The present volume is concerned with bone surgery in the area of the facial skeleton. We find this branch of maxillofacial surgery espe- cially challenging because in our work within the Surgical Depart- ment of the University of Basle, we are constantly being confronted with the principles of internal fixation - in the care of poly- 1 traumatized patients, in organizing joint AO-ASIF courses or dur- ing trauma conferences. The problems of fracture disease and the unpleasant sequelae of unanatomical healing are by no means alien to maxillofacial surgery. Our main aim is to broaden our experience of the basic principles of stable anatomical fixation and early function in this branch of trauma and corrective surgery. It soon became apparent that pri- mary healing of fractures and osteotomies, as well as undisturbed re- vascularization of bone transplants and long-term tolerance of inert implants and joint prostheses depend on the stability of fixation un- der preload.

At the beginning of this century, the state of surgical technique only provided for concepts with an extracardial approach to therapy of coronary heart dis eases. Decreasing the heart activity by means of denervating the heart or thyr oidectomy, resulting in a reduction of the heart's oxygen demand, was strived at. Later, the progress of clinical surgery at the closed beating heart allowed for procedures with myocardial access. In this historical stage of indirect revascu larisation, a compensation was supposed to be stimulated operatively by pro viding an adhesion to the surrounding organs or by manipulating the larger heart veins. The simple ligation of the Arteria thoracica interna in the middle third of its course - intended to increase the perfusion of pericardial branches - is based on the fundamental ignorance or misunderstanding of the haemody namic laws. The first intervention to reach temporary popularity was the im plantation of the Arteria thoracica interna into the left ventricular myocardial wall. This so-called "Vineberg procedure" was not very risky and did show some permanent improvements with respect to the patient's complaints or even the prognosis. However, this procedure has been almost completely aban doned, despite the fact that some positive long-term courses have been docu mented. Other indirect revascularisation procedures carried out in the fifties, e. g."

Hemorheologic therapy has gained considerably in importance in recent years. This detailed and comprehensive book enumerates, discusses, and critically evaluates those treatment methods in which therapeutic success rests essentially on achieving an improvement in hemodynamics. After a general account of clinical hemorheology, fundamental aspects of hemorheologic methods and the eval- uation and assessment of hemorheologic parameters are discussed and the pathophysiology is described in detail. The treatment methods and substances that bring about improvement of the hemodynamics are described in chronologic order of first publication, and in each case all known later publications are also discussed in the order in which they appeared. This topical account of hemorheologic therapy - the results reported to date and the spectrum of applications - will be a valuable addition to the library both of the specialist and of all interested doctors in hospital and general practice.

I have particular pleasure in introducing this publication by Gian Pietro Marzoli and Sergio Vesentini. Years ago they enthusiastically accepted my suggestion that they should take specific interest in the clinical and surgical problem of portal hypertension, and assess the proposals of surgical ex- perience with regard to this debated physiopathological picture. These thanks are all the more real because in this way the school's attention remained fixed on a subject that had already attracted it profoundly from the start - with Giovanni Castiglioni and Vittorio Pettinari as heads of the school - and then threatened to die away into general con- formism. In Italy "precariousness" is easily extended to the concept of school continuity. In Warren's proposal (1967) of "distal splenorenal anas- tomosis with disconnection of the spleno-oesophageal from the mesenteric district", I felt there was an intelligent at- tempt to solve all the basic problems, albeit in different ways. An attempt, that is to say, at alleviating the gastro- oesophageal circulation, thus avoiding* haemorrhage, and at ensuring that the liver would maintain the circulatory ef- ficiency with which it was still endowed. The spleen was re- tained, but there was reason to think that, by reducing blood stasis within its ambit, it would be possible to manage or alleviate any hypersplenism: not an absurd hypothesis if the Americans had sometimes noted in their material function- al and even anatomical reversion of the splenopathy after a simple portacaval shunt.

The Fourth International Copenhagen Symposium on Detec tion of Breast Cancer, which took place in Copenhagen August 1988, made it possible once again for scientists from all over the world to come together to present the latest advances in the fight against breast cancer. This book forms a synthesis of important contributions, with special reference to follow-up screening trials, stereotactic X-ray guided fine-needle aspira tion biopsy procedures, and new and important contributions to our knowledge concerning nonpalpable breast tumors. It is our fervent hope that the reader of this book will be encouraged to join in the struggle against breast cancer, especially screening programs, in order to detect the disease as early as possible, bearing in mind that breast cancer, in spite of recent advances, still is a dreadful strain on women throughout the world. S. Brunner B. Langfeldt Contents E. L. Kitts, Jr., J. Beutel, R. S. Holland, and B. Blank Relative Doses in Mammography: The Future Development of Film/Screen Mammography Systems . . . . '. . . . . . . . . . . . . . . . . . . . . 1 R. McLelland . Earlier Detection of Breast Cancer: An Overview 10 J. Leveque, e. O. Lorino, and J. J. Ferrara Inflammatory Disease of the Breast. . . . . 18 R. McLelland Stellate Lesions of the Breast 24 R. McLelland Screening for Breast Cancer: Opportunities, Status and Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . 29 S. A. Feig Follow-up Studies of the Health Insurance Plan Study and the Breast Cancer Detection Demonstration Project Screening Trials in the USA. . . . . . . . . . . . . . . . 39 R."

After the Second World War the number of biliary diseases has abruptly risen and lithiasis has become in many regions the most frequent surgical disease of the abdomen. At present, though there are perspectives of rational conservative treat ment and though endoscopic techniques permit removing some of its complications even without laparotomy, the basic treatment method still remains, and probably shall remain for long the classical surgical intervention. On the contrary, the indications for such intervention are always widening, as its risks become always smaller and the requirements for prevention higher. Many books have been written on the surgery of biliary ducts, but recent knowledge is growing so rapidly that it forces within short periods its new integration and critical assessment. Attention is mostly paid to interventions on the biliary ducts with their wide scope of problems and to the prevention and treatment of postoperative disturbances. New and more perfect diagnostic possibilities and some more suitable technical procedures as well require comparison and verification, introduce new aspects on old problems, and even change some established rules."

General pathologists see many biopsies from transplanted organs but few are in large enough centres so that this forms the bulk of their work. The book describes the changes which can be observed in transplantation in all of the major organ systems that are routinely transplanted and there are accounts of the pathology of infections and of the immunological difficulties that are faced by these patients. The volume will be a valuable guide for those who wish to braoden their knowledge in this field.

Boston University School of Medicine has established a series of Medical Education Programs in Nutrition held each summer since 1975. These deal with controversies in human clinical nutrition. The subjects have covered various topics, including those dealing with the relation ships between diet and heart disease, diet and cancer, breast. versus bottle-feeding, and dietary fiber and disease. Other noncontroversial topics were also covered at these conferences; they were discussed simply to bring to the attention of the health professional new happenings in nutritional research. These topics dealt with the relationships of nutrition to immune function, to neurotransmitters, to infection, to obesity, and to chemotherapy. This text is a compilation of selected manuscripts of interest to the health professional in the area of human clinical nutrition. Whatever success this text enjoys is in no small way due to the ad ministrative and editorial efforts of our administrative assistant, Mrs Geraldine Rankin - our sincere thanks."

by Dr. Nathaniel R. Bronson, 11 This volume serves a two-fold purpose very nieely. For the ophthalmologist there is a presentation of the teehniques and results of ultrasonie examination of the eye and orbit. For the radiologist or general ultrasonographer the essential oeular anat- omy and pathology are deseribed with these findings. Unlike eon- ventional x-rays or statie general body ultrasonograms, the exami- nation of the eye by real-time ultrasonography must be done by an examiner with extensive personal knowledge of the eye and the orbit, both anatomieally and pathologieally. The student must realize that the Polaroid photographs ean only show an example of what was transiently seen, such as spot films taken during fturo- seopy. This is further eomplieated by the poor reproduetion by Polaroid films of the aetual gray sc ale seen during the examination. Considerable work has been done to prepare this text. The author has done elinieal ultrasonography of many eyes and presents the findings of his experienee. As in most fields of medieal diagnostie work this experienee is essential to aehieve the best results. The beginner in ophthalmie ultrasonography is eneouraged to work with known pathology. Fortunately, pathologie ehanges in the eye vii FOREWORD can frequently be seen with a slit lamp or an compared our ultrasonic diagnosis of orbital ophthalmoscope. For example, a known retinal masses with those of the same patient done on a detachment is an ideal case with which to start. CAT scanner.

The Nd: YAG laser has finally become the multidisciplinary and muitispeciaity tool of the 1980s. Primarily developed for gastrointestinal applications for controlling bleeding, at present it is also used for endoscopic treatment of gastrointestinal tumors, endobronchial cancer, and bladder and gynecological lesions and finding applications in otorhinolaryngology and neurosurgery. De velopment of laser scalpels and focusing head-pieces has now allowed the Nd: YAG laser to be used for open surgical procedures in general and plastic surgery, head and neck surgery, urology, gynecology, dermatology, and neu rosurgery. The rapid development in ceramic technology has led to contact surgery allowing physicians a choice of excision, vaporization, coagulation, incision, or combinations thereof by easily changing probes rather than having to select new laser wavelengths. This technology is rapidly replacing the carbon dioxide laser which currently has no adequate flexible waveguide for fiberoptic en doscopy, cannot be used in a water medium (e.g., bladder), and has poor coagulation properties when compared to the Nd: YAG laser. Future developments may see the Nd: YAG laser even replacing electro cautery in the operating room due to its greater safety and efficacy. Local hyperthermia (laserthermia) with computer control, photodynamic therapy, and ophthalmic applications make the Nd: YAG laser the most exciting tech nological advancement in medicine and surgery for the 1980s."

The "shoulder-hand syndrome" or pain in the shoulder or arm is an extremely vital subject for the multi-disciplinary approach and usually re quires more than one speciality for complete evaluation. The proceedings of this symposium - organized by the department of general surgery of the University of Limburg - cover the field thoroughly with contributions from outstanding specialists from all over the world. Rheumatological, neuro surgical, orthopedic, and traumatological aspects are covered. Vascular surgeons considering both venous and arterial problems entwine with thoracic surgeons to review the thoracic outlet problem. Establishing a diagnosis in this multi-disciplinary field is extremely important and encom passes a combination of disciplines including neurology, orthopedics, sur gery, and physical medicine. Likewise, the role of each contributing factor must be assessed when multiple sources were responsible for pain. In addition to adequate diagnosis, it is important to institute the appropriate therapy and to establish the proper priority and timing of such therapies. The follow-up techniques particularly regarding thoracic outlet syndrome are extremely important to provide an objective basis for evaluation. Although many advances have been made in the field of objective diagnosis and therapy, there still is a great deal of overlap and confusion which has to be clarified. Professor Greep and his organizing committee have done a wonderful job in composing a program covering all aspects of this field. They are to be congratulated on bringing us a "timely current status" report on pain in the shoulder and arm."

It was not too many years ago that the role of chemotherapy for head and neck cancer consisted of single-agent methotrexate for selected patients with recurrent disease. In the past decade, multiple new agents, high-dose chemotherapy, combinations, and intra-arterial approaches have been used for the patient with recurrent disease. Wheeler critically assesses the current status of these approaches. When oncologists began testing chemotherapy in the combined modality approach, trials consisted of induction chemotherapy and use of single agents as radiosensitizers. Although a great deal has been learned from these trials, benefit in terms of survival has been marginal. Even more promising may be the concomitant use of combination chemo therapy and radiation. Taylor describes the encouraging results as well as the potential. Induction chemotherapy may have a second important goal in addition to improving curability-it could be used for organ preservation. Dimery et al., present the background for this approach in the patient with laryngeal cancer as well as a description of their randomized trial for voice preservation. Head and neck squamous cancers are a heterogeneous group of diseases, and surgeons have long sought parameters that will help predict outcome."

Dear colleagues, Promotion of the development of ENT is one of the most important tasks of IFOS (International Federation of Otorhinolaryngology). Apart from organizing the World Congresses it supports different international and regional meetings, organizes symposiums on well determined subjects, etc. Since the last World Congress in 1981, in addition to the Danube Symposium in 1982 and the Congress of ENT Societies in Asia Oceania in 1983, an international symposium was organized in Antwerp by the Belgian ENT Society on evaluation problems of middle ear surgery. This is a very controversial question on which there is no concensus. During a four-day meeting many anatomical and pathological aspects, operative methods, possibilities of the evaluation of the results with computers, were widely discussed. You will find all the lectures presented in this book. I am convinced that these papers will prove to be a good basis for further discussion and hope that finally we shall achieve an international agreement on the evaluation of our results in middle ear surgery. My thanks go to Professor Marquet for organizing the meeting and for publishing the papers. Professor Dr. L. Surjan President of IFOS 10 WELCOME Dear colleagues and especially dear Professor Marquet, In my function as pro-rector of the University of Antwerp I am very proud of welcoming you to the opening of the International Conference on "The Postoperative Evaluation in Middle Ear Surgery." It gives me the opportunity to stress the importance of this congress and to honour Prof. Marquet."

During the past decade extensive investigations have been done on the testis. Since the observations have been published in many different journals. it seemed appropriate to bring together and summarize some of the pertinent findings in a single volume. Twenty-eight scientists and clinicians from nine countries have contributed to this book. They have reviewed the literature and presented their own, new observations on the developmentaL anatomicaL physiologicaL biochemical and pathological aspects of the descended and cryptorchid testis. In addition, several contributors have evaluated the usefulness of certain animals as models for systematically studying specific aspects of cryptorchidism. It is hoped that this volume will serve as a useful summary and reference for those working in this area and that it will encourage further research in testicular physiopathology. The editor thanks the contributors for their enthusiasm, cooperation and meticulous writing of the chapters. The support of the Departments of GynecologyjObstetrics and the Department of Physiology of Wayne State University School of Medicine. Detroit and the assistance from the staff of Martinus Nijhoff are gratefully acknowledged. The cheerful cooperation of Miss Lori Rust and Miss Penny Stoops who helped to type and assemble the volume is most deeply appreciated.

As a clinical discipline blood transfusion encompasses enormous vista, vary ing from biotechnology to molecular biology, from plasma products, cell biology and growth factors to interleukines. Growth of knowledge in this field has been rapid, and expertise is now required to be mastered and renewed in translating these ideas for patient care. Various types of cells could be harvested - progenitor stem cells derived from bone marrow or from circulating blood as a source for transplants; in the hemostatic armoury platelets could be used prophylactically; granulocytes and mononuclear cells are available for treatment of infections or immune modulations. However, their therapeutic use carries potential complications including graft versus host disease and CMV-infection. Prevention of such complications by irradiation and by removal of immunocompetent leukocytes are important issues. Thus, production of such therapeutic materials ought to address the issues at the earliest, to eliminate those problems while adhering to the con cept of high quality; the impact of storing platelets for longer periods by using improved plastic containers or storing almost indefinitely in frozen state should be explored. Rapid progress in cell culture techniques and bio technology have enriched the transfusion medicine armoury with lympho kines, interferons and cell colony growth factors which have great potentials for enhancement of basic knowledge as well as considerable therapeutic applications in patients.

This text was designed for the physicians, nurses, technical personnel, and staff members of medical facilities using lasers for surgical, therapeutic, and diagnostic purposes. The objective is to provide an understanding of the potential health and safety hazards associated with the use of medical laser systems and the precautions needed to use them safely. To do this, it is necessary to have an awareness of applicable standargs and regula tions that apply to laser use. This book is not intended as a substitute for the American National Standards Institute (ANSI) Z-136. 3, "Safe Use of Lasers in Health Care Facilities," but to facilitate its implementation as well as the implementation of the many other related regulations and guidelines that are pertinent. These other regulations include the Medical Device Amendments to the Food and Drug Act, the Federal Laser Product Performance Standards issued under the Radiation Control for Health and Safety Act, and applicable regulations of the Occupational Safety and Health Administration (OSHA). The text is organized to provide first an overview of laser hazards, laser surgical applications, and laser biological effects. General safety control measures and safety standards are then presented. Because laser tech nology is rapidly evolving, these general guidelines will allow safe use of new laser systems as they become available. Finally, specific safety guide lines and precautions are provided for specialized laser applications in the different health care specialties."

DR. R. E. SMITH The first and second Coventry conferences on "Surgery of the Oesophagus" and "Surgery of the Lung" were arranged by Mr. Roger Abbey Smith, and they were so successful that he asked his colleague, Mr. J. A. Dyde to arrange one on "Surgery of the Heart." He willingly accepted this task and has also been joint Editor. This book reproduces as faithfully as possible the papers and the discussion on the various subjects included in the Coventry conference. The simple title "Surgery of the Heart" could be expanded to include the blood vessels. Especially important is the anatomy of the various combinations and permutations of the pulmonary and systemic vessels. These playa major role in the production of pulmonary hypertension. First class investigations by radiologists, and physiologists ascertain the precise situation which the surgeon will expect to find when he opens the chest; indeed will help him to make the right approach. Mr. W. G. Williams helped with the social programme which enabled people to meet people. Mr. A. Martin gave us valuable help in taping the recordings which Mrs. J. Jelley and Mrs. V. Bayliss-Stranks ably transcribed. The editorial staff of Plenum Publications have given us unsparing advice and guidance. v PROLOGUE DR. R. E. SMITH I welcome you all to this conference on Surgery of the Heart.

A variety of new cancer therapy modalities are discussed and evaluated in this book. It aims to demonstrate that the combination of classical chemo- and radiotherapy with new approaches in the field of immunotherapy can result in an improved treatment modality. Immunotherapy in this context consists of therapy with monoclonal antibodies, hematopoietic growth factors and other lymphokines. Results of early clinical trials with IL-2, GM-CSF and monoclonal antibodies against gastrointestinal tumors and melanoma are included. The progress in regional chemotherapy strategies, for example of the liver, is shown. In addition, the development of new chemotherapeutic agents with a different mode of action as well as better tolerability is presented. The use of hormones, such as LH-RH agonists, allows hormone-dependent tumors such as prostatic and breast cancer to be treated without strong adverse reactions. These recent findings give the reader insight into exciting therapeutic directions made possible by such combined, rather than single, modalities.

Readers of the first volume of Progress in Orthopaedic Surgery may remember the introductory remarks of Drs. Wagner and Hungerford. It is the intention of the editors of this publication to familiarize English - speaking orthopaedists with articles published in the European literature which, because of language barriers, would otherwise be inaccessible to them. Most articles in this second volume also are translations of papers originally printed in Der Orthopiide. The purpose of this German medical journal is to disseminate the newest experiences of orthopaedic problems in a form that is of particular value to the practising orthopaedic surgeon. In 1973 eight articles were published on acetabular dysplasia. In his fore word to this issue Dr. Wagner stated some of the reasons why such an indepth study was deemed necessary. He was of the opinion that the shallowness and increase in acclivity of the acetabulum was of such central importance in the development and treatment of hip dysplasias that a volume dealing with this subject was fully justified. Another reason for this collection of papers was the advances made in correcting the results of a dysplastic acetabulum by surgical means and thereby improving hip joint function in later years, or at least pre venting its early deterioration."

After a practical description of the endoscopic anatomy, the first part of the book deals with such topics as preparing and positioning the patient, anaesthesia, operation theatre layout and operating team, inducing pneumothorax, general operative steps, after-care in the hospital, prevention of thrombosis, prophylactic antibiotics, dangers and risks of the method, and the use of documentation. General operative steps such as thoracoscopic exploration and palpation intervention haemostasis andparenchymal leaks are described in a separate section. A special part isdevoted to the diagnostic possibilities and current indications for thoroscopy including: spontaneous pneumothorax, haemothorax, chylothorax; pleural empyema, bronchopleural fistula, extrathoracic and intrapulmonary cysts and tumours, pericardial fenestration, treatment of malignant effusions, and thoracal sympathectomy.

Heart surgery is still a relatively recent advance in medical technology. The first open-heart procedure was closure of an atrial septal defect in a child at the University of Minnesota Hospital in 1953. This issued in a life-saving advance, the use of which has expanded enormously to in clude treatment of many areas of cardiac disease. Not unexpectedly, surgical techniques allowed through the use of the heart-lung machine (open-heart surgery) came to be applied in 1967 to the major killer of Americans, namely, coronary artery disease. This operation, known as coronary artery bypass, has become one of the most common surgical operations. Coronary artery disease, with the possibility of total incapacitation or sudden death from a heart attack, can alter severely the personality of the patient. Corrective surgery can sometimes intensify rather than ame liorate a patient's fears. To the surgeon, occupied by increasing numbers of patients, there is not time enough to give the preoperative attention that might be helpful. Also, the surgeon and cardiologist are limited in their ability to recognize those patients near the breaking point. The research outlined in these chapters by Drs. Pimm, Feist, and their associates is welcomed by cardiologists and cardiac surgeons. It provides insight into what appears to be reliable recognition of those patients likely to have an adversely affected mental status by coronary bypass surgery and "crisis intervention" to avert this effect and allow the complete benefit of returning the patient to a normal life."

J. Navratil The performance of operations on the heart and its replacement by a trans planted or artificial heart has been an age old dream of man. Rehn for example in an early attempt, in 1868 performed a closure of a heart wound after a thoracic puncture. At that time noone thought that this attempt was the beginning of cardiac surgery. The dream was partially realized when the replacement of the heart function by the heart-lungmachine became possible. Immediately following the first operations, cardiac surgeons and cardiologists saw with great enthusiasm that this machine could be an important tool for correcting congenital and non congenital heart diseases. However, the heart-lungmachine was soon seen to not be an optimal instrument for controlling cardiac failure after cardiopulmonary bypass or myocardial infarction. then arose for the development of mechanical assistance to the heart. Concepts The rollerpump was first designed for assisted circulation and could be applied clinically in 1962. A new concept of mechanical assistance to the heart was pro vided by the intra aortic balloon pump and later by the bypass ventricles. Use of the intra aortic balloon pump can reduce cardiac work by counterpulsation in accord with the natural ECG. The bypass ventricle can functionally replace the heart in series or parallel to the natural heart. The intra aortic balloon pump, now an established method, has reduced the number of patients who used to die from cardiac failure."

Many pathologists have little acquaintance with ear, nose concomitant biopsy have become commonplace in the and throat pathology. Some receive few specimens from management of throat disorders. It is hoped that. by ENT tissues; others are deterred from deeper study of the publication of this Atlas, pathologists receiving only material that emanates from regions the normal anatomy occasional specimens will be guided in their provision of of which is so forbidding in its complexity and holds no a report helpful to the clinician and those who are involved familiarity through autopsy investigation, for, apart from with a larger ENT service may be providec with a guide the larynx, there is usually no compelling indication for to the deeper understanding of the subject. examination of the ear, nose or throat at postmortem. Yet. The modern tendency in publication of ristopatholog equally with biopsy specimens from other parts of the ical microphotographs is to omit any statement of their body, the pathologist's report is consequential for the magnification, since it will usually be clear to the reader efficient handling of ear, nose and throat illnesses and what order of enlargement is involved. I n this Atlas, sometimes even for the patient's survival."

Ultrasonic surgical techniques were first used by Dr. Kelman in the 1960s to fragment cataracts through a 2-mm incision allowing for minimally invasive surgery. The results from this procedure stimulated the development of a larger, move powerful ultrasonic unit that was used in neurosurgery. This instrument allowed the neurosurgeon to selectively remove tumor tissue with decreased blood loss and tissue trauma. The ability now of ultrasonic equipment to selectively fragment, irrigate, and aspirate tissue with minimal coagulation effect spurred its rapid use in surgery on the liver, spleen, kidney, and other intra-abdominal organs. This instrument has been invaluable in ovarian cancer cytoreduction and intricate segmental organ resection. The newest technical developments include electro cautery capability built into the hand piece and extended hand pieces for laparoscopic surgery. The impetus for assembling this volume has been to provide an extensive review of the field of ultrasonic surgery as it has currently developed including principles, equipment features, and surgical tech niques. It is hoped that the information will be of use to physicians in training and surgeons in practice. The book takes a multidisciplinary approach with chapters authored by a diversity of subspecialists in gen eral surgery, urology, surgical oncology, and gynecologic oncology. Each chapter contains basic information on surgical techniques. Together, these chapters cover surgery of the GI tract, kidney, liver, and lower genital tract, and present a number of personal approaches."

All general surgeons, and especially hernia surgeons, will benefit from this book. It contains a complete update on the research and pathogenesis of the incisional hernia. The volume describes all important diagnostic and therapeutic procedures and evaluates the appropriate use of each procedure for each particular case. Pitfalls and unresolved issues are discussed in depth, and experts of international standing weigh in on each topic.