The computed radiography (FCR), a new x-ray system, was just recently developed. The characteristics of the FCR is that an “imaging plate” is utilized to record the image. The image is then converted to electric signals, processed in a computer and reproduced on film.
This FCR was applied to 30 cases of carcinoma of the breast and to 20 cases of benign tumor of the breast. Radiological monitoring of irradiation dosage requirements was also investigated in 20 cases.
The accurate diagnosis of carcinoma of the breast cases was 73.3%, making the diagnostic rates in FCR and conventional mammography identical.
The accurate diagnosis of benign tumor of the breast cases was 22.7%.
With FCR the dosage requirement decreased 15 to 58%.
When compared with conventional mammography, the image is clearer in FCR, especially in tumor and skin shadows. With FCR it is possible to reduce dosage requirements.

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Immunohistochemical staining was undertaken in 30 lesions of breast cancer and 117 benign lesions by the Avidin-Biotin method using anti-17β-estradiol serum. The following three items were defined as the criteria for the judgment of positive staining: 1) The color development should be of a clear-brown granular pattern. 2) Color development variation should be found within each cell and among the cells. 3) More than 30 percent of the stained cells should have the above findings. The rate of positive staining was high in cases of cancer, fibroadenoma, papilloma and papillomatosis, while it tended to be low in other benign lesions. The stain findings in cases of papilloma and papillomatosis reflected the two-cell type. All positive cells were classified into four types. Type I cells show a color development localized at the cytoplasm on the side of the glandular lumen proximal to the nucleus. Type II cells show a very fine or fine granular color development, which was distributed diffusely over the cytoplasm. Type III cells show a coarse or middle-grade granular color development. Type IV cells show a volute color development centering around the nucleus. The rates of appearance of types III and IV were higher in breast in breast cancer cells than in papilloma or papillomatosis cells. These results led us to the consideration that proliferative epithelial lesions of the breast should be recognized as showning sequential spectra extending from benignancy to malignancy.

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To increase the changes of a surgical cure, an extensive node dissection was carried out with no additional skin incision following a modified radical mastectomy that preserved the major pectoral muscle and lateral anterior thoracic nerve. The subclavian muscle was divided through its tendinous portion to ensure the adequate resection of lymph node-bearing tissue in the cervico-axillary canal through the full extent of its course. Subsequent of the dissection of the supraclavicular nodes, longitudinal sternotomy was performed. This sternum-splitting approach offered complete access for en block dissection of the parasternal nodes in continuity with the fat and areolar tissue around the jugulosubclavian region, in which a number of lymphatic trunks are embeded. Moreover, anterosuperior mediastinal nodes such as retromanubrial nodes, pre- and paratracheal nodes and inferior jugular nodes were also harvested at the same time. Blood transfusion was given in only a few cases. Neither cosmetic impairment nor any deficit in function was observed postoperatively, compared with the usual results of modified mastectomy. The postsurgical course was also favorable in all cases insofar as no unpleasant complications were encountered. It was therefore considered that this extensive dissection method was an effective mode of therapy and is to be preferred in hope of obtaining a complete cure for breast carcinoma.

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Six hundred thirty-six patients underwent open heart surgery under myocardial protection with cold Young's and high potassium (K⁺: 20mEq/l) and high magnesium (Mg⁺⁺: 24.1mEq/l) cardioplegia at Sapporo Medical College and Hospital between May 1980 and September 1984. We classified the procedure of myocardial protection into three stages as follows:
Stage I: To obtain cardiac arrest as soon as possible so as to reduce the high-energy phosphates in the myocardium.
Stage II: To keep the myocardium in a hypothermic stage, to use membrane stabilization (K⁺, Mg⁺⁺), to prevent acidosis and edema (pH and osmotic pressure), and to give chemical substances (CoQ¹⁰, Anti Ca⁺⁺).
Stage III: To prevent reperfusion injury (minimum differences between the heart and the reperfusate blood temperature, low flow and low pressure).
We also had the advantage of developing new equipment and instruments for these procedures. In this study, the maximum periods of ischemic arrest, as long as four hours, have been well tolerated, and there were 22 hospital deaths out of 636 patients, i.e., 3.5% mortality. However, there were also 48 patients who had aortic cross-clamping time prolonged to two hours and had higher incidences of postoperative low cardiac output syndrome than the other patients undergoing this procedure. We are now planning to use cold blood cardioplegic solution in elective patients who are suspected before surgery to require prolonged arotic cross-clamping time.

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Radical surgery was performed in 44 patients with tetralogy of Fallot between April 1980 and December 1983. Three patients (6.8%) died in the early stage. Materials and techniques used for the reconstruction of the right ventricular outflow tract were investigated in 40 patients in whom hemodynamics could be determined.
The 40 patients ranged in age from 4 to 56 at the time of surgery, with a mean age of 11 and a male/female ratio of 22:18. For surgery, in all patients, atonic cardiac arrest was induced during the use of Young's solution, and cardiac muscles were protected and maintained at about 15°C. Excision of abnormal muscle bundles at the right ventricular outflow tract was performed in all patients, followed by patch closure of interventricular septal defect and right ventricular outflow tract reconstruction. The techniques of this reconstruction were formation of the pulmonary valve in three patients (Group I, mean age 24), right ventricular patch reconstruction using EPTFE in four (Group II, mean age 31), right ventricular and pulmonary arterial reconstruction using a glutaraldehyde-treated single-valve-containing porcine pericardial patch (Rygg) in five (Group III, mean age 27), and right ventricular and pulmonary arterial reconstruction by a combined patch of single-valve containing autologous pericardium and EPTFE in 28 (Group IV, mean age 7).
Development in Group I was better than in other groups, with the ratio of the diameter of the main pulmonary artery to that of the ascending aorta being 0.67±0.31. A relative right ventricular-pulmonary artery pressure difference remained in Group III as compared with the other groups. This was because patients in Group III were adults after shunt surgery, in whom stenosis of the right ventricular outflow tract advanced and the right intraventricular narrowing was not fully improved even by minimal cardiac muscle resection and patch enlargement. In Group IV, the pulmonary arterial diastolic pressure (13.8±0.8mmHg) was comparatively well maintained, showing a tendency of mild pulmonary insufficiency.
Enlargement of the right ventricular outflow tract by using a combined patch of single-valve-containing autologous pericardium and EPTFE is said to be unsatisfactory in long-term prognosis. However, our cases showed stable results, and this method is therefore considered to be an almost perfect procedure for right ventricular outflow tract reconstruction.

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In 31 patients with bullous emphysema who underwent surgical treatment, the morphology of bullae and remaining lungs were classified retrospectively in terms of the surgical findings and techniques in order to compare the kinds and characteristics of postoperative complications. Intrathoracic electrophrenic respiration under negative pressure was used in 14 patients after pulmonary surgery, and considerations were made as to whether this method was adequate for postoperative respiratory management patients with bullous emphysema. The results were as follows.
1) When there were no emphysematous changes in the remaining lungs and the bullae formed congregations of multiple small bullae or were large or giant bullae having constricted portions (15 cases), no problems arose in either the performance of surgery or the postoperative course.
2) Surgical treatment was difficult in patients who had severe emphysematous changes in the remaining lungs with congregations of multiple small bullae and who did not respond to conservative treatment (five cases). In these patients, the currently most adequate surgical method seemed to be the one by which the affected lung was fully collapsed by means of double-tube endotracheal intubation and subjected to a minimum of reduction suture in combination with the application of fibrin paste at that site.
3) When the bullae had no constricted portions and were large or giant (11 cases), regardless of the morphology of the remaining lungs, various postoperative complications in the lung on the operation side and/or on the opposite side occurred in about half of the patients. As to causes, lobectomy, the Naclerio-Langer method for cystectomy, and postoperative transitory positive pressure respiration were cited. To decrease these complications, cystectomy plus reduction suture of the lung was devised, and the method of negative pressure respiration was investigated.
4) As negative pressure respiration, transitory electric stimulation of the intrathoracic phrenic nerve was used in 14 patients after pulmonary surgery. The results were almost completely satisfactory in both ventilation and circulation. In particular, this method exerted a right cardiac assisting effect. It was suggested that our method is simple and useful for postoperative temporary respiration assistance in patients with bullous emphysema who have undergone surgery and in whom change in the capacity of lung on the side opposite to that receiving surgery is predicted.

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In the past 15 years, 101 cases of peptic ulcer in patients over 60 years of age were treated in our department. Of 101 patients, 76 had gastric ulcer, 16 had duodenal ulcer and 9 had combined gastric and duodenal ulcer. The number of peptic ulcers treated surgically has been decreasing recently, while the percentage of peptic ulcers in the aged has been increasing.
Of these 101 cases, 52.4% of the patients had no past history of ulcer, and 49.3% had suffered from the disease for less than six months. In regard to symptoms, 71.3% of patients complained of abdominal pain, and 36.6% showed gastrointestinal hemorrhage. The indications for laparotomy were hemorrhage, perforation and stenosis in 48.6% and intractability in 47.2%.
The rate of preoperative complications and the rate of emergency operations tended to increase with age.
Although there was a complete absence of mortality in the patients without preoperative complications, that among patients with preoperative complications in emergency operations was a high 46.2%. How to avoid emergency operations in the aged remains a problem to be solved in the future.

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Intravenous reinfusion of autogenous ascitic fluid was primarily applied for intractable ascites in the cirrhotic patient. Recently, this procedure was modified using a technique of cell removal and fluid concentration and applied for intractable ascites in the terminal cancer patient.
In the present study, the effect of the reinfusion of cell-free and concentrated autogenous ascitic fluid for in-tractable ascites in the terminal cancer patient was evaluated.
Fourteen cases of terminal cancer with intractable ascites were treated with 21 reinfusions.
The reinfusion was effective in 85.7% of the cases decreasing the complaints caused by ascitic retension. It caused neither hypoprotenemia nor imbalance of serum electrolytes. In addition, the repeated reinfusion led to a restraint of the re-retension of ascitic fluid. Although pyrexia occurred in 71.4% of the reinfusions, in most of the cases, this was subsided with the administration of the usual antipyretics.
These results indicate that the reinfusion of cell-free and concentrated autogenous ascitic fluid is useful for the control of intractable ascites in the terminal cancer patient.

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As postoperative multiple organ failure has a poor prognosis, many surgeons have great interest in this problem. In the present study, among 1, 392 patients who had undergone surgery of the digestive system under general anesthesia in our department during the last 11 years, incidents of multiple organ failure after surgery were investigated.
Multiple organ failure occurred in 38 patients (2.7%), many of them elderly men, and the prognosis was very poor, only eight patients survived.
The average number of the involved organs in the patients with severe infectious complications was larger than that without such complications. The time of the initial organ failure was an average of 5.9 days after surgery, long enough to be explained by an infectious complication. Moreover, many Gram-negative bacilli were found among prophlogistic bacilli. These results suggested a close relationship between multiple organ failure and severe infection.
None of the patients with failure of four or more organs survived, suggesting that early diagnosis and treatment are desirable.

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A safe method for extracorporeal circulation was investigated by utilizing clinical changes in hemodynamic condition, various metabolic processes and components of the blood cells, and the following results were obtained.
1) The combination of a holofiber-type lung with a centrifugal type pump has been the safest to date.
2) In extracorporeal circulation combined with core cooling, the lower the temperature was below 28°C, the greater was the disturbance in homeostasis.
3) The contents of the transfusion during the extracorporeal circulation had more effect on the postoperative hemorrhage volume than the number of thrombocytes at the end of extracorporeal circulation.
4) Improving the apparatus for extracorporeal circulation is thought to be more effective for protection of thrombocytes than drug therapy.
5) Miniaturization of the apparatus and establishment of a valid pulsation flow are needed to enhance the safety of open heart surgery.

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Primary squamous cell carcinoma of the breast is relatively rare, although reports concerning this condition have been increasing recently. The patient was a 50-year-old woman who had a lump with inflammatory change in the left breast. smear cytology of the tumor showed squamous cell carcinoma, and radical mastectomy was performed. Histologically, the tumor was well-keratinized squamous cell carcinoma, with no connection to the skin surface. No evidence of adenocarcinoma was denonstrated by alcian blue or PAS stain. This was interpreted as pure squamous cell carcinoma.
There are two types of primary squamous cell carcinoma of the breast. One is squamous cell carcinoma with adenocarcinoma, and the other is pure squamous cell carcinoma. The former is regarded as squamous metaplasia with adenocarcinoma and the latter as originating in the glandular tissue or metaplastic ductal epithelia of the breast. Clinically, the former type is much more common. In the last 10 years, there have been nine detailed reports of these two types of squamous cell carcinoma in Japan. It is very interesting that, among them, four (44.4%) had inflammatory change. As for the prognosis, primary squamous cell carcinoma of the breast is much the same as the other carcinomas of this tissue.

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A case of a 31-year-old man who had chronic constrictive pericarditis and underwent long-term hemodialysis for chronic renal failure is reported.
Chest and limb roentgenograms showed severe metastatic calcification in the heart and peripheral arteries, and a high serum PTH level and fibrous osteitis indicated secondary hyperparathyroidism.
Pericardiectomy, removal of calcified epicardium and subsequently total parathyroidectomy were successfully performed. Histologically, all parathyroid glands showed diffuse hyperplasia.
It is considered that the main cause of this case was metastatic calcification involving the pericardium and myocardium associated with secondary hyperparathyroidism.

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The incidence of subclavian artery aneurysm is very low. We have recently performed surgical repair of three cases of this aneurysm: in a 10-year-old boy, a 26-year-old woman and a 49-year-old man. Surgical repair was undertaken with the resection of aneurysm. The subclavian artery reconstructions were performed with end-to-end anastomosis (in two cases) and replacement with a double velour dacron graft (in one). The postoperative courses were uneventful. The incidence, diagnosis, pathogenesis and operative procedure for subclavian artery aneurysm are discussed.

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A child with the complaint of dyspnea was followed from birth emphysematous change in the right upper field and a cyst with air-fluid level increased progressively on serial chest films. Bronchography and bronchofiberscopy at one year of age demonstrated atresia of the right upper bronchus when the patient 17 months old, lobectomy was performed. The resected lobe had a bronchogenic cyst 2cm in diameter, and the histology of the distal parts of the resected lobe showed that of congenital cystic adenomatoid malformation.
A review of 70 cases in the literature indicated that most children who suffer from bronchial atresia complain respiratory symptoms, and some of them had other combined pulmonary lesions such as bronchogenic cyst, cystic adenomatoid malformation and lobar emphysema, though adult patients, for the most part, had no clinical complaints.

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A case of primary early gastric malignant lymphoma which was diagnosed preoperatively by characteristic findings in an upper GI X-ray examination is reported.
The patient, a 42-year-old man, was examined for nausea and vomiting over a period of nine months. Two years prior to admission, he was treated in another hospital for benign gastric ulcer. Current upper GI X-ray examination showed a IIc-like superficial depression extending from the middle gastric body to the pylorus. In the depression, multiple irregular ulcers with intervening nodularity were seen (Figs. 1, 2). These X-ray findings were considered characteristic of early gastric malignant lymphoma, which was later confirmed by a gastrofiberscope (Figs. 3, 4) and histologic examination of a biopsied specimen. The patient underwent subtotal gastrectomy (R₂) (Fig. 5, 6). Histopathologically, tumor cells were seen in the mucosal and submucosal layers (sm) (Fig. 7), and a diagnosis-diffuse malignant lymphoma, large cell type, as based on the Lymphoma Study Group classification-was made (Fig. 8). Metastases involving lymph nodes of the lesser curvature (No. 3) were found and he was considered to be at stage II of the Nagvi staging system. He was placed on combination chemotherapy (vincristine 4mg, Endoxan 1500mg, prednisolone 3500mg). His postoperative course was uneventful, and he is currently leading a normal life three years after surgery.

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This 50 year-old male was indicated as having his liver dysfunction with high serum ALP though screening examination, and sent to Toshiba Rinkan Hospital for further evaluation. On duodenal endoscopy, the papilla of Vater appeared enlarged and reddened. In September 1978, EST was performed with a diagnosis of papillitis. After this procedure, the patient's serum ALP soon recovered within normal range. At that time no biopsy specimen was obtained.
However in November 1979, fourteen months after the EST, he was admitted to the hospital again with complaints of jaundice and general fatigue. The PTC showed complete obstruction of the lower common bile duct with marked dilatation of the upper portion. Adenocarcinoma was detieled by the endoscopic biopsy of papilla of Vater. Pancreaticoduodenal resection was carried out. The size of the tumor was 1.2cm in diameter, and moderately differentiated adenocarcinoma was confirmed histologically. Postoperatively, the patient is in good health.

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A 77-year-old female with Von Recklinghausen's disease who presented with jaundice and fever was found to have carcinoma of the papillary region in the duodenum on barium meal examination, CT scan, ultrasound and percutaneous transhepatic cholangiogram. At laparotomy, multiple leiomyomas were discovered on the serosal surface of the jejunum. Only three cases of primary duodenal carcinoma with small bowel leiomyomas in a patient with Von Recklinghausen's disease have been reported in the literature.

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Of 32 patients with chronic pancreatitis who could be followed for more than six months postoperatively, those showing no dilatation of the pancreatic duct, defined as having a main pancreatic duct less than 6mm in diameter, underwent an analysis of their clinical pictures and operative results to investigate a desirable method of surgical treatment for this condition.
Of eight patients with an absence of pancreatic duct dilatation, localized lesions were found in five. These were disorders of pancreatic endocrine and exocrine functions and pancreatic fibrosis, the dogree being mild in most cases. In one patient with lesions in the head of the pancreas, plastic surgery of the papillopancreatic duct orifice for the purpose of removing pain seemed to be sufficient because there was no stenosis of the main pancreatic duct or other accessory lesions. In four patients with lesions in the caudal area, which were accompanied by accessory lesions such as stenosis of the main pancreatic duct at that area, cyst, and abscess, pain removal procedure or partial pancreatectomy on the caudal side for the accessory lesions was considered necessary.
Diffuse lesions were found in three patients, who also showed moderate or severe disorders of pancreatic endocrine and exocrine functions and pancreatic fibrosis. In such cases, extensive pancreatectomy including total pancreatectomy, is usually indicated. However, there are some doubts about the propriety of extensive pancreatectomy only for the purpose of removing pain. In this regard, we consider infusion of a sclerosing agent into the main pancreatic duct and total excision of the pancreatic plexus. The former method, however, has various problems to solve before its clinical application, requiring development of a new sclerosing agent. As for total excision of the pancreatic plexus, we have so far experienced only one patient, who has been followed up for a relatively short period of three months, with an extremely favorable course of postoperative conditions. It seems that this technique is a nromising surgical method for this condition.

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Two hyndred and seventy-one cases of acute appendicitis in children have been treated surgically at Kariya General Hospital during the period 1974-1983. There were the fact-finding studies of clinical practice with all these children. The incidence of acute appendicitis in children, especially perforative cases, has been moderately increased. A role of various factors about the increase is largely considered due to the possibility of delay in operation using preoperative administered antibiotics. Consequently, postoperative complications were increased than before. Therefore, we emphasize that the high potency antibiotics should not be administrated before surgery to set the earlier operation.

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A case of non-functioning neuroblastoma of the adrenal in a 28-year-old woman is reported. She was admitted complaining of left upper abdominal pain and high fever. Physiological examination revealed an elastic, well delimtted mass with smooth surface at the left hypochondrium. The findings from aortogram and abdominal CT suggested that the tumor originated in the left adrenal gland. However, this tumor was diagnosed clinically as a non-functioning adrenal tumor, because any abnormality was not detected in biochemical examinations, for example, urinary excretion of VMA, HVA, adrenalin, noradrenalin and dopamine, serum value of cortisol and aldosteron, etc. At the operation, the elastic hard tumor which had a well vasculized capsule, was found in the left retroperitoneal space. The tumor adhered to the left kidney so tightly that combined removal of the tumor and the left kidney was performed. Moreover, neither swelling of lymphnodes nor liver metastasis was not observed. Surgical specimen measured 14×11×8cm in size and the cut surface was gray with hemorrhage in part.
The histopathological diagnosis was rossete-forming neuroblastoma. There has been no evidence of recurrence for more than one year postoperatively.

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Some physicians use Bergmann's operation or Winklemann's operation for idiopathic scrotal and funicular hydroceles in infants, because it is said that hypersecretion or incomplete absorption in the remnant of the processus vaginalis causes retention of fluid.
I have excised 19 cords (remnant of the processus vaginalis) from 16 patients. No communicating channel between the peritoneal cavity and hydrocele was observed macroscopically, but the existence of a communicating channel was revealed microscopically, except in one serial section.
Thinking that the etiology of idiopathic hydrocele is the movement of ascites through this communicating channel, only high ligation of the hernia sac was used according to Ferguson's operation. As a result, sixteen scrotal hydroceles (fourteen patients), eighteen funicular hydroceles, and two Nuck's hydroceles have been cured. Therefore, high ligation of the processus vaginalis is recommended for idiopathic hydrocele in infants as well as for herniorrhaphy.

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