Exposure to stresses, nociceptive or non-nociceptive stress, induce antinociceptive effect (stress-induced analgesia: SIA) in experimental animals. The underlaying mechanism for their induction depend on the nature of the stresses, mediated via various kind of neurotransmitter receptors such as opioid-, catecholamine- and benzodiazepin-receptors, and adrenal cortical hormone and brain vasopressin also play a role in the mechanisms. The development of tolerance to the analgesic effect of morphine was blocked by FS or PSY stress, but not by SW stress, as far as the concomitant treatment with morphine was continued without affecting the analgesic effect and the development of physical dependence. These phenomena are consistent with the fact that development of tolerance and/or dependence to opioid is not apparent in the patients suffering from severe pain, and also may suggest the possible dissociation of analgesic effect, tolerance and dependence of morphine by the underlying mechanism. On the other hand, it is suggested that the processes of the development of tolerance to opioid and the formation of learning/memory are underlaid with a common mechanism, for instance, both phenomena are blocked by the pretreatment with protein synthesis inhibitors, such as cycloheximide, puromycin and actinomycin D. In the experiments using one-trial step-through type passive avoidance learning task, exposure of mice to FS, SW and PSY stress at various time, pre-, post-training and pre-test, produced diverse effects in the test trial latencies, facilitation by pre-, post-training, pre-test FS and pre-training PSY, impairment by post-training SW, depending on the timing of exposure and the character of their acute effect. Precise analysis of the mechanism of these discrepancies may lead to the clarification of the biological regulatory mechanism when the living organism are exposed to the nociceptive stresses.

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We experienced 69 cases of the endoscopic thoracic sympathectomy, ETS, for the cases indicated for the alcohol block of the sympathetic nerve during period of November, 1993 to July, 1997. We successfully carried out for the safe, less-invasive and simple practice of surgical and anesthetic techniques on these cases.
Instead of the special endotracheal tube for one lung ventilation, we used common single-lumen endotracheal tube. Superimposing of high frequency jet ventilation during operation is remarkable for our anesthetic technique.
The ETS is performed using thorocar with 3mm of diameter by the two-ports technique.
Sufficient view were obtained by purposeful pneumothorax with filtered air. The sympathetic block was performed by the coagulation using electric cautery or YAG laser. For essential hyperhidrosis, bilateral ETS was completed at a time. Neither of intrathoracic drainage nor skin suture was made.
The curative effect of 63 cases, that is 122 procedures of essential hyperhidrosis was summarized as follows.
Complete inhibition of the palmar perspiration was obtained in all cases. For the axillary perspiration, forty five of 63 cases (71%) valued exellent and eighteen (29%) good. None of the less effective was experienced in the case of axillary perspiration treatment. For the plantar perspiration, exellent, good, and less effective were found 15 cases (24%), 27 cases (43%) and 21 cases (33%) out of 63 cases, respectively. We experienced complications of the pneumothorax (3 cases), subcutaneous emphysema (2 cases) and allodynia (4 cases). The compensatory perspiration was found in many cases.

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We report our experience on a method of endoscopic thoracic sympathectomy (ETS) reported by Claes et al. which is electrocautery of the sympathetic chain under thoracic endoscopy. We treated of thirty-five patients with palmar hyperhidrosis and three with peripheral arterial insufficiency in the upper extremities. Results were excellent for the relief of palmar hyperhidrosis and improvement of peripheral arterial insufficiency. Instead of 26Fr urological resectoscope originally used by Claes et al., we introduced small diameter hysteroresectoscope (21Fr, Olympus^™) and anterior-axillar line approach at the forth intercostal space. They were useful to improve patients' cosmetical satisfaction to the surgery. The results of Claes method of ETS for both of palmar hyperhidrosis and peripheral arterial insufficiency in the upper extremities were excellent, however, we believe that we should be careful to apply the technique to treat chronic pain in the upper extremities because little scientific evidence in efficacy of ETS in patients with such pain has been established.

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Endoscopic thoracic sympathectomy for idiopathic palmar hyperhidrosis, thromboangitis obliterance, Raynaud's phenomenon, and reflex sympathetic dystrophy. A reviw of 113 sympathectomies: Endoscopic electrocautery of the thoracic sympathetic chain was conducted in 113 cases between January 1994 and February 1997. We report the results of treatment in these cases.
Methods: The surgical technique using a urological resectoscope introduced by Claes was performed. The sympathetic chain was made visible through the resectoscope beneath the pleura over the heads of ribs. The tract was cauterized on the ribs ranging from the first to fourth.
Paitent: Surgery was performed on 104 patients with palmar hyperhidrosis, Raynaud's phenomenon in 1 patient, thromboangitis obliterance in 2 patients, and reflex sympathetic distrophy in 6 patients. The follow-up study was done by questionaire.
Results: Endoscopic electrocautery was unable to be completed in 6 sites of 113 patients, because of sever pleural adhesion. Complete perspiration recovered in 3 out of 74 patients who replied the questionaire.
Two patients who had surgery for thromboangitis obliterance, one patient for Raynaud's phenomenon, 104 patients for palmar hyperhidrosis and two out of 6 patients for RSD showed an immediate improvement in symptoms. In early postoperative period, 214 of 221 palms (113 patients) showed remarkable decrese in sweating. Perspiration maintained in 2 palms.
Conclusions: These results confirmed that the thoracoscopic sympathectomy was effective, safe and minimally invasive surgical method for the patients with palmar hyperhidrosis, RSD and chronic upper extremity ischemia.

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Transthoracic endoscopic electrocautery of the sympathetic chain (ETS) is increasingly being used as a technique for producing the effect of upper thoracic sympathectomy. In May 1995 we introduced this operation and have assessed the results in patients with 115 patients. The underlying conditions were palmar hyperhidrosis in 99 cases, craniofacial hyperhidrosis in 2 cases, traumatic cervical syndrome in 5 cases, CRPS (complex regional pain syndrome) in 4 cases and the other in 5 cases.
Methods: ETS was achieved under balanced anesthesia (Air-O₂-epidural-propofol) using a double lumen endo-bronchial tube. After being placed in a 30-40 degrees head-up position, we were surgically managed by coagulation of bilateral Th_{2, 3, (4)} sympathetic ganglia using video thoracoscopic techniques. The surgical procedure is simple and allows bilateral treatment in a single procedure.
Results: There was no mortality or life threatening complication. All were relieved of excessive sweating in their upper extremities immediately after operation. In pain syndromes we observed initial relief of symptoms in all cases but as time passed the results became questionable.
Concerning postoperative complications, a transient Horner's syndrome was observed in five patients out of 115. Several patients had a mild residual pneumothorax lasting a couple of postoperative days that resolved without insertion of a chest tube.
Conclusion: Hyperhidrosis of the palms, axillae and face has a strong negative impact on the quality of life for many persons, it may cause considerable psychological, social and occupational disturbances.
ETS is an efficient, safe and minimally invasive surgical method. Patient selection, however, is important especially concerning pain syndromes and the risk of compensatory hyperhidrosis must be fully explained.

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We retrospectively studied the effects of continuous epidural analgesia with bupivacaine and fentanyl on postoperative pain after abdominal surgery in 58 patients aged 70 years and over. They underwent cholecystectomy (n=15), gastrectomy (n=19), and colonectomy (n=24), and they received continuous epidural analgesia (2ml of 0.25% bupivacaine and 8.3-12.5μg of fentanyl per hour), which was started immediately before the end surgery. Changes in the level of pain, duration of postoperative epidural analgesia, additional analgesic (diclofenac suppository), and adverse effects associated with epidural analgesia were investigated. The duration of epidural analgesia was significantly (p<0.05) shorter for the patients who underwent cholecystectomy than for those who underwent gastrectomy and colonectomy. However, additional analgesics were needed after discontinuation of epidural analgesia in the three groups. Patients who underwent gastrectomy had more adverse effects associated with epidural analgesia.
We conclude that continuous epidural analgesia with bupivacaine and fentanyl gave satisfactory analgesia in geriatric patients after abdominal surgery. However, the optimal duration of epidural analgesia awaits further studies.

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We investigated the effects of combined therapy with low frequency electro-acupuncture stimulation and low reactive level laser (LLL) in patients suffering from osteoarthritis of knee joints.
Methods: Eighty-seven knee joints of sixty-three patients were divided into four grades by upright X-ray findings: Grade 1 (n=38): osteosclerosis or osteopathic degeneration, Grade 2 (n=41): narrowing of joint space less than 3mm, Grade 3 (n=5): closure of joint space or subluxation, Grade 4 (n=3): defect of articular surface less than 5mm.
These patients were treated with electro-acupuncture therapy for ten minutes and LLL therapy at a tender point of the knee for two or three minutes. After the therapy we evaluated the effects by assessing numerical criteria of the Japanese Orthopaedic Association (JOA).
Results: For patients in Grade 1 & 2 the treatments with electro-acupuncture stimulation and LLL alleviated the patient's pain. The JOA score improved significantly in Grade 1 from 67.9± 2.6 to 86.7±1.7 and in Grade 2 from 67.9±3.0 to 86.3±1.5 (p<0.01). But the effect of the treatment in Grade 3 and Grade 4 were not statistically significant.
Conclusion: The therapy combined with electro-acupuncture and LLL was effective in the pain treatment and management of early and moderate stage of osteoarthritis of the knee.

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An atypical course of complications was observed after a mandibular nerve blocking was performed on an 80-year-old female outpatient. The block needle was inserted into the midpoint of the zygomatic arch. After confirmation of needle placement by eliciting severe pain which spread over the area of innervation of the mandibular nerve, 0.2ml of 1% lidocaine was injected. During the following 20-minute observation, the patient's condition remained stable. The same amount of 10% phenol in glycerin was then injected. Satisfactory anesthesia was provided 30 minutes after the block. However at the same time patient complained of severe nausea, vomiting and vertigo. These symptoms peaked within 3 hours, and then gradually decreased. They completely disappeared within 10 hours. We believe the cause of these symptoms was most likely the spread of the solution into the Eustachian tube (auditory tube) (either by direct injection or diffusion through the tissue). Another possibility is vasospasm in the arteries feeding the otolabyrinth, creating transient local circulatory disturbance. To reduce the incidence of such complications the needle tip should be guided as close to the nerve as possible under X-ray imaging with contrast enhancement and the volume of solution should be kept to a minimum.

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We report on a case of bilateral simultaneous facial palsy in a fifty-year-old man. One day, after symptoms of a common cold and involuntary movements of the right cheek, the patient became unable to close his right eye and mouth. Two days later, he also noticed the hypokinesis of the left side of his face, and consulted us. He was diagnosed with bilateral simultaneous facial palsy. We could not find any disorders of the central nervous system, but we found that he was suffering from poorly controlled diabetes mellitus (DM) which also can cause the nerve palsy. In addition to this, we found herpes simplex virus (HSV) titer elevation. HSV is reported to associate with idiopathic facial palsy (Bell's palsy). We concluded that the etiology of his bilateral simultaneous facial palsy was caused by the infection of HSV based on poorly controlled DM. Bilateral stellate ganglion block with 6ml of 1% mepivacaine was performed on the both sides on every day for 50 days. Predonisolone was administered orally for 3 weeks, and insulin was given for the treatment of DM. Bilateral facial palsy disappeared completely 6 months after the start of the therapy.

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