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Anesthesiology:
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The Academic Highway between the United States and Japan

Takeshita, Hiroshi M.D., Ph.D.*; Bacon, Douglas R. M.D., M.A.†

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THIS issue of Anesthesiology contains a unique and impressive account of a young Japanese physician, Dr. Michinosuke Amano, who in 1950 journeyed to the United States to learn modern clinical anesthesia, supported by the Government Account for Relief in Occupied Area program.1 He returned to his mother country and planted the first seeds of modern academic and clinical anesthesia in Japan. This article is similar to two others documenting the significant American contribution to Chinese and German anesthesia. These articles focused on the role played by specific pioneer anesthesiologists, rather than a comprehensive review of the state of anesthesia at the time. However, through these articles, the reader begins to understand the state of clinical anesthesia and of medicine in general in these countries. These are narratives of humanity and the medical sciences beyond the borders of the United States, rather than a biography of important anesthesiologists in each country.
At the end of the Second World War, America stood at the forefront of medical advancement in the world. Governmental and private organizations began to help Japanese medicine advance to the levels experienced in the United States. The Government Account for Relief in Occupied Area program was one scholarship opportunity for Japanese physicians, and others were funded through the China Medical Board, the Rockefeller Foundation, and the Fulbright Foundation. Gracious in victory, America helped the defeated Japanese who were struggling in hunger and poverty after the war.
The most significant American contribution, among many, to Japanese medicine was provided by the Unitarian Service Committee, sending American physicians to Japan to help initiate reforms of medical care. Dr. Meyer Saklad (Director of Anesthesia, Rhode Island Hospital) was a participant in the Joint Meeting of the Japanese and American Educators. Although misnamed, the meeting was organized under the direction of the General Head Quarters of the Allied Forces in 1950.2 This was a revolutionary event for Japanese medicine, not only for anesthesiology, but for all disciplines within the healthcare system. One of the most important contributions made by Dr. Saklad was that he emphasized the importance of the basic sciences as they related to the delivery of clinical anesthesia. Through his lectures, Japanese physicians learned that clinical anesthesia must have its base in pharmacology and physiology. This approach surprised many people who had regarded anesthesia as a “small art,” subservient to the powerful surgeons. Dr. Saklad’s visit to Japan gave impetus to the beginnings of research activity in anesthesiology.
Up until the end of the Second World War, anesthesia in Japan was essentially conduction anesthesia: spinal anesthesia, supplemented with opioid and scopolamine, for everything, including laparotomy, thoracotomy, and even craniotomy! General anesthesia for children was performed with ether by the open drop method. The reason for this lack of sophistication in anesthesia before World War II can be traced back to at least 1922, when the Japanese Surgical Society debated whether positive-pressure respiration was necessary for open chest surgery. After serious discussion, which lasted a couple of years, the belief that positive-pressure respiration in open chest surgery was not necessary was accepted in 1938. Dr. Fujita,3 who is a historian of Japanese anesthesia, examined this conviction and believes it to be a retarding factor in the development of Japanese anesthesia. Furthermore, Dr. Fujita described the case of Dr. Nagae, who was a teacher at the Japanese army medical school. Dr. Nagae was sent to the Mayo Clinic in 1936 to study experimental surgery under Dr. Mann and to observe Dr. Lundy’s anesthetic techniques, which included local, spinal, and epidural anesthesia, as well as intravenous and general anesthesia. His report contained the details on the use of carbon dioxide absorbance in general anesthesia and endotracheal anesthesia and also included a description of the size and shape of endotracheal tubes. Unfortunately, his report never received attention from either the Army Medical Office or from public hospitals within Japan. Dr. Fujita’s comment on this story was that modern Japanese anesthesia would have significantly advanced before the Second World War if his report had been seriously evaluated at that time.3
The first academic anesthesiology department was established at Tokyo University in 1952 and was followed by several university hospitals shortly thereafter. When it became an established presence in medical schools, anesthesiology started to grow as an independent specialty. Promising medical students who were highly motivated entered these anesthesia departments training to become specialists. In the early 1970s, Japanese anesthesiology branched out into critical care and pain medicine. At the same time, research activity became increasingly prominent in major academic departments, a result of the training of young Japanese anesthesiologists at American institutions. In the United States, these trainees learned basic science, clinical skills, and an educational system in anesthesiology that had been practiced for decades.
In the late 1970s, young Japanese anesthesiologists still desired to travel to America to further their training; however, it had become difficult to do clinical anesthesia in America because of licensure requirements. Alternatively, many Japanese anesthesiologists journeyed to American academic departments to engage in research. Some of them had previous research experience and publications before going to America, and they further advanced their skills by hard work with their American mentors. Thus, it is not an exaggeration to say that most of the current academic departments in Japan have strong connections to American departments through either clinical or laboratory work. Although American training has greatly magnified the quality of research in Japanese academic departments, it has remained mostly within the area of the basic sciences, and there is a lack of clinical investigation on a large scale because surgical cases are scattered over the different hospitals, with each having a relatively small number of cases to study. It is interesting to note that the rapid expansion of research activity in Japan almost paralleled economic development. Currently, Japan seems to represent one of the largest contributors to anesthesiology research outside the United States.
No one could imagine the current state of Japanese anesthesiology soon after the end of the Second World War. In the intervening 60 yr, academic university departments have grown to 124, while the number of Board Certified Anesthesiologists increased to 5,548 from 44 in 1963. However, the increasing demand of surgical cases and the resultant increased clinical load in both the operating room and the intensive care unit has forced anesthesiologists to increase the time spent in clinical setting endeavors. This shortage of personnel and time allotted for research may decrease the number of anesthesiologists who can work in the laboratory.
In summary, American influences on Japanese anesthesia have been very significant, allowing for rapid progress mainly due to American anesthesiologists who were willing to accept and encouraged Japanese anesthesiologists in both the clinical and basic science arenas for the past 60 yr. Japan’s research-minded anesthesiologists, despite a critical shortage of manpower, took advantage of increased research funds to create a successful research enterprise. However, the future of Japanese anesthesiology is unclear because of the somewhat anticipated drastic changes in health care associated with an aging population that will peak in the coming 30 yr. Nevertheless, it is hoped that Japanese academic anesthesiology will continue to prosper and grow and that the academic highway between America and Japan will be shortened and strengthened for the betterment of patient care in both countries.
Hiroshi Takeshita, M.D., Ph.D.,*
Douglas R. Bacon, M.D., M.A.†
* Ube Frontier University, Ube, Japan. † Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota. bacon.douglas@mayo.edu
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References

1. Ikeda S: Government Account for Relief in Occupied Area: A Japanese physician’s journey to a new medical specialty. Anesthesiology 2005; 103:1089–94

2. Matuki A: Background of Dr. Saklad’s visit to Japan: From the documents of GHQ, History of Japanese Anesthesiology 3: Dr. Saklad and Japanese Anesthesia [in Japanese]. Edited by Matuki A, Fujita T. Tokyo, Kokuseidou, 1989, pp 25–39

3. Toshio F: History of Japanese anesthesiology in Meiji, Taishou, Shouwa eras, in 50th Anniversary of Japanese Society of Anesthesiologists [in Japanese]. Masui 2004; 53:28–9

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