Cholera and the Environment in Nineteenth-Century Japan · As recent works such as Anna Lowenhaupt...

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CholeraandtheEnvironmentinNineteenth-CenturyJapanWilliamJohnston,WesleyanUniversityJohnston,William.2019."CholeraandtheEnvironmentinNineteenth-CenturyJapan."Cross-Currents:EastAsianHistoryandCultureReview(e-journal)30:9–34.http://cross-currents.berkeley.edu/issue-30/johnston.

AbstractAmongacuteinfectiousdiseases,choleragainedmoreattentioninJapanesepopularculture and among policymakers than any other. Although many facts aboutcholera’shistoricalexistence seemsettled,whenone looks closelyat themedical,biological, andenvironmental science, severalof these facts—especially about thedefinitionsofpandemics,epidemics,andendemicity—becomefuzzy.Inanattempttoreachamodicumofclarity, thisarticleasks:Whatbiologicalandenvironmentalconditions allowed cholera to become endemic in nineteenth-century Japan? Inansweringthisquestion,itmakesthecasethatunderstandingthisdiseaseinhistoryand,morespecifically,whyittookthecoursethatitdidinnineteenth-centuryJapanrequires knowledge of the scientific literature. This claim is part of a broaderargument about how understanding the physical world in its concretemanifestations through biological and environmental science is important tounderstanding human history. It is applicable not only to the history of disease,epidemics,andpandemicsbuttoother fields, includingenvironmentalhistory, thehistoryof technology,and thehistoryofwar,aswell. Thisarticlealsoquestionsanumber of boundaries: between disciplines, across time and space, and betweenevidenceandassumptioninwhatweconsiderfacts.Keywords:Japan,disease,cholera,pandemic,epidemic,endemic,environment,history,science,biology,historiographyofcholera,GISanalysisIntroduction:Cholera,Science,andHistoryMorethananyotheracuteinfectiousdisease,cholerawasadefiningelementofthenineteenthcentury.ThiswasastrueforthoselivingontheJapanesearchipelagoasforotherpeopleacrosstheglobe.Cholera’spandemicsareestablishedashistoricalfacts, but how its worldwide spread depended on environmental forces is lessknown. This article examines the role those forces played on the course that thedisease took in Japan during the nineteenth century. It begins with the epidemicwaves that then established cholera’s endemicity, punctuated by later epidemicsthataroseautochthonously.Afterthat,choleraremainedendemicbutinsignificantintermsofmortalityratesthroughoutthetwentiethcentury.Thisarticleasks:Whatbiologicalandenvironmental conditionsallowedcholera tobecomeendemic?Theanswer to thisquestion canhelpusunderstandwhy thediseaseunfolded in time

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and space as it did across the Japanese archipelago. The answer also can suggestexplanations why cholera in Japan quickly declined during the early twentiethcentury,althoughspacelimitationsherepreventafullexplorationofthisquestion.

Themedical and biological sciences related to cholera open other usefulepistemological windows. They help us empathize with the experiences thatindividualsandpopulationshadwiththisdisease.Itssignsandsymptomsallcarriedstigmaandotherculturalbaggagethatwereparticulartoatimeandplace.Yettheeffectsof thediseaseonthehumanbody—inparticular,when leftuntreatedwithmodernmedicine—were and remainmore similar than different across time andspace.Clearly,theJapaneseexperiencewithcholeraresembledotherindividualandnationalexperienceswiththedisease.Thosecommonalitiesbecomeapparentwhenlooking at thephysical realities of thedisease andof theorganism that causes it,Vibrio cholerae, in both the body and the environment. In short, a clearunderstanding of cholera’s historical trajectory in a specific geographic locationrequires more than archival sleuthing and a close reading of contemporaryobservations.Thesciencescanhelp.

Morebroadly,thisisyetanothercalltobridgethe“twocultures”thatC.P.SnowdiscussedintheRedeLectureattheUniversityofCambridgein1959andlaterpublished inTheTwoCulturesandtheScientificRevolution (Snow2008).AlthoughThe Two Cultures has received its share of criticism, themain ideas still resonatetoday.Snow,whowasbothaphysicistandnovelist,urgedthatthegapbetweenthecultureofscientistsandthatofhumanistsbebridgedbyeducatingpeople ineachcampabout theother.Twoyears later,Snowpresentedhis ideasonhowa“thirdculture” can exist through genuine interdisciplinarity (Fins 2010). Hence, althoughthis article focuses on issues regarding both epidemic—indeed pandemic—andendemic disease, it is part of a broader argument about how understanding thephysical world in its concrete manifestations through biology and environmentalscienceisimportanttounderstandinghumanhistory.Itisapplicabletonotonlythehistory of disease, epidemics, and pandemics but also other fields includingenvironmentalhistory,thehistoryoftechnology,andthehistoryofwar.

The literature on the history of cholera is extensive, yet little has beenwritteninwhichthebiologicalandenvironmentalsciencesofthediseasehaveanyrole.ThisisastrueinJapanasfortherestoftheworld.Inordertoproperlyexaminethe relevant science about cholera, it is useful to take a look at how previoushistorianshaveunderstoodthisdisease.Withthegoalofpositioningthisarticle inthecontextoftheliteraturethathasprecededit,withoutdisruptingthearticle,theAppendix: The Historiography of Cholera at the end of the article offers a briefdiscussionofsomeofthemajorworksonthehistoryofcholera,especiallyinJapan.TheEmergenceofPandemicCholeraAdiseasewithsymptomsmuchlikethoseofcholeraaswedefineittodayseemstohave existed in South Asia at least since the sixteenth century and possibly sinceancienttimes(MacPherson1884;Pollitzer1954;Colwell1996,2025;Barua1992,1–7).Yetitdidnot,atleastinitsvirulentform,spreadbeyondtheBayofBengaluntil1817.GeneticanalysissuggeststhatthisvirulentformofVibriocholeraemightnot

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have existed long before then (Devault et al. 2014). Previously, “cholera,” oftenreferred to as “cholera morbus,” signified a set of bilious symptoms that usuallyincludeddiarrhea;thiswastrueinmostEuropeanlanguages(SydenhamandRush,1809).After thisnewafflictionappeared,“choleramorbus”wasusuallyassociatedwith the peculiar signs and symptoms of the pre-1817 affliction, and “Asiaticcholera,” leaving aside the question of whether it actually originated in Asia,designatedthenewdisease(Speck1993,642–643).Nevertheless,throughoutmuchof the nineteenth century “cholera” and “choleramorbus” were sometimes usedinterchangeablywith“Asiaticcholera”both in Japanandacrosstheglobe(Nagayo1877,ii–iii).Thiswasnotunusual.Untilthetwentiethcenturywhennosologiesandnosographies became fairly standardized, disease names were frequently usedinconsistently.Yetmany,ifnotall,observersatthetimesawthisasanewdiseaseorat least one that they believedwas previously limited to the Indian subcontinent(Whitney1833,307).“Asiaticcholera”wasthepre-1817choleramorbusonsteroids.Whereascholeramorbuswastedious,sometimesterrible,andinfrequentlydeadly,“Asiatic cholera” tended to be lethal. Left untreated, it could kill more than 70percent of those who developed symptoms (Harris et al. 2012, 2469). Mostnineteenth-centurytreatmentswereineffectiveatbest.Atworst,theywere,asonehistorian of medicine remarked, “a form of benevolent homicide” (Howard-Jones1972,373).

This new form of cholera appeared just as a new political entity, themodernnation-state,wasemerging globally.Modernpolitical organizations, alongwith the technologies of biopower and forms of environmental and social controlthatemergedofteninresponsetocholera,madethediseaseadriverofmodernity.The resultingpolicies largely subdued thedisease in the long runbutwith certaincosts.AsrecentworkssuchasAnnaLowenhauptTsing’sTheMushroomattheEndof the World: On the Possibility of Life in Capitalist Ruins (2017) and Donna J.Haraway’s Staying with the Trouble: Making Kin in the Chthulucene (2016) haveshown, the idea that modernity inevitably goes in the direction of enlightenedbenevolence is illusory.Althoughmodernityhas improvedthe livesofmany, ifnotall, peopleworldwide, it also has provided new tools of oppression—often in thename of protecting lives. State policies regarding cholera were similarlydouble-edged. In various countries, thedisease caused innumerabledeaths,but italsoledtothecreationofthecleanwatersuppliesandwastetreatmentprocessesonwhichcapitalisticcivilizationdepends.Italsoledtoquarantinepoliciesinwhichhouseholdswhosemembers suffered from thediseasewere sealedoff from theircommunitiesandhospitalizationpoliciesinwhichpatientsweresenttoquarantinehospitalswhere the patients diedmore frequently than they recovered. Thiswasverymuchthecaseinnineteenth-centuryJapan—whosebiopoliticswereoftenneckandneckwiththoseofcontemporaryEuropeannation-states.CholerainJapanandtheQuestionofEndemicity


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The Japaneseexperiencewithcholeraparalleled thatofpeople inmanyEuropeanandotherWesterncountries.Arichdocumentaryrecordrevealsthecourseofthediseasethroughthecountryandthevariousmedicalandstate-basedresponsestoit.Thestatistical records for theepidemics thatoccurred in1822,1858–1860,and1861–1862 are vague. However, by the last quarter of the century, when thecountry experiencedmultiple epidemics, national and prefectural records provideseparatesnapshotsofdiseasepatterns.

Beforecholera first reachedJapan in1822,DutchphysicianswarnedtheirJapanesecolleaguesthatanewanddangerousepidemicdiseasehadspreadthroughits colony inBatavia (Jakarta), so its first appearance inKyushuwasnotentirely asurprise(Bunseijingoakitenkōbyōkorerimorubusukeiken1822).OnceitdidreachJapan, some thought it had come from Korea; others believed the Dutch hadbrought it from Java (Hirahara 1842; Nagayo 1877, 2–3; Yamamoto 1982, 6–8).Possiblybothexplanationswerecorrect.Forwhateverreasons,thisepidemic,whichstarted in Kyushu duringOctober of that year, did not gomuch farther east thanKyoto and for the most part was over by December (Fujikawa 1944, 157–163;Kikuchi 1978, 63; Yamamoto 1982, 8–13). Despite its geographic limitation, thisepidemicleftanindeliblemarkonJapanesemedicalcultureandsociety,especiallyinthenamemikkakorori(literally,“three-daydrop-dead”),andthefactthatitwasadisease that at least some Japanese physicians described as previously unknown(Hirahara1842).

Choleraspreadwidelyacrosstheglobeduringthe1830s,reachingWesternEuropeandNorthAmerica,but itdidnotemergeagain in Japanuntil1858.Somewhohadlivedthroughtheepidemicof1822recognizedthedisease,anditwasonceagaincalledmikkakorori (Shingū,Ōmura,andShingū1858).Thissobriquetspreadwidely and remained in national circulation until the end of the century, thoughnamesdiffereddependingonlocale(Fujikawa1944,155–157;Yamamoto1982,15).CholerareachedJapanin1858whenAmericansailorsonboardtheU.S.S.Mississippibrought the disease toNagasaki. Some scholars have doubted this explanation ofthis epidemic’s origins in Japan, but there is evidence for it.WilliamF.Gragg, thestewardtotheMississippi’ssurgeon,describedan“epidemicform”ofdiarrheathatoccurred twodaysafter theship leftHongKong forNagasaki.Once there,healsonotedthattheJapaneseallowed“some[American]officers”whoweresicktocomeashoretorecover(Gragg1860,31–32).TheMississippiarrivedonJune23,1858;bymid-July,J.L.C.PompevanMeerdevort,theDutchphysicianinNagasaki,reportedthatcholerahadspreadthroughoutthecity(Yamamoto1982,16).Fromthere,thedisease moved eastward across the Japanese archipelago. Whereas the previousepidemichadstoppedbeforereachingEdo,thisonedecimatedmuchofthecityandreached into northeastern Honshu. Record-keeping for causes ofmortality at thistimewas looseatbest.Nevertheless,deathsfromthediseaseclearlyreached intothe tens of thousands in Edo alone (Kanagaki 1858; Fujikawa 1944, 165–167;Yamamoto1982, 19–23).Moreover, although theepidemic stalled late in 1858, itreemerged in the followingyear (Kikuchi1978,453–455;Yamamoto1982,24–26).Thenextepidemicsoccurred in1861and1862,ascontemporaryobserverswidelyreported(“InterestingfromJapan”1862;“AffairsinJapan”1863;Simmons1880,4;Fujikawa1944,169;Kikuchi1978,455–460).

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CholeraapparentlydisappearedfromtheJapanesearchipelagoforthenextfifteenyears.In1877,itspreadacrossmuchofChinaandlikelyfromtheretoJapan(Simmons 1880, 6–8; Yamamoto 1982, 29). The previous year, the Japanesegovernment had begun to collect national statistics for acute infectious diseases,includingcholera;therewerecasesoftyphoid,dysentery,andsmallpoxreportedin1876, but none for cholera. The following year,more than eight thousanddeathsfrom cholerawere reported. Figures in the Statistical Yearbook of Imperial Japanreporteitherpatientsordeaths fromthediseaseeveryyear from1877 to1924—oddly, in 1904, 1905, 1915, and 1918, no patients were reported in the nationalstatistics,butseveraldozendeathsappearedintheofficialrecord.Majorepidemics,causingmore than ten thousand recorded deaths, occurred in 1879, 1882, 1886,1890,and1895,afterwhichcholera causeddeaths reaching into four figuresonlyduring sixmore years in the twentieth century. All themajor epidemics in Japanoccurredbefore1900.

Withtheexceptionoftheepidemicthatoccurredin1822,cholerainJapanwas a disease of the last half of the nineteenth century. Nevertheless, it left aprofound mark on popular culture and, in particular, on expressions of fear. Ofimportance here are theways those expressions of cholera-induced fear changedbetweenthe1850sand1860sandthelateryearsofthecentury.Intheepidemicsofthe 1850s and 1860s, many Japanese associated cholera with traditional demonsand evil spirits, as did many people across the globe, despite the fact thatwidespreadreportsdescribedhowAmericansailorshadbroughtthe1858epidemiconboardtheU.S.S.MississippitoNagasaki.ManycontemporaryJapaneseknewthis,as indicated by the popular name for the disease at the time, amerika kitsune(Americanfox),whichprovidedaninterpretationofthediseaseinJapaneseterms—asafoxspirit—whilealsosuggestingaforeignorigin(Takahashi2005,62–68).

Nevertheless, many others understood the cholera epidemic that swept1858 Japan in theestablished termsofepidemicdiseasewithoutany reference toforeign origins. It was widely believed that the disease was the result of kami(unhappydeities), and couldbe appeasedorwardedoff throughprayer, amulets,the action of benevolent spirits, or the use of other time-trusted offerings andmethods.WhatisremarkableisthatduringitsfirstepidemicyearsinJapan,peoplethought of the disease both as a foreign invader and an expression of domesticdeitiesgonerogue—inmuchthesamewaytheythoughtofepidemicsmallpoxandmeasles.Whenthenextcholeraepidemicoccurredin1877,thiswasnolongerthecase.PopularimagerydepictedthisepidemicasoriginatinginChinaorKorea;manyJapanese similarly responded to later epidemics (Padilla 2009, 19, 115; Johnston2017).Thisviewwasbasedontheideathatcholeraepidemicsinvariablycamefromabroad and could not have been repeated outbreaks of endemic disease.NagayoSensai concurred. In his report on the epidemic of 1877, he wrote that endemiccholeracouldbe foundonly in Indiaand thatepidemiccholera invariablycametoJapaneitherfromJavaorChina(Nagayo1877,i,iv).

Later government documents offer mixed accounts regarding cholera’sendemicity. TheanonymouslywrittenBriefReviewof theOperationsof theHomeDepartmentinConnectionwiththeCholeraEpidemicofthe18thYearofMeiji(1885)([1886?])presentsahistoricalaccountofcholera inJapanuptothatyear. Itnotes


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that the disease was epidemic in 1822, 1858–1860, and 1877–1879; strikingly, itelidesthewell-documentedepidemicthatoccurredin1862(ABriefReview[1886?],2–3).Itthennotesthatafterthediseasewasabsentin1880and1881,itreappearedin1882butwasabsentthesubsequenttwoyears.Itsnextdocumentedoutbreakisin 1885,with a note that cholera spread fromNagasaki that year (ABrief Review[1886?], 15–17). The following year, however, an outbreak that started in Osakaspreadthroughoutthecountrywithaseveritythatsurpassedtheepidemicof1879(“Causes of the Cholera Epidemic in Japan in 1886” 1888). This later narrativeaccountimpliesthatthediseasewasreintroducedfromabroadmultipletimesuntil1886.Asnotedearlier, therewerecholerapatientsordeathseveryyearbetween1877 and 1924.Nevertheless, at least until the 1880s, there existed the viewnotonly in thepopularmediabutalsoamongat least somegovernmentofficials thatcholeracamefromtheoutsideandwasnotendemic(Padilla2009,119–120).

The perceived ambiguity of cholera’s reintroduction raises severalquestions.Wascholeraadiseasethattraveledaroundtheglobeinepidemicwaves,transmittedfrompersontoperson likesmallpoxorpolio?Or,didotherorganismsactasvectors for thecholerabacterium in the sameway that rodents canharborthe plague bacterium? Was it possible that the disease-causing organism couldremain in the environment but invisible to humans? These are key questions notonlyinhistoricalperspectivebutalsoinconsideringhowbesttocontrolthisdisease.It is helpful to examine the recent biological, environmental, and epidemiologicalsciencethatanswersthesequestionsandapplyittothecaseofnineteenth-centuryJapan.First,abriefreviewofcholera’sglobalspreadand itsmultiplepandemics isusefulforputtingtheJapaneseexperienceintoawiderperspective.ADifficultywithPandemics:FuzzyBordersCholerapandemicsandmodernmedicalscienceandtechnologyaroseatthesametime. As previously noted, the disease apparently first spread beyond the Bay ofBengalin1817.ThatwastheyearafterFrenchphysicianRené-Théophile-HyacintheLaennecinventedthestethoscope.Duringthenextfewdecades,cholerabecameaglobal scourge, and by the end of the century it was as widespread as thestethoscope. The disease’s epidemics coincided with the rise of cell theory,anesthetics, asepsis, bacteriology, and other cornerstones of modern medicine.According to many histories of epidemiology, British physician John Snow’sdemonstration in 1854 that cholera was definitely a water-borne disease wasfoundational to the field. That same year, Filippo Pacini, an Italian anatomist,discovered the cholera bacterium, which he calledVibrio because of its vibratingmotion (Bentivoglio and Pacini 1995). Pacini’s discovery, however, was neglecteduntil after German physician and microbiologist Heinrich Hermann Robert Kochrediscovered the bacterium nearly thirty years later, something contemporariesconsideredamilestoneinthehistoryofbacteriology(BritishMedicalJournal1884).Nevertheless,muchabout theepidemiologyandtransmissionofcholeraremainedobscureuntilwellintothetwentiethcentury.

Epidemiologistshave longconsideredcholeraaquintessentiallypandemicdisease.AlthoughcholerafirstspreadfromIndiatootherpartsoftheglobein1817,

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reachingJapanin1822,ittookanotherdecadetoreachWesternEuropeandNorthAmerica. Most historians and epidemiologists concur that 1817 marked thebeginningofsevencholerapandemics,thelastofwhichmostconsiderasongoing.Manyhavedisagreedoverexactlywhen thosepandemicsoccurred,althoughmostagree that six of those seven either occurred or started during the nineteenthcentury. There has been considerable disagreement regarding the beginning andendpointsof thepandemics. J.N.Hays,ahistorianwhohaswrittenontheglobalimpact of epidemics and pandemics, dates the seven pandemics as 1817–1824,1827–1835, 1839–1856, 1863–1875, 1881–1896, 1899–1923, and 1961 to thepresent (Hays 2005). Notably, Hays does not include 1858, the year of Japan’ssecondcholeraepidemic.

Thehistoryofcholerawritten in1992byDhimanBarua,aphysician fromBangladeshwho specialized in cholera control, lists six different sets of dates forcholerapandemics.Barua’shistoryusesthedatesestablishedbyRobertPollitzer,anAustrianphysicianwhoworkedfortheWorldHealthOrganizationduringthe1950s(Barua1992,8).Theseare1817–1823,1829–1851,1852–1859,1863–1875,1881–1896,1899–1923,and1961–present.AnybodywholooksupthedatesofthesevencholerapandemicsonWikipediawillseeyetadifferentsetofdatesthataresimilarto, but not identical with, those used by Pollitzer for the first six pandemics.Proximityintimedidnotmakethematteranymoreobvioustoobserverswholivedthroughmuchof thenineteenthcentury. In1910,A. J.McLaughlin,whoserved intheU.S.PublicHealthService,describedsixpandemicsbetween1817and1910,butassigned different beginning and end dates from any of those listed above(McLaughlin1910,129).1In1919,E.D.W.Greig,aBritishphysicianandspecialistintropicalmedicine, described sevenpandemics in thenineteenth century alone, allwithdifferentdatesfromanylistedabove,thefirstbeginningonlyin1826;itseemsthat for him, pandemics countedwhen they affectedWestern populations (Greig1919, 4–5).2 All of this points to the difficulty of establishing the temporal andgeographical boundaries of epidemic and pandemic cholera and an inevitablearbitrarinessinestablishingthoseboundaries,althoughrecentgeneticstudieshaveenabled a more finely tuned dating of the seventh pandemic (Chun et al. 2009).Indeed, based on bacteriological evidence, one observer has ventured to say thatthefirstsixpandemicswerenothingmorethanasingle,continuingpandemic(Blake1994,294).

The symptoms, course, and outcomes of cholera as most texts todaydescribe them are so distinct that the disease would seem easy to spot: cholerabeginswithmildbutincreasingnauseaandmalaisefollowedsometimesbyvomitingand almost inevitably by severe diarrhea that starts soon after the onset ofsymptoms.Inreality,infectionwithVibriocholeraecanresultinaclinicalspectrumranging from asymptomatic infection to cholera gravis, the current term for themostsevereformofthedisease(Nelsonetal.2009,694).Ifleftuntreated,thelatter 1McLaughlin’sdatesforthepandemicswere1817–1823,1826–1837,1846–1862,1864–1875,1883–1896,and1902–1910.2Greig’sdatesforthepandemicswere1826–1837,1840–1849,1853–1856,1863–1868,1868–1873,1881–1885,and1892–94.


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cancauserapiddehydrationwitha lossofuptoone liter (aboutaquart)of fluidsperhour,resultinginlethargy,coldskin,sunkeneyes,cyanosis,cardiacarrhythmia,anddeath inupto70percentofcases (Harrisetal.2012,2469–2470).Yetnotallcasespresent so clearly.Dependingonaperson’s immunesystem, theamountofacid in thestomach,andanumberofotherphysiological factors, infectioncanbeasymptomaticorcausenothingmorethanmildsymptomsmimickingmoreordinarygastroenteritis or a minor case of food poisoning. Even more importantly, thereporting of cases in the past was frequently spotty and inconsistent, and theEuropean and North American men who created the category of pandemic andestablishedthedatesandplacestobeincludedhadaselectionbias.

At thebeginningof anepidemic, symptoms tend tobemore severe. Themainreasonishyperinfectivity,acharacteristicofthebacteriumthatmakesiteasiertotransmitbetweenindividualsimmediatelyafterithasbeenfirstintroducedfromthe environment into the human body (Nelson et al. 2008, 697–698; Harris et al.2012, 2468–2469). Another reason is that as populations are exposed to cholera,they build up immunity to the disease (Harris et al. 2010, 1963). Over time, thesymptomsbecomelesssevere,sometimesmaskingthedistinctionbetweencholeraand other gastrointestinal infections—yet another reason that historical andsometimes even contemporary data regarding both the numbers of cases anddeaths from the disease are less than completely reliable. Nevertheless, thehistoricaldata isusefulasan indexofcholera’spresence,even if it isnotanexactmeasure of its epidemiological and demographic consequences. This index ofcholera’spresenceisimportantinthefollowinganalysis,whichmakesuseofJapan’shistoricalcholeramorbidityandmortalitydatanot to reveal theexactnumbersofcasesbuttodemonstratetherelativepresenceofthedisease.

A look at other relevant dimensions of Vibrio cholerae will help set thestage for this article’s argument that after 1877, cholera epidemics in Japanweremorelikelytohaveoccurredasaresultofindigenizedbacteriathanfromrepeatedinvasionsbybacteriafromabroad.Thereasonsarebasednotonlyonthehistoricaldata but also the biological and environmental circumstances that make thebacteriumdangeroustohumansandallow it toexist forextendedperiodsoftimewithout human contact. The scienceonwhich this reasoning is based is relativelyrecent. Some of it dates from the last half of the twentieth century, and otherstudiescomefromthefirsttwodecadesofthetwenty-firstcentury.TheCholeraBacterium,theEnvironment,andDiseaseIt took what might seem a surprisingly long time to discover how the cholerabacteriumcausesdisease.Atotalofsixty-sixyearspassedbetweenthebeginningofthefirstcholerapandemicin1817andKoch’srediscoveryofVibriocholeraein1883,despite Pacini’s initial discovery in 1854. It took even longer, seventy-six years,between Koch’s confirmation that Vibrio cholerae caused the disease and thediscovery of the cholera toxin. This protein causes the human body to loseenormous volumes of water and electrolytes, especially sodium,whose depletioncanleadtoarapiddeath.In1959,anIndianscientist,SambuNathDe,identifiedthecholera toxinby taking it outside thebacteriumand subsequently showing that it

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couldcausefluiddepletionina livinganimal(De1959).Anotherthirty-sevenyearspassed between De’s discovery and the realization in the late 1990s that thepresence of the cholera toxin inVibrio choleraewas the result of horizontal genetransferbetweenafilamentousbacteriophage,anindependentvirus(whichwillbediscussedlater),andthecholerabacterium(WaldorandMekalanos1996).Sincethe1990s,researchershavesignificantlyexpandedourknowledgeoftheenvironment’sroleinthelifecyclesofVibriocholerae.Foryears,therewasapopularandscientificopinionthatcholeracouldbetransmittedonlybetweenhumansviacontaminatedfoodandwater,aviewthathasbeenslowtochangeevenamonghighly informedwriters (Quammen 2012, 381). The progress in the scientific knowledge aboutcholeraanditstransmissionhasbeenhelpfulforhealthpolicymakers—andisjustaspromising for helping us understand the history of the disease and, morespecifically,howitbecameendemicinJapan.

Beginningwith theheydayofbacteriology in the latenineteenthcentury,medical specialists and laypeople alike equated the presence of a bacteriumwiththedisease itself.Thiswasmostobvious inthecaseoftuberculosis,adiseasealsoknownbytheinitialsTB,whichstandfortuberclebacillus.Muchthesameoccurredwithcholera.ThediseaseandthebacteriumVibriocholerae tendedtobeequateduntil it became clear by the early twentieth century that there existed numerousspecies of theVibrio genus aswell as sub-types ofVibrio cholerae. By the 1930s,researchershaddiscoveredmultiplestrainsofVibriocholerae,realizingthatnotallofthemcausedthesymptomsofcholera(GardnerandVenkatraman1935).Laterinthe twentieth century, researchers discovered that the cholera bacterium existedglobally inaquaticenvironments.MorethanthirtyspeciesofVibrioandmoretwohundred serogroupsofVibrio cholerae—ofwhichonly two, theO1andO139, areassociatedwithepidemiccholera—havebeendiscovered(Kaper,Morris,andLevine1995,54–56;Pruzzoetal.2005,217).Inshort,bynomeansdoesitmakesensetoequate thediseasecholerawith thebacteriumVibriocholerae. Sciencehasshownthat conditions for the outbreak of epidemic cholera dependonmuchmore thanthe presence of the bacterium. Indeed, this multifactored model of cholera’scausalityisclosertothemodelforwardedbyoneofthefoundersofmodernpublichealth, Bavarian chemist and hygienistMax von Pettenkofer,who believed that aconfluence of water, soil, and bacterial conditions needed to occur before thedisease could be transmitted from person to person (Morabia 2007, 1234–1235).AlthoughPettenkofer’stheoryaboutsoilandtheimportanceofthebacteriumwasincorrect, its approach was closer to contemporary ideas about multifactorialcausationofdiseasethanKoch’sideasaboutbacteriabeingthesolecause(Morabia2007, 1236–1237). Although the bacterium is a necessary cause, it is not in itselfsufficient.

Oneofthemostimportantdiscoveriesleadingtoabetterunderstandingofthe relationship between cholera and the environment was that bacteriophagesneeded to insert geneticmaterial into the bacterium tomake it toxic to humans.Bacteriophages—literally, “eaters of bacteria”—are viruses that constitute one ofthemostpervasivebiological entitiesonearth (Weinbauer2004; Srinivasiahet al.2008).Therearetwomaincycles,orways inwhichphages,astheyarecommonlycalled, reproduce inbacteria: lyticand lysogenic. Ina lyticcycle, thephages insert


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genetic material into the bacteria; that material uses the bacteria’s systems toreproduceandformnewphages,whichthenburstoutofthebacteria,killingthem.These phages are called virulent phages. In a lysogenic cycle, the phage isreproduced through the reproductive cycle of the bacterium,which then remainsviable; these are called temperate phages. Only under special circumstances dotemperatephagesinitiatealyticcycle,killingthebacterialhostandsendingphagesintotheenvironment(Touchon,MouradeSousa,andRocha2017).

Innaturalenvironments,bothaquaticand terrestrial, there is anongoingcontest between phages and bacteria. The relative presence of phages in theenvironment depends on conditions such as temperature, pH, and salinity; theirpresence is a powerful controlling force on bacteria populations, including Vibriocholerae (Faruque et al. 2005a, 2005b;Nelson et al. 2009, 699–700; Faruque andMekalanos2012;Faruque2014).YetinthecaseofVibriocholerae,phagesnotonlyhave a limiting impact on populations, but also are the origin of toxicity in thebacterium.ForVibriocholeraetocauseepidemicdisease,itrequiresthesequentialinsertionofgeneticmaterialfromtwolysogenicbacteriophages.Thefirstisaphagewhose genes create pili, filamentous structures on the surface of the cholerabacterium,whichtakesaformreminiscentofawienersausagewithalong,thintail;keepinmindthatthisisanorganismwhosesizeallowsthousandstofitontheheadofapin.Thepiliaddakindoffuzztotheoutsideofthebacteriumandhavethreefunctions:(1)toanchorthebacteriumtothecellwallofthehumanintestine;(2)toactasareceptor for thephage,which,afterattaching itself toapilus, inserts intothe bacterium the genetic code for the production of the cholera toxin; (3) tofacilitate the creation of biofilm, which allows the bacterium to attach itself tochitinous surfaces, such as the outside of zooplankton (Vezzulli et al. 2008). Tobecome toxic to humans, the Vibrio cholerae must undergo two separate lateralgenetransfers(WaldorandMekalanos1996;Donnenberg2000;Nelsonetal.2009).The toxic cholera bacterium constitutes a chimera in the classical Greek sense: itrequireselementsfrommultipleorganismstomakeitdangeroustohumans.Vibriocholeraewithoutinfectionwiththesephagescancausegastroenteritis,septicemia,and wound infections. Its gastrointestinal infections tend to be mild and rarelycontagious (Pruzzo et al. 2005, 217). Depending on the environmental conditions,horizontalgenetransferthroughphageinfectionscanturnautochthonouslyexistingyet benign Vibrio cholerae in aquatic environments into new epidemic strains(Faruque and Mekalanos 2012). In other words, this process makes it entirelyplausibleforVibriocholeraetoexistinaquaticsettingsforextendedperiodswithoutcausing disease, only to appear in epidemic form as a result of changes inenvironmentalconditions(Huqetal.1983;ColwellandHuq2001;deMagnyetal.2008;Vezzullietal.2008;Nelsonetal.2009).

Other environmental conditions facilitate not only the existence but theflourishing ofVibrio cholerae in various aquatic settings. The bacterium has beendiscoveredworldwide,inareasrangingfromChesapeakeBayintheUnitedStatestolocations in Australia, England, Italy, and Sweden—all places where outbreaks ofcholerahavenotoccurredforvery longperiods (ColwellandHuq2001;Lutzetal.2013). Most importantly, Vibrio cholerae has been shown to survive in aquaticenvironments ranging from those with little or no salinity, such as freshwater

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streamsandrivers,tomoresalinewaterfoundinestuariesandevenopenseawater(Colwell 1996, 2027; Vezzulli et al. 2008; Nelson et al. 2009). These conditions inconjunctionwiththeactivityofbacteriophageshelpexplaincholera’sendemicityininlandsearegions,apatternmademoreapparentinalatersectionofthisarticle.

As researchers looked for ways that Vibrio cholerae could exist forextended periods of time in such a range of environmental conditions withoutcontact with the human body, they discovered new qualities about both thebacterium itself andpreviously unidentifiedplaces it inhabited.One keydiscoverywas that Vibrio cholerae could enter a state that scientists call viable butnonculturable (VBNC). Reports of this state appeared as early as 1982, but someresearchersquestionedwhetherbacteriacouldassumesuchaform(Xuetal.1982;Nyström2001). This debate continueduntil the early twenty-first century but hasbeensettledwith the identificationofviablebutnonculturable states fornotonlythe cholera bacterium but numerous bacteria species as well (Barcina and Arana2009; Oliver 2010). It is clear that Vibrio cholerae enters this state dependingprimarilyonenvironmental conditions, especially changes in salinity, temperature,sunlight, and the presence of nutrients. Once conditions become favorable again,thebacteriainthisstatecanreverttotheiractiveforminwhichtheyagainbecomeinfectious.Justhowlongbacteriacansurviveinthisstateisunclear,butithasbeenshowntorangebetweenoneandatleastsixyears(Oliver2010,418).ThelengthofsurvivalimpliesthatVibriocholeraeintheenvironmentcancauseepidemicdiseaselong after having disappeared from human populations. This finding has greatsignificancewhenconsidering theendemicityof thedisease innineteenth-centuryJapan.

AnothersurvivalmethodforVibriocholerae is itsabilitytoattach itselftothe surface of numerous other species. These include copepods and otherzooplankton, phytoplankton, various other aquatic plants, and numerousmacroscopicseacreaturesrangingfromoysters,shrimp,andcrabstofishandevenbirds (Huq et al. 1983; Sedas 2007, 232; Vezzulli et al. 2008, 255; Halpern,Senderovich,and Izhaki2008;Senderovich, Izhaki,andHalpern,2010). Itdoes thisgenerally through the formation of biofilm, which establishes a surface adhesionbetween the bacterium and the various host organisms to which it becomesattached(Lekshmietal.2018).TheseinteractionswithotherorganismsallowVibriocholerae tonotonlyexist forextendedperiodsoutsidethehumanbodybutmoveconsiderable distances, especially when ships carry infected zooplankton ormollusks. Outbreaks of epidemic cholera can occur when seasonal conditionsstimulate the increase of phytoplankton, providing increased nourishment forcopepodsandother zooplanktonand in turn forVibrio cholerae itself, resulting insignificantly higher concentrations of the bacterium in ways that can facilitate itstransmission to humans. For example, oysters filter copepods and otherzooplanktoncontainingVibriocholerae,leadingtoconcentrationsoveronehundredtimesthosefoundinambientwaters(Morris2003,272).

Asshownhere,theenvironmentalbiologyofVibriocholeraeindicatesthatthebacteriumhastheabilitytoremainviableinaquaticenvironmentsforextendedperiods. In short, epidemic cholera can arise from the consumption of infectedoysters and othermollusks, fish, and some forms of seaweed—all of whichwere


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common foods innineteenth-century Japan.More importantly, theenvironmentalbiology of cholera strongly suggests that the Japanese coastline could easily haveprovided a highly suitable environment for the long-term sustenance of Vibriocholerae, facilitating swings between endemicity and epidemic disease. There iscompelling evidence that this indeed occurred. It appears in the prefectural datafromtheStatisticalYearbookof Imperial Japan.Theuseofgeographic informationsystem (GIS) analysis in conjunction with this data makes patterns visible thatotherwisewouldbemoredifficulttodiscern.TheEpidemiologicalRecordofCholerainJapanInadvanceofexaminingthedatausingaGISanalysis,itishelpfultolookbrieflyatthe epidemiological record regarding cholera in Japan as a country and in thecontext of several specific prefectures. Despite the attention given to cholera, itsnationalmortalityratesthroughouttheentireperiodbetween1877and1920wererelatively low. The disease was the focus of numerous health policies and muchpublic attention primarily because its epidemics were socially and economicallydisruptive, especially in prefectures with high mortality rates. Between 1877 and1920,crudecholeramortalityratesper100,000ofthepopulationrangedfromhighsof 290 in 1879 and283 in 1886—theonly two years inwhich they reached threefigures—to lowsofzero inthirteenofthefortyyearsstudied.After1920,nationalcholeramortalityratesneveragainrosepast1per100,000(calculatedbasedontheStatistical Yearbook of Imperial Japan). The average national mortality rate fromcholera for theentireperiodbetween1877and1920stoodat22per100,000.Bycomparison,mortalityfrompulmonaryconsumptionandtuberculosisbetween1886(thefirstyearforwhichfiguresareavailable)and1920rangedfromalowof86per100,000in1886andahighof257per100,000in1918;theaverageforthatperiodwas180per100,000—overeighttimesthemortalitycausedbycholera.Asanotherbasis for comparison, the mortality rate for heart disease, the leading cause ofmortality in the United States in 2016, stood at 197 per 100,000; malignantneoplasms stood at 185 per 100,000 (CDC).3 Nationalmortality rates for cholera,however, mask significant prefectural differences. In the epidemic of 1886, forexample, Tokyo Prefecture experienced a mortality rate from cholera of 926 per100,000; for Osaka, the rate that year was even higher, at 983. The rate forKagoshima that year, however, did not even reach 3 per 100,000 (Naikaku TōkeiKyoku,ed.1888).Nationalaverages,inotherwords,hardlybegintotellthestoryofcholera’sregionalimpact;rather,theyhideimportantdifferences.ThePrefecturalRecordthroughGISAnalysis 3Nationalandstatemortalitydatafor2016canbefoundathttps://www.cdc.gov/nchs/data/dvs/lcwk/lcwk5_hr_2016.pdf.

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Prefecturaldataobviouslydoesrevealregionalpatterns,yetdisplayingthedataforallforty-sevenprefecturesoverthecourseoffortyyearsisunwieldyatbest.ThisiswheretheuseofGISanalysis,illustratingannualmortalityratesforeachprefecture,is extremelyhelpful.4 Theprefecturalmortalitydata,whenanimated, allowsus toseethegeographicaldistributionofcholeramortalitybyyearandtoconsider thatdistributioninlightoftheenvironmentalbiologyofVibriocholerae.

Theprefecturaldatadoeshaveitslimitations.Itdoesnotbeginuntil1881,thoughnationaldataregardinginfectiousdiseasesisavailablefrom1876.Thedataforsomeregions isnotcompletelysequential; forHokkaido,forexample, itbeginswithseparatedataforKaitakushi(Thecolonialoffice)during1882,andforSapporo,Nemuro, and Hakodate during the years 1883 and 1884. No prefectural data isavailableintheStatisticalYearbookofImperialJapanbetween1901and1909.Evenmoreproblematically, thepopulationdata for eachprefecture,whichof course isnecessary for the calculationof crudemortality rates, is not consistent across theentireperiodfrom1880to1920.From1880to1897,thepopulationdatadependson thehonseki jinkō (registered population); only from1898 does thegenjū jinkō(actual population) become available. It is assumed that when a person died ofcholeraitwasreportedtothepoliceinthelocationwherethedeathoccurredandthatthosearethenumbersavailableforannualdeathsfromthediseaseinanyoneprefecture.Thehonseki jinkō forplaces suchasTokyowas smaller than thegenjūjinkōasshowninthefiguresfor1898,whentheformerwas1,507,642andthelatter1,877,412; this difference would have skewed mortality rates per 100,000 ofpopulationupwardbefore1897anddownwardafterthatyear.Thisuseofdifferentpopulationdataisunavoidableafter1897becausehonsekijinkōisavailableannuallybeforethatbutonlyonceeveryfiveyearsthereafter.Ruralprefecturesoutofwhichresidents moved to work in urban areas have larger registered than actualpopulations,meaningthatthecrudemortalityratesfromcholerawouldhavebeenskewed in the opposite direction. Another problem is simply that of reporting. Itmustbeassumedthatreportingofcholeracaseswasnotconsistentthroughoutthecountry in that many people wished to avoid association with such a malignantaffliction.Inshort,theprefecturalmortalityratesforcholeraaswellasthoseforallofJapanmustbeinterpretedasanindexratherthananexactmeasure.

Yetevenasanindex,thesefiguresandthevisual informationtheyimpartthroughthisanimatedmaprevealimportantpatterns.Inparticular,innon-epidemicyears,choleraremainsendemic inmostoftheprefecturesof Japanthat facedtheInlandSea.Throughoutthe1880sand1890s, theseprefecturesrarelywentayearwithoutreporteddeathsfromcholera.BasedonthecurrentenvironmentalbiologyofVibriocholerae,thisfindingshouldbeunsurprising.Thisareahaslargestretchesof complex coastlines and contains hundreds of small islands; a large number ofriversdrainintotheInlandSeafrombothHonshuandShikoku,providingnutrientsfor bothVibrio cholerae itself and the various organisms that it can colonize. The 4AnanimatedmapofJapanillustratingchangesincrudemortalityratesfromcholerabyprefecturebetween1881(theyearinwhichprefecturaldataisfirstavailable)and1920(afterwhich,aspreviouslynoted,choleramortalityinJapanbecomesrelativelyinsignificant)isavailableonlineathttps://cross-currents.berkeley.edu/e-journal/issue-30/johnston.


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result is a favorable environment forVibrio cholerae, one that is rich in planktonbloomsandlargenumbersofmollusks.Hiroshima,forexample,wasfamousforitsoysters, but experience limited their consumption to the coldmonths.Becauseoftheabilityofoysters to concentrate thebacterium in their tissue, asnoted in thediscussion about the environmental biology ofVibrio cholerae above, it is easy toimagine them becoming infected with Vibrio cholerae and providing a vector forcholerawhenwarmerwatersprovideda favorable climate for thebacterium. It isconclusive that cholerawas indeed endemic to Japan at least during the last twodecades of the nineteenth century. Moreover, it is probable that Vibrio choleraeremained viable in the Inland Sea between 1901 and 1909, when deaths fromcholerawerenotreportedontheprefecturallevelbutwerereportednationally;in1902, 8,104 deaths from cholera were reported, and in 1907, there were 1,702.When prefectural data again becomes available in 1910 through 1920, theconsistenthotspotscontinuetobetheprefecturessurroundingtheInlandSeaandcoastalareasinwesternHonshu.

Another pattern that the animatedmap available onlinemakes visible isthe impact of cholera on populations that hadminimal previous exposure to thedisease. Areas such as large parts of northeastern Japan (Tōhoku) and Hokkaidotendedtohavelowmortalityratesfromcholera,butinepidemicyearssuchas1886and1895theyexperiencedhighmortality rates.Thisoccurrencematchespatternsobserved inotherpartsof theworld inwhichpopulations thatpreviouslyhad lowexposuretothediseasethensufferedrelativelyhighmortalityonceVibriocholeraebegantospread(Nelsonetal.2009,694).Bynomeansdoesthisknowledgeamountto an epidemiological history of cholera in Japan, but that is not the goal of thisarticle,whichis,rather,toshowthatthebiologicalandenvironmentalscienceofthediseasecanhelpusunderstandsomeofthepatternsofitshistoricalepidemiology.ConclusionBasedoncurrentscienceregardingtheVibriocholeraebacteriumandthediseaseitcausesinconjunctionwithaGIS-enabledillustrationofregionalmortalitypatterns,itisclearthatcholerawasindeedendemicinJapanduringthelasttwodecadesofthenineteenth century, a time when popular media if not public health officialsdepictedthediseaseascomingfromabroad(Johnston2017).Thisendemicitywasinnosmallparttheresultofcholera’sbeingprimarilyazoonosis,ordiseaseofanimals,that infectscopepods (Huqetal.1983;ColwellandHuq2001).As inotherplaces,cholerainJapanduringthesedecadesinfectedhumanswholivedincoastalregions,especiallyinnon-epidemicyears.Inthisway,theoverallepidemiologicalpatternofcholerafitspatternsseeninmanyotherregionsacrosstheglobe.

Bythe1910s,thediseasehadbecomelocalizedprimarilyinareaswhereithadexistedendemicallybeforethat,andbythe1920scholera’snationalmortalityand morbidity rates had become insignificant. This decline remained true evenduringthehardshipyearsofWorldWarII,withaminoruptickincholeramortalityin1946,when560individualsdiedofthediseasenationwide—notenoughtoregistersignificantlyamongothercausesofdisease,muchlessothercausesofmortality.Thedecline certainlywas not from the expansion of sewage systems, thewidespread

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construction of which had to wait until after the 1970s. Until then, most humanwaste was collected in septic tanks that dealers in night soil regularly emptied.Although sewage systems remained rudimentary through the first half of thetwentieth century, it appears that the current methods of treating individualsinfected with cholera did, for the most part, help prevent the spread of thebacterium.Forexample,apopularmanualforhomenursingandfirstaidpublishedin1910emphasizedtheneedbothtotakecarewitheffluentsthatcholerapatientsproduced and to wash hands to prevent the spread of the cholera bacterium(Kodama1910,34–35).Arguably,thekeychangewastostopthereintroductionofVibrio cholerae from the environment into human populations. This decline incholera mortality likely was tied to the rapid expansion of pure water suppliesthroughout Japan during the late nineteenth and early twentieth centuries(Kasahara2003;Kojima2018).

Definitiveproofthattheeffectiveseparationofwatersuppliesandhumanwastecombinedwithincreasinglyeffectivemethodsofdealingwitheffluentsfromcholera patients calls for yet another study. Yet this article does illustrate howcurrentsciencecaninformanswerstohistoricalquestions,especiallyregardingtheenvironmentanddiseasepatterns.Indoingsoitoffersadegreeofagencytoactorssuchasbacteriophagesthatdonotappearinthearchivalrecordbutclearlyplayedan important role in thehistoryof thisdisease.Thisworkmightencourageotherswhospecialize inthehistoryofdiseasetomakethemselvesas familiaraspossiblewiththecurrentscienceontheirsubjects,aslongasthatknowledgecancontributeto understanding how people in the past experienced disease or how diseaseswaxed andwaned in time and space. In addition, it would be beneficial to applysimilar methods to the study of environmental pollution, climate change, andhabitatdestruction inhistoricalperspective,providinguseful analyses fornotonlyhistoriansbutpolicymakersaswell.InthiswayC.P.Snow’scallforabridgebetweenthehumanitiesandthenaturalsciencesisasurgenttodayasitwashefirstmadeitoversixtyyearsago.AppendixFor many decades, historians left the histories of diseases and epidemics tophysicians based on the assumption that they required medical rather thanhistoricaltraining.Ratherthanbeingconsideredasworld-shapingforces,thehistoryofdiseaseandepidemicsbecameanichefield.Earlyhistoriesofcholeratendedtoexaminequestionsofinteresttophysiciansandothermedicalspecialists.Asidefromthe earliest histories of cholera by nineteenth-century observers such as JohnMacPhersonandDuaneB.Simmons,themodernhistoryofthediseasewaslargelyinitiated by Robert Pollitzer. He tracked its history from earliest times to thetwentiethcenturybasedontheassumptionthattoday’s“cholera”wasthesameaswhat premodern writers meant by that term—or translations of it. Pollitzer wasthoroughlygroundedinthecontemporarysciencerelevanttothehistoryofcholera,buthewrotebeforegenetic,environmental,andotherdiscoverieschangedthewaypeoplethoughtaboutthedisease(Pollitzer1954;1959;Hamlin2009,268).DhimanBaruawroteamoreup-to-dateversionofcholera’shistoryinthisvein,extendinghis


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study to include the seventh pandemic (Barua 1992). More recently, twocardiologists, S. L. Kotar and J. E.Gessler, havewritten a global historyof cholerathattracksitspandemicsfromtheearliestonein1817tothepresentera(KotarandGessler2014).Theseworks focusedon thecourseofpandemiccholeraacross theglobeoronchangingmedicalresponsestothedisease.Althoughtheirauthorsweremedically trained, they did not generally use current science to explain howpandemiccholeraspreadandintegrateditselfinlocalenvironments.

AnearlyforayintothehistoryofcholerabyatrainedhistorianwasCharlesE. Rosenberg’s The Cholera Years: The United States in 1832, 1849, and 1866.Published when he was twenty-six years old, its relevance remains perennial. Itfocusesonthereligious,cultural,andpublichealthresponsestothediseaseinthoseyears (Rosenberg 1962). Anothermonumentalwork is Richard J. Evans’sDeath inHamburg: Society and Politics in the Cholera Years, 1830–1910. It provides an in-depth look at the scientific, social, and political events relevant to that city’sexperience with the disease, especially Max Joseph von Pettenkofer’s tragicobjectionstoRobertKoch’stheorythataspecificgerm,Vibriocholerae,causedthedisease(Evans1987).FrankM.Snowden’sNaplesintheTimeofCholera,1884–1911is anothermodel study not only of this disease in a single city but of its broaderculturalimplicationsandwhy,unliketuberculosisorsyphilis,itssymptomspreventitfrom being the stuff of romantic novels, narratives of rebellion, or operatic arias(Snowden 1995, 112–113). Going geographically and temporally to the otherextremeisMyronEchenberg’sAfricaintheTimeofCholera:AHistoryofPandemicsfrom1817tothePresent,whichexaminesthehistoryofthediseaseonacontinentalscale from the first pandemic to the time of its publication. To a certain extent,Echenberg does examine relevant scientific sources, especially with regard totransmission and endemicity (Echenberg 2011). Notably, at least one scholar hasengaged fully with the literature regarding themedical, biological, and ecologicalsciences relevant to cholera’s transmissionandendemicity.ChristopherHamlin, inCholera: The Biography, argues that the currentmedical and scientific knowledgeabout Vibrio cholerae and its global environmental distribution decenters thedisease from Asia, with which it had been associated from the time of its firstpandemic in 1817. He points out how current science has made the boundariesaround our conceptions of choleramuch fuzzier than previously thought (Hamlin2009,268).Althoughtheterm“Asiaticcholera”haslongbeenincirculation,itisnomore accurate than calling the 1918 influenza pandemic by themoniker “Spanishflu.”Inmanyrespects,Hamlin’sworkisamodelforinterdisciplinaryworkinclusiveofthesciencesaswellassocialsciencetheory inthehistoryofdiseaseandpublichealth(Hamlin2012).

ThehistoriographyofcholerainJapanisrich,especiallywhencomparedtothat of most other non-Western countries. Fujikawa Yū, the doyen of medicalhistory in Japan, who trained as a physician but practiced as a historian, firstpublishedhisNihonshippeishi(AhistoryofdiseaseinJapan)in1912.Itincludedanextensivediscussionofcholerabutfocusedonunderstandingsofthediseaseinthemedical literatures in Japan (both Chinese- andWestern-based) and, to a certaindegree, in popular culture (Fujikawa [1912] 1944). Another physician, YamamotoShunsuke,whotaughtmedicineatTokyoUniversity,publishedhismagisterialNihon

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korera shi (A history of cholera in Japan) in 1982. It makes an enormouscontribution, especially as a compendiumof primary sources on cholera in Japan,but offers minimal analysis. This work’s contradiction of many other studies byclaimingthatnocholeraepidemicoccurredin1862suggeststhatitsstrengthsareinits examination of the disease during and after theMeiji-era reforms (Yamamoto1982).FujikawaYūalsoinitiatedformalstudiesofthemedicalhistoryofcholerainJapan—focusingontheoriesofcausation,prevention,andcure—withtheinitialpublicationof hisNihon igaku shi (A history of Japanesemedicine) in 1904 (Fujikawa [1904]1979). Tatsukawa Shōji’s Kinsei yamai zôshi (Stories of maladies in early modernJapan) includes a chapter on cholera before the Meiji Restoration in 1868, withsectionsonthe1858epidemic,thewidespreadconfusionthatepidemiccaused,andpopular beliefs about the disease (Tatsukawa1979). Similarly,Nakajima Yōichirō’sByōkiNihonshi(DiseaseinJapanesehistory)includesasectiononcholera,focusingonpremodernconceptionsofthedisease’scause,names,andfamouspeoplewhosuffered from it (Nakajima 1982). An examination of how the changing names ofcholera-like diseases in nineteenth-century Japan reflected changing medicalepistemologies can be found in my essay (Johnston 2014). Roberto Padilla haswritten a more tightly focused essay that examines problems associated withdisease categories that the Japanese military used during the First Sino-JapaneseWar(1894–1895)(Padilla2016).

Anumberofwell-researchedworkshavebeenwrittenon theEdo-periodexperiencewith cholera,mostly focusing on the epidemics that occurred in 1858and1862,although theepidemicof1822doesnotgocompletelyunmentioned inthesecondaryliterature.AnexaminationofdeathrecordsfromBuddhisttemplesindifferent regions of the country during the three major Edo-period epidemicsappears in an article by Kikuchi Kazuo. Kikuchi (1978) demonstrates that in 1859cholera was likely more deadly than in 1858, but the earlier year gains greaterattention because of its impact on the city of Edo. In addition, he persuasivelyarguesthatthe1862epidemicwastheworstofthethreethatoccurredduringtheEdoperiod.BettinaGramlich-Oka’s“TheBodyEconomic: Japan’sCholeraEpidemicof 1858 in Popular Discourse” provides, at this point in time, the mostcomprehensiveEnglish-languageoverviewofthepopularculturalresponsestothatepidemic (Gramlich-Oka2009). In Japanese, Takahashi Satoshi’sBakumatsuorugii:Koreragayattekita!(ABakumatsuorgy:Cholerahasarrived!),despiteitsluridtitle,provides a rich analysis of local reactions, primarily based on religious and folkbeliefs among villagers and townspeople, to the epidemics of 1858 and 1862(Takahashi2005).AcloseexaminationoftheinteractionbetweenJ.L.C.PompevanMeerdervoort, aDutchphysician inNagasaki, andOgataKōan, the founderof theschoolofWesternLearninginOsaka,Tekijuku,andhowtheytreatedcholerainthe1858epidemic canbe found inHärmenBeukers’s 1992 “Ponpe toOgataKōannokorera chiryōhō” (Remedies for cholera of Pompe and Ogata Kōan).My “CholeraandPopularCultureinNineteenthCenturyJapan”(2017)contextualizesthepopularresponsestocholeraduringthethreeepidemicsoftheEdoperiodbutalsodiscussescontinuities and discontinuities in those responses before and after the MeijiRestorationin1868.


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In one of themost important English-language studies of epidemics andpublichealthinmodernJapan,SusanL.Burnsarguedin“ConstructingtheNationalBody:PublicHealthandtheBodyinNineteenth-CenturyJapan”(2000)thatcholerawasJapan’sfirstmodernepidemic,andshowedhowitwascentraltotheformationofmodernJapan’spublichealthsystem.Anotherstudyofhowthebodybecamethesubject of hygienic modernization and state control is the subject of MiriNakamura’sMonstrousBodies:TheRiseoftheUncannyinModernJapan, inwhichshe showshowcholera, an invisibleyetpotenthealth threat,wasvisualizedusingcontemporarymetaphorsand tropes (Nakamura2015,16–23). Inanother seminalessay that examines the obstacles that contemporary public health officials facedamongthegeneralpublic,AkihitoSuzukiandMikaSuzukiexplorethemodernizationof medicine in nineteenth-century Japan through the lens of consumerism andcitizenship (Suzuki and Suzuki 2009).OginoNatsuki’s studyof public health in thecontextof“civilizationandenlightenment”showshowofficialsattemptedtochangethewaylaypeoplethoughtaboutcholeraandreplacetheirthinkingwith“civilized”ideasduring theepidemic thatoccurred in1879 (Ogino2012).Another importantpublic health response was the establishment of quarantines on ships enteringJapanese harbors, which raised important issues of international law. “InformalImperialism and the 1879 Hesperia Incident: Containing Cholera and ChallengingExtraterritoriality in Japan”byHaraldFuess (2014)examinesmanyof these issues.AnessayontheJapanesequarantineplacedatapproximatelythesametimeontheKoreanportofBusanandthemeetingofempireandinternationallawisJeong-RamKim’s“TheBorderlineof ‘Empire’:JapaneseMaritimeQuarantineinBusanc.1876–1910”(2013).ChesterJ.Proshan’sstudyofepidemiccholerainYokohamatakesupmanyofthesameissuesofquarantinewhilelookingmorebroadlyattheexpatriatecommunities there from the late Edo period to the end of the century (Proshan2018).

As onemight expect because of cholera’s impact on public health policyformation and institutional reforms, the body of literature dealing with thesethemes is relatively largeandwell developed,withBurns’s (2000) groundbreakingessay examining these themes in comparison with other infectious diseaseswidespreadatthetime.Similarly,HozukiRie’sstudyofthedevelopmentandsocialintegrationofeisei(hygiene)emphasizestheimmenserolecholerahadintheriseofhygienic thought and public health practices in modern Japan (Hozuki 2010).Numerousotherstudiesdetailcholera’simportanceinthisrespect.UtsumiTakeshidescribedhygienicmeasuresaimedateliminatingunsanitaryconditionsthroughoutthecountryduringthecholeraepidemicof1877(Utsumi1992).Followingaparallelargument, my article examines how the Meiji state collaborated with theestablishedBuddhistchurchesaftertheepidemicof1879inanattempttopersuadepeoplethroughoutJapanthat,althoughduringepidemicstheycertainlyshouldprayto the kami and buddhas, they also should complement those responses with“scientific” approaches to prevention and treatment (Johnston 2016). Twogovernmentbureaucrats,NagayoSensai,DirectoroftheCentralSanitaryBureauofthe Home Ministry, and Gotō Shinpei, who also worked in the Central SanitaryBureauandlaterbecamegovernorofTaiwan,andtheirresponsestocholerastandoutinthehistoryofpublichealthinJapan(Nagayo1877;Gotō1890).Manyworks,

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includingBurns,discussNagayo,butmorefocusedstudiescanbefoundinessaysbyKasahara Hidehiko (2007) and Kojima Kazutaka (2009). These works build onKasahara’s earlier essay that examined the impact of Nagayo and Gotō on theestablishmentofmodernJapan’spublichealthadministration;choleracontrolwasamainobjective (Kasahara1996).Notsurprisingly,Nagayoalsoplayedan importantrole ineiseikōji (publichealthengineering)projects,oneofwhosemaingoalswascholera prevention through the establishment of reliable clean water sources(Kasahara2003;Kojima2018). Severalworks have raised issues that link geographywith cholera duringthenineteenthandearly twentiethcenturies in Japan. Inhisdoctoraldissertation,Padilla(2009)discussesat lengthJapaneseperceptionsoftherestofAsiaasbeingdiseased and the idea that China and Korea in particular harbored infestations ofcholerathatthreatenedJapan,atleastuntilthe1880s.YetPadillaemphasizesthatby1886, Japanesehealthofficials considered cholera tohavebecomeendemic tothe country (2009, 120). Taking a different perspective onmodernization and thespreadofcholera,economistJohnP.Tang(2017)claimsthatthegrowthofrailroadsduring the 1880s and later facilitated the spread of acute infectious diseases,especiallycholera.TwogroundbreakingessaysthatuseGIS-basedanalysisappearedin 2007. One focuses on the cholera outbreak in 1890, using GIS to examine thespreadofthediseaseprimarily innorthernKyushubutalsothroughoutJapan.Thisstudy reveals the general course of the disease across the country during thisepidemic,withhotspotslocatedlongtransportationroutes(KuoandFukui2007a).Theother,astudyofcholerainFukushimaPrefectureduringtheepidemicsof1882and 1895, uses similar methods and also reveals that cholera outbreaks wereconcentrated in areas surrounding transportationhubs, especiallywhere theyhadhighdegreesoftrafficfromoutsidetheprefecture(KuoandFukui2007b). Thisisbynomeansanexhaustivesurveyofthesecondaryliteratureonthehistory of cholera in Japan. Nevertheless, it seems safe to conclude that, so far,worksbyhistoriansof cholera in Japanhave takenabroadvarietyofapproaches,but virtually none have attempted to show how the physical reality of Vibriocholerae in its environment was a major determinant in its epidemics andestablishmentasanendemicdisease.ReferencesABriefReviewoftheOperationsoftheHomeDepartmentinConnectionwiththe

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AbouttheAuthorWilliamJohnstonisProfessorofHistoryatWesleyanUniversity.Hewouldliketothankthetwoanonymousreadersoftheoriginalmanuscript.IkumiKaminishiproofreadthemanuscript.ResearchwassupportedbygrantsfromtheAssociationforAsianStudiesandtheJapanFoundation.SaraKimproducedtheGISanimation.

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