The spectrum of respiratory diseases has changed drastically in these twenty years. It seems to be the biggest change among all the clinical subjects. That is from tubercu-losis to lung cancer and immunologic respiratory disease.
The most epoch-making clinical progress was made by the invention of the flexible fiberoptic bronchoscope.
Bronchoalveolar lavage (BAL) was started in 1974 and since then it has been playing great roles in diagnosis, examination of pathophysiology, and pathogenetic approach of the unknown origin of pulmonary diseases.
BAL method was shown in detail. BAL lymphocytes are increase in hypersensitivity pneumonia and sarcoidosis.
Neutrophils increase markedly in diffuse panbronchiolitis. Various new evidences have been disclosed in bronchial asthma.
We use BAL in diagnosis of pulmonary infiltrates in immunosuppressed patients and in drug induced pneumonia.
We also report new evidences in ARDS, lymphangiosis carcinomatosa and so on.

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Among 4 major coronary risk factors, we hypothesized that coronary atherogenic index ('5.0) and cigarette smoking ('20/day) promote coronary spasm, while hypertension and diabetes mellitus inhibit coronary spasm. Coronary atherogenic index (CAI) is defined as follows: TC/HDL-C ×Apolipoprotein B/A-I. Concerning Coronary Risk Score (CRS), +1 point is given to each risk factor, and summation of the points is the CRS of the patient. With regard to Coronary Spasm Risk Score (CSRS), +1 point is given to the former two risk factors: and -1 point is given to the latter two risk factors. Also the summation of these points defines the CSRS of the patient.
One hundred and seventy two patients with ischemic heart disease, 104 men and 68 women on an average 61 years old, were classified into three groups;a) myocardial in-farction, b) rest &effort angina, c) effort angina. Each group had 2.2, 1.9 and 1.8 CRS, and 1.3, 1.1 and 0.25 CSRS respectively. Among these groups, CRSs were not different, but patients with effort angina had a lower CSRS significantly compared with other groups.
In general, it is considered that the rest angina is closely related to coronary spasm or constriction compared with effort angina, so the hypothsesis seems valid from the data.

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R-R interval variations were investigated in severely retarded children to evaluate autonomic function. 62 patients and 51 normal control subjects were evaluated according to the age. The patients were divided into 2 groups, spastic and athetotic. Both groups showed no significant reductions in R-R interval variations, but 3 patients showed significant reductions in R-R interval variations. These patients had severe brain damage including brain stem dysfunction and symptoms of autonomic dysfunction. Patients who had abnormal brain stem tests, blink reflex and auditory brain stem response, were likely to have low value of R-R interval variations.

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The changes of hemodynamics and pulmonary gas exchange at rest and on exercise were studied in 15 patients with chronic pulmonary disease. The following results were obtained. 1) Patients who developed exertional hypoxemia (group B) had a higher resting heart rate and a lower %VC than patients who did not (group A). 2) Heart rate was positively correlated with mean pulmonary arterial pressure (PPA) and cardiac output, but inversely correlated with arterial oxygen tension (PaO₂) and oxygen saturation (SaO₂) both at rest and on exercise. 3) %VC was positively correlated with PaO₂, but inversely correlated with heart rate and PPA both at rest and on exercise. 4) Right ventricular e-jection fraction at rest remained well preserved in our patients of both groups. However, occult right ventricular dysfunction became apparent in group B on exercise, as compared to group A.

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One of the most severe and fatal complications in extremely premature infants (ELBW) is hyperkalemia. The hyperkalemia in ELBW is caused by three factors as follows:
1) premature function of the kidney
2) catabolic states in metabolism
3) hypokalemia in muscle cells
Especially in these factors, the hypokalemia in muscle cells has a most important roll in ELBW. Birth asphyxia makes ELBW severe hyperkalemia. While it is low grade hyperkalemia yet, we can see the marked ECG changes in ELBW compared to children or adults.
The most effective and reasonable therapy of hyperkalemia in ELBW is glucose-insulin therapy. (G. I, therapy)
This is our protocol to hyperkalemia in ELBW.
1) Severe type; Insulin i. m. (1-2 U) +DIV (add 1 U insulin to 100 ml 10% glucose)
2) Mild type; DIV only 3) Preventive therapy; DIV (add 0.5 U insulin to 100 ml 1096 glucose)

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From October 1966 to March 1983, 780 cases of cervical cancer were treated with radiotherapy. Retrospective study was performed to compare between the following two groups. The first group treated from October 1966 to December 1974 included 393 cases and the second one treated from January 1975 to March 1983 included 387 cases. The mean age, stage balance and histological balance were not different between the two groups. The number of patients treated with external irradiation alone decreased in the second group. Five year-survival rate in the first group was 71.4% for stage I, 58.5% for stage II, 37.1% for stage III, 17.6% for stage IV, and in the second group, 83.7% for stage I, 71.7% for stage II, 47.9% for stage III, 0% for stage lY respectively. Therewas a significant difference (p<0.01) in the five year survival rates in stage I, II and III.
Appropriate diagnosis as well as treatment in the individual cases might be contribu-tory factors for the improvement of prognosis.

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From Mar. 1988 to Jan. 1990, 12 patients including 7 primary lung cancers, 2 lung metastases of colorectal cancer, and each 1 gall bladder cancer, ovarian cancer, and spinal cord metastasis of prostatic cancer, received 60Co-irradiation with high dose by hyperfrac-tionation. This hyperfractionation consisted of 1. 2 Gy per fraction, twice a day with 6 hour interval, and 5 days (10 fractions) a week. The total dose administered was 81. 6-100 Gy. The acute reaction of skin, lung, and intestines was tolerable, and it seemed that the late damage of normal tissues was slighter and the treatment result was favorable in comparison with the conventional fractionation, but this estimation was not definite because of short observation period. It was discussed that further reduction of dose per fraction (iGy or below) and more increased total dose (100 Gy or more) would be promis-ing in hyperfractionation.

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To determine the normal variability and scalp distribution of the auditory evoked mid-dle latency responses (MLRs), we recorded MLRs on click stimulation in 68 randomly selected healthy subjects, ages range from 21 to 59 years.
The raw responses were obtained with the time constant of 0.3 sec using 16 scalp e-lectrodes referred to a non-cephalic reference. In the raw responses of some cases, iden-tification of Na and Pa components was occasionally difficult due to the marked baseline drift. Then, we applied the digital filtration of the raw responses to clarify the Na and Pa peaks. Results were summarized as follow: 1) Through these procedure, we could obtain clear Na and Pa components in all the subjects and we confirmed the fronto-cent-ral predominant distribution of these components. 2) The amplitudes of Na and Pa were slightly higher on the contralateral area to the stimulation than on the ipsilateral area, however, not a little intersubject variability was found. 3) As to the F3/F4 amplitude ratio of Pa, almost all cases ranged between 0. 6 to 1. 6, and this ratio seemed to be useful for the judgment of abnormality. 4) Na and/or Pa showed latency difference between frontal and occipital areas in about one third of the subjects, which suggested the existence of complex dipoles. 5) There was strong correlation between Na and Pa ampli-tudes on the frontal area, and this fact seemed to suggest that the origin of frontal Na and Pa were closely related.

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We studied 49 ears of 27 children with otitis media with effusion (OME), undergoing insertion of the ventilation tube between February, 1986 and January, 1989. The tube used for the study included a Goode T-tube for 7 ears and a Paparella type j for 42 ears. A simultaneous adenoidectomy was performed on 13 patients. Follow-up examinations consisting of observation of ear drums, audiometric evaluation such as pure tone audiometry and tympanometry, were scheduled routinely every month. The overall mean follow-up period was 18 months. Mean extrusion time was averaged at 5.1 months. In May 1989, 25 ears appeard to be effusion-free, however 21 ears developed recurrence of OME. Mean extrusion time was significantly shorter in the patients of the recurrent group compared to those of effusion-free group. The children in the recurrent group have had AOM or acute upper respiratory infection after extrusion of ventilation tube more frequently than those in the effusion-free group. Therefore it was suggested that these episodes may be closely related with OME recurrence

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Prenatal diagnosis of chromosome abnormality has been carried out in our hospital in pregnant women for various medical reasons. Amniocentesis was done at 16-17 weeks of gestation, and chromosome examination was performed in amniotic fluid cells cultured for 10-14 days in vitro. We prenatally diagnosed chromosome abnormalities in 16 cases out of a total of 210 cases examined so far. Those were 8 cases in the higher maternal age group, 6 cases in the translocation carrier group, and 2 cases in the miscellaneous group. We selected and described 5 cases of them, in which interpretation of chromosomal findings was fairly difficult or apt to lead to a misdiagnosis.
We discussed that reliability of chromosomal diagnosis was very high, but misdiagnosis due to mosaicism, maternal cell contamination, and micro-level chromosome abnormality was inevitable in the material of cultured amniotic cells. We stressed here the importance of mutual reliable relationships among patients, doctors, and chromosome examiners to prevent troubles and smolderings

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Flurbiprof en ester incorporated in lipid emulsion (LFP83) is a new injectable nonsteroidal analgesic. Its prostaglandin inhibitory activity and analgesice fficacy were evaluated.
LFP83 showed potent and long-lasting analgesic effect on the arthritic pain induced by silver nitrate in rats. Its effect was more potent than those of aspirin-DL-lysine and Ketoprofen.
The prostaglandin inhibitory activity of LFP83 in the surgical patients was equal to that of aspirin-DL-lysine. In the patients with the severe postoperative pain, LFP83 was more effective than aspirin-DL-lysin and ketoprofen in the pain relief, but without statistically significant diffenrence. The onset of the pain relief was observed during the first 30 minutes in the most of the patients. No adverse effect was observed.
These results suggest that LFP83 was effective and safe for the control of postoperative pain

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A 17 year old male was injured by the traffic accident and developed right subdural hematoma. Forty minutes after the injury, he received 2500 u of factor IX (FIX) concen-trates (PPSB), followed by sequential administration of FIX concentrates to keep the plasma level of FXI up to more than 80%. From the day two after the injury, decrease in platelet count was observed. Sequentially the treatment for DIC was started and the FIX was replaced by the monoclonal-antibody-purified FIX. In spite of the treatment including aggressive infusion of fresh frozen plasma, DIC did not improve and low plasma fibrinogen level and high FDP level persisted. However, brain hematoma did not enlarge and DIC improved after the tapering of FIX. DIC by FIX concentrates was strongly suspected. This case is the second case of DIC by FIX concentrates in Japan and the first case of DIC by monoclonal antibody purified FIX

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We encountered two cases of so-called postoperative erythroderma following open heart surgery. A 61-year-old female and a 60-year-old male developed fever, erythroderma, liver dysfunction, and pancytopenia about 10 days after coronary artery bypass grafting and subsequently died.
Skin biopsy disclosed infiltration of lymphocytes in the basal epidermal layer, and immunohistological examination showed that most of these infiltrating cells were T cells. Although the chimerism of the patient's lymphocytes could not be identified, the typical clinical course and pathological findings of the skin biopsy coincided with previous reports of GVHD following blood transfusion. This disease is a fatal complication of transfusion. Therefore, we are attempting to prevent GVHD by avoiding the use of fresh blood, and decreasing the amount of transfusion by autotransfusion, same-day transfusion of the patient's own fresh blood, and the recycling of drained blood.

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A few long-term survival cases by resection of local recurrence of the rectal cancer are found. We experienced 3 such cases from July, 1182 to June, 1989. In these cases, abdominoperineal resection was done in the second operation. Case 1(49-year-old man) was operated on 14 months after primary operation and survives for 71 months free from recurrence. In case 2(34-year-old woman), resection of local recurrence was done 4 months after primary operation and 19 months later, this case died of recurrence again. Case 3(61-year-old man) was operated on 12 months after primary operation and survives for 3 months. Resection of local recurrence was difficult because of hard pelvic tissue. In case 2, operative time amounted to 8 hours 32 minutes and massive bleeding of 8427 ml occurred. In conclusion, resection of local recurrence should be done actively but care-fully.

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The case was a 42-year-old male patient, who was diagnosed as having melancholia with deprressed mood, psychomotor retardation, feeling of fretfulness, insomnia, and dysorexia. Those symptoms improved at about 4 weeks after administration of antidepressant drugs (sulpride and amoxapine), an antianxiety drug (etizolam), and hypnotic drugs (nitrazepam and haloxazolam). However, approximately 4 months later, the depressive condition re-appeared. Thus, 225mg/day of initial dose of amoxapine was administered with gradual increase in dose every two weeks. About 2 weeks later, the patient showed a sudden disturbance of consciousness, muscle rigidity, and perspiration, leading to emergency hospitalization. At admission, examinations demonstrated of consciousness, muscle rigidity, perspiration, fever (38.3°C), tachycardia (126/min), abnormal blood pressure (170/100), increase of leukocytes (12800/mm3), and elevated CPK (1327 IU/l), which aroused suspicion of the malignant syndrome. Accordingly, subsequent suspension of antidepressive drugs and administration of adjuvant fluid led to rapid improvement of the disturbance of consciousness, muscle rigidity, perspiration, tachycardia, and abnormal blood pressure. The leukocytosis normalized about 4 days later, the fever about 7 days later, and the elevated CPK about 9 days later. Cases of malignant syndrome due to amoxapine have rarely been reported.

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