A classic revisited: Loewald on the therapeutic action of psychoanalysis.

Versions of the following papers were presented at the panel "Psychoanalytic Classics Revisited: Hans Loewald's "On the Therapeutic Action of Psychoanalysis' " (Gerald I. Fogel, chair) at the meetings of the American Psychoanalytic Association, December 1993. As a tribute to Loewald's lifetime of achievement, and in belated recognition of his preeminent position in the field of psychoanalysis, the exchange appears here almost in its entirety, rather than as a conventional panel report.

Brain abscess and its surgical management.

A series of 56 patients with brain abscesses who were treated over a period of 23 years is reviewed. Patients with posttraumatic infections were not included. The operative mortality was 11%. Aspiration of purulent material, radical excision of the abscess, drainage of pus, or a combination of these procedures was used according to the patient's condition and the location of the abscess. The relatively low mortality may be related to the preoperative condition of these patients, who were operated upon in the subacute or chronic stage of their disease. Conservative surgery, especially when functionally important parts of the brain are involved, helps to keep the postoperative neurological deficit as low as possible. Computerized tomography is of primary importance in localizing, diagnosing, and following the evolution of a brain abscess.

Penetrating cranio-cerebral injuries due to unusual foreign bodies.

Seven cases of penetrating cranio-cerebral injury by peculiar foreign bodies are described. The clinical-pathological picture is reported wherever possible. Lack of adequate safety measures and untrained careless handling of instruments were at the root of these tragic accidents. Greater awareness of such dangers in industry and in school might help to promote the adoption of adequate safety measures.

Aneurysmal bone cyst of spine.

Four patients (aged 5, 7, 18, and 42) suffering from spinal cord involvement due to an aneurysmal bone cyst are reported. In two cases only a preoperative radiological diagnosis was made, one of them by a CT scan. Combined surgical and radiological treatments were done in three cases with a follow-up of 16 years in one patient and 9 years in the other two. In the fourth case, presenting with a C1 lesion, after radical excision and curettage X-ray therapy was not instituted. Pathological and radiological manifestations are discussed. Therapeutic measures are reviewed.

Incidence, prognostic significance and therapeutic modalities of central nervous system involvement in multiple myeloma.

In 114 patients with systemic malignant gammopathies followed during a 10-year period in the hematology clinic of the Rambam Medical Center, 23 episodes of CNS involvement were recorded. 19 cases with spinal cord compression and 4 cases of intracranial plasmacytomas. Early diagnosis followed by prompt laminectomy and subsequent radiotherapy resulted in complete recovery in 50% and partial improvement in 30% of the patients with spinal cord involvement. In good responders. overall survival was not affected by the neurological complication. In the 4 patients with intracranial involvement, external plasmacytomas of the skull preceded the neurological symptoms. 3 of them were diagnosed late, which led to delay and failure of accurate treatment. Only 1 patient was immediately operated and continued to be well for the past 2 years.

Correlation between radionuclides uptake and ultrastructural features of tight junctions in the capillary wall of meningiomas.

The uptake of Tc-99m pertechnetate and Co-57 bleomycin and the ultrastructure of small blood vessels were studied in 10 cases of meningioma. When thin sections of 120 contact areas between adjacent endothelial cells were examined, 92% of the intercellular contacts contained one to three punctate tight junctions. Freeze fracture preparations revealed fascia occludens with one to four sealing strands. These findings are consistent with the high permeability the meningiomas displayed for both of the radiopharmaceuticals.

Supratentorial and parafalcial subdural empyema diagnosed by computerized tomography. Case report.

A case is presented in which computerized tomography (CT) demonstrated a supratentorial and parafalcial purulent collection. However, neither carotid angiography nor CT revealed the small scattered pockets of pus that were found over the convexity at operation. The entire subdural space was exposed by a wide craniectomy, permitting adequate subdural drainage and decompression of the brain. It is thought that thorough drainage of the entire subdural space is crucial for the attainment of a successful result in a single-state operation.

Spinal intradural metastases of extraneural origin.

Three cases of intradural extramedullary (spinal subdural) metastases, originating from outside the central nervous system, are presented. Two were located at the cervico-dorsal junction, and one was mid-dorsal. A breast ductus carcinoma, a cervical neuroblastoma, and an apoduma of unknown origin, were the primary neoplasms. All presented clinically with a short history typical of cancerous spinal cord compression. Plain X-rays of the spine did not show areas of destruction. Myelography in two cases clearly suggested that intradural location of the tumour. The relative frequency of these tumours and their pathogenesis are briefly reviewed. It is stressed that primary tumours are mainly in the breast or lung. Their metastases are mainly found in the cervico-dorsal region. It is assumed that they really are metastases of the dura mater itself, growing inward. The importance of the lymphatic and venous pathways in their spread into the dura mater is emphasized.

Spinal intradural enterogenous cyst: report of a case.

Enterogenous cysts are relatively rare causes of spinal cord compression. Recently, such a case was observed in a 13-year-old boy. The cyst was located at the L1 level and was surgically removed. Histological examination revealed the true nature of the lesion.

Extracranial bone metastases from intracranial meningiomas.

Distant bone metastases in cases of intracranial meningiomas are uncommon. Two patients with meningiomas showing malignant histological features are described, in both of whom bone metastases were observed many years after cranial surgery.

Ultrastructural basis for different pertechnetate uptake patterns by various human brain tumours.

Patterns of pertechnetate uptake were correlated with ultrastructural properties of the endothelial wall in 14 human brain tumours. In tumours with reduced uptake of the radionuclide, intercellular tight junctions were observed whereas absence of intercellular tight junctions was characteristic of all tumours with an increased uptake of pertechnetate. In some tumours with increased uptake, fenestrated endothelial wall was seen while in others non-fenestrated wall was evident. We concluded that intercellular junctions and not fenestrations affect the permeability of brain tumours to pertechnetate.

Acute central and intermediate cervical cord injury.

Six cases with cervical cord contusion are described. All were over 50 years old, had an hyperextension injury of their cervical spine, suffered from tetraparesis predominant in the upper limbs and showed no X-ray evidence of injury to the cervical spine. Marked cervical spondylosis was present in five cases, one also had a narrow spinal canal. Cases No. 3 and 4 had an atypical recovery pattern. Shoulder and elbow movements improved last or not at all, while in the classic cases the hand muscles recovered last. Upper motor neuron damage was thought to be the cause, a result of intermediate instead of central cord traumatic necrosis or ischaemia. Pathological findings in case No. 5 emphasizes the possible diagnostic importance of taking lateral X-rays of the cervical spine in hyperextension. It also shows why laminectomy and/or myelotomy cannot help. Case No. 6 shows the noxious effect of shock and the effectiveness of steroid therapy.

Intradural rupture of lumbar intervertebral disk: report of two cases with review of the literature.

Two cases of intradural rupture of lumbar intervertebral disks are described, in addition to 22 cases reported in the literature. Our case occurred among 753 herniated disks surgically treated in this department, an incidence similar to that in the literature. Clinically most cases presented as an acute cauda equina syndrome, and a myelographic block was almost always present. Prognosis is not made worse by the perforation. Various factors that might contribute to this relatively rate complication of disk disease are mentioned.

Benign osteoblastoma of vertebral column and skull.

Three cases of benign osteoblastoma in children are reported; two in the spine and one in the occipital bone. clinical, pathological and X-ray appearance are discussed. The importance of complete removal whenever possible is stressed. Radiation therapy is not considered to be beneficial.

Multifocal glioma of the brain. Case report.

A case is presented in which two separate concurrent astrocytomas of the brain in the same patient were successfully operated on. The patient has been followed for 3 years and remains well. The authors believe that the diagnosis of multifocal tumors can be established on clinical grounds when the tumors are remote from each other, and when there has been no recurrence of neoplasm between the lesions after a long follow-up period. It is felt that a more optimistic approach to the treatment of multifocal tumors may yield good results.

Traumatic intracerebral haematoma: complication of skull caliper traction. Case report.

Recently, a unique case of traumatic intracerebral haematoma complicating the insertion of skull calipers, has been observed. It is assumed it was due to: 1. the accidental penetration of the burr into the skull, while making the insertion hole for the caliper; 1. the failure to grip the skull with the special metal sleeve, the Blackburn skull caliper is provided with, so that the end plates were free to move in and out of the skull in this restless patient. The correct diagnosis was made only after severe uncal herniation had developed. The reasons for missing the correct diagnosis within useful time for proper treatment are considered to be: 1. carotid angiography performed too early in the process of haematoma formation: 2. the vascular displacements were only slight and not fully diagnostic; 3. a recognized complication, extradural haematoma, had already been excluded.