The beginning of human life: medical observations and ethical reflections.
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Biomedical subjects
Publications and source records attributed to F K Beller.
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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.
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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.
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.
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.
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.
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The current debate regarding the suitability of anencephalics as organ donors is due primarily to misunderstandings. The anatomical and neurophysiological literature shows that the anencephalic lacks a cerebrum because of the failure of neuralplate fusion. However, even the incomplete function of an atrophic brain stem is currently accepted at law in most if not all countries as sufficient for brain life: which is to say, cessation of breathing is currently required in order to make the diagnosis of brain death. Because of the extensive incompleteness of the anencephalic's brain, it is not possible to postpone death significantly by mechanical ventilation and intravenous feeding. It is acceptable to maintain life for a short period of time in order to allow organ transplantation subsequent to the declaration of death at the point of cessation of the capacity for spontaneous respiration. The most important issue is not transplantation, but the issue of brain life raised by the case of anencephalics. Since brain life in any significant sense begins only after the closure of the neural tube on the 30th day after conception, it is reasonable to take this as the point at which brain life begins. Laws should be amended in all countries to allow the abortion of anencephalics at any time, in that they do not at any time possess brain life.
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Second trimester abortion was induced by the intraamniotic infusion of ethacridine. Coagulation studies revealed no change in 10 cases. It is felt that the intraamniotic use of ethacridine is probably safe.
In 86 woman patients having a histologically confirmed carcinoma of the breast we examined during primary treatment the CA 15-3 data in the compartments serum, cytosol and a membrane fraction. Low CA 15-3 levels in the serum combined with high concentrations in cytosol and the membrane fraction were associated with a good prognosis, whereas a poor prognosis was seen in case of high serum values and simultaneously low values in the cytosol and the membrane fraction. Hence, it seems that prognoses of the future course of the disease are possible if the CA 15-3 values are simultaneously determined in the serum, in cytosol and in a membrane fraction.
As a part of the Central European Study a long-term study of the pubertal development of 687 Hungarian girls was undertaken and the findings compared with those of a cross-sectional study of a group of girls from Münster. In addition to assessment of the breast and pubic hair according to Tanner's classification, the development of axillary hair was, for the first time, subdivided into five stages (A1 to A5). This pubertal feature was related to the characteristics already known and, because of the absence of literature, compared with the author's own data. Stage A1 is the infantile stage, in which there is no hair development. In Stage A2, isolated, long, barely visible hairs appear. Stage A3 is marked by the development of a narrow band of sparse hair. In Stage A4 the area covered by hair is larger, and the hair has become more dense. Stage A5 is the adult stage, with a longish, rectangular area covered by hair of a density and texture found in adults. The development of axillary hair began at a average age of 11.94 years, with a standard deviation of 0.93 years. The subsequent stage (A3) was reached at a mean age of 12.53 +/- 0.92 years. At age 12.99 +/- 0.87 years Stage A4 was well developed. The adult hair covering appeared at a mean age of 13.58 +/- 0.66 years. The mean duration of development of the axillary hair was 2.28 +/- 0.60 years. Axillary hair was generally the last pubertal characteristic of development. Only in 5.5% of the girls was axillary hair the first sign of puberty.
Tumorous manifestations of myelosis with or without leukemia are rarely seen today as they appear at a very late stage of the disease. They are of importance to the gynecologist in the differential diagnoses concerning the breast, the endometrium and uterus, the placenta and the fetus. The case report of a myeloreticulosis of the uterus, three years after an acute myeloid leukemia was treated, is described.
In contrast to earlier operating standards some authors have in the past few years, also removed pelvic lymphnodes when ovarian cancer was diagnosed. From 26 of our patients suffering from ovarian cancer, one third proved to have positive lymphnodes, when pelvic lymphonodectomy was carried out. Our data, along with-data from other authors, were reviewed and included in a statistical evaluation.
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