The History of Anesthesia in Japan

Fig. 31.1

Seishu Hanaoka. (Open source)

In 1850, Seikei Sugita (1817–1859) translated the Dutch version of J. Schlesinger’s monograph on ether anesthesia (in German) into Japanese. He also coined the word “Masui”, literally meaning “paralysis” plus “unconsciousness”. In 1855, Sugita himself gave ether anesthesia, probably the first inhalational anesthetic given in Japan. The record indicates that he performed a mastectomy under ether anesthesia, but no additional details are available. There are also records describing Genboku Ito administering chloroform anesthesia for limb amputation in 1861, as taught by Franz von Siebold (1796–1866), who was a German physician and scientist. Chloroform was imported from Holland by a Dutch Navy doctor.

1868 to 1950

In 1853, Commodore Perry, a US naval officer commanding four battle-ships, forced Japan to open herself to various Western countries. In 1868, the Shogun officially resigned, starting the Meiji Era, and initiating aggressive efforts to obtain information from Western civilizations.

In 1878, cocaine was imported, but its use was not recorded until 1885, when it was administered for pain relief during tooth extraction. The route of administration is not known. In 1887, a pharmacist Nagayoshi Nagai discovered ephedrine, extracting it from a Chinese herb. This was reported to a German journal, [3,4] and mentioned by KK Chen and Carl Schmidt who rediscovered this agent in 1924 [5]. Before 1900, a few sporadic records described importation of nitrous oxide and the equipment required for its use.

In 1901, Otoziro Kitagawa performed spinal anesthesia for the first time in Japan using the local anesthetic “eucaine” (C₁₅H₂₁NO₂), an agent supplied as either alpha or beta eucaine (the latter known also as betacaine). This anesthesia was given to patients with intractable pain. It was used for some time around the turn of twentieth century because it was less toxic than cocaine, yet later abandoned because of its side-effects.

In two patients, Kitagawa injected 10 mg of morphine intrathecally. One patient was a 33-year-old man who was relieved of severe pain for several days, and the other was a 43-year-old woman who was relieved of pain in the lower back for two days. This may be the earliest description of narcotic use in the subarachnoid space [6]. Recognizing that this intrathecal dose of morphine might have been associated with profound respiratory depression, Matsuki comments that Kitagawa used a large needle, possibly enabling a leakage of CSF and preventing (of course, fortuitously) respiratory depression [6].

In 1912, surgeon Hakaru Hashimoto of Kyushu University reported four cases of an unusual type of thyroid disease, later known as “Hashimoto disease” or “Hashimoto’ thyroiditis” [7]. In this report, he performed surgery in all four cases under “chloroform anesthesia”.

1900 to 1930 saw the use of various techniques and instruments, including epidural anesthesia, intravenous alcohol administration, and tracheal tubes. In 1934, a Department of Dental Anesthesia was established at Nippon Dental Junior College (now the Nippon Dental College). This is believed to be the first Japanese academic department specializing in anesthesia, more than 20 years before any department in a Japanese medical school.

Beginning in 1936, Daisuke Nagae, an Army surgeon, spent two years at the Mayo Clinic in Rochester, Minnesota, observing the practice of medicine. Upon returning in 1938, he published a report entitled “Trends in Surgical Anesthesia at Mayo Clinic [8].” In retrospect, although this superb report clearly described various aspects of general anesthesia including tracheal intubation, it had little impact upon Japanese medicine because it was published in the Journal of Army Medicine, and access was not only difficult but was more or less deliberately kept secret. This period immediately preceded hostilities between Japan and the US, and Nagae, an Army Surgeon, could not officially report the superiority of American techniques, although he did publish the article.

In 1941, Japan attacked Pearl Harbor, and following the war, was occupied by the US until 1952. Despite his contributions to medicine and his sympathies towards the US, Nagae was excluded from official or governmental positions because he was a high ranking official in the Army when the war ended, and was considered to have contributed to the war effort. He died in 1957 and his contributions to Japanese medicine became known only after his death, mainly due to the efforts of Matsuki [9].

There is little published information describing how anesthesia was practiced during this period. Anecdotal evidence suggests that the youngest member of the surgical team administered open drop ether and spinal anesthesia. There were no known formally trained anesthetists, although there might have been a few individuals who gave anesthesia routinely. There are records showing that Japan manufactured a small amount of anesthesia equipment. Tracheal tubes, if used at all, were probably inserted by dentists rather than by physicians, and even most thoracic surgery was done under local anesthesia. Clearly, Nagae’s revolutionary report made little impact.

1950 to the Present: Various Academic Anesthesia Departments

The Impact of Meyer Saklad’s Lecture on Japanese Medicine/Anesthesia

In August 1950, Meyer Saklad of Rhode Island Hospital attended the Japanese-American Joint Conference of Medical Educators, held in Tokyo. This meeting was a part of Unitarian Service Committee (USC) activities, American efforts aimed at the exchange of medical information and the establishment of close relationships between the American medical profession and members of the profession in post-war foreign countries.

This Conference had a major impact on Japanese surgeons (there were no anesthetists at that time) attending the meeting. They were particularly interested in tracheal intubation and maintenance of artificial respiration. Saklad’s lecture was translated into Japanese by Kentaro Shimizu (Fig. 31.2), a leading surgeon of the University of Tokyo who had just returned from a visit to the US. Hideo Yamamura (Fig. 31.3), a 30 year old surgeon in Shimizu’s department, attended the meeting only reluctantly to satisfy the request of Shimizu, but was soon attracted to anesthesia. (This story was told to me by Yamamura himself.) Recognizing Yamamura’s interest, Shimizu suggested that Yamamura abandon surgery and concentrate on anesthesia. Yamamura agreed and in 1952, Shimizu established a small section of anesthesia in the department of surgery at the University Hospital, and then sent Yamamura to the US for further study.

Fig. 31.2

Kentaro Shimizu. (From the author’s collection.)

Fig. 31.3

Hideo Yamamura. (From the author’s collection.)

Saklad’s lecture attracted many other surgeons to this new field, particularly because of the delivery of anesthesia via tracheal tubes, resulting in an enormous increase in the number of anesthesia-related reports at surgical meetings. In 1954, Shimizu organized the first meeting of the Japanese Society of Anesthesiology (JSA). In the same year, publication of the Journal ,Masui (The Japanese Journal of Anesthesiology) began. This journal was, and still is, published only in Japanese, yet it achieved semi-official status as the journal of JSA. On return from the US in 1956, Yamamura became the Professor and Chief of the Department of Anesthesia at the University of Tokyo, the first such department in a Japanese Medical School. Yamamura retired from academic medicine in 1980 at age 60, and in 2010 at the age of 90, still practices medicine in his clinic. He does not smoke, drink, or take coffee. He ate little even when he was young. He is not active in any sport, but does play the piano, his only hobby besides studying, of which I am aware.

At this time, many young physicians went to the US for anesthesia training, adding to those already in the US who were training in other fields but switched to anesthesia. The information describing who studied in which institutions and when they were there, was mostly lost, but fortunately the “The Aqualumni Tree” by Lucien Morris, appearing in the September 2001 ASA Newsletter, prompted discussion and interest among Japanese anesthesiologists about this matter. The following list of those who were trained in 1950 resulted from that discussion (Table 31.1) [10]. Alas, I am certain that I must be missing many other names due to the difficulty in tracing them.

Table 31.1

Each of these individuals became professors and chiefs of their departments

Names	Affiliation	Mentor and training site
Kenichi Iwatuki	Tohoku University	Benjamin Etsten, Boston University
Etsutaro Ikezono	Tokyo Medical and Dental University	Merel Harmel, Johns Hopkins University
Tohru Yamamoto*	Nihon University	Ferdinand Greifenstein, Wayne State University
Yoshio Kurosu*	Toho University	Leroy Vandam, Peter Bent Brigham, William Derrick, Arthur Keats, Baylor Medical College
Yu Miyake*	Tokyo Medical College	Meyer Saklad, Rhode Island Hospital
Tatsushi Fujita	Gumma University	Solomon Albert, George Washington University
Kunio Ichiyanagi*	NiigataUniversity	Robert Dripps, University of Pennsylvania
Seizo Iwai*	Kobe University	Digby Leigh, Los Angeles Children’s Hospital
Tetsuji Furukawa*	Kyushu University	Ferdinand Greifenstein, Wayne State University
Tohru Morioka	Kumamoto University	Louis Orkin, Albert Einstein Medical School
Ryo Tanaka*	Kitasato University	Francis Foldes, Mercy Hospital Pittsburg
Ryo Tanaka*	Kitasato University	Robert Virtue, University of Colorado
Mitsugu Fugimori	Osaka City University	Robert Dripps, University of Pennsylvania
Yusuke Itoh	Toyama University	Merel Harmel, Johns Hopkins University

* Deceased

In the meantime, several companies began producing carbon-dioxide absorbents (Soda-lime: Wako Junyaku Co.), thiopental (Tanabe Co., Now Tanabe-Mitsubishi Drug Co.) and nitrous oxide (Showa Denko Co.). Ether and chloroform were already available for inhalational anesthetic use. Anesthesia machines and equipment were originally imported, but were soon manufactured locally (Senkosha Co., Acoma Co, and AIKA Co.).

Establishment of the Specialty

Until recently, once qualified (holds a permanent medical license) a Japanese physician could practice any specialty. The names of these specialties were legally recognized, but as late as the middle of the 1950s, anesthesia was not included in the list of recognized specialties, because at the time the law was written, anesthesia as a specialty was unknown in Japan. As it became widely known, pressure increased, to include anesthesia as a legally recognized specialty. Subsequent discussion resulted in making anesthesia a “special” specialty which meant that unlike all other specialties, anesthesia could not be chosen (as could other specialties), without fulfilling one of two requirements: completion of two years of training, or experience administering general anesthesia to 300 patients using anesthesia equipment. In addition, a category for those not satisfying the above requirements that allowed the “choice” of anesthesia was extended to the “pioneers” trained in overseas programs.

This system was established in 1961 and still exists. It consists of a permanent qualification (i.e., medical license) that once obtained, remains in force indefinitely. According to the law, therefore, any physician of any specialty may practice anesthesia as long as he or she is qualified once, as described above.

Currently a debate exists as to whether this system should be maintained. In some respects, it is a stronger and more legitimate qualification than that required to practice any other specialty because the training requirements are written into law, and thus established officially. Qualification in other specialties is weaker because it is determined by individual private societies.

Recognizing that this system provided only a limited test of the quality of training in anesthesia, ten leading anesthesiologists decided to establish a specialty board using an American model’the first formal certification of and by a medical specialty in Japan. The Japanese Society of Anesthesiology conducted the first examination in 1963, and although the exact number of candidates is no longer known, 44 anesthesiologists qualified by passing the examination consisting of oral and written examinations, and the testing of skills. The JSA initiated certification of “Instructing Hospitals” (i.e., residency programs) in 1973, dictating minimum standards for the instructing staff and residency experience. In 1991, Renewal of Instructor and Instructing Hospital Certification became necessary every 5 years. In 2004, guidelines for certification and accreditation common to all specialties were established. To comply, the JSA certification mandated a three stage system: Certified Anesthesiologist, Certified Anesthesia Specialist, and Certified Anesthesia Instructor. Certification had to be renewed every 5 years, and was judged by document review.

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