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Francia, Bd. 26 Nr. 3 (1999)

Zika virus is an arbovirus from the family of flaviviruses, which is transmitted by the mosquito Aedes aegyptii and also by the Asian mosquito Aedes albopticus. The largest observed Zika virus epidemic is currently taking place in North and South America, in the Caribbean, southern USA and Southeast Asia. In most cases the infection is an unspecific, acute, febrile disease. Neurological manifestations consist mainly of microcephaly in newborns and Guillain-Barré syndrome but other rare manifestations have also become known in the meantime, such as meningoencephalitis and myelitis. Therefore, the Zika virus, similar to other flaviviruses, has neuropathogenic properties. In particular, the drastic increase in microcephaly cases in Brazil has induced great research activities. The virus is transmitted perinatally and can be detected in the amniotic fluid, placenta and brain tissue of the newborn. Vaccination or a causal therapy does not yet exist. The significant increase in Guillain-Barré syndrome induced by the Zika virus was observed during earlier outbreaks. In the meantime, scientifically clear connections between a Zika virus infection and these neurological manifestations have been shown. Long-term studies and animal models should be used for a better understanding of the pathomechanisms of this disease.

Idiopathic Parkinson's disease is still a clinical diagnosis. However, modern imaging and nuclear techniques allow very early diagnosis and lead to higher security in the differential diagnosis between idiopathic Parkinson's disease and atypical Parkinson syndromes. At early stages of the disease, modification of disease progression and symptom control are key factors of the therapy. Continuous dopaminergic stimulation is even more important at later stages with first fluctuations. In stages where conservative medical options have been exhausted continuous pump therapies with Duodopa and apomorphine are attractive options. Deep brain stimulation in the subthalamic nucleus has turned out in the last years, especially in younger patients, to be a highly successful treatment option. Deep drain stimulation requires, however, a close preoperative work-up and individual consideration of potential effects and side effects.

The diagnostic work-up in the case of a suspected cerebral involvement of Whipple's disease involves neuroimaging and analysis of cerebrospinal fluid (CSF) including polymerase chain reaction (PCR) assays for Tropheryma whipplei. As neurological findings may be complex and unspecific, extracerebral symptoms often lead to the suspicion of Whipple's disease. We report the cases of two patients in whom the suspected diagnosis of Whipple's disease could not be proved either by endoscopy or by the analysis of CSF. Only by means of a cerebral biopsy was the diagnosis assumed and specific therapy was initiated.

Subarachnoid haemorrhage constitutes a neurological emergency. In most cases the diagnosis is easy to establish by cerebral computed tomography or cerebrospinal fluid tap. However, in rare cases verification of the diagnosis is more difficult and a residual uncertainty remains. We describe three patients supposed to have a subarachnoid haemorrhage without pathological findings in both cerebral computed tomography and cerebrospinal fluid. In these cases vasospasm or cerebral aneurysm were detected by means of transcranial Doppler sonography and/or conventional angiography. We comment on the special features of this rare presentation of a severe acute neurological emergency, and we discuss diagnostic work-up and differential diagnoses.

Cognitive decline is a common disorder in idiopathic Parkinson's syndrome, the risk for the development of a dementia is four- to six-fold higher for Parkinsonian patients. The cognitive profile in Parkinson's disease dementia (PDD) differs from that of Alzheimer-type dementias. The affected cognitive functions include attention, executive functions, visual-spatial functions and recall. The main differential diagnosis for PDD is the Lewy body dementia (LBD), which can be differentiated through the temporal development of motor and cognitive symptoms. Cognitive symptoms in Parkinsonian syndromes have a relevant negative impact on quality of life, on the burden for the care-givers, on the prognosis of the disease and on the possible referral to a nursing home. Dementias in Parkinsonian syndromes (PDD and LBD) need a confirmatory diagnosis at an early stage in order to initiate further therapeutic steps with, e. g., acetylcholine esterase inhibitors or, perspectively, neuropsychological training methods.

Syncope is a common and difficult differential diagnosis for epilepsy. One possible cause for a cardiac syncope is a long QT syndrome (LQTS). LQTS with torsade de pointes tachycardia can lead to lethal ventricular fibrillation and cardiac arrest. Patients with LQTS when first diagnosed as suffering from epileptic fits often experience a particularly long diagnostic delay which may even take years. In some cases, the diagnosis of LQTS is not made until the patient needs resuscitation due to a cardiac arrest. Therefore, ECG recording should be performed for every patient presenting with a seizure considered to be of epileptic origin not only at the beginning of the disease but also when fits occur in spite of antiepileptic treatment in order to prevent an incorrect diagnosis and delay in making the correct diagnosis.

We here report on a 43-year-old man who was repeatedly admitted to our stroke unit with acute onset of sensorimotor hemisyndrome of acute onset. In most cases symptoms ceased shortly after admission, but twice when symptoms persisted thrombolytic therapy was applied. This case demonstrates that in emergency situations a rare differential diagnosis like conversion disorder with sensorimotor deficits may be hard to establish even if the patient presents to the same emergency unit.

Childhood-onset schizophrenia (COS, age of onset between 7 and 14 years) is a rare and severe form of the disorder. The prevalence is about 1 / 50 of the rate of adult-onset schizophrenia. In COS-children emotional, cognitive and behavioural abnormalities are often seen years before illness onset. Premorbid symptoms including social withdrawal, isolation, introversion, peculiar behaviour, unmotivated temper tantrums, auto- and heteroaggressive acts, suicidal thoughts, anxiousness, paranoid ideas, represent early warning symptoms and are associated with an unfavourable outcome. About 60 % of 67 patients with COS examined by us (44 long-term-, 23 short-term-follow-up examinations) demonstrated premorbid abnormalities prior to the onset of their psychosis. We found a significant correlation between high M-PAS-scores, insidious onset, negative PANSS-Items, and early onset of age (12 years). High M-PAS-Scores were positively related to long duration of psychotic and residual states, and vice versa there was a negative correlation between M-PAS and a favourable outcome (long duration of recovery states). It is necessary to identify clinical states of elevated risk for psychosis as early as possible. This is difficult especially in young patients, in whom psychical peculiarities are ambiguous, and they may develop in different directions, most of them into normalization. Nevertheless, it is important to recognize risk-groups by time and to study their development carefully. Thus they could benefit from multiprofessional family-oriented early interventions.

Patients with spine metastases due to lung cancer suffer from a reduced lifespan. For a more precise prognosis, it is important to define parameters which influence the individual survival time. This study reviewed the mean survival time of patients who had undergone surgery because of spine metastases due to lung cancer. It should be evaluated whether the postsurgical survival time is dependent on the length of time between diagnosis and surgery and from the histological type of the tumor.Between January 1999 and December 2003, 68 patients had undergone spine surgery because of spine metastases due to lung cancer at the department of traumatology of the St. Georg General Hospital in Hamburg, Germany. Retrospective data were collected from the hospital documentary system regarding the period between diagnosis of lung cancer and date of surgical treatment, and regarding the histological type of the tumor. The postsurgical survival times were evaluated using data from the Hamburger Cancer Index and from general practitioners. These times were analysed afterward according to the defined parameters.The average age was 62.6 years, and 24 female and 44 male patients were included. It was possible to evaluate the survival time of 65 patients. The average survival time of those with preoperative unknown primary manifestation (20 patients) was 88 days, in the group of patients with lung cancer histories of less than 12 months (35 patients) 141 days, and with patients with lung cancer histories of lung cancer longer than 12 months (13 patients) it was 171 days. The mean survival times after surgical treatment were 122 days for patients suffering from non-small-cell lung cancer (45 patients), 128 days for those with small-cell lung cancer (20 patients), and 247 days for patients with other histological types (three patients).The prognosis of patients after spine surgery for lung cancer metastases is poor. The indication for surgical treatment of spinal metastases due to lung cancer should be critically discussed. Especially patients with unknown primary manifestation might benefit from a conservative approach. With respect to the patients' reduced lifespan, they, their relatives, and the nursing staff should be carefully informed.

This study evaluated the intra- and post-surgical complications on tumor affected spines. Complications were analyzed according to selected patient groups so that risk factors could be determined.Between January 1999 and December 2004, 401 patients underwent surgery because of spinal metastases in the Department of Traumatology, General Hospital St. Georg in Hamburg. Data were obtained from the hospital's documentary system. The results of this study were compared to other published studies.The average age of patients was 63 years (24-88) and there were 172 (42.9%) females and 229 (57.1%) males. A total of 118 (29.4%) patients suffered from 235 complications and 22 (5.5%) died.Patient's age70 years, patients with a preoperative neurological deficit, and patients with heavily bleeding metastases are at high risk for complications. The dorsoventral/dorsolateral approach had the highest complication rate.

Fixed-angle implants are being increasingly used in surgery of fractures of the proximal humerus. The aim of this retrospective investigation was to evaluate the outcome after fracture reduction utilizing a fixed-angle plate (Königsee).Between January 2003 and April 2004, 58 patients were operated, 52 of whom received a fixed-angle implant; 46 cases were harvested for a follow-up examination. Each patient was re examined clinically and radiologically at least 6 and 18 months after surgery. The functional outcome was evaluated using the Constant Score and the Simple Shoulder Test. The results were compared to results of other investigations.The mean patient age was 68.8 years (34-94 years). Fractures were classified using the Neer Classification: 12 were classified as two-part, 25 as three-part, and 9 as four-part fractures. Three of the three-part and four of the four-part fractures were rated as luxation fractures. The overall functional outcome of all cases was good. More than 18 months after surgery the mean general "Constant Score" was 57; the mean side-related "Constant Score" was 89%. The Simple Shoulder Test revealed a pain-free range of motion in 41 (89.1%) of the individuals. The majority of the patients were satisfied with the results regarding remaining range of activity of the injured limb. In five cases significant complications occurred. In two cases the head of the humerus collapsed, and in one case a necrosis of the head occurred. In one individual the implant broke after an additional trauma. In this case a re-osteosynthesis utilizing a tibia plate was performed and the patient was excluded from further follow-up investigations. One soft tissue infection occurred after initial surgery.It has been shown that results after fixation of proximal humerus fractures with fixed-angle implants are good. The functional outcome is good and complications are rare. Our results correlate with other investigations regarding fracture reduction using fixed-angle plates and nails.

A vertebroplasty was carried out on an 86 year old patient with a lumbar fracture involving impression of the cranial and caudal endplate by moderate osteoporosis. The vertebral column tilted with gibbous development and subluxation. As correcting treatment, corporectomy and spacer implantation using a dorsolateral approach and spondylodesis were necessary. This case draws attention to the mechanical conditions needed for an indication for vertebroplasty. The indication for vertebroplasty should be critical for patients with central impression of the vertebral body.

In order to allow speedy mobilization after vertebral body replacement, high primary stability as well as prevention of implant dislocation are required. It is unclear whether differences between common vertebral body replacement systems exist and whether spreadable implants improve primary stability. Migration characteristics of 3 different vertebral body replacement systems were determined using human lumbar spine specimens. Primary stability was assessed by loading specimens successively in 5 conditions: native, after dorsal spondylodesis, after laminectomy and after vertebral body replacement. Migration was shown to depend on cage design and spike shape. Dorsal spondylodesis in combination with vertebral body replacement reduced flexion/extension movement effectively independent of cage design. Stabilization potential in lateral bending was limited. None of the cages limited movement under torsional loading effectively. The possibility to spread the cage had a positive effect on stabilization.

Totally misplaced pedicle screws will lead to major stability problems. There are no publications about the stability behavior of screws, which have no pure trabecular position and perforate the pedicle slightly. Since neurological problems are only described with screws perforating the pedicle medially by at least 4 mm, this question has great relevance concerning the definition of pedicular malposition. Sixty-eight pedicle screws were tested in human cadaveric lumbar spines. Their vertical path was measured at the beginning and end of 1000 sinusoidal cycles with a force amplitude of 160 N. They were divided into four groups according to their screw position as mentioned in the title. We found no significant differences in primary stability or loosening between the groups. The cortical contact and perforation groups had slightly better results, which were not significant in comparison to the other two groups.

A well-known problem occurring with thoracolumbar spondylodesis is the perforation of pedicle screws through the pedicle wall. It occurs in up to 40% of the implanted screws. To reduce this problem, computed tomography (CT)-based navigation systems have been introduced, which allow the surgeon multidimensional control of the screw position in virtual reality and real time during insertion. In the recent past, fluoroscopy-based navigation systems have also been built. We inserted 77 pedicle screws in human lumbar cadaveric spine specimens either without navigation, with CT-based navigation, or with fluoroscopy-based navigation. In the critical sizes of pedicles between 6.5 and 9 mm, we found the best results with CT-based navigation, but there was no significant difference between the three methods. The minimal pedicle and the screw diameters should be reported in every study on pedicle screw misplacement and spine navigation since they represent the most important factor in pedicle wall perforations.

Regularly the unsolved problems of addiction- and dependence-research are discussed in the sense of the psycho-body-dichotomy, arguing that the biological mechanisms of reward-systems and their pathobiochemistry have to be confronted with the psychological and philosophical/anthropological dimensions within persons. The present paper, however, tries to demonstrate that this dichotomy is insufficient insofar as social-anthropological components of being addicted, which represent integrative constituents of a theory of addiction, are neglected within such a scheme. The developmental-psychological and philosophical-psychological aspects of socialization are considered and related to internal valuating systems and reality models regarding the problems of drugs and dependency. Herein it is shown that especially the model of René Girard, constituting "mimetic triangulation", is applicable to the understanding of the microsocialization of drug-consumers. This is also demonstrated in film-examples. It is shown that the problem of drug-addiction cannot be solved from a neurobiological/biochemical--and also a psychotherapeutic/psychoanalytic concept--without incorporating the dynamics and the value-worlds within groups which should also be considered to be therapeutically influenceable.

Research on communication skills in psychotic patients demonstrates that in dialogues schizophrenics neglect the needs of the listener. There are only few linguistic studies which investigate the speech of schizophrenic children and adolescents. The verbal and non-verbal communication of schizophrenic, neurotic, and healthy adolescents during a problem solving situation was transcribed and compared by a content analysis. The transcripts were screened for dialogue control and communication disturbance of verbal/non-verbal activities of the speaker and listener: Dialogue control was defined by the variables signals of the speaker or signals of hearer and eye or body contact of the test person to the experimenter. Communication disturbance was defined as the amount of incomprehensible articulation and selections. Neurotic test persons produce the highest signals of speaker rate. In dialogues with neurotic and schizophrenic test persons the experimenter uses more signals of hearer than in dialogues with healthy test persons. In dialogues with neurotic test persons the experimenter shows more signals of the speaker than in dialogues with healthy test persons. Schizophrenics neglect more often the statements of the experimenter than in other dialogues and vice versa. Although the experimenter was instructed to restricted verbal behavior the communication intensified in the neurotic group. The communication in the schizophrenic group was characterized by frequent communication disturbance.

In the last few years neurobiological research has made a substantial contribution to an improved understanding of the neurodevelopmental origins of schizophrenia. Studies of functional and local brain-damage have illuminated the mechanisms of action of both the classical and the atypical neuroleptics and thus have considerable implications for a rational pharmacotherapy. Taking into account modern research on bonding, it is possible to elaborate a somato-psychosomatic model for the development of schizophrenia in childhood. The present review discusses the implications of this model for the treatment of children and adolescents with schizophrenia.

We reviewed 77 conservatively and 164 operatively treated cases of rupture of the long head of the biceps documented in the literature. Refixation offers a small but relatively constant improvement of flexion and supination power and thus reduces the number of cases with remaining light or marked weakness by one third. Deformity by the slipped muscle can be corrected effectively. As complications are uncommon surgery should be recommended to young and active patients and should at least be offered to less active patients. Thirteen patients were re-examined after operative repair for distal biceps tendon avulsion and 277 reported cases were reviewed. After conservative management (n = 20) the power of flexion remains reduced by 30%-40%, that of supination by more than 50%. The loss of flexion power, as well as the deformity can be nicely diminished by attachment of the distal biceps to the brachialis muscle (n = 22). There are no complications documented regarding this procedure. The anatomic reinsertion (n = 248) additionally reduces the loss of supination power to 0%-25%, but bears a higher risk of complications. The double-incision technique (n = 105 of 248) does not necessarily decrease this risk. There are as many nerve injuries reported as with the single-anterior approach. Additionally we are faced with the problem of radioulnar synostosis. The use of suture anchors provides a nice way of fixation of the tendon but does not facilitate the approach to the tuberosity. The distal biceps tendon rupture should be treated operatively. The adequate method of repair is to be determined individually.

Since its first definition 100 years ago, the term conversion underwent many changes, a fact that is proved by various re-evaluations with respect to classification (DSM-IV, ICD-10). In the context of a psychodynamically-oriented diagnostic there are--in addition to that--actual attempts to reach a valid operationalization of the conversion concept. From a psychodynamic point of view a differentiation of traditional concepts has been made. Results of examinations of 45 children and adolescents (average age: 14 years, range: 8-18 years) who had been treated in the Department of Child and Adolescent Psychiatry of the University of Essen for conversion symptoms, revealed a strong interaction of oedipal and pre-oedipal conflicts and that in case that there was no help from a third object during early triangulation, the child's endeavor to break out of the primordial relationship with the primary love object had been impeded and thus individuation processes were impaired or even prevented. Our results lead to the conclusion that for the young patients, who came to us with a conversion symptom, the early pre-oedipal triangulation failed and thus primary separation and dependency conflicts could not be solved adequately.

Forty-four first-admission patients with childhood-onset schizophrenia (age at onsetor = 14 years) were examined retrospectively for 30 clinical symptoms using the Positive and Negative Syndrome Scale (PANSS; 15). A principal component analysis with varimax rotation was applied to the full item set of this scale and revealed five orthogonal independent symptom groups: cognition affect, social withdrawal, anti-social behavior, excitement, and reality distortion. In order to validate these psychopathological dimensions we analyzed the relation between the five factor scores and outcome variables (Disability Assessment Schedule, DAS-M; 13) several years after onset: Social withdrawal was correlated with poor outcome; reality distortion was related to good outcome (P0.01). A multivariate ANOVA identified group differences in the anti-social behavior factor between acute and insidious onset of illness and between boys and girls; patients with an acute onset scored significantly higher on the excitement factor than those with an insidious onset (P0.05). According to our results more than two dimensions are necessary to describe the psychopathology of childhood-onset schizophrenia, similar to adolescent- and adult-onset schizophrenia.

Schizophrenic psychoses with early onset (or = 10) are very rare; they occur in approx. 0.5-1% of the total number of patients. Long-term research with sufficiently long observation periods may be able to answer the question whether there is a nosological continuity between early-onset schizophrenia and schizophrenic psychoses in adults. We report on the results of a study on 13 patients with onset at the age of 10 years or earlier (7 girls, 6 boys) with an average duration of illness of 36.1 years (SD = 10.2 years). 3 patients had deceased in the meantime, one patient could not be reached by mail. 9 of the original 13 patients could be examined during the second follow-up by the same interviewer (on the average 27 years after the first follow-up). In 5 children the onset was acute (less than one week), in 8 children insidious (more than 4 weeks). Among the 5 patients with acute onset of childhood psychoses the positive PANSS-type (60%) predominated, in the 8 patients with at first barely perceptible beginning, the negative PANSS-type (45%) prevailed. In respect of the diagnostic division into subcategories, we found a remarkably large variability: At the beginning the disorganised type, at the first follow-up the paranoid, and at the second follow-up the catatonic and the disorganised type were diagnosed most frequently by 4 independent raters. The evaluation of the whole course shows that the incidence of the paranoid type was most frequent. Clear positive-productive psychotic symptoms occurred very early in our patients, i.e. already at the age of 7 years. On the whole, 77% of the patients showed positive symptoms from the beginning of psychotic breakdown; more than half of them had hallucinations from the beginning. This is contrary of the current opinion that childhood-onset schizophrenia begins predominantly with negative symptoms. However, at the beginning of insidious courses, negative symptoms prevail. The prognosis for the 8 insidious courses on the whole was unfavourable (only one full remission, one partial remission, the rest poor or very poor remissions). No connection between the total diagnosis (subtype) and the remission grade was seen.

This paper discusses psychosocial influences of diabetes mellitus type 1 on children and young patients. A group of 21 patients, age 9 to 14 years with Diabetes mellitus type 1 attended a course in "Autogenic Training" for a period of 11 weeks. From the multidimensional questionnaire for children (PFK 9-14, SETZ U. RAUSCHE 1976) 15 dimensions of personality and 5 second rank factors were extracted at the beginning and at the end of training and 5 months later. Additionally HbA1-scores were assessed at the beginning and at the end at a 2 month and a 5 month-follow-up. At the beginning of the course only on one of the 15 scales a significant difference could be observed between experimental group and age related normal population. After training 5 scales and one second rank factor showed significant changes. Significant reduction was observed in: "need for aggressive forms of dominance behaviour" "feeling of submission with respects to other:", "emotional lability" and "tendency for dependence on adults". A significantly increased score was observed in the scale measuring "self confidence regarding one's own meaning, decisions and planning ability". The second rank faktor "neuroticism" was significantly reduced. Against expectations there was no reduction in HbA1 scores. At the end of training HbA1 scores even had increased significantly. But this might have been related to the high frequency of infections during this course. In subjective ratings of training evaluation most of the course members and their parents described fewer problems with attention, less test-anxiety and less aggression and nervousness. The results of this prospective pilot-study are discussed in terms of the psychodynamic influence on diabetes.

A psychoeducational approach of the nursing staff's work with parents is presented. By offering a family visit to the unit prior to admission, systematic preparation of the admission process, reflected interactions with parents during their visits, by parents' evenings and parents' weekends, the nursing team makes a distinct contribution to the families' treatments. Pros and cons are dealt with, concerning issues of professional self-image, goal planning of the team as a whole, structures of team conferences, and supervision. As to evaluation, some parameters (incidence of dismissals for reasons of discipline, withdrawal of children against medical advice, patients referred to care of public authorities after treatment) are discussed for their usefulness.

In contrast to angloamerican countries there are no national figures for the incidence and prevalence of sexual abuse in Germany. Reports based on criminal statistics are inappropriate and are often misinterpreted.In this report we present the main results of a regional study of the prevalence of sexual abuse in childhood and compare them with angloamerican studies.Based on replies from 1009 students and apprentices (age18y) the prevalence for criminal sexual abuse was found to be 25.2% for females and 6.2% for males. A breakdown of these figures showed that females reported having to experience anal, oral or sexual intercourse (2.3%), physical contact (11.7%), exhibitionism (4.6%) and other sexual behaviour without physical contact (6.6%). For males the prevalence rates for these categories of sexual abuse were 1.5%, 2.4%, 0.9% and 1.5% respectively. All these figures, especially those for males, should be evaluated critically as actual prevalence rates are probably higher. Girls, particularly those aged 6-10 years, are more often involved than boys. Ninety percent of physical abuse happens with persons known to the victim (60% within the family, only 8% with strangers. In general 95% of abusers are male, however in 25% of cases of hands-on-contact with boys the abusers are female. From the relative frequency of reported abuse we estimate the potential incidence to be 1:30 within the family, 1:23 with other acquaintances and 1:6 with strangers.The importance of regional differences should not be underestimated. These results cannot be generalized for the whole of Germany. Only prevalence studies appropriately reflect the scale of the problem; they are necessary for a broad, a rational and a sufficient planning of strategies designed for prevention, intervention and rehabilitation. More scientifically based epidemiological studies on the extend of sexual abuse are required in Germany.

This study focuses on psychiatric disorders following extreme traumatisation experienced by children born during the Holocaust in World War II. According to numerous epidemiological investigations and case studies on survivors who lived through the Holocaust as children or in adulthood, these traumatic experiences are associated with a higher risk for various psychiatric disturbances during the entire life span. Besides the extreme psychological and physical distress during persecution and following traumatisation (parent-child-separation, discrimination while living in other countries) the coping with the trauma and the development of autonomy and ego-strength is additionally impaired by the specific psychodynamics of families with psychologically altered and disturbed parents.What sort of psychodynamic parent-child relationships developed during traumatisation and after the war in subjects currently suffering from chronic impairment of mental health?Retrospective analysis of 22 cases with applications for pensions of invalids evaluated by diagnostic categories.The implicit pressure on the children to be sensitive to the needs of their deprived parents places a sense of guilt on their attempts to develop autonomy. The parents were experienced as restrictive or overprotective on the one hand or liable to be rejected or to be intolerant on the other. The suffering and trauma continues to be perceived in family communication to the extent that coping with loss of relatives and the development of independence are impaired.The results are discussed critically in terms of current procedures for expertise on pension applications.

This study addresses the question whether children taken for treatment to a psychiatric hospital for children and adolescents differ from other, not noticeably disturbed children in their use of a transitional object. Parents of mentally disturbed children between six and eight years of age were interviewed about the transitional objects used by their children. The control group was made up of children of corresponding ages from an ordinary nursery school. Based on the extant literature, the concept of "transitional object" is described and defined. Twenty two research hypotheses were formed and subjected to statistical tests. As the main result concerning the research question it emerged that the children suffering from psychiatrical disturbances needed a transitional object mainly in their fourth year of life, but to some extent even in their fifth and sixth year whereas the "healthy" children in the control group without noticeable disturbances used a transitional object mainly in their first and second years. It could be shown with statistical significance that psychiatrically disturbed children had a transitional object at a later age and for a longer period of time than healthy, undisturbed children.

Sixty-five patients with cervical spine injuries and varied neurological deficits were treated operatively. Evaluation revealed an improvement in neurological findings dependent upon the promptness of anatomical reduction in patients with incomplete lesions. The more frequent neurological improvement seen with open reduction and internal fixation as compared with closed reduction was not statistically significant but was felt to justify the additional resources required for internal fixation. In complete lesions, there was no evidence that the time of anatomical reduction was related to improvement in neurological findings.

A hip-joint endoprosthesis, comprising a carbon fiber-reinforced stem, aluminum oxide head, and polyethylene acetabular cup, was studied in vivo trials in ten foxhounds after implantation with bone cement. Observations over 6 months and 1 year demonstrated that carbon fiber-reinforced carbon exhibits adequate strength for use as a stem material under the observed conditions.

By introducing the definition "hallucinosis" (Wernicke) it has become possible to confine the psychoses of organic origin more closely. Therefore, this term should also be used in pediatry and pedopsychiatry in order to designate cases with corresponding clinical aspects. Thus, accordance to the phenomenological characteristics of such syndromes as described in this paper, it is justified to emphasize that the acute hallucinosis in children is a special type of disease as compared to other psychoses caused by exogenic influences in this age group. The 10 case reports deal with visual hallucinoses which turned out to be characteristically different compared to those in adults. Hallucinating children at the age of 3 to 9 years predominantly visualized animals and legendary beings. Contrary to findings in adults, scenic and systematized visions were scarcely noticed, which psychodevelopmentally may be attributed to the fact that creative power in children is still little pronounced. Etiologically intoxications and infectious diseases were the cause for the visual hallucinations of the 10 children described. In the development of visual hallucinations somatic and psychic factors are significant. They have been discussed on the basis of today's knowledge. As today, however, there exists no satisfactory theory concerning the conditions favoring the development of hallucinations. To explain the somatogenesis of visual hallucinations three theories have been outlined, based on the present neurophysiological findings. It has been worked out that especially in children emotion plays an essential role in the origin of hallucinations. In infancy and early school age, while rational control of reality is still suppressed to a great extent, domination of emotional life goes along with lack of differentiation. At the same time the difference between imagination and perception is still little precise; therefore, phenomena, impressing as hallucinations in the adult, occur with greater facility in children.

Neurologic hemisyndromes in childhood may be due to congenital or acquired changes in cerebral vessels. Among the congenital vascular malformations, which very rarely become manifest already in children, the arteriovenous angiomata and saccular aneurysms are relatively the most common (in childhood about 4-8% manifest, 1-2% of all diseases). Venous angiomata, micro-angiomata and congenital dissecting aneurysms are very rare. But acquired thrombotic blocks of cerebral arteries are of greater importance as causes of acute neurologic hemisyndromes in childhood. Most often they have an inflammatory or traumatic cause, often the cause is unknown. Rare diseases only very recently described as arterial blocks of cerebral vessels are fibromuscular dysplasia and Moya-Moya-disease, the etiology of which is not yet fully understood. The prognosis of these diseases is generally unfavorable, but the focal signs in migraine as visual, sensory, aphasic and motoric defector irritative signs are as a rule reversible. In order to establish, where possible, the cause of acute neurologic hemisyndromes in childhood, early angiography may-classic migraine accompagnee types excepted-help. But also modern biochemical, immunologic, virologic, serologic, bacteriologic, clotting analytic and, possibly, histologic and histochemical techniques should be employed with particular attention to fat metabolism and to auto-immune disease.

The highest aim of every treatment in child and adolescent psychiatry is the encouragement of maturity. This also applies to pharmacotherapy with substances which reduce fear, suppress impulses, inhibit aggression, brighten the moods and promote efficiency. The indication for these should be made strictly in consideration of both the psychological development and biological maturity aspects as well as the family dynamic relation and interaction structure in which the child grew up. Psychopharmacotherapy must be limited to closely defined diseases, especially to psychotic disturbances, malignant tics, the hyperkinetic syndrome, pediatric emergencies and to supporting the treatment of enuresis or as concomitant medication in some disordered behaviors of abnormal mental and neurotic development. The administration of psychodrugs is moreover only to be considered if psychological measures alone are insufficient to help the child.

There is an increasing occurrence of drug-intoxications in infancy, thus psychopathological changes due to intoxication also occur more frequently in children. 6 children were described with cases of acute and reversible toxic psychoses whose--mainly visual--hallucinations together with conditions of excitation and hyperactivity were the most striking features of the psychopathological picture; in contrast to the more frequent delirious confusion (delirium) disturbances of consciousness and orientation were missing. The phenomenological characteristics of halucinosis in children-a condition so far not specified in the case of infants and children-have been elaborated with regard to other psychotic phenomena during infancy and adult age. Relevant neurophysiological and psychodevelopmental findings lead to the following four theorems: 1. Drugs with hallucinotic effects facilitate the occurrence of "internal" pictures independent of external perceptions which are described phenomenologically as hallucinations. This theory is based on the fact that hallucinogenic drugs intensify the electrical potentials which are evoked by optic stimulation in the visual area, while an intracortical impulse propagation is inhibited. 2. A change in emotion either caused by situation or by exogenous or endogenous factors facilitates the development of hallucinations, especially if emotions dominate to such a degree that rational control of reality is being suppressed. Since hallucinogenic drugs exert their effects not only on the sensory system but also on brain structures which influence directly or indirectly emotional functions, hallucinations might also be evoked via this mechanism. 3. Brain stem has-apart from its importance in emotional processes-a filter effect and a controlling function of sensoric stimuli originating in the periphery. Hallucinogenic drugs can influence this screening function and have a disinhibitory effect which cause an inundation of the brain cortex by sensoric stimuli which again facilitate hallucinations. 4. The neurophysiological actions discussed above which are caused by intoxications have a synergistic effect together with the psycho-developmental facts relevant to infancy. This synergism can explain the frequent occurrence of fever hallucinoses as well as the fact that agents primarily not hallucinogenic as e.g. benzydamine can also cause hallucinations in infancy.