The History of Japanese Anesthesiology.

Anesthesia in Japan has a 200-year history, beginning when Seishu 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).

[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.

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.

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.

[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.

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.

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.

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 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.

[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.

[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.

[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.

[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.