With the recent developments in science and technology, medicine has witnessed significant progress. The result is a dramatic advancement in specialization in internal medicine and a growing trend toward further compartmentalization so that the question arises as to what internal medicine should be like.
Here, I would like to address may view on this subject.

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The prevalence of myasthenia gravis in Graves' disease was 0.14% in the 22, 956 patients with Graves' disease who came during 1968-1979 to the Ito Hospital, Tokyo. While age at the onset of Graves' disease in patients with myasthenia gravis was slightly lower than that in those with Graves' disease without myasthenia gravis, age at the onset of myasthenia gravis in patients with Graves' disease was not different from that of myasthenia gravis patients without Graves' disease. Of 33 patients with both myasthenia gravis and Graves' disease, 8 developed myasthenia gravis first, 13 developed Graves' disease first, and in 12 the two diseases occurred concurrently. Most patients in whom Graves' disease developed first had clinical manifestations of myasthenia gravis within 2 years of the onset of Graves' disease. The dosage of an anticholinergic drug required to control symptoms decreased as the thyroid function was normalized, and no cases showed the "see-saw phenomenon."

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Two different methods of causing myocardial oxygen demand and supply imbalance; symptom limited treadmill exercise and right atrial pacing stimulation, were used to examine the alteration of hemodynamics and the effects upon sympathetic nerve activities, platelet functions and prostaglandin synthesis in patients with coronary artery disease (CAD). Age and sex distributions, the cardiothoracic ratio, left ventricular endiastolic pressure, ejection fraction and coronary artery obstructions of the patients did not differ significantly between the two tests. Arterial blood samples were obtained to assay for plasma catecholamine, β-thromboglubulin (βTG), platelet factor 4 (PF4), TXB₂ (thromboxane B₂) and 6 ketoPGF_1-α (6 ketoprostaglandin F_1-α) without any difficulties before and immediately after testing. The arterial systolic pressure and pressure rate product (PRP) were changed more significantly by treadmill exercise than pacing, while the DPTI/TTI (diastolic pressure time index/tention time index) ratio and ST segment deviations showed similar changes with both tests. The plasma NE(norepinephrine) level, βTG, PF₄, and TXB₂/6 ketoPGF_1-α were significantly elevated by treadmill exercise, but not by pacing. 6 ketoPGF_1-α was not markedly affected by either tests. There were no significant differences between the patients with and without anginal pain either in hemodynamics or metabolites. Significant relationships were observed between changes in plasma NE levels and the PRP(r=0.76, n=26, p < 0.01) and also changes in the arterial systolic pressure (r=0.64, n=26, p < 0.01), but there were no significant correlations between any other hemodynamic parameters with plasma NE, platelet function, prostaglandin activity, or between each metabolite. These results suggest that the hemodynamic effects might have a more significant influence on platelet function and arachidonic acid metabolism in patients with CAD than limited cardiac stimulation even if myocardial ischemia can be provoked.

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Among 39 cases with acute-onset amnestic syndrome having unilateral localized infarct, 8 cases with anteromedial thalamic infarct ("thalamic" amnesia), and 18 cases with medial temporal lobe infarct including hippocampus in the posterior cerebral artery territory ("PCA" amnesia) were studied in terms of X-CTand MRI findings and neuropsychologial examinations. Results were as follows: 1) 7 out of 8 cases with thalamic amnesia (88%), and 15 of 19 cases with PCA amnesia (78%) showed left side lesions on CT scan. 2) All groups showed a) a prolonged recent memory loss with little loss of immediate recall and remote memory, and b) disorientation and dyscalculia. 3) In both types of amnesia, patients having a left sided lesion showed recent memory loss with new learning disabilities of verbal materials. Patients having a right sided lesion showed recent memory loss with new learning disabilities of both verbal and visuospatial materials. 4) Judging from the X-CT and MRI findings, the lesions most probably causing amnesia in these cases seemed to be the anterior and dorsomedial nuclei of the thalamus in thalamic amnesia and hippocampus in PCA amnesia. Differential diagnosis in amnestic syndrome with localized infarct is also discussed.

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This study was designed to elucidate the long-term effect of excess alcohol intake on the upper gastrointestinal tract. The subjects of the study were patients with alcohol dependence (n=91). All of the subjects had been hospitalized to overcome their alcohol dependence. They underwent endoscopic examination of upper gastrointestinal tract, whether they had symptoms and a personal history of digestive organs trouble or not. Gastric ulcer (n=14), gastroduodenal ulcer (n=3), duodenal ulcer (n=2), gastritis erosiva (n=23), resected stomach (n=13), esophageal cancer (n=l), esophageal varix (n=8), and esophagitis (n=l) were among the lesions found by the endoscopic examination. This study indicated a close association of chronic upper gastrointestinal lesion with long-term excessive intake of alcohol.

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A new, simplified computerized glucose clamp method was performed for estimation of glucose utilization at the insulin level of postprandial level. The program for the method is based on the mathematical algorithm using values of blood glucose, changes of its concentrastion and the desired glucose level. The coefficients of variation of the clamped blood glucose values during the last 60 minutes was 6.3 ± 1.7(%) in normal, 3.7 ± 0.3(%) in NIDDM, which was within satisfactory limit, and also indicated an attainment of steady state. Glucose infusion curves showed some bumps for the initial 60 min, which did not seriously affect the glucose utilization rate at steady state. In some cases, whose insulin sensitivity was high, CV was not low enough and occasional manual adjustment of K values was required. Average glucose infusion rate was 7.59 ± 0.85 (mg/kg/min) in normal, and this was significantly lowered in NIDDM (42.3 ± 3.4) at steady state, indicating a decreased insulin sensitivity for glucose utilization in NIDDM.

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Pupillary dynamics were investigated in 41 patients with hemispheric CVD by means of computerized open-loop videopupillography. The patients were alert and showed either abnormal high- or low-density areas on CTscan. Fourteen cases were examined in the acute stage (within 7 days from onset), 28 cases in the subacute stage (between 8 and 28 days) and 11 cases in the chronic stage (over 29 days). In the acute stage, the parasympathetic nervous functions (maximum velocity and acceleration of pupillary constriction) were hyporeactive and showed no significant differences between the ipsilateral and contralateral side of the lesion. In the subacute stage, these functions were significantly more hyperreactive on the ipsilateral side than on the contralateral side, that is, the parasympathetic functions of the healthy hemisphere became significantly improved in comparison with those in the acute stage. In the chronic stage, no significant differences were observed between the two sides. In contrast, the sympathetic nervous function (maximum velocity of dilatation) showed no differences with respect to either laterality or the time course after onset. The above data suggest that bilateral parasympathetic hypofunctions exist in the acute stage of hemispheric CVD, with an ipsilateral improvement of these functions with the passage of time, and that such autonomic dysfunctions may play some role in the pathophysiology of CVD.

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To examine whether sarcoid epithelioid cells of granulomatous lesions produce colony-stimulating factor (CSF), a growth factor of monocyte-macrophage series, the primary culture of sarcoid epithelioid cells was carried out from 16 biopsied lymph nodes which contained sarcoid granulomas, CSF activity was demonstrated at high titer in the conditioned media from all the epithelioid cell cultures. The conditioned medium of the epithelioid cell culture was harvested, concentrated by Amicon YM-10 membrane, and loaded on a Sephadex G-75 column. Two distinct peaks of CSF activity were noted just before and after bovine serum albumin region. The molecular weights were estimated at about 75, 000 and 36, 000, respectively. Both CSF fractions stimulated colony formation by murine bone marrow cells. The lower molecular weight CSF was active on human bone marrow cells, but the higher molecular weight CSF did not stimulate colony formation by human bone marrow cells.

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Gonadal function in male patients with various liver disease has been evaluated by basal plasma testosterone level and a response of plasma testosterone to human chorionic gonadotropin. Compared with healthy male subjects of similar age, gonadal function was not reduced in chronic hepatitis, but in alcoholic liver disease without cirrhosis and in alcoholic and non-alcoholic cirrhosis. Gonadal dysfunction in patients with chronic hepatitis and cirrhosis was correlated with abnormal liver tests. It may be concluded that gonadal function in chronic liver disease is reduced either by alcohol abuse or disturbances of hepatic function and/or hepatic hemodynamics.

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A highly sensitive radioimmunoassay for α-human atrial natriuretic peptide (α-hANP) was established and applied to measure the human plasma α-hANP levels. In our assay system, anti-α-hANP antiserum was raised in albino rabbits by intradermally injecting synthetic α-hANP which was conjugated with bovine serum albumin. The final antiserum dilution was 1:50, 000. Sensitivity was 2 pg/tube and the 50% intercept was at 28 pg/tube. The plasma α-hANP was extracted using a Sep-Pak C-18 cartridge. According to this procedure, the mean recovery was 73.8 ± 3.4% (mean ± SE). The averaged plasma levels of immunoreactive α-hANP (iα-hANP) in normal subjects were 24.8 ± 2.1 pg/tube. In patients with chronic renal failure undergoing hemodialysis, the averaged plasma iα-hANP levels were 56.4 ± 5.0 pg/ml before hemodialysis. Plasma iα-hANP levels were significantly higher in the patients with chronic renal failure than in the normal subjects. After hemodialysis, plasma iα-hANP levels decreased significantly (32.2 ± 2.8 pg/ml). These results suggest that the alteration in extracellular fluid volume (EGFV) may affect the plasma levels of iα-hANP in patients with chronic renal failure under hemodialysis; i.e., an increase in ECFV elevates and a decrease in ECFV lowers the circulating levels of α-hANP.

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We evaluated 246 cases having clinically primary chronic glomerulonephritis and histologically mesangial proliferative glomerulonephritis of varying degrees. 190 patients conservatively followed with serial measurements of GFR served as delineating the natural history. The remaining, randomly selected 56 subjects were treated with Dextran sulfate, a mild anticoagulant, for 7 to 56 months (average, 25.4). 55 cases underwent repeated renal biopsy at the mean interval of 3.3 years. It became evident clinically and morphologically that the severity of diffuse mesangial proliferation and the presence of focal and segmental lesions in more than 20% were two critical determinants of the natural history. All cases with mild mesangial proliferative alteration alone survived more than 10 years, but none of the patients with global sclerosis in more than 50% in the initial biopsy did. 10-year survival rates in mild, and moderate or greater mesangial prliferation with the focal-segmental lesions were 45.0% and 19.3%, respectively. In the treated group, renal function improved or was maintained, along with histologic confirmation in some, during the follow-up period. Moreover, the survival rate of subjects with global sclerosis in more than 50% ameliorated beyond the natural history. Thus, Dextran sulfate appeared promising for a possible suppression of the coagulatory process associated with the focal-segmental lesions.

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One patient with gastric carcinoma and secondary myelofibrosis due to disseminated bone marrow metastasis had markedly elevated lysozyme (LZM) levels in serum and urine with the intense presence of LZM within tumor tissues. It is considered to be a case of gastric carcinoma with LZM secreting functional capacities. To date, there were many reported cases to verify the LZM positive cells by LZM staining in the tissue of gastric carcinoma and to demonstrate the elevated serum levels of LZM in malignant tumor bearing patients, whereas no papers to disclose the elevated levels of LZM in serum and urine originated from the productions and secretions of gastric carcinoma cells. So, this report might be the first reported case of LZM secreting tumor verified by LZM staining of carcinoma cells except for haematological malignancies such as acute monocytic leukemia or myelomonocytic leukemia.

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Chronic idiopathic neutropenia can occur in spite of the normocellular bone marrow in myeloid series with or without anti-neutrophilic antibody. We report a patient with chronic neutropenia and severe polyclonal hypergammaglobulinemia. The patient demonstrated a positive anti-neutrophil antibody by fluorocytometry, although granulocyte-specific anti-nuclear factor and anti-stem cell (CFU-GM) antibody were negative. Thus, neutropenia of this patient appeared to be due to the antibody-mediated destruction of neutrophils. Both neutropenia and hypergammaglobulinemia were normalized by the administration of prednisone.

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A case of recurrent bilateral pneumothoraces is described in a young patient with sarcoidosis. An intercostal tube drainage was done for right sided pneumothorax. Patient was put on corticosteroid treatment and with this treatment there has been no recurrence of pneumothorax.

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A 53-year-old male with Bence Jones lambda myeloma developed hypercalcemia and acute renal failure (calcium 14.4 mg/dl, BUN 40 mg/dl, creatinine 3.0 mg/dl) after initial response to chemotherapy. A ^99mTc-MDP bone scan revealed unusual isotope accumulation in the left hypochondrium. Extensive calcium deposition was confirmed in the gastric mucosa in the postmortem examination. Detection of gastric calcification by a bone scan is very rare. Only two cases of gastric calcification visualized on bone scans can be found in the literature, one with muliple myeloma¹) and one in Hodgkin's disease²).

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Rhabdomyolysis can be induced by a variety of physical and chemical insults to skeletal muscle. Though there are only a few reports of myositis associated with viral diseases, and no reported cases of virus-induced rhabdomyolysis in uremic patients. Chronic uremic states have been known to potentiate a variety of metabolic and immunological abnormalities. Present case had an acute, progressive and fatal rhabdomyolysis which was thought to be induced by virus infection. A 43-year-old man had received hemodialysis therapy for 8 years. He suffered from an upper respiratory tract infection ll days before admission. On admission, he was diagnosed as rhabdomyolysis with severe lactic acidosis and marked hyperkalemia. Although intensive care had been performed, he died of uncontrollable hyperkalemia (10.0 mEq/L) 2 days after admission. Maximum CPK and GOT levels were 105, 200 and 56, 800 mU/ml, respectively. Most probable cause of rhabdomyolysis was thought to be Parainfluenza type-3 infection, though histological examination failed to prove virus infection.

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A patient with hereditary spherocytosis and silicosis who developed an IgA (λ.) monoclonal gammopathy is reported. It was thought that a combination of hereditary factors, a chronic hemolytic stimulus to the reticuloendothelial system and an adjuvant effect provided by presence of diffuse silica might have contributed to the development of monoclonal gammopathy.

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Encephalitis by Herpes Simplex virus type-2 in adults is rare and has been described as part of a disseminated infection in settings of immunosupression, pregnancy being one of them. The virus was isolated from CSF of a young female, who during puerperium, presented with hepatitis, encephalitis and subsequently developed persistent vegetative state. Case history of another womanat term pregnancy is described who had similar illness but virological proof could not be obtained.

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Hyperglycemia is a common symptom of pheochromocytoma. In the present paper, a 57-year-old man with transient hyperinsulinemia and reactive hypoglycemia is reported. His blood pressure was 100/50 mmHg.Following 75 g oral glucose intake, his blood sugar and insulin levels were 150 mg/dl and 15 μIu/ml at 0 min, 373 mg/dl and 757 μIu/ml at 60 min and 34 mg/dl and greater than 1000 μIu/ml at 120 min, respectively. High plasma epinephrine and norepinephrine levels and histological findings of adrenal tumor confirmed the diagnosis of pheochromocytoma. Pheochromocytoma should be considered as one of the diseases which account for unexplained transient hyperinsulinemia with reactive hypoglycemia.

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