Diseases of the Premodern Period in Japan

Hell Really Exists

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The role of disease in Japanese history is a topic that has attracted the interest of Western historians only recently. The strongest stimulus for the study of disease and its effects on Japan's premodern society was the publication of a new edition of Fujikawa Yu's classic Nihon shippei shi in 1969 with a foreword by Matsuda Michio (A History of Disease in Japan, originally published in 1912). Along with his History of Japanese Medicine (Nihon igaku shi, 1904), A History of Disease in Japan provided historians with a detailed list of many of the epidemics that ravaged the Japanese population in the premodern era, including original sources of information and a diagnosis of many diseases in terms of Western medicine. Hattori Toshiro supplemented and updated Fujikawa's work in the postwar era with a series of books on Japanese medicine from the eighth through the sixteenth century.

William McNeill also kindled interest with Plagues and Peoples (1976), a book that fit the disease history of East Asia into the context of world history. Both William Wayne Farris (1985) and Ann Bowman Jannetta (1987) have investigated pestilence in premodern Japan in detail, but the field is still relatively undeveloped, as compared to work on Western history. The influence of the Annates school of France on Japanese scholars, which began in the late 1970s, may draw more scholars into work on disease, especially for the well-reported but unstudied period between 1300 and 1600.

Data for the study of disease in Japan present both opportunities and frustrations. The quantity of information on disease, especially epidemic afflictions, is better than for most other civilizations, including possibly western Europe. The reason for this is that the Japanese imported the Chinese practice of reporting diseases among the common people around 700. Many of these reports were included in court chronicles in abbreviated form. The custom of reporting epidemics suffered, however, as the links between the provinces and the capital waned after 900, and many outbreaks of pestilence undoubtedly went unnoticed by the aristocrats at court who did the recording of disease. Moreover, even when the reporting system was operating at its best, the sources often do not provide important facts such as the nature of the disease, the regions afflicted, or levels of mortality inflicted. In addition, local records that would enhance our knowledge of diseases that prevailed are largely lacking before 1100, and the job of ferreting through village and town documents for signs of pestilence after 1100 has yet to be attempted.

About the time that the Japanese government borrowed the Chinese custom of recording outbreaks of pestilence, it also borrowed their medical theory. The description, diagnosis, and treatment of disease in premodern Japan almost always derive from Chinese texts. Buddhist scriptures from India also influenced how disease and medicine were perceived in early Japan. It is unclear how much the Japanese knew about disease and its treatment before Chinese and Indian influences. Some medical practices reported during early epidemics may well derive from native roots, as during the Great Smallpox Epidemic of 735-7 (Farris 1985). For the most part, however, the native Japanese view of disease was that it was demonic possession to be exorcised by shamans and witch doctors.

It is important to distinguish between infectious diseases, which can create epidemics, and other afflictions, which, to use McNeill's terminology (1976), form the "background noise" to history. Japanese sources provide information on a wide variety of diseases, especially when they attacked a statesman, artist, or priest. However, it is often difficult to classify the illness in Western terms. For this reason, the focus of this essay will be chiefly on epidemic outbreaks, with occasional reference to identifiable, noninfectious ailments.

The relationship between disease and Japan's geography is significant in two respects. First, Japan presents a good case of "island epidemiology" (McNeill 1976). Because of its comparative isolation, Japan remained relatively free of epidemic outbreaks as long as communication with the continent was infrequent. Consequently, the populations grew dense. However, once an infectious disease was introduced to the archipelago, it ravaged those dense populations that had had virtually no opportunity to develop resistance to it. Thus, immunities were built up only slowly in a process that took centuries.

Second, because of Japan's mountainous terrain, one cannot always assume that an epidemic reached the entire Japanese populace at once. Severe outbreaks undoubtedly afflicted isolated villages and regions even in the Edo period (1600-1868). Certainly, more study of the important relationship between Japan's topography and transportation routes and disease transmission is needed.

The history of epidemics in Japan until 1600 (when Japan banned travel and trade with most nations) falls into four periods: (1) from earliest times to 700, when little is known about disease; (2) 700-1050, an age of severe epidemics; (3) 1050-1260, a transitional stage when some killer diseases of the past became endemic in the population; and (4) 1260-1600, a time of lessening disease influence despite the introduction of some new ailments from the West.

The record of disease in Japan's prehistory is a matter of guesswork. In the earliest times, the Paleolithic (150,000 B.C. to 10,000 B.C.) and Neolithic (10,000 B.C. to 200 B.C.) periods, population was too sparse to sustain many afflictions. Evidence indicates that there was a Malthusian crisis in the late Neolithic epoch, about 1000 B.C., but archaeologists have not been able to discern any signs of infectious diseases in the skeletons of Neolithic peoples (Kito 1983). The bronze and iron ages (200 B.C. to A.D. 300), when rice agriculture was imported from the Asian mainland, would seen to have been an age of great population increase and therefore of potential disease outbreak as well. However, again the archaeological record gives no indication of illnesses in those few skeletons that remain. Similarly, there is little evidence on disease for the era from 300 to 500.


Most scholars of Japan agree that the historical age begins with the sixth century, and hard evidence of disease in the region also originates with this time. Japan's first court history, The Chronicles of Japan, records that in 552 many were stricken with disease. It is no accident that this epidemic occurred at the same time that the gifts of a statue of the Buddha along with sutras arrived at the Japanese court from Korea (Aston 1972). Disease doubtless also arrived with the carriers, although the court blamed the outbreak on the introduction of a foreign religion and destroyed the gifts.

In 585, the court again banned the worship of the Buddha, and this time chroniclers noted that many people were afflicted with sores. The Chronicles of Japan states that those attacked by the sores were "as if they were burnt," a condition suggesting fever. According to Hattori Toshiro (1943), the 585 epidemic was the first outbreak of smallpox in Japanese history, although it should be noted that some sources from later centuries record that the 585 epidemic was measles.

The 552 and 585 (not 587, as some have reported) outbreaks are the only signs of pestilence between 500 and the end of the seventh century. There are two ways to interpret the absence of data on disease for this epoch. First, the sixth and seventh centuries may have been relatively disease-free, in which case the era must have seen a population boom - a boom that would have coincided with the introduction of Chinese institutions into Japan. A second and more likely answer is that the chroniclers simply did not record epidemics. Sources from the period 500 to 700 are notoriously scarce and inaccurate. Moreover, during these two centuries Japan sent 11 embassies to China, received 7 from China, and had about 80 exchanges with Korea (Farris 1985). Given these contacts with the outside world, it is therefore conceivable that disease was an important feature of Japanese demographic history for the era 500 to 700.

Beginning in 698, it definitely was. Historical sources disclose an alarming number of epidemic outbreaks. There are 34 epidemics for the eighth century, 35 for the ninth century, 26 for the tenth century (despite a marked decline in the number of records), and 24 for the eleventh century, 16 of which occur between the year 1000 and 1052 (SZKT 1933 and 1966; Hattori 1945; Tsuchida 1965; Fujikawa 1969; and Farris 1985).

Because of this spate of pestilential outbreaks, the period from about 700 to about 1050 stands out as Japan's age of plagues. Records suggest that the diseases were imported from the Asian mainland as the Japanese traveled to China and Korea to learn of superior continental political and cultural systems and to trade. Disease became a major influence on Japanese society, shaping tax structure, local government, land tenure, labor, technology, religion, literature, education, and many other aspects of life. Certainly, the epidemics in these centuries held back economic development of the islands. On the other hand, by undergoing such trauma early in their history, the Japanese people built immunities at a relatively early date and thus escaped the onslaught of diseases that came to the civilizations of the Incas, Aztecs, and others with Western contact in the sixteenth century.

Unfortunately, historical documents do not often reveal the nature of the diseases in question. Historians can identify only five of them: smallpox, measles, influenza, mumps, and dysentery. In addition, McNeill (1976) has suggested that plague may have found its way to Japan in 808, and his argument has a great deal to recommend it. Plague was then afflicting the Mediterranean and the Middle East, and

Arabic traders and sailors frequented Chinese, Korean, and Japanese ports. Denis Twitchett (1979) has shown that China received many diseases from the West via the Silk Route. The presence of plague in Japan would also go a long way in explaining several severe epidemics that have yet to be identified. Yet because there is no description of symptoms by the Japanese sources, the existence of plague in Japan during this period remains in doubt.


The most deadly killer among the five diseases that are known to have assaulted early Japan was smallpox (mogasa, "funeral pox"). Epidemics of the pestilence are listed for the years 735-7, 790, 812-14, 853, 915, 947, 974, 993-5, 1020, and 1036 (compiled from data in SZKT 1933; Hattori 1955; Fujikawa 1969; Farris 1985). During this era, especially in the eighth and ninth centuries, smallpox was primarily a killer of adults. According to Jannetta (1987), smallpox had become endemic in the population by 1100 or even earlier, but the basis for this belief is not clear.

The best example of a smallpox, and indeed of any epidemic in this period, is the Great Smallpox Epidemic of 735-7, the earliest well-reported smallpox epidemic in world history (Farris 1985). It began in northern Kyushu, transported there by a Korean fisherman. The foreign port of Dazaifu was the first to feel the effects of the disease, a sure sign that the affliction was imported. Kyushu suffered throughout the summer and fall of 735, and the disease raged again in 736. Just as the epidemic was burning itself out in western Japan, a group of official emissaries to Korea passing through northern Kyushu encountered the ailment and carried it to the capital and eastern Japan. The epidemic assaulted all levels of Japanese society, killing peasant and aristocrat alike. One record reads that "in recent times, there has been nothing like this" (Farris 1985).

Two remarkable records survive that describe the symptoms and treatment of smallpox. The disease began as a fever, with the patient suffering in bed for from 3 to 6 days. Blotches then began to appear, and the limbs and internal organs became fevered. After the fever diminished and the blotches started to disappear, diarrhea became common. Patients also suffered from coughs, vomiting, nosebleeds, and the regurgitation of blood.

The prescribed remedies are as fascinating as the descriptions of the symptoms. Government doctors trained in Chinese, Indian, and native medicine ad vocated a variety of palliatives, including wrapping the patient in warm covers, drinking rice gruel, eating boiled scallions to stop the diarrhea, and forcing patients with no appetite to eat. Medicines were seen as of little use against the disease. After the illness, those who recovered were admonished not to eat raw fish or fresh fruit or vegetables, drink water, take a bath, have sex, or walk in the wind or rain. Doctors also advocated mixing flour from red beans and the white of an egg, and applying the mixture to the skin to eliminate the pox. Bathing in a woman's menstrual flow or wrapping a baby in a menstrual cloth to wipe out the blotches; and applying honey, powdered silkworm cocoons, white lead, or powdered falcon feathers and lard was also suggested.

Tax records extant from the time of the epidemic provide a glimpse of the mortality inflicted by the Great Smallpox Epidemic of 735-7. In the year 737 alone, the province of Izumi near the capital lost 44 percent of its adult populace, while Bungo in northern Kyushu and Suruga in eastern Japan sustained death rates of about 30 percent. The average mortality for all known areas was about 25 percent in 737 alone. Population depletion for the 3 years probably amounted to between 25 and 35 percent, making the Great Smallpox Epidemic of 735-7 comparable in its death toll to the European Black Death of the fourteenth century.

Disastrous as it may have been, one great outbreak of pestilence would not have halted demographic growth for long. But harsh epidemics continued to follow on its heels. In 790, smallpox struck again, borne from Chinese ports and afflicting those aged 30 or less. The historical record is fragmentary and difficult to read for the epidemic of 812-14, but it seems likely that the dread killer entered Japan via its foreign port in northern Kyushu as early as 807 and spread across the archipelago to the east. According to the records, "almost half" of the population died. In 853, the disease seems to have focused on the capital, Heian (modern Kyoto), but the epidemic also spread to the countryside.

The disease, however, still seems to have been primarily an ailment of adults. In 925, for example, the Emperor Daigo contracted smallpox at the age of 41. The smallpox outbreak of 993-5 was particularly severe. In 993, the Emperor Ichijo was a victim at the age of 15, but the disease was probably not yet endemic, as smallpox appeared in Kyushu the next spring, suggesting a foreign source. The disease was so bad in the capital that 70 officials of the fifth court rank or higher died; the roads were littered with corpses serving as food for dogs and vultures. In

1020 smallpox returned to Kyushu again, possibly reaching Japan with one of the continental invaders the year before. A diary states that those aged 28 and under were especially afflicted (Tsuchida 1965; Farris 1985).


The second killer disease that attacked the Japanese populace in the era between 700 and 1050 was measles (akamogasa, "red pox"). Two epidemics are known, in 998 and 1025, although it is not clear that Japanese doctors were always able to distinguish between measles and smallpox in this early age. Nonetheless, A Tale of Flowering Fortunes, a chronicle of the tenth and eleventh centuries, clearly differentiates the 998 affliction from smallpox, stating that the disease caused a "heavy rash of bright red spots" (McCullough and McCullough 1980). The pestilence began in the early summer in the capital, where the wives of high officials were the first affected. Foreigners did not die from the disease, a clue that reinforces McNeill's (1976) thesis about Japan's island epidemiology. Later in the year, the ailment attacked the rest of Japan, killing more people than any other in recent memory.

In 1025, measles once again returned to Japan. The disease afflicted people of all classes who.had not suffered from the disease in the 998 epidemic. The diaries of aristocrats indicate that several noble houses suffered from the illness. The focus of the disease seems to have been the capital, although one source states that "all under heaven" caught the malady.


A third ailment was influenza (gai byo or gaigyaku byo, "coughing sickness"), which struck in 862-4, 872, 920, 923, 993, and 1015 (Hattori 1955; Fujikawa 1969). Unlike smallpox and measles, which were most active in the spring, summer, and fall, influenza generally struck in the late winter and early spring. The epidemics of 862-4 and 872 were particularly severe, killing many people in the capital region. In general, however, the death toll from influenza probably did not match the mortality from smallpox or measles.


Mumps (fukurai byo, "swelling sickness") was the fourth epidemic illness encountered by the Japanese in this period. Records state that the disease flourished in 959 and 1029, mainly in Heian, the populous capital of the era. In both epidemics, historians indicated that the sickness was marked by a swelling of the neck.

The final pestilence of the age of plagues was dysentery (sekiri, "red diarrhea"). Epidemics are documented for 861, 915, and 947 (Hattori 1955). The season for dysentery was the late summer and fall. Often dysentery appeared in tandem with other afflictions, as in the Great Smallpox Epidemic of 735-7. The dysentery epidemic of 861 was followed by influenza in 862 and 863. In 915 and 947, smallpox was again an accompanying malady. The measles epidemic of 1025 was also probably related to dysentery infections among the Heian nobility. Their diaries indicate that when patients caught dysentery they quickly lost their appetites and suffered from fever.

Other Maladies

In addition to these five epidemic afflictions, other illnesses were common among the populace. According to The Pillow Book, a series of essays written by a lady at court (Sei Shonagon) about the year 1000, the three diseases most feared by the tiny coterie of aristocrats at the Heian court were chest trouble (munenoke), evil spirits (mononoke), and beriberi (ashinoke). Chest trouble undoubtedly refers to tuberculosis, although Hattori (1975) suspects that heart-related afflictions were also common. Tuberculosis is one of the oldest diseases known to humanity, and it may have been that because the tuberculosis bacillus is often transmitted via unpasteurized milk, the aristocracy contracted the malady by eating a yogurtlike food product of which they were fond. Evil spirits suggest mental illnesses, and Hattori (1975) has found evidence of schizophrenia, autism, and manic-depressive behavior in the imperial line. Beriberi, a disease caused by a deficiency of thiamine (probably due to a lack of fats in aristocratic diets), is noted in several sources for the early period (Hattori 1964).

Some diseases were never diagnosed by court doctors who were trained only in Chinese medicine. Japanese records tell of a "water-drinking illness" (mizu nomi yami) common to the Fujiwara family, the mating line for the imperial house (Hattori 1975). According to Hattori, this disease was diabetes, and was hereditary in that family. Several prominent Fujiwara statesmen, including the great Michinaga (the model for Prince Genji in The Tale of Genji), complained of the malady and its related afflictions such as glaucoma and impotence (Hurst 1979).

Another malady that did not kill many victims but had a great effect on all levels of society was malaria (warawayami, furuiyami, or okori, "the chills"). Even Prince Genji himself suffered from the malady (Seidenstecker 1985). Doctors of this era were unaware that the disease could be carried by mosquitoes, although a court lady seemed to believe that butterflies were common where the disease broke out. Japan is a land with many swamps; it is interesting to speculate about the effects of malaria on a peasantry trying to convert these low-lying lands into productive rice paddies.

In addition to the plentiful information on diseases supplied by court histories, literature, and other records, medical texts and an encyclopedia called the Wamyo ruiju sho also list medical terminology (Hattori 1945). Among the infections included are idiopathic cholera (shiri yori kuchi yori koku yamai, kakuran), leprosy (raibyd), elephantiasis igeju), bronchitis (shiwabuki yami), hepatitis (kibamu yamai), dropsy (harafukuru yamai), asca-rids (kaichu), threadworms (gyochu), meningitis (fubyo), infantile dysentery (shoji kakuran), diphtheria (bahi), bronchial asthma (zensoku), epilepsy (tenkari), chronic nephritis (shokatsu), tonsilitis (kdhi), osteomyelitis (fukotsuso), thyroiditis (ei), erysipelas (tandokuso), ringworm (senso), gastritis (iso), palsy (kuchi yugamu), and scabies (kaiso). Records from the era 700-1050 also have led scholars to infer the existence of cancer, pneumonia, tapeworms, rheumatoid arthritis, and hookworms.

Effects of Plagues on Japanese Society The effects of the age of plagues (700-1050) on Japanese society and culture were many and varied. Parallels with the Black Death pandemic that struck western Europe in the fourteenth and fifteenth centuries are tempting to draw, and it may be true that pestilence stimulates the same human responses in widely disparate societies. In the social and economic realm, the epidemics were responsible for several phenomena. First, disease caused population stagnation. Sawada Goichi estimated the population of Japan at 6 million in the eighth century, and it is unlikely that population grew significantly through the year 1050 (Kito 1983).

Second, plagues caused the desertion of villages. After the Great Smallpox Epidemic of 735-7, an entire layer of village administration was abolished. Later, after the epidemics of 990-1030, the court once again abandoned the current village system in favor of new laws.

Third, pestilence inhibited agriculture, especially rice monoculture, because it became difficult to culti vate lands continuously. In 743, after the 735-7 outbreak, the aristocracy attempted to stimulate farming by enacting a policy giving permanent private tenure to anyone who would take up a hoe. In 1045, lawgivers countered unparalleled field abandonment by recognizing all previously banned estates.

Fourth, outbreaks of pestilence stimulated migration and made for a shortage of laborers. The court enacted legislation to bind peasants to their land throughout the eighth and ninth centuries, but to little effect. Labor shortages often made it difficult to finish temple construction or rice planting on time, and by the year 800, the court had given up capital construction and the conscription army.

Fifth, disease was responsible for a growing maldistribution of income. A new class of regional strongmen, called the "rich" in the documents, came into being by capitalizing on opportunities arising from famines and epidemics. The "rich" often resorted to violence to resist provincial tax collectors and exploit the peasantry.

Sixth, the stagnation of population growth resulting from disease reduced the demand for manufactured goods. At the same time, because epidemics kill people but do not destroy wealth, survivors of the pandemic among the aristocracy were left with great riches. Reduced overall demand and the increased opulence of a few gave rise to industry that produced luxury goods for a tiny elite.

In the political realm, epidemics brought several alterations in tax structure. After the Great Smallpox Epidemic, provincial governors were converted into tax farmers, which put them into competition for revenues with the leaders of the smaller district units that comprised the province. The competition for taxes among local officials while the tax base was shrinking helped engender a society that looked to violence to solve its problems. By 1050, the district had disappeared as a unit of administration, primarily because it could not compete with the larger province. Moreover, epidemics provided political opportunities. After the 735-7 epidemic, for example, all four of the Fujiwara brothers from a powerful aristocratic family had passed away, and Tachibana no Moroe, a bitter rival, became the new head of the government. Or again in 994, when smallpox raged in the capital and many aristocrats fell victim, a beneficiary of the deaths was Fujiwara no Michinaga, who became perhaps the greatest of all Fujiwara leaders.

In addition, disease influenced inheritance. To cope with the horrendous number of deaths of family members from plagues, the aristocracy practiced polygamy. Often property and children were retained in the woman's line against the advent of an untimely demise by her husband. Survivors inherited unparalleled wealth and political power.

Finally, plagues reduced the size of administration. In the early eighth century, the government bureaucracy numbered about 10,000 persons. By the early ninth century, leaders were already cutting back the size of government, and although hard figures are difficult to come by, the bureaucracy did not again reach that size until the fourteenth century.

The age of plagues also influenced religion and culture. Unquestionably, the epidemics played a role in both the adoption of Chinese culture in the eighth century and a return to the native culture in the tenth and eleventh centuries. It is unlikely that the Japanese of the 700s borrowed Chinese civilization simply because it seemed superior to their own. Only coercion, such as military force or epidemic disease, would have inspired the Japanese to adopt such an obviously foreign culture. On the other hand, disease played a role in the demise of Chinese culture in Japan because the constant plagues killed off experts in Chinese language and the classics, thus making these subjects harder to learn. Disease was also a factor in the development of a major motif in Japanese literature, mono no aware, the ephemeral nature of all living things. Disease is a constant presence in the classic The Tale of Genji, which includes reference to an epidemic (Seidenstecker 1985). Many of Genji's friends and lovers pass away after the briefest time, and in most cases the villain was disease. To have reached one's forties was considered to have lived a long life (Hattori 1975).

The repeated outbreaks of pestilence also influenced Japanese religion profoundly. The introduction of Buddhism occurred amidst a plague of smallpox. As a transcendental religion, Buddhism was perfectly adapted for an environment in which disease outbreaks were common. Early believers reached out to Buddhism because of the promise of protection from illness. After the Great Smallpox Epidemic of 735-7, the Emperor Shômu increased state support of the religion by ordering the construction of the great state temple Tôdaiji and branch temples throughout the countryside. By the tenth and eleventh centuries, Buddhism had become a faith of good works, as Christianity was during the plague pandemic in the fourteenth and fifteenth centuries. The frequency of pilgrimage in both religions is another striking parallel. By the eleventh century, Japanese religious thought was characterized by pessimism and a flight from the intellect. Millen-nialism, symbolized by "the latter day of the law"

(mappo), dominated Japanese thought. According to this doctrine, three ages of 500 years each followed the death of the Buddha: the first era, when salvation was simple; the second, when it was more difficult; and the latter day, when delivery from hell would come to just a few. Ironically, the latter day was believed to begin in 1052, just as the epoch of plagues drew to a close.

Popular culture also reflected a concern for disease. The Gion Festival, today celebrated from the July 17 to July 24 (the 14th of the sixth month according to the old lunar calendar) began as an attempt to rid the capital of Heian of epidemics. The festival was first conducted by Gion Shrine (later Yasaka Shrine) in eastern Heian in 869, just after an epidemic. Sixty-six spears, one for each province in Japan, were placed on end and marched through the city to chase the disease away. In 970 the festival became an annual affair, suggesting the growing endemicity of disease in the capital.

The smallpox pestilence of 993-5 gives another rare glimpse of popular reaction to epidemics. Late in the sixth month of 993, a festival to drive away disease gods was held in the Kitano section of the capital. Two palanquins were built by the government, Buddhist monks recited a sutra, and music was provided. Several thousand persons gathered and offered prayers to the gods. The palanquins, invested with the gods of the epidemic, were then borne by the populace several miles to the ocean to wash the smallpox affliction away (Tsuchida 1965; Fujikawa 1969).

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  • Eveliina Jokinen
    How did Japanese peasants of the ninth century (and later) explain disease and epidemics?
    2 years ago

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