Neurol Med Chir () 45, 433¿437, 2005

377777777777777777777777777777777777777777777777777774 9 : 9 : 9 .-# %MM;S#FO< : 9 : 9 : 9 : 9 Role of Japan in the Future of in Asia : 9 : 9 Iftikhar Ali RAJA, F.R.C.S., F.C.P.S. and Ali I. RAJA, M.D., M.S.* : 9 : 9 * : 9 Former Professor of Neurosurgery, K.E. Medical College, Lahore, Pakistan; Resident in : 9 Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A. : 9 : 9 Key words: role of , neurosurgery, Asia : 9 : 9 : 9 : 9 : 9 : 9 : 9 Preface tions and historical facts, some of Imperial . : 9 which have been published Dr. Hayari Miyake (1867–1945) : 9 As a visitor to Japan over the last already. was an assistant to Dr. Julius : 9 : 9 17 years as well as other countries Scribaandissaidtohaveper- : 9 in Asia, I was convinced that with Introduction formed the first successful enbloc : 9 the increasing demand on Western removal of a meningioma from the : 9 countries for training of young Before I elaborate my view point left rolandic area in 1905. He was : 9 neurosurgeons from Asia, it was ontheroleofJapaninthefutureof later appointed as professor of : 9 : 9 Japan that could play a very useful neurosurgery in Asia, I would like at the in : 9 role. The numbers of training slots to mention briefly the history of Fukuoka, Kyushu, which is now : 9 and opportunities for ``hands on Japanese neurosurgery, because a medical university.6) Professor : 9 training'' in the West have virtual- this will reflect as to how the Banju Sekiguchi of Tohoku : 9 ly become non-existent for the Japanese neurosurgeons have University and Prof. Hayazo Ito : 9 : 9 developing countries. The develop- achieved their current status. This of Kyoto University were other : 9 ing and underdeveloped Asian will also act as a roadmap for the pioneer general surgeons who : 9 countries should look for training development and better practice contributed to the development of : 9 in Asia. For this Japan stands out of neurosurgery for other Asian neurosurgery in Japan.7) In 1902, : 9 as the most conspicuous possibili- countries. Neurological surgery in Dr. Hayazo Ito gave a special : 9 : 9 ty.Iwassohappy,whenProf. Japan was started by a number of lecture titled ``The brain surgery'' : 9 Kazuo Hashi, Department of general surgeons in the late 18th in the 1st general meeting of the : 9 Neurosurgery at Sapporo Medical century and became organized in Japan Medical Association and : 9 University, Sapporo, Japan, asked its modern form after World War showed results of 46 neurosurgical : 9 me if I could deliver a talk on this II. The first neurosurgical opera- operations including three for : 9 : 9 subject during a symposium being tion was performed by Dr. Susumu hydrocephalus, two for meningi- : 9 organized at the time of his Sato in 1877. The operation was tis, one for gumma, one for : 9 retirement 3 years ago. Professor trepanation and removal of a bullet trigeminal neuralgia, and 39 for : 9 Kawase, who happened to be there and bone from the left frontal lobe. epilepsy. : 9 after the presentation, asked me to The report was published in his I understand from Prof. K. Hashi : 9 : 9 give the same talk later during a book in 1880. Dr. Sato became the that the first neurosurgery : 9 meeting at Tokyo in November president of Tokyo University department in Japan was started : 9 2001. Hospital in 1885. The first perfor- at Sapporo Medical College, : 9 This presentation has been lying mance of craniectomy for simple Sapporo. Professor Teruyoshi : 9 with me since. I thought that it depressed skull fracture is credited Hashiba after receiving training : 9 : 9 mightbeworthwhilehavingitpub- to Julius Scriba (1848–1905), a for nearly 2 years under Prof. : 9 lished as it contains some sugges- German professor of surgery at the White at Massachusetts General : 9 : 588888888888888888888888888888888888888888888888888886

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9 : 9 Hospital in Boston started the neurological disorders.1,6) so named in Japan. Superfine : 9 department of neurosurgery at This is because Japanese neu- fiberscopes are also developed in : 9 : 9 Sapporo in 1954 on his return. rosurgeons also specialize in Japan for endovasculoscopy, ven- : 9 TokyoandKyotoUniversitieshad various other fields related to triculoscopy, and myeloscopy.6) : 9 been practicing neurosurgery for neurosurgery like neuropathology, Japanese neurosurgery since : 9 quitesometimebutthesewere neuroradiology, radiosurgery, World War II has progressed so : 9 government institutions and hence molecular biology, neurosurgical much that one can confidently : 9 : 9 could not have independent oncology, cerebrovascular sur- express the standard of neurologi- : 9 departments till 8 and 11 years gery, and endovascular surgery, cal surgery in various university : 9 later.TheJapanesegovernment in contrast to other developed hospitals in the following words, : 9 officially approved Tokyo and countries.6) ``Here is the state of art practice of : 9 Kyoto as departments of neurosur- neurosurgery.'' : 9 : gery in 1962 and 1964, respec- Role of Japan The answer to the question of 9 4) : 9 tively. Sapporo Medical College roleofJapaninfutureofneurosur- : 9 was a prefecture school, and was The Japanese used the slogan of gery in Asia is not as simple as : 9 more or less independent from WAKON YOSAI after World War wemaythink.Thisisbecause : 9 Government control. II for pursuing their future de- neurosurgery and for that matter : 9 velopment according to the devel- neurosurgeons are affected in : 9 : 9 Some Facts About Japanese oped Western society. WAKON many ways by socio-economic, : 9 Neurosurgery means Japanese spirit and YOSAI political, cultural, and historical : 9 Western knowledge. In their factors. Asia is the planet's largest : 9 The Japan Neurosurgical Society slogan it was said ``The Japanese, continent, and includes 47 coun- : 9 for their future development tries and assorted island depen- : 9 was founded in 1948 and its first : 9 meeting was held at Niigata with should maintain their originality dencies. The constituent countries : 9 nearly 100 participants consisting of Japanese spirit but must can be divided into developed like : 9 of neurosurgeons, neurologists, acquire the advanced Western Japan and South Korea, developing : 9 and basic scientists. The Japanese knowledge.''5) Professor Keiji Sano like India and Pakistan, and : 9 wrote ``If there will be any impact underdeveloped like Mongolia and : 9 Congress of Neurological Sur- : 9 geons was established in 1981. In of Japan on the future of neurosur- Vietnam. It includes the world's : 9 2004 Japan had 7987 neurosur- gery, it will be attributed to the two most populated countries, : 9 geons, 5812 certified and 2175 in Thymos or Yamato spirit of China and India. Because of the : 9 training. In Japan there are 80 Japanese neurosurgeons and their diversity of development of neu- : 9 esteem of harmony within their rosurgery, the requirements of no : 9 medical schools, and 373 training : 9 hospitals (Class A) with 844 at- groups based on the spirit of the two countries of Asia like Vietnam : 9 tached Class C hospitals, which first clause or Article 1 of the and Pakistan are the same, hence it : 9 are approved by the Japan Neu- Seventeen Clause Constitution in would be helpful, to look at each : 9 rosurgery Board for training 604 AD, Harmony is to be country on an individual basis. : 9 (written communication with valued.''6) Professor Sano also There are some key factors, which : 9 quoted ``when new thought was need to be considered when trying : 9 Akira Teramoto, M.D., February : 9 2004). The U.S.A. has only 95 brought to Japan from abroad, the to answer this question. : 9 training centers with double the special characteristics of the in- 1. The general level of skill and : 9 population of Japan. According to digenous world-view were seldom knowledge of neurosurgeons in the : 9 the available data, Japan with a damaged, and the question of a developing nations is probably : 9 : population of 120 million has one crisis in cultural integrity and very similar to their colleagues 9 3) : 9 neurosurgeon for every 22000 peo- autonomy never arose.'' in the developed world. In some : 9 ple. It is always questioned The current millennium is the ways, it may be even better, : 9 weather Japan has more neurosur- era of computers, genetics, and because there may be certain : 9 geons than required. The Japanese robotics. Among high-tech de- problems peculiar and common : 9 velopments, priority should be in their countries and they may : 9 answer is ``NO.'' Japanese neu- : 9 rosurgeons are of the view that given to Japanese neurosurgeons have more knowledge about their : 9 Japan needs three times more neu- in the invention of the neuronavi- management. : 9 rosurgeons to treat patients with gator which was first devised and : 9 : 588888888888888888888888888888888888888888888888888886 435

9 : 9 2. The paying capacity of the research. The developed nations survey taking into consideration : 9 patients and the subsidizing power like Japan have a much greater all aspects of neurosurgery and : 9 : 9 of the government are far less in edge with public and private collect the required information : 9 the developing nations. This trans- universities. These are supported from various underdeveloped and : 9 latesintoveryfewfundsforby money from well-funded developing countries of Asia in a : 9 buying technology inside and out- government institutions as well as variety of following ways: : 9 side the operating room and hence hefty private endowments. These a) The Task Force may visit vari- : 9 : 9 reliance mostly on the skill of funds not only support the ous Asian countries and discuss : 9 doctors and nurses. This may be research equipment costs but also with their national societies the : 9 one reason why some of the attract the best scientists and areas of improvements. : 9 healthcare professionals in de- researchers in each individual b) The Task Force may ask various : 9 veloping countries acquire strong- field. As a consequence, more national neurosurgical societies to : 9 er clinical skills and innovate research takes place, more discov- describe their areas of improve- : 9 : 9 techniques for the diagnosis and eries are made, more patents are ments on the designed special : 9 treatment of neurosurgical disor- filed, and eventually more survey. : 9 ders. revenues generated. This turns out c) The Task Force may discuss : 9 3. The difference in the surgical to be a very productive cycle. In such topics in the various meetings : 9 outcome can be attributed to the Japan, out of a minimum of 6 years of the Asian countries like the : 9 : 9 available facilities of better diagno- of training in neurosurgery, 2 Asian Conference of Neurological : 9 sis, well-equipped aseptic opera- years must be spent in academic Surgeons, Association of South : 9 tion theaters, and excellent research. Some training programs East Asian Nations, or South : 9 postoperative management in stretch over 7–8 years. The first 3 Asian Association for Regional : 9 Western countries. Practically years are spent in the clinical Cooperation meetings. : 9 : 9 speaking, in many Asian coun- service, the next 2–3 years in the Once these surveys have been : 9 tries, there are fewer angiography laboratory, and the final 1–2 years completed, the Task Force will be : 9 machines, computed tomography on the clinical service again. On able to analyze each country's : 9 scanners, and magnetic resonance the whole, the Japanese neurosur- individual requirement. : 9 imaging units for patient work-up geons are better research scientists Japan could play a very positive : 9 : 9 and similarly fewer numbers of because they spent at least 2–3 role in the following ways. : 9 operating microscopes, microsur- years in the laboratory before : 9 gical instruments, aneurysm clips, certification.1) I. Training of Asian neurosurgi- : 9 and other basic tools of modern The developing nations on the cal personnel : 9 neurosurgery, let alone more ex- other hand get stuck in a more This is one area where Japan : 9 : 9 pensive aids like intraoperative vicious cycle. This starts when a could help. It could be accom- : 9 magnetic resonance imaging and qualified and accomplished scien- plished in many ways. : 9 image-guided systems. tist like a neurosurgeon trained in Full residency training pro- : 9 4. The situation with regards to the developed world returns home gram: At the moment there is no : 9 very high-tech modalities like and subsequently decides to leave provision in Japan that a foreign : 9 radiosurgery is very similar. But it because of inadequate facilities medical graduate could be taken : 9 : 9 would be prudent to say that and incentives, and lack of cooper- into a full residency program. : 9 before installing such technology ation from health officials. This is Some of the training slots could be : 9 in the developing countries one the ``Brain Drain'' that developing reserved for Asian countries but : 9 should ensure the provision of countries have been suffering from with the clear understanding that : 9 maintenance facilities and con- decades. No money, no scientists, the Asian neurosurgeons will not : 9 : 9 tinued optimal use, especially in no research. be considered for employment in : 9 light of the fact that the supporting Japan, so that the neurosurgeons : 9 infrastructure may be non-existent Task Force return at the end of their training. : 9 in many of these countries. Nearly I am told by Prof. K. Hashi that : 9 50% of the gamma knife machines The objective of identifying in- at least three doctors, one from : 9 : 9 in Asia are installed in Japan. dividual needs could be achieved Egypt and two from China Medi- : 9 5.Theotherareawherewemight by constituting a Task Force, cal School from Shan yang : 9 find room for improvement is who should design a special Province,Dr.UandDr.Piaohave : 9 : 588888888888888888888888888888888888888888888888888886 436

9 : 9 so far passed Japanese Board Ex- could be trained for a shorter he is operating from time to time. : 9 amination, the first from Osaka or period. This will make all the : 9 : 9 Shinshu University and the later difference to surgical outcome. IV. Teleconferences : 9 two from Sapporo Medical Univer- The Department of Neurosurgery Development of such a system : 9 sity about 2–3 years ago. at Fujita Health University is between Japan and various coun- : 9 Fellowships of shorter dura- alreadyoffering3monthsfellow- tries of Asia will be very useful : 9 tion: These are probably the best ships for training young neurosur- becauseonlineadvicecouldbe : 9 : 9 and could be clinical or research geons, nurses, and paramedical obtained from the experts of vari- : 9 fellowships. The duration of these staff from countries like Sri Lanka, ous neurosurgical procedures in : 9 fellowships may vary between 6 India, Pakistan, Nepal, and Ban- Japan. Such a system has been : 9 months to 2 years. I understand gladesh. established between Department : 9 that a clinical fellow in Japan has of Neurosurgery at Hokkaido Uni- : 9 observer status only. Necessary II. Holding of conferences versity and Malaysia since 1999. : 9 : 9 amendments might have to be The Asian Conference of Neuro- BeforeIfinishIwouldliketo : 9 made so that the clinical fellow can logical Surgeons originated from stress that conditions cannot be : 9 actively participate in the program the organization of the first changed unless one strives for it. : 9 although I understand that the seminar of ``Neurosurgery Update No matter how much help Japan : 9 fellow can be allowed to do the for Young Neurosurgeons in Asia'' extends to various Asian coun- : 9 : 9 clinical work under supervision at at Nagoya in November 1993. It tries, it ultimately will be the self- : 9 the discretion of the chairman of was the brainchild of Prof. Tetsuo determination and hard work of : 9 the department but this can create Kanno. Professor Kanno explained the neurosurgeons in the develop- : 9 problems. that he is deeply committed to ing countries that will make the : 9 Special Ph.D. programs:Some developing neurosurgery in Asian difference. The responsibility of : 9 : 9 neurosurgeons have been trained countries where neurosurgery is filling the gap between various : 9 and awarded a Ph.D. by some still a dream. Through these Asian countries and Japan in : 9 universities and those neurosur- meetings and hands on workshops providing better quality neurosur- : 9 geons have gone back home. They he promised to raise the level of gery for their patients in the 21st : 9 are holding important positions practice of neurosurgery, in Asian century and beyond is the sole : 9 : 9 and taking care of neurosurgical countries where it was most responsibility of neurosurgeons : 9 patients in their countries. Such a needed, and promote mutual working in those countries. Profes- : 9 Ph.D. program could be made a friendship between Asian neu- sor Hashi in one of his messages : 9 regular feature by some of the rosurgeons. These conferences are said and I quote: ``Each Asian : 9 Japanese universities for Asian being held regularly since then and country has its own requirements : 9 : 9 graduates. This will amount to the serving a very useful purpose. andtheyhavetoworkhardon : 9 same as a full residency training their existing resources and de- : 9 program. III. Donation of equipment and velopintheirownwaytomeet : 9 Short training courses for instruments these demands.''2) : 9 younger neurosurgeons:Short Since the establishment of the : 9 training courses of 2–4 weeks Asian Conference of Neurological : 9 References : 9 duration that have become availa- Surgeons, Prof. Kanno, Dr. Yoko : 9 ble at some of the Japanese Kato, and their team has visited 1) Handa H: An interview with : 9 hospitals have proven to be very many countries of Asia like Professor Hajime Handa. Surg : 9 useful. The neurosurgeons become Mongolia, Bangladesh, Vietnam, Neurol 51: 679, 1999 : 9 familiar with the technology and andIndiawherepeoplehavebeen 2) Hashi K, Ohta T: Brief remarks for : 9 : procedures. Such courses also practicing neurosurgery with the the 3rd Asian CNS Meeting, in: 9 ACNS/AWNA Newsletter, vol 2, no : keep them abreast of the research minimum of equipment and instru- 9 2 (Dec. 1999) : 9 and advancements in Japan. ments. Donation of equipment : 3) Kato S; Chibbett D, Sanderson D 9 : Training of nurses and para- has been done very generously (trans-eds): AHistoryofJapanese 9 medical staff:Thisisasimportant through their personal efforts. : 9 Literature. Tokyo, New York, : 9 as training of neurosurgeons. Professor Hakuba is taking a keen London, Kodansha International, : 9 Opportunities could be created in interest and has donated a lot of 1979 (The original Japanese edi- : 9 some hospitals in Japan where they equipment to Bangladesh where tion in 1975 published by Chikuma : 9 : 588888888888888888888888888888888888888888888888888886 437

9 : 9 Shobo, Tokyo) 6) Sano K: The impact of Japan on the : 9 4) Kikuchi H: The department of neu- future of neurosurgery. Surg Neu- Address reprint requests to:I.A.Raja, : 9 rosurgery, Kyoto University rol 39: 429–436, 1993 F.R.C.S., F.C.P.S., 40-C, Zafar Ali : 9 : School of . Neurosurgery 7) Sano K, Handa H, Ishii S: Pioneers 9 Road, Gulberg V, Lahore 54660, : 9 38: 558–562, 1996 in Japanese neurosurgery. Surg Pakistan. : 9 5) NewsWeek 2001 May 7 Neurol 7: 321–323, 1977 e-mail:aliraja＠brain.net.pk : 9 (June 9, 2005 received) : 9 : 588888888888888888888888888888888888888888888888888886