Is has been known from ancient times that emotion induces an asthmatic attack. This fact may show that asthma is a psychosomatic desease. Namely, in a wide sense, psychological factors may promote an antigen-antibody reaction, snd in a narrow sense, an asthmatic attack may occur only by psychological factors and not by antigen-antibody reaction. In the latter, emotion is said to act as a stressor to the diencephalon through the brain cortex or limbic system, then to influence the hypothelamus, the pituitary anterior lobe and the adrenal cortex system and/or the hypothalamus and the automic nervous system and to accerelate the broncho-pulmonary reaction. For diagnosis of asthma as a psychosomatic disease, psychological examination is necessary besides physical examination. Psychological diagnosis is performed by interview and various pasychological tests snd also by CAI (comprehensive asthma inventory). Results obtained were as followes : 1.Psychological examination 1) CMI : III and and IV fields were 60.7% 2) YG : B and E types were 28.5%. 3) MAS : Score more than 20 were 44%. 4) SDS : Score more than 50 were 8.3%. 5) PF study : GCR under 46% was 49.5% and overadaptation was 72.7%. These reactions were analyzed. 6) Large Rorschach test : Superficial adaptation was found in 68.5% of the patients. 7) CAI : In severe asthmatics, dependence, frudtration, negative attitudes toward prognosis and decreased motivation toward therapy were high in incidence. All these results were remarkable in severe cases. 2. Clinical examination. 1) Provocation test : Under suggestion of a severe asthmatic attack during hypnosis , ild and moderate attacks occurred in 8 of 24 cases. In these 8 cases eosinophile leukocytes tend to increase in blood and sputa. Plasma levels of histamine and cortisol showed no definte changes. 2) MDT (mirrow drawing test) : By MDT an asthmatic attack did not occur In asthmatics MDT types showed some difference as compared with those of healthy subjects and speed was sle and accurecy was inferior. 3) MV (microvibration) : As compared with healthy subjects asthmatics had high incidence in parasympathicotony. Parasympathicotony was seen frequently in the patients who had low threshold titer in acetylcholine and histamine inhalation tests. From the above-mentioned results, it is assumed that if the first asthmatic attack occurred without prrof of antigen, infection or any relationship with chemical mediators and also if a subsequent attack occurred similarly, then an expression "psychosomatic facror" may still be usable. LAmpen supposed an allergic center in the diencephalon. Is it permitted to think that whatever subjects which are seen, head and thought of go through the diencephalon and reach the allergic center and then an asthmatic attack is constructed? From the results of psychological and clinical examinations, psychological factors are considered to relate frequently to severe asthma. An asthmatic attack provocated under suggestion during hypnosis was thought to be induced by psychological factors. However, in these patients, histamine and cortisol did not show a definite change. Did the parasympathetic tension rize from suggestion centrally? As these patients had an asthmatic attack very often, they were thought to be in the condition prepared for an asthmatic attack (pre-asthmatic condition). In the patients who are under these conditions, an asthmatic symptom may occur easily. In 2 to 6 percent of the patients whose attack was reported to occur only by psychological factors, these conditions had already exsisted and by psychological factors an asthmatic attack might be induced. Along with the progress of examination technique, these hidden condetions preparing for an asthmatic attack will gradually be alarfied.

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As the principal theories of psychosomatic madecine, there are two that should ne mentioned : The Theory of Psychoanalysis by Freud and The Theory of Conditioned Reflex by Pavlov. These two theories, which are often quoted in contrast, have many incompatible elements. Thus, there is the need for developing a third theory which could be commonly acceptable to both of them. Wiener's Cybernetics and Bertalanffy's General System Theory can be considered to comply with this requirement. Although full details on these theories can be not be given here due to space limitations, we will try to explain the theory of psychomatic madicine, with a special emphasis on the rationale for diagnosis of psychodomatic disease, and that for treatment, in the light of the following principles adopted from the Cybernatics the General System Theory : In our daily psychosomatic medicine clinics, we have adopted the following four principles from Wiener's Cybernetics and Bertalanffy's General System Theory. 1. The black box principle 2. The feedback principle 3. The open and closed system principle 4. The information and energy principle Namely, we are using the polygraphic method for the diagnosis of psychosomatic disease, which corresponds to the black box principle. And for control of psychosomatic symptoms, we are using the biofeedback method, which corresponds to the feedback principle. We then use systematic desensitization to relieve the social stressed the psychosomatic disease. This corresponds to the open and closed system principle. Lastly, the Transactional Analysis corresponds to the information and energy principle.

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In the realm of primary care, the home care is one of the practical assignments which are given to us. I would like to report on how important the psychosomatic approach is in home care on the basis of my clinical experiences with 475 patients who were seen during the 19 months, consisting of December, 1977,July through December of 1978 and the entire year of 1979. In these 475 patients, the average of 25 were seen per month ; the average of 22.6 patients (88%) were over the age of 65. Concerning the number of home visits, the same groupe required 70 visits (87%) per month on the average. The main diseases included apoplexy (34.2%), lumbago and neuralgia (11.1%), heart trouble (8.8%), and cancer (8.4%). To these patients who are stayig at home, mechanically oriented modern treatment practiced in hospitals is not applicable They need medical care which is humane and more patient-orientated, of which the psychosomatic approach should constiture the very base. As Dr.A.J. Krakowski, President of the International Psychosomatic Medical Association stated that, if psychosomatic medicine is meant to be the all round medicine for human care, it should be a biopsuchosocial one. Here, the word 'social' means a life of the patients as a normal human being. He lives a life just like others. The patient's home therefore, is the only place where real, humane care can be given. Thus, development of the care system and study of care techniques are most definitely required. The comprehensive care system for each local district will be conducted by the family doctor in change of primary care, becase he knows each patient and his family vary well as members of the community, and has comprehensive knowledge about each patient's disease from a biological point of view. For development of such service under the leadership of family doctors, public nurses, visiting nurses, physical therapists, clinical psychologists, social workers, home helpers, and even residents of the community should take part. They will learn most in attending medical service in this manner. What should be emphasized here is that appropriate mental and physical care should be given to the patient's family, who are enganed in the care of the patient and tend to exhaust themselves as the illiness prolongs. While promotiong this system as such, it is essential for the family doctor to realize the great value of the psychosomatic approach as it is related to the care techniques as well as to the study of care techniques. Care includes both varbal and non-varbal communication. Under clinically critical situations, such as the terminal stage of cancer, empathetic and emotional, non-verbal communication appeals most to the patient as a human being.

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From a standpoint of psychosomatic primary care which we have conducted for the past five years, we reported on the way of initial contact and the kind psychosomatic approach which were used as follows. 1) The initial interview was the most important tool to select psychosomatic patients from among the ambulance patients. 2) In order to make the initial interview a success, the doctors accepting attitudes toward the patient's mind, proper arrangement in the out-patient room, co-operation of nurses, observations if the patients behavior, the doctor's active listening and positive anticipation were among the important factors. 3) With regard to diagnosis, 28.2% out of the total number of ambulace patients were diagnosed as psychosomatic disease. There were sex differences as to the frequency and type of psychosomatic disease. 4) Treatment is being continued every patient whom a psychosomatic approach was found to be possible. 5) The most frequently used psychosomatic treatment was supportive psychotherapy, which was followed by soutgenic training, behavior therapy and group therapy. In addition, transactional analysis and fasting therapy were used in a few cases. 6) Through out experience with ambulance patients we have come to recognize that primary care psychosicians should acquire psychosomatic knowledge for their own clinical practice.

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1. As a primary care phusician, the author's role in a clinic of psychosomatic madicine is multiple such as a home doctor, a school doctor, an industrial doctor, a doctor of an asylum for the aged and a watch doctor at night. Under these circumstances, a psychosomatic approach has been necessary for each role to take thorough effect. In co-operation with one other doctor, 8 nurses and 2 counselors, the author has been conducting psychosomatic tratment. 2. Two hundred-sixty three were treated with psychosomatic therapy in our clinic in the last 2 years. the patients consisted of 98 men and 165 women, ranging in age from 5 to 75 years. they were 71 cases of automic disorders, 28 school phobia, 19 colon syndrome, 16 peptic ulcer, 11 cardiac neurosis, 11 anxiety neurosis, 11 insomnia, 9 conversion hysteria, 9 hypertention, 8 arteriosclerosis, 7 chronic gastritis, 6 hypochondriasis, 6 maked depression, 5 nycturia, 4 diabetes mellitus, 4 psychogenic headache and other 21 different kinds of diseases. the results were as follows : On the whole, 80% patients were improved, 10% slightly improved, 8% ineffective and 2% refered to other doctors. But the treatment failed in a few patients of idiopathic autonomic disorders, alopecia areata and school phobia.

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The purpose of this paper the practical psychosomatic approach through the medical out-patients clinic of St. Luke's Internatinal Hospital, Tokyo, Japan and to discuss the relationship between psychosomatic approach and primary care. At first, author studied 100 patients who made their first visit to our medical out-patient department in recent 2 weeks in order to analyze the nature of their sicknesses. Author tried to divide these material into illness and disease according to Anthony Reading's Theory. Consequently, these materials were divied into about 80% of illness and 20% of disease. This results suggested that the psychosomatic approach was necessary to treat these patients with practicing first, second and continuous rtimary care through the out0patient clinic. Author used various psychosomatic approaches such as comprehensive interview including psychological approach, mental and physical examinations as diagnostic procedure ; medication, brief psychotherapy and as behavioral approach as thrapeutic procedure. An illustrative case was presented who received the above-mentioned procedure ; a 42 year-old man with unstable hypertension whole clinical course was a great success as his blood presure was made stable through a behavioral approach. Author believes that it is necessary to use comprehensive approach to treat, to cure or to care the entire group of medical patients visiting our clinic as a part of primary care.

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Psychosomatic consideration is essential in the problem of primary care. The present status of medicine in our country does not allow full recognition of this problem. In this paper, we presented actual data and information in order to show how unfortunate situation could be induced when doctors were lacking in psychosomatic compatibility and considerations. It is common that patients were not given sufficient explanation by their doctors at the time of their first consulation. This tendency was particularly maked in those with unsettled complaints and psychosomatic disorders. Of these patients, about 25% were given only madication without any explanation, and 24% were told that nothing was wrong in particular. Among those who were considered normal, many did not improve, wandering from one doctor to another. At any rate, about 70% of these cases said that they were not satisfied with the kind of ecplanation which was given at their intial contact with their doctors. In addition, in 11% of the cases, patients had the impression that their anxiety was increased and their symptoms aggravated due to careless explanations of doctors at time of their first visit. The theme of primary care still hold unsolved problems such as that 1) only 20% of general physicians examine their patients having depressive reactions on their mind which are often found in their daily practice, 2) as many as 51% of doctors give psychotropic drugs to the patients with multiple and obstinate complaints without inquiring about them in them in detail and 3) Such indiscreet administration of drugs can sometimes distort the disease state and even produce habituation on the part of the patients.

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Since our Sosiety has benn approved as an affiliate of the Japanese Medical Association last September, there has heen an authentic and pressing demand to refine a training program for a non-dualistic and holistic medical practice by primary care physicians. In terms of research, psychosomatic madicine in our country i snot lagging the United States and West Germany, But in terms of training, we are 10 to 20 years behind them. Thus, in the United States, I consulted a pioneer in this field, Dr. W. Dorfman of the Academy of Psychosomatic Medicine, who referred me to Dr. J. V. Fisher, a professor of Family Practice at the Medical University of South Carolina who is an authority in this area. Professor Fisher immediately sent me information concerning the policies that had actually succueeded in the United States. In the United States the Academy of Psychosomatic Medicine, the Academy of Family Physicians and the American Medical Assoxiation selected representatives to serve on a steering committee to discuss the establishment of goals and methods for this kind of education. then, the beed for psychosomatic care in the everyday practice of primary physicians was surveyed and its data were analyzed by computers. Based upon these data, an educational program was put together, pointing out verious conditions for actual practice. Finally, the training program is evalutioned periodically. In the United States since 17 years ago, 3 series of 4 year post-graduate training programs for Family Practice physicians have been conducted with the support of the National Institure of Mental Health. In the third post-graduate program of the series starting in 1971,a program was arranged to meet the demand for the improvement of the family physicians' own mental health. In light of these Amerian developments, it can be seen that : (1) as young physicians trained in psychosomatic medicine during medical school are more responsive to psychosomatics symptoms than others, it is necessary to institure such a training program within medical school ; (2) post-graduate training program should be effective for young physicians as well as for senior physicians who did not receive psychosomatic training in medical school (thus a continous education system is desirable) ; (3) if family physicians are so trained they will be also to provide psychotherapy for themselves for most psychosomatic disorders that they encounter in everyday practice. In addition, for this kind of training, a participatory and exaperiential learning is preferable to a lecture atyle learning. It can be said further that the physicians' own understanding of the self and the deveropment of a therapeutic self is basic to this kind of training. Added to these information from the United States, we are considering Balint groups, a widely used psychosomatic approach in the training of doctors, nurses and students in Europe, for the deveropment of a practical post-graduate program.

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It is important to know the history of primary care in order to understand the need of primary care medicine in the world. In the United States the Specialty Board of Family Practice was organized in 1969. Primary care includes two components in it. The first is that it is the first contact medicine dealing with episodic care and also distributive care dealing with chronic diseases, prevenive medicine and guidance of lifestyle of the individuals and their families. The second is the fundamental knowledge and skills rwquired of every physician engaged in family practice. When family physicians deal with their community people personally, it is difficult to understand the problems of consumers and give needed guidance and care to them without the knowledge and skills of approaching them from psychological, social as well as physical aspects of the problems. Without the training of clinical medicine including psychosomatic medicine, it is difficult to educate physicians to be the primary care or family physians in the real meaning of the words. Psychosomatic medicine should be the core of clinical medicine, as well as in primary care medicine which deals with the patient as a holistic person with body and mind.

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