Diseases of the digestive system have been the most frequently occurring malady in Japan. Foremost among them is stomach cancer in terms of the frequency of incidence and poor prognosis. In recent years however the incidence of colorectal cancer, a well-known malignancy of plaguing. Western countries, has been increasing also in Japan apparently as a result of the change in eating habit, and is expected to become the highest of all the rates of malignancies affecting the Japanese population in due course of time.
Under such circumstances, it is worthwhile to grasp the current exact status of occurrence of cancer of the digestive system in farming areas of Japan and to know the actual status of mass screening which is known to be effective in early detection of cancer, if it is to improve therapeutic results and thereby to establish ways and means of further effective cancer therapy.
The recent improvement in therapeutic results of gastric cancer is due largely to energetic mass screening and/or complete medical checkup activities of participating institutions and a marked increase in early detection rate of disease.Positive performance of an extended radical operation, such as total gastrectomy or extra-gastric organ resection, facilitated or aided by the improved anesthetic technique and postoperative management as well as by advances in surgical technique for advanced gastric cancer certainly is also a contributing factor. In fact, therapeutic results obtained by some of the participating institutinons were not at all inferior to those achieved by national institutions as far as gastric cancer is concerned.
Since mass screening for colorectal cancer is a formidable task apparently beyond each private institution's capacity and since, because of the anatomical position of a lesion, it may occasionally be difficult to have examinees cooperate, the mass colorectal survey system generally was less well organized and working as compared with the mass gastric survey system.
However, the availability of immunologic testing for occult blood in stools, enema fluoroscopy and colonoscopy has made it possible to raise detection rates of early-stage cancer. As in the case with gastric cancer, extended radical operation has been performed positively andtherapeutic results improved markedly thanks to recent progress in diagnostic and operative techniques.

I graduated from the Tokyo Medical and Dental Professional School in 1948. After I completed a 1-year internship, I joined the hospital attached to the alma mater as a member of the First Department of Surgery headed by Prof. Kenkichi Kawashima in April 1949 and worked at the hospital and school for 24 years and 9 months.
Professor Kawashima was a master surgeon having the highest surgical skill, as well as a true educator with exemplary character.
During this period, I received a basic training and instruction in surgical techniques as a surgeon from him, while I conducted research on liver, gallbladder, and pancreas diseases.
Subseqently, on October 1, 1973, I succeeded Prof. emeritus Kawashima in his position as the head director of Tsuchiura Kyodo General Hospital and have since there for 21 years. What I always kept in mind was not to damage Prof. Kawashima's reputation, to treat patients with sympathy, which Prof. Kawashima taught, and to manage the hospital soundly while training our juniors.
As such, my 45-year life as a physician can be divided into the school period and the hospital period.
[I The school period]
Majoring in abdoninal and thoracic surgery, I particularly threw myself into the studies of liver, gallbladder and pancreas diseases, and contributed to (1) the development of a cholangioscope, (2) advances in the treatment of malignant diseases in the liver, gallbladder and pancreas, and (3) clarification of pathogenesis of cholelithiasis, in particular strawberry-like gallbladder.
[II The Tsuchiura Kyodo General Hospital period]
In this period, I put emphasis on the providing of medical care to regional farmers and residents. For that purpose, I strove to restructure the hospital as a full-scale complete medical care facility, namely, a congregation of differently specialized centers.
The subjects that I concentrated on included (1) enlargement and improvement of the facilities in the Rural Health Care Center, (2) establishmeht of a perinatal center, (3) construction of a new Emergency Life-saving Center, (4) approval as a Local Cancer Center of Ibaraki Prefecture, (5) cooperation with Santenu Senile Care House, and (6) AIDS.
When I look back on my 45-year career as a physician, my respected professors who taught us in the school and the juniors with whom studies were conducted together were recalled.
I express my sincere gratitude to the chairman of Ibaraki Prefectural Koseiren and the officers who entrusted me with all the responsibillities of the hospital management, and the entire medical staff who were devoted to developing the hospital together with me.
These are friends with whom I have openly consulted for all problems which I faced since I entered the Japanese Association of Rural Medicine. I will share that joy by living together with friends.
Finally, what I would like to say is that I wish to continue to work for activating the association and medicine in which foresight and creative opinions of vigorous young people are respected and encouraged.

1) Japan made a remarkable recovery from ashes in the aftermath of World War II due to the people's effort to rebuild their lives and policy markers strong leadership. Moreover, great progress in medicine improved the quality of life.
2) A sweeping change in the living environment brought about a salient change in “disease structure.” There is no major difference between diseases endemic in the rural area and those in urban area.
3) Services provided by hospitals affiliated Koseiren (the Agricultural Cooperation for Health and Welfare) include internal medicine, pediatrics, surgery, orthopedics and obstetrics and gynecology. Medical services are provided by expert doctors in each department, and their mission is to improve the quality of rural medicine.
4) Apart from department-wise treatment, there is an interdisciplinary system making it easier for clinicians in different departments to cooperate. More attention should therefore be given to medical practices by these clinicians. Clinical medicine needs not be considered a particular type of practice in a rural setting. Rural medicine should be included in the category of general medicine.
5) Unlike teaching hospitals affiliated with a university, Koseiren hospitals have an extensive range of services including treatment of common diseases (eg, common cold or diarrhea, etc.), primary care, prevention of the three most common causes of death, treatment of lifestyle-related diseases, emergency treatment, a routine health checkup, home-visit nursing care services and home care. Given the present status surrounding a rural hospital which offers extensive services, young clinicians should no longer be equally encouraged to embrace the traditional idea of rural medicine. They should rather make better use of their expertise in the management of community-based medical services.
6) Studies on clinical medicine have gradually outnumberd those on rural medicine in the collection of lectures given at the general meeting of the Japanese Association of Rural Medicine (JARM) since its establishment indicating a change in the trend of rural medicine.
7) A course in rural medicine is not offered by the faculty of medicine in Japanese universities, which indicates that Japanese Ministry of Education, Culture, Sports, Science and Technology underestimates the importance of rural medicine.
8) Rural medicine dedicated to maintaining and improving the health of the rural populace is not related to the declining tendency of agriculture and rural population as a result of irresponsible Japanese agricultural administration. Rural clinicians are not responsible for that.
9) There is no point in discussing a definition of rural medicine usually influeneced by the thought, career and religious idea of those who govern. From my standpoint as a director of a community general hospital, I think clinical medicine should cover a broad range of areas.
10) Last but not least, my strongest hope is that an increasing number of young researchers will be interested in rural medicine besides pursuing their interests im their own area of expertise, and will be enrolled a members of the JARM. With a reduced number of members, the society's idea will die. I will follow the way that the JARM changes over time hoping for its further develpoment.

The effects of coronary artery bypass grafting (CABG) to conpletely obstructed coronary arteries (COCA), with angiographically demonstrable collaterals distal to the occulusion, on the lef ventricular contractility and postoperative symptoms were studied in 18 patients consisted of 10 with transmural myocardial infarction (TMMI) on ECG in the area perfused by COCA and 8 without TMMI. Of 19 CABGs including 13 to left anterior descending coronary artery (LAD), 5 to right coronary artery (RCA), 1 to left circumflex coronary (LCX), all 13 grafts to LAD and 1 to LCX were patent, whereas 2 of 5 to RCA were obstructed on the postoperative angiogram. The following evaluations were undertaken in 16 patients with patent grafts. In 8 patients with TMMI, left ventricular ejection fraction increased from 0.56±0.08 (Mean±SD) preperatively to 0.65±0.07 postoperatively (p<0.005), left ventricular segmental wall motion improved from 21.6±6.7% to 29.6±6.5%(p<0.01). Angina disappeared postoperatively in all patients but one with TMMI. All patients showed clinical symptoms of NYHA class III or IV preoperatively, which were improved to be of class I or II postoperatively. In conclusion, it was found that CABG to COCA, especially to LAD was associated with an excellent graft patency rate and with significant improvement of left ventricular contractility, even in the patients with TMMI.

We retrospectively studied the physical and neurological prognoses of 51 small-for-date infants (SFD) who had been taken care in our faculty during the neonatal period. The values of physical measurements of SFD at one and two years of age were both significantly smaller than those of the controlled appropriate-for-date infants. Majority of infants with symmetrical intrauterine growth retardation, whose head circumferences at birth were under -1.5 S. D., showed many complications during the neonatal period, for example; hypoglycemia and polycytemia, and their neurological prognoses were poorer than those with asymmetrical intrauterine growth retardation. To improve these grave prognoses, we stressed the necessity of the system which can provide strict maternal and neonatal care as well as the continuous observation even during the grownup under the co-operation of obstetrician and pediatrician.

The surgical treatment cases of 452 colorectal cancer patients at Tsuchiura Kyodo Hospital in the years 1973-87 were analyzed and the following results were obtained.
1) Operative cases of colorectal cancer have increased among the elderly. There was no difference between men and women. Recently, elder patients have been increasing with the advent of an aging society.
2) Survival prospects were better for women and younger patients.
3) There were no deaths in patients below 53 years of age. A high post-operative mortality rate was found in non-resectable cases.
4) Survival was significantly related to involvement of lymph nodes. Significant difference was recognized between the lymph node metastasis of n0 and n1. It showed good correlations with lymphtic invasion. Histological stages would reflect survival rates well as a factor predicting prognosis.
5) The cases of peritoneal dissemination were found more in younger patients than older ones. Age had nothing to do with liver metastasis. It was found more frequently in patients with serosal invasion, invaded by moderately differentiated adenocarcinoma and marked lymphtic and venous invasion.
6) There was a fall in the survival rate of patients undergoing curative resection almost according to age. Among them, significantly worse survival was found in patients aged 40-50 years, whose condition was mostly advanced on histological stage and Dukes classification.
7) Sufficient clearing of regional lymph node and considering of serosal invation for good prognosis from the surgical treatment are very important. For the future subject, to improve the surival rate, education about cancer. early detection and effect of multidisciplinary treatment are imperative.

During the twelve years from January 1978 to December 1989, a total of 1, 409 cases of gastric cancer were treated in the surgical department of Tsuchiura Kyodo Hospital, located in the southern agricultural district of Ibaraki Prefecture.
Observations on these cases revealed: 1) Cases of gastric cancer tend to decrease, 2) Results of surgical treatment are improving remarkably, in terms of the resection rate and five-year survival rate, and 3) Most of the patients who survived more than five years after surgery are in satisfactory conditions.
The main factor contributing to the improvement of the results of surgical treatment of gastric cancer was increased detections of cancer in relatively early stages through mass survey or total check-up in the asymptomatic stage.
The decline of the morbidity rate of gastric cancer is reported to be more prominent in younger generations. This fact and the aging of the population in our society, especially in rural areas, will increase the number of elderly gastric cancer patients.
The future of surgery of gastric cancer depends on how early we can detect cancer and treat elderly patients. For this purpose, mass survey and total check-up on older people will be the most effective means.

Three main factors that sway the postoperative prognosis of stomach cancer are, the curability of the surgical operation, the depth of the cancer lesion and the stage of the disease. With these factors in mind, we further studied what other factors could influence the long-term prognosis of stomach cancer.
We picked up two categories of patients from our file of stomach cancer cases. Category one; those patients who survived five years or longer after surgery, although the operations for them were not curative, or the depth of the lesion in these patients reached to the serosa, or the cancer was in stage IV. Category two; those patients who died of stomach cancer within five years after surgery, although the operations were curative, or the depth of the lesion reached only the submucosal layer, or the cancer was in stage I.
By comparing these two groups, we found out the factors that influence the prognosis.
1) In the cases of absolutely curative operations, the factors that made the prognosis worse, were that the lesion was advanced, that the lesion existed in the C region, and that the lesion was poorly differentiated histologically.
2) In the cases of noncurative operations, caused by P1, H1, ow (+) or aw (+), factors that brought a good prognosis were, that the lesion was not of diffuse type, that there was no lymph node metastasis, and that lymph node dissection was done effectively.
3) In the cases of early gastric cancer, lymph node metastases made the prognosis worse. Even when the lesion reached the serosa, prognosis was favorable if cancer cells did not invade other organs, had no peritoneal dissemination, or if lymph node dissection was perfect.
4) In the cases of stage I histologically, prognosis was poor when the cancer looked advanced to the naked eye.
5) In the cases of stage IV, when the degrees of lymph node metastasis was slight and lymph node dissection was done adequate, prognosis was good.

An investigation was performed about clinical histories before hospitalization in 1142 cases of gastric cancer during 16 years from 1969 to 1984.
The average term from onset of the disease to hospitalization was 4.53 months which tends to decrease becoming 3.49 months in the latest 5 years. The patients had visited 0.72 other doctor in average before coming to our hospital, 0.35 in early cancer cases and 0.83 in advanced cases. The sources of patients of our surgery were as follows ; 60.5% were introduced from medical department of our hospital, 20.2% were introduced from other clinics or hospitals, 10.6% visited our surgical department directly, and 8.7% came to us after visiting one or some other doctors. The rate of early cancer cases were high and unresectable cases were low relatively in cases from our medical department and direct visitors to our surgical department.
The causative factors of delay of hospitalization more than one month were considered from both sides of patient and doctor. The results were ; no delay 55.3%, delay due to patient's fault 28.2%, delay due to doctor's fault 19.9%. The delay of hospitalization due to either side's fault was one factor of decreasing early cancers and increasing advanced cases. Among those with no delay, however, 22.6% were unresectable cases. Gastric cancers are too malignant to be cured by visiting hospitals with complaints. Gastric mass survey among symptomeless people is the only reasonable way to come out of this difficult situation.

We began gastric mass survey at our hospital in May, 1980. During 3 years and 8 months since then, (May, 1980-December, 1983) we performed screening examinations to 16, 341 people by indirect radiography, and checked 2, 824 cases (17.3%) for thorough examination. Among these cases, 2, 083 (73.8%) received endoscopic examination actually, and 55 cases of gastric cancer were discovered. The discovery rate of gastric cancer was 0.336 per cent.
35 cases of these 55 gastric cancer were operated in the surgical department of our hospital. 34 cases were resected (rate of resection was 97.1%) and 33 cases were resected curatively (rate of curative resection was 94.3%). These results were better than that of gastric cancer cases from out-patient clinic of the same period. The results of cases from out-patient clinic of our hospital were: total number of cases 321, resected cases 254 (79.1%), curative resection 189 cases (58.9%), respectively.