As regards hypertension in rural areas, many studies have so far been conducted in Japan by members of the Japanese Association of Rural Medicine and other medical societies. The findings have greatly contributed to the lowering of the incidence of cerebrovascular diseases. However, due to their still high incidence and problematic complications, they as yet remain to be one of the most serious health problems of rural people. On November 24, 1983, the author in had an opportunity to attend the 8th Congress of the Korean Association of Rural Medicine Seoul and had the honor of delivering lectures on the hypertension in Japanese rural areas. This paper was prepared in regard to the following four major aspects primarily on the basis of the relevent recent reports filed with the Japanese Association of Rural Medicine.
1 Epidemiology of Cerebrovascular Diseases and Hypertension. In terms of the mortality rate from cerebrovascular diseases, Niigata Prefecture ranks among the 10 top regions in Japan. This fact had led many medical scientists to believe that the incidence rate of the hypertensives in rural areas in the northern prefecture must be high. Actually, however, it was found to be low when compared with the national average registered in a nationwide survey of nutrition. The fact that replacing cerebral hemorrhage cerebral infarction has emerged as a primary cause of the deaths from cerebrovascular diseases in Japanese rural areas, suggests that it is necessary to probe into the factors that may lie in the process of transition from hypertension to cerebral Infarction, with emphasis on their possible link with the lifestyles and other environmental factors in rural settings.
2. Association between Hypertension and Lifestyles in Rural Areas. Aside from genetic predisposition, high salt intake is the most important factor contributing to the incidence of hypertension. Salt consumption should be reduced along with improvement of dietary habits. Especially important is proper intake of protein.
3. Hypertension Control and Clinical Tests. Before everything else, regular checkups on blood pressure are necessary for bringing hypertension under control. Among evaluating test results, electrocardiographic findings should be given a preferential status. Apperance ofe high R with strain pattern and atrial fibrillation should be taken special note of as a problem indicative of the onset of cerebral infarction. These findings suggest the occurence of heart failure in the development of cerebral infarction.
4, Ischemic Heart Disease among Rural Inhabitants. More Japanese-Americans who have emigrated from Hiroshima Prefecture than their relatives living in the rural areas of the prefecture were found to be suffering from hypertension, obesity, hyperlimpemia and abnormal glucose tolerance. And ischemic changes on ECG were more evident among these Americans of Japanese descent than the people in Hiroshima. Such findings suggest that the traditional daily fare of the rural communities in Hiroshima contains something that can prevent ischemic heart disease.
In conclusion, to bring hypertension under control in the agrarian society in Japan, strong willpower to that end is required at both individual and community levels.
Encouragement should also be given to farmers so as to have their blood pressure measured and receive ECG tests on a regular basis. On the otherhand, Japan's traditional dietary patterns are considered worth reviewing with a view to further reducing cerebrovascular disease incidence rate and preventing ischemic heart disease whose incidence is anticipated to go up in the future

Incidence of rheumatic diseases including rheumatoid arthritis falls to about 3 per cent of the whole population in Japan, but there has been no particular survey made so far in regard to rural population. With a view to grasping the situation of rheumatic diseases among rural people, we sent out a questionnaire to each medical service under the Agricultural Cooperative Association, and tried to surmise the incidence of these diseases in the locality on the basis of the number of patients treated by it. Disgnostic criteria of rheumatic diseases rested with each service. For each type of disease the rate of cases treated in each district against the total number of cases was obtained. Throughout the four year period of survey, the following trends were observed with regard to such rates:(1) Incidence of rheumatoid arthritis (RA) was higher in Kanto, Tokai and Chugoku districts, while it was lower in Hokkaido and Hokuriku-Shin-etsu districts;(2) Incidence of systemic lupus erythematosus (SLE) was higher in Chugoku and Tohoku districts, and was lower in Shikoku district;(3) Incidence of dermatomyositis (DM) was higer in Chugoku, Tohoku and Hokkaido districts, and lower in Kanto and Shikoku districts;(4) Incidence of polymyositis (PM) was higher in Tokai and Chugoku districts, while it was not reported from Hokkaido and Shikoku districts;(5) Incidence of scleroderma (PSS) was higher in Tohoku and Chugoku districts, but it was not reported from Hokkaido and Shikoku districts;(6) Incidence of periarteritis nodosa (PN) was higher in Tokai district, but was not reported from Hokkaido, Kanto and Shikoku districts;(7) Incidence of rheumatic fever (RF) was higher in Kanto district and lower in Tokai and Hokkaido districts;(8) Incidence of Behcet's syndrome (Beh), Sjogren's syndrome (SjS), Felty's syndrome (F), mixed connective tissue disease (MCTD), juvenile rheumatoid arthritis (JRA), overlap syndrome (OS) was on the whole higer in Tohoku and Chugoku districts, and lower in Tokai district.
Through this survey, we could at least gain a general view of rheumatic diseases treated in medical services under the Agricultural Cooperative Association. It became also clear that all of these diseases were on the increase. Further survey will have to be made in the near future in the light of respective diagnostic criteria.

Aging, hypertension and diabetes are the three major risk factors that predispose to atherosclerosis. The authors tried to elucidate the terminal clinical pictures of these three major factors in terms of the mechanocardiographical findings and blood chemistry parameters related to nutrition (NBC), which are considered to be useful for the determination of the signifying or trigger risk factors of impending cerebral attacks.
As the terminal clinical pictures of each of these three major factors, increase in peripheral resistance and inclination to low cardiac functions were observed. And in the process of transition to terminal pictures, increase in serum lipids and decrease in albumin, accordingly, increase in lipid/protein ratio were observed. Increase in such ratio is considered to be important for the development of atherosclerosis and low cardiac function.
In rural areas mortality rate of strokes is markedly higher than in urban areas. Such high stroke incidence may be ascribed to the marked increase in cardiac impairments, as compared with the urban hypertensives of the same age groups. The factor of cardiac impairments may be ascribable to different nutritional conditions.
Therefore, for the purpose of prevention against predisposition to strokes, early detection, as well as treatment, of cardiac impairments of elderly people, hypertensives and diabetics are deemed necessary. In this connection, improvement of nutritional conditions is very important.

It is to be noted that in rural districts where they live and work in fresh and clean air the incidence of chronic obstructive pulmonary diseases is as high as in the districts of air-pollution. Besides, there are a variety of respiratory diseases particularly incidental to life-environment and farm work. To be more informed of their actual conditions, the Japanese Association of Rural Medicine organized a special study group and has carried out various studies for four consecutive years with grants from the Ministry of Health and Welfare. The major results obtained are as follows:
(1) There were a variety of farm operations which produced or increased respiratory symptoms, including thrashing and scatteringof agricultural chemicals;
(2) It became clear that there existed in an advanced age group certain cases of “agricultural pneumoconiosis” which could be regarded as the terminal of the so-called “thrash-bronchitis”
(3) Among the cultivators of rush, raw material for Tatami, there existed cases of pneumoconiosis;
(4) There were a variety of agents to produce bronchial asthma, such as rice straw, chaff, tea-leaves and chrysanthemum-leaves;
(5) In Japan only two cases of farmer's lung were reported prior to this study. One more case was added to the list by this study group. Besides, cases positive to fungous agents were found among farmers in considerably high percentage.

Cerebral stroke in rural areas is a very important disease both from medical and social aspects. Among strokes, infarction which occurs most frequently in elderly persons is liable to result from atherosclerosis. And for the development of atherosclerosis, essential hypertension is the most important predisposing factor. Other than hypertension, aging, diabetes mellitus, hyperlipemia, esp. low HDL/Tch ratio, increased hematocrit values, coronary insufficiency, cardiac failure, arythmia, esp. atrial fibrillation, are also accepted important risk factors. Affirmative of such findings, the authors are convinced of the fact that atrial fibrillation which is increasing recently is closely related to both cerebral thrombosis and embolism.
But, in regard to cerebral infarction no signifying or trigger factor, similar to very high blood pressure, that trigger cerebral hemorrhage, is clarified as yet. It is made clear in this connection that cardiac failure predisposed by hypertensive heart disease in old age, assisted by pathophysiological and other environmental conditions, is the important factor. The authors also studied the clinical predisposing parameters and preventive measures about strokes.

Cerebrovascular disease is still considered a serious health problem in Japanese rural areas. The rate of death from the disease is very high. Many clinical and epidemiological studies have been conducted so far. However, they have failed to come up with answers effective for prediction and prevention of the scourge.
As part of the agricultural coop commissioned research project entitled “Study of Cerebral Apoplexy: Its Prediction and Prevention, ” we took a questionnaire survey in 1985-86, to obtain data as regards patients' subjective symptoms, electrocardiographic observations, hematological findings and many others before the onset of cerebral apoplexy. Five medical research institutes affiliated with the national welfare federation of agricultural cooperatives responded to our questionnaire.
As a result, the subjective symptoms that showed stochastically significant increases from one year to three months before the onset of the disease as a whole were fatigue, forgetfulness and insomnia. When it comes to cerebrovascular infarction, shortness of breath, angina, forgetfulness, and nocturia were particularly notable.
All these symptoms are not peculiar to cerebral apoplexy, but it should be noted that these are the warning signals of the killer disease.

It is to be noted that in rural districts where they live and work in fresh and clean air the incidence of chronic obstructive pulmonary diseases is as high as in the districts of air-pollution. Besides, there are a variety of respiratory diseases particularly incidental to life-environment and farm work. To be more informed of their actual conditions, the Japanese Association of Rural Medicine organized a special study group and has carried out various studies for four consecutive years with grants from the Ministry of Health and Welfare. The major results obtained are as follows
(1) There were a variety of farm operations which produced or increased respiratory symptoms, including thrashing and scattering of agricultural chemicals;
(2) It became clear that there existed in an advanced age group certain cases of “agricultural pneumoconiosis” which could be regarded as the terminal of the so-called “thrash-bronchitis”
(3) Among the cultivators of rush, raw material for Tatami, There existed cases of pneumoconiosis;
(4) There were a variety of agents to produce bronchial asthma, such as rice straw, chaff, tea-leaves and chrysanthemum-leaves;
(5) In Japan only two cases of farmer's lung were reported prior to this study. One more case was added to the list by this study group. Besides, cases positive to fungous agents were found among farmers in considerably high percentage.

One is inclined to imagine that the incidence of respiratory diseases will be negligible among rural people who live and work in fresh and clean air. On the contrary, however, we have reports on the high incidence of chronic obstructive pulmonary diseases and on the existence of a variety of specific respiratory diseases which are incidental to farm work. To clarify this situation, the Japanese Association of Rural Medicine organized a special study group and carried out various studies with grants from the Ministry of Health and Welfare. This is the study group's summary report of the four year research project prepared in conclusion of the project.
The actual state of respiratory diseases among rural people, as investigated by the present study group, can be summarized as follows:
1) In rural districts, in spite of its freedom air-pollution, there exist in high percentages people suffering from respiratory symptoms and patients of obstructive pulmonary diseases. As the important cause of this phenomenon, farm operations, especially thrashing, rice-hulling, compost preparation, scattering of agricultural chemicals can bementioned, which invite the development of symptoms and their aggravation.
2) Pathologically, farmer's pneumoconiosis attributable to farm operation dust was evidenced, crying for the necessity of dust prevention measure during farm operations.
3) In connection with atopic asthma the study group proved the antigenicity of rice-straw, wheat-straw, celiae of tea-sprout, young leaves, and chrysanthemum leaves. There are also anumber of already known antigens. It is necessary to establish measures for its prevention and treatment.
4) In rural districts of Japan, esp. in stock-raising farm houses, there are in comparatively high percentages those who react positive to fungous antigens which are the causes of farmer's lung. However, there have hitherto been reported only two cases, and the study group added one more. In the future, more extensive practice of immunological tests and clinical follow-ups of the positive cases will be necessary.
5) In view of the results reported above, it is considered that there are numerous questions concerning respiratory troubles and diseases in rural districts which are awaiting further study.