[Present relation of obstetrics and gynecology between the USA and Germany]. / Der gegenwärtige Stand der Beziehungen der Gynäkologie und Geburtshilfe zwischen den USA und Deutschland.

After World War II there was a blooming association between German and American Obstetricians-Gynecologists. When young German scientists began Fellowships in the US, they found German Professors of all ranks teaching in the various medical schools. At present there is no connection between the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) and the American College of Obstetricians and Gynecologists ACOG. There is however a close cooperation between ACOG and the Berufsverband der Frauenärzte (BVF) who invite their presidents on a yearly basis. An advanced formalization of the affilitiation between the two German Societies and ACOG is expected to benefit all Societies while not interfering with European connections.

[Incidence and etiology of brachial plexus upper arm paralysis in newborn infants. A review and basic principles for legal assessment]. / Häufigkeit und Ursachen der Oberarm-Plexus-Lähmungen beim Neugeborenen. Eine Ubersicht und Grundlage für juristische Uberlegungen.

OBJECTIVE: Brachial plexus injury (BPI) is a rare complication of pregnancy which is out of proportion involved in medical litigation. The aim of this study was to establish the relationship between shoulder dystocia (SD) and BPI and the frequency of BPI without explanation. METHOD: The pertinent literature was reviewed. In total 86 papers of the international literature were evaluated in regard to the frequency of SD and BPI and their relationship. Also BPI without obstetrical explanation were of interest (birth weight < 4000 g, cesarian section, palsies without SD). CONCLUSIONS: This literature review allows for the following conclusions: 1. The large number of papers describing SD in contrast to the much smaller numbers of BPI justifies the proposal to use the term SD only when it is associated with BPI. Otherwise the term "difficult shoulder delivery" seems more adequate and might reduce the number of papers. 2. The large number of BPI without SD, unexplained palsies without explanation and PPI at newborns with a birthweight < 4000 g do not allow a prima facie conclusion that BPI is the result of poor obstetrics (especially pulling on the head). 3. The lack of an operating note might establish such an association as well as the misinterpretation or failure of appropriate manoeuvers published in the literature. 4. The lack of a service regulation regarding the treatment of SD might be considered as failure of organisational standards.

[The future of the German language in science]. / Die Zukunft der deutschen Sprache in der Wissenschaft.

The German language served the scientific community for decades during the 20th century. The shift to the English language was considered by some as a loss of cultural identity. A view difficult to support, since not only Germany but also countries like Switzerland and Austria are part of the cultural heritage. The development of the impact factor, which is derived predominantly from Anglo-American journals, has also contributed to this situation. This may be of concern, since it influences the scientific future of young scientists from German-speaking countries. At present, no exclusively German-language journal in obstetrics and gynecology is listed in the Index Medicus anymore. If this means that the German-language scientific journals are not needed for the transmission of scientific data, they may evolve as organs for postgraduation studies. Interest in postgraduate papers only recently became evident in academic circles. In American CVs a rubric of postgraduate studies is separately provided. These are highly esteemed. The need for such postgraduate journals will be established when postgraduate studies become mandatory also in German-speaking countries. A lack of postgraduate papers may be overcome by an impact factor for postgraduate studies to encourage young academics to write such papers. Until German-language postgraduate papers are submitted in larger numbers, the editors of German-language journals are referred to the Anglo-American literature where such articles are available. Since a scientific journal, even when there are large subscription numbers, requires advertisements of the pharmaceutical industry, there is a potential for a conflict of interest between physicians and advertisers. In general, it can be expected that the number of German-language journals will drastically decline.

The beginning of human life.

The beginning of human life is seen differently by different individuals, groups, cultures, and religions. Embryonic and fetal life are a continuum, within which are time sequences and points--birth of a newborn, viability, neuromaturation, implantation, and conception--that may be declared as the beginning of human life. For each of these there are ethical and legal implications and considerations. Abortion laws reflect the interests of a given society at a given time. Although we have witnessed a change in the United States from virtual denial of the right to abortion to acceptance for certain reasons, abortion laws remain ambiguous. With the recent introduction of the antiprogesterones, it is conceivable that we will soon witness yet another procreation revolution with consequent increased controversy. Fundamental to productive debate and reconciliation between minority and majority groups is an understanding of the ill-defined concept of "the beginning of human life."

[The "cerebral palsy story": a misunderstanding and its sequelae]. / Die "Cerebral Palsy Story": Ein Missverständnis und seine Folgen.

Applying unproven medical technology to poorly understood fetal physiology resulted in a costly catastrophic mistake. Assumptions and false analogous conclusions led to the expectation that prevention of "fetal distress" could prevent brain damage. Hopefully the story of this mistake will be a warning for unproven medical technology.

[Theoretical medical considerations with reference to fetal and maternal rights in pregnancy termination]. / Medizintheorethische Uberlegungen hinsichtlich des fetalen und mütterlichen Rechtes beim Schwangerschaftsabbruch.

PIP: The question is when does human life begin. Whether it begins with fertilization depends on how human life is imagined: if as a conglomeration of gametes, sperm, and oocytes, then the placenta or a chorionic carcinoma also represent human life. The question is better asked: when begins the genetically, singly determined new human life. The biologically right answer to this is: the union of the haploid genome, which follows, at the earliest in a 8-cell stage, after 48 hours. It must also be considered that genetically unalterable life can also result from the division of an egg cell. Not every conception is fertilization, but every fertilization is conception. A genetic identity is only one of many representations including individual identity. However, many bioethicists hold the view that the embryo is not a person but a human in being. The legal position on human life in Germany is not clear, partly because there is no specific perception of the value of human life, which is defined in a time frame relating to pregnancy (terms, trimesters). The German Basic Law declared that the worth of human beings starts with fertilization i.e., before the beginning of genetic identity. On the other hand, Section 218 of the abortion law states that pregnancy begins with implantation. This raises the question of whether the embryo is accorded more protection than the fetus. The right of the embryo/fetus to life versus the right of the woman to autonomy is also relevant. Two major monolithic religions reject the right of the woman in the abortion issue where the right of the fetus prevails. Only Ireland and Louisiana do not recognize such a maternal right when the mother's life is endangered. Regarding eugenic indication the German law states that the pregnancy can be terminated on account of severe impairment of the fetus thereby reiterating maternal autonomy and evaluating less perfect life. The America abortion decision of 1973, which allows abortion up to the 22nd week of pregnancy, seems to be more straightforward.^ieng

[Do sex steroids cause breast and genital cancers? Epidemiologic data--the current status (July 1993)]. / Verursachen Sexualsteroide Brust- und Genitalkarzinome? Epidemiologische Daten--der gegenwärtige Stand (Juli 1993).

Present literature on epidemiology shows, that estrogens administered either in the form of contraceptives or as replacement therapy will reduce the relative risk of ovarian carcinoma to less than 0.5. Likewise this result was also seen in all studies without exception. The reduction becomes manifest after four months and is maintained for many years following discontinuation. The same applies to corpus carcinoma, provided estrogens are administered concomitantly with gestagens. Administration of estrogens alone results in enhancing the relative risk up to 3-4. Hyperproliferation can lead to carcinoma of the endometrium. No data are presently available for cervical carcinoma, that would justify the assumption, that the relative risk for squamous cell carcinoma of the cervix is increased. This statement does not apply to the adenocarcinoma of the cervix, since too few cases have been studied. The following statements apply to carcinoma of the breast: OC's (oral contraceptives) taken before the age of 45 do not increase the relative risk. This is also true of females, for whom a risk factor exists, as for example family case history, period of administration, benign diseases of the breast, use of OC's before the first pregnancy, nulliparity, no breast-feeding. Possible, but not proven is a slight increase in relative risk to 1.3 in females, in whom carcinoma of the breast had been diagnosed before the age of 34. If this increase is accepted, one must likewise expect a decrease in relative risk after the age of 45. A hormonal replacement therapy for up to four years will not increase the relative risk. This applies also to replacement therapy with gestagens, even though only few data are available at present. It has been concluded from the results of some studies, that a slight increase in relative risk to 1.3 is possible after long-term therapy (more than 15 years). However, no causal relationship to cancer of the breast has been established. It has not been claimed so far, that estrogens cause cancer of the breast. Should the slight relative risk increase be confirmed, this would mean, that in a small group of very young females, estrogens may promote the growth of an already existing cancer of the breast.

Confusion of trimester and viability. Consequences for abortion laws in the United States and abroad.

The present U.S. abortion law, Roe v Wade, is based on the trimester/viability concept. However, both concepts seem to be biologically ill founded and are likely to contribute to confusion regarding abortion laws. A survey of the abortion laws in individual states revealed a lack of uniformity. The time limit for abortion upon request varies from 13 to 28 weeks; nine states have no specific abortion law. This confusion also exists in other countries. Standards are lacking regarding requests for the dates of the last menstrual period, fertilization and implantation. Some states do not allow termination of pregnancy for maternal indications after 24 weeks, and the definition of maternal endangerment has rarely been addressed and remains vague. Only a few states have provisions for fetal malformation. Such terms as trimester and viability are not biologically founded and are likely to contribute to the confusion. The terminology should be clarified so abortion, contraception, birth control and other such terms are uniform.

Abortion: is there a rational precept?

Recent Supreme Court rulings have augmented the potential role of the individual states in abortion regulation. As a result, largely political influences have escalated the abortion debate to the point that there is currently no identifiable center, and consensus seems impossible. The traditional concept of viability has proven an inadequate basis for extension of personal rights and protections to the fetus. Conservative interpretation of a proposed neurologic definition of human life would suggest that human life does not start until approximately 70 days post-conception. Standardization and widespread acceptance of a definition of "brain life" would potentially clarify many medical and legal questions regarding elective abortion and would parallel currently accepted medical and legal definitions of death.

Benign breast disease.

Perhaps the most remarkable trend relevant to benign breast disease during the past year is the relative paucity of new investigations. This interesting trend is reflected in one of the most remarkable recent texts on this subject. In The Breast: Comprehensive Management of Benign and Malignant Disorders (Bland et al., eds. WB Saunders, 1991), only 70 of 1100 pages are devoted to benign breast disease. The majority of recent reports have focused on three issues: symptomatic treatment of breast pain, expectant management of clinically benign masses in younger women, and cytologic differentiation of benign and precancerous cystic lesions.

[Sexual development: development of secondary sex characteristics--Tanner stages 25 years later]. / Geschlechtsentwicklung: Die Entwicklung der sekundären Geschlechtsmerkmale--die Tannerstadien 25 Jahre später.

In a longitudinal study the british pediatrician J.M. Tanner evaluated the development of breasts (thelarche), of pubic hairs (pubarche) and age of menarche. In Hungary we did a similar evaluation in 680 girls in the years 1980 to 1986. Comparing these data in a cross-sectional study with similar data from Münster we named the results central-european study. The results are similar the Tanner ones exceptionally the duration of breast development, which was shorter than in the hitherto published longitudinal studies. Mean age of menarche in our study was 12.5 years compared with 13.5 years in the former ones. This is not a confirmation to acceleration of puberty, because in other countries age of menarche was stabile. Additionally, to thelarche, pubarche and menarche we collected data about axillarche.

[Therapy and prognosis of small breast cancers. Comparison of subcutaneous mastectomy procedures with ablatio mammae]. / Therapie und Prognose des kleinen Mammakarzinomas. Vergleich von subkutanen Mastektomieverfahren und Ablatio mammae.

A retrospective clinical study included 1283 patients with breast cancer. 307 of 762 tumours with known diameter (mm) were classified as stage pT1 (TNM, 70). Four groups were formed to compare the prognosis in subgroups of pT1 cancers: 0-5 mm (n = 22), 6-9 mm (n = 22), 10 mm (n = 53) and 11-20 mm (n = 210). A comparison of three types of surgery was made: Radical subcutaneous mastectomy (12), bilateral modified subcutaneous mastectomy (10, 11), and modified radical mastectomy (Auchincloss, 3). Both forms of subcutaneous mastectomy were combined with adjuvant postoperative radiotherapy to the side of the tumour. In this trial, patients were younger at diagnosis than usually stated in the literature. Small breast cancers had the same localisation and histology as large ones. Axillary lymph node metastases were identified from a tumour diameter of 6 mm upwards. Bilateral tumours were seen in 2 of 22 patients with tumours less than or equal to 5 mm. Multifocal growth was observed also in the same size range. Histologically different simultaneous invasive unilateral cancers were seen starting at a diameter of 8 mm of the larger tumour. Systemic metastases were observed in tumours of 10 mm in diameter. Local recurrences occurred in breast cancers with a diameter of 2 mm and more. There were no recurrences in the area of the nipple or areola in pT1 cancers. Small breast cancers did not appear to be biologically different from larger lesions. No prognostic subgroups of pT1 were evident beyond the established TNM staging. Disease-free survival was not significantly different between the three surgical approaches. Local recurrence was significantly less frequent after breast-conserving surgery. A negative influence of local recurrence on the prognosis was observed to a similar extent irrespective of the type of surgery. The concept of "minimal breast cancer" suggesting ablative surgery for a heterogeneous group of preinvasive and small invasive lesions is outdated. The different forms of subcutaneous mastectomy are a therapeutic alternative in the context of breast-conserving surgery of small infiltrating breast cancers. Especially the modified subcutaneous mastectomy (Beller) combines a good cosmetic result without prognostic impairment and with a potential reduction of the risc of contralateral breast cancer. Further potential applications include prophylactic treatment of high-risk patients with preinvasive lesions.