The Surgeon as a Humanist Medicine is the most humane of the sciences and the most scientific of the humanities. Cardiac surgery today provides a most natural confluence for the high technology of medicine and the humanistic values traditional in the practice of medicine. The cardiac surgeon must, of necessity, be knowledgeable in physiology and cardio logy, and must also possess consummate surgical technical skill. The attainment of these skills over long years of training leads many of these surgeons to believe or per ceive this long struggle as an apotheosis of their position in life, rather than as an education in bringing the latest scientific advances to the care of patients. The problem lies not only with the cardiac surgeon; it is also contributed to by the patients' perception of heart surgery, heart disease, and the mystery of the science and physiology involved. The patient with heart disease expecting surgery may, for the first time, be facing the finiteness of his existence. The low risk of cardiac surgery to day not withstanding, the coronary surgery patients, most likely a type A personality, is faced with a perceived threat to his invulnerability, his self-image, his family, his independence, his control of situations, and his very existence.

D. B. LONGMORE The concept ofthe meeting on which this book is based is unique. There has never be fore been a multi-disciplinary meeting based entirely on the concept of making a major branch of surgery safer. Hopefully, this meeting will be archetypal and will set a precedent for similar attempts in other disciplines as well as future efforts to make cardiac surgery safer. Cardiac surgery is still a rapidly growing discipline even after a quarter of a century of experience. Like any new area of science, or medicine, initially there is an exponential growth ofwork, publications, meetings, options of available equipment and all the ancillary and peripheral disciplines associated with it. The ideas of the handful of original surgical pioneers, some of whom have contributed to this book, formed the basis of a still rapidly growing young branch of surgery with a whole new medical discipline of total extracorporeal circulation involving biochemical and haemodynamic control of a patient.

Great strides have been made in the past several decades in clarifying brain behavior relationships. Most of the research has focused on the direct effects of a brain injury on behavioral functioning. Only recently has attention been given to documenting the mechanisms by which the disruption of various organs and systems compromise cerebral integrity and ultimately how such disruption affects cognition and behavior. It is this relatively new topic of inquiry, medical neuropsychology, that comprises the subject of this book. As will be noted, the chapters are organized on a system-by-system basis. Each of the organ systems contributes in a unique and specialized fashion to maintaining the integrity of brain functioning. Thus, the chapters by Prigatano and Levin, Stanton, and Ryan address the consequences of disturbed energy regulation and oxygen supply. Other chapters, specifically those by Tarter, Edwards, and Van Thiel and by Hart and Kreutzer examine the effects on the brain when the liver and kidney cannot efficiently cata bolize or eliminate cerebrotoxic substances. The effects of metabolic disrup tion mediated through pituitary and thyroid gland mechanisms illustrate the complex and synergistic relationship among the various organs and systems and the brain. As discussed by Gordon, Lee, and Tamres, diverse intercorre lated processes regulate physical growth, cerebral specialization of function, and complex cognitive capacities. Beckwith and Tucker underscore the in terrelationships among cognitive, affective, behavioral, and neurophysio logical processes pertinent to thyroid functioning. The book concludes with discussions of three rather specialized topics of current interest.

When I gave a presentation on return to work after heart valve replacement at the Tenth Congress of the German Society for Thoracic and Cardiovascular Surgery in 1981, I was surprised by the relatively low level of interest that cardiac surgeons seemed to have in this subject. This stimulated me to intensify my research in this area and to extend it to patients with coron ary heart disease. Obviously, physiological and mechanical aspects of medical treatment are of special interest to the surgeon. For the majority of cardiac surgical patients, that is those with coronary heart disease, the technical problems of the operative procedure have been solved to a great extent. Many studies have demonstrated that, aside from reduction of symptoms, aortocoronary bypass operation can lead to improvement of cardiac performance un der stress conditions. However in spite of the technical solutions to hemodynamic problems, it has become very clear that the reintegration of patients into their social sphere has not been accomplished to the extent that might be expected, as exempli fied by the relatively low rate of postoperative return to work.

Georg Rodewald University of Hamburg Hamburg, Federal Republic of Germany Allen E. Willner Hillside Hospital Glen Oaks, NY In contrast to the initial years of cardiac surgery (37 years ago), there is now increasing interest in cerebral protection. Rodewald [1] in 1978 was among the first to point out the surgeon's concern with "psychopathological problems" and Taylor [2] in 1989 stressed that" ••• the awareness of the cerebral consequences of open heart surgery has risen considerably in recent years • • • " This book reviews the evidence for neurological, psychological, and neuropsycho logical reactions to cardiac surgery. In previous studies one problem is that small samples of patients were studied with different measuring instruments so that it was difficult to ma~e sense of inconsistent findings. Considerable controversy resulted with little ability to sort out discrepant findings. It appeared that a large multi center study using uniform measures might help clarify the picture.

primary goal of all forms of therapy is not just prolonging life, but improving the quality of life, has forced analysis of what constitutes quality of life, a concept whose structure pervades all walks of life and eludes definition. Global well being, happiness, morale, vitality, fullness of social life, and satisfaction must be integrated and assessed for the effects of the disease and the therapy, in the context of specific personality traits, attitudes to life, family situation, and socio-economic and political freedom. A growing inter est in research on this subject has led to a clearer understanding of the components which come to determine quality of a patient's life, and how they can be measured in a reproducible manner so that valid comparisons can be made. Keeping these recommendations of analysing quality of life within the context of patients who have undergone open heart surgery, it seemed appro priate to me to separate the influence of various forms of open heart surgery into five aspects of life which can comprehensively reflect the quality of life outcome of the operation. These five 'components' are (1) Physiological state, which summarises the traditionally reported incidence of operative mortality and morbidity, objectively and subjectively measured physical ca pacity, and the residual symptoms, treatment and long-term survival. (2) Intellectual functioning relates to the psychoneurolgocial deficit in memory, reasoning or judgement because of cerebral microembolism and hypo perfusion during cardiopulmonary bypass.

A keyword listing of serial titles currently received by the National Library of Medicine.

It is our pleasure to introduce to the readers of Advances in Psychosomatic Medicine: I, the authors of 88 papers presented at the VIth World Congress of the International College of Psychosomatic Medicine in Montreal, September 13-18, 1981. These papers are re presentative of more than 700 presentations and discussions that occurred in the course of lectures, symposia, panels and workshops. Adam J. Krakowski, M.D., primary editor of this volume, together with Chase P. Kimball, M.D., GUnsel Koptagel-Ila1, M.D. and Hellmuth Freyberger, M.D. are responsible for the solicitation and final editing of the papers included in this volume. Most of the plenary papers presented at the Congress and subsequently received for pub lication are in preparation for a volume to be issued by S. Karger, Basel, Switzerland, as a special number edited by us with the assistance of Drs. Freyberger and Koptagel-Ilal. The papers in cluded in this volume represent the main substance of the Congress. The editors regret that a number of presentations were either re ceived too late or in insufficient form to allow for publication at this time. A number of other papers presented at the Congress have been released for publication in the Journal of Psychosomatic Re search, the Psychiatric Journal of the University of Ottawa, General Hospital Psychiatry, Psychosomatics and other journals.

Heart and brain interaction is an increasingly vital area of clinical investigation. This is the most comprehensive review of the subject available, presented by internationally recognized authorities in the field. The book offers extensive coverage of cardioembolic stroke, including a brand new contribution on the mechanism of hemorrhagic infarction. Controversial topics such as anticoagulation, combined carotid and coronary surgery and screening for silent coronary disease are covered. Also included are a comprehensive review of the cardiovascular/neurobiological role of the central nervous system in hypertension and sudden death, and a practical approach to the patient with syncope. This integrated, topical presentation makes essential reading for neurologists, cardiologists, internists and anyone caring for patients with stroke or cardiac disease.