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The rapid increase in medical knowledge and the introduction of new diagnostic and therapeutic techniques has also led to increasing specialisation in the field of internal medicine. For this reason controversy has arisen, particularly in university centres, about the importance and role of "general" internal medicine compared to the medical specialties. In this paper the most important tasks of internal medicine in patient care, in graduate and postgraduate training and in clinical research are analysed. The prime task of internal medicine is comprehensive care for the increasing number of elderly patients with multiple co-existing diseases. In this respect generalists cannot be adequately replaced by specialists. Mutual critical co-operation between internists and specialists also reduces the risk of overuse of medical technology and leads to a corresponding reduction in hospital costs. In medical schools internists have a major task in teaching bedside clinical examination and a general approach in the diagnosis and treatment of the most relevant medical disorders, while specialised knowledge becomes more important during the postgraduate training period. Hospital-based internal medicine remains an essential basis for clinical training not only for general internists and family physicians but also for all medical sub-specialties. In continuous medical education internists have the task of synthesising and transmitting new knowledge from the various special fields, including their application in a non-selected broad patient population. Also in clinical research several tasks remain for internists, such as clinical epidemiology, cost-benefit analysis and critical evidence-based assessment of diagnostic and therapeutic methods. Discontinuance or drastic reduction of internal medicine in university centres would not be justified and could lead to a negative balance between general internists and specialists, with negative consequences for health care, as experienced in the USA. Instead of fragmentation and rivalry for positions and resources, better co-ordination and co-operation between internists and specialists is needed in university centres, if possible in integrated medical departments.

Since the revision of the KVG (Art. 58) (Health Insurance Law) in 1995, systematic scientific monitoring is laid down by statute in order to ensure quality (Health Insurance Regulations; KVV Art. 77). In addition, the statistics law of 1992 prescribes the BFS statistics (with ICD coding) (model 1). Since 1983 the "Arbeitsgemeinschaft Schweizerischer Frauenkliniken" (ASF) (The Swiss Working Group of Obstetrical and Gynecological Institutions) has been maintaining a common set of statistics which amongst other things also serves for quality assurance purposes (model 2). In 1995 a number of surgical hospitals joined together under the title "Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie" (AQC) (Swiss Surgical Quality Assurance Working Group) and now also maintain similar common statistics (model 3). In this paper the three above-mentioned models are described with regard to their suitability for process quality assurance. Whilst the BFS statistics are unsuitable for this purpose, the two other methods of data collection largely fulfil the requirements for process quality assurance by using statistical models. The largest deficiency in the ASF and AQC statistics is the lack of comprehensive geographical coverage which in contrast is provided by the BFS statistics thanks to statutory requirements. However, all three models are unsuitable for the areas of structure and outcome quality assurance. Therefore other solutions must be sought for these purposes.

The reemergence of tuberculosis in the industrialized countries has hastened the development of new laboratory techniques. Hence, well-known shortcomings of traditional techniques such as the lack of a rapid and specific detection system, the delayed availability of species identification and drug susceptibility results, and the lack of a reliable method for determining strain identity for epidemiological purposes, have become immediate targets for implementing molecular biology techniques. In particular, nucleic acid amplification techniques, restriction fragment-length polymorphism and single-strand conformation polymorphism analyses have dramatically improved diagnostic timeliness and accuracy of mycobacteriology laboratory results. Our paper reviews recent developments and comments on the diagnostic applications of the new tools as compared to traditional techniques.

Primary prevention of colorectal carcinoma aims at interruption of the adenoma-carcinoma sequence. Colonoscopy is the most reliable screening method, but up to now has only been recommended for persons at high risk. The ongoing 10-year study defines a possible risk group and determines the efficacy of a preventive screening program based on family history. This paper reports on the descriptive statistics of the first five years. All patients with colonic carcinoma diagnosed between 1987 and 1991 living in the upper part of Canton Basel-Land were registered. According to the family history, patients with at least one first degree relative with colonic carcinoma were defined as index patients. Their first degree relatives entered a prospective screening program which includes colonoscopy. 230 colonic carcinomas were diagnosed in the upper part of Basel-Land, representing an incidence of 48/year/100,000 persons. They included 3 (1.3%) hereditary and 227 (98.7%) sporadic carcinomas. 23 (10%) patients had a positive family history. These patients defined 94 relatives at risk. The incidence of colonic carcinoma in the Canton studied does not differ from that reported in Switzerland. Therefore, this part of Basel-Land can be considered representative. The 1.3% hereditary carcinomas are in contrast to the published data of 6%.

Against the background of rapid progress in the field of reproduction medicine and gene technology, the governments of various countries have set up commissions to discuss the moral, legal and social problems involved and make proposals for regulation. Thus, in 1986 the Swiss Federal Council convened an expert commission which, after two years of discussion, has recently published a voluminous document (the "Amstad Report"). The present paper attempts to analyze, from the philosophical viewpoint, some of the problems associated with such processes for the further development of morality for specific ends. A leading question in this regard is the role of philosophical thought in these processes, i.e. the potentialities and limits of ethics for the creation of a moral consensus on the problems surrounding technical intervention in human reproduction. There are four schools of thought: 1. The activities of expert commissions are evidence of the fact that man is at present endeavouring consciously to "construct" his morality. He may always have been the subject of his mortality, but this was without his own knowledge and awareness. Today, under the pressure of new means of action, man is becoming the conscious subject of his mortality and the formation of a morality is a process aimed at a specific result. 2. The fundamental difficulty of such a scheme arises from the absence of a theoretical and socially tested system for the "construction" of a new morality. This is also true of philosophy: on questions of morality it possesses analytic competence but no specific methods of generating new norms and values.(ABSTRACT TRUNCATED AT 250 WORDS)

57 papers dealing with the prevention of postoperative thromboembolic complications have been analyzed. They comprise 28 prospective, randomized, comparative studies using objective diagnostic techniques. 2 X 5000 IU daily of heparin-DHE lowers the incidence of deep vein thrombosis in general surgery, thoracic surgery and gynecology significantly better than 2 X 5000 IU heparin alone. In hip surgery 3 X 5000 IU heparin-DHE is more effective than the same amount of heparin alone. In the entire field of orthopedic surgery, heparin-DHE, in a dosage of 2 X 5000 IU, lowers the incidence of fatal pulmonary emboli just as well as dextran 70. With regard to prevention of deep vein thrombosis in general surgery, there is no statistically significant difference between prevention with 2 X 2500 IU heparin-DHE and 2 X 5000 IU heparin. 2 X 2500 IU heparin-DHE significantly lowers the incidence of bleeding complications in general surgery, as evaluated in double-blind studies and compared to 2 X 5000 IU heparin alone.

A literature study was performed in four German-language medical journals of 1985 and 1986 on the methodology of published diagnostic studies. A total of 93 papers was investigated. The results showed that fundamental requirements for the evaluation of diagnostic tests, such as blindness of judgement, were met only in 5% of the papers. In more than half of the publications the use of test parameters (sensitivity, specificity) was insufficient and the relationship between pretest and posttest probability was considered only in isolated cases. It is concluded that the methodologic criteria for the evaluation of diagnostic tests do not seem to be widely known and that a significant improvement is desirable.