smallpox was primarily a disease of children, the Ogen-ji records permit a closer look at the ages of those who died of smallpox. Table 4.3 shows the age distribution of all deaths attributed to smallpox. Ninety-five percent of smallpox deaths occurred before the 44Sidney Siegel, Nonparametnc StatisticsJor the Behavioral Sciences (New York McGraw-Hill, 1956) 45 Suda, Hida "O" pin, pp 22-185

90

CHAPTER IV

Table 4.3

Distribution of Smallpox Deaths by Age, Hida Villages: 1771-1852

Age (adjusted)

Deaths

Relative frequency

Cumulative frequency

(N)

(%)

(%)

Birth—1 year 1 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 19 21 22 23 24 25 29 32 59 80 Total

236 139 87 67 88 48 33 12 10 15 8 2 6 1 3 3 1 1 1 3 2 1 1 1 2 1 1 773a

30.5 18.0 11.3 8.7 11.4 6.2 4.3 1.6 1.3 1.9 1.0 0.3 0.8 0.1 0.4 0.4 0.1 0.1 0.1 0.4 0.2 0.1 0.1 0.1 0.3 0.1 0.1 100.0

30.5 48.5 59.8 68.4 79.8 86.0 90.3 91.8 93.1 95.1 96.1 96.4 97.2 97.3 97.7 98.1 98.2 98.3 98.4 98.8 99.1 99.2 99.4 99.5 99.7 99.9 100.0

Original Data Source: Suda, Hida "O" jiin. * In 26 cases, no age at death was given.

SMALLPOX: MINISTER OF DEATH

91

age of IO.46 Most of the remaining smallpox deaths were concen­ trated in the teen years.47 Deaths after the teenage years represent only 1.6 percent of the total, indicating that a few people managed to avoid smallpox in spite of its frequent presence in the community. Possibly they entered the Ogen-ji population as adults from villages that were even more isolated than those represented by the kakochd. Nothing other than age distinguishes the deaths of the older people who died from smallpox. Men and women died in equal numbers, and their deaths were not concentrated in any one epidemic period. One might expect to find smallpox deaths among older persons dur­ ing the Temp5 famine year of 1837, when many persons from other areas were moving through the villages; however, there were no smallpox deaths of persons older than age 10 recorded in that year. The impact of smallpox on child mortality in the Hida villages was substantial. Smallpox accounted for 26 percent of the deaths of all children who died before the age of 10. It was the most important identifiable cause of death in early childhood. Figure 4.22 shows the distribution of smallpox deaths under age 10. The average age of those who died of smallpox was 3.1 years.48 A high proportion—83.9 percent—of children who died of smallpox were exposed before age 5, and most deaths—slightly over half—occurred in the first two years of life. It is important to remember that the age adjustment method that was used here overestimates the age at death: many of the children entered in the death register as age 1 or 2 had actually lived less than one year, so that smallpox mortality in the first year of life was even higher than Figure 4.22 indicates. * Before preventive immunization, smallpox was virtually a univer­ sal disease in populations in which the disease was endemic. We can 46 TheJapanese recorded age at death has been adjusted downward to approximate its Western equivalent, which would be one to two years less. This has been done to facilitate comparison with data from Western sources. The age adjustment was also necessary to allow correlation of ages at death with the intervals between epidemics, which were adjusted to the twelve-month Gregorian calendar year. The age adjust­ ment was made by subtracting one year from the Japanese age of death recorded in the kakochd. For further explanation of problems encountered with the conversion of Japanese ages, see Chapter III. 47 In England smallpox mortality was also lower in the teen years than for younger children. Peter Razzell, The Conquest of Smallpox: The Impact of Innoculation on Small­ pox Mortality in Eighteenth Century Britain (Firle, Sussex: Caliban Books, 1977), p. 127. 48 The average age at death of a child who died from smallpox would be expected to be close to the average time interval between epidemics, and in fact it is: the average age of 3.1 years at death approximates the average time interval of 3.5 years between epidemics. Such a close correlation confirms the internal consistency of the Ogen-ji records.

92

CHAPTER IV

c a> ο i. Ο)

CL

11.8

12

1.6 1.4

2

Birth-I 23456789 IO Age at Death 4.22 Age Distribution of Smallpox Deaths of Children to Age 10, Hida Villages: 1771-1852

therefore reasonably assume that in Hida almost all children born became infected if they lived long enough to be exposed to the virus. It would have been difficult to avoid exposure in the Hida villages, where epidemics recurred every three to four years. If we accept Suda's estimates of births for the period and assume that everyone born contracted smallpox, 10 percent of all children born died of smallpox. Smallpox was also the most common cause of sharp mortality peaks between 1771 and 1852. No other epidemic disease had so great an impact on child mortality. Figure 4.23, which distinguishes small­ pox deaths from other causes of death under age 5, illustrates this point. It shows that typical smallpox periods accounted for most of the high peaks in child mortality. Atypical smallpox periods in 1827 and 1839—1840 do not appear as peaks, because, as discussed previ­ ously, the smallpox cycle followed the high peaks in child mortality caused by dysentery in 1826 and the Tempo famine in 1837. Did the likelihood of dying of smallpox change or remain constant

SMALLPOX

MINISTER OF DEATH

93

125

• Smallpox Deaths 100-

Π Deaths from other causes

75-

50

25-

1771

1781

1791

1801

1811

1821

1831

1841

1851

Gregorian Year 4 23 Distributions of Smallpox Deaths and Deaths from All Other Causes by Year, Children Under Age 5, Hida Villages 1771-1852

during the period of study7 An analysis of the number of deaths in successive smallpox epidemics shows that smallpox mortality declined after 1824.49 The numbers of deaths per smallpox period (Table 4.2) are nonrandomly distributed (chi-square = 309.89; probability less than 001), indicating some kind of trend in smallpox mortality. The trend is one of declining mortality from smallpox. The mean number of deaths per epidemic for the first nine epidemics was 63.7; for the last eight epidemics it was 34.4. The total number of smallpox deaths in the first half of the period—between 1771 and 1812—was 467; between 1813 and 1852 the total was 332. If Suda's estimates of population size are correct, the population m the Hida region grew between 1771 and 1852. This makes the decrease in mortahty due to smallpox even more striking. There are several reasons why smallpox mortahty might have fallen in the Hida villages during the late Tokugawa period First, mortahty from other causes may have risen Further analysis of infant and child 49 The death rates calculated from Suda's estimates of total population size for the two periods were 2 3 percent for 1771—1812 and 1 15 percent for 1813-1852 How­ ever, since the population at risk was the group under age 10, and we do not know the size of this population, these death rates are not very meaningful

94

CHAPTER IV

mortality, a topic about which little is known, may show that small­ pox mortality fell because other causes of death became more im­ portant. Second, the increasing frequency with which the temple population was exposed to smallpox may have brought about a de­ cline in smallpox mortality. In England it was believed that smallpox mortality was lower among more-frequently exposed populations: "of young Children that have it, one in six or seven commonly die of it; and of grown Persons, at least one in three."50 However, this argument is less convincing, because few adults contracted small­ pox even in earlier periods. A third possibility is that the decline in smallpox mortality was caused by a temporary alteration in the virus. English records show that the smallpox case-fatality rate fell during certain periods in the eighteenth and nineteenth centuries, although the fall was temporary and the long-term trend was a rising case-fatality rate.51 One impor­ tant reason given for the decline in case-fatality rates in Europe in the nineteenth century was the appearance of a new variant, V. minor, which immunized victims against V. major, yet was associated with a much lower mortality rate. V. minor is considered to be a European form of the smallpox virus, but since there has been so little research on the history of smallpox in East Asia, it is premature to decide that V. minor had no influence there. We cannot calculate case-fatality rates for Hida, but if a similar decline in smallpox mortality can be demonstrated for other parts of Japan in the nineteenth century, the idea that V. minor was a purely European phenomenon should be reconsidered. It is more than likely that the decline in smallpox mortality was due to a combination of factors. An increase in child mortality from causes other than smallpox, more frequent exposure to the virus, and a decline in the case-fatality rate due to the introduction of a new strain of the virus are offered as possibilities. For whatever reasons, the gradually increasing population in the Hida villages was exposed to smallpox more frequently and suffered fewer deaths from this disease after 1825. The Hida death records can be used to address one further question about smallpox mortality: To what extent did the age of those who died of smallpox change during the period in question? When the ages of those who died of smallpox before age 20 are broken down by epidemic periods, no trend emerges. The ages at death from smallpox remained quite stable throughout the entire period. The average age 50 The Reverend David Some, quoted by Razzell, The Conquest of Smallpox, p. 132. 51 Razzell, The Conquest of Smallpox, pp. 127-32.

SMALLPOX: MINISTER OF DEATH

95

at death for each smallpox period was about 3.5 years—the mean age was 3.45, and the standard deviation was 0.30. When the age-at-death statistic is averaged for epidemic periods, there is almost no difference between early and late smallpox periods.52 Between 1771 and 1824, the average age at death from smallpox was 3.37; between 1825 and 1852 it was 3.51. In spite of the increasing frequency of smallpox epidemics and the marked decline in both the total number of deaths attributed to smallpox and the deaths per epidemic in the second half of the period, there was no change in the age group affected. Even in this remote region of Japan, smallpox was a disease of very young children at the beginning of the period, and it remained so until at least 1853, when the records no longer specified causes of death. Smallpox mortality had probably reached the lowest level possible without a preventive therapy that could significantly reduce the number of susceptibles in the population. This therapy—mass immunization—was three de­ cades away. Until then, the smallpox virus would continue tc5 make its appointed rounds, relying on an ever-replenished supply of infants and young children for its survival. POPULATION GROWTH

If smallpox was the important killer of young children that this analy­ sis suggests, there is no doubt that it had a negative effect on popula­ tion growth. As noted, smallpox regularly reduced the number of persons who might otherwise have lived to reproduce by 10 percent. Suda's estimates of the temple's population size between 1771 and 1852 permit speculation of a general nature about the effect that smallpox mortality had on population growth in the Hida region. Natural population growth is generated by a surplus of births over deaths. In the villages affiliated with Ogen-ji, births exceeded deaths in forty-nine years between 1771 and 1852; deaths exceeded births in thirty-one years; in two years they were equal. When deaths due to smallpox are excluded, the results are striking. Births exceeded deaths in sixty of the years, often by a wide margin; deaths exceeded births in only twenty years; in two years births and deaths were equal. Figure 4.24 shows the relationship between births and deaths due to all causes. Most of the mortality peaks were due to smallpox. Figure 4.25 shows the relationship between births and deaths when deaths due to smallpox are excluded: most of the high mortality peaks disappear, and deaths fall well below births in most years. The mortality peaks 52 Thirteen smallpox deaths from a total of 773 were excluded because no age at death was entered into the register.

96

C H A P T E R IV

Gregorian Year

4 24 Distributions of Estimated Births and Deaths by Year, Hida Villages 1771h1852

Gregorian Year

4 25 Distributions of Estimated Births and Deaths by Year, with Smallpox Deaths Removed, Hida Villages 1771-1852

SMALLPOX: MINISTER OF DEATH

97

that remain were caused by the dysentery epidemic of 1826 and the Tempo famine in 1834 and 1837. It is obvious that without smallpox the temple's population would have grown more rapidly. Suda estimated the temple's population size at 2,677 in 1771 and 3,142 in 1852. The overall growth rate between these years was 17.3 percent, with an average annual growth rate of 0.20 percent. If deaths due to smallpox are eliminated, the overall growth rate becomes 47.2 percent, the average annual growth rate 0.57 percent. Of course, this projection is unrealistic, because many of the smallpox victims would have died at a young age of some other cause if not from smallpox, but it helps to show the significant role that smallpox played in checking population growth in Hida during the late Tokugawa period. The kakocho of Ogen-ji confirm that smallpox was an important epidemic disease in the Hida villages from the late eighteenth through the mid-nineteenth century. To summarize, epidemics were regular and frequent, and smallpox caused severe fluctuations in mortality. Virtually everyone was infected with smallpox at some point in his life, and in Hida most people got the disease by age 3. Smallpox remained a disease of very young children throughout the period of study, although the average interval between smallpox periods de­ creased with time. The increase in the frequency with which smallpox epidemics occurred probably came about because the population was growing, causing herd immunity to fall more quickly, and because contact between members of the Hida villages and outsiders was increasing. The decline in mortality due to smallpox may have been due, at least in part, to the increasing frequency of exposure, although it could also have been mediated by increases in mortality due to other causes, or by a decrease in the virulence of the smallpox virus. Because smallpox had a negligible effect on adult mortality, it did not disrupt the political or social structure of the population, but by repeatedly decimating the size of the population under 5 years of age, it played an important role in slowing population growth. Smallpox in Edo Castle

During the Tokugawa period, smallpox must have been always pre­ sent in large cities such as Edo and Osaka. Edo had a population of approximately one million inhabitants by the beginning of the eigh­ teenth century, and both cities had considerable contact with other cities and regions. It was noted earlier in this chapter that the major chronologies made little mention of smallpox after the mideighteenth century, and it was suggested that the disease had become so commonplace that it no longer attracted much attention. In sup-

CHAPTER IV

2. Sasuyu Ceremony for Recovery from Smallpox. (Courtesy of the National Library of Medi­ cine, Washington, D.C.)

port of this view, an interesting set of Tokugawa family documents shows that smallpox was prevalent in Edo far more frequently than general accounts indicate. Maekawa Kyutard has reviewed historical documents that contain records of the sasuyu ceremony, a ritual to celebrate recovery from smallpox, measles, and chicken pox. Although the timing of the ceremony varied somewhat depending upon the patient's condition, the ceremony was usually held ten days after the onset of the disease, when the patient was considered to be out of danger.53 This ritual ceremony was performed for twenty-five Tokugawa offspring born between 1789 and 1827. The children of the Tokugawa shoguns who were raised in the Ooku, the innermost part of Edo Castle, had very little direct contact 53 Maekawa Kyutaro, "Sasuyu kiroku yori mita toso, mashin, suito, no Ooku e no denpa," Nihon ishigaku zasshi 22 (1976):157-58. The sasuyu began as a method of treating smallpox in the early Edo period. It later became a ceremony to celebrate recovery from measles and chicken pox as well. Maekawa's study is based on the Gokafu and Bakufu soin den.

SMALLPOX

MINISTER OF DEATH

99

Table 4.4

Ages of 25 Children for Whom Sasuyu for Smallpox Were Held in Edo Castle: 1812—1840 Age (Western)

Cases

Age (Western)

Cases (N)

Age (Western)

Cases

(N)

8 months 1 year 2 3 4 5

1 1 2 1 3 1

6 years 7 8 9 10 11

1 3 1 3 2 0

'12 years 13 14

1 1 1

22 26

(N)

2 1

Source Maekawa Kyutaro, "Sasuyu kiroku yon," pp 160-61

with the outside world. The accounts of the Edo bakufu indicate that the Ooku was a secluded society whose members were isolated from the rest of the city.54 Every effort was made to protect the children of the inner castle from exposure to smallpox,55 and these efforts were at least temporarily successful, because the sasuyu records show that the Tokugawa children got smallpox at a much later age than the chil­ dren who lived m the Hida villages. The ages at which sasuyu for smallpox were held for the Tokugawa offspring are shown in Table 4.4. Between 1789 and 1827 the sasuyu was held for children who ranged in age from 8 months to 26 years, the average age was 9.1 years (Western age). The records also show that all of the Tokugawa children who lived in Edo Castle during this period and who survived to adulthood contracted smallpox at some point in their lives. Their isolation from general society and the efforts ρ 157 An official notice (Ofuregakι of Empo 8) in 1680 established a policy for preven­ tion of disease dissemination In the case of smallpox, persons who worked in the castle and who contracted the disease could not return to work until thirty-five days after the onset of the disease Those who had merely attended persons who died of smallpox could return when the mourning period was over A notice in 1825 (Ofuregaki of Bunsei 8) stated that the thirty-five-day policy applied to those who had contact with princes and princesses It also exempted doctors and others who attended smallpox patients from the policy and stated that smallpox patients need not refrain from sending gifts to the princes Maekawa, "Sasuyu kiroku yon," pp 160—61 These exceptions to the strictures of the policy would have increased the risk of exposure to the virus 54Ibid, 55

100

CHAPTER IV

of the household to protect them from infection only delayed ex­ posure until they were older. The sasuyu records are unlike the Ogen-ji records m that they are survival records, not death records; they tell us who recovered, but not who died. We learn, almost by accident, that at least two of the children for whom sasuyu were held must have died of smallpox, because the dates of their deaths were the same as the dates of the ceremonies intended to celebrate their recovery.56 All of the other children, for whom no ceremonies to celebrate recovery from small­ pox were held, died at very young ages. Most of these children were less than six months old, and there is a strong possibility that at least some of them died of smallpox. Newborn infants did not acquire maternal immunity from smallpox, and as the Hida records have demonstrated, smallpox mortality was highest m the first year of life. The sasuyu records show that the smallpox virus circulated through the inner castle rather frequently. Ceremonies celebrating recovery from smallpox—twenty-five between 1812 and 1840—were held in Edo Castle in 1812, 1817, 1818, 1820, 1823, 1826, 1830, 1833, and 1840. The Bukd nenpyo mentions a smallpox epidemic in Edo in 1825· "During the fall and winter, smallpox was prevalent";57 however, there were no sasuyu ceremonies in the Ooku in that year to indicate whether smallpox reached the castle. The sasuyu records of Edo Castle help to confirm the endemicity of smallpox in the city of Edo: for smallpox to be infecting the well-protected Tokugawa offspring so frequently, the smallpox virus must have been ever-present and in­ fecting many more children in the general population of the city.

SMALLPOX IN ISOLATED COMMUNITIES

At the other end of the spectrum from the densely populated cities of TokugawaJapan were a few isolated populations that were touched by smallpox very infrequently Small islands distant from the main islands of Honshu, Shikoku, and Kyushu that had little contact with other regions fall into this category. The island of Tanegashima lies nine kilometers south of Kyushu's Kagoshima peninsula, and records exist that document smallpox epidemics on this island during the 56Maekawa,

"Sasuyu kiroku yon," pp 160—61 Saito Yukinan, Buko nenpyo, ed Mitsuharu Kaneko, 2 vols (Tokyo Heibonsha, 1968), 2 76 Maekawa considers that the Bukd nenpyo provides the most reliable accounts of the daily lives of the commoners of Edo Maekawa, "Sasuyu kiroku yon," ρ 157 57

SMALLPOX

MINISTER OF DEATH

101

Tokugawa period.58 Local records show that smallpox came infre­ quently to Tanegashima and that epidemics were severe. According to the Tanegashima kafu, smallpox epidemics occurred with increasing frequency during the Edo period: epidemic years were 1682, 1737, 1750, 1762, 1791, 1801, 1817, 1836-1837, 1843, and 1847. After 1836, smallpox epidemics in Tanegashima were about as frequent as in Hida, which suggests that Tanegashima's contact with the main islands increased significantly in the final years of the Tokugawa period. Several accounts show that the expected correlation between length of time between epidemics and severity of epidemics holds for this island community. The first recorded smallpox epidemic in Tanegashima was in 1682. The Tanegashima kafu indicate that during that spring and summer many people suffered from smallpox, and that both young and old died of the disease. The records for the next epidemic in 1137 claim that approximately 1,000 people died of small­ pox. This seems to be a large number, even if the estimate is exagger­ ated, since a census taken the following year counted a population of 13,719.59 Subsequent accounts say little about mortality due to small­ pox, but it must have been high. If smallpox occurred as infrequently as the records indicate, smallpox would have infected most of the population under 20 years of age. A diary written by Habu Rokurozaemon in the late 1830s confirms both the mfrequency and the severity of smallpox epidemics on the island of Tanegashima. He wrote of an especially severe smallpox epidemic that circulated on the island from November 1836 to April 1837. Smallpox was probably imported as early as 1834. It appar­ ently took some time for the disease to reach the villages of Nishi-noomote, where RokurSzaemon lived. A portion of his account presents the following description of the epidemic Smallpox was last seen here nineteen years ago It has been turning up here and there in different parts of the island for some time. This is an exceptionally difficult smallpox. Many people are fleeing to the countryside with their children. Others have gone into the mountains to build cottages, taking children from several families with them 60 58Kawauchi Kazuo, "Tanegashima m okeru tos5 m tsuite," Nihon tshigaku zasshi 19 (June 1973) 174 The Tanegashima kafit are genealogies of families who lived on Tanegashima 59Kawauchi Kazuo, "Tanegashima m okeru Edojidai no jinko sui-i no jokyo m tsuite no ikko sai," Nihon tshigaku zasshi 19 (December 1973) 320 60 Habu Rokurozaemon, Michtkiyo ichidai kiroku (A record of Michikiyo's gener­ ation), quoted by Kawauchi, "Tanegashima ni okeru toso," ρ 173

102

CHAPTER IV

In his diary, Rokurozaemon described the course of the disease and its disastrous effect on the family of a close relative, Habu Michikiyo. In every case, the onset of the disease was marked by a high fever, and a doctor was called for diagnosis and treatment. Six of Michikiyo's grandchildren contracted smallpox during this epidemic, and four of the six died. The diary mentions that 17- and 18-year-olds, who would have been the oldest susceptible persons in 1836, were particularly likely to die of the disease.61 Of the four grandchildren who died, one was age 9 and the other three were age 18. Michikiyo's granddaughter, who was 18 years old and pregnant, was considered to be at special risk. Even though she appeared to be suffering only a mild case of small­ pox, she was advised to have an abortion, and it is clear from the account that she died not from smallpox but from the aftereffects of the abortion.62 The children who lived were age 7 and age 12; the 12year-old had a mild case and the 7-year-old had a severe case but, according to Rokurozaemon, both made a full recovery. Rokurozaemon estimated that the smallpox epidemic of 1836— 1837 claimed more than 200 lives in the villages of Nishi-no-omote, but it is not known what proportion of the population this repre­ sented. A comment by an old practitioner of Chinese medicine, Yanagida Shusui, who treated patients in the region and kept a diary during the epidemic, also confirmed that smallpox came infrequently to the island and that mortality was high: "Again I have experienced smallpox. It is only the second time. Although several hundred have been cured, this epidemic is very severe." 63 An even more extreme case of an isolated population subjected to smallpox during the Tokugawa period can be found in a treatise on smallpox written by Hara Nanyo around 1800.64 He wrote about an unusual epidemic on Hachijojima in the last decade of the eighteenth century. Hachijojima is the southernmost island in the Izu chain, and it lies 280 kilometers south of Tokyo. Mikura, the nearest island, is 90 kilometers to the north, and the closest part of Honshu is 180 kilo­ meters away. According to a story told by inhabitants of the island, smallpox was first noted in Hachijdjima in 1795. It was brought there by a ship 61 It has been thought that young children and old people are most likely to die of smallpox. Razzell shows that case-fatality rates were highest between age 1 and age 2, lowest from age 10 to age 15, then fairly sharply rising after age 15 in late nineteenthcentury England. Razzell, The Conquest of Smallpox, p. 127. 62Kawauchi, "Tanegashima ni okeru toso," p. 178. 63 Quoted by Kawauchi, "Tanegashima ni okeru toso," ρ 179. 64 Hara, Sdkei Guki.

SMALLPOX

MINISTER OF DEATH

103

carrying a sick passenger Efforts to contain the disease failed, and it spread slowly from village to village The disease was still circulating two years later when a group of men from the island was cast ashore at Naka-mmato, Hitachi (present-day Ibaraki prefecture) m the spring of 1797 They had come from Hachy5jima in order to report the epidemic to the proper authorities Among those who had died of smallpox were many who were old or of middle age, and it was said that older persons were more likely to die of the disease than those who were younger Smallpox had severely disrupted the island economy, which consisted of farming, fishing, woodcutting, sericul­ ture, and silk-weavmg Because many of the silk weavers had been taken ill or had fled from the disease, there was a problem about delivering the silk cloth required for payment of taxes The effects of smallpox among this unexposed population were similar to those experienced on the mam islands ten centuries before The inhabitants of Hachijojima knew of smallpox by reputation before 1795 People who had left the island had been stricken with it, and stories about smallpox in islands to the north had reached Hachijojima in earlier years The islanders had responded with a policy of self-isolation, and when smallpox did finally reach them, they continued to use isolation techmques to try to protect themselves The first victims and their families were sent away from their villages, and later on, the first victims in new villages were moved to villages that had already been stricken Many people fled to the mountains, but not infrequently smallpox broke out among those who had fled They would then return to their villages These strategies imply that the inhabitants of Hachijojima had a rather clear idea that the disease was transmitted, by some means, from one person to another 65 And further, they knew that people who had been exposed to smallpox but who were not yet sick needed to be isolated as well In the end, these efforts were probably in vain, but they undoubtedly served to delay the dissemination of smallpox throughout the island These personal accounts make it clear that, before the midnineteenth century, the effects of smallpox on the isolated populations of islands like Tanegashima and Hachijojima differed from its effects 65 Although this seems self-evident today, it was by no means a common view at the time in other societies The ideas of the anti-contagionists, who attributed disease to local phenomena, dominated medical thought in Europe and the United States until Pasteur's theories became accepted at the end of the nineteenth century Chinese medical theories attributed smallpox to a poison that a fetus carried with it from its mother's womb because of an illness the mother suffered during pregnancy, the avoidance of certain foods and activities was recommended to prevent the poison from creating smallpox Yamazaki, Nthon ekishi oyobi, ρ 359

104

CHAPTER IV

on the majority of the Japanese who lived on the main islands. It is unclear whether smallpox mortality for the period as a whole was higher or lower in these areas. This would depend to some extent upon whether smallpox contracted at a later age actually did have a higher case-fatality rate, as the inhabitants of both islands believed. But even if mortality was lower over the long run, smallpox dis­ rupted social life and population structure to a much greater extent in isolated populations. If Tanegashima and Hachijojima are typical cases, a smallpox epidemic was still an unusual occurrence in certain isolated places at the end of the eighteenth century, but by the middle of the nineteenth century it was more common everywhere in Japan. To summarize, records of every sort show that smallpox was an extremely important disease in premodern Japan. As Japan's popula­ tion grew and became increasingly dense, and as urban centers and trading networks developed, smallpox, originally imported from the Asian mainland, became an endemic disease. TheJapanese descriptive accounts indicate that by the twelfth century, smallpox was pri­ marily a disease of children in the major cities, and, given Japan's population size and density, it probably became an endemic disease even earlier. The devastating effects of the early epidemics, which caused high mortality throughout the entire population, ameliorated in later centuries as shorter intervals between epidemics reduced the proportion and the age of the population at risk. It was a case of early exposure and early adaptation between host and parasite. By the tenth century, Japan had already passed through the stage of severe popula­ tion reduction that smallpox would cause several centuries later in the large, but more isolated populations of Central America. There is nothing to suggest that Japan's isolation, natural or self-imposed, deterred the arrival of smallpox in Japan. By the Tokugawa period, smallpox was viewed as a common illness that directly affected every member of society at some time in his or her life. Records from different parts of Japan show that smallpox reached all regions of the country, but how often it was epidemic varied considerably from place to place. The smallpox virus was probably present at all times in large cities like Edo and Osaka, whereas isolated island populations were exposed to the virus in­ frequently and with more serious consequences. By the nineteenth century, however, even these island outposts had been drawn into a national network of smallpox transmission. Smallpox was an ordeal through which all children had to pass. In Hida, a family knew not only that smallpox epidemics were inevita­ ble, but also almost exactly when the next epidemic would appear. A child born shortly after a smallpox epidemic had ended in his village

SMALLPOX: MINISTER OF DEATH

105

could be expected to contract the disease at age 3 or 4, if he lived that long. Given the predictability of smallpox epidemics, it is even pos­ sible that efforts at family planning included attempts to adjust to the smallpox cycle. For example, parents may have waited to see if living children survived the next smallpox epidemic before deciding whether to have another child. Smallpox had to be a matter of great concern to parents, not only because it killed and disfigured their children, but also because it posed a very serious threat to family survival. Faced with the certainty of eventual infection, it would not have been unreasonable for parents to deliberately expose their children to smallpox, a strategy followed in other countries where smallpox was endemic. That, in fact, seems to be just what was done—in Yoko­ hama at least. According to John R. Black, an Englishjournalist and a sensitive observer of the Japanese scene between 1858 and 1875, Japa­ nese parents exposed their children to smallpox at a young age in the belief that it improved their chances for survival. The following excerpt, written in the early 1860s and first published in 1883, pro­ vides an insightful glimpse of Japanese attitudes toward this dread disease and suggests that, in spite of the grim death statistics, smallpox was taken pretty much in stride. amongst the Japanese certain diseases were always more or less present in their respective seasons:—the much-dreaded smallpox invariably making its appearance in the native quarters in the winter and the spring. This was a disease so common among the natives that it appeared to have no terrors for them. They quite counted on having it at some time or other, and were glad if it came to their children in very early youth, as they considered that it was more easily got over in the tender years of childhood, than it was later in life. Few of them escaped, and its effects were seen on the countenances of a large proportion of the population. It carried many off by death, but nothing like so many as might have been expected; and how it happened that the disease was ever absent was a marvel to foreigners, seeing that children covered with it, and to whom foreigners would instinctively give a very wide berth, were not kept indoors, or separated from the rest of the family, but were carried ... on the backs of other children only a few years older than themselves, or on their mothers' backs, in the open air; their bearers mixing quite freely with their friends and acquaintance as if nothing was the matter. That they acknowledged that danger did exist was evidenced by the fact that any house in which the disease was, had to be marked by certain slips of paper suspended in a straw string

106

CHAPTER IV

across the doorway; and the children themselves had a scarlet cloth wrapped round their heads, to call attention to the fact of their being infected. There was, however, no special purification of the houses nor destruction of the clothes of those who had been afflicted, but everything was left to chance.66 But, however accurate, it would be wrong to conclude from Black's observations that smallpox was a disease to be taken lightly. The real drama of smallpox was acted out in the privacy of individual households. Mori Ogai's biography of Shibue Chusai describes the tragic deaths from smallpox of Chusai's two daughters in 1851 They were the children of his fourth wife, Shibue Io. The older child, age 6, died on the seventh day of the third month, the younger, age 2, on the eighteenth day. A third child, who survived, was a daughter, age 4, who was not living in the household at the time. Shibue Chusai was a noted physician, a specialist in smallpox in fact, but neither wealth nor expertise could prevent death once smallpox had struck. Ogai writes that for about six months Io's mind was unbalanced as a result of this loss, and his recollections reveal, better than any statistics, the human dimension of the history of smallpox 67 Although smallpox established itself as an endemic disease earlier in Japan than in Europe, Japan's experience with smallpox seems not unlike that of European countries. English records suggest that small­ pox was a disease of children in London by the end of the sixteenth century and in other large towns during the seventeenth century, whereas smallpox is described as a disease of children in Japanese cities as early as 1243. These records simply reflect the realities of population characteristics in the two world regions. Kamakura, with an estimated population of 200,000 people in 1250, was larger than any European city at that time, and from A D 800 to 1400, Japan almost always had at least one and sometimes two cities among the ten largest in the world.68 In 1600 the population of London reached an estimated 187,000; by 1650 London had joined Edo, Kyoto, and Osaka, as one of the world's twelve largest cities.69 66John

R Black, Young Japan Yokohama and Yedo 1858-79, 2 vols (Oxford Oxford University Press, 1968), 1 287—88 The practice of deliberate exposure to smallpox was not uncommon in some parts of Europe, Scotland and Sweden m particular, although apparently the English went to great lengths to avoid persons and places where the disease was Razzell, The Conquest of Smallpox, pp 114-15 67Edwin McClellan, Woman in the Crested Kimono The Life of Shibue Io and Her Family Drawn from Mori Ogai's "Shtbue Chusai," (New Haven, Conn Yale Univer­ sity Press, 1985), pp 42-43 68Tertius Chandler and Gerald Fox, 3000 Years of Urban Growth (New York Academic Press, 1974), pp 306—15 69Ibid, ρ 320

SMALLPOX: MINISTER OF DEATH

107

In the early modern period, smallpox seems to have been regionally more endemic in Japan than in parts of the West. In eighteenth-century England, smallpox epidemics occurred at intervals ranging from 5 to 12.5 years, much less frequently than the 3.5 year intervals found in the Hida villages. Razzell found one isolated area of England where 40 percent of all individuals who contracted smallpox in an epidemic in 1723—1724 were over 20 years of age, which sug­ gests that it had been at least 20 years since the previous epidemic.70 These differences in smallpox frequency may reflect differences in settlement patterns in the two countries—dispersed dwellings in Eng­ land versus clustered settlements in Japan—but they also suggest that there was more regular contact between cities and remote rural vil­ lages in Japan. In parts of Europe where population density was higher than it was in England, the pattern of smallpox epidemics may have been more similar to that found in Japan. Smallpox was an endemic national disease in the Tokugawa period, and the very regularity with which it claimed the lives of infants and young children means that in Japan, as in the rest of the world, this particular disease played a crucial role in curbing population growth. But there is no evidence that the case-fatality rate from smallpox was higher in preindustrial Japan than elsewhere in the preindustrial world. And as we have seen, there is no evidence that mortality due to smallpox increased during the late Tokugawa period. In fact, if the pattern of smallpox mortality in the villages affiliated with Ogen-ji is at all typical of the rest of Japan, smallpox mortality fell during this period. Hence, the history of smallpox in Japan offers no explanation of why Japan's population ceased to grow between 1725 and 1850. 70 Razzell

1

The Conquest of Smallpox, p. 116.

CHAPTER V

MEASLES: AN EPIDEMIOLOGICAL PUZZLE

The history of measles in Japan is remarkably different from that of smallpox, and different also from the history of measles in Europe.1 By the sixteenth century, measles was a well-known epidemic disease in Europe.2 Its importance before this time is uncertain, because measles was often confused with smallpox in early accounts of the disease.3 But by the early seventeenth century, measles deaths were being recorded in London every year,4 and by the end of the eigh­ teenth century, measles epidemics were occurring in England in about one out of three years.5 At about this same time, measles epidemics occurred at regular intervals of about four to five years in Germany.6 On the American continent, measles epidemics were irregular, and the disease appears not to have been endemic, but rather to have been imported into the major port cities of the northeast.7 Isolated islands were able to avoid measles epidemics for long periods: measles was imported into the Faeroe Islands in 1781, 1846, 1862, and 1875,8 and the Fiji Islands suffered its first known epidemic of measles in 1875.9 Measles epidemics, like smallpox epidemics, occurred most often in areas with large populations that were m frequent contact with one 1The author is indebted to Alan Hinman, MD., Director of the Division of Immunization at the Centers for Disease Control; and to Doug Ewbank and Susan Zimicki, Population Studies Center, University of Pennsylvania, for their comments on this chapter. For general background information on the history of measles, see Arthur L. Bloomfield, A Bibliography of Internal Medicine. Communicable Disease (Chicago, 111.: University of Chicago Press, 1958). 2Fredenck F. Cartwnght, Disease and History (New York: Thomas Y. Crowell Co., 1972), p. 131. 3Charles Creighton, A History of Epidemics in Britain, 2nd ed., 2 vols (London. Frank Cass and Co., Ltd., 1965), 2:632. It is thought that early observers confused the two diseases because skin lesions were more difficult to interpret in early and very severe epidemics. Bloomfield, A Bibliography of Internal Medicine, p. 444 4Creighton, A History of Epidemics 2:641. 5 Cartwight, Disease and History, p. 132. 6August Hirsch, Handbook of Geographical and Historical Pathology, 3 vols. (London. New Sydenham Society, 1883), 1:160 7Ibid. 8Ibid., pp. 156-57. 9Cartwnght, Disease and History, pp. 135-36.

MEASLES: EPIDEMIOLOGICAL PUZZLE

109

another, and least often in communities that had little contact with population centers. The disease of measles is well established in pre-Tokugawa litera­ ture, but unlike smallpox, measles epidemics did not establish a pat­ tern of increasing frequency. Japanese sources indicate that during the Tokugawa period measles epidemics were infrequent, occurring at intervals of about twenty to thirty years. This is an unexpected finding. Measles is a disease that is highly dependent on large, densely settled populations, and one would expect to find epidemics occurring frequently in a country that by the eighteenth century had a population of approximately 30 million people. However, in some respects, Japan was similar to isolated island communities that witnessed measles epidemics very infre­ quently. Japan was an island nation, far from the major sea lanes, with extremely limited contact with other population centers. Be­ tween 1639 and the early 1860s, foreign trade was strictly controlled and limited to the port of Nagasaki. Evidence from Japanese historical sources indicates that, despite Japan's large population, measles remained an imported disease until the end of the Tokugawa period. It will be argued here that the unique characteristics of the measles virus, Japan's geographic posi­ tion, and her limited contact with the outside world meant that measles did not reach Japan very often. When it did, measles would cause a great epidemic, and then the virus would die out. Although individual measles epidemics caused high mortality, analysis of the evidence suggests that measles mortality for the Tokugawa period as a whole was lower than in other countries that were exposed more frequently. Japan is a highly unusual case. Few large and densely settled popu­ lations were as isolated as the Japanese were in the nineteenth century. There are accounts of measles epidemics in small, isolated populations in the nineteenth and twentieth centuries,10 but there is no literature that documents the epidemiology of measles in a population that was both large and isolated. The excellent source materials of premodern Japan provide this opportunity, but before turning to the history of measles in Japan, it is essential to consider the characteristics of the measles virus and the epidemiology of measles. 10 Peter

Ludwig Panum, Observations Made During the Epidemic of Measles on the

Faroe Islands in the Year 1846, trans. Ada S. Hatcher (New York: Delta Omega

Society, 1940); P. E. Christiansen et al., "An Epidemic of Measles in Southern Green­ land, 1951," Acta Medica Scandinavia 144 (1952-53) :313-22, 430—49, 450—54; and an account of the 1875 measles epidemic in the Fiji Islands can be found in Burnet and White, Natural History, pp. 16—17.

110

CHAPTER V

DISEASE CHARACTERISTICS

The measles virus is host-specific to man. It is very fragile, and unlike smallpox, its infectivity dissipates rapidly outside the human host. The measles virus has no natural reservoir in man or other species; there­ fore, it must be passed directly and quickly from one human host to another.11 Transmission of the virus depends on direct contact and occurs by means of droplet emission from the upper respiratory tract of an infected person to the nose of a susceptible contact. The period of communicability is quite short, usually not more than a week, but the most infectious stage of the disease occurs several days before the appearance of the rash.12 This means that measles is often trans­ mitted before the person even knows he has the disease The need for direct host-to-host transmission, the short period of communicability, and the fact that lifetime immunity follows recov­ ery from an attack of measles13 mean that a continuous chain of susceptibles is necessary for the virus to survive. As a result, measles is highly dependent on large dense populations, and it is one of the most contagious of all human diseases. Within a single epidemic, measles has an almost universal attack rate (i.e , virtually all susceptibles who are exposed to the virus will contract the disease).14 During an epidemic, measles rapidly infects all susceptibles who are exposed, and when there are no susceptibles left, the virus dies out. After an epidemic, herd immunity is very high As the susceptible group grows—primarily through births—the previously immune population is diluted, however, an important fact m the case of measles is that infants whose mothers have had measles have an im­ munity to the disease during the first six to seven months of life 15 When the number of susceptibles reaches a certain proportion of the population, a return of the virus to the community triggers a new epidemic, and the cycle begins again Measles also has a seasonal 11A P Ball, "Measles," m A World Geography of Human Diseases, ed G Melvyn Howe (London Academic Press, 1977), ρ 238 12Christie, Infectious Diseases, ρ 385 13The Faeroe Islands experienced an epidemic of measles in 1781 when the virus was introduced from the outside Measles did not recur until 1846, when there were ninety-eight people still alive who had contracted the disease in the previous epi­ demic A high proportion of the rest of the population was infected, but none of the ninety-eight persons previously exposed contracted measles James A Doull, in his introduction to Panum, Observations, ρ xvii 14In 1951, 99 9 percent of the indigenous population of Greenland contracted measles The island was not known to have been previously invaded by the disease Christiansen et al, "A Epidemic of Measles," ρ 449 The same high attack rate was observed among isolated tribes in Micronesia Ball, "Measles," ρ 244 15Chnstie Infectious Diseases, ρ 386 1

MEASLES: EPIDEMIOLOGICAL PUZZLE

111

pattern of prevalence, preferring colder weather, and in populations that experience frequent exposure to measles, epidemics usually occur in late winter or early spring. In certain circumstances, it is difficult for measles to establish itself as an endemic disease. Recent research has tried to determine by means of mathematical models the critical population size needed for measles to become endemic, that is, the size that a population must be for the virus to sustain itself indefinitely. Maurice S. Bartlett's study of U.S. and British cities concluded that measles will die out in a com­ munity with a population of less than 250,000.16 And Francis L. Black measured rates of measles infection from 1949 to 1964 in island popu­ lations and found that today, in island communities of less than 500,000 persons, measles disappears after an epidemic and must be reintro­ duced from the outside before another epidemic can occur.17 It is no longer possible to test measles endemicity in large isolated popu­ lations because such populations no longer exist. In isolated populations, measles epidemics begin whenever the virus is introduced—regardless of season—and the unusual severity of measles epidemics in such populations is well documented. It is thought that early in the sixteenth century, Europeans carried measles to New Spain, where the disease was previously unknown. The result was a precipitous decline in the native populations. The devastating effects of measles in isolated island populations have been observed even in modern times. In 1875, the son of a native ruler in the Fiji Islands visited Sydney, Australia and returned home just before the symptoms of measles became evident. Festivities were being held to celebrate the acceptance of Fiji as a British Crown colony, and the occasion provided a concentrated host population that dispersed and quickly disseminated the disease throughout the islands. Twenty per­ cent of the Fiji population is believed to have died in this one epidemic. The high measles mortality rate was due, in large measure, to the enormous social disruption caused by this severe disease that infected all members of the community at the same time. There were virtually no healthy people to care for the sick.18 Measles is an extremely unpleasant disease that is acutely debilitat­ ing to the patient. The first signs of illness are fever, malaise, and headache. Within hours, ocular symptoms appear, with burning eye 16Maurice S. Bartlett, "Measles Periodicity and Community Size," Journal of the Royal Statistical Society 19 (1957) :48-70. 17Francis L. Black, "Measles Endemicity in Insular Populations: Critical Com­ munity Size and Its Evolutionary Implications," Journal of Theoretical Biology 11 (1966):207. 18Burnet and White, Natural History, pp. 16-17.

112

CHAPTER V

pain and extreme sensitivity to light. At the same time, or shortly thereafter, catarrhal symptoms—inflammation of the respiratory tract, with sneezing, coughing, and nasal discharge—are manifested. This prodromal stage of the disease, which lasts two or three days, is followed by an elevation of the fever, and the appearance of the measles rash—a blotchy, reddish-purple, raised eruption—which spreads from the face downward. The period of the most extreme visible symptoms is from the sixth to the ninth days, when all signs of illness are present. There is a fairly rapid regression of symptoms from the tenth day. Death is usually caused, not by the primary infection, but by secondary infections such as bacterial or viral pneumonia or measles encephalitis, which appear as complications following the disease.19 The course of measles is highly typical with few variations from one case to the next, which made it easy for those who were familiar with both to distinguish measles from smallpox.20 Identification of measles in very early historical records depends upon accounts that mention the symptoms noted above, particularly the cough, the ocular symptoms, and the typical secondary complications that follow measles. Measles mortality has fluctuated considerably over the centuries. In the eighteenth and nineteenth centuries in Britain and other countries of western Europe, measles resembled the severe disease that is found today in underdeveloped and isolated countries. In London, more deaths were attributed to measles than to smallpox in some years. The disease then seemed to decline in virulence but resurfaced later in the nineteenth century as a more serious infection.21 Since the measles virus does not vary or mutate, the differential severity of measles has been attributed to variations in standards of living.22 Today, measles mortality is lowest in countries with the highest standards of living. People who are malnourished are believed to be more susceptible to the secondary infections and complications that are the major causes of measles mortality. However, living conditions cannot account for the wide historical variations in measles morbidity and mortality. Epidemics of measles 19

Christie, Infectious Diseases, pp. 390-94. Differentiating measles from scarlet fever is more difficult. A major problem in identifying measles in historical sources is the different character of the disease in older descriptions. Severe outbreaks with high mortality, especially from broncho­ pneumonia, were confused with violent types of scarlet fever and smallpox. Bloomfield, A Bibliography p. 432. 21Ball, "Measles," p. 241. 22 Nicholaas W. N. M. Dekkers, The Cornea in Measles (The Hague: Dr W. Junk Β. V., 1981), p. 9. 20

MEASLES: EPIDEMIOLOGICAL PUZZLE

113

in Europe during the late nineteenth century were particularly severe and had no respect for people, weak, strong, or otherwise. And the unusual severity of the disease among previously unexposed popu­ lations with no immunity to the disease—primarily non-European populations who were first exposed to the virus during the period of European expansion—cannot be attributed to malnutrition or poor health. It has been observed that measles is most severe and mortality highest whenever there is a high concentration of susceptibles, regardless of environmental standards. MiUtary history provides several examples. In France during the nineteenth century, many soldiers recruited from outlying villages had not been exposed to measles. They lived to­ gether in barracks and formed a population with a higher proportion of nonimmune persons than the rest of the population. Measles was an important cause of death among these men: the death rate was 116 per thousand, a mortality rate that far exceeded that of the general population.23 Many recruits also died of measles during the American Civil War and in Australian military training camps in 1915—1916. Susceptibles were crowded together in close quarters, and the measles virus pro­ duced a more severe disease and higher mortality. Secondary bacterial infections spread easily in wards filled with soldiers whose lungs were rendered more susceptible by the measles virus. Highly virulent strains of streptococci and pneumococci formed, and a lethal epidemic of bacterial pneumonia developed.24 In Africa today, where mortality from measles is still high among children under the age of 2, recent research suggests that, regardless of economic status, measles is most severe where there is a clustering of cases. Mortality is highest among younger siblings who get the disease from an older brother or sister with whom they have extended and close contact. It is not uncommon for a family to lose more than one child to measles in a single epidemic. This suggests that factors other than malnutrition contribute to high measles mortality.25 The decline of measles mortality in developed countries in the twentieth century is thought to have resulted from an improvement in living conditions and fewer children per family. But it should be kept in mind that trends and phases in the secular history of a disease cannot always be explained by a simple formula, because they repre23 Christie, 24Burnet,

Infectious Diseases, p. 384.

Natural History, p. 121.

25Peter Aaby, "The Black Child's Grave: Measles, Overcrowding, and Child Mortality in Africa.. (Paper presented at the Institute of Ethnology and Anthro­ pology, University of Copenhagen, Denmark, September 1984).

CHAPTER V

114

sent changes in the interactions between host, parasite, and environ­ ment that are highly complex. THE EARLY HISTORY OF MEASLES IN JAPAN

It is well established that measles has a long history in Japan. The earliest known Japanese accounts that clearly describe measles are from the late tenth century, although evidence will be presented here that suggests that measles caused epidemics in Japan even earlier. There is little doubt that the disease described in several contemporary accounts from A.D. 998 was measles. The Eiga monogatari, a chrono­ logical account of events written by an unknown woman author at the Heian court, provides the following description of the disease that was prevalent in 998: That year, instead of the usual smallpox, a disease characterized by a heavy rash of bright red spots was claiming victims of all ages and classes. Some of the sufferers had died, and people were depressed and uneasy.... The epidemic raged on sparing no one.26 The writer distinguishes between smallpox, which was apparently well known at the time, and measles, which was not. Whether measles was regarded as a new disease is not clear, but the fact that everyone, including the elderly, contracted measles strongly suggests that there had not been a measles epidemic within the lifetime of most of the inhabitants. The next year for which there are existing records of a measles epidemic is 1025, and this epidemic is also described in the Eiga monogatari:

A measles epidemic, which had broken out that year, was claim­ ing victims of every class from among those who had not previ­ ously contracted the disease. There was great fear for the safety of the Emperor, the Crown Prince, the Empress, and Kishi, who were all at vulnerable ages.27 The author's mention of vulnerable ages is curious. According to William and Helen Craig McCullough, whose translation of Eiga monogatari is excerpted here, the ages of the Emperor Go-Ichijo, the Crown Prince, Empress Ishi, and Kishi were 18, 17, 27, and 19 sai, 26 McCullough 27 Ibid.,

2:665.

and McCullough, trans., A Tale of Flowering Fortunes, 1:211-14.

MEASLES: EPIDEMIOLOGICAL PUZZLE

115

respectively. In their annotations of the text, the McCulloughs suggest that the concern for each of those mentioned may have been based on a belief that a person was particularly liable to suffer misfortune in certain years of his life. However, none of the ages mentioned cor­ responds to any of the known unlucky years.28 Another explanation seems possible. It is worthy of note that all who were regarded as being at vulnerable ages were born after the measles epidemic of 998. This suggests, first of all, that there were no measles epidemics between 998 and 1025. If so, each of the persons mentioned would have been susceptible to measles in 1025, and those born before 998 would not have been susceptible. The writer seems to be well aware that those who had measles before would not be infected this time. In fact, her fears for those whom she mentions were quite appropriate, and her assessment suggests a rather sophisticated under­ standing of how measles would affect individual members of the community. But such an understanding could only have been based on prior experience—either her own or the experience of others. If the measles epidemic of 998 were the first measles epidemic in Japan, no one could have predicted in 1025 who would have been most likely to get measles. This suggests that some of the early unidentified epidemics in Japan were caused by measles. The clear terminology used for measles in Japan makes it possible to trace the history of this disease after 998. A brief review of the evo­ lution of this terminology demonstrates that important differences between smallpox and measles were observed very early in Japan. The earliest terminology in Japanese sources was devised to distinguish between these two diseases. In accounts of the measles epidemic of 998, several different character combinations were used to modify mogasa, the term for smallpox.29 All of the new combinations begin with akai (3¾), the character for "red," which notes the color of the measles rash and calls to mind the common English term "red measles." Aka-mogasa, written (^SfS), literally means "red-spotspox"; it was also written (0'MX ), or (¾¾¾¾), meaning "red small­ pox." These character combinations for measles were devised in order to distinguish a new or less familiar disease from the better-known smallpox.30 2eIbid.,

2:665, n. 29. Yu, N S S , p. 178. 30The accounts are confusing because so many different character combinations were used. The attempt to distinguish a new disease from an old familiar one is obvious, but whether both diseases were prevalent at the same time is not entirely clear. Fujikawa believed that both smallpox and measles were prevalent in 998. Fujikawa, NSS, p. 30. 29Fujikawa

116

CHAPTER V

After 1113 it is not difficult to distinguish between smallpox and measles epidemics in Japanese sources because they usually occurred in different years. Moreover, the terminology used for the two diseases was distinctive. The character combination (:¾¾¾¾) became the most common written form for measles, and these characters continued to be used until the end of the fifteenth century.31 By the sixteenth century, the written terminology for smallpox and measles no longer retained any common characters, and there is no difficulty whatsoever in distinguishing between these two diseases in the accounts and litera­ ture of the Tokugawa period. The popular Japanese name for measles—hashika—was used as early as the Kamakura period (1192—1333), and it is still the common term for measles today. In the sixteenth century, hashika was written in several ways-—using katakana (/iyi) or the Chinese characters (#>) or (M$S)·32 Toward the end of the Muromachi period (1392—1593), the second combination had become the formal medical term for measles, and it was used in all the official accounts of Tokugawa epidemics. This written form (¾¾), pronounced either hashika or mashin, is still used today. Fujikawa Yu found accounts of thirty-six measles epidemics be­ tween 998 and 1868. A chronology of these epidemics and the inter­ vals between them is shown in Table 5.1. It is immediately evident that measles epidemics were not so frequent as smallpox epidemics. There are only half as many accounts of measles before 1600, and the inter­ vals between the accounts were longer and more erratic than between smallpox epidemics. Moreover, there is no evidence of a trend toward more frequent epidemics as the Japanese population grew larger. It is possible, of course, that only the most severe epidemics were noted, and undoubtedly accounts of measles epidemics are missing in the twelve-century period covered by Fujikawa. But the chronology sug­ gests that measles remained an imported disease in Japan. In the six­ teenth century, when there was increasing contact with neighboring countries and new contact with Europeans, measles epidemics oc­ curred more frequently. But after 1616, when the Tokugawa govern­ ment began to restrict trade and other foreign contacts, measles epi­ demics became less frequent again. This suggests that the most important factor influencing the frequency of measles epidemics in Japan was the extent of contact with the outside world. 31Fujikawa,

N S S , pp. 180—1. term "hashika" written in katakana can be found in the accounts of 1405, 1535, and 1607. Fujikawa, NSS, p. 172. It means "a sore and prickly throat," a prominent symptom of measles. Fujikawa, NSS, pp. 180-82. 32The

117

MEASLES: EPIDEMIOLOGICAL PUZZLE

Table 5.1

Years of Recorded Measles Epidemics and Intervals Between Epidemics: Japan to 1868

Japanese year

Interval (Japanese years)

998 1025 1077 1093-1094 1113 1127 1163 1206 1224 1227 1256 1307 1380 1405 1441 1471 1484 1489

27 52 16 19 14 36 43 18 3 29 51 73 25 36 30 13 5

Japanese year 1506 1513 1523 1535 1578 1587 1607 1616 1649 1690-1691 1708 1730 1753 1776 1803 1824 1836 1862

Interval (Japanese years) 17 7 10 12 43 9 20 9 33 41 17 22 23 23 27 21 12 26

Source: Fujikawa Yu, NSS.

THE TOKUGAWA MEASLES EPIDEMICS

The Tokugawa period records pertaining to measles are excellent, and they indicate that a measles epidemic was considered a rare event in early modern Japan. They also show that measles epidemics were severe and socially disruptive. Given the size of Japan's population in the Tokugawa period and her large cities, we would expect to find that measles epidemics were at least as frequent in Japan as they were in eighteenth-century Eng­ land, whose population was much smaller and less dense. We would assume that measles—documented as an epidemic disease in Japan in the tenth century—would have become endemic long before the

118

CHAPTER V

seventeenth century. Instead, Japanese sources provide compelling evidence that the measles virus died out between epidemics and was reimported from outside the country. This interpretation of the sources not only supports the major thesis being argued here—that certain acute infectious diseases had difficulty reaching Japan—but it also challenges the accepted view of measles epidemiology. For this reason, the historical evidence that supports this argument will be presented in detail. Periodicity

If we accept the Tokugawa historical sources at their face value, there were only eleven measles epidemics in the two and one-half centuries between 1616 and 1862. The years of these epidemics are shown in Table 5.2: the average interval between measles epidemics was twenty-two years; the shortest interval was twelve years and the longest was forty-one years.33 Table 5.2 also notes Japanese calendar years of recorded measles epidemics and the seasons m which measles was prevalent in Edo and in the Hida and Sendai regions The following summaries of contemporary accounts of each of these eleven measles epidemics pay particular attention to comments about the symptoms of the disease, the routes it followed through the Japanese islands, its regional periodicity, who got sick, and the effect of measles on mortality. The accounts of measles epidemics compiled by Fujikawa are supplemented by evidence from local histories and kakochd from the Sendai and Hida regions. Special attention is given to nineteenth-century accounts, which provide the greatest amount of information. These accounts should be the most important ones to consider, because if later measles epidemics were imported it is likely that earlier epidemics were also. The Buko nenpyo, a chronology of events in Edo, tells of a measles epidemic in 1616. The account states simply: "In the tenth month, measles was prevalent."34 There are no known accounts from the Sendai or Hida regions to indicate whether this epidemic was preva­ lent in those areas. In 1649, the Buko nenpyo mentions an epidemic of measles in Edo in 33 Fujikawa mentions twelve epidemics, but evidence of measles in 1782 is meager, the only reference being a brief statement in Kyorei tutsan "In May, Dainagon-sama got measles," quoted by Fujikawa, NSS, ρ 184 There is no evidence of an epidemic in other sources, and this year is usually disregarded by Japanese scholars of medical history Matsuda Takeshi omits 1782 as an epidemic year Matsuda Takeshi, "Edo jidai no mashin ryuko," Nihon ishigaku zasshi 27 (1981) 29 34 Bukd nenpyo, quoted by Fujikawa, NSS, ρ 52

MEASLES: EPIDEMIOLOGICAL PUZZLE

119

Table 5.2

Chronology of Measles Epidemics in the Tokugawa Period

Japanese year

Intervals (Japanese years)

1616 (Genna 2) 1649 (Keian 2)

29 33

1690—1691 (Genroku 3—4)

41

1708 (Hoei 5) 1730 (Ky6h0 15)

17 22

1753 (Horeki 3)

23

1776 (An'ei 5)

23

1803 (Ky5wa 3)

27

1824 (Bunsei 7)

21

1836 (Tempo 7)

12

1862 (Bunkyu 2)

26

Place

Season

Edo Edo Sendai Edo Sendai/Hida Edo Edo Sendai/Hida Edo Sendai Hida Edo Sendai/Hida Edo Hida/Sendai Edo Sendai Edo Hida Edo Sendai Hida

Autumn Winter (unknown) Spring (unknown) Autumn-Spring Winter (unknown) Summer-Autumn Summer-Autumn Winter Spring-Autumn Summer Spring Spring-Summer Spring Summer Summer-Winter Winter (1837) Spring-Winter Summer (unknown)

Source: Fujikawa Yu, NSS.

the third month. Presumably this epidemic reached the Sendai region because it is noted in a local history of Tome-gun, which states, "In this year hashika was prevalent." 35 There are no accounts from other districts, and the kakocho of temples in Ishinomaki and the city of Sendai do not show an unusual increase in mortality. There is no evidence of this epidemic in the local histories of the Hida region. Forty-one years later, several different sources tell of an epidemic of 35 Aoki Daisuke, "Mashin," in Saigai hen vol. 22 of Miyagt-ken sht (Sendai: Miyagiken shi hensan unkai, 1962), p. 382.

120

CHAPTER V

measles that began to spread in the early part of the third month of 1690 and that lasted until the fifth month of the following year.36 "This disease afflicted men and women, young and old; there were none who did not suffer from it."37 The Bukd nenpyd mentions that measles was prevalent in Edo in the fourth month of 1691,38 and two local histories of the Sendai area also tell of a measles epidemic of great scale in that year.39 Aoki Daisuke found no noticeable increase in the number of deaths registered in the kakochd of the region, and he concluded that this measles epidemic was not a cause of high mortality in Sendai domain.40 As sources from the Hida region also mention an epidemic of measles in 1691,41 we can assume that this epidemic of measles infected a high proportion of the Japanese popu­ lation, Neither the Sendai nor the Hida sources state the months or seasons of measles prevalence, so it is not possible to determine the path that the epidemic followed. The next epidemic, in 1708, reached Edo during the winter.42 A contemporary account reads as follows: "Hashika invaded the sixty provinces of Japan, starting in the fall and lasting until the spring of the following year. Everyone—men and women, young and old, rich and poor—was affected. Many died."43 Again, Aoki found no ref­ erence to this epidemic in the Sendai sources, nor any noticeable change in the kakocho of the region.44 The existing sources from the Hida region also neglect to mention this epidemic. Did the epidemic go unrecorded or have the sources been lost? Or did this measles epidemic fail to reach these two regions? This epidemic may simply have been less noteworthy than the epidemic of 1690—1691. It oc­ curred after a much shorter time interval and would therefore have affected a much smaller proportion of the population—primarily those under 18 years of age. In the case of Hida, the answer is found in the accounts of the next epidemic. The next measles epidemic struck the densely populated Kinki region in the tenth month of 1730.45 This epidemic was first noted in Kyushu in 1730. It reached Edo during the winter, where it was prevalent until the spring of 1731.46 Hida sources also tell of a measles 36Ibid. 37

Kokuji igyo, quoted by Aoki Daisuke "Mashin," p. 382. 1 NSS, p. 54. 39Aoki Daisuke "Mashin," p. 382. 40Ibid. 41 Hida hennen shiyo (Gifu: Jiii shoten, 1921), p. 264. 42Fujikawa, NSS, p. 182. 43 Ushiyama Katsuto, quoted by Fujikawa, NSS, p. 182. 44Aoki Daisuke, "Mashin," p. 383. 45Ibid. 46Ibid. 38Fujikawa

MEASLES: EPIDEMIOLOGICAL PUZZLE

121

epidemic in 1730,47 and two local histories of the Sendai region mention measles in 1731, but no noticeable rise in deaths appears in the kakochd reviewed by Aoki.48 The fact that measles was epidemic in western Japan in the autumn, and in Edo, the eastern capital, in the winter indicates that this epidemic spread in a northeasterly direction. Neither Sendai sources nor Hida sources mention the months or seasons in which this epidemic occurred, but the question of whether the measles epidemic of 1708 reached Hida is clarified in an account written in Takayama City in 1730: "This year [1730] there was an epidemic of measles. It has been forty years since Genroku 4 [1691], when this disease was last seen here."49 For some reason, the measles epidemic of 1708 failed to reach the remote Hida region. Many accounts describe the measles epidemic of 1753, and when accounts from different regions of Japan are pieced together, it is obvious that this epidemic also followed a route from southwest to northeast. The epidemic started in Kyushu in the fourth month. It then spread eastward, reaching Kyoto and Osaka by summer. In Edo, measles was epidemic in the summer and fall, and one observer claimed that this epidemic was severe and that many people died.50 Aoki found no mention of measles in Sendai sources, but temple death records throughout the domain show a marked increase in the number of deaths among both adults and children between the eighth and tenth month. The timing and distribution of deaths is typical of measles, and Aoki thought it likely that the increase in mortality in the late summer of 1753 was caused by measles.51 The epidemic of 1753 shows up in the Hida sources also.52 The first death to be attributed to measles in the kakochd of Ogen-ji was recorded late in the eleventh month of that year.53 Sources for Hokkaido, Japan's north­ ernmost island, also indicate that the epidemic reached that area in the fall of the year: "In the autumn, measles was prevalent and many people died." 54 The epidemic of 1753 was clearly a national epidemic that spread throughout Japan within a period of eight months. The records of the 1776 epidemic suggest that measles spread, once again, from southwest to northeast. The disease was epidemic in 47

Hida hennen shiyd, p. 282; Miyamura shi, p. 680. Aoki Daisuke, "Mashin," p. 383. 49 Takayama-shi shi, 2 vols. (Takayama: Takayama insatsu kabushiki kaisha, 1981), 2:725. 50Fujikawa, NSS, p. 182. 51 Aoki Daisuke, "Mashin," p. 384. 52 Miyamura shi, p. 681. 53Suda Kcizo, Hida "O" jiin, p. 14. 54Matsuki Akitomo, "Meiji-zen Hokkaido shippei shi," Nihon ishigaku zasshi 17 (1971): 208. Matsuki notes that measles epidemics were less frequent in Hokkaido than on the main island of Honshu. 48

122

CHAPTER V

Osaka in the third month, and by the end of that month measles had reached Edo, where it continued to circulate until early autumn.55 Local sources identify measles in the Sendai region from the sixth to eighth month, and kakochd from six temples in different parts of Sendai show that mortality was high throughout the entire prefecture at this time 56 Measles is also mentioned in a local history of the Hida region in 1776;57 and this time the kakochd of Ogen-ji attributed nine deaths to measles m seven different villages affiliated with the temple 58 The death records indicate that measles was epidemic in Hida from the beginning of the sixth to the middle of the eighth month. This epidemic also reached Hokkaido, but the months that measles was epidemic are not known.59 In 1803, a great measles epidemic raged through all of Japan be­ tween the spring and the fall The Japanese accounts show that this epidemic also started in southwestern Japan, spread to the population centers of centralJapan, and then moved to interior regions and to the northeast. The epidemic of 1803 was said to have come from Korea Although there was some disagreement as to whether measles first entered the country through the port of Nagasaki or the island of Tsushima, contemporary reports say that a Korean ship carried the disease to Japan. The epidemic reached its peak in Nagasaki in the second month; it then spread to Osaka, where it was epidemic from the third month through the fourth month.60 The Buko nenpyo de­ scribes its course in Edo: "From the fourth through the sixth month measles was prevalent and people died in great numbers " 61 Until the middle of the fourth month, few people were infected, but starting around the fifth day of the fifth month, there was a sudden increase in those who caught the disease, and almost everyone got ill.62 The epidemic reached the Hida region in the fourth month,63 and the villages of Ogen-ji by the beginning of the fifth month, where it remained epidemic until the middle of the eighth month 64 Sendai local histories indicate that measles was epidemic there from the fifth month through the sixth month, and the kakochd show an increase in deaths throughout the prefecture between the seventh and ninth Fujikawa, N S S , ρ 183 Aoki Daisuke, "Mashin," ρ 385 57 Mtyamura shi, ρ 681 58 Suda, Hida "Ο" μιη, ρρ 32—33 59Matsuki, "Meiji-zen Hokkaido," ρ 208 60 Fujikawa, N S S , ρρ 184, 186 61 Ibid, ρ 182 62 Jikan doku gasho (1838), quoted by Aoki Daisuke, "Mashm," ρ 386 63 Hida hennen shtyo, ρ 334 64 Suda, Ilula ρρ 86—87 55

56

MEASLES

EPIDEMIOLOGICAL PUZZLE

123

months 65 Once again, we see a severe national epidemic occurring after a lapse of more than a quarter of a century. This time the routes of contagion were altered slightly measles appears to have reached Hida before it traveled up the coast to Sendai. The epidemic of 1803 evoked considerable comment in the litera­ ture of the time. The descriptions of the disease note the symptoms and complications typical of measles: countless numbers of people suffered from convulsions caused by this poison The poison sometimes entered one's eyes, and pro­ duced pain in the hips and in the arms and legs Those who died were not necessarily direct victims of measles but of com­ plications afterwards... .66 It was further noted that people who suffered from measles frequently became blind, and that pregnant women who got measles often aborted.67 These observations are typical of those written about severe measles epidemics in other parts of the world 68 The measles epidemic of 1824 also acted like an imported epidemic disease. In the eleventh month of 1823, there was a rumor that an epidemic of measles had begun in the western part of Japan. Although accounts differ about when measles first reached Edo, all accounts agree that it was present from the fourth to the sixth month. Some accounts say it started earlier, and the Bukd nenpyo claims that the epidemic lasted until autumn.69 Sendai records mention a measles epidemic of great scale in the northernmost part of the domain, and the kakocho show a sharp rise in the number of deaths in the seventh and eighth months in several localities 70 This epidemic does not show up in either the local histories of Hida or the kakocho of Ogen-ji. Accounts agree that the epidemic of 1824 was unlike that of 1803. Although twenty-one years had passed since the previous epidemic, observers noted that the disease was not especially severe. It is possible that this epidemic was not measles but some similar disease, or that an epidemic of measles had occurred in the interim and was not re­ corded 71 However, even today in regions where measles epidemics Aoki Daisuke, "Mashm," ρ 387 Yamazaki, Nihon ektsh oyobi, pp 387-88 67 Ibid, ρ 388 68 Permanent blindness as a consequence of measles is still noted today in West Africa Dekkers, The Cornea m Measles, ρ 7 69 Fujikawa, NSS, ρ 186 70 Aoki Daisuke, "Mashin," ρ 388 71 That there was a measles epidemic between 1803 and 1824 is unlikely because the carefully kept records of sasuyu ceremonies m Edo castle show no evidence of measles during this period Maekawa, "Sasuyu kiroku yon," pp 160—161 65

66

124

CHAPTER V

occur frequently, there can be considerable variation in severity. The fact that the epidemic of 1824 was not a severe one may explain why it does not show up in Hida sources or in the death records of Ogen-ji. Or as in 1708, measles may not have reached the Hida region. Not enough information is available at present to document the path taken by this seemingly mild epidemic. Only twelve years later, in 1836, we find reports of another measles epidemic. Again, the epidemic was not serious, and few people died. The accounts stress, however, that the disease must be measles because those who escaped this time were those who had been infected before. Measles appeared in Kyoto and Edo in the sixth and seventh months and remained in some areas until the following winter.72 The epidemic of 1836 is not singled out in the Sendai sources, perhaps because it would have reached Sendai at the height of the Tempo famine, a disaster that caused widespread mortality in the region. It does show up in the Hida villages, however, in the second month of 1837, and the kakocho of Ogen-ji attribute three deaths to measles in that year. The last measles epidemic to be documented in Tokugawa literature—after an interval of 26 years—was the devastating measles epidemic of 1862. According to the Bukd ηεηργδ measles was brought to Nagasaki on a foreign ship in the second month, and reached Kyoto and Osaka by the third or fourth month. Its presence was documented in Edo in the sixth month, although some sources indi­ cate that the epidemic arrived in that city as early as the fourth month. The epidemic peaked in Edo during the seventh month. Apparently there were cases in Edo as late as the tenth month, when the Shogun Iemochi is said to have suffered from measles.73 Sendai sources indi­ cate that measles reached Sendai domain by the end of the sixth month, spreading from the city of Sendai to many other parts of the domain. The epidemic peaked in the eighth month in Sendai.74 Local histories of the Hida region also mention an epidemic of measles in the eighth month and comment on the high number of deaths.75 Unfor­ tunately, the death records of Ogen-ji do not give causes of death after 1852, so there is no direct evidence of measles in that year; however, 7 2 Jikan

doku gasho, quoted by Fujikawa, NSS, p. 187. Daisuke, "Mashin," p. 389. Iemochi, the fourteenth Shogun (1858—1866), was 16 years old in 1862. He was born after the epidemic of 1836, in 1846, and the fact that he had not had measles previously provides additional evidence that there were no measles epidemics between 1836 and 1862. 74Ibid., p. 391. 75Hida hennen shiyo, p. 371; Miyamura sht, p. 681. 73Aoki

MEASLES: EPIDEMIOLOGICAL PUZZLE

125

there was a marked rise in mortality in the population under age 26 in 1862.76 All of these accounts show that measles epidemics had a distinctive epidemiological pattern. In contrast to smallpox, which had local or regional prevalence, a measles epidemic was a national phenomenon. Within a short period of time measles would traverse the country, usually within the span of a single calendar year, and it would travel along the same general route. Detailed accounts of the measles epidemic of 1862 tell of its arrival on a foreign ship and of its progress northward from Nagasaki to the major population centers of central Japan,77 Such detailed accounts are rare for earlier epidemics, but when accounts from different parts of the country are pieced together, it is clear that the Tokugawa measles epidemics advanced in a north­ easterly direction from Kyushu. The evidence is virtually overwhelming that measles remained an imported disease until the end of the Tokugawa period. If measles had been an endemic disease, epidemics would typically have started in Edo or other large cities and radiated outward to other parts of the country. In fact, almost all accounts mention that measles came to Edo from the southwest, where it arrived several weeks after it had made its appearance in Kyoto and Osaka, One nineteenth-century observer tells us that the south-to-north route was the expected one for measles: "since olden times epidemics of hashika have always started in the south and gradually moved to the north." 78 Were the eleven epidemics just reviewed the only measles epi­ demics that occurred during the Tokugawa period, or were they simply the most severe? It is difficult to imagine that any event as dramatic as a measles epidemic could escape mention in the well-kept records of Tokugawa Japan. After the seventeenth century it is most unlikely that there are significant gaps in the records. But it can be argued that measles epidemics occurred more frequently and, like smallpox epidemics, were only recorded when they were very severe. Fortunately, there is abundant anecdotal evidence suggesting that measles epidemics occurred as infrequently as the accounts indicate. The writings of Tokugawa observers contain a surprising amount of information about the puzzling disease called hashika. These observers wrote that measles epidemics occurred only every twenty to thirty years. And they emphasized that measles was very different from smallpox, which was epidemic every five to six years. Particularly Suda, Hida "O" jiitt, pp. 204-5. Aoki Daisuke, "Mashin," p. 389. 78Honma Soken, quoted by Aoki Daisuke, "Mashin," p. 389.

76 77

126

CHAPTER V

telling is an observation that measles was seen so seldom that a doctor would treat patients with measles only twice or, at most, three times during his lifetime.79 These writers believed that measles disappeared between epidemics. Hara Nanyo, writing around 1800, elaborated on the mysterious na­ ture of this strange disease that came out of nowhere. The origins of this disease [hashika] have been the subject of much debate. How to make sense of it' In some years it is epidemic; at other times there is not a trace of it. It affects even those of extreme age; however, it affects one only once in an entire lifetime, and though a man may attain 100 sat, it will not afflict him twice. Unlike smallpox, which may be epidemic in some regions while it is absent in others, hashika occurs over the whole country, all at once, and there is no place that escapes it. How this can happen is beyond human understanding.80 Measles, as it is described in these contemporary accounts, has all the earmarks of an imported epidemic disease. Measles followed an epidemiological pattern fundamentally different from that of small­ pox. We see long intervals between epidemics and a disease that afflicted the entire country in a relatively short period of time. Be­ tween epidemics, apparently, all traces of measles disappeared We see a pattern of dissemination that an imported disease would have fol­ lowed: the routes of contagion were from southwest to northeast because the only official ports of entry into Japan—Nagasaki and Tsushima—were located m the southwest. We see that the most severe epidemics occurred after long intervals and infected adults as well as children. And we see that imported epidemics occurred ran­ domly, not at regular intervals. All of the above suggests that the timing of measles epidemics was due to chance—that is, whenever a ship happened to bring a carrier of measles to a Japanese port—not to changes in herd immunity in the Japanese population. Age Incidence of Measles

The epidemiological pattern for measles just described has not been demonstrated for any other large population. As was mentioned ear­ lier, epidemiologists have believed that measles will become endemic in populations over 500,000. Since this review of the Japanese sources suggests that the measles virus died out in a population of approxiNihon ekishi oyobi, ρ 384 Hara Nanyo, Sokeitei iji shogen (1803), quoted by Fujikawa, NSS, ρ 191

79 Yamazaki, 80

MEASLES: EPIDEMIOLOGICAL PUZZLE

127

mately 30 million, it is important to look at the ages of those who contracted measles in particular epidemics. This will help to deter­ mine whether the intervals between measles epidemics were actually as long as the existing accounts suggest. One way to determine the time interval between measles epidemics is to analyze the ages of those who contracted the disease and those who did not. This is possible in the case of measles because of the universal attack rate among susceptibles. Japanese accounts that say that both young and old were affected are numerous, but the actual ages of those who were infected are more difficult to find. Some accounts do mention the ages of measles victims, however, and a few of these are worth citing. A few personal journals from Sendai do­ main have been found that give details about those who got sick. Some of these mention the ages of individuals who were infected. The following account was written by a 16-year-old boy who survived the severe measles epidemic of 1776. This epidemic reached Sendai in the fifth month, and mortality was high throughout the domain. At the beginning of the sixth month of this year hashika pre­ vailed in a great epidemic. My younger sister and younger brother were the first to catch the disease in my family. Around the sixteenth or seventeenth day of the seventh month I became ill, and about ten days later my mother became ill also. She was seriously affected and her life was in danger. About the sixth or seventh day of the eighth month, both my mother and I began to improve a little. On the eighteenth day of the same month, my grandmother died of old age without getting ill In the ninth month, both my mother and I got well.81 The fact that everyone in the family under age 16 got measles is not surprising because the records tell us that twenty-three years had passed since the previous epidemic in 1753. The mother, who must have been older than 23, had apparently escaped infection in 1753, and the grandmother had obviously been infected in some earlier epidemic. The epidemic of 1862—the last recorded measles epidemic of the Tokugawa period—affected both adults and children throughout Japan. The following account of measles, which was epidemic in Sendai from the sixth month through the tenth month, is from a diary written by Inogari Konosuke. This account is quite specific about the ages of those who got the disease, and it is clear that many who were infected were adults: 81

From a diary by Ito Hachiemon, quoted by Aoki Daisuke, "Mashin," p. 385.

CHAPTER V

128

8/2 The majority of those who are susceptible to the disease are from age one to about thirty sai. Therefore, usually three to five people are sick in bed in one household. Those big stores in Omachi, Kokubu-cho and Minami-cho had to close for five to six days at a time because their clerks had hashika. Usually there are more than enough doctors around, but this time, even a most incapable physician has thirty to forty families to take care of, and he must work day and night. Popular doctors are now worn out as a result of not having enough time to eat or sleep. Government officials are also affected, and very few can go to work. Pupils at Yokendo had to stay out because of illness, and so did the teacher I hear that in Edo three or four of every ten courtesans died in Yoshiwara and many ... also died in Shiogama. 8/25 Ide Ukon and his wife died of hashika. Many people are dying in the city. They say that there are twenty to thirty funerals a day in Yatsuka and Kitayama. 8/25 Endo Koshird and Ito Magobei, who were working in Edo, died of hashika.82 An account from another diary written during the measles epidemic of 1862 elaborates upon the disruptive aspects of this epidemic: 8/26 In addition to bad weather, because of hashika, there are not enough people to harvest the rice crop. The supply of rice is running out. Also, because of the disease, people are not bringing down coals from the mountains, and there is no coal for the blacksmith. Both the public and the samurai were victims of the epidemic, and so the community was paralyzed for a time.83 This was not a children's epidemic but one that affected a large seg­ ment of the population. These accounts are not unlike the eighteenthcentury reports of smallpox on the isolated islands of Tanegashima and Hachijojima. The measles epidemic of 1862 caused a major dis­ ruption of community life. Measles was behaving like an imported disease that occurred very infrequently. Local records from different parts of Japan seem to confirm the timing of measles epidemics established in the official chronologies. Temple death records used in conjunction with local histories dem­ onstrate the periodicity of measles in specific regions of Japan (see Table 5.2), and these records confirm that measles epidemics occurred 82Quoted 83Ibid.,

by Aoki Daisuke, "Mashin," pp. 391—92. The dates are Japanese dates. p. 392.

MEASLES: EPIDEMIOLOGICAL PUZZLE

129

everywhere in the same years. More importantly, no evidence of measles in Japan has been found for other years. Death records that give ages at death also help to establish the timing of measles epidemics in the Tokugawa period. Age at death from measles can be misleading, however, because typically measles mortality is highest among the very young. Persons over age 6 rarely die of measles; consequently, the ages of those who died does not necessarily represent the ages of those who were infected. For ex­ ample, if measles were to occur after an interval of thirty-five years, a very high percentage of the population under age 35 would be in­ fected; however, most deaths due to measles would still be among children under age 6.84 In spite of this problem, it is useful to look at ages at death in specific measles epidemics to see if the range of ages at death falls within the time interval set by the previous epidemic. Sendai temple death records indicate that both adults and children were susceptible to measles in several of the epidemics that appear in the historical accounts of Sendai domain. There is certainly no doubt that both adults and children died in considerable numbers in the last measles epidemic of the Tokugawa period—the epidemic of 1862. Aoki reviewed records from 150 temples throughout Sendai, and found that deaths in both age groups—under 15 sai, and 15 sai and over—rose significantly during the three-month period in which measles was epidemic in the summer of 1862. If the chronologies of national epidemics are correct, the most recent epidemic had occurred in 1836—twenty-six years before. The ages of most susceptibles in 1862 would have ranged from birth to Western age 26, or 27 sai. Since Sendai registers do not give specific ages of death, Aoki could only make a general assessment of the ages of those who died of measles in 1862. But the diary of Inogari Κδηοsuke, quoted earlier, reveals more: "the majority of those who are sick from this disease are from one to about thirty sai."85 This one sen­ tence, casually mentioning the ages of those who got measles in 84Today, measles is a child's disease throughout the world. It is necessary, there­ fore, to go back to nineteenth-century records to find the age distribution of deaths from measles when epidemics were infrequent and adults as well as children got the disease. Panum's classic work on a measles epidemic in the Faeroe Islands shows that when measles occurred after an interval of sixty-five years, 75 percent of the popu­ lation got the disease. The case-fatality rate of those under age 1 who died was 28.6 percent; the overall case-fatality rate was 2.8 percent. Panum, Observations, p. 82. 85Aoki Daisuke, "Mashin," p. 391. This statement about the age range of suscep­ tibles includes everyone from birth to Western age 29. The actual age is important: if children age 1 were infected, it means that they were not protected by maternal immunity, as would have been the case if there had been measles epidemics between 1836 and 1862.

130

CHAPTER V

Table 5.3

Distribution of Measles Deaths by Age and Epidemic Year, Hida Villages Deaths (N) per epidemic year (intervals in parentheses) Age (adjusted) Birth—1 year 1 year 2 3 4 5 17 20 39 42 48 Age unknown Total

1776 (23 years)

1803 (27 years)

1837 (12 years)2

1 2 0 1 1 0 1 1 1 0 0 1 9

4 8 2 1 4 0 0 0 0 1 1 1 22

1 0 0 0 1 1 0 0 0 0 0 0 3

Original Data Source·. Suda, Hida "O" jiin. aInterval assumes national epidemic of 1824 reached Hida but no measles deaths recorded.

Sendai in 1862, is more helpful than a sophisticated analysis of ages at death. Inogari's observation constitutes strong evidence that there were no measles epidemics in Japan between 1836 and 1862. The kakocho of Ogen-ji are even more helpful than the Sendai records, because they give specific ages for those who died of measles in the epidemics of 1776, 1803, and 1837. The age distribution of deaths attributed to measles in each of these years is shown in Table 5.3. Most of those who died had been born in the intervals between recorded measles epidemics. In 1776, one person who died of measles at age 39 was born before the preceding epidemic in 1753; presumably he was not exposed at that time. In 1803 two persons, ages 42 and 48, were in this category. In 1837, the ages of those who died from measles are in the expected, under-12 age group—-if one assumes that the national measles epidemic of 1824 did come through Hida. The sensitivity of the Ogen-ji kakocho to disease patterns reflects the

MEASLES: EPIDEMIOLOGICAL PUZZLE

131

Table 5.4

Distribution of Measles Cases by Age, Edo Castle: 1824 Age (Western)

Cases (N)

Age (Western)

Cases

8 months 2 years 3 4 5

0 1 1 1 2

9 years 11 13 20 22

1 1 2 1 2

(N)

Source: Maekawa Kyutaro, "Sasuyu kiroku yori," pp. 160—61.

care with which they were kept. Although the sample is too small to be more than impressionistic, it is interesting that the same relative severity of measles epidemics described in the descriptive accounts is found in the Hida death records. The epidemic of 1803 attracted much attention in contemporary literature because of its unusual severity, whereas the epidemic of 1837 was said to be very mild. In Hida, measles mortality was high in 1803, but in 1837 measles seems to have claimed very few lives. The sasuyu records of Edo Castle provide further evidence that measles epidemics occurred as infrequently as the Japanese sources indicate.86 Table 5.4 shows the age distribution of twelve members of the Tokugawa family who contracted measles during the epidemic of 1824. With one exception, all were born during the twenty-one years following the measles epidemic of 1803. One person who got measles in 1824 was born in 1802. The sasuyu records show that susceptible members of the Tokugawa family contracted measles in every year recognized as a measles year and in no other years. After 1824, no sasuyu for recovery from measles were held until 1836—the next epidemic year on recordwhen two of the three persons not infected in 1824 got measles. One of those infected in 1836 was Tokugawa Ieyoshi, who was to become the twelfth Shogun in the following year. Remarkably, a sasuyu ceremony was held to celebrate his recovery from measles when he was 43 years old.87 The sasuyu records, which document cases of measles in the castle 86 Maekawa,

"Sasuyu kiroku yori," pp. 160—61. born in 1793, was Shogun from 1837 to 1853. As the heir, he may have had more rigorous protection from disease than other members of the family. Ieyoshi was also the oldest, at age 26, to contract smallpox. 87 Ieyoshi,

CHAPTER V

132

Age Group 5.1

Proportion of Measles Cases by Age Group (Japanese Age), Izumi Province, 1862

for the first half of the nineteenth century, show that the members of the Tokugawa family contracted measles at the same time as the general population of Edo. This demonstrates the highly infectious nature of the disease, and how difficult it was to protect anyone from measles during an epidemic. The most impressive research on the ages of those susceptible to measles during the Tokugawa period is that of Matsuda Takeshi.88 Matsuda has analyzed 1,864 case records from Izumi province that give the ages of those who contracted measles in the epidemic of 1862, and he has calculated by age groups the percentage of the population that was infected.89 Matsuda found that 63 percent of the population—-an extraordinarily high percentage—contracted measles in 1862. Figure 5.1 shows the proportion of the population, by age group, that contracted measles in 1862. Of the population under 26 sai, 93.48 percent were stricken with measles; only 8.43 percent of the popula­ tion over 30 sai were infected. Figure 5.2 shows the proportion that contracted measles in the 21—30 age group alone. A clear drop in the percentage of those affected can be seen between 27 and 28 sai. Matsuda's analysis of the Izumi records provides the strongest pos88Matsuda,

"Edo jidai no mashin ryuk5," pp. 29-32. Izumi is the former name for a region that today has been incorporated into the southern part of Osaka city, a region that would have been in the main path of measles epidemics during the Tokugawa period. 89

MEASLES: EPIDEMIOLOGICAL PUZZLE

133

100 90

80 70

60 50 40 30 20 IO 0 21

22

23

24

25

26

27

28

29

30

Age Group 5.2

P r o p o r t i o n o f M e a s l e s C a s e s , 2 1 t o 3 0 sai, Izumi Province, 1862

sible evidence that twenty-six years had elapsed since the previous measles epidemic. TheJapanese who had attained 27 sai in 1862 would have been born in 1836, the year of the last recorded epidemic. Many of them would have had temporary immunity to measles at that time because their mothers would have been infected with measles in the epidemic of 1824. In other words, some of the people who were 27 sai in 1862 would still have been susceptible to measles, even though they were exposed to the virus in 1836. The exceptionally high percentage of the population born after 1836 that got measles in 1862 demon­ strates beyond a reasonable doubt that there were no measles epidemics in Japan between 1836 and 1862. Such convincing evidence has not been found for earlier epidemics, but all of the evidence on measles in early modern Japan supports the "import" hypothesis. The cumulative weight of the evidence pre­ sented here permits several general observations to be made about measles epidemics in Tokugawa Japan. First, a measles epidemic was a rare event. Second, measles had a distinctive pattern of dissemination. Epidemics did not start in the largest cities and radiate outward to other parts of the country, but invariably moved from Nagasaki—the only port open to foreign trade—to the major cities of Osaka, Kyoto, and Edo. Third, a measles epidemic was a national phenomenon. Measles would traverse the

CHAPTER V

134

country within a short period of time—usually within the span of a single calendar year. Fourth, measles epidemics were severe, and since measles epidemics occurred so infrequently, morbidity was high. Measles was not like smallpox. It was not primarily a disease of children, even if young children were those most likely to die of it. Although Japan's population was large, measles did not circulate every two or three years as it did in England. But if we accept the clear message of the Tokugawa writings—that a measles epidemic was ex­ perienced only once or twice in a lifetime—what does this tell us about mortality? Mortality

There is no doubt that measles caused high morbidity during the Tokugawa period. That is what the accounts are telling us—every­ body got sick. But although the evidence is mixed, measles does not appear to have had a major impact on mortality in early modern Japan. The writings of contemporary observers leave some question as to how seriously the disease of measles was regarded. There is no doubt that a measles epidemic was a thing to be feared. Measles was a wretched illness that infected everyone who had not already had it, and accounts stress its universal attack rate: "the epidemic affected male, female, young and old, rich and poor on a nationwide scale."90 No one could escape it, not even the wealthy, who usually fared better than the poor in epidemics. Popular art of the Tokugawa period reinforces this cataclysmic view of measles. In nineteenth-century woodblock prints, the disease was portrayed as a dire threat to the entire community. A typical scene depicted people of all walks of life grappling with the measles demon or demons. Other scenes showed a valiant samurai taking on one or more of these demons. The measles demons were covered with spots, and they were usually large, wild-looking men or frail older women. Some prints show both adults and children with measles spots; others suggest that magical cures and preventive measures were sought. Some prints even provided a chronology of measles epi­ demics with the intervals between them. Artistic interpretations of measles and smallpox are quite different. A typical smallpox print, for example, shows a child sick with smallpox, sitting in bed with his toys and a doctor in attendance. But was measles regarded as a serious threat to life? Contemporary 90 Ushiyama

Katsuto, quoted by Aoki Daisuke, p. 383.

3. Subduing the Measles Demon. (Courtesy of the National Library of Medicine, Washington, D.C.)

4. Samurai and Measles Demons. (Courtesy of the National Library of Medicine, Washington, D.C.)

5. Magical Treatment of Child with Measles. (Courtesy of Clements C. Fry Collection, Yale Medical Library)

138

CHAPTER V

opinion varied on this question At one extreme was a saying that was popular during the epidemic of 1862 "Hoso determines one's looks, but hashika determines one's life."91 And an account from 1803 stated that "this time only one out of ten patients died"—a high mortality rate for measles.92 Taken at face value, one might conclude that a person was more likely to die of measles than of smallpox. But there are also indications that although measles was considered a very serious illness, it was normally not a fatal one One account of the epidemic of 1708 claimed that of 530 people stricken with measles, only one died. Similarly, in 1803, "not a single person died out of 158 infected."93 Accounts of the measles epidemics of 1824 and 1836 say that the disease was mild and "many got well without medication."94 Yamazaki believed that measles was not so important as other infec­ tious diseases, because it was rarely epidemic and few people died of it.95 He wrote that measles "was quite different from other more serious diseases, because the average fatality was only three to five persons per hundred cases."96 When the Meiji government estab­ lished the first laws to control infectious diseases in 1881, measles was not included, which may indicate that it was not considered a major threat to life. Environment, nutrition, and quality of nursing care are important factors that influence measles mortality, a fact that may be reflected in the differential mortality rate m Edo Castle and in the less-pnvileged population studied by Matsuda Takeshi. According to the records of Edo Castle, the Tokugawa children, who would obviously have re­ ceived good care, suffered no deaths from measles. The sasuyu records indicate that the sixteen people who got measles all recovered. The sasuyu records do not show deaths, but independent death records indicate that none of the persons born in the Ooku between 1789 and 1827 died at a time when measles was epidemic. By contrast, in the Izumi population there were 100 deaths in 1,174 cases of measles—a high case-fatality rate of 8.5 percent 97 Aoki's study of kakochd from 150 temples in Sendai suggests that measles mortality during the epidemic of 1862 was high. The total number of deaths was more than twice as high m 1862 as in 1861 and Daisuke, "Mashin," ρ 389 Yamazaki, Nihon ektsht oyobt, ρ 405 93 Ibid, ρ 389 94 Ibid 95 Ibid, ρ 394 96 Ibid,p 403 97 Matsuda Takeshi, "Edojidai hashika wa inochiton datta," Yomturt shtnbun (July 8, 1981) 91 Aoki

92

MEASLES

EPIDEMIOLOGICAL PUZZLE

1771 ' 1781 ' 1791 ' 1801 ' 1811

' 1821 ' 1831 ' 1841

139

1851

Gregorian Year 53

DistnbutionofMeaslesDeathsbyYear j HidaVillages 1771-1852

1863, and half of the deaths for the entire year occurred in the threemonth period of the measles epidemic. However, the increase in the number of deaths cannot be attributed to measles alone, because cholera, which has a very high mortality rate, was epidemic during the same period. The epidemiologies of these two diseases are quite dif­ ferent, and this diiference is reflected in the Sendai temple records: measles was widely distributed throughout the domain, whereas chol­ era was epidemic only in certain regions of Sendai.98 Without popu­ lation data and a careful examination of local mortality, it is not possible to estimate the impact of measles on mortality in Sendai. The kakocho of Ogen-ji suggest that measles had little impact on mortality in the Hida villages. In fact, during the eighty-two-year period during which causes of death were entered in the temple records, only thirty-four deaths were attributed to measles. Measles deaths accounted for only .004 percent of all deaths. The yearly distribution of measles deaths can be seen m Figure 5.3, and the duration and the number of deaths in each epidemic are shown in Table 5.5. Deaths from measles were recorded very infrequently. But what is most significant is that no deaths were attributed to measles in the temple death records except in the years of national epidemics described in the major chronologies. Measles epidemics in the Hida villages were of very short duration, a characteristic that is typical of the disease. In the epidemics of 1776 and 1803, measles deaths were distributed over a three-month period; m 1837, the three deaths were recorded in the same month." This pattern contrasts sharply with the duration of smallpox epidemics in the same villages, which typically lasted for two or more years. The three epidemics show no seasonal measles pattern. This is to be expected " Mashin ," pp 394-95 in Gregorian months

98 AokiDaisuke, 99 Calculated

CHAPTER V

140

Table 5.5 Measles Mortality in the Hida Villages: 1771-1852

Epidemic year

Deaths (N)

1776 1803 1837 Total

9 22 3 34

Duration (Gregorian months) 3 3 1

Original Data Source: Suda, Hida "O" jiin.

if measles was an imported disease. The first measles deaths in 1776 were recorded in the summer, in 1803 in the spring, and in 1837 in the winter. In each case, the recording of measles deaths at Ogen-ji followed a measles epidemic in Edo (see Table 5.2). Of the four national epidemics that occurred between 1771 and 1852, only the measles epidemic of 1824 does not show up in the Ogen-ji records or in the local histories of the Hida region. This does not seem to be a case in which the recorder neglected to enter measles as a cause of death, because the kakocho show no evidence of an important epidemic in 1824. Overall mortality did not rise in 1824, and mortality of children under age 5—the group most likely to die of measles—was lower than in either 1823 or 1825.100 Either measles did not reach Hida or this particular epidemic, considered elsewhere to be mild, had Httle effect on mortality in the region. Although the sample is small, the records of Ogen-ji do permit analysis of measles deaths by age. Table 5.6 shows the age distribution of deaths attributed to measles between 1771 and 1852. Deaths were concentrated in the youngest age group even though a large part of the adult population must have been infected with measles in the epidemics of 1776,1803, and 1837. Fifty percent of measles deaths occurred in the first two years of life and 84 percent occurred before age 6. There is little conclusive evidence about measles mortality to be gathered from these scattered references or from the death records of Sendai and Hida. The case-fatality rate from measles varies consider­ ably in different circumstances, which perhaps accounts for the diver100 Suda,

Hida "O" jiin, pp. 128—32.

MEASLES: EPIDEMIOLOGICAL PUZZLE

141

Table 5.6

Distribution of Measles Deaths by Age, Hida Villages: 1771-1852

Age (adjusted) Birth—1 year 1 year 2 3 4 5 17 20 39 42 48 Total

Deaths

Relative frequency

Cumulative frequency

(N)

(%)

(%)

6 10 2 2 6 1 1 1 1 1 1 32a

18.8 31.3 6.3 6.3 18.8 3.1 3.1 3.1 3.1 3.1 3.1 100.0

18.8 50.0 56.3 62.5 81.3 84.4 87.5 90.6 93.8 96.9 100.0

Original Data Source: Suda, Hida "O" jiin. * Age is unknown in 2 cases.

sity of contemporary opinion concerning the virulence of this disease. However, this analysis of the Tokugawa sources leaves little doubt that even though measles caused epidemics that were more visible and more disruptive than smallpox, it was not nearly so important a cause of death. MEASLES MORTALITY IN OTHER SOCIETIES

Studies of measles in other societies can also shed some light on measles mortality in early modern Japan. It has been emphasized that age is a major factor in measles mortality. Today, in West Africa, where measles mortality is still high, there is a saying, "Count your children after measles."101 There are typically two measles cycles a year there, and a high proportion of children are infected during the first two years of life. This is a relatively young age compared with Europe or the United States, and the greater frequency of measles epidemics in West 101

Dekkers, The Cornea in Measles, p. 9.

142

CHAPTER V

Afnca is associated with a higher birth rate. The case-fatality rate in the young West African group is 6 to 7 percent, a high rate that is linked to the lower age of infection. Mortahty is highest between the ages of 7 months and 2 years because temporary maternal immunity remains effective before that age. As late as the early twentieth century, measles was regarded as a serious disease in western Europe.102 In large cities at the turn of the century more individuals died of measles and its aftereffects than from scarlatina, diphtheria, and whooping-cough combined.103 High mor­ tality was associated with frequent measles epidemics that affected primarily children, and early in this century 91.12 percent of measles deaths occurred among children under 6 years of age 104 The question of whether measles mortality was also highest among very young children when epidemics were infrequent, and when adults as well as children were stricken, is not well documented It is this question that is pertinent to a study of measles mortality in Tokugawa Japan. The best data on age-specific mortality in such an epi­ demic was collected during the famous measles epidemic of 1846 in the Faeroe Islands. The natural isolation of these islands, plus restric­ tions on trade, had prevented the transfer of measles from the Euro­ pean continent for sixty-five years. The population of the Faeroe Islands was small and scattered over several small islands. In 1846, of 7,782 inhabitants, 6,000 were stricken with measles withm about six months.105 Although this was a disastrous epidemic in terms of mor­ bidity, the estimated case-fatality rate was only 2.8 percent, with twenty-three deaths per thousand inhabitants.106 Peter Ludwig Panum, a Danish physician who collected detailed records during the epidemic, was the first to document the differential effect of measles on mortality according to age.107 His account reads as follows: measles, perhaps associated with the epidemic of influenza which prevailed with it in the spring, was destructive to the young chddren under one year of age, but, on the other hand, did not remarkably increase the mortality between the first and twentieth years of life, because the disease was less dangerous in this period; and ... mortality rose from the thirtieth year, until it became 102 Ibid 103 M Pfaundler and A Schlossmann, The Diseases of Children, 5 vols (Philadel­ phia J B Lippincott Co , 1910), 3 205 104 Ibid, ρ 206 105 Panum, Observations, ρ 49 106 James A Doull, in his introduction to Panum, Observations, ρ xv 107 Doull, using Panum's figures, estimated a case-fatality rate of 28 6 percent for children under age 1 Panum, Observations, ρ 82

MEASLES: EPIDEMIOLOGICAL PUZZLE

143

Table 5.7 Measles Mortality in the Faeroe Islands, 1846

Age

Population

Cases (N)

Under 1 year 1-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80 and over Total

198 1,440 1,525 1,470 842 791 728 480 272 118 7,864

154 1,117 1,183 1,140 653 613 565 372 211 92 6,100

Deaths (N) 44 3 2 4 10 19 27 27 19 15 170

Case Fatality (%)

28.6 0.3 0.2 0.3 1.5 3.1 4.8 7.3 9.0 16.3 2.8

Source: Reproduced by permission of the publisher from Peter Ludwig Panum, Observations Made During the Epidemic of Measles on the Faroe Islands in the year 1846, trans. Ada S. Thatcher (New York: Delta Omega Society, 1940), p. 82. Note. These statistics are estimates by James A. Doull based on Panum's figures.

greatest for the ages between the fiftieth and sixtieth years, that is, five times as great as usual; it then descended again after the sixtieth year, not because the disease was less dangerous for those still older, which was by no means the case, but because it was precisely sixty-five years ago that measles had last prevailed on the Faroes, and those who had recovered from the disease at that time were now spared.108 Unfortunately, in Panum's records, the 1,117 children between ages 1 and 9 that contracted measles are grouped together, and it is not possible to determine the precise age at which the case-fatality rate began to fall. However, as Table 5.7 indicates, mortality in the Faeroe Islands epidemic of 1846 was very low among infected adults. There are many differences between the Faeroe and Japanese islands. For this discussion the most important difference is the oppo­ site population characteristics of the two societies. But records of the Faeroe Islands epidemic of 1846 provide concrete evidence that even 108Panum,

Observations, p. 52.

144

CHAPTER V

when everyone up to age 60 was infected with measles, mortality was still concentrated in the youngest age group. This confirms that mortality from measles over the long term should have been lower in societies that experienced the disease less often, because most of those who contracted the disease would have been above the age of greatest risk of dying from it. In spite of severe epidemics, measles mortality in early modern Japan may have been considerably lower than in either early modern Europe or present-day West Africa. Japan had a double advantage: fewer epidemics, and possibly a lower mortality rate. It is not likely that mortality from measles was as high during the Tokugawa period as it was in the Fiji Island epidemic of 1875. The longest interval between epidemics in Japan was forty-one years; therefore, unlike more isolated islands or the sixteenth-century New World, about one-third of the population in Japan would have been immune during most of the Tokugawa epidemics. There would always have been healthy people to care for those who were sick. In the case of measles, Japan's isolation in Tokugawa times did make a difference. It reduced her exposure to one of the major epidemic diseases of the early mod­ ern period.

CHAPTER VI

DYSENTERY AND CHOLERA: EARLY AND LATE ARRIVALS Early in the nineteenth century a severe enteric infection that had previously been confined to India broke upon the world scene.1 The disease was known as "Asiatic" cholera, and it spread in great epi­ demic waves throughout all the major regions of the world. Before this time, "cholera" was simply a common name for gastroenteritis: it was used in the West to mean dysentery and other diarrheal diseases. Cholera infantum, for example, was a diarrheal disease in the United States that caused high mortality among young children at the end of the nineteenth century. Enteric diseases were an important cause of premature death every­ where in the preindustrial world. The diseases that make up this group are caused by different pathogenic agents. Some of the betterknown enteric diseases that occur as epidemics are typhoid fever, amoebic dysentery, and bacillary dysentery. There is little point in describing the microorganisms that cause these diseases, because it is seldom possible to distinguish between them in Japanese or other historical records. Epidemics of these different diseases seemed much the same to those who were affected and to observers who wrote about them. Although the term "dysentery" is used today for very specific diseases, it will be used here as a generic term to refer to an unidentified group of diseases that share a common symptom: acute and debilitating diarrhea. "Asiatic" cholera was different from the dysentery epidemics with which everyone was familiar. The clinical manifestations of these two types of enteric infections are quite distinct. Dysentery refers to a complex of symptoms that includes bloody diarrhea, mucus in stool, and fever. "Asiatic" cholera, on the other hand, is a disease character­ ized by watery diarrhea with no blood in stool, and generally no fever. It was obvious to contemporary observers everywhere that this "new" cholera was quite unlike the common choleras that had been around for centuries. Further use of the term "cholera" here will refer 1The author is grateful to Lee W. Riley, M.D., an authority on enteric diseases; Paul Blake, M.D., an expert on cholera; and Philip S. Brachman, M.D., of the Centers for Disease Control. They read early drafts of this chapter and offered critical suggestions that greatly sharpened the interpretation of the Japanese historical sources.

CHAPTER VI

146

specifically to the enteric disease known as "Asiatic" or "epidemic" cholera The history of cholera is well documented in the sources of many different countries And because of the seriousness of this new epi­ demic disease, cholera was distinguished in nineteenth-century litera­ ture from dysentery and other intestinal infections caused by less pathogenic organisms "Asiatic" cholera was a highly virulent and unpredictable disease that created increasing panic as successive epi­ demics moved through the civilized world Its newness and its dis­ tinctive symptoms meant that cholera's journeys were well monitored and well reported everywhere, consequently, it is possible to compare the timing of cholera epidemics in Japan and other countries This chapter will argue that Tokugawa isolationist policies that reduced contact with outsiders during the early cholera pandemics served to deter cholera's arrival m Japan It is important to view the history of cholera in Japan against the background of other enteric infections that caused epidemics in premodern Japan Since all kinds of enteric infections, including cholera, flourish under similar conditions, it is worthwhile to consider some of the factors that promote their propagation and transmission and that precipitate epidemics DISEASE CHARACTERISTICS

Enteric infections are caused by microorganisms—both bacteria and viruses—that enter the human host through the month and multiply in the human bowel 2 Diarrheal diseases are most often spread by means of common vehicles, such as food or water, that have become contaminated by infected human wastes Hence environmental fac­ tors and living standards play a major role in both the propagation and transmission of enteric diseases The prevention of these diseases is associated primarily with a clean supply of water, hygienic methods of handling and preparing foods, sanitary procedures for sewage dis­ posal, and high standards of personal hygiene Pathogenic agents that cause diarrheal infections are capable of surviving in water for long periods, consequently, maintaining a pure supply of drinking water is the most important means of preventing these diseases Problems are most likely to arise when a community's water supply becomes contaminated with sewage And in places where it is customary to use human wastes as fertilizer, pathogens can 2 Background information on the characteristics of enteric diseases is taken from G Sangster, "Diarrheal Diseases," in A World Geography of Human Diseases, ed G Melvyn Howe (London Academic Press, 1977), pp 145-74, and Christie, Infec­ tious Diseases, Chapters 3 and 4

DYSENTERY AND CHOLERA

147

establish an endemic focus of infection In preindustrial societies, out­ breaks of dysentery were often local phenomena, because water supply and waste disposal systems were usually locally organized It was not unusual for one village to be severely stricken while another nearby remained unaffected On the other hand, enteric diseases could spread from one village to the next when infected people, food, and water moved from place to place Temperature also has a marked effect on the propagation of micro­ organisms that cause diarrheal diseases 3 These organisms multiply more rapidly in hot weather, in temperate climates where there is a wide seasonal variation in temperature, peak mortality from enteric diseases occurs during the warmest months 4 Like other acute infectious diseases, enteric infections thrive in large, high-density populations or where there is overcrowding But, unlike smallpox and measles, these diseases do not confer life immu­ nity The absence of long-term immunity means that intestinal infec­ tions affect all age groups within a community Death rates, however, are usually highest among the very young and the elderly 5 In the past, large cities were especially vulnerable to diarrheal epidemics, because it was difficult to dispose of large amounts of human waste Enteric diseases also reached epidemic proportions in times of war and following natural disasters, when sanitary standards fell Until the twentieth century, enteric infections were a common cause of high infant mortality throughout the world, and m some countries such infections are accepted as a natural part of everyday life Today m India, an estimated one and one-half million infants and young children die each year from diarrheal diseases, excluding cholera 6 DYSENTERY EPIDEMICS IN PREMODERN JAPAN

Japanese contemporary descriptions of dysentery epidemics are much less dramatic than accounts of smallpox and measles but they were recorded very early Fujikawa did not try to include all historical accounts of diarrheal epidemics in his chronology, but he did find accounts of dysentery epidemics for the years shown in Table 6 1 He included only those accounts that clearly used the terms sekin, nbyo, or ekirt 7 Sektri (¾¾¾) means "red, or bloody, diarrhea " It is a term that is very similar to the "bloudie flux" found in English sources Infectious Diseases, ρ 533 Sakamoto-Momoyama, Seasonality in Human Mortality, ρ 15 5 Sangster, "Diarrheal Diseases," ρ 151 6 Ibid, ρ 145 7 Fujikawa NSS, pp 298—99

3 Christie, 4

148

CHAPTER VI

Table 6.1

Years and Seasons of Dysentery Epidemics: Japan to 1868 Japanese year

Japanese month or season

Japanese year

Japanese month or season

861 915 947 1016 1025 1027 1077 1144 1240 1243

8 9 8 6 8 11 8 10 (unknown) 5

1256 1260 1708 1746 1799 1817 1819 1829 1841

(unknown) 8 8 Autumn Autumn Autumn 6-8 6 Summer-Autumn

Source: Fujikawa Yu1 N.SS.

Ribyd (#0 #|) means simply "diarrhea sickness," and ekiri (USO) trans­ lates as "epidemic diarrhea." All of these terms were commonly used in historical accounts. The earliest Japanese reference to dysentery is an account that men­ tions an epidemic in Kyoto in the eighth month of A.D. 861: "In the capital many people are suffering from dysentery. Among patients under ten sai, the death rate has been very high."8 This account, which mentions month, place, and the age group affected, is more detailed than most. The early accounts of dysentery epidemics in Japan were primarily concerned with the city in which the ruler resided. The accounts of 861, 915, and 947 describe conditions in the Heian capital at Kyoto. Accounts written in 1240, 1243, and 1260 mention that the shogun's household in Kamakura suffered from dysentery. Table 6.1 shows, as expected, that epidemics occurred during the warmest months of the year, which in Japan are during the late summer and autumn. Descriptive accounts of the Tokugawa period differ very little from earlier ones. An account written in 1708 mentions that dysentery was spread to several localities by the sickness god; another tells of an epidemic in 1746 that occurred in the autumn, spread to surrounding 8

Sandaijitsuroku, quoted by Fujikawa, NSS, p. 299.

DYSENTERY AND CHOLERA

149

areas, and affected young children and old people most severely. A diarrheal epidemic struck the Hiroshima area in 1817, and another was reported in Edo in 1819. The latter was said to have claimed many lives, and it prevailed from the end of the fifth month to the eighth month. A typical account, written in 1841, states that "this summer was very hot and in the fall dysentery was prevalent." 9 The most detailed of the accounts compiled by Fujikawa was writ­ ten in 1829: "In the sixth month, there was a typhoon and afterward people suffered from sekiri. Their bodies turned red and within two or three days many became deranged and died. It is said that men died as they ran through the city naked. Afterward, dysentery spread and many people died."10 The symptoms described suggest those of typhoid or paratyphoid fever, and the sequence of a typhoon fol­ lowed by a dysentery epidemic suggests that the water became con­ taminated after the storm. The following clinical description of the course of typhoid fever shows a remarkable resemblance to the symptoms described in the Japanese account.11 The onset of the disease is marked by a gradually rising, fluctuating fever. Diarrhea is not common during the first or second week of the disease, but often appears during the third week. The rose-colored spots of typhoid appear toward the end of the first week and can be seen for four to five days; a profuse rash that re­ sembles measles is typical of paratyphoid B. "Sometimes mental symptoms dominate the picture, and one is presented with a confused, stuporous, psychotic or even comatose patient." 12 Contemporary accounts of dysentery epidemics establish the Japa­ nese terminology that was used to describe diarrheal diseases, but they give little indication of the frequency or importance of such epidemics in premodern Japan. The symptoms of diarrhea can be found in numerous accounts of epidemics that were simply labeled ekibyd (epidemic sickness), and a careful search of selected local histories would undoubtedly produce many more records. According to Fuji­ kawa, "The symptoms of sekiri existed previously, and from ancient times there have been large epidemics. But even in times when there were no large epidemics, dysentery broke out sporadically and has existed until now, unceasingly."13 This brief review of contemporary accounts tells us only that dys­ entery epidemics were common in premodern Japan. Even so, this 9

Ijizatsuwa, quoted by Fujikawa, NSS, p. 63.

10Ibid.,

p. 302. Christie, Infectious Diseases, pp. 94-102. 12Ibid., p. 97. 13Fujikawa, NSS, p. 303. 11

150

CHAPTER VI

kind of epidemic left only a slight imprint on the historical record. The epidemics may have been ignored because they were regarded as a part of everyday life, or they may not have been especially frequent or severe. Possibly, the fact that dysentery epidemics were usually local phenomena made them seem less threatening than epidemics like measles, which spread rapidly through the country. If the Japanese descriptive accounts tell us little about the frequency of dysentery epidemics, they tell us even less about the severity of such epidemics or their impact on mortality. Yamazaki Tasuku believed that diarrheal epidemics were not so devastating as smallpox and measles epidemics.14 He wrote that few measures were developed in Japan's early history to prevent or contain enteric diseases. The au­ thorities apparently felt no need to issue proclamations ordering re­ ligious or political responses such as prayers, pardons of offenders, or changes in the era names. Such procedures were routine when severe epidemics of other kinds of diseases were prevalent. Until the middle of the Tokugawa period, many medical author­ ities relied upon the old Chinese medicine, which stressed that dysen­ tery was produced by internal causes and that preventive measures were useless. However, by the eighteenth century, some Japanese medical writers were writing that one should avoid unsuitable food to prevent dysentery. This suggests that the infectious nature of enteric diseases was recognized, even though no legal measures were invoked to contain them. And one advanced thinker demonstrated remarkable perception concerning the mode of transmission in enteric infections when he claimed that dysentery was caused by an infectious poison that was contained in the intestines and that stayed in human wastes.15 In 1875, for the first time, dysentery was officially recognized as a serious infectious disease when the medical laws of the early Meiji gov­ ernment required that cases of dysentery be reported to the authorities.16 These laws, which were aimed at preventing the spread of enteric diseases in Japan, were issued during an epidemic outbreak in Okayama in 1877. The residents were ordered to pour sterilized liquid over a patient's waste material and to dispose of it in an isolated place far from houses and wells. Contaminated clothing was to be sterilized or burned. Similar public health measures were not adopted in the United States until much later, and it is possible that this new interest in controlling diarrheal infections in the early Meiji period indicates an increase in the incidence of these diseases following the opening of Japanese ports. 14 Yamazaki,

Nihon ekishi oyobi, p. 511. Ryozan, quoted by Yamazaki, Nihon ekishi oyobi, p. 512. 16 Ibid., p. 518. 15 Gotd

DYSENTERY AND CHOLERA

151

60 £ 50 ο 40 ο 30 k. 0)

"I 20 Z 10 1781

r\ H P 1791

1801

TiriI—Γ1811 1821 1831

C

1771

"Γ

in hn

Γ

0

1841

JL 1851

Gregorian Year 6.1

Distribution o f Dysentery Deaths b y Year, Hida Villages: 1771-1852

Yamazaki's analysis of the Tokugawa and early Meiji literature suggests that severe large-scale dysentery epidemics were uncommon during the Edo period, but it would be wrong to conclude that enteric diseases had little effect on mortality. Because they were local rather than national in scope, it is necessary once again to consult local histories and death records to assess the importance of enteric infec­ tions in early modern Japan. Aoki Daisuke did not include enteric diseases in his study of the epidemic diseases of the Sendai region; however, the priests of Ogen-ji did list diarrhea as a cause of death in the kakocho. These records were used to examine the pattern of en­ teric infections and their effect on mortality in the Hida region. The kakocho of Ogen-ji attributed many deaths to dysentery be­ tween 1771 and 1852. The term that was used consistently in the death records is ribyo or "diarrhea sickness." The 267 deaths attributed to ribyo in the death records represent 3.3 percent of all deaths recorded during this period. The yearly distribution of deaths from dysentery is shown in Figure 6.1. Unlike deaths from smallpox and measles, deaths from dysentery do not show an epidemic pattern of prevalence. Diarrheal diseases did not occur in cycles or clusters; instead, they claimed a few lives in many years. Only occasionally was there a year of high mortality caused by dysentery. This pattern is appropriate for diseases that are not influenced by changes in herd immunity. It may also indicate that diarrheal infections were fairly common, but had a low mortality rate, as is often typical of this kind of disease. Between 1813 and 1823 there was an unusual period of ten years when no deaths from ribyo were recorded in the temple records. It is not likely that this represents a hiatus in enteric infections, because all causes of death were recorded less meticulously during this period.

CHAPTER VI

152

£ 10-

6.2

Distribution of Dysentery Deaths by Month, Hida Villages: 1771—1852

With the exception of smallpox, few causes of death were recorded during those years.17 It is doubtful that there was any significant environmental improvement that would account for a decline in mortality from diarrheal diseases. And the same pattern of mortality that existed before 1814 can be seen again after 1826, when deaths were once again regularly attributed to "diarrheal sickness." When all deaths attributed to ribyo are distributed by month (Figure 6.2), the expected seasonality of enteric diseases—increased incidence in the summer months—is evident. Deaths from dysentery increased sharply in August, the warmest month in Hida, and most of these deaths occurred in the late summer and autumn months. Mor­ tality fell abruptly at the end of the year when the weather turned cold, and very few deaths were attributed to dysentery during the winter and spring months. Mortality from dysentery in Hida fol­ lowed the same seasonal tendencies that were noted in the descriptive Japanese accounts from other parts of Japan, where dysentery was primarily a disease of late summer and autumn. The Ogen-ji records also show the high mortality among young children that is expected from enteric diseases (Table 6.2). Although dysentery killed adults as well as children, 68.3 percent of all deaths attributed to ribyd were concentrated in the under-5 age group. The mean age at death from ribyd was 10.6; the mode, age 2. Herd im­ munity does not account for the skewed age distribution. Young children are more likaly to die of enteric infections because severe diarrhea causes rapid dehydration, and children are less able than adults to tolerate the loss of body fluids. Epidemic years with high mortality from diarrheal diseases were rare in the Hida villages. In fact, only 1826, when fifty-nine deaths 17The

chief priest who began the meticulous recording of causes of death in the

kakocho of Ogen-ji recorded deaths from 1761 to 1813. The priest who replaced him

served from 1813 to 1823, and causes of death were reported much less frequently than they were before or after this period

DYSENTERY AND CHOLERA

153

Table 6.2

Distribution of Dysentery Deaths by Age Group, Hida Villages: 1771-1852

Age (adjusted) 0—4 years 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 Total

Deaths (N) 177 38 3 3 4 2 1 2 2 1 5 3 4 6 5 1 0 1 1 259a

Relative frequency

Cumulative frequency

(%)

(%)

68.3 14.7 1.2 1.2 1.5 0.8 0.4 0.8 0.8 0.4 1.9 1.2 1.5 2.3 1.9 0.4 0.0 0.4 0.4 100.0

68.3 83.0 84.2 85.3 86.9 87.6 88.0 88.8 89.6 90.0 91.9 93.1 94.6 96.9 98.8 99.2 99.2 99.6 100.0

Original Data Source: Suda, Hida "O" jiin. Age at death was not given in 8 cases.

a

were attributed to ribyo, can be considered an epidemic year. The deaths in this one year represent 22 percent of all deaths from dysen­ tery between 1771 and 1852. The epidemic of 1826 began in the fall. For three months, deaths attributed to ribyo completely dominate the temple registers. The first death was recorded on September 18.18 Others followed in rapid succession: ten more deaths by the end of September, twenty-nine in October, and nineteen in November. The 18The Japanese dates of death were converted to Gregorian dates in order to emphasize the season in which the dysentery epidemic of 1826 occurred.

154

CHAPTER VI

last death was recorded on November 28. Within two and one-half months, forty-three children under age 5 died of dysentery; the other sixteen who died represented every age group from the teens through the seventies. The dysentery epidemic of 1826 is the epidemic that seems to have influenced smallpox mortality in 1827. As noted earlier, persons sus­ ceptible to smallpox were primarily children under 3 years of age, and the dysentery epidemic of 1826 claimed thirty-eight lives in this age group. When smallpox returned to the villages in 1827 after an ab­ sence of three years, only two deaths from smallpox were recorded. The most likely explanation of the exceptionally low smallpox mor­ tality in 1827 is that the composition of the local population was unusual: the dysentery epidemic of 1826 killed so many young chil­ dren that few children remained to succumb to smallpox the follow­ ing year. The temple records also indicate that certain villages had higher mortality from enteric infections than others. In the villages around Ogen-ji, these differences seem to reflect differences in population density. They may also reflect variations in the quality of the water supply in different villages. Fifteen of the seventeen villages reported deaths attributed to ribyo to the temple between 1771 and 1852. Four of these villages had significantly higher mortality from diarrheal infections than the others. Ribyo deaths in villages H, E, C, and O represented 7.5, 4.6, 4.2, and 4.9 percent, respectively, of deaths from all causes in those villages (the mean was 3.3 percent). Villages Η, E, and C are situated close together on a stream that flows into the Hida River (see map, p. xv). They lie just upstream from the point of juncture where the town of Kuguno now lies. The proximity of these villages to one another and the higher mortality from dysentery suggest that population density was higher in these villages. Villages that were farther apart had much lower mortality from dysentery. For example, village D, which is located further upstream on the same tributary as villages Η, E, and C, attributed only 2.6 percent of all deaths to dysentery. Village O, which was actually part of the city of Takayama, also reported a higher-than-average percentage of deaths from dysentery. The kakocho suggest a positive correlation between population density and mortality from enteric diseases. The Ogen-ji records indicate that diarrheal diseases were more destructive of human life in some areas than in others, and they confirm that one cannot generalize about the importance of this kind of infection based on evidence from one village or region. The Hida records provide a clear example of what can only be inferred from descriptive Japanese source materials—that dysentery

DYSENTERY AND CHOLERA

155

epidemics were rarely a major cause of high mortality in the late Tokugawa period. Relative to other causes of death, diarrheal diseases were unimportant, and epidemics were rare. Children under age 5 were those most likely to die of dysentery, but even in this age group other causes of death were much more important. However, the Hida villages cannot be considered typical ofJapan as a whole. Analysis of local records from other parts of Japan, parti­ cularly hot, low-lying regions, might present an entirely different picture. Even so, it seems likely that Japan had lower mortality from enteric diseases than other premodern societies. Environmental and social factors peculiar to the Japanese may have lowered the incidence of enteric diseases in preindustrial Japan. Susan Hanley's analysis of water quality and supply systems, customs regarding housing and food, and methods of waste disposal suggests that health standards in the late Tokugawa period were relatively high compared to the in­ dustrializing West.19 The most that can be said here is that neither the descriptive accounts compiled by Fujikawa and Yamazaki nor the death records from the Hida region of Japan suggest that dysentery epidemics were common or that diarrheal diseases were an important cause of death in the Edo period. CHOLERA EPIDEMICS IN TOKUGAWAJAPAN

Against this background, the enteric infection known as "Asiatic" cholera stands out in Japanese sources. The distinctive characteristics of cholera and its epidemiological pattern forced people to take no­ tice. The pathogenic agent in cholera is a vibrio, a kind of curved bacillus known as "the comma bacillus." The vibrio develops when it reaches the intestine, and the onset of grave symptoms may begin from within a few hours to five days after exposure. The primary symptom is watery diarrhea with no blood in the stool, which recurs with increasing frequency, and which results in enormous loss of water from all tissues. This is often accompanied by severe vomiting, painful abdominal cramps, a drop in body temperature, and a charac­ teristic darkening of the skin caused by cyanosis. Unlike dysentery, cholera is seldom accompanied by fever. Cholera can be fatal within two to six days; the usual cause of death is acute dehydration. When cholera is untreated, the symptoms typically last three to five days, and death follows in 50 percent of all severe cases.20 19 Susan B. Hanley, "A High Standard of Living in Nineteenth Century Japan: Fact or Fantasy," Journal of Economic History 43, 1 (1983): 183—92. 20H. Jusatz, "Cholera," in A World Geography of Human Disease, ed. G. Melvyn Howe (London: Academic Press, 1977), p. 131-32.

156

CHAPTER VI

Man is the sole host of the cholera vibrio, which enters the human body by way of the mouth. Usually the source of infection is water contaminated with the excreta of another cholera sufferer, but cholera can also be spread by means of spoiled food. Not everyone who ingests the germs becomes sick Many cases are mild, but healthy individuals who are infected but not ill can carry the germs and spread the infection to others.21 Thus cholera spreads easily, and "the arrival of a single cholera-infected person in a hitherto cholera-free district is sufficient to cause an epidemic in a country." 22 Many different environmental and social conditions influence the transmission of cholera. As with other enteric diseases, water is a prerequisite for any significant diffusion of the infection. The quality of the water plays an important role as alkaline water promotes cholera and acid water inhibits it.23 Temperature has a great influence on cholera, and epidemics usually terminate at the onset of winter. Sometimes cholera will disappear entirely; at other times it will reemerge in the following spring or summer. Cholera has always moved wherever infected people have carried it, but it was the ad­ vent of more rapid land and sea transport in the nineteenth cen­ tury that provided the means of transmitting the cholera bacillus to new populations that were far from the initial focus of infection in India. Considering the conditions under which cholera is transmitted, its chances of reaching Japan from India should have been fairly good. Japan is not far from India, so distance should not have been a prob­ lem. The pathogen can be carried by a person of any age, and a carrier may show no signs of illness to alert port authorities of the need for quarantine or isolation. Moreover, without a single person leaving an infected ship, the dumping of sewage into waters near a port or har­ bor can contaminate fish and other seafood and thus precipitate an epidemic. Despite the ease with which it is transmitted, cholera was unknown in Japan until late in the Tokugawa period. Cholera was first noted in Nagasaki in 1822, the final year of the first cholera pandemic A pandemic is an epidemic that extends over a large geographic region At times, pandemics—the influenza pandemic of 1918, for example— become worldwide. There were six cholera pandemics in the nine­ teenth century, some of which were worldwide epidemics Of the four that occurred during the Tokugawa period, the first pandemic 21 R J Moms, Cholera 1831 The Social Response to An Epidemic (New York Holmes and Meier Publishers, Inc , 1976), ρ 15 22 Jusatz, "Cholera," ρ 131 23 Ibid,p 136

DYSENTERY AND CHOLERA

157

began in 1817 and ended in 1823; the second lasted from 1826 to 1837; the third from 1846 to 1863; and the fourth from 1865 to 1875.24 The first three pandemics occurred before Japanese ports were opened to international trade. The fourth pandemic began after Japanese ports were opened to Western military ships. A review of the routes that cholera followed in these four pandemics will show that Japan's geo­ graphic position and trading policies provided a highly effective bar­ rier against this destructive disease. There is general agreement that the first cholera pandemic began in 1817, when the disease broke out of its endemic focus in the Bengal region of India, traveled down the Ganges river, and spread through­ out India. Cholera had caused many epidemics in India prior to this time. The difference in 1817 was that British troops were stationed in India. They contracted the disease and carried the bacillus by land and sea to other parts of the world. From Calcutta, on the east coast of India, cholera spread by land to the northeast, toward Burma and China. At the same time, it traveled to the southeast by sea to Batavia, Java, the Philippines, and from there to China. From Bombay, on the west coast of India, the disease spread by ship to ports on the Persian Gulf, and then up the Euphrates River to Baghdad and northward into Russia. Cholera reached Astrakhan by land and in ships via the Caspian Sea in September 1823. This first pandemic then died out in the winter of 1823 without crossing into Europe. However, cholera retained its endemic focus in India.25 The preceding description is based on an account written by E. C. Wendt in 1885. It is fairly typical of Western reports on the spread of cholera in the nineteenth century. The whereabouts of cholera in the West were closely watched, but the impact of the disease known as "Asiatic" cholera on Asian countries was barely mentioned. The con­ cern of European observers was for their own countries or colonies, and their accounts reflect this interest. Wendt's account does mention that the disease extended to China, but Western accounts of cholera in Japan are hard to come by for the simple reason that there were few Westerners in Japan to observe and record what happened. The following account by August Hirsch, published in 1883, is unusual in that it mentions Japan and claims that cholera reached the port of Nagasaki in 1822: 24This periodization is given in Hirsch, Handbook, 1: 394; and with slight variation m Andre Siegfried, Routes of Contagion, trans. Jean Henderson and Mercedes Claraso (New York: Harcourt, Brace and World, Inc , 1965), p. 38. The fifth pandemic began m 1881 and the sixth in 1889. 25Edmund Charles Wendt, ed., A Treatise on Asiatic Cholera (New York: Wilham Wood and Co., 1885), p. 8.

158

CHAPTER VI

The Moluccas and Philippines were reached in 1820, and in the same year the cholera appeared for the first time in the Chinese Empire, through which it spread devastation from one end to the other during the two years following, and crossed to Nagasaki (Japan) in 1822.... Within the period from 1817 to 1823 the disease had spread over a territory of nearly one hundred degrees of longitude (from Nagasaki in 147° E. to the coast of Syria in 52° E.), and upwards of sixty-seven degrees of latitude (from Bourbon m 21° S. to Astrakhan in 46° 21' N.), and in its western course it had come close to the frontiers of Europe, but without crossing them. The winter of 1823—24 had brought with it the complete extinction of the plague throughout the whole territory of Cen­ tral Asia that had been affected by it. For a space of four years, the disease was again confined within the country of its origin, to begin, on the expiry of that period, a new career towards the borders of Europe and of Northern Africa, and thereafter, with rapid flight, to make the circuit of the whole globe 26 Japanese sources confirm Hirsch's assertion that cholera reached Japan via the port of Nagasaki m 1822. Many Japanese sources de­ scribe a new and unusually severe epidemic that entered the country in that year.27 These accounts describe a fatal illness that caused vomit­ ing, diarrhea, and severe abdominal pain: "the victim's entire body became cold, and his countenance suddenly transformed; his pulse became faint, and he suffered great anguish. In some cases, death came within two to three days; in others, the patient lived for five to seven days.. ." 28 This is a classic description of cholera. TheJapanese called this disease the "three-day koron," and contemporary accounts said that many people died of it. InJapan the epidemic of 1822 is known as the korera epidemic of Bunsei 2. The exact route by which cholera entered Japan in 1822 is unclear. Some accounts claim that cholera reached the port of Nagasaki from Java; others state that it came by way of China and Korea to Tsushima and Shimonoseki.29 It is possible that the infection came to Japan by both routes, but all accounts agree that cholera was epidemic in Naga­ saki in 1822. Official records and local records from Daion-ji temple both mention a sickness called korera.30 It is significant that in Naga26

Hirsch, Handbook, 1 396-97 Fujikawa, NSS, pp 215—21 28Ibid, ρ 218 29 Yamashita Yoshiaki, "Nihon keneki shi," Nihon tgakushi zasshi 14 (May 1968) 3 30 Kikuchi Kazuo, Nthon no satgai Edo gokt no Jitn kakocho m yoru jtssho (Tokyo Kokon shorn, 1980), ρ 268 There were reports of 600 deaths during a twelve-day period in Hagi, Choshii-han, and 134 deaths in a two-day period in Osaka 27

DYSENTERY AND CHOLERA

159

saki the disease was called by this Japanese version of its Western name and written in katakana, the writing system for foreign-loan words. This suggests that the disease was new in the experience of the Japa­ nese and that they had no Japanese term for it. It appears that cholera was brought to Japan on foreign ships that had stopped at ports in Java and south China, where the disease was raging in the summer of 1822. Cholera is said to have spread within Japan from Nagasaki, across the straits of Shimonoseki, along the San'm-d5 from Kyushu to Choshu, but it could also have reached Choshu directly on unauthorized ships from Korea The early pro­ gress of the disease can be seen by looking at the timing of changes in mortality m different regions of southwestern Japan. There was a sharp rise in the number of deaths in Nagasaki at the beginning of the eighth month;31 in Hagi, a city in Ch5shu, mortality rose in the middle of the eighth month; and in Hiroshima there was a similar increase at the end of the eighth month.32 The infection spread simul­ taneously along the Sanyo-do to Osaka, where it arrived late in the eighth month. Kyoto was also affected, but cases were sporadic, and accounts say that the epidemic was not so severe as it was m Osaka.33 It appears that this first epidemic was confined to western Japan. Contemporary accounts say that the cholera epidemic of 1822 did not spread east of Hakone,34 a region high m the mountains that served as both a natural and political barrier between western and eastern Japan. There is certainly no evidence that this first cholera epidemic reached Edo. Since Edo was the seat of government and had the largest urban population in the country, an outbreak of cholera would have had disastrous consequences that could not have been ignored in the re­ cords of the city Moreover, there is no sign of this epidemic in other parts of central and northern Japan: Aoki Daisuke found no evidence of cholera m Sendai domain in 1822, and the local histories and Ogenji records show no trace of a severe and fatal epidemic in Hida in that year.35 The fact that this first epidemic of cholera arrived late in the year may have been the crucial factor in its rapid demise and its failure to spread the length of the country. Some accounts state that the "threeday korort" was prevalent in the late autumn and early winter. Others state that it began in the latter part of the eighth month and gradually 31Months are according to the Japanese calendar as given in contemporary accounts 32Kikuchi, Nihon no satgai, ρ 273 33 Aoki Daisuke, "Korera," in Saigai hen, vol 22 of Miyagi-ken shi (Sendai Miyagiken shi hensan nnkai, 1962), ρ 414 34 Ibid 35 Suda, Hida "Ο" jnn, pp 124—25

CHAPTER VI

160

disappeared by the end of the tenth month.36 This discrepancy should not be attributed to differences of opinion or to inaccuracies in the accounts. Both accounts are talking about the same interval of time. In 1822 the first day of the eighth month in the Japanese calendar fell on September 12 in the Gregorian calendar. This means that, accord­ ing to the Western calendar, cholera was prevalent in Japan from midOctober to mid-December, that is, from late autumn to early winter. It is colder in eastern Japan during these months than it is in the Nagasaki area, and temperatures would have fallen as the epidemic spread eastward. Had cholera reached Japan in the early summer, the epidemic might have been much more widespread and severe, and it could easily have reached Edo. It appears that the high mountain barrier between east and west together with the onset of winter Hmited the spread of cholera to the western part of Japan, where it died out fairly quickly. Cholera was apparently unable to hold out through the winter and gain a foothold in western Japan, because it did not flare up again the following summer. In Japan, as in other parts of the world, a great impression was made upon those who observed the catastrophic effects of this new epidemic disease. But we know little about the effect of the 1822 cholera epidemic on mortality. The fact that it was not an epidemic of nationwide scale and that cholera did not reach Edo or any region north of Hakone obviously Umited its influence on mortality. The cholera epidemic of 1822 had a great psychological impact, but later epidemics would be worse. It was merely a precursor of what was to come. The second cholera pandemic dates from the year 1826.37 Once again, cholera spread throughout Bengal, advancing along the Ganges River and its tributaries and starting its trek westward. By 1829 it had spread along the caravan routes to Persia and the Caspian Sea, and before the end of 1830 it had gained an extensive foothold in Russia. The infection continued to advance, even during the cold winter of 1830—1831, and by the spring and summer of 1831 it had reached St. Petersburg, several cities in Poland, and Finland. During this same period cholera was also spreading into Arabia, Mesopotamia, Syria, and Palestine, and it reached Egypt via the Suez Canal. Before the end of 1831, cholera had entered Germany from three different directions and spread from there to Great Britain. The dis­ ease had an uneven distribution in Britain: it followed the commercial highways and moved along the rivers and coastal routes; however, 36 Fujikawa, 37 Hirsch,

N S S , p. 216. Handbook, 1:397-403.

DYSENTERY AND CHOLERA

161

the mountainous parts of the country were affected very little and the Scottish highlands not at all. Almost all of northern Europe was affected by the end of 1832, but even before cholera reached south­ western Europe, it had crossed the Atlantic Ocean to Canada. In North America, spreading southward down the St. Lawrence River and along the shores of the Great Lakes, the infection entered the United States through Detroit. It also came into New York City directly on ships coming from European ports. Cholera spread down the Mississippi River and infected all the major regions of the United States. In 1835, it reached the South American continent for the first time, where it apparently remained a mild epidemic. Little is known about the epidemic in Central America except that it reached Nica­ ragua and Guatemala at the end of the pandemic in 1837. The south­ ern part of Europe was the last to be affected: Portugal and Spain witnessed the infection in 1833, Marseilles in 1834, and Sicily in 1837. It moved from there into North Africa, and then in its final year it took a second swing through central Europe and returned again to Germany and western Russia. This lengthy account of the routes followed by the second cholera pandemic has been presented in some detail in order to provide a sense of the international scope of this epidemic disease in the 1820s and 1830s, and to demonstrate how thoroughly the spread of cholera was documented in Western sources. Hirsch concludes his lengthy dis­ course on the western course of the second cholera pandemic with a single sentence concerning its eastern course: "Spreading from India in an easterly direction, cholera had meanwhile in 1830 reached China for the second time, and Japan in 1831."38 But this time the Japanese sources are silent. They make no men­ tion of any epidemic resembling cholera in 1831. And a review of Japanese historical accounts between 1826 and 1837 reveals no sign that cholera entered Japan at any point during the twelve-year period of the second pandemic. There is no shortage of Japanese accounts of other kinds of epidemics during this period. The measles epidemic of 1836, presumably imported, was prominently featured, and there are accounts of influenza epidemics in 1827 and in 1831—1832. There are, however, no accounts of korera or the three-day korori. It is possible that the dysentery epidemic of 1829 described earlier in this chapter was actually cholera—it followed a typhoon, and people were said to have died after two or three days—but this disease was called by the centuries-old name of sekiri, and neither Fujikawa nor later Japanese scholars believed that this sickness was cholera. 3 8 Ibid.,

1:403.

162

CHAPTER VI

One account written in 1830 tells of an epidemic that prevailed from the fourth to the sixth and seventh months, when a great many people became ill.39 The following symptoms were given in the account: high fever, diarrhea, and a craving for water, which was followed by a severe red rash; at times there were nosebleeds, bloody stools, or bleeding gums. A particular medicine was thought to be of considerable benefit, but in many cases the disease could not be cured. The account goes on to say that it often took many days for the fever to break; a light case lasted more than a month, but more severe cases could last for two or three months.40 Although diarrhea is mentioned as a symptom of this illness, the distinguishing symptoms seem to be the prolonged fever and the rash, which are typical of other acute infectious diseases but not cholera. Epidemic typhus is the first disease that comes to mind. The illness did not run a short course of two to five days, but instead lingered for two to three months, after which many patients apparently recovered. Once again, neither Fujikawa nor other Japanese scholars of disease history have believed that this epidemic was cholera. One other account written during the period of the second cholera pandemic should be mentioned. It tells of a grain shortage in 1836 that continued into 1837. "A terrible epidemic circulated from the spring to autumn, when it seemed to come to an end.... Poor people, especially, were sick with diarrhea."41 Might this have been an epidemic of cholera? The account mentions no specific location or region, and it appears to be recording the general conditions of the time rather than describing the course of a cholera epidemic. It seems likely that the account is describing the great Tempo famine of the 1830s, a topic that will be discussed in detail in the next chapter. In short, none of the accounts of epidemics in Japan between 1826 and 1837 seem to be describing cholera; consequently, there is no reason to believe that cholera reached Japan during the second pan­ demic.42 If it did, its impact must have been very slight, because Japanese sources, which include graphic descriptions of cholera during the first pandemic less than a decade before, and which contain 39

Gregorian months were May to August. Fujikawa, N S S y p. 62. 41 Ibid., p. 63. 42Aoki Daisuke suggests that cholera may have reached Japan late in the Tempo period, twenty years after its first intrusion in 1822 (the Tempo era ended in 1843). But cholera is thought to have retreated to India between 1837 and 1846, and Aoki does not cite any evidence to suggest that cholera was in Japan in the early 1840s. Aoki Daisuke, "Korera," p. 414. 40

DYSENTERY AND CHOLERA

163

accounts of influenza and measles epidemics during the years of the second pandemic, make no mention of cholera. The absence of comment in Japanese sources during this period is in striking contrast to the attention cholera was receiving elsewhere in the world. The appearance of cholera in an adjacent country or dis­ trict created a crisis atmosphere because of the frightening symptoms and the high rate of death among those attacked, and because the course of the disease was unpredictable. In fact, cholera attracted more attention during the second pandemic than did other diseases that had a much more serious impact on mortality.43 Therefore, until new evidence from Japanese sources comes to light, Hirsch's statement that cholera spread to Japan in 1830 should be regarded as unsubstantiated. When one considers that cholera was one of the major epidemic diseases of the nineteenth century, that it is easily transmitted, and that it reached many countries of the world between 1826 and 1837, the fact that cholera failed to travel the relatively short distance between India and Japan during those years is remarkable. It underscores Japan's lack of contact with the outside world, just as the speed with which cholera spread the much greater distance to the British Isles reflects England's position at the apex of a world empire and at the center of world trade routes. In the early nineteenth century, the most important international trade routes led from Asia toward Europe and the New World, and the cholera bacillus traveled these same routes. TheJapanese islands lay outside these established routes until the midnineteenth century. But as accounts of the next cholera pandemic will show, Japan's geographic position and trading policies were not to protect her much longer. The hiatus between the second and third cholera pandemic did not last long: the third pandemic is dated from 1846 to 1863.44 Cholera had an unusually wide distribution in India in the early 1840s, and by 1844 its presence was noted once again in the eastern provinces of Persia. By 1847 the epidemic reached Russia; in 1848 cholera arrived in Poland, Germany, England, and Scotland, and an epidemic broke out simultaneously in New York City and New Orleans. Cholera remained epidemic in England in 1849, spreading from there to the Netherlands, Belgium, Austria, France, and Italy. It reached Mexico by two separate routes in the same year. Without further detail, it is obvious that during the third pandemic the rate of dissemination of cholera was extremely rapid. The transmission of this disease had 43 Morris, 44 Hirsch,

Cholera 1831, pp. 12—14. Handbook , 1:404-407.

CHAPTER VI

164

accelerated tremendously since the previous pandemic. But there is no evidence that cholera reached Japan during the 1840s. There was a brief respite from the ravages of cholera between 1850 and 1852. During this period cholera was almost completely gone from regions outside India. But in 1852 the entire sequence began anew as this virulent disease moved once again toward the West. This time, according to Hirsch, an endemic focus of infection was estab­ lished in eastern Europe, and this new source of cholera on European soil fueled an extension of the pandemic that was to afflict the coun­ tries of Europe for the next eight years. Hirsch concludes his lengthy account of the third cholera pandemic with the following statement: The third pandemic of cholera embraces, therefore, a period of some fifteen years, during which the disease had spread over the whole Northern Hemisphere, and to 25° S. in the Old World, and to 30° S. in the New. Regarded as a whole, this pandemic shows numerous fluctuations of intensity, the maxima falling in the years 1849—50 and 1853—55. In none of the intervening years was the disease altogether extinguished on extra-Indian soil, and there is no reason for attributing the fresh outbreak of 1853 in Europe, Africa, and America, to a new importation of the mor­ bid poison from its native habitat. All the facts tell rather in favour of a continuous reproduction of the poison in extraIndian countries, and that power of reproduction was exhausted only after the lapse of more than ten years.45 Hence, the third pandemic represented a new phase in the history of cholera. It became an endemic disease in new regions, and in the 1850s "numerous fluctuations of intensity" were observed throughout much of the civilized world. Only at the very end of this period described by Hirsch is there any evidence that cholera reached Japan. Both Western and Japanese accounts agree that cholera did not reach Japan until the final years of the third pandemic, although there is a slight discrepancy about exactly when it arrived. Hirsch relates the progress of cholera moving eastward from India beginning in 1852: Starting from India . . . i t [ c h o l e r a ] p e n e t r a t e d i n 1 8 5 2 t o J a v a , Banda, and Sumatra, and spread next year over a large part of the East Indies. It appeared there anew in 1858 (especially in Celebes), and at the same time broke out in the Philippines. Japan was visited by severe epidemics of cholera in 1854 and 1857—59; within the same period fall the destructive outbreaks of the dis45 Ibid.,

1:412-13.

DYSENTERY AND CHOLERA

165

ease in China (where it continued prevalent till 1860), and in the peninsula of Corea, the southern and western regions of which received the epidemic from the capital.46 Japanese accounts indicate that epidemic cholera did not reach Japan again until 1858—thirty-six years after the first cholera epi­ demic in Japan, approximately twelve years after the beginning of the third world pandemic, and four years after the first Western ships were granted permission to enter a Japanese port. In 1858 mortality peaks that can be attributed to cholera still moved in a northeasterly direction from Nagasaki.47 The epidemic of 1858 started in Nagasaki in the sixth month. Contemporary accounts claim that cholera was brought to Japan when the U.S. warship Mississippi came into Naga­ saki from China carrying a cholera patient. This time cholera reached Edo within a month. And this time the infection spread the entire length of the Japanese islands, apparently spreading by both land and sea routes.48 This second cholera epidemic in Japan (1858—1859) was much more severe than the first.49 What is known in Japan as the cholera epidemic of Ansei 5 and 6 is usually regarded as the most severe outbreak of cholera in Japanese history.50 It is not clear which areas suffered most or which managed to avoid infection. But this time, unlike 1822, the population of Edo witnessed the full force of the epidemic, and mortality injapan's largest city was said to be unusually high. Japanese accounts written in 1858 say that cholera reached Edo late in the seventh month, that the epidemic peaked in the eighth month, and that it began to decline in the ninth month.51 In terms of the Western calendar, the main impact of the epidemic was during September and October of 1858, when warm temperatures would have encouraged its spread. By mid-winter only a few deaths were being attributed to cholera. In 1859 and 1860 there was a resurgence of cholera, but gradually the disease died out.52 It is difficult to assess the impact of cholera on mortality in Japan. Each epidemic must be studied by region, because like other enteric diseases, cholera can have a dire effect on one locality and no impact at 46 Ibid.,

1:411. Kikuchi, Nihon no saigat, ρ 276. 48 Cholera seems to have reached Edo, Osaka, and Ishinomaki, in Sendai domain, by sea, but whether the disease was carried in Japanese or Western ships is not clear. Kikuchi, Nihoti no saigat, pp 278—80. 49 Yaniazaki, Nihon ekishi oyobt, p. 552. 50 Yamashita, "Nihon keneki shi," p. 4. 51 Yamazaki, Nihon ektsht oyobi, pp. 552—55. 52 Ibid., p. 591. 47

166

CHAPTER VI

all on another.53 The Sendai records show that the second cholera epidemic reached Sendai and the surrounding areas in the ninth month and that mortality peaked in the tenth month of 1858. Aoki Daisuke's sources do not indicate exactly which areas were affected in the domain, but cholera first entered the region by ship. Ishinomaki, the port of Sendai, was affected first, and the disease then spread along the coastal regions, later moving inland along the Kitakami River. Temple records and local histories from many parts of Sendai domain attest to the presence of cholera in both 1858 and 1859. In the Sendai region, the epidemic appears to have been more severe in 1859.54 In Hida, the death registers of Ogen-ji show no evidence of cholera in 1858 or 1859 Mortality was unusually low in both years.55 It is worth noting that on July 29, 1858, just five weeks prior to the epidemic of cholera that most Japanese consider to have been the worst in their history, what were to be known as the "unequal trea­ ties" were signed on an American warship in Edo Bay. These treaties represented the successful conclusion, from the American point of view, of negotiations to open the port cities ofEdo, Osaka, Kanagawa (Yokohama), Nagasaki, Niigata, and Hyogo (Kobe) to foreign ships, foreign trade, and in certain port cities, a foreign resident population. Within the next twelve months the major European powers—Great Britain, Holland, Russia, and France—were to gain similar conces­ sions.56 To the Japanese it meant the loss of control over their port cities, and it signified a national defeat by the Western powers. The connection between the unwelcome foreign ships and the dreadful "foreign disease" could not have been lost on the inhabitants ofEdo, but the signing of the treaties was primarily symbolic, because barriers to the entry of Western ships into other Japanese ports had fallen earher. The unsuccessful attempt of the American expedition under Commodore Perry in 1853 to enter the port of Uruga had been followed by a successful effort in February of 1854 On March 31 of that year, the Treaty of Kanagawa provided for the opening of the ports of Shimoda in Izu and Hakodate in Hokkaido to American ships.57 On October 16, 1857, a Dutch and Russian agreement ended 53Kikuchi Kazuo has written the best accounts of the mid-nineteenth century cholera epidemics using the kakocho of different regions to show the paths of disse­ mination and cholera's impact on mortality Kikuchi, Nihort no saigai, pp 267-91 54Detailed accounts of the cholera epidemic of 1858 and 1859 in old Sendai domain can be found in Aoki Daisuke, "Korera," pp 416-58 55 Suda, Hida "O" jtin, pp 196—99 56George Sansom, A History of Japan, 1615—1867 (Stanford, Calif Stanford Uni­ versity Press, 1963), ρ 238, and W G Beasley, The Meiji Restoration (Stanford, Calif Stanford University Press, 1972), ρ 108 57 Beasley, The Meiji Restoration, ρ 78

6.

Incineration of Corpses During the Cholera Epidemic of 1858. (Courtesy of Les Editions Roger Dacosta)

168

CHAPTER VI

virtually all bakufu control over foreign trade in Nagasaki and Hakodate.58 Thus, the barriers that separated Japanese and outsiders had fallen before 1858. Perhaps Hirsch was right when he claimed that cholera got to Japan in 1854; however, a recognizable cholera infection of epidemic proportions that caused high mortality does not show up in the Japanese records until 1858. TheJapanese had known for centuries that epidemic diseases came into the country on foreign ships, and perhaps this helps to explain their harsh policies toward the ships of other countries. But in 1858 the new, frightening, and fatal disease of cholera was brought directly into major Japanese cities that had not served as foreign ports before. Moreover, cholera came on Western military ships that had entered the country by show of force. It is somewhat ironic that what was called "Asiatic cholera" in Western countries was known to the Japa­ nese as the disease of the "Western barbarians." 59 We can conclude, from the evidence just presented, that the Tokugawa pohcies to control foreign trade and to limit the number of ports of entry were effective in preventing the importation of cholera before the arrival of the Western ships at mid-century. Of the first three cholera pandemics, the first reached Japan only in its final year, the second, apparently not at all, and the third arrived in the last four years of a sixteen-year pandemic, only after the Tokugawa policies failed. Cholera became a national menace only after Japan was forced to open its doors to foreign ships. It comes as no surprise that, given Japan's new trade policies, the fourth cholera pandemic reached Japan even before it was recognized as a pandemic in the West. Hirsch dates the fourth pandemic from 1865 to 1875 and Siegfried from 1863 to 1865.60 Japan suffered a serious outbreak of cholera m 1862, which the Japanese count as the third cholera epidemic in their country—the epidemic of Bunkyu 2.61 It may have come from India to Japan by way of the East Indies as Hirsch suggests,62 but it makes little difference what route it took. Ibid, ρ 104 Detailed accounts of the 1858 epidemic (Ansei 5) can be found in Fujikawa, NSS, pp 223-31 60 Hirsch, Handbook, 1 413, Siegfried, Routes of Contagion, ρ 38 Itisdifficulttosee why any distinction is made between the third and fourth pandemics, Hirsch dates the third pandemic from 1846 to 1863, Siegfried from 1846 to 1862 That leaves an interval of zero to two years between pandemics, depending upon whose penodization one accepts 61 Fujikawa, NSS, pp 64—65 Fujikawa's compiled accounts end in 1867, the last year of the Tokugawa period These accounts mention cholera epidemics in 1858, 1859, 1862,and 1863 62Hirsch, Handbook, 1 413 58

59

DYSENTERY AND CHOLERA

169

Once the Western ships that efficiently carried cholera from port to port throughout the world could enter Japan's harbors at will, cholera epidemics became as common in Japan as in the rest of the world. The work of Kikuchi Kazuo on the history of cholera epidemics in the Tokugawa period supports the analysis presented here. Kikuchi's study of death records from various parts of Japan during periods in which cholera was epidemic pays special attention to the records of Nagasaki and northeastern Japan, because Kikuchi is interested in the paths of transmission, the rate of spread, and the distribution of the disease at different times.63 Kikuchi concludes that the epidemic of 1822 was the first cholera epidemic in Japan, entering the country through the port of Nagasaki and affecting only western Japan. He has found no evidence that the epidemic of 1822 reached eastern Japan—the city of Edo or any regions north of the city. Kikuchi agrees that cholera did not reach Japan again until the summer of 1858, four years after Western ships gained entrance to Japanese harbors. This second epidemic in 1858 entered Japan through Nagasaki and became widespread in 1858 and 1859. Moving northeast from Nagasaki, it spread to eastern Japan, to Edo, and to parts of the interior in 1858. Kikuchi agrees that this was the first cholera epidemic to appear in Edo, and that it was quite severe; however, he does not agree that 1858 was the worst cholera year in Japan. Kikuchi claims that many more districts were involved in the recurrence of the disease in 1859. In his opinion, the epidemic of 1858 has been considered the most severe cholera epidemic in Japan only because it was the first to reach Edo. For this reason, it generated much commentary and many documents, and its place in Japanese history was assured. Some scholars believe that the second nationwide epidemic of chol­ era in 1862 was merely a continuation of the epidemic of 1858—1859. Kikuchi does not agree. He believes that the 1862 epidemic was even worse than the preceding one in 1858—1859 because it affected a much wider area. The epidemic subsided completely in Bunkyu 1 (1861), nor­ malizing everything. Then, in Bunkyu 2, a new one started.... It is clear that the epidemic of this year also entered by way of Nagasaki because mortality peaks in different regions become farther apart as their distance from Nagasaki increased. This epidemic spread over the entire nation producing a great increase in the number of deaths. It was the biggest epidemic of the Edo era.64 63

Kikuchi, Nihon no saigai, pp. 290-91.

64Ibid.

CHAPTER VI

170

Mortality

It is impossible to make realistic estimates of cholera mortality during the Edo period for the country as a whole, or for any city or region, on the basis of the contemporary accounts that have been analyzed here. Fujikawa used a number of different sources to assemble various death statistics for Edo during the period of the 1858 epidemic; how­ ever, he provided no frame of reference to show the extent to which mortality during the period of the epidemic differed from other months or other years.65 His figures appear to be for all deaths, not just cholera deaths. But his account of the epidemic in Edo does provide a set of daily death figures for the eighth month of 1858 that shows that mortality reached a peak between the thirteenth and seven­ teenth day (mid-September in the Gregorian calendar). However, little else can be learned about cholera mortality from the figures he provides.66 The descriptive accounts, especially those written in 1858, suggest a disaster of major proportions. Yamazaki tells of a major government relief effort in Edo to assist young children and others who were left without means of support.67 Since all age groups were vulnerable to infection, many adults as well as children died in this epidemic. But descriptive accounts of cholera epidemics can be misleading when it comes to assessing the disease's impact on mortality. Accord­ ing to R. W. Morris, a scholar who has studied cholera epidemics in Great Britain, the demographic impact of cholera there was signifi­ cant but small. He suggests that the effect of cholera on mortality needs to be put in better perspective. Cholera deaths in England and Wales in 1849, which are estimated at 53,293 (3,034 deaths per 1,000,000), just exceeded those from typhus in that year. Moreover, for a five-year period including 1849, deaths from common diarrhea exceeded deaths from cholera. Even in those villages hardest hit by cholera, death rates were never as high as earlier death rates from bubonic plague.68 Morris argues that the cholera epidemics of the nineteenth century 65Fujikawa, NSS, pp. 227-31. Japanese scholars have tended to interpret Fuji­ kawa's figures in different ways, and the result has been a wide range of estimates for mortality in Edo during the epidemic of 1858. Yamazaki simply repeats the statistics given by Fujikawa without interpretation. Yamazaki, Nihon ekishi oyobi, pp 558-59. Aoki Daisuke suggests 30,000—40,000 deaths. Aoki, "Korera," p. 415. Kikuchi esti­ mates 280,000 deaths in a population of 1,000,000, but does not provide any indication of how he arrived at such a figure. Kikuchi, Nthon no saigai, p. 273. 66Fujikawa, NSS, pp. 229-31. 67Yamazaki, Nihon ekishi oyobi, p. 559—60 68Morns, Cholera 1813, ρ 12.

DYSENTERY AND CHOLERA

171

created a psychological crisis atmosphere not unlike that of a foreign invasion, but cautions that they should not be considered demo­ graphic crises "Many diseases killed more widely and killed more people than cholera, but few had such concentrated attention from so many "69 To emphasize his point, he quotes a correspondent of the Edinburgh Courant writing in 1849, who compares cholera to small­ pox "The smallpox is still raging amongst us, numbering even more victims than the cholera, being as it were indigenous to the country, the dread of it is absorbed in the all pervading thought of cholera " 70 Certainly the atmosphere of crisis caused by cholera in Japan must have been equal to that in the British Isles In Japan, the first epidemic of cholera to strike Edo—its largest and most important city and, more importantly, its seat of government—was in fact accompanied by a foreign invasion For this reason it is risky to speculate about the impact of cholera on mortality in the last years of the Tokugawa shogunate, because mortality estimates may be highly exaggerated Regional studies, like those of Aoki Daisuke in Sendai, show that during the epidemic mortality rose sharply for a period of several weeks in some areas of the domain, but in other areas there is little evidence that cholera had any impact at all Thus, although it is clear that cholera was epidemic in Japan in certain years of the nineteenth century, its impact on mortality and its demographic effect are not easily measured It is also difficult to separate cholera mortality from mortality caused by other epidemic diseases in the late Tokugawa period In 1862—the worst cholera year in Japan's history according to Kikuchi—a severe measles epidemic also raged throughout Japan It is generally believed that this measles epidemic immediately preceded the cholera epidemic,71 but in some regions they must have run concurrently The symptoms of the two diseases can be confused, because measles, like cholera, was often accompanied by acute diar­ rhea Christie, discussing the complications of measles, writes as fol­ lows "Enteritis was a common complication 30 years ago in England, I can remember in the measles wards that half the children might have severe diarrhoea, and some times this enteritis appeared to be the main cause of death " 72 Christie is referring to measles cases in England in the 1940s, when measles would have been almost exclusively a disease of children, but there is no reason to believe that the large adult population that was infected with measles m Japan m 1862 might not 6 9 Ibid

,p 14

7 0 Ibid 7 1 Kikuchi, Nthon no saigai, 72

Christie

ρ 284 ρ 392

Infectious Diseases,

CHAPTER VI

172

have suffered from the same complications. In fact, Aoki Daisuke explicitly mentions this symptom in his description of the measles epidemic of 1862: "A considerable number of people died of diarrhea, a complication that accompanied the disease."73 Thus, a rise in mor­ tality during the summer of 1862 cannot automatically be attributed to cholera because measles was also causing high mortality at that time. But even without any cholera mortality figures, it is obvious that until the very end of the Tokugawa period, Japan was spared the serious epidemics of cholera to which other regions of the world were repeatedly exposed. This reduced exposure to cholera must mean that during this time, Japan had lower mortality from cholera than many other countries in which the disease was epidemic for long periods. Once the cholera bacillus reached Japan, her population was as vulnerable as any other. Some scholars have argued, of course, that Japan avoided cholera because the environmental factors that influence the propa­ gation and transmission of the cholera bacillus—water supply and sewage disposal—were superior in Japan in the nineteenth century. Nonetheless, it is clear that the isolationist policies that reduced Japan's contacts with foreign countries helped to keep out foreign diseases Hke cholera, and that these policies continued to be effective until the arrival of the Western powers in the mid-nineteenth century. 73 Aoki

Daisuke "Korera," p. 391.

CHAPTER VII

EPIDEMICS AND FAMINE The problem of distinguishing subsistence crises from disease crises is as troublesome for those using Japanese sources as for those who use the sources of other premodern societies. The basic problem is two­ fold: 1) people who suffer from severe malnutrition may actually die of infection, or they may exhibit symptoms similar to those caused by certain acute infectious diseases; and 2) the mortality rate from some infectious diseases may be higher among people who are malnourished. However, the fundamental nature of a mortality crisis can often be determined by a careful examination of the descriptive sources. In many cases the underlying cause is quite obvious, and many mortality crises that have been attributed to acute infectious diseases appear, on closer examination, to have been caused by severe malnutrition m times of famine. In European historiography, the relationship between famines and epidemics has been the subject of considerable interest.1 Contempor­ ary European accounts frequently noted the concurrence of dearth and pestilence and assumed a causal relationship between the two. The relationship was generally viewed as one-way, because epidemics often followed periods of severe and prolonged food shortage. In other words, epidemics that occurred during or following a famine have been considered to be a consequence of chronic or acute mal­ nutrition that had lowered resistance to disease. At certain times, however, it was observed that the causal relationship worked in the opposite direction. An epidemic that was sufficiently severe to infect persons of all ages within a short period of time could result in a tem­ porary breakdown of society For example, a sudden depletion of the labor force, whether permanent or temporary, could prevent the planting or harvesting of crops, later causing food shortages and famine. In some cases, accounts are sufficiently detailed for one to dis1Appleby, Famine in Tudor and Stuart England, Pierre Goubert 1 Beauvais et Ie Beauvaisis de 1600 a 1730 (Paris, S E V P E N , 1960), J Meuvret, "Demographic Crisis

in France From the Sixteenth to the Eighteenth Century," trans Margaret Hilton, m Population i n History Essays i n Historical Demography, e d D V Glass a n d D E C Eversley (Chicago, 111 Aldme Publishing Co , 1965) See also A K Sen, Poverty and Famines An Essay on Entitlement and Deprivation (Oxford Clarendon Press, 1981), Chapter 10, for a discussion of the relationship between famine and epidemics m India

174

CHAPTER VII

cern the primary cause of a disaster in which both epidemics and famine were present However, records do not always divulge the sequence of events, and it is often impossible to tell whether famines and epidemics oc­ curred independently or whether there was a causal relationship be­ tween them. Contemporary observers were most interested in telling of the effects of disasters on the community or on certain individuals, and their writings reflect this interest. In most historical records when large numbers of people died of starvation in a famine year, the crisis was recorded in much the same fashion as when large numbers died from an epidemic disease There are several reasons for this. First, the consequences of both kinds of disasters were similar, and many of the problems of dealing with them were the same. Both calamities precipitated a characteristic and sizable movement of people fleeing the disaster. In famine years people moved in search of food, often to cities or places where grain was stored, when epidemics struck, those who could do so fled crowded urban areas where epidemics were most severe.2 In addition, the accounts of both famine and epidemics stress the problem of corpses that could not be buried for lack of coffins and of people to do the burying Although few contemporaries could have been confused about whether the basic cause of a mortality crisis was a shortage of food or an epidemic disease, accounts of the event often failed to make this distinction. For the researcher, the problem of separating accounts of autono­ mous epidemics from those of famine is compounded because the out­ ward appearance of death from starvation mimics the symptoms of certain acute infectious diseases. Not only are the indigestible food substitutes that are eaten when food is scarce likely to cause gastroin­ testinal distress, but acute, debilitating diarrhea is a manifestation of the terminal stage of starvation.3 A better understanding of the ways in which severe malnutrition affects human physiology has resulted in a clearer, if more complicated, picture of the relationship between these two calamities, and has provided a basis for interpreting the historical evidence on famines and epidemics. Many historical accounts that appear to be describing epidemic diseases are, in fact, describing the symptoms of mass starvation One example is a description of famine in 1597 in England where sources tell of the "bloodie flux," a terminal stage of starvation in which the most obvious symptom was severe diarrhea with as many as thirty to "Demographic Crisis," ρ 512 Ancel Keys et al , The Biology of Human Starvation, 2 vols (Minneapolis Univer­ sity of Minnesota Press, 1950), 2 955 2 Meuvret,

3

EPIDEMICS AND FAMINE

175

forty bloody stools a day. Although reported as an epidemic disease— "Dyvers died of the bloudie flixe" 4—this affliction was probably the result of a breakdown of the intestinal tract, which represents the final stage before death from starvation. It has often been assumed that famines cause epidemics, but even severe malnutrition does not cause infection. There is, however, an indirect relationship between them, and there are many reasons why epidemics accompany or follow famines. Most of the reasons have to do with increased opportunities for pathogenic agents to reach suscep­ tible hosts- the breakdown of established hygiene or immunization procedures that inhibit the reproduction or transfer of disease-causing organisms, for example, or an increase in the number of people mov­ ing from place to place in search of food, which facilitates the trans­ mission of germs over a wide area. Even so, immunity-producing diseases, like smallpox, remain dependent on the number of susceptibles. No matter how many people were suffering from malnutrition, the incidence of smallpox in a population would not have increased without a rise in the number of susceptibles. And famine conditions, as we have seen, can actually reduce the number of susceptibles. In places where smallpox was an endemic, childhood disease, the number of smallpox susceptibles in a community was likely to fall during a famine. This is because severe malnutrition causes birth rates to decline and death rates among young children to rise. On the other hand, when susceptibles who are scattered move into an area in search of food, they sometimes create a new population with low herd immunity. Even if the population is temporary, it can become a new focus of infection that spawns epidemic outbreaks. The principle is the same as when soldiers collect in great numbers for a campaign: an environment is created that encourages pathogenic agents to multiply rapidly. Changes in morbidity and mortality from acute infectious diseases are often a response to environmental changes that affect one or more links in the chain of infection. The pathogenic agent, the patterns of transmission, and the human host are all sensitive to changes that increase or decrease the incidence of infection. Even so, modern fam­ ines provide little empirical evidence that contagious diseases have a higher incidence or increased morbidity among severely malnour­ ished susceptibles.5 J. D Chambers, in his study of preindustrial 4 Tamworth

parish register, quoted by Appleby, Famine in Tudor and Stuart Eng­

land, ρ 8 5 Keys, The Biology of Human Starvation, 2 1011-12 Typhus is the exception to this generalization

176

CHAPTER VII

England, found little correlation between major epidemics and subsis­ tence problems. Chambers has argued convincingly that severe epi­ demics occurred in periods of good harvests as well as bad, and that epidemic diseases had a largely autonomous influence on mortality.6

THE DESCRIPTIVE SOURCES The Japanese sources can add to our general knowledge of the re­ lationship between famine and epidemics in the premodern world. Even in very early periods, Japanese accounts that tell of epidemics unrelated to famine look very different from accounts that describe periods of "famine and epidemics." The latter often told of conditions of bad weather and other disasters that ruined the crops, and they typically made specific reference to widespread starvation or to gov­ ernment actions that were designed to alleviate the effects of famine. Fujikawa included many accounts in his history of Japanese epi­ demics that were clearly describing severe subsistence crises. The fol­ lowing excerpts taken from an account for A.D. 823 illustrate the content of such accounts: Fifth month. The government sent food to the people in Iga who suffered from starvation and disease. Epidemics spread all over the country and the government ceased collection of the labor tax. Seventh month. In Nagato, where they produce coins, there have been droughts and epidemics year after year. Therefore the population has been greatly decreased. The government has granted relief from the labor tax and sent food to the farmers in Mino and Awa who have been suffering from starvation and epidemics.7 There are similar accounts for both 824 and 826, which suggests that the famine lasted for several years. In 824, the major temples were called upon by the government to offer prayers for relief from epidemics and drought, making it evident that at least one cause of the famine was the lack of rain. The Yowa famine of 1181—1182 has been immortalized by Kamo no Chomei (1153—1216), whose graphic ac­ count of the people's suffering in the Hojoki is often used to illustrate 6 J. D. Chambers, Population, Economy, and Society in Pre-Industrial England (Oxford: Oxford University Press, 1972). 7 Ruijii kokushi, quoted by Fujikawa, NSS, p. 20.

EPIDEMICS AND FAMINE

177

the severity of famines in premodern Japan.8 An account of the Yowa famine in the Konendaiki, eloquent in its simplicity, points to the combined aspects of this disaster " Tenka, ktkin, kanbatsu, gashi, ekirei"—"Under heaven, famine, drought, starvation, pestilence "9 These descriptions, and many like them, show a clear connection between famine and a general sickness, and although one cannot be certain, it appears as though people were suffering from "starvation sickness"—not an acute infectious disease, but a terminal stage of starvation The terminology that was used indicates that people at the time lmked the epidemic sickness to the famine. The words for fam­ ine, ktkin (Dili), and pestilence, ekirei (¾¾), were combined in such accounts, using the first characters of each word. These characters form a new word, ktekt (®U$), which means "starvation epidemic." Ktbyo (UL?W), which means "starvation sickness," was also used.10 The important eighteenth- and nineteenth-century famines were the Kyoh5 famine (1732—1733), the Temmei famine (1783—1787), and the Temp5 famine (1833—1837). Accounts of these famines, which affected different regions of Japan, all mention high mortality from starvation and "famine sickness."11 The content of the Japanese contemporary accounts is not the only way to distinguish years of "famine sickness" from epidemic years It is often the cumulative effect of a succession of poor harvests that causes a shortage of food, reduces large numbers of people to starva­ tion, and results in a widespread famine Fujikawa's chronology of epidemics also includes reports of major famines. Forty of the sixtyfive years in which famine and epidemics are mentioned together are clustered in series of two, three, or four years. Accounts of epidemics with no mention of famine, on the other hand, rarely show epidemics lasting more than one year Thus, subsistence crises can often be recognized because the reports indicate that the crisis lasted for several years. Arakawa Hidetoshi, who has done considerable research on natural disasters and famines of the past, claims that the major cause of famine m Japan changed over the centuries He believes that drought was the 8Kamo no Chomei, Hdjoki, vol 30 of Nthon koten bungaku taikei (Tokyo Iwanami shoten, 1966), pp 3—51 An English translation, "An Account of My Hut," is in­ cluded in An Anthology of Japanese Ltteraturefrom the Earliest Era to the Mid-nineteenth Century, ed Donald Keene (New York Grove Press, 1955), pp 197-212 9 Konendaiki, quoted by Fujikawa, NSS, ρ 37 10 The term kteki was used in accounts that told of famine in A D 780, 785, 823, 833, 1182, and many other famine years See Fujikawa, NSS, pp 18—37 11 Ibid , pp 56, 59, 63

178

CHAPTER VII

major cause in early centuries, and that unseasonable, cold, rainy weather was the most important cause after the sixteenth century By the Tokugawa period, he argues, irrigation and water storage systems were sufficiently advanced to prevent a water shortage except under the most severe drought conditions 12 The accounts compiled by Fujikawa illustrate this argument Drought was commonly men­ tioned in the early famine accounts, but the Tokugawa famines, which had their greatest impact in northeastern Japan, followed several successive years of cold, wet weather 13 Hence, crises of subsistence can often be distinguished from epi­ demic crises by examining the content and the chronology ofjapanese contemporary accounts There seem to have been few "mixed crises," that is, crises in which specific acute infectious diseases can be iden­ tified in a famine year 14 Even unidentified epidemics usually occurred in years in which contemporary accounts made no mention of famine THE HIDA RECORDS

There has been little analysis of the causes and consequences of the Tokugawa famines, even though there has been much controversy over whether or not they were an important check on population growth in early modern Japan The role of famine m the demo­ graphic history of Tokugawa Japan is beyond the scope of this study, but the local histories and temple death registers of the Hida region provide an opportunity to take a close look at the relationship be­ tween famine and epidemics The Temmei and Tempo famines are well documented in local and regional histories, and the kakocho of Ogen-ji show the impact of these famines on epidemic patterns in the villages affiliated with the temple One of the more unusual features of the C)gen-ji death records is that starvation was recorded as a cause of death A few deaths were said to have been caused by starvation in years when there is no other evidence of food shortage, but, as expected, most deaths attributed to starvation were recorded during the years of the Temmei and Tempo famines Figure 7 1 shows the yearly distribution of deaths attributed to starvation 12 Arakawa Hidetoshi, Kikin, Nihon shi, no 94 (Tokyo Kyoiku sha, 1979), pp 12—13 13 Fujikawa, N S S , pp 11—66 14 The earliest recorded smallpox epidemic, in the eighth century, occurred in a famine year, however, after that, identifiable epidemic diseases were recorded in famine years on only five other occasions—once each in the ninth, tenth, fifteenth, eighteenth, and nineteenth centuries

EPIDEMICS AND FAMINE

179

80-

70J= 60-

S

50-

o 400> -Q 30E ζ

20-

10o -

I

1771

l

I

1781

l

I

1791

I

Γ

1801

1

1 1 Γ 1821 1831

1841

1851

Gregorian Year 7.1 Distribution of Deaths Attributed to Starvation by Year, Hida Villages: 1771-1852

Figure 7.2 illustrates the different timing exhibited by mortality due to acute infectious diseases and mortality that occurred during a fam­ ine. Curve 1 shows the yearly distribution of all deaths. Most peaks were caused by smallpox deaths, which recurred in predictable cycles of three to four years. The peak in 1826 reflects increased mortality from the epidemic of dysentery in that year. Three mortality peaks reflect famine conditions: the impact of the Temmei famine on mor­ tality shows up in the Hida villages in 1784; the Tempo famine was responsible for the increase in mortality both in 1834 and in 1837, the highest mortality peak of the series. Curve 2 shows the yearly distribution of deaths when all deaths attributed to epidemic-type diseases—smallpox, measles, dysentery, and influenza—are excluded. The cyclical mortality peaks disappear, and the remaining peaks, which identify the Temmei and Tempo famine years in the Hida villages, stand out prominently. As the mortality curve indicates, the Tempo famine of the 1830s was by far the greatest crisis in the villages affiliated with Ogen-ji. Difficulties in the Hida region began in 1831 when a flood in the sixth month was followed by a poor harvest and a food shortage in the following year.15 In 1833 a long rainy spell in the fifth month was blamed for that year's poor harvest.16 It was said that rain fell end15

Miyamura shi, p. 660. hennen shiyo, p. 352; Miyamura shi, p. 661.

16 Hida

C H A P T E R VII

180

Gregorian Year

7 2 Differential Mortality Curves Curve 1 = Distribution of All Deaths by Year, Curve 2 = Distribution of Deaths by Year, with Deaths Attributed to Epidemic Diseases Excluded lessly in 1834, and famine conditions were noted in the region around Takayama. 1 7 The death records of Ogen-ji show a sharp rise in the number of deaths m 1834. For the first time since the Temmei famine, deaths attributed to starvation were entered in the temple death register. 18 In 1835, it was claimed that many people died of starvation between winter and spring. 19 In 1836, unusually cold weather in the sixth month followed a period of excessive rain, and six deaths from an epidemic sickness called jteki were recorded m the kakocho. A culmination of six years of bad harvests was reached in 1837 In that year many deaths were attributed to starvation and jteki. A history of the Hida region describes the famine of that year as follows: 20

This spring the shortage of food became increasingly more desperate in the villages. People fought over grass roots and budding leaves which they collected for food. The roads were full of people who had starved to death. Toward the end of the fifth 1 7

Hida hennen shiyd, p 352

Suda, Hida "O" jiin, pp 148-49 Kuguno-cho shi (Kuguno, Gifu-ken Ono-gun Kuguno-cho yakuba, 1957), p 732 In 1834 the number of deaths rose to 145, well above the average of 97 deaths per year Hida hennen shiyd, p 353, Suda, Hida "O" Jim, pp 152-53 18

1 9

2 0

EPIDEMICS AND FAMINE

181

month an epidemic sickness prevailed. Those who died of star­ vation were followed by those who died of the sickness, and corpses lay on the ground in the fields and villages.21 The Tempo famine caused a mortality crisis of great magnitude in the Hida villages. The 367 deaths recorded at Ogen-ji in 1837 represent nearly four times the yearly average for the entire eighty-two-year period. Approximately 9 percent of the estimated population died in 1837.22 In 1838 the crisis diminished considerably, with the number of recorded deaths declining to 132. The following year mortality fell well below the norm: only 67 deaths were recorded in 1839.23 The histories of the Hida region leave no doubt that the mortality crisis of 1837 was a crisis of subsistence. Cold and wet conditions caused the crops to fail in Hida as in much of eastern Japan in the 1830s. But epidemics were also mentioned in the local accounts. Were epidemics caused by the usual diseases that just happened to be prevalent in that year? Were these epidemics independent of the subsistence crisis? Or were the epidemics that were mentioned in contemporary accounts actually mass starvation? The evidence suggests that epidemics were ihdependent of subsis­ tence crises in most cases, but in 1837 the Ogen-ji records suggest that a "new" epidemic called jieki was a direct consequence of the famine.24 A literal translation of the term jieki is "current epidemic," "prevailing epidemic," or "epidemic of the time." Before 1836, the term jieki was entered in the record only once as a cause of death: in 1803, a 52-year-old woman was said to have died of this sickness. BetweenJuly of 1836 and September of 1839, the years of the famine in Hida, 113 deaths were attributed to this sickness. After 1839, two more deaths were attributed to jieki—one death in 1840 and another in 1842. Jieki then disappears from the death records. In Hida, 97 percent of all deaths that were attributed to jieki in the eighty-twoyear series of death records occurred during the worst years of the Tempo famine or immediately afterwards. The temple records also show that 90.4 percent of all deaths attributed to starvation were concentrated in this same period.25 21

Hida hennen shiyB, p. 354. 1771 and 1852 the average number of deaths per year was 97. 23 These figures differ slightly from those of Suda Keizo because they are based on the Gregorian calendar. Suda, Hida "O" jnn, pp. 154-59. 24The Buko nenpyo uses the term jieki to describe an epidemic sickness that was concurrent with the Temmei famine, so apparently jtekt was not merely a local term. Fujikawa, NSS, p. 59. 25 One death was attributed to starvation in each of the following years: 1771, 1772, 1773, 1842. In 1784, during the Temmei famine, six deaths were attributed to starvation. 22Between

CHAPTER VII

182

Table 7.1

Deaths Attributed to Starvation and Jieki, Hida Villages Starvation

Jieki

Year

JVof deaths

% of deaths

N of deaths

% of deaths

1834 1835 1836 1837 1838 1839 Other Total

9 O O 79 5 2 10 105

8.6 0.0 0.0 75.2 4.8 1.9 9.5 100.0

0 0 5 64 38 6 3 116

0.0 0.0 4.3 55.2 32.8 5.1 2.6 100.0

Original Data Source: Suda, Hida u O n jiin.

In addition to jieki another nonspecific term was used during the Tempo famine to note deaths from an unidentified epidemic disease. Ekibyo (Slra) was the term used most frequently in local descriptive accounts of the famine, and it was also entered eleven times as a cause of death in the death registers—five times in 1837 and six times in 1838. Ekibyδ, which means "epidemic sickness," was given as a cause of death only during the Temp5 famine. Table 7.1 shows the yearly distribution of deaths attributed to starvation and jieki during the Temp5 famine and the years immedi­ ately following. Deaths from both causes were highly concentrated in 1837. Starvation deaths dropped sharply in 1838; jieki deaths declined less precipitously, but were reduced by almost half in the same year. Neither cause was recorded again after 1842. The timing of these two causes of death—jieki and starvation—is unlikely to have been coincidental. Figure 7.3 shows the monthly distribution of deaths attributed to starvation and jieki in 1837 and 1838. Starvation deaths rose first, followed by a strong upsurge in jieki deaths; both reached a peak in the summer months of 1837. Starvation deaths fell first—only five deaths were attributed to starvation in 1838—but jieki deaths con­ tinued, increasing in the early winter months and finally tapering off during the summer of 1838. The highest mortality from both causes occurred between the spring of 1837 and the spring of 1838.

EPIDEMICS AND FAMINE

183

7.3 Distribution of Starvation and Jieki Deaths by Month, Hida Villages, 1837-1838 What acute infectious disease or diseases might have caused an epidemic in 1837 and 1838? No information concerning the symptoms of jieki or ekibyo was found in the local histories of the area; however, the fact that mortality rose in the summer of 1837 suggests that a dysentery epidemic might have run concurrently with the famine. If so, the greatest mortality was due, not to acute malnutrition, but to an epidemic of some enteric disease that was circulating in the region at the same time. However, a closer look at the temple death records suggests that jieki deaths did not conform to the usual pattern of mortality from dysentery ( r i b y o ) discussed in Chapter VI. First, jieki deaths did not follow the normal seasonal pattern of deaths attributed to dysentery in other years. Although jieki deaths rose sharply in the summer months of 1837, they did not fall at the end of the year when the cold weather set in. Instead, jieki deaths continued into 1838 and even increased in February. Second, deaths attributed to jieki were not concentrated in the same age group as deaths attributed to dysentery in other years. As noted earlier, the mean age of death from enteric diseases in the Hida villages was 10.6, the mode, age 2. The most striking fact about jieki is that it was a disease that killed only adults—the same age group whose deaths were attributed to starvation. The mean age of those who were said to have died of jieki was 45.6, the mode, age 50; the mean age of deaths

184

CHAPTER VII

attributed to starvation was 45.9, the mode, age 40. Whereas most epidemic diseases that occurred between 1771 and 1852 were killers of children, during the Tempo famine the great rise in mortality was caused by an increase in adult mortality. And the causes most fre­ quently given for these adult deaths during the famine were starvation and jieki. Deaths attributed to ekibyo, the other unidentified epidemic disease in the kakocho, show a similar age distribution. Those who died of ekibyo were even older than those who died of jieki: the mean age was 63.1, the mode, age 51. In other words, the age-specific pat­ tern of deaths from starvation, jieki, and ekibyo were essentially the same. Finally, we should be reminded that there was a specific term that was used for dysentery in the kakocho of Ogen-ji. The term was ribyo, and this term was not used in 1837 or the winter of 1838. It was used, however, in the summer of 1838, when dysentery followed its typical seasonal pattern: seventeen deaths were attributed to ribyo in 1838— ten in August, five in September, and two in November. The use of both terms in 1838 would seem to indicate that jieki, "the prevail­ ing epidemic," was regarded as being different in some way from ribyo.

One possibility, as yet unexplored, is that the "prevailing epi­ demic" in the Hida villages in 1837 was cholera. Since 1837 was the final year of a worldwide cholera pandemic, and since it is known that cholera reached Japan at the end of the earlier cholera pandemic in 1822, one could argue that the deaths attributed to an unidentified epidemic disease in Hida in 1837 and 1838 were caused by cholera. This is a most improbable explanation of jieki deaths in Hida during the Tempo famine. The highest mountains of central Honshu, with its steep terrain and rapid mountain streams, would be the last place to look for cholera, especially in the absence of any evidence that a disease resembling cholera was epidemic elsewhere in Japan. Local histories first report cholera in the Hida region in 1876. However, there were familiar and identifiable epidemic diseases that occurred during the period of the Temp5 famine. These diseases fol­ lowed much the same pattern as they had in earlier years. Smallpox was epidemic in 1836 and 1837, and it followed its normal cycle and its usual seasonal pattern. The peak in smallpox mortality came early in 1837, during the winter months, and it was not especially high. It preceded the peak in overall mortality created by starvation and jieki deaths by several months. Measles also was epidemic during the fam­ ine, making one of its infrequent appearances in the Hida villages in 1837. As both diseases had occurred a relatively short time before— smallpox followed an interval of thirty-five months and measles fol-

EPIDEMICS AND FAMINE

185

lowed an interval of ten years26—mortality from both diseases was low, and it was confined to young children. The essential fact concerning the deaths attributed to the epidemics called jieki and ekibyS is that they began and ended with the famine. These terms were entered as causes of death early in the famine. Both causes affected the same age group as deaths attributed to starvation, and both terms disappeared from the death records when the famine ended. Familiar infectious diseases that were epidemic in 1837 and 1838 followed their own characteristic patterns. They did not follow the mortality pattern imposed by the famine. Analysis of the evidence provided in the death records of Ogen-ji suggests that the terms jieki and ekibyo were general terms that meant "starvation sickness," and that the high mortality attributed to these "epidemic diseases" in 1837 and 1838 was caused by severe malnutrition. In Hida, mortality was augmented during the Temp5 famine by epidemic diseases that were following their own autonomous course, but the greatest mortality—that attributed to starvation and epi­ demics that were recorded as jieki and ekibyo—was directly or in­ directly related to the subsistence crisis that was caused by six or seven years of crop failures due to unusually cold, wet weather. In the Hida villages, the effect of the Temp5 famine on mortality seems to have been immediate, although further analysis might show long-term effects as well. Mortality was concentrated at the height of the famine. By 1839 mortality had fallen to abnormally low levels. There was no unusual increase in mortality from any identifiable epidemic disease during or after the famine. The conclusions drawn here about the relationship between famine and epidemics during the Temp5 famine in Hida are very different from those of A. K. Sen, who studied a severe famine in Bengal, India in 1943.27 Sen argues that mortality from a broad range of epidemic diseases increased after the Bengal famine and that epidemic mortality remained high for several years. He claims that diseases, which in­ cluded smallpox, malaria, and enteric infections, were "induced" by the famine, and that the greatest increase in mortality was caused by epidemic diseases that continued to circulate up to five years after the period of food shortage.28 Sen's analysis does not take the characteristics of the diseases he 26This assumes that the measles epidemic of 1824 reached Hida but that no deaths were recorded. 27A. K. Sen, "Famine Mortality: A Study of the Bengal Famine of 1943," in Peasants in History, ed. E. J. Hobsbawm et al. (Oxford: Oxford University Press, 1980). 28 Sen, Poverty and Famines, p. 50.

186

CHAPTER VII

considers into account, and to state that they were "induced" by the famine is misleading. The increased mortality from enteric diseases may well have been related to the famine, but the relationship was indirect. It is quite unlikely that the sharp rise in smallpox mortality in 1944 and 1945, for example, was a result of malnutrition. Smallpox was an endemic disease in India, and smallpox mortality might have been as high or even higher without the famine. The incidence of smallpox in the 1940s in India, as elsewhere in the world, depended on the number of susceptibles. In Hida, as we have seen, smallpox mor­ tality was lower after the Temp5 famine because there were fewer susceptibles. If it can be shown that the famine caused the redistri­ bution of susceptibles so as to trigger an epidemic, it can be claimed that the famine "induced" an epidemic of smallpox. Or if effective immunization procedures broke down because of the famine, it can be argued that there was a correlation between the famine and high smallpox mortality a year or two later. An understanding of the mechanisms that function between patho­ genic agents and their hosts is essential when assessing the impact of disease on mortality under unusual conditions such as war or famine. Then, if changes occur in the pattern of mortality during a period of crisis, it is important to ask why these changes occurred. Was the rise in mortality due to an increase in the number of susceptibles? If so, why did the number of susceptibles rise? Was the increase due to a heavy influx of new susceptibles or to a rise in the birth rate? Was greater mortality from disease caused by changes in the water supply, sanitation, or disease-prevention programs, or was it directly or in­ directly related to the effects of severe malnutrition? Which of these factors were important, and how were they related to the crisis? Calamities like famine and war do not induce acute infectious diseases, which are always in existence somewhere; they merely change the conditions under which they operate. TheJapanese source materials reviewed here present only a sketchy picture of the relationship between famine and epidemics in Japan. The two derive, essentially, from different causes; however, historical analysis frequently fails to differentiate between them. The Japanese sources indicate that mortality crises caused by epidemics can fre­ quently be separated from those caused by famine. In regions where there are local histories that describe calamities and death registers that record causes of death, it is possible to look at mortality from specific acute infectious diseases in good times and bad, and to com­ pare general mortality during a period of famine with mortality in more normal times. The Hida sources provide an unusual glimpse of preindustrial mortality patterns during a subsistence crisis, and they

EPIDEMICS AND FAMINE

187

show that the pattern of mortality from epidemic diseases changed very little during the Tempo famine. Moreover, the impact of the famine and of epidemic diseases on mortality were quite different. This general survey of the Japanese sources, both qualitative and quantitative, supports the conclusions of J. D. Chamber's research on preindustrial England: mortality crises caused by acute infectious dis­ eases and those precipitated by famine were, for the most part, inde­ pendent of one another.

CHAPTER VIII

CONCLUSIONS This book has reviewed the history of the most prominent epidemic diseases of the Tokugawa period. These diseases—smallpox, measles, dysentery, and cholera—were chosen because they were important epidemic diseases in all urbanized societies of the premodern world, and because there is an excellent clinical and historical literature that pertains to them. Every effort has been made to interpret the Japanese sources and death records in terms of the unique characteristics of these diseases. The Japanese sources have proved more than adequate to the task, and each of the diseases studied emerges from the records with its distinctive personality intact. It is well known that acute infectious diseases were a primary cause of premature death and a stabilizer of population in the preindustrial world, and this study has asked whether this maxim also applies to Japan. A related set of questions has been addressed in the analysis presented here. First, what were the important epidemic diseases of premodern Japan? Second, what impact did they have on mortality in the Tokugawa period? Third, did epidemics play a major role in checking pouplation growth in Japan during the prolonged period of national population stability in the late Tokugawa period? And fin­ ally, how does the history of these particular epidemic diseases in Japan compare with that of the West? The Japanese sources indicate that some epidemic diseases of the early modern world were known in Japan, whereas others were not. Smallpox was the major killer. Contemporary accounts suggest that smallpox was epidemic in Japan as early as the sixth century. By the twelfth century, and probably earlier, smallpox seems to have been an endemic disease in the country as a whole. Buddhist temple death records from different regions of Japan indicate that by the late eigh­ teenth century smallpox was an endemic disease in even very remote regions of central Honshu; in Edo and the larger cities the smallpox virus circulated continuously. Only relatively isolated offshore islands managed to avoid this disease for long periods, and by the end of the Edo period smallpox epidemics were increasing even in those regions. Just about everyone contracted smallpox in early modern Japan, usually during childhood. High rank was no protector: records from Edo Castle tell us that all of the Tokugawa children who lived very long came down with this disease. In fact, most children in Japan

CONCLUSIONS

189

contracted smallpox before the age of 5. And since many children died of the disease, we must conclude that smallpox did check popu­ lation growth by significantly reducing the number of children that lived to the age of reproduction. Smallpox also checked population growth by lowering fertility. Recent research indicates that smallpox caused significantly reduced fertility in males who survived the disease. A study of males with infertility problems in India has shown an extremely high incidence of obstructive lesions in patients who have had smallpox, and smallpox infection is thought to be "the most important and most frequently encountered single etiologic factor in India which produces obstruc­ tive azoospermia in man."1 Seemingly insidious and seldom worthy of mention in the chro­ nologies of the period, smallpox was a natural part of human existence to a contemporary observer. But its impact on mortality and fertility was sufficient to depress the national rate of population growth in early modern Japan. To estimate the extent to which smallpox limited population growth in the late Tokugawa period would require a systematic investigation of regional population growth before and after the massive vaccination program that was instituted in the early Meiji period, a topic that exceeds the scope and time period of this study. However, there can be little doubt that before 1850 smallpox did serve as an important check on population growth. Still, smallpox was an endemic disease that checked population growth in most populous countries between 1600 and 1850, and there is no evidence that smallpox mortality was higher m Japan than in similar populations elsewhere. The estimated case-mortality rate from smallpox in the Hida region—one death in ten cases—is rather low for a country not practicing preventive immunization. Approximate­ ly the same rate was estimated for European countries that were using preventive immunization: William Black, an English surgeon, wrote in 1798 that in London, where innoculation to immunize against smallpox was in use, approximately one-tenth to one-twelfth of the inhabitants succumbed to smallpox. He noted further that in countries where natural smallpox was endemic, one person in seven died of the disease.2 Comparisons between smallpox mortality rates in Japan and Europe after the mid-eighteenth century must take into consideration 1A

M Phadke et al, "Smallpox as an Etiological Factor in Male Infertility,"

Fertility and Sterility 24 (1973) 804 2William

Black, A Comparative View of the Mortality of the Human Species at All

Ages and of the Diseases and Casualties by Which They are Destroyed or Annoyed (Lon­

don C DiUy 1788), ρ 103

190

CHAPTER VIII

the fact that smallpox mortality was beginning to fall in certain parts of Europe in the late eighteenth century because of preventive im­ munization, a practice that did not become widespread in Japan until almost a century later. But having argued that smallpox was an important factor in reduc­ ing population growth, and that smallpox mortality in Japan was comparable to smallpox mortality in other parts of the world during the same period, it must be emphasized that there is no evidence that smallpox caused higher mortality in Japan during the second half of the Tokugawa period than it had previously. The Hida records, in fact, show a trend in the opposite direction: smallpox mortality de­ clined after 1825 even though smallpox epidemics occurred with greater frequency. Smallpox had been an endemic disease in Japan for so many centuries that, except for temporary changes in the virulence of the virus, its impact on mortality could change very little without preventive therapy. Measles also reached Japan very early in her history. Tenth-century accounts describe an epidemic of measles, and measles had probably reached Japan even earlier. But unlike smallpox, measles epidemics did not increase in frequency, and measles did not become an endemic disease in early modern Japan. Tokugawa sources indicate that measles epidemics occurred at varying intervals of twenty to thirty years, and the evidence presented here strongly suggests that measles was still an imported disease in the second half of the nineteenth century. The failure of measles to become an endemic disease in a population of 30 million people is a puzzle. There is no other such case in the historical literature on measles. Since the evidence is impressive, it is important to ask how the virus could have died out in such a large population. Although this is a matter for epidemiologists to ponder, an important part of the answer must have to do with the spatial distribution of Japan's premodern population. As we have seen, the measles virus invariably entered Japan through the port of Nagasaki in the southwest corner of Japan. Each measles epidemic typically traveled eastward along the major routes to the large urban concen­ trations of Honshu. From there the epidemics moved inland to re­ mote settlements like the Hida villages, north along the coast to regions like Sendai, and then to the sparsely settled regions of north­ ern Honshu and Hokkaido. Most of Japan's population was concentrated along these routes, and the heavy concentration of human susceptibles provided an ideal environment for the transmission of a disease as contagious as measles. In most measles epidemics, perhaps a third of Japan's population had not been previously exposed to the virus, which meant that the disease

CONCLUSIONS

191

spread very rapidly. When the measles virus reached the more sparse­ ly settled regions of northern Honshu, it ran out of new hosts to infect. Before a new pool of susceptibles could develop in the more populous regions of the country, the virus died out. These population characteristics—a continuous chain of susceptibles from one end of a long narrow country to the other—were probably unique to Japan, and they may explain why the fragile measles virus failed to become endemic in such a large population. But in spite of severe epidemics and high morbidity among adults as well as children, the evidence suggests that measles mortality was lower in early modern Japan than in early modern Europe. This is to be expected, because adults are much less likely than children to die of measles. In Europe, where measles was primarily a disease of children, case-fatality rates would have been higher than in Japan, where a large proportion of persons infected consisted of those past the age when one is most likely to die of measles. Early Japanese descriptive accounts also tell of epidemics of dys­ entery in the cities of Nara, Kyoto, and Kamakura, although such accounts are less numerous than accounts of smallpox and measles epidemics. They tell us little about these epidemics except that enteric infections were usually epidemic in the hot weather of late summer or early fall. Local death records provide more detailed information about diarrheal diseases in the early modern period. They show that mortality from enteric infections was considerably higher in some villages than in others, and that mortality from dysentery was highest in regions with the highest population density. The discovery of differential mortality from dysentery in small villages in the same region warns against any general conclusion about the overall im­ portance of enteric diseases as a cause of death in early modern Japan. One of the most important findings of this study is that two of the most disastrous epidemic diseases of premodern Europe—bubonic plague and epidemic typhus—do not appear in premodern Japanese accounts. Although one may speculate that accounts of plague were lost or that they were not sufficiently explicit to permit identification of the disease, such arguments are hardly convincing. The symptoms of bubonic plague are among the most graphic of all diseases. Large, extremely painful swellings, known as buboes, appear in the armpit or groin, and although septicemic and pneumonic forms of plague do not manifest this symptom, these forms of plague are not believed to exist in the absence of the bubonic type.3 3J. F. D. Shrewsbury, A History of Bubonic Plague in the British Isles (Cambridge: Cambridge University Press, 1971), p. 6.

192

CHAPTER VIII

Mortality among those stricken with bubonic plague in medieval and early modern Europe was extremely high,4 and the demographic effects of plague, although still a matter of debate, were enormous.5 Moreover, the psychological effects on those who witnessed an epidemic of plague were long-lasting. This one disease continued to engage the attention of contemporary European writers for several centuries.6 Given the population characteristics of early modern Japan, there is no reason to believe that the demographic or psych­ ological impact of this disease would have been less severe in Japan than it was in Europe. It is highly improbable that epidemics of such a violent disease could have escaped mention, or that all accounts could have totally disappeared, when precise, detailed Japanese accounts of the most ordinary infectious diseases exist in great number. There are plausible explanations for the absence of plague epi­ demics in Japan. The plague bacillus in Europe was dependent upon a particular species of rat to serve as its host population, and upon a particular rat flea to transmit it to man. If either or both of these species were absent in Japan, the plague bacillus would not have sur­ vived. It is possible that the absence of trade in grain between Japan and other countries prevented the transfer of the necessary hosts and carriers to Japan. Rattus rattus, also known as the black rat or the house rat, was the important host in European epidemics. The black rat followed the caravan trade and was "wholly dependent upon passive transport by man across terrestrial barriers such as seas, rivers, deserts, and mountains...." 7 The black rat's colonization of Europe began early in the Christian era. By the sixth century, it was probably well established as a house­ hold pest throughout the eastern Mediterranean littoral, accounting for the plague pandemic that broke out during the reign of Justinian. Shrewsbury believes that R. rattus had spread as far westward as southern France by this time.8 References to the black rat in the British Isles can be found from the twelfth century, when its role as a public nuisance became apparent.9 Michael W. Dols's excellent analysis of the Arabic sources on 4 Ibid , p. 5. Shrewsbury suggests a case-mortality rate of 90 percent in the initial weeks of the European epidemics, which occurred frequently between the fourteenth and seventeenth centuries. As an epidemic subsided, the rate commonly fell to as low as 30 percent. 5 See M. W. Flinn, "Plague in Europe and the Mediterranean Countries," Journal of European Economic History 8 (Spring 1979):131. Flmn suggests a case-fatality rate ranging from 60 to 100 percent 6 Ibid., p. 133. 7 Shrewsbury, A History of Bubonic Plague, p. 10. 8 Ibid., p. 11 9 Ibid., pp. 12-13.

CONCLUSIONS

193

bubonic plague makes a great contribution to our understanding of the origins and transmission routes of plague pandemics. He considers the sixth-century pandemic to have originated in East Africa. He believes that the pandemic known as Black Death in the fourteenth century began on the steppe of Central Asia.10 The latter pandemic can be traced in its movements westward along the major artery of international trade, the northern transcontinental route that connected Genoa and Venice with Peking. Unfortunately, little is known about the eastward movements of plague because there has been no systema­ tic search of the Chinese sources for evidence of plague. However, there was no caravan trade toJapan. And there was little sea transport of the kind of goods that would attract rats.11 The black rat could have migrated to Japan by way of China, but there is no evidence of this, and the presence of bubonic plague in China is not well substantiated before the nineteenth century. William H. McNeill assumes that bubonic plague was common in China from the early seventh century, and that it reached the Canton area by sea about two generations after it had penetrated the Mediterranean region.12 But without a systematic analysis of the Chinese sources, it is premature to decide that bubonic plague was a disease of consequence in China.13 The epidemiology of plague is extremely complex, and experts like Shrewsbury caution against hasty identification of this disease from historical sources: The confirmatory evidence that is required to identify a pes­ tilence in olden times as an epidemic of bubonic plague may be either a contemporary description of the clinical picture of the pestilence that is pathognomonic of plague or a conjunction of certain observations that are exclusive to the epidemiology of plague. Unless one—and preferably both—these conditions are fulfilled the assumption that an ancient pestilence was an epi­ demic of bubonic plague is not justified.14 Even when bubonic plague can be identified in a particular ac­ count, it does not indicate that plague became an endemic disease in that region or that it caused frequent epidemics thereafter. Shrews10Michael W Dols, The Black Death in the Middle East (Princeton, N. J.: Princeton University Press, 1978), pp. 49-50. 11 An excellent review of the European literature on the transmission of bubonic plague can be found in Flinn, "Plague in Europe," pp. 138—47. 12McNeill, Plagues and Peoples, p. 116. 13Helen Dunstan found a Chinese account written in 1644 that presents a clinical picture resembling bubonic plague, but the evidence is not conclusive. Helen Dunstan, "The Late Ming Epidemics. A Prehminary Survey," Ch'ing-shih wen-t't 3, 3 (November 1975): 19—23. 14Shrewsbury, A History of Bubontc Plague, p. 1.

194

CHAPTER VIII

bury claims that, following an epidemic, the rat population had to rebuild to a critical level, and that another epidemic could not occur in a given location without a reimportation of the pathogen. He argues that epidemics continued to flare up in Europe because the pathogen returned and repeatedly caused new infestations of the rat population. Shrewsbury speculates that plague ceased to be a major threat in the West after the old Near Eastern trade route was replaced by ships sailing around Africa. Infected rats and their fleas, he ob­ serves, would have been dead long before they reached Europe.15 There are so many variables that affected the transmission of the plague bacillus, and so many theories about which variables were most important, that without any clear evidence that plague was a major problem m China or Japan, it is pointless to try to construct the routes it might have taken. We do know that m the 1890s, a severe epidemic of plague in both its bubonic and pneumonic form broke out in Manchuria in the city of Harbin. It was carried along the railway routes to Hong Kong and other port cities, where it claimed many thousands of lives.16 This Far Eastern outbreak turned into a worldwide pandemic, and in 1899 the first known cases of bubonic plague in Japan broke out in Kobe and Osaka.17 In short, once we have clear evidence of plague in China, and a commodity trade that linked infected Chinese ports with Japa­ nese ports, we have clear evidence of plague in Japan. Plague was regarded as a new disease in Japan at the time. It was called "pesuto" from the Italian or French, and written in katakana, the writing system used for foreign words. Epidemic typhus, another disease that had an enormous impact on mortality in early modern Europe, also seems to have been unimpor­ tant in premodern Japan. Typhus is regarded as a relatively new dis­ ease in human history. It was first noted in fifteenth-century Europe, where it flourished in the unsanitary conditions that found men, rats, fleas, and lice—all of which play a part in the transmission of typhus— inhabiting the same overcrowded environment.18 The strong associa­ tion between typhus epidemics and large-scale military campaigns in Europe may help to explain its absence m Japan during the period of the Tokugawa peace; however, the explanation may once again lie 15

Ibid, pp 157-58,485-86 It was during the Hong Kong epidemic that the plague bacillus Pasturella pestts was finally isolated by two researchers, Yersin and Kitasato, working independently Knowledge of plague's association with rats and fleas followed within a few years 17Kasuga T , "Nihon no pesuto ryuko shi kara mita saikin gaku, ekigaku no ni, san no ten m tsuite," Nthon saikin gaku zasshi 32, 1 (1977) 33 18Fiennes, Zoonoses, pp 76—84 16

CONCLUSIONS

195

with the need for the disease-causing organism to have a full comple­ ment of hosts and vectors that may not have been indigenous to Japan.19 Like bubonic plague, the European version of typhus became pre­ valent in Japan in the late nineteenth century. It was called chifusu, the Japanese equivalent of the Western word "typhus," and it also was written in katakana.20 The fact that there was no native Japanese word for typhus suggests that it also was viewed as a new disease in Japan. What is clear is that Japanese accounts written before the arrival of Western trade contain no descriptions of epidemics similar to typhus. Thus, it seems reasonable to conclude that typhus, like plague, was not a cause of high mortality in Japan during the Tokugawa period. Typhus, cholera, and plague seem to have been new and imported diseases in Japan in the late nineteenth century. The fact that no confirmatory evidence of bubonic plague has been found in Japanese sources before the late nineteenth century does not mean that the plague bacillus did not reach Japan. But the most plausible explanation of the absence of plague and typhus epidemics in Japanese accounts written before 1850 is that these diseases did not cause epidemics in Japan. It is difficult to prove that an event did not occur, but the quality and continuity of Japanese accounts of many lesser diseases suggests that had severe epidemics of plague and typhus been a major cause of mortahty in Japan, they would have been recorded, and knowledge of them would have survived. Whether there were no epidemics of plague and typhus because the micro­ organisms that cause them did not get to Japan, or because the hosts and vectors and other conditions necessary to support and transmit these diseases to man were not there must remain a matter for conjec­ ture. Given the size, density, and distribution of the Japanese popu­ lation from the eighth century onward, the pathogens that cause plague and typhus would have had an ample supply of human hosts 19The famous typhus of European history is known as "epidemic typhus" or "classic typhus " It is carried from man to man by the human louse, but it is believed to have evolved from a murine typhus, which is a disease of rats and other rodents The Japanese have been subject to another kind of murine typhus known as tsutsugamusht disease or scrub typhus (See Fiennes, Zoonoses, ρ 84 ) This disease is carried by a mite and has high incidence in the Shinano River region While scrub typhus can be fatal, it has a much more benign history than the epidemic typhus known in Europe 20 The terminology for typhus is extremely confusing in all nmeteenth-century sources because the terms "typhus fever" and "typhoid fever" were used interchange­ ably The differing etiologies of the two diseases were as yet not understood This confusion was transferred intact to the Japanese language sources, consequently, any reference to either of these diseases before the twentieth century cannot be considered accurate The Japanese used the term chifusu for both diseases

196

CHAPTER VIII

and every reason to flourish had other necessary conditions been present. The extraordinary size and density of Japan's population in 1700 can perhaps be attributed to the absence of these two diseases that were a major cause of depopulation in early modern Europe. The reports of the first Westerners to arrive in Japan in the midnineteenth century suggest that plague and typhus were not the only diseases that were conspicuous by their absence. Nineteenth-century Western observers were often military medical personnel or mission­ aries, and they wrote descriptions of disease and treatment in Japan. Their accounts are much more detailed than those of the European observers who arrived in Japan in the sixteenth century. The message, however, was the same: many of the familiar common diseases of the West were not important causes of infection in Japan. Edward Morse, an American visiting Japan in the 1870s, comments in his journal on the low incidence of diseases that were common in the United States: Dr. Eldridge, an eminent American physician, who has practiced in Japan for a number of years and who has been for two years connected with the Medical College in Tokyo, has given me much information regarding his practice among theJapanese and the experiences of other physicians some of whom have been here sixteen years. The climate of Japan is considered remarkably healthful. Smallpox, which has always been epidemic, is now coming under control, the government taking vigorous measures to secure general vaccination and maintaining a vaccine farm for this purpose. In this matter as in many others, the Japanese are far ahead of occidental nations. Scarlet fever is almost unknown, never epidemic; diphtheria also is rarely seen, never epidemic; severer forms of bowel complaint, such as dysentery and chronic diarrhoea are very rare; phthisis [tuberculosis] is not more com­ mon than in the Middle States of our country; malarial diseases of severe nature are uncommon, even milder forms in most regions not being common; acute articular rheumatism is rare, muscular rheumatism very common; typhoid and typhus are rarely epidemic, the latter uncommon; relapsing fever is occa­ sionally seen... .21 If we assume that these Western physicians were reasonably well informed, what accounts for these differences between Japan and Eu­ rope? Since it is clear that Japan's population was sufficiently large and 21 Edwqrd Morse, Japan, Day by Day, 1877, 1878—79, 1882—83, 2 vols. (Boston and New York: Houghton Mifflin Co., 1917), 1:39-40.

CONCLUSIONS

197

dense to support any of the density-dependent diseases of early mod­ ern Europe, the answer obviously lies elsewhere. Japan's geographical position and her limited contact with other population centers before 1850 would seem to account for at least some of these differences. An important postulate of epidemiology is that the "isolation of a population modifies its infectious diseases."22 Andre Siegfried, who has traced the routes followed by major diseases of the past, describes the importance of isolation as follows: "It soon becomes apparent that the degree of infection is in direct proportion to the progress of communications. Geographical isolation is m itself a form of defense- islands lying outside customary sea lanes, and selfsupporting mountain regions, constitute fortresses of passive resistance." 23 Siegfried argues that Europe was unusually vulnerable to attack from acute infectious diseases because there was a double convergence of disease routes into Europe: from tropical America and Atlantic Africa towards southwestern Europe, and from Asia towards Eastern or Mediterranean Europe by sea through the Suez, or by caravan routes from India over the steppes of central Asia.24 Japan, by contrast, was situated a great distance from both of these major disease routes. But how isolated was Japan before 1854' Ronald Toby has argued convincingly that the notion that Japan was a "closed country" from 1639 to 1854 is a myth conceived by Western scholars who viewed Japan as being isolated because Westerners were kept out.25 Japan was never completely cut off from contact with the outside world, and trade with East Asian countries, particularly the Ryukyu Islands, con­ tinued throughout the period. Chinese ships that entered the port of Nagasaki between 1635 and 1852 numbered 5,536—an average of 25.87 ships per year.26 It is evident, then, that there was sufficient human traffic between Japan and other parts of East Asia to permit the transfer of contagious diseases. How then can we account for the absence of important infectious diseases in Japan before 18507 From the evidence presented here, it is obvious that some diseases had no difficulty getting to Japan, whereas Cockburn, The Evolution and Eradication, ρ 99 Siegfried, Routes of Contagion, ρ 17 24 Ibid, ρ 32 25 Ronald P Toby, State and Diplomacy in Early Modern Japan Asia in the Develop­ ment of the Tokugawa Bakufu (Princeton, N J Princeton University Press, 1984) 26Iwao Seuchi, ed , Kaigai kosho shi no shiten, 3 vols (Nihon Shoseki, 1975—1976), 2 323—309 The author is indebted to Ronald P Toby for suggesting this source and for supplying information on the number of Chinese ships that entered Nagasaki during this period 22

23

CHAPTER VIII

198

others were unsuccessful. The characteristics of each individual disease seem to have been the determining factor. Smallpox made the trip from the mainland rather easily because the smallpox virus was re­ sistant to environmental influences and was able to survive even after its host had recovered or died. After smallpox became an endemic disease in Japan, it is difficult for the historian to detect new impor­ tations of the virus, but smallpox would have continued to reenter Japan from the outside. But the history of measles epidemics in Japan suggests that Japan's geographic position and relative isolation did make it difficult for some diseases to reach the Japanese islands. The periodicity of measles epidemics in TokugawaJapan resembles that of isolated island coun­ tries whose populations were very much smaller. The fragility of the measles virus must be regarded as the major reason why measles failed to cross the short distance from the Asian mainland more frequently. Climate may also have been important: the measles virus thrives best in cold temperatures, and the average yearly temperature around Nagasaki (x = 61° F.) is considerably higher than in northern Europe (England: χ = 50° F.; Germany: χ = 48° F.), where measles epidemics were much more frequent.27 The measles virus would have had to cross the sea to Japan under less than ideal conditions, and it may be significant that all measles epidemics for which we have seasonal information began in Nagasaki in the coldest months of the year. Before we can determine why measles reached Japan so infrequent­ ly, we must know more about the history of measles in the neighbor­ ing world of East Asia. Where were the human reservoirs from which measles came? China's large, densely settled, highly urbanized popu­ lation would seem to be the most likely candidate, but unfortunately we know little about the history of measles or other acute infectious diseases in China or in Korea, Japan's closest neighbor. We also need to know more about the timing and conditions of trade in different periods. Since some diseases got to Japan quite easily, the reason why measles did not must have to do with the fragility of the measles virus and its short period of communicability. How long after a ship left an Asian port did it arrive in Japan? Were children aboard the Dutch and Chinese ships that docked in Nagasaki? If measles was an endemic disease in China, it would have been prima­ rily a disease of children, and would therefore have required children who were infected with measles to transmit it. In addition, we need to know more about the routines of com­ merce and the kinds of contact that took place between the Japanese 27

Encyclopaedia Britannica World Atlas , 1960, Plate 25.

CONCLUSIONS

199

and outsiders. The transfer of the measles virus requires close contact between a person in the communicable stage of measles and a person not previously exposed. Officials of the Tokugawa government were in charge of the port of Nagasaki, trade was strictly supervised, and it would not have been difficult to operate some kind of quarantine system that reduced the likelihood of this kind of contact. The Japa­ nese were well aware that measles came to Japan on ships from other countries and that it could cause devastating epidemics. There would have been every motivation to try to develop a system that would keep measles out. For whatever reason, before the last quarter of the nineteenth cen­ tury the measles virus did not get to Japan very often, and when it did, it died out within a short period of time. This suggests that measles may not have been an endemic disease in early modern Europe either. Given the great volume and velocity of trade in Europe, the measles virus may simply have been continuously circulated between the countries of Europe and repeatedly reintroduced into cities like Lon­ don where cases were reported every year. The unusual, but clear, epidemiological pattern of measles in premodern Japan suggests that the criterion of population size alone is not sufficient to determine whether or not transmission of the measles virus can be sustained: the size and, particularly, the density of the pool of susceptibles and the speed with which the pool is replenished are crucial, as are the range and type of international contact. Japan's isolation during the Tokugawa period did make a difference in the case of measles. And the history of cholera in Japan also suggests that her isola­ tion—however imperfect—continued to protect her from infectious diseases well into the nineteenth century. There is only one way to explain the absence of cholera epidemics in Japan between 1822 and 1858: people who were infected with cholera did not enter Japan and contaminate the food or drinking water there. But a precise under­ standing of why cholera failed to reach Japan, when it managed to circle the world many times during this period, requires a systematic investigation of the location and timing of cholera epidemics in neighboring countries, of shipping patterns between Japan and other regions, and of inspection procedures and quarantine methods used by the Japanese to prevent infections from entering Nagasaki. When we consider the epidemiology of bubonic plague and the methods that were successful in stopping its spread elsewhere, it is not so surprising that Japan managed to avoid epidemics of this disease. Scholars who have traced the movements of bubonic plague in Eu­ rope have found that geographical barriers and quarantines that were

200

CHAPTER VIII

rigorously enforced by strong governments were often effective in preventing bubonic plague from spreading to regions that were free of infection.28 They argue that quarantines against plague were suc­ cessful in Europe only after national governments had gained suffi­ cient authority to close borders and ports for long periods. In Europe, diseases gained entry through many different ports, and there were few formidable barriers between countries. Japan's situ­ ation was very different: diseases had to cross the Japan Sea, ports of entry were few, and the bakufu or its agents had complete control over these ports until 1854. In Austria, a cordon sanitaire that was created in 1728 to keep bubonic plague from entering from Turkey was success­ ful, but the quarantine required an enormous effort on the part of the Austrian government.29 Unlike Austria, Japan had the advantage of being surrounded on all sides by a natural cordon sanitaire that was apparently able to keep bubonic plague out of the country until the end of the nineteenth century. This study has shown that certain diseases failed to reach Japan in spite of the fact that foreign trade with neighboring Asian countries continued throughout the Tokugawa period. Therefore, Japan's geo­ graphic position and her island status must be only part of the answer. England also was an island nation, and the New World was much farther from the disease pools of Eurasia than was Japan. Bubonic plague, measles, and cholera reached these regions with little dif­ ficulty. It seems likely therefore that the Japanese may have played an active role in keeping foreign diseases out of the country. For example, Japanese port officials may have tried to identify and quarantine ships that had visibly sick persons aboard. Certainly the tendency for measles and other infections to enter Japan by way of Nagasaki was general knowledge at the time. And although it seems obvious that geographic isolation served to protect Japan from im­ portant Eurasian diseases, much more needs to be learned about the nature of Japan's contacts with the outside world before Japan's dis­ ease history can be fully understood. Once acute infectious diseases reached Japan, they followed typical epidemiological patterns that were entirely appropriate given Japan's population and environmental characteristics. In the case of smallpox and measles, population density, population distribution, and herd immunity were the most important factors. Community standards of sanitation and personal hygiene had little influence on the multitudes who became infected with these two diseases. In the case of enteric 28

Flinn, "Plague in Europe," pp. 138-47.

29Ibid.,

pp. 143-47.

CONCLUSIONS

201

infections, however, environmental factors are of much greater im­ portance, and it is worth mentioning some of the ways in which cultural and environmental factors that influence the propagation and dissemination of disease-causing organisms may have been different in Japan than they were in premdustnal Europe. Studies by historians and statisticians have documented the high death rates in early modern European cities. Crowded conditions created a dense population of human hosts, and the enormous dif­ ficulties of disposing of sewage and supplying drinking water for large numbers of people meant that premdustnal cities were human death traps. Several important studies focus on the remarkably bad conditions and high death rates that were typical of the city of London.30 William Farr, a pioneering reformer and statistician in England (1807—1883), spent much of his life exposing the conditions that he believed promoted disease and premature death in London. "The mortality of children under 5 years of age," he reported, "is twice as great m London as in adjacent counties, including several towns."31 Farr held the sanitary condition of the Thames responsible for the spread of cholera, and he believed that the infecting agent came from sewage deposited in the river. He wrote, "The contents of the greater part of the drains, sinks, and water-closets of this vast city and of 2,360,000 people on its sides, are discharged through the sewers into its waters; which ... have now lost all their cleanness and purity." 32 Other Western cities of this same period were also notorious for high disease rates and poor living conditions. By the nmeteenth cen­ tury, some American cities, although still much smaller, were begin­ ning to rival European cities m terms of squalor.33 In New York City m 1865, grossly unsanitary conditions were common knowledge, and 30 The following references represent a small sample of the hterature on disease and high death rates m London in different periods Andrew B Appleby, "Nutrition and Diseases The Case of London 1550—1750," The Journal of Interdisciplinary History 6 (1975), Roger Finlay, Population and Metropolis The Demography of London, 1580— 1650 (Cambridge Cambridge University Press, 1981), Francis Sheppard, The History of London, 1808—1870 The Infernal Wen (Berkeley and Los Angeles University of California Press, 1971), E A Wngley, "A Simple Model of London's Importance in Changing English Society and Economy, 1650—1750," Past and Present 37 (June 1967) 44-70 31Noel A Humphreys, ed , Vital Statistics A Memorial Volume of Selections from the Reports and Writings of William Farr, MD,DCL,CB,FRS, Late Superintendent of the Statistical Department of the Registrar General's Office, England (London Offices of the Sanitary Institute, 1885), ρ 154 32 Ibid , ρ 341 33 Charles E Rosenberg, The Cholera Years the United States in 1832, 1849, and 1866 (Chicago, 111 University of Chicago Press, 1962), ρ 178

202

C H A P T E R VIII

overcrowded tenements made "periodic outbreaks of typhoid, dysen­ tery, and typhus inevitable." 34 In the spring of 1866, a new Metropo­ litan Board of Health, frightened into action by an approaching chol­ era epidemic, took reponsibility for cleaning the city streets for the first time. "One of the board's first tasks ... was the removal of some one hundred and sixty thousand tons of manure from vacant lots." 35 Did preindustrial Japanese cities have similar problems? In the eigh­ teenth century, the Japanese islands claimed three of the world's ten largest cities. This fact alone means that Japan was predisposed to high levels of infectious disease because of the large concentrations of po­ tential hosts. It is difficult to compare conditions and death rates in different preindustrial cities, but the following account from the jour­ nal of Edward Morse is especially telling: Somewhat astonished at learning that the death-rate of Tokyo was lower than that of Boston, I made some inquiries about health matters. I learned that dysentery and cholera infantum are never known here; some fevers due to malaria occur, but are not common But those diseases which at home are attributed to bad drainage, imperfect closets, and the Hke seem to be unknown or rare, and this freedom from such complaints is probably due to the fact that all excrementitious matter is carried out of the city by men who utilize it for their farms or rice-fields. With us the sewage is allowed to flow into our coves and harbors, pollut­ ing the water and killing all aquatic life; and the stenches arising from the decomposition and filth are swept over the community to the misery of all. In Japan this material is scrupulously saved and goes to enrich the soil. It seems incredible that in a vast city like Tokyo this service should be performed by hundreds of men who have their regular routes. The buckets are suspended on carrying-sticks and the weight of these full buckets would tax a giant. This stuff is often transported miles into the countryside where it is allowed to remain in open half oil-barrels for a time and then is distributed to the rice-fields by means of longhandled wooden dippers.36 Other Japanese customs may also have helped to reduce the in­ cidence of infection from enteric diseases inJapan. It was customary to boil drinking water in Japan and to eat only food that was cooked. There were also religious taboos against eating meat. All of these 3 4 Ibid., 3 5 Ibid.,

p. 184. p. 210.

36Morse, Japan, Day by Day, 1:23-24.

CONCLUSIONS

203

customs would have reduced the opportunities to ingest pathogens that cause enteric diseases. Unquestionably, this is impressionistic evidence. But before we assume that the cities of preindustrial Japan resembled the diseaseridden cities of Europe, we must try to determine the quality of the drinking water, how wastes were disposed of, and what general stan­ dards of public health and personal hygiene were in effect. Epidemic diseases claim the greatest number of lives in big cities, and death rates were obviously higher in Japanese cities than in the Hida villages, but it is also possible that Japanese cities of the Edo period had lower death rates than Western cities. There is an impressive literature, for the most part European, to show that acute infectious diseases were the primary cause of prema­ ture death in preindustrial societies, but little has been written about preindustrial societies that managed to successfully avoid the ravages of the worst infections—presumably because there were so few such societies. One exception is Panum's fascinating analysis of gen­ eral mortality and length of life in the Faeroe Islands. Panum found that in spite of extremely primitive living conditions, a very limited diet, and cold, wet weather, the inhabitants of the Faeroe Islands had lower death rates and a considerably longer life span than any Eu­ ropean country at that time. Panum cited the lowest average length of life as 21.3 years in Russia, and the highest as 38.5 years in England. He calculated the average length of Hfe in the Faeroe Islands, based on ages of death, to be 44.6 years. This longer life span occurred, not because of a higher standard of living or better nutrition, but because at that time, the Faeroes were visited by very few epidemic diseases. Only influenza reached there regularly; smallpox was not an endemic disease, scarlet fever was unknown, and there were no measles epi­ demics in the Faeroe Islands between 1781 and 1846.37 Panum's conclusions concerning the favorable rates of mortality in the Faeroes were expressed as follows: we are led to accept the assumption that the entire or partial exemption of the Faroe Islands from a number of diseases, espe­ cially those which are infectious, which decimate the populations of other countries, is the most important of all reasons for the favorable rates on these islands, and the high limit of life of the inhabitants.38 37 Panum

mentions typhus, but it is not believed that he was able to distinguish between typhus and typhoid fever. See Panum, Observations, p. 80 n. 26. 38 Panum, Observations, p. 41. Panum was judging Hfe span by calculating average ages at death.

204

CHAPTER VIII

It appears that Japan benefited in similar fashion even though many more diseases were present there. Lower mortality from epidemic disease may mean that the average life span in Japan before 1850 was longer than in early modern Europe. Laurel Cornell, using the shUmon aratame ώδ of Yokouchi, demonstrates that the average age at which men retired as household head was 59.3 years (mode = age 60).39 And most men lived to the age of retirement: "In the 1700s, slightly over half of the successions occur prior to the death of the household head; in the 1800s seventy percent do so."40 The mean age of those who died before retirement was 53.4 years (mode = age 53).41 Hirata Kinitsu, using kakocho from 251 temples in Gifu prefecture between 1700 and 1850, reports an average age of death of 59.7 sai.42 These studies suggest that many Japanese in early modern times had a remarkably long life span, and they complement earlier findings of low mortality in the late Tokugawa period. In some important respects, this analysis of epidemics and mortality in Japan supports the arguments of the "early modern economic development" school of Japanese history. It helps to explain the low mortality rates that Susan Hanley and Thomas C. Smith have found for eighteenth- and nineteenth-century Japanese villages, because low mortality from acute infectious diseases would have effectively lowered overall mortality. This study suggests that mortality was low because two of Malthus's "positive" checks on population growth— war and pestilence—-were both relatively unimportant during the Tokugawa period. These conclusions also provide a noneconomic rationale in support of Smith's theory that the Japanese population was practicing abor­ tion and infanticide as a means of birth control or family planning. Such strategies would have made little sense if mortality levels were high and few children survived to adulthood. It has been shown that low mortality levels play an important role in decisions about family size and composition, and "known low mortality is one of the neces­ sary conditions for an effective social policy for reducing fertility."43 This study suggests that "positive" checks to population growth were weak in Japan, and that strong "preventive" checks were needed if family size was not to grow beyond family resources. 39Laurel

L. Cornell, "Peasant Family and Inheritance," p.86. pp. 84-86. 41Ibid., p. 86. 42Hirata Kinitsu, "Kakocho kara mita mukashi hito no jumyd," Minzoku eisei 29 (July 1964):95. 43 Ronald Freedman, "Norms for Family Size in Underdeveloped Areas," Proceed­ ings of the Royal SocietY of London, Series B, 159 (December 1963) :227. 40Ibid.,

CONCLUSIONS

205

However, Smith's view that population growth in Japan was con­ trolled by a widespread system of infanticide may be overstated. The findings and conclusions of this study point to the need for further research on infant and child mortality in early modern Japan. As we have seen, young children under the age of 5 were far more likely to die of acute infectious diseases than any other age group, and mor­ tality from other causes may also have been high among young chil­ dren. In the Hida villages, most children who died did not die of smallpox, measles, or dysentery. They died of other causes—as yet unknown—and most died during their first year of life. Even in Edo Castle, where poverty was obviously not a problem, half of the Tokugawa offspring born in the early nineteenth century died in infancy. There has been virtually no research on infant mortality in preindustrial Japan because of the nature of the sources used in research on historical demography. The village population registers, the shiimon aratame cho, cannot be used to study infant mortality because children who were born and died between annual censuses were never counted. However, kakochd do include deaths of infants, and new demographic techniques have been worked out to construct Ufe tables and to estimate birth and death rates using records of deaths.44 If infant mortality was high in Japan, Ufe tables constructed from temple death registers will look very different from Ufe tables based on the shiimon aratame cho.45 Such research is needed to further eval­ uate the importance of abortion and infanticide in Tokugawa Japan. This study concludes that the cessation of national population growth between 1728 and 1850 was not due to any increase in the frequency or severity of epidemic diseases. It also suggests that peri­ odic famines—the third "positive" check on population growth— may have had an important impact on mortaUty in some regions dur­ ing the Tokugawa period. The most severe mortality crisis in the Hida region between 1771 and 1852 was caused by the Tempo famine of the 1830s.46 Subsistence crises were severe in some regions of Japan, and further research is needed to determine the importance of 44Samuel H. Preston and Ansley J. Coale "Age Structure, Growth, Attrition, and 1 Accession: A New Synthesis," Population Index 48, 2 (Summer 1982) :217-59. 45 Susan B. Hanley, "Fertility, Mortality, and Life Expectancy in Premodern Japan," Population Studies 28 (March 1974): 127—41. 46 Kalland and Pedersen's study of kakochd from several temples in Fukuoka domain in Kyushu shows that about 20 percent of the population died in the Kyoh5 famine of the early 1730s. Kalland and Pedersen, "Famine and Population in Fukuoka Domain," p. 32.

206

CHAPTER VIII

malnutrition—periodic or chronic—in limiting population growth during this period. But even if future research indicates that famines played a major role in limiting population in early modern Japan, the absence of war and the minor role of epidemics suggest that preindustrial Japan and Europe had very different demographic regimes. The demographic reverses of seventeenth-century Europe, where years without war or plague were few, were not part of the Japanese experience. Japan's already large population grew even larger in the seventeenth century. And when Japan's population stopped growing in the early eigh­ teenth century, it was not because of either wars or epidemics. Japan's population equilibrium was achieved by other means. This represents a qualitative difference of considerable significance. It implies different political, cultural, and environmental conditions in Japan and the West, and it suggests that the changes needed to transform Japan into a modern society were also different from those needed in the West. In the 1850s, Japan's ability to limit her contact with the outside world ended abruptly, and it is clear that in the years following the opening of new Japanese ports to foreign ships, Japan suffered increas­ ingly from epidemic diseases. The remarks of Dr. Duane Simmons, made as he left Japan in 1881 after residing there for many years, indicate the difficulties caused by epidemics in the early years of contact with foreigners: There was that cruel epidemic of Asiatic cholera in 1861—1862, which raged from end to end of the Empire, and carrying off a hundred and fifty thousand persons in Tokyo alone, completely overshadowed everything that we have since experienced. Alto­ gether, indeed, Japan had a good many calamities to endure in those days. These cholera ravages were the successors, by a short interval, of a plague of measles, which is said to have attacked no less than fifteen millions of the people in six months and to have killed seventy-five thousand in Tokyo. These figures may be a little unreliable, but what is quite certain is that in some cases every servant in the principal homes was prostrated by the dis­ ease at the same time, so that the foreigners were obliged to cook their own food.47 The cordon sanitaire that had protected Japan for centuries was perma­ nently breached. Japan had entered the international community, new 47 Japan Daily Mail, December 1, 1881. The cholera epidemic may have started in 1861 in the southwest, as Simmons suggests, and only have reached Edo in 1862; however, all Japanese sources refer to the epidemic of Bunkyu 2. In the Gregorian calendar, Bunkyu 2 began on January 30, 1862.

CONCLUSIONS

207

diseases came into the country, and mortality patterns were perma­ nently altered. If there was a period when epidemics caused "a great dying" in Japan, it was probably between the seventh and eleventh centuries. But this was early in Japan's development, and Japan's early exposure and adaptation to certain diseases and her Umited or late exposure to others had lasting historical consequences. According to Bumet and White: "We might reasonably expect that if a densely populated area remained isolated from all other populous regions, an equilibrium condition would eventually be developed, irrespective of what para­ sites were initially present."48 InJapan this equilibrium remained relatively undisturbed for many centuries: the very size of Japan's population in the Tokugawa period suggests that a balance had been struck between hosts and parasites, and that Japan's adaptation to infectious diseases was largely a successful one. The fact that Japan was spared the legendary epidemics of late medieval and early modern Europe helps to explain Tokugawa Japan's remarkably large popula­ tion, and perhaps the need for strong preventive checks to population growth. 48 Burnet

and White, Natural

History,

p. 13.

GLOSSARY

Smallpox mogasa, tōsō hoso tennentō Chicken pox suitō Measles aka-mogasa

mashin, hashika hashika Rubella mikkahashika fushin Influenza fubyo tenka gaibyo ryuko seikanbo

Enteric infections sekiri ribyo geri ekiri Cholera korera korori Epidemic or Pestilence ekibyo' ekirei jieki Famine kikin Famine kieki kibyo

epidemic

BIBLIOGRAPHY

Aaby, Peter. "The Black Child's Grave: Measles, Overcrowding, and Child Mortality in Africa." Paper presented at the Institute of Ethnology and Anthropology, University of Copenhagen, Denmark, September 1984. Abe K5ki. "Rekishi jinko no minzoku eisei gakuteki kenkyu" (A study of race hygiene in historical demography). Nihon minzoku eisei 36 (January 1970): 1—12. Aikens, C. M., and T. Higuchi. Prehistory of Japan. New York: Academic Press, 1982. Aoki Daisuke, "Ekirei shi." In Saigai hen. Miyagi-ken shi, vol. 22 ("History of epidemics." In Disaster volume. A history of Miyagi prefecture, vol. 22). Sendai: Miyagi-ken shi hensan iinkai, 1962. . "Korera." In Saigai hen. Miyagi-ken shi, vol. 22 ("Cholera." In Disaster volume. A history of Miyagi prefecture, vol. 22). Sendai: Miyagi-ken shi hensan iinkai, 1962. . "Mashin." In Saigai hen. Miyagi-ken shi, vol. 22 ("Measles." In Disaster volume. A history of Miyagi prefecture, vol. 22). Sendai: Miyagi-ken shi hensan iinkai, 1962. . "T5so." In Saigai hen. Miyagi-ken shi, vol. 22 ("Smallpox." In Disaster volume. A history of Miyagi prefecture, vol. 22). Sendai: Miyagi-ken shi hensan iinkai, 1962. Aoki Kazuo. Wara no miyako. Nihon no rekishi, vol. 3 (Our capital. Japanese history, vol. 3). Tokyo: Chuo koronsha, 1965. Appleby, Andrew. Famine in Tudor and Stuart England. Stanford, Cahf.: Stanford University Press, 1978. Arakawa Hidetoshi. Kikin. Nihon shi, no. 94 (Famine. Japanese his­ tory, no. 94). Tokyo: Kyoikusha, 1979. Aston, W. G., trans. Nihongi: Chronicles of Japanfrom the Earliest Times to A.D. 697. Reprint (2 vols, in 1). London: George Allen and Unwin, Ltd., 1956. Ball, A. P. "Measles." In A World Geography of Human Diseases, edited by G. Melvyn Howe. London: Academic Press, 1977. Bartlett, Maurice S. "Measles Periodicity and Community Size," Journal of the Royal Statistical Society 19 (1957) :48-70. Beasley, W. G. The Meiji Restoration. Stanford, Cahf.: Stanford Uni­ versity Press, 1972. Black, Francis L. "Measles Endemicity in Insular Populations: Critical Community Size and Its Evolutionary Implications." Journal of

212

BIBLIOGRAPHY

Theoretical Biology 11 (1966) :207-11. Black, John R. Young Japan: Yokohama and Yedo 1858—79. 2 vols. Oxford: Oxford University Press, 1968. Black, William. A Comparative View of the Mortality of the Human Species at All Ages; and of the Diseases and Casualties by Which They are Destroyed or Annoyed. London: C. Dilly Co., 1788. Bloomfield, Arthur L. A Bibliography of Internal Medicine: Communi­ cable Diseases. Chicago, 111.: University of Chicago Press, 1958. Brachman, PhiHp S. "Epidemiology of Infectious Disease." In Prin­ ciples and Practice of Infectious Diseases, edited by G. L. Mandell,

R. G. Douglas, Jr., and J. G. Bennett. 2 vols. New York: John Wiley and Sons, 1979. Burnet, MacFarlane, and David O. White. Natural History of Infectious Disease. 4th ed. Cambridge: Cambridge University Press, 1972. Burton, Lloyd E., and Hugh H. Smith. Public Health and Community Medicine. Baltimore, Md.: Williams and Wilkins, 1975. Cartwright, Frederick F. Disease and History. New York: Thomas Y. Crowell Co., 1972. Chambers, J. D. Population, Economy, and Society in Pre-Industrial England. Oxford: Oxford University Press, 1972. Chandler, Tertius, and Gerald Fox. 3000 Years of Urban Growth. New York: Academic Press, 1974. Christiansen, P. E., Povl Elo, Henning Schmidt, Oskar Jensen, H. O. Bang, Vera Anderson, and Bjarne Jordal. "An Epidemic of Measles in Southern Greenland, 1951." 3 parts. Acta Medica Scandinavia 144 (1952-53):313-22; 430-49; 450-54. Christie, A. B. Infectious Diseases: Epidemiology and Clinical Practice. 2nd ed. Edinburgh: Churchill Livingstone, 1974. . "Smallpox." In A World Geography of Human Diseases, edited by G. Melvyn Howe. London: Academic Press, 1977. Cockburn, Aiden. The Evolution and Eradication of Infectious Diseases. Baltimore, Md.: Johns Hopkins University Press, 1963. Concannon, R. J. G. "The Third Enemy: The Role of Epidemics in the Thirty Years' War." Cahiers d'histoire mondiale 10 (1967): 500-511. Cooper, Michael, ed. They Came to Japan: An Anthology of European Reports on Japan, 1543—1640. Berkeley and Los Angeles: Univer­ sity of CaUfornia Press, 1965. Cornell, Laurel L. "Peasant Family and Inheritance in a Japanese Community: 1671—1980." Ph.D. diss., Johns Hopkins Univer­ sity, 1981. Creighton, Charles. A History of Epidemics in Britain. 2nd ed. 2 vols. London: Frank Cass and Co, Ltd., 1965.

BIBLIOGRAPHY

213

Dekkers, Nicholaas W. Ν. Μ. The Cornea in Measles. The Hague: Dr W. Junk Β. V., 1981. Dunstan, Helen. "The Late Ming Epidemics: A Preliminary Survey." Ch'ing-shih wen-t'i 3, 3 (November 1975): 1—59. Durand, John. "Historical Estimates of World Population: An Eval­ uation." Population and Development Review 3 (September 1977): 253-96. Farris, William Wayne. Population, Disease, and Land in Early Japan, 645—900. Cambridge, Mass.: Harvard University Press, 1985. Fenner, Frank. "Infectious Disease and Social Change." Parts 1, 2. Medical Journal of Australia 1, 20 and 21 (May 15 and 22, 1971): 1043-47, 1099-1102. Fiennes, Richard N. T-W-. Zoonoses and the Origins and Ecology of Human Disease. London: Academic Press, 1978. Flinn, M. W. The European Demographic System, 1500—1820. Bal­ timore, Md.: Johns Hopkins University Press, 1981. . "Plague in Europe and the Mediterranean Countries," Journal of European Economic History 8 (Spring 1979): 131—48. . "The Stabilization of Mortality in Pre-Industrial Western Europe." Journal of European Economic History 3 (1974) :285-318. Francis, Thomas, Jr. "Influenza." In Viral and Rickettsial Infections of Man, edited by Τ. M. Rivers and F. L. Horsfall, Jr. 3rd ed. Philadelphia, Pa.: J. B. Lippincott Co., 1959. Freedman, Ronald. "Norms for Family Size in Underdeveloped Areas," Proceedings of the Royal Society of London, Series B, vol. 159 (December 1963) :220-45. Fujikawa Yu. Nihon shippei shi (A history of epidemics in Japan). 3rd ed. Tokyo: Heibonsha, 1969. Gotibert, Pierre. Beauvais et Ie Beauvaisis de 1600 a 1730. Paris: S.E.V.P.E.N., 1960. Greenwood, Major. Epidemics and Crowd Diseases: An Introduction to the Study of Epidemiology. New York: Arno Press, 1977. Habbakuk, H. J. "English Population in the Eighteenth Century." In Population in History, edited by D. V. Glass and D. E. C. Eversley. Chicago, 111.: Aldine Publishing Co., 1965, pp. 269—84. Hall, John W. Government and Local Power in Japan, 500 to 1700: A Study Based on Bizen Province. Princeton, N.J.: Princeton Uni­ versity Press, 1973. Hanley, Susan B. "FertiMty, Mortality, and Life Expectancy in Premodern Japan." Population Studies 28, 1 (March 1974):127—41. . "A High Standard of Living in Nineteenth Century Japan: Fact or Fantasy."Journal of Economic History 43,1 (1983):183—92. . "Toward an Analysis of Demographic and Economic

214

BIBLIOGRAPHY

Change in Tokugawa Japan: A Village Study." Journal of Asian Studies 31, 3 (May 1972) :515-37. Hanley, Susan B., and Kozo Yamamura. Economic and Demographic Change in Pre-Industrial Japan, 1600—1868. Princeton, N.J.: Princeton University Press, 1977. Hara Nany5. Sokei Guki (Accounts of various matters). 1800. Harper, G.J. "Airborne Micro-organisms: Survival Tests With Four Viruses." Journal of Hygiene 59 (1961) :479-86. Hauser, William B. Economic Institutional Change in Tokugawa Japan: Osaka and the Kinai Cotton Trade. Cambridge: Cambridge Uni­ versity Press, 1974. Hayami Akira. "The Population at the Beginning of the Tokugawa Period." Keio Economic Studies 4 (1966—67): 1—28. . "Thank You Francisco Xavier: An Essay in the Use of Micro-Data for Historical Demography of Japan." Keio Eco­ nomic Studies 16, 1—2 (1979) :65-81. and Nobuko Uchida. "Size of Household in a Japanese County throughout the Tokugawa Era." In Household and Family in Past Time, edited by Peter Laslett with Richard Wall. Cambridge: Cambridge University Press, 1972. Hida hennen shiyd (A chronological history of Hida province). Gifu: Jui shoten, 1921. Hirata Kinitsu. "Kakocho kara mita mukashi hito no jumyd" (An analysis of the length of life in former times based on temple death registers). Minzoku eisei 29 (July 1964):73-96. Hirsch, August. Handbook of Geographical and Historical Pathology. 3 vols. London: New Sydenham Society, 1883. Honjo Eijiro. The Social and Economic History of Japan. New York: Russell and Russell, 1965. Hopkins, Donald R. Princes and Peasants: Smallpox in History. Chi­ cago, 111.: University of Chicago Press, 1983. Howe, G. Melvyn. "The Environment, Its Influences and Hazards to Health." In A World Geography of Human Diseases, edited by G. Melvyn Howe. London: Academic Press, 1977. Huard, P. "La syphilis vue par Ies Avabo-persans, Indiens et SinoJaponais du XVe et XVIe siecle." Histoire de Ie Medecine 6 (July 1965):9-13. Humphreys, Noel A., ed. Vital Statistics: A Memorial Volume of Selec­ tions from the Reports and Writings of William Farr, M.D., D.C.L., C.B., F.R.S., Late Superintendent of the Statistical Department of the Registrar General's Office, England. London: Offices of the Sani­

tary Institute, 1885. Iwao Seiichi, ed. Kaigai koshd shi no shiten (An investigation into the

BIBLIOGRAPHY

215

history of foreign trade relations). 3 vols. Tokyo: Nihon shoseki, 1975-1976. Jusatz, H. "Cholera." In A World Geography of Human Diseases, edited by G. Melvyn Howe. London: Academic Press, 1977. Kaempfer, Engelbert. The History of Japan Together With a Description of the Kingdom of Siam 1690—1692. Translated by J. G. Scheuzer. 3 vols. Glasgow: James MacLehose and Sons, 1906. Kalland, Arne, and Jon Pedersen. "Famine and Population in Fukuoka Domain During the Tokugawa Period." The Journal of Japanese Studies 10, 1 (Winter 1984):31-72. Kamo no Chomei. Hojoki. Nihon koten bungaku taikei, vol. 30. (An account of my hut. A compendium of classical Japanese litera­ ture, vol. 30). Tokyo: Iwanami shoten, 1966. Kasuga T. "Nihon no pesuto ryuko shi kara mita saikin gaku, ekigaku jo no ni, san no ten ni tsuite (Two or three points concerning the history of bubonic plague in Japan based on bacteriology and epidemiology)." Nihon saikin gaku zasshi 32, 1 (1977) :33-34. Kawauchi Kazuo. "Tanegashima ni okeru Edojidai no jink5 sui-i no jokyo ni tsuite no ikko sai" (A consideration of the population transition on Tanegashima during the Edo period). Nihon ishigaku zasshi 19 (December 1973) :317-33. . "Tanegashima ni okeru toso ni tsuite" (Smallpox on Tane­ gashima). Nihon ishigaku zasshi 19 (June 1973): 174—92. Keys, Ancel, Josef Brozek, Austin Henschel, Olaf Mickelsen, and Henry Longstreet Taylor. The Biology of Human Starvation. 2 vols. Minneapolis: University of Minnesota Press, 1950. Kikuchi Kazuo. Nihon no saigai: Edo goki nojiin kakocho ni yoru jisshd (A history of disasters in Japan based on evidence from temple death registers of the late Edo period). Tokyo: Kokon shoin, 1980. Kuguno-cho shi (A history of Kuguno district). Kuguno, Gifu-ken: Ono-gun Kuguno-cho yakuba, 1957. McClellan, Edwin. Woman in the Crested Kimono: The Life of Shihue Io and Her Family Drawn from Mori Ogai's "Shibue Chiisai." New Haven, Conn.: Yale University Press, 1985. McCullough, William H., and Helen Craig McCullough, trans. A Tale of Flowering Fortunes: Annals of Japanese Aristocratic Life in the Heian Period. 2 vols. Stanford, Calif.: Stanford University Press,

1980. McKeown, Thomas. The Modern Rise of Population. New York: Academic Press, 1976. McNeill, William H. Plagues and Peoples. Garden City, N.Y.: Anchor Press, 1977.

216

BIBLIOGRAPHY

Maekawa Kyutaro. "Sasuyu kiroku yori mita toso, mashin, suito, no Ooku e no denpa" (The dissemination of smallpox, measles, and chicken pox to the Ooku as shown in the records of the sasuyu ceremony). Nihon ishigaku zasshi 22 (1976): 157—68. Malthus, Thomas Robert. Population: The First Essay. Ann Arbor: University of Michigan Press, 1959. Matsuda Michio. "Kaisetsu" (A commentary). In Fujikawa Yu, Nihon shippei shi. Tokyo: Heibonsha, 1969, pp. 320—43. Matsuda Takeshi. "Edo jidai hashika wa inochitori datta" (Measles, a life-threatening disease in the Edo period). Yomiuri shinbun (July 8,1981). . "Edo jidai no mashin ryuko" (Measles epidemics in the Edo period). Nihon ishigaku zasshi Tl (1981) :29-32. Matsuki Akitomo. "Meiji-zen Hokkaido shippei shi" (A history of epidemics in pre-Meiji Hokkaido). Nihon ishigaku zasshi 17 (1971):206-12. Meuvret, J. "Demographic Crisis in France From the Sixteenth to the Eighteenth Century." Translated by Margaret Hilton. In Popu­ lation in History: Essays in Historical Demography, edited by D. V. Glass and D. E. C. Eversley. Chicago, 111.: Aldine Publishing Co., 1965. Miller, Roy Andrew. The Origins of the Japanese Language. Seattle: University of Washington Press, 1980. Miyamura shi (A history of Miyamura). Miyamura: Kyoiku iinkai, 1968. Morris, R.J. Cholera 1831: The Social Response to An Epidemic. New York: Holmes and Meier Publishers, Inc., 1976. Morse, Edward. Japan, Day by Day, 1877, 1878—79, 1882—83. 2 vols. Boston and New York: Houghton Mifflin Co., 1917. Mosk, Carl. "Fertility Transitions in Japan and Korea: A Com­ parison." Paper delivered at a Regional Conference sponsored by the Committee for the Chinese Economy of the Social Science Research Council, Hoover Institution, Stanford Uni­ versity, January 1979. Panum, Peter Ludwig. Observations Made During the Epidemic of Measles on the Faroe Islands in the Year 1846. Translated by Ada S. Hatcher. New York: Delta Omega Society, 1940. Pfaundler, M., and A. Schlossmann. The Diseases of Children. 5 vols. Philadelphia, Pa.: J. B. Lippincott Co., 1910. Phadke, A. M., N. R. Samant, and S. D. Dewal. "Smallpox as an Etiologic Factor in Male Infertility." Fertility and Sterility 24 (1973) n802—804. Preston, Samuel H. Mortality Patterns in National Populations: With

BIBLIOGRAPHY

217

Special References to Recorded Causes of Death. New York: Aca­ demic Press, 1976. , and Ansley J. Coale. "Age Structure, Growth, Attrition, and Accession: A New Synthesis." Population Index 48, 2 (Summer 1982):217-59. Razzell, Peter. The Conquest of Smallpox: The Impact of Innoculation on Smallpox Mortality in Eighteenth Century Britain. Firle, Sussex: Caliban Books, 1977. Rozman, Gilbert. Urban Networks in Ch'ing China and Tokugawa Japan. Princeton, N.J.: Princeton University Press, 1973. Saito Yukinari. Bukd nenpyo (Chronological table of Edo). Edited by Kaneko Mitsuharu. 2 vols. Tokyo: Heibonsha, 1968. Sakamoto-Momoyama Masako. Seasonality in Human Mortality. Tokyo: University of Tokyo Press, 1977. Sangster, G. "Diarrheal Diseases." In A World Geography of Human Diseases, edited by G. Melvyn Howe. London: Academic Press, 1977. Sansom, George. A History of Japan to i334. Stanford, Calif.: Stanford University Press, 1958. . A History of Japan, 1615—1867. Stanford, Calif.: Stanford University Press, 1963. Sen, Amartyr Kumar. "Famine Mortality: A Study of the Bengal Famine of 1943." In Peasants in History, edited by E. J. Hobsbawm, Witold Kula, Ashok Mitra, K. W. Raj, and Ignacy Sachs. Oxford: Oxford University Press, 1980. . Poverty and Famines: An Essay on Entitlement and Deprivation.

Oxford: Clarendon Press, 1981. Shrewsbury, J. F. D. A History of Bubonic Plague in the British Isles. Cambridge: Cambridge University Press, 1971. Siegel, Sidney. Nonparametric Statisticsfor the Behavioral Sciences. New York: McGraw-Hill, 1956. Siegfried, Andre. Routes of Contagion. Translated by Jean Henderson and Mercedes Claraso. New York: Harcourt, Brace and World, Inc., 1965. Slack, Paul. "Mortality Crises and Epidemic Disease in England, 1485—1610." In Health, Medicine, and Mortality in the Sixteenth Century, edited by Charles Webster. Cambridge: Cambridge University Press, 1979. Smith, Thomas C. The Agrarian Origins of Modern Japan. Stanford, Calif.: Stanford University Press, 1959. , Robert Y. Eng, and Robert T. Lundy. Nakahara: Family Farming and Population in a Japanese Village, 1717—1830. Stanford, Cahf.: Stanford University Press, 1977.

218

BIBLIOGRAPHY

Stone, Lawrence. The Family, Sex and Marriage in England, 1500—1800. New York: Harper and Row, 1977. Suda Keiz5. Hida "O" jiin kakocho no kenkyu. (A study of the death records of "O" temple in Hida province). Takayama: Private edition, 1973. Taeuber, Irene. The Population of Japan. Princeton, N.J.: Princeton University Press, 1958. Takayama-shi shi (A history of Takayama city). 2 vols. Takayama: Takayama insatsu kabushiki kaisha, 1981. Tatsukawa Shoji. Nihonjin no byoreki (A history of illnesses of the Japanese people). Tokyo: Chiiko shinsho, 1976. . "Shomin shiryo ni miru Edo jidai no shippei" (Diseases in the Edo period as described in popular literature). Nihon ishigaku zasshi 20 (1974):313-35. Toby, Ronald P. State and Diplomacy in Early Modern Japan: Asia in the Development of the Tokugawa Bakufu. Princeton, N.J.: Princeton University Press, 1984. Uchida Masao, comp. Nihon rekijitsu genten (Japanese calendar con­ version tables). Tokyo: Yusankaku shuppan, 1975. Webster, Charles, ed. Health, Medicine, and Mortality in the Sixteenth Century. New York: Cambridge University Press, 1979. Webster, Noah. A Brief History of Epidemic and Pestilential Diseases; With the Principal Phenomena of the Physical World, Which Precede and Accompany Them, and Observations Deduced From the Facts Stated. 2 vols. Hartford, Conn.: Hudson and Goodwin, 1799. Wendt, Edmund Charles, ed. A Treatise on Asiatic Cholera. New

York: William Wood and Co., 1885. Wolf, Eric R. Europe and the People Without History. Berkeley: Uni­ versity of Cahfornia Press, 1982. Wrigley, E. A. "A Simple Model of London's Importance in Chang­ ing English Society and Economy, 1650-1750." Past and Present 37 (June 1967):44-70. Wrigley, Ε. A., and R. S. Schofield. The Population of England, 1540— 1981: A Reconstruction. Cambridge, Mass.: Harvard University Press, 1981. Yamagiwa, Joseph K., trans. The Okagami: A Japanese Historical Tale. Rutland, Vt.: Charles E. Tuttle, 1966. Yamashita Yoshiaki. "Nihon keneki shi" (A history of quarantine in Japan). Nihon igakushi zasshi 14 (May 1968):1—35. Yamazaki Tasuku. Nihon ekishi oyobi boeki shi (A history of epidemics and their prevention in Japan). Tokyo: Kokuseido, 1931.

INDEX

abortion in Japan, 204, responsible for low fertility, 7 acute infections disease, 19 See also disease adjusted age definition, 56, for Japanese statistics, 91 η age calculation in Japan, 55-56 agricultural practices, influence on density-dependent diseases, 22 agricultural productivity, influence on population growth, 8 animals, domestication of, 26 antibodies, 19 anti-contagiomsts, 103n Aoki Daisuke, 51—52, 71, 151 Arakawa Hidetoshi, 177-78 Asiatic cholera, see cholera azoospermia, effect of smallpox, 189 Bartlett, Maurice S , 111 Bengal famine, 1943, 185—86 See also famine birth rates, 17-18th centuries, 10 births, lack of data in Tokugawa period, 55 Black, Francis L , 111 Black, John R , 105 Black, William, 189 Black Death, xix, 193 black rat, see Rattus rattus bubonic plague, xix, absence of epidemic in Japan, 191-92, 195-98, account of manifestation, 192—94, China, 193, control in Europe and Japan, 199-200, cordon samtaire in Austria, 200, epidemiology, 193, Europe, 192, Far East, 194, Japan, 15, origin, 27 Buko nenpyo, 100 calendar, Japanese, 56 Chambers, J D , 175-76 children, deliberate exposure to small­ pox, 105 cholera carried from India to Japan, 156-57, as common name for gastro­

enteritis, 145, conditions influencing transmission, 156, contemporary accounts of symptoms, 158, creation of psychological crisis atmosphere, 171, disease characteristics, 146-47, distinguished from dysentery, 146, effect ofjapanese isolation on epidemiology, 199, entry routes to Japan, 158-59, epidemic of 1822, 159—60, first pandemic, 157, first noted in Nagasaki, 156, fourth pandemic, 168, historical dispute about epidemics of, 169—70, impact on mortality, 165-66, Japanese terms for, 47, 49, 159, mortality in Japan, 170-72, pandemics, timing of, 156—57, patho­ genic agent in, 155, personal accounts, 157—58, prevention, 146—47, second epidemic in Japan, 165, second pan­ demic of 1826—37, 160—63, Sendai region, 166, symptoms, 155, and Temp famine, 184, third pandemic 1846-1863, 163—65, third pandemic in Japan, 164-65, third pandemic personal accounts, 164—65, unclear evidence for impact on mortality, 171 cholera infantum, 145 Cocks, Richard, 31 community disease pattern, 20-21 Concannon, R J G , 24 contagious disease, definition, 19 See also disease Cornell, Laurel, 204 cotton trade, 9 Dazaifu, smallpox epidemic in, 67 death causes in rural pre-industnal society, 57—58, distribution by age group, 60, recording of causes in temple register, 53-54 death rates vs changes in number of deaths, 55, Nakahara, 11, 17-18th centuries, 10 death registers, xxi See also kakocho demographic trends, Japan and Europe compared, 6

220 density-dependent diseases definition, 25, importance in Western Europe, 27, origins, 26 See also disease disease absence of important ones in Japan before 1850, 197—98, account of low amount in Japan, 196, agricultural influences, 22, causes, 16—17, characteristics, 17, effects, 19-20, endemic, 20, epidemiology in Japan, 200—201, evolution of terminology, 46, history of in Japan, xx, imprecise terminology, 33—34, incubation period, 18, influence of physical environment, 22-23, influence of social environment, 23, influence of trade, 23, influence of war, 23—25, names, 33, names designated by Chmese characters, 38, patterns of pre­ valence, 20, period of commumcability, 18, as result of malnutrition, 43, symptoms of death from, compared with those of starvation, 174-75, transmissibihty, 17—18, virulence, 17 See also acute infections disease, contagious disease, density-dependent diseases, endemic, epidemic disease crisis distinguished from sub­ sistence crisis, 173 disease exchange, 27 disease prevention, official policy, 99n drought, mentioned in early famine accounts, 178 dysentery brief history of early Japanese accounts, 191-92, definition, 145, distribution of deaths by age group, 153, distribution of deaths m Hida villages, 151-52, epidemic of 1826 and effect on smallpox epidemic of 1827, 154, first recognized as serious infectious disease, 150, frequency in Japan, 47, high mortality attributed to population density in certain villages, 154, Japanese epidemic, 147—55, Japanese accounts of Tokugawa period, 148—49, Japanese contempo­ rary accounts, 149-50, Japaneseearly accounts, 148, Japanese terminology, 147, Kyoto, 148, listed as cause of death in kakacho, 151, major cause of high mortality in late Tokugawa period, 154-55, mean age of death from, 152, seasonality, 152, treatment, 150, uncommon during Edo period, 151

INDEX economic development and epidemic outbreaks, 45 Edo, population m beginning of 18th century, 97 Etga monogatart, 114 ekibyd, 182-85 endemic definition, 20, pattern, 21 See also disease, epidemic enteric diseases, 145, death rates, 147 enteric infections, characteristics, 146—47 environment (physical), effect on disease processes, 22-23 environment (social), influence on history of human disease, 23 epidemic as check on population growth, 12, chronology in Tokugawa period, 48-49, concurrence with famine, 43, contemporary Japanese accounts, 35, definition, 5, 20, documentation differences in Japan and West, 49—50, Europe, 41n, first Japanese accounts, 40, frequency, 45, 49, identification m sources, 45, independent of famine in Japan, 15, independent of subsistence crisis, 181, influencing factors of severity and impact, 33, inverse relationship with severity and frequency, 22, Japanese accounts, 41-43, Japanese statistics 8—19 centuries, 44, as killers of adults, 184, as killers of children, 184, non­ specific terminology, 58, relation to famine, 173-76, seasons for increase in frequency, 45, as topic m Japanese history, xix—xx See also disease, endemic epidemic diseases autonomous influence on mortality, 176, early accounts in Japan, 38, identification from historical records, 33, role in population growth, 3, seasonality in Japan, 41, source material, xx—xxi, study of, xx FaeroeIslands measles, IlOn, 142—44, mortality, 203 family planning adjustment to smallpox cycle, 105, role of infanticide, 11—12 famme concurrence with epidemic, 43, early Japanese accounts, 176-78, in­ dependent of epidemics in Japan, 15, influence on population growth in Japan, 205-206, Japanese termi­ nology, 177, relation to epidemic,

INDEX 173-76 See also Temmei famine, Tempo famine Farr, William, 201-202 Farns, William, 66 Fenner, Frank, 25 fertility effect on population growth, 3, as factor in low population growth, 8, relation to mortality, 5 Fiji Islands, measles in, 111 food preparation in Japan 202 foreign trade as cause for epidemics, 13 Fujikawa Yu, 13, 39-40, 68 German measles in Nagasaki, 42 See also measles great pox, 63 group immunity, 21 Habu Michikiyo, 102 Habu Rokurozaemon, 101—102 Hachijojima, smallpox m, 102-104 Hall, John, 29 Hanley, Susan, 10, 35, 204 Hara Nanyo, 102, 126 hashtka as common term for measles, 116, evolution of term, 46 Hatch, Arthur, 31 Hauser, William, 9 Hayami Akira, 9, 35 herd immunity, see group immunity Hida region, 14, description, 52, famine and epidemic, 178—85 population growth, 95-97, Tempo famine and mortality, 185 Hida temple registers, 58-59 Hippocrates, 20 Hirata Kimtsu, 204 Hirsch, August, 157-58, 164-65 Hojoki, 176 Honjδ EijirS, 7 Hopkins, Donald R , 61 host, definition, 16-17 house rat, see Rattus rattus household size, late Tokugawa period, 10 Hyakurensho, 68 immunity definition, 19, effect on communities, 20 incubation period, 18 Indus Valley, population density, 26 infant mortality preindustrial Japan, 205, use of death registers to determine, 55

221 infanticide effect on fertility rate, 11, in Japan, 204—205, responsible for low fertility, 7 infectious diseases penetration to Japan from outside, 13, laws for control, 138 influenza reasons for omitting from study, 14n influenza epidemics Japan, 47 Inogan Konosuke, 127-29 invasiveness, 17 irrigation systems Japan, 28-29 isolation as factor in spread of disease, 197 Japan early European accounts, 30-32, geography, 28, isolation as reason for protection from cholera, 163, migration from Asian mamland, 28, nomadic groups, 28, population, 29, sanitary conditions, 202 jieki, 181-85, deaths attributed to, 182, fluctuation in mortality from, 183-84 Kaempfer, Engelbert, 30 kakocho, xxi, 36, content, 50, form of data, 55, high quality of, 57, impor­ tance of, 50, types of death causes recorded, 57, prevalence in Japan, 51, problem with use, 51, use by Japanese medical historians, 51 Kamo no Chomei, 176—77 Kanagawa, Treaty of, 166 Kikuchi Kazuo, 169 Koch, Robert, 40 Kozo Yamamura, 10 Kyoho famine, 1732—1733, 177 Kyushu, smallpox epidemic in, 66 life span, statistics, 203 living standard, role in propagation of enteric diseases, 146 London, sanitary conditions in, 201 Malthus, Thomas, 3 marriage patterns, effect on population growth, 9 Matsuda Takeshi, 132 McNeill, William H , 27 measles age at death, 129—30, age distribution of deaths, 140—41, age incidence, 126-34, American Civil War, 113, American continent, 108,

222 Australian military training camps, 113, bnefhistory of in Japan, 190-91, cause of death, 112, compared with cholera mortality rate, 139, confused with smallpox, 108, correspondence of local and official records, 128-29, decline in mortality in 20th century, 113-14, dependency on human host, 110, disease characteristics, 110—14, disease patterns records, 130—33, distinctive pattern of dissemination, 133, early Japanese accounts, 114-16, Edo, 118—19, effect of temperature on spread of, 198, as endemic disease, 111, entry into Japan, 198, epidemic of 1824, 140, epidemic as natural phenomenon, 125, epidemic as rare event, 133, Faeroe Islands, 110η, Fiji Islands, 111, frequency of epidemics, 109, Germany, 108, herd immunity, 110, Hida, 129-40, history of name, 33, as imported disease, 109, 125, on isolated islands, 108, Izumi province, 132, Japanese anecdotal evidence, 125—26, Japanese epidemic of 1691, 120, Japanese epidemic of 1708, 120, Japanese epidemic of 1753, 121, Japanese epidemic of 1803, 122-23, Japanese epidemic of 1824, 123—24, Japanese epidemic of 1836, 124, Japanese epidemic of 1862, 124, Japanese personal accounts, 127-28, in Japanese popular art, 134—37, Japanese source material, 118, Kinki region, 120—21, London, 108, low mortality in Japan, 191, mortality m Faeroe Islands, 142-44, mortality fluc­ tuation, 112, mortality's influencing factors, 138, mortality m Japan, 13441, mortality in West Africa, 141-42, mortality in Western Europe, 142, as natural phenomenon, 133—34, New Spain, 111, occurrence of epidemics, 108—109, overview of Japanese epidemics, 116-17, period of commumcability, 110, periodicity of epidemics, 118, reimportation to Japan, 118, route through Japan, 190-91, seasonal pattern, 110—11, severity, 112—13, among soldiers, 113, symptoms, 111—12, and Tempo famine, 184—85, terminology, 46, 115-16, transmission,

INDEX 110, unanswered questions, 198—99, vulnerable ages, 114—15 measles demons, 134-38 meat, taboo agamst consumption in Japan, 202 medical laws requiring dysentery cases to be reported, 150 medicine, history in Japan, xx microorganisms as cause of disease, 16-17 migration to Japan, 28—29 morbidity, reasons for changes in, 175-76 Morris, R W , 170 Morse, Edward, 196, 202 mortality crisis of 1837, 181, effect of epidemic disease, 44, fluctuation curves, 57, impact of disease on under unusual conditions, 186-87, importance for society, 12, reasons for changes in, 175—76, related to frequency of epidemics, 45, relation to fertility, 5, trends in 18th-century Europe, 10 mortality crises Europe, 3, Japan, 181 Mosk, Carl, 8 Nagasaki German measles in, 42, rubella in, 42 Nakahara, birth and death rates in, 11 natural disasters, Japanese interest in, 40 New Spam, measles in, 111 New York, sanitary conditions in, 201-202 Nthon ishigaku zassht, xx Nthon shtppei sht, 39-40 Nihongi, 40 mnbetsu cho, 35 Nishi-no-omote, smallpox epidemic of 1836-1837, 102 nutrition, effect on population growth,

8 Ogen-ji temple, 14, description, 52-53, importance of, 53 Okayama, birth and death rates m, 10 Ooku, 98-99 pandemic, definition, 156 See also disease, cholera, dysentery, measles, smallpox Panum, Peter Ludwig, 142-43, 203

INDEX parasite, definition, 17 Pasteur, Louis, 40, 103n pathogenicity, 17 pathogens, definition, 17 Pax Tokugawa, 1

period of commumcabihty, 18 periodical literature, Japanese guides to, xx Perry, Commodore, 166 plague, indiscriminate use of term, 34 See also bubonic plague population characteristics important to history of epidemic diseases, 21, increase in late neolithic period, 26, Japan, 41n, spatial distribution, 22, unknown for Ogen-ji, 54 population centers, growth, 26 population growth causal factors in preindustnal Europe, 3-4, cessation in Japan, 205, effect on frequency of epi­ demic, 43, effect on smallpox, 95-97, Japan in early Tokugawa period, 29, low, 8, reason for lack of in Japan, 107, role of epidemics, 3, role of fertility, 3-4, weak positive check in Japan, 204 population records Japan, 35 population size insufficient to explain epidemiological pattern of measles in Japan, 199, Japan in 1600, 5—6 population stability Japan, 6 population stagnation, related to economic stagnation, 7 ports, Japanese open to West, 166 pox viruses, 62-63 Preston, Samuel, 12 Rattus rattus, Tl, 192 record keeping, Japan, 37 records, advantage of using Japanese, 37 rtbyo, 184 Rodngues, Joao, 30-31 rubella in Nagasaki, 42, terminology, 47

sanitation as factor in spread of disease,

201 sasuyu records and measles epidemics,

131—32, survival records, 100 sasuyu ceremony, 98

scribes, characteristics of Japanese, 38 scrub typhus, 195n Sen, A K , 185

223 Sendai domain, 14, description, 52, extent in Tokugawa period, 52 Shibue Chusai daughters' death by smallpox, 106 shigo aratame, 35 Shinkyu (priest), 53 Shogun Iemochi, sufferer of measles, 124 Shoku mhongi, 37, reliability, 65 shiimon aratame cho, 9, defects, 36, description, 36, use in demographic history, 35 Siegfried, Andre, 197 Simmons, Duane, 206 smallpox in ancient world, 61—62, average age of death for children, 91, briefhistory in Japan, 188-90, charac­ teristics, 62-65, as check of population growth, 189, child mortality, 91—92, among children in Japan, 68-69, clinical course, 63, confused with measles, 108, decline of case-fatahty rate, 94, as disease of children, 106, earliest accounts in Japan, 65, earliest terminology in Japan, 65-66, in Edo Castle, 97—100, effect on child mortahty, 73, effect of climate on infectivity, 64, effect of dysentery epidemic of 1826, 154, effect on fer­ tility, 189, effect of herd immunity, 89, effect of immunization agamst, 18990, effect on mortality, 72-73, effect on population growth, 95-97, effects on tax payment, 103, as endemic disease in Japan, 68-70, in England, 106-107, entry to human host, 63, entry to Japan, 198, epidemic of 735—737 in Japan, 66—67, epidemic of 1827, epidemic status achieved, 104, evidence for mortality, 75, fatal variety, 64, Hachijojima, 102-104, Hida, 76—97, history of name, 33, isolated communities, 100—104, Japan and Europe compared, 106—107, Kyushu, 66, Miyagi-gun, 74, morta­ lity, 89—91, 93—94, Nagasaki epidemic, 1615, 31, Nishi-no-omote, 102, numbers of deaths per epidemic, 93, pattern and frequency of epidemics in Japan, 67—68, person-to-person trans­ mission, 64, probable first epidemic, 66, protection through isolation, 103, records in Japan, 62, Sendai, 71-76,

INDEX

224 spread by migratory populations, 64—65, Tanegashima, 100—102, Tempo famine, 184—85; terminology, 46, topic of interest in Tokugawa popular literature, 70, T6sei-gun, 74; view of during Tokugawa period, 104 Smith, Thomas C., 8, 11, 204 source materials, quality of, 33-34 starvation as cause of death in Ogen-ji death records, 178, deaths attributed to, 182; distribution of death in Hida, 179; symptoms of death compared with those of disease, 174-75 subsistence crises, distinguished from disease crises, 173 Suda Keizo, 54 susceptibles: effect of famine on, 174; reduction by disease, 175 syphilis, 63

Thirty Years' War, 24-25 three-day measles. See rubella Toby, Ronald, 197 Tome-gun, 73 toso, derivation of term, 46 trade: influence on disease, 23, Japanese loss of control, 166-68 trade policies, Tokugawa period, 32 transmissibility, 17-18 Treaty of Kanagawa, 166 typhoid fever, 149 typhus, absence of epidemic from Japan, 191, 195-98, first noted, 194; Japan, 15, terminology, 195n

Taeuber, Irene, 7 Taigi (priest), 54 Tanegashima, smallpox in, 100—102 Tatsukawa Shoji, 13, 70 Temmei famine, 1783-1787, 177 temperature, effect on spread of diarrheal diseases, 147 temple death registers, see kakocho Tempo famine, 88, 162, 177, 179-82, 184—85, 205; and cholera, 184; effect on Hida mortality, 185; and smallpox, 184—85

virulence, 17

unequal treaties, 166 variola, definition, 63 vibrio, 155 village population records, see shumon aratame cho

war, influence on disease, 23-25 water quality correlated with enteric diseases, 23 Webster, Noah, 21 Wendt, E C., 157 West Africa, measles in, 141-42 Yamazaki Tasuku, 13, 70 Yanagida Shusui, 102 Yowa famine, 1181-1182, 176-77

Library of Congress Cataloging-in Publication Data Jannetta, Ann Bowman, 1932— Epidemics and mortality in early modern Japan. Bibliography: p. Includes index. 1. Epidemics—Japan—History. 2. Mortality— Japan—History. 3. Japan—History—Tokigawa period, 1600-1868. I. Title. RA650.7.J3J36 1986 952'.025 86-15108 ISBN 0-691-05484-3 (alk. paper)