This long-awaited follow-up to the New York Times bestselling The MELT Method introduces a unique, scientific-based proactive training program for improving overall balance, performance, and control while preventing pain and injury. Are you an athlete facing constant injuries that hold you back from achieving peak performance? Are you someone who wants to stay fit, but are dealing with aches and pains that make it more difficult to work out? Do you want to exercise or train without being sidelined by stress fractures, strained ligaments, and painful joints? If you answered yes to any of these questions, you need MELT Performance. The conditioning you do to stay in shape and perfect and improve performance-running on a treadmill, doing squats or bicep curls, practicing our backhand, even doing downward dog-requires repetitive movements. Yet 80% of orthopedic injuries are the result of repetitive motion, not trauma or accidents. In MELT Performance, nationally recognized educator, manual therapist, and exercise physiologist Sue Hitzmann introduces a revolutionary program centered on neurological joint stability or Neurostrength, that will revolutionize your health and performance. The foundation of MELT Performance is stability. To stay injury free, our joints must stable before we do repetitive motions. Acquiring stability allows the body to respond to the demands of motion. It's the way we were designed to function-and allows us to move more efficiently, improve coordination, and save our joints. Knowing how to check in, restore, and reintegrate joint stability before it's compromised gives an unparalleled advantage to anyone who trains hard to perform at their best. Hitzmann's techniques are proven to work-they're already used by world renowned professional athletes and fitness enthusiasts. If you're ready to improve your performance and prevent injury, MELT Performance is essential no matter what sport or activity you pursue. MELT Performance includes black-and-white instructional images throughout.

Sportliche HAchstleistungen werden heute oft nur noch unter Schmerzen erbracht und viele Sporttreibende leiden unter schmerzhaften Bewegungs- und LeistungseinschrAnkungen. Der mit groAen Schmerzen verbundene Tod einer begabten Hochleistungssportlerin ging in jA1/4ngster Vergangenheit durch alle Medien. In diesem Buch wird erstmals der aktuelle Themenbereich Schmerz und Sport aus interdisziplinArer Sicht umfassend abgehandelt. Sportmediziner, OrthopAden, Physiologen, Schmerz- und Physiotherapeuten, Psychologen, Trainer und Sportler vermitteln in ihren BeitrAgen wichtige Hinweise fA1/4r eine richtige und schmerzfreie SportausA1/4bung und eine interdisziplinAre schmerztherapeutische Versorgung der sporttreibenden BevAlkerung. AuAerdem wird die Frage angesprochen, inwieweit es vertretbar ist, das physiologische Warnsignal Schmerz durch Arztliche und andere MaAnahmen auszuschalten. Ein aktuelles Buch zu einem aktuellen Thema.

In 1981, the Institute of Anesthesiology at the Ludwig Maximil- ian University of Munich organized a first international sympo- sium on inhalation anesthetics. In 1982, the most important con- tributions were published in the series Anaesthesiology and Inten- sive Care Medicine. At that time, the interest of European anes- thesiologists was focused on isoflurane, which had just been in- troduced for clinical purposes. Studies on this product had al- ready been appearing for years in the American literature. This book deals once more with all three inhalation anesthetics, but places particular emphasis on isoflurane. In contrast to the situa- tion in 1981, extensive experimental and clinical investigations on isoflurane have by now become available in the European litera- ture. From its conception, the objective of this symposium was not to discuss the relative value of inhalation anesthesia (bal- anced anesthesia) as compared with intravenous anesthesia. On the contrary, the major effects and interactions of isoflurane were to be explored. The side effects and their relative significance in different patient groups were also of interest. eurrent knowledge concerning a range of topics related to inhalation anesthetics (es- pecially isoflurane) was to be presented in a comprehensive and critical manner. The effects of isoflurane on the cardiovascular system were the focus of interest during the symposium and are accordingly dealt with extensively in this volume. The comparative effects on cor- onary perfusion of isoflurane, enflurane, and halothane are de- scribed in detail.

This book is intended to bring together data and clinical guidelines for those involved in the practice of anaesthesia, whether they be specialists or not. It is designed to be a true handbook that will accompany its owner into the operating theatre, where it will serve as a practical reference guide, not as a textbook. We welcome comment, criticism, and suggestions for improvement of the contents; correspondence may be addressed to the authors at P. O. Box 63, Tygerberg 7505, Republic of South Africa. We wish to acknowledge help received from our colleagues over the years of publication: Dr. T.J.V.Voss, Prof. G.G.Harrison, Dr. C. M. Lewis, Dr. W. B. Murray, Prof. A. R. Coetzee, and Dr. W. L. van der Merwe. Acknowledgement is also made to "Anaesthesia Guidelines," long since out of print, on which the first edition of this handbook was based in 1978. Tygerberg, South Africa, May 1987 P.A.Foster l.A. Roelofse v Contents Chapter 1 I. Pre-anaesthetic Assessment and Preparation 3 A. Anaesthetic Risk Assessment 3 B. Cardiac Risk Index . . . . . . 6 C. Respiratory Risk Assessment 7 D. Hepatic Reserve and Anaesthetic Risk 8 E. Pre-anaesthetic Check List . . . . . . . 8 F. Detailed Check of Anaesthetic Machine 10 G. Requirements for Paediatric Anaesthesia .

This volume contains the lectures and discussion papers presented at the II. In ternational Symposium on Innovations in Management, Technology and Phar macology held on 26-28 May 1984 in Liidenscheid. This symposium delt with fur ther developments in the sector of the closed-circuit system; non-invasive mea surement and monitoring systems; new aspects of cardiovascular and pulmonary physiology; oxygen-transporting substances; and particular questions in pharma cology. The purpose of this meeting was to allow a mutual international exchange of news on interesting new developments, particularly as these relate to the closed-circuit system, and the encouragement of further scientific developments. It must be made clear that the large-scale introduction of the closed-circuit sys tem has to be the occasion of completely new quality standards both in anesthesia and in all related technological sectors, combined with the highest demands in terms of precision and measuring techniques. The conventional and still quite crude clinical anesthetic procedures will have to make way for much more phys iological, micromolecular precision techniques, which will compare with our present methods rather in the same way as a microelectrode to a spear and will allow new levels of achievement in anesthesiology. All our tasks will need to be rethought and thoroughly understood from these aspects. Some anesthesists, physiologists and engineers already see the closed-circuit system as a challenge, while for others this system will still mean a great deal of work and creativity be fore the problems are finally solved in the future."

Major conduction blocks utilizing local anesthetics or opiates are find ing ever increasing applications in daily routine. However, two serious drawbacks are associated with their use: hypotension during surgery and the development of tolerance in long-term epidural analgesia. When opiates are injected epidurally or intrathecally, numerous side effects such as itching, nausea and vomiting, or respiratory depression have been reported. The pathophysiology of complications arising during a major conduction block and measures to prevent them were discussed by 19 experts at the 4th International Symposium at DUsseldorf. This volume contains 21 papers presented on three topics: 1. tachyphylaxis in long-term epidural anesthesia, 2. hypotension due to epidural and spinal anesthesia, and 3. effects and dangers of epidural and intrathecal opiates. With regard to the safety of our patients during anesthesia, current practices of preventing complications were evaluated, and preliminary guidelines for a more rational approach toward prevention and treat ment based on a knowledge of pathophysiologic mechanisms were developed. It is our hope that the anesthesiologist will profit from the discussion of regional anesthesia contained in this volume, many aspects of which have never before been presented in such detail."

thesiologist, were not included. Perhaps the next symposium will have a paper on his many contributions. Even though his dates are not quite modem (1813-1858), his accomplishments were, especially his book On Chloroform and Other Anaesthetics (1858), the first comprehensive textbook on anaesthesia [2]. There has been a real renaissance of interest in the history of anaesthesia. Among those responsible for this rebirth, besides Dr. Rupreht and Dr. Erdmann, are Dr. Selma Calmes and Dr. Rod Calverley, now on the Board of the new American society, the Anesthesia History Association. It held its inaugural meeting in Atlanta, Georgia, during the annual meeting of the American Society of Anesthesiologists, on 9 October 1983. The meeting was well attended, and the evening was profitable and delightful. Mention should also be made of the accomplishments of the nurse anaesthetists [3]. They are many in number, and generally they work under the direction of a physician- anaesthesiologist. Although modem anaesthesia was Ameriea's first great medieal diseovery, it soon traversed the globe and found worldwide acceptance. The British, for example, have made many coeval and historie contributions. Besides Dr. Duncum one thinks of Prof. T. Cecil Gray, who pioneered the British use ofeurare [4], andDr. J. Alfred Lee, whowas a pioneerin the use ofspin~l anaesthesia and is currently working on the fifth edition of a textbook on spinal analgesia [7]. Dr.

In spite of all the progress made by modern science and technology in penetrating the mysteries of nature and providing new possibilities for its transformation, we remain largely helpless in the face of such natural phenomena as earthquakes, tsunami, typhoons, floods, and droughts. Natural disasters occur suddenly, but with periodicity, and man has been confronted by their devastating consequences throughout history. The way people deal with these problems is primarily predetermined: by charac ter, by conditions, and by the social and economic development of society. Industri ous efforts to reconstruct nature, and exploitation of her resources, have brought about additional damage, and there is the apparent danger that our interference with the atmosphere and other areas such as climate, soil, and hydrology has initiated devastating processes which may well be irreversible. As a result, the effects of natural disasters, and all the ensuing repercussions, become ever more aggravating. Their scope becomes global, and for the time being we have no effective countermeasures at our disposal with which to fight them. The contemporary world, then, faces the interconnected and interdependent phenomena of ecological crises and natural disasters: the problem of protecting man from the environment, and the concurrent problem of protecting the environment from man."

R. Droh Ladies and gentlemen. dear friends and colleagues. we welcome you very cordially to our symposium "Innovations in Management and Technic and Pharmacol ogy." We are very glad that you have come to Liidenscheid and we do hope that our programme will fulfil your expectations. We decided to hold this symposium, because it is getting more and more dif ficult to select innovations at international congresses around the world which are important for our clinical work. Now and in the future our intention is to present the actual state of technology. management and pharmacology. We would be very glad to receive your suggestions for further symposia. The industry has the same problems as we have. They do not only have to search for those things which can be realized and which are desirable, but also for those things which can be sold. But the industry must also be stimulated by the inventors and by the users, so we want to bring together the industry, the physicians and the inventors for fruitful discussions. And we hope that in the fu ture the industry will provide us more quickly with those technical and organiz ational aids that we need. We want the indu try no longer running behind the market but heading the market. At present too many interesting developments are killed by so-called market analysis, in the beliefing that such analysis can always prove what cannot be sold. In anaesthesia many companies are always busy with the same product."

Almost a hundred years passed from the time of the first description of an intracranial aneurysm by Morgagni in 1761 to the year 1859, when Sir William Withey Gull arrived at the conclusion that haemorrhage in the subarachnoid space is caused by ruptured aneurysms. The introduction of lumbar puncture by Quincke 1891 and cerebral angiography by Moniz 1927 made it possible to establish the diagnosis of haemorrhage and its source. In recent decades the problems of treatment have come into prominence, first of all because of the inadequacy of conservative methods of treatment in most of the cases, and from surgical experience and its limitations which became apparent before very long. Because of the erratic development of neurosurgery and vascular surgery, above all, since the technique of microsurgery has been used, the entire removal of the source of haemorrhage has become a possibility, even though there were still quite different views taken regarding the most convenient time for surgical intervention, apart from the prevailing local conditions 134, 143, 144,261. In an up-to-date plan of treatment of subarachnoid haem orrhage (SAH) conservative measures are appropriate for bridging the pre-operative period, and must be considered the only solution in those cases in which the source of haemorrhage cannot be found. As far as the effectiveness of such conservative therapy is con cerned, the rate of re bleeding and the mortality provide sufficient comment.

The existence of a differential block is still part of the theory of regional anaesthesia. In 1980 it was described in detail by Cousins and Bridenbough in their standard work Neural Blockade. The theory of differential sensitivity of fibres in the peripheral nervous system essentially goes back to Gasser and Erlanger, who in 1929 established that when isolated peripheral nerves are electri- cally stimulated in the presence of increasing concentrations of co- caine, the compound action potentials of slow-conducting fibres are blocked before those of fast-conducting fibres show any measur- able changes. In man, regional anaesthesia begins subjectively with a feeling of warmth, objectively with a corresponding increase in skin tem- perature. There is then, in order of occurence, loss of sensation of cold, heat and pain, and pressure and touch, and fmally loss of voluntary motoricity. In recovery from anaesthesia, these return in the reverse order. The theory of differential block is by no means undisputed. In 1981, de Jong, commenting in Anesthesiology on the work pub- lished in that journal by Gissen et al. which showed a new sequence of differential sensitivity in the rabbit, wrote, "There remains plen- ty to be done yet before the book on differential nerve block can be closed".

In September 1983 the First International Headache Congress took place, the founding congress of the International Headache Society (lHS). This meeting was attended by around 200 headache specialists from some 20 countries. One of the principal goals of the IHS, which was formed in London in 1982, is to promote and stimulate interest and research in the headache field. In addition to the sponsorship of continued-education events, this also involves the coordination of scientific pro jects and the organization of future conferences. There is no doubt that headaches represent an everyday problem in medical practice. When the first headache clinics were established some years ago, they were regarded as very progressive. Today there are special outpatient centers and clinics for headache patients. However, this specialization has certainly not progressed very far. The fact is that differential diagnosis and treatment of recurrent and chron ic headaches represents a broad field that cuts across many disciplines. Headaches are thus relevant not only to the neurologist, but also to the psychiatrist, the neuro surgeon, the internist, the endocrinologist, the psychologist, the pharmacologist, and the biochemist. Despite intensive research in numerous and very disparate medical disciplines there are still no generally accepted pathophysiologic concepts for many headache syndromes. Realizing the importance of a multidisciplinary fo rum, the IHS assumed the organization of this congress in collaboration with the German Migraine Society."

The anesthetist-computer interface tends to be a problem for the utilization of computer systems for anesthesia. Ergonomic interface design with an emphasis on the coherency of the interface's static and dynamic structure may improve this situation. To investigate this proposition we developed an Anesthesia Information System (AIS) with a touch-sensitive monitor as the hardware-user interface. Basic data input and system control techniques were defined and implemented. Record keeping is integrated into the user interface. Ventilator control from the same interface is an additional feature for laboratory simulations. The system is being evaluated using a technique that simulates live operations. References Anthony J (1982) BAS - A major change coming in delivery. IEEE EMB 1 (1): 36-42 Apple HP, Schneider AJL, Fadel J (1982) Design and evaluation of a semiautomatic anesthesia record system. Med lnstrum 16 (1): 69-71 Arnell WJ, Schultz DG (1983) Computers in anesthesiology - a look ahead. Med Instrum 17 (6): 393-395 Bender HJ, Osswald PM, Hartung HJ, Lutz H (1983) On line - Erfassung haemodynamischer und respiratorischer GraBen in der Anaesthesie. Anaesth Intensivther Notfallmed 18: 37-40 Cooper JB et al. (1982) A graphics-tablet for data entry in computer assisted recordkeeping Proc.

Mehr als 40.000 Behandlungsfehler werden Medizinern jedes Jahr vorgeworfen - Tendenz steigend. Die Auswirkungen koennen gravierend sein. Umso wichtiger sind detaillierte Kenntnisse uber das richtige Vorgehen nach einem Vorfall. Das Werk zeigt anhand von Fallbeispielen aus der Praxis, wie AErzte sich im Schadensfall richtig verhalten. Erlautert werden u. a. der Umgang mit Angehoerigen, die aussergerichtliche Einigung, die zivil-und strafrechtliche Auseinandersetzung vor den Gerichten sowie die Rolle von Versicherungen, AErztekammern und Krankenhausern.

The hemodynamic significance of the flow properties of blood was put into perspective only during the past decade. Advances in modern technologies today allow the quantitative analy- sis of the fluidity of blood and its components under conditions approximating the flow in vivo, particularly those in the microcirculation. The hematocrit is the most important of the determinants of blood fluidity (reciprocal value of blood viscosity); acute increases in the hematocrit exert deleterious effects on circulation and oxygen transport owing to impaired fluidity of blood. High viscosity of plasma due to hyper- or dysproteinemias initiates the microcirculatory dysfunctions in hyperviscosity syndromes. Furthermore, the fluidity or deformability of red cells might be critically diminished and therefore cause redistribution of blood elements and adversely affect the resistance to flow within the microvessels. In low- flow states blood fluidity most likely becomes the key determinant for microvessel perfu- sion, overriding the neural and local metabolic control mechanisms operative at physiological conditions to adjust blood supply to tissue demand. Microcirculatory disturbances are there- fore encountered whenever driving pressures are reduced, as in shock or hypotension, and distal to stenoses of macrovessels, but also in hemoconcentration due to plasma volume con- traction, polycythemia, leukemia, and dysproteinemia. Based on experimental studies exploring the possibilities and limitations, with regard to improving the fluidity of blood by reducing the hematocrit, the concept of intentional hemo- dilution has been introduced to clinical medicine.

The significance of a change in Pa02 occuring in a patient with cardiovascular instability cannot be ascertained unless the values for PV0 and CV02 are known. A fall in Pa02 could 2 reflect worsening of pulmonary function or deterioration of cardiac output (with resultant increase in systemic oxygen extraction). PEEP/CPAP would be an appropriate therapy in the former case but frankly deleterious in the latter if applied prior to cardiovascular stabiliza- tion. References 1. Douglas ME, Downs JB, Dannemiller FJ et al (1976) Change in pulmonary venous admixture with varying inspired oxygen. Anesthesia and Analgesia 55:688-695 2. Kelman GR, Nunn JF, Prys-Roberts C et al (1967) The influence of cardiac output on arterial oxygena- tion. A theoretical study. Br J Anaesth 39:450-458 3. Kirby RR (1986) Respiratory vs cardiovascular dysfunction - How can we differentiate? ASA Refresher Course Lectures, 102 4. Nunn JF (1977) Applied respiratory physiology (2nd ed). Butterworth et Co 5. Van Aken H, Lawin P (1981) Der EinfluB des Herzminutenvolumens auf die arterielle Oxygenation.

113 This system of monitoring might be improved further if all cases in this category were investigated jointly by a forensic pathologist and an anaesthesiologist at the very outset of the investigation and during the actual autopsy. Free Papers The Influence of Pancuronium on Primary Conjugated Bile Acids A. Fassoulaki, T. Mihas, A. Mihas and P. Kaniaris Experimental studies have been reported in which a prolonged action of steroid neuro- muscular blocking agents followed bile acids administration(1, 2). A prolonged neuro- muscular action of pancuronium has also been detected in patients with biliary obstruc- tion(3). In the present study serum bile acids and intracellular liver enzymes were estimated after anaesthesia in which pancuronium was used as a muscle relaxant (Fig. 1). An at- tempt is made to investigate the effect of pancuronium on bile acid levels. Material and Methods Twelve female patients aged between 40 and 50 years were studied. All of them were visited in the ward the night before the operation by the anaesthesiologist where their clinical condition was assessed and their consent was obtained to participate in the pre- sent study. None of them had a history of hepatic disease or was taking drugs. The oper- ation performed in all cases was modified radical mastectomy and intracellular liver en- zymes are routinely determined in these patients preoperatively. The twelve patients were reassured and stated that they did not want to have any tranquillizer for premedi- cation.

The advances in the field of anaesthesiology and reanimation have contributed in all developed countries to the decrease in deaths occurring on the operating table (exitus in tabula), from the ratio 1: 100 (in the nineteenth century) down to approximately 1: 1000 (in the first half of the twentieth century) and finally to approxi mately 1: 10 000 (nowadays). Numerous human lives were saved not only through the intro duction of new medicine and methods but even more so by better training for the doctors and nurses who apply these new techni ques. I am happy about the splendid initiative of my student and friend Georg Kamm, which has now made these advances acces sible to the developing countries. He knows very well how to make his colleagues understand the theory and the practical side of modern anaesthesiology, under the most difficult conditions and in a completely different world, to such an extent that to day in his country all of his patients are given the benefit of the advances of medicine. There is nothing more rewarding for an academic teacher than to see how his students continue developing his ideas and spread them far and wide. I am therefore happy and proud to write this foreword for Georg Kamm, one of the pioneers of anaesthesiology in Africa."

The recent development of the use of spinal opiates as a rational therapy for pain rests on clear and certain experimental data. We have long known the spinal cord to be a highly complex structure. Anatomical studies of the substantia gelatinosa have repeatedly demonstrated signs of massive synaptic interaction between primary afferents, descending pathways and intrinsic neurons. Yet, to date that knowledge, insofar as clinical therapy is concerned, has permitted us only to destroy certain connections within the spinal cord in the hopes that the substrate mediating pain could be anatomically differentiated from those which mediate other function. Though cordotomies are clearly effective under certain circumstances, they suffer from the fact the spinal cord is not organized in such an anatomically discrete fashion as is often times drawn in basic medical text. Rather, functions intertwine exquisitely and specific physical interventions are no more likely to produce a specific effect than smashing of the fmgertip with a hammer will produce just a loss of the fingernail. The development of specific therapies of the spinal cord has come about by our growing aware ness of the intricate organization of the pharmacological substrates associated with specific neural function."

bei cardio-chirurgischen EingrifIen U. Brenken, G. Karliczek und H. Oldenziel Einleitung 1 2 Seit einigen Jahren werden an unserer Klinik Etomidate und Piritramid aufgrund der gUn* stigen Mitteilungen in der Literatur [3-9, 12, 13, 15, 17] routinemae,ig zur Narkoseeinlei- tung fill Koronar- und Klappenersatzoperationen eingesetzt. In dieser Untersuchung sollte gezeigt werden, inwieweit auch bei schwerstkranken Herzpatienten Narkosen ohne wesent- liche Veriinderungen der Haemodynamik eingeleitet werden konnen. Entsprechende Unter- suchungen haben sich bisher auf den Vorgang der Schlafinduktion beschrankt. In Wirklich- keit umfae,t die Narkoseeinleitung Muskelerschlaffung, endotracheale Intubation und den Ubergang zur kontrollierten Beatmung mit meist Lachgas-Sauerstoff. Diesen Sachverhalt ha- ben wir in unserer Untersuchung mitberiicksichtigt Methoden Die Messungen erfolgten an 12 Patienten mit ernster Koronarsklerose und an 12 weiteren Patienten mit Herzklappenfehlern im klinischen Stadium III, III bis IV und IV der NYHA- Klassifikation. Die verwendeten Mee,methoden wurden an anderer Stelle eingehend be- schrieben [10]. Praemedikation: 10-15 mg Valium, kein Atropin. Unter Lokalanaesthesie wurde ein 7-F-Swan-Ganz-Katheter (KMA) eingebracht. Nach Messung der Basiswerte: Herzfrequenz, arterieller Blutdruck (Riva-Rocci), zentralvenoser Druck, Pulmonalarteriendmck und Cardiac Output (Thermodilution) wurde die Anaesthesie durch langsame Injektion von Etomidate 0,2-0,3 mg/kg in 30 Sekunden und Piritramid 0,3-0,5 mg/kg eingeleitet. Bis zur Intuba- tion unter Pancuroniumbromid (pavulon) 0,1 mg/kg in der 5. Minute wurden die Patienten tiber eine Maske mit 100% Sauerstoff beatmet. Nach der Intubation erfolgte die Beatmung mit dem Servo-Ventilator mit einem Lachgas/Sauerstoffgemisch (Fi0 = 0,5). Es wurde eine 2 endexpiratorische CO -Konzentration von 5% angestrebt.