Penetrating neck injuries: experience with selective exploration

Although many authors have stated that surgical exploration should be mandatory for all neck wounds that penetrate the platysma, recent reports from many centers now claim that selective exploration is both safe and reasonable. A policy of selective exploration based on clinical presentation, anatomic location, and results of diagnostic studies has been followed at The Cooper Green Hospital in Birmingham, Alabama, for the past 13 years. We report a study of penetrating neck wounds in 136 consecutive patients admitted to The Cooper Green Hospital from 1972 to 1984. Seventy-seven patients (57%) had exploration immediately, with one death, while the remaining 59 (43%) were admitted and observed. Of these 59 patients, ten had arch aortography and nine had esophagography, all of which yielded normal results. The remainder of the patients observed had no clinical signs or symptoms to suggest a major injury. There were no deaths or complications related to the neck wounds in the 59 patients observed. Results of 27 explorations (35%) were negative. We conclude that selective exploration of penetrating neck wounds is both safe and reasonable.

Autonomy and paternalism: two goals in conflict

The development of concepts of autonomy and paternalism, as applied to children, women, the mentally ill and mentally retarded, and the elderly, has been a remarkable journey for philosophers, lawyers, physicians, caregivers, and politicians. Autonomy and paternalism have moved together in uneasy company to new definitions and applications derived in an extended dialectical process that has not only refined the definitions but also moved them away from the extreme ends of the gamut. To the extent that autonomy is equated with independence of action and paternalism is equated with coercive actions contrary to an individual's wishes or desires in order to achieve a beneficent end, we have exercised some of the most extreme and benighted paternalism while permitting in some sectors of our lives great independence on grounds of classical autonomy. Refinements of these concepts have moved us to new levels of sophistication and have made us aware of new issues and problems with which we have yet to wrestle.

Theory and practice of radon monitoring with charcoal adsorption

Because of interest in charcoal adsorption as an inexpensive radon monitoring technique that may be suitable for mass data collection, the theory of radon adsorption from air by a charcoal bed is developed, giving numerical estimates at all stages. The method is practical down to air concentrations of about 0.1 pCi/l. A simple charcoal bed is limited by the fact that its response is highly sensitive to the time interval before termination of the exposure, but two simple methods of avoiding this problem are developed. Simple methods for determining the diffusion constant for the charcoal being used, and for optimizing the depth of the charcoal bed, are presented.

Aortic aneurysm: a multifocal disease. Presidential address

A review of 1,510 patients treated for aortic aneurysms at all levels found that 191 (12.6%) had multiple ones. More than half of those with thoracic aneurysms had other lesions, and 12% of those with abdominal aneurysms had thoracic aneurysms. Abdominal lesions were the most common secondary lesions in the former group. Early results of treatment varied with method: 90% survived when both aneurysms were treated at one operation; 84%, when operations were staged; and 80% when operation was limited to symptomatic lesions. Most of the early deaths in the latter two groups were caused by rupture of the second aneurysm. Long-term survival was much better in patients with complete treatment. Aortic aneurysmal disease is multifocal and needs total aortic screening for diagnosis; best results are obtained by complete replacement of all disease.

The use of hypnosis in treating the temporomandibular joint pain dysfunction syndrome. Report of two cases

This article, jointly authored by an oral and maxillofacial surgeon and a psychiatrist, presents two case studies of conjoint treatment of the temporomandibular joint pain dysfunction syndrome. The authors present a short review from the literature that supports the multifactorial etiology of temporomandibular joint dysfunction and provide, in two case studies, a combination of conservative dental treatment and hypnotherapy. The two case studies show a successful resolution of temporomandibular joint dysfunction with hypnosis in one case and failure of hypnotherapy to relieve the pain in a second case. Reasons for the success and failure are discussed. The article closes with some thoughts and ideas that dental practitioners can use in treating temporomandibular joint pain via hypnosis.

Osmotically induced electrical changes in isolated bullfrog small intestine

1. Steady state values of cell water, intracellular Na+ and K+ concentrations, and the electrical parameters ETr, Em, and Isc in the mucosa of isolated bullfrog small intestine were determined following immersion in sodium sulfate Ringer solutions with identical ionic composition but different osmolalities. 2. Cell water and intracellular K+ concentration were inversely related to the osmolality of the bathing medium. During 1 h immersion, intracellular Na+ concentration was not significantly affected by an increase or decrease in external osmolality. 3. Replacement of a hypotonic or an approximately isotonic (normal) medium by a medium of greater osmolality caused statistically significant decreases in ETr, Isc and the (inside negative) magnitude of Em. Conversely, when a hypertonic or a normal medium was replaced by one of lower osmolality, significant increases in the magnitude of these parameters were observed. 4. An equivalent circuit model for the epithelial cell layer, in which the resistance of a relatively highly conducting extracellular shunt pathway is assumed to be the major determinant of the electrical responses of the small intestine to external osmolality, has been shown to account satisfactorily for the observed changes in ETr and Em. In terms of this model, the experimentally observed dependence of Isc on external osmolality requires that, even when both the mucosal and the serosal sides of the tissue are bathed by identical media, isolated bullfrog small intestine maintains a finite diffusion potential across the shunt pathway. This is consistent with current views concerning transepithelial ionic transfer mechanisms.

Some considerations in the formulation of psychiatric diagnoses

This paper attempts to show that psychiatric diagnosis depends to a significant degree on not only the patient's presenting symptoms but also on the psychiatrist's psychosocial biases. The importance of a psychiatric diagnosis is seen in terms of the potential social restrictions and prejudices that can be a consequence of a person labeled with a mental illness. Also, current treatment techniques and valid statistics for research are based on reliable and consistent psychiatric diagnoses. A study of 267 cases from a major psychiatric hospital revealed over 12 per cent discrepancy between the official discharge diagnosis and a resident's training report diagnosis that is used only for teaching purposes. This discrepancy is statistically significant and the paper attempts to elucidate some of the characteristics of the special population that had its diagnosis made less severe on discharge. Of the 267 charts surveyed, 33 patients had their diagnosis changed from a psychotic diagnosis on the resident's training report to a neurotic or characterological diagnosis on the official discharge summary. In addition, interviews were arranged with the 18 psychiatric residents who had been involved in changing the diagnosis of target group patients. The results obtained from these interviews definitely confirm that psychiatric diagnoses are changed due to social conditions unrelated to the psychopathological state. From the demographic data of the patient groups, a pattern evolved showing that men were generally more protected than women, that black males were more protected than black females, that unskilled laborers and those on the lower end of the socioeconomic scale were more protected than professionals, and that housewives were less protected than other categories. A number of conclusions were made by the authors concerning the data. The authors hope that these findings will enable other mental health workers to be more aware of their psychosocial biases that may be influencing their diagnostic skills.