It is important for the anaesthetist to recognize the physical status of emergency surgical patients, because emergency anaesthesia and surgery could be sometimes hazardous. The anaesthetist should always make an effort to investigate the patient before he is brought to the theatre.
There are several grades of physical status for emergency patients. This article describes the division of physical status into five grades by the ASA, the classification of Thornton's three main groups of emergency anaesthesia, the Boston EMS system and Dr. Ohta's classification of the level of consciousness of patients suffering from head injury.
Finally, the monitoring system, choice of anaesthesia, and preparation of drugs for emergency patients are stated.

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Pre- and intraoperative conditions of 130 patients over 60 years of age who underwent epidural anesthesia were evaluated in our institution.
Preoperatively, cardiopulmonaly abnormalities were observed in many of these patients. (Abnormal electrocardiogram in 49.2%, abnormal pulmonaly function test in 51.0%)
Intraoperatively, blood pressure was fluctuated markedly in cases of upper abdominal or thoracic surgery, and vasopressor agents were required for these cases. In surgical cases of the lower abdomen or lower extremities, blood pressure remained comparatively stable even in patients over 80 years of age. Blood gas analysis during surgrey showed reduced PaO₂(≤100mmHg)in 14.6% of patients in their 60s and 20.0% in 70s, and elevated PaCO₂(≥46mmHg) in 29.3% in 60s, 12.0% in 70s, and 42.9% in 80s, while they inhaled nitrous oxide (4l/min) and oxygen (2l/min). It is recommended to perform blood gas analysis for all elderly patients during anesthesia.

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Early spontaneously aborted fetuses or fetal tissues were collected by mail from the Department of Obstetrics and Gynecology of 4 national hospitals, and chromosomal investigation was performed using the tissue culture method to evaluate the genetic cause of spontaneous abortion. A total of 316 specimens with a mean gestational age of 11 weeks were cultured, in which chromosome analysis was successful in 145 specimens. It was found that chromosome abnormality was a major cause for abortion and it was seen in about 50% cases of abortion. Seventy-two specimens (50%) showed chromosomally abnormal karyotypes;triploidy in 15, tetraploidy in 4, monosomy in 16, trisomy in 31, and translocation chromosomes in 6 specimens. The frequencies and types of chromosome abnormality found in the present study were generally compatible with those of published studies. As an etiologic factor, the effect of maternal age was found in the trisomy group which showed advanced maternal ages deviated significantly from maternal ages of the chromosomally normal group. Chromosome examinations in parents of abortuses with translocation chromosomes revealed that all of the mothers were translocation carriers of a balanced type, and therefore, the necessity of chromosome examination in couples with a history of repeated abortion was emphasized.

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Pregnancy is figuratively known as a “nature's transplantation”. Nonetheless, relationship between pregnancy and HLA that plays an important role in organ transplantation is rather ill-defined.
In this study, the authors studied presence or absence of HLA antibody in parous women by using the maternal blood obtained in delivery, and carried out a comparative analysis between the antibody positive cases and the negative cases as regards the obstetrical backgrounds;i. e., age of parous women, number of pregnancy, number of delivery, number of spontaneous abortion, number of artificial abortion, sex of the infant, weight of the infant, weight of the fetal appendage, bleeding volume and ABO blood typing (mother and infant).
Positive antibody rate was 24.2%, i. e., 226 of the 935 cases were positve. Multigravida and multipara had significantly higher rates of positive antibody as compared to the primigravida and primipara. Monospecific sera required in HLA typing could be obtained from gravida II at the greatest proportion.

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An ultrasonic diagnosis was made in 29 cases out of 47 cases with extrauterine pregnancy in which the laparotomy was carried out during the recent 7 years in our hospital, and studies were done on the relationship between criteria of ultrasonic diagnosis of extrauterine pregnancy, and characteristics of ultrasonographic findings and its clinical patterns.
The criteria of ultrasonic diagnosis of extrauterine pregnancy are summarized as the following 3 items: 1) as the intrauterine findings, (a) deficiency of intrauterine nidation conceptus, (b) development of uterine hypertrophy and diffuse echo in the myometrium, (c) development of decidual changes in endometrium, growth of echo due to the proliferation and decidua ring patterns similar to gestational sac;2) as the extrauterine findings, detection of extrauterine pregnant tumorous patterns or nidation findings of extrauterine conceptus, and 3) detection of extrauterine pregnant findings in cul-de-sac (Douglas's pouch), and extrauterine pregnancy can be diagnosed according to the above mentioned intra- and extrauterine findings and cul-de-sac finding.
As the ultrasonographic findings for the diagnosis of extrauterine pregnancy, the following 3 items were analyzed: 1) extrauterine pregnant tumorous patterns, 2) findings of cul-de-sac fluid collection and 3) findings similar to intrauterine gestational sac. Because extrauterine pregnant tumorous patterns are composed of pregnant tissue componen tand blood component, that is, pregnant nidation tissues, gestational sac and embryo (fetus), furthermore, retention blood and coagulant mass, most cases revealed partially cystic and complete tumorous structures. Other cystic and complete tumorous structures were assumed to reveal various ultrasonographic findings depending on the presence or absence of the interruption of pregnancy, and the timing or means of the interruption. Findings of cul-de-sac retention blood were detected in most cases of the extrauterine pregnancy with the crisis of interruption, and also detected in the extrauterine pregnancy before crisis of the interruption or rarely in the extrauterine pregnancy with the detection of fetal cardiac motion. Thus, these are not always specific findings for the extrauterine pregnancy with the crisis of the interruption. The findings similar to intrauterine gestational sac pattern caused the decidual changes and proliferations as well as intrauterine pregnancy, and accompanied by the hemorrhage in the internal membrane due to the crisis of the interruption or retrograde degeneration, and those were detected as similar decidua ring structure with gestational sac pattern in the intrauterine fluid collections.
In conclusion, it is clinically considered most important that the fixation of gestational sac should be carefully carried out based on the white ring findings originated from chorionic villous tissue of the margin of the ring-shaped structure.

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A total of 113 cases including 109 cases with tubal pregnancy, 2 cases with ovarian pregnancy and 2 cases with peritoneal pregnancy were definitely diagnosed as extrauterine pregnancy based on the pathohistological examinations of the resected samples. All underwent the operations in our hospital during the recent 9 years, and we statistically analysed the following factors and the following results were obtained. 1) incidence according to age of patients, 2) incidences according to the number of pregnancy, delivery and interruption during pregnancy, 3) symptoms, laboratory tests and diagnosis, 4) laparotomy, 5) conceptus nidation sites and incidences according to the affected side, 6) miscellaneous factors;repeated extrauterine pregnancy, contents and incidences of complication with intrapelvic tumors.
The number of patients with 25-29 years of age was highest, half of patients were over 30 years of age and a quarter of patients were over 35 years of age. There was a tendency to high incidence of extrauterine pregnancy in multigravida, multipara and women with a history of pregnancy interruption. The lower abdominal pain and genital hemorrhage were the most common symptoms, and these two symptoms were noted in 2/3 of the cases. The rate of positive results of the puncture of cul-de-sac was extremely high. The majority of the negative test for pregnancy was abortive cases, while the majority of these cases revealed values over LH level determined by the low unit measurement of urinary hCG value. Ultrasonic method was extremely reliable in the diagnosis of conceptus nidation sites and the rate of correct diagnosis was very high. Therefore, this method was considered to be very useful in extrauterine pregnancy when the preoperative diagnosis before crisis and immediately after crisis of the interruption was difficult. A half of the patients underwent laparotomy within 7 weeks of pregnancy and emergency operation was performed in 85.5% of the cases. The mean volume of hemorrhage was 991ml and blood transfusion was performed in 60.2% of the cases. The mean volume of blood transfusion was 914ml. As to the conceptus nidation sites, 96.5% of the cases were tubal pregnancy;ampulla in 70.7%, isthmus in 16.8%, interstitial in 9.9%, fimbria and inf undibular in 4.0%. There were two cases of ovarian and two cases of peritoneal pregnancy. Moreover, the percentage of the group of non-rupture was 50.4% and that of rupture was 49.6%. The rate of correct diagnosis before operation based on clinical symptoms and findings was high, and it was suggested that the differential diagnosis was very important in extrauterine pregnancy associated with intrapelvic tumors. These intrapelvic tumors were detailed as follows: 19 cases (16.8%) of ovarian tumor, 1 case (0.9%) of paraovarian cyst, 1 case (0.9%) of hydrosalpinx and 2 cases (1.8%) of myoma uteri.

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Thirty-nine cases of ectopic pregnancy treated during these 3 years have been clinically analysed. The rate of incidence was 2.44% to all live birth. The history of artificial termination and pelvic infection was noted in these patients, showing 40% and 64% respectively. In 35 cases of tubal pregnancy, there were no differences in the clinical symptoms between the ruptured cases and the non-ruptured, although the difference in the volume of intraperitoneal hemorrhage was remarkable. As the volume increased, the clinical signs and physical findings became evident, whereas the signs could not be obtained from the cases under 100 g of hemorrhage.
The culdocentesis demonstrated non-clotting blood in only 81% of the 33 cases. This comparatively low rate was due to the fact that the patients with negative culdocentesis mostly had minimal hemorrhage. Ultrasonographic examination revealed the extrauterine gestational sac in 6 cases of 37 patients, and three of them also showed fetal heart movement. The sign of hemorrhage was detected as an echo-free space of Douglas cul-de-sac, seen only in 74% of the cases with over 100g of hemorrhage, but we couldn't find such findings in any cases with under 100g of hemorrhage.
When compared the group of early diagnosis and that of delayed one, in terms of their volume of hemorrhage and the rate of treated unruptured ectopy, remarkable differences were present. The mean volume of hemorrhage was 128g in the former group, while that of the latter was 710g. Eight of the latter group required blood transfusion. The rate of unruptured ectopy was 100% in the former, and 61% in the latter group.
In conclusion, the clinical advantages of the early diagnosis were evident and recommendations should be made for a maximal effort for the early diagnosis in the management of ectopic pregnancy.

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The questionaires were distributed to 818 physicians, the members of Medical Association, in the areas where 8 national hospitals of the whole country are located. The following problems were investigated, that is to say, the present status and the analysis of needs for the continuing medical education for the physicians and the desirable task of regional national hospitals.
From the answers of 418 persons, the following results were obtained:
In spite of a strong desire for study, the majority of them considered that they were too busy for daily clinical work to have sufficient study. They also mentioned the shortage of media for study and the present media for study do not meet the needs for physicians.
The regional public hospitals close to the physicians should be highly expected to be semi-opened. Concerning the patients whom they referred to the hospital, many physicians would like to receive a discharge summary, to order some laboratory examinations, to read medical records and to participate in bedside meetings.
With regard to the medical treatment for emergency or common diseases, many physicians wanted to attend a short-term course dealing with the demand of participants or the practical guidance by the small-group system.
National hospitals should undoubtedly become substantial medical centers for the treatment of emergency and fatal diseases, or for highly developed treatment. In addition to them, they are expected to become the center of continuing medical education for the physicians in cooperation with the medical association of the area.
According to these results, national hospitals should play a great role for the continuing medical education.

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A case of bowenoid papulosis of the genitalia is reported in which electron microscopic observations of the small papular lesion were performed. A thirty-year-old housewife became aware of the pigmented papular lesion on her vulvar and perianal areas in the 4th month of her pregnancy. She was treated for the vulvar candidiasis by an obstetrician, who pointed out the multiple small papules on her genitalia. She was referred to our hospital in February, 1983.
Histopathological findings of the small papule revealed acanthosis with elongation and thickening of the rete ridges and incontinence of pigment. Epidermal keratinocytes revealed considerable atypism such as frequent mitotic figures, variety in size, individual cell keratinization, etc. The diagnosis was bowenoid papulosis of the genitalia.
These papules disappeared spontaneously during the course of her pregnancy.
Electron microscopic observation revealed marked aggregation of the tonofilaments (dyskeratosis), mitotic figures of the large atypical cells in the malpighian layer and cytoid bodies with relatively poor electron density which appeared to be phagocytized by other epidermal keratinocytes. Intranuclear virus-like particles were not observed in the present study.

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Two cases of tension pneumocephalus (TP) occurring as a complication of trans-sphenoidal surgery are presented.
Case 1: A 19-year-old woman underwent a trans-sphenoidal hypophysectomy because of prolactinoma. On the 6th postoperative day the patient developed rhinorrhea of cerebrospinal fluid. On the 14th postoperative day, a CT scan revealed a large air collection over the convexities. Direct repair of the fistula was immediately performed via transnasal approach.
Case 2: A 72-year-old woman was treated with a trans-sphenoidal surgery because of empty sella syndrome. A cerebrospinal fluid leak was detected on the seventh postoperative day. On the 27th postoperative day, a CT scan revealed marked air collection both in the subarachnoid space and in the ventricles. Immediate packing of her sphenoid sinuses to terminate a cerebrospinal fluid leak was performed.
The pathophysiology of TP was discussed and emphasis was placed on the potentially life threatening increase in intracranial pressure that occured. Prompt diagnosis and rapid treatment, the release of air and repair of cerebrospinal fluid fistula were required in TP.

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Twenty cases of circulatory disturbances of the lower limb in hemiplegic patients were treated during the past 10 years. The circulatory disturbances occurred on the paralysed limb in 17 cases, non-paralysed leg in one and bilateral (Leriche's syndrome) in two. Three cases recovered with prophylactic treatment, 2 cases of Leriche's syndrome were unable to be surgically treated because of poor general condition, thus a total of 15 amputations were performed. Nine cases were amputated above the knee, 4 were below the knee, and 2 midtarsal or forefoot amputation. All of these limb were on the paralysed side. The etiology of the circulatory disturbances in these 15 cases was arteriosclerosis obliterans. Thirteen cases had some other general abnormalities such as diabetes mellitus and/or hypetension, but the surgery of amputation was performed without any trouble. With respect to walking ability of these 15 cases, 13 could walk before the vascular accident of the leg, only 3 cases could walk with an artificial limb after amputation (1 amputation above the knee and 2 below the knee). In these 3 cases the walking ability were achieved by their volitions for walking. The severity of paralysis and general condition was not consistently related to the walking abilty after amputation.

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A 12 year old girl with SLE complained of abdominal pain, diarrhea and vomiting. She had been treated with steroid (10mg of prednisolone daily, per os). She was thought to have abdominal complication secondary to lupus vasculitis. Sixty mg of prednisolone was given daily with no clinical improvement. On the 9th hospital day, she complained of abdominal pain localized to the ileocecal region. Physical examination at that time revealed abdominal tenderness. Because of the suspicion of acute appendicitis, an exploratory laparotomy was performed. But she was found to have catarrhal appendicitis. After the operation, 1g of intravenous methylprednisolone was given daily as a single dose for 3 days, and complete resolution of abdominal symptoms was obtained.

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The term nonimmune hydrops fetalis is referred to infants born with anasarca secondary to factors other than erythroblastosis fetalis (secondary to Rh or other blood type incompatibility). Twin to twin transfusion is one of the causes. A case of male twin reported here was the second baby of the twin and was born at the 32 nd of gestation with normal delivery, and weighed 2090g. The first baby of the twin was still born weighing 1050g. The pregnancy was complicated by polyhydramnios. Although the patient had severe edema on the whole body, his Apgar score was 9 and had no respiratory distress. He had no blood type incompatibility with his mother. The hematocrit was 32% and the serum protein was 2.4g/dl. Because of low level of serum protein, plasmanate was started on the first day after birth. At the same time, the patient was given extract of Goreisan with a dosage of 0.5g/day orally for eight days. One mg of furosemide was given only twice on the second day after birth. There was 200ml of urine on the second day and 300ml on the third day after birth. The body weight decreased to 1700g on the forth day after birth. Despite this rapid diuresis, the baby had no oliguria nor electrolyte imbalance. The baby survived after several days of artificial respiration.

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A statistical analysis was made on inpatients at the Department of Urology during the period between April, 1969 when the Department was started, and December, 1983. The number of inpatients was 3, 320. There were 2, 470 (74.4%) male and 850 (25.6%) female patients. With respect to the age for male patients, the number of the patients in the age group of 61-70 years was the highest and it was 443 (13.3%) followed by 377(11.4%) for 71-80 years of age, 327 (9.8%) for 51-60, 322 (9.7%) for 41-50, 261 (7.8%) 0-10, 259 (7.8%) 31-40 and 248 (7.5%) 21-30 in order of frequency. The numbers of patients with 11-20 years of age and over 91 years of age were low and they were 168 and 3 respectively. As for the female patients, the number of the patients in the age group of 41-50 was the highest and it was 155 (4.6%), followed by 148 (4.5%) for 51-60 years of age, 135 (4.1%) for 21-30, 124 (3.7%) for 31-40 and 107 (3.3%) for 61-70 in order of frequency. The numbers of the patients in the age group of 11-20 years, 71-80 years, 0-10 years and 81-90 years were low and they were 73, 71, 21 and 15 respectively, the age distribution being different from that of men. The large number of elderly persons in men was due to many cases of hypertrophy of the prostate.
The etiology of the diseases were kidney disease in 1174 cases (27.4%), vesical disease in 738 (17.3%), ureteral disease in 526 (12.3%) prostatic disease in 552 (12.9%), scrotal and intrascrotal diseases in 440 (10.3%), urethral disease in 208 (4.9%), penile disease in 117 (2.7%), retroperitoneal disease in 19 (0.4%) and other diseases in 503 cases (11.8%).
Of the renal diseases, those frequently encountered included nephrolithiasis in 276 cases, pyelonephritis in 179, glomerulonephritis in 102, hydronephrosis in 83, chronic renal insufficiency in 71 and tumor of the renal parenchyma in 45 cases. As for the vesical diseases, tumor of the urinary bladder was found most frequently in 254 cases, followed by neurogenic bladder in 103, cystolithiasis in 87, ischuria in 62 and cystoureteral reflex in 44 in order of frequency.
As for the ureteral diseases, ureterolithiasis was found most frequently in 474 cases, while ureteral tumor was observed in only 16 cases. Prostatic diseases were hypertrophy of the prostate in 342 cases and carcinoma of the prostate in 108 cases. Scrotal diseases consisted of 127 cases of crypxorchism, 97 cases of epididymitis, 46 cases of hydrocele testis and 45 cases of the tumor of the testis.
Furthermore, urethral diseases were made up of 97 cases of urethral stricture and 23 cases of hypospadias.
As for the penile diseases, there were 96 cases of phimosis and 13 cases of the carcinoma of the penis.

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