At the 47th General Meeting of the Japanese Association of Rural Medicine, I had the opportunity to present my experiences in rural medicine together with the philosophy developed through these settlement activities.
My involvement in rural medicine started at the end of the 1950s after working as a medical student in a farming village in Gifu prefecture, Japan. Also, during my internship I worked with people living on the boart in the Sumida river, Tokyo.
Through these settlement activities I found my mission as a physician.
That is, the physician must learn the patterns of human living and the circumstances surrounding them to find the key to medical philosophy.
At the meeting, I also presented additional experiences and opinions based on practicing medicine at the front-lines of community health care. Even if social circumstances change, the philosophy of medicine based on my rural medical activities will not. I believe we should create more balanced farming areas (with safe foods, pure natural resources, and a symbiosis between urban and rural areas) and should support these ideas by establishing a rural community health care program.

Since 1993, our hospital has been entrusted by the Gifu Prefectural Government with the operation of the home health care system in the region. Hospital healthnurses, keeping in close contact with other medical institutions and self-goverinig bodies, have endeavored to support the health and medical care of home patients.
Initially, there was much to be desired in the way some government offices were addressing to home health care and care coordination for patients when they were discharged from hospital. These inadequacies have largely been corrected and in 1998 a comprehensive home care system came into being.
Our effort to restructure the home care system has been crowned with success in many ways. Formerly there were many cases in which individual organizations rendered services separately, but now hospitals, local medical associations and government offices have come to play on the team, which has made it possible to provide home care effectively and efficiently. Moreover, the hospital staff have become fully aware of the importance of home care.

Telomerase has been reported to increase its activity in more than 80% of human pulmonary cancer tissue samples, thus potentially contributing to cancer diagnosis. This led us to try the measurement of telomerase activity in bronchoalveolar lavage fluid in cases clinically suspected to be primary pulmonary cancer. Methodologically, the measurement was made by means of TRAP (telometric repeat amplification protocol) assay, a high-sensitivity assay system using the technique known as polymerase chain reaction (PCR). The resultsshowed that telomerase activity in all the 6 cases, diagnosed as primary lung cancer histologically, was positive. On the other hand, on cytologic examination, 4 out of these 6 cases were positive, and the remaining 2 cases (squamous cell carcinoma and adenocarcinoma) were negative. Histologic examination revealed that of these 4 cases, 2 and 2 were pulmonary cancers and pulmonary tuberculoses, respectively. The above results suggested that examination of telomerase activity in bronchoalveolar lavage fluid may be useful for cancer diagnosis clinically.

Hereditary spherocytosis (HS) is a condition characterized by jaundice, hepato-splenomegaly tumors, and the presence of spherocytes. It accounts for about 70% of the reported cases of congenital hemolytic anemia in Japan. Many researchers state that this pathologic condition primarily arises from an abnormality of the red blood cell membrane. We have encountered a familiy, all the members (23-year-old daughter, 20-year-old son, 53-year-old-father, and 46-year-old-mother) of which had their cases diagnosed as HS by peripheral blood examination and electron microscopy. Excluding the farher, the peripheral blood examination also revealed anemia in the other family members. Moreover, the common HLA was found in all the members of these two families including the one on the mother's side, but human parvovirus B19 was not detected at all. We are providing the socalledprophylactic visiting care for the two families, while giving them information about HS which is arelatively easily-misunderstood hereditary disease. We did not find any report about married coupleswith hereditary spherocythosis. In this paper, we report our findings so far obtained through visiting care with some bibliographic discussion on HS.

During the one-year period from April 1992 through March 1993, we measured 25, 498 blood samples by the use of a sequential multichannel autoanalyzer, which our hospital installed in August 1991. Of the total, 4, 707 samples were thoroughly examined under the microscope. They included those from the patients for which physicians indicated laboratory testing, those samples whose white cell counts were less than 3, 000/μlor more than 10, 000/μl, the cases in which the amount of hemoglobin was less than 10.0g/dl, and the samples which defied blood typing. The result was that three cases of myelodysplastic syndrome were detected, although the autoanalyzer failed to find any abnormalities in these three cases.
Laboratory technicians in hospital are so busy that they hardly have time enough for thoroughgoing examination of hemogram. Nevertheless, the recent experience has brought home to us the importance of a microscopic scrutiny, into hemogram and its application to diagnosis.

With the diagnosis of metastatic tumor of the lung suspected, we had a chance to experience a histopathological case of carcinoma of the uterine cervix (adenoid squamous cell carcinoma), which was thought to coexist with carcinoid tumor. In this paper, we report the results of cytological as well as histological examinations of the case.
The patient was as 43-year-old woman. She visited our hospital, complaining about abnormally prolonged uterine bleeding (metrorrhagia). Cytodiagnosis was performed with a Papanicolaou smear. A microscopic examination revealed squamous cell carcinoma occurring together with adenocarcinoma. A similar finding was obtained by cervical biopsy. Thus, the case was diagnosed as adenoid squamous cell carcinoma.
Then the patient underwent radical hysterectomy and lymphadenectomy, followed by chemotherapy. After leaving the hospital, she was put under doctor-monitored observation. About 4 years after the surgery, a chest x-ray examination found abnormal shadows. For inspection, bronchoscopy was performed. Carcinoid of the lung was diagnosed through histopathological as well as electron microscopic examination of specimens taken from bronchial polyps during bronchoscopy. At the same time a cytologic study was conducted. It also revealed neoplasms strongly suspected of caricinoid tumors. Retrospective studies of cytological and histopathological images of the uterine cervix when the patient first visited us found only adenocarcinoma and squamous cell carcinoma, but no signs of carcinoid tumors. However, the immunohistological staining of NSE and chromoganins A, both neuroendocrine markers, showed positive findings in some adenocarcinomatous parts of the tissues of the unterine cervix. Therefore, we considered that the cervical cancer is compounded of adenoid squamous cell carcinomas and tumors having properties of neuroendocrine cells.
From this, we concluded that it is necessary to take into account a differential diagnosis of neuroendocrine tumors including carcinoid of the uterine cervix when less differentiated adenocarcinoma and squamous cell carcinoma are suspected in histological and cytological examinations. Furthermore, we thought it important to make a definite diagnosis after meticulous examinations by immunohistological staining and electron microscopy.

With household digital compact wrist blood pressure monitors, blood pressure was measured in hemiplegic patients who were receiving kinesitherapy.
During the training program routinely worked out by physical therapists, most patients had shown elevated levels of both systolic and diastolic blood pressure. There were some patients whose blood pressure went up so high as to call doctors' attention.
As changes in blood pressure are affected by various factors, we cannot say at once that doing exercise alone adds to blood pressure. Nonetheless, by using a household blood pressure monitor, it would be easy to know the extent to which blood pressure rises in accordance with the amount of exercise, so that it would be possible to make patients and their family aware of the importance of blood pressure readings. We thought it possible to obtain an index of the amount of exercise at home.

Magnetic resonance imaging (MRI) for diagnostic evaluation of the breast was performed in 61 patients who visted the Breast Clinic of our hospital and were suspected to have malignant tumors by physical examination and mammography between January and December 1999. In 58 patients undergoing histological diagnostic tests (8 with benignancy and 50 with breast cancer), we compared the imaging characteristics and the time-signal intensity curves acquired by dynamic imaging between benign and malignant lesions, and evaluated the usefulness of analyzing enhancement patterns on contrast MRI. Contrast MRI revealed strong tumor enhancement in all patients; the mean time required for the signal intensity to reach a peak was about 7 min in patients with benign tumors and about 2 min in those with breast cancer. Peripheral ring enhancement was observed in 40 of the 50 patients with breast cancer (80.0%), while such enhancement was not noted in any of the patients with benign tumors.
Although diagnosis of breast disease by imaging has primarily relied on mammography and ultrasonography, the pattern of contrast enhancement on dynamic MRI also appears to be useful for determining the treatment method of breast tumors.