The two failed Mongol invasions of Japan in 1274 and 1281 launched a new phase in the history of Sino-Japanese trade, during which religious institutions played an even more important role. This chapter shows that despite the occasional conflicts between Chinese officials and merchants from Japan, Sino-Japanese trade continued on a large scale with the direct participation of prominent Japanese monasteries in both Kyoto and the newly developed political and religious center of Kamakura. Monasteries directly sending trade ships to China, often in the name of financing monastery construction, constituted a further development in the integration of religious and trade networks predating the Mongol invasions. In the mid-fourteenth century, increasing piracy and the changing political environment in both China and Japan prompted monasteries to adopt precautionary procedures to secure their profit, including signing contract-like documents with the merchants they commissioned.

A regional block, also known as a localized block, is a type of anesthetic that blocks nerve transmission to prevent or alleviate pain. Regional anesthesia is the process of injecting an anesthetic substance into a peripheral nerve and inhibiting transmission to avoid or treat pain. It is distinct from general anesthesia in that it does not alter the patient’s level of awareness to alleviate pain. There are numerous advantages of regional anesthesia over general anesthesia, including avoidance of airway manipulation, lower dosages, fewer systemic medication adverse effects, shorter recovery period, and considerably less discomfort following surgery.

After the suspension of tribute missions, Japanese pilgrim monks actively sought assistance from Chinese merchants for their travel and for acquiring scriptures and objects from the continent. Using two sets of private records written by merchants, which have never been explored in Western scholarship, this chapter shows how the pilgrim monks and sea merchants started to build a network both for transmitting Buddhist teaching and for profit-making. Correspondence between monks and merchants suggests that certain Chinese merchants traveled on a regular basis between the continent and the archipelago, and they therefore formed a close relationship with monks in Japan. The monks designated the merchants as their envoys, sending gifts and letters containing Buddhist-teaching inquiries to Chinese monks, while the merchants hoped to gain access to Japanese authorities via the monks’ introductions.

This chapter focuses on three Japanese pilgrim monks who visited Northern Song China (960–1127) and had extensive interactions with Chinese emperors, court officials, and merchants. Monks’ diaries and other court records indicate that by the eleventh century, the authorities in both China and Japan were aware of the collaboration between monks and merchants and were even taking advantage of the newly formed network. Japanese aristocrats hoped to acquire desirable continental commodities via the monk-merchant cooperation, and Emperor Shenzong of the Song asked a Japanese pilgrim monk to bring his gifts and letter to the Japanese authorities.

Shoulder surgery can be accomplished arthroscopically or open, and is usually performed in either a lateral decubitus (LDP) or beach-chair (BCP) position. The LDP involves placing the patient on their side on a padded table on top of a bean bag to support the pelvis and lower torso. For the BCP, the patient is placed on a table with a headrest and the bed is positioned in Trendelenburg, with the feet elevated to 15 degrees and the knees flexed to 30 degrees. Some potential advantages of the BCP over the LDP include shorter surgical times, less difficult conversion to an open procedure, and a lower incidence of neuropathies. The BCP can present a unique challenge for the anesthesia provider in accessing the airway and has been associated with rare, but catastrophic, neurologic complications, including transient visual loss, spinal cord ischemia, and strokes. These complications have been suggested to be from the gravitational effects of the sitting position and the blunting of cerebral autoregulation under general anesthesia (GA). There is some evidence that patients in the BCP have diminished cerebral autoregulation and lower regional cerebral oxygenation, when compared to the LDP. This, however, do not relate to cognitive outcomes.

The Ashikaga military government’s enormous interest in Sino-Japanese trade and the founding of the new Ming dynasty on the continent in 1368 led to the restoration of tribute relations. When the Ashikaga bakufu ignored domestic critics and accepted an inferior position as a tributary to the Ming court, it did so to regain the opportunity to trade with China. Formal tribute trade resumed for the first time since Ennin’s day. However, the nearly six centuries preceding had left their mark: religion maintained its important position in official trade. Monks frequently traveled on trade missions and assumed the position of ambassador or vice ambassador. And the Ashikaga bakufu was not the only participant nor the only beneficiary in the resumed tribute trade: prestigious monasteries had their own ships in the tribute delegations.

This chapter presents a “thick description” of a single prolonged trade relationship between a Chinese and Japanese monastery in which a Chinese merchant functioned as the go-between. This allows the reader to see the precise workings of the religio-commercial network. In 1242, the prominent Chinese monastery Jingshan was severely damaged by fire, and via his former Japanese student’s introduction, the abbot of the Jingshan monastery purchased one thousand wooden planks from a wealthy Chinese sea merchant, Xie Guoming, who was based in Hakata. To embed himself into the Buddhist network, Xie founded a monastery in Hakata to spread Zen Buddhism from the continent to the archipelago. The letters from the Jingshan abbot indicate that Xie’s efforts were not in vain: the abbot showed exceptional trust in Xie and his fellow merchants, helped them when their cargo was detained on the Chinese coast, and even praised Xie’s interpretation of Buddhist scriptures.

The early twelfth century marked a crucial point in the formation of the religio-commercial network. Archeological discoveries show that around 1100, a “Chinese quarter” with residents who were mostly sea merchants took shape in the port city of Hakata on Japan’s Kyushu Island. After taking up permanent residence in Japan, those Chinese merchants also sought patronage from local religious establishments in Kyushu for protection. During this period, merchants and the religious establishments grew increasingly closer to each other, and the merchants from the “Chinese quarter” even appeared in Buddhist texts and helped facilitate the spread of Buddhist teachings to Japan.

The introduction begins with Ennin, the eminent Japanese monk who traveled to China in 838 with the last Japanese embassy to the Tang court. Then sojourning for nine years in China, Ennin witnessed that more-private forms of shipping and trade had already begun to displace the tribute system. Tracing Ennin’s experience in China, this chapter introduces three main themes of the book: Buddhist material culture and the monastic economy, trade via religious networks, and the relationship among monks, merchants, and the secular authorities. This chapter also explains the nontraditional sources that this book uses and the new readings of monastic records that it offers.

The intercostal nerves are the continuations of the ventral ramus of the thoracic spinal nerves. To perform an effective ICB, the block should be performed proximal to the mid-axillary line, where the lateral cutaneous branch takes off. ICBs can be performed using landmarks, a nerve stimulator, or under ultrasound guidance. Evidence supports the effectiveness of ICBs for chest tube placement, rib fractures, and procedures of the breast and chest wall. Limitations of ICBs include the need to perform blocks at multiple levels (each level of fractured rib) and their association with a shorter duration of action, compared to other chest wall fascial plane blocks such as pectoralis (PECS) II block and serratus anterior plane block (SAP). This is mainly related to a high rate of absorption of local anesthetic within the intercostal space. These considerations make ICBs a less favorable option, as with each injection, there is a potential risk of complications, such as neurovascular injury and pneumothorax. The risk of local anesthetic systemic toxicity (LAST) may also be increased with multiple intercostal injections related to the highly vascularized bundle located underneath each rib, resulting in a high rate of absorption.