The authors report six difficult emergency tracheostomy cases recently encountered at Jikei University Hospital. They include three cases of thyroid cancer and one each of subglottic cancer, esophageal cancer and cervical trauma, respectively. Of the six cases, one of the patients with thyroid cancer died during the tracheostomy operation because of acute obstruction of the airway due to extensive infiltration of cancer in the anterior neck associated with paralysis of the reccurrent nerve. The authors comment on the technical aspect in performing emergency tracheostomy.

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A rare case of candida esophagitis was reported. The patient was a 47-year old female and diagnosed as chronic mucocutaneous candidiasis bacteriologically, immunologically as well as histopathologically. There were no suggestive causes such as improper use of antibiotics or steroid. Immunological studies revealed depression of cellularr immunity associated with enhancement of humoral immunity, which may indicate the presence of characteristic immune deviation phenomenon. Additional discussions were made on the clinical entity, cause, symptoms, diagnosis and therapy of chronic mucocutaneous candidiasis.

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Four cases of air way malignancy were reported in persons who used to work in a factory for poisonous gas at Okunojima, Takehara city, Hiroshima prefecture, during the second world war. These were a 61 year old man with tracheal cancer, a 45 year old woman with tracheal cancer, a 63 year old man with laryngeal cancer and a 65 year old man with pharyngeal cancer. These patients were operated upon and specimens were examined by the SEM. Some interesting findings were obtained. The relation of poisonous gas to their malignancies was discussed

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Nine years have passed since the first flexible bronchoscope was developed in Japan. At present, approximately 3, 000 bronchofiberscopes are in use by specialists in all the world. Recently, the author has established the technique and indication for bronchofiberscopy together with the photographic recording system for endoscopic images and a complete set for biopsy and specimen collection. It should be realized that the general use of bronchofiberscope in many hospitals can be accompanied by unexpected accidents during the procedure. In particular, bleeding from the site of biopsy can be a serious problem and careful preparation for hemostasis and a composed attitude of the examiner are mandatory.

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Mediastinoscopy, requiring short general anesthesia but associated with very rapid course of postoperative recovery, has achieved widespread acceptance as a useful diagnositic procedure for chest disorders in Europe and America. However, the procedure is not yet so popular in Japan.
At the Chest Disease Research Institute, Kyoto University and the Kyoto Katsura Hospital, 413 mediastinoscopic examinations were carried out and a positive tissue diagnosis was obtained in 52.3%. In patients with chest disease, especially with sarcoidosis, silicosis, systemic lymphatic diseases and mediastinal tumors, mediastinoscopy was proved to be of great diagnostic significance. Among 213 patients with lung cancer, metastasis in the mediastinal lymph nodes was found in 42.3%, while contralateral metastases of right to left and left to right were found in a ratio of 7% and 12%, respectively. Thus, in case of lung cancer, mediastinoscopy was found to be of great value in exploringthe existence, site and extent of metastasis and/or invasion of carcinoma to the mediastinal tissues and in selecting the therapeutic procedure. The anatomy, technique, limitation and complications of mediastinoscopy were also analyzed and fully discussed.
The results of 4250 mediastinoscopic examinations at the Ruhrlandklinik, Essen, West Germany, were presented at the symposium by courtesy of Director Prof. W. Maassen.

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Mediastinoscopy, devised by Prof. Carlens in 1959, is a method of exploration and biopsy of the superior mediastinum. Historically it has been developed from mediastinostomy step by step.
In general, the extent of the mediastinoscopical examination is limited to the anterior and superior parts of the mediastinum. In 1917 a flexible mediastinoscope was developed by the present author in Japan to investigate not only the superior and anterior parts but also the posterior or the lower part of the mediastinum. This scope is 40cm in length and 10mm in diameter. It has a firm but round end with which the connective tissues in the mediastinum can be safely divided. The tip can be bent by remote control. It has also a guide-tube through which either a special dissector or biopsy forceps can be inserted.
In practical use of this scope, the upper mediastinum must be dissected by a normal rigid scope first and a flexible scope is then introduced through the rigid scope. The flexible mediastinoscope must be controlled by the operator himself under his direct vision and by the radiologist observing in a fluoroscopical television.
Clinically, flexible mediastinoscopy is particularly useful for diagnosis of mediastinal tumors situated in the lower part of the mediastinum.

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The diagnositic values, indications and complications of thoracoscopy and our new method “Trans-thoracoscopic lung biopsy with tissue adhesive” are described. These methods are usuful for diagnosis of small peripheral lung cancer, for deciding indication of surgery for lung cancer, for diagnosis and therapy (pleurodesis) of carcinomatous pleuritis and for diagnosis of those cases with disseminated lung shadows and mediastinal tumors. No serious complication will be expected, if these methods are carefully performed under intubation anethesia.

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During the 8 year period from 1954 to 1961, rigid bronchoscopy was successful to visualize the tumor only in 75 (34%) of 224 cases with definitive lung cancer. Cellular samples were obtained by bronchial lavage through the rigid bronchoscope and cytologic diagnosis was positive in 73 (96%) of the 75 cases with visible tumor and in 118 (79%) of 149 cases with invisible tumor.
For the past 6 years (1970-'75), flexible fiberoptic bronchoscopy was successful for revealing the tumor in 83 (66%) of 126 cases with lung cancer. Cellular samples were obtained by bronchial brushing through the flexible fiberoptic bronchoscope and cytologic diagnosis was positive in 81 (98%) of the cases with visible tumor, while in 21 (49%) of 43 cases with invisible tumor.
It could be concluded from the above that the percentage of success for visual diagnosis for bronchial cancer increased twice as much due to the introduction of flexible fiberoptic bronchoscope. However, positive cytological diagnosis could not always easily be obtained in case of lung cancer located beyond the visible extent of flexible fiberoptic bronchoscopy.

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Continuous effort has been made for further development of mediastinoscopy since the author's presentation at the annual meeting of this Society in 1971 and the results of experiences at 12 different medical institutes are summarized as follows:
1. Based on the anatomy of the mediastinum, it is more rational to devide the superior mediastinum into the anterior, middle and posterior parts.
2. THE JAPANESE RESEARCH GROUP OF THE NEW DIAGNOSTIC METHODS FOR THE MEDIASTINAL LESION has collected 1383 cases referred to mediastinoscopy. Our diagnostic methods are very helpful for;
a) Determining lymphnode involvement in the contralateral mediastinum from the primary lesion of the bronchogenic carcinoma and providing a great deal of information on resectabilty of the lesion and proper assessment of radiation therapy.
b) Making diagnosis of other mediastinal disease such as thymic or lymphatic tumor, excision of which is sometimes possible during the procedures.
3. There were 40 complications encountered in 1383 procedures, none of which resulted in grave morbidity.
4. Improvement of mediastinoscope and trial of extended mediastinoscopy for the esophageal disease, inferior mediastinal or retrosternal lesion were discussed.
This study was supported by the grant from the Cancer Control Program of the Japan Ministry of Health and Welfare.

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