Bacteriological studies of expectorated sputum specimens from 1924 cases of respiratory diseases were done to clarify the feasibility of the bacteriological culture of the causative organisms in the lower respiratory tract infections. The following results were obtained.
1) There were no significant bacteria in about 50% of the cases and oropharyngeal flora contaminants in 16.7% to 30.7% of the cases of the lower respiratory tract infections.
2) Bacteria that were cultured over one-third of the surface of the plate seemed to be true bacterial flora in the lower respiratory tract.
3) The detection of S. pneumoniae and H. influenzae in pneumonia with chronic airway diseases and S. aureus, K. pneumoniae and P. aeruginosa in bronchitis with chronic airway diseases were significantly high.
4) By consecutive culture of expectorated sputum for 3 days on admission M. tuberculosis was isolated in about 60% of the cases of active pulmonary tuberculosis and atypical mycobacterium was isolated in about 80% of the cases of atypical mycobacteriosis. Atypical mycobacterium was also detected in about 2.3% of the cases in the respiratory diseases except for atypical mycobacteriosis.
These results suggest that we should determine the causative organisms with much caution based on the results of bacteriological culture of expectorated sputum and that mycobacterial culture is very useful in the diagnosis of pulmonary tuberculosis and atypical mycobacteriosis.

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We evaluated the clinical significance of serum BFP levels in patients with lung cancer and benign lung diseases, in order to assess the role of BFP as a tumor marker for the detection of lung cancer. For comparison, CEA, SCC and NSE were also measured. Of the 63 patients with lung cancer, BFP levels higher than normal value were determined at the time of diagnosis in 58.7%. On the other hand 35.7% of the 70 patients with non-neoplastic lung diseases had a raised serum BFP. In comparison of the cancer group and the non-malignancy group, the rate of positive BFP was significantly higher in patients with lung cancer than patients with no malignancy (p<0.01). The rate of positive BFP was the highest among all the markers determined at the same time when BFP levels were measured. With respect to the clinical tage, the rate of positive BFP was found in 50.0% of the patients regardless of having stage I. In relation to histologic types, the incidence of positive BFP was high in all types of histology, that is, 60.9% in squamous cell carcinoma, 57.6% in adenocarcinoma and 57.1% in small cell carcinoma. Between serum levels of BFP and other markers in patients with lung cancer, poor relationships were found and determination of BFP concomitantly with CEA, SCC and NSE showed very high sensitivity of over 79%. From these observations, it seems useful to determine BFP in combination with CEA, SCC or NSE for the diagnostic aid in the detection of patients with lung cancer.

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Investigation on the family history of tuberculosis (TB) was conducted on 1782 patients admitted in the 12 sanatoriums between 1988 and 1989. Among them, 348 patients (19.5%) gave a history of TB in their families. The similar ratio (21.8%) of positive family history of TB was recognized among lung cancer patients in the same period suggesting that about 20% in the Japanese people generally have positive family history of TB. Nevertheless, young TB patients under 30 were distinguished by the higher ratio of positive family history (male 28.3%, female 27.0%).
It seems to indicate that the family contact of TB patients weighs heavily to the spread of TB in this age group. It may be desirable to shift toward more intensive or extensive examination and preventive treatment for family members of TB Patients.

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In Japan, new medical graduates are likely to choose to enter special medical disciplines directly even at the initial stage of postgraduate training. This often means that they lose their opportunity to have comprehensive primary care training which is essential for all physicians. From the patient's viewpoint, it is inconvenient and confusing for medical specialities to be highly diversified. Patients often have multipathological conditions and often have questions such as “Which clinic should j go to and who is my doctor?”.
In these circumstances, the Ministry of Health and Welfare has been emphasizing the importance of primary care training for physicians, sending young physicians working for National Hospitals to the United States to learn primary care and ancillary education and research since 1979.
For this reason, National Hospitals are now among the best centers for training of young physicians in primary care and the establishment of primary care training programs.
There are also several advantages for hospitals that have established primary care departments or divisions of general medical clinics.
(1) Comprehensive and continuous care can be provided.
(2) Education and training of primary care for interns and residents can be undertaken.
(3) The process of development and advancement of a primary care department would improve the level of clinical competence of specialists, since they would be able to concentrate more on their own field and provide more support to the primary care department.
(4) Continuous education would be provided for private practitioners, giving new information about primary care to support their practice.
These advantages, together with the current status and problems of the departments of primary care in National Hospitals are discussed.

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A case of steroid-resistant severe idiopathic thrombocytopenic purpura (ITP) was reported. Following the unsuccessful corticosteroid treatment, a pregnant woman received a high dose gammaglobulin (400mg/kg/day) intravenously at the 29th gestational week, resulting in a slight recovery of the platelet count. Premature rupture of the membrane occurred on the third day of the gammaglobulin treatment. Because of difficulty of fetal blood sampling from the cord, a ceasarian section was performed following platelet transfusion to avoid hemorrhagic disorders of the infant. A normal female infant was delivered without excessive blood loss throughout the operation. Splenectomy was finally carried out because of the persistent thrombocytopenic status despite high dose gammaglobulin therapy. ITP during pregnancy is intra table and the optimal management still remains to be solved.

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Vitamin D₃ cytological differentiation induction therapy is established for myelodysplastic syndrome (MDS) as low dose Ara-C therapy. We experienced a paradoxical MDS case of vitamin D₃ inducing thrombocytopenia. The patient was a 78-year-old male complaining of oral herpes, general fatigue and lumbago, who was admitted to a local hospital in Dec. 1989. He was transfered to our hospital because of pancytopenia. At the admission, he showed anemia, no tendency of bleeding, no splenomegaly nor lymphadenopathy.
Laboratory study showed WBC 8100/μ, Hb 10.4g/dl, Plt 6.6×10⁴, and 3% blasts. Biochemical study showed LDH 618IU/l, no liver dysfunction and no renal impairment. Bone marrow study revealed 59.9×10⁴/μl nuclear cells, Megakaryocytes 7×31.2/μl and 0.5% blast. Trilineage cell abnormality and chromosome anomaly was compatible for MDS-Refractory Anemia. He had a respiratory symptom and his sputum contained Branhamella Catarrhalis, which was successfully treated with NFLX. Though 0.75μg/day vitamin D₃ was administered which increased to 3μg/day, pancytopenia worsened. The decreasing peripheral and bone marrow cellularity advanced up to WBC 2000/μl, Hb 5.2g/dl Pit 0.9×10⁴/μl and 1.4×01⁴ bone marrow cells. Cytological change was not obtained. Ceasing of vitamin D₃ recovered thrombocyte count to 13.8×10⁸. Provoking test brought pancytepenia again but no G nor GM colony formation was seen through the D₃ treatment.

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Gastric malignant lymphoma is a rare disease. Early gastric lymphoma of surface type is particularly difficult to determine operative indication because of difficulty in differentiating malignant lymphoma from benign diseases such as gastric ulcer and reactive lymphoreticular hyperplasia (RLH). We experienced a case of early gastric malignant lymphoma that underwent curative operation because we suspected malignant disease from features of gastrofiberscopic and double contrast roentgenographic findings, though histological diagnoses from biopsy specimen were benign several times. The patient was a 59-year-old man. His chief complaints were hematemesis and abdominal pain. He had been treated at a nearby hospital with the diagnosis of gastric ulcer for eight months and was admitted to our hospital because of hematemesis at night.
Histological diagnoses from gastrofiberscopic biopsies were Group j at first time and Group II at second time, but he was operated on because early gastric cancer of type II c was suspected by macroscopic findings. The pathohistological diagnosis was non-Hodgikin lymphoma. The infiltrating grade was sm. Lymph nodes metastasis was not seen. The histological staging was stage I_E. It is more difficult to diagnose gastric lymphoma than gastric cancer. In particular, the diagnosis of early gastric lymphoma is needed with special emphasis on macroscopic features and complaints.

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This report represents one case of infiltrative thymoma followed by squamous cell carcinoma of the lung. A 69-year-old man suffered from infiltrative thymoma which reduced by the radiation therapy. Seven years later its relapse and the onset of squamous cell carcinoma were found simultaneously. Infiltrative thymoma metastatized not only to mediastinum but also to liver and bronchus. Squamous cell carcinoma developed in the right upper lobe. In spite of chemotherapy against them, the patient died.
There are many cases in which infiltrative thymoma is accompanied by squamous cell carcinoma of the lung simultaneously, however, secondary onset of squamous cell carcinoma after the radiation therapy of infiltrative thymoma is rare.
Secondary carcinogenesis of this case was considered to be closely related with immunological abnormalities caused by thymoma, effects of radiation, smoking and so on.

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A patient with traumatic occlusion of the right internal carotid artery (ICA) was treated by a superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. This 10-year-old girl had cervical hyperextension in a fall. Six hours later, she suffered progressive left hemiparesis. After 24 hours from the trauma, she was admitted to our hospital.
Neurological examination revealed mild disturbance of consciousness and left hemiparesis. Computed tomography showed a small low density area in right frontal lobe. Angiography demonstrated a postsinus tapering stenosis of the right cervical ICA, and occlusion of the anterior clinoid portion of the right ICA. By the fifth hospital day, left hemiparesis disappeared with conservative treatments. However, she repeated still transient motor weakness of the left upper extremity. Four weeks later, a right STA-MCA anastomosis was performed. After the operation, transient motor weakness quickly disappeared. Postoperative angiography showed good filling of the middle cerebral arteries from the STA.
The patient has had no recurrence of transient motor weakness for 3 years since the operation. This result suggested that transient motor weakness was related to hypoperfusion.

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Menetrier's disease is an uncommon disease with an increased risk of gastric cancer. We have recently encountered a case of Menetrier's disease associated with an early gastric cancer. The patient was a 65-year-old male who had been known to have giant rugae in the stomach since 17 months before. He was admitted to our hospital for surgical treatment because the latest follow-up endoscopy with biopsy had revealed early cancerous focus in the gastric body.
Elective total gastrectomy was performed for both Menetrier's disease and early gastric cancer. Macroscopically, the resected specimen demonstrated prominent mucosal folds involving the gastric fundus and body, and a small erosive lesion with mucosal convergence at the anterior wall in the gastric body. Histologically, sections of gastric folds demonstrated features of Menetrier's disease with thickened gastric mucosa and cystic dilatation of glands. The erosive lesion was defined as intramucosal signet-ring cell carcinoma. It has been suggested that we should manage Menetrier's disease considering the possibility of development of gastric malignancy especially cancer and the difficulty in detecting a small cancerous lesion among giant rugae even under careful endoscopic observation.

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A rare case of early submucosal gastric cancer with left supraclavicular and numerous para-aortic lymph node metastais is presented. The patient was a 66-year-old man whose chief complaint was epigastralgia. On physical examination, an index-finger-head sized, firm lymph node was palpated at his left supraclavicular fossa. Double contrast study and gastrofiberscopy of the stomach showed an irregularly depressed, partly polypoid lesion at the posterior wall of the mid-corpus, suggesting a case of type IIc+I early gastric cancer. An intraoperative frozen section of the lymph node showed metastatic adenocarcinoma, then partial gastrectomy with lymph nodes dissection was performed. The resected stomach revealed a depressed cancer of type IIc, 47×28mm in size. Histologically the tumor was composed of moderately differentiaed tubular adenocarcinoma invading the submucosa, accompanied with marked lymphatic permeation at the submucosa and the subserosa. The patient tolerated the operation well, and he received radiation therapy to the left supraclavicular fossa and the para-aortic region. The patient died due to cachexia 7 months after the gastrectomy. We also reviewed the literatures of early gastric cancer with widespread n4 lymph node metastases in Japan.

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A case of adenosquamous carcinoma of pancreas in a 56-year-old male patient is reported, He was admitted to the National Kyushu Cancer Center Hospital on Oct, 22, 1988, complaining of epigastralgia associated with elevation of WBC and serum amylase level. The abdominal ultrasonography and CT showed pancreatic head mass having a diameter of about 5cm. The serum CA 19-9 was negative. The blood group Lewis type was Lewis a (-) b (-), pancreatic cancer and inflammatory pancreatic mass were suspected. Though ERCP findings suggested infalmmatory changes, celiac artery angiography showed the findings of carcinoma. The laparotomy was performed, and metastatic lesions were found in the liver. The biopsy of pancreatic head mass showed adenosquamous carcinoma of the pancreas. The patient died on Mar, 20, 1989 in spite of chemotherapy, radiotherapy, bypass procedures and plexus nerve block. In this case, we had very difficulty in making a differentiation between inflammatory mass and pancreatic cancer because of (1) the discrepancy in ERCP and angiographic findings and (2) no elevation of serum CA 19-9 level. The latter was maybe due to the fact that few cases of adenosquamous pancreatic carcinoma or of Lewis a (-) b (-) as the expression of blood group-related antigens showed elevation of serum CA 19-9 level.

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Survey on autopsied cases in the National Hospitals and the National Sanatorium Hospitals in Japan was done by a questionaire method. Autopsy was performed outside the hospitals more often for the cases of the National Sanatorium Hospitals compared with those of the National Hospitals. Pathological diagnosis was also made outside the hospitals and the autopsied materials were preserved in those hospitals. The rate of autopsy in individual hospital was different, and had a tendency to decrease. However, the rate of brain examination was slightly increased. It is considered to be very important to form the brain tissue banking system for careful examination, pathological diagnosis, material preservation and brain disease research.

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