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. In 1954, the Japanese Society of Anesthesiologists was established; in 1960, "Anesthesiology" was accredited by Japanese government as an officially approved medical specialty; and in 1963, board examinations were established to be an instructor of anesthesia. In 2011, the Japanese Museum of Anesthesiology opened in Kobe, with the mission to collect and preserve literature and equipment related to the history of Japanese anesthesia (Figure 1).

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. A manuscript of Ben-nyugansho narabini Chiho Soko, written by Ryozo Chiba in 1811, includes descriptions of an oral medicine and four ointments routinely given after breast cancer surgery. Although Choeito was only a common oral concoction in Nyugan-jun and Chiba's manuscript, the latter bears an original trace of Nyugan-jun. This indicates that Nyugan-jun and Nyugan-jun Furoku were completed by the end of February 1812, and their completion dates were not before August 1811.

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. Contained in this document is a list of fourteen prescriptions for earlier attempts by other doctors to create-a general anesthetic. These prescriptions, which Nakagawa had passed along to Hanaoka, were the foundation for the scientific breakthrough. The preface suggests that Hanaoka had nearly perfected Mafutsusan by 1796. Nakagawa's original manuscript has been lost, but copies of it are extant. Until recently, we knew of four, all of them in Japan. I have discovered three more: one in the University of Tokyo Library (Gakken Collection), another in the Keio University Shinanomachi Media Center, and the third in the Asahikawa Medical University Library (Sekiba-Samejima Collection). After carefully examiiing the new ones, I put the seven known copies of Mayaku Ko into four groups, A to D, according to the order in which they were likely transcribed. One of the copies in Group A, which is from the Matsuki Collection, appears to have been the first.

[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. In 1862, Imamura published a book titled Iji Keigen, wherein he disclosed the prescription of "Mafutsusan". Every disciple of the Hanaoka's schools was sternly asked not to leak the secrets of the prescription. In the background of his divulgence, there may have been the circumstances in which he had a deliberate intension to insist on the significance of traditional Kampo medicine, coping with emerging Western medicine.

[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. Although Namba did not provide the exact dates of these opera- tions, it is highly likely that the patient with breast cancer in 7 months of pregnancy received the tumor excision during a period between 1815 and 1830. To the best of our knowledge, this is considered the first general anesthesia for surgery in a pregnant woman to be documented in the world literature.

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. I reviewed previous articles on these subjects and, using several unpublished manuscripts, provided new information on disseminated general anesthetics in Japan during the decade after the first general anesthesia for Kan Aiya in 1804.

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. Chiba's original manuscript is considered important because the transcriber and the year of transcription of the manuscript are identified, and it unfolds the practice of Hanaoka's breast canicer surgery as of 1811.

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. Although there are scrolls written by Hanaoka showing the four Chinese characters of Katsubutsu Kyuri, no calligraphy including the four Chinese characters of Naigai Goitsu is extant. Gencho Honma, one of the leading disciples of Hanaoka and who published Zoku Yoka Hiroku in 1859, mentioned in the preface that the phrase Katsubutsu Kyuri was the maxim that Hanaoka proposed. Considering these facts, the phrase Katsubutsu Kyuri is the very maxim chosen by Hanaoka. He appreciated the significance of skillfulness in the practice of surgery, which was difficult to acquire by reading books and listening to lectures. One of his important phrases, which reads Toku to Futoku wa Sonohito ni Ari in seven Chinese characters, is discussed, regarding how to be adept at technical skills in the practice of surgery.

[[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. According to this article, an opportunity to be a candidate was provided once in seven years. Accordingly, bitter and more intensive election cam- paigns were conducted. Although there was such inconvenience, the report contributed greatly to the improvement of the subsequent administration of JSA, including the presidential election.

[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.

[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 (23.2%, 83/357) died postopera- tively, no severe anesthetic complications were observed.

[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. A total of 21 papers on the subjects were reviewed.

[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). In this book, he coined new Japa- nese phrases Kyokusho Masui and Zenshin Masui which corresponded to German phrases Lokale Anaes- thesie and Allgemneine Anaesthesie, and he described the definition of those terms. Since then, the terms, local anesthesia and general anesthesia, have prevailed in Japan.

[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. Then,"Zenshin Masui", indicating general anesthesia, was made to form a set of "Kyokusho Masui" and "Zenshin Masui". It was 1876 when Tadanori Ishiguro published "Geka Tsujutsu", in which he described a clear definition of "Kyokusho Masui" and "Zenshin Masui". This is one of the earliest uses of "Kyokusho Masui" together with "Zenshin Masui" in Japan.

[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. The colloquium was advocated by Michino- suke Amano of Keio University and was established in March 1955. Thus, the colloquium is considered the starting point of the society. Further, the origin of the colloquium dates back to the Anesthesia Conference held at the suggestion of Professor Wasaburo Maeda of Keio University. The first Anesthesia Conference was held in July 1952 immediately after Amano's return from the United States to Japan.

[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.

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. The manuscript, titled Seishu sensei ryo nyugan zuki, is extant and this is considered to be the one that Nomura gave Hirose because there has been no other manuscript with this title and the manuscript is carefully recorded and bound. This suggests that there must be a draft of Seishu sensei ryo nyugan zuki. A manuscript titled Nyugan no zu is in the possession of the National Diet Library and it is considered to have been originally stitched temporarily, and then bound later. However, the contents of this manuscript are identical to those of Seishu sensei ryo nyugan zuki. In particular, illustrations in both manuscripts are highly likely have been made by the same illustrator, although sentences in both manuscripts are recorded by different hands. Thus, it is likely that Nomura asked an illustrator to make two sets of illustrations and Nomura used one for his presentation to Hirose and another for a draft, and that Nyugan no zu is a draft of Seishu sensei ryo nyugan zuki.

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. Because the manuscript lacks the original illustrations, Kure transcribed them from other unidenti- fied manuscripts to reproduce them in his monograph Seishu Hanaoka and His Surgery, but they were illustrations viewed from the side, suggesting that they were different from the original figures. A manuscript in the Kyou Library titled Nyuganzu is considered to convey the original style because its illustrations are presented from a front view. Sixteen sheets of drawing, which are in the possession of the Flower Hill Museum, are considered rough sketches for the original illustrations because they are of Hanaoka's family provenance. Careful examination of these manuscripts and the rough sketches leads to further elucidation of the mysteries of Nyugan Chiken Roku.

[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. They discussed on details of the journal's publication and determined that the title of the journal was to be Japanese Anaesthesia Journals' Review and four issues were to be published in a year. Eight Japanese editors including Hideo Yamamura were to select excellent papers from Japanese journals, and Oyama as editor- in-chief asked original authors to summarize them in about 2,500 English words. After much meandering the first issue of the first volume was published in May 1985. The publication of the journal encountered diffi- culty due to several causes including delayed re-writ- ing of revised manuscripts. After all, volume 1 was published in 1985 and 1986, volume 2 in 1987, volume 3 in 1988 and 1989, and volume 4 in 1990 and 1991. The publisher decided to cease publishing the journal due to financial difficulties. Although this journal was short-lived, it was likely. a catalyst for the publication of Journal of Anesthesia issued in 1987.

[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. Because the former issue in the jour- nal "Rinsho" was published before Maeda's presidential address in 1951 at the Annual Meeting of the 51st Japan Surgical Society and Volpitto's lectures at the second JAJCME in 1952, the influence of Maeda's and Volpitto's lectures is excluded from this issue. The traces of Saklad's influence are detected only in two articles by Shimizu et al and Maeda et al, who enjoyed Saklad's lectures.

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. On the request of Akaishi, however, Hanaoka responded with neither "Yes" nor "No" because Hanaoka thought that it was impossible to accurately describe his diverse medical practices. Although Akaishi failed to obtain Hanaoka's permission to publish it, he tried to move further for the publication. He showed a manuscript containing Akaishi's preface and illustrations of 13 cases of breast cancer surgery to Yuya Kishi (1734-1813), asking him to write a foreword to the manuscript. Kishi was a scholar of Chinese literature of the Wakayama domain and a close friend of Hanaoka. A manuscript tentatively titled "Nyugan Zufu" is most likely the manuscript that Akaishi showed to Kishi, and the preface by Akaishi and the foreword by Kishi from other manuscripts elucidated the situation of the unirealized publication of the brochure.

[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. The procedure was most likely performed under chloroform anesthesia because chloroform was the only general anesthetic that the hospitals prepared. This grafting was not described in most of his biographies. In December 1916, he suffered from acute appendicitis and he was brought to the University of Tokyo Hospital, where an appendectomy was undertaken by Professor Tsugushige Kondo using chloroform ansthesia because Kondo had a great dislike for spinal anesthesia.

[Seishu Hanaoka Did Not Describe His Anesthetic as Tsusensan--A Misunderstanding of the Terms Mafutsusan and Tsusensan]

It is widespread even among medical professionals as well as medical historians that the formal term of the general anesthetic that Hanaoka developed is Tsusensan and its alias name is Mafutsusan. Hanaoka himself, however, described it as Mafutsusan in his Nyugan Chikenroku, the case report of the first breast cancer excision under general anesthesia with the anesthetic, and a large number of his disciples all used the term Mafutsusan to denote the anesthetic in their manuscripts. The description of Tsusensan has not been found in the documents written in the Edo period, and this name is detected only in the epitaph of Hanaoka. Consequently, we should refer to Hanaoka's anesththetic as "Mafutsusan, another name Tsusensan" instead of "Tsusensan, another name Mafutsusan."

[Did Seikyo Sugita Perform Two Surgical Operations under Ether Anesthesia in 1855?]

Although Seikyou Sugita is said to have provided ether anesthesia for two surgical oprations in 1855 including the scur resection of burned fingers of a man and the resection of a breast cancer of a woman. The details of his administration of the drug were not known because he did not describe these cases at all. According to Treatise on Inhalation of Ether written in 1863 by Shinryo Tsuboi, Sugita failed to provide successful general anesthesia using ether for these patients. The ether he used was prepared by Ryuho Shima, and the failures were likely to be due to impure nature of the agent.

[Several Issues before and after the Recognition of "Anesthesiology" as "Specially Approved Specialty"]

A movement occurred at the end of 1940's among members of the Japan Medical Association (JMA) to recognize "specially approved specialty" in the practice of medicine, but their petition was rejected by the Medical Ethics Committee. Thus, the JMA expanded an energetic campaign for the recognition, by the support from four diet members. Consequently, six specialties including neurology and venereology were eventually accredited as "generally approved specialty" in 1950. About 1960, several years after anesthesiology having been recognized as a "specially approved medical specialty", some elder members of the Japan Society of Anesthesiology (JSA) discussed to change the term "specially approved specialty" to "generally approved medical specialty"in the Medical Service Law, but their motion could not gain majority support at the Councils of Elders of the JSA. The council also presented to the Ministry of Health and Welfare (MHW), a written request to alter the eligibility criteria of a registered anesthesiologist; however, the request was declined because of a strong opposition of the MHW which was under the strong influence of the JMA. The JSA did never show interest to these issues since then, and the situation remains unchanged to the present.

[Background for governmental accreditation of "anesthesiology" as a specially approved medical specialty]

In 1960, "Anesthesiology" was accredited as a "specially approved medical specialty" for approving registered anesthesiologists. Exclusive training for more than two years of anesthesia under an adequate mentor is required for candidates to be qualified as registered anesthesiologists. In 1963, the Japan Society of Anesthesiology (JSA) established the system to qualify board certificated anesthesiologists as proper mentors responsible for the training of the candidates. This ranks as one of the most significant events in the JSA history and the society launched the first qualification system in the history of medical practice in Japan. Every member of the present society should fully understand the hidden background of the qualification system of the specialty for achieving greater social recognition of anesthesiologists in this country.

Ketamine and its isomers have equipotent relaxant effects on tracheal smooth muscle contracted by tachykinins

Recent studies indicate that not only inflammatory cells but also neural mechanisms by which tachykinins such as substance P (SP) and neurokinin A (NKA) are released from vagal afferent C-fiber contribute to asthma. Although ketamine (K) has been used in the anesthetic management of asthmatic patients, the mechanism by which K relaxes the airway smooth muscle is still uncertain, and no information exists on any differential effect of K and its isomers. We determined the spasmolytic effect of racemic [R(±)]K and its isomers S(+) K and R(-) K on SP and NKA-induced contraction of tracheal smooth muscle in guinea pigs. Strips of guinea pig trachea were mounted in an organ bath filled with Tyrode's solution at 37°C bubbled with 95% O2/5% CO2. Strip tension was measured isometrically with a force displacement transducer. Strip contraction was elicited with SP 10(-6) M or NKA 5×10(-7) M.R(±), R(-), or S(+) K (4.5-18.0×10(-4)M) was cumulatively administered into the bath. The calculated ED50 values (the concentration that relaxed the contraction by 50%) of R(±), R(-) and S(+) K were 7.6±0.5, 7.8±0.6, and 7.6±0.5 (10(-4)M), respectively, when the contraction was elicited with SP, and 8.0±1.0, 8.2±1.2, and 7.9±1.3 (10(-4)M), respectively, when NKA was used. We concluded that K and its isomers have equipotent spasmolytic effects on airway smooth muscle precontracted with tachykinins.

Atomic-resolution imaging in liquid by frequency modulation atomic force microscopy using small cantilevers with megahertz-order resonance frequencies

In this study, we have investigated the performance of liquid-environment FM-AFM with various cantilevers having different dimensions from theoretical and experimental aspects. The results show that reduction of the cantilever dimensions provides improvement in the minimum detectable force as long as the tip height is sufficiently long compared with the width of the cantilever. However, we also found two important issues to be overcome to achieve this theoretically expected performance. The stable photothermal excitation of a small cantilever requires much higher pointing stability of the exciting laser beam than that for a long cantilever. We present a way to satisfy this stringent requirement using a temperature controlled laser diode module and a polarization-maintaining optical fiber. Another issue is associated with the tip. While a small carbon tip formed by electron beam deposition (EBD) is desirable for small cantilevers, we found that an EBD tip is not suitable for atomic-scale applications due to the weak tip-sample interaction. Here we show that the tip-sample interaction can be greatly enhanced by coating the tip with Si. With these improvements, we demonstrate atomic-resolution imaging of mica in liquid using a small cantilever with a megahertz-order resonance frequency. In addition, we experimentally demonstrate the improvement in the minimum detectable force obtained by the small cantilever in measurements of oscillatory hydration forces.

[A consideration of the picture "Vaccination of Ainos" painted by Byozan Hirasawa, in the possession of the Omsk Museum of Fine Arts]

In 1857, Norimasa Muragaki (1813-1880), a magistrate of Hakodate, proposed to the Tokugawa shougunate the compulsory vaccination of the Ainos. The shougunate accepted this and dispatched Ryusai Kuwata (1811-1868) and his colleagues to the Ezo area. They practiced the compulsory vaccination of the Ainos, with huge difficulty, from 1857 to 1858. A merchant Kashichi Sugiura of Hakodate presented to Muragaki a picture of the scene of Kuwata's vaccination practice to praise his excellent decision on vaccination, made in October, 1857. This was painted by Byozan Hirasawa (1822-1876). Another picture of vaccination, painted by Hirasawa, has been found in the possession of the Omsk Museum of Fine Arts. The detailed composition of this picture is somewhat different from those of known copies. This suggests us that there might have been several sketches of the scene of vaccination. However, Hirasawa is believed not to have witnessed the actual scene as depicted in the picture, because Kuwata and other physicians did not practice in front of Muragaki during Kuwata's stay in Hakodate, as Muragaki did not describe anything about the vaccination practice in his formal diary.

Schwannoma of the esophagus: a case exhibiting high 18F-fluorodeoxyglucose uptake in positron emission tomography imaging

Esophageal schwannoma is rare and it is difficult preoperatively to confirm a definitive diagnosis, even using current imaging techniques. We present a case of a benign esophageal schwannoma that was surgically excised and confirmed by immunohistochemical staining. Conventional radiological studies, including barium meal, computed tomography and endoscopic examination had shown a solid submucosal tumor of the upper thoracic esophagus but had been unable to confirm the diagnosis. Positron emission tomography was carried out to evaluate the malignant potential and showed a high uptake of 18F-fluorodeoxyglucose (FDG) into the tumor in both the early and delayed phase, suggesting that the tumor was a potentially malignant tumor such as a gastrointestinal stromal tumor. This is the first reported case of esophageal schwannoma that indicated a high FDG uptake. Although consensus has not been reached regarding the precise mechanism of FDG accumulation in schwannomas, we discuss our clinicopathological findings and review other studies of the subject.

[The disciples of Goroji Nakagawa and their practice of vaccination in the northern area of Japan]

Goroji Nakagawa (1768-1848), who returned to Japan from Siberia in 1812, introduced Jennerian vaccination. At present three persons have been identified as his disciples. Yuzo Shiratori (1813?-1851) was the most senior among them. He was the second son of a wealthy merchant in Hakodate and learned medicine under Teisai Hino (1797-1850), a leading physician in Kyoto. It is unknown when he came back to Hakodate; however, Nakagawa taught him the Russian method of vaccination in about 1840. Shiratori went to Akita of the Satake domain to learn medicine further and there he practiced vaccination to prevent smallpox epidemics. Because his method was recognized as being effective, the Satake domain accepted to employ it formally and asked him to teach the method among domain physicians in the period from about 1841-1844. Details of biographies of the other two disciples, Keisaku Takagi and Kozen Sakurai, as well as their practical method of vaccination, have still not yet been clarified; however, it has been established that they used it with many people of Matsuma-e and neighboring areas. In September of 1849 Hino failed to successfully vaccinate on seven consecutive occasions using cow pox crusts obtained from Nagasaki, but he was finally successful in the last trial, using the Russian method as informed by Shiratori. Thus Hino could distribute much lymph among many physicians in the west half of Japan. Considering the above matters, we can conclude that Nakagawa's method had a significant influence on the history of Jennerian vaccination in Japan.

[A medical study on the winter march accident at Mount Hakkoda]

About two hundred soldiers of the Fifth Regiment of the Eighth Military Division were frozen to death during the winter march at Mount Hakkoda at the end of January 1902. The disaster was the largest in the history of the Japanese army. The Fifth Regiment published a report to describe the details of the accident, but no medical information of the accident was made available by it. The author rediscovered an investigative report written by army surgeons titled "Investigative Report on the Winter March of The Fifth Regiment" This report describes the physical status of seventeen survivors, their medical cure and care, treatment of the bodies of soldiers frozen to death, hygienic aspects of marching soldiers, and rescue parties. According to this report both hands of Major Yamaguchi were severely frostbitten, such that he was unable to fire a pistol. The Fifth Regiment strongly persuaded the family of Major Yamaguchi that he committed suicide by using a gun; however, this must have been presumed a camouflage by the army, when we consider the physical status of his both hands as described above.

[Jennerian vaccination introduced via the trans-Siberian route by Goroji Nakagawa--his influence on the first successful vaccination by Teisai Hino in Kyoto]

Goroji Nakagawa, a head guard of Itrup Island, was unwillingly brought to Siberia on a Russian vessel in 1807 and he returned to Japan with two Russian vaccination books after five years' stay in Siberia in 1812. He learned how to practice the Jennerian method in Yakutsk and Okhotsk just before his return to Japan in that year. One of the two Russian books was translated into Japanese by Sadayosi Baba, a translator of the Tokugawa shogunate, and was titled "Tonka Hiketsu", but it remained unpublished. Sen-an Tosimitsu, a physician of Mikawa, obtained a manuscript of "Tonka Hiketsu" and published it with the modified title "Rosia Gyuto Zensho" in 1850. As Nakagawa did not write down anything about his method of vaccination, the details of the method have not been known to us and this has resulted in an underestimated evaluation of him in the history of Jennerian vaccination in Japan because his method was introduced and transmitted only to the limited area of the northern part of Japan with no significant influence on the spread of the Jennerian method in Japan. The author reevaluated his vaccination method by careful examination of the documents describing Nakagawa's method to find that he had essentially followed the method described in the Russian book; however, how he made vaccine lymph or crust is still unknown to us. As there is no hearsay evidence of deaths by his method, it is suggested that he might have employed cowpox vaccine, not small pox lymph or crust. Nakagawa's method was conveyed to Teisai Hino, a leading physician in Kyoto, via Yuzo Shiratori, one of the disciples of Nakagawa, and after repeated failures with the Dutch method Hino was successful in the final trial of vaccination using cowpox crust, supposedly with the Russian method, in September of 1849. Hino's vaccine lymph was widely distributed among various districts of western Japan to promote further prevalence of the vaccination. Considering these facts, Nakagawa's method had a significant influence on the subsequent wide prevalence of Jennerian vaccination in Japan.

[Sleep and anesthesia--part 2, on the relationship between sleep and general anesthesia]

We reviewed historical and current trends on study regarding the relationship between sleep and general anesthesia. Historically, sleep has been recognized as a completely different physiological phenomenon from general anesthesia. Therefore, sleep study has been thought that it has no merit in anesthesia study. However, on the basis of recent evidence, sleep may share some part of its mechanism with general anesthesia; thus, studies focusing sleep mechanism may also contribute to elucidate some mechanism of general anesthesia. Moreover, research to solve anesthesia related-sleep disorder would be useful to improve patient's quality of life and save much medical resource.

[Sleep and anesthesia--Part 1, Recent findings in research]

We described how modern neuroscience has elucidated what is sleep and its implication, and also reviewed histological and current trends in search of sleep mechanism from view of neurocirculatory or hormonary basis studies. We conclude that anesthesia and sleep share some neuronal structure in their action and mechanism of anesthesia could be elucidated through sleep study. In addition, anesthesia-related sleep disturbance must be settled to serve satisfied quality of life of patients and to save economic and medical resources.

[A review of biographical studies on Goroji Nakagawa, a Japanese pioneer of Jennerian vaccination]

The first detailed biographical study of Goroji Nakagawa, a Japanese pioneer of Jennerian vaccination, dates back to 1885, when Yotoku Onuki wrote his paper on Nakagawa after his field survey in the Matsumae district. Since then information about him gradually began to be compiled by medical historians as well as local historians. Tatsuo Abe, a pediatrician, studied about Nakagawa in depth to publish a monograph entitled "Goroji Nakagawa and the Introduction of Vaccination" in 1943, on the 120th anniversary of the first trial of vaccination by him. This marked a great progress in the biographical study of Nakagawa. At the beginning of the 1960s Sichiro Murayama of Juntendo University identified one of the two Russian books that had been brought back by Nakagawa from Siberia and he translated it into modern Japanese. At that time the author made extensive bibliographical studies on various manuscripts of "Tonka Hiketu," a classical Japanese translation of the Russian book by Sadayosi Baba in 1820. The author also made a wide field survey on burial records and gravestones of the Nakagawa's family at Matsumae and Kawauchi where Nakagawa was born and died, and elucidated that Nakagawa was buried at Hogenji temple at Matsumae. The most recent advance was observed in the beginning of the Heisei period, when the author edited and published three volumes of "Hokkaido Iji Siryo Shusei" (Collected Papers on Medical Culture in Hokkaido) in which almost all the papers and manuscripts concerning Nakagawa which would be very beneficial for investigators were reproduced. During the past 120 years since 1885 numerous educational and medical historical papers about Nakagawa have appeared for the public as well as medical historians; however, most of them have conveyed incorrect information of his biography, resulting from repeated citation of inadequate and erroneous references.

Neonatal tactile stimulation reverses the effect of neonatal isolation on open-field and anxiety-like behavior, and pain sensitivity in male and female adult Sprague-Dawley rats

It is well known that early life events induce long-lasting psychophysiological and psychobiological influences in later life. In rodent studies, environmental enrichment after weaning prevents the adulthood behavioral and emotional disturbances in response to early adversities. We compared the behavioral effect of neonatal isolation (NI) with the effect of NI accompanied by tactile stimulation (NTS) to determine whether NTS could reverse or prevent the effects of NI on the adulthood behavioral and emotional responses to environmental stimuli. In addition, we also examined the sex difference of the NTS effect. Measurements of body weights, an open-field locomotor test, an elevated plus maze test, a hot-plate test, and a contextual fear-conditioning test were performed on postnatal day 60. As compared with rats subjected to NI, rats subjected to NTS showed significantly higher activity and exploration in the open-field locomotor test, lower anxiety-like behavior in the elevated plus maze test, and significantly prolonged latencies in the hot-plate test, and this effect was equal among males and females. In the contextual fear-conditioning test, whereas NTS significantly reduced the enhanced freezing time due to NI in females, no significant difference in the freezing time between NI and NTS was found in males. These findings indicate that adequate tactile stimulation in early life plays an important role in the prevention of disturbances in the behavioral and emotional responses to environmental stimuli in adulthood induced by early adverse experiences.

[A bibliographical study on sixteen extant manuscripts of "Tonka Hiketsu" translated by Sadayosi Baba]

Goroji Nakagawa, a chief keeper of a trading house on Iturup Island, was brought unwillingly to Siberia by Russian vessels in 1807. In 1812, after about five years of hard life in Siberia, he was permitted to return to his homeland with two Russian books on vaccination. Sadayosi Baba, who stayed at Matsumae in 1813, happened to read one of the two books that had been published in 1803 in Peterburg and he translated it into Japanese. Within several months Baba finished his translation, however, he was clearly aware that the translation was far from perfect. Baba revised his draft in 1820 and titled it "Tonka Hiketu" or "The complete method for relieving small pox infection." But it remained unpublished until 1850, when Sen-an Tosimitsu obtained one of the manuscripts at Nagasaki and published it as "Rosia Gyuto Zensho" or "A Synopsis of Russian Vaccination." At present, sixteen manuscripts of "Tonka Hiketu" are extant in Japan and most of them are in public libraries. Bibliographical considerations of their contents, phonogramic descriptions of the original Russian title, comparisons of their illustrations with the originals and differences among Japanese translations reveal to us that the manuscript "Takeda A," among sixteen extant manuscripts, is the closest to the original manuscript of Sadayosi Baba, which remains lost.