Surgical therapy of vertebral metastases. Are there predictive parameters for intraoperative excessive blood loss despite preoperative embolization?

AIMS AND BACKGROUND: Preoperative embolization of vertebral metastases has been shown to lower intraoperative blood loss. Nevertheless, excessive up to life-threatening blood loss can occur despite embolization. We therefore decided to evaluate possible parameters for predicting significant blood loss in a surgically homogeneous group of patients with vertebral metastases. METHODS: Patients with vertebral metastases of the thoracic and thoracolumbar spine who underwent preoperative embolization were included. All patients had existing or impending neurological deficit as the main indication for direct metastasis reduction. The parameters evaluated were the technical feasibility of embolization, vascularization grade of metastasis, success of embolization, tumor type in relation to blood loss, and interval between embolization and surgery. RESULTS: Twenty-seven patients fullfilled the inclusion criteria. Technically complete embolization was feasible in 14 patients (52%) and fully successful embolization was obtained in 10 patients (37%). Eighty-three percent of the renal cell carcinomas were hypervascularized, but also 67% of the breast carcinoma patients had hypervascularized tumors. No permanent complications occurred during embolization, but two patients had pain and another two experienced a transient burning sensation. A significant difference in intraoperative blood loss was only found between patients achieving partially or fully successful embolization in the subgroup of hypervascularized grade III metastases. CONCLUSIONS: The success of embolization in the group of hypervascularized grade III metastases was the only predictor for the extent of blood loss in our study. Due to the inaccuracy of predicting high blood loss in general all possible precautions for excessive blood loss should be taken despite preoperative embolization. Further randomized studies to determine the indications and results of embolization seem desirable.

Eugen Bleuler's Dementia praecox or the group of schizophrenias (1911): a centenary appreciation and reconsideration.

On the 100th anniversary of the publication of Eugen Bleuler's Dementia Praecox or the Group of Schizophrenias, his teachings on schizophrenia from that seminal book are reviewed and reassessed, and implications for the current revision of the category of schizophrenia, with its emphasis on psychotic symptoms, drawn. Bleuler's methods are contrasted with Kraepelin's, and 4 myths about his concept of schizophrenia addressed. We demonstrate that (1) Bleuler's concept of schizophrenia has close ties to historical and contemporary concepts of dissociation and as such the public interpretation of schizophrenia as split personality has some historical basis; (2) Bleuler's concept of loosening of associations does not refer narrowly to a disorder of thought but broadly to a core organically based psychological deficit which underlies the other symptoms of schizophrenia; (3) the "4 A's," for association, affect, ambivalence, and autism, do not adequately summarize Bleuler's teachings on schizophrenia and marginalize the central role of splitting in his conception; and (4) Bleuler's ideas were more powerfully influenced by Pierre Janet, particularly with regard to his diagnostic category Psychasthenia, than by Sigmund Freud. We conclude that Bleuler's ideas on schizophrenia warrant reexamination in the light of current criticism of the emphasis on psychotic symptoms in the schizophrenia diagnosis and argue for the recognition of the dissociative roots of this most important psychiatric category.

Etiology, pathogenesis, and therapy according to Pierre Janet concerning conversion disorders and dissociative disorders.

Pierre Janet's works on conversion disorders or dissociative disorders has mainly fallen to the wayside in favour of Freud's works. In the first part of this paper, Janet's conception of hysteria is discussed and his place in French psychiatry described. Different aspects of Janet's diathesis-stress approach are presented (particularly the pathogenic concept of fixed ideas), which refer not only to a conception of hysteria but also to traumatic (stress) disorders and other psychological disturbances. The second part of the paper details the varieties of Janetian therapeutic treatments of these disorders: the "liquidation" of fixed ideas by hypnosis and suggestion, confrontation techniques, which resemble contemporary cognitive behavioural approaches, and special cognitive ("logagogic") interventions. Finally, we discuss the various treatment strategies based on psychoeconomic considerations such as physical or psycho-phyical therapies, psychoeducation, treatment through rest, and simplification of life for dealing with basic disturbances of psychic disorders.

[Pierre Janet's views on the etiology, pathogenesis and therapy of dissociative and conversion disorders ("hysterias")]. / Atiologie, Pathogenese und Therapie der dissoziativen und Konversionsstörungen (Hysterien) nach Pierre Janet.

Pierre Janet (1859-1947) is one of those more or less forgotten authors whose approach differed significantly from Freud's psychoanalysis. In the first part of this paper, Janet's conception of hysteria is discussed and his place in French psychiatry described. Different aspects of Janet's diathesis-stress-approach are presented (particularly his important pathogenic concept of fixed ideas) which refer not only to a conception of hysteria, but also to traumatic (stress) disorders and other psychological disturbances. The second part of the paper details the varieties of Janetian therapeutic treatments for these disorders: the 'liquidation' of fixed ideas by hypnosis and suggestion, confrontation techniques which resemble contemporary cognitive behavioural approaches, and special cognitive ("logagogic") interventions. Finally, we also discuss the various treatment strategies Janet proposes for dealing with symptoms, such as asthenic or depressive states, from his psycho-economic perspective.

Psychopathological approaches in Pierre Janet's conception of the subconscious.

Janet's conceptions of the subconscious are restrictively conceived but show important differentiations which are discussed in detail. First, an outline of Janet's conception of consciousness is presented as well as of the terms of psychic synthesis and the notion of the field of consciousness. This is defined as a system of elementary or relatively elementary psychic phenomena which are connected with the personal ego in a given moment. Herbart's conception of the relation of conscious and unconscious psychic phenomena is analysed. Concerning Janet's psychology of tendencies, several kinds of subconsciousness are distinguished: dissociative subconsciousness, habit formation, adaptation, psychological automatism, dispositional subconsciousness and threshold-related subconsciousness or subliminal consciousness. The problem of dissociative subconsciousness caused by fixed ideas is discussed, and adaptation, habitualization and psychic automatism are described, all notions which are important for the conception of dissociative subconsciousness. Janet's understanding of double personality is outlined. Finally, the problem of the threshold of consciousness is explained.

[Pierre Janet's conception of the subconscious]. / Pierre Janets Konzeption des Unterbewussten.

Janet's conceptions of the subconscious are restrictively conceived but show important differentiations which are discussed in detail. First, an outline of Janet's conception of consciousness is presented, then the terms of psychic synthesis and the notion of field of consciousness which is defined as a system of elementary or relatively elementary psychic phenomena, which are in a given moment in connection with the personal ego. Herbart's conception of the relation of conscious and unconscious psychic phenomena are analysed. Concerning Janet's psychology of tendencies several kinds of subconsciousness are distinguished: Dissociative subconsciousness, habit formation, adaptation, and psychological automatism, dispositional subconsciousness and threshold related subconsciouness or subliminal consciousness. The problem of dissociative subconsciousness caused by fixed ideas is discussed; then adaptation, habitualisation and psychic automatism as notions which are important for a conception of dissociative subconsciousness are described. Janet's understanding of double personality is outlined. Finally, the problem of a threshold of consciousness is explained.

Psychological trauma and fixed ideas in Pierre Janet's conception of dissociative disorders.

This article describes Janet's concept of psychological trauma and the formation of rigid thought complexes (fixed ideas). This concept forms the basis for Janet's functional nosology of the neuroses, and is related to his dynamic psychology of conduct or action. It can be viewed as an early self-regulation model, because it contains a stratified bio-, socio-, and psycho-genetic hierarchy of behavioral "tendencies" that produce a more or less adaptive act by means of two hypothesized intervening variables: psychological force and psychological tension. Fixed ideas are viewed within this framework as an outcome of deficient processes of adaptation to psychological trauma. The article closes by pointing out affinities between Janet's psychological concept and modern cognitive and behavioral therapies.