Seishu Hanaoka (1760-1835) was a village physician of Kishu, currently Wakayama prefecture, and has been widely known as the first to perform the excision of breast cancer on a woman under general anesthesia by administrating his oral anesthetics “Mafutsu-san” in October of 1804.
  As he did not write any medical books and detailed records on his family himself, many things associated with him, his family and the developing process of “Mafutsu-san” remain unknown to us. For example, the name and age of his youngest daughter has never been clarified.
  The author repeated animal experiments using “Mafutsu-san” the same as Seishu did, to understand the process of “Mafutsu-san” development.
  Furthermore, the author found the necrology of Jizo-ji temple, formerly Hanaoka's family temple, to add new information about his family tree. The thoughts of Seishu Hanaoka on medicine, such as internal medicine and surgery should not be specialized but should be united, and patients should be treated as living bodies and as a whole, considering their pathophysiology, can be accepted as true even in our day.

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  Coaching is a communication technique for supporting a person in achieving specific objectives by amplifying the individual's own knowledge and thought process through the development of critical thinking skills which lead to new ideas, behaviors and proactive actions. Although coaching prevails in business fields in Japan, Europe and the USA, it is relatively unknown in the medical field. Medical support coaching is designed especially for use in medical communication. Medical support coaching is rearranged into 27 different skills from the conventional coaching method, and organized into systematic medical approach for use in communication between doctor and patient, among medical staffmembers and in teaching medical students. In this article, three basic core skills — 'listening', 'questioning' and 'speaking' — are explained and their practical uses for instant implementation are described.

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  Pharmacokinetics of anesthetics is predominantly dependent on hepatic blood flow or hepatic enzyme activity. Pharmacokinetics of drugs with a high hepatic extraction ratio is also predominantly dependent on hepatic blood flow, and conditions such as heart failure, intermittent positive pressure ventilation, and laparotomy decrease hepatic blood flow, resulting in decreased clearance. Pharmacokinetics of drugs with a low hepatic extraction ratio is predominantly dependent on hepatic enzyme activity. Cytochrome P450 is the predominant hepatic enzyme involved in the metabolism of anesthetics. Because of interindividual variation of the activity of P450 isozyme, there is a wide interindividual variation in the pharmacokinetics of drugs with a low hepatic extraction ratio. Competitive or non-competitive inhibition of the activity of these P450 isozymes by simultaneously administered drugs is important for elucidating the pharmacokinetics of agents with a low hepatic extraction ratio.

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  The trend of the policy of a medical insurance system is heading towards medical-expense reduction. This is not the only problem in the financial crisis of medical insurance. Aging, a decrease in the birthrate, and the trend toward the nuclear family are causes, and the problem has come out in the structure of Japan. The prospective payment system based on the DPC (Diagnosis Procedure Combination) system was introduced into special functioning hospital in 2003. In diagnosis groups in which surgery is performed, shorter hospitalization generally means increased profits. However, income increases are not proportional to patient increases, but they are proportional to material cost increases. Consequently, profits remain low.
  In diagnosis groups without surgery, the material cost rates at break-even points are very low, but when they exceed these values, shortening the length of stay results in decreased profits. There is a tendency generally to think that, in DPC, incentives to shorten the length of stay help to the balance sheet. However, in the non-surgical diagnosis groups, shortening the length of stay decreases profits, while in some cases, extending it increases profits unless material costs are reduced as much as possible.

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Objective: To study measures taken to adjust the medical workforce in 5 countries.
Method: Questionnaire and interview study of the medical workforce policy makers in the U.S.A., Québec, U.K., France and Germany were undertaken.
Reults: Statistics on the medical workforce were collected and reported by non-governmental, neutral organizations. The implementation of the policy depended on whether the medical workforce was sufficient or not. In those countries with an insufficient number of physicians, the government employed several measures, such as reimbursement for physicians working in underserved areas or those with rare specialties.
Discussion: Although it is difficult to employ the same measures as those of countries with different historical backgrounds, it is necessary at least to have a good picture of current medical manpower to implement effective measures.

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  Recent increasing need for anesthesiologists in city hospitals has exceeded the supply from University. Because of the steadily increasing number of women who are specialized in anesthesia, it is important to prevent them leaving the field following childbirth. Considering that the social support for these women anesthesiologists in Japan is insufficient now, systemic cooperation by Universities, Hospitals, the Japan Society of Anesthesiologists and the Japan Medical Association will be required to increase in the retention rate of practicing women anesthesiologists.

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  Various issues related to women doctors have been discussed several times during the meetings for Anesthesiologists. A current topic is to realize raised issues in these meetings as concrete forms.
  For example, such a committee has already been established in some medical offices and academic meetings, and there is attempting building of a system that ensures that the human rights of the women doctors are fully respected. It is necessary to ask qualified women doctors who aren't working to work while the shortage of anesthesiologists is a serious issue. However, there is another issue that we can't fully grasp about the working conditions of women doctors.
  It is the pressing need that we establish a working group in academic meetings to create a database about the entire employment and all the working systems of the anesthesiologists to support each anesthesiologist.

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  Based on the Physicians Dentists Pharmacists Survey (Ishi Shikaishi Yakuzaishi Chousa) , analysis on the number of physicians stratified by age bracket, sexuality and specialty was conducted. As a result, change in selection of specialty by age and sexuality was founded in same generation. And this proposed method is effective to estimate future physician supply in each specialty. The change tendency found in this study is considered to be a result of the physician's attitude toward selection of specialties based on her/his motivation that came from age and gender. In anesthesiology, difficulties are suggested in gaining registration as anesthesiologist, and in returning to clinical practice after a temporary leave from work.

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  The number of female physicians is increasing in Japan. But there is a gender inequity regarding family responsibilities. Social and family effort is required to grapple with gender inequality problems. We must make changes in the social organization of the field of medicine. Social systems only for female physicians are not needed now.

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  In 2002, the estimated number of anesthesia performed in Japan was more than 3,120,000 of which more than 1,880,000 were performed under general anesthesia. However, there were only 6,087 anesthesiologists engaged in anesthesia in the operating room. It was difficult for anesthesiologists to perform anesthesia in private practice with their main work being anesthesia in the operating room under the medical insurance system. In recent years, the Ministry of Health, Labour, and Welfare has recognized that visiting anesthesia by anesthesiologists in private practice is treatment covered by the medical insurance. However, in some self-governing bodies, the door to the establishment of anesthesiological clinics with visiting anesthesia as the main work is shut, and there are only a few visiting anesthesiologists in private practice. There are various working forms of anesthesiologists at present. Among these forms, only private practice of anesthesia as an insurance medical facility allows anesthesiologists to work on equal terms with hospitals, not on terms of employment. Private practice of anesthesia with visiting anesthesia as the main work does not immediately solve the manpower shortage problem. However, from a long-term standpoint, private practice will be a choice when anesthesiologists make plans for their future and there is an increase in people who aspire to be anesthesiologists, slowing the withdrawal from anesthesia work in the operating room.

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  I review a method for monitoring neuromuscular block using acceleration transducer in anesthetized patients in the prone position. If the muscular branch of the femoral nerve is stimulated and the movement of the vastus medialis muscle is measured accelerographically, the degree of neuromuscular block can be assessed. The duration of vecuronium-induced neuromuscular block is prolonged in diabetic patients under isoflurane or sevoflurane anesthesia, however, it is not slowed in diabetic patients under total intravenous anesthesia. The reversal effect of neostigmine on vecuronium-induced neuromuscular block in diabetic patients is less than that in non-diabetic patients. Ulinastatin, gabexate mesilate, nicorandil, milrinone, and amino acid solution speed recovery from neuromuscular block in anesthetized patients receiving vecuronium.

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  Management of pain in cancer patients according to the WHO ladder using morphine is still the standard in treating cancer pain, even after both oxycontin^® and fentanyl patch became available in Japan. One reason is that rescue opioids other than morphine are not available. Immediate opioids are useful not only in treating breakthrough pain, but also in assessing whether the cancer pain is refractory to opioids or not. Although opioid rotation is sometimes performed to control side effects, it should be used only after appropriate side effect treatment. If the side effects are well controlled, side effect control with other opioids is much easier.

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  Technological advances including improvement in transducer resolution of diagnostic ultrasound system and introduction of multiple imaging planes have allowed for evolving applications of intraoperative transesophageal echocardiography (TEE) in the diagnosis of all forms of heart disease. The miniaturization of TEE probes has increased the use of TEE in pediatric cardiovascular surgery. Many researchers have shown that intraoperative TEE can define the anatomy of the useful spectrum of congenital heart defects in infants and children and also provide for accurate assessment of the adequacy of surgical repair. Though few complications have been reported with use of TEE in adults and older children, complications may be associated with TEE in small children and infants. The biggest problem is inadvertent tracheal extubation, and special care must be taken to avoid this.

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  We reviewed the post-anesthetic consultation notes of 812 elective pediatric surgical patients, who were under 12 years of age, seen at the Nara Medical University Hospital from 1999 to 2003 to investigate what the perioperative problems were for them and to evaluate the efficacy of a pediatric pre-anesthetic consultation clinic. Although 2.3% of patients were dissatisfied with anesthetic care, 60.8% were satisfied. 32% of them complained of unpleasant experiences including drip/injection, postoperative pain, premedication, urethral catheterization, or postoperative nausea/vomiting. After determination of the date of the surgery, having the anesthetic assessment again in the anesthetic consultation clinic before hospitalization, reduced the rating of dissatisfaction with anesthesia and postponement of surgery after hospitalization. In elective pediatric surgery, it is necessary for anesthetic consultations to provide information about safe anesthetic management and these expected perioperative anesthesia-related problems. Increase in opportunity for having the anesthetic consultation was effective to help families better understand anesthesia.

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  We report a case of heparin resistance caused by thrombocytosis. A 75-year-old man with complicated essential thrombocythemia was scheduled for vascular prosthesis replacement for the abdominal aortic aneurysm. 10,000 units of heparin was administered but resulted a top-short activated coagulation time (ACT) . Alternatively, argatroban was administered to maintain anticoagulant activity. Remarkable increase of platelet factor 4 (PF4) in essential thrombocythemia is often observed, and large quantity of PF4 was released by heparin administration. PF4 is a substance that neutralizes heparin. As a result, activity of heparin became ineffective. It was considered that argatroban is a useful anticoagulant for patients with essential thrombocythemia.

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  Two patients who needed Automatic Implantable Cardioverter Defibrillator (AICD) implantation were scheduled for noncardiac surgery. One patient had Brugada syndrome, in whom AICD implantation preceded the noncardiac surgery, and the other patient had spontaneous ventricular fibrillation associated with dilated cardiomyopathy, in whom noncardiac surgery preceded AICD implantation. We discussed the order of AICD implantation and surgery and also perioperative evaluation and management for these patients.

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  A 69-year-old male was referred to our pain clinic because of aggravation of pain over the last 3 months, the pain being thought to be central pain syndrome in origin. He had a history of cerebral infarction 16 years ago and presented right hemiparalysis and aphasia. The evaluation and diagnosis was extremely difficult because of aphasia, but lumbar radiculopathy was diagnosed by adopting of modified interview and physical examination, using multiple questions which can be answered by choosing “yes” or “no” . The patient was successfully treated with right nerve root block (L5) and ketamine infusion. Modification of the medical interview and physical examination appears important in the patient with aphasia.

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