Max Brödel (1870–1941): his life and his role in the development of surgery

Summary. Max Br?del (1870–1941), from Leipzig, Germany, is often referred to in the USA as the father of modern medical illustration and mentioned in the same breath as Leonardo da Vinci or Andreas Vesal. After a classical formal art education in Leipzig he worked in Carl Ludwig's laboratory of physiology and anatomy, where he came in contact with American physicians. In 1894, the anatomist F. P. Mall convinced him to work for the recently inaugurated Johns Hopkins School of Medicine in Baltimore, where he collaborated with world-famous surgeons such as H. A. Kelly, W. S. Halsted, and H. Cushing. His illustrations were characterized by meticulous observation, both realistic and explanatory intention, technical superiority, and artistic merit. In 1911 he established the first “Department of Art as applied to Medicine”. Here, he proved to be an innovative artist, a creative scientist, and an inspiring and skillful instructor. By the time of Br?del's retirement in 1939, 160 students had graduated as medical illustrators. His pupils spread his principles and style throughout the USA and Canada, and several similar academic programs for medical illustration have been founded in these countries.      

Prolongierte Muskelschwäche des Intensivpatienten unter besonderer Berücksichtigung der sog. Intensiv-Polyneuromyopathie

Generalized muscle weakness in critically ill patients can result in prolonged periods of artificial ventilation and longer stays in the intensive care unit. Both neuropathic (critical illness polyneuropathy) and myopathic (critical illness myopathy) abnormalities seem to play an important role for this prolonged weakness. This article reviews its complex differential diagnosis with special emphasis on the current understanding of the neuromuscular syndromes. An efficient diagnostic plan is necessary for the exclusion of other curable causes of prolonged muscle weakness even in the presence of polyneuromyopathic changes. Psychological support of the patient and prophylaxis of secondary complications of prolonged immobilization are crucial when specific therapy is not possible.     

Postoperative Resistenzentwicklung gegenüber Atracurium

Zusammenfassung Zwei F?lle einer postoperativ aufgetretenen Atracuriumresistenz werden vorgestellt. In beiden F?llen handelte es sich um Patienten, welche nach einem intrathorakalen Elektiveingriff eine septische Komplikation entwickelten. Kasuistik: Beim ersten Patienten (39 Jahre) entwickelte sich wenige Tage nach einer Pneumonektomie eine Bronchusfistel mit einer Superinfektion der Thoraxresth?hle. Zum Zeitpunkt des Revisionseingriffs war die Wirkung von Atracurium im Vergleich zur Prim?roperation deutlich ver?ndert: Die Anschlagzeit war verl?ngert (7 vs. 3,5 min), die Erholungszeit (DUR 10%) war verkürzt (14 vs. 28 min), und die Infusionsrate zur Aufrechterhaltung der Relaxation mu?te um ca. das 3fache gesteigert werden (14,3 vs. 5,0 μg/kg·min). Beim zweiten Patienten (56 Jahre) kam es im Anschlu? an eine Oberlappenresektion rechts zu einer Gangr?n des Mittellappens, welcher operativ entfernt werden mu?te. Die zur Intubation erforderliche Atracuriumdosis mu?te im Vergleich zur Prim?roperation deutlich gesteigert werden (70 vs. 40 mg), ohne da? hierdurch eine komplette neuromuskul?re Blockade zu erzielen war. Darüber hinaus war zur Ruhigstellung des Patienten eine wesentlich h?here Erhaltungsdosis als beim Ersteingriff erforderlich (11,8–16,5 vs. 5,5 μg/kg·min). Schlu?folgerung: Die Beispiele zeigen, da? sich innerhalb relativ kurzer Zeit eine Resistenz gegenüber Atracurium entwickeln kann, und wir nehmen an, da? diese Ver?nderungen durch die schweren, entzündlichen Komplikationen ausgel?st wurden.      

Ethik in der Intensivmedizin

In more than 30 years of development of intensive care medicine (ICM), our speciality has acquired moral and ethical standpoints, although not without public pressure and discussions. Special commissions dealing, e.g., with brain death, terminal care, ethics of foregoing life-sustaining treatment in the critically ill, withholding or withdrawing mechanical ventilation, and other issues have meen formed in a number of medical societies. International consensus conferences have helped to clarify some of the issues. With increasing experience, a multitude of ethical problems have arisen in ICM that have to be dealt with, such as the issue of quality of life. What is an unworthy life? Are we allowed to make judgments for our patients? What is cost-effectiveness in ICM? Other restrictions include bed and equipment shortages in the intensive care unit (ICU), the necessity for triage – undisputed in catastrophe medicine – and how one should proceed in managing elective patients? In situations of limited ICU bed availability, sicker patients will be admitted, sparing out patients who are less ill for observation and those with poor quality of life and poor prognosis. For the future, it will likely be necessary to define the patients who should be admitted to an ICU more than those who should not be admitted. An ICU treatment entitlement index would be directly proportional to the probability of successful outcome and the quality of the remaining life, and would be inversely related to costs for achieving success. The ICU outcome with survival, hospital mortality, and follow-up of ICU patients is considered. DNR (do not resuscitate), the dying patient, terminal care, terminal weaning – DNT (do not treat) – active and passive euthanasia, living wills, quality of life, and cost-effectiveness for ICU patients are defined. Their application in the ICU will be discussed and problems pointed out. Outcome predictions using scores (APACHE III, SAPS II, MPM) have been developed based on previous experience, but should only be applied to patient groups and for quality assurance in ICUs. The most frequent and difficult problem in the ICU is the vegetative state, which requires an exact diagnosis. The differential diagnosis from other comatose states such as coma, brain death, and locked-in-syndrome is depicted. The ethics of interrupting life-sustaining treatment in critically ill patients have been worked out by a Task Force on Ethics of the Society of Critical Care Medicine (1990). A consensus was found that the patient may judge to forego therapy; ethically it is then appropriate to withhold or withdraw therapy. According to the consensus, withdrawing an already initiated treatment should not necessarily be regarded as more problematic than a decision not to initiate treatment. In my mind, however, there is a great difference between withdrawing or withholding, e.g., ventilation. A dissentive opinion by some members of the Task Force stated that hydration and nutrition other than high-technology or parenteral nutrition are key components of patient care, and should not be equated with medical intervention. The ethical problems associated with active euthanasia (physician-assisted suicide or death) as practised in the Netherlands are also discussed. In most countries this practice seems unacceptable. From 30 years experience in ICM, there are many more ethical questions and case reports without clear solutions. Care decisions for single patients in unacceptable situations should be made after medical evaluation by the intensivist with the medical team and, if possible, by the patient and/or his or her surrogate. Legislation and solutions cannot be expected for single patients, but ethics committees could be helpful in decision-making.     

Alzheimer-Demenz und normales Altern Klinische,neuroradiologische, neurophysiologische und molekularbiologische Verlaufsdaten

Zusammenfassung 30 Patienten mit klinisch diagnostizierter Alzheimer-Demenz (AD) und 55 etwa gleichaltrige Kontrollprobanden wurden über einen 2-Jahres-Zeitraum prospektiv klinisch, neuroradiologisch und elektroenzephalographisch untersucht, um die longitudinalen Ver?nderungen auf diesen Untersuchungsebenen und ihre Zusammenh?nge zu studieren. In der Kontrollgruppe waren im Beobachtungszeitraum keine wesentlichen Ver?nderungen auf einer der Untersuchungsebenen zu verzeichnen. Bereits inital bestanden signifikante Unterschiede zwischen Patienten und Kontrollen hinsichtlich der kognitiven Leistung, der Ventrikelweite und der absoluten Theta- und Delta-Power. Innerhalb der Patientengruppe verschlechterten sich w?hrend des zweij?hrigen Beobachtungszeitraums die Werte der Blessed-Demenzskala um 7 ± 7 Punkte und im Mini-Mental-State Test um 8 ± 4 Punkte. Die Volumina der Seitenventrikel weiteten sich um mehr als 30 % des Ausgangswertes und die absolute Delta- oder Theta-Power stieg um mehr als 10 % des Ausgangswertes an. Hierdurch nahmen die Unterschiede zwischen Kontroll- und Patientengruppe nochmals zu. Wir konnten keine Zusammenh?nge zwischen Krankheitsbeginn, Alter, Apolipoprotein E4 Gendosis und Krankheitsverlauf belegen. Ein initial schlechter Wert der Patienten auf der Blessed-Skala war mit st?rkeren morphologischen und EEG-Ver?nderungen im Verlauf korreliert, w?hrend initial hohe Theta-Power eine st?rkere funktionelle und kognitive Verschlechterung innerhalb der Patientengruppe pr?dizierte.      

Korrektureingriffe am Fuß nach posttraumatischen ischämischen Kontrakturen

Operationsprinzip Korrektur eines Pes equinus adductus durch keilf?rmige Resektion des Chopart-Gelenkes mit Keilbasis dorsolateral. Bei gleichzeitigem Pes varus keilf?rmige Resektion des subtalaren Gelenkes mit Keilbasis lateral (Lange 1962 [7], Myerson et al. 1986 [8], Witt et al. 1985 [13]) (Abbildungen 1a bis 1f). Bei gleichzeitigem Tarsaltunnelsyndrom Dekompression des Nervus tibialis durch Spaltung des Retinaculum musculi flexorum. Zur Korrektur von Krallenzehen Resektion der jeweiligen distalen Grundphalangen nach Hohmann; bei flektierten Endgelenken Resektion der distalen Mittelphalangen. (Auf diese Techniken wird hier nicht eingegangen).      

Predictors of Maternal Responsiveness

PURPOSE: To explore maternal responsiveness in the first 2 to 4 months after delivery and to evaluate potential predictors of maternal responsiveness, including infant feeding, maternal characteristics, and demographic factors such as age, socioeconomic status, and educational level. DESIGN AND METHODS: A cross-sectional survey design was used to assess the variables of maternal responsiveness, feeding patterns, and maternal characteristics in a convenience sample of 177 mothers in the first 2 to 4 months after delivery. The 60-item self-report instrument included scales to measure maternal responsiveness, self-esteem, and satisfaction with life as well as infant feeding questions and sociodemographic items. An online data-collection strategy was used, resulting in participants from 41 U.S. states. FINDINGS: Multiple regression analysis showed that satisfaction with life, self-esteem, and number of children, but not breastfeeding, explained a significant portion of the variance in self-reported maternal responsiveness scores. In this analysis, sociodemographic variables such as age, education, income, and work status showed little or no relationship to maternal responsiveness scores. CONCLUSIONS: This study provides additional information about patterns of maternal behavior in the transition to motherhood and some of the variables that influence that transition. Satisfaction with life was a new predictor of maternal responsiveness. However, with only 15% of the variance explained by the predictors in this study, a large portion of the variance in maternal responsiveness remains unexplained. Further research in this area is needed.     

Neues und Bewährtes in der Kinderchirurgie

Zusammenfassung Die in den letzten 25 Jahren erzielten Fortschritte der Kinderchirurgie werden vor allem in der Anwendung der Ergebnisse der Grundlagenforschung, in neuen Untersuchungsverfahren, wie der Sonographie und der Computertomographie, sowie in der zunehmenden klinischen Erfahrung mit, entsprechender Adaptierung der Operationsmethoden gesehen. Dafür werden einige, für die Praxis relevante Beispiele angeführt.