The History of Japanese Anesthesiology.

Anesthesia in Japan has a 200-year history, beginning when Seishū Hanaoka first conducted surgery successfully under general anesthesia in 1804. Despite common belief, Hanaoka was not secretive about his technique using Mafutsusan, and he spawned a generation of Japanese anesthetists, including Gendai Kamada, author of several influential texts. Japanese anesthetists adopted inhalational techniques as they became available.

Three Newly-Discovered Copies of the Manuscript Mayaku Ko, Written by Shutei Nakagawa, with Special Reference to their Appearance and Genealogy.

Seishu Hanaoka's greatest achievement was the anesthetic Mafutsusan. He developed it and then used it successfully for various operations, primarily breast cancer tumor excisions. The developmental process can be traced in Mayaku Ko, a memorandum written and edited in 1796 by Hanaoka's close friend Shutei Nakagawa.

A Consideration on the Origin of Seishu Hanaoka's Nyugan-jun and Nyugan-jun Furoku.

Nyugan-jun is a manual that was used at Hanaoka's school, Shunrinken, describing two oral medicines and three ointments routinely administered after breast cancer surgery. Nyugan-jun Furoku is also a manual that was used at the school, depicting a variety of diseases of the breast, and oral concoctions to be administered. The earliest manuscript of both manuals was transcribed in February 1812.

[Ryoan Imamura and his Iji Keigen (1862) -Public Disclosure of the Prescription of "Mafutsusan" -].

In 1846, Ryoan Imamura joined the Gassuido school in Osaka, which was a branch of the Shunrinken school in Hirayama, Kishu. At that time the Gassuido school was presided by Nanyo Hanaoka, the son-in-law of Sei- shu Hanaoka. It remains unknown how long Imamura studied surgery at the school.

[Hosetsu Namba and the First General Anesthesia for a Pregnant Woman in the World].

Hosetsu Namba (1760-1859), a practitioner at Kanagawa, Bizen (presently Okayama Prefecture) and a disciple of Rokujo Hanaoka, described in his Taisan Shinsho three cases of general anesthesia with Mafu- tsusan. They are breast cancer tumor excisions in two patients in 7 and 3 months of pregnancy, respectively, and anal fistulectomy in a patient in 3 months of preg- nancy. Their postoperative courses were uneventful, and all of them had smooth deliveries.

The Four Chinese Characters of Katsubutsu Kyuri Express the Maxim Chosen by Seishu Hanaoka.

Koko Niida composed an epitaph for Seishu Hanaoka in 1836 and in it he employed a phrase consisting of eight Chinese characters to describe Hanaoka's medicine. The phrase reads Naigai Goitsu Katsubutsu Kyuri. Since then, the phrase has prevailed as Hanaoka's motto, even among lay people as well as medical historians.

Ryozo Chiba's Ben-nyugansho narabini Chiho Soko and Nyuganbensho or Nyuganben: The Practice of Hanaoka's Breast Cancer Surgery in 1811.

In 1811, Ryozo Chiba (1789-1861) from Sendai Province enrolled in a private school of Shunrinken, presided by Seishu Hanaoka and wrote up a manuscript titled Nanki Seishu Sensei Nyugan Chyutu Koju (the title on the first page is Ben-nyugansho narabini Chiho Soko) in August 1811, only 6 months after enrollment. The manuscript describes Hanaoka's teachings about breast cancer surgery; signs and symptoms of breast cancer, differential diagnosis, preoperative care, administration of Mafutsusan, operative procedures, hemostatic techniques, wound suture; wound dressing, recovery from anesthesia with Mafutsusan, postoperative care, and prescriptions of drugs for internal and external use. After repeated transcriptions and the addition of various papers on other subjects, the title of the manuscript changed to Nyuganbenshio or Nyuganben.

Development of Mafutsusan by Seishu Hanaoka and General Anesthetics in the Very Early Part of the 19th Century in Japan.

Seishu Hanaoka's medicine is famed for its breast cancer surgery. Hanaoka, who,was motivated by Dokushoan Nagatomi's Man-yu zakki, published in 1771, had the idea to excise a breast cancer tumor and not to perform a breast amputation. Because he recognized that general anesthesia was indispensable for performing a surgical operation of the breast, he developed a general anesthetic and surmounted various difficulties: selection of an anesthetic method, anesthetic ingredients, determination of the opti- mal dosage, administration methods, indications and contra-indications, evaluation of the depth of anesthesia, facilitation of the smooth emergence from anesthesia, and postoperative care.

[Papers in English on the History of Anesthesia in Japan Published in a Period between 1950 and 2010].

The origin of the history of anesthesia in Japan dates back to 1804 when Seishu Hanaoka administered the first general anesthesia for breast cancer surgery; however, academic anesthesiology was not established in Japan until Meyer Saklad, a member of the Unitar- ian Service Committee medical mission, introduced modern anesthesiology in 1950 into the country. Therefore, it is rational that there was no study of the history of anesthesiology before 1950 in Japan. It was after the mid-1980's that papers in English of the his- torical study of the specialty appeared in journals.

[[The Report from the Committee on Future Policy and Its Significance in the History of Anesthesia in Japan-Focusing on an Article Regarding the Presidential Election]-].

In 1980, the Committee on Future Policy of the Japan Society of Anesthesiology (JSA) submitted a draft of the report to the Board of Directors of the society. An article on the presidential election was included in the draft. It reads: Candidates within three are recommended from one of seven districts (the whole of Japan is divided into seven districts), and Elders of JSA elect the president by vote at the Coun- cil of Elders.

[Anesthesia for War Wounded at the Osaka Military Wartime Hospital: From Ishiguro's Report of the Osaka Military Wartime Hospital].

8,569 government soldiers were transferred from Kyushu areas to the Osaka Military Wartime Hospital during the Seinan War in 1877. Among them, 5,990 soldiers were wounded, and 357 out of them under- went moderate to major surgeries including amputa- tion of the extremities under chloroform or chloro- form-ether (50%: 50%) anesthesia using Skinner's mask. Although 83 (23.

[Misunderstandings of Seishu Hanaoka's Medicine and Philosophy].

Although Seishu Hanaoka glories in the history of anesthesia in Japan, misunderstandings of his medicine and philosophy are widespread among the public as well as physicians. The incorrect opinions include: 1) he kept his art under wraps, 2) therefore his medicine did not prevail through the country, 3) the general anesthetic that he developed was formally called Tsu- sensan but not Mafutsusan, 4) his surgical art was too transcendent to be learned by his disciples, and 5) erroneous views of Seishu's maxim Naigai Goitsu Ka- tsubutsu Kyuri. Teachers of anesthesiology in any edu- cational institution are required to have correct under- standings of these subjects because the name of Hana- oka is well known among foreign anesthesiologists and they have much interests in his medicine and philoso- phy.

[On Anaesthetica by Johann N. von Nussbaum who Introduced the Concept of Local Anesthesia to Japan].

Because the Japanese word of Masui (Anesthesia) was originally coined to mean general anesthesia in 1850, there was no Japanese phrase corresponding to general anesthesia in the period between 1850 and 1877. In 1878, Tadanori Ishiguro, a military surgeon who was impressed by Johann N. von Nussbaum's Andsthetica, published Shitu narabini Masuiho (Analge- sia and Anesthesia).

Kihan Akaishi's Publication Plan of an Illustrated Brochure on Breast Cancer Surgery by Seishu Hanaoka.

In 1809, Kihan Akaishi (1785-1847), one of the disciples of Seishu Hanaoka who ran a private medical school "Shunrinken," planed to publish an illustrated brochure, on breast cancer surgery by Hanaoka. It was only two months after he enrolled at the school. Although details remain unknown as to why Akaishi was so active in publishing the brochure, it is likely that he was impressed by the skillful breast cancer surgeries done by Hanaoka and determined to prevail upon him to share information about them among his colleagues.

A Consideration of Four Illustrations of Surgical Operation Referred to in Nyugan Chiken Roku.

Four illustrations of a breast cancer operation of Kan Aiya in 1804 are referred to as Figures 2 to 5 in the manuscript Nyugan Chiken Roku. One of Hanaoka's disciples depicted them, standing at the patient's feet, in order not to block the sunlight. Thus, the drawings may have been illustrated as viewed from the front.

A Study of the Manuscript Nyugan no zu, in the Possession of the National Diet Library: A Comparison with the Manuscript Seishu sensei ryo nyugan zuki.

In May 1810, the wife of Rihei Hiroseya, from Takayama, Hida Province, received an excision of a breast cancer tumor at Shunrinken in Hirayama, Kishu Province. Hirose asked Gaku Nomura, one of the Hanaoka's disciples, to make a manuscript describing his wife's surgery. In reply to Hirose's request, Nomura made the manuscript including her history and operative procedures, with illustrations of 13 other surgical cases of breast cancer, and he gave it to him the next month.

[Another Short-lived Journal "Japanese Anaesthesia Journals' Review"-Circumstances of the Start and End of its Publication-].

It was in 1978 when Professor Tsutomu Oyama at Hirosaki University had an idea of publishing an Eng- lish journal to introduce Japanese articles on anesthesia to foreign readers. In October 1981, a meeting was held in Tokyo, and Oyama discussed with Hideo Yamamura, Emeritus professor of the University of Tokyo, Professor Wilhelm Erdmann from Erasmus University, Dr. Roland Droh, Chief in Anesthesia at Sportklinik, Lüdenscheide, West Germany, and a repre- sentative of the VNU Press from the Netherlands.

[Anesthesia Conference and Anesthesia Colloquium -Michinosuke Amano and the Origin of the Tokyo Society of Anesthesiologists.].

In October 1958, seven anesthesiologists from Tokyo area, who had frequently met at the Anesthesia Collo- quium, discussed founding a society of anesthesiologists to improve their social status. Next month, the Tokyo Society of Anesthesiologists was founded. The society was active in campaigning for the governmental approval of anesthesiology as a specially designated specialty.

[Influence of Meyer Saklad's Lectures on the Development of Modem Anesthesiology in Japan -An Assessment of their Influence on the Publication of Special Issues on Anesthesiology in Japanese Medical Journals.].

Modern anesthesiology in Japan developed after Meyer Sakad's lectures at the Japanese-American Joint Conference on Medical Education (JAJCME) in 1950. To assess their influence on the subsequent advance in the specialty, the author surveyed Japanese clinical journals between 1949 and 1953 to find special issues on anesthesiology. Only two special issues were found in the journals published in March 1951 and February 1953.

[Influence of the Unitarian Service Committee Medical Mission on the Development of Anesthesiology in Japan -Focusing on the Influence of Saklad's Lectures of the First Mission in 1950.].

Considering the fact that even in Japan the modern development of anesthesia triggered the simultaneous -advances in surgery and related specialties, it is impor- tant to elucidate the formative history of anesthesia to comprehend the modem history of medicine in Japan. The most significant influence on the modern advance of anesthesia in Japan was made in 1950 by Saklad's lectures at the Japanese-American Joint Conference on Medical Education, held by the Unitarian Service Com- mittee Medical Mission. Their direct and indirect influ- ence was assessed by means of subsequent roles of several eminent professors in the specialty, number of anesthesia-related presentations in annual meetings of the Japan Surgical Society and Japanese Association for Thoracic Surgery, and number of anesthesia- related papers in various medical journals before and after his lectures.

[The Origins of the Words : Zenshin Masui and Kyokusho Masui.].

In 1850, Seikei Sugita coined the word "Masui" to describe a physical condition induced by ether inhala- tion. Therefore, the word"Masui"initially meant general anesthesia. After physical methods to produce local numbness were introduced to Japan, it was necessary to make a new phrase to express the methods and the physical condition produced by them, and "Kyokusho Masui" was made, in which "kyokusho" means local.

[The Formative Years of Modern Anesthesiology in Japan--A Dialogue between Hideo Yamamura and Akitomo Matsuki].

In a dialogue with Akitomo Matsuki as the moderator, Hideo Yamamura, the first Professor of Anesthesiology in Japan at the University of Tokyo who had enormously contributed toward improving the standard of the specialty in Japan, gave detailed accounts of following topics: his training as a surgeon, Saklad's lectures in 1950, the establishment of a departmental anesthesia group, the conversion to anesthesiologist, studying in the United States, the foundation of the Japan Society of Anesthesiology, movements for the governmental approval of registered anesthesiologists and the qualification system of board certified anesthesiologists, international activities in holding the Second Asian Australasian Congress of Anaesthesiologists in 1966 and the Fifth World Congress of Anaesthesiologists in 1972, and the opening of pain clinics and the foundation of its society. Yamamura's accounts illustrate unknown episodes in the history of the formative period of modern anesthesiology in Japan.

[Admiral Isoroku Yamamoto and Chloroform Anesthesia].

Isoroku Yamamoto (1884-1943) who was on the Nisshin, an armored cruiser, received injuries to the left hand and right calf on May 27, 1905, at the Battle of Tsushima during the Russo-Japanese War. Three days later, he was admitted to the Sasebo Naval Hospital to undergo emergency amputations of the index and middle fingers of the left hand under chloroform anesthesia. He was, then, evacuated to the Yokosuka Naval Hospital, one of the naval background hospitals, and approximately, a month later, he received a muscle grafting taken from the left gluteal region.