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• 1 2019-11-18T17:16:28-05:00 Physicians' Social Bodies and Networks 23 plain 2020-12-10T06:55:55-05:00 Maren Ehlers The introduction of the smallpox vaccine to Japan owed much to existing networks among Japanese specialists of Dutch medicine [Janetta]. Most physicians of the Tokugawa period spent some time training with one or more prominent doctors outside their home region. Often, they moved to one of the larger cities for a few years in their youth and then returned to practice medicine at home, only to move again if they desired further training. In the process, most doctors forged permanent ties with teachers that situated them within wider, trans-regional lineages of medical learning. The network of Dutch medicine specialists, which consisted of many interconnected student-teacher relationships, was a site of particularly lively exchanges of knowledge and ideas. 
  
  At the same time, physicians in Tokugawa Japan were also part of localized groups of medical professionals. These groups comprised domain and town doctors of all specialties and served as vehicles for both occupational self-government and seigneurial control. They were status groups in the sense that they situated their members within the structure of Tokugawa rule and managed their members' status and public obligations. While these groups were structured hierarchically and dominated by the domain doctors, all members participated in the tasks of self-government and consensus-building, drawing on their shared medical knowledge.
  
  Broadly speaking, there were two types of medical professionals in Tokugawa Japan: domain physicians, who directly served the lord and received stipends according to rank, and town and village physicians, who lived among commoners and primarily treated commoner patients. Both types, however, performed certain duties for their lords as mediated by their status group. In addition to self-control, they were often expected to treat prisoners, for example, or accompany the lord on his travels or pay their respect at the palace at certain times of the year. 
  
  In the course of the nineteenth century, many feudal rulers in Japan intensified their oversight of medical practice in their territories. In the castle towns of Fukui and Fuchū, for example, domain and town doctors began to coalesce around newly established medical academies and exercised stricter control over the practices of village doctors and the sale of medicinal herbs to domain subjects. Medical academies issued rules that defined physicians' respective responsibilities within the group. In Fuchū, physicians affiliated with the academy referred to themselves as a shachū (society) [Umihara]. 
  
  The status groups of physicians were organized by domain. When Kasahara Ryōsaku, a town doctor of Fukui domain, brought the smallpox vaccine to Echizen, he established a regional network of vaccinators that rested on top of the local status groups of doctors. To explore this new network, go directly to "A New Regional Network of Vaccinators". Or continue on the pathway "The Networks and Vehicles of Vaccine Transmission."
   
   
• 1 2019-11-18T17:16:23-05:00 A Separate Clinic for Nishikata 23 plain 2020-12-10T16:32:24-05:00 35.984878, 136.487725 35.959045, 136.054641 35.991555, 136.097231 36.069758, 136.217013 35.902981, 136.166517 Maren Ehlers

  In 1857, Koyama Yōju finally received a legitimate transmission. He had been working toward this goal at least since his vaccine theft of 1853. As Kasahara Ryōsaku noted in his journal in 1857 (click here for a translation), Koyama had also received vaccines from Fuchū’s society at one point, and vaccinators from Fuchū (a town close to Nishikata) once asked Kasahara whether they were allowed to share vaccines with Koyama. At that time, Kasahara still rejected this transfer between neighbors, arguing that Koyama was neither from Fuchū nor represented a “separate clinic” within Ōno domain. In other words, he deemed the transfer incompatible with the institutional framework he was hoping to build for vaccinations in Echizen province. It seems that Kasahara was eager to have each vaccinators’ society overlap with a domain territory, and if the vaccine ever went extinct, he wanted domain governments to send a formal request for retransmission to their counterpart in Fukui. Perhaps Kasahara believed that with such a high hurdle for retransmission, physicians would try harder to keep the vaccine alive. It is possible that he saw this principle endangered by Koyama’s request.

  In 1857, Kasahara and his colleagues in Ōno came up with a workaround to authorize Koyama’s operation without damaging their institutional framework. They probably felt pressured to act after domain officials had tried to appoint an unauthorized vaccinator for Nishikata. First, Ōno’s physicians invited Koyama and “carefully instructed him in Ōno on the assessment of pocks and other things.” They transmitted the vaccine to him, then “went to his place and imposed on him rules about all kinds of things on the basis of an inspection.” This initiation turned Koyama into a legitimate vaccinator who could be trusted to act in a responsible manner.

  Second, Koyama's operation received the status of a “separate clinic” (bekkan) of Ōno domain. As Kasahara explained to his Ōno colleagues, this status would allow Koyama to receive retransmissions from Sabae and Fuchū in case he lost his chain of supply. He cautioned that if Koyama requested a retransmission without such status, he could not receive one “without Ōno’s domain leadership sending a correspondence to the leading officials at the domain office in Fukui.” This was an outcome Kasahara was hoping to avoid because he felt it would taint the achievement of Ōno’s vaccinators, who “had not let the vaccine go extinct even once.” Clearly, Kasahara was hoping to maintain domain-based retransmission as a lever to discipline and motivate vaccinators within each domain. At the same time, he acknowledged that clinics in rural exclaves like Nishikata might require retransmissions from neighboring territories to remain feasible. When Ōno’s vaccinators notified Kasahara that they intended to follow his recommendation and open a “separate clinic” in Nishikata, Kasahara sent a letter to the chapters in Fuchū and Sabae to inform them of that fact (click here for a translation of the letter).

  In this manner, the perpetuation of vaccinations in Echizen province depended on the authority of domain rule, yet was impeded by its fragmentation. It took the abolition of domain rule in 1871 to bring the territorial geography in line with the vaccinators’ need for stronger and more centralized governmental control. But even centralization did not result in full coverage right away. In the second half of the 1880s, the vaccination rate in Fukui prefecture finally crossed the eighty-percent mark [Yanagisawa, 2018, p. 59].
  
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