The effect of steroid therapy on acute cerebrovascular accidents was studied in 66 elderly patients, 38 of which were cases of cerebral infarction, and 28 of cerebral hemorrhage. Twenty three cases of cerebral infarction and 18 cases of cerebral hemorrhage were treated with steroids. The diagnosis was confirmed by autopsy in 47 cases. The average age was 76.2 years. Of 41 steroid treated patients, 22 were treated with predonisolone, 14 with Dexamethasone and 5 with other steroids. The average daily dose of steroids was 10.0mg as a Dexamethasone dose and the average total dose to each patients was 40.4mg. In all cases intravenous administration of steroids was started within 40 hours after stroke and the mean dosed time was 7.2 days. Improvement of the state of consciousness or survival rate was used as indicators of clinical effect. Consciousness level was divided into 7 grades. Improvement of consciousness level by one grade or more was considered to indicate the effectiveness of the treatment. Survival rate was determined at the end of the second or fourth week. Results: 1). In cerebral infarction, 9 of 23 treated cases (39%) were improved in their consciousness, whereas 5 of 15 controls (33%) were improved during the same periods. Sixteen of 23 treated cases (70%) survived 4 weeks, while 12 of 15 controls (80%) survived. These differences were not significant. When comparison was made among cases with almost the same level of consciousness, there was no indication of the effectiveness of steroid therapy. 2) In cerebral hemorrhage, 5 of 18 treated cases (27%) were improved in their consciousness, whereas 1 of 10 controls (10%) were improved during the same period. Ten of 18 treated cases (56%) survived 4 weeks, while 1 of 10 controls (10%) survived the same period. In cases of cerebral hemorrhage, disturbance of consciousness at the time of admission was severer in controls than in the cases treated with steroids. because many control cases of cerebral hemorrhage died before they had an opportunity to be treated with steroids. This must be taken into consideration when the results described above are interpreted. 3) Among cases with steroid therapy 3 had gastrointestinal bleeding and 1 had nonketotic hyperosmolar diabetic coma. Gastrointestinal bleeding was also found in one case of controls.
Many reports on the cholelithiasis have been published. The gallstones are frequently found at autopsy materials and the increasing incidence of gallstones with advancing age is well known. Cholelithiasis is one of the most important diseases in the aged. In this paper, cholelithiasis was studied upon an analysis of 1070 autopsy cases of elderly patients over the age of 60 at Yokufukai Geriatric Hospital, Tokyo, during a period of 11.5 years from the beginning of 1962 to July 1973. Results are shown below. 1) The gallstones were present in 201 cases (18.8%) of 1070 autopsied patients. The incidence of gallstones was high in the elderly group and greater in the female (21.4%) than in the male (13.9%) with a ratio of 1.5 to 1. 2) Of 201 autopsied patients with cholelithiasis, 191 (95.0%) had gallstones in the gallbladder, 24 (11.9%) in the common bile duct, 6 (3.0%) in the intra-hepatic duct, 6 (3.0%) in the cystic duct, and 2 (1.0%) in the hepatic duct. 3) There was a ratio of 4.3 to 1 of cholesterol stone to bilirubin stone in the male and a ratio of 9.2 to 1 in the female. 4) Fifty-two per cent of cholelithiasis in the gallbladder had been asymptomatic in the male and 58per cent in the female. On the other hand, 50per cent of cholelithiasis in the biliary ducts had been asymptomatic in the male and 41.7per cent in the female. 5) Most of clinical diagnosis in 201 cases with gallstones were central nervous, cardiovascular or respiratory diseases. The diagnosis of cholelithiasis had been made correctly in 9.6per cent in the male and in 8.7per cent in the female. 6) The mortality of cholelithiasis proved to be 7.7per cent in the male and 4.7per cent in the female. 7) The percentage of developing cancer of the gallbladder in the presence of cholelithiasis was 2.1per cent in the female. On the other hand, the incidence of gallstones in the presence of carcinoma of gallbladder was 60per cent.
Using recently developed radioimmunoassay, the fact that the incidence of digitalis intoxication clinically increased with age in the adult population prompted us to measure serum digitoxin concentrations in patients with oral maintenance doses of digitoxin, and to investigate their clinical significance by a comparative study between the elderly (sixty or more years) and the younger (below sixty years) patients. The results were as the following. 1. While the average serum concentration for the nontoxic group was 18.4ng/ml, that for the toxic group was as high as 35.5ng/ml. The difference was statistically significant. (P<0.0001) 2. The comparison of clinical data between the toxic group and the nontoxic was performed. The cardiothoracic ratio, GOT and GPT showed a significant difference between the two groups. 3. The serum concentrations significantly increased in proportion to the increase of the maintenance doses of digitoxin, and the regression equation was calculated as: y=194x+4.87. All the cases with serum concentrations above 35ng/ml manifested toxicity, while none of the cases with serum concentrations below 24.5ng/ml were toxic. An overlapping existed in the range between 24.5 and 35.0ng/ml. 4. In each group of three different maintenance doses (0.05mg/day, 0.07-0.08mg/day, 0.1mg/day), the average serum concentration was higher in the elderly than in the younger, and the differences were statistically significant. The regression equations were calculated as: y=231x+3.91 (in the elderly group), y=148x+5.39 (in the younger). While only 3 cases of 53 patients, that is 5.6% had manifestations of toxicity among the younger group, 21 cases of 62, or about 34% of the patients had manifestations of toxicity among the elderly. 5. The body-weight and the cardiothoracic ratio were not significantly different between the two groups. Among the blood chemistry examinations, total serum protein was significantly different, but no significant differences were noted in BUN, creatinine, sodium and potassium. Thus, renal function as revealed by BUN and creatinine was not thought to be different between the two groups. However, it seems that as 24-hour endogenous serum creatinine clearances decreases, serum digitoxin concentration and hence the incidence of toxicity tend to increase. However, taking into consideration the fact that the more polar metabolites of digitoxin are mainly excreted by the urinary route, it is appropriate that the diminution of GFR by aging is counted as one of the main factors contributing to the high serum digitoxin concentration in the elderly. Furthermore, various factors such as the impairment of the activity of drug metabolising enzymes were discussed in this pages. Accordingly, cautious consideration of dosage and careful observation of the clinical condition are required in treating the elderly patients. It is very useful to dertermine the serum digitalis concentrations frequently in the clinical course for the early detection of digitalis intoxication.
Arteriosclerotic changes are most frequently observed in cerebral angiography of the elderly. In addition, cerebral arteriosclerosis is considered as a main cause of stroke. But relatively little work has been done about the predisposing factors of arteriosclerosis visualized by cerebral angiography. Carotid angiograms were reviewed to investigate the risk factors of cerebral arteriosclerosis in 315 patients who visited Research Institute of Brain and Blood Vessels, Akita from 1969 to 1974. In all patients examined in the present study some reason for carotid angiography was present, but any organic brain disease could not be confirmed other than cerebral arteriosclerosis. Arteriosclerotic lesions were classified into three grade according to the degree of stenosis and the extent of arterial wall irregularity in three arterial groups of extracranial carotid arteries, intracranial major arteries and intracranial small arteries. The grade of cerebral arteriosclerosis was correlated with age, blood pressure and serum cholesterol level. The results were as follows. 1) Age was closely related with arteriosclerosis in each of three arterial groups. The frequency of arteriosclerosis in intracranial major arteries was higher than in other arterial groups. 2) An increase in the severity of arteriosclerosis of each arterial group was noted in the presence of hypertension. But statistical analysis of cases matched in age revealed a significant difference only in assessement of intracranial small arteries at ages of fifty (P<0.001) and sixty years (P<0.01). Therefore, it was concluded that a much closer relationship existed between blood pressure and arteriosclerosis in intracranial small arteries than in other arterial groups. 3) In hypertensive cases, the frequency of arteriosclerosis in extracranial carotid and intracranial major arteries tended to increase with serum cholesterol level. The relationship between serum cholesterol and arteriosclerosis of intracranial major arteries was significant (P<0.05). Especially stenosis of greater than one-fourth was observed in 26.5% of cases with serum cholesterol over 210mg/dl and its incidence was about five times those of less than 184mg/dl. No significant relationship between cerebral arteriosclerosis and cholesterol level was found in the cases without hypertension.
Seven elderly cases with the typical electrocardiographic changes of acute myocardial infarction in the absence of myocardial infarction on postmortem examination were observed following the blood transfusion. The underlying diseases were cancer in gastrointestinal tract or gall bladder in four cases, gastric ulcer in two cases, and a case of pseudomembranous enterocolitis. The electrocardiogram revealed the abnormal Q waves with monophasic ST elevation and following coronary T inversion. These characteristic findings lasted only for 2 to 7 days and returned to the previous normal tracings. The hematocrit was elevated from 28.9 to 47.7 after the blood transfusion of 800 to 1800ml. The disseminated intravascular coagulation was shown in five cases. GOT levels were within normal ranges except in one case. Pathological findings in cases with recent electrocardiographic changes were characterized by the mural thrombi, extending into the myocardium through the thebesian vein. The focal small necroses of the adjacent myocardium and the thrombosis of small vessels were also observed. In cases with relatively long interval the fine interstitial fibrosis took place after the resorption of the thrombi and necrotic foci. From these clinical and pathological findings we proposed the new concept of reversible myocardial infarction induced from the hypercoagulability and elevated hematocrit.
Cardio-thoracic ratio (CTR) was measured in 1671 subjects (617 male, 1054 female) aged sixty years and over. Relationship between CTR and other clinical findings was observed in order to assess the usefulness of this method. Results obtained were as follows: (1) Mean value of CTR was significantly higher in female than in male. (2) CTR tended to develope with increasing age in both sexes, significant only in female. (3) Higher value of CTR was found in subjects with higher blood pressure level. (4) Obesity elevated value of CTR. (5) Female with higher hematocrit level had significantly higher value of CTR, on the other hand, CTR was independent on hematocrit value in male. (6) Left axis deviation and T wave abnormality in electrocardiogram were significantly prevalent among higher CTR subjects in both sexes, however, positive correlation between high voltage and CTR existed not in female but in male. (7) Cerebral hemorrhage, cerebral infarction, and myocardial infarction occured more frequently in subjects with higher CTR, but it was not significant. Sex difference in value of CTR is considered to be due to small thoracic size and high obesity index in female. Significant age difference found only in female may be attributed to anemia rather than hypertension. It could be concluded that CTR is a useful clinical parameter although it is modified by various factors.
Dementia is one of the very common conditions in the elderly, as it becomes increasingly prevalent with advancing age. Among a variety of dementias, senile (i. e. primary neuronal or degenerative), vascular (so-called arteriosclerotic) and mixed-type (mixture of the two) dementias account for most of the cases. As senile and vascular dementias are based on different pathological process, they should be differentiated precisely, not only from academic but also practical viewpoints. The diagnostic criteria in these dementias, however, have been hazy and more or less traditional. The present study was undertaken in an attempt to determine whether these dementias could be differentiated by analysis of the temporal profile of dementia. The temporal profile of dementia means the mode of onset of dementia and the relationship of the appearance of neurological deficits or episode of cerebrovascular attack to the progress of dementia. The temporal profile of dementia could be classified into three types: Types I, II and III. Type I dementia, which develops inciduously and progressively without episode of stroke or neurological deficit, corresponded to senile dementia. Type II dementia was proved to be of vascular origin, most of the cases in this group being post-apoplectic. In this group, the patients with left hemiplegia showed a higher incidence of psychotic symptoms than those with right hemiplegia (p<0.05). Two demented cases due to recurrent episodes of transient global amnesia were also included in this group. Autopsy cases belonging to Type III revealed both marked senile and vascular changes, thus indicating that this type was the mixture of the two conditions (i. e. mixed-type dementia). As regards the incidence of clinical manifestations of these dementias, several symptoms, including wandering tendency, purposeless activity, crying in the daytime etc. appeared more frequently in Type I than in Type II, while emotional incontinence was more frequent in Type II. From these results it was concluded that the temporal profile of dementia is useful for the differentiation of senile and vascular dementias.
Examinations of PAS positive inclusions (Biondi bodies), which were seen in the choroid epithelial cells of monkeys (Macaca fuscata), were performed on the structures, the histochemical features and the relationship between the appearance rate of inclusions and the age of monkeys. The inclusions generally showed a tendency to increase in number and size according to age. Structurally, the inclusions were classified into four groups, as follows: Group 1-a small, granular type, in which many granules were commonly scattered in one epithelial cell; Group 2-a round type, composed of an aggregation of small, ring-like structures; Group 3-large, ring-like structures; Group 4-an intermediate type between those in Group 2 and Group 3. As for Groups 2, 3 and 4, there was commonly only one inclusion in one epithelial cell, but sometimes some inclusions were seen. The appearance rate of each group varied according to age. Group 1 appeared most commonly in the immature monkeys, and Groups 3 and 4 were generally seen in the aged monkeys. Group 2 was seen in the mature and aged monkeys, and the size of the inclusions showed a tendency to increase according to age. Histochemically, almost all of the inclusions of Group 1 consisted of lipid, and those of Groups 2, 3 and 4 consisted of both lipid and lipofuscin. In addition to these components, an amyloid-like substance also existed in a part of the inclusions of the aged monkeys. The genesis of the inclusions is unknown. As the inclusions are not only structural aggregations of subunits but also are made up of a histochemical coexistence of some different substances, it is considered that they are closely similar to Biondi bodies of human choroid plexus.
In order to study the cardiac function in ischemic heart disease and its hemodynamic property which contributes in the aspect of myocardial oxygen demand to the genetic mechanism of coronary insufficiency, hemodynamic responses to the stair-climbing exercise which is one of the typical causes of anginal attack were observed under physiological condition by employing a non-invasive method. In 17 patients with angina pectoris whose electrocardiograms revealed positive Master's tests (IHD group) and 30 normal, age-matched controls (normal group), the mechanocardiogram consisting of simultaneous recordings of the electrocardiogram, phonocardiogram and carotid pulse tracing was recorded and the blood pressure was measured before and after the exercise of the Master two step test. The pre-ejection period (PEP), ejection time (ET) and RR-interval were determined on the mechanocardiogram obtained. As indices of cardiac function, PEP, ETc, ET/PEP, Pd (diastolic blood pressure)/PEP and (ETc/PEP). RR were estimated. As an index of myocardial oxygen consumption, the Katz's index (KI) was calculated. In 10 subjects of each group, moreover, the responses to the mild exercise (single Master) and the severe one (triple Master) were compared. At rest, the IHD group showed a prolonged PEP, normal ETc and diminished ET/PEP. After exercise, the PEP was longer, the ETc shorter and the ET/PEP lower than those of the normal group. Although this pattern of cardiac function indices shows a depressed cardiac function, there were no significant differences in the degree of responses of these indices between the IHD group and the normal. In the severe exercise, however, the responses of the blood pressure and heart rate in the IHD group became marked, compared with the normal group. The Pd/PEP responded more greatly than in the mild exercise, contrary to the normal group in which the Pd/PEP responded in the same manner as in the mild exercise. These results suggest an excessive hemodynamic response to the severe exercise in the IHD group. On the other hand, the index for evaluation of cardiac function devised by us, (ETc/PEP). RR, was lowered in the severe exercise. The cardiac function in the IHD group, therefore, is considered to be in a depressed state. The KI was increased distinctly after the severe exercise, suggesting conspicuous augmentation of the myocardial oxygen consumption. From the results mentioned above, it is concluded that the ischemic heart is in the depressed functional state, however, it responds excessively to exercise and such response in turn increases abnormally the myocardial oxygen consumption, and that this excessive hemodynamic response is one of the important factors in the genetic mechanism of coronary insufficiency in ischemic heart disease.