Asthma has been known since the era of Hippocrates. Asthma can be caused by various reasons. Among them, allergy is the most important in the etiology. In allergic reaction, various chemical mediators are involved and play the important role in asthma. Whatever the cause might be, however, the bronchial hyperreactivity is the common finding in asthma and the research in this aspect has been focused quite extensively.
Prevalence of asthma has been increased in the last 30 years and this is the common trend in the developed countries. In the next century, asthma is thought to become the one of the diseases which will cause big medical problems, because of the increase in number. We have to put our effort on preventing this from now on.

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In 1973, we successfully performed to extract the esophagus by inverting the structure without thoracotomy for a 71-year-old patient who had an advanced cervico-upper thoracic esophageal cancer. We named this procedure “esophageal stripping”. Since then, 68 cases of esophageal cancer and 2 cases of benign Barrett esophagus underwent this procedure. Elderly patients above 70 years old were 37 cases (52.9%) and the entire operative mortality rate was 11.7%. The lesion of esophageal cancer was cervical (Ce) in 3 cases, cervico upper thoracic (Ce+Iu) in 3, upper thoracic (Iu) in 3, middle thoracic (Im) in 20, middle thoracic and lower thoracic (Im+Ei) in 10, lower thoracic (Ei) in 13, abdominal and cardia (Ea+C) in 14, and another lesion in two, respectively. Reconstructive organ after esophagectomy was stomach in 62 cases, small intestine and colon in 7, and in one case reconstruction was not performed primarily. The operation time was within four hours in 40 cases and it was markedly shorter than that of standard method with thoracotomy. Postoperative prognosis (5-year survival rate) was 30% in esophageal stripping group and 10% in standard thoracotomy group. Intraoperative bleeding and postoperative complications decreased significantly and operative indications have been extended recently. This esophageal stripping is now technically feasible for thoracic esophageal cancer and the operative technique is shown herein.

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We studied the extent of pleural injury and intra-mediastinal bleeding during esophageal stripping by using 20 adult mongrel dogs; 7 dogs underwent upward esophageal stripping, 7 dogs underwent downward esophageal stripping and other 6 dogs underwent esophageal stripping with simultaneous gauze tamponade of the mediastinal cavity. After esophageal stripping, the pleural injury was 1.4cm to 3.1cm in length and it was thought to be slight. The mean intra-operative bleeding was 109.3cc in upward stripping, and 90.0cc in downward stripping. However, in the tamponade group, intramediastinal bleeding decreased to about one third (32.0cc). In clinical data, operation time was shortened to 62 minutes in 24 cases of esophageal stripping group compared to 20 cases of standard thoracotomy group and intra-operative bleeding also markedly decreased to 464cc on average in esophageal stripping group. Furthermore, by means of gauze tamponade of mediastinal cavity, intra-operative bleeding reduced by half. Post-operative pulmonary complication occurred in 250 of stripping group, and in 45% of thoracotomy group and post-operative prolonged tachypnea was also rare in stripping group.
These data showed that the esophageal stripping had the advantage of reduction of surgical stress and intra-operative bleeding and shortening of the operative time.

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Pancreato-duodenectomy (P-D) has been commonly performed as a safe surgical treatment with lowered mortality rate. However, P-D is still one of the time-consuming operations and is also associated with much amount of operative bleeding and complications are not rare.
We performed P-D for 53 patients between January 1972 and May 1990, at the Department of Surgery, Nagasaki Chuo National Hospital. Subjects included 15 patients with pancreatic head cancer, 13 with carcinoma of bile duct, 10 with carcinoma of papilla of Vater, 2 with chronic pancreatitis or other deseases. This is a report on the results of clinical investigation of these cases. No operative death occurred. Complications associated with pancreato-jejunostomy (P-J) were pancreatic fistula in one patient, and transient leakage of pancreatic fluid in one patient. These two complicatins were mitigated by conservative treatment. We were able to avoid the major complications of P-J by emplacing a pancreatic duct drain in all patients.
It is suggested that these securing pancreatic drainage may be responsible for no operative death in these cases. Additionally, pancreatic duct ligation without P-J may result in diminished digestive and absorptive function. This procedure should therefore not be performed in cases where substantial longevity is possible.

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A study was done on responsible factors in 170 elderly patients with chronic subdural hematoma (chronic SDH) who were over 65 years old. They were operated during the three years from 1986 to 1988. Burr-hole craniotomy and external drainage of the subdural collection was mostly accepted todays as the rational approach to this chronic SDH. The result was generally excellent.
CT-findings of chronic SDH, which was classified into the 4 groups, revealed the combind type (34.7%) and other types presented more or less than 20 percent. The factor most strongly affecting the prognosis was considered to be the presence of cerebral atrophy. But brain re-expansion was not always correlated with the prognosis. This unexpected result may be attributed to the difference between cerebral atrophy and cerebral elasticity. Other factors seemed to include disappearing time of residual air in the hematoma cavity and neurological grade on admission.
There were some cases of chronic SDH resulting from subdural hygroma (11.8%) and acute subdural hematoma (3.5%). Out of our elderly patients, 7 cases (4.1%) showed re-currence of symptoms due to reaccumulation of hematoma 2 or 3 months after the operation. As to the factors promoting chronic SDH, there was a tendency to increased incidence in patients with cerebral atrophy who had the head injury. Other factors showed low rate in patients with cerebral atrophy, and head injury.
From these results, these elderly patients might have the cerebral atrophy to some extent, and will increase frequently the chance to meet with head trauma. Then, it seems to be reasonable to think that elderly patients have slightly abnormal coagulation-fibrinolysis system and systemic cancer. Therefore, this would contribute to increase patients with chronic SDH.

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It has been shown that eicosapentaenoic acid (EPA) reduces platelet aggregation and is useful to prevent thrombosis. We examined the plasma polyunsaturated fatty acids of nineteen patients with cardiovascular disorders but without hyperlipidemia or diabetes mellitus before and six months after our hospital diet. Relative percent of EPA on total plasma lipids increased from 1.98±0.70 to 2.72±0.85 but other fatty acids did not change. The 20:5/20:4 ratio also increased from 0.40±0.12 to 0.54±0.17. Serum cholesterol reduced from 192.7±37.3 to 173.8±32.6. These studies show that hospital diet containg rich fish oil is useful to change EPA percent on total plasma lipids.

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Adenosquamous carcinoma of the lung is relatively rare and reports of the cases have been few. In the Lung Cancer Study Group of the National Chest Hospitals, between 1980 and 1984, 56 patients with adenosquamous carcinoma were reported, being 2.1% of the operated lung cancer patients at that time. We took here a new criteria or a combined one that each component of adenocarcinoma and squamous cell carcinoma (WHO) must be contained more than 20% (Japan Lung Cancer Society) of the tumor, though WHO criteria declares “the tubular formation and squamoid tissue components”. According to the more strict criteria of the adenosquamous carcinoma, 25 patients (group A) were recognized as the “adenosquamous carcinoma in a narrow sense”, while the other 27 patients (group B) were recognized as adenocarcinoma (22), squamous cell carcinoma (5) and small cell carcinoma (1) by microscopic findings. Median survival time for the patients of group A was 22.4 months, shorter than that of group B (34 months), although there was no difference between the two groups as to the distribution of the patients with regard to tumor stage and resection curability (p=0.068). In conclusion, the more strict criteria for adenocarcinoma would be useful to predict the prognosis of the surgical patients.

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The Regional Medical Training Center was established for the purpose of life-time education in primary care to doctors and other staffs in medically related fields. Methods and activities to achieve the aims and purpose of the Center are discussed with particular attention to: Creation of training and educating programs; mutual confidence with doctors in the region; increasing the opportunities to learn through actual experiences; effective use of medical resources. Learning through actual experiences was considered to be the chief object of the operation of the Center.

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A 62-year-old man with idiopathic enlargement of the right atrium and persistent atrial standstill was described. He was admitted to the Sapporo National Hospital for further evaluation of cardiomegaly found by the chest X-ray examination (CTR 72%), He had had cardiomegaly at least for 20 years. Physical examination did not reveal any significant abnormality except a slow pulse rate of 40 a minute. Routine laboratory tests were normal. ECG showed junctional rhythm and absence of the P wave. Two-dimensional echocardiography showed a large saccular dilation of the right atrium without significant enlargement of the other cardiac chambers. No displacement of the tricuspid valve leaflets was observed. Cardiac catheterization was indispensable for the diagnosis of idiopathic enlargement of the right atrium and atrial standstill. Intracardiac ECG showed partial atrial electrical activity. This case is valuable because of the rarity of combinations of idiopathic enlargement of the right atrium and a partial type of persistent atrial standstill.

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A 64-year-old woman with a histologically proven PBC stage I was treated with ursodeoxycholic acid, 600mg/day, for about 30 months. The levels of serum ALP and γ-GTP decreased significantly within 1 year of ursodeoxycholic acid treatment as well as the level of serum bilirubin. However, the level of serum IgM, known as a humoral immunological marker, did not change during ursodeoxycholic acid therapy. The changes of concentration of serum bile acids composition were observed during ursodeoxycholic acid therapy, whereas total bile acids in serum did not change. The absolute and relative concentration of serum chenodeoxycholic acid decreased during ursodeoxycholic acid therapy, although the relative concentration of serum ursodeoxycholic acid increased. In the follow up liver biopsy after ursodeoxycholic acid therapy for about 30 months, the histological improvement was observed in relation to the small cell infiltration and fibrosis in portal area. It was concluded that the long-term ursodeoxycholic acid therapy for PBC was safe and effective.

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Myelodysplastic syndrome associated with macroamylasemia was reported. The patient was a 81-year-old male who had mild anemia and leukopenia. Serum amylase was elevated but urinary amylase was not elevated. Amylase creatinine clearance ratio was decreased, Myelodysplastic syndrome is usually associated with autoantibodies and autoimmune diseases. Macroamylasemia was considered to be an autoimmune disorder. The association of myelodysplastic syndrome and macroamylasemia is quite rare and hence this report.

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A rare case of severe epileptic status associated with hyperprolinemia is reported. The patient developed an abnormal circadian rhythm after multiple epileptic seisures followed by personality change and autism.
Hyperprolinemia has not been previously reported as a cause of autism. This case suggests a certain interrelationship between autism and circadian rhythm.
Work-ups to rule out metabolic disorders for patients with intractable convulsions are emphasized.

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Alport's syndrome and benign familial hematuria are typical conditions of familial hematuria. The former is a disease with poor prognosis. It complicates with neurological hearing impairment and develops into terminal renal failure. The latter continues to produce hematuria for a long time, however, clinical situation is benign. It is very important to distinguish both diseases early. We investigated electronmicroscopically renal biopsy specimens from members of families with familial hematuria. We concluded that electronmicroscopic examination is useful to distinguish between Alport's syndrome and benign hematuria.

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A case of Parkinson's disease, who complained of limb-shaking caused by transient ischemic attack (TIA), is reported. The 61-year-old male patient complained of resting tremor since April 1988. He was diagnosed as Parkinson's disease and received levodopa (L-DOPA) therapy. On May 1989, he complained of 5-hour lasting, shaking-like, and rhythmical involuntary movement in the left arm and leg (limb-shaking). After that the same episodes occurred almost every day. The brain CT scan revealed a small infarction in the right parastriate white matter. The selective angiographic examination revealed marked dilatation of the right internal carotid artery and a pooling of contrast medium in the dilated portion until late venous phase. The limb-shaking attacks occurred either after addition of L-DOPA or after discontinuation of L-DOPA. After all, the attacks disappeared after the aspirin administration. Neurologists or internists should note that treatable involuntary movement as TIA could occur in patients with Parkinson's disease.
From another facet, this case implies that the basal ganglia might be a responsible lesion of limb-shaking.

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Two cases of acute subdural hematoma in amateur boxers were reported.
Case 1: A 23-year-old college student was knocked out technically in the third round of a boxing match and was unconscious for fifteen minutes. CT scan showed left subdural-hematoma, midline shift to opposite side and disappearance of perimesencephalic cisterns (PMC) for forty five minutes after boxing injury. A surgical evacuation of left subdural hematoma was done immediately. Three months after brain injury, he was in a vegetative state.
Case 2: A 20-year-old college student from the same college as in case 1 was knocked out technically in the third round and unconscious for 75 minutes. CT scan revealed left thin subdural hematoma at the complaint of headache. CT scan showed increasing subdural hematoma for 75 minutes. After surgical removal of hematoma, he recovered rapidly. After 29 days he was discharged from the hospital.
The severe head injury caused by boxing was discussed and the literature reviewed.

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We made a clinico-statistic observation on the general anesthesia cases operated at the Dentistry and Oral Surgery of the Nagoya National Hospital over 11 years and 9 months from April of 1978 to December of 1989. The general anesthesia cases were 190 in number. In view of the cases by year, they have a tendency to increase year by year and the yearly mean were 17 cases. The male to female ratio was 57.4% to 42.6%.
In view of the cases by ages, the cases from 60 to 69 years old were the largest, accounting for 16.3% of the total cases.
The cases of those under one year old and those from 80 to 89 years old were low to be 1.6%. With regard to the type of operation, removal of the cyst was most frequent, accounting for 18.2%, followed by the reduction of fracture (15.3%), the dental surgery (14.0%) such as exodontia, and the radical surgery for maxillary sinus. With regard to the time of anesthesia, the cases required from 2 to 3 hours were the most common, accounting for 52 cases (27.4%), followed by 36 cases from 3 to 4 hours (18.9%), and by 27 cases over 6 hours (14.2%).

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A total of 4, 423 patients was admitted to the Emergency Medical Center of Nagoya National Hospital from 1979 to 1989, of which age distribution, classification of diseases, motality, admission days and so on, were studied.
While patients over the age of seventy years were recently increasing, the mortality rate was about 15% and stayed almost constant. The most common diseases were cerebrovascular diseases (cerebral infarction, thrombosis, subarachnoid hemorrhage. intracerebral hematoma etc) and head injury, but gastrointestinal diseases (stomach or duodenal ulcer, rectal hemorrhage, jaundice etc) were also common cardio-vascular diseases (myocardial infarction, angina pectoris etc) and pediatric diseases were not so common, probably because there are CCU and pediatric beds in another stations in our hospital.
The author has also discussed on satellite hospital or other problems about the system of emergency medicine.

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