Epidemics and Mortality in Early Modern Japan by Ann Bowman JannettaReview by: Robert S. GottfriedIsis, Vol. 78, No. 3 (Sep., 1987), pp. 472-473Published by: The University of Chicago Press on behalf of The History of Science SocietyStable URL: http://www.jstor.org/stable/232047 .

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BOOK REVIEWS-ISIS, 78: 3 : 293 (1987) BOOK REVIEWS-ISIS, 78: 3 : 293 (1987)

nonetheless provided physicians with the aura of expertise and in some areas, such as surgery, gave them a definite, recog- nized advantage over nonacademically trained healers.

Loss of autonomy was the price exacted by the state for providing the legal and in- stitutional tools that extended physicians' sphere of authority and improved their so- cial position. While their relationship to the state was advantageous in the circum- stances of the 1860s and 1870s, in the al- tered conditions of the 1880s, when the number of medical students leaving the uni- versities doubled, the physicians' position of subservience to the state threatened to reduce them to an educated proletariat. To the stresses of competition was added the control exercised over them by the new health insurance organizations. Owing to the absence of a professional organiza- tion among physicians, the Krankenkassen could, in the overstocked market of the 1890s, hire and dismiss any physician they pleased; dictate fees (in many cases only 25 percent of the fee paid by private patients for the same service); and even determine therapeutic regimens by controlling drug prescriptions, length of hospitalization, and recuperation. The physician-patient rela- tionship was in reality a tripartite Kran- kenkasse-patient-physician relationship in which the administrators of the insurance group (which in some instances included workers) were the dominant partner. Es- tablishing their sovereign autonomy in their struggle against the Krankenkassen was the last step in the professionalization of Ger- man physicians.

Some of the most interesting material in Huerkamp's book is to be found in her dis- cussion of the forces driving German phy- sicians to overcome their educated-middle- class prejudices against organizing in trade union fashion for a brief but critical period at the turn of the century. She convincingly portrays how physicians, splintered into various interest groups by the intense eco- nomic pressures of the 1890s, adopted a code of ethics ostensibly in order to regu- late practice but more directly in order to regulate competition within their ranks. To gain the legal clout necessary to force com- pliance among their professional brethren, physicians exploited the state bureau- cracy's fear of the spread of social demo- cratic views by convincing it to grant local and state associations of physicians the

nonetheless provided physicians with the aura of expertise and in some areas, such as surgery, gave them a definite, recog- nized advantage over nonacademically trained healers.

Loss of autonomy was the price exacted by the state for providing the legal and in- stitutional tools that extended physicians' sphere of authority and improved their so- cial position. While their relationship to the state was advantageous in the circum- stances of the 1860s and 1870s, in the al- tered conditions of the 1880s, when the number of medical students leaving the uni- versities doubled, the physicians' position of subservience to the state threatened to reduce them to an educated proletariat. To the stresses of competition was added the control exercised over them by the new health insurance organizations. Owing to the absence of a professional organiza- tion among physicians, the Krankenkassen could, in the overstocked market of the 1890s, hire and dismiss any physician they pleased; dictate fees (in many cases only 25 percent of the fee paid by private patients for the same service); and even determine therapeutic regimens by controlling drug prescriptions, length of hospitalization, and recuperation. The physician-patient rela- tionship was in reality a tripartite Kran- kenkasse-patient-physician relationship in which the administrators of the insurance group (which in some instances included workers) were the dominant partner. Es- tablishing their sovereign autonomy in their struggle against the Krankenkassen was the last step in the professionalization of Ger- man physicians.

Some of the most interesting material in Huerkamp's book is to be found in her dis- cussion of the forces driving German phy- sicians to overcome their educated-middle- class prejudices against organizing in trade union fashion for a brief but critical period at the turn of the century. She convincingly portrays how physicians, splintered into various interest groups by the intense eco- nomic pressures of the 1890s, adopted a code of ethics ostensibly in order to regu- late practice but more directly in order to regulate competition within their ranks. To gain the legal clout necessary to force com- pliance among their professional brethren, physicians exploited the state bureau- cracy's fear of the spread of social demo- cratic views by convincing it to grant local and state associations of physicians the

power to police their own membership and to impose punitive sanctions for improper behavior. The Leipzig Physicians Associa- tion did not hesitate to turn this newly ac- quired autonomy into a powerful tool for demonstrating that by maintaining profes- sional solidarity, physicians could defend their economic interests against the Kran- kenkassen. Following the dramatic physi- cians' strike in 1904, the Krankenkassen capitulated en masse to the economic de- mands of the physicians. United, German physicians were at last the sovereigns of their professional destinies as well as the masters of their fortunes.

The only flaw of this brilliant study is its failure to integrate fully the role of science into the account of the social and institu- tional forces affecting the professionaliza- tion of medicine. For this part of her story Huerkamp relies on dated accounts of he- roic medicine. In spite of her criticism of functionalist sociology, Huerkamp's study treats scientific knowledge as an indepen- dent variable with its own internal dy- namic. A more fitting companion for the new social history would be an ecology of knowledge that embeds knowledge and its instrumentation within the political econ- omy.

TIMOTHY LENOIR

Ann Bowman Jannetta. Epidemics and Mortality in Early Modern Japan. xxii + 224 pp., illus., figs., bibl., index. Princeton/ Guildford, Surrey: Princeton University Press, 1987. $30.

Ann Bowman Jannetta discusses the in- cidence and effect of epidemic disease in Tokugawa Japan from 1600 to 1868. She argues that epidemics were less important there than they were in Europe. Japan had famines and natural disasters, including earthquakes and tidal waves, but by Euro- pean standards few epidemics, and no plague. Indeed, natural disasters played a greater role in checking population growth than did disease, a circumstance quite dif- ferent from that of the West.

Jannetta analyzes two regions: the Sen- dai, in northeastern Japan; and the Hida, in central Honshu. The first comprised moun- tains and a coastal plain facing the Pacific and had a cool, mild climate. The second was isolated, had deep snows in winter, and was remote and often inaccessible. Jannetta's sources include medical and lit-

power to police their own membership and to impose punitive sanctions for improper behavior. The Leipzig Physicians Associa- tion did not hesitate to turn this newly ac- quired autonomy into a powerful tool for demonstrating that by maintaining profes- sional solidarity, physicians could defend their economic interests against the Kran- kenkassen. Following the dramatic physi- cians' strike in 1904, the Krankenkassen capitulated en masse to the economic de- mands of the physicians. United, German physicians were at last the sovereigns of their professional destinies as well as the masters of their fortunes.

The only flaw of this brilliant study is its failure to integrate fully the role of science into the account of the social and institu- tional forces affecting the professionaliza- tion of medicine. For this part of her story Huerkamp relies on dated accounts of he- roic medicine. In spite of her criticism of functionalist sociology, Huerkamp's study treats scientific knowledge as an indepen- dent variable with its own internal dy- namic. A more fitting companion for the new social history would be an ecology of knowledge that embeds knowledge and its instrumentation within the political econ- omy.

TIMOTHY LENOIR

Ann Bowman Jannetta. Epidemics and Mortality in Early Modern Japan. xxii + 224 pp., illus., figs., bibl., index. Princeton/ Guildford, Surrey: Princeton University Press, 1987. $30.

Ann Bowman Jannetta discusses the in- cidence and effect of epidemic disease in Tokugawa Japan from 1600 to 1868. She argues that epidemics were less important there than they were in Europe. Japan had famines and natural disasters, including earthquakes and tidal waves, but by Euro- pean standards few epidemics, and no plague. Indeed, natural disasters played a greater role in checking population growth than did disease, a circumstance quite dif- ferent from that of the West.

Jannetta analyzes two regions: the Sen- dai, in northeastern Japan; and the Hida, in central Honshu. The first comprised moun- tains and a coastal plain facing the Pacific and had a cool, mild climate. The second was isolated, had deep snows in winter, and was remote and often inaccessible. Jannetta's sources include medical and lit-

472 472

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BOOK REVIEWS-ISIS, 78 : 3 : 293 (1987) BOOK REVIEWS-ISIS, 78 : 3 : 293 (1987)

erary descriptions, paintings, and adminis- trative records, especially the kakocho, or Buddhist temple death registers, which identify causes of death and provide mor- tality data.

Smallpox was the most lethal disease. It dated from the sixth century, at which time it was epidemic. But at some point, per- haps as early as the twelfth century, it be- came endemic, and by the fifteenth century it was identified as an affliction of children. Indeed, smallpox was so common that, like plague in late medieval Europe, a few chroniclers failed to mention some epi- demics. Moreover, between 1771 and 1852 smallpox became even more frequent. There may have been greater exposure or a drop in "herd" immunity, the latter a result of an increase in birthrates. Smallpox was responsible for ten to twelve percent of all deaths in Hida villages, and for ninety-five percent of those of children. Indeed, the average age of death was about three and one-half years. Smallpox was the "minister of death."

But other diseases were less important. Plague and typhus did not exist in Japan until late in the nineteenth century. Measles, given Japan's density of popula- tion, should have been a great killer. Yet it was not: in fact, there were only eleven measles epidemics between 1616 and 1862, with an average interval between outbreaks of twenty-two years. Measles had no natu- ral reservoir in humans, and its infectivity dissipated quickly. New epidemics had to be introduced from abroad, and since Japan was relatively isolated this rarely hap- pened. Enteric diseases were also rare. Dysentery, the bane of European armies and cities, was primarily an affliction of children-but much less so than smallpox. And cholera was unimportant until the middle of the nineteenth century. This, Jannetta argues again, was the result of Japan's comparative isolation and of the traditions of boiling water and cooking most foods. Indeed, the author claims that the Japanese sensed that epidemics were foreign and that this contributed to Japan's separatism. Ironically-but not coinciden- tally-the most severe epidemics of cholera came after 1858, when American warships opened up Japanese ports.

Jannetta's emphasis on isolation as the principal reason for the absence of epi- demics is only partly convincing. She barely mentions public health, medical

erary descriptions, paintings, and adminis- trative records, especially the kakocho, or Buddhist temple death registers, which identify causes of death and provide mor- tality data.

Smallpox was the most lethal disease. It dated from the sixth century, at which time it was epidemic. But at some point, per- haps as early as the twelfth century, it be- came endemic, and by the fifteenth century it was identified as an affliction of children. Indeed, smallpox was so common that, like plague in late medieval Europe, a few chroniclers failed to mention some epi- demics. Moreover, between 1771 and 1852 smallpox became even more frequent. There may have been greater exposure or a drop in "herd" immunity, the latter a result of an increase in birthrates. Smallpox was responsible for ten to twelve percent of all deaths in Hida villages, and for ninety-five percent of those of children. Indeed, the average age of death was about three and one-half years. Smallpox was the "minister of death."

But other diseases were less important. Plague and typhus did not exist in Japan until late in the nineteenth century. Measles, given Japan's density of popula- tion, should have been a great killer. Yet it was not: in fact, there were only eleven measles epidemics between 1616 and 1862, with an average interval between outbreaks of twenty-two years. Measles had no natu- ral reservoir in humans, and its infectivity dissipated quickly. New epidemics had to be introduced from abroad, and since Japan was relatively isolated this rarely hap- pened. Enteric diseases were also rare. Dysentery, the bane of European armies and cities, was primarily an affliction of children-but much less so than smallpox. And cholera was unimportant until the middle of the nineteenth century. This, Jannetta argues again, was the result of Japan's comparative isolation and of the traditions of boiling water and cooking most foods. Indeed, the author claims that the Japanese sensed that epidemics were foreign and that this contributed to Japan's separatism. Ironically-but not coinciden- tally-the most severe epidemics of cholera came after 1858, when American warships opened up Japanese ports.

Jannetta's emphasis on isolation as the principal reason for the absence of epi- demics is only partly convincing. She barely mentions public health, medical

Print of child with smallpox Print of child with smallpox

practices, and sanitation, surely seminal factors if she is to argue that social con- straints and quarantine lessened the impact of disease. Similarly, she mentions the im- portance of climate only in passing. And while Jannetta is well read in most areas, she has missed much of the plague litera- ture. This prevents her from arguing from an ecological perspective, that is, from the natural history of rats and fleas, which would provide an alternative explanation for the absence of plague-and typhus and perhaps other diseases as well. In the light of the evidence presented, ecological and climatological explanations seem as plausi- ble as isolation for explaining the lack of disease in the Tokugawa period.

Yet this book is, at the very least, a wel- come exploratory volume. Jannetta pro- vides excellent data and graphs. The book itself, like all those published by Princeton University Press, is beautifully made, has splendid maps and illustrations, and has footnotes at the bottoms of the pages. Jan- netta is never dogmatic and always infor- mative, and she fills a gap in the history of epidemiology.

ROBERT S. GOTTFRIED

Judith Walzer Leavitt. Brought to Bed: Childbearing in America, 1750-1950. 284 pp., illus., index. New York/Oxford: Ox- ford University Press, 1986, $21.95.

Fear of dying in childbed haunted women's lives from colonial times well into the twentieth century. In this impressive

practices, and sanitation, surely seminal factors if she is to argue that social con- straints and quarantine lessened the impact of disease. Similarly, she mentions the im- portance of climate only in passing. And while Jannetta is well read in most areas, she has missed much of the plague litera- ture. This prevents her from arguing from an ecological perspective, that is, from the natural history of rats and fleas, which would provide an alternative explanation for the absence of plague-and typhus and perhaps other diseases as well. In the light of the evidence presented, ecological and climatological explanations seem as plausi- ble as isolation for explaining the lack of disease in the Tokugawa period.

Yet this book is, at the very least, a wel- come exploratory volume. Jannetta pro- vides excellent data and graphs. The book itself, like all those published by Princeton University Press, is beautifully made, has splendid maps and illustrations, and has footnotes at the bottoms of the pages. Jan- netta is never dogmatic and always infor- mative, and she fills a gap in the history of epidemiology.

ROBERT S. GOTTFRIED

Judith Walzer Leavitt. Brought to Bed: Childbearing in America, 1750-1950. 284 pp., illus., index. New York/Oxford: Ox- ford University Press, 1986, $21.95.

Fear of dying in childbed haunted women's lives from colonial times well into the twentieth century. In this impressive

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