Intracranial injury, caused by a transorbital penetrating object, is a neglected topic in neurosurgery. With few exceptions, only occasional publications, often containing merely case histories, are present in the literature. Through a perusal of the world literature - for the first time - the author has collected and combined all available and relevant information, trying to give a thorough description of this rare, but extremely dangerous injury. This book is a major and definitive contribution to neurosurgery, but is also of importance to ophthalmology, neurology, traumatology, neuro-radiology and pediatrics.

The first international symposium on brain edema was held in Vienna/ Austria in 1965 followed by altogether eight meetings since. The most recent was organized in Y okohama by the Department of Neurosurgery of the Musashino Red Cross Hospital, Tokyo. The continuing interest of both, clinicians and experimental scientists alike may be attributable to the fact that brain edema is a common denominator of many cerebral disorders, which under acute conditions threatens life and weIl-being of afflicted patients. Although progress in understanding as weIl as treatment can be recognized since 1965 many problems remain, particularly concerning the control of brain edema under acute conditions, as in trauma or ischemia. A quantum leap was the distinction of the cytotoxic and vasogenic brain edema prototypes as advanced by Igor Klatzo, providing for transition from a morphological to functional understanding now. The recent brain edema meetings were certainly benefiting from developments of both, molecular neurobiology on the one hand side and functional brain imaging at an ever-increasing resolution on the other, such as magnetic resonance imaging orpositron emission tomography. The international symposium in San Diego 1996 may witness further breakthroughs, hopefully also of effective treatment modalities. The symposium in Y okohama was dedicated to the "Legacy of 28 Years of Brain Edema Research" as a reminder of accomplishments as weIl as remaining challenges.

Until recently, monitoring of cerebral blood flow and metabolism was an unattained goal. Determination of cerebral blood flow was limited to intermittent measurements and particularly difficult to perform in critically ill patients. Meanwhile there are techniques available, however, to monitor cerebral blood flow and cerebral oxygenation, both globally and regionally. Therefore we thought it worthwhile to discuss these new continuous techniques and to compare them with well-known techniques which discontinuously measure CBF. For that purpose, an international workshop with some leading experts in the field was held in October 1992 in Berlin. The workshop consisted of about 20 lectures, either reviews on a special topic, or latest results. These contributions were given by invitation and were extensively discussed. Unfortunately it is impossible to reproduce the discussions. On the other hand, all speakers delivered a manuscript promptly after the meeting so that we were able to edit them within a short time. Since monitoring of cerebral blood flow in intensive care is a rapidly growing and changing topic, the written contributions should be quickly available. Authors, editors and publishers have tried to come close to this ideal. As editors we would like to thank the authors and the publishers who enabled us to come out with this volume of the proceedings as early as possible.

25 years have passed since a small group met for the First International Symposia on Brain Edema in Vienna. Subsequent Symposia were held in Mainz, Montreal, Berlin, Groningen, Tokyo and Baltimore. During this time we have witnessed a virtual explosion of the number of publications in this field and our basic and clinical understanding of this disease process has increased tremendously. Our meetings have always been a landmark to take stock of our experience so far and to provide perspectives toward future developments. In addition, it always was a good opportunity to renew old friendship and to make new friends. This volume is a compilation of papers presented at the Eighth International Symposium on Brain Edema held on June 17-20, 1990 in Bern, Switzerland. During this Symposium 158 papers were presented as oral or poster presentations. This considerable number of papers was chosen from more than 230 abstracts that were received. The organizers wish to thank the Advisory Committee for the work done in paper selection and focus on the Symposium. Appreciation is also given to all persons, who have contributed to the success of this meeting, the Chairmen, the participants and last but not least all the staff who worked behind the scene.

This volume contains contributions by well-known scientists and clinicians in the fields of microbiology, infectious diseases, physiology, internal medicine, surgery, anaesthesiology, and intensive care medicine. It provides an up-to-date overview of the mediators and pathophysology of sepsis and septic shock as well as the latest therapeutic approaches.

A multidisciplinary overview of techniques for monitoring acute head trauma patients is given in this book. It includes neuroimaging procedures (TCD, MRI, SPECT) and multiple neurophysiological approaches: EEG, videomonitoring and integrated computer systems with clinical applications. Results that have been obtained by using new drugs to protect the brain as well as progress made in recovering techniques are emphasized. The long-term consequences of acute lesions are also discussed. The relationship between acute and long-term seizures is studied in posttraumatic epilepsy cases, and the relationship between neurophysiological and long-term clinical patterns, especially in posttraumatic epilepsy, is discussed. The socio-economic costs of traffic accidents are analysed - based on data from epidemiological studies - and then compared with reported data.

by E.K. ZSIGMOND, M.D. Department of Anesthesiology University of Illinois Chicago U.S.A. It is, indeed, a distinct honor and privilege to be invited by the authors to write a preface to this monumental monograph, Regional Opioid Analgesia. Regional Opioid Analgesia is a colossal undertaking by Drs. De Castro, Meynadier and Zenz shortly after the introduction of this revolutionary approach to pain relief which opened a new epoch in analgesiology. This is, indeed, the first authentic and comprehensive textbook encompassing the current knowl edge on this novel approach to pain relief. We are indebted to the authors for introducing the new opioids to regional analgesia with the scientists, who de veloped the potent short and ultrashort acting opioids with high therapeutic indices, which many researchers dreamt about but never before materialized. The side effect liabilities of these new opioids are minute as compared to morphine and meperidine. Regional Opioid Analgesia could not have been more authentically written than by Drs. De Castro, Zenz and Meynadier, who have conducted daily clinical investigations on all known opioids for regional analgesia as well as for neurolept analgesia. Therein lies the great value of this monograph: it is the most authentic work on this topic."

Great progress has been made in the understanding and prevention of secondary brain damage from acute cerebral disorders, such as trauma and ischemia. Advances may be concerned in particular with better organization and logistics of preclinical emergency care, including rapid arrival of well-trained medical staff on the scene of an accident and of transportation to a competent hospital. Nevertheless, it is a safe assumption that development of secondary brain damage from both intra- and extracranial causes still represents a major factor for the final outcome in severe head injury. Thus, exchanges of experiences and information between various disciplines involved with this important clinical problem - trauma still assumes the number one position as a cause of morbidity and mortality up to an age of 45 years - may provide a basis for in-depth analysis of remaining problems as well as of methods of their solution. This exactly is the purpose of the present publication on concepts and findings pertinent for the general subject of secondary brain damage from various experimental as well as clinical viewpoints. An internationally high-ranking group of experts has been contributing to this collection of reviews on cerebral trauma and ischemia and its adverse sequelae, including cerebral exploration by most modern technologies, such as NMR spectroscopy or PET scanning, among others.

The Yearbook compiles the most recent developments in experimental and clinical research and practice in one comprehensive reference book. The chapters are written by well recognized experts in the field of intensive care and emergency medicine. It is addressed to everyone involved in internal medicine, anesthesia, surgery, pediatrics, intensive care and emergency medicine.

Despite a worldwide reduction in its incidence, stroke remains one of the most common diseases generally and the most important cause of premature and persistent disability in the industrialized countries. The most frequent cause of stroke is a localized disturbance of cerebral circulation, i.e., cerebral ischemia. Less common are spon taneous intracerebral and subarachnoid hemorrhages and sinus ve nous thromboses. The introduction of new diagnostic procedures such as cranial computed tomography, magnetic resonance imaging, digi tal subtraction radiologic techniques, and various ultrasound tech niques has led to impressive advances in the diagnosis of stroke. Through the planned application of these techniques, it is even possible to identify the pathogenetic mechanisms underlying focal cerebral ischemia in humans. However, these diagnostic advances have made the gap between diagnostic accuracy and therapeutic implications even greater than before. This fact can be easily explained. In the past, therapeutic studies had to be based on the symptoms and temporal aspects of stroke; it was impossible for early investigations to consider the various pathogeneses of cerebral ischemia. Inevitably, stroke patients were treated as suffering from a uniform disease.

Over the last 10 years the syndrome of severe acute renal failure has progressively changed in its epidemiology. It is now most frequently seen in critically ill patients, typically in the context of sepsis and multiorgan failure. This epidemiologic change has meant that intensive care physicians and nephrologists must now work in close cooperation at all times and must take many com plex issues of prevention, pathogenesis, and management into account that they did not previously have to tackle. Simultaneously, the last 10 years have seen the development of major technical and conceptual changes in the field of renal replacement therapy. There are now previously unavailable therapeutic options that provide physicians with a flexible and rapidly evolving armamentarium. The nutrition of these patients, previously limited by the par tial efficacy of renal replacement therapies, has also become more aggressive and more in tune with the needs of critically ill patients. Increased understanding of the pathogenesis of the multi organ failure syndrome has focused on the role of many soluble "mediators of injury" (cytokines, leukotrienes, prostanoids etc.). These molecules are likely to participate in the pathogenesis of acute renal failure. Their generation and disposal is also affected by different techniques of artificial renal support."

This book reviews the most recent developments in the patho- physiology and therapy of ventilatory failure. It contains contributions by twenty-five internationally recognized aut- horities on respiratory muscle function and investigators actively contributing to our knowledge of the cause, diagno- sis and therapy of ventilatory failure. Of particular inter- estare the descriptions of new modalities of partial and complete ventilatory assistance as well as new knowledge re- garding ventilatory control and fatigue during stressful breathing. The reader will find here a state-of-the-art re- view of the latest research and practical applications in this most critical area of intensive care medicine.

The publication of the Vth International Symposium 1995 on "Mechanisms of Secondary Brain Damage" in Mauls/ltaly is a collection of focused reviews reaching from novel molecular- and cell biological findings to aspects of clinical management in head injury and cerebral ischemia. A specific purpose of these series of meetings introduced in 1984 is for an exchange on problems of mutual interest by international high ranking experts from the basic sciences and related clinical disciplines, such as intensive care medicine, neurology, or neurosurgery. The present volume covers three major areas: (a) Molecular and cell biological mechanisms including inflammation (b) Novel findings on mechanisms and treatment in cerebral ischemia (c) Secondary processes in head injury, regeneration and treatment Molecular-and cell biology is currently attracting attention towards activation of genomic processes associated with the demise of cells referred to as "programmed cell death" and "apoptosis" which, actually, might be distinguished from each other. Thus, the phenomenon of delayed neuronal death in selectively vulnerable brain areas following brief interruption of blood flow is scrutinized as to the contribution of the activation of suicide genes. The physiological role of such a response, among others, is removal of surplus neurons during ontogenesis of the brain. Yet, evidence is accumulating that similar mechanisms playa role in cerebral ischemia, probably also trauma, where nerve-and other cells demonstrate features of apoptosis. Observations on protection of neurons by administration of protein synthesis inhibitors in cerebral ischemia provide more direct support.

International experts examine the role of nitric oxide in various metabolic events such as septic shock, cardiovascular dysfunction, and trauma and hemorrhagic shock. The nitric oxide pathway and nitric oxide synthesis regulation are also discussed.

A shocking look at how the idea of romantic love can justify and excuse the killing of women by their partners, and lead to sympathy and reduced sentences for the killers. The author explores how stories of domestic homicide are told in the news, by the police, and in the courts, drawing from 72 cases which took place over a twelve month period.

The period that followed World War II has witnessed a dramatic change in neurology. From being a discipline in which its partici- pants were castigated for being interested solely in diagnosis, usually of disorders of unknown causation without effective therapy, neurology has evolved into a highly active treatment- orientated subject. This transition is clearly reflected in the ap- proach to diseases of the peripheral nervous system, and to the Guillain-Barre syndrome (GBS) in particular. In a state-of-the- art review made in 1952, Elkington (1952) observed that no less than 56% of neuropathies remained undiagnosed, and amongst those of unknown causation he listed GBS. With intensive in- vestigation and follow-up, the proportion of neuropathies seen at tertiary referral centres which elude diagnosis is now as little as 13% (McLeod et al. 1984). Overall, of course, the proportion is even less. This change is partly because of the introduction of new diagnostic techniques and partly because of the application of the great expansion in knowledge evident throughout medicine. In this book, Professor Richard Hughes has assembled current information on GBS and related disorders, including chronic in- flammatory demyelinating polyneuropathy (CIDP), the existence of which was not appreciated until Austin's perspicacious study published in 1958. In the Introduction, Professor Hughes gives an account of the way in which recognition of the GBS emerged and matured, and shows that it followed, pari passu, with the realisation that paral- ysis and sensory loss may result from peripheral nerve disorders.

Die Infektion ist nach wie vor ein gravierendes Problem bei der Behandlung brandverletzter Patienten. Erkenntnisse uber die Pathophysiologie des Verbrennungstraumas und der Sepsis zeigen neue Therapieansatze auf und stellen konventionelle Behandlungsschemata teilweise in Frage. Die neuen Erkenntnisse uber Pathologie und Pathophysiologie septischer Komplikationen, die Aetiologie der Infektion, Infektionswege und Infektionskontrolle stellt dieses Buch dar. Es bietet allen, die Verbrennungen medizinisch behandeln, Hilfestellung bei der taglichen Arbeit.

Sepsis is still the leading cause of death in surgical and general intensive care units. Although our knowledge of this complex syndrome has increased in recent years, it is still far from com- plete. New therapeutic approaches have been developed. Some did not fullfill the high expectations for their use in clinical prac- tice; others are still under clinical evaluation. is the aim of this monograph to offer basic information on the It etiology, definition, pathophysiology, prevention and therapy of sepsis and septic shock to both the clinician and the scientist. We believe that it presents an extensive overview that may help the clinician to better understand and treat sepsis and septic shock. We also hope that this work will give some directions for future research both in the clinical field as well as the laboratory. Jena, Berlin, Jerusalem, K.Reinhart February 1994 K.Eyrich C.Sprung TableofContents I.Definition/Prognosis Sepsis and Septic Shock: Update on Definitions (Jo-L.Vincent) 0 0 0 0 0 0 0 0 0 0 0 0 ******** 3 Clinical Manifestations and Prognostic Indicators in Sepsis (R.C.Bone) ...0 * * * * * * * * * * * * * * * * * * * 16 What Determines Prognosis in Sepsis? Evidence for a Comprehensive Individual Patient Risk Assessment Approach to the Design and Analysis of Clinical Trials (W.A.Knaus, D.P.Wagner, F.E.Harrell, Jr.

Orthopedic Trauma Call for the Attending Surgeon is a clinically focused book that will help guide the orthopedic surgeon through the most commonly encountered injuries when on call. Drs. David J. Hak, Kyros R. Ipaktchi and Steven Morgan are joined by over 50 leading experts to provide a succinct and quick review of the key points that will allow you to provide patients with expert and immediate care. Inside Orthopedic Trauma Call for the Attending Surgeon each chapter is written in an easy to read bulleted format that will allow for a quick review of the key facts you need to know while taking call. Chapters also cover emergent and definitive management and provide guidelines for when to consider referral to a higher level of care. The authors also share their tips and tricks for successful outcomes, while highlighting potential pitfalls and how to avoid them. Since it can be difficult to find time to read a traditional textbook or review article, Orthopedic Trauma Call for the Attending Surgeon is perfect for orthopedic surgeons, physician assistants, extenders who cover ER call, and orthopedic trainees.

This book concentrates on problems generated by acute care in severely traumatized patients during the first 24 hours after injury. During this hectic period, highly complicated problems have to be solved at the site of the accident, during transport to hospital, and in hospital. Multiple medical and paramedical disciplines are involved in providing care to the severely injured. This book endeavors to present a problem-oriented approach to the diagnostic, therapeutic, and organizational aspects that may be encountered.

The book is based on papers presented at the recently held international meeting on central-nervous-system monitoring in Hamburg, Germany. Experts inthe fields of neurophysiology, experimental and clincial anesthesia and intensive care discussed the state of the art in noninvasive central-nervous-system monitoring. Starting with the principles of CNS monitoring in humans, the topics covered include pharmacokinetic pharmacodynamic interactions, the usefulness of spontaneous and evoked brain electrical activity as an overall-control for afferent systems andfor the assessment of analgesic drug treatment, perioperative anesthesiological monitoring, and intraoperative awareness. Recently developed specific EEG and EP indices such as spectral edge frequency, median frequency, auditory and somatosensory evoked responses for the assessment of depth of anesthesia are evaluated for intraoperative monitoring. The surgical and anesthesiological perspective in intraoperativemonitoring during vascular surgery are presented, as is the state of theart in the monitoring of afferent central-nervous-system pathways by monitoring transcranial motor evoked potentials. Bispectral EEG analysis forthe assessment of anesthetic adequacy represents the future trend in intraoperative monitoring. In addition to neurophysiological methods, assessment of jugular bulb venous oxygen saturation and transcranial Doppler sonography may give additional information for the interpretation of brain fuction. In the field of intensive care, topics in multimodal long-term monitoring of brain function are presented. The application of an expert system supporting the diagnosis of brain death is also included.

Nitric Oxide (NO) is a free radical, a gas, and a pluripotent product of mammalian cells. Only a few years ago, scientific discussions of NO were largely held in the context of the chemistry of air pollution. Now, however, the great significance of NO as a signalling and cytotoxic molecule has captured the attention of the biomedical community. This book provides a very up-to-date review of the role of NO in sepsis and ARDS. Consideration is given to NO both as a pathophysiologic mediator as well as a therapeutic agent. An internationally recognized group of scientists and clinicians have contributed chapters dealing with cutting-edge science and practical clinical strategies. Numerous tables and charts have been included to aid the reader in understanding this fascinating and important subject.

I am very happy and honoured to have so many famous contrib utors from around the world presenting their knowledge and experience in this book, including Dr. Rufer who, as early as 1967, attempted to improve the pressure-volume curve of a child dying from RDS using dried surfactant from dogs; Drs. Enhorn ing and Robertson who were the first to treat rabbit fetuses with surfactant replacement and impressively demonstrated that sur factant improved lung mechanics; and Dr. Fujiwara who at the end of the 1970's had already successfully treated the first babies with surfactant replacement and published this work al ready in 1980. Thus, the idea of surfactant replacement therapy is now more or less 20 years old and almost 10 years have passed since the first publication by Dr. Fujiwara of his impressive clinical results. Up to now (September, 1988) about 2,200 babies have been treated worldwide with tracheal instillation of surfactant, with most promising results. The type of surfactant used varies from pure natural extracts from bovine or pig lungs, to surfactant extracted from human amniotic fluid, to pure phospholipids. To date, however, there is still no surfactant commercially available (except in Japan), in spite of the fact that it is urgently awaited by neonatologists and intensive care doctors throughout the world. This volume is based on the contributions presented at the international congress on Surfactant Replacement Therapy which was held in Rotterdam, The Netherlands, in November 1987."

Nephrology, initially born as a small branch of medicine, has, in the last few decades, become an extraordinary large field of medicine. The recent development of renal medicine is mirrored by the numerous nephrological journals published, a natural consequence of the increasing number of basic and clinical research studies performed continuously all over the world. Undoubtedly the progress which has occurred in the different, specific fields of renal medicine has given rise to subspecialities which range from renal physiology and pathology to hemo- and peritoneal dialysis and renal transplantation. Even the diagnostic methodology in nephrology, very useful in the clinical practice, has become a speciality within the speciality. Thus, the problem for clinical nephrologists, as well as for internists, is to remain continuously up-dated in all fields of nephrology. Nephrology textbooks are published continuously and in great number. However, the time required for having authors appointed, chapters completed, manuscript edited, galley proofs corrected and the whole book printed makes many textbooks already out of date when they go on sale and their half lives are very short. On the other hand, nephrological journals are so many and the articles so numerous and detailed, that it is often impossible to rely on them for up-dating practicing clinicians.

Perinatal medicine, which is concerned with the problems of the fetus and newborn, has rapidly developed in the last two decades as an important and challenging specialty. Rapid advances in the field, coupled with tech nological advances, now are making survival of infants with weights as low as 500 grams possible. Ventilator care for severe respiratory problems is on the verge of being replaced by surfactant replacement therapy; on the other hand, development of such technologies as extracorporeal mem brane oxygenation and jet ventilation has revolutionized the care of these sick infants. The advances taking place today in the field of perinatal medicine make periodic updates, like the one provided by this volume, a virtual necessity for clinicians and paramedical personnel alike. A distinguished group of specialists in various aspects of perinatal medicine has contributed to this book. Their wide-ranging experience and points of view should make this book a valuable reference for all physicians and allied health personnel involved in the care of the high-risk fetus and newborn. MANOHAR RATHI, M.D. Acknowledgements. I am grateful to the contributors for their cooperation in preparing the manuscripts, to my associates for their help and support, and to the publishers for their continued interest in this work. Above all, I thank Ms. Rose Aiello-Lech and Ms. MaryAnn Cichowski for their hard work in making this publication possible."