We produced a still image filing system of electronic pictures taken by electronic endoscopy, utilizing its following advantage; digital expression of fine optical image by charged coupled device (CCD). This system was composed of electronic endoscopy (Fujinon EVE system) and image file processor (SONY, SID-100). Still images were recorded on the optical memory disk by digital forming. It was managed in conjunction with the personal computer and the image file processor. It was found that the quality of the color picture digitally recorded on the optical memory disk was extremely better than the one recorded on the video tape or optical disk in the analog format. It was possible that this filing system was available to an image database as well as an image analysis.

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Since 1980 we have engaged in developing the cuirass respirator (CR) apparatus to improve the management of respiratory failure in patients with progressive muscular dystrophy of terminal stage, and also used it clinically. This apparatus consists of two parts, ventilator system and body jaket. The former was designed to regulate air pressure, the ratio of expiration to inspiration and respiratory rate to meet various conditions of patients, and the latter was made to keep airtightness and comfortability. Next we examined the efficacy and the safety of this apparatus by two types of pilot tests, animal experiments and short-period application to the patients, before its clinical use. The optimal condition was observed under the negative pressure of -10 to -15cm H₂O in this apparatus.
Seven cases, in which there is a case of application for longer than 4 years long, have been under good control by CR apparatus of our 20 cases (DMD: 16 cases, LG: 4 cases). We were obliged to perform tracheostomy in 7 cases in the course of CR application (3; died), nine patiennts died of cardio-pulmonary failure or pneumonia. We began to apply the CR apparatus when the level of blood gas Paco₂ increased more than that of Pao₂ (60 Torr). First it was used for preventing nocturnal dyspnea, and then even during daytime according to the blood gas level of the patients. We mentioned the application and management of our CR apparatus as above.
The DMD patients must wear the CR apparatus for a long period during their lives, so it is necessary for us not only to keep their respiration in good condition but also to elevate their quality of lives. This study suggests that it is useful to use the CR apparatus as first application instead of conventional tracheostomy in the treatment of respiratory failure of PMD patients.

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Thirty-seven patients with chronic subdural hematomas and thirteen patients with subdural effusions aged older than 65 were analyzed.
On admission, while 75% of the patients presented mental signs and consciousness disturbance, 71% of patients revealed motor weakness, only 42% had signs of increased intracranial pressure.
Forty one cases of chronic subdural hematomas and subdural effusions were operated by burr-hole evacuation. In the twenty cases, the Ommaya reservoir was used after burrhole irrigation. The reservoir was placed in the subcutaneous space, the tip of the tube was placed in the subdural space. The reservoir was punctured with a needle, thereby allowing aspiration of fluid from the subdural space at bedside. Reaccumulation of subdural fluid collection on the follow-up CT scans was detected in twenty cases, but percutaneous needling of the reservoir curedthe disease in eighteen patients. Among our fortyone operated cases, 90% of the cases were fully recovered. The authors proposed this technique and discussed about it.

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Factors which accelerate the development of cerebrovascular disease were analyzed among patients with various heart diseases associated with atrial fibrillation (AF). There were 172 patients with only AF, 136 patients with heart valvular disease associated with AF and 48 patients with ischemic heart disease associated with AF among 390 patients with various heart disease with AF. The incidences of ischemic cerebrovascular disease were approximately 25% among those patients with various heart diseases associated with AF. The incidence of ischemic cerebrovascular disease was statistically significantly higher in patients with chronic AF than in patients with paroxysmal AF. Also, in patients with only AF, the incidence of ischemic cerebrovascular disease increased statically signifficantly with age and increase of cardiothoracic ratio and was statistically significantly higher in the slow heart rate group than in the rapid. Therefore, to prevent effectively the development of ischemic cerebrovascular disease in patients with AF, it is important to analyszage, cardiothoracic ratio, heart rate and the type of AF (chronic or paroxysmal).

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From April 1980 through April 1989, 36 patients with abdominal aortic aneurysms (33 men and 3 women, mean age 67.9 years) just or distal to the level of renal arteries underwent reconstructive surgery (30 intact aortic aneurysms, 6 ruptured aortic aneurysms). Five of the 36 patients died after surgery (3 of them died early due to bleeding, multiple organ failure and necrosis of small intestine and colon, and other 2 died late due to myocardial infarction and acute renal failure).
This report of 36 patients indicated that large aortic aneurysm greater than 5.0cm in transverse diameter had a correlation with a length of operation time, the volume of operative blood loss and the incidence of postoperative critical complications. Optimal management after surgery were also required for patients older than 70 years old with various complications preoperatively or postoperatively.
These results suggest that even patients with small aortic aneurysm less than 5.0cm in transverse diameter, if found, should undergo early operation for aortic reconstruction except for those with preoperative severe complications.

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We have studied anomalous arrangement of the pancreaticobiliary ductal system (AAPBDS) which is a high risk group of carcinoma of the biliary tract. Fourteen cases of AAPBDS were diagnosed by FRCP, which we performed on 1432 cases during the past nine years. Six of the 14 cases were complicated by gallbladder carcinoma, and two of them were resected. During the same period we treated 30 cases of gallbladder carcinoma. However, no cases of bile duct carcinoma had complications.
Four cases of cholelithiasis were combined with AAPBDS, and one of these four was complicated by gallbladder carcinoma. There were 14 cases (58.3%) of cholelithiasis among patients with gallbladder carcinoma without AAPBDS. Bile amylase collected during the operations was elevated in eight of nine cases.
Although AAPBDS is relatively rare, carcinoma of the biliary tract is often complicated. Therefore, it is necessary to choose surgical resection in the treatment of patients with AAPBDS.

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We treated 82 cases of intrahepatic gallstones during the period from January 1977 to May 1988. Because this disease is benign, our standard procedure is cholecystectomy with choledocholithotomy and T-shaped tube drainage of common bile duct, followed by postoperative cholangioscopic lithotomy through the fistula where T-shaped tube was located. Of the 82, 73 cases (89.0%) underwent postoperative cholangioscopic lithotomy. The procedure was done in each patient on the average number of 3.9 times. Six (8.2%) out of 73 cases had residual intrahepatic gallstones, and 9 (13.4%) had recurrences of stones after complete lithotomy. In 8 out of the 9 recurrent cases the procedure was done before 1982. The average of 4.9 years passed before the recurrences. Nine (11.0%) patients died. Causes of death were infection of the biliary tract in 4, cancer in 2, and unkown in three. Electrohydraulic lithotriptor was very effective in cases of impacted giant gallstones.

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We studied 30 cases of intrauterine growth, retardation (IUGR) children 0-3, years of age, born in this hospital at the 28th week or later with birth weights of less than 2500 grams from mothers with toxemia during the period from January 1, 1984 to December 1988. Also, 103 cases of IUGR children 0-3 years of age, born at 28 weeks or later with birth weights of less than 2500 grams from non-toxemic mothers in 1984, 1985 and 1987 were studied. Development quotients were evaluated using the Tsumori questionnaire-type mental development test.
Among the toxemic IUGR's, one case of cerebral palsy was observed. In the non-toxemic IUGR's, two cases of cerebral type paralysis and two cases of mental developmental retardation were observed. These abnormalities were 2.7896 of the toxemic group and 3.88% of the non-toxemic group.
The cause of all three cases of cerebral paralysis was thought to be hypoxic ischemic encephalopathy, which was diagnosed in two cases after fetal monitoring detected fetal asphyxia neonatorum. In the third case, however, fetal monitoring did not detect asphyxia neonatorum due to the absence of Wharton's jelly in a 10-centimeter portion of the umbilical cord.
In the two diagnosed cases of fetal non-asphyxia neonatorum, mental development retardation appeared with complications of neuroblastoma in one case and hemilateral maniphalanx rigidity in the other. The causes, however, are still unknown.

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Forty-four patients (approximately 10 per cent) had low back pain with psychogenic overlay among 405 new patients suffering from low back pain who visited our hospital from April to October in 1987. The psychogenic component of the pain was evaluated by the treating orthopedists based on the characteristics of psychogenic pain. The Cornell Medical Index (CMI) test as a diagnostic aid was done on 43 patients of low back pain with psychogenic overlay. As the result of the CMI tests, 24 patients (54.5%) were neurotic or provisionally neurotic and 19 patients were normal or provisionally normal. The diagnosis was valid when the agreement between orthopedic evaluation and CMI datum was obtained. In these cases the CMI data were of practical value for application as a diagnostic aid. In two cases the orthopedic evaluations indicated distinct psychogenic overlay, but their CMI data were normal. One of these two cases was a multiply operated back patient. As the reason for this discrepancy we thought that the CMI indicated normal data becanse they were stabilized emotionally and they were not conscious of the psychogenic effect. In conclusion, we recognized the limitation of CMI as psychological test for a certain kind of cases.

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The sterilization technique of intravenous hyperalimentation agents is important to prevent septicemia. This work has been established since June 1987 in Osaka National Hospital and has been favorably received among doctors and nurses.
However, considering the original purpose of intravenous hyperalimentation technique, it is advisable to perform sterilization and to support intravenous hyperalimentation based on estimation of nutritional assesment for each patient. From this point an attempt was made to prescribe intravenous hyperalimentation agents and to perform its sterilization. This attempt turned out to be able. Furthermore, the medication history including various medical and pharmaceutical data could be formulated and was useful for group practice in clinical nutritional care.

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In order to study a psychiatric rehabilitation framework in national mental hospitals, we looked into the details of the rehabilitation programs, their system and budget in twenty psychiatric hospitals in 1987 and 1988. It appeared that the concept of psychiatric rehabilitation has clearly changed. Formerly it meant that it was for helping the “long-stay” patients to enable them to resettle more easily or to provide a habit or social skill training for deteriorating patients. Today it is more realistic to look at the patient as a disease process and a person with its remaining disabilities. Accordingly it has been considered that psychiatric rehabilitation program should begin with the onset of the disease and the activities should extend from the ward to the program in the community facilities.
Our survey included out-patient clinics, hospitals in-patient treatment, programs in day-hospitals and night care facilities and collaboration between local health and hospital authorities and others.
The results in the present study were as follow:
1. It was revealed that the mental hospitals surveyed are critically short of staff, particularly co-medical professionals. To maintain the liaison with community resources, it is quite necessary to have sufficient numbers of psychiatric social workers.
2. The data showed that in only 40% of the wards the doors were open. Unlocking the doors was not enough by itself. Since living in unlocked wards is quite necessary for psychiatric rehabilitation, the policy of unlocking should be encouraged.
3. The schizophrenic patients have occupied 60% of the whole psychiatric beds. It was estimated that about half of these patients had been in the hospital for five years or more and could be released if they would have had appropriate community resources. It was found that 44% of the in-patient was on the voluntary basis. As the new Mental Health Act encourages the voluntary admission, it is expected to have more cases of this type of admission.
4. The numbers of the out-patients increased by 50% during the past ten years. In order to expand the out-patient services it is necessary to have the sufficient numbers of the staff.
5. As far as the budget of the rehabilitation program is concerned, we have suffered from poor budget. It was roughly estimated that it would need at least two million yen per one psychiatric bed per year by the study.
6. Although each national mental hospital has their own rehabilitation system, it appeared that their program did not fulfil its function effectively and properly.

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One hundred and twenty-six patients with chronic pancreatitis (55 in group I, 38 in group II and 33 insuspected cases) were investigated and treated for 1.5 years (from 1986 to 1987) by the National Hospital Cooperative Medical Treatment Study Group. Their average ages were 50.5, 52.9, 49.9, the average duration of illness was 5.0, 4.0, 3.3 years, and the average frequency of admission during the latter period was 2.5, 0.7, 0.6 times, respectively. There were 75 men and 51 women. Of all these men, 69.4% had financial family responsibilities and a job, 15.4% had the responsibilities but no job, 10% had neither and 1.4% had no responsibilities but a job. The cause of their illness was thought to be alcohol-related in 38.3%, idiopathic in 376%, gallstones in 15.1% and various other causes in 9.0%. Drinking and smoking had continued in 47.9% and 58.1% of the alcoholic pancreatitis patients, respectively. Abdominal pain and diabetes were recognized in 70.6% and 20.6% (38.2% of group I chronic pancreatitis patients) of the patients, respectively. Sixty-nine per cent of all the patients recovered sufficiently to be able to work as well as they did before their illness. Health insurance for the aged covered 8.3% of the patients while social security covered 9.3%. There were no problems during treatment in only 27.0% of the 126 patients. Various kind of symptoms developed including abdominal pain. Diabetes mellitus and continued drinking were also observed. Secretin therapy, in which 30 to 50 units of secretin were given by drip infusion once or twice a month, was performed in 20 of the above-mentioned cases. It was found to be effective in 40% of the patients i. e. peain disappeared in 7 patients, the protein-plug in the main pancreatic duct disappeared in 2, exocrine pancreatic functions improved in 2 and endocrine pancreatic functions improved in 1. Secretin therapy was, however, found to be effective in only those patients who had non-calcific chronic pancreatitis. No side-effects were recognized during the therapy.

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Seven patients, 3 with severe aplastic anemia (SAA) and 4 with pure red cell aplasia (PRCA), none suitable for bone marrow transplantation, were treated with cyclosporin A (CsA). CsA was given orally at 200-300mg everyday. Short case records are presented. Aplastic anemia: AA 1: Male aged 20. The patient was first shown to be refractory to anti-lymphocyte globulin (ALG) and bolus methylprednisolone (b-MP). Treatment with danazol was temporarily effective. AA 2: Female aged 66. The patient was refractory to ALG, prednisolone and mepitiostane. Her clinical and hematological status improved after two months of therapy with CsA alone. AA 3: Female aged 22 with pregnancy. She was treated with ALG and b-MP without effect after delivery. In case 1 and case 3, CsA combined with mepitiostane was used. Pure red cell aplasia: PRCA 1: Female aged 49. The patient had a refractory PRCA of 4 years' duration, treated with prednisolone, cyclophosphamide and lymphocytapheresis. Temporarily reticulocytosis after ALG was noted. PRCA 2: Female aged 52 with thymoma and hypo-gammaglobulinemia. She was shown to be refractory to ALG and b-MP after thymectomy. PRGA 3: Female aged 53 with Sjogren syndrome, treated with prednisolone without effect. PRCA 4: Female aged 69. A temporary remission was noted after prednisolone and cyclophosphamide. All four patients with PRCA showed a significant reticulocytosis after 16-39 days of CsA therapy. There have been no CsA-related toxicities.
It is suggested that CsA appear to have a place as a primary form of treatment for the patients with PRCA and may be beneficial in patients with AA who are refractory to conventional therapy.

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The association of a prolonged Q-T interval, congenital deafness, and syncopal attacks due to ventricular fibrillation is a clinical entity known as “Jervell and Lange-Nielsen” syndrome. The absence of the congenital deafness characterizes the otherwise identical “Romano-Ward” syndrome. Both conditions (long Q-T syndrome) have a very high mortality rate and are recognized to contribute to sudden death in children.
We had 5 cases of the long Q-T syndrome. Two cases (siblings) were “Jarvell and Lange Nielsen syndrome”. Three cases were “Romano-Ward syndrome”, When we suspect this syndrome, we should check the shape of T waves and T waves alterans at first and then check the Q-T interval.

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Lidocaine is one of the most frequently-used drugs to suppress ventricular arrhythmias; however, it has arrhythmogenic action when given in excess or along with other antiarrhythmic agents.
A case of ventricular tachycardia (torsades de pointes) after a conventional dose of lidocaine with successful resuscitation following discontinuation of the drug is reported. Although such complications are rare, one would anticipate an enhanced effect of lidocaine to a patient with prolonged Q-Tc interval due to bradycardia, congestive heart failure or ischemic heart disease.

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The patint was a 66-year-old woman suffering from hypertrophic cardiomyopathy. After 225mg/day of glycyrrhizin was administered for 2 weeks before her admission, she developed congestive heart failure. On admission, an X-ray film of the chest showed the large heart size with pulmonary vascular congestion and a massive pleural effusion. Serum potassium was 3.2mEq/l and suppression of both plasma renin activity (0.1ng/ml/hr) and plasma aldosterone concentration (25pg/ml) was observed. Further glycyrrhizin preparation was withheld, and with bed rest, but no medication, the patient lost 5kg of body weight over the next 1 week by diuresis. The x-ray film of the chest totally cleared and potassium, renin activity and aldosterone level became normal.

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Congenital fistula in the coronary artery was first reported in 1865 by Krause. Since then, this disease was regarded as a comparatively rare disease. As a result of recent popularization of the use of selective coronary angiography, the number of reported cases of this disease has been increasing. Of these, however, the coronary artery fistula to left ventricle is still rare, and it is reported that the incidence of this type of fistula makes up only ago of all coronary artery fistulas. In Japan, only about 30 cases have been reported so far.
The symptoms of the disease included the ones related to shunt between right and left ventricles, those of cardiac ischemia and bacterial endocarditis if it is complicated. However, some cases are asymptomatic. In many cases, the disease is found by the presence of continuous heart murmur. Final diagnosis is made by coronary angiography, but tomographic echocardiogram is also helpful in differentiating this disease from other diseases.
We report a case of a 49-year-old female. She had angina-like pain. An electrocardiogram showed an ischemic change, so she underwent detailed examinations of the heart. Systolic murmur of samuel-Levine grade 1/6 and decrescendo distolic murmur were audible. Meanwhile, two-dimensional echocardiograms showed an expansion and calcification of the orifice of the right coronary artery. Besides, it was found by coronary angiography that the right coronary artery was flowing into the left ventricle. According to the standards for surgical indication set by Konno et al, this patient should undergo operation as the electrocardiogram showed an ischemic change. However, the left ventricular overload was not remarkable, and no aneurysmal formation was observed. Therefore, the patient has been followed up medically.

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Primary pulmonary hypertension (PPH) is an uncommon disease of unknown causes. The clinical diagnosis requires the demonstration of an elevated pulmonary artery pressure in the absence of known causes or other lung and heart disease. Many studies have reported that PPH is a progressive disease, with an average survival period ranging 2-3 years after diagnosis. A 39-year-old man, who was diagnosed as PPH four years ago, was admitted because of exertional shortness of breath and a mild chest pain. Right and left heart catheterization with coronary arteriography were performed. Pulmonary arterial pressure was elevated (84/32mmHg, mean 49), without any shunt or valvular disease. Coronary arteriogram revealed large and tortuous vessels arising from the atrial circumflex branch to left bronchial artery, and from the sinus node branch to right bronchial artery.
Anastomosis between the coronary and bronchial arteries are known to exist but very rare especially in adult. Large anastomosis like this case may be congenital anomalies of coronary artery. The shunting of blood caused the coronary steal syndrome resulting in angina-like chest pain. We report here a case of PPH with rare abnormalities, in which both bronchial arteries arising from coronary arteries, and the relationship between PPH and anastomosis of coronary artery to bronchial artery is discussed.

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Antibiotics associated-colitis is the disease paid new attention due to the high frequency of using antibiotics. Acute hemorrhagic colitis (AHC) is important among the antibiotics associated-colitis because of acute onset and severity of bleeding. AHC is mainly caused by administration of penicillins such as aminobenzyl penicillin (ABPC), especially by enteral route. To the best of our knowledge, there is no report of AHC due to Sulbactum/Cefoperazone (S/C). Therefore, we report the first case of a 44-year-old patient with AHC after intravenous administration of S/C, who complained of abdominal pain, diarrhea and melena. The sigmoidoscopy showed redness, erosion and hemorrhage at the rectum that appeared unusual for ACH. It was necessary to differentiate AHC from ulcerative colitis. Klebsiella oxytoca which was resistant with ABPC, was detected in the stool culture but Clostridivm difficile and its toxins were not detected. Inspite of many reports suggesting relationship between AHC and Clostridivm difficile and its toxins, Klebsiella oxytoca might have caused AHC in our case as in Totani's report.

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A case of malignant Brenner tumor (stage c) is presented. A 57-year-old woman visited our hospital complaining of lower abdominal mass. As malignant ovarian tumor was suspected on pelvic and ultrasonic examination, abdominal total hysterectomy with salpingo-oophorectomy and partial omentectomy were performed. The child head-sized tumor originated from the left ovary and the cut surface showed the mixed pattern with solid and cystic component. Microscopically, the tumor was composed of nests of transitional and squamous-appearing epitherial cells which showed atypia with 3-4 mitoses per 10 high power field and stromal invasion. The stroma consisted of fibrous connective tissue. The component of benign Brenner tumor was not found. There were no malignancies in the urinary tract. On these pathological findings, a diagnosis of malignant Brenner tumor was made. After operation, combined chemotherapy of cisplatinum, vinblastin and bleomycin were perfomed. Follow-up laparoscopy after 16 months revealed no recurrence.

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We experienced eight cases of malignant bone tumors arising in shoulder girdle. The minimum follow up period was 52 months. Four cases with scapular lesion underwent wide local excision, that is the resection of scapula, distal end of clavicle and proximal end of humerus, resulting in the preservation of upper extremity. Three cases with the lesions in proximal part of humerus underwent wide local excision and prosthetic humeral head replacement. One case with the lesion in proximal part of humerus underwent forequarter amputation because of extensive tumors invading into soft tissue around humerus. Local recurrence was noted in two cases, and distant metastasis was observed in three cases.
We recommend, for this kind of condition, wide local excision preserving upper extremities, because the procedure enables patients, if not completely, to regain their previous activities early. Of course, recent progress of adjuvant chemotherapy will be of great help for this method.

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In this study, we intended to have the basis for educating patients and their attendants how to take medicines. Two hundreds mothers of the patients were asked to fill out questionnairs as to how to let their children take medicine. The recovery rate of the questionnairs was 80%. Seventy-eight percent of the patients were between one year and six years old. The most mothers answered that they followed the directions by doctors and had their children take medicine which were mostly in the form of powder or liquid. About 30% of the mothers were not satisfied with the explanations how to take medicine by doctors or pharmacists. Forty-one percent wanted more explanations or informations about side effects of the medicines.

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