Japanese Immigration in America: Fleeing Riots, Escaping Imprisonment, and Assimilating.

When 13-year-old Teruichi Nakayama, my grandfather, came to San Francisco from Osaka in 1906, he was assured of an education in a public school by an 1894 treaty between the United States and Japan that gave the latter most-favored-nation status. In 1906, racist mobs forced a decision by the school board to assign 41 school aged Japanese children, including him, to a segregated school for Asian children in violation of the pact. In 1907, he escaped street violence to work as a migrant laborer on inland farms. Settling in the state's Central Coast, he started a confectionary, the family business he knew from his childhood in Japan. He eked enough money to raise a family with a wife arranged for him in the traditional manner by a go-between in Japan. The school board action opened a diplomatic rift between the 2 countries that never resolved and ended in war in 1941. Just days ahead of the imprisonment of Japanese living in California in 1942, he and his family fled to Colorado, a sanctuary state where he reestablished the confectionery. He faced every misapprehension of the current immigration crisis: racism, unfair labor competition, the impossibility of assimilation, and suspicion of a fifth column. Now 5 generations later, none of the fearful predictions when he first arrived came true. His legacy proves immigration as an essential rejuvenating force in America.

The Great Migration and Healthcare to Black America.

The Great Migration, the movement of 6,000,000 black Americans from the South to the great urban centers of the eastern seaboard, the industrial Midwest, and West Coast port cities from roughly 1915-1970, was one of the defining demographic events in American history. It dwarfed the 100,000 49ers who swarmed westward in search of gold, the incarceration of 110,000 Japanese to concentration camps in the American interior during World War II, and the 300,000 Okies who escaped the Dust Bowl to California. In the words of writer Isabel Wilkerson, "[It] swept a good portion of all the black people alive in the United States at the time into a river that carried them to all points north and west."Blacks crammed into urban districts rife with crime and communicable disease, subjecting them to risks of death far higher than their proportion of the population. Without access to adequate inpatient hospital facilities, they received care in public hospitals run by hospital staffs that excluded black physicians from their membership and medical schools that refused admission to black students. The untenable health station of Black America was one of the leading causes of the civil rights movement of the 1950s and 1960s, activism that succeeded in integrating the hospitals and medical schools by federal acts passed in 1964 and 1965 that transformed American medicine.

Chinese Railroad Workers, the Transcontinental Railroad, and the Indispensability of Immigration to America.

Asian migration to America began with Chinese railroad workers on the transcontinental railroad (1862-1869). Their labor saved the foundering Central Pacific Railroad, challenged by building a rail line through the Sierra Nevada. By mid-1864 only 50 miles of track had been laid, grueling work that dissuaded its white workforce from going any further. To save the railroad 50 Cantonese workers were hired in early 1864 from neighboring mines to lay rail through forests, canyons, and granite mountains. High explosives, rockslides, cave-ins, and winter avalanches were constant dangers. The trial worked so well that thousands of Chinese joined the effort, many from the rural districts surrounding Guangzhou (Canton). The wages, less than half of that paid to white workers, were beyond the imaginations of subsistence farmers escaping abject poverty, plague, and famine. A good proportion of their earnings were remitted to families back home. As many as 20,000 may have worked on the railway. The death toll was staggering, estimated in the thousands. After Promontory Summit in 1869, Chinese were in great demand, building scores of rail lines throughout the country and Canada. Just 13 years later rising anti-Asian sentiment led to the passage of the Chinese Restriction Act of 1882 that for the first time barred a racial group from American shores. But they opened America to Asian immigrants that includes today's Asian surgical community, which owes its present-day success to the hardworking forebears that created a global country with ribbons of steel rail.

The Opium Wars of China in the Nineteenth Century and America in the Twenty-First.

The Opium Wars of 1839-1843 and 1856-1860 revealed the devastating effects of narcotic addiction on the health of the body politic of China. The defeated Qing dynasty lost effective sovereignty to the British, leaving it helpless against more than 100 years of exploitation by the European powers, the United States, and Japan. Today we see the same risk posed by prescription narcotics and illegal opioids imported from China that can be seen as retribution for the "Century of Humiliation" nearly two centuries ago.

Pediatric Patients as a Source of Bias in Joseph Lister's Study of Antisepsis.

Joseph Lister's (1827-1912) use of carbolic acid to prevent wound infection in open fractures of the extremities (1865) provided a basic science rationale for the practice of surgery. His series of 11 patients included 4 children, aged 7 to 13. Children, today known to better survive a given injury when compared with adults, may have biased his results in favor of survival, and led him to conclude that his method of carbolic-soaked dressing changes prevented fatal wound sepsis. His success with antisepsis may have been less a testament to his application of germ theory to surgery than to the physiological resilience of his young patients.

The Immigrant Backstories of Asian American Surgeons.

The stories of Asian immigrants have both shared themes and ones that are unique to the histories of their homelands. Their labor was essential to the settlement and economic development of America, yet their presence incited riots and official restrictions to their rights to immigration and citizenship. Chinese laborers mined the Gold Country, built the transcontinental railroad, and reclaimed tillable land in the Central Valley. Yet they were denied the immense bounty they created, and their immigration was blocked by the Chinese Exclusion Act of 1882.Japanese, Asian Indians, and Filipinos replaced them on farms as migrant laborers. As foreign nationals they were not allowed to own land, but they thrived as independent farmers on leased plots. Their success attracted discrimination and racist violence. They, too, were barred from immigration and citizenship (Johnson-Reed Act, 1924).World War II was a watershed event for Asians in America. Japanese Americans, ethnically identical to the enemy, were imprisoned in concentration camps in the American interior. China, the Philippines, and India, all allies of the US, were rewarded with naturalization rights for their nationals. In 1965 Congress liberalized immigration quotas and reversed the 1924 restrictions, with priority given to those with advanced technical ability in science, including medicine. Asians from Taiwan and India took advantage of the new regulations and predominated among the newcomers. After the fall of Saigon in 1975, America accommodated yet another Asian population in the country, the tens of thousands of refugees from Southeast Asia.

Asian American Surgery: A Short History of Immigration, Naturalization, and Refugee Laws and Policies that Brought Asians to America.

Chinese immigration in America in the mid-nineteenth century incited violence and governmental sanctions to restrict Asian immigration and reject citizenship rights. In 1870, Chinese strikebreakers in Massachusetts ignited nationwide demonstrations against Chinese immigration, which ended altogether with the Chinese Exclusion Act (1882). Japanese schoolchildren in San Francisco public schools sparked rioting in 1907, leading Japan to unilaterally limit emigration to the United States (Gentlemen's Agreement, 1908). Congress responded to anti-Punjabi riots (Bellingham, WA, 1907) by refusing naturalization rights to Asians (Barred Zone Act, 1917), policies supported by the Supreme Court (Ozawa, 1922; Thind, 1923). All immigration from Asia was soon prohibited (Johnson-Reed Act, 1924). Anti-Asian measures peaked in 1942 with imprisonment of Japanese in concentration camps, including those with birthright citizenship. Anti-Asian policies unwound in the last half of the 20th century, culminating in sweeping changes in US immunization policy. Naturalization rights were granted to wartime allies against Japan (China, 1943; the Philippines and India, 1946) and the Japanese themselves (1952). Asian women marrying American servicemen were allowed entry into the country (1945, 1950). Prohibitions against Asian immigration were lifted in 1965 (Hart-Celler Act), with preference for those trained in science, technology, and medicine. The refugee crisis that followed the fall of Saigon (1975) drove humanitarian policies that brought evacuees from Southeast Asia and others from throughout the world seeking freedom from persecution (Refugee Act, 1980). Hundreds of thousands from China, South Asia, the Philippines, and Southeast Asia thus settled in the United States, changing American society and medicine.

St. Zenobius, the Patron Saint of Injured Children and Non-accidental Trauma.

St. Zenobius (337-417), second only to John the Baptist as a Patron Saint of Florence, revived a 5-year-old boy who appeared to be dead after he was struck by an ox cart, one of his several acts of resurrection for which he was revered. His miracles inspired some of the greatest artists of the Florentine Republic, including Ghiberti and Botticelli. Celebrated from Late Antiquity as protector of the city, St. Zenobius might also be considered the guardian of injured children. But it wasn't the only instance where he had to revivify an injured child: a boy died while he was entrusted to the saint's care, a circumstance that today would qualify as non-accidental trauma (NAT) from neglect and prompt an investigation from the police and child protective services.

A Japanese Family Experience in America.

Even though my uncle was not in the health professions, much less surgery, I share his memorial as the story of one family that had one of its offspring become integrated into the professional mainstream through the opportunity of medical education.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children.

BACKGROUND: Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. METHODS: A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. RESULTS: Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. DISCUSSION: African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

John Hunter and the Descent of the Testis.

The descent of the testis and the development of an inguinal hernia were the earliest published scientific work by John Hunter, the Scottish surgeon and anatomist who is acknowledged as the father of scientific surgery. Hunter's anatomic descriptions are the ones we use today to describe the prenatal descent of the testis and to explain the pathogenesis of an undescended testis and inguinal hernia in infancy. His work appeared in print in 1762, not as a formal publication but as an addendum to a screed written by his older brother William publicly accusing Percival Pott of pirating John's observations on the pathogenesis of an inguinal hernia and publishing them as his own, an early example of scientific rivalry.

Guild Rivalries Between Barbers and Surgeons in Medieval London and England.

The origins of today's surgical societies are the guilds of medieval London. The Company of Barbers and the Guild of Surgeons vied for dominance no different from the scores of conflicts between rival artisans and merchants whose trades overlapped. The Company dates from 1308, when the council of London passed ordinances that installed its first master, Richard le Barber. When the surgeons received ordinances of their own in 1368, the barbers had the Council reassert theirs in 1376, 1390, 1415, and 1424. Faced with a vigorous organization with greater numbers the surgeons aligned with the physicians in 1423 to form a short-lived ruling "commonalty" with an elite membership based on educational achievement and proven ability that excluded the barbers. The surgeons were thereby granted authority over all of surgery, including that practiced by barbers, an arrangement that failed after only a year. The surgeons formed a guild in 1435 but could not compete with the barbers. The barbers' primacy became complete in 1462 when Edward IV chartered them to govern all aspects of surgery, along with the power to fine and imprison. From then barbers and surgeons amiably coexisted, likely because the rapidly growing population and the democratization of the practice of physic provided plenty of work. Henry VIII formally united the barbers and surgeons in 1540 under the Worshipful Company of Barbers and Surgeons, an amalgamation that lasted for two centuries until the surgeons broke away in 1745.

Accountability in Healthcare: Sovereign Authority to Democratization.

While accountability in healthcare is associated with Ernest Amory Codman (1869-1940), its origins can be traced to the beginning of recorded history. A physician guilty of a medical misdeed under the Code of Hammurabi (ca. 1755 BCE) had his fingers severed. The authority to regulate medical practice passed from sovereign to physicians in 1241 when emperor Frederick II gave the medical faculty of the University of Salerno the responsibility of examination and licensure to practice medicine. Thomas Linacre (1460-1524) convinced Henry VIII to assign licensure to a newly constituted College of Physicians (1518) that set standards for education and practice. In his code of medical ethics (1803) Thomas Percival (1740-1804) introduced the notion that medical misdeeds be judged by a panel of peers. In enacting an analogous code (1847) the American Medical Association incited strong opposition from a prevailing attitude of professional autonomy distrustful of outside interference (1883). Codman's innovation, the End Result system (1914), reflected his belief that surgery was an industrial process where the goal was perfection: survival without complications and full recovery to complete health. This required the systematic collection of clinical data on all surgical patients and an objective assessment of outcome. The approach evolved decades later to modern concepts of quality improvement (QI), using scientifically derived data to standardize processes and minimize variability and sources of error. With the objective tools of QI physicians and their patients judge for themselves the care they offer and select under the democratization of healthcare.

Racial Disparity, Social Determinates of Health, and Slavery During the Boston Smallpox Epidemics of the Eighteenth Century.

When Benjamin Franklin published the mortality rates from smallpox during the Boston smallpox epidemic of 1752, he revealed that Blacks not only had a higher mortality rate from smallpox (12.8%, 62/485; 8.9% for whites, 452/5,059), but once inoculated, had less protection from fatal disease (mortality rate 5.0%, 7/139; 1.2% for whites, 23/1,954). His report was thus the first publication to document racial disparities in a disease and its treatment. The differential outcomes came about in the context of slavery, poverty, and war, the predecessors of the social determinates of health that we observe today.During the 1752 outbreak only 28 percent of the Boston's occupants were inoculated, a level that failed to protect the community. When the contagion returned in 1764, the town selectmen decided to provide inoculations at no cost to all that needed them. That year inoculated smallpox reached 87 percent of the total caseload. "This lowered the death rate for smallpox so markedly,' wrote John Blake, historian at the National Library of Medicine, "that for the first time a smallpox year failed to stand out as one of unusual mortality." One final observation came from Franklin's data: the unexpectedly high prevalence of inoculations among Blacks (6.8% of those inoculated, 146/2,143; 8.5% of all those contracting the disease, 693/8,201). Boston's whites had made certain enslaved Blacks were inoculated, evidence the extent to which slavery was essential to the economy of colonial Boston.

Queen Caroline's Umbilical Hernia.

Never a monarch nor head of state, Queen Caroline of Ansbach (1683-1737) is among the legendary women rulers of England and Great Britain alongside Queens Elizabeth I and II, Queen Victoria, and Lady Margaret Thatcher. As queen consort, she was the acknowledged power behind the throne of her husband, King George II (1683-1760), working with Robert Walpole, the first Prime Minister of England. George accepted her intellectual superiority and backstage dominance even before he acceded to the throne in 1727. "[He had] no pretensions toward intellect and [was] basically interested in little more than military glory, political power, and a wife who would do her duty by providing him with male heirs," wrote popular historian John Van de Kiste. After they were wed in 1705, Caroline carried out her task with a remarkable fecundity: a male heir, Frederick Louis, in 1707, followed by Anne (1709), Amelia (1711), Caroline (1713), George William (1717), William (1721), Mary (1723), and Louise (1724). With good reason she believed that her influence over George came from his sexual attraction to her. It was a conceit that proved to be her undoing as she strove to hide from common knowledge an unsightly umbilical hernia. The rupture caused her death in 1737 at age 54. It strangulated, perforated, and spilled feculent succus entericus and fetid fluid onto the royal bed, a vivid example of the consequences of an untreated surgical condition.

Surgical Professionalism, the White Owl, and Tar Heel Basketball.

The University of North Carolina (UNC) has storied traditions beyond its champion Tar Heel basketball teams. One of its best-and least known off campus-is the white owl, today a lapel pin given to chief residents in surgery at Memorial Hospital in Chapel Hill. Former residents in anesthesia and surgery at the San Francisco General Hospital (SFGH) remember it as a stuffed owl that anesthesia residents brought into the operating room whenever there was an appendectomy for appendicitis and the appendix was normal, an operation familiarly called a negative appendectomy. Standing at the table closing the incision their surgical counterpart endured the imagined smirks of the anesthesiologists behind their masks and the scrub techs and circulating nurses who also knew of the bird's significance. Alumni of the SFGH training programs also remember it as evidence of the good-natured repartee between anesthesia and surgery, teams that worked hard at all hours to serve the injured and disadvantaged populations of the city. In retrospect, the white owl signifies owning one's decisions and mistakes, an essential aspect of surgical professionalism.