About 30% of tuberculosis patients admitted to our hospital are above 60 years of age. Development of potent chemotherapy regimen containing INH and RFP has been successful in overcoming difference in the rate of sputum conversion between young and old patients. But as residual lung lesions after chemotherapy are by far more marked in old patients, they suffer, accelerated by the influence of aging, from severe respiratory insufficiency. About 50% of the aged tuberculosis patients are complicated with other diseases, sometimes difficult to treat, and 6-9% of the new admission to the nontuberculous chest disease ward under the diagnosis of lung cancer or lung abscess were tuberculosis. It is also necessary to differentiate atypical mycobacteria especially Myc intracellulare from Myc. tuberculosis, for it is very frequently found in the aged.

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The present study shows that Tween 80 serves as a good carbon source of slowly growing mycobacteria.
The basic media used were sterilized by autoclaving at 120°C for 20 minutes. They were dissolved before its use by heating in a water bath, and added with additional carbon or nitrogen sources, which were sterillized separately by heating at 100°C for 10 minutes. The medium was poured at 8 ml quantities into tubes (17 by 170 mm), and re-sterilized at 100°C for 10 minutes. The pH was adjusted to 7.0 by adding 10% KOH (and if necessary 10% HC1). The medium was inoculated with one loopful of the test organism, and the growth in it was observed after incubation at 37°C for 4 weeks.
1. When Tween 80 was used as carbon source, use of glutamate as nitrogen source supported the growth of almost all mycobacteria, except for fresh isolates of M. tuberculosis. Use of ammonium sulfate supported the growth of mycobacteria except for M. tuberculosis, M. bovis and M. kansasii. Nitrite supported growth of many slowly growing mycobacteria, although it was reported that in the presence of glycerol, it did not support the growth of slowly growing my cobacteria. The use of nitrate supported the growth of all mycobacteria except for M. tuberculosis (and M. bovis) (Table 1). It was remarkable that M. xenopi showed good growth in the presence of Tween 80 as carbon source, in spite of poor growth of this organism on Ogawa egg medium and Löwenstein-Jensen medium.

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Cavernoplasty for pulmonary tuberculosis is a local surgical technique that aims to lead the cavity to an appropriate state of healing by means of incision, curettage of the caseous materials in the cavity and its primary closure.
Reviewed here are 78 cases surgically treated during the period from January, 1965, to the end of the March, 1977. Their results are discussed and types of cases for which the procedure is not indicated are noted. The cases have been divided into 5 groups according to the classification of severity for surgical treatment by the Tuberculosis Research Committee, Ryoken, as follows: non-severe 18, mild 26, moderately 21 and highly and above 13.
Since 1971, the method has been positively applied in cases where lobectomy had been formerly considered the recommended procedure. This is the reason why the number of operations on non-severe and mildly severe patients has been increased rescently.
Good results were obtained in 60 cases without postoperative complications. Eighteen cases including three late postoperative deaths showed postoperative complications, namely the persistence of positive bacilli, the re-opening of cavity or insufficient closure of the dead space in thorax. However, good results were finally obtained in 10 out of these 18 cases.
Our experience indicates that the main causes of operative failures are nadequate pneu molysis or insufficient postoperative re-expansion of the lung in cases with low lung compliance, because the healing of the lesion is attained not only by local mechanical curettage, but also through the compression of the surrounding lung tissue. The latter is the most important factor in achieving the desired results in cavernoplasty and is an essential difference between cavernoplasty and another local surgical procedure, cavernostomy.
In cases where good results have been obtained, ibrocicatrization is observed on the site of the operation and this has been confirmed histologically in a specimen accidentally obtained. The method is a local procedure, so postoperative lung function is hardly injured.
Due to remarkable advances in antituberculous drugs, most tuberculosis patients can be controlled by chemotherapy alone, and surgery is thought to be playing a supplementary role. As a local surgical procedure, cavernoplasty is recommended as one of the leading contemporary methods, well-suited for this purpose.
But, because of the healing mechanism mentioned above, there are some cases in which cavernoplasty should not be used. For example, it is not indicated for cases with low lung compliance or for cases difficult to separate the pleural adhesion. Cavernostomy is recommended for these cases.

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I. On the disease due to M. kansasii
The disease due to M. kansasii occupied only 2 per cent (4 cases) of the total cases (200 cases) of atypical mycobacteriosis in Japan in 1966. Therefore, it was thought that this disease was very rare in Japan. But, since then the frequency of M. kansasii increased year by year, and recently 6 to 11 cases of the infection with M. kansasii were found every year. This disease had probably been overlooked before 1966.
i) Some problems in diagnosis Photochromogenicity of M. kansasii was not found on the culture medium which was not ventilated, and yellow pigmentation of colonies did not occure if colonies were exposed to light 4 weeks after cultivation on Ogawa's medium at 37. Moreover, the colony of M. tuberculosis is more similar in shape and color to that of M. kansasii than to other atypical mycobacteria. Therefore, the laboratory technicians may misinterprete M. kansasii as M. tuberculosis, and a considerable number of strains may escape their notice.
On smear, M. kansasii looked like a long beaded rod and occured in curl-like heaps. The morphological observation of organisms may be useful for the diagnosis of the disease due to M. kansasii.
The sensitivity to rifampicin (RFP), ethionamide (TH) and cycloserine (CS) was a characteristic feature of the drug susceptibility of M. kansasii.
ii) Geographic distribution The majority (80.6%) of the patients were living in Tokyo and its vicinity, and the disease due to M. kansasii amounts to 10 percent of the total cases of atypical mycobacteriosis in this district. Therefore, it is suggested that the incidence of the infection with M. kansasii is different geographically in Japan.
iii) Clinical characteristics and chest
The majority (94.1%) of the disease occured in men. Many patients were found among younger and middle aged persons without any previous lung disease.
On the chest radiogram, cavitary lesions were found in the lung field in the majority (72.8%) of the cases of the disease due to M. kansasii, while subpleural cavitary lesions were found in many cases of the disease due to M. intracellulare.
iv) Chemotherapy
SM, PAS and INH were used most frequently. RFP, TH and CS were used in many cases.
In non-cavitary cases, bacteriological conversion occured in 4 patients (100%) by chemothe rapy excluding RFP and TH, and in 5 patients (100%) treated with the regimen containing RFP or TH. But, in cavitary cases, the negative conversion occured in 7 cases of moderate extent and 5 for advanced cases (70 or 50%) by chemotherapy excluding RFP and TH, and in 12 and 20 patients (100 or 86.9), respectively, treated with the regimen containing RFP or TH.
v) Diagnostic criteria
The diagnostic criteria for atypical mycobacteriosis established by Hibino and Yamamoto are not applicable to the disease due to M. kansasii. If there are discharge of the organism even in small amount twice and the presence of clinical symptoms which might relate to bacilli discharge, such cases are diagnosed as the disease due to M. kansasii.
II. On the disease due to M. intracellulare
As the initial radiographic changes, the pleural-thickening-like shadow and the linear shadow extending from the pleura into the lung field were found most frequently, and the appearance of the bulla and the thickening of its wall were found not rarely.
In the disease due to M. intracellulare, radiographic changes usually showed progression very slowly and the interval from the initial appearance of pulmonary changes to the cavitation was considerably long (over 2 to 4 years in many cases).
Subpleural cavitary lesions were found in many cases, but in the majority of the cases complicated with neumoconiosis, cavitary lesions were found in the lung field.

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It has been shown that mycobacterial cells including tubercle bacilli were very useful tool for the study on cellular immunology. In this review, I summarize the results of our immunological study on tubercle bacilli.
1. Experimental cavity formation in rabbits. We have clearly shown that experimental tuberculous cavity was produced by the intrathoratic injection of heat-killed mycobacterial cells suspended in mineral oil. Recently it was also shown that the intrathoratic injection of my cobacterial protein antigen together with potent adjuvant substance such as BCG cell-wall skeleton emulsified in Freund's incomplete adjuvant produced experimental cavity in rabbits.
2. Tuberculin active peptide (TAP). TAP purified from the defatted cells of mycobacteria and nocardia was shown to be low molecular weight (<10, 000 dalton) and stable. The specificity of TAP in skin-reaction is almost similar with that of PPDs.
3. Cancer immunotherapy with BCG cell-wall skeleton (CWS).
BCG-CWS was shown to have principal chemical structure of “mycolic acid-arabinogalactanmucopeptide” complex, and the adjuvant activity of BCG-CWS was examined in detail. We have also shown that oil-attached BCG-CWS had potent anti-tumor activity in transplantable tumors in syngeneic mice, rats and guinea pigs. BCG-CWS stimulated the depressed T cell function to normal level in tumor-bearing host. The incidence of carcinogenicity with chemical carcinogens in mice, rats and rabbits was inhibited by the administration of BCG-CWS. BCG-CWS is now being used as immunotherapeutic agent for the treatment of human malignant diseases especially in the patients with lung cancer and leukemia.
4. Synthetic peptidoglycan subunits.
The minimum adjuvant-active subunit of bacterial cell-wall was established to be N-acetyl muramyl-L-alanyl-D-isoglutamine (MDP). MDP was shown to have adjuvant activity, but no antitumor activity. 6-O-Mycoloyl-MDP showed potent adjuvant activity on cellular immune response and antitumor activity in transplantable tumor in syngeneic mice. It was also found that the immunization with DNP-6-OMycoloyl-MDP induced the IgE specific suppressor cells which did not affect on the production of IgG class antibody to DNP.

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