I described about the actual condition of emergency patient and about the outline of the emergency medical service in Numazu and Mishima districts. I make mention of that the emergency medical service must be established as soon as possible. I think that the national hospital is charged with a mission which have to do medical services to protect “the wholesome and cultured life of the people” guaranteed by the Constitution of Japan.
From this point of view, it is desirable that national hospital should be satisfied articles mentioned below.
1. Emergency medical center have to be set up in proper national hospitals, and this center must be opened all day long in order to treat emergency patient.
2. Medical case-worker must be arranged in all national hospitals.
3. Rehabilitation room must be set up in proper national hospitals.
4. National hospital medical office must be set up in doctorless area.
5. Central laboratory and X-ray service in national hospitals must be opened to general practitioner.

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The concept of “iatrogenic disease” is here defined in its original proper sense as “any harmful change in the mind and body of a patient caused by words or actions of the doctor.” The following problems that arise when this concept is actually applied to patients are described. Some observations are made on actual cases with respect to the circumstances in which iatrogenic diseases began and developed and the measures to prevent them, and the significance the psychosomatic approach in everyday clinical situations is stated.
1) Causes are tended to be regarded as lying on the part of doctors, but usually they also lie on the part of patients in their particular situations and personalities.
2) latrogenic causes are frequently attributed to a doctor or doctors who have previously treated the patient. The aim of the concept of “iatrogenic disease”, however, is not to criticize other doctors, but to reflect on one's own conduct.

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1. In vitro incorporation of acetate-1-C¹⁴ into fatty acids by whole blood from diabetics is suppressed when compared to that of healthy controls. C¹⁴ incorporation into palmitate myristate, probably derived from malonyl CoA pathway, is greatly suppressed and that into 18- and 20 carbon fatty acids, formed via mitochondrial pathway, is relatively less suppressed.
2. As oxaloacetate added in diabetic whole blood corrected the above abnormalities in vitro, aspartates and the amino-derivatives of oxaloacetate were examined both in vitro and in vivo.
3. In vitro, L-monopotassium aspartate (abbreviated as K-asp) and L-magnesium aspartate (Mg-asp) selectively increased the C¹⁴ incorporation by healthy whole blood into palmitate at the concentrations of 10^-2, 10^-3 and 10^-4 Mol/Liter. Increased C¹⁴ incorporation into a fatty acid group 14:0+16:0, namely the increased activity of malonyl CoA pathway was observed by the addition of either 10^-2 to 10^-4 Mol/L K-asp or 10^-3 Mol/L Mg asp. The maximal stimulation of the pathway was brought up by K-asp at 10^-3 Mol/L concentration.
4. The patterns of C¹⁴ incorporation into fatty acids by whole blood from 6 diabetics were compared before and after 6 week administration of aspartates as the mixture of K-and Mg-asp in equal weight. The aspartates at the daily doses of 8.7, 18.8 and 20.3 mg/kg body weight increased C¹⁴ incorporation into total fatty acids; the C¹⁴ incorporation via not only malonyl CoA pathway but also mitochondrial pathway was stimulated. The maximal stimulation of malonyl CoA pathway was obtained at the dose of 20.3 mg/kg body weight /day. At the doses over 20.3 mg C¹⁴ incorporation into oleate was selectively increased inspite of the decreased incorporation into the other fatty acids; C¹⁴ incorporation into total fatty acids was significantly suppressed. C¹⁴ inc rporation into sterols was increased at the doses ranging from 8.7 to 28.3 mg/kg body weight per day and was decreased at the doses over 28.3 mg.
5. After the above period of the aspartate administration to the diabetics the serumm levels of total lipids, total fatty acids, phospholipids, total cholesterol, esterized and free cholesterols and triglycerides showed the trend toward decrease. There was no relationship between the trend and the aspartate doses. On the other hand, the percent composition of arachidonic acid to total fatty acids in whole blood was increased with a statistic significance.6. After aspartate administration to 19 diabetic patients at the daily doses ranging from 6 to 45 mg per kg dody weight for 3 to 6 months, the moderate improvement of their glucose tolerance was observed in 9 cases (47.4%). Medium and remarkable improvement were seen in 2 cases (10.5%) respectively. The improvement was predominantly seen in those patients with either ideal body weight or less than 150 mg fasting blood sugar or more than 7 years of diabetic history.

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We have performed selective celiac and superior mesenteric arteriography in the 55 consecutive cases by using Ödman's technic. Of 55 cases, 2 malignant hepatic tumors, 5 carcinomas of the biliary tract, 15 carcinomas of the pancreas, 12 gastric carcinomas, 1 malignant splenic tumor and 1 colonic carcinoma were included.
Angiographic diagnosis of tumor was made in 19 cases; that is, 1 primary hepatoma, 6 metastatic carcinomas of the liver, 3 carcinomas of the biliary tract, 7 carcinomas of the pancreas, 3 gastric carcinomas, 1 malignant splenic tumor and 1 colonic carcinoma, and the diagnosis was secured by exploration or autopsy.
Tumor vessels and tumor stain are the specific finding of the tumor, and displacement and distortion of vessels indicate the presence of a mass, Hepatomas are the rich vascular malignant neopiastic lesions, but carcinomas of the stomach, biliary tract and pancreas are relatively avascular.
In the portal hypertension, dilatation and distortion of the portal vein and the splenic vein are noticed on the venous phase of the arteriogram.
This method has been proved of aid in the diagnosis of the disease of the liver, biliary tract, pancreas, spleen, stomach, intestine and colon.

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An investigation has been done on characteristics of fibrinolytic activities in twelve cases of peptic ulcer with excessive bleeding in comparison with twenty four non-excessive bleeding cases. The former involves five cases of gastric ulcer, three cases of duodenal ulcer and four cases of upper gastrointestinal haemorrhage. while the latter consists of twelve cases of gastric ulcer and twelve cases of duodenal ulcer.
The investigation has revealed the following three characteristics of fibrinolytic activities in peptic ulcer with excessive bleeding.
1. Decreased plasma fibrinogen level.
2. Increased plasminogen activator activity was disclosed by means of Astrup's Fibrin Plate.
3. Both activator and inhibitor activities were increased and remained at high energy equilibrant in view of activator-inhibitor ratio.
These three characteristics are believed to indicate that fibrinolytic activities were increasing at the time of the investigation, or a situation as a result of fibrinolytic activities which had been enhancing.
It is considered that fibrinogenolysis is responsible for this decreased plasma fibrinogen level. It is also believed that the increased plasminogen activator activities were induced by general fibrinolytic response followed by bleeding or secondary fibrinolytic response to thromboplastic material which flowed into blood stream from tissues through injured blood vessels.
In spite of foregoing, however, such an increased general fibrinolytic activity and locall fibrinolytic activity might have promoted bleeding at “Locus minoris” such as pepticc ulcer.
In either case, changes of the fibrinolytic activitiy are related to strengthen or weaken defense factor of mucous membrane, and through these effects, the fibrinolytic activity is believed to play a significant role of pathogenesis in bleeding peptic ulcer. It should be a factor which has influence upon healing process of peptic ulcer.
In view of this, a standard procedure pertaining to the use of anti-plasmin drugs should be established after complete investigation on both fibrinolysis and coagulation.
Before this gist is closed, it is strongly recommended that Sp-Eug, L. A. of Astrup's Fibrin Plate should be utilized for assay since this method has best reflected the process of ulceration and bleeding.

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Patients with rheunatoid arthritis who have bilateral hip joints ankylosis can not stand and walk unless at least one hip joint obtains its mobility. For the purpose of mobilization of the ankylosed hip joint the mold arthroplasty, prosthetic arthroplasty, or Whitmanis or Colonna's hip reconstruction has been performed.
Weight-bearing on the operated fragile hip, however, frequently results in postoperative fracture or severe pain which necessitates to make re-operation. Accordingly, it seems that mobilization by means of resection of the head or neck of the femur in bilateral hip joints ankylosis with fragile bone particularly as in rheumatoid patients is the first choice of the surgery.
We had two cases involved in bilateral hip-joints ankylosis due to rheumatoid arthritis. One was 29 years old female, the other was 28 years old female. These two patients have had to be recumbent on the bed for around 10 years.
Their bones were markedly fragile in X-ray findings with former surgery of the other joints.
The 29 years old patient had resection of the head and neck of the right femur. One and half year after the surgery, she could walk several handred meters with a Thomas' splint adapted on the operated leg using forearm crutches.
The other case had resection of the neck of the right femur, eight months thereafter, she had osteotmy in supracondylar region of the left femur to get functional position of the left knee ankylosed on flexion. In this case also, much better functional capacities in the daily life activity were obtained.
At present time, one year after the mobilization of the hip, she has been taken bed exercise, and it is expected that she will get ability of standing and walking in near future.

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There were 152 cases of aseptic meningoencephalo-myelitis, including thirty-one cases of postinfectious ones, during the past twelve years up to the end of 1966.
The following results were obtained:
1) Viral encephalitis and Poliomyelitis had definitely diminished since 1962, but aseptic menigitis has increased year and year. Generally they were developed one and half to two times as frequently as in males than females. Poliomyelitis was seen most frequently between one and three years of age, but no age preponderance was found in the meningoencephalitis.
2) The postinfectious ones was 15 cases with mumps, 8 cases with meales, 7 cases with chickenpox and 1 case with german meales. The age and seasonal distribution was similar with each primary diseases.
Main clinical type following mumps and measles was meningitis and encephalitis respectively. Cases following chickenpox was divided in 3 cases of meningitis and 4 cases of encephalitis with 3 cases of ataxia.
The mean duration between the first signs of primary diseases and onset of meningoencephalitis was four days in mumps, six days in measles and nine days in chickenpox.
The main clinical symptome was headach, nausea in the case following mumps, unconsciousness in measles and cerebellar ataxia in chickenpox.
A marked pleocytosis was found in the meningitis following mumps especially.
3) Abnormal electroencephalographic findings was def initly corresponded with the first clinical signs, especially of unconsciousness and hemi- or monoplegia and the serial examinations of E. E. G. was very usefull with estimation of the prognosis.

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It has been well known since 1961, following the beginning of mass administration of Sabin type attenuated polio-vaccin virus, that the occurrence of paralytic poliomyelitis has extremely decreased in number. To the contrary, however, it has been also well known that the incidence of aseptic meningitis or polio-like paralytic disorder owing to various non-polio enteroviruses has remarkably increased in this country. Thus recentry, many reports for epidemics or outbreaks of aseptic meningitis attributed to other enterovirus than poliomyelitis virus (e. g. Coxsackie A-9, B-5, ECHO-4, -6 and -12) have been successively presented from varous districts in this country.
The present report deals with a series of aseptic meningitis and polio-like paralytic disease that took place in Kyoto city and the adjacent rural communities, on which we investigated during 1902-1966, for it would be of value for epidemiological point of view to report our data concerned with its clinical and virological studies.
In brief, despite sporadic cases of aseptic meningitis and 14 cases of polio-like paralytic diseases seen in this period, (ECHO-6, 3 cases; ECHO-7, -11, Coxsakie A-7, A-10, B-1, B-3, Adeno-2, -3, -5, 1 case respectively; Coxsackie A type unknown, Coxsackie B type unknown, 4 cases respectively), we have not been able to recognize epidemic or outbreak of aseptic meningitis or paralytic diseases related to any special type of non-polio enterovirus.
It seems to be desirable to gain further information regarding the possible relationship between the outbreak of non-polio enteroviral illness and the systemic administration of attenuated live polio-vaccin virus.

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During summer time in 1965, an aseptic meningitis spread over with epidemic type in several districts in Japan. In the area of Hokkaido, more than 3, 000 peoples were suffer-ed from this type of aseptic meningitis at that time. 47 patients admitted into Sapporo National Hospital to be placed on virological examination.
Age of patients ranged from younger than 1 year old to 25 years. Sex ratio (M/F)was 2:1.
FL and Vero cell were utilized for the purpose of isolation of virus. ECHO 6 was isolated in 6.25% of examined cerebro-spinal fluid. From forty-five feces specimen, CPE agent was yielded, 41 sample of them were identified as ECHO 6, leaving rest of 4 as un identified. 33 sample were brought to antibody response by means of neutralization as well as hemagglutination title. Significant rise in antibody response against ECHO 6 was demonstrated in 27 cases. Unfortunately, adequate paired sera was not available in 14 cases, while in 8 cases, ECHO 6 shedding was observed.
As a conclusion, the epidemic of aseptic meningitis in Sapporo City in 1965, was positively assumed to be related with ECHO Virus Type 6.

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An epidemic of aseptic meningitis due to ECHO virus type 6 had occured in Hokkaido Japan in the summer and fall of 1965.
Fifty one patients who had been admitted in Sapporo National Hospital were asled to return to the Hospital for clinical evaluation including the electroencephalography 6 months and 1 year after infection.
Results
1) ECHO virus type 6 was the predominant enterovirus associated with aseptic meningitis (73%), as demonstrated by virus isolation, neutralizing antibody studies and hemagglutination inhibition test.
2) The peak of the age distribution of the disease was 5 years old, the sex ratio (male/female) was 2.4/1.
3) The history prior to hospital admission and the physical findings were not different from aseptic meningitis due to other enteroviruses.
4) In the follow up studies 6 mouths and 1 year after infection 35% of patients complain some functional abnormalities.
5) E. E. G. recordings were taken three times-at the stage that the patients had clinically recovered, 6 months, and 1 year after recovery, in each recording the abnormal E. E. G. patterns had been revealed 57.9%, 44%, and 39% respectively.

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The following knowledge of urolithiasis in Cambodia was obtained by the author, having worked for eight months and half-from August 1964 until April 1965-as a surgeon, one of Japanese specialists at a rural medical center, situated in the north-western part of that country.
1. Among 87 urological patients, during the above period in its surgical clinic, 58 patients (57 per cent) were diagnosed as urolithiasis, 49 of which were patients of vesical stones. Twenty nine of these 58 urolithiasis were young patients, younger than 20 years old, and 17 patients among them were under 10 years old. That center had three clinics, those were of internal medicine, surgery and gyneco-tocology. The number of patients of these three clinics during that period was 7, 564 in all. Eigthy six patients among them (1.1 per ceni) were those of urolithiasis.
2. The Hospital of Friendship between Cambodia and Soviet is one of the greatest general hospitals in Phnom-Penh, capital of Cambodia. For the comparison of our data, statistic figures of this hospital during nearly the same year were quoted here. The patients of this hospital for one year of 1964 numbered 32, 270, and 83 among them (0.3 per cent) were those of urolithiasis. Therefore, it would be supposed that many infantile patients of vesical stones exist in Cambodian rural regions.
3. Formerly in West-Europe or in Japan, most cases of urolithiasis were those of infants with vesical stones, yet in recent years the ratio of the patients of vesical stone to the total number of persons of whole urolithiasis, as well as the ratio of the infantile patients of vesical stone to the total number of persons of this disease were reduced remarkably.
4. In the present world, several districts are still found, where numerous infants having vesical stone exist. They are called “stone areas”. Hereupon Cambodia should be also considered one of them.
5. For the measures to be adapted henceforth, by which the number of infantile patients of vesical stone could be reduced in this country, first of all, it may be necessary to place the rural inhabitants under the better nutritious conditions, pursuing the good examples of West-Europe and Japan.
6. Nineteen patients among the above-mentioned 49 cases of vesical stone were operated. These were all single-stone cases, hence 19 stones were removed. Several physical characters of these stones were described. Beside that, the components of 19 vesical stones, except for one case, were qualitatively analysed by infrared spectrometry.
a) Chemical components at the central portion of stones: five components were proved in all; those were calcium oxalate (7 cases), magnesium ammonium phosphate (2 cases), ammonium orate acid (11 cases), xanthine (4 cases) and 1-cystine (1 case).
b) Chemical components at the cortical portion of stones: seven components were proved in all, being added two new components to the above mentioned five; those were, calcium oxalate (7 cases), trimagnesium ammonium phosphate (6 cases), calcium phosphate (4 cases), trimagnesium phosphate (2 cases), ammonium urate acid (8 cases), xanthine (2 cases), and 1-cystine (1 case).
7. These data obtained from the chemical examination were compared with the data about the Japanese, which were reported formerly by Tokuji Ichikawa.

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A review of cases is presented here with emphasis on the problems of the antibiotic-resistant strains of bacilli, their management and on details of operative maneuvers.
summary:
1. 85 cases were found to be resistant to anti-tuberculous drugs among the total of 232 operated upon during the period from September 1961, to March, 1966.
2. Positive cultures on admission were obtained in 75 cases; 33 had never received anti-tuberculous drugs, and 15 of these were found to be resistant to the drug therapy already.
3. With vigorous pre-operative anti-tuberculous chemotherapy, cultures turned negative by the month before operation in most of the cases, except for the 20 patients who underwent operation with persistently positive cultures.
4. Those patients who had received anti-tuberculous drugs on previous occasion and came back for second treatment, showed less favorable response to the present treatment in regards to disappearance of positive cultures, development of resistance to the drug and overall post-operative course, as compared with those who were receiving their initial treatment for the disease.

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On the previous report (Part 1), we proposed a rating scale for measuring of the pharmacological treatment of the schizophrenia.
Using this rating scale, comparison of Chlorpromazine and Perphenazine was carried out.
The subjects were newly admitted schizophrenics from 2/1/66 to 4/30/66 on 14 hospitals, Chlorpromazine-64 cases. Perphenazine-55 cases.
Ratings were carried out at previous treatment, after 1 month and after 3 months.
As a whole, changes of the rating values between each 3 rating periods were very distinct. On all 12 items, the differences between each periods were significant (almost Pr.<.01). This fact indicate sufficient discriminant property of the rating scale.
As compaired Chlorpromazine group and Perphenazine group, differences were surprisingly minimum. Perphenazine was superior for the deprresive symptom.

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Three patients known to be clinically or chemically diabetic are described. In these patients the development of a pancreatic carcinoma was prefaced by loss of weight, abdominal pain and deteriorating diabetic control. Case-reports
Case 1
A 58-year-old man presented in 1965, with polyuria, loss of weight and polydipsia. 171 cm, in height, 69.5 kilograms in weight. Examination revealed BSP 27% (30 minutes) and blood sedimentation rate 48 mm (1 hour), but otherwise he was normal. A fasting blood--sugar was 175-160 mg, per 100 ml.
His diabetes was controlled with ‘Insulin Lente’ 12 units and subsequently by diet and tolubutamide 1.5 gm. His fasting blood-sugar was 120 mg, per 100ml, and glycosuria was infrequently recorded.
When aged 58 he developed polydipsia, lassitude and loss of weight. His bodyweight was 59 kg, when he attended the clinic. His fasting blood-sugar was 255 mg per 100 ml. Other examination revealed normal. His diabetes was controlled with ‘Insulin Lente’ 20 units, diets and metformin 1.5 gm.
In August 1966 his control deteriorated. He had also noted mild abdominal pain and lost weight from 59 kg to 52 kg. In November he noticed darkening of his urine and subsequently developed jaundice.
Examination revealed obstructive jaundice and palpable gall-bladder. Laparotomy was undertaken. At operation carcinoma of the body of the pancreas was found extending from the pancreas to the posterior wall of the stomach. Cholecysto-jejunoston-iy wass performed. In December he died.
Case 2
A 51-year-old man was diagnosed as diabetes by routine examination in 1959. He developed mild episode of insomnia and a vague left-sided snd right-sided abdominal pain.
In February 1950 his diabetes was controlled with ‘Insulin Lente’ 20 units, but he had also noted abdominal pain of a nonspecific nature and lost weight. No abdominal signs were detected initially and chest X-ray & G. I. series showed no abnormality.
Abdominal pain was attributed to psychogenic factors. In 1959 he developed obstructive jaundice and abdominal swelling. The ascitic fluid contained many clusters of cell from an adenocarcinoma. His condition deteriorated rapidly and he died.
At necropsy a carcinoma of the body of the pancreas was found with hepatic, duodenal and peritoeal metastases. Atrophy of the pancreas weighing 60 gm, was found.
Case 3
A 61-year-old man presented in May 1965, with polydipsia and suppurative skin. He noticed polyuria, polydipsia and lassitude for 4 months. Diabetes was confirmed by a fasting blood-sugar of 300 mg per 140 ml, Blood-sugar were controlled with lente insulin 40 units and DBI-TD 100 mg. He developed lower abdominal pain and epigastric pain. Examination revealed stomach ulcer and gastritis. In ealy 1966 he had lost weight from 46.5 kg to 42.5 kg and control deteriorated. The tumour of the pancreas was palpable in the left hypochondrium and free fluid was present in the abdomen. Severe abdominal pain and back pain continued. He later had glycosuria and was then confused. Random blood-sugars were in the range 300-400 mg per 100 ml. In April 1966 he died of hypogly-cemia after insulin administration.
In these cases Intravenous Tolubutamide Tolerance Test was performed. No or little fall of blood-sugar concentration from the fasting blood-sugar level at twenty and thirty minutes after injection of the test dose was found in these diabetics with carcinoma of pancreas.
Cohen described: pancreatic carcinoma being so much more common in diabetics it is hoped that the association of weight-loss with deteriorating diabetic control may alert clinicians to the possibility of its development.

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