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r/76 Nebraska State 
Medical Journal 


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[biition to the practice of medicine 


(CHLORAMPHENICOL) 


(^mplete information for usage available to physicians upon request. 






ACTINEX 


TABLETS & 
GRANULES 


LACTINEX — a viable culture 
containing both Lactobacillus 
acidophilus and L, hulgaricus — was 
first introduced to help restore 
the flora of the intestinal tract 
in infants and adults/’ ^ 

Further clinical work showed 
LACTINEX to be successful in the 
treatment of fever blisters and canker 
sores of herpetic origin/’ ^ 

No untoward side effects have been 
reported in 12 years of clinical use. 

Literature on indications and dosage 
available on request. 

(/) Frykman, H.M.: Minn. Med., Vol. 38, Jan. 1955. (2) 
Path, E.J.: The J.A.M.A., Vol. 163, No. 15, April 13, 1957. 
(i) McGivney, J.: Texas State Jour, of Med., Vol. 51, No. 1, 
Jan. 1955. (4) Stern, F. H.: Jour, of The Amer. Ger. Soc., 
Vol. 11, No. 3, Mar. 1963. (5) Weekes, D. J.: N.Y. State 
Jour, of Med., Vol. 58, No. 16, Aug. 1958. (6) Abbott, P.L.: 
Jour, of Oral Surg., Anes. & Hasp. Dental Serv., Vol. 19, 
July 1961. (7) IVeekes, D. J.: E.E.N.T. Digest, Vol. 25, 
No. 12, Dec. 1963. 




HYNSON, 

(LX02) 

•r^ ^ 

A" ^ ' J 


WESTCOTT & DUNNING, INC. 


NOV 1 1 190S 



BALTIMORE, MARYLAND 21201 





THE NEBRASKA STATE 
MEDICAL JOURNAL 

2430 Lake Street, Lincoln 2, Nebraska 


CONTENTS: 

EDITORIALS: 

Happy New Year 1 

The Philadelphia Story 1 

The Wonderful World of Words 1 

Prevailing Fees 3 

The President's Page 4 

ORIGINAL SECTION- 


The Acute Abdomen Coniplicating 


Pregnancy 5 

Keith M. McCormick, MD 

Etiology of Carcinoma: Genetic Determinism 8 


H. T. Lynch, MD 
P. G. Rigby, MD 
C. W. Magnuson, MD 
A. J. Larsen, MD 
A. J. Krush, MS 

Pediatric Conditions Related to Diseases and 

Functions of the Placenta 1 1 

Robert Murphy, MD 

Birth Trends in Nebraska - 14 

Warren H. Pearse, MD 

Neurologic Manifestations of Dysbarism 


(Decompression Sickness) 17 

John A. Aita, MD 

ORGANIZATION SECTION- 

Coming Meetings 21 

Welcome, New Members 23 

The Military Dependents' Medical Care 23 

The Month in Washington 24 

Doctors in the News 26 

News From Our Medical Schools 26 

Human Interest Tales 27 

Deaths 28 

The Woman's Auxiliary 28 

Know Your Blue Shield Plan 29 

Books 31 

Organizations, State 32 




JANUARY, 1966 

VOL. 51, NO. 1 


EDITOR- 

FRANK COLE, MD 
2430 Lake St,, Lincoln 2 

ASSOCIATE EDITORS— 

FREDERICK M. NEBE. MD 
Review Editor 

943 Stuart Building, Lincoln 8 

C. R. HANKINS. MD 

822 The Doctors Building, Omaha 31 

J. MARSHALL NEELY. MD 
4201 Calvert, Lincoln 6 

W. MAX GENTRY. MD 
1720 Tenth Street. Gering 

GEORGE E. STAFFORD. MD 
800 South 13th St.. Lincoln 8 

B. R. BANCROFT. MD 

Kearney Medical Arts Building, Kearney 

JAMES J. O’NEIL. MD 

612 Medical Arts Building, Omaha 2 

FRANK P. STONE. MD 
2300 South 13th, Lincoln 2 

ROBERT J. STEIN, MD 
930 Stuait Building, Lincoln 8 

J. H. BARTHELL. MD 

1012 Sharp Building. Lincoln 8 

HAROLD E. HARVEY, MD 
140 South 27th Street, Lincoln 6 

H. V. MONGER. MD 
3705 South Street, Lincoln 

BERNARD F. WENDT. MD 

735 South 56th Street. Lincoln 6 

FRANK H. TANNER. M.D. 

1835 South Pershing Road. Lincoln 2 

K. D. ROSE. MD 

University Health Service, Lincoln 8 

KEN NEFF. Business Manager 
1315 Sharp Building, Lincoln 
Telephone HEmlock 2-7585 


SUBSCRIPTION RATE 
$5.00 Per Year Single Copies 50c Elach 


The Editor of this Journal assume? no re- 
sponsibility for opinions and claims ex- 
pressed in the articles published herein. 

Manuscripts to be presented for publica- 
tion in the JOURNAL should be typewritten, 
double-spaced, on one side only of firm (not 
onion skin or flimsy), standard letter sized 
(8*/^ by 11 in.) white paper. Wide margins 
(at least 1 % in. on left) should be left free 
of typing. On the first or title-page should 
be shown the title of the article, the name 
(or names) of the author, his degree and 
other significant credits. Pages should be 
numbered consecutively, the page number 
being shown in the right upper corner along 
with the surname of the author. 

Illustrations should be numbered and their 
locations shown in the text. Each should be 
identified by placing on its back the author’s 
name, its number and an indication of its 
“top.’" Di-awings and charts intended for 
cuts should be in black (India ink) on pure 
white. Photographs should be on glossy 
paper and minimum of about 5 by 7 in. in 
size. A legend should be provided for each 
illustration and, preferably, attached to it. 

Manuscripts (original, not a carbon) should 
be sent directly to the Editor at the Journal’s 
address. 

Reprints should be ordered from the print- 
er, NEWS Printing Company. Norfolk, Nebr. 

Copyright 1964 by The Nebraska State 
Medical Association. 

Published monthly and postage paid at the 
Post Office at Norfolk, Nebraska, as second 
class matter. 


4-A 


You can enhance the value of your own Journal by patronizing its advertisers 




Announcing 

EUTRON 

pargyline hydrochloride 25 mg. and methyclothiazide 5 mg. 

for control of 
moderate to severe 
hypertension 


Unique combination produces greater 
antihypertensive effect with lower doses 


Eutron is the combination in a single tablet 
of 25 mg. Eutonyl (pargyline hydrochlo- 
ride) and 5 mg. Enduron (methyclothia- 
zide). This combination produces greater 
therapeutic effect than that of either com- 
ponent used alone. Side effects may be 
milder, too, as dosages are generally lower. 
The effective dosage is usually one tablet, 
once daily. Tablets are scored for greater 
dosage flexibility. 



tS8 No. E8?8 


EUTONYL' 


nc PARGYUNE 
ZJ HYDRO 
CHIORIOE 

Cuboo festal 
(USlA itdwtMOMh 
th orth- 

oul pj«ftlp4K>fl 






Each Eutron tablet contains two proven antihypertensives 
in the ratio shown to be most effective in most patients. 

TM— TRADEMARK 


January, 1966 


4-A 





Eight out of 10 patients respond 

In clinical trials, Eutron produced normo- 
tension or a significant reduction in blood 
pressure in eight out of 10 patients studied. 
The rationale for the product is this: 
Eutonyl used alone is a potent antihyperten- 
sive. Its antihypertensive action is markedly 
enhanced by Enduron, a potassium-sparing 
thiazide.’-'* The combination (Eutron) 
thus produces greater antihypertensive ef- 
fect with lower dosages of the Eutonyl com- 
ponent, and milder side effects may be seen. 


1. Torosdag. S.. Schvartz, N., Fletcher. L., Fertig. H., 
Schwartz, M. S., Quart, R. F. B., and Bryant, J. M., 
Pargyline Hydrochloride as an Antihypertensive Agent 
With and Without A Thiazide, Am. J. Cardiol., 12:822, 
Dec.. 196.1. 

2. Pollack, P. J., Pargyline Hydrochloride and Meth- 
yclothiazide Combined In The Treatment of Hyperten- 
sion, Cur. Thera. Res., 7:10, Jan., 1965. 

3. Bryant, J. M. et al.. Antihypertensive Properties of 
Pargyline Hydrochloride, New Non-Hydrazine Mono- 
amine Oxidase Inhibitor Compared with Sulphonamide 
Diuretics, J.A.M.A., 178; 406. Oct., 1961. 


New EUTRON 

extends your range 
of treatment in 
moderate to severe 
hypertension 


A single product 
you can use even 
in the presence 
of congestive heart 
failure or edema 


B 


Nebraska S. M. J. 



BP reductions in the recumbent and sitting posi- 
tions often are nearly as great as in the standing. 
In clinical trials, the average reciimhcnt BP 
reduction was 36/18 mm. Hg. 



The average standing reduction in clinical trials 
was 45/22 mm. Hg. Thus the difference between 
the standing and recumbent readings was only 
9/4 mm. Hg. 



Significantly lowers 
blood pressure in all 
body positions; 
less likelihood of 
orthostatic hypotension 

In clinical trials, the average reduction in 
standing blood pressure was 45/22 mm. 
Hg.; in the sitting position it was 48/20 
mm. Hg.; and in the recumbent position, 
36/18 mm. Hg. 

Because Eutron effectively reduces blood 
pressure in all body positions, there is re- 
duced likelihood of orthostatic symptoms 
or hypotension. 

This was reflected in the relatively mild 
character of side effects seen in clinical trials 
(see below). 

Smooth and gradual onset 

Onset of antihypertensive action is usually 
quite smooth. Initial reduction of systolic 
and diastolic readings is usually seen within 
a week — maximum reduction in seven to 
ten days. 

Less troublesome 
side effects may be 
seen; frequent 
improvement in 
“sense of well-being” 

Fewer than 1 % of patients studied discon- 
tinued Eutron therapy because of side ef- 
fects. This is due in part to the relatively low 
dosage needed with the combination. Usual 
recommended dose is one tablet daily— that 
is, 25 mg. Eutonyl with 5 mg. Enduron. This 
is about half the usual therapeutic dose of 
Eutonyl given alone. As a consequence side 
effects may be milder. And, as with Eutonyl 
given alone, the patient may well note an 
increased sense of well being, 

This is in distinct contrast to most I 

Other antihypertensive therapy. vHiiv 


January, 1966 


4-C 


Prescribing 
information for 

EUTROIM 


INDICATIONS: Eutron (pargyline hydrochlo- 
ride and methyclothiazide) is indicated in the 
treatment of patients with moderate to severe 
hypertension, especially those with severe dias- 
tolic hypertension. It is not recommended for 
use in patients with mild or labile hypertension 
amenable to therapy with sedatives and/or 
thiazide diuretics alone. 


CONTRAINDICATIONS: Eutron is contrain- 
dicated in patients with pheochromocytoma, 
advanced renal disease, paranoid schizophre- 
nia and hyperthyroidism. Until further expe- 
rience is gained it cannot be recommended 
for use in patients with malignant hyperten- 
sion, children (under 12 years of age), or 
pregnant patients. 

The concomitant use of the following is 
contraindicated: other monoamine oxidase in- 
hibitors; parenteral forms of reserpine or 
guanethidine; sympathomimetic drugs; foods 
high in tyramine such as cheese; imipramine 
and amitriptyline, or similar antidepressants; 
methyldopa. A drug-free interval of two weeks 
should separate therapy and use of these 
agents. 


WARNINGS: Pargyline hydrochloride is a 
monoamine oxidase inhibitor. Patients should 
be warned against eating cheese, and using 
alcohol, proprietary drugs or other medication 
without the knowledge of the physician. When 
it is necessary to administer alcohol, narcotics 
(notably meperidine), antihistamines, anesthet- 
ics, barbiturates and other hypnotics, sedatives, 
tranquilizers, or caffeine, these agents can be 
used cautiously at a dosage of 14 to Vs the 
usual amount. Avoid parenteral administra- 
tion where possible. Withdraw pargyline two 
weeks before elective surgery. 

Patients should be warned about the possi- 
bility of postural orthostatic hypotension. 
Those with angina or other evidence of cor- 
onary disease should not increase physical 
activity. Pargyline may lower blood sugar. 
Potassium depletion is unlikely at the recom- 
mended dosage, but if it occurs, adjust dosage 
or withdraw or provide added natural food 
sources of potassium; potassium tablets should 
be avoided wherever possible, as bleeding or 
obstructive ulceration of the small bowel has 

912314 


been associated with their use; potassium 
levels should be especially watched if the pa- 
tient is on digitalis or steroids, or if hepatic 
coma is impending. 


PRECAUTIONS: When determ.ining the anti- 
hypertensive effect of Eutron, blood pressure 
should be measured while the patient is stand- 
ing. Use with caution in hyperactive or hyper- 
excitable persons. Such persons may show in- 
creased restlessness and agitation. Withdraw 
drug during acute febrile illness. Watch pa- 
tients with impaired renal function for in- 
creasing drug effects or elevation of BUN 
and other evidence of progressive renal fail- 
ure; withdraw drug if such alterations persist 
and progress. Pargyline has not been shown 
to cause damage to body organs or systems. 
As with all new drugs, complete blood counts, 
urinalyses, and liver function tests should be 
performed periodically. The drug should be 
used with caution in patients with liver dys- 
function. With prolonged therapy, examine 
patients for change in color perception, visual 
fields, and fundi. 

Elevated blood urea nitrogen, serum uric 
acid or blood sugar are possibilities attribut- 
able to the methyclothiazide in Eutron. Me- 
thyclothiazide may also reduce arterial re- 
sponse to pressor amines. Blood dyscrasias, 
including thrombocytopemia with purpura, 
agranulocytosis and aplastic anemia, have been 
seen with thiazide drugs. 


SIDE EFFECTS: The use of pargyline may 
be associated with orthostatic hypotension. 
Mild constipation, slight edema, dry mouth, 
sweating, increased appetite, arthralgia, nausea 
and vomiting, headache, insomnia, difficulty in 
micturition, nightmares, impotence, delayed 
ejaculation, rash, and purpura have been en- 
countered with pargyline. Hyperexcitability, in- 
creased neuromuscular activity (muscle twitch- 
ing) and other extra-pyramidal symptoms have 
been reported. Drug fever is extremely rare. 
Congestive heart failure has been reported in 
a few patients with reduced cardiac reserve. 
Nocturia has been observed with the combina- 
tion. If side effects persist, despite 
symptomatic therapy or reduction 
of the dose, discontinue the drug. 



4-D 


Nebraska S. M. ^ 



help drain 

the stagnant sinus 

gently 



Neo-Synephrine is a standard among 
topical vasoconstrictors. It is unsurpassed 
for reducing nasal turgescence in colds; 
and a most valuable aid in preventing 
and treating sinusitis. 

Neo-Synephrine stops the boggy feeling of 
colds at once— works against factors that 
induce sinusitis. With Neo-Synephrine 
nose drops, spray or jelly, turbinates shrink 
on contact, obstructed ostia open and 
drainage is re-established. 


In sinusitis, Neo-Synephrine helps to pro- 
mote drainage and hasten recovery.* Used 
promptly, it helps clear the stagnant sinus 
and iessen the chances of chronicity. 

Neo-Synephrine HCI is available in: 

Vs‘7o solution for infants 
’AVo solution for children and adults 
V4'7 o pediatric nasal spray for children 
solution for adults 
V2‘7 o nasal spray for adults 
Vi'yo jelly for children and adults 
1°7o solution for adults (resistant cases) 


*Proctor, D. F.: The Nose, Paranasal Sinuses, and 
Ears in Childhood, Springfield, III., Charles C 
Thomas, 1963, p. 34. 


Winthrop Laboratories, New York, N. Y. 10016 




In colds and sinusitis 



(brand of phenylephrine hydrochloride) 


solutions/sprays/jeily 


Current Comment 

A Nebraska Centennial Health Fair — 

The Lancaster County Medical Society 
has started plans for a Nebraska Centen- 
nial Health Fair to be held in 1967. Al- i 
though not yet 100% definite as to timing, i 
the Pershing Memorial Auditorium in Lin- 
coln has been reserved for the week of 29 
April 1967 through 5 May 1967. 

Two main objectives will be achieved by 
the Health Fair. The first will be to in- 
form the general public of the great progress 
that has been made in medical science and 
all the related fields. Those who attend the t 
Health Fair will see live exhibits with audi- 
ence participation. They will see closed cir- 
cuit television showings of operations per- 
formed locally. They will be able to talk 
personally with experts in virtually every 
area of medical science. 

The second purpose of the Health Fair 
will be to stimulate young Nebraskans to 
consider careers in the medical science and 
health fields. School children from all over 
Nebraska will be urged to attend. They will 
be able to talk with representatives of the 
medical, dental, veterinary, and pharmacy 
fields. They will be able to talk with mem- 
bers of the nursing profession, social work- 
ers, music therapists, physical therapists, 
occupational therapists, w o r k e r s in the 
health insurance industry, laboratory tech- 
nicians, X-ray technicians, inhalation thera- 
pists, nursing home operators, hospital ad- 
ministrators, members of the pharmaceutical 
industry and members of the many other 
medical and paramedical groups that are a 
part of the health field. 

Associate sponsorship of the Health Fair 
will be offered to medical and paramedical 
groups throughout the entire state, and the , 
Lancaster County doctors are hoping for 
wide-spread cooperation in their most worth- | 
while venture. It should be noted that sim- 
ilar ventures have met with unqualified suc- 
cess in Denver, Colorado and in Fort Worth, 
Texas. In the latter city the Health Fail- 
had a larger attendance than the annual 
Fort Worth Rodeo and Stock Show. This 
proposed Health Fair in Nebraska will be 
(Continued on paRe 8-A) 


6-A 


DEPROL 

meprobamate 400 mg. -I- 
benactyzine hydrochloride 1 mg. 

Indications: ‘Deprol’ is useful in the manage- 
ment of depression, both acute (reactive) and 
chronic. It is particularly useful in the less 
severe depressions and where the depression is 
accompanied by anxiety, insomnia, agitation, 
or rumination. It is also useful for management 
of depression and associated anxiety accom- 
panying or related to organic illnesses. 
Contraindications: Benactyzine hydrochloride 
is contraindicated in glaucoma. Previous aller- 
gic or idiosyncratic reactions to meprobamate 
contraindicate subsequent use. 

Precautions: Meprobamate— Czitlul super- 
vision of dose and amounts prescribed is 
advised. Consider possibility of dependence, 
particularly in patients with history of drug or 
alcohol addiction; withdraw gradually after use 
for weeks or months at excessive dosage. Abrupt 
withdrawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions in- 
cluding, rarely, epileptiform seizures. Should 
meprobamate cause drowsiness or visual dis- 
turbances, the dose should be reduced and 
operation of motor vehicles or machinery or 
other activity requiring alertness should be 
avoided if these symptoms are present. Effects 
of excessive alcohol may possibly be increased 
by meprobamate. Grand mal seizures may be 
precipitated in persons suffering from both 
grand and petit mal. Prescribe cautiously and 
in small quantities to patients with suicidal 
tendencies. 

Side effects: Side effects associated with recom- 
mended doses of ‘Deprol’ have been infrequent 
and usually easily controlled. These have in- 
cluded drowsiness and occasional dizziness, 
headache, infrequent skin rash, dryness of 
mouth, gastrointestinal symptoms, paresthesias, 
rare instances of syncope, and one case each of 
severe nervousness, loss of power of concen- 
tration, and withdrawal reaction (status epilep- 
ticus) after sudden discontinuation of excessive 
dosage. 

Benactyzine hydrochloride— Benaclyzine 
hydrochloride, particularly in high dosage, may 
produce dizziness, thought-blocking, a sense of 
depersonalization, aggravation of anxiety or 
disturbance of sleep patterns, and a subjective 
feeling of muscle relaxation, as well as anti- 
cholinergic effects such as blurred vision, dry- 
ness of mouth, or failure of visual accommoda- 
tion. Other reported side effects have included 
gastric distress, allergic response, ataxia, and 
euphoria. 

MeproAa/uafe— Drowsiness may occur and, 
rarely, ataxia, usually controlled by decreasing 
the dose. Allergic or idiosyncratic reactions are 
rare, generally developing after one to four 
doses. Mild reactions are characterized by an 
urticarial or erythematous, maculopapular rash. 
Acute nonthrombocytopenic purpura with pe- 
ripheral edema and fever, transient leukopenia, 
and a single case of fatal bullous dermatitis 
after administration of meprobamate and pred- 
nisolone have been reported. More severe and 
very rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises (1 
fatal case), anuria, anaphylaxis, stomatitis and 
proctitis. Treatment should be symptomatic in 
such cases, and the drug should not be reinsti- 
tuted. Isolated cases of agranulocytosis, throm- 
bocytopenic purpura, and a single fatal instance 
of aplastic anemia have been reported, but only 
when other drugs known to elicit these con- 
ditions were given concomitantly. Fast EEG 
activity has been reported, usually after exces- 
sive meprobamate dosage. Suicidal attempts 
may produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Dosage: Usual starting dose, one tablet three or 
four times daily. May be increased gradually 
to six tablets daily and gradually reduced to 
maintenance levels upon establishment of relief. 
Doses above six tablets daily are not recom- 
mended even though higher doses have been 
used by some clinicians to control depression 
and in chronic psychotic patients. 

Supplied: Light-pink, scored tablets, each con- 
taining meprobamate 400 mg. and benactyzine 
hydrochloride 1 mg. 

Before prescribing, consult package circular. 

Wallace Laboratories / Cranbury, N. J. 

CO-S726 


EDITORIALS 


THE NEBRASKA STATE MEDICAL JOURNAL 


HAPPY NEW YEAR 

^ This is the holiday season. It’s only a 
I week from Christmas to New Year’s, but 
there’s a long fifty-one week wait until 
the holidays are once more upon us. A 
state association has this characteristic dis- 
tinguishing it from national groups: we all 
pretty well know each other and names rep- 

I resent people and friends, not nonentities. 
There may be nothing at all medical about 
the turn of the year, but it is a grand 
■ thing to stop and wish us well each time we 
' go around the sun, and what better time 

. than now, and what better wish than Happy 

I New Year. 

— F.C. 

1 

THE PHILADELPHIA STORY 

j The House of Delegates acted on the fol- 
lowing subjects during the 19th Clinical 
Convention of the AMA, November 28 to 
I December 1, in Philadelphia. 

1. The “usual and customary’’ fee con- 
cept and the prevailing fees program of the 
National Association of Blue Shield Plans; 
these are discussed elsewhere in this issue 
of the Journal. The house supported the 
“usual and customary’’ fee concept in par- 
ticipation in government programs and urged 
this concept to “all third parties.” It rec- 
ommended that “the concept of the prevail- 
ing fees program of the NABSP be noted 
as one of the methods of compensation in 
those regions where the prevailing fees pro- 
gram is approved by the local or state medi- 
cal society.” 

2. Abortion and sterilization. The House 
suggested that the AMA confer with other 
groups, but that it is not appropriate to rec- 
ommend legislation for all states. 

3. Billing and payment for Medical Serv- 
ices. 

4. Membership dues. A $25 per year in- 
crease, effective January 1, 1967, was en- 
dorsed, but must go before the House for 
final action at the 1966 Annual Convention. 


5. Organization of the House of Dele- 
gates. When the number of delegates 
reaches 250 (it is now 236), the ratio will 
be changed from one delegate per 1000 mem- 
bers or fraction thereof, to one per 1250 
members or fraction thereof, “in electing 
further delegates to represent each state 
association.” As accurately as we can count, 
we have 1333 members. 

6. Federal health care laws: Medicare 
and the Heart Disease, Cancer and Stroke 
Amendments. 

—F.C. 


THE WONDERFUL WORLD OF WORDS 

The surgeon wanted to know the size 
of his suture and the nurse was counting 
sponges. 

“Is this number three,” said the doctor. 

“One, two,” said the nurse. 

“or four?” he went on. 

“three,” said she, still counting sponges. 

This is a perfect example of nonmeeting 
of minds. It represents a complete break- 
down in communication; neither doctor nor 
nurse knew what the other was saying. The 
danger was little, but how often is it great, 
for our very lives have now come to depend 
on communication in modern medicine. 
“The patient’s blood” should make even an 
eavesdropper’s hackles rise. 

“Dr. Smith’s X ray” is a dangerous ex- 
pression; “room 356 bed two’s blood pres- 
sure” is confusing; “the new patient’s white 
count” is careless. We have pleaded long 
to have a patient called by name, but it so 
often comes out “room 356 bed two,” or 
“the emergency,” or “this afternoon’s case,” 
or “the D and C.” The “emergency” that is 
scheduled on Saturday morning for Sunday 
surgery is a strange sort of emergency, for 
if it is urgent, it ought not wait until the 
next day, and if it need not be done the day 
it is scheduled, it is hard to see why Mon- 
day will not do. Physical examination re- 
veals, the patient denies, the cicatrix are all 


January, 1966 


1 



stilted and circumlocutional substitutions for 
simpler and better phrases ; bibliography, 
where one means references, is a wonderful 
illustration of this sort of thing. What de- 
tergent means can be a deep dark secret. 
It means something, but it is an elusive 
word and difficult to look up with any sort 
of success, and I doubt that it means what 
it is supposed to mean to many who use it 
unthinkingly. What was once identified as 
sterile distilled water has become sterile 
deionized water. This was done without ad- 
vance information and was accepted without 
question ; we can only guess at what it means 
and hope that it is what we think it is. 

There is a vast amount of nonmedical non- 
sense too, as stalemate for draw, alibi for 
excuse, presume for assume, cleansed for 
cleaned, and gambit for opening. In addi- 
tion to these, we now hear I’ll be there 
hopefully and he reportedly left his home. 
Some of this may be all right; if one can 
probably leave, hopefully and reportedly may 
be no worse, but they have not ceased to 
grate on our ears. Periphrasis, or putting 
things in a roundabout way, has engulfed 
latinisms, as in situ for in its original posi- 
tion or in place, per se for by itself, bona 
fide for in good faith, and of course per 
annum for a year. Biennial and biannual, 
as well as bimonthly, will always send us, 
muttering, to the dictionary, often to find 
that the author has made the usual mistake ; 
how much better are half-yearly and two- 
yearly. It all reminds us of the prison 
whose exits were guarded while the con- 
vict escaped through an entrance. And of 
being asked to have more of the au jus, 
or to admire a chaise lounge. When we 
were undergraduates, our football team had 
a captain. To us, a team has one captain; 
the term co-captain makes us wince. How 
any organization can have more than one 
leader escapes us, but we are now exposed 
to the phenomenon of six or eight co-cap- 
tains meeting in midfield. Perhaps one day 
we will have 22 leaders and no one to follow. 

What does it mean when an enquirer is 
told, “He is doing as well as can be ex- 
pected?” Probably the prize example of 
saying nothing is “his condition is fair.” 
Fair can sound good and it may have an 


ominous ring. The one who is deceived by 
this kind of nonsense is oftener the speaker 
than the listener. “He is holding his own” 
means little, if anything; it does not sound 
good, though it seems to want to. This 
kind of language becomes quite different 
when the patient has achieved national or 
better prominence. Nonsense then piles on 
absurdity, till we have all come to recog- 
nize the words or what they mean. As a 
president expires, we are told that he is 
weaker or that his condition is deteriorat- 
ting; as the silly ones translate dying into 
weakening or worsening, we have learned 
to retranslate all of this back into dying, and 
what is the use of all this running away 
from saying what you mean? No one gains 
anything from all this foolishness. We know 
how communiques (were they not once re- 
ports, or even bulletins?) read when a king 
dies (he is usually gathered to his fore- 
bears or passes away peacefully in his 
sleep and only a little while after a reliably 
close informant is certain that the mori- 
bund celebrity has recognized him) and we 
are not deceived. But to be told that this 
(king or president) “is no ordinary man” is to 
imply that kings and presidents are chosen 
on the basis of physical fitness, or that they 
have something to saj^ about when they will 
die. 

We cannot leave the world of words with- 
out saying that we have found two words 
that have no definition, just none at all. They 
are north (or south) and left (or right). 
East is where the sun rises, and north is to 
its left. Left is where north is if you face 
the rising sun, or where the heart usually 
is, and we have gone senselessly around. And 
at the poles, where there is no east, and 
where the sun does not come up every day? 
We knoH' which is our left hand, but how 
do we know? We should be happy to hear 
from anyone who can come up with defini- 
tions of these words. 

Item : “The blood pressure is stable.” 

Now stable sounds good if you do not think 
about it, but it means nothing. It was 70 and 
we should have preferred one fluctuating 
wildly at 120. 

Item; “Prior to and following.” Isn’t 
that before and after? 


2 


Nebraska S. M. J. 


Item: “Acceptable risk.” It all depends 

on who accepts it. 

Item : “Currently.” Why not now, as the 
ad used to say? 

Item: “Satisfactory.” To whom? 

Item: “Don’t give me gas.” Now air is 

a gas, cyclopropane is an anesthetic gas (so 
is halothane vapor and so is “ether” vapor), 
nitrous oxide is “gas.” We have tried first, 
to distinguish between these, and second, to 
translate don’t give me gas into don’t put 
a mask on my face while I am wake, but 
none of this was any good; it has always 
appeared after merely beginning such a dis- 
cussion, that the patient neither knew what 
he meant nor cared very much. 

Item: “The patient is being prepared 

for definitive surgery.” This word makes 
up in sound for what it lacks in meaning. 

Item: “The prognosis is guarded.” 

That did it. 

— F.C. 


PREVAILING FEES 

An activity of the past year has been 
the development and experimental use of the 
“Prevailing Fee” concept as a further step 
in Medical Association sponsored Blue Shield 
benefit programs. 

If the medical profession is to continue its 
outstanding leadership in the field of volun- 
tary prepayment health insurance, it must 
continue to experiment, to explore unchar- 
tered areas, to conduct some pilot plans, to 
expand the “service benefit” principle. 

“Prevailing Fees” are based on the usual 
and customary fee approach. The “Usual 
and Customary” concept has been delineated 
by some state Medical Associations as fol- 
lows. The “Usual Fee” is that fee usually 
charged, for a given service, by an indi- 
vidual physician to his private patient. A 
fee is “Customary” when it is within the 
range of “Usual Fees” charged by physicians 
of similar training and experience for the 
same service within the same specific and 
limited geographical area. A fee is “Rea- 


sonable” only when it satisfies the above 
two criteria. 

Service benefits or paid in full programs 
are in more demand than ever before in 
our present credit card economy. In our 
present economy of total consumption, where 
all out customer spending is the essential 
ingredient for continued prosperity, few 
families with an income of less than $9,000 
a year have ready cash available for a medi- 
cal or any other kind of an emergency. 
Hence, it is necessary for Medical Associa- 
tions and their subsidiary Blue Shield Plans 
to develop programs and contracts that will 
satisfy both the subscriber and the physician. 
The “Prevailing Fee” concept is a method 
of providing coverage for members on a 
basis that would include both predictability 
of cost as well as “Paid in Full” benefits 
for approximately 90% of members covered 
in a plan area. Enactment of the Prevail- 
ing Fee concept is direct and tangible evi- 
dence that the medical profession is ready, 
willing and able to provide a high quality of 
medical care and a practical method to fi- 
nance the care. It is indeed proof that the 
medical profession is dedicated and respon- 
sible in changing times. 

— Arthur Offerman, MD 


Another Warning Concerning Antibiotics — 

Ormond S. Culp, MD, Head of the Sec- 
tion on Urology at the Mayo Clinic, and a 
frequent visitor to Nebraska medical meet- 
ings, re-emphasized the need for caution 
in the use of antibiotics when he talked be- 
fore members of the Omaha-Midwest Clinical 
Society at their recent annual meeting. He 
said, “I do not object to first-bout treatment 
of urinary tract infections with antibiotics 
or drugs as long as the physician is certain 
an infection exists and as long as he does 
not continue such treatment over excessively 
long periods of time. But for long-continued 
infection, or for recurrent infections, the doc- 
tor must consider the possibility of underly- 
ing causes, such as tumors, stones, and stag- 
nation of urine due to impaired drainage. 
These underlying sources must be discovered 
and cured before the infection will disap- 
pear.” 


January, 1966 


3 




Comments from 
Your President 

There has never been or ever will be com- 
plete agreement between the majority of 
physicians, particularly in Nebraska, and 
i\Ir. W'ilbur Cohen on the physiological view- 
point and convictions with reference to 
^Medicare and his principles of government. 
At present, Mr. Cohen has the upper hand. 
Because of this, the medical profession has 
to be constantly vigilant in regard to the 
interpretation of all federal health laws and 
their regulations. At the present time un- 
derstanding Public Law 89-97 is almost like 
grabbing hold of an ameba. The Associa- 
tion’s Committees and our Representative 
on the Governor’s Board supervising impli- 
cation of this law have a complexity of 
duties. The task has not been and will not 
be easy. Title XVIII is still under considera- 
tion by almost daily meetings by advisory 
groups. 

Title XIX is another problem. It is in- 
tended to provide a more effective program 
for the needy in all age groups. This part 
of the law is really the physician’s concept 
of helping the needy. Interpretation and 
physician participation in this section is go- 
ing to be formulated at a state level. Legal 
advice and probable new state legislation 
may be required to implement this section. 
The AMA will sponsor a meeting in Chicago 
January 20th and 21st, 1966 to discuss Title 
XIX. ^Members of your Association will at- 
tend this meeting. 

Public Law 89-237, Heart Disease, Can- 
cer, and Stroke, also places major respon- 
sibility on the states for both state and re- 



gional programs. The Advisorj' Committee 
must have major physician participation. 
Preliminary meetings have been held re- 
garding this State Advisoiy Committee and 
will probably be announced in the near fu- 
ture. 

Responsibility in the present day medical 
economic program presented by recent na- 
tional legislation cannot be delegated to out- 
siders. Your Association and its Staff must 
formulate and carry out today’s and tomor- 
row’s program. This requires adequate fi- 
nancial support. Our budget, with the in- 
creased activities during this last year, is 
now narrowly in balance. This problem will 
have to be discussed by the Board of Coun- 
cilors and their decisions sanctioned by the 
House of Delegates. If we are going to con- 
tinue to attempt to work out of the trap we 
are in, there must be a few nickels “tossed 
on the drum head.’’ 

W. D. WRIGHT, 

President 



4 


Nebraska S. M. J. 



When 

insomnia 


in the 







.... 


^'S’iVsiO^^ 


TRY DEPROE- 

meprobamate 400 mg. + benactyzine hydrochloride 1 mg. 

A LOGICAL FIRST CHOICE 

usually restores 
normal sleep quickly 
by helping 
to lift depression .. . 
calm associated anxiety, 
tension, and rumination 

Wallace Laboratories / Crcmbury, N. J . c-=v4i 



j 

11:47 pm 11:53 pm 12:06 am 


The meaningful pause. The energy 
it gives. The bright little lift. 
Coca-Cola with its never too sweet 
taste, refreshes best. Helps people 
meet the stress of the busy hours. 
This is why we say 


TRAD£-MARK <Sl 


things go 

better,! 

^with 

Coke 


A Nebra.ska Centennial Health Fair — 

(Continued from page 6-A) 
of benefit to all Nebraskans. School children 
will learn about the vast opportunities in the 
medical area. This will enable them to make 
more intelligent choices concerning a pos- 
sible career in medicine or allied health 
fields. Families will benefit as mothers and 
fathers learn much of the why and how of 
health. Aging persons will learn of modern 
methods for treating diseases common to the 
older age group. All public and private 
groups and organizations seeking specific 
goals in medicine and health fields will 
benefit through better public understanding. 
The general public will benefit by the pres- 
tige brought to Nebraska by this ambitious 
program. 

I’hysicians Hit the Books — 

The American Medical Association has ob- 
served that good doctors never stop study- 
ing and that today’s doctors are studying 
more than ever. Attendance has gone up 
sharply in recent years at medical “refresh- 
er” courses offered in this country. The 


number of post-graduate courses offered has 
increased more than 50% in the past five 
years. Enrollment figures are incomplete, 
but 71,000 doctors registered in half of the 
total number of courses offered in 1964. 
Ten years ago there was a comparable en- 
rollment of 18,800. 

Nebraska Doctors Attend White House 
Conference on Health — 

Dan Nye, MD of Kearney, President- 
Elect of the Nebraska State Medical Asso- 
ciation; Cecil Wittson, MD, Dean of the 
University of Nebraska College of Medi- 
cine, and Richard Egan, MD, Dean of the 
Creighton University School of Medicine 
were among 800 persons who attended a re- 
cent two-day conference on health called by 
President L. B. Johnson. 

Dr. Wittson reported that subjects dis- 
cussed included methods to provide for the 
additional medical manpower needed in the 
future, international cooperation in the 
health fields, and improvement of medical 
libraries. 


8-/^ 


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"All Interns are Alike" 


It stands to reason. They all go through the same 
training; they all have to pass the same tests; they 
all have to measure up to the same standards; they 
all are underpaid, too. Therefore, all interns are 
alike. 

That's utter nonsense, of course. But it's no 
more nonsensical than what some people say 
about aspirin. Namely: since all aspirin is at least 
supposed to come up to certain required stand- 
ards, then all aspirin tablets must be alike. 

Bayer's standards are far more demanding. In 
fact, there are at least nine specific differences in- 


volving purity, potency and speed of tablet disinte- 
gration. These Bayer® standards result in significant 
product benefits including gentleness to the stom- 
ach, and product stability that enables Bayer tab- 
lets to stay strong and gentle until they are taken. 

So next time you hear someone say that all 
aspirin tablets are alike, you can say, with confi- 
dence, that it just isn't so. 

You might also say that all interns aren't alike, 



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9-A 




ilmour-Danielson 

DRUG COMPANY 

142 South 13th Street 800 South 13th Street 
Phone 432- 1 246 Phone 432-885 1 

Medical Village, 48th and "A" St. 
Phone 488-2305 


— FREE DELIVERY — 

PRESCRIPTIONS - ETHICAL SERVICE 


I 

Esfablished 1927 



‘There goes Junior’s birthplace!” 


10-A 


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i lower mg. intake per 24 hours 
I 600 mg. versus 1000 mg. 


Days 1 

2 

3 

4 

5 

6 


duration of 

herapy, tetra 

cycline 


duration of activity, tetra 

cycline 








duration of therapy 
DECLOMYCIN demethytc 

hlortetracycl 

ne 

duration of activity | I 

1 DECLOMYCIN demethylchlortetracycline 

1 1 *- » 





1-2 days’“extra”activity 


higher 

activity ieveis 
than other 
tetracyciines- 
with iess 
peak-and-vailey 
fluctuation 


3.0- 





12 hours 

between doses 

the option of b.i.d. dosage 


the“extra”beneflts raise the jOlV/TViPTlV^ 

level of antibiotic control DEMEliraX3HIX)KrETRACYCLINE 


150 mg. CAPSULES 


Effective in a wide range of everyday infections— respiratory, urinary 
tract and others— in the young and aged— the acutely or chroni- 
cally i||_when the offending organisms are tetracycline-sensitive. 
Side effects typical of tetracyclines include glossitis, stomatitis, 
proctitis, nausea, diarrhea, vaginitis, dermatitis, overgrowth of 
nonsusceptible organisms, tooth discoloration (if given during 
tooth formation) and increased intracranial pressure (in young 
infants). Also, very rarely, anaphylactoid reaction. Reduce dosage 


in impaired renal function. Because of reactions to artificial or 
natural sunlight (even from short exposure and at low dosage), 
patient should be warned to avoid direct exposure. Stop drug 
immediately at the first sign of adverse reaction. It should not be 
taken with high calcium drugs or food; and should not be taken 
less than one hour before, or two hours after meals. 

Capsules, 150 mg. and 75 mg. of demethylchlortetracycline HCI. 
Average Adult Daily Dosage: 150 mg. q.i.d. or 300 mg. b.i.d. 


LEDERLE laboratories, a Division of AMERICAN CYANAMID COMPANY, Pearl River, New York( 


8035*9720 


at Merck Sharp & Dohme... 



understanding 


• • • 


precedes development 


The development of chlorothiazide and probene- 
cid were events of major importance, but perhaps 
even more important for the future was the Renal 
Research Program by which they were developed. 
When Merck Sharp & Dohme organized this pro- 
gram in 1943, it was expressing in action some of 
its basic beliefs about research: 

• Many problems connected with renal structure 
and function were still undefined or unsolved. The 
Renal Research Program would begin its basic 
research in some of these problem areas. 

• From knowledge thusacquired might comeclues 
to the development of new therapeutic agents of 
significant value to the physician. 


For example, the Renal Research Program put 
fifteen years into this search before chlorothiazide 
became available. But because these years had 
first led to a greater understanding of basic 
problems, the desired criteria for chlorothiazide 
existed before the drug was developed. 

Along with other research teams at Merck Sharp 
& Dohme, the Renal Research Program continues 
to add new understanding of basic problems — 
understanding which will lead to important new 
therapeutic agents. 

^MERCK SHARP& DOHME Division 0 ( Merck 4 Co .InC . WesI Po'ml. Pa. 

where today’s theory is tomorrow’s therapy 


12-A 


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Butazolidin^alka 

phenylbutazone 
dried aluminum 

100 mg. 

hydroxide gel 

100 mg. 

magnesium trisilicate 
homatropine 

150 mg. 

methylbromide 

1.25 mg. 


Usually works within 3 to 4 days 
in osteoarthritis 



The trial period need not exceed 1 week. In 
contrast, the recommended trial period for 
indomethacin is at least 1 month. 

That's why it’s logical to start therapy with 
I Butazolidin alka — you'll know quickly whether 
or not it works. And usually, it will. 

A large number of investigators have re- 
ported major improvement in about 75% of 
cases. Some patients have gone into remis- 
sion. Relief of stiffness and pain may be fol- 
lowed quickly by improved function and res- 
olution of other signs of inflammation. And 
Butazolidin alka is well tolerated, especially 
since it contains antacids and an antispas- 
modic to minimize gastric upset. 

Contraindications 

Edema, danger of cardiac decompensation; 
history or symptoms of peptic ulcer; renal, 
hepatic or cardiac damage; history of drug 
allergy; history of blood dyscrasia. The drug 
should not be given when the patient is se- 
nile, or when other potent drugs are given 
concurrently. Large doses are contraindi- 
cated in patients with glaucoma. 

Precautions 

I Obtain a detailed history and a complete 
I physical and laboratory examination, includ- 


ing a blood count. The patient should be 
closely supervised and should be warned to 
report immediately fever, sore throat, or 
mouth lesions (symptoms of blood dyscrasia); 
sudden weight gain (water retention); skin 
reactions; black or tarry stools. Make regular 
blood counts. Use greater care in the elderly. 

Warning 

If coumarin-type anticoagulants are given 
simultaneously, watch for excessive increase 
in prothrombin time. Pyrazole compounds 
may potentiate the pharmacologic action of 
sulfonylurea, sulfonamide-type agents and 
insulin. Carefully observe patients receiving 
such therapy. 

Adverse Reactions 

The most common are nausea, edema and 
drug rash. Hemodilution may cause mod- 
erate fall in red cell count. The drug may 
reactivate a latent peptic ulcer. Infrequently, 
agranulocytosis, generalized allergic reac- 
tion, stomatitis, salivary gland enlargement, 
vertigo and languor may occur. Leukemia 
and leukemoid reactions have been re- 
ported but cannot definitely be attributed to 
the drug. Thrombocytopenic purpura and 
aplastic anemia may occur. Confusional 
states, agitation, headache, blurred vision, 
optic neuritis and transient hearing loss 


have been reported, as have hepatitis, 
jaundice, and several cases of anuria and 
hematuria. With long-term use, reversible 
thyroid hyperplasia may occur infrequently. 

Dosage 

The initial daily dosage in adults is 300-600 
mg. daily in divided doses. In most in- 
stances, 400 mg. daily is sufficient. When 
improvement occurs, dosage should be de- 
creased to the minimum effective level: this 
should not exceed 400 mg. daily, and is 
often achieved with only 100-200 mg. daily. 

Also available: Butazolidin®, 
brand of phenylbutazone 
Tablets of 100 mg. 

Geigy Pharmaceuticals 

Division of Geigy Chemical Corporation 

Ardsley, New York BU-3804 P 


Geigy 


I 




On Stelazine brand of trifluoperazine 

she’s calm and alert 


When a tranquilizer is needed, 
‘Stelazine’ can regulate the 
level of anxiety so that the 
patient is unlikely to overreact 
to stress but is not tranquilized 
into psychic inertia. Patients 
on ‘Stelazine’ often experience 
a sense of mental alertness and, 
because they feel so much better, 
are more interested in their 
normal activities. 

Contraindicated in comatose or 
greatly depressed states due to CNS 
depressants and in cases of existing 
blood dyscrasias, bone marrow 
depression and pre-existing liver 
damage. Principal side effects, 
usually dose-related, may include 


mild skin reaction, dry mouth, 
insomnia, fatigue, drowsiness, 
dizziness and neuromuscular 
(extrapyramidal) reactions. 
Muscular weakness, anorexia, rash, 
lactation and blurred vision may 
also be observed. Blood dyscrasias 
and jaundice have been extremely 
rare. Use with caution in patients 
with impaired cardiovascular 
systems. 

Before prescribing, see SK&F 
product Prescribing Information. 

Photograph professionally posed. 



Smith Kline &■ French Laboratories 


14-A 


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An antibiotic 
of choice 
is one that works 

TAO works 


Susceptibility Results 
Staphylococci ^ ^ ‘ 

# OF CULTURES YEAR % EFFECTIVE 


6,725 1962 88.6% 

5,440 1963 88.0% 

10,384 1964 88.5% 


y^-Hemolytic Streptococci ‘ 


2,448 1962 89.5% 

1,519 1963 95.2% 

2,492 1964 96.7% 


The Product 

In a world study of antibiotics in v/fro', TA O had an over - 
all effectiveness of 87.3%, higher than chloramphenicol 
and erythromycin, and significantly higher than tetracy- 
cline and penicillin. 

The Plus... Consistent Performance 

Yet antibiotics must not only work. They must work con- 
sistently. Here are the results from the largest study of 
microbial susceptibility ever undertaken. In 29,048 cul- 
tures of overt staphylococcal and /f-hemolytic streptococ- 
cal infections, note the consistency of results with TAO. 


TAO 


TAO Rx information 

Indications: The bacterial spectrum includes: streptococci, sfaphy- 
locci, pneumococci and gonococci. Recommended for acute, 
severe infections where adequate sensitivity testing has demon- 
strated susceptibility to this antibiotic and resistance to less toxic 
agents. Contraindications and Precautions: TAO (triacetyloleandomycin) is not recommended for prophylaxis or in the treatment of infectious processes 
which may require more than ten days continuous therapy. In view of the possible hepatotoxicity of this drug when therapy beyond ten days proves 
necessary, other less toxic agents, of course, should be used. If clinical judgement dictates continuation of therapy for longer periods, serial monitor- 
ing of liver profile is recommended, and the drug should be discontinued at the first evidence of any form of liver abnormality. It is contraindicated in 
pre-existing liver disease or dysfunction, and in individuals who have shown hypersensitivity to the drug. Although reactions of an allergic nature are 
infrequent and seldom severe, those of the anaphylactoid type have occurred on rare occasions. References: 1. Isenberg, Henry D.: Health Laboratory 
Science 2:163-173 (July) 1965. 2. Fowler, J. Ralph et al: Clinical Medicine 70.547 (Mar.) 1963. 3. Isenberg, Henry D.: Health Laboratory Science 
1:185-256 Uuly-Aug.) 1964. 


[triacetyloleandomycin] 


J. B Roerig and Company, New York, New York 10017 

Division, Chas. Pfizer & Co., Inc., Science for the World's Well-Being ■ 



You can enhance the value of your own Journal by patronizing its advertisers 


15-A 








OMAHA OFFICE: Robert C. Schmitz, Representative 
9132 Dorcas Street, Omaha Telephone 402-393-5797 

Mailing Address: Elmwood Station, Box 6076, Omaha 68106 





16-A 


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Indications: ‘Miltown’ (meprobamate) is ef- 
fective in relief of anxiety and tension states. 
Also as adjunctive therapy when anxiety 
may be a causative or otherwise disturbing 
factor. Although not a hypnotic, ‘Miltown’ 
fosters normal sleep through both its anti- 
anxiety and muscle-relaxant properties. 
Contraindications: Previous allergic or idio- 
syncratic reactions to meprobamate or 
meprobamate<ontaining drugs. 
Precautions: Careful supervision of dose 
and amounts prescribed is advised. Consider 
possibility of dependence, particularly in pa- 
tients with history of drug or alcohol addic- 
tion; withdraw gradually after use for weeks 
or months at excessive dosage. Abrupt with- 
drawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions 
including, rarely, epileptiform seizures. 
Should meprobamate cause drowsiness or 
visual disturbances, the dose should be re- 
duced and operation of motor vehicles or 
machinery or other activity requiring alert- 
ness should be avoided if these symptoms 
are present. Effects of excessive alcohol may 


An eminent role in 
medical practice 

• Clinicians throughout the world con- 
sider meprobamate a therapeutic 
standard in the management of anxi- 
ety and tension. 

• The high safety-efficacy ratio of 
‘Miltown’ has been demonstrated by 
more than a decade of clinical use. 

Miltowir 

(meprobamate) 

possibly be increased by meprobamate. 
Grand mal seizures may be precipitated in 
persons suffering from both grand and petit 
mal. Prescribe cautiously and in small quan- 
tities to patients with suicidal tendencies. 

Side effects: Drowsiness may occur and, 
rarely, ataxia, usually controlled by decreas- 
ing the dose. Allergic or idiosyncratic re- 
actions are rare, generally developing after 
one to four doses. Mild reactions are char- 
acterized by an urticarial or erythematous, 
maculopapular rash. Acute nonthrombocy- 
topenic purpura with peripheral edema and 
fever, transient leukopenia, and a single 
case of fatal bullous dermatitis after admin- 
istration of meprobamate and prednisolone 
have been reported. More severe and very 


rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises 
(1 fatal case), anuria, anaphylaxis, stoma- 
titis and proctitis. Treatment should be 
symptomatic in such cases, and the drug 
should not be reinstituted. Isolated cases of 
agranulocytosis, thrombocytopenic purpura, 
and a single fatal instance of aplastic ane- 
mia have been reported, but only when other 
drugs known to elicit these conditions were 
given concomitantly. Fast EEG activity has 
been reported, usually after excessive me- 
probamate dosage. Suicidal attempts may 
produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Usual adult dosage: One or two 400 mg. 
tablets three times daily. Doses above 2400 
mg. daily are not recommended. 

Supplied: In two strengths: 400 mg. scored 
tablets and 200 mg. coated tablets. 

Before prescribing, consult package circular. 
4??* WALLACE LABORATORIES 
\£f,Cranbury, N.J. cm.s76i 



Low 

host resistance? 

Consider the 
“extra” antibacterial 
activity 
of Ilosone* 


Occasionally, therapeutic failure is 
due to the patient’s inability to 
mobilize his defenses sufficiently to 
overcome infection. Typical of this 
is the debilitated patient, the 
premature infant, or the diabetic. 

It is in these patients that the high 
levels of antimicrobial activity of 
Ilosone are especially useful. Ilosone 
has demonstrated antibacterial levels 
two to four times those of erythro- 
mycin base or stearate. Furthermore, 
it attains them earlier and maintains 
them longer. Even the presence of 
food does not appear to affect the 
activity of Ilosone. 


Contraindications: Ilosone is contraindicated in 
patients with a known history of sensitivity to this 
drug and in those with preexisting liver disease 
or dysfunction. 

Side-Effects: Even though Ilosone is the most 
active oral form of erythromycin, the incidence of 
side-effects is low. Infrequent cases of drug idio- 
syncrasy, manifested by a form of intrahepatic 
cholestatic jaundice, have been reported. There 
have been no known fatal or definite residual ef- 
fects. Gastro-intestinal disturbances not associ- 
ated with hepatic effects are observed in a small 
proportion of patients as a result of a local stimu- 
lating action of Ilosone on the alimentary tract. Al- 
though allergic manifestations are uncommon with 
the use of erythromycin, there have been occasion- 
al reports of urticaria, skin eruptions, and, on rare 
occasions, anaphylaxis. 


Dosage: Children under 25 pounds— 5 mg. per 
pound of body weight every six hours. Children 
25 to 50 pounds— ^25 mg. every six hours. Adults 
and children over 50 pounds— 250 mg. every six 
hours. For severe infections, these dosages may 
be doubled. 

Available in Pulvules®, suspension, drops, and 
chewable tablets. Ilosone Chewable tablets should 
be chewed or crushed and swallowed with water. 

Ilosone 

Erythromycin Estol ate 

Additional information available to physicians 

upon request. Eli Lilly and Company, oiiEfy 

Indianapolis, Indiana. 50 ' 2 «> 


18-A 


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ARTICLES 


The Acute Abdomen 

Complicating Pregnancy* 


A cute abdominal problems com- 
plicating pregnancy are re- 
markably uncommon. For ex- 
ample, it is variably reported that acute 
appendicitis will occur in from one per 1000 
to one per 5000 pregnancies. This would 
result in less than ten such cases per year 
in the state of Nebraska. Surgical interven- 
tion for cholecystitis is deemed necessary in 
about one per 6000 pregnancies. Sand- 
weiss,® in a review of the world literature, 
could find only 14 cases of maternal mortal- 
ity resulting from complications of peptic 
ulcer. Harei’2 found an incidence of one 
in 3600 pregnancies that required laparot- 
omy for bowel obstruction. The one dis- 
senting note seems to be the rising incidence 
of complications from blunt trauma. This, 
of course, reflects an increasing number of 
automobile accidents. From this recitation 
it is obvious that no one is able to speak 
with any degree of authority on the sub- 
ject. In reviewing the literature, it becomes 
evident that the tendency is to over-diag- 
nose the acute abdomen in pregnancy. 

Undoubtedly one of the most perplexing 
problems in pregnancy is the differential di- 
agnosis of appendicitis. Confusion frequent- 
ly stems from the nausea, vomiting, and leu- 
kocytosis of pregnancy. Add to this the 
frequently occurring so-called round liga- 
ment pain, constipation, and the possibility 
of appendicitis becomes a frequent specter. 
In the early months of pregnancy, appendi- 
citis is not much different from its non- 
gravid appearance. In the latter months, 
however, because of the loss of gastric tone, 
the commonly seen epigastric onset of pain is 
absent. As the cecum is moved up and lat- 
eral, the onset is in the right flank. For 
the same reason, the point of maximum ten- 
derness usually moves upward. Rigidity is 
often lacking, due to the stretching of the 
abdominal musculature, even in a fairly ad- 
vanced peritonitis. Referred pain, so dear 
to the clinician’s heart, is frequently miss- 
ing because of the inter-position of the en- 


KEITH M. McCORMICK, MD 
Omaha, Nebraska 


larging uterus. Rectal and vaginal exam- 
inations are useful only in a negative sense. 
The temperature will remain under 102°, ex- 
cept in advanced peritonitis, and is helpful 
in the differential diagnosis of right pyelo- 
nephritis. In Bassett’s^ series, three-fourths 
of the cases reviewed showed a temperature 
under 100° F. Most authors feel that the 
leukocytosis of pregnancy rarely extends 
above the 12,000 per cubic mm mark. Ap- 
pendicitis will practically never present with 
a count below 8000. In the 59 cases re- 
viewed by Bassett,! 13 had counts less 
than 12,000, and five less than 10,000. In 
McCorriston’s® series, one third were below 
12 , 000 . 

Appendicitis is more treacherous during 
pregnancy, basically because of the pregnant 
abdomen’s inability to localize the process. 
This is partly due to the upper displace- 
ment of the small bowel and omentum away 
from the semi-fixed cecum. Also, when the 
uterus forms part of the abscess wall, as is 
often the case, its constant changing of po- 
sition and contraction prevents proper local- 
ization. The removal of a non-ruptured ap- 
pendix will only occasionally result in a pre- 
mature labor. On the other hand, general- 
ized peritonitis, or abscess formation, involv- 
ing the uterus, will almost invariably result 
in rapid onset of labor. Only when in active 
labor is there a question of delaying surgical 
removal. This delay should never consist 
of more than three to four hours, and that 
tempered by the general condition of both 
the mother and fetus. 

Prior to analgesia, the point of maximum 
tenderness is marked in the abdominal wall 
and the patient is placed on the table in a 

♦Presented at the Tenth Meeting of Nebraska State Obstetrics- 
Gynecology Society, Las Vegas, December, 1964. 


January, 196£ 


5 



semi-left-lateral position by supporting the 
right half of the body on soft sand bags or 
rubber pillows. The patient is then se- 
cured in this modified kidney position with 
wide strips of adhesive. Thus positioned, 
the large uterus will fall into the left lower 
abdomen. A muscle-splitting incision over 
the point of maximum tenderness is gener- 
ally favored, but it has been pointed out by 
Bassett^ that even vertical incisions just 
prior to labor seem to produce no increased 
incidence of hernia or dehiscence. Only very 
rarely will it be necessary to evacuate the 
uterine content for proper exposure of the 
appendix. Developing fetal distress during 
appendectomy is indication for immediate 
cesarean section. This is best accomplished 
through a second incision, utilizing the extra- 
peritoneal approach to avoid contamination. 
Exploration of the pelvis at the time of ap- 
pendectomy; the use of drains, antibiotics, 
or Progesterone seem to have little to do 
with the outcome of pregnancy. 

In general, although appendicitis is rare, 
it is a treacherous disease in the latter 
months of pregnancy and if allowed to pro- 
ceed to perforation is attended by a re- 
markably high fetal and maternal mortality. 

I think it can be concluded that a carefully 
performed appendectomy on an unperforated 
appendix will result in so few incidents of 
premature labor that one may Avell be justi- 
fied in the removal of a greater number of 
normal appendices. The rapidity Avith Avhich 
appendicitis proceeds to perforation in the 
pregnant state Avould make prolonged ob- 
servation a most hazardous course and it 
Avould seem perfectly legitimate to break a 
surgery schedule Avhen this diagnosis has 
been reached. 

The inflamed gallbladder represents al- 
most a diametrically opposite problem to 
that of appendicitis complicating pregnancy. 
Only rarely is surgical removal indicated. 
Careful medical management, including diet, 
antispasmodics, and antibiotics Avill usually 
control the situation. The interposition of 
the elevated omentum helps to protect the 
uterine Avail from the irritation of the in- 
fectious process. Recurring episodes of colic 
or developing jaundice make surgery man- 
datory and most authors generally feel that 


pregnancy adds little to the difficulty of 
removal. Cholecystectomy is generally fav- 
ored OA’er drainage, although maternal or 
fetal distress or difficult exposure are indi- 
cations for the latter. A fetal loss of up- 
AA^ard to 15% can be expected. 

Bowel obstructions during pregnancy, par- 
ticularly those due to adhesions, are becom- 
ing more common. This reflects an increas- 
ing number of abdominal operations. Harer,^ 
in revieAving the University of Pennsyl- 
A’ania’s material, found an incidence of one 
per 3600 pregnancies. The classic triad of 
pain, vomiting, and obstipation must direct 
the obstetrician’s attention to the possibility 
of intestinal obstruction. The overAvhelming 
number of these Avomen Avill give a history of 
moderate to severe constipation during the 
early months of pregnancy. The pain in the 
early stages of obstruction Avill be crampy 
in nature and easily confused Avith gastro- 
enteritis, or even early labor, and it is only 
Avhen the character of the pain becomes se- 
A'ere and unremitting that Ave are able to 
distinguish betAveen the tAvo. The findings 
of distention, generalized tenderness Avith a 
localized area of maximum tenderness, and 
high pitched peristaltic rushes, lead one to 
a diagnosis of closed loop obstruction. Early 
X rays are of little value, but a typical ob- 
struction gas pattern develops in most in- 
stances. A barium enema Avill help to rule 
out volvulus of the sigmoid and definitely 
should be used, as indicated. Questionable 
or incomplete obstructions are legitimately 
treated Avith enemas, long tube decompres- 
sion and supportive therapy. Once the di- 
agnosis of a’oIa’uIus is settled upon, the cor- 
rection of electrolyte imbalance and anemia, 
followed by laparotomy, is the treatment of 
choice. A Levine tube Avith gastric decom- 
pression should be in place prior to sur- 
gery. Nausea and A’omiting are more promi- 
nent in small boAvel obstructions, Avhereas 
obstipation is more apparent in a^oIvuIus of 
the large boAA'el, particularly of the sigmoid 
colon. As volvulus progresses, more and 
more of the maternal blood volume is divert- 
ed to the boAvel and the patient gradually 
drifts into shock. Frequently at this point, 
the uterus becomes irritable and contractions 
appear. This, plus the loAver maternal pres- 


6 


Nebriska S. M. J. 


sure, combines to reduce circulation of the 
placenta, and fetal distress results. 

It is easy to see how an obstetrician con- 
fronted by a patient with apparent uterine 
tenderness, fetal distress and in incipient 
shock, may arrive at the erroneous diag- 
nosis of concealed abruptio placentae. When 
there is a progressive deterioration of the 
maternal condition, even when one is unable 
to distinguish between intestinal obstruction 
and abruptio placentae, laparotomy should 
be done as soon as possible. It may be 
fatal to permit delay, either for extensive 
diagnostic procedures or to permit induced 
spontaneous vaginal delivery. In a group 
of 26 cases reviewed by Harer,^ a fetal mor- 
tality of 31% was found. It was distress- 
ing to see that six of these deaths occurred 
in patients who had carried their babies to 


viability, but who lost the infant at the 
time of volvulus. It would seem likely that 
early operative interference would have 
yielded better fetal salvage. 

Generally speaking, I think it can be said 
that the treatment of acute abdominal prob- 
lems during pregnancy is a rapid and de- 
cisive attack on the cause. Evacuation of 
the uterus should be done only for better ex- 
posure, or for the classic indications for 
cesarean section. Acute appendicitis is par- 
ticularly treacherous in the third trimester 
and is justifiably subject to “over-diagno- 
sis.” Gallbladder disease is best left in the 
hands of the internist, except on rare occa- 
sions. Peptic ulcer during pregnancy is 
practically non-existent. Bowel obstruction 
will yield a much higher fetal salvage if ag- 
gressive surgical intervention is applied. 


The average patient’s hospital stay is nearly half as long 
today as it was 30 years ago. The average stay in 1935 was 14 
days and today it is 7.7 days. The decline is attributed by the 
American Hospital Association to better medicines, new- equipment 
and improved treatment. 


January, 1966 


7 


Etiology of Carcinoma 
Genetic Determinism 


Introduction 

E xtensive research has been 
carried out over the years in 
quest of the etiologj' of malig- 
nant neoplasms in man. Although specific 
factors have been implicated in certain situ- 
ations, cancer has remained an enigma so 
far as cause is concerned. 

The purpose of this brief communication 
is to present a summary of some of the 
known facts concerning the etiology" of car- 
cinoma. A diagram (Fig. 1), which is part 
of an exhibit to be presented at the annual 
meeting of the American Society of Human 
Genetics, Seattle, Washington, in August, 
1965, will be used to illustrate these features. 
A hypothesis will be advanced to explain 
existing data on “cancer families.” 

Comment 

As seen in Figure 1, heredity is given 
major emphasis in the etiology' of carcinoma. 
This is as it should be since every living 
thing has “heredity.” The critical point is 
that heredity may confer resistance or sus- 
ceptibility to carcinoma. This undoubtedly 
is not an all-or-none phenomenon, but rath- 
er acts as a continuum in the general popu- 
lation. Hence by “selection,” we occasion- 
ally see “cancer families’” (Fig. 1) which 
may represent a strong hereditary deter- 
minism for susceptibility to cancer. On the 
other hand, certain families appear to have 
“resistance” (Fig. 1) to cai’cinoma which, in 
turn, may indicate hereditary determinism 
against malignant neoplasia. 

When statistics on cancer incidence are 
appraised, it is found that about fifteen per 
cent of the population can be expected to 
succumb to a malignancy.^ However, these 
figures are misleading, in that they are 
based on population samples which do not 
take hereditary factors into account. In 
other words, how much of this 15 per cent 
is concentrated in particular families? 


H. T. LYNCH, MD; 

P. G. RIGBY, MD; 

C. W, MAGNUSON, MD: 

A. L. LARSEN, MD, 
and 

A. I. KRUSH, MS 

Departments of Internal Medicine and Pathology, 
Eppley Institute for Research in Cancer 
and Allied Diseases, 

Omaha Veterans Administration Hospital 
Omaha, Nebraska 


An integral part of this concept is that 
every human is constantly exposed to both 
living (microbiological) and nonliving 
(physico-chemical) carcinogens (Fig. 1). 
Of the living carcinogens, vinises have been 
under strong suspicion; but as yet, their 
oncogenic properties have not been docu- 
mented in man. However, viruses have been 
clearly demonstrated to cause malignancies 
in some infrahuman species, and unknown 
“viral-like” particles have been identified in 
patients with various malignancies.^ 

Research in “cancer families”® currently 
in progress at the University of Nebraska 
College of Medicine is being directed toward 
each parameter of this diagram. Two of 
these large kindreds show sevei'al common 
features: (a) vertical transmission of a wide 
variety of malignant neoplasms with heavy 
concentration of multiple primary malignant 
tumors in several sibships (hereditary fac- 
tor?) ; (b) the features described in A ap- 
pear to be similar to known facts relevant 
to the polyoma virus and its oncogenic effect 
in mice.^ Do we have a human polyoma?; 
(c) Practically all members of these two 
families are or have been farmers. Is there 
anything common in this occupation which 
maj^ be carcinogenic? Contact with domes- 
tic animals? — bovine leukosis? — Rous 
sarcoma producing a myxosarcoma in chick- 
ens? — physico-chemical factors?® 

A trilogic hypothesis encompassing these 


8 


Nebraska S. M. J. 


possibilities is advanced. Could there be a 
“cancer susceptible genotype” harboring a 
latent oncogenic virus which is “triggered” 
by some unknown environmental factor or 
factors ? 


The undisputable factor is heredity. The 
genetic constitution of each individual would 
seem to be an instrument played upon by a 
variable environmental sj^mphony. A virus 
contains DNA or RNA, and thus differs 



nitrogen mustards 

NON LIVING 
CARCINOGENS 

>‘ZZ 


UPPER CASE (i.e., POLYPOSIS cou ) — PROVE N 
LOWER CASE ( I.6., leukemia )— NOT PROVEN 


^-^Ttotal number of malignant tumors per generation 

I?"- '|-^ GENERATION NUMBER 

Ntotal number of individuals per generation 


Figure 1. Illustration of multiple factors contributing to the etiology of carcinoma. 


January, 1966 


9 



from physico-chemical factors in the ability 
to directly relate its effects to the genetic 
constitution of the host. The “fit” between 
host DNA/RNA and viral substance may 
determine virus incorporation into host cell 
nucleic acid and thus be a measure of the 
malignant potential of a given virus. The 
dose and timing of the introduction of viral 
or physico-chemical material may well play 
a determining role in oncogenesis; their in- 
teraction may have a potentiating effect. 
The nature of the cellular change produced 
(i.e. antigenic determinants, chromosomal 
aberrations) undoubtedly influences the host 
defense processes (i.e. tolerance). The inter- 
relationships between heredity and environ- 
ment in the genesis of the cancer process 
may be complex but dissectable and thus 
ultimately understandable. 

ACKNOWLEDGEMENT 
We wish to express appreciation to 


Dr. Heniy M. Lemon for his many ideas 
pertinent to our hypothesis and to Miss 
Rose Reynolds for medical illustrations. 


References 

1. Gordon, T.; Crittenden, M., and Haenszel, W.: 
Cancer mortality trends in the United States, 1930- 
1955. In End Results and Mortality Trends in Can- 
cer. Edited by S. J. Cutler et al, pp 350, Washing- 
ton, D.C., Government Printing Office, 1961. (No. 
6, National Cancer Institute Monograph) pp 133- 
290. 

2. Sorenson, G. D.: Virus-like particles in myelo- 
ma cells of man. Proc Soc Exp Biol Med 250-252, 
Jan, 1965. 

3. Lynch, H. T.; Shaw, M. W.; Magnuson, C. 

W.; Larsen, A. L., and Krash, A. J.: Hereditary 

factors in cancer: study of two lai’ge midwestern 
kindreds. (To be published). 

4. Chang, Shueh-Shen, and Hildemann, W. A.: 
Inheritance of susceptibility to polyoma virus in 
mice. J Nat Cancer Inst 33:303-313, 1964. 

5. Roe, F. J.: Natural, metallic and other sub- 

stances, as carcinogens. Brit Med Bull 20:127-133, 
May, 1964. 


Thirty years ago a person with lobar pneumonia might spend 
five weeks in the hospital and pay doctor and nursing bills of about 
$400 — if he suiwived. Today’s patient can be treated in his home 
and cured in about two weeks with doctor and diaig bills totaling 
about $60. 


10 


Nebraska S. M. J. 


Pediatric Conditions Related to 

Diseases and Functions of the Placenta* 


T [E placenta is one of the poor- 
ly understood organs found in 
the human. Since the organ 
is disposed of, few people have taken time 
to study its function. In general terms, if 
the placenta does not perform correctly the 
fetus is affected by hypoxia, hemorrhage, 
polycythemia, anomalies, or by infections. 
(Table 1). 

As noted in Table 1, hypoxia to a mild 
or major degree is seen in a number of con- 
ditions, none of which are unusual. Mono- 
amniotic twin cords often become entangled, 
causing hypoxia and also a high mortality 
rate up to 50 per cent. 

In looking at the causes of hemorrhages, 
this bleeding into the placenta actually rep- 
resents a retro-placental hematoma. Bleed- 
ing also may occur into the mother and can 
be detected by estimating fetal hemoglobin 
in the mother’s blood. This figure should 
be less than 2 per cent normally. 

Intertwin vascular anastomosis can cause 
either hemorrhage or polycythemia, and will 
be discussed later. 

The other cause for polycythemia is the 
maternal-fetal transfusion. The mechanism 
here is not understood, and the placenta is 
normal. Besides the increased red blood cell 
count, the B 2 (BetUa) M globulin is elevated. 
This protein is never seen in the normal 
neonatal period and so represents transfu- 
sion of maternal blood into the infant. 


ROBERT MURPHY, MD 
Omaha, Nebraska 


Table 1 

FETAL CONDITIONS RESULTING FROM 
PLACENTAL PROBLEMS 

Fetal Hypoxia 

Placenta praevia 
Abruptio placenta 
Umbilical cord occlusion 
prolapse 

cord around neck 
knots 

torsion or stricture 
shortening 
monoamniotic twins 
tumors 

Fetal Hemorrhage 
Placenta praevia 
Abruptio placenta 
Cesarean section 

Rupture of umbilical cord varices 
Hemangiomas 

Ulceration of persistant omphalomesenteric 
duct 

Rupture of cord 
Bleeding into placenta 
Bleeding into mother 
Intertwin vascular anastomosis 
Polycythemia 

Mateinal fetal tranfusion 
Intertwin vascular anastomosis 
Anomalies 

Vascular shunts 
Single umbilical artery 
Tumors 

Amnion nodosum 
Infections 
Systemic 
Local extensions 
Miscellaneous 

Erythroblastosis 

Diabetes 

Toxemia 

Postmaturity or interuterine growth failure 
Repeated prematures 


Absence of the umbilical artery is prob- 
ably the most common of all major congen- 
ital abnormalities (1 to 2.5 per cent). The 
incidence is 1 per cent in all births and is 
seen in 7 per cent of all twin births. The 
mother often has preeclampsia, hemor- 
rhage, or polyhydramnios. The child with 
a single umbilical artery has been reported 
with 10 to 50 per cent congenital anomalies. 
These anomalies involve the G.I. and G.U. 
tracts mainly. Multiple anomalies are the 


rule (76 per cent). This incidence applies 
only to the single infant, as the twins are 
not adversely affected. Follow-up on these 
infants shows some retardation of growth 
in many, probably from the anoxia. 

Tumors of the placenta lead to hypoxia 
and fetal abnormalities. Chorioangiomas 
are often associated with polyhydramnios 

*Presented at the Tenth Meeting of the Nebraska Ob- 
stetrics-Gynecology Society, Las Vegas, December, 1964. 


fanuary, 1966 


11 


and prematurity in the mother, and heman- 
giomas and congenital malformations of the 
fetus. The chorionepithelioma may also 
metastasize to the fetus. 

Of all the infections of the fetus, bacterial 
causes by far predominate. Viral and proto- 
zoan infections are rare. Systemic infec- 
tions refer to transplacental infections from 
the mother and are hematogenous in entry 
to the fetus. In the literature, bacteria of 
all types are most common, but a multitude 
of viruses mainly of the small tji)e, fungi, 
and protozoa are listed as having infected 
the fetus. 

Local extensions of infections have been 
called the amniotic infection syndrome and 
represent ascending infections from the 
cervix. This syndrome occurs whether the 
membranes are ruptured or not. The same 
type of bacteria can be found in the vagina. 
The exact type varies and may be any known 
bacteria. In this situation, sections of the 
cord and membranes will show a leukocytic 
infiltration. This is not a specific finding 
for infection alone, as hypoxia from any 
cause will produce the same pathologic pic- 
ture. 

The last group of miscellaneous conditions 
probably is related to the qualitative func- 
tion of the placenta. These may have, as a 
factor, the reduced maternal blood flow and 
oxygen pressure gradients through the inter- 
villous spaces. 

One of the conditions that can be recog- 
nized easily on the placenta is amnion nodo- 
sum. These are 1 to 2 mm firm, rounded, 
and raised yellow areas on the amnion of the 
membranes and the fetal surface of the pla- 
centa. ^Microscopically, the nodule is on or 
occasionally embedded in the amnion. The 
nodule is made up of squamous cells of the 
amniotic fluid. ^ 

The incidence of this condition is about 
one per one thousand deliveries. The breech 
position is seen in about half of the report- 
ed cases and is thought to be due to the 
oligohydramnios which interferes with the 
normal positional changes of the fetus. 

The mechanism for the production of the 
nodule is the oligohydramnios. This allows 


concentration of the amniotic squamous 
cells with adhesions to the placental surface, 
thus producing the nodule. 

To delineate the causes of oligohydram- 
nios we must stop and review the origin 
and disposal of the amniotic fluid. Broadly 
speaking the origin is first from the am- 
nion, where in early fetal life transudation 
occurs but is later changed to a secretion 
of fluid. The second source of the amniotic 
fluid is the fetus itself with fluid coming 
from the skin, respiratory tract, and lastly 
from the kidney after 20 weeks. 

The disposal of the fluid is via the am- 
nion back to the maternal circulation and 
also by absorption by the fetus through the 
skin, respiratory tract, and mainly through 
the gastrointestinal tract. ^ 

Now what are the actual causes of am- 
nion nodosum? Blanc® states that five con- 
ditions may produce the nodules. First is 
fetal anuria or oliguria, resulting from apla- 
sia or dysplasia of the kidney or from ob- 
struction of the urinaiy passages. Second, 
a functional fetal oliguria may be seen 
in one of monochorionic twins with the 
transfusion syndrome. Next, a chronic 
leakage of amniotic fluid may cause the 
nodules. Fourth, retention of a dead fetus 
leads to no urine production and resorption 
of amniotic fluid. Finally, extensive lesions 
of the membranes or anomalies of the pla- 
centa will reduce the amniotic surface so 
that production of amniotic fluid is reduced. 

To the pediatrician, knowledge of amnion 
nodosum becomes important in the outlook 
and treatment of the infant. 

The G.U. tract problems usually are renal 
agenesis, polycystic kidney, or some ureteral 
obstruction. These patients have become fa- 
mous with their so called Potter’s facies, 
with the flattened nose, accentuated epican- 
thic folds, receded chin, large and low-set 
ear lobes lying below the level of the angle 
of the jaw. This infant also shows severe 
respiratory distress, has pulmonary hypo- 
plasia at autopsy, and frequently has deform- 
ities of the feet. 

To explain amnion nodosum in twins, we 
must review briefly the placentas of twins. 


12 


Nebraska S. M. J. 


Dizygous twins (from two fertilized ova) 
always have dichorial placentas and as such 
will not have vascular anastomosis. In 
monozygous twins the placenta is usually 
monochorial diamniotic, with rarely a mono- 
chorial monoamniotic type being seen. The 
mortality rate is always higher in the mono- 
chorial twins, due either to entangled cords 
or to the vascular shunts that produce the 
transfusion syndrome. 

The shunts in the monochorial diamniotic 
placenta may be artery-to-artery, vein-to- 
vein or artery-to-vein. A large A-A and 
large V-V shunt occurring concomitantly 
will lead to an acardiac monster. The A-V 
shunt produces the transfusion syndrome.^ 

Here blood courses through the fistula to 
the recipient twin, producing a state of hy- 
peiwolemia. The other twin shows a state 
of hypovolemia. 

As a result of the hypervolemia, the recipi- 
ent twin becomes plethoric from polycy- 
themia, develops a cardiac hypertrophy and 
pulmonary hypertension that increases blood 
flow. This also produces an increased urine 
production, and so a polyhydramnios leading 
to premature labor. Clinically, this baby 
will develop respiratory distress, jaundice, 
and possibly kernicterus. 

The donor or hypovolemic infant becomes 
anemic and produces less urine; this in turn 
creates an oligohydramnios, amnion nodo- 
sum in its sac, and small size of the infant. 
In fact several of the reported cases retain 
a low blood count and small size until ten 
to twelve months of age.® 

Treatment for the transfusion syndrome 
may be a life-saving affair. The little ane- 
mic twin may go into shock from the hypo- 
volemia and need blood. More commonly the 


larger plethoric twin needs to have the 
venous pressure reduced by bleedings. 

Recently I treated triplets of which thei 
two males were monozygous and had the 
transfusion syndrome. The female infant 
was completely normal. One male twin was 
seven pounds at birth, number two male 
twin five pounds and ten ounces. The first 
male had 24.6 gm of hemoglobin per 100 
ml of blood, and a 76 per cent hematocrit 
while the second twin showed 21.1 gm of 
hemoglobin per 100 ml of blood and a 62 
per cent hematocrit. The larger twin was 
darker than the pale, listless, and smaller 
twin. Removal of 25 ml of blood helped 
the plethoric twin, and all three infants were 
dismissed in excellent condition. The small- 
er male remained small throughout the fii’st 
year. 

Although the A-V anastomosis was not 
looked for in the placentas of the triplets, 
we know that the difference in the bloods is 
significant, especially since the last member 
of twins or triplets should have the higher 
blood count.® 

References 

1. Landing, B.: Amnion nodosum: a lesion of 

the placenta apparently associated with deficient 
secretion of fetal urine. Amer J Obst Gynec 60: 
1339-1342, 1950. 

2. Jeffcoate, T. N. A., and Scott, J. S.: Poly- 
hydramnios and oligohydramnios. Canad Med Ass 
J 80:77-86, 1959. 

3. Blanc, W. A. ; Apperson, J. W., and McNally, 

J.: Pathology of the newborn and of the placenta 

in oligohydramnios. Bull Sloane Hosp Worn 8: 
51-64, 1962. 

4. Benirschke, K.: A review of the pathologic 

anatomy of the human placenta. Amer J Obst 
Gynec 84:1595-1622, 1962. 

5. Sydow, G., and Pinne, A.: Very unequal 

“identical” twins. Acta Paediat 47:163-171, 1958. 

6. Seip, M. : A comparison of hemoglobin and 

erythrocyte values in the first-born and the second- 
born twin and in first, second and third triplet dur- 
ing the neonatal period. Acta paediat 45:58-62, 1956. 


Of 604 new drugs developed worldwide 1941-64, the U. S. 
originated 366 of them; 167 were developed in 16 foreign countries; 
the sources for 44 are not identified; 16 are new uses of previously 
known compounds; and 11 are credited to more than one country. 


January, 1966 


13 


Birth Trends In Nebraska 


T he 1965 baby situation is con- 
fusing! We are told on one 
hand that there is a “baby 
boom” and that the “population explosion” 
is a national and indeed world emergency 
requiring immediate attack. Yet the popu- 
larity of family planning is at an all time 
high, old taboos against contraceptives are 
being broken down, and even the Catholic 
Church is seriously considering the moral 
implications of the “pill.” 

Many hospitals have experienced sharp 
drops in the number of babies born, and ex- 
pensive maternity units stand half empty. 
Most physicians are now caring for fewer 
obstetric patients; yet we read it may be 
necessary to train nurse-midwives to care 
for the onslaught of maternity patients. 
What are the facts? 

Births 

A brief summary of past birth trends in 
Nebraska is of interest. 

Table 1 


Total Rate/1000 

1920 30,749 23.7 

1930 27,006 19.6 

1940 22,153 16.8 

1950 31,713 23.9 

1960 34,257 24.3 

1964 30,737 21.1 


A peak of over 30,000 deliveries was 
reached in 1920 with a crude birth rate per 
1000 population of 23.7. This figure actu- 
ally reached a maximum of 32,000 in 1921 
and then declined continuously, until the 
low point of 22,000 deliveries and a crude 
birth rate of 16.8 was reached in 1940. This 
level then continued essentially unchanged 
through the war years, but the postwar 
baby boom began in 1946 when the number 
of deliveries jumped to 27,000 . The follow- 
ing year they reached 32,000 and continued 
at about this level, with essentially little 
change in the number of biidhs or the birth 
rate, reaching a peak of over 34,000 in 
1960 and in 1961. Since that time, the num- 
ber of births and the birth rate have been 
falling sharply, reaching in 1964 their low- 


WARREN H. PEARSE, MD 
Department of Obstetrics and Gynecology, 
University of Nebraska College of Medicine 
Omaha, Nebraska 


est point since 1946. Indications are that 
the total births and the birth rate will drop 
even lower than this in 1965. 

Are these trends surprising to us? They 
should have been easily anticipated by a 
backward look at the numbers of women 
in the reproductive years. The reproduc- 
tive years for the female population are 
generally considered to be between the ages 
of 15 and 44. However, the average age 
at marriage in this country is a little over 
20 years and the median age at which 
families averaging 2.9 children are being 
completed is 6 years following the mar- 
riage. These figures are in marked contrast 
to those of 30 years ago, but tell us that 
most children are born to mothers between 
the ages of 20 and 29. Women who in 1965 
are between the ages of 20 and 29 were 
born in the decade between 1936 and 1945 
when the total births in this state and in the 
nation were unusually low. Thus the present 
falling birth rate might have been antici- 
pated, even without oral contraceptives, and 
a look into the future may also tell us what 
to expect. 

Two factors control the number of births ; 
the first of these is known, the second is 
unknown and can only be estimated. At the 
present time all the females are living who 
will comprise the age 15 to 44 reproductive 
group in the years through 1980. This is 
the known factor. How many children these 
women will have, and what their specific 
fertility rate will be is the unknown factor. 
It is, however, possible to make some pre- 
dictions of the fertility rate based on past 
considerations. 

The fertility rate — that is, the number 
of children born each year to each 1000 
women in this age bracket — was 120 in 1960. 
These figures represent the 4,300,000 births 


14 


Nebraska S. M. J. 


Table 2 

UNITED STATES FERTILITY 

Million U.S. 

Women Fertility Million 

15 - 44 Rate Births 


I960 36 120 4.3 

1965 38 100 3.8 

1970 43 100 4.3 

1980 54 100 5.4 


which occurred in that year. Since that 
time, although the number of women in the 
reproductive age has risen slowly, the fer- 
tility rate has fallen sharply and it is anti- 
cipated that this year for the first time 
in 20 years the total number of births in the 
United States will fall below four million, to 
approximately 3,800,000. Varying explan- 
ations are offered for the fall of the fer- 
tility rate. Demographers believe that this 
is largely due to a reduction in the average 
number of children which couples have and 
that the wide use of oral contraceptives 
plays only a small part. The practicing 
physician holds a considerably different 
view, I believe. It is apparent that it is 
the wide availability of familly planning 
advice — particularly the effectiveness and 
simplicity of oral contraceptives — that have 
both allowed the newly married couple to 
postpone child bearing, and permitted the 
family who in the past might have desired 
to reduce the average family size but failed 
to use contraceptives effectively, to limit the 
number of children. While both factors are 
operative, it seems to the clinician that the 
availability of family planning and the use 
of oral contraceptives is the factor which 
has indeed made the major difference. 

In 1970 there will be 43 million women 
in the reproductive age groups and this 
figui’e will rise to 54 million by 1980. This 
sharp rise will be caused by the continuing 
entrance into the reproductive age range 
of the large number of children born be- 
tween 1946 and 1963. If we assume that 
the fertility rate remains at its present 
level of 100, the actual number of births 
will increase to 4.3 million by 1970, and far 
above any previous level to 5.4 million in 
1980. 

These figures may well be too conseiwa- 
tive. The U.S. Census Bureau has estimat- 
ed these birth numbers to be 4.5 and 6.0 mil- 


lion respectively and indeed, despite con- 
traceptives, the fertility rate may rise. The 
age range of 15 to 44 is now weighted 
heavily toward the high side in years. Not 
only will the numbers increase, but the 
women in the reproductive age range will 
be increasingly at a younger average age over 
the next 15 years. It is, of course, the 
group from 20 to 29 that has the highest 
fertility rate and thus the overall birth rate 
may well rise above 100. 

Comparable figures for the State of Ne- 
braska are illustrated in Table 3. In 1960 
there were 274,000 women in the reproduc- 
tive age range and the fertility rate was 
125 per thousand — somewhat above the 
national average. In that year there were 
over 34,000 births. In 1964 the number of 
women in the reproductive age range had 
risen slightly; and while there had been a 
fall in the fertility rate it was not as precip- 
itous as that obseiwed in the entire United 
States. As a matter of fact, the peak year 
for births in the United States was reached 
in 1957 and there has been a slow decline 
since that date, while the peak year in Ne- 
braska was 1961 with a more rapid decline 
since. 

Table 3 



NEBRASKA 

FERTILITY 



Thousand 

Nebraska 

Women 

Fertility 

Rate 

Births 

1960 

274 

125 

34,257 

1964 

280 

110 

30,727 

1970 

328 

105 

34,500 

1980 

. 412 

105 

43,500 


In 1970 there will be 328,000 women in the 
reproductive age range and presuming, be- 
cause of the previous four to five year lag 
behind national trends, a continuing decline 
of the birth rate to 105, there would be 
34,500 births in 1970, approximately equal 
to the peak of 1960 - 61. In 1980 there will 
be 412,000 women in the reproductive age 
range in Nebraska, assuming there is no 
significant in or out migi-ation. If the birth 
rate remains at 105, there would be 43,500 
deliveries that year; almost a 50% increase 
over the present level. As previously indi- 
cated, this may be a somewhat conservative 


January, 1966 


15 


figure and it is entirely possible that the 
increase may be even larger. 

Physicians 

There have been many surveys of physi- 
cian population and needs nationwide, as well 
as in the State of Nebraska. It is not our 
intention again to describe this area exten- 
sively. The following information may be 
of general interest, however. 

It is fully realized that not all babies 
are delivered by obstetricians, nor are they 
ever likely to be. The total number of physi- 
cians who perform obstetrics is an unknown 
quantity (it is about 50% of those licensed 
in a state such as Indiana), but the number 
of obstetricians available to care for this 
rapidly rising number of births in the 1970’s 
can be calculated with some accuracy. As 
Table 4 indicates, in 1930 there were 1,418 
obstetricians in the country, comprising 1% 
of the physician population. This figure 
rose to almost 15,000, or 5% of the physi- 
cian population, in 1963, and will increase 
to 17,500, or 6% of the physician population, 
by 1970. Information concerning obstetric 
residencies indicates that an average of 700 
new obstetricians are being added to the 
national physician population each year. 
Approximately 200 are lost through death or 
retirement. 

Table 4 

OBSTETRICIANS 


Per Cent of 

Year Number Physicians 

1930 1,418 1% 

1963 14,788 5% 

1970 (est) 17,500 6% 

1980 (est) 22,500 7% 


2797 positions in 483 residencies; 909r filled 
(1963). 

As Table 5 indicates, on a nationwide 
basis, and with the presumption, obviously 
in error, that obstetricians are supplying 
all maternity care, the increase in obstetri- 
cians at least until 1970 would appear to be 
more than adequate to care for the in- 
creased number of deliveries. While it is 
difficult to predict trends of medical prac- 
tice even five years in advance in these con- 
fused times, if the number of physicians 
entering obstetrics remains at essentially 


the present level, substantially the same 
conditions will prevail in 1980 as will in 1970. 

Table 5 

DELIVERIES PER OBSTETRICIAN 


1963 278 

1970 (est) 246 

1980 (est) 240 


Physician distribution is not a subject for 
further detailed review. It is interesting 
to note, however, that in 1963 there were 
109 deliveries per obstetrician in New York 
State. The Directory of Medical Specialists 
indicates 37 board certified obstetricians in 
the State of Nebraska, while membership 
in the American College of Obstetrics and 
Gynecology is 59. Utilizing the latter figure, 
there were 509 deliveries per obstetrician 
in the State of Nebraska — 2 V 2 times that 
of New York State. The figure for Ne- 
braska is higher than that for any of the 
rural Southern States, but compares with 
sparsely populated neighboring states such 
as North Dakota, South Dakota and Wyo- 
ming. 

Summary 

1. The number of births in the nation and 
in Nebraska have declined sharply in 
the past five years. 

2. This trend is now at its lowest levels. 

3. The large number of births of the 
late 1950’s should be reached again 
by 1970, and in 1980 births may be 
50% or more above present levels. 

4. While patterns of care may change, 
there is no present reason to suspect 
any gross inability of physicians in 
the United States to care for this 
increased number of obstetric patients. 

References 

Schneider, Jon: (Personal communication). 

Nebraska State Department of Health, Maternal 
and Chi'd Health Statistics. 

Bogue, Donald J.: in the Population Dilemma, 

ed. Philip M. Hauser, Twenty-third American As- 
sembly. 

Nebraska Blue Book: 1964, Legislative Council, 

Lincoln. 


16 


Nebraska S. M. J. 


NEUROLOGIC MANIFESTATIONS of 

Dysbarism 

(DECOMPRESSION SICKNESS) 


A s a man leaves his near sea- 
level existence to make ever 
greater ascents and descents, 
he is beset by physiologic problems of com- 
pression and decompression of atmospheric 
environment. The basic (and over-simpli- 
fied) problem is known to every high school 
student of physics : under compression, 
liquids absorb more gas into solution, and 
under decompression, the gas bubbles off ; 
under compression, gaseous volume shrinks, 
under decompression, it expands. 

While dysbarism is a concern of physi- 
cians in armed forces, under-water and 
space-exploratory installations, it involves 
other physicians increasingly as civilian air 
travel includes greater altitudes (including 
now the “business man’s” small jet air- 
plane) and the growing popularity of scuba 
diving.i®’ * 

High Altitude Decompression 

Through lack of attention to, or failure 
of pressurized suits or cabins, persons be- 
yond altitude of 20,000 feet incur increas- 
ing risk of dysbarism. The risk of symp- 
toms increases also with age (beyond 30 
years), obesity (even “minimal obesity”) and 
exercise. There appears to be also an indi- 
vidual susceptibility and multiple other fac- 
tors yet undiscerned which explain why rare 
individuals develop symptoms at 20,000 feet 
and a small number of hardy adventurers 
remain symptom-free to 40,000 feet. Breath- 
ing 100 per cent oxygen for 30-60 minutes 
before ascent markedly reduces incidences 
of dysbarism by washing out considerable 
of the body’s nitrogen. (Nitrogen plays an 
important part in producing symptoms since 
it stores well in adipose tissue ).i'® 

A particular risk at much lower altitudes 
has been noted in those who enjoy scuba 
diving.® Dysbarism may occur at altitudes 
of 5000-8000 feet if the individual had been 


JOHN A. AITA, MD 

Associate Professor, Neurology and Psychiatry 
University of Nebraska College of Medicine 
Omaha, Nebraska 


diving to depths over 15 feet within 24 
hours ! 

If an orderly progression of the classi- 
cal and complete syndrome occurred, it 
would move from subjective distress of 
trapped gas, (as in bowel) to joint pains, 
then respiratory distress to culminate in 
circulatory collapse or cerebral symp- 
toms. ®> 11- 12, 14, 15. 17 This sequence 

may occur. The syndrome may, however, 
cease at any stage or it may present sud- 
denly with circulatory collapse or cerebral 
symptoms. 12 On occasion symptoms appear 
belatedly — after the pilot had returned to 
earth several hours. 

One should recall that at altitude also 
there may occur hypoxia, hyperventilation, 
cardiac arrythmia and emotional reac- 
tions.!® In jet fighters spatial disorienta- 
tion, vertigo, gravitational stresses, and 
fatigue may be included. i® 

(Hypoxia is a great hazard at high altitude, 
symptoms appearing commonly at 10,000- 

12.000 feet with loss of consciousness not un- 
usual at 20,000 feet. Aviators breathe pure 
oxygen by mask to offset this and this pro- 
vides adequate oxygen tension to at least 

30.000 feet. As 38,000-40,000 feet are ap- 
proached, the value of breathing pure oxygen 
drops off to an equivalent of air at 10,000- 

12.000 feet).i®“ 

The complete and classical syndrome of 
high altitude decompression may be outlined 
thus : 

Trapped ga.s: abdominal distention, flatus, 

belching; otitis, sinusitLs, dental pain. 

Skin: itching, prickling, paresthesias, hot or 


January, 1966 


17 


cold sensations. Later subcutaneous bubbles, 
mottling. 

“The bends”: pains, commonly about joints. 
“Xeuralgias.” 

“The chokes”: respiratory distress; substernal 
discomfort, burning; coughing, choking, hy- 
perventilation, tachycardia. 

Neurologic symptoms (“The Staggers”) : 

These are predominantly cerebral. 

Seldom appear in exposures below 30,000 
feet.^ 

Paresis, ataxia. 

Scotoma, visual difficulty. 

Dizziness. 

Diplopia. 

Headache. 

Nausea, vomiting. 

Focal cerebral deficit. 

Single 

Multiple 

Often shifting, changing. 

Diffuse encephalopathy syndromes (wax and 
wane). 

Mental impairment. 

Stupor, coma. 

Convulsions; focal or generalized. 

Occasionally, spinal cord syndromes. 

Circulatory collapse (shock). 

Syncope 

Hypotension 

Hypovolemic signs 

Cardiac arrrythmias 

Coronary insufficiency, infarction 

Cyanosis 

In most critically ill patients, both neuro- 
logic and circulatory collapse appear togeth- 
er; occasional exceptions occur, with one 
system only presenting outstandingly. 

An onset with mental impairment predom- 
inant is usually more characteristic of hj"- 
poxia than dysbarism but exceptions are 
known. 

Sequelae are not common in those who 
survive but cerebral deficit syndromes may 
remain permanently. 

A precise understanding of pathophysiology 
of dysparism is aAvaited. At sea level a 
human weighing 150 pounds has 1 liter of 
nitrogen dissolved in his tissues and body 
fluids. Intravascular air embolism and 
bubble formation in tissue (extra vascular) 
may suffice in explanation but authorities 
are not yet certain. Are the effects simply 
mechanical, infarctive, vasospastic or irrita- 
tive — or do more complex ionic and chemical 
reactions occur in the presence of micro- 
scopic air bubbles? Some investigators have 
felt that dysbarism sets off fat embolism and 
that this may be the significant lesion. 


Recent studies demonstrate that wide- 
spread capillary damage occurs, leading to 
disturbed permeability, then to a loss of 
plasma into extravascular tissues. Remark- 
able hemoconcentration and hypovolemia ap- 
pear, to precipitate the severe state of shock 
often present. 

Pathologic examination discloses vascular 
congestion (particularly at arteriolar and 
capillary level), diapedesis, effusion, edema, 
and microinfarctions in many organs, par- 
ticularly lungs and brain.®* ■*- 

Treatment of more serious reactions, par- 
ticularly when neurologic and circulatory 
failure appear, requires compression to great- 
er than sea level pressure and plasma-ex- 
panders to restore plasma volume. Coronary 
arteries and myocardium may require spe- 
cial attention. Cerebral edema may need 
reduction. Hypothermia may provide life- 
saving support.^ 1®* 1® 

High Pressure (Compression) 
Dysbarism 

Living under conditions of increased at- 
mospheric pressure may occur in : 

Divers 

Pressurized tunnel workers 
Caisson workers 
Submarine personnel 
Shaft sinkers 
Cofferdam workers 
Flooded mine workers 
Hyperbaric therapy20a 

Decompression chambers 
Hyperbaric oxygen chambers 

As man soars ever further into space, so 
is he sending divers to greater depths. 
Several general medical (and neurologic) 
problems associated with existence under 
atmospheric pressures greater than at sea 
level have been discerned to date : 

Nitrogen narcosis 
Oxygen toxicity 
Decompression 

Pulmonary alveolar rupture with air embolism 

Nitrogen Narcosis. With each 33 feet 
depth of water, the pressure of one more 
atmosphere (sea level) is added. Nitrogen 
comprises the greatest portion of air and 
under pressure has been discerned to produce 
narcosis resembling that seen with alcohol. 


18 


Nebraska S. M. J. 


Euphoria, exhilaration, performance impair- 
ment, and poor judgment appear progres- 
sively, beginning insidiously at approxi- 
mately two atmospheres pressure (33 feet 
depth). At 300 feet a diver becomes men- 
tally incapacitated.22. 23, 24 -phe “Martini” rule 
of thumb is grossly helpful, citing that : 

100 feet depth is equivalent to one Martini 
cocktail. 

200 feet depth is equivalent to two or three 
^lartinis. 

300 feet depth is equivalent to four Martinis. 

Employment of artificial air with helium 
in place of nitrogen has proved a reasonably 
successful means of circumventing nitrogen 
narcosis. 

Effects of high partial pressure of nitro- 
gen are noted on EEC tracings. The normal 
disappearance of alpha rhythm with mental 
concentration does not occur now. The am- 
plitude of alpha rhythms decreases as at- 
mospheric pressure increases. With helium, 
taking the place of nitrogen, the EEG re- 
verts to tracings seen under normal pres- 
sures.25 

Hyperbaric Oxygen Toxicity. In ignor- 
ance, accident or desperation, high concen- 
trations of oxygen may be used by divers at 
great pressures. Hyperbaric oxygen is now 
being employed in the therapy of anaerobic 
infections and hypoxic states.^® Breathing 
pure oxygen below 25-30 feet depth carries 
risk of oxygen toxicity including syncope or 
convulsion. 2'^' 28 terms of atmospheric 

pressure, oxygen toxicity makes its appear- 
ance in some individuals shortly beyond two 
atmospheres pressure of pure oxygen. Over 
three atmospheres, all persons respond with 
convulsions in approximately five to 95 min- 
utes. At four atmospheres this occurs with- 
in 45 minutes. There appears to be a con- 
siderable range of individual tolerance and a 
precise cuiwe cannot be drawn. However, 
rapidity of symptoms varies directly with 
oxygen pressure and duration of expo- 
sure.2'^' 29. 30 jf increased partial pressure of 
CO, is also added to hyperbaric oxygen, ap- 
pearance of toxic syndrome is hastened . 22 

Breathing pure oxygen at sea level pres- 
sures often results in pulmonary irritation 
in 24-48 hours. The more critical symptoms 


of pure oxygen inhaled under pressure start 
with general malaise, fatigue, nausea and 
minor neurologic symptoms, and culminate 
in syncope or convulsion. The convulsive 
episode appears distinctly reversible with no 
sequelae. The complete and progressive 
range of symptoms of hyperbaric oxygen 
toxicity include ; 24 . 27, 29, 31, 32 

Tracheopulmonary irritation, dyspnea, sub- 
stemal distress 
Tingling, paresthesia 
Dizziness 
Nausea 

General malaise, fatigue 
Visual disturbances 
Auditory hallucinations 
Tremor, twitching 
Confusion, delirium 
Syncope 
Convulsion 

A number of pathophysiologic factors may 
be involved in hyperbaric oxygen toxi- 
city ;2’^- 23 

CO- retention (since erythrocytes and serum are 
saturated with oxygen) 

Increased tissue acidity 
Enzyme inactivation 
Cerebral vasoconstriction 

Decompression. Each 33 feet depth of 
water adds another atmosphere of pressure 
(sea level). As divers now descend to 1300 
feet, they withstand atmospheric pressure 
approaching 40 times that of sea level .24 
Supersaturated with the air they breathe, 
divers must lose this excess air (particularly 
nitrogen) on return to sea level. Precise 
schedules and decompression chambers are 
used for this, with depth and time at depth 
as important factors.22. 28 . 34 general the 
following exposures may occur without re- 
quiring decompression : 

40 feet for 120 minutes. 

60 feet for 55 minutes. 

80 feet for 35 minutes. 

100 feet for 25 minutes. 

120 feet for 18 minutes. 

It should be noted that decompression 
sickness may appear occasionally despite ade- 
quate decompressive routine, and that it 
may occur in personnel operating decompres- 
sive chambers.2'^ 

Symptoms of decompression commonly ap- 


January, 1966 


19 


pear \\-ithin four to six hours of surfacing 
but may appear belatedly, up to 24 hours 
after retum.^^- Clinical features are not 
unlike those of altitude decompression ^vith 
ti-apped gas pains, skin discomfort, “the 
bends,” “chokes,” neurologic deficits, and 
cardiovascular collapse. Noteworthy is the 
fact that, of neurologic syndi'omes, spinal 
cord sjmdromes predominate following high 
compression whereas cerebral sjmdromes oc- 
cur more frequently \rfth high altitude.®®’ 

“The bends” comprise the commonest 
s>Tnptoms, manifested by pains especially 
about joints. In more severe involvement, 
numbness, paresthesias, and motor weakness 
appear, heralding neural implication. In 
more acute and critical cases, sudden col- 
lapse and death shortly appear due to larg- 
er embolism of lungs, coronaiw arteries or 
brain or both.®®-^® 

^lyelopathic (spinal) sjmdromes vary 
from minimal to complete, transective catas- 
ti'ophes. The thoracic segments are the 
most often implicated. Spinal fluid protein 
has been reported as high as 150 mg per 100 
ml. 

Mixed s>Tidromes combining variously 
spinal cord, brainstem, cerebellar and cere- 
bral lesions are not rare.®® 

Patients with quickest onset of sjTnptoms 
after decompression resjwnd better to re- 
compression than those with belated onset. 

Treatment requires the same considera- 
tions described for altitude decompression.®" 
Some patients are beset with stubborn, re- 
lentless, or recuiTing paralysis despite heroic- 
measures. Sequelae may remain penna- 
nently : 

Myelopathy 
Encephalomyelopathy 
Autonomic dysfunction 
Psychoneurosis 

Pulmonai'y Alveolar Rupture. Com- 
pressed air entrapped in lung will expand 
sufficiently on decompression to tear alveoli. 


allowing entrance of air into pulmonaiw 
veins.-®’ This occurs particularly with 
pulmonaiy lesions which block exit of air 
from a small segment of lung. A broncho- 
lith, stenotic bronchiole, cyst, bleb, (per- 
haps even bronchitis or emphysema) may do 
this. A lung injuiy increases this risk. 
Failure to exhale properly paidicularly with 
rapid ascent will rupture aveoli. The con- 
sequence, of coui*se, is gi’oss air embolism 
into the left cardiac ventricle, thence to coro- 
naiy and systemic circulation. 

Comparison: High Altitude vs. High 
Pressure Dysbarism 

Several basic differences appear as these 
two pressure syndromes are compared and 
these will be better defined ^rith future 
study. One may assume that the aviator is 
diffusely saturated with air and as he 
ascends, bubbles may arise from a gi’eat 
number of tissues. The diver, however, 
must first absorb excess air (particularly 
nitrogen) ; since his stay at depth is limited, 
bubbles appear in tissues which absorbed 
the excess gas readily.^®* 

Well saturated from a stay at five at- 
mospheres (132 feet depth), a diver must 
lose 2400 ml nitrogen on retuiTi to sea level. 
An aviator rising to 1/5 atmosphere (38,- 
500 feet) will lose only 1000 ml nitrogen 
from his tissues.^ 

Other tentative comparisons disclose that 
with high pressure dysbarism i^®* 

Obesity and age are less important. 

Vertigo is a common symptom. 

Myelopathy predominates over encephalopathy. 

Chronically, septic bone necrosis is more com- 
mon. 

Gross air embolism may occur. 

“The chokes” are usually an ill-defined phase, 
“the bends” well defined. 

Higher incidence of permanent sequellae. 

Circulatory failure (shock) less frequently de- 
scribed. 

Nitrogen narcosis, oxygen toxicity may occur. 

Pulmonary alveolar rupture may occur. 

(References are available from the author). 


Some large hospitals have 200 or more different job classifications. 


20 


Nebraska S. M. J. 


ORGANIZATION SECTION 


Coming Meetings 

CRIPPLED CHILDREN’S CLINICS— 
January 8 — Lexington, High School 
Building 

January 15 — Wayne, Wayne State Teach- 
ers College 

January 29 — Scottsbluff, St. Mary’s Hos- 
pital 

NEBRASKA CHAPTER OF AMERICAN 
MEDICAL WRITERS ASSOCIATION — 
First annual distinguished writers ban- 
quet ; members and spouses. Refresh- 
ments and dinner, 6:30 p.m. at Hilltop 
House, Omaha. Speaker: Dan Snively, 
MD, Medical Director, Mead Johnson, 
former President of AMWA. Meeting is 
January 13, 1966. 

DIABETES CONFERENCE — Diabetes in 
Review: Clinical Conference, 1966, the 
Thirteenth Postgraduate Course under the 
direction of the Committee on Profession- 
al Education of the American Diabetes 
Association will be held January 19, 20, 
and 21 at the Mayflower, Washington, D. 
C. Write to the American Diabetes Asso- 
ciation, 18 East 48th Street, New York, 
N.Y. 10017. 

1965 POSTGRADUATE COURSES SPON- 
SORED BY THE AMERICAN COLLEGE 
OF CHEST PHYSICIANS — Clinical ap- 
plication of cardiopulmonary physiology: 
What’s new in the diagnosis and treat- 
ment of cardiovascular and pulmonary dis- 
eases : Fountainebleau Hotel, Miami Beach, 
January 24-28, 1966. Clinical application 
of cardiopulmonary physiology: Ambassa- 
dor Hotel, Los Angeles, February 14-18, 
1966. Cine - angiographic techniques in 
cardiovascular diseases: Cleveland Clinic, 
Cleveland, April 11-13. Write to: Ameri- 
can College of Chest Physicians, 112 East 
Chestnut Street, Chicago 11, Illinois. 

American College of Physician.s 
Postgraduate Courses, 1965-1966 — 

The following courses are made possible 
by the generous cooperation of the directors 
and institutions involved. Tuition fees: 
Members, $60; Nonmembers, $100. Regis- 
tration forms and requests for information 


are to be directed to: Edward C. Rosenow, 

Jr., MD, Executive Director, The American 

College of Physicians, 4200 Pine Street, 

Philadelphia, Pa. 19104. 

MEDICINE OF TOMORROW: RECENT 
ADVANCES IN INTERNAL MEDI- 
CINE — Jan. 10-14, University of Ala- 
bama Medical Center, Birmingham, Ala- 
bama; Howard L. Holley, MD, FACP, Di- 
rector. 

CURRENT CONCEPTS OF INFECTIOUS 
DISEASE — Jefferson Medical College, 
Philadelphia, Pa.; Robert I. Wise, M.D., 
F.A.C.P., Director; Joseph F. Rodgers, 
M.D., Co-Director. February 7-11, 1966. 

MEDICAL GENETICS — The Johns Hop- 
kins Hospital, Baltimore, Md. ; Victor A. 
McKusick, M.D., F.A.C.P., Director. Feb. 
14-18, 1966. 

CANCER — Presbyterian-St. Luke’s Hos- 
pital, Chicago, 111. ; Samuel G. Taylor, HI, 
M.D., F.A.C.P., Director. Feb. 21-25, 1966. 

THE BIG HEART, Cardiac Work and Car- 
diac Plypertrophy ; Clinical Appraisals, 
Therapeutic Considerations and Pathologic 
Correlations — Baylor University College 
of Medicine, Houston, Texas; Raymond D. 
Pruitt, MD, FACP, Director. March 7-11, 
1966. 

BASIC MECHANISMS IN INTERNAL 
MEDICINE, University of Toronto, Tor- 
onto, Ontario, Canada; K. J. R. Wight- 
man, MD, FACP, Director. March 28- 
April 1, 1966. 

CURRENT CONCEPTS OF RENAL, GAS- 
TROINTESTINAL AND CIRCULATION 
PHYSIOLOGY — Co-sponsored by the 
American Physiological Society, Barbizon- 
Plaza Hotel, New York, N.Y.; Daniel H. 
Simmons, MD, FACP, and Charles Klee- 
man, MD, FACP, Co-Directors. 

Future Meetings of the American 

College of Surgeons — 

BAL HARBOUR, FLORIDA, January 13- 
15. Sectional Meeting. Americana Hotel. 

HOUSTON, TEXAS, January 31 - February 
2. Sectional Meeting. Sheraton-Lincoln 
Hotel. 


January, 1966 


21 



CLEVELAND, OHIO, March 14-17. Annual 
4-Day Sectional Meeting for Doctors and 
Graduate Nurses. Sheraton-Cleveland and 
nearby hotels. 

ANNUAL CLINICAL CONGRESS, Octo- 
ber 10-14, 1966. San Francisco, Cali- 
fornia. 

For any advance information address: 

Secretary, American College of Surgeons, 55 

East Erie Street, Chicago, Illinois 60611. 

THE HAHNEMAN MEDICAL COLLEGE 
AND HOSPITAL of Philadelphia offers 
the following Postgraduate Education 
Courses during 1965 and 1966 : 

— April 20-23, 1966: 16th Hahneman 

SjTnposium, Arterial Occlusive Disease; 
Dr. Albert N. Brest; Marriott Motor 
Hotel. 

— December, 1966 : 17th Hahneman Sym- 
posium, Nutritional Dysfunction; Dr. 
Donald Berkowitz ; S h e ra ton Hotel, 
Philadelphia. 

STUDY AND SKI — Scientific meetings, 
a winter ski vacation, a cocktail party, 
and a dinner-dance are planned for the 
31st ^Midwinter Clinical Session of the 
Colorado iMedical Society, March 1 through 
3. Write to the Colorado i\Iedical Society, 
1809 East 18th Avenue, Denver, Colorado 
80218. 

CONFERENCE ON AIR POLUTION RE- 
SEARCH — The AMA has scheduled the 
first Air Pollution Medical Research Con- 
ference foi March 2-4, 1966, at the Am- 
bassador Hotel in Los Angeles. Six ad- 
ditional cooperating organizations include 
The American College of Chest Physi- 
cians, the American Thoracic Society, the 
U.S. Public Health Service, the California 
State Department of Public Health, the 
California iNIedical Association, and the 
Los Angeles County Medical Association. 
Write to Air Pollution Medical Research 
Conference, Department of Environmen- 
tal Health, Ai\IA, 535 N. Dearborn St., 
Chicago, Illinois 60610. 

CONTINUING EDUCATION — Closed 
Chest Resuscitation ; University of Nebras- 


ka College of Medicine, at Eppley Research 
Institute, March 8, 1966 (for physicians, 
9th for dentists, and 10th for nurses). 
Info : Continuing Education, University of 
Nebraska College of Medicine, 42nd and 
Dewey, Omaha 5. 

MICROCIRCULATION — Microcirculation 
is to be the topic of discussion at the 
Heart Association of Southeastern Penn- 
sylvania’s Fifth National Sjunposium to 
be held at the Philadelphia’s Sheraton 
Hotel on March 10 and 11, 1966. Write 
to Lyle L. Perry, Heart Association of 
Southeastern Pennsylvania, 318 S. 19th 
Street, Philadelphia, Pa. 19103. 

NATIONAL SOCIETY FOR THE PRE- 
VENTION OF BLINDNESS — “Vision 
for the Space Age;” Houston, Texas, Rice 
Hotel, March 24-26, 1966. Info: Director 
of Information John D. Coleman, 16 East 
40th Street, New York 10016. 

MAYO CLINIC AND FOUNDATION — 
Clinical Reviews, a program of lectures 
and discussions on problems of general 
interest in medicine and surgery, will be 
presented on March 28, 29 and 30, 1966, 
and will be repeated (they will be iden- 
tical sessions) on April 4, 5, and 6, 1966. 
Write to i\L G. Brataas (Secretary, Clini- 
cal Reviews Committee), Mayo Clinic, 
Rochester, ^Minnesota. 

SIGHT -SAVING CONFERENCE — The 
1966 annual Sight-Saving Conference of 
the National Society for the Prevention of 
Blindness, Inc., will take place from March 
30 through April 1, 1966, at the Hotel 
Roosevelt, New York, N.Y. Write to John 
D. Coleman, Director of Information, Na- 
tional Society for the Prevention of Blind- 
ness, Inc., 16 East 40th St., N.Y.C. 

ENWIRONMENTAL HEALTH — The Third 
Congress on Environmental Health Prob- 
lems of the AMA will be held April 4-5 
at the Drake Hotel in Chicago. Write to 
EHC, Department of Environmental 
Health, AMA, 535 N. Dearborn St., Chi- 
cago, Illinois 60610. 


22 


Nebraska S. M. J. 


TERATOLOGY WORKSHOP — The Third 
Teratology Workshop will be held April 
4-8, 1966 at Boulder, Colorado; it is spon- 
sored jointly by the AMA, the Teratology 
Society, and the University of Colorado, 
with the support of the National Academy 
of Sciences - National Research Council. 
Write to William Kitto, MD, Associate Di- 
rector, Department of Drugs, AMA, 535 
North Dearborn Street, Chicago, Illinois 
60610. 

INDUSTRIAL HEALTH — The 1966 Amer- 
ican Industrial Health Conference will 
take place April 25-28 in Detroit, Mich- 
igan. Headquarters will be at the Sher- 
aton Cadillac Hotel, meetings in Cobo Hall. 
Write to: American Industrial Health 

Conference, 55 East Washington Street, 
Chicago, Illinois 60602. 

ANESTHESIOLOGY — Third Annual Mid- 
west Conference on Anesthesiology. Con- 
tinental Plaza Hotel, Chicago, Illinois, 
April 28-30, 1966. Write to T. L. Ash- 
craft, M.D., 33 East Cedar Street, Chi- 
cago, Illinois 60611. 

POSTGRADUATE COURSE IN LARYN- 
GOLOGY AND BRONCHOESOPHA- 
GOLOGY — A postgraduate course in 
laryngology and bronchoesophagology will 
be conducted by the Department of 
Otolaryngology of the Illinois Eye and 
Ear Infirmary and the College of Medi- 
cine of the University of Illinois at the 
Medical Center, Chicago, from March 21 
through April 2, 1966. Write to the De- 
partment of Otolaryngology, College of 
Medicine of the University of Illinois at 
the Medical Center, Postoffice Box 6998, 
Chicago, Illinois 60680. 

FIRST ANNUAL BIOMEDICAL LASER 
CONFERENCE — June 17-18, Sheraton- 

Boston Hotel, Boston, Massachusetts. 

TENTH WORLD CONGRESS OF THE IN- 
TERNATIONAL SOCIETY FOR RE- 
HABILITATION OF THE DISABLED 
— September 11-17, 1966, Rhein-Main- 
Hall, Wiesbaden, Gennany. 


INTERNATIONAL CANCER CONGRESS 
— The IX International Cancer Congress 
will be held in Tokyo, Japan, fi*om October 
23-29, 1966. Write to Hirsch Marks, MD, 
435 East 57th St., New York 22, N.Y. 


Welcome, New Members 

Althouse, Ivan, MD 
Lynch, Nebraska 

Grubbs, Loran C., MD 
Scottsbluff, Nebraska 

Hadley, Clifford M., MD 
Osceola, Nebraska 

Harvey, Donald A., MD 
Omaha, Nebraska 

Haukebo, Noel, MD 
Scottsbluff, Nebraska 

Taylor, Bernie, MD 
North Platte, Nebraska 

Whitney, Mark, MD 
Lynch, Nebraska 


The Military Dependents' 
Medical Care 

Coverage for Postoperative Care Under the 
Military Dependents’ Medical Care — 

Postoperative care is that care necessary 
for the proper management of the case until 
the patient is released from professional 
custody. The payment made to the surgeon 
for his services is to include all postopera- 
tive care. 

When the surgeon is not available to 
render postoperative care, the percentage of 
the surgical fee to be paid to the physician 
who renders this care is established at a 
maximum of 20 per cent and is to be de- 
ducted from the surgical fee. The post- 
operative care payment to a physician other 
than the operating surgeon, where the sur- 
geon is available to render these services, 
is not allowable. However, there is an ex- 
ception to the above rule: If the surgeon 
feels that a second physician is required 
on the case following surgery because of his 


January, 1966 


23 


supplemental skills, then the postoperative 
fee will be apportioned in accordance with 
the amount of work done and the responsi- 
bility accepted. Cases such as these are ad- 
judicated by the Policy Committee of the 
Nebraska State Medical Association. There- 
fore, when a physician is filing for post- 
operative care, he should attach a letter, 
adequately explaining why his supplemental 
skills were necessary postoperatively. 


THE MONTH IN WASHINGTON 

The Public Health Service has expanded 
its “pap” test program with a goal of pro- 
viding cervical cancer tests for most women 
who enter hospitals and many of those who 
see physicians for any reason. 

A total of $6 million has been allotted for 
the expanded nationwide campaign. 

Grants will be made to hospitals, medical 
schools, state and local health departments, 
and nongovernment health groups for train- 
ing of technicians, post-residency training 
of physicians, purchase of laboratory equip- 
ment, examination of hospital outpatients 
and other such expenditures. 

Since last March, the American Academy 
of General Practice has been implementing 
for the PHS an office cancer detection pro- 
gram. A PHS spokesman termed the pro- 
gram “most effective,” although not costly. 

The PHS said it expects to achieve its 
goal in hospital tests within the next five 
years, with the number of hospitals provid- 
ing this service to all adult women patients 
increasing each year during this period. 

Hospitals providing care for the poor and 
medically indigent will receive first consid- 
eration in the awarding of grants. These 
patients have not been tested usually for 
cervical cancer, the PHS said. PHS Sur- 
geon General William H. Stewart said the 
new hospital-based screening program reach- 
ing high-risk, low-socio-economic groups of- 
fered “a truly effective” means of fighting 
cancer through the “pap” test for early de- 
tection. 


Although the “pap” test was developed 
more than 20 years ago, only 20 per cent 
of the nation’s 62 million adult women had 
received the test last year, the PHS said. 

The report of the President’s Commission 
on Heart Disease, Cancer, and Stroke pro- 
posed a national cervical-cancer detection 
program as the next logical step to expand 
the limited program previously carried out 
by the PHS’ Cancer Control Program. The 
clinical training programs for cancer control 
will have $6 million in funds for the next 
12 months, double the amount previously 
available. The grant-aided programs will 
be carried out by medical schools, hospitals, 
and such health groups as the American 
Cancer Society, the American Academy of 
General Practice, and state and local health 
departments. 

After President Johnson named the Na- 
tional Advisory Council on Regional Medical 
Programs to advise the government on pro- 
grams authorized by the Heart Disease, Can- 
cer and Stroke law. Dr. James Z. Appel, 
AMA President, expressed regret that “the 
AMA was not asked to submit any nomina- 
tions to this important body.” 

“Frankly, we are disturbed that the PHS 
has taken this action in view of our known 
interest in this Act and the inclusion before 
its enactment of the 20 amendments we 
had proposed,” Appel said. “You may re- 
member that one of the amendments incor- 
porated into the final bill was our suggestion 
that the Advisory Council have final au- 
thority in approving or disapproving grant 
requests rather than only advisory authority 
as initially provided.” 

Nonetheless, Appel told the AMA House 
of Delegates in Philadelphia ; 

“If we provide effective leadership, and 
if the PHS cooperates, it may be that this 
law will permit the development of pro- 
grams which will benefit the public and be 
acceptable to the profession. I cannot urge 
you strongly enough, therefore, to take 
steps now through appropriate state and 
local society committees to meet with medical 
school deans, state health department direc- 


24 


Nebraska S. M. J. 


tors, teaching hospital administrators, and 
department heads in an effort to establish 
jointly a series of programs under the Act 
that would be wholly beneficial.” 

Named to the Advisory Council : 

Dr. Michael E. DeBakey, Houston, who 
headed the commission that recommended 
the program; Dr. John Willis Hurst, At- 
lanta, the President’s heart specialist; Dr. 
George E. Moore, Buffalo, N.Y. ; Dr. Clark 
M. Millikan, Mayo Clinic, Rochester, Minn. ; 
Dr. Cornelius M. Traeger, New York, N.Y. ; 
Dr. Leonidas H. Better, Chicago; Mary I. 
Bunting, President of Radcliffe College; 
Gordon Gumming, Sacramento, Calif.; Dr. 
Bruce Everist, Ruston, La. ; Dr. William 
Peeples, Maryland Health Commissioner ; 
Dr. Robert J. Slater, Burlington, Vt., and 
Dr. James T. Howell, Detroit. 

Surgeon General Stewart will be chair- 
man. 

Clinical testing of the experimental drug 
DMSO has been discontinued by voluntary 
agreement of the drug sponsors and the Food 
and Drug Administration. The action was 
prompted by reports of adverse effects on 
the eyes of laboratory animals. About 1000 
investigators had been testing the drug on 
thousands of human patients. Both the 
AMA and FDA previously had warned that 
attempted self-medication with the material 
was dangerous. 

DMSO is produced as an industrial sol- 
vent as well as grades for medical research 
purposes. 

A special advisory committee of non- 
government medical experts is conducting a 
comprehensive review of side-effects of birth 
control pills. 

The Advisory Committee on Obstetrics 
and Gynecology was appointed in November 
by the Food and Drug Administration be- 
cause of reports that women who had taken 
oral contraceptive pills had suffered throm- 
boembolic phenomena including strokes, 
thrombophlebitis and pulmonary embolism, 
and various eye and vision manifestations. 
An article in the AMA’s Archives of Oph- 
thalmology reported 69 cases of eye ail- 


ments, migraine and strokes among women 
who had taken the pills. 

As an interim measure, the FDA directed 
manufacturers of the pills to put on package 
labels two warnings — (1) use should be 
stopped if eye problems occur, and (2) wom- 
en who have had strokes should not take 
them. 

It is estimated that more than four mil- 
lion American women have been taking 
birth control pills which are manufactured 
by seven U.S. drug firms. 

At its first meeting the seven mem- 
bers of the special committee — all medical 
school g>mecologists and obstetricians — 
concluded that there was no immediate need 
for immediate action on the reports of ad- 
verse experience with oral contraceptive 
pills. The committee believed that “final 
recommendations . . . can safely await ^he 
conclusion of its deliberations.” 

Two more Committee meetings were 
scheduled, in January and March. Dr. Jo- 
seph F. Sadusk, Jr., FDA Medical Direc- 
tor, said the Committee probably would issue 
its final report following the March meeting. 

The FDA put on computer tape and turned 
over to the Committee for evaluation all of 
the clinical reports it had received on sus- 
pected adverse reactions from oral contra- 
ceptive drugs. The FDA pointed out that 
it had “emphasized previously that these 
are naturally occurring conditions in some 
women which have been noted as far back 
as medical experience extends.” 

In a non-related action, a thirteen-member 
panel, one of 30 making up the White House 
Conference on International Cooperation, 
proposed that the United States make $100 
million available over the next three years 
to help foreign governments carry out fam- 
ily planning programs. The panel also 
urged that the Federal government set ar 
international example by cooperating with 
state and local agencies to make birth con- 
trol information services readily available in 
this country. Richard N. Gardner, profes- 
sor of law at Columbia University, headed 
the panel. 


January, 1966 


25 


Doctors in the News 

Dr. Lynn Thompson, associate in anes- 
thesiology, has been appointed by the Na- 
tional Academy of Sciences - National Re- 
search Council, Division of Medical Sciences 
to a national task force on ambulance serv- 
ices. 


News From Our Medical Schools 

Butterworth and Stollerman Will Head Program — 

Omaha — Dr. J. Scott Butterworth and 
Dr. Gene H. Stollerman will head a program 
on the “Current Status of Cardiovascular 
Disease” at the University of Nebraska Col- 
lege of Medicine on February 3 and 4, 1966. 

Dr. Butterworth, president of the Ameri- 
can Heart Association in 1962, is an asso- 
ciate professor of medicine at New York 
University. Also, he is the author of a well 
known book. Auscultation of the Heart, 
which was published in 1960. 

Dr. Stollerman is professor and chairman 
of the department of internal medicine at the 
University of Tennessee. He is a member of 
the committee on prevention of rheumatic 
fever and bacterial endocarditis and of the 
Council on Rheumatic Fever and Congenital 
Heart Disease of the American Heart As- 
sociation. 

Dr. Stollerman will consider “strepto- 
cocci and rheumatic fever” and “acute rheu- 
matic fever : treatment and prognosis.” 
Other sessions during the two day course 
will be given by Nebraska physicians. 

The course is applicable for 12 hours of 
Category I credit with the American Acad- 
emy of General Practice. Fee is $40. 

Continuing Education Course for Physicians 
At I’niversity of Nebraska College of Medicine — 

Omaha — IMany facets of clinical labora- 
tory medicine was considered at a con- 
tinuing education course for physicians on 
December 16 and 17 at the University of 
Nebraska College of Medicine. 

Director of the Pathology department at 
St. Joseph’s Hospital in Wichita, Kansas, 


Dr. William J. Reals was guest speaker for 
the course which was conducted at the medi- 
cal college’s Eppley Cancer Institute. 

Dr. Reals discussed “bacteriology for 
the doctor’s office” and “cytologic techniques 
in office practice.” 

Other sessions during the two day course 
were presented by the members of the 
pathologj’ department at the medical col- 
lege. 

Dr. C. A. McWhorter was course coor- 
dinator. He is professor and chairman of 
the pathology department. 

Course enrollees received 12 hours of 
Category I credit with the American Acad- 
emy of General Practice. 

University of Nebraska College of Medicine 
Staff Members Are Co-Authors — 

Omaha — Four University of Nebraska 
College of Medicine staff members are co- 
authors of an article which appears in the 
November issue of the AmeHcan Journal of 
Medical Sciences. 

The article, “Iatrogenic Hypothyroidism 
in a Patient with Turner’s Sjmdrome,” was 
prepared by Drs. Henry T. Lynch, assist- 
ant instructor in internal medicine; John J. 
Matoole, assistant professor of internal medi- 
cine; Mary Jo Henn, associate professor of 
internal medicine ; Mrs. Anne J. Krush, so- 
cial worker in the heredity, growth and de- 
velopment section at the Eppley Cancer In- 
stitute ; and Dr. Robert L. Tips of the Baylor 
Medical Center. 

Drs. Lemon and Foley Publish New Book — 

Omaha — Dr. Henry M. Lemon and Dr. 
John F. Foley of the University of Nebras- 
ka College of Medicine have prepared a 
chapter in a book. Controversy in Intey'nal 
Medicine, recently published by the W. B. 
Saunders Co. 

Dr. Lemon is director of the Eppley Can- 
cer Institute and Dr. Foley is associate pro- 
fessor of internal medicine and chief co- 
ordinator of the medical cancer therapy pro- 
gram at the Eppley Institute. 

The article, on pages 575-90, is entitled 


26 


Nebraska S. M. J. 


“Antimetabolite Therapy of Advanced Car- 
cinoma and Sarcoma.” The book was edited 
by Ingelfinger, Reiman and Finland and will 
be available in early 1966. 

Edwin F. Ross Resigns — 

Omaha — The resignation of Edwin F. 
Ross, administrator of University Hospital, 
was announced recently by the University of 
Nebraska College of Medicine. 

Mr. Ross will become executive director of 
Fairview Park Hospital in Cleveland, Ohio, 
on February 1. 

Mr. Ross has been administrator of Uni- 
versity Hospital since September, 1962. Pri- 
or to that time he was assistant director of 
University Hospitals in Cleveland for nine 
years, and also served as administrator of 
Doctors Hospital in Cleveland Heights, Ohio. 

No successor to Mr. Ross has been named. 

Obstetrics and Gynecology — 

The more recent advances in obstetrics and 
gynecology are to be presented at a course 
for physicians on the University of Nebraska 
College of Medicine campus, January 20 and 
21, 1966. 

U. N. Medical Student Receives Grant — 

A tuition grant of $625 has been given by 
the Pennington Fund, a Subsidiary of the 
Christian Medical Society, to Kathleen Bliese, 
a junior medical student at the University of 
Nebraska College of Medicine. Mrs. Bliese 
will receive her Doctor of Medicine degree 
in 1967 ; her husband is a senior at the Cen- 
tral Lutheran Seminary in Fremont; they 
both hope to work in the mission field in 
India. 

Closed Chest Cardiopulmonary Resuscitation — 

Closed chest cardiopulmonary resuscita- 
tion techniques will be taught at continuing 
education courses on March 7, 1966 for phy- 
sicians, March 8 for dentists, and March 9 
for nurses. Write to the Office of Continuing 
Education, University of Nebraska College 
of Medicine, 42nd and Dewey Avenue, Oma- 
ha, Nebraska. The course is being offered 


for the second consecutive year, and will be 
held at the Eppley Cancer Institute. 

Clyde Butz Elected Secretary of the 
American Occupation Therapy Association — 

Omaha — Clyde Butz, an instructor in 
occupational therapy, department of neu- 
rology and psychiatry at the University of 
Nebraska College of Medicine, has been elect- 
ed secretary of the American Occupational 
Therapy Association. 

Mr. Butz was elected to the national of- 
fice at the Occupational Therapy Associa- 
tion’s annual meeting in Miami, Fla. He 
will serve as secretary for the next three 
years. 


Human Interest Tales 

Doctor F. X. Rudloff, Battle Creek, was 
recently honored by his community for pro- 
viding 45 years service. 

Doctor Henry J. Quiring, Omaha, spoke 
at the homecoming program of the Omaha 
Baptist Bible College in November. 

Doctor Laverne C. Steffens, Kearney, re- 
cently completed a post-doctoral course at 
the Massachusetts General Hospital. 

Doctor Claude H. Organ, Omaha, narrated 
a film, produced by him, at an October meet- 
ing of the American College of Surgeons. 

Doctor Charles Way, Wahoo, announced in 
November his retirement as Chief of Out- 
Patient Services at the Veterans Hospital 
in Omaha. 

Doctor James L. Lodge, Lincoln, was 
elected a Fellow of the American Academy 
of Pediatrics at the organizations convention 
in Chicago. 

Doctors J. F. Kelly and J. Harry Murphy, 
Omaha, were recently honored as 50- Year 
graduates of the Creighton University School 
of Medicine. 

Doctor E. C. Foote, Hastings, was awarded 
a plaque in recognition of 60 years service 
by the Adams County Medical Society at a 
November meeting. 


January, 1966 


27 


Doctor and Mrs. Richard Gentry, Falls 
City, were awarded Young Alumni Service 
Awards at a Nebraska University convoca- 
tion held in November. 


Deaths 

DOCTOR GEORGE E. CHARLTON — 
Doctor Charlton, 83, of Norfolk, Nebraska, 
died November 3, 1965. A native of Fill- 
more County, Nebraska, he attended Lincoln 
High School, Cotner College, Bethany Col- 
lege, and the Lincoln Academy. He received 
his medical degree from the Lincoln Medical 
College in 1907. He was a member of the 
Nebraska State IMedical Association, the 
American Medical Association, and the 
American Psychiatric Association. 


The Woman's Auxiliary 

The fall of 1965 has been busy indeed for 
your State President and President-Elect. 
On September 1, 1965, I was privileged to 
visit the Adams County Auxiliary. They 
had a joint dinner with their husbands, and 
following dinner they had a very well planned 
meeting. On September 7, I was the hon- 
ored guest at a luncheon meeting of the 
Platte County Auxiliary. I was delighted 
to be able to visit both of these groups. They 
are very active and work hard to improve 
their Auxiliaries. 

November was truly a very busy month 
for Mrs. Smith and me. We began a 
month of traveling and visitations by at- 
tending the Lancaster County Auxiliary 
meeting in Lincoln on November 1, 1965. 
What a “live-wire” group is this Auxiliary! 
On November 3, we were delighted for the 
opportunity to be guests at a regional meet- 
ing of the Woman’s Auxiliary to the Iowa 
State Medical Society. (The inter-state re- 
lationship is good). 

On November 4, we attended the meeting 
of the Madison-Four County Auxiliary, after 
which we spent the night as guests of Dr. 
and Mrs. George Salter of Norfolk. 

On November 9 we attended the meeting 


of the Omaha-Douglas County Auxiliary. 
With our car all packed, we left immediately 
following the meeting for our long trek 
westward. We spent that night at the home 
of Dr. and Mrs. S. H. Perry in Gothenburg. 
(Mrs. Perry is the Second Vice President) of 
the State Auxiliary. 

November 10 saw us driving to Chadron 
for a visit with the Northwest County Aux- 
iliary. While there we were the house guests 
of Dr. and I\Irs. L. M. Hoevet. November 
11 was spent in seeing the beautiful country 
in and around Chadron. 

We were scheduled to attend a luncheon 
meeting of the Scotts Bluff County Aux- 
iliary on November 12. The following day 
was a free day which was spent in being 
lazy — playing bridge, listening to the Ne- 
braska-Oklahoma State football game (and 
nearly having a heart attack — What a 
game!) and being entertained for dinner 
by Dr. and Mrs. Joe T. Hanna. 

November 14 found us wending our way 
back toward Kearney where we were to at- 
tend a meeting of the Buffalo County Aux- 
iliary on November 16. This meeting co- 
incided with the State Medical Association 
Councilor’s meeting so that evening we were 
privileged to attend the dinner and hear a 
fine talk by Dr. Cecil Wittson. 

On November 17 we were the honored 
guests at the dinner meeting of the Lincoln 
County Medical Auxiliary. Ordinarily this 
Auxiliary conducts its meeting in the after- 
noon but once during the year the members 
invite their doctor husbands to be guests for 
a dinner meeting. Mrs. Smith and I felt 
pretty important sharing honors with such 
distinguished guests. 

November 19 we were scheduled for a 
meeting of the Dawson County Auxiliary. 
This was a luncheon meeting, and I might 
add — a very delightful one. During our 
stay in Lexington we were the house guests 
of Dr. and Mrs. Dean McGee and the dinner 
guests of Mrs. William B. Long, Dawson 
County President. 

November 20 found us wending our way 
homeward — tired — yes, but with a feeling 
of accomplishment, and with hearts over- 


28 


Nebraska S. M. J. 


flowing because of the friendliness and hos- 
pitality accorded us throughout the entire 
trip. 

We were home one day and again took to 
the highway. Mrs. Smith and Mrs. B. T. 
Mead, our State AMA-ERF chairman were 
the guests for the silver tea given by the 
Tri-County Auxiliary on Monday, November 
22. This tea is an annual event to raise money 
for AMA-ERF. Those gals in and around 
Fremont really do a fine job of money rais- 
ing for this important committee. 

Our journeys took Mrs. Smith and me 
over many miles — somewhat over 1800 
miles as a matter of fact — but what a won- 
derful experience for both of us. I wish 
that each and everyone of you could have the 
same opportunity. The many wonderful 
ladies whom we met and realizing the fine 
work they are doing, really strengthens my 
faith in the Woman’s Auxiliary to the Ne- 
braska State Medical Association, because 
with the “Grass Roots,” or the County Aux- 
iliaries, working as they do, we can’t fail. 

At the present time visitations have been 
made to eleven of the sixteen County Aux- 
iliaries. Mrs. Smith and I hope to visit 
the remaining five County Auxiliaries after 
January 1, 1966. We have already received 
invitations to visit the Sixth Councilor Dis- 
trict Auxiliary and Hall County and Four 
County Auxiliary, and we do hope that the 
remaining two County Auxiliaries want us 
too. 

We of the Auxiliary, because we have the 
time available, have been able to become more 
widely and intimately associated with our 
sisters in the various parts of our own state 
and a neighboring state as well. We have 
found that, in the last analysis, we have few 
differences of opinion. 

It is our belief that real cooperation be- 
tween all parts of our own state and with 
other states, is not only possible but is a 
growing reality. 

What more opportune time for such unity 
could exist? 

My very best wishes to each and every one 


of you for a happy and prospei'ous New 
Year. 

Irene Kelley, Pi-esident, 
Woman’s Auxiliary to the 
Nebr. State Med. Assn. 

The Auxiliary Advisor Speaks — 

I, as the six foot two and a half inch, 225 
pound tail that wags the 5 foot, 115 pound 
president have a few comments on this 
little dog 1 wag so well. 1 am a silent (who 
ever heard of a silent psychiatrist) uncom- 
plaining, unobtrusive hulk of a guy who 
takes plenty of kidding because 1 sit at the 
head table of medical meetings, as my wife’s 
husband. 

Oddly, enough, my interest in medical so- 
ciety activities is being reawakened as a 
result. For the first time, I am an alter- 
nate delegate and have, in part at least, 
earned the right to sit at my wife’s side. 

If the county medical societies would like 
to please us, remember that we are proud 
of our little gals, just as you are of yours, 
and would like to see them in action. If you 
would invite Dr. Smith and me to your coun- 
ty meetings when our wives are there, we 
could be better advisors and have a darn 
good “deductible” short vacation as well. 

J. Whitney Kelley, MD 


Know Your 
Blue Shield Plan 

Blue Cross - Blue Shield Is Not Ma^ic — 

There is no magic in the financing of 
Blue Cross - Blue Shield any more than there 
is in any other form of prepayment for hos- 
pital-medical-surgical care. 

Blue Cross - Blue Shield financing is a 
simple process of members prepaying their 
dollars on a voluntary budget basis for neces- 
sary benefits to be furnished by hospitals 
and physicians when needed. 

True, Blue Cross with Contracting Hos- 
pitals, Blue Shield with Participating Physi- 

continued 



January, 1966 


29 



Il 




29A 


Nebraska S. M. J. 


Flagyl eliminates the difficulties and frus- 
trations that have long attended the treat- 
ment of trichomonal infection. 

These difficulties arose mainly from: 

1 ) the failure of any previously known 
agent to destroy the protozoan in para- 
vaginal crypts and glands; 

2) the failure of any previously known 
agent to prevent reinfection by eradicat- 
ing the disease in male consorts. 

The introduction of Flagyl removed both 
of these long-standing deficiencies. Hun- 
dreds of published investigations in thou- 
sands of patients have confirmed the ability 
of Flagyl to cure trichomoniasis. 

Correctly used, with due attention to re- 
peat courses of treatment for resistant, 
deep-seated invasion and to the presump- 
tion of reinfection from male consorts, 
Flagyl has repeatedly produced a cure rate 
of up to 100 per cent in large series of 
patients. 

Nothing cures trichomoniasis like Flagyl. 

Dosage and Administration 

In women: one 250-mg. oral tablet t.i.d. for 
ten days. A vaginal insert of 500 mg. is avail- 
able for local therapy when desired. When the 
inserts are used one vaginal insert should be 
placed high in the vaginal vault each day for 
ten days, and concurrently two oral tablets 
should be taken daily. 

In men: in whom trichomonads have been 
demonstrated, one 250-mg. oral tablet b.i.d. 
for ten days. 

Contraindications 

Pregnancy; disease of the central nervous sys- 
tem; evidence or history of blood dyscrasia. 

Precautions and Side Effects 

Complete blood cell counts should be made 
before and after therapy, especially if a sec- 
ond course is necessary. 

Infrequent and minor side effects include; 
nausea, unpleasant taste, furry tongue, head- 
ache, darkened urine, diarrhea, dizziness, dry- 
ness of mouth or vagina, skin rash, dysuria, 
depression, insomnia, edema. Elimination of 
trichomonads may aggravate monihasis. 

Dosage Forms 

Oral-250-mg.tablets/Vaginal-500-mg.inserts 


SEARLE 


Research in the Service of Medicine 



cians, and the extremely low overhead of 
both Plans, can normally make the mem- 
ber’s dollar stretch further in prepaying for 
health care coverages. 

Nevertheless, Blue Cross-Blue Shield is not 
a magic panacea for prepaying these health 
care costs. Good, sound, proven actuarial 
principles still have to be used. 

Even though the inherent desire of all 
those associated with Blue Cross-Blue Shield 
is to provide all Americans with a means 
of prepaying for adequate, good health care 
on a voluntary, budget basis regardless of 
age, occupation, physical condition or insur- 
ability, it still remains a fact that you have 
to take in as many dollars as you pay out 
or you are out of business. 

One sure way of getting into financial dif- 
ficulties when insurance principles are in- 
volved — is poor underwriting. 

Insurance underwriting — although sound- 
ing quite mysterious — is really rather sim- 
ple. It merely means getting enough infor- 
mation about the risk to be insured so that 
you can charge a rate adequate to pay for 
any losses incurred by the insured, plus 
overhead and reserves for future losses and 
development. 


Blue Cross-Blue Shield — with its policy 
of never canceling a member because of 
usage — has found it increasingly important 
to properly underwrite its prospective mem- 
bers — especially Non-Group Members. 

You don’t have to seek a man out to sell 
him fire insurance when he knows he is go- 
ing to have a fire — he’ll find you. The 
same applies to health coverage. 

It is Blue Cross-Blue Shield’s responsibil- 
ity in fairness to its Participating Physi- 
cians, Contracting Hospitals and Members 
that they don’t go out and enroll only sick 
people in the community. Otherwise, the 
rates would soon become so high that no 
one could afford the coverages no matter how 
excellent they were. 

So, if your office is asked to supply in- 
formation to Blue Cross-Blue Shield on a 
physical condition of a member or prospec- 
tive member — please bear with them — 
they are only tiying to protect the inter- 
ests of the great majority against the selfish 
interests of a very few. 

An inquiry does not necessarily mean no 
coverage. An inquiry just means that Blue 
Cross-Blue Shield is trying to justify cov- 
erage. 


The number of admissions of patients with psychiatric diag- 
noses to general hospitals is estimated to be as great as the 
number of patients admitted to state and county mental hospitals 
(342,483 to state and county psychiatric hospitals). 


30 


Nebraska S. M. J. 



Books 



The Burn Wound by S. E. Order, MD and J. A. 
Moncrief, MD. Published November 20, 196.5 by 
Charles C. Thomas, Springfield, Illinois. 72 
pages (9" by 11") 34 pages of illustrations. Price 
$7.7.5. 

Doctor Order is Chief of the Experimental Studies 
Branch of the Brooke Army Medical Center Surgi- 
cal Research Unit. Doctor Moncrief is the direc- 
tor of this unit. In this well-illustrated monograph 
they have reviewed the dynamics of the burn wound 
and its relationship to clinical management. 

They report their observations with experimental 
second and third degree burns, bacterial invasion 
of these wounds, and tell of the successful clinical 
progi'am for the treatment of major burns which 
has been the result of their experimental work. 

The Locomotor System: Functional Anatomy by 

Michael C. Hall, FACS. Published October 2.5, 
196.5 by Charles C. Thomas of Springfield, Illinois. 
562 pages (6" by 9") with 282 illustrations. Price 
$19.75. 

Doctor Hall is an Associate Professor in the De- 
partment of Anatomy at the University of Tor- 
onto, Ontario, Canada. He also has served as an 
Orthopedic Surgeon at the Cho Ray Hospital in 
Saigon, Republic of Vietnam. 

He has written a postgraduate anatomical text- 
book — designed especially for use by orthopedic 
surgeons and physiatrists. This book includes a 
description of present knowledge in this area, cur- 
rent trends in research, and extensive refeiences 
for additional reading. The spine and limbs are 
considered as living, working structures. Morpho- 
logical details are included where required to em- 
phasize function and where recent additions to 
knowledge have been made. 

Special attention has been given to the mechani- 
cal properties of the intervertebral disc and to the 
position of major structures as encountered in sur- 
gical approaches. 

Therapeutic Radiology (2nd edition) by William T. 
Moss, MD. Published November 17, 1965 by The 
C. V. Mosby Company of St. Louis, Missouri. 514 
pages (7" by 10") with 170 illustrations. Price 
$18.75. 

The author of this book is a Professor of Radi- 
ology at Northwestern University School of Medi- 
cine, Director of the Department of Therapeutic 
Radiology at Chicago Wesley Memorial Hospital, 
and Chief of the Department of Therapeutic Radi- 
ology at the Veterans Administration Research in 
Chicago, Illinois. 

This unique and practical book on radiation ther- 
apy critically appraises and well illustrates the 
indications for and the limitations of conventional 
and supervoltage therapy. The effects of irra- 
diation on normal tissue are detailed preliminary 
to discussing the therapy for cancers of individual 


organs. The surgeon, otolaryngologist, and gyne- 
cologist in particular will find here a dispassionate 
discussion of the merits and contraindications of 
radiation therapy. The author has described the 
ideal results as well as the complications to be ex- 
pected under certain circumstances. 

This current edition has been completely revised 
to include new concepts, techniques, and results. 
A new chapter has been added on the combinations 
of radiotherapy and surgery. The increased avail- 
ability of megavoltage and telecobalt equipment 
has brought about changes in techniques which 
have been described. 

Current Problems in Tuberculosis by Samuel Phil- 
lips, MD. Published December 10, 1965 by 

Charles C. Thomas, Springfield, Illinois. 123 
pages (7" by 10") with 36 illustrations. Price 
$7.50. 

The author of this book is an Associate Profes- 
sor at the University of Tennessee College of Medi- 
cine and Chief of the Pulmonary Disease Section of 
the Veterans Administration Hospital in Memphis, 
Tennessee. 

Aided by six eminent contributors, he has writ- 
ten an informative and concise text which proceeds 
from a discussion of problems of diagnosis and the 
latest concepts of tuberculosis therapy to a con- 
sideration of complications and their management. 

Special problems considered include the follow- 
ing: 

a. the recalcitrant patient 

b. infections due to unclassified mycobacteria 

c. present indications for the use of surgery 

d. adrenocorticosteroid therapy 

e. management of extrapulmonary infections. 

Knox: The Anatomist by Isobel Rae. Published 

September 21, 1965 by Charles C. Thomas of 
Springfield, Illinois. 164 pages (6" by 9"). Price 
$6.50. 

For over one-hundred years doctors have re- 
mained complacent at the obloquy heaped upon the 
head of the unfortunate Doctor Robert Knox in 
connection with the Burke and Hare murders after 
the body of one victim was discovered in the cellar 
of Dr. Knox’s School of Anatomy. 

In this book the author tells the complete life- 
story of Dr. Knox; his years of success before 
1828 and the tragic years which followed. Knox 
emerges as a dedicated scientist, a brilliant teacher 
of anatomy to whom nineteenth century surgeons 
owed much; a man, probably genuinely unaware of 
the methods used by Burke and Hare, who found 
the Victorian world relentlessly unforgiving. 

Miss Rae, in seeking to vindicate him both as a 
man and as a doctor, has given us a sympathetic and 
highly readable study of one of the pioneers of 
modern medicine. 


January, 1966 


31 


ORGANIZATIONS. STATE 

Alcoholics Anonymous 
1345 N Street, Lincoln 

American Red Cross 

W. J. Frenzel, State Representative 
2631 Garfield, Lincoln 

Cerebral Palsy Association of Nebraska 
Mrs. Ben H. Cosdery 
201 South Elmwood Road, Omaha 

Creighton University School of Medicine 
Richard Egan, Dean 
302 North 14th, Omaha, Nebraska 
International College of Surgeons 
James J. O’Neil, M.D., Regent for Nebraska 
612 Medical Arts Building, Omaha 2, Nebraska 
Multiple Sclerosis Society 

Mrs. Harold Stoehr, Executive Secretary 
3648 Folsom Street, Lincoln, Nebraska 
Muscular Dystrophy Society 
Mrs. Marvin Traeger, President 
Fairbury, Nebraska 
National Foundation, Inc. 

Clinton Belknap 
State House Station 

Post Office Box 4813, Lincoln, Nebraska 
Nebraska Chapter, 

Arthritis and Rheumatism Foundation 
Lloyd E. Skinner, President 
Box 2, Elmwood Station, Omaha 6, Nebraska 
Nebraska Association of Pathologists 
Dr. Robert A. Brooks, Secy-Treas. 

1403 Sharp Building, Lincoln, Nebraska 
Nebraska Blue Cross-Blue Shield 
Wm. H. Heavey, Executive Director 
518 Kilpatrick Building, Omaha, Nebraska 
Nebraska Chapter 

American Academy of General Practice 
John A. Brown, M.D., Secy. 

402 Lincoln Liberty Life Bldg., Lincoln, Nebraska 
Nebraska Chapter 
American College of Physicians 

Henry J. Lehnhoff, Jr., MD, Governor for Nebr. 
720 Doctors Building, Omaha, Nebraska 69131 
Nebraska Chapter 
American College of Surgeons 
Robert W. Gillespie, MD, Secy.-Treas. 

500 South 17th St., Lincoln, Nebraska 
Nebraska Chapters 

National Cystic Fibrosis Research Foundation 
Greater Omaha Chapter 

Miss Betty Seibert, 510 South 42nd St., Omaha 
Lancaster County Chapter 

Mr. and Mi's. Gayle Voller, 530 North 75th St., 
Lincoln 

Nebraska Dental Association 
D. W. Edwards, D.D.S., Secy. 

1220 Federal Securities Bldg., Lincoln, Nebraska 
Nebraska Diabetes Association 
J. William Herv'ert, M.D., President 
Mr. Tom Skillman, Secretary 
7611 Lawndale Drive, Omaha, Nebraska 
Nebraska Dietetic Association 
Barbara Holvick, President 
26th and Dewey, Omaha 
Nebraska Division American Cancer Society 
Ray E. Achelpohl, Executive Director 
4201 Dodge, Omaha, Nebraska 
Nebraska Heart Association 

Paul S. Archambault, Executive Director 
514 South 40th Street, Omaha 5, Nebraska 
Nebraska Hospital Association 
Stuart Mount, Executive Director 
1335 “H” Street, Lincoln, Nebraska 


Nebr. Academy of Ophthalmology & Otolaryngology 
C. Rex Latta, MD, Secretary 
710 Doctors Building, Omaha,' Nebraska 68131 
Nebraska Pediatric Society 
Otto G. Rath, Secretaiy 
3929 Harney, Omaha 
Nebraska Pharmaceutical Association 
Miss Cora Mae Briggs, Executive Secretary 
1001 Anderson Building, Lincoln 8, Nebraska 
Nebraska Psychiatric Institute 
602 South 44th Avenue, Omaha 
Nebraska Public Health Association 
George R. Under\vood, M.D., President 
935 “R” Street, Lincoln, Nebraska 

Nebraska Radiological Society 
Jack Zastera, M.D., Secy.-Treas. 

816 Medical Arts Bldg., Omaha, Nebraska 

Nebraska Rheumatism Association 
Vernon G. Ward, President 
5 West 31st Street, Kearney, Nebraska 

Nebraska Society for Crippled Children 
S. Orson Perkins, Director 
402 South 17th, Omaha, Nebraska 

Nebraska Society for Internal Medicine 
Robert S. Long, M.D., President 
8721 Shamrock Road, Omaha, Nebraska 
Nebraska Society of Anesthesiologists 
Frank Cole, M.D., President 
2430 Lake St., Lincoln, Nebraska 
Nebraska Society of Medical Technologists 

Gladys Jeurink, MT, ASCP, 4600 Spruce, Lincoln 
Nebraska State Department of Health 
E. A. Rogers, M.D., Director 
State Capitol Building, Lincoln, Nebraska 
Nebraska State Medical Association 
Ken Neff, Executive Secy. 

1315 Sharp Building, Lincoln 8, Nebraska 
Nebraska State Nurses Association 
Mrs. Zelda Nelson, Executive Director 
510 Securities Building, Omaha, Nebraska 
Nebraska State Obstetric and Gynecologic Society 
W. Riley Kovar, M.D., Secretary-Treasurer 
3610 Dodge Street, Omaha 31 
Nebraska State Orthopedic Society 
Harold Horn, MD, Secretary 
3145 “0” Street, Lincoln, Nebraska 
Nebraska State Pediatric Society 

Otto Rath, M.D., Secretary-Treasurer 
3929 Harney, Omaha, Nebraska 
Nebraska, South Dakota, North Dakota District 
Branch of the American Psychiatric Association 
Harry C. Henderson, M.D., President 
105 South 49th St., Omaha, Nebraska 68132 
Nebraska Tuberculosis Association 
Delmer Serafy, Executive Secy. 

406 W.O.W'. Building, Omaha, Nebraska 
Nebraska Urological Association 

Louis W. Gilbert, MD, Secretary-Treasurer 
903 Sharp Building, Lincoln 8, Nebraska 
Omaha Mid-West Clinical Society 
1040 Medical Arts Building (68102) 

Rita M. Crowell, Executive Secretary 

POISON CONTROL CENTER 
Children’s Memorial Hospital 
502 South 44th, Omaha, Nebraska 
Rehabilitation Services Division 

Fred A. Novak, Assistant Commissioner 
Room 1518, State Capitol Bldg., Lincoln, Nebr. 
L'niversity of Nebraska College of Medicine 
Cecil L. Wittson, MD, Dean 
42nd and Dewey, Omaha, Nebraska 
(Please help us keep these addresses correct, by 
notifying the Editor of any changes). 


32 


Nebraska S. M. J. 



The tell-tale lesion on the back of her neck 



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inflammatory symptoms of many dermatoses including neuro- 
dermatitis, atopic dermatitis, eczematous dermatitis, seborrheic 
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ment is usually effective in abating symptoms of skin conditions 
responsive to topical triamcinolone, but the 0.5^ Cream may be 
preferable in more resistant cases. Dosage: Apply small quantity 
to area 3 or 4 times daily. Side effects are rare. Contraindications : 
tuberculosis of the skin, herpes simplex, chickenpox, and vaccinia. 
Use with care on infected areas. Do not use in the eyes. Supplied in 
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‘Now, sir, if you want anything just ring!” 


Current Comment 

The Family Doctor: How Old? — 

The American Academy of General Prac- 
tice has come up with one answer to the 
question : “What happened to the old family 
doctor?” 

An electronic tabulation of the academy’s 
29,000 general practitioner members shows 
that “the family doctor is not old anymore.” 

More than 54% of the general practition- 
ers are under 50 years of age. Three are 
25 or younger and eight are 90 or older. 
The patriarch is a Nebraskan, 97-year-old 
Doctor Homer Davis of Genoa, who has re- 
tired from active practice. 


Lincoln Veterans Administration Hospital — 

J. Melvin Boykin, MD, Administrator of 
the Lincoln Veterans Administration Hos- 
pital, states that the patient load is steadi- 
ly increasing and that a second surgical 
ward is due to be opened early this month. 
Irving B. Margolis, MD, has started work 
as Chief of the Surgical Section, and C. Gene 
Gross, MD (formerly of Cambridge, Ne- 
braska) has started work on the medical 
service. Applicants are still being inter- 
viewed for one vacancy on the surgical staff, 
one opening for a Chief of the Orthopedic 
Service, and two vacancies on the medical 
service. 

Mr. William Driver, Veterans Adminis- 
tration Director, recently visited the Lincoln 
hospital and stated that plans for extensive 
modernization of the existing facilities are 
on the drawing board. 


Ministers and Doctors — 

Frequently county medical societies have 
joint meetings with members of the dental 
societies, with pharmacists, and with law- 
yers. Members of the Nuckolls County Med- 
ical Society have extended the scope of these 
joint meetings to include members of the 
Nuckolls County Ministerial Association. 
Drs. C. T. Mason of Superior; Robert Howe 
of Nelson ; Theodore Kiekhaefer of Superior, 
and Paul Hallgrimson of Superior recently 
met with ten ministers from Superior, Nel- 
son, Oak, Salem, and Edgar, Nebraska. 


20-A 


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Indications: Indicated in the therapy of acute severe infec- 
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agent is available. Triacetyloleandomycin, a constituent of 
Signemycin, has been associated with deleterious changes 
in liver function. See precautions and adverse reactions. 
Contraindications: Contraindicated in individuals who have 
shown hypersensitivity to any of its components. Not recom- 
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tinuous therapy. If clinical judgement dictates therapy for 
longer periods, serial monitoring of liver function is recom- 
mended. Not recommended for subjects who have shown 
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triacetyloleandomycin. 

Precautions and Adverse Reactions: Triacetyloleandomycin, 
administered to adults in daily oral doses of 1.0 gm. for 10 
or more days, may produce hepatic dysfunction and jaun- 
dice. Adults requiring 3 gm. of Signemycin initially should 
have liver function followed carefully and the dosage should 
be reduced as promptly as possible to the usual recom- 
mended range of 1.0 to 2.0 gm. per day. Present clinical 
experience indicates that the observed changes in liver 


function are reversible after discontinuation of the drug. 

Use with caution in lower than usual doses in cases with 
renal impairment to avoid accumulation of tetracycline and 
possible liver toxicity. If therapy is prolonged under such 
circumstances, tetracycline serum levels may be advisable. 
In long term therapy or with intensive treatment or in known 
or suspected renal dysfunction, periodic laboratory evalua- 
tion of the hematopoietic, renal and hepatic systems should 
be done. Formation of an apparently harmless calcium com- 
plex with tetracycline in any bone forming tissue may occur. 
Use of tetracycline during tooth development (3rd trimester 
of pregnancy, infancy and early childhood) may cause dis- 
coloration of the teeth. Reversible increased intracranial 
pressure due to an unknown mechanism has been observed 
occasionally in infants receiving tetracycline. Glossitis, sto- 
matitis, proctitis, nausea, diarrhea, vaginitis and definite 
allergic reactions occur rarely. Severe anaphylactoid reac- 
tions have been reported as due to triacetyloleandomycin. 
Photosensitivity and photoallergic reactions (due to the 
tetracycline) occur rarely. Medication should be discon- 
tinued when evidence of significant adverse side effects or 
reaction is present. Patients should be carefully observed 
for evidence of overgrowth of nonsusceptible organisms 
including fungi, which occurs occasionally, and which in- 
dicates this drug should be discontinued and appropriate 
therapy instituted. Steps should be taken to avoid masking 
syphilis when treating gonorrhea. 



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Division, Chas. Pfizer & Co., Inc. 
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PHYSICIANS' EXCHANGE 


Advertisements in this column are at a rate of ten 
cents per word with a minimum of $4.00 per insertion. 
Copy must be received by the fifth of the month pre- 
ceding date of publication and should not exceed 50 
words. Advertisements from members of the Ne- 
braska State Medical Association will be accepted 
without chargre for one issue. Each advertisement 
will be taken out followingr its first appearance unless 
otherwise instructed. Where numbers follow adver- 
tisements, replies should be addressed in care of The 
Nebraska State Medical Journal, 1315 Sharp Building, 
Lincoln, Nebraska. 


CLINIC AVAILABLE — General practice in fur- 
nished clinic. County seat town, SW Nebraska, 3 
nursing homes in town, good territory. Write Box 
8, Beaver City, Nebraska. 

USED MEDICAL AND SURGICAL EQUIP- 
MENT — For sale including X-ray and Ritter 
Table. Many smaller items. R. T. Satterfield, MD, 
724 East Jefferson Street, Millard, Nebraska. Phone 
308-334-2563. 


INTERNIST — For 5-man department in busy 
and steadily growing north central Kansas 13- 
member multispecialty group. Partnership after 
salary for two years. Board eligible or certified. 
Write Gelvin-Haughey Clinic, Concordia, Kansas. 


Excellent Opportunity for GENERAL PRACTI- 
TIONER in community of 15,000; central Florida; 
76-bed JCAH Hospital. Write or call collect: R. C. 
Thompson, Bartow Memorial Hospital, Bartow, 
Florida. 


USED MEDICAL AND SURGICAL EQUIP- 
MENT FOR SALE — Including 100 MA Picker 
X ray, Leitz Photrometer, Medco Sonulator, Cardi- 
All and Cambridge E.K.G., New Hamilton Exam- 
ination Table. Many small items. J. L. Dyer, 
M.D., 1508 South 79th Street, Omaha, Nebraska. 


GENERAL PRACTICE OPPORTUNITY — Of- 
fice equipment and building of the late H. B. Rae, 
M.D., for sale or lease. A general practice of 35 
years leaves a good opening in a community of 
15,000, in which a new doctor would be readily 
accepted. Call or write Mrs. H. B. Rae, Torring- 
ton, Wyoming. Phone 532-3156. 

GENERAL PRACTITIONER — Locum tenens in 
a thriving suburban in Omaha, Nebraska, March, 
April and May 1966. Financial arrangements, 
negotiated, could lead to permanent association. 
Send full particulars in first letter. An excellent 
opportunity for the right man. Write Box 63. 

PSYCHIATRIC RESIDENCIES — July 1, 1966 — 
600-bed psychiatric hospital with active out-patient 
department for adults and children. Intensive train- 
ing program directed toward Board Certification. 
NIMH grant of $12,000 annually to General Prac- 
titioner or physicians with 4 or more years ex- 
perience in other than psychiatry. Write: Dr. W. 
C. Brinegar, Superintendent, Mental Health Insti- 
tute, Cherokee, Iowa. 






1701 "K" Street 
500 South 17th Street 

Some of the best medical-dental office 
space in Lincoln will soon be available 
for lease on exceptionally attractive rental 
figures. Approximately 900 square feet 
with a private entrance and exit located 
on the first floor in the South portion of 
this lovely building designed specifically 
for Physicians and Dentists. Excellent 
accessibility and ample parking facilities. 
Walking proximity to State Capitol, office 
buildings, apartments and downtown re- 
tail area. We invite your inquiry. Con- 
tact 64, Nebraska State Medical Journal, 
1315 Sharp Building, Lincoln, Nebraska. 



“Doctor Jones, want to hear something 
funny ?” 


24-A 


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Ames Company 25 

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Burroughs Wellcome 21 

C 

Coca-Cola 8 

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Donley Medical Supply 24 

G 

Geigy Pharmaceuticals 13 

Gilmour-Danielson 10 

Glenbrook Laboratories 9 

H 

Hynson, Westcott & Dunning 3 

L 

Lederle Laboratories 11, 19, 25 

Eli Lilly 18 

M 

Medical Protective Company 16 

Merck, Sharp & Dohme 12 

N 

News Printing Company 24 

P 

Parke, Davis & Company 2 

R 

W. K. Realty Company 20 

Roche Laboratories 26 

J. B. Roerig 15, 22, 23 

S 

G. D. Searle & Company 29-A, 29-B 

Smith Kline & French Labs. 14 

W 

Wallace Laboratories 6, 7, 17 

Winthrop Laboratories 5 


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THE NEBRASKA STATE 
MEDICAL JOURNAL 

2430 Lake Street, Lincoln 2, Nebraska 


CONTENTS: 

EDITORIALS- 

We're Too Fat 33 

Those Lovely Checks and Balances 34 

Look, JAMA 34 

We've Sent for a Nonspecialist 35 

What Should We Tell the Patient? . . 35 

ORIGINAL SECTION- 

Evaluation of Obesity in Young Women..- 37 

Robert L. Delaney, MD 
James F. Sullivan, MD, FACP 

Obesity and the Emotions 41 

S. D. Kaplan, PhD 

Brdicka Serum Filtrate Reaction Applied 

to Normal and Cancerous Menstrual Fluids 48 

Richard Rappolt, Sr., MD 

Diaphragmatic Hernia in a Premature 

Infant — A Case Report 53 


Sabatino DiCenso, MD 
E. M. Greaney, Jr., MD 

Neurologic Manifestations Accompanying 


Burns (Burn Encephalopathy) . 57 

John A. Aita, MD 

ORGANIZATION SECTION- 

Coming Meetings 59 

The Military Dependents' Medical Care 62 

The Month in Washington 62 

Announcements 64 

News and Views 65 

Our Medical Schools 65 

All About Us - -- 67 

Deaths 68 

Woman's Auxiliary 69 

Hobby Shop 69 

Know Your Blue Shield Plan 69 

Books - 71 

Organizations, National 73 

Organizations, State 74 


FEBRUARY, 1966 VOL. 51, NO. 2 


EDITOR- 
FRANK COLE. MD 
2430 Lake St., Lincoln 2 

ASSOCIATE EDITORS — 

FREDERICK M. NEBE. MD 
Review Editor 

943 Stuart Building, Lincoln 8 

C. R. HANKINS, MD 

822 The Doctors Building. Omaha 31 

J. MARSHALL NEELY, MD 
4201 Calvert, Lincoln 6 

W. MAX GENTRY, MD 
1720 Tenth Street, Gering 

GEORGE E. STAFFORD, MD 
800 South 13th St., Lincoln 8 

B. R. BANCROFT, MD 

Kearney Medical Arts Building, Kearney 

JAMES J. O’NEIL, MD 

612 Medical Arts Building, Omaha 2 

FRANK P. STONE. MD 
2300 South 13th, Lincoln 2 

ROBERT J. STEIN. MD 
930 Stuart Building. Lincoln 8 

J. H. BARTHELL, MD 

1012 Sharp Building, Lincoln 8 

HAROLD E. HARVEY, MD 
140 South 27th Street. Lincoln 6 

H. V. MONGER, MD 
3705 South Street, Lincoln 

BERNARD F. WENDT. MD 

735 South 56th Street, Lincoln 6 

FRANK H. TANNER, M.D. 

1835 South Pershing Road. Lincoln 2 

K. D. ROSE, MD 

University Health Service, Lincoln 8 

KEN NEFF, Business Manager 
1315 Sharp Building, Lincoln 
Telephone HEmlock 2-7585 


SUBSCRIPTION RATE 
$5.00 Per Year Single Copies 50c Each 


The Editor of this Journal assumes no re- 
sponsibility for opinions and claims ex- 
pressed in the articles published herein. 

Manuscripts to be presented for publica- 
tion in the JOURNAL should be typewritten, 
double-spaced, on one side only of firm (not 
onion skin or flimsy), standard letter sized 
(8', 5 by 11 in.) white paper. Wide margins 
(at least lt4 ■". on left) should be left free 
of typing. On the first or title-page should 
be shewn the title of the article, the name 
(or names) of the author, his degree and 
other significant credits. Pages should be 
numbered consecutively, the page number 
being shown in the right upper corner along 
with the surname of the author. 

Illustrations should be numbered and their 
locations shown in the text. Each should be 
identified by placing on its back the author’s 
name, its number and an indication of its 
"top.” Drawings and charts intended for 
cuts should be in black (India ink) on pure 
white. Photographs should be on glossy 
paper and minimum of about 5 by 7 in. in 
size. A legend should be provided for each 
illustration and, preferably, attached to it. 

Manuscripts (original, not a carbon) should 
be sent directly to the Editor at the Journal’s 
address. 

Reprints should be ordered from the print- 
er, NEWS Printing Company, Norfolk, Nebr. 

Copyright 1964 by The Nebraska State 
Medical Association. 

Published monthly and postage paid at the 
Post Office at Norfolk, Nebraska, as second 
class matter. 


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Open the nose- 

help drain 

the stagnant sinus 

gently 





Neo-Synephrine is a standard among 
topical vasoconstrictors. It is unsurpassed 
for reducing nasal turgescence in colds; 
and a most valuable aid in preventing 
and treating sinusitis. 

Neo-Synephrine stops the boggy feeling of 
colds at once— works against factors that 
induce sinusitis. With Neo-Synephrine 
nose drops, spray or jelly, turbinates shrink 
on contact, obstructed ostia open and 
drainage is re-established. 


In sinusitis, Neo-Synephrine helps to pro- 
mote drainage and hasten recovery. - Used 
promptly, it helps clear the stagnant sinus 
and lessen the chances of chronicity. 

Neo-Synephrine HCI is available in: 

Vs'Vo solution for infants 

’AVo solution for children and adults 

ViVa pediatric nasal spray for children 

VzVo solution for adults 

V2°7o nasal spray for adults 

V2°7o jelly for children and adults 

1“7o solution for adults (resistant cases) 


‘’Proctor, D. F.: The Nose, Paranasal Sinuses, and 
Ears in Childhood, Springfield, III., Charles C 
Thomas, 1963, p. 34. . — , 

^/7ffyfU p\ 

Winthrop Laboratories, New York, N.Y. 10016 


In colds and sinusitis 



(brand of phenylephrine hydrochloride) 


solutions/sprays/jelly 


Current Comment 

Engineering Courses for Doctors — 

Selected medical students are getting the 
opportunity for a year’s study of engineering 
principles. The goal is to open the way to a 
better understanding of the human heart. 
The University of Nebraska, with a $655,000 
grant from the National Heart Institute has 
started a special teaching program for stu- 
dents of medicine and biology. Dr. Edwin 
l.owenberg. Professor of Engineering, and 
Dr. Robert Stratbucker, Assistant Professor 
of Physiology and Pharmacology’, are direct- 
ing the program. The hope is that theory 
and methods developed by engineers in re- 
cent years may be applied to research on the 
heart and circulation. Students will be given 
instruction in the use of computers and will 
study such subjects as analytical geometry, 
calculus, probability and statistics, applied 
physics, and electrical circuits. Four sec- 
ond year medical students and one graduate 
physician are enrolled this year. These five 
students now enrolled are: 

Joseph Anderson of Stromsburg 
Charles Blair of Hastings 
Gerald Wilks of Scottsbluff 
Richard Miles of Omaha 
Dr. Andrew Kraphol of Omaha 


Ectopic Pregnancy: A 17- Year Review — 
H. D. Webster, Jr. (Tulane University 
School of Medicine, New Orleans), D. L. 
Barclay, and C. K. Fischer. Amer J Obstet 
Gynec 92:23-34 (May 1) 1965. 

The diagnosis and the management of 699 
consecutive cases of tubal or interstitial preg- 
nancy during a 17-year period are reviewed. 
The principal predisposing factors appear to 
be prior pelvic infection or operation. Culdo- 
centesis performed in the outpatient clinic 
proved to be the most important single diag- 
nostic procedure. Salpingectomy was the 
most com.monly employed operative proce- 
dure, although the incidence of associated 
hysterectomy increased to 42.5% during the 
last five years. There was one death in the 
entire series, giving a mortality rate of 
0.14% during a 17-year period. 


6-A 


DEPROE 

meprobamate 400 mg. + 
benactyzine hydrocbloride 1 mg. 

Indications: ‘Deprol’ is useful in the manage- 
ment of depression, both acute (reactive) and 
chronic. It is particularly useful in the less 
severe depressions and where the depression is 
accompanied by anxiety, insomnia, agitation, 
or rumination. It is also useful for management 
of depression and associated anxiety accom- 
panying or related to organic illnesses. 
Contraindications: Benactyzine hydrochloride 
is contraindicated in glaucoma. Previous aller- 
gic or idiosyncratic reactions to meprobamate 
contraindicate subsequent use. 

Precautions: Meprobamate— Careful super- 
vision of dose and amounts prescribed is 
advised. Consider possibility of dependence, 
particularly in patients with history of drug or 
alcohol addiction; withdraw gradually after use 
for weeks or months at excessive dosage. Abrupt 
withdrawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions in- 
cluding, rarely, epileptiform seizures. Should 
meprobamate cause drowsiness or visual dis- 
turbances, the dose should be reduced and 
operation of motor vehicles or machinery or 
other activity requiring alertness should be 
avoided if these symptoms are present. Effects 
of excessive alcohol may possibly be increased 
by meprobamate. Grand mal seizures may be 
precipitated in persons suffering from both 
grand and petit mal. Prescribe cautiously and 
in small quantities to patients with suicidal 
tendencies. 

Side effects: Side effects associated with recom- 
mended doses of ‘Deprol’ have been infrequent 
and usually easily controlled. These have in- 
cluded drowsiness and occasional dizziness, 
headache, infrequent skin rash, dryness of 
mouth, gastrointestinal symptoms, paresthesias, 
rare instances of syncope, and one case each of 
severe nervousness, loss of power of concen- 
tration, and withdrawal reaction (status epilep- 
ticus) after sudden discontinuation of excessive 
dosage. 

Benactyzine hydrochloride— Benactyzine 
hydrochloride, particularly in high dosage, may 
produce dizziness, thought-bloclung, a sense of 
depersonalization, aggravation of anxiety or 
disturbance of sleep patterns, and a subjective 
feeling of muscle relaxation, as well as anti- 
cholinergic effects such as blurred vision, dry- 
ness of mouth, or failure of visual accommoda- 
tion. Other reported side effects have included 
gastric distress, allergic response, ataxia, and 
euphoria. 

Meprobamate— r>TOV/siness may occur and, 
rarely, ataxia, usually controlled by decreasing 
the dose. Allergic or idiosyncratic reactions are 
rare, generally developing after one to four 
doses. Mild reactions are characterized by an 
urticarial or erythematous, maculopapular rash. 
Acute nonthrombocytopenic purpura with pe- 
ripheral edema and fever, transient leukopenia, 
and a single case of fatal bullous dermatitis 
after administration of meprobamate and pred- 
nisolone have been reported. More severe and 
very rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises (1 
fatal case), anuria, anaphylaxis, stomatitis and 
proctitis. Treatment should be symptomatic in 
such cases, and the drug should not be reinsti- 
tuted. Isolated cases of agranulocytosis, throm- 
bocytopenic purpura, and a single fatal instance 
of aplastic anemia have been reported, but only 
when other drugs known to elicit these con- 
ditions were given concomitantly. Fast EEG 
activity has been reported, usually after exces- 
sive meprobamate dosage. Suicidal attempts 
may produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Dosage: Usual starting dose, one tablet three or 
four times daily. May be increased gradually 
to six tablets daily and gradually reduced to 
maintenance levels upon establishment of relief. 
Doses above six tablets daily are not recom- 
mended even though higher doses have been 
used by some clinicians to control depression 
and in chronic psychotic patients. 

Supplied: Light-pink, scored tablets, each con- 
taining meprobamate 400 mg. and benactyzine 
hydrochloride 1 mg. 

Before prescribing, consult package circular. 

Wallace Laboratories / Cranbury, N. J. 




FOR THE 


COMPLEX 


^^ivsio^ 


^ I ^ I ^ meprobamate 400 mg. + 

JL Ji\.J. benactyzine hydrochloride 1 

a logical first choice 

FOR DEPRESSION 

even when complicated by anxiety, tension, insomnia, 

agitation or rumination. 

• Acts rapidly. ^ 

• Side effects at recom^endi|d dt^|^ infrequent, 
usually easi& conlfolli^. 


now... introducing a new high-strength dosage forn 

SIGNEM 


A 'MAXIMUM SECURITY’ ANTIBIOTIC*' 


THE BROAD RANGE DEPENDABILITY OF TETRACYCLINE 

long established as the broad-spectrum agent of first choice in a wide 

variety of infections 


^ WITH THE ADDED SECURITY OF MEDIUM-SPECTRUM REINFORCEMENT 
triacetyloleandomycin is highly active against the common ‘coccal’ 
pathogens, including certain strains of staphylococci resistant to penicillin 
and tetracycline 


ESPECIALLY VALUABLE IN U.R.I. 

provides decisive therapy in acute respiratory infections and other 
conditions in which staphylococci, streptococci or mixed flora are 
frequently encountered 


NOW AVAILABLE IN NEW STRENGTH FOR NEW CONVENIENCE AND 

fign^mycm 375 — high-potency capsules for simpler administration, 
greater patient economy 


(tetracycline 250 mg. 
triacetyloleandomycin 125 mg.) 



Indications: Indicated in the therapy of acute severe infec- 
tions caused by susceptible organisms and primarily by 
bacteria more sensitive to the combination than to either 
component alone. In any infection in which the patient can 
be expected to respond to a single antibiotic, the combina- 
tion is not recommended. Signemycin should not be used 
where a bacteriologically more effective or less toxic 
agent is available. Triacetyloleandomycin, a constituent of 
Signemycin, has been associated with deleterious changes 
in liver function. See precautions and adverse reactions. 
Contraindications: Contraindicated in individuals who have 
shown hypersensitivity to any of its components. Not recom- 
mended for prophylaxis or in the management of infectious 
processes which may require more than 10 days of con- 
tinuous therapy. If clinical judgement dictates therapy for 
longer periods, serial monitoring of liver function is recom- 
mended. Not recommended for subjects who have shown 
abnormal liver function tests, or hepatotoxic reactions to 
triacetyloleandomycin. 

Precautions and Adverse Reactions: Triacetyloleandomycin, 
administered to adults in daily oral doses of 1.0 gm. for 10 
or more days, may produce hepatic dysfunction and jaun- 
dice. Adults requiring 3 gm. of Signemycin initially should 
have liver function followed carefully and the dosage should 
be reduced as promptly as possible to the usual recom- 
mended range of 1.0 to 2.0 gm. per day. Present clinical 
experience indicates that the observed changes in liver 


function are reversible after discontinuation of the drug. 

Use with caution in lower than usual doses in cases with 
renal impairment to avoid accumulation of tetracycline and 
possible liver toxicity. If therapy is prolonged under such 
circumstances, tetracycline serum levels may be advisable. 
In long term therapy or with intensive treatment or in known 
or suspected renal dysfunction, periodic laboratory evalua- 
tion of the hematopoietic, renal and hepatic systems should 
be done. Formation of an apparently harmless calcium com- 
plex with tetracycline in any bone forming tissue may occur. 
Use of tetracycline during tooth development (3rd trirrester 
of pregnancy. Infancy and early childhood) may cause dis- 
coloration of the teeth. Reversible increased intracranial 
pressure due to an unknown mechanism has been observed 
occasionally in infants receiving tetracycline. Glossitis, sto- 
matitis, proctitis, nausea, diarrhea, vaginitis and definite 
allergic reactions occur rarely. Severe anaphylactoid reac- 
tions have been reported as due to triacetyloleandomycin. 
Photosensitivity and photoallergic reactions (due to the 
tetracycline) occur rarely. Medication should be discon- 
tinued when evidence of significant adverse side effects or 
reaction is present. Patients should be carefully observed 
for evidence of overgrowth of nonsusceptible organisms 
including fungi, which occurs occasionally, and which in- 
dicates this drug should be discontinued and appropriate 
therapy instituted. Steps should be taken to avoid masking 
syphilis when treating gonorrhea. 



J. B. ROERIG AND COMPANY 
Division, Chas. Pfizer & Co., Inc. 
Science for the World's Well-being^ 
New York, N.Y. 10017 



Current Comment 

“Doctor Ruth” in “New” Location — 

Good news for Miller area communities! 
“Doctor Ruth” may stay on permanently. 

For the uninitiated, “Doctor Ruth” is Doc- 
tor Ruth Christensen, the one woman staff 
of the Wood River Valley Medical Associa- 
tion Clinic. A native of Lincoln, she spent 
her summers in childhood visiting her grand- 
parents, all four of whom lived in Miller. 
When her father, a professor in chemical 
engineering at the University of Nebraska, 
died in 1955, Ruth’s mother returned to 
^Miller to live. Meanwhile “Doctor Ruth” 
graduated from the University of Nebraska 
College of Medicine and then took her in- 
ternship and residency training in New Or- 
leans. She served as chief resident of her 
hospital — the first woman physician ever 
accorded this position. 

After practicing in Colorado Springs, Colo- 
rado, “Dr. Ruth” joined the staff of the 
Leavenworth (Kansas) Veterans Adminis- 
tration Hospital. And then came disaster. 


A car wreck in 1961 resulted in extensive 
injuries to both lower legs. She came “home” 
to Miller to recuperate — she still wears a 
brace on one leg — and her medical prac- 
tice “just sort of happened.” As she ex- 
plains it, “People I knew kept asking me for 
advice, and before I knew it I was almost 
in practice. So when a group approached 
me and asked me if I’d stay if they would 
provide a clinic and equipment, I said that 
I would.” 

One of the few country doctors in Nebras- 
ka, she is quite probably practicing in the 
smallest town (population 140) that has a 
physician. And the fact that she is a woman 
makes her position all the more unique — 
although no less revered by the prideful 
citizens of the Miller vicinity who have gone 
all out in an effort to retain her services. 

* 

ooooooooooooocoooooooooooooooooocxxx> 
DOCTOR — Please take each copy of 
your Journal home. The wives complain ' 
that they never get to read the Aux- 
iliaiy column. * 

OOOQOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO I 


10-A 


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I 



Indications; ‘Miltown’ fmeprobamate) is ef- 
fective in relief of anxiety and tension states. 
Also as adjunctive therapy when anxiety 
may be a causative or otherwise disturbing 
factor. Although not a hypnotic, ‘Miltown’ 
fosters normal sleep through both its anti- 
anxiety and muscle-relaxant properties. 
Contraindications: Previous allergic or idio- 
syncratic reactions to meprobamate or 
meprobamate-containing drugs. 
Precautions: Careful supervision of dose 
and amounts prescribed is advised. Consider 
possibility of dependence, particularly in pa- 
tients with history of drug or alcohol addic- 
tion; withdraw gradually after use for weeks 
or months at excessive dosage. Abrupt with- 
drawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions 
including, rarely, epileptiform seizures. 
Should meprobamate cause drowsiness or 
visual disturbances, the dose should be re- 
duced and operation of motor vehicles or 
machinery or other activity requiring alert- 
ness should be avoided if these symptoms 
are present. Effects of excessive alcohol may 


An eminent role in 
medical practice 

• Clinicians throughout the world con- 
sider meprobamate a therapeutic 
standard in the management of anxi- 
ety and tension. 

• The high safety-efficacy ratio of 
‘Miltown' has been demonstrated by 
more than a decade of clinical use. 

Miltowir 

(meprobamate) 

possibly be increased by meprobamate. 
Grand mal seizures may be precipitated in 
persons suffering from both grand and petit 
mal. Prescribe cautiously and in small quan- 
tities to patients with suicidal tendencies. 

Side effects: Drowsiness may occur and. 
rarely, ataxia, usually controlled by decreas- 
ing the dose. Allergic or idiosyncratic re- 
actions are rare, generally developing after 
one to four doses. Mild reactions are char- 
acterized by an urticarial or erythematous, 
maculopapular rash. Acute nonthrombocy- 
topenic purpura with peripheral edema and 
fever, transient leukopenia, and a single 
case of fatal bullous dermatitis after admin- 
istration of meprobamate and prednisolone 
have been reported. More severe and very 


rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises 
(1 fatal case), anuria, anaphylaxis, stoma- 
titis and proctitis. Treatment should be 
symptomatic in such cases, and the drug 
should not be reinstituted. Isolated cases of 
agranulocytosis, thrombocytopenic purpura, 
and a single fatal instance of aplastic ane- 
mia have been reported, but only when other 
drugs known to elicit these conditions were 
given concomitantly. Fast EEG activity has 
been reported, usually after excessive me- 
probamate dosage. Suicidal attempts may 
produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Usual adult dosage: One or two 400 mg. 
tablets three times daily. Doses above 2400 
mg. daily are not recommended. 

Supplied: In two strengths: 400 mg. scored 
tablets and 200 mg. coated tablets. 

Before prescribing, consult package circular. 

® WALLACE LABOR.ATORIES 
Cranbury, N.J. 


Gilmour- Danielson 

DRUG COMPANY 

142 South 13th Street 800 South 13th Street 
Phone 432- 1 246 Phone 432-885 1 

Medical Village, 48th and "A" St. 
Phone 488-2305 

— FREE DELIVERY — 

PRESCRIPTIONS - ETHICAL SERVICE 

Established 1927 


Potential Hazards of Psychoactive Drugs in 
Association With Anesthesia — L. C. Jen- 
kins and H. B. Graves (Vancouver Gen- 
eral Hosp., ^"ancouver, B.C.). Can ad 
Anaesth Soc J 12:121-128 (March) 1965. 

The majority of the psychoanaleptics in 
current use are monoamine-oxidase inhibi- 
tors. By virtue of their ability to inhibit 
monoamine-oxidase, there are increased lev- 
els of brain serotonin and norepinephrine, 
with resultant psychoactive effects. Four 
representative patients illustrate that hypo- 
tension, hypertensive crises, hyperthermia, 
convulsions, coma, and potentiation of atro- 
pine, corticosteroids, and trimethaphan cam- 
sylate have all been observed as untoward 
reactions when anesthesia or anesthetic 
agents are given to patients on psychoactive 
drugs. Management of these reactions is pri- 
marily supportive. Caution must be used in 
the administration of vasopressors (nore- 
pinephrine) or adrenergic blockers ( phen- 
tolamine) in the treatment of hypotensive or 
hypertensive reactions, respectively. Avoid- 
ance of these reactions is desirable. ^^.gre ice - fishing!” 




12A 


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J 


when treatment 
might precipitate 
a problem 
with monilia 

especially in 
elderly or 
debilitated 
patients 


and in diabetics — patients ivith a history of fungal over- l' 
growth — patients on steroids ivho require antibiotics. The 

antimonilial specificity of Nystatin plus the extra benefits of DKC’LOMYCTN 
Demethylchlortetracycline allow lower mg intake per dose per day, the op- 
tion of b.i.d. dosage, higher activity levels, 1-2 days’ “extra” activity. 

Side Effects typical of tetracyclines include glossitis, stomatitis, proctitis, 
nausea, diarrhea, vaginitis, dermatitis, overgrowth of nonsuscej)tible or- 
ganisms, tooth discoloration (if given during tooth formation) and increased 
intracranial pressure (in young infants). Also, very rarely, anaphylactoid 
reaction. Reduce dosage in impaired renal function. Because of reactions to 
artificial or natural sunlight (even from short exposure and at low dosage), 
patient should be warned to avoid direct exposure. Stop drug immediately at 
the first sign of adverse reaction. It should not be taken with high calcium 
drugs or food; and should not be taken less than one hour before, or two 
hours after meals. 

Average Adult Daily Dosage: four divided doses of 1 capsule each or two 
divided doses of 2 capsules. 


LEDERLE LABORATORIES. A Division of AMERICAN CYANAMID COMPANY. Pearl River. New York 

65S5-1 999 





Current Comment 

Nebraska Centennial Health Fair; 

Progress Report — 

The Lancaster County Medical Society 
gave the “go-ahead signal” to its Nebraska 
Centennial Health Fair Committee. This 
committee is headed by Doctor E. D. Zeman, 
Director of Laboratory Services and Chief 
Pathologist at St. Elizabeth Hospital in Lin- 
coln. His co-chairmen are Dr. Samuel I. 
Fuenning, Director of Health Services for 
the University of Nebraska, and Dr. Keith 
Sehnert, Assistant Medical Director of Dor- 
sey Laboratories. They have met with Dr. 
Earl A. Rogers, Dii’ector of the State of Ne- 
braska Health Department, who has pledged 
his support of the project. In mid-January 
representatives of the American Medical 
Association came to Lincoln to meet with the 
Health Fair planning committee to arrange 
for support of this project by the American 
Medical Association. Dr. Sehnert is active- 


ly soliciting the support of the nation’s phar- 
maceutical manufacturers. 

The dates for the Nebraska Centennial 
Health Fair have been definitely set for the 
week of April 29, 1967 through May 5, 1967. 

Officers of county medical associations 
throughout the entire state will soon re- 
ceiving additional information along v ith a 
request to join with the doctors of Lancaster 
County in sponsoring this most worth-while 
venture. 


Congratulations to Aurora — 

The Century Manufacturing Company, 
with its line of specialized hospital and nurs- 
ing home bathing and therapy equipment, 
has announced plans to move from its tem- 
porary quarters in Lincoln to a new 12,000 
square foot concrete building located in the 
new 40-acre industrial tract in Aurora. 



“Now if Dr. Rumphrey is here try not to monopolize his entire 
evening. Remember, you’re not the only one who would like a little 
free advice.” 


14-A 


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I 

I 


I coughing 
Clear the 


ahead . . . 

Respiratory Tract with Rohitussin. 


Much more than just a slogan, "clear the tract" reflects the dependable 
antitussive-expectorant action of the three Robitussin formulations. 

All contain glyceryl guaiacolate, the time-tested expectorant 
that greatly enhances the output of lower respiratory tract fluid. 
Increased RTF volume exerts a demulcent effect on the tracheobronchial 
mucosa, promotes ciliary action, and makes thick, inspissated 
mucus less viscid and easier to raise. Glyceryl guaiacolate is safe, 
non-narcotic, and almost universally accepted by patients of all ages. 


NOW! 

THREE 

ROBITUSSIN 

FORMULATIONS 

ROBITUSSIN 

ROBITUSSIN A-C 

ROBITUSSIN-DM 

EXPECTORANT 

• 

• 

• 

DEMULCENT 

• 

• 

• 

COUGH SUPPRESSANT 


• 

• 

ANTIHISTAMINE 


• 


LONG-ACTING 

(6-8 hours) 



• 


FORMULAS 


ROBITUSSIN^ 

in each 5 cc. teaspoonful: 
Glyceryl guaiacolate 
(Alcohol 3.5%) 

100 mg. 

ROBITUSSIN® A-C 


(exempt narcotic) 


in each 5 cc. teaspoonful: 


Glyceryl guaiacolate 

100 mg. 

Pheniramine maleate 

7.5 mg. 

Codeine phosphate 

10.0 mg. 

(warning: may be habit forming) 


(Alcohol 3.5%) 


ROBITUSSIN®-DM 


new, non-narcotic 


in each 5 cc. teaspoonful: 


Glyceryl guaiacolate 

100 mg. 

Dextromethorphan hydrobromide 15 mg. 


Robitussin and Robitussin-DM are avail- 
able at pharmacies everywhere on your 
prescription or recommendation. 


A. H. Robins Company, Inc. Richmond, Va. 


OUR PHOTO: 

Engine No. 89 of the Monadnock, Steamtown 
& Northern Railway pulls a trainload of 
steam enthusiasts through the New England 
countryside between Bellows Falls and Chester, Vermont. 


AH'I^OBINS 


ONE OF THE ROBITUSSIN FORMULAS 


Metastatic Malignant Melanoma From Moth- 
er to Fetus — I. Brodsky et al (Hahnemann 
Medical College and Hosp, 230 N Broad St, 
Philadelphia). Cancer 18:1048-1054 (Aug) 
1965. 

A case of metastatic melanoma from moth- 
er to placenta and infant is presented. The 
primary tumor was removed from the moth- 
er three years prior to delivery. A meta- 
static nodule w'as noted on the abdomen by 
the mother two weeks after the last normal 
menstrual period. During pregnancy multi- 
ple nodules appeared over the entire body. 
Cesarean section was performed at teraa with 
delivery of a 7 pound 13 oz male infant. 
The mother expired from disseminated meta- 
static melanoma 17 days after delivery. Tu- 
mor cells were noted in the infant’s cord 
blood at birth, and an unusual hematologic 
picture characterized by a mild anemia, 
macrocytosis, normoblastosis, thrombocyto- 
penia, leukopenia and agranulocytosis was 
observed. The abnormal hematologic state 
was related in part to folic acid deficiency 
in both the mother and infant. A pigmented 
lesion was noted on the anterior chest wall 
on the 11th day of life. Biopsy revealed 
malignant melanoma. Many new lesions de- 
veloped and the infant expired 48 days after 
birth from disseminated melanoma. An un- 
successful attempt was made to overcome the 
infant’s tolerance to the maternal melanoma 
cells by maternal grandmother’s skin homo- 
gi’afts. 


Acute Appendicitis in the Very Young — J. 
L. Quintner and J. E. Wright (Royal New- 
castle Hosp, Newcastle, NSW, Australia). 
Med J Aust 1:922-925 (June 19) 1965. 

The authors report observations on 100 
children under 10 years of age with his- 
tologically proved appendicitis. The number 
included 21 children under 5 years of age. 
The only death occurred in a 10-year-old 
girl, in whom pneumococcal septicemia and 
peritonitis developed following surgery; she 
died in cardiac arrest during induction of 
anesthesia for her second laparotomy. About 
50% of the children had been ill for one 
day or less on admission, and nearly 90% 
had been ill for less than two days. The 


younger children (under 5 years of age) 
were generally admitted later than the old- 
er ones. Eight were admitted with an er- 
roneous diagnosis such as gastroenteritis or 
urinary tract infection. Diarrhea occurred 
in 13% of all patients, and urinary symp- 
toms in another 13%. An attempt was made 
to assess the morbidity in terms of wound 
infection rate, postoperative abscess forma- 
tion, and stay in hospital. Morbidity so 
measured could not be strictly correlated 
with the duration of illness prior to opera- 
tion, and it was concluded that the rate of 
progression of the disease varies in differ- 
ent patients. There was a correlation be- 
tween the pathological changes seen at oper- 
ation and the morbidity. Treatment with or 
without antibiotics had no influence on the 
convalescence of clinically similar groups. 


Effect of X-ray Therapy on Oligodendrog- 
liomas of the Brain — H. A. Shenkin 
(Episcopal Hosp., Philadelphia). J Neuro- 
surg 22 (Jan.) 1965 (in press). 

A review of the postoperative course of 
15 patients with oligodendrogliomas of the 
brain confirms previous reports that the 
time of recurrence is unpredictable. Data 
are offered giving unequivocal evidence that 
this type of glioma is sensitive to X-ray 
therapy. However, from analysis of the en- 
tire series of cases it is suggested that X-ray 
therapy be delayed until evidence of recur- 
rence of tumor growth is noted postopera- 
tively. 


Intraocular Optic Neuritis With Normal 

Visual Acuity — R. B. Daroff and J. L. 

Smith (1638 NW Tenth Ave., Miami, Fla.). 

Neurology 15:409 (April) 1965. 

This report presents three cases in which 
a choked disk was seen in the presence of 
normal visual acuity, yet the cause was papil- 
litis and not papilledema. Such a diagnosis 
is made on the basis of three signs: (1) a 
Marcus Gunn pupil, (2) cells in the vitreous 
on biomicroscopy, and (3) a nerve-fiber-bun- 
dle visual field defect on quantitative perim- 
etry. 


16-A 


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following 

infection 


STRESSCAPS B and C vitamins in therapeutic amounts ... help the body 
mobilize defenses during convalescence. ..aid response to primary therapy. 
The patient with a severe infection, and many others undergoing physio- 
logic stress, may benefit from STRESSCAPS. 



Each capsule contains: 


Vitamin B i (as Thiamine Mononitrate) 10 mg. 

Vitamin B 2 (Riboflavin) 

10 mg. 

Niacinamide 

100 mg. 

Vitamin C (Ascorbic Acid) 

300 mg. 

Vitamin 06 (Pyridoxine HCi) 

2 mg. 

Vitamin B i 2 Crystalline 

4 mcgm. 

Calcium Pantothenate 

20 mg. 

Recommended intake: Adults, 1 

capsule 

daily, for the treatment of vitamin 

deficien- 

cies. Supplied in decorative “reminder” 

jars of 30 (one month’s supply) 
(three months’ supply). 

and 100 


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or Sur^ 
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toolI 

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For \ 
E»oer, 
20*4_l 


16 - Section 3 


Lost and Found 


chihuahua — Lost*fem. Tan and 
svn.te Regard Irwinq-Calif IR 8-0341 


Lost 


THE BIHER TASTE OF 
ORAL PENICILLIN. 
See V-Cillin K® 
for full details. 


DOG found— Black Peke. temaie. 
10-26 Lincoln Park 943-0?9k 

DOBER'.'.an lost — brown. 

Cni'dren Vtc 

G E R 


10-2' 47 - 


be 8-0698 


brow 


lokl. 


coherd 


side 


N. W 


laroe r^ 


,VE 7-’>C09 


Town 


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oer. per 


Reward 


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ITTEN-LOSI on 


mos'^O «« 


Enoaaemen 

- Re* 


rings 'os' 




Found 

.caUT UlkYTO 


I MOBE PLUSW1 
UU OBU 

Check V-CiUin K. 
for the facts. 


A uaf’ 

ntaior 

manu'd 

dividur 

minlst' 
a traU 


white, collie. 


®vi? ioih A*nv 'nt5"n*’ 'O" 


*«r lost-Peoinaese 

dog 'o>'“r,G.a w 
Fem»'e...re MH ia»M 


Patients won’t complain about 
bitter penicillin taste when you 
specify V-Cillin K. Here’s why: It 
has a special coating, only one and 
a half thousandths of an inch thick. 
Because it is designed to dissolve 
after approximately six seconds, this 
barrier to bitterness remains on the 
tablet as it slides past the tongue. 
When the tablet reaches the 
stomach, however, the coating has 
dissolved, and the penicillin is ready 
for inunediate absorption into 
the bloodstream. 

Result? The proved efficacy of 
potassium penicillin V without the 
penalty of bitter taste. 

Indications: V-Cillin K is an antibiotic 
useful in the treatment of streptococcus, 
pneumococcus, and gonococcus infections and 
infections caused by sensitive strains 
of staphylococci. 

Contraindications and Precautions: 
Although sensitivity reactions are much less 
common after oral than after parenteral 
administration, V-Cillin K should not be 
administered to patients with a history 
of allergy to penicillin. As with any antibiotic, 
observation for overgrowth of nonsusceptible 
organisms during treatment is important. 

Usual Dosage Range: 125 mg. (200,000 
units) three times a day to 250 mg. every 
four hours. 

Supplied: Tablets V-Cillin K, 125 or 250 mg., 
and V-Cillin K, Pediatric, 125 mg. per 5-cc. 
teaspoonful, in 40, 80, and 150-cc.-size packages. 




V-Cillin K’ 

Potassium Phenoxymethyl Penicillin 


Additional information 
available to physicians 
upon request. 
Eli Lilly and Company, 
Indianapolis, Indiana. 

600050 


18-A 


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EDITORIALS 



THE NEBRASKA STATE MEDICAL JOURNAL 


WE’RE TOO FAT 

All food, like Gaul, is divided into three 
parts. They are, of course, protein, carbo- 
hydrate, and fat; we do not know why food 
is divided thus, it seems artificial, meaning- 
less, and arbitrary. This was done long ago, 
it has never been questioned, and we take 
this occasion to dispute what seems to us 
to be a rather strange sort of classification. 
You might, if you like, come up with a sys- 
tem of your own, and probably with as much 
cause; we prefer to classify our own intake 
into steak and potatoes. Food is, of course, 
simply fuel ; we almost never think of it that 
way; we do not like to think of it so, but in 
needier countries it is and must be so con- 
sidered. It is a source of energy, and like 
gasoline in the automobile tank, some of it 
can be stored and used later. This leads to 
overstorage, since nature has somehow seen 
to it that eating is a source of pleasure, and 
to calorie-counting: the food calorie is not 
at all the same as the heat and energy cal- 
orie, but is 1000 times as large. The calorie 
theory may be entirely justified, else should 
I not gain weight by lying in the sun? But 
when we come to weigh more than becomes 
us, and more than is good for us, we do not 
become overly protein or overly carbohy- 
drate, we become “fat.” Having a poor fig- 
ure is the result of two unfortunate caprices 
of Time: overweight and muscular flaccid- 
ity. It is more than possible that dieting is 
specific for one, and exercise, the other. 

We have read a great deal about obesity 
and its nonrelation to overeating, and we 
are not convinced. There may be some cases, 
but we are too fat, and we are not uniformly 
glandular misfits. We see too many 220 
pound men, and certainly too many two hun- 
dred pound women. Gland theory discus- 
sions often contain illustrative cases instead 
of a large series. We have thought for a 
long time that the more you eat, the more 
you weigh, that some foods are more fatten- 
ing than others, that this applies to the glan- 
dulars and to the others, that nonglandulars 
outnumber the glandulars, and that the 
gland theory is a too-convenient escape for 

February, 1966 


people who eat too much and who eat what- 
ever they like. We have become accustomed, 
during our rounds, to asking patients what 
they weigh. They all (we will take editorial 
license here, by “they all” we mean most of 
them or certainly too many of them) weigh 
too much. They all say “too much,” as 
though it were a matter of chance. They 
profess not to know, and perhaps some of 
them do not know, which is to say that they 
no longer care. Their shapes become almost 
spherical, their appearance unattractive, 
they are generally hypertensive (do they not 
see the obvious connection?), and they are 
poor risks for anesthesia and surgery. 

It is not a matter of chance, and there 
is no trick to losing weight. We have done 
it when it seemed wise, and we have done it 
repeatedly, which reminds us of Mark T^vain 
when he said that giving up smoking was 
easy, he had done it lots of times. It is not 
entirely pleasant, nor is it completely un- 
pleasant. Succumbing to overeating is like 
yielding to vice in other forms. What is 
needed is motivation, intelligence, and a 
moderate amount of will-power. We have 
noticed that women’s dress sizes in expensive 
shops go from 4, 6, or 8 to only 12, while 
elsewhere they begin at 12 and continue up- 
ward. Perhaps rich people become thin, or 
it may be that thin persons acquire money. 
But perhaps intelligent individuals amass 
wealth as well as pride in their personal ap- 
pearance. We observe, too, that there are no 
fat business executives. 

The coffee-break has helped to make us 
fatter. This is, of course, a misnomer; 
if they must rest from their “work” several 
times a day, it is surely not necessary to 
eat all day long. But continuous eating has 
become a feature of our lives; television 
eating usually begins when the coffee-breaks 
stop. Anesthesiologists are unhappy; no- 
body’s stomach is empty; employers are ex- 
ploited; does not our moral fiber decay? 
The coffee-break is here to stay, and it may 
be good for Brazil, but it is bad for us. Your 
Editor has yet to take his first C.B., he has 

33 


I 


not been able to, and is lucky to get his 
lunch. 

We would suggest more power in every 
vdll, fewer elevators in every climb, intelli- 
gence in every mind, information (some 
foods are so very obviously “fattening”) in 
eveiy direction, fewer taxis in every trip, and 
pride in every person. 

And a scale in every bathroom. 

F.C. 

(Now read our two articles on obesity). 


THOSE LOVELY CHECKS AND 
BALANCES 

Our Declaration of Independence is a 
masterpiece of logic and writing. Our Con- 
stitution is little, if anjdhing, short of per- 
fection in governmental organization, par- 
ticularly so when we realize that it was an 
innovation. Those who had felt the sting of 
tyranny in the past were happily anxious 
to avoid it in the future, and therefore as- 
sured both themselves and those who fol- 
lowed of freedom from one-man or one- 
group rule. Having seen oppression come 
about, and being familiar with both its na- 
ture and its development, they sought not 
only to abolish it by creating a republican 
form of government (we do not have a 
democracy), but also to perpetuate their 
freedom by eliminating those things that 
make tyranny possible. This they did by 
setting up a tripartite organization, with 
checks and balances so designed that no one 
part or one man could become strong enough 
to assume absolute power. 

But what has happened to our wonderful 
checks and balances? Is our legislative body 
as strong as, and independent of, the execu- 
tive? It would not seem to be. And so we 
have Medicare with its inequities and its in- 
iquities, and its reasonable fees. Are we 
not tyrannized? Have we not lost our free- 
dom? Can we decide whether to accept a 
case when we are desperately needed? Can 
we determine what is reasonable? Who will 
decide, and who will watch over those who 
do? Qui Custodet custodies? 


As the old song went (and does anyone 
remember Bert Williams?), nobody, that’s 
who. 

—F.C. 


LOOK, JAMA 

The Nebraska State Medical Journal is 
primarily medical, that is, a scientific pub- 
lication. It contains original articles of as 
much merit as we can get into them. But 
while we are American, we are not the 
whole United States; we are Nebraska, and 
there is the difference. IMany of our manu- 
scripts are submitted by Nebraskans, we 
try to keep our readers informed of state 
(as well as national) happenings, and we 
go on telling you what your colleagues are 
doing in the way of having honors bestowed 
on them, or lecturing to people, or retiring, 
and even leaving us. The things we do dur- 
ing the little time left over from the prac- 
tice of medicine are our life-saving hobbies. 
Some of us paint, some are slaves to lawns 
and gardens, some join clubs, some make 
music, and some write. There are those 
who play with power saws and those who 
watch television (and those who turn it 
off) ; those who ride, and who fish and 
hunt, those who indulge their families, those 
who dance, the ones who shoot at targets or 
at beasts, those who like to cook, those who 
play with cards, and those who take pictures 
and show slides. 


Your Editor would be happy to publish re- 
ports of what our members do when they 
have patience but no patients, in their own 
words or in his. Do you write poetiy? Or 
compose music? Are you a star-gazer, or a 
bird-watcher? Do you collect things? Do 
you travel? Or play the cello? Do you 
read? Do you fence? We’d all enjoy know- 
ing about it. 

We might even fence, too. 

As the internal revenuers say, send it in. 


We will begin with a well-known rug- 
hooker. 


—F.C. 


34 


Nebraska S. M. J. 


WE’VE SENT FOR A NONSPECIALIST 

The physician who limited his practice to 
only a small part of medicine carried with 
him the connotation of being unusual and 
of being extremely skilled in his narrow field. 
There were always more nonspecialists than 
specialists, and there were few fields in 
which one specialized. When one developed 
an ailment in a restricted part of the body, 
or involving a single part of his anatomy or 
physiology, what was wanted was the physi- 
cian who knew the most about that disease 
or that part of anatomy or physiology or 
pathology, or surgery, or medicine. Today 
there are more specialists than nonspecial- 
ists, so that the unusualness of specializing 
has disappeared, and with it the wonder and 
the glory, and thus the value of it all. To- 
gether with this, so much has been said and 
written about thinking and caring for the 
entire body, and for the patient as a whole, 
so that we may be coming to regard the spe- 
cialist as regarding the patient with tunnel 
vision, while failing to see things that, being 
out of his field, may be outside his visual 
area, and which may be of paramount im- 
portance. With all this, the general prac- 
titioner, or nonspecialist (if we do not be- 
gin to call him a generalist) has assumed 
skills never before accorded him, to the 
point where he is able to do what only the 
specialist could do but a little while ago. 

We do not have the old family doctor, but 
we have something much better. We have 
someone who does everything exceedingly 
well. And while the specialist may re- 
gard you from the standpoint of only your 
nervous system and forget your muscles, or 
examine your feet and neglect your head, 
or think of your abdominal pain and ignore 
your history, the time may come, nay, it 
may well be here, when, after deliberation 
and following consultation, we may have to 
turn to the patient or to the family, and, 
having summoned a member of the minority, 
and finding ourselves in need of someone 
specializing in the individual, and knowing 
more about him than we could hope to, and 
possessing skills we had denied him for 
too long, saying, “we’ve sent for a non- 
specialist.” 

— F.C. 


WHAT SHOULD WE TELL THE 
PATIENT? 

The role of father confessor is one that 
does not sit lightly on our shoulders, yet it 
is a burden that we assume when we first 
become doctors. We cannot escape it, it is 
thrust upon us, and our reactions are nearly 
as varied as our numbers. There are many 
things that we may or may not tell the pa- 
tient; they vary with the severity and the 
nature of the awesome responsibility, the 
familial and other environmental consider- 
ations, and particularly with the doctor. 
Some of these confidences are of the nature 
of life and death itself; others are relatively 
trifling, but the question is always the same. 
Shall we diagnose and tell the patient, shall 
we treat and tell how we are treating, shall 
we answer only when asked, or ought we 
only to practice medicine? 

I have known surgeons who told their pa- 
tients, as soon as they had awakened fpom 
the anesthesia, and without waiting to be 
asked, that they had cancer. I associate 
daily with those who answer the question 
truthfully when it is asked. And I have re- 
cently read a letter written by a physician 
who believes that both of these methods are 
wrong. He may be right; when we can no 
longer heal, it is always our responsibility 
and our duty to relieve pain. And when we 
know that we can not cure, it is our func- 
tion, he states, still to hold out to the pa- 
tient what he needs and what he wants 
so much : hope. To this end, therefore, we 
must say (I am merely repeating) what 
we may not at all believe. But it is like mor- 
phine. We do not cure the disease, but must 
we let the ravages of pain go on? So some 
of us, then, reassure the patient, and hold 
out false hope. It is no good pretending to 
ourselves that the hope may be real, what 
with cobalt and mustards ; this is begging the 
question. I mean telling the patient that 
there is hope when there is none. But the 
difference between these physician-attitudes 
is unfortunately not based on individual pa- 
tient differences; it is derived from our own 
differences. Some among us tell the truth 
without being asked, some wait and answer 
truthfully, some righteously deceive. And 
who will judge us? 


February, 1966 


35 


Shall we tell the patient what medicine 
he is getting? Well, some of us do, some 
doctors label their prescriptions, and others 
do not. The arguments are obvious to a 
point, whereupon we wonder. With the com- 
ing of governmental influence, we may find 
ourselves relieved of the burdensome deci- 
sion. If it is important for a patient, on 
finding himself in another city or in another 
doctor’s hands, to know what medication 
was being thrust upon him, then perhaps he 
should know. If this is not unduly perti- 
nent, then the question disappears of its 
own accord, and finally, if the success that 
attends the therapy being used at the moment 
depends to any extent on the patient’s not 
knowing what drug he is consuming, then 
it becomes a mistake of a high order, indeed, 
to tell him. If we are going to take him 
into our confidence every step of the way, 
then our task becomes tiresome, and the 
prospect of cure even more remote. For does 
not what we do consist often of what is not 
obvious or even specific? Shall we then label 
our medicines? 

Must we tell a patient what his blood pres- 
sure is, when we have just measured it? It 
is important for us to say at the start that 
patients do not know what blood is, nor 
pressure, nor blood pressure. When the 
pressure is normal, and we both know this, 
and we then confide in him, we have merely 
put off the question, for he then knows that 
when we do not tell him, something is wrong. 

Shall we tell him what his treatment com- 
prises? In so doing, must we not make him 
party to our own doubts and misgivings? 
Is it not better, perhaps, that he does not 
share what he cannot understand, and what 
he should, in any case, prefer not to know? 
The doctor as patient is peculiarly vulner- 
able. He is not allowed to share the lay- 
man’s feeling of security when there is none. 
He will not be put off by well-meant assur- 
ances; he knows the significance of pain, of 
its absence in jaundice, and of bleeding. This 
may at times be one of the severest penalties 
of being a physician. 

Doctor Holmes said that the patient should 
be told as much as is good for him; he is no 
jnore entitled to all the truth, he said, than 


to all the medicine in your saddlebag. We 
do not have saddlebags now, but his words 
must be judged as though we did. For we 
still have truth, and dignity, and respon- 
sibility. 

And duty, whose heart-heaviness is often 
more than we should like to bear. But we 
cannot dislodge it. 

— F.C. 


Evaluation of the De Bono Whistle as a 
Screening Test of Lung Function — J. R. 
T. Colley and W. W. Holland (St. Thomas’s 
Hospital Medical School, London). Lancet 
2:212-214 (July 31) 1965. 

The De Bono whistle was designed as a 
simple, portable, and cheap instrument for 
measuring lung function. It consists of a 
plastic tube that has a small fixed orifice 
at one end (the whistle). A disposable card- 
board mouthpiece fits over the other end. A 
critical level of air-flow through the fixed 
orifice is needed to produce a whistle. The 
lung function of 286 miners was measured on 
two occasions with the De Bono whistle and 
compared with the responses to a respira- 
tory-symptom questionnaire, measurements 
of forced expiratory volume in one second, 
forced ventilatory capacity, and morning- 
sputum volume. Although men with symp- 
toms, low ventilatory function, and large 
sputum-volumes had lower whistle grades 
than those without respiratory symptoms, 
normal ventilatory function, and small sput- 
um-volumes, the whistle grades did not cor- 
relate well with changes in respiratory func- 
tion within individuals. Comparison of dif- 
ferent whistles on 60 occasions in a chronic 
bronchitis clinic also showed discrepancies 
between whistles produced at different times 
and difficulties of within-observer repeat- 
ability. It is concluded that although these 
whistles may be satisfactory in group com- 
parisons, they are not suitable for use in 
screening individual patients. 
sosooceoooocoeoosooQooooooooocooosoo 
NOTICE TO ALL CONTRIBUTORS 
The deadline for items to appear in the fol- 
lowing issue of the JOURNAL is the 8th of the 
month. The JOURN.A.L goes to press on the 10th. 

eosoosooeeooeooQooeooeeoosooeeeeeoeG 


36 


Nebraska S. M. J. 


I 


Announcing 

EUTRON 

pargyline hydrochloride 25 mg. and methyclothiazide 5 mg. 

for control of 
moderate to severe 
hypertension 


Unique combination produces greater 
antihypertensive effect with lower doses 


Eutron is the combination in a single tablet 
of 25 mg. Eutonyl (pargyline hydrochlo- 
ride) and 5 mg. Enduron (methyclothia- 
zide). This combination produces greater 
therapeutic effect than that of either com- 
ponent used alone. Side effects may be 
milder, too, as dosages are generally lower. 
The effective dosage is usually one tablet, 
once daily. Tablets are scored for greater 
dosage flexibility. 





m No ivt 

ilm! 



Each Eutron tablet contains two proven antihypertensives 
in the ratio shown to be most effective in most patients. 

TM —TRADEMARK 


February, 1966 


36-A 




New EUTROIM 

extends your range 
of treatment in 
moderate to severe 
hypertension 


A single product 
you can use even 
in the presence 
of congestive heart 
failure or edema 


Eight out of 10 patients respond 

In clinical trials, Eutron produced normo- 
tension or a significant reduction in blood 
pressure in eight out of 10 patients studied. 
The rationale for the product is this: 
Eutonyl used alone is a potent antihyperten- 
sive. Its antihypertensive action is markedly 
enhanced by Enduron, a potassium-sparing 
thiazide. The combination (Eutron) 
thus produces greater antihypertensive ef- 
fect with lower dosages of the Eutonyl com- 
ponent, and milder side effects may be seen. 


1. Torosdag. S.. Schvartz. N.. Fletcher, L.. Fertig, H., 
Schwartz. M. S.. Quart. R. F. B., and Bo'ant, J. M., 
Pargyline Hydrochloride as an Antihypertensive Agent 
With and Without A Thiazide, Am. J. Cardiol., 12:822, 
Dec., 1963. 

2. Pollack. P. J-, Pargyline Hydrochloride and Meth- 
yclothiazide Combined In The Treatment of Hyperten- 
sion. Cur. Thera. Res., 7:10. Jan., 1965. 

3. Bryant. J. M, et al.. Antihypertensive Properties of 
Pargyline Hydrochloride. New Non-Hydrazine Mono- 
amine Oxidase Inhibitor Compared with Sulphonamide 
Diuretics. J.A.M..\., 178; 406, Oct., 1961. 


36- B 


Nebraska S. M. J. 


Significantly lowers 
blood pressure in all 
body positions; 
less likelihood of 
orthostatic hypotension 



BP reductions in the recumbent and sitting posi- 
tions often are nearly as great as in the standing. 
In clinical trials, the average recumbent BP 
reduction was 36/18 mm. Hg. 



The average standing reduction in clinical trials 
was 45/22 mm. Hg. Thus the difference between 
the standing and recumbent readings was only 
9/4 mm. Hg. 



In clinical trials, the average reduction in 
standing blood pressure was 45/22 mm. 
Hg.; in the sitting position it was 48/20 
mm. Hg.; and in the recumbent position, 
36/18 mm. Hg. 

Because Eutron effectively reduces blood 
pressure in all body positions, there is re- 
duced likelihood of orthostatic symptoms 
or hypotension. 

This was reflected in the relatively mild 
character of side effects seen in clinical trials 
(see below). 

Smooth and gradual onset 

Onset of antihypertensive action is usually 
quite smooth. Initial reduction of systolic 
and diastolic readings is usually seen within 
a week — maximum reduction in seven to 
ten days. 


Fewer than 1 % of patients studied discon- 
tinued Eutron therapy because of side ef- 
fects. This is due in part to the relatively low 
dosage needed with the combination. Usual 
recommended dose is one tablet daily— that 
is, 25 mg. Eutonyl with 5 mg. Enduron. This 
is about half the usual therapeutic dose of 
Eutonyl given alone. As a consequence side 
effects may be milder. And, as with Eutonyl 
given alone, the patient may well note an 
increased sense of well being. ■■■■» 
This is in distinct contrast to most I 

Other antihypertensive therapy, vhihv 


Less troublesome 
side effects may be 
seen; frequent 
improvement in 
“sense of well-being” 


February, 1966 


36-C 



Prescribing 
information for 

EUTROIM 


INDICATIONS: Eutron (pargyline hydrochlo- 
ride and methyclothiazide) is indicated in the 
treatment of patients with moderate to severe 
hypertension, especially those with severe dias- 
tolic hypertension. It is not recommended for 
use in patients with mild or labile hypertension 
amenable to therapy with sedatives and/or 
thiazide diuretics alone. 


CONTRAINDICATIONS: Eutron is contrain- 
dicated in patients with pheochromocytoma, 
advanced renal disease, paranoid schizophre- 
nia and hyperthyroidism. Until further expe- 
rience is gained it cannot be recommended 
for use in patients with malignant hyperten- 
sion, children (under 12 years of age), or 
pregnant patients. 

The concomitant use of the following is 
contraindicated: other monoamine oxidase in- 
hibitors; parenteral forms of reserpine or 
guanethidine; sympathomimetic drugs; foods 
high in tyramine such as cheese; imipramine 
and amitriptyline, or similar antidepressants; 
methyldopa. A drug-free interval of two weeks 
should separate therapy and use of these 
agents. 


WARNINGS: Pargyline hydrochloride is a 
monoamine oxidase inhibitor. Patients should 
be warned against eating cheese, and using 
alcohol, proprietary drugs or other medication 
without the knowledge of the physician. When 
it is necessary to administer alcohol, narcotics 
(notably meperidine), antihistamines, anesthet- 
ics, barbiturates and other hypnotics, sedatives, 
tranquilizers, or caffeine, these agents can be 
used cautiously at a dosage of Va to Vs the 
usual amount. Avoid parenteral administra- 
tion where possible. Withdraw pargyline two 
weeks before elective surgery. 

Patients should be warned about the possi- 
bility of postural orthostatic hypotension. 
Those with angina or other evidence of cor- 
onary disease should not increase physical 
activity. Pargyline may lower blood sugar. 
Potassium depletion is unlikely at the recom- 
mended dosage, but if it occurs, adjust dosage 
or withdraw or provide added natural food 
sources of potassium; potassium tablets should 
be avoided wherever possible, as bleeding or 
obstructive ulceration of the small bowel has 

51?214 


been associated with their use; potassium 
levels should be especially watched if the pa- 
tient is on digitalis or steroids, or if hepatic 
coma is impending. 

PRECAUTIONS: When determining the anti- 
hypertensive effect of Eutron, blood pressure 
should be measured while the patient is stand- 
ing. Use with caution in hyperactive or hyper- 
excitable persons. Such persons may show in- 
creased restlessness and agitation. Withdraw 
drug during acute febrile illness. Watch pa- 
tients with impaired renal function for in- 
creasing drug effects or elevation of BUN 
and other evidence of progressive renal fail- 
ure; withdraw drug if such alterations persist 
and progress. Pargyline has not been shown 
to cause damage to body organs or systems. 
As with all new drugs, complete blood counts, 
urinalyses, and liver function tests should be 
performed periodically. The drug should be 
used with caution in patients with liver dys- 
function. With prolonged therapy, examine 
patients for change in color perception, visual 
fields, and fundi. 

Elevated blood urea nitrogen, serum uric 
acid or blood sugar are possibilities attribut- 
able to the methyclothiazide in Eutron. Me- 
thyclothiazide may also reduce arterial re- 
sponse to pressor amines. Blood dyscrasias, 
including thrombocytopemia with purpura, 
agranulocytosis and aplastic anemia, have been 
seen with thiazide drugs. 


SIDE EFEECTS: The use of pargyline may 
be associated with orthostatic hypotension. 
Mild constipation, slight edema, dry mouth, 
sweating, increased appetite, arthralgia, nausea 
and vomiting, headache, insomnia, difficulty in 
micturition, nightmares, impotence, delayed 
ejaculation, rash, and purpura have been en- 
countered with pargyline. Hyperexcitability, in- 
creased neuromuscular activity (muscle twitch- 
ing) and other extra-pyramidal symptoms have 
been reported. Drug fever is extremely rare. 
Congestive heart failure has been reported in 
a few patients with reduced cardiac reserve. 
Nocturia has been observed with the combina- 
tion. If side effects persist, despite 
symptomatic therapy or reduction 
of the dose, discontinue the drug. 



36- D 


Nebraska S. M. J. 


ARTICLES 


Evdiudtion Of Obesity In Young Women 


Introduction 

T he problem of obesity has be- 
come one of increasing clinical 
significance in the U. S. which 
now has an estimated 25 million overweight 
citizens.! The effects of excess body weight 
with its adverse anatomical, physiological, 
biochemical, and psychological sequelae are 
becoming increasingly more evident. 

Clinical evaluation of obesity includes 
not only its diagnosis, but the determination 
of its degree, its etiology, and its signifi- 
cance to the individual patient. Although 
densitometry, body measurement, and skin- 
fold measurements correlate roughly, ac- 
curate assessment of the degree of obesity 
and hence the feasibility of a weight reduc- 
tion program in the individual patient re- 
mains a perplexing problem. 2- ^ 

Of interest have been the recent studies 
indicating significant alteration of serum 
lipids associated with rapid changes in body 
weight.!-^ Various lipid components have 
been assigned major roles in the energy 
metabolism of the different body tissues 
and derangement of lipid metabolism has 
been implicated as perhaps the most sig- 
nificant factor in the obese state.!- 4 

The purposes of this study therefore are 


ROBERT L. DELANEY, MD 
and 

JAMES F. SULLIVAN, MD, FACP 
Department of Medicine, 
Creighton University School of Medicine 
Omaha, Nebraska 


to determine the incidence and degree of 
obesity present in a selected group of adoles- 
cent females, to evaluate skin thickness 
measurements as an index of obesity before 
and after weight reduction, and to make 
preliminary observations regarding the 
effect of weight reduction on serum trigly- 
cerides. 

Materials and Methods 

A survey of height and weight of the 
entire student body of 176 nursing students 
at Creighton Memorial St. Joseph’s Hospital 
was made and compared to ideal height and 
weight relationships derived from actuarial 
tables, (table 1). Skin fold thickness was 
determined by caliper measurements four 
inches above the olecranon process on the 
deltoid surface of the arm,®- with the in- 
strument calibrated to produce 30 mm pres- 
sure at the point of measurement. Each 
measurement was performed three times. 


Table 1 

STANDARD WEIGHT TABLE FOR WOMEN 
IN INDOOR CLOTHES 

(Based on 1959 Study by Society of Actuaries) 
AGE GROUP 


Height 

15-16 

17-19 

20-24 

25-29 

30-39 

40-49 

50-59 

60-69 

4'10" 

97 

99 

102 

107 

115 

122 

125 

127 

11" 

100 

102 

105 

110 

117 

124 

127 

129 

5' 0" 

103 

105 

108 

113 

120 

127 

130 

131 

1" 

107 

109 

112 

116 

123 

130 

133 

134 

2" 

111 

113 

115 

119 

126 

133 

136 

137 

3" 

114 

116 

118 

122 

129 

136 

140 

141 

4" _ . 

117 

120 

121 

125 

132 

140 

144 

145 

5” _ 

121 

124 

125 

129 

135 

143 

148 

149 

6" 

125 

127 

129 

133 

139 

147 

152 

153 

7" 

128 

130 

132 

136 

142 

151 

156 

157 

8" 

132 

134 

136 

140 

146 

155 

160 

161 

9" 

136 

138 

140 

144 

150 

159 

164 

165 

10" 


142 

144 

148 

154 

164 

169 


11" 


147 

149 

153 

159 

169 

174 


6' 0" 


152 

154 

158 

164 

174 

180 



February, 1966 


37 



and the average taken. From this group, 
49 subjects who desired to lose weight were 
admitted to the weight-reduction progi'ani 
which consisted of a brief orientation re- 
garding relative caloric value of foods, in- 
struction to eliminate or decrease the intake 
of sugar ingested and the administration of 
anorectic taken b.i.d. midmorning and mid- 
afternoon. The drug used was a new chem- 
ical compound, i\IcX-742, under investiga- 
tion with a structure dissimilar to the am- 
phetamines, but with anorexigenic proper- 
ties in man and animals.* Weights were 
determined weekly for a period of 12 weeks, 
with skin fold thickness determined both 
before and at the completion of the study. 
Serum triglyceride determinations were made 
before and following the study on 31 of 
the 49 subjects under identical experimental 
conditions. Triglycerides were determined 
following an eight hour fast, according to 
the method of Van Handel and Zilversmit.® 


ity, based on table 1, at an earlier age 
than the examiners had anticipated. 

The determination of norms with regards 
to skin fold thickness presented difficulties. 
The 86 subjects who were not overweight 
seemed clearly to fall into two populations. 
Ten of these averaged 13.5 lb (range 6-19) 
less than the normal Aveight limit for their 
height. The mean skin fold measurement 
in these 10 subjects was 6 mm, each measur- 
ing less than 10 mm. The remaining 76 
subjects, whose weight fell within the nor- 
mal range, showed a mean skin fold thick- 
ness of 16 mm Avith a standard deAuation 
of 3.5. Accordingly a skin fold thickness 
greater than 7 mm above the mean of 16 
mm Avas deemed abnormal in eA'aluation of 
the 176 subjects in this study. The incidence 
of abnormalities in skin fold thickness occur- 
ring in the normal and overAveight groups 
is shoAvn in table 3. 


RESULTS 
Initial EA'aluation 

The height-Aveight distribution for the en- 
tire gi’oup is shoAA'n in table 2. The subjects 
are grouped according to height in one inch 
increments Avith the number of normal (N) 
and overAveight (0) designated for each 
height category. The designation as obese 
or normal Avas derived from table 1. 

Although no clear pattern of predilection 
for obesity at any height is discernible, 
it is remarkable that 90 of the 176 sub- 
jects, or 51%, AA’ere oA’er the ideal AA^eight, 
indicating a much higher incidence of obes- 

*McN 742 supplied hy McNeil Company, Camp Hill Road, 

Fort Washington. Pennsylvania. 


Table 2 

Distribution of nonnal (X) and obese (O) sub- 
jects according to one inch increments in height. 


Height 

(N) 

(O) 

.'i' n" 

1 

5 

5' 1" 

4 

3 

5' 2" 

12 

7 

5' 3" - - 

13 

12 

5' 4" _ _ 

10 

15 

5' 5 " _ 

14 

13 


7 

13 

5' 7" - 

n 

6 

8" 

8 

6 

5' 9" 

9 

8 

5'10" 

4 

2 


Table 3 


Skin fold thickness in nonnal and obese subjects 
(mean of nonnal 16 ± 3.5 mm). 


Normal Subjects 
( 86 ) 

Skin Fold < 23 mm. 
(83) 

Skin Fold > 23 mm. 
(3) 


Obese Subjects 
(90) 

Skin Fold < 23 mm. 
(57) 

Skin Fold > 23 mm. 
(33) 


Using these criteria only three of the 86 
subjects in the normal Aveight range shoAved 
increased skin fold thickness, AA'hile of the 
90 termed obese, skin fold thickness Avas 
increased in 33. 

Effect of Weight Reduction 
Forty-nine subjects started the Aveight 
reduction program as outlined, on a volun- 
tary basis, thus selection according to de- 
gree of obesity Avas not present. Tavo sub- 
jects discontinued their studies for per- 
sonal or academic reasons and AA'ere elim- 
inated in evaluation of results, as AA^ere tAAm 
other subjects AA'ho developed nausea and 
tachycardia. 


Table 4 

Correlation of weight loss with mean decrease 
in skin fold thickness. 


Wt. Loss in Lb. 0 1-6 6-12 12 

No. Subjects 4 10 24 11 

Decrease in SFT 

in mm. 0 1.2 1.7 5.1 


38 


Nebraska S. M. J. 


In table 4 the absolute decrease in body 
weight is correlated with the change in skin 
fold thickness at the end of the 12 week 
program. It may be noted that an appre- 
ciable decrease in skin fold thickness is 
demonstrable only in the 11 subjects show- 
ing a weight reduction of at least 12 lbs. 
The 41 subjects losing less than 12 lb. 
showed a mean decrease of 1.7 mm in skin 
fold thickness, within the error range (2 
mm) of the caliper measurement. 

In table 5 the weight loss is expressed 
as the per cent of excess weight from table 
1 and correlated with degree of obesity. 
For those subjects losing less than 5 lb. 
the per cent of decrease was not determined. 


Table 7 


Mean triglyceride 
loss. 

elevation as 

related to weight 

Wt. Loss 

No. 

Mean 

in Pounds 

Subjects 

Triglyceride 

Elevation 

>12 

11 

17 mg% 

7-12 

6 

49 mg% 

<6 

14 

27 mg% 


correlation of weight loss with triglyceride 
elevation. 

The known variation in individual fasting 
triglyceride values and small numbers in- 
volved precludes definite conclusions re- 
garding the significance of these changes 
and renders statistical evaluation impos- 
sible. 


Table 5 


Mean weight loss expressed as per cent of excess 


weiglit lost. 
No. 

Mean Value 

Mean Value 

Per Cent 

Subjects 

Excess Wt. 

Wt. Lost 

Excess Lost 

11 

26 

15 

56 

24 

19 

7 

37 

10 

35 

5 

__ 


It is obvious from this table that a signifi- 
cant reduction of excess weight, 27% -56%, 
occurred during this 12 week period. Al- 
though verifying statistical evaluation has 
been eliminated, it would seem that those 
with most marked obesity show the greatest 
resistance to weight reduction. The 10 sub- 
jects with a mean excess weight of 35 lb. 
averaged only 5 lb. weight loss, in contrast 
to the more satisfactory reduction in the 
less obese. 

Fasting serum triglycerides were deter- 
mined before and after the 12 week weight 
reduction period in 31 subjects as shown 
in table 6. An increase, although of minor 
degree, in the fasting triglyceride level is 
demonstrable after weight reduction. 


Table 6 


Mean Serum Triglyceride levels before and after 
weight reduction. 


No. 

Subjects 


Triglycerides 
Prior to Wt. 
Reduction 


Triglycerides 
Following Wt. 
Reduction 


31 


57±30 mg% 83±44 mg% 


Table 7 correlates the degree of trigly- 
ceride elevation following weight reduction 
with the amount of weight lost. There is no 


Discussion 

Physicians have come to realize that the 
metabolic machinery of the obese patient is 
appreciably different from that of his as- 
thenic peers and that obesity cannot be 
attributed simply to overeating.®- This 

study of obesity includes a particular 
group of individuals who are presumably 
strongly motivated for esthetic reasons to- 
wards maintenance of body weight consist- 
ent with their individual conception of an 
ideal personal weight appearance relation- 
ship. Thus it is of some interest that 90 of 
the 176, or 51%, are over their ideal body 
weight, and that only 54% of these desired 
to alter this status by a weight reduction 
program. 

In a recent study correlating body build 
with obesity. Seltzer and Mayer® report that 
while the obese are not a somatotypically 
homogenous group, there was a greater 
mesomorphic tendency in obese adolescent 
girls than among similar age girls selected 
from the population at large. Recognition 
of these constitutional as well as metabolic 
factors explain the common obseiwation that 
under identical environmental circumstances 
some people will become obsese while others 
will not.^®- 

Skin fold thickness was disappointing as 
an index in calculating the degree of obesity 
in the individual subject. A correlation be- 
tween change in weight and change in skin 
fold thickness appeared only in the group 
losing 50% of their excess weight. Al- 


February, 1966 


39 


though an apparent increase in the fasting 
serum triglyceride level is demonstrable 
following weight loss, it is recognized that 
the degree of alteration is probably of no 
physiological significance. A similar alter- 
ation of serum triglyceride levels following 
weight reduction has been reported by Dre- 
nick and co-workers. Increased mobiliza- 
tion of fat from peripheral stores induced 
by caloric restrictions, and the sympatho- 
mimetic action of McN 742 may each con- 
tribute to these serum triglyceride changes. 
It is to be noted that weight gain during 
adult life rather than weight loss is asso- 
ciated with hypertriglj’ceridemia.^ 0 u r 
findings support those of Berkowitz in 
which no significant alteration in serum 
triglyceride was noted with obesity or sec- 
ondary to weight loss.i It is interesting to 
note, however, that elevation in free fatty 
acid has been reported in studies to date, 
thus emphasizing the role of that lipid frac- 
tion in the deranged metabolism of the 
obese subject.^- 

The anorectic agent McN 742 used in this 
study provided subjective assistance in re- 
straint of appetite with minimal mood ele- 
vation, lack of insomnia, and no allergic 
manifestations. No change in urinary func- 
tion, as determined by serial urinalysis or 
alterations in the hemogram, were noted. 
Tachycardia and nausea which necessitated 
withdrawal of the drug in two cases is dif- 
ficult to evaluate, since each subject had 
similar episodes at other times. In each 
case the abnormalities disappeared within 
48 hours without the necessity of further 
therapy. 

Summary 

Evaluation of 176 female student nurses 
in the 18 to 20 year age group showed 90 
of the 176, or 51%, to be obese. Weight 
reduction based on voluntary dietary re- 
striction and an anorectic agent McN 742 
resulted in a significant decrease in excess 
body weight ranging from 37% to 56% in 


35 of 45, or 78% of the subjects partici- 
pating in this program. Skin fold thickness 
was correlated with body weight as a meas- 
urement of obesity before and after weight 
reduction but was a relatively insensitive 
means of determining excess body weight. A 
slight increase in fasting serum triglycerides 
of questionable significance was noted fol- 
lowing weight reduction, indicating the need 
for further study in this field. The anorectic 
agent McN 742 used in this study produced 
significant weight loss in 78% of the cases 
studied, with virtually no significant side 
effects. 

References 

1. Berkowitz, D.: Metabolic changes associated 

with obesity before and after weight reduction. 
JAMA 187:399, 1964. 

2. Keys, A.: Obesity measurement and the com- 

position of the body. Proceedings No. 6, National 
Symposium Series National Vitamin Foundation, 
New York, 1953. 

3. MacBrj'de, C.: The diagnosis of obesity. 

MCNA 48:1307, September, 1964. 

4. Gordon, E. : New concepts of the biochemistry 
and physiology of obesity. MCNA 48:1215, Septem- 
ber, 1964. 

5. Society of Actuaries: Build and blood pressure 
study. Vols. I (Oct., 1959) and II (Mai'ch, 1960). 

6. Keys, A.: Recommendations concerning body 

measurements for the characterization of nutrition 
and status in body measurements and human nu- 
trition. Edited by Brozek, J., Detroit, 1956, Wayne 
State University Press. 

7. Montoye, H.; Epstein, F., and Kjelsberg, M.: 
The measurement of body fatness. Amer J of 
Clin Nutr 16:417. 

8. Van Handel, E , and Zilversmit, D.: Micro- 

method for direct determination of serum trigly- 
cerides. J Lab Clin Med 50:152, 1957. 

9. Seltzer, C., and Mayer, J.: Body build and 

obesity — Who are the obese? JAMA 189:677, 
1964. 

10. Astwood. E.: The heritage of corpulence 

(Presidential Addi’ess). Endocrinology 71:377, 1962. 

11. Gordon, E.; Goldberg, M., and Chosey, G.: 
A new concept in treatment of obesity. JAMA 
186:50, 1963. 

12. Mayer, J.: Genetic factors in obesity. Bull 

NY Acad Med 36:42, 1960. 

13. Drenick, E.; Swendseid, M.; Blahd, W., and 

Tuttle, S. : Prolonged starvation as treatment for 

severe obesity. JAMA 187:100, 1964. 

14. Albrink, M.; Mergs, J., and Granoff, M.: 
Weight gain and serum triglycerides in normal men. 
New Eng J Med 266:484, 1962. 

15. Dole, V.: A relation between non-ester- 

fied fatty acids in plasm and the metabolism of 
glucose. J Clin Invest 37:1504, 1958. 


“I am sorry for the man who can’t feel the whip when it 
is laid on the other man’s back.” (Abraham Lincoln, quoted by 
Graham in Secret of Happiness, p. 23). 


40 


Nebraska S. M. J. 


Obesity and the Emotions* 


W E might as well come to an 
understanding at the begin- 
ning. I don’t have any Do-It- 
Yourself-Kit on How to Eat Yourself Skinny 
in Five Easy Lessons. Not only can’t I 
give you a ready-made solution, but I can’t 
even promise you an easy time during my 
talk. I have worked seriously on applying 
scientific knowledge to the problem of 
obesity, and I am going to ask you to bear 
with me. 

Let us understand why you need to use 
psychologj' to help you diet while someone 
who is not obese just needs ordinary will 
power. A person who has been grossly fat 
for a long time has a different problem 
from the person who has been a little care- 
less about his weight. You are not in the 
same boat because you have a much harder 
job. 

There are frequently some biological and 
physiological differences between a person 
of normal weight and the obese individual 
who has been very fat for a matter of years. 
One proof that your goal of reducing is more 
than a simple matter of will power by itself 
is the evidence that obesity runs in families. 
It has been known for a long time that 
when the parents are fat the children are 
more likely to be fat, but no one knew 
whether this was hereditary or whether it 
was because families who overeat together 
tend to grow fat together. Now it can be 
said with certainty that genetic factors do 
play a part in obesity. Statistical studies of 
twins and adopted children show results 
which are very easy to understand. Chil- 
dren of obese parents have been adopted into 
foster homes where the parents are not fat, 
but the children became obese despite the 
fact that they ate what their foster parents 
ate. Twins with obese parents have become 
separated from each other and have had to 
live in different households. Yet they were 
more like each other in becoming obese 
than they were like the foster parents. The 
only difference between separated twins 
is that one can be fatter than the other. 
The studies of heredity show that obesity 


S. D. KAPLAN, PhD 
Chief Clinical Psychologist and 
Director of Research, Lincoln State Hospital; 
Visiting Professor of Psychology, 
Nebraska Wesleyan University 
Lincoln, Nebraska 


as such is not inherited, but that the type 
of body build is — plus a predisposition to 
obesity just like some people have a predis- 
position to tuberculosis or heart trouble. 
You can prevent a predisposition from be- 
coming a reality, but you have to struggle 
for what the normal person takes for grant- 
ed. 

The latest evidence supports what all of 
you have been trying to tell everyone for 
years. Namely, you get fat on an intake 
of calories which does not fatten the nor- 
mal person. Why? 

We have to study a little biology to know 
why. Whenever a normal person is under 
any kind of stress, his nerves signal some 
of his endocrine glands to pour some chem- 
ical hormones into the blood. The hor- 
mones break down the fatty flesh into fatty 
acid which in turn can be burned for energy 
to meet the stress. As obesity lasts and 
gets worse with time, the stress fails to 
stimulate the release of those hormones 
necessary for the breakdown of fatty tissues 
into liquid fuel. 

Let me give you an example of the failure 
of the breakdown of fatty tissue in the 
obese person. Have you ever wondered why 
so many of you are very sensitive to cold 
despite the insulation which the heavy layer 
of fat gives you? When the normal person 
is exposed to cold, the sympathetic division 
of the autonomic nervous system releases 
a hormone into the blood stream. The hor- 
mone is called epinephrine, and it makes a 
person shiver and has many effects through- 
out the body. One effect of epinephrine is 
to break down fat into fatty acids. The 
burning of the fatty acids keeps the per- 

‘Address to Nebraska Tenth Annual TOPS (Take Off 
Pounds Sensibly I Convention, Pershing Auditorium, April 10, 
1965, Lincoln. Nebraska. 


February, 1966 


41 


compulsive eater cannot put on the brakes, 
and the drive to eat keeps rolling along until 
the person is gorged. He steps hard on the 
brake pedal as he tries to assert his will 
power, but his will power is futile until he 
restores the lost inhibitory power to the 
nerve cells. The shortage of inhibition in 
the nerve cells which regulate food consump- 
tion corresponds to the failure of brakes in 
a moving vehicle. 

Let us call the behavior of seeking and 
consuming food, appetite. The behavior of 
turning food down we shall call satiety. The 
center for the regulation of appetite and 
satiety in the brain is the hypothalamus. 
The hypothalamus has centers which regu- 
late most other body functions and also the 
emotional side of our behavior. 

Disturbed functioning of the hypothalamic 
centers for appetite and satiety is not due to 
a permanent destruction of brain tissue, but 
is a functional impairment. A functional 
impairment means that some of the nerve 
cells have been overstrained, and that with 
rest and time they can recover. Until the 
overstrained nerves recover, a proper bal- 
ance of excitation and inhibition to make 
the centers work right can be borrowed 
from other undamaged nerve cells by the 
use of psychological procedures. The func- 
tional impairment can be corrected psycho- 
logically while the overstrained nerve cells 
recuperate. 

What kind of stress can strain the appe- 
tite and satiety centers in the hypothalamus? 
It may be a physical illness. It may be 
due to a lack of satisfaction in life. The 
stress can come from inside the body and 
from outside the body because the hypo- 
thalamus is connected with the organs of 
the body and also with the cerebral cortex. 
Whenever the organs of the body are the 
target of infection, injury, or rapid changes 
such as childbirth or menopause, then the 
stricken organs put too much stress on the 
nerves which carry messages to the hypo- 
thalamus. Whenever a person is the target 
of misfortune, exploitation, or abuse beyond 
his endurance, then the victim’s cortex be- 
comes overstrained, and with it parts of the 
hypothalamus. This is how sickness and 


troubles in life can produce a loss of ability 
to control appetite according to need. 

How can psychology' correct the failure 
of normal physiological control of appetite 
and satiety ? The cortex is concerned with 
events that are psychological, with language 
and thought, and the cortex enables us to 
experience the continuity that we think of 
as ourselves in the flux of changing social 
roles and flow of many experiences reflect- 
ing the ever-changing world about us. We 
have an ego or a self ; we have an identity ; 
and we are not reducible to a bundle of 
blubber, a hank of hair, and a network of 
nerves. This fact, that the cortex lets us 
know who we are just as it lets us know 
when we are hungry or thirsty, is im- 
portant. It is a vital fact because what 
we are, our role in life, provides the basis 
for the cortex to develop large areas of ex- 
citation. As a person experiences that he 
is needed by others, that he is liked, that he 
is important, and that life is interesting 
and pleasurable, then larger and larger 
areas of his cortex become aroused. 

The person’s experience in life is a neces- 
sary source of nervous energy to keep the 
parts of his brain which regulate his body 
and his appetites working correctly. 

I would like to have you realize the psy- 
chological implications of the dynamics 
which I have just outlined. In addition to 
the truth contained in Victor Lindlahr’s say- 
ing, “You are what you eat,’’ we can say, 
“You fail to stop eating because of what 
you are not.” You are too fat because you 
can’t stop eating, and some of you can’t stop 
eating because your existence does not pro- 
vide you with enough cortical excitation to 
assist the satiety center in making you stop 
eating. 

It would be a mistake to suppose that 
you will discover the real cause of your 
obesity in the social stresses and unhappy 
conflicts of your life. While you do experi- 
ence social stress, more often than not you)' 
obesity aggravates discord and also makes 
you less able to ignore it. A miserable life 
is not the main cause of obesity, but can be 
a contributing cause, a precipitating cause, 
sometimes nothing more than the straw 


44 


Nebraska S. M. J. 


that breaks the camel’s back, and is always 
one of several causes. 

Whether it is a biological mechanism like 
the oversecretion of insulin or whether it 
is a social stress like disappointment in love, 
or both types of mechanisms together, a 
mechanical rearrangement of the working of 
the body by medicine or a mechanical 
change of environment will leave unaffected 
the basic cause of obesity. The basic cause, 
as I have said before, is in the faulty work- 
ing of the nervous system. The malfunction- 
ing partly brings about these misfortunes 
and then escalates them into major handi- 
caps. 

When we come to the nervous system after 
looking over all the physical and social ills 
which can contribute to obesity, the situa- 
tion is like Pandora’s box. After letting out 
all the evil spirits, the box was almost shut 
on the spirit of Hope. For a fundamental 
truth in the treatment of obesity is that some 
experience of success in dealing with the 
separate biological or social mechanisms of 
obesity can affect the nervous system itself. 
Hope is not just a state of mind, but it cor- 
rects imbalance between excitation and in- 
hibition in the nervous system. The per- 
sonality of your physician as well as his 
technical skill helps to impart hope. The 
participation with others in improving your 
way of life gives you hope. Recognizing 
the limitations of medical knowledge today 
and the realistic difficulties which prevent 
us from improving our lot in life, the most 
obvious and important source of hope for 
the obese persons is the TOPS organization. 
Meeting with others and encouraging each 
other promotes a cortically-centered focus 
of nervous excitation around the motive to 
diet. The weak satiety center or the strong 
appetite center can be regulated more easily 
with the help of such cortical excitation. 
The powerful effect of other people on an 
individual’s nervous system can turn the 
tide on what otherwise is a task beyond the 
strength of his nervous system alone. 

The fact that what might seem like a 
superficial social gathering may actually be 
the best way to treat the improperly work- 
ing nervous system reminds me of another 


Greek fable. It is called Even the Saints 
Fear an Angry Man. A Greek shepherd 
passed a church by the roadside and thought 
he would go inside to pray. As he tried 
to enter, his shepherd’s staff which he car- 
ried across his shoulders blocked his for- 
ward motion and threw him back. He tried 
several times with the same failure. In an- 
ger he drew his staff from its sling and 
waved it at the icons he could see through 
the doorway. The next thing he knew he 
was inside. He put his staff back and said, 
“Even the saints fear an angry man.” 

The fable shows, I think, how even with- 
out medical treatment of the biological por- 
tions of its many causes and also without 
correcting the injustices of one’s life, the 
struggle against obesity by joining with oth- 
ers in TOPS is itself a method of changing 
the nervous system whose improper func- 
tioning is the basic reason that these miseries 
have got under your skin in the form of fat. 
Even with the help of TOPS, the struggle 
to reduce is not, as you all know, easy Every 
once in a while you get tired of starving 
with results which seem so poor. Every 
time you give up and feel, “What’s the 
use?” then cortical inhibition of the mid- 
brain fails. Then the appetite center is un- 
leashed and the satiety center is paralyzed. 
Up pops that old devil, the craving for 
food, and he will not go away. Even worse, 
eating is pleasurable. When life affords so 
little pleasure and when you are too tired 
to care, then a genuine depression sets in. 
You don’t care whether you live or die, 
and you ease your anguish with the tem- 
porary pleasure of eating. 

A person who is trying to escape the 
hell of obesity needs special consideration. 
He needs praise for his success, and en- 
couragement to overcome his failures. If he 
can’t get it any place else, he gets praise and 
encouragement in TOPS, and gets it there 
better than anywhere else because the oth- 
ers are in the same boat and understand his 
position better. 

Another special feature of TOPS is that 
it is an organization of, by, and for people 
who have the same problem. In other 
words, the obese person is doing something 


February, 1966 


45 


for himself. The act of doing something 
for himself helps fight against depression 
which makes the person want, in the extreme 
situation, to destroy himself. TOPS is an 
expression of healthy selfishness in people 
who are often unselfish to the point of de- 
stroying themselves. The obese person has 
been scolded as a glutton, but little has been 
said about the obese housewife who must 
prepare food for others and yet refrain from 
eating but a morsel of it. Even in her own 
bailiwick of the kitchen, the dieting house- 
wife is reduced to being a drudge for others, 
while her own needs go unsatisfied. To be 
unselfish, there must first be a self. For 
such a housewife to join TOPS is a correc- 
tive experience because she is learning how 
to do something for herself once again. By 
supplying hope, TOPS is an antidote for de- 
pression. 

Unfortunately, many obese people fight 
against depression by eating. The situation 
I am talking about now is different from the 
one I have just discussed in which the per- 
son succumbs to depression and is satisfied, 
so to speak, in finding a good way to die. 
When some people feel overly excited, then 
they find that they must eat to calm down. 
They use food as a pacifier. Psychology’ 
and psychiatry are now developing methods 
of teaching such people how to relax them- 
selves by training in relaxation of the 
muscles without the use of drugs. To learn 
the skill of relaxation is a goal which all 
obese people ought to set for themselves. 
There are such techniques and they can be 
very helpful. 

Aside from medical treatment of the bio- 
logical mechanisms of obesity, many physi- 
cians attempt to alter the functioning of the 
nervous system by tranquilizers and energiz- 
ers. I should like to see more widespread 
teaching by physicians of relaxation tech- 
niques as a substitute for or as a powerful 
assistant to tranquilizers. I wish to endorse 
the viewpoints of those doctors who have 
criticized their colleagues for prescribing too 
many tranquilizers and also too many “pep 
pills.” 

Such appetite control by chemical inter- 
vention is artificial and not without risk. 


There can occur an increased tolerance to 
the drug and the need for larger doses. 
There is then a possibility of liver damage, 
depression, or drug addiction. The medi- 
cine may make the patient more irritable. 
When the patient stops taking the medicine, 
the faulty ability of the cortex to inhibit 
the hypothalamus is usually still there unless 
the struggle to reduce has been associated 
with other changes in the patient’s life. Per- 
haps worst of all, occasionally the “pep pills” 
may over -stimulate the cortex. 

This last possibility is worth considering 
in more detail. The use of “pep pills” to kill 
the appetite deprives the cortex of protec- 
tive inhibition it may need. Without atten- 
tion to such physiological considerations, 
the use of reducing medicines may be short- 
sighted and harmful in the long run. 

Another possibly harmful effect of exclu- 
sively drug centered treatment is that the 
“pep pills” given to reduce the appetite may 
interfere with sleep. The hypothalamus is 
not onlj’ inhibited by the excited cortex but 
it can absorb inhibition from sleep. Sleep 
is the spread of inhibition over large por- 
tions of the nervous system including the 
subcortex. The compulsive eater is often 
most helpless toward bed time when the 
tired cortex is able to inhibit the hypothala- 
mus less and less. The compulsion to eat 
weakens after sleep because the hypothala- 
mus has renewed some of its deficient sup- 
ply of inhibition and the cortex has par- 
tially replenished its ability to become more 
fully excited. Incidentally, many who spurn 
the “pep pills” do substantially the same 
thing without benefit of prescription by 
stimulating themselves with caffeine and 
nicotine in the form of coffee and cigarettes. 

No obese person can be cured just by 
losing weight. The fundamental cure re- 
quires the correction of the failure of a prop- 
er working relation between cortical and sub- 
cortical excitation and inhibition. Unless 
the weight loss reflects such underlying neu- 
rodynamic change, which in turn depends on 
both the person’s entire way of life and 
also on his recovery through time from past 
overstrains to particular parts of his nerv- 
ous system, then even after a successful 


46 


Nebraska S. M. J. 


return to normal weight the person is still 
obese in his basic personality and nervous 
system type. He is like the compulsive 
drinker who, even though he never touches 
another drink, is rightly thought of as a 
latent alcoholic. The symptom is gone, but 
the basic cause remains. 

My comparison of obesity with alcholism 
in terms of similar neurodynamics will be 
more useful when we consider some dif- 
ferences also. The alcoholic who joins Al- 
coholics Anonymous is told that he must 
never touch another drink. What about the 
obese person who tries to reduce? Wouldn’t 
it be nice if you could decide never to take 
another bite? Such simplicity is not the 
lot of the obese person. You have to make 
a distinction between the food providing 
enough calories to live and the food whose 
calories are associated with the sheer pleas- 
ure of eating or the function of easing 
anxiety. The obese person has to become 
a calorie-counter and has to draw a line de- 
liberately which is done more or less auto- 
matically for the person with normal in- 
hibition of the appetite center. To carry out 
the analogy with the alcoholic, the obese 
person is a “caloric.” For the rest of your 
life, you dare not touch one calorie which 
is not necessary for healthful living. 

I confess, at my conclusion, that I have 
painted a grim picture. Yet I have shown 
you several things which you can do besides 
spending the rest of your days counting 
calories. You ought to seek medical treat- 
ment for biological faults which have made 
you vulnerable to obesity. Many of them 
have been discovered just within the past 
few years, new methods of medical treat- 
ment are being developed with greater suc- 
cess all the time, and I predict with com- 
plete confidence that there will be a major 
breakthrough in the treatment of obesity 
based on the recent physiological discoveries. 
You must re-examine your way of life to 


see where you can derive more satisfaction 
from it. The heavy load which you have had 
to bear at critical times in your life need not 
be a permanent burden. Until medical 
knowledge and skill succeeds in providing a 
real cure for your metabolic disturbances, 
and until you can free jmurself from duties 
which are presently inescapable, then you 
need to join with others afflicted as you 
are with obesity, and lose weight together in 
TOPS. By doing all of these things, a per- 
son has a chance despite the crushing odds 
which make obesity such an unfortunate 
sickness. 

In your situation of struggle and compro- 
mise, I believe strength can be gained from 
the saying: “God grant me the serenity to 
accept what I cannot change, the courage 
to change what I can change, and the wis- 
dom to know the difference.” 

The courage to change what you can 
change can be strengthened by a deliberate 
policy of assertiveness and emotional expres- 
siveness in the many little things of your 
daily life. Stop being so self-sacrificing and 
compliant. Most of you are too inhibited, 
and the daily exercise of self-assertiveness 
in little things will toughen you for larger 
struggles which you are not ready to face 
yet. In this respect, it is crucial that your 
TOPS organization continue to be the demo- 
cratic organization it is now, responsive 
to your needs and run by you. If you can’t 
assert yourself in TOPS, then it is failing 
you. 

Finally, the wisdom to know the differ- 
ence between what you can change and can- 
not change can often be brightened by con- 
sulting a minister or a psychotherapist. 
While some of you need such professional 
help, most of you have a good enough under- 
standing of your situation to start helping 
yourself right now. That’s why you are 
here. You can help yourself. It’s up to 
you. 


Quotation from Better Health that defines the “Rock Hound:” 
“The man who moved the mountain, began by carrying away 
small pieces.” 


February, 1966 


47 


Brdicka Serum Filtrate Reaction Applied To 
Normal And Cancerous Menstrual Fluids'^ 


ABSTRACT 

A new polarographic method util- 
izing menstrual blood, taken on 
three successive periods with 
a special vaginal cup, from seven females, 
shows that wave height and configuration 
approximates that of normal peripheral 
blood. Tracings of the genital blood taken 
from two early cases of proven gynecologi- 
cal neoplasia show consistant elevation 
when compared to the peripheral venous 
blood of these same two patients. 

The utilization of the Brdicka Serum Fil- 
trate Reaction (BSFR) in laboratory studies 
of normal and cancerous serum, the metho- 
dolog>’, instrumentation, and serial tracings 
of a protracted therapeutic remission have 
been previously reported by the author. ^ 

Recently, the opportunity presented itself 
to obtain patients in various stages of gyne- 
cological cancer for the polarographic in- 
vestigation of their sera. A review of the 
literature revealed that previous work^ 
showed a high degree of correlation (89.1% ) 
between cancer of the female organs and a 
positive BSFR, as was its relation to the 
clinical stage of same.^ Failures, it was 
stressed, were encountered predominantly in 
what appeared to be stages 0 and early I in 
the international classifications-* of carcinoma 
of the endometrium (uterus) and portio vag- 
inalis (cervix). This is unfortunate in that 
80-90% of the cases in these classifications 
have a better than 5 year survival rate after 
appropriate treatment.® This failure of the 
BSFR to detect increments of acid glycopro- 
teins (MP-2 and 3) in the alpha-2 globulin 
fraction®’ " of peripheral venous serum is pre- 
sumably due to the fact that by definition, a 
stage 0 (in situ or intraepithelial) carcinoma 
of the cervix has not penetrated the basal 
epithelium,® and its proteolytic breakdown 
metabolites are extruded and removed from 
the body along with its exfoliative products 
via the female introitus. 


RICHARD RAPPOLT, SR., MD 
University of Nebraska College of Medicine, 
Eppley Institute 
Omaha, Nebraska 

It occurred to me that perhaps the peri- 
odic flow of menstrual fluid, or frank bleed- 
ing from the vaginal orifice, which is often 
the herald of a gjmecologic neoplasia, might 
be utilized for the BSFR in that these natur- 
ally occurring biologic fluids perfuse those 
areas of the female genitalia where malig- 
nancies are most wont to initiate themselves. 

The esthetic problem of collection was 
satisfactorily solved with an internally worn, 
rubber menstrual cup,® Tassette,i® the ca- 
pacity of which approaches 28 ml ; this rep- 
resents 25-50% of the average menstrual 
flow (see Figure 1). 

•Read at Third International Congress of Polarography. 
Southampton. England, July, 1964. 



Figure 1. Tassette. rubber menstrual cup. 


48 


Ntbraska S. M. J. 


For normal controls, seven healthy female 
volunteers from a nonclinical population 
were sampled on three successive periods, 
representing 21 normal BSFR. No conclu- 
sions were made as to the height of the wave 
relating to age (22-38), marital status (five 
married, one divorced, and one single), par- 
ity (one - four children) or chronic dis- 
ease state (one unspecified vaginitis, one 
hypothyroid). 

The first day of “spotting” was noted by 
the subjects, and the Tassette was not in- 
serted until the morning of the second day. 
The contents of the cup were emptied into 
a plastic, rubber stoppered, refrigerated, 
centrifuge tube until its 15 ml capacity was 
half-full; this represented two or three col- 
lections from the menstrual cup at three to 
four hour intervals. The fluids as received 
by our service were unclotted, viscous, and 
partially hemolysed. The lack of clots was 
attributed in part to the practice of initiating 
collection on the second day of the flow. 

After centrifugation, the port - colored 
serum was denatured and deproteinated in 
the usual manner. During the deproteina- 
tion with the 20% sulfosalicylic acid, it was 
noted that the precipitated insoluble protein 


instead of forming white curds, as was to be 
expected with peripheral supernate, formed 
brownish-red curds, which carried along with 
them, apparently, the highly colored portion 
of the menstrual serum, as the physical ap- 
pearance of the clear, aqueous filtrate was 
identical to that of the treated peripheral 
venous serum. 

The polarographic double wave of nor- 
mal, fresh menstrual blood (see Figure 2) 
approaches sameness in configuration and 
height range of normal peripheral venous 
blood, and varies only slightly with consecu- 
tive periods. This correlates well with the 
report that the (polarographically active) 
mucoproteins in the peripheral blood of 
healthy females do not change appreciably 
during various days in their menstrual 
cycle. '2 

The wave heights reported are those of 
our particular laboratory techniques, and 
although the polarographic constant B, as 
suggested by Kalous and Pavlicek,i® might 
easily have been applied to the results of our 
controls, it was felt that the publication of 
the heights per se would be more appropri- 
ate in the nascent stages of investigation. 



February, 1966 


49 


BflOiCKA riLTRATC RCACTiONS : lO MONTH PERIOD 



Figure 3. 21 normal BSFR on menstrual controls. Brdicka Filtrate 

Reactions: 10 month period. 


especially in recording the pathological 
waves. 

Figure 3 is the tabulation of all the nor- 
mal controls completed to date in groups 
of three. Previous work with normal per- 
ipheral blood gave catalytic double wave 
height spans of from 31 mm to 49 mm, meas- 
ured from the diffusion current of the co- 
baltic wave. 

Report of Two Cases With 
Gynecological Cancer 

1. Cervical Carcinoma. 

A white, married female, age 32, para 
O-O-O-O, noted heavy period with clots 
in November 1962; examined by her 
physician December 21 ; appropriate di- 
agnostic tests indicated a poorly differ- 
entiated squamous cell carcinoma of the 
cervix with extension into the endo- 
metrium (Stage II) ; first radium treat- 
ment, December 26, and second radium 
treatment, January 4; total hysterec- 
tomy, January 29, 1963. 

The peripheral blood and menstrual 
blood from this patient was done one 
week prior to surgery (see Figure 4) at 
the time it was felt there was no residual 
radiation inflammation. An additional 
peripheral blood tracing (68.4 mm, not 
illustrated) was made two days post- 


surgery delineating the inflammatory 
reaction of a surgical manipulation plus 
possibly the action of a recently admin- 
istered cytotoxic agent, Thio-TEPA. 
The conclusion was made that the great- 
er wave height in the genital blood as 
contrasted to the preoperative peripheral 
blood tracing is due to its association 
with the cancerous lesion; furthermore, 
prognostic conclusions can be more 
fruitful with concurrent tracings of both 
the genital and peripheral serums. 



50 


Nebraska S. M. J. 


2. Endometrial Carcinomad® 

A white female, age 65, para 5-2-1-2, 
two years postmenopausal, 40 years a 
diabetic, with chronic pyelonephritis, 
had bleeding and passage of clots for 
the past 11/2 years and lower abdom- 
inal pain for the past two years. Geni- 
tal blood, which contained multiple 
clots and purulent material, and per- 
ipheral venous blood recorded the BSFR 
on the second hospital day (see Fig- 
ure 5). Serial sections of the oper- 
ative specimen, following X-ray ther- 
apy and surgery, revealed a poorly dif- 



ferentiated adenocarcinoma of the en- 
dometrium without myometrial inva- 
sion, though a diffuse inflammatory re- 
action was present. It was felt that de- 
spite the fact that no local extension 
was present, the peripheral BSFR was 
increased due to the secondary infection 
of the endometrium plus the chronic 
pyelonephritis, emphasizing again the 
total clinical picture of the patient that 
must be considered in interpreting the 
BSFR intelligently. 

It is to be stressed that this study 
does not purport to make any hard and 
fast conclusions about the clinical prac- 


ticality of the method herein described. 
It is intended to be a pilot study only, 
in the hopes that more informed col- 
leagues will be able to adopt it, possibly 
as an investigational adjunct of the 
Papanicolaou smear, Schiller test, col- 
poscopic examination, punch or coniza- 
tion biopsy,^® and other newer screening 
tests for gynecological cancers such as 
the interference microscopic exam of 
fresh cancer cells, tampon smears, 
Von Bartalanffy’s acridine orange flu- 
orochrome dye,i® the Davis examination- 
by-mail irrigating solution pipette,2o and 
the plastic cervical cap used in vivo 
radioautography of the cervix . 21 

Despite the fact that no statistical con- 
clusions can be made, it would seem that 
the greater part of the sulfosalicylic 
acid soluble, polarographically active, 
mucoproteins are most probably concen- 
trated in the vicinity of the growing 
neoplasm. 

NOTES 

I thank Mrs. Bernice Hetzner and her Staff of 
the University of Nebraska College of Medicine Li- 
brary; Mrs. Elizabeth Olmstead and her staff of 
the Harvard Medical School Library; Miss Clara 
Meckel of the University of Chicago Medical School 
Library for their valuable assistance, and Mrs. Bea 
Hoffmeister for the preparation of the final manu- 
script. 

An addendum was prepared at the Polarographic 
Congress in response to queries by Prof. Bruno 
Breyer, State Hospital, Lidcomber, N.S.W., Aus- 
tralia, and Dr. Imanuel Bergman, Department of 
Chemistry, Harvard University, Cambridge, Mass, 
(present address: Safety in Mines Research Estab- 
lishment, Ministry of Power, Sheffield, England) 
concerning the fact that the . “pathologic” glyco- 
mucoproteins, which are present in the serum in 
the greatest amount by nonpolarographic quan- 
titative analysis, paradoxically show little polaro- 
graphic activity, and that parallels between the 
quantitative pathologic increase and the polaro- 
graphically active mucoprotein increase in these 
seimm proteins by other methods cannot be drawn. 
I chose to call the BSFR active component the peri- 
neoplastic glycomucoproteins and, in this theoretical 
realm, what I would like to stress is that the BSFR 
is not a test for cancer per se, as up to the present 
time there are not any measurable humoral or bio- 
chemical substances indigenous to all malignant 
neoplastic growths. What it is specific for though 
is an inflammatory response in any body tissue in- 
asmuch as the pathological increment of serum gly- 
comucoproteins over the baseline level found in nor- 
mal sera (which is for the most part probably manu- 
factured in the liver) is obviously pi’oduced by non- 
specific inflammatory reaction in the perineoplastic 


February, 1966 


51 


tissues in question. In those organs whose proteo- 
lytic breakdown products follow the growth of its 
epithelium (such as in the gastrointestinal, integu- 
mental and genitourinaiy system) without the 
body, the BSFR is consistently false-negative till 
rather extensive local extension or metastasis takes 
place. Attested to this fact is the recent work by 
H. Hamperl, Pathological Institute of the Univer- 
sity of Bonn (CIBA Foundation Study Group No. 
3 (1959) Little & Brown), with PAS staining spe- 
cific for acid mucopolysacchai'ides in which none 
were detected in the superficial layers on in situ 
ceiwical cancer. It is in these clinical applications 
of the BSFR that absolute cooperation is necessaiy 
between the clinician and the polarographic labora- 
tory so that false-negatives or positives can be 
dealt with in an intelligent openminded discussion. 


References 

1. Rappolt, R. T. ; Nebraska Med J 47:7 (1962). 

2. Fort, M.; Brdicka, R.; Ott, K., and Voriskova, 
M.: Casopis Lekaru Ceskych 82:432 and 474 (1943). 

3. Hrdlicka, M., and Melka, J.: Casopis Lekaru 

Ceskych 85:506 (1946). 

4. Ullery, J. C., and Pomeroy, T.: CA 12:4, 123 

(1962). 

5. Ullery, J. C., and Pomeroy, T.: CA 12:4, 135 

(1962). 

6. Musil, J.: ACTA Univ Carol Med 9:10 (1968) 


7. Annals of the New York Academy of Sci- 
ences 94, Art 1 (1961), pp 1-336. 

8. TeLinde, R. W.: Postgrad Med 29:5 (1961). 

9. Supplied for this study by Tassette, Inc., 170 
Atlantic Avenue,, Stamford, Connecticut, through 
the courtesy of Robert P. Orek. 

10. Liswood, R.: Obstet Gync 26:9 (1959). 

11. Brdicka, R.: Research 1:1 (1947). 

12. Sturmei’, and Warkalla, H. J. : Geburtsch 

and Fravenheilk 13:460 (1953). 

13. Kalous, V., and Pavlicek, Z.: ACTA Biochem 
Biophys 57:44 (1962). 

14. Patient made available for this study through 
the courtesy of Irving Shapiro, MD, and Colin 
Schack, MD, Omaha, Nebraska. 

15. Patient made available for this study through 
the courtesy of Warren Pearse, MD, Chairman, De- 
partment of Obstetrics and Gynecology, University 
of Nebraska College of Medicine. 

16. McCormack, et al. : Postgrad Med Sept 

(1962) 

17. Hirst, D. V.: Abbott — What’s New 223, 

April-May (1961). 

18. Arch Indst Health 18:261-267 (1958). 

19. Von Bartalanffy, F. D.: Pfitzer’s - Spectrum 

8:8 (1960). 

20. AM A News: 18 Feb p 2 (1963). 

21. Ackerman, N. B.; McFee, A.; Blum, J.; 
Makowski, E., and Wangensteen, 0.: JAMA 183:1, 
(1963). 


RESEARCH AND MEDICAL TEACHING 

“In fact, in some schools as previously mentioned, this ‘extra’ 
research, instead of aiding medical education, actually interferes 
with it by keeping members of the senior faculty so busy that many 
of them lose contact with the students . . .” Davison: The Pharos 
of AOA, October, 1963, p. 101). 


52 


Nebraska S. M. J. 


Diaphragmatic Hernia in a Premature Infant 


A Case Report 

D espite recent advances in pe- 
diatric surgery, the mortality 
rate remains high in infants 
with posterolateral diaphragmatic hernias 
(Bochdalek type). The rate has ranged 
from 15% to 38% in some recent re- 
ports. 4. 7, 8 Thg mortality for all white 
male infants weighing between 1001 and 
1500 grams at birth is 64.3% and 52.5% for 
non-white males.® The chance of survival 
of an infant at this weight with a postero- 
lateral diaphragmatic hernia would certain- 
ly be small. 

A premature male infant with a birth 
weight of 1182 grams (2 lbs. 91/2 ounces) 
was successfully treated with surgery at the 
Childrens Hospital of Los Angeles. The in- 
fant is the subject of this report. 

Case Report 

A two-week-old Eurasian male in- 
fant was admitted to the Childrens Hos- 
pital of Los Angeles with a history of 
cyanosis and respiratory distress since 
birth. The infant, one of twins, was the 
product of a seven-month gestation. His 
birth weight was 1182 grams (2 lbs. 
91/2 ounces) and his admission weight 
was 1108 grams (2 lbs. 7 ounces). He 
remained acyanotic when placed in an 
incubator with oxygen until the day 
prior to admission. At that time, 
there developed progressive cyanosis 
and respiratoiy distress. A roentgeno- 
gram of the abdomen and chest (figure 
1) revealed a gas-filled loop of bowel 
above the right diaphragm. Antero- 
posterior and lateral views taken after 
the administration of contrast media 
substantiated the above findings (fig- 
ures 2 and 3). The films also indicated 
that at least a portion of the liver was 
above the diaphragm as there was lack 
of liver density below the diaphragm. 

On admission to this hospital, the in- 
fant was in marked respiratory distress 
with cyanosis and rib retraction. The 


SABATINO DiCENSO, MD 
and 

E. M. GREANEY, JR., MD 
From the Department of Surgery, 
Childrens Hospital of Los Angeles and the 
University of Southern California 
School of Medicine 



Figure 1 — Anteroposterior view of the chest and abdo- 
men showing a gas-filled loop of bowel above the right 
hemidiaphragm. 


respirations were 75 per minute. Dull- 
ness was present over the right base pos- 
teriorly where bowel sounds were heard. 
Bilateral inguinal hernias were also 
present. 

Approximately 2 hours after admis- 
sion, a repair of the diaphragmatic 
hernia was effected through a trans- 
verse abdominal incision. The defect in 
the diaphragm was 2.5 cm. x 5 cm. 
Through this defect, a loop of colon 
and a large sequestered lobe of liver 
herniated into the chest. The viscera 


February, 1966 


53 



Figure 2 - — Anteroposterior view of the chest and abdo- 
men following administration of contrast media. The 
presence of bowel above the right hemidiaphragm is dem- 
onstrated. 



Figure 3 — I^ateral view of the chest and abdomen 
following administration of contrast media. Bowel is 
seen above the hemidiaphragm. 


were delivered into the abdomen and the 
defect closed. A gastrostomy was per- 
formed and the wound closed by ap- 
proximating the skin only. A large 
ventral hernia was thus created (figure 
4). Intravenous fluid therapy was ini- 
tiated. Following operation, the gen- 
eral condition of the infant improved 
and the cyanosis disappeared. Two days 
postoperatively, gastrostomy feedings of 
one-half strength Nutramigen were 
started. The feedings were gradually in- 
creased in amount and concentration. 
By the 14th postoperative day, full 
strength formula feedings were begun. 
The infant continued to do well and was 
discharged approximately 2 months aft- 
er admission. His weight at that time 
was 2500 grams (5 lbs. 8 ounces) (fig- 
ure 5). 

At 41/2 months of age, the infant was 
readmitted to the hospital with symp- 
toms and physical findings compatible 
with a partial small bowel obstruction. 
Roentgenograms showed several loops 
of small bowel with multiple air-fluid 
levels in the ventral hernia. With naso- 
gastric suction and intravenous fluids, 
he made a rapid recovei-y. At the 
time of discharge, his weight was 4659 
grams (10 lbs. 4 ounces). 

Discussion 

A review of the literature revealed one 
report that made specific reference to pre- 
maturity and diaphragmatic hernia.® The 
infant in that case report weighed 4 lbs. 10 
ounces and she survived. Carter, Waterston, 
and Aberdeen^ mention a weight range of 
4 lbs. 8 ounces to 9 lbs. 5 ounces in their 
series, but they do not give any other in- 
formation regarding weight and survival. 
Butler and Claireauxi included 11 infants 
weighing less than 1500 grams in their 
series, but these were from a necropsy study. 

At the Childrens Hospital of Los Angeles, 
posterolateral hernia is the most common 
congenital hernia of the diaphragm (table 
1). It accounted for 68% of the total. The 
left side is involved ten times as frequently 
as is the right. 

The overall mortality rate was 34% from 


54 


Nebraska S. M. J. 



Rigure 4 — The infant approximately one week post operatively. The large 
ventral hernia created at surgery is seen. 


1934 to 1964, and 29% over the past 10 
years. Thus no significant change has been 
noted in more recent times. The reason for 
this failure to obtain a better sui’vival rate 



Figure 5 — The infant at time of initial discharge from 
the hospital. Age, 2Y^ months. 


is probably due to the marked increase 
which has occurred during the last decade 
in the number of patients admitted under 
one week of age. The greatly increased mor- 
tality in this age group is well known. A 
review of the patients that died showed a 
large number to have a hypoplastic lung on 
the side of the hernia and a few had cardiac 
anomalies. 

Table 1 

CLASSIFICATION AND MORTALITY RATE OF 
126 CASES OF CONGENITAL DIAPHRAGMATIC 
HERNIA REVIEWED AT THE CHILDRENS 
HOSPITAL OF LOS ANGELES (1934-1964) 


Type 

No. of 
Cases 

% of 
Total 

Mortality 

Posterolateral 

86 

68 

34% 

left 

78 

62 

33% 

right 

8 

6 

38% 

Esophageal Hiatus 

___ 21 

17 

14% 

Eventration of 
Diaphragm 

18 

14 

11% 

left 

11 

9 

0% 

right 

6 

5 

33% 

bilateral _ 

1 

0.8 

0% 

Parasternal _ 

1 

0.8 

0% 

In addition to the patient 

reported, only 

two infants in 

the series 

weighed 

under 


2000 grams (table 2). One weighed 1986 
grams (4 lbs. 6 ounces) and the other in- 
fant weighed 1577 grams (3 lbs. 71/^ ounces). 


February, 1966 


55 


Table 2 

COMPARISON OF BIRTH WEIGHTS AND 
MORTALITY RATES OF 79 CASES OF 
POSTEROLATERAL DIAPHRAGMATIC 
HERNIA 


Weight (grams) 

No. of 
Cases 

Mortality 

Rate 

1001-1500 

1* 

0% 

1501-2000 

2 

0% 

2001-2500 

14 

507c 

2501-3000 

17 

24% 

Greater than 3000 

46 

37% 


* — Case Report 


These infants both survived. The mortality 
rate is highest in the 2001 to 2500 gram 
group but the difference between the groups 
is probably not statisticallj' significant. 

When the infants are divided into groups 
comprised of those less than one week of 
age and those over one week of age at the 
time of surgery, a marked contrast is noted 
in the mortality rate. Sixty infants were 
less than one week of age at the time of 
surgery. The mortality rate in this group 
was 45%. In twenty-six who were older 
than one week, the mortality rate was only 
8%. This finding indicates that if an infant 
requires surgical intervention shortly after 
birth, the prognosis is generally worse. This 
group includes more of the cases, with unde- 
veloped lungs and other anomalies. 

IMeeker and Snyder^ have re-emphasized 
the value of constructing a ventral hernia at 
the time of the repair in certain cases. The 
infant reported here had such a procedure. 

Finallj', we would like to mention the de- 
sirability of performing a gastrostomy in 
selected cases. This procedure allows de- 
compression of the intestinal tract post- 
operatively and provides an easy route for 
feeding the infant later. 

Summary 

The case histoiy of a premature male in- 


fant weighing 1182 grams at birth who had 
a right posterolateral diaphragmatic hernia 
(Bochdalek type) is presented. The infant 
was successfully treated with surgery. 

Eighty - six cases of posterolateral dia- 
phragmatic hernias treated at the Childrens 
Hospital of Los Angeles were reviewed. The 
overall mortality rate was 34%, with no sig- 
nificant improvement noted in more recent 
times. The mortality rate was markedly 
higher in those infants requiring surgical 
intervention shortly after birth. 


ACKNOWLEDGMENT : 

We wish to thank Doctor Solomon A. 
Kaplan, the pediatrician in charge of 
the infant in this report, for his per- 
mission to use the case and for his help- 
ful suggestions in writing this paper. 


References 

1. Butler, N., and Claireaux, A. E.: Congenital 

diaphragmatic hernia as a cause of perinatal mor- 
tality. Lancet 1 :659-663, 1962. 

2. Carter, R. E.; Waterston, D. J., and Aber- 
deen, E.: Hernia and eventration of the diaphragm 

in childhood. Lancet 1:656-659, 1962. 

3. Cerilli, G. J.: Foramen of Bochdalek hernia: 
a review of the experience at Children’s Hospital 
of Denver, Colorado. Ann Surg 159:385-389, 1964. 

4. Kiesewetter, W. B.; Gutierrez, I. Z., and 

Sieber, W. K.: Diaphragmatic hernia in infants 

under one year of age. AMA Arch Surg 83:561- 
572, 1961. 

5. Meeker, I. A., Jr., and Snyder, W. H., Jr.: 
Surgical management of diaphragmatic defects in 
the newborn infant. Amer J Surg 104:196-203, 
1962. 

6. Menes, S.; Fores, P., and Yalta, J.: Diaphrag- 
matic hernia in a premature. Phillip J Surgery 
16:331-333, 1961. 

7. Moore, T. C.; Battersby, J. S.; Roggenkamp, 

M. W., and Campbell, J. A.: Congenital postero- 

lateral diaphragmatic hernia. Surg Gynec Obstet 
104:675-689, 1957. 

8. Riker, W. L.: Congenital diaphragmatic her- 

nia. AMA Arch Surg 69:291-308, 1954. 

9. Silverman, W. A.: Dunham’s Premature In- 
fants. Paul B. Hoeber, Inc., 3rd Ed 1961. 


“History is lai-gely the record of man’s inhumanity to man.” 
(Graham: The Secret of Happiness, p. 23). 


56 


Nebraska S. M. J. 


NEUROLOGIC MANIFESTATIONS Accompanying Burns 

(BURN ENCEPHALOPATHY) 


A severe burn of the human body 
provokes multiple and far- 
reaching patho-physiologic dis- 
turbances. In a small per cent of patients, 
particularly but not exclusively children, 
there appears an unexepected encephalo- 
pathy. Such encephalopathy usually devel- 
ops in the seriously burned groups, but it 
has been reported in patients (especially 
children) with relatively minor burns, also.^ 
In most instances, the encephalopathy is 
noted in the first few days after burn, less 
frequently after a week and, in but few 
patients recorded, after 6-10 weeks. Symp- 
tomatology follows a not unusual pattern to 
include one or more of the following, tran- 
siently, with sequelae or fatally 

Stupor, coma 

Organic mental changes (confusional states) 
Muscular twitching 
Convulsions 
Cerebral deficits 
Focal 
Multifocal 
Diffuse 

Chorea, athetosis, hyperkinesia 

Cerebral edema (with cerebellar herniation) 

The most common and outstanding acute 
neuropathologic finding is cerebral edema, 
often accompanied by cerebellar and medul- 
lary .herniation into foramen magnum. 
Ventricular dilatation is commonly reported 
in later examination of survivors. Menin- 
gitis, brain abscess, or venous thrombosis are 
rare findings. Microscopically one finds 

Perivascular spaces distended with edema fluid 
Hyperemia, thrombosis of small vessels 
.Small perivascular hemorrhages 
Toxic neuronal changes (especially cortex, 
hypothalmus) 

.Small foci of demyelinization 

The etiology of burn encephalopathy is not 
known today. It may lie in the multiple dis- 
turbances reverberating through many body 
sites and functions. 

During the acute phase following burn, 
the following factors, particularly if severe 


JOHN A. AITA, MD 

Associate Professor, Neurology and Psychiatry 
University of Nebraska College of Medicine 
Omaha, Nebraska 


or in combinations, may have important ef- 
fects on cerebral circulation and paren- 
chyma 20-31 

Hypoxia 

Oligemic (hemo-concentration) shock 

Therapeutic overhydration 

Acidosis (metabolic and respiratory) 

Hypoproteinemia 

Hemoglobinemia 

Anemia 

Renal failure (due to shock and bemo- 
globinuria) 

Blood (erythrocytic) sludging 
On 3 - .5th day, remobilization of edema fluid 
may overload circulation, leading to pulmon- 
ary edema, myocardial failure. 

Hypoxia may be an important factor in 
cerebral involvement. Its severity is com- 
monly in direct proportion to severity and 
extent of burn. Arterial oxygen tension was 
found significantly lowered in about 50 per 
cent of one series of burn patients. The 
following conditions contribute to hy- 
poxia 22 , 25 , 27 

Respiratory tract burn, edema 
Burn of cbest wall, abdomen 
Carbon monoxide inhalation 
Smoke, fumes, irritant gases 
Excessive sedation 
Hypovolemic shock 

Medullary compression (cerebral edema) 
Pneumonia 

Shock adds its circulatory impairment, 
arising from marked loss of fluid into exu- 
dation and edema. Sodium, chlorides, plas- 
ma proteins and water are likewise depleted. 
Shock is common in patients with over 15 
per cent body surface burn. 

In the subacute and chronic phase the fol- 
lowing factors may, particularly if severe 
or in combinations, affect important dis- 


February, 1966 


57 


turbances in cerebral circulation and paren- 
ch\Tna 

Renal, hepatic failure. Adrenal failure (rare). 

“Toxemia” 

Drug reactions 

Peptic ulceration (Curling’s ulcer: anemia, per- 
foration) 

Late shock^i 

Infection 

Defects remaining from acute phase 

“Toxemia” in various forms has appeared 
a likelj’ explanation for many occurrences 
in burned patients. It has not been clearly 
demonstrated as yet although some investi- 
gators are pursuing this possibility with 
vigor.®2-36 The following definitions are un- 
der consideration: 

Absorbed exudates of burned tissue or blood 
are toxic. 

Auto-immunologic reactions may develop from 
burned tissue. 

Absorption of bacterial products with infection. 

Infection provides a major hurdle in sur- 
vival and recovery from burns. The burned 
sites provide a rich attraction for bacteria, 
common among which are Staphjdococcus 
aureus and pseudomonas. The absorption of 
great quantities of bacterial products as 
well as septicemia occur. Viremia and subtle 
fungus disseminations are possible in the 
debilitated state. Tetanus, and rarely diph- 
theria, may also entrench in burned tissue. 


Pre-existing, serious disease occurs in at 
least 10 per cent of burned patients .®’ 27 
This may account not only for their being 
burned but also for some subsequent cerebral 
patholog)'. Delirium tremens, acute alco- 
holism, drug use, cerebrovascular accident, 
senile dementia, syncope or convulsion may 
result in accidental burns. A noteworthy 
number of children in one gi’oup of burn 
encephalopathies appeared to have incurred 
prior cerebral damage which may have 
rendered them incapable of withstanding 
transient cerebral changes (edema?) asso- 
ciated with burns.®’® 

Psychogenic factors are common in burn 
patients, outstandingly noted in chil- 
dren.®’ ®"’ ®® Emotional and behavioral dis- 
turbances following burns are more common- 
ly of psychogenic origin than of organic 
cerebral damage. However, each patient 
warrants individual study, for the presence 
of concomitant organic and psychogenic de- 
fects is possible. 

With little known today concerning spe- 
cific etiologj’ of burn encephalopathy, treat- 
ment requires immediate reappraisal of the 
many biochemical and physiologic facets 
cited above. The appearance of burn en- 
cephalopathy often signifies a gi’ave turn. 
Supportive and symptomatic care may in- 
clude anticonvulsants and tranquilizers. 

(References are available from the author). 


“. . . Somehow I cannot help thinking that any threat to Ameri- 
can drug companies like Lederle is a threat to everybody like me 
who wants to be around for the next chapter in the conquest of 
disease.” (From Dabiel: Threats to the Battle Against Disease, 
Reader’s Digest, October, 1964, p. 118). 


58 


Nebraska S. M. J. 


ORGANIZATION SECTION 


Coming Meetings 

CRIPPLED CHILDREN’S CLINICS— 
February 5 — Hastings, Elks Club 
February 19 — Ainsworth, Elementary 
Grade School 

March 5 — North Platte, Elks Club 
March 19 — Broken Bow, Elks Club 

CONTINUING EDUCATION COURSES — 
For physicians sponsored by the Univer- 
sity of Nebraska College of Medicine’s 
Office of Continuing Education — 

February 3-4, 1966 — “Current Status 
of Cardiovascular Disease” (Omaha 
Campus) 

February 17-18, 1966 — “Community 
Psychiatry and the G.P.” (Omaha 
Campus) 

March 7, 1966 ■ — ■ “Closed Chest Cardiac 
Resuscitation” (Omaha Campus) 
March 24, 1966 — “Newer Concepts of 
Hypertension” (Omaha Campus) 

1965 POSTGRADUATE COURSES SPON- 
SORED BY THE AMERICAN COLLEGE 
OF CHEST PHYSICIANS — Clinical ap- 
plication of cardiopulmonaiy physiology; 
What’s new in the diagnosis and treat- 
ment of cardiovascular and pulmonary dis- 
eases : Fountainebleau Hotel, Miami Beach, 
January 24-28, 1966. Clinical application 
of cardiopulmonary physiology: Ambassa- 
dor Hotel, Los Angeles, February 14-18, 
1966. Cine - angiographic techniques in 
cardiovascular diseases: Cleveland Clinic, 
Cleveland, April 11-13. Write to: Ameri- 
can College of Chest Physicians, 112 East 
Chestnut Street, Chicago 11, Illinois. 

MID-WINTER MEETING BOARD OF 
COUNCILORS — February 11, 1966, 

Holiday Inn, Kearney, Nebraska. 

MID-WINTER MEETING HOUSE OF 
DELEGATES — February 12-13, 1966, 
Holiday Inn, Kearney, Nebraska. 

SIOUX VALLEY MEDICAL ASSOCIA- 
TION — February 24 and 25, 1966 ; Shera- 
ton-Warrior Motor Inn, Sioux City, Iowa. 


ETV PROGRAMS FOR REGISTERED 
NURSES— 

February 1 — The Assignment of Nurs- 
ing Personnel (1 p.m.) 

February 8 — The Patient - Centered 
Conference (1 p.m.) 

February 15 — The Nursing Care of the 
Patient with Short-Term Illness (1 
p.m.) 

February 22 — The Nursing Care of the 
Patient with Long-Term Illness (1 
p.m.) 

March 1 — Nursing Care of the Hemi- 
plegic Patient (1 p.m.) 

March 8 — The Nursing Care of a Pa- 
tient Requiring a Bird Respirator (1 
p.m.) 

March 15 — Nursing Care of a Patient 
Requiring a Pacemaker (1 p.m.) 

American College of Physicians 
Postgraduate Courses, 196.5-1966 — 

The following courses are made possible 
by the generous cooperation of the directors 
and institutions involved. Tuition fees: 
Members, $60; Nonmembers, $100. Regis- 
tration forms and requests for information 
are to be directed to: Edward C. Rosenow, 
Jr., MD, Executive Director, The American 
College of Physicians, 4200 Pine Street, 
Philadelphia, Pa. 19104. 

CURRENT CONCEPTS OF INFECTIOUS 
DISEASE — Jefferson Medical College, 
Philadelphia, Pa. ; Robert I. Wise, M.D., 
F.A.C.P., Director; Joseph F. Rodgers, 
M.D., Co-Director. February 7-11, 1966. 

MEDICAL GENETICS — The Johns Hop- 
kins Hospital, Baltimore, Md. ; Victor A. 
McKusick, M.D., F.A.C.P., Director. Feb. 
14-18, 1966. 

CANCER — Presbyterian-St. Luke’s Hos- 
pital, Chicago, 111.; Samuel G. Taylor, HI, 
M.D., F.A.C.P., Director. Feb. 21-25, 1966. 

THE BIG HEART, Cardiac Work and Car- 
diac Hypertrophy; Clinical Appraisals, 
Therapeutic Considerations and Pathologic 
Correlations — Baylor University College 
of Medicine, Houston, Texas; Raymond D. 
Pruitt, MD, FACP, Director. March 7-11, 
1966. 


February, 1966 


59 



BASIC MECHANISMS IN INTERNAL 
MEDICINE, University of Toronto, Tor- 
onto, Ontario, Canada; K. J. R. Wight- 
man, MD, FACP, Director. March 28- 
April 1, 1966. 

CURRENT CONCEPTS OF RENAL, GAS- 
TROINTESTINAL AND CIRCULATION 
PHYSIOLOGY — Co-sponsored by the 
American Physiological Society, Barbizon- 
Plaza Hotel, New York, N.Y.; Daniel H. 
Simmons, MD, FACP, and Charles Klee- 
man, MD, FACP, Co-Directors. 

RURAL HEALTH CONFERENCE — Farm 
and health leaders are to meet March 18- 
19, 1966 at Colorado Springs, in the 
Broadmoor Hotel, for the 19th National 
Conference on Rural Health, sponsored by 
the Council on Rural Health of the AMA 
in association with state medical associa- 
tions ; and farm, educational, and allied 
health organizations. 

STL’DY AND SKI — Scientific meetings, 
a winter ski vacation, a cocktail party, 
and a dinner-dance are planned for the 
31st Midwinter Clinical Session of the 
Colorado Medical Society, March 1 through 
3. Write to the Colorado Medical Society, 
1809 East 18th Avenue, Denver, Colorado 
80218. 

CONFERENCE ON AIR POLUTION RE- 
SEARCH — The AMA has scheduled the 
first Air Pollution Medical Research Con- 
ference foi March 2-4, 1966, at the Am- 
bassador Hotel in Los Angeles. Six ad- 
ditional cooperating organizations include 
The American College of Chest Physi- 
cians, the American Thoracic Society, the 
U.S. Public Health Service, the California 
State Department of Public Health, the 
California Medical Association, and the 
Los Angeles County Medical Association. 
Write to Air Pollution Medical Research 
Conference, Department of Environmen- 
tal Health, AIMA, 535 N. Dearborn St., 
Chicago, Illinois 60610. 

CONTINUING EDUCATION — Closed 
Chest Resuscitation ; University of Nebras- 
ka College of IMedicine, at Eppley Research 


Institute, March 8, 1966 (for physicians, 
9th for dentists, and 10th for nurses). 
Info : Continuing Education, University of 
Nebraska College of Medicine, 42nd and 
Dewey, Omaha 5. 

MICROCIRCULATION — Microcirculation 
is to be the topic of discussion at the 
Heart Association of Southeastern Penn- 
sylvania’s Fifth National Symposium to 
be held at the Philadelphia’s Sheraton 
Hotel on March 10 and 11, 1966. Write 
to Lyle L. Perry, Heart Association of 
Southeastern Pennsylvania, 318 S. 19th 
Street, Philadelphia, Pa. 19103. 

NATIONAL SOCIETY FOR THE PRE- 
VENTION OF BLINDNESS — “Vision 
for the Space Age;’’ Houston, Texas, Rice 
Hotel, March 24-26, 1966. Info: Director 
of Information John D. Coleman, 16 East 
40th Street, New York 10016. 

MAYO CLINIC AND FOUNDATION — 
Clinical Reviews, a program of lectures 
and discussions on problems of general 
interest in medicine and surgery, will be 
presented on March 28, 29 and 30, 1966, 
and will be repeated (they will be iden- 
tical sessions) on April 4, 5, and 6, 1966. 
Write to M. G. Brataas (Secretary, Clini- 
cal Reviews Committee), Mayo Clinic, 
Rochester, Minnesota. 

Future Meetings of the American 

College of Surgeons — 

CLEVELAND, OHIO, March 14-17. Annual 
4-Day Sectional Meeting for Doctors and 
Graduate Nurses. Sheraton-Cleveland and 
nearby hotels. 

ANNUAL CLINICAL CONGRESS, Octo- 
ber 10-14, 1966. San Francisco, Cali- 
fornia. 

For any advance information address: 

Secretary, American College of Surgeons, 55 

East Erie Street, Chicago, Illinois 60311. 

THE SOUTHWESTERN SURGICAL CON- 
GRESS — Flamingo Hotel, Las ^"egas, 
Nevada, April 18, 19, 20, 21, 1966. 


60 


Nebraska S. M. J. 


SIGHT -SAVING CONFERENCE — The 
1966 annual Sight-Saving Conference of 
the National Society for the Prevention of 
Blindness, Inc., will take place from March 
30 through April 1, 1966, at the Hotel 
Roosevelt, New York, N.Y. Write to John 
D. Coleman, Director of Information, Na- 
tional Society for the Prevention of Blind- 
ness, Inc., 16 East 40th St., N.Y.C. 

ENVIRONMENTAL HEALTH — The Third 
Congress on Environmental Health Prob- 
lems of the AMA will be held April 4-5 
at the Drake Hotel in Chicago. Write to 
EHC, Department of Environmental 
Health, AMA, 535 N. Dearborn St., Chi- 
cago, Illinois 60610. 

TERATOLOGY WORKSHOP — The Third 
Teratology Workshop will be held April 
4-8, 1966 at Boulder-, Colorado; it is spon- 
sored jointly by the AMA, the Teratology 
Society, and the University of Colorado, 
with the support of the National Academy 
of Sciences - National Research Council. 
Write to William Kitto, MD, Associate Di- 
rector, Department of Drugs, AMA, 535 
North Dearborn Street, Chicago, Illinois 
60610. 

INDUSTRIAL HEALTH — The 1966 Amer- 
ican Industrial Health Conference will 
take place April 25-28 in Detroit, Mich- 
igan. Headquarters will be at the Sher- 
aton Cadillac Hotel, meetings in Cobo Hall. 
Write to: American Industrial Health 

Conference, 55 East Washington Street, 
Chicago, Illinois 60602. 

ANESTHESIOLOGY — Third Annual Mid- 
west Conference on Anesthesiology. Con- 
tinental Plaza Hotel, Chicago, Illinois, 
April 28-30, 1966. Write to T. L. Ash- 
craft, M.D., 33 East Cedar Street, Chi- 
cago, Illinois 60611. 

POSTGRADUATE COURSE IN LARYN- 
GOLOGY AND BRONCHOESOPHA- 
GOLOGY — A postgraduate course in 
laryngology and bronchoesophagology will 
be conducted by the Department of 
Otolaryngology of the Illinois Eye and 


Ear Infirmary and the College of Medi- 
cine of the University of Illinois at the 
Medical Center, Chicago, from March 21 
through April 2, 1966. Write to the De- 
partment of Otolaryngology, College of 
Medicine of the University of Illinois at 
the Medical Center, Postoffice Box 6998, 
Chicago, Illinois 60680. 

THE HAHNEMAN MEDICAL COLLEGE 
AND HOSPITAL of Philadelphia offers 
the following Postgraduate Education 
Courses during 1965 and 1966: 

— April 20-23, 1966: 16th Hahneman 

Symposium, Arterial Occlusive Disease; 
Dr. Albert N. Brest; Marriott Motor 
Hotel. 

— December, 1966: 17th Hahneman Sym- 
posium, Nutritional Dysfunction; Dr. 
Donald Berkowitz ; S h e ra ton Hotel, 
Philadelphia. 

ARTHRITIS FOUNDATION — A two-day 
Postgraduate Seminar on Rheumatic Dis- 
eases will be held May 6 and 7, 1966 at the 
A. B. Dick Auditorium of Presbyterian- 
St. Luke’s Hospital, 1753 West Congress 
Parkway, Chicago, Illinois. The Seminar 
is sponsored by The Illinois Chapter, The 
Arthritis Foundation, 159 North Dear- 
born, Chicago. There will be a registra- 
tion fee of $20. 

FIRST ANNUAL BIOMEDICAL LASER 
CONFERENCE — June 17-18, Sheraton- 

Boston Hotel, Boston, Massachusetts. 


TENTH WORLD CONGRESS OF THE IN- 
TERNATIONAL SOCIETY FOR RE- 
HABILITATION OF THE DISABLED 
— September 11-17, 1966, Rhein-Main- 
Hall, Wiesbaden, Gei-many. 

INTERNATIONAL CANCER CONGRESS 
— The IX International Cancer Congress 
will be held in Tokyo, Japan, from October 
23-29, 1966. Write to Hirsch Marks, MD, 
435 East 57th St., New York 22, N.Y. 


February, 1966 


61 


The Military Dependents' 
Medical Care 

Coverage for Accident Care As An Out-patient 
Cnder the Military Dependents Medical Care — 

Dependents who are treated for an injury 
in the doctor’s office or as an out-patient at 
the hospital shall pay the first $15 of the 
physician’s fee for each different cause or 
accident for which treatment and services 
are rendered, except that multiple injuries to 
the same person resulting from a single ac- 
cident shall be considered as one injury for 
payment of the maximum required fee 
($15.00) by the patient. The Government 
shall pay for all costs in excess of $15.00 as 
authorized in the local schedules of allow- 
ances. 

However, payment by the Government for 
laboratory tests and radiologj’ examinations 
shall not exceed the $75.00 maximum except 
in special cases, provided that the physician 
authorizing the tests, for which charges ex- 
ceed the amount specified above, submits a 
special report which shall be reviewed by a 
contractor’s physician review board. 


THE MONTH IN WASHINGTON 

1. The staff of the Senate Antitrust Sub- 
committee has been investigating the rise in 
quinine prices. 

The investigation resulted from receipt by 
members of Congress of complaints from 
constituents. Many of the complaints re- 
ported a sharp rise in the price of quinidine, 
a quinine derivative prescribed for irregular 
heart beats. 

The Pharmaceutical Manufacturers Asso- 
ciation attributed the price rise to a com- 
bination of decreased supplies and rising de- 
mands. 

A spokesman for the association said that 
it had become increasingly difficult to ob- 
tain quinine’s raw material, the bark of the 
cinchona tree. He said that Indonesia, once 
the principal supplier, had virtually cut off 
its exports of the cinchona bark to the West- 
ern world. 


Other suppliers, he said, include the Congo 
and some South American countries. He 
said these sources were seriously limited, 
but that the shortage was not expected to 
reach critical proportions. 

The PMA spokesman attributed the ris- 
ing demand to the appearance of new strains 
of malaria that are resistant to synthetic 
drugs developed during World War II as 
quinine substitutes. This has caused de- 
mands for natural quinine to rise sharply in 
such malaria-infested areas as Vietnam. 

2. The Food and Drug Administration 
has taken the first steps in implementation 
of the new law designed to halt illegal ti'af- 
fic in depressant and stimulant drugs. 

Acting FDA Commissioner Wilton B. Ran- 
kin announced proposed regulations and ap- 
pointed an advisory committee of experts as 
authorized by the Drug Abuse Control 
Amendments law enacted last year. 

The Advisory Committee on Abuse of De- 
pressant and Stimulant Drugs, which held 
its first meeting in late December, assisted 
the FDA in determining the drugs covered 
under the new, tighter controls effective Feb- 
ruary 1, 1966. The new law specified am- 
phetamines and barbiturates but also author- 
ized designation of other depressant and 
stimulant drugs by regulatory orders of the 
FDA. 

At its first meeting, the advisory com- 
mittee considered several classes of such 
drugs, including certain tranquilizers, LSD- 
25 and other hallucinogenic agents. 

The FDA regulations listed details of the 
records which the new law requires to be 
kept bj' every person manufacturing, com- 
pounding, processing, selling or otherwise 
distributing the designated drugs. The first 
required record is an inventory of stocks on 
hand of such drugs as of Febr. 1. This 
initial inventory must contain the identity 
and quantity of all the specified drugs in 
finished form under the control of the regis- 
trant. Records thereafter must accurately 
list further manufacture, receipt and dispo- 
sition of the drugs. 

The system of record keeping was designed 


62 


Nebraska S. M. J. 


to permit government agents to follow the 
movement of the drugs — all of which are 
prescription drugs — from producer to con- 
sumer. 

The FDA commissioner is authorized to 
determine that a stimulant or depressant 
drug has a potential for abuse, and therefore 
should be covered under the law, if there is 
evidence of : 

— Individuals taking the drug in amounts 
sufficient to create a hazard to their health 
or to the safety of other individuals or the 
community. 

— Significant diversion of the drug from 
legitimate drug channels. 

— Individuals taking the drug on their 
own initiative rather than on advice of a 
physician or osteopath licensed by law to ad- 
minister such drugs. 

Most physicians won’t be affected directly 
by the new federal regulations which state : 

“The maintaining of small supplies of 
these drugs for dispensing or administering 
in the course of professional practice in 
emergency or special situations will not be 
considered as regularly engaged in dispens- 
ing for a fee.” 

3. A panel of leading businessmen has 
warned of the dangers of relying too heavily 
on government for administration of health 
and retirement plans. 

Such government programs should be 
used to help the sick, disabled and aged, the 
panel said, “only if voluntary and private 
means — truly and tested — cannot ade- 
quately meet society’s needs . . . Heavy re- 
liance on government can discourage the ex- 
perimentation and innovation needed to solve 
our health and retirement problems. Such 
reliance also can narrow the freedom of 
choice of people who prefer to meet their 
needs in their own ways.” 

This statement was a highlight of a 263- 
page report by the Task Force on Economic 
Growth and Opportunity, which was an inde- 
pendent group set up under the sponsorship 
of the U.S. Chamber of Commerce. The re- 


port was titled “Poverty: The Sick, Disabled 
and Aged.” 

The report cited medicare as an example, 
as follows: 

“In an attempt to help low income aged 
people obtain health care at little personal 
cost, medicare was attached to the tradition- 
bound Social Security program. As a re- 
sult, medicare will help millions of Ameri- 
cans who are not needy by any stretch of the 
imagination. 

“It will be financed by the Social Security 
payroll tax, a highly regressive tax that 
places heaviest burdens, in relation to in- 
come, on low income workers and on low in- 
come consumers who pay higher prices to 
absorb the cost of payroll taxes levied on em- 
ployers.” 

4. Measles incidence in 1965 was the low- 
est in recent years, according to the Public 
Health Service’s Communicable Disease Cen- 
ter. 

Through the first 49 weeks of the year, 
256,443 cases were reported, far below the 
average of more than 400,000 annual cases 
since 1960. There were 478,518 cases in the 
first 49 weeks of 1964. 

But PHS warned that, if past experience 
is repeated, major epidemics can be expected 
in many sections of the country during the 
first half of 1966. 

5. The federal government is going to 
spend more on health and education pro- 
grams in 1966 — but not as much as origin- 
ally expected, principally because of the 
Viet Nam war. 

HEW Secretary John W. Gardner says 
1966 would not be a “slowdown year” in his 
department because of the start of new pro- 
grams in elementary and secondary educa- 
tion, medicare, water pollution, disease con- 
trol and other areas. 

But, he added, a certain slackening in 
other programs might be useful. He de- 
clined to identify specific projects. He said, 
however, that they “might be done better 
if they are started slowly.” 


February, 1966 


63 


Announcements 

1966 ACP Award Winners — 

Awards for 1966 in internal medicine and 
related fields have been announced by the 
American College of Physicians ; the honors 
will be bestowed on four physicians and a 
philanthropist at the annual meeting of the 
ACP in April. 

The winners are Helen B. Taussig, MD, 
Baltimore, Md. ; Robert A. Phillips, MD, 
Dacca, East Pakistan; Charles P. LeBlond, 
j\ID, Montreal, Canada; Mrs. Albert D. Las- 
ker, New York, N.Y.; and Howard P. Lewis, 
MD, Portland, Ore. 

Pediatricians to Meet — 

Evanston, 111. — More than 3,000 pedia- 
tricians, their families and guests, are ex- 
pected to attend the annual Spring Session 
of the American Academj^ of Pediatrics, 
April 25-27, 1966, at the Queen Elizabeth 
Hotel, Montreal, Canada. 

The scientific program will feature closed 
circuit television presentations on subjects 
including cerebral palsy, learning disorders, 
and growth problems. 

Scientific presentations will cover subjects 
including newborn and prematurity, prob- 
lems of carbohydrate metabolism, manage- 
ment of cardiac failure in children with 
acyanotic congenital heart disease, pulmon- 
ary hypertension, pediatric surgery, and 
genetics and congenital disorders. 

Pediatricians and other physicians inter- 
ested in the care of children are invited to 
attend the meeting, according to E. H. 
Christopherson, MD, executive director. 

The Academy, with headquarters in 
Evanston, 111., is the Pan-American associa- 
tion of physicians certified in the care of 
infants, children, and adolescents. 

It has some 9,100 members in the U.S., 
Canada and Latin America. 

Registration for the meeting will open 
Sunday, April 24 with a reception that eve- 
ning. Several luncheon and dinner events, 
and activities for the wives of physicians 
have been planned. 


The meeting is open to nonpediatricians. 
Registration fees are $15 for Academy mem- 
bers, applicants to the Academy, applicants 
to the American Board of Pediatrics, non- 
members out of school less than five years, 
and physicians in the Armed Forces. Regis- 
tration fees for nonmember physicians are 
$25. 

Physicians interested in attending the 
meeting should write the American Academy 
of Pediatrics, 1801 Hinman Avenue, Evans- 
ton, Illinois 60204, for a preliminary pro- 
gram and housing and registration forms. 

Dr. Johnson Named Cancer Trainee — 

Omaha — Dr. Joel Johnson, a surgery 
resident at the University of Nebraska Hos- 
pital, was named a Senior Clinical Cancel- 
Trainee by the National Institutes of Health. 

Under the traineeship. Dr. Johnson will 
actively conduct research primarily con- 
cerned with cancer training. 

Last year’s trainee from University Hos- 
pital was Dr. Robert Westfall, an instructor 
in surgery at the College of Medicine. 

Michael Newton, MD, Named Director- 
Elect of the College — 

Chicago, 111. — Dr. Michael Newton, Pro- 
fessor and Chairman of the Department of 
Obstetrics and Gynecology at the University 
of Mississippi, has been named Director- 
Elect of The American College of Obstetri- 
cians and Gynecologists. Dr. Newton will 
join the College’s administrative office on 
July 1 and will assume the full directorship 
one month later. 

Postgraduate Seminar; Childrens 
Memorial Hospital — 

Liver Disease and Bilirubin Metabolism 
will be the subject of the Sixth Annual Post- 
graduate Seminar of Childrens Memorial 
Hospital, Omaha, Nebraska on Friday and 
Saturday, June 3 and 4, 1966. 

Guest speakers will be Sydney S. Gellis, 
MD, and Jerold F. Lucey, MD. 

For further information write to : Carol 
R. Angle, MD, Childrens Memorial Hospital, 
Omaha, Nebraska 68105. 


64 


Nebraska S. M. J. 


News and Views 

Hospital-based Physicians and Medicare — 

The principles to be followed in reimburs- 
ing hospital-based physicians for services 
provided to older people under the Medicare 
program have been announced by Robert M. 
Ball, Commissioner of Social Security. 

“T h e principles,” he said, “will leave 
physicians and hospitals entirely free to de- 
termine arrangements between them. They 
will be able to follow their existing local prac- 
tices or to make any new arrangements they 
may decide upon.” 

Farewell for S. S. HOPE — 

A gala sea and air salute will accompany 
the S. S. HOPE as it weighs anchor on Sun- 
day and sails for its newest mission of 
mercy in Nicaragua. The famed hospital- 
teaching ship leaves Pier 96 in South Phila- 
delphia at 2:00 p.m., the scene of her tri- 
umphant arrival to the City of Brotherly 
Love four months ago. City, State and Nic- 
araguan officials and the Ferko String Band 
of the Philadelphia Mummers will be on hand 
for farewell ceremonies prior to departure. 
Dr. William B. Walsh, originator of Project 
HOPE in 1958 and currently President of 
the nonprofit organization, will officiate. 

On board will be the permanent staff of 98 
doctors, nurses and technicians including 28 
veteran Hopies who have served on previous 
missions of the HOPE to Southeast Asia, 
Peru, Ecuador and, most recently Guinea, 
West Africa. Senior among this dedicated 
group will be Chief Nurse Ann Roden, from 
South Bend, Indiana, who has served on all 
four voyages. 

The HOPE will be anchored for ten months 
in Corinto on the west coast of Nicaragua, 
commencing on January 19 her first program 
in Central America. The ship under the 
operation of the Grace Line will be com- 
manded by Captain Elijah J. Howe who 
skippered the ship during the Peruvian voy- 
age in 1962-63 and, like so many other men 
and women who have served on the HOPE’S 
staff, requested reassignment to the world’s 
only peacetime hospital ship. 

The floating medical center which visits 


developing nations by invitation is funda- 
mentally a cooperative effort between the 
ship’s medical, dental and nursing staff and 
those of the host nation. Its main objective 
is international cooperation of professional 
knowledge and continued elevation of health 
care for people on three continents. 

Busier Blue Shield — 

Blue Shield enrollment exceeded 57 million 
during the first nine 1965 months, over a mil- 
lion more than the 1964 year end total. 
Benefits paid during 1964 were almost one 
and a quarter billion dollars; they have al- 
ready exceeded a billion dollars during the 
first three quarters of 1965, which is almost 
90 million dollars over last year’s third quar- 
ter. 

That’s a lot of people and a lot of money. 
They must know what they’re doing. 


Our Medical Schools 

Dr. Wittson to Continue on Aging Committee — 

Omaha — Dr. Cecil L. Wittson has ac- 
cepted an invitation to serve for another 
three-year term on the American Medical 
Association’s Committee on Aging. 

He is Dean of the University of Nebraska 
College of Medicine. 

Dr. Wittson has served three previous 
terms on the Aging Committee. 

University of Nebraska School of Nursing — 

Omaha — Three administrators of the 
University of Nebraska School of Nursing 
will attend a meeting of the Baccalaureate 
and Higher Degrees Department of the Na- 
tional League for Nursing in St. Louis, Mo. 
this month. 

Representing the nursing school will be 
IMiss Irma M. Kyle, director and professor 
of nursing; Mrs. Regina Barenston, asso- 
ciate director and associate professor of 
nursing; and Miss Clare Fleming, assistant 
director and associate professor of nursing. 

For nursing educators, the conference will 
deal with the baccalaureate education of 


February, 1966 


65 


registered nurses who Avere graduated from 
hospital schools of nursing. 

Approximately 200 representatives are ex- 
pected to attend the January 20 and 21 meet- 
ing at the Hilton Hotel. 

Dr. Lemmon Consults With Wyoming: Group — 

Omaha — Dr. Henry i\I. Lemon met 
with the \^Voming Cancer Society Board in 
Casper, Wyo., Saturday, January 8, to dis- 
cuss plans for a future leukemia epidemiol- 
ogy' study in that state. 

He is director of the Eppley Cancer In- 
stitute at the University of Nebraska College 
of Medicine. 

He was invited to the Casper meeting as 
a consultant, since a survey of this type is 
being conducted in a six-county Nebraska 
area by several Nebraska College of i\Iedi- 
cine faculty members. 

The W’yoming Division of the American 
Cancer Society and the Wyoming State De- 
partment of Health are cooperating Avith the 
Earl and Bessie Whedon Cancer Detection 
Foundation in the leukemia epidemiology 
project in Wyoming. 

New AOA Members — 

Four physicians have been selected for 
membership in the Creighton University 
Chapter of Alpha Omega Alpha, national 
medical honor society. 

They are Doctors Joseph M. Holthaus, 
Richard J. Fangman, Claude H. Organ and 
Alfred W. Brody. 

Nine senior medical students and three 
juniors complete the neAv memberships in 
the Creighton chapter. 

Postgraduate Seminars — 

The chairman of the Department of Phar- 
macology from the Indiana UniA’ersity Medi- 
cal School Avill present the second of a series 
of postgraduate biochemistry seminars at 
Creighton UniA’ersity Feb. 18. 

Dr. James Ashmore AA’ill discuss “Factors 
Regulating Hepatic Glucose Production.” 
The seminar Avill be at 8 p.m. in the Eppley 
Lecture Hall on the Hilltop campus. 


Other seminars, all scheduled at 8 p.m. 
at the Lecture Hall, are: 

iMarch 18, Dr. Dean Watt, Senior Re- 
search Biochemist, JMidAvestern Research In- 
stitute, Kansas City, Mo., “Purification and 
Mechanism of Action of Toxic Peptides.” 

April 22, Dr. Salih Wakil, Professor of 
Biochemistry, Duke University Medical 
School, “The Biosynthesis and Control of 
Fatty Acids.” 

Dr. Henry Lardy, Director of the Enzyme 
Institute at the University of Wisconsin, and 
Dr. Nicholas Giarman, Chairman of the De- 
partment of PharmacologA’ at Yale Univer- 
sity Medical School, Avill conduct seminars to 
be scheduled in May or June. 

The series is co-sponsored by Creighton 
University and the Progi’am of Postgradu- 
ate Medical Education of Merck, Sharp and 
Dohme Pharmaceutical Company. 

Twenty-five Pass Exams — 

Omaha — TAventy-five 1965 graduates of 
the University of Nebraska College of Medi- 
cine’s medical technology program passed the 
national certification examination conducted 
by the Board of Registry of Medical Tech- 
nologists, American Society of Clinical Path- 
ologists. The announcement Avas made this 
week by Dr. Arthur L. Larsen, director of 
medical technology’ training and assistant 
professor of pathology at the College of Med- 
icine. 

These students may noAv place the letters 
M.T. (ASCP) after their names, shoAving 
they are accredited members of their profes- 
sion and of the medical team. 

“Methods Improvement in Nursing” — 

Omaha — A collegiate course in adminis- 
tratiA’e techniques necessary to the profes- 
sional nurse in her job Avill be offered by 
the UniA’ersity of Nebraska School of Nurs- 
ing and College of Business Administration. 

“^Methods Improvement in Nursing” Avill 
be conducted at the Nebraska School of Nurs- 
ing, Omaha, from 9 to 12 noon each Satur- 
day beginning February 5 and ending March 
19. The course is fourth in a special non- 


66 


Nebraska S. M. J. 


credit series on “Toward Self-Improvement 
in Administrative Technique.” 

HEW Grant— 

Omaha — A $7,387 grant from the De- 
partment of Health, Education and Welfare’s 
IMaternal and Child Health Services has 
been awarded to Dr. Dale Cruise and Dr. 
Robert IMesser. 

Granted for programmed instruction in 
prenatal and infant care at the University 
of Nebraska College of Medicine, the grant 
covers the j^ear beginning December 1 and 
ending November 30, 1966. 

The department of obstetrics and g>me- 
cology in conjunction with the University 
of Nebraska audio-visual department have 
produced a 12-program series on prenatal 
and infant care for ETV, Channel 12. 

Monies from the grant will be used to con- 
vert the video-taped programs into 16 mm 
sound movies. A selected group of prenatal 
patients will view these movies and, via pro- 
grammed instruction, will be informed of 
obstetrical care. These patients will be pre- 
tested and post-tested, and then compared 
to a control group of prenatal patients who 
attended regular prenatal classes, to deter- 
mine the effectiveness of programmed in- 
structions. 

The films cover all phases of maternal 
care, for example: recent advances in ob- 

stetrics; prenatal care; maternal nutrition; 
mechanisms of labor and deliveries; care of 
the infant after birth ; and agencies for baby 
care. 

Dr. Cruise is project director of the Oma- 
ha Maternal and Infant Care Project; Dr. 
Messer is an assistant professor of ob- 
stetrics and gynecology. 

Video Tapes in Psychotherapy — 

Omaha — How video tapes are used in 
teaching psychotherapy at the Nebraska 
Psychiatric Institute is the subject of an 
article in the current Journal of Medical 
Education. 

The article was written by Reba Ann Ben- 
schoter, chief of NPPs Communications Di- 


vision ; Dr. Merrill T. Eaton and Pringle 
Smith. 

Residents in training interview patients, 
and the interview is filmed on video tape. 
Later the resident and his supervising psy- 
chiatrist view the film and evaluate the in- 
terview. 

Each video tape psychotherapy session 
lasted about 45 minutes. 

The authors are all faculty members of 
the University of Nebraska College of Medi- 
cine. 

The Journal of Medical Education is the 
official publication of the Association of 
American Medical Colleges. 


All About Us 

Doctor Robert S. Long of Omaha is one 
of the 1965 winners of the Medical Econom- 
ics Awards. 

The Omaha-Douglas County Medical So- 
ciety Christmas party was held December 
14th in Omaha. 

Doctors L. L. Ericson and E. L. Sucha, 
West Point, are constructing a new Elkhorn 
Valley Clinic Building. 

The Tri-County Medical Society and Aux- 
iliary met in December and had Mr. J. M. 
McPhail of Omaha as its guest speaker. 

Doctor R. E. Penry was elected Chief of 
Staff and President of the Thayer County 
Memorial Hospital at the group’s Decem- 
ber meeting. 

Doctor C. G. Gross, formerly of Cam- 
bridge, has moved to Lincoln, where he is 
associated with the Veterans Administra- 
tion Hospital. 

Members of the Adams County Medical 
Society and Auxiliary met for a dinner-party 
at the Meadow Brook Club at Hastings in 
December. 

Doctor Henry J. Lennhoff, Jr., was elected 
President of the Omaha-Midwest Clinical 
Society at the group’s annual business meet- 
ing held in December. 


February, 1966 


67 


Doctor John A. Brown, III, Lincoln, was 
installed as President of the Nebraska Ob- 
sterical and Gynecology society at the 
group’s annual meeting held in December at 
Las \’egas. 

Doctor M. D. Frazer, Lincoln, was re- 
elected Secretary - Treasurer of the Radio- 
logical Society of North America at the 
group’s annual convention in Chicago held 
in December. 

Doctor Paul J. Maxwell, Lincoln, was se- 
lected as President-elect of the Lancaster 
County Medical Society at the group’s De- 
cember meeting. Doctor Louis J. Gogela was 
installed as President of the Society. 


Deaths 

BLACK — Paul Black, MD, retired Lin- 
coln ophthalmologist, died in December, 
1965, at the age of 79. He was graduated 
from Eastern Illinois State Normal School 
in 1908, spent three years in the Philippines 
doing educational work, and then attended 
Rush Medical School in Chicago, graduat- 
ing in 1915. He then interned at Grand and 
Cook County Hospitals in Chicago where he 
also took his resident training. During 
World War I he served in the U.S. Army 
medical corps. Dr. Black was a life-member 
of the American Medical Association, a fel- 
low of the American College of Surgeons, 
and a member of the American Academy of 
Otorhinolaryngology and Ophthalomolgy. 
Survivors include his daughters, Mrs. Mary 
E. Sullivan of Lincoln, and Mrs. Dorothy C. 
Batchelder of San Diego. 

SMITH — Arthur L. Smith, Sr., MD, died 
December 8, 1965 at the age of 85. Born 
January 10, 1880 in Dunlap, Iowa, he came 
to Nebraska to attend the University of Ne- 
braska Medical School in Lincoln, and later 
Rush Medical College in Chicago. He gradu- 
ated from the latter college in 1913. He then 
went to the University of Tennessee Medical 
School where he served on the medical fac- 
ulty until he returned to Lincoln in 1916 
to begin practice. Prior to his medical edu- 
cation Dr. Smith was a member of the U.S. 
Army and was on active duty during the 


Spanish- American War (seeing action in 
Cuba and the Philippines) and the Boxer 
Rebellion (seeing action in China). 

Dr. Smith went to Vienna in 1923 and 
spent a year studying with Wenckebach. 
When he returned to Nebraska he ordered 
the parts for what is thought to be the 
first electrocardiograph in Nebraska. The 
parts came from Paris, and Dr. Smith con- 
structed the machine himself. He returned 
to Paris in 1929 for additional postgraduate 
study. In 1937 he recorded the first tracing 
of fetal heart sounds using an intravaginal 
approach. 

He was an early worker in the field of 
ballistocardiography and in recent years 
had been doing research in the field of spa- 
tial vectorcardiography. He served as medi- 
cal director and chief of staff at St. Eliza- 
beth Hospital in Lincoln from 1931 to 1949. 
He was a member of the American Medical 
Association, Sigma Xi, Phi Beta Kappa, the 
Ameidcan Board of Internal Medicine, and 
many other professional societies. He was a 
fellow in the American College of Physicians. 
He was a Vice President in the American 
College of Angiology and the Internal Col- 
College of Angiology and the Inteimational 
College of Angiology. 

According to his son. Doctor A. L. Smith, 
Jr., of Lincoln, perhaps the project that 
gave his father the most satisfaction (out- 
side of his lifelong interest in medicine, 
which he practiced until shortly before his 
death) was his work in the Boy Scout or- 
ganization. Many of the members of his 
Boy Scout troop have become doctors and 
dentists in the State of Nebraska, and they 
attribute their interest in medicine to their 
early association with Dr. Smith, Sr. It is 
also interesting that Dr. Smith, Sr. was one 
of our early Nebraska phj-sician airplane 
pilots, learning to fly after he was 65 years 
of age. 

DOCTOR — Please take each copy of 
your Journal home. The wives complain 
that they never get to read the Aux- 
iliary column. 


68 


Nebraska S. M. J. 


;4uxClca%(f 

The Lancaster County Medical Auxiliary 
held its December meeting at the home of 
Mrs. \¥. G. Wiedman, on December 6, 1965. 

A delightful program of Christmas music 
was presented by the Southeast Noblemen. 

In keeping with its annual tradition, the 
Lancaster County Auxiliary collected many 
lovely dolls, which were given to the Family 
Service Organization. 

Mrs. Palmer Johnson and Mrs. Y. Scott 
Moore were co-chairmen of the meeting. 



Hobby Shop 

Dr. Robert 0. Garlinghouse is no more a 
Nebraskan than your Editor; he was born in 
Kansas, in lola. He is a Diplomate of the 
American Board of Surgery, he is Assistant 
Clinical Professor of Surgery (Nebraska), 
he got all the way up to Lt. Col. MC AUS 
in WW2, he has been Chief at Fort Riley, he 
is at this moment Chairman of our own De- 
partment of Surgery. 

We must admit, right here, publicly, and 
in print, that his surgery is pretty good. His 
avocations include fishing (he seems to use 
the scale all fishers use) and family-indul- 
gence. 

And hooking rugs. 

As this maj^ not sound honest to some 



of our readers, we hasten to assure them 
that this is a perfectly respectable sport. 
It means only that our friend has diverted 
his surgical skill to a field of artistry and 
beauty. Rug-hooking or making or weav- 
ing is one of the oldest and grandest of the 
artistical pursuits; it is the means of com- 
ing into being of the world’s famous tapes- 
tries; it is a wonderful return to Ameri- 
can handiwork and folklore and tradition. 
Dr. Garlinghouse began to do this some two 
years ago. He spent one month doing the 
rug whose picture we show you here. He 
has done eight different designs. Special 
designs take three months to get back; 
they’re sent to England. 

We have seen the original shown in the 
picture ; we wish we could have done it. We 
think it’s a work of art. 

F.C. 



Know Your 
Blue Shield Plan 


How Prevailing Fees Operate — 

In response to market demands of major 
purchases for more adequate, predictable 
medical-surgical benefits, the Blue Shield 
Prevailing Fees Program was developed. 

Originated by the National Association of 
Blue Shield Plans in October, 1964, work- 
shops, meetings, discussions, and research 
projects have been held throughout the na- 
tion to finalize a marketable product. 

Study Costs 

In an effort to develop a program more 
acceptable generally to the major purchasers 
of health coverage and their employees, as 
well as to the providers of service, the Na- 
tional Association of Blue Shield Plans car- 
ried out extensive cost studies and interviews 
with the principals who would be involved. 

To assure members that the cost of health 
care benefits they receive will be “paid in 
full” by their Blue Shield coverage, it was 
necessary to devise a program where pay- 


February, 1966 


69 




Which Is Pyloroplasty with Vagotomy? 
Which Is Pro-Banthlne? 



Photographs— Harry Barowsky, M.D., Lawrence Greene, M.D., and Robert 
Bennett, M.D., from a Scientific Exhibit presented at the Annual Meeting 
of the American College of Gastroenterology, Bar Harbour, Florida, Oct. 
24-27, 1965. 


69-A 


Nebraska S. M. J. 


Another example of 

Pro -Banthine 

(propantheline bromide) 

a true anticholinergic in action 


atropine resulted in expectedly 
adverse side effects. 

Pro-Banthine, in minimal dosage, 
produces effects similar to pyloro- 
plasty and vagotomy without the 
disadvantages of permanent post- 
vagotomy sequelae. 

The intragastric photograph A 
is of a patient who has had pyloro- 
plasty with vagotomy. Photograph 
B is of a patient given 6 mg. of Pro- 
Banthine. 

Indications: Peptic ulcer, functional hy- 
permotility, irritable colon, pyloro- 
spasm and biliary dyskinesia. 

Oral Dosage: The maximal tolerated 
dosage is usually the most effective. 
For most adult patients this will be four 
to six 15-mg. tablets daily in divided 
doses. In severe conditions as many as 
two tablets four to six times daily may 
be required. Pro-Banthine (brand of 
propantheline bromide) is supplied as 
tablets of 15 mg., as prolonged-acting 
tablets of 30 mg. and, for parenteral use, 
as serum-type ampuls of 30 mg. 

Side Effects and Contraindications: 

Urinary hesitancy, xerostomia, mydri- 
asis and, theoretically, a curare-like 
action may occur. Pro-Banthine is con- 
traindicated in patients with glaucoma, 
severe cardiac disease and prostatic 
hypertrophy. 


SEARLE 


Research in the Service of Medicine 



Normal relaxed pyloric antrum; con- 
tracted pylorus (pyloric fleurette) 


The true anticholinergic values of 
Pro-Banthine have never been so 
graphically realized as they are 
with the recent development of 
fibergastroscopy and the intragas- 
tric camera. 

Pro-Banthine consistently pro- 
duces complete relaxation and im- 
mobility of the stomach with a dose 
of only 6 to 8 mg. intravenously. 
This is less than half the usual dose 
orally. 

Atropine, on the other hand, 
required 0.8 mg. intravenously, or 
twice the normal dose, to achieve 
a similar effect. This high dose of 


February, 1966 


69- B 



ments to physicians would be related to fees 
physicians are known to be charging their 
patients. 

In the Prevailing Fees Program, the physi- 
cians, in effect, set their own fees. They 
report their usual charges to the local Blue 
Shield Plan. From these reports, the Plan 
develops a profile of charges for each physi- 
cian and then computes the levels of prevail- 
ing charges to include approximately 90 per 
cent of physicians in each economic area. 

The physician profiles are composed of 
each physician’s usual fees for every proce- 
dure which comprises any significant portion 
of his practice. This is based on the premise 
that each physician has a fee for each pro- 
cedure which does not vary to patients ex- 
cept for those in very high or low income 
brackets. 

Economic Areas 

By analyzing the individual profiles in 
terms of economic areas, it is possible (a) 
to achieve community charge levels which 
accurately reflect the local practice of medi- 
cine; and (b) to ascertain at which point the 
fees of 90 per cent of the physicians in the 
area would be covered. 

By collecting fee information from doc- 
tors only on those procedures which make 
up the bulk of his practice, the unique charg- 
ing patterns of specialty physicians are re- 
flected. 

Meets Community Costs 

While the payment of “prevailing fees’’ per- 
mits physicians latitude with respect to the 
establishment of their charges, the program 
is structured to meet the costs known to rep- 
resent the charges of at least 90 per cent 
of the medical community. This is sufficient 
to provide “paid in full’’ benefits to virtually 
all subscribers and yet assure that a limiting 
factor would be imposed on the payment of 
charges exceeding the fees that prevail in an 
area. 

Few Over 90 Per Cent 

In the final analysis, the percentage of 
physicians whose charges would exceed those 
of 90 per cent of their colleagues is minimal 


when considered in relation to the capability 
of the program to provide. 

Physicians whose charges fall in the 90 
per cent range are offered participation cer- 
tificates. They are paid their usual charges 
filed with the Plan which they agree in writ- 
ing to accept as payment in full for services 
rendered Blue Shield members. These par- 
ticipating physicians are paid directly, while 
payments for services performed by non- 
participating physicians are an indemnity 
reflecting the predetermined average value 
for the service or procedure rendered. 

No Fixed Fee Schedule 

The Prevailing Fees Program — while 
providing “paid in full’’ benefits — is not 
based on a fixed fee schedule which every 
physician is required to accept regardless of 
its applicability to his practice of charging 
patients. 

Physicians can take the initiative to change 
fees. Requests for fee increases are ap- 
proved if the increased fees are still with- 
in the current 90th percentile limit of actual 
area charges, and the physician is charg- 
ing the same amount to all of his patients 
for similar procedures or services. 

A physician may request additional com- 
pensation from Blue Shield by filing a spe- 
cial report with his claim. Provisions are 
made for a review of claims, usually in co- 
operation with the local medical society, 
when unusual circumstances require that a 
physician’s fee exceed his normal charge. 
The cooperation of the society is also soli- 
cited to adjudicate any differences which 
arise. 

Range of Fees 

Most Blue Shield Plans developing the pro- 
gram are determining a range of prevailing 
fees for each of several geographic areas 
in which the Plan operates. This factor 
guarantees that Plan payments for medical 
services will be related to the various eco- 
nomic characteristics of the area served by 
the Plan. 

— Reprinted from the October, 1965, “The Blue 
Shield” published by the National Association 
of Blue Shield Plans. 


70 


Nebraska S. M. J. 





Books 



LSL 


Radiologic Diagnosis in Infants and Children by 
Armand E. Brodeiir, MD. Published December 
6, 1965 by the C. V. Mosby Company of St. Louis, 
Missouri. 503 pages (7" by 10") with 757 illus- 
trations. I’rice $26.50. 

The author is Associate Professor of Radiology 
and Associate Dean of the St. Louis University 
School of Medicine. He also serves as a Consultant 
to the Division of Radiological Health of the U.S. 
Public Health Service. He is also Chief Radiologist 
for the Cardinal Glennon Memorial Hospital for 
Children in St. Louis. In the belief that radiology 
is best taught by examples rather than by words, 
the author has provided a relatively large ratio 
of illustrations. All of these radiographs, with 
two exceptions, were taken from the files of the 
Cardinal Glennon Memorial Hospital for Children. 

This book has been written for medical stu- 
dents, interns, residents, pediatricians, general 
radiologists, pathologists, and all other physicians 
treating infants and children. The subject matter 
has been uniformly presented with normal anatomy, 
abnormalities, both congenital and acquired, and 
pitfalls in diagnosis following in that order. This 
book should prove valuable to any physician respon- 
sible for the care of our “little people.” 

Cardiac Evaluation in Normal Infants by Robert 
F. Ziegler, MD. Published November 23, 1965 
by the C. V. Mosby Company of St. Louis, Mis- 
souri. 170 pages (7" by 10") with 29 illustra- 
tions. Price $12.75. 

The author is Physician-in-Charge, Division of 
Pediatric Cardiology, Henry Ford Hospital, Detroit, 
Michigan. Chapter headings and subjects discussed 
include the following: 

1. The Concept of Normal 

2. Fetal Circulation — changes occurring at birth 
and during the neonatal period 

3. Normal Neonatal and Infant Physiology 

4. Evaluation of Heart Murmurs — including 
a discussion of heai’t disease without murmurs 

5. Eva'uation of Cyanosis 

6. Evaluation of Cardiac Rate and Rhythm 

7. Evaluation of Heart Size 

8. Special Problems — including 

a. recognition of cardiac failure in infants 

b. the heart is respiratoiy distress 

9. Evaluation of the Heart in Other, Primarily 
Noncardiac Diseases in Infants 


Surgery of the Foot (2nd edition) by Henri L. Du- 
Vries, MD. Published November 19, 1965 by the 
C. V. Moshy Company of St. Louis, Missouri. 586 
pages (7" by 10") with 448 illustrations. Price 
$17.50. 

The author is an Assistant Clinical Professor of 


Orthopedic Surgery at the University of California 
School of Medicine in San Francisco, California. 
He also is Chief of Foot Surgery at the Highland- 
Alameda County Hospital and is Emeritus Profes- 
sor of Surgery and formerly Chairman of the De- 
partment of Surgery at the Illinois College of Podi- 
atry in Chicago, Illinois. This book has been writ- 
ten in collaboration with 15 other orthopedic sur- 
geons, most of whom are also on the teaching staff 
of the University of California School of Medicine. 
The present (2nd) edition was prepared as a re- 
sult of the favorable acceptance accorded the previ- 
ous (1959) edition. All of the chapters have received 
major revision, and much new material and many 
new illustrations have been added. 

The human foot has been neglected during the last 
hundred years despite the rapid advances of medi- 
cal science. Schools and clinics exist to emphasize 
and teach surgery of the hand but not the foot — 
and yet for every hand problem there are at least 
ten foot problems. 

This book is a scholarly presentation that de- 
serves a wide audience. It should prove to be very 
valuable to any physician who does surgery in this 
area. Medical students, interns and residents 
should also find it valuable. 


Neurocutaneous Diseases by John A. Aita , MD. 

Published December 15, 1965 by Charles C. 

Thomas of Springfield, Illinois. 85 pages (h'/z" 

by 9"). Price $4.75. 

Tbe author of this book is well-known to Ne- 
braska physicians. He is a practicing psychiatrist 
in Omaha and serves as an Associate Professor 
of Neurology and Psychiatry at the University of 
Nebraska College of Medicine. 

European neurologists have long described a 
number of neuiocutaneous diseases which have re- 
ceived little attention on this side of the Atlantic. 
The present review now seems in order — to pro- 
voke further research and to stimulate clinical 
geneticists, neurologists, and dermatologists to look 
beyond the visual fields of their specialties. Forty- 
two neurocutaneous diseases are briefly and suc- 
cinctly described as to sex incidence, genetic fea- 
tures, age onset, dermatologic features, neurologic 
features, frequency of neurologic symptoms, EEG 
findings, neuropathology, diagnostic ocular involve- 
ment, and other system involvement. Included are 
over 450 references to the published literature. 


Splenoportography — Diagnostic Phlebography of 
the Portal Venous System by Lucien Leger, MD. 
Published December 20, 1965 by Charles C. Thomas 
of Springfield, Illinois. 121 pages (7" by 10") 
with 89 illustrations. Price $8.50. 

The author is Professor of Clinical Surgery of 
the Medicine Faculty of Paris and Chief Surgeon 


February, 1966 


71 



of Cochin Hospital in that city. He is a member of 
the French Academy of Surgery. 

Dr. Leger was the first to employ splenoportog- 
raphy clinically. He describes how this procedure 
may be used as a routine method of demonstrating 
salient anatomic and physiologic features of the 
portal system. He also describes its use in such 
instances as: 

a. Differentiation of prehepatic and intra- 
hepatic portal obstruction 

b. Preoperative evaluation of patients with por- 
tal hypertension prior to shunting procedures 
and postoperative evaluation of shunt patency 

c. Emergency diffei’ential diagnosis of upper 
gastrointestinal bleeding 

d. Evaluation of idiopathic splenomegaly. 

This safe, simple, and now universally accepted 
procedure is described in detail as to method, indica- 
tions, limits, and results. 


Closing the Gap Between Medicine and Psychiatry 
by M’ilfred Dorfman, MD. Published November 
2.5, 1965 by Charles C. Thomas of Springfield, 
Illinois. 209 pages (6" by 9")- Price $8.50. 

The author is Editor-in-Chief of Psychosomatics 
and a Past-President of the Academy of Psychoso- 
matic Medicine. He has been a pioneer in the be- 
lief that the practicing physician can be trained 
to practice more comprehensive medicine by increas- 
ing his psychiatric orientation. In this book gastro- 
intestinal, cardiovascular, dermatological, metabolic 
and endocrine problems as well as obesity, arthritis, 
and allergy are examined in detail from a multi- 
causal reference. Problems created by the presence 
of somatic disease are discussed so that full con- 
sideration is given to the potential emotional im- 
pact created by a somatic disorder. Also presented 
in detail are principles in the management of emo- 
tional illness . . . stressing early recognition, goals 
and limitations of the nonpsychiatrist, and the po- 
tentialities and limitations of drug therapy. 


A Current Technique of Aortoiliac and Femoro- 
popliteal Endarterectomy for Obliterative Ather- 
osclerosis by Jack A. Cannon, MD. Published 
November 25, 1965 by Charles C. Thomas of 
Springfield, Illinois. 54 pages (7" by 10") with 
20 illustrations. Price $4.75. 

The author is a member of the Department of 
Surgery in the School of Medicine of the Univer- 
sity of California Center for Health Sciences at 
Los Angeles, California. He has written a text, 
adequately illustrated, dealing exclusively with the 
management of obliterative atherosclerosis by en- 
darterectomy. He discusses indications, the selec- 
tion of patients, surgical technique, and pre- and 
postoperative care. 


Guide Questions for Medical Technology Examina- 
tions by Rose M. Morgan, BS, MT (ASCP). Pub- 
lished December 3, 196.5 by Charles C. Thomas of 
Springfield, Illinois. 240 pages (9" by 11"). 
Price $14.00. 


The author is President of the North 

Dakota So- 

ciety 

of Medical Technologists. She has compiled 

over 

2800 multiple-choice, one best-answer questions 

(and 

answers) dealing with medical 

technology. 

These questions are arranged according 
lowing subject areas: 

to the fol- 

a. 

Hematology 


b. 

Bacteriology 


c. 

Clinical Chemistiy 


d. 

Blood Banking and Serology 


e. 

Parasitology 


f. 

Viral and Rickettsial Diseases 


S- 

Mycology 


h. 

Histology 


i. 

Urinalysis 


j- 

Medical Etymology 



This book should be useful for the student pre- 
paring for his registry and licensure examinations 
It should also help instructors formulate tests. 


Caries-Resistant Teeth, a Ciba Foundation Sym- 
posium. Edited by G. E. W. Molstenholme, 
FRCP, and Maeve O’Connor, BA. Published in 
1965 by Little, Brown and Company of Baston, 
Massachusetts. 338 pages (5' 2 " by 8") with 43 
illustrations. Price $12.50. 

For its initial venture into the field of dental 
science, the Ciba Foundation brought together, in 
London, 25 distinguished investigators from England, 
Belgium, Australia, Sweden, Norway, Germany, 
France, Canada, Switzerland, Scotland, Finland, and 
the United States. They discussed the problems of 
dental caries, and examined the research that has 
been done in this field. Their discussions included 
the following: 

a. Epidemiological studies in relation to caries 
resistance 

b. Heredity in relation to caries resistance 

c. Caries resistance in relation to tooth surfaces 

d. Caries resistance in experimental animals 

e. Caries resistance as related to the chemistry 
of enamel 

f. Physical features of caries-resistant teeth 

g. Ultrastructure of caries-resistant teeth 

h. Dental caries and trace elements 

i. The bacteriology of caries resistance 

j. The role of saliva in caries resistance 

k. Dietary and environmental factors influencing 
caries resistance. 


“He who wears his mortality but as his best gaiTnent were 
better naked.” (Gibran: The Prophet, New York, Alfred A. Knoff, 
1962, p. 84). 


72 


Nebraska S. M. J. 


Value of Shaving the Pudendal - Perineal 

Area in Delivery Preparation — H. I. Kan- 

tor et al (712 N. Washington, Dallas). 

Obstet Gynec 25:509 (April) 1965. 

Shaving the perineal area in preparation 
for vaginal delivery is traditional among ob- 
stetric routines, yet the regrowth of the 
pubic hair during the postpartum period and 
the pruritic stubble can be most irritating 
to the mother. Some years ago. Dr. William 
Mengert questioned the need for this proce- 
dure. Our bacteriological and symptomatic 
studies demonstrated that shaving may well 
be eliminated from the preparations for de- 
livery. A comparison of the merits of hexa- 
chlorophene soap (pHisohex) and pavidone- 
iodine (Betadine) as perineal cleansing solu- 
tions is also presented. Hexachlorophene 
soap is a “scrub” preparation which, when 
undiluted, is not bacteriocidal on contact alone. 
Topical pavidone-iodine permitted less bac- 
terial growth on the perineum, as deter- 
mined by culture, than did the pavidone- 
iodine scrub solution. A novel method of 
culture is suggested for this purpose. 


DNA Repair of Radiation — The Therapeu- 
tic Efficiency of DNA Administered to 
Rats After Whole Body Irradiation — T. 

Wilczok and J. Mendecki (Institute of On- 
cology, Gliwice, Poland). Int J Radiat Biol 
9:201-211 (No. 3) 1965. 

The therapeutic effect of desoxyribonucleic 
acid (DNA) from different sources, such as 
calf thymus, rat liver and spleen, herring and 
salmon sperm, and Ehrlich ascites-carcinoma 
cells studied on Wistar rats given lethal doses 
of gamma-irradiation. A single injection of 
DNA was administered intraperitoneally 24 
hours after irradiation. All forms of DNA 
significantly increased the survival of the 
irradiated rats. The quantitative differences 
in the effects of DNA from different sources 
were directly related to their molecular 
weight. When native calf-thymus DNA was 
sheared or denatured, there was a reduction 
in its therapeutic efficiency proportional to 
the reduction in molecular size. Therefore 
heterologous as well as homologous DNA 
have a marked therapeutic effect quantita- 
tively dependent on their molecular weight. 


ORGANIZATIONS, NATIONAL 

American Academy of General Practice 
Mr. Mac F. Cahal 
Volker at Brookside 
Kansas City 12, Missouri 

American Academy of Pediatrics 
E. H. Christopherson, Secy. 

1801 Hinman Ave. 

Evanston, Illinois 

American College of Legal Medicine 

Glenn W. Bricker, M.D., F.C.L.M., Secretai-y 
1003-06 Medical Tower 
Philadelphia 3, Pennsylvania 
American College of Obstetricians & Gynecologists 
Craig W. Muckle, M.D. 

1806 Garrett Road 
Lansdowne, Pa. 

American College of Physicians 
Edward C. Rosenow, Jr., M.D., F.A.C.P., Secy. 
4200 Pine St. 

Philadelphia 4, Pennsylvania 
American College of Radiology 
Mr. W. C. Stronach 
20 North Wacker Drive 
Chicago 6, Illinois 
American College of Surgeons 
John P. North 
40 East Erie Street 
Chicago 11, Illinois 

American Diabetes Association 
Laurentius O. Underdahl, M.D. 

1 East 45 Street 
New York 17, New York 


American Heart Association 
Mr. Rome A. Betts, Secy. 

44 East 23rd Street, New York 10, New York 
National Hemophilia Foundation 

25 West 39th St., New York, N.Y. 10018 
American Hospital Association 
Edwin L. Crosby, M.D., Director 
840 Lake Shore Drive, Chicago 11, Illinois 
American Society of Anesthesiology 
Mr. J. W. Andes 

515 Busse Hy., Park Ridge, Illinois 
American Society of Internal Medicine 
Mr. Albert V. Whitehall, Executive Secy. 

3410 Geary Boulevard 
San Francisco 18, California 
The American Society of Clinical Pathologists 
Miss Eleanor F. Larson 
445 Lake Shore Drive, Chicago 11, Illinois 
American Medical Association 

F. J. L. Blasingame, Executive Vice Pres. 

535 North Dearbon St., Chicago 10, Illinois 
American Urological Association 
Rubin Flocks, M.D., Secretary 
State University of Iowa Hospitals, 

Iowa City, Iowa 

Arthritis and Rheumatism Foundation 
Floyd B. Odium, Chairman 
10 Columbus Circle, New York 19, New York 

International College of Surgeons 
John B. O’Donoghue, M.D. 

1516 North Lake Shore Dr., Chicago 10, Illinois 
National Multiple Sclerosis Society 

257 Park Avenue South, New York 10, N.Y. 
Vocational Rehabilitation Administration 

Mary E. Switzer, Commissioner, Washington, D.C. 


February, 1966 


73 


ORGANIZATIONS, STATE = 

Alcoholics Anonymous 
1345 N Street, Lincoln 

American Red Cross 

W. J. Frenzel, State Representative 
2631 Garfield, Lincoln 

Cerebral Palsy Association of Nebraska 
Mrs. Ben H. Cosdery 
201 South Elmwood Road, Omaha 

Creighton University School of Medicine 
Richard Egan, Dean 
302 North 14th, Omaha, Nebraska 
International College of Surgeons 
James J. O’Neil, M.D., Regent for Nebraska 
612 Medical Arts Building, Omaha 2, Nebraska 
Multiple Sclerosis Society 
Mrs. Harold Stoehr, Executive Secretary 
3648 Folsom Street, Lincoln, Nebraska 
Muscular Dystrophy Society 

Mrs. Marvin Traeger, President 
Fairbuiy, Nebraska 
National Foundation, Inc. 

Clinton Belknap 
State House Station 

Post Office Box 4813, Lincoln, Nebraska 
Nebraska Chapter, 

Arthritis and Rheumatism Foundation 
Lloyd E. Skinner, President 
Box 2, Elmwood Station, Omaha 6, Nebraska 
Nebraska Association of Pathologists 
Dr. Robert A. Brooks, Secy-Treas. 

1403 Sharp Building, Lincoln, Nebraska 
Nebraska Blue Cross-Blue Shield 
Wm. H. Heavey, Executive Director 
518 Kilpatrick Building, Omaha, Nebraska 
Nebraska Chapter 

American Academy of General Practice 
John A. Brown, M.D., Secy. 

402 Lincoln Liberty Life Bldg., Lincoln, Nebraska 
Nebraska Chapter 
American College of Physicians 

Henry J. Lehnhoff, Jr., MD, Governor for Nebr. 
720 Doctors Building, Omaha, Nebraska 69131 
Nebraska Chapter 
American College of Surgeons 
Robert W. Gillespie, MD, Secy.-Treas. 

500 South 17th St., Lincoln, Nebraska 
Nebraska Chapters 

National Cystic Fibrosis Research Foundation 
Greater Omaha Chapter 

Miss Betty Seibert, 510 South 42nd St., Omaha 
Lancaster County Chapter 
Mr. and Mrs. Gayle Voller, 530 North 75th St., 
Lincoln 

Nebraska Dental Association 
D. W. Edwards, D.D.S., Secy. 

1220 Federal Securities Bldg., Lincoln, Nebraska 
Nebraska Diabetes Association 
J. William Hervert, M.D., President 
Mr. Tom Skillman, Secretary 
7611 Lawndale Drive, Omaha, Nebraska 
Nebraska Dietetic Association 
Barbara Holvick, President 
26tb and Dewey, Omaha 
Nebraska Division American Cancer Society 
Ray E. Achelpohl, Executive Director 
4201 Dodge, Omaha, Nebraska 
Nebraska Heart Association 
Paul S. Archambault, Executive Director 
514 South 40th Street, Omaha 5, Nebraska 
Nebraska Hospital Association 
Stuart Mount, Executive Director 
1335 “H” Street, Lincoln, Nebraska 


Nebr. Academy of Ophthalmology & Otolaryngology 
C. Rex Latta, MD, Secretary 
710 Doctors Building, Omaha, Nebraska 68131 
Nebraska Pediatric Society 
Otto G. Rath, Secretaiy 
3929 Harney, Omaha 
Nebraska Pharmaceutical Association 
Miss Cora Mae Briggs, Executive Secretary 
1001 Anderson Building, Lincoln 8, Nebraska 
Nebraska Psychiatric Institute 
602 South 44th Avenue, Omaha 
Nebraska Public Health Association 
George R. Underwood, M.D., President 
935 “R” Street, Lincoln, Nebraska 

Nebraska Radiological Society 
Jack Zastera, M.D., Secy.-Treas. 

816 Medical Arts Bldg., Omaha, Nebraska 

Nebraska Rheumatism Association 
Vernon G. Ward, President 
5 West 31st Street, Kearney, Nebraska 

Nebraska Society for Crippled Children 
S. Orson Perkins, Director 
402 South 17th, Omaha, Nebraska 

Nebraska Society for Internal Medicine 
Robert S. Long, M.D., President 
8721 Shamrock Road, Omaha, Nebraska 
Nebraska Society of Anesthesiologists 
Frank Cole, M.D., President 
2430 Lake St., Lincoln, Nebraska 
Nebraska Society of Medical Technologists 

Gladys Jeurink, MT, ASCP, 4600 Spruce, Lincoln 
Nebraska State Department of Health 
E. A. Rogers,M.D., Director 
State Capitol Building, Lincoln, Nebraska 
Nebraska State Medical Association 
Ken Neff, Executive Secy. 

1315 Sharp Building, Lincoln 8, Nebraska 
Nebraska State Nurses Association 
Zelda Nelson, Executive Director 
307 Baird Bldg., Omaha, Nebraska 
Nebraska State Obstetric and Gynecologic Society 
W. Riley Kovar, M.D., Secretary-Treasurer 
3610 Dodge Street, Omaha 31 
Nebraska State Orthopedic Society 
Harold Horn, MD, Secretary 
3145 “0” Street, Lincoln, Nebraska 
Nebraska State Pediatric Society 
Otto Rath, M.D., Secretary-Treasuier 
3929 Harney, Omaha, Nebraska 
Nebraska, South Dakota, North Dakota District 
Branch of the American Psychiatric Association 
Harry C. Henderson, M.D., President 
105 South 49th St., Omaha, Nebraska 68132 
Nebraska Tuberculosis Association 
Delmer Serafy, Executive Secy. 

406 W.O.W. Building, Omaha, Nebraska 
Nebraska Urological Association 

Louis W. Gilbert, MD, Secretary-Treasurer 
903 Sharp Building, Lincoln 8, Nebraska 
Omaha Mid-West Clinical Society 
1040 Medical Arts Building (68102) 

Rita M. Crowell, Executive Secretary 
POISON CONTROL CENTER 
Children’s Memorial Hospital 
502 South 44th, Omaha, Nebraska 
Rehabilitation Services Division 

Fred A. Novak, Assistant Commissioner 
707 Lincoln Bldg., 1001 0 St., Lincoln 68508 
University of Nebraska College of Medicine 
Cecil L. Wittson, MD, Dean 
42nd and Dewey, Omaha, Nebraska 
(Please help us keep these addresses correct, by 
notifying the Editor of any changes). 


74 


Nebraska S. M. J. 


An antibiotic 
of choice 
is one that works 

TAO works 

— «Y' ■ 


Susceptibility Results 
Staphylococci ‘ 


# OF CULTURES YEAR % EFFECTIVE 


6,725 1962 88.6% 

5,440 1^63 88.0% 

10,384 1964 88.5% 


y^-Hemolytic Streptococci ^ ^ ‘ 



The Product 

In a world study of antibiotics in vitro\ TAO had an over - 
all effectiveness of 87.3%, higher than chloramphenicol 
and erythromycin, and significantly higher than tetracy- 
cline and penicillin. 

The Plus. ..Consistent Performance 

Yet antibiotics must not only work. They must work con- 
sistently. Here are the results from the largest study of 
microbial susceptibility ever undertaken. In 29,048 cul- 
tures of overt staphylococcal and /f-hemolytic streptococ- 
cal infections, note the consistency of results with TAO. 


TAO 

[triacetyloleandomycin] 



J. B Roerig and Company, New York, New York 10017 

Division, Chas. Pfizer S Co., Inc., Science for the World's Well-Being"' 


TAO Rx information 

Indications: The bacterial spectrum includes: streptococci, staphy- 
locci, pneumococci and gonococci. Recommended for acute, 
severe infections where adequate sensitivity testing has demon- 
strated susceptibility to this antibiotic and resistance to less toxic 
agents. Contraindications and Precautions: TAO (triacetyloleandomycin) is not recommended for prophylaxis or in the treatment of infectious processes 
which may require more than ten days continuous therapy. In view of the possible hepatotoxicity of this drug when therapy beyond ten days proves 
necessary, other less toxic agents, of course, should be used. If clinical judgement dictates continuation of therapy for longer periods, serial monitor- 
ing of liver profile is recommended, and the drug should be discontinued at the first evidence of any form of liver abnormality. It is contraindicated in 
pre-existing liver disease or dysfunction, and in individuals who have shown hypersensitivity to the drug. Although reactions of an allergic nature are 
infrequent and seldom severe, those of the anaphylactoid type have occurred on rare occasions. References: 1. Isenberg, Henry D.: Health Laboratory 
Science 2:163-173 (July) 1965. 2. Fowler, J. Ralph et aL Clinical Medicine 70:547 (Mar.) 1963. 3. Isenberg, Henry D.: Health Laboratory Science 
1:185-256 Uuly-Aug.) 1964, 


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Gastroschisis — B. Goodhead (Children’s 
Hosp., Ladywood Rd., Birmingham, Eng- 
land). Brit Med J 1:771 (March 20) 
1965. 

A case of gastroschisis successfully treated 
is reported. A clear distinction between 
exomphalos and gastroschisis is emphasized. 
Repair by the two stage method of Gross 
for large exomphalos is recommended and 
the importance of careful postoperative cor- 
rection of any acid-base disturbance is em- 
phasized. 

Constrictive Pericarditis — S. S. Anand, V. 
K. Saini, and P. L. Wahi. Dis Chest 47 :291 
(March) 1965. 

Surgical decortication, as it is done today, 
has an excellent chance for good results 
with treatment of chronic pericardial con- 
triction. The authors’ experience with 21 
consecutive pericardiectomies performed dur- 
ing the last ten years is presented. Opera- 
tive mortality was 19%. Satisfactory results 
were obtained with the bilateral transverse 
incision and an extensive decortication. 



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CREMOMYCIN combines the bacteriostatic 
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PHYSICIANS' EXCHANGE 

Advertisements in this column are at a rate of ten 
cents per word with a minimum of $4.00 per insertion. 
Copy must be received by the fifth of the month pre- 
ceding date of publication and should not exceed 50 
words. Advertisements from members of the Ne- 
braska State Medical Association will be accepted 
without charge for one issue. Each advertisement 
will be taken out following its first appearance unless 
otherwise instructed. Where numbers follow adver- 
tisements, replies should be addressed in care of The 
Nebraska State Medical Journal, 1315 Sharp Building, 
Lincoln. Nebraska. 

CLINIC AVAILABLE — General practice in fur- 
nished clinic. County seat town, SW Nebraska, 3 
nursing homes in town, good territory. Write Box 
8, Beaver City, Nebraska. 

YOUNG GENERAL PRACTITIONER — Is desir- 
ing temporary position in Omaha area. Write full 
particulars to 1005 South 30th Avenue, Omaha, Ne- 
braska. 

USED MEDICAL AND SURGICAL EQUIP- 
MENT — For sale including X-ray and Ritter 
Table. Many smaller items. R. T. Satterfield, MD, 
724 East Jefferson Street, Millard, Nebraska. Phone 
308-334-2563. 

INTERNIST — For 5-man department in busy 
and steadily growing north central Kansas 13- 
member multispecialty group. Partnership after 
salary for two years. Board eligible or certified. 
Write Gelvin-Haughey Clinic, Concordia, Kansas. 

Excellent Opportunity for GENERAL PRACTI- 
TIONER in community of 15,000; central Florida; 
76-bed JCAH Hospital. Write or call collect: R. C. 
Thompson, Bartow Memorial Hospital, Bartow, 
Florida. 

USED MEDICAL AND SURGICAL EQUIP- 
MENT FOR SALE — Including 100 MA Picker 
X ray, Leitz Photrometer, Medco Sonulator, Cardi- 
All and Cambridge E.K.G., New Hamilton Exam- 
ination Table. Many small items. J. L. Dyer, 
M.D., 1508 South 79th Street, Omaha, Nebraska. 

PSYCHI.4TRIC RESIDENCIES — July 1, 1966 — 
600-bed psychiatric hospital with active out-patient 
department for adults and children. Intensive train- 
ing program directed toward Board Certification. 
NIMH grant of $12,000 annually to General Prac- 
titioner or physicians with 4 or more years ex- 
perience in other than psychiatry. Write: Dr. W. 
C. Brinegar, Superintendent, Mental Health Insti- 
tute, Cherokee, Iowa. 


SOUTH WEST SURGICAL CONGRESS — 18th 
.Annual Meeting, Flamingo Hotel, Las Vegas, Ne- 
vada, April 18, 19, 20, and 21, 1966. 




1701 "K" Street 
500 South 17th Street 

Some of the best medical-dental office 
space in Lincoln will soon be available 
for lease on exceptionally attractive rental 
figures. Approximately 900 square feet 
with a private entrance and exit located 
on the first floor in the South portion of 
this lovely building designed specifically 
for Physicians and Dentists. Excellent 
accessibility and ample parking facilities. 
Walking proximity to State Capitol, office 
buildings, apartments and downtown re- 
tail area. We invite your inquiry. Con- 
tact 64, Nebraska State Medical Journal, 
1315 Sharp Building, Lincoln, Nebraska. 



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THE NEBRASKA STATE 
MEDICAL JOURNAL 

2430 Lake Street, Lincoln 2, Nebraska 


CONTENTS: 

EDITORIALS: 

Do We Police Ourselves? - 75 

Guilt by Association 75 

ORIGINAL SECTION- 

Abnormal Bleeding Conditions in Urologic 

Patients - 79 

Jon T. Williams, AAD 
H. V. AAunger, AAD 

AAanagement of Crushed Chest Injuries 83 

Stephen W. Carveth, AAD 
Kai Rehder, AAD 


Gas Gangrene Infection: Combined Treat- 
ment Including 3,432,000 International 

Units of Polyvalent Gas Gangrene Antitoxin 85 

W. R. Hamsa, AA D 
Dwight W. Burney, Jr., AAD 

Brachial Artery Puncture: An Oft Neglected 
Clinical Tool in the Evaluation of 

Hypertension 90 

Hugh S. Levin, AAD 
Anthony J. Carnazzo, AAD 
Vincent Runco, Jr., AAD 
Richard W. Booth, AAD 

Carcinoma of the Tongue: The Role of 


Chronic Irritation 94 

Donovan B. Foote, AAD 
Thomas A. Graves, AAD 
Harold G. Tabb, AAD 

ORGANIZATION SECTION- 

Welcome, New AAembers .. 98 

Coming AAeetings . 98 

The AAilitary Dependents' AAedical Care 100 

The AAonth in Washington 101 

Drug Abuse Control Amendments 102 

Announcements 104 

All About Us 106 

News and Views 107 

Hobby Shop 108 

Our AAedical Schools .. 110 

Woman's Auxiliary 115 

Know Your Blue Shield Plan 115 

Books 1 1 7 

Organizations, National 119 

Organizations, State 120 


MARCH. 1966 VOL. 51, NO. 3 


EDITOR- 
FRANK COLE. MD 

2430 Lake St., Lincoln 2 

ASSOCIATE EDITORS— 

FREDERICK M. NEBE, MD 
Review Editor 

943 Stuart Building, Lincoln 8 

C. R. HANKINS, MD 

822 The Doctors Building. Omaha 31 

J. MARSHALL NEELY, MD 
4201 Calvert, Lincoln 6 

W. MAX GENTRY, MD 
1720 Tenth Street, Gering 

GEORGE E. STAFFORD. MD 
800 South 13th St., Lincoln 8 

B. R. BANCROFT, MD 

Kearney Medical Arts Building, Kearney 

JAMES J. O’NEIL, MD 

612 Medical Arts Building, Omaha 2 

FRANK P. STONE, MD 
2300 South 13th, Lincoln 2 

ROBERT J. STEIN, MD 
930 Stuart Building, Lincoln 8 

J. H. BARTHELL, MD 

1012 Sharp Building, Lincoln 8 

HAROLD E. HARVEY, MD 
140 South 27th Street, Lincoln 6 

H. V. MONGER, MD 
3705 South Street, Lincoln 

BERNARD F. WENDT, MD 

735 South 56th Street, Lincoln 6 

FRANK H. TANNER, M.D. 

1835 South Pershing Road, Lincoln 2 

K. D. ROSE, MD 

University Health Service, Lincoln 8 

KEN NEFF, Business Manager 
1315 Sharp Building, Lincoln 
Telephone HEmlock 2-7585 


SUBSCRIPTION RATE 
$5.00 Per Year Single Copies 50c Each 


The Editor of this Journal assumes no re- 
sponsibility for opinions and claims ex- 
pressed in the articles published herein. 

Manuscripts to be presented for publica- 
tion in the JOURNAL should be typewritten, 
double-spaced, on one side only of firm (not 
onion skin or flimsy), standard letter sized 
(8(4 by 11 in.) white paper. Wide margins 
(at least 1(4 in. on left) should be left free 
of typing. On the first or title-page should 
be shown the title of the article, the name 
(or names) of the author, his degree and 
other significant credits. Pages should be 
numbered consecutively, the page number 
being shown in the right upper corner along 
with the surname of the author. 

Illustrations should be numbered and their 
locations shown in the text. Each should be 
identified by placing on its back the author’s 
name, its number and an indication of its 
"top.” Drawings and charts intended for 
cuts should be in black (India ink) on pure 
white. Photographs should be on glossy 
paper and minimum of about 5 by 7 in. in 
size. A legend should be provided for each 
illustration and, preferably, attached to it. 

Manuscripts (original, not a carbon) should 
be sent directly to the Editor at the Journal’s 
address. 

Reprints should be ordered from the print- 
er, NEWS Printing Company, Norfolk, Nebr. 

Copyright 1964 by The Nebraska State 
Medical Association. 

Published monthly and postage paid at the 
Post Office at Norfolk, Nebraska, as second 
class matter. 


4-A 


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Neo-Synephrine is a standard among 
topical vasoconstrictors. It is unsurpassed 
for reducing nasal turgescence in colds; 
and a most valuable aid in preventing 
and treating sinusitis. 

Neo-Synephrine stops the boggy feeling of 
colds at once— \works against factors that 
induce sinusitis. With Neo-Synephrine 
nose drops, spray or jelly, turbinates shrink 
on contact, obstructed ostia open and 
drainage is re-established. 


In sinusitis, Neo-Synephrine helps to pro- 
mote drainage and hasten recovery.* Used 
promptly, it helps clear the stagnant sinus 
and lessen the chances of chronicity. 

Neo-Synephrine HCI is available in: 

Vs^Zo solution for infants 

’A'Vo solution for children and adults 

V4°7o pediatric nasal spray for children 

V2°7o solution for adults 

V2‘7o nasal spray for adults 

V2°7o jelly for children and adults 

1“7o solution for adults (resistant cases) 


‘Proctor, D. F.: The Nose, Paranasal Sinuses, and 
Ears in Childhood, Springfield, III., Charles C 
Thomas, 1963, p. 34. 


\M'/7yAro’/7 


Winthrop Laboratories, New York, N, Y. 10016 


In colds and sinusitis 



(brand of phenylephrine hydrochloride) 


solutions/sprays/jeiiy 


Current Comment 

Infectious Hepatitis in Nebraska — 

Southwest Nebraska apparently is emerg- 
ing from what some have described as a mild I 
epidemic of infectious hepatitis. At least 15 
cases were reported in the last part of 1965. 
All persons who had the disease recovered. 

In Wauneta, Doctor Robert C. Carlson diag- 
nosed and treated 10 cases. He said that 
four of the patients were in the first grade j 
at the Wauneta Public School. All first 
grade students were given gamma globulin, 
as were the members of the patients’ fam- 
ilies. Doctor Carlson said that there was , 
one case at Hayes Center. Doctor Kenneth 
Stout of Benkelman said that he diagnosed 
three cases of hepatitis in November of 1965 
in patients aged 16, 18, and 29. Doctor J. 

T. Harris of Stratton, in practice for more 
than 20 years, said, “I can’t remember hav- 
ing seen any more cases in such a small 
area.” The Nebraska State Health Depart- 
ment has noted infectious hepatitis cases in 
Chase, Dundy and Hitchcock counties. Other 
cases have been reported in Douglas county. | 

In past years the cases of infectious hepa- 
titis have seemed to center in the counties j 
bordering the Missouri river, apparently indi- 
cating a water-borne method of spread for 
this disease. 1 



“A Mrs. Brown called and wanted to know if 
you made house calls, whatever they are!” 

6- A 


DEPROL 

meprobamate 400 mg. -h 
benactyzine hydrochloride 1 mg. 

Indications: ‘Deprol’ is useful in the manage- 
ment of depression, both acute (reactive) and 
chronic. It is particularly useful in the less 
severe depressions and where the depression is 
accompanied by anxiety, insomnia, agitation, 
or rumination. It is also useful for management 
of depression and associated anxiety accom- 
panying or related to organic illnesses. 
Contraindications: Benactyzine hydrochloride 
is contraindicated in glaucoma. Previous aller- 
gic or idiosyncratic reactions to meprobamate 
contraindicate subsequent use. 

Precautions: Meprobamate— Cireful super- 
vision of dose and amounts prescribed is 
advised. Consider possibility of dependence, 
particularly in patients with history of drug or 
alcohol addiction; withdraw gradually after use 
for weeks or months at excessive dosage. Abrupt 
withdrawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions in- 
cluding, rarely, epileptiform seizures. Should 
meprobamate cause drowsiness or visual dis- 
turbances, the dose should be reduced and 
operation of motor vehicles or machinery or 
other activity requiring alertness should be 
avoided if these symptoms are present. Effects 
of excessive alcohol may possibly be increased 
by meprobamate. Grand mal seizures may be 
precipitated in persons suffering from both 
grand and petit mal. Prescribe cautiously and 
in small quantities to patients with suicidal 
tendencies. 

Side effects: Side effects associated with recom- 
mended doses of ‘Deprol’ have been infrequent 
and usually easily controlled. These have in- 
cluded drowsiness and occasional dizziness, 
headache, infrequent skin rash, dryness of 
mouth, gastrointestinal symptoms, paresthesias, 
rare instances of syncope, and one case each of 
severe nervousness, loss of power of concen- 
tration, and withdrawal reaction (status epilep- 
ticus) after sudden discontinuation of excessive 
dosage. 

Benactyzine hydrochloride— Benactyzine 
hydrochloride, particularly in high dosage, may 
produce dizziness, thought-blocking, a sense of 
depersonalization, aggravation of anxiety or 
disturbance of sleep patterns, and a subjective 
feeling of muscle relaxation, as well as anti- 
cholinergic effects such as blurred vision, dry- 
ness of mouth, or failure of visual accommoda- 
tion. Other reported side effects have included 
gastric distress, allergic response, ataxia, and 
euphoria. 

Meprobamaie-Dtov/smess may occur and, 
rarely, ataxia, usually controlled by decreasing 
the dose. Allergic or idiosyncratic reactions are 
rare, generally developing after one to four 
doses. Mild reactions are characterized by an 
urticarial or erythematous, maculopapular rash. 
Acute nonthrombocytopenic purpura with pe- 
ripheral edema and fever, transient leukopenia, 
and a single case of fatal bullous dermatitis 
after administration of meprobamate and pred- 
nisolone have been reported. More severe and 
very rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises (1 
fatal case), anuria, anaphylaxis, stomatitis and 
proctitis. Treatment should be symptomatic in 
such cases, and the drug should not be reinsti- 
tuted. Isolated cases of agranulocytosis, throm- 
bocytopenic purpura, and a single fatal instance 
of aplastic anemia have been reported, but only 
when other drugs known to elicit these con- 
ditions were given concomitantly. Fast EEG 
activity has been reported, usually after exces- 
sive meprobamate dosage. Suicidal attempts 
may produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Dosage: Usual starting dose, one tablet three or 
four times daily. May be increased gradually 
to six tablets daily and gradually reduced to 
maintenance levels upon establishment of relief. 
Doses above six tablets daily are not recom- 
mended even though higher doses have been 
used by some clinicians to control depression 
and in chronic psychotic patients. 

Supplied: Light-pink, scored tablets, each con- 
taining meprobamate 400 mg. and benactyzine 
hydrochloride 1 mg. 

Before prescribing, consult package circular. 

Wallace Laboratories / Cranbury, N. J. 


FOR THE 



COMPLEX 


I \ 13 1^ meprobamate 400 mg. + 

^ -IX. JL JL^ M^JL JIXX^-LJ benactyzine hydrochloride 1 mg, 

a logical first choice 

FOR DEPRESSION 

even when complicated by anxiety, tension, insomnia, 

agitation or rumination. 

• Acts rapidly. 

• Side effects at recommended dosage infrequent, 
usually easily controlled. 


When uncontrolled 
diarrhea brings 
a call for help 



When the diarrhea sufferer has run the 
gamut of home remedies without success, 
pleasant-tasting CREMOMYCIN can answer 
the call for help. It can be counted on to 
consolidate fluid stools, soothe intestinal 
inflammation, inhibit enteric pathogens, 
and detoxify putrefactive materials — usu- 
ally within a few hours. 


CREMOMYCIN combines the bacteriostatic 
agents, succinylsulfathiazole and neomy- 
cin, with the adsorbent and protective de- 
mulcents, kaolin and pectin, for compre- 
hensive control of diarrhea. 


Indications: Diarrhea. Contraindications: Kaolin: 
Withhold if diverticulosis is present or suspected. 
Precautions: Sulfonamide: Continued use requires 
supplementary administration of thiamine and vita- 


your for 
Cremomycin 
can provide relief 



min K. Neomycin: Patient should be observed for 
new infections due to bacteria or fungi. Side Effects: 
Sulfonamide: Sensitivity reactions may occur (e.g., 
skin rashes, anemia, polyneuritis, fever; agranulo- 
cytosis with a fatal outcome has been reported). 
Reduction of thiamine output in the feces and of 
vitamin K synthesis has been observed. Neomycin: 
Nausea, loose stools possible. 

Before prescribing or administering, read product 
circular with package or available on request. 


promptly relieves diarrheal distress 

Cremomyciii 

ANTIDIARRHEAL ^ 

Composition: Each 30 cc. contains neomycin sulfate 
300 mg. (equivalent to 210 mg. of neomycin base), 
succinylsulfathiazole 3.0 Gm., colloidal kaolin 3.0 
Gm., pectin 0.27 Gm. 

® MERCK SHARP & DOHME Division o( Merck i Co , Inc . West Point. Pa. 

Where today’s theory is tomorrow’s therapy 


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Want An Extra $2500 A Year In Profits? 


Here’s How to Gel It: 


i 


That's right. Just sell Coca-Cola! 

For instance, did you know over 19,000 
drug stores with fountains sell Coke? And 
they're making an average of $2500 a year 
gross profit from Coke? 

just think; an average $2500 a year from just 
one — and only one — product, Coca-Cola. 

But what about the almost 34,000 drug stores 
that don't have fountains? They must not real- 
ize how easy it is to add $2500 to the year's 
profit picture. Or how fountains build traffic 



things go 

better^ 


Coke 


for prescription departments. 

What about you? Even if you feel a fountain 
wouldn't fit into your operation, have you ever 
considered installing a snack bar? It serves the 
same purpose. And both keep your customers in 
the store longer. That means extra sales and 
more profit. 

For the full story ask your local Fountain Rep- 
resentative for Coca-Cola to show you the book- 
let, "Snack Bars — Today and Tomorrow," pre- 
pared by Tbe Coca-Cola Company. 


Current Comment 

A New Drug for the Treatment 
Of Schistosomiasis — 

Nebraska physicians responsible for the 
care of foreign students from Africa and 
South America will be interested in learn- 
ing that CIBA Limited (Basle, Switzerland) 
has introduced a new type of Chemothera- 
peutic agent for the treatment of schistoso- 
miasis (Bilharziasis) caused by S. haema- 
tobium or S. Mansoni. This drug, admin- 
istered orally, is a nitrothiazole derivative 
and has been given the trade name of Am- 
bilhar. 

Although this product is not at present 
available in the United States, clinical trials 
are in progress, and it is expected that it 
will be introduced in the not too distant fu- 
ture. Results in over 1500 patients have 
shown a cure rate of approximately 90%, 
far better than any results previously ob- 
tained with the use of the antimonial deriva- 
tives. 



“. . . and Doctor, if you pass an all-night lunch- 
stand on the way over, will you bring me a 
hamburger ?” 


10-A 


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Elastic Stockings so sheer they look 
like support hose. Both Ultreer and 
support hose are sheer, shapely, cool 
and comfortable. But that's where 
the similarities end. New Ultreer fits 
firmly and evenly over the entire leg. 
Gives true therapeutic compression 
necessary to relieve varicose veins and 
other leg disorders. They provide 
the therapy you prescribe. The fashion 
and economy she demands. 

Ultreer stockings have a new low price. 
So low, she can afford two pairs of 
Ultreer instead of one pair of regular 
elastic stockings. There'll be no 
disagreements there. Ultreer stockings 
are as comforting to her purse as 
they are to her 
legs. New Ultreer 
are the elastic 
stockings doctors 
and women can 
agree on. 



Kcpdalli 


BAUER B B4ACK SURRORTS' OfVISrON 


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11-A 


First aid for a button popper 



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SEQUELS* 

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3y providing combined anorexigenic-tranquilizing action, 
3AMADEX SEQUELS Capsules help your nonshrinking 
patients to establish new patterns of eating less. The am- 
)hetamine component suppresses the appetite, while the 
neprobamate helps allay nervousness and tension. And for 
nost patients, the sustained release of the active ingredients 
)rovides convenient one-capsule-a-day dosage. 

Side Effects commonly associated with either compo- 
lent are possible but, to the extent these are dose-related, 
hey should normally be mild and infrequent, since the 
otal dosage of each component on the usual one-capsule- 
laily regimen is quite low. Also, the sedating effect of 
neprobamate and the stimulating effect of d-amphetamine 
ulfate tend, to some extent, to cancel each other out. Ad- 
'erse effects not peculiar to either component have not 
)een reported. Side effects associated with d-amphetamine 
ulfate include: insomnia, excitability, increased motor 
ictivity, confusion, anxiety, aggressiveness, increased li- 
)ido, hallucinations, rebound fatigue, depression, dry 
nouth, anorexia, nausea, vomiting, diarrhea and increased 
ardiovascular reactivity. Effects associated with meproba- 


mate include: skin rash, nonthrombocytopenic purpura 
with petechiae, ecchymoses, peripheral edema, fever and 
transient leukopenia; also, very rarely, fainting spells, angi- 
oneurotic edema, bronchial spasm, hypotensive crisis, 
anuria, stomatitis, proctitis and anaphylaxis. Other serious 
effects have occurred after concomitant administration of 
meprobamate and other drugs. Massive overdosage may 
produce grave effects. 

Precautions: BAMADEX SEQUELS should be given 
only under close supervision to patients hypersensitive to 
sympathomimetic drugs, with cardiovascular or coronary 
disease or who are severely hypertensive; to emotionally 
unstable persons and to epileptics. Patients should be 
cautioned not to drink alcoholic beverages while on the 
drug, and not to drive vehicles if they become drowsy. In 
all patients kept on the drug for long periods, the drug 
should be withdrawn gradually to avoid possible serious 
reactions. 

Contraindications: Hyperexcitability, agitated prepsy- 
chotic states and a history of previous reactions to mepro- 
bamate. 


Bamadex* Sequels' 

d-amphetamine sulfate ( 1 5 mg. ) Sustained Release Capsules 
and meprobamate (300 mg.) 


LEDERLE LABORATORIES • A Division of American Cyanamid Company, Pearl River, New York 



66S& 


Gilmour- Danielson 

DRUG COMPANY 

142 South 13th Street 800 South 13th Street 
Phone 432- 1 246 Phone 432-885 1 

Medical Village, 48th and "A" St. 
Phone 488-2305 

— FREE DELIVERY — 

PRESCRIPTIONS - ETHICAL SERVICE 

Esfablisbed 1927 




14A 


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Indications; ‘Miltown’ (meprobamate) is ef- 
fective in relief of anxiety and tension states. 
Also as adjunctive therapy when anxiety 
may be a causative or otherwise disturbing 
factor. Although not a hypnotic, ‘Miltown’ 
fosters normal sleep through both its anti- 
anxiety and muscle-relaxant properties. 
Contraindications: Previous allergic or idio- 
syncratic reactions to meprobamate or 
meprobamate-containing drugs. 
Precautions: Careful supervision of dose 
and amounts prescribed is advised. Consider 
possibility of dependence, particularly in pa- 
tients with history of drug or alcohol addic- 
tion; withdraw gradually after use for weeks 
or months at excessive dosage. Abrupt with- 
drawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions 
including, rarely, epileptiform seizures. 
Should meprobamate cause drowsiness or 
visual disturbances, the dose should be re- 
duced and operation of motor vehicles or 
machinery or other activity requiring alert- 
ness should be avoided if these symptoms 
are present. Effects of excessive alcohol may 


An eminent role in 
medical practice 

Clinicians throughout the world con- 
sider meprobamate a therapeutic 
standard in the management of anxi- 
ety and tension. 

The high safety-efficacy ratio of 
‘Miltown’ has been demonstrated by 
more than a decade of clinical use. 

Miltown* 

(meprobamate) 

possibly be increased by meprobamate. 
Grand mal seizures may be precipitated in 
persons suffering from both grand and petit 
mal. Prescribe cautiously and in small quan- 
tities to patients with suicidal tendencies. 

Side effects: Drowsiness may occur and, 
rarely, ataxia, usually controlled by decreas- 
ing the dose. Allergic or idiosyncratic re- 
actions are rare, generally developing after 
one to four doses. Mild reactions are char- 
acterized by an urticarial or erythematous, 
maculopapular rash. Acute nonthrombocy- 
topenic purpura with peripheral edema and 
fever, transient leukopenia, and a single 
case of fatal bullous dermatitis after admin- 
istration of meprobamate and prednisolone 
have been reported. More severe and very 


rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises 
(1 fatal case), anuria, anaphylaxis, stoma- 
titis and proctitis. Treatment should be 
symptomatic in such cases, and the drug 
should not be reinstituted. Isolated cases of 
agranulocytosis, thrombocytopenic purpura, 
and a single fatal instance of aplastic ane- 
mia have been reported, but only when other 
drugs known to elicit these conditions were 
given concomitantly. Fast EEG activity has 
been reported, usually after excessive me- 
probamate dosage. Suicidal attempts may 
produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Usual adult dosage: One or two 400 mg. 
tablets three times daily. Doses above 2400 
mg. daily are not recommended. 

Supplied: In two strengths: 400 mg. scored 
tablets and 200 mg. coated tablets. 

Before prescribing, consult package circular, 
WALLACE LABOR.4TORIES 
\£f,Cranbury. N.J. cM-vei 


...introducing a new high-strength dosage form 

SIGNEM 


A 'MAXIMUM SECURITY' ANTIBIOTIC* 


THE BROAD RANGE DEPENDABILITY OF TETRACYCLINE 

long established as the broad-spectrum agent of first choice in a wide 

variety of infections 

^ WITH THE ADDED SECURITY OF MEDIUM-SPECTRUM REINFORCEMENT 
triacetyloleandomycin is highly active against the common 'coccal' 
pathogens, including certain strains of staphylococci resistant to penicillin 
and tetracycline 

ESPECIALLY VALUABLE IN U.R.I. 

provides decisive therapy in acute respiratory infections and other 
conditions in which staphylococci, streptococci or mixed flora are 
frequently encountered 

NOW AVAILABLE IN NEW STRENGTH FOR NEW CONVENIENCE AND 
ECONOMY 

Signemycin 375 — high-potency capsules for simpler administration, 
greater patient economy 



VCIJT 375 

(tetracycline 250 mg. 
triacetyloleandomycin 125 mg.) 


Indications: Indicated in the therapy of acute severe infec- 
tions caused by susceptible organisms and primarily by 
bacteria more sensitive to the combination than to either 
component alone. In any infection in which the patient can 
be expected to respond to a single antibiotic, the combina- 
tion is not recommended. Signemycin should not be used 
where a bacteriologically more effective or less toxic 
agent is available. Triacetyloleandomycin, a constituent of 
Signemycin, has been associated with deleterious changes 
in liver function. See precautions and adverse reactions. 
Contraindications: Contraindicated in individuals who have 
shown hypersensitivity to any of its components. Not recom- 
mended for prophylaxis or in the management of infectious 
processes which may require more than 10 days of con- 
tinuous therapy. If clinical judgement dictates therapy for 
longer periods, serial monitoring of liver function is recom- 
mended. Not recommended for subjects who have shown 
abnormal liver function tests, or hepatotoxic reactions to 
triacetyloleandomycin. 

Precautions and Adverse Reactions: Triacetyloleandomycin, 
administered to adults in daily oral doses of 1.0 gm. for 10 
or more days, may produce hepatic dysfunction and jaun- 
dice. Adults requiring 3 gm. of Signemycin initially should 
have liver function followed carefully and the dosage should 
be reduced as promptly as possible to the usual recom- 
mended range of 1.0 to 2.0 gm. per day. Present clinical 
experience indicates that the observed changes in liver 


function are reversible after discontinuation of the drug. 

Use with caution in lower than usual doses in cases with 
renal impairment to avoid accumulation of tetracycline and 
possible liver toxicity. If therapy is prolonged under such 
circumstances, tetracycline serum levels may be advisable. 
In long term therapy or with intensive treatment or in known 
or suspected renal dysfunction, periodic laboratory evalua- 
tion of the hematopoietic, renal and hepatic systems should 
be done. Formation of an apparently harmless calcium com- 
plex with tetracycline in any bone forming tissue may occur. 
Use of tetracycline during tooth development (3rd trimester 
of pregnancy, infancy and early childhood) may cause dis- 
coloration of the teeth. Reversible increased intracranial 
pressure due to an unknown mechanism has been observed 
occasionally in infants receiving tetracycline. Glossitis, sto- 
matitis, proctitis, nausea, diarrhea, vaginitis and definite 
allergic reactions occur rarely. Severe anaphylactoid reac- 
tions have been reported as due to triacetyloleandomycin. 
Photosensitivity and photoallergic reactions (due to the 
tetracycline) occur rarely. Medication should be discon- 
tinued when evidence of significant adverse side effects or 
reaction is present. Patients should be carefully observed 
for evidence of overgrowth of nonsusceptible organisms 
including fungi, which occurs occasionally, and which in- 
dicates this drug should be discontinued and appropriate 
therapy instituted. Steps should be taken to avoid masking 
syphilis when treating gonorrhea. 



J. B. ROERIG AND COMPANY 
Division, Chas. Pfizer & Co., Inc. 
Science for the World’s Well-being® 
New York, N.Y. 10017 



Low 

host resistance? 

Consider the 
“extra ” antibacterial 
activity 
of Ilosone* 


Occasionally, therapeutic failure is 
due to the patient’s inability to 
mobilize his defenses sufficiently to 
overcome infection. Typical of this 
is the debilitated patient, the 
premature infant, or the diabetic. 

It is in these patients that the high 
levels of antimicrobial activity of 
Ilosone are especially useful. Ilosone 
has demonstrated antibacterial levels 
two to four times those of erythro- 
mycin base or stearate. Furthermore, 
it attains them earlier and maintains 
them longer. Even the presence of 
food does not appear to affect the 
activity of Ilosone. 


Contraindications: Ilosone is contraindicated in 
patients with a known history of sensitivity to this 
drug and in those with preexisting liver disease 
or dysfunction. 

Side-Effects: Even though Ilosone is the most 
active oral form of erythromycin, the incidence of 
side-effects is low. Infrequent cases of drug idio- 
syncrasy, manifested by a form of intrahepatic 
cholestatic jaundice, have been reported. There 
have been no known fatal or definite residual ef- 
fects. Gastro-intestinal disturbances not associ- 
ated with hepatic effects are observed in a small 
proportion of patients as a result of a local stimu- 
lating action of Ilosone on the alimentary tract. Al- 
though allergic manifestations are uncommon with 
the use of erythromycin, there have been occasion- 
al reports of urticaria, skin eruptions, and, on rare 
occasions, anaphylaxis. 


Dosage: Children under 25 pounds— 5 mg. per 
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25 to 50 pounds— ^2b mg. every six hours. Adults 
and children over 50 pounds— 250 mg. every six 
hours. For severe infections, these dosages may 
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Available in Pulvules®, suspension, drops, and 
chewable tablets. Ilosone Chewable tablets should 
be chewed or crushed and swallowed with water. 


Ilosone 


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EDITORIALS 


THE NEBRASKA STATE MEDICAL JOURNAL 


DO WE POLICE OURSELVES? 

Well, we try, and nobody else does. It 
is no good saying that lawyers disbar them- 
selves; they don’t, the state does, and that’s 
different. Engineers don’t and merchants 
don’t, physicists don’t and actors don’t, writ- 
ers don’t and insurance salesmen don’t. Just 
nobody else does. But what is important to 
know is do we do it, why do we do it, and 
how well do we do it? 

We do it because if it needs doing, it is 
something instinctive to our profession that 
we purify ourselves. It is only a secondary 
argument that if we did not police ourselves, 
somebody else would do it to us; in that 
connection, we would prefer to do it our- 
selves, and we can obviously do a better job 
than others can do. 

Do we do it well? We do it as well as 
it can be done without setting up a police 
state with all its machinery and evils. We 
have tissue committees, utilization commit- 
tees, executive committees, credentials com- 
mittees, grievance committees, library com- 
mittees, ethics committees, governing 
boards, and hospital and professional rela- 
tions committees. We have operating room 
committees and we have regularly sched- 
uled meetings of medical and surgical hos- 
pital departments, and we review hospital 
deaths honestly and candidly and with a rath- 
er remarkable accuracy. Staff appointments 
are passed on with painstaking care and are 
reviewed, promotions are subjected to rigid 
examination, questionnaires are constantly 
conducted pertaining to patients’ reactions, 
we have accident (or “incident”) reports and 
patient care committees. 

We call doctors before committees. We 
require doctors to assist doctors, we insist 
on supervision of doctors. We do it to an 
extent that is sufficient to protect our pa- 
tients and so that other policing is com- 
pletely unnecessary. With all this, we may 
never stop what we are doing. 

This does not mean that we have not solved 
our problem, it is more like the eternal vigil- 
ance we read about. Our continuing to do 


it, nay, that we do it to an ever-increasing 
degree, bespeaks our sincerity, our dedica- 
tion, and our vigilance. Perhaps we do not 
succeed as well as we should always like. 
To a large extent, the patient must hold 
himself responsible for this; his opinion of 
his doctor is too often too good or too bad. 
But that we do not always succeed complete- 
ly is a poor sort of criticism. We do what 
others do not, and we try harder than they 
know. 

Do we police ourselves? I think we do. 

— F.C. 


GUILT BY ASSOCIATION 

Legislation by judicial decision has been 
popularized in recent years to the extent that 
in some instances original legislative intent 
has been modified by legal decision at all 
juridical levels. A recent example from Ne- 
braska Supi'eme Court Journal is of interest 
to physicians and should be brought to their 
attention. 1 

In this instance a fireman died of coro- 
nary artery disease on March 11, 1963. He 
had a known diagnosis of coronary arterios- 
clerosis from December, 1961, but in spite 
of this had continued to work as a fireman 
and had “moonlighted” as a land surveyor. 
On July 7, 1962, the 15th day since his last 
fire call and his third day off duty, during 
which time he worked as a surveyor, he suf- 
fered a coronary occlusion which kept him 
off duty until October, 1962. Upon return- 
ing to work he was limited to station duty. 
On March 11, 1963, after working from 
2 p.m. to 4 p.m., he returned home. Death 
occurred suddenly at 9 :30 p.m. Under the 
fireman’s pension plan (Sec. 35-202, R.R.S. 
1943) payment is provided for when “death 
is caused by or is the result of injuries re- 
ceived while in the line of duty.” The dis- 
trict court found for the defendant but the 
Nebraska Supreme Court, by a 4 to 3 ma- 
jority, reversed the decision and found for 
the plaintiff, the deceased’s widow. This 


March, 1966 


75 



decision apparently was based on expert 
testimony of an internist who “depreciated 
the effect of physical exertion alone” (thus 
discounting the factor of physical labor 
associated with land surveying), “but em- 
phasized emotional stress, emotional-physical 
strain, and toxic effects. Indeed, they con- 
stituted his frame of reference for diag- 
nosis.” There was no expert testimony for 
the defense. Writing the dissenting opinion. 
Judge Spencer noted that the interpretation 
of Section 35-202 of the pension act had been 
changed from “In case of death while in 
the line of duty” to read “In case of death 
while in the employ.” He further stated, 
“I am in accord with the thought that ample 
provision should be made for the protection 
of the families of public employees engaged 
in hazardous occupations. It should, how- 
ever, be initiated by the legislative process 
and not accomplished by judicial legislation.” 

Emotional stress is not peculiar to fire- 
men, but exists in all human endeavor. It 
is particularly prevalent in the business and 
professional fields. It is more a function of 
the specific individual’s personality than of 
his occupation, a fact not considered in the 
above decision. Evidence of the concern that 
this pension act decision and others might 
spread to the realm of Workman’s Compen- 
sation is found in the recent analysis of this 
and other similar cases by Gradwohl and 
Holtorf2 and in the report by Brill and Glass.® 
In the latter instance a case is cited where 
“the Supreme Court ... in effect ruled that 
schizophrenic breakdown due to ordinary 
work pressures constitutes a compensable 
injuiy.” Although to date no Nebraska Su- 
preme Court decision has awarded compen- 
sation benefits in a heart attack death case,® 
the implication of the Campbell case and 
those reported in the cited references sug- 
gests that the judicial temperament may 
change. The legislative temperament is al- 
ready changing. In fact, a 1963 amendment 
to the act has removed the “unusual from 
of exertion” limitation and has substituted 
“compensation for disability or death 
caused by exertion or strain in performing 
any of the duties of their employment, usual 
or unusual.” Carried to absurdity, death or 
disability from heart atack, or in fact any 


disease may be compensable merely because 
the deceased worked, i.e., guilt by association. 

It is undeniable that the tragedy of a 
mother saddled with a family burden brought 
on by the untimely death of a husband from 
natural causes must be ameliorated or pre- 
vented. Ordinarily this is the responsibility 
of the immediate family, but in certain in- 
stances it becomes the responsibility of gov- 
ernmental agencies which are instituted, reg- 
ulated, and supported by legislative decree. 
For the courts to assume this legislative pre- 
rogative is not only inappropriate, it is ba- 
sically of doubtful constitutionality and 
should be resisted whenever possible. At the 
same time broadened employer-employee sup- 
ported disability-compensation plans must 
be instituted, if not for compassionate rea- 
sons at least to prevent further diluting of 
our basic democratic freedom. 

— Kenneth D. Rose, MD 

1. Campbell vs. City of North Platte (Lincoln 
Co.) 35758 47 SCJ 244, 178 Neb. 244. 

2. Gradwohl, J., and Holtorf, H. J., Jr.: Employ- 
ment-precipitated heai't attacks: a few legal issues 
in establishing compensability. Nebraska Law Re- 
view 44:809-828 (July) 1965. 

3. Brill, Norman Q. and John F. Glass: Work- 
men’s compensation for psychiatric disorders. JAMA 
193:345-348 (August) 1965. 


Current Comment 

Nebraska’s Participation in the Federal Heart, 
Cancer, and Stroke Program (Public Law 89-239) — 
Formation of a gi’oup designed to study 
Nebraska’s possible participation in the 
Federal Heart, Cancer, and Stroke Program 
was completed at a meeting called for by 
The Nebraska State Medical Association 
and presided over by Doctor Willis Wright, 
President of the Association. Members of 
the newly-formed group include representa- 
tives of the Nebraska State Medical Associa- 
tion, the Creighton University School of 
Medicine, the University of Nebraska College 
of Medicine, the Nebraska State Health De- 
partment, the Nebraska Hospital Associa- 
tion, the Nebraska Heart Association, and 
the Nebraska Division of the American Can- 
cer Society. Former U.S. Senator Eva Bow- 
ring of Merriman was named to the group 


76 


Nebraska S. M. J. 


as a representative of the public. The study 
group indicated that it may expand to in- 
clude representatives of other groups and 
more members from the public. It also indi- 
cated that it would explore the possibility 
of including representatives from areas in 
adjacent states with the possibility of form- 
ing a regional planning group. 

Named to the executive committee of the 
advisory group were the deans of the Uni- 
versity of Nebraska and Creighton Univer- 
sity medical schools, Dr. Cecil L. Witson 
and Richard I. Egan, respectively, and the 
president-elect of the Nebraska State Medi- 
cal Association, Doctor Dan A. Nye of Kear- 
ney. 

Public Law 89-239, passed during the last 
session of Congress, authorized the Surgeon 
General to make grants to assist in the de- 
velopment of regional cooperative programs 
among medical schools, research institutions 
and hospitals, for research and training dem- 
onstrations of patient care in fields of heart 
disease, cancer, stroke, and related fields. 

Nebraska Centennial Health Fair — 

Representatives from the American Medi- 
cal Association’s Headquarters in Chicago 
journeyed to Lincoln recently to help in the 
planning of the Nebraska Centennial Health 
Fair to be held in Lincoln 29 April 1967 
through 5 May 1967. The week-long, day- 
and-night event will take place on both floors 
of the Pershing Auditorium. 

Anticipated as a $50,000 operation, the 
health fair will have two main objectives ; 

a. Informing the general public of the 
great progress made in medical science 
and all related fields, and 

b. Stimulating young Nebraskans to con- 
sider careers in the medical science and 
related health fields. 

School children from all over Nebraska 
will be urged to attend and to talk with rep- 
resentatives of all the medical and paramedi- 
cal groups making up today’s health corps. 
Sponsored by the Lancaster County Medical 
Society initially, the planning group hopes 
to enlist the associate sponsorship of other 


county medical groups throughout the entire 
state, as well as the sponsorship and active 
support of such groups as the dentists, phar- 
macists, and veterinarians. Additional sup- 
port will be actively sought from all para- 
medical groups. Assurance of active aid has 
already been received from such organiza- 
tions as the U.S. Public Health Service, the 
American Medical Association, the National 
Institutes of Health, in addition to the Ne- 
braska State Medical Association, and the 
Nebraska State Health Department. 

Chairman of this event is Doctor E. D. 
Zeman. His associate chairmen are Doc- 
tor Samuel I. Fuenning, Director of the Uni- 
versity of Nebraska Health Services, and 
Doctor Keith Sehnert, Associate Medical Di- 
rector of Dorsey Laboi-atories. Other com- 
mittee members are Doctor E. A. Rogers, 
Director of the State Health Department; 
Doctor E. S. Maness; and Doctor Fred Nebe. 
Working full-time on this project is Mr. 
Leonard Peterson, Executive Secretary of 
the Lancaster County Medical Society. 

Doctor Zeman has stated that “This will 
not be a fair of posters, but one with live 
exhibits calling for audience participation. 
Closed circuit television showings of actual 
operations performed in local hospitals will 
be one major feature. Less than a dozen of 
these major health-science shows have been 
staged thus far, and most of these have been 
in large cities such as Denver, Fort Worth, 
and Kansas City. This event should be a 
major event in Nebraska’s Centennial Cele- 
bration and should reflect great credit upon 
the doctors and paramedical groups of the 
entire state.’’ 


Home Health Care Services Under Medicare — 

Only three Nebraska cities have applied 
for Federal funds available for establishing 
home health care services when Medicare 
takes effect on July 1, 1966. Filing applica- 
tions with the Nebraska State Health De- 
partment were Omaha, Scottsbluff and Lin- 
coln. These cities requested $61,000. State 
Health Director E. A. Rogers said that the 
applications plus a $6,000 request to cover 
administrative costs, leave $11,000 still 
available. If no other Nebraska city bids 


March, 1966 


77 


soon for the remaining money, said Dr. 
Rogers, it probably will be reallocated to 
some other state. Dr. Edwin Lyman, Omaha- 
Douglas County health director said that his 
department can use the money if no one else 
wants it. “We limited our first request,” 
said Dr. Lyman. “However, if additional 
funds are available and no other city wants 
them, we’d like to have our original request 
reconsidered rather than see the money go 
out of the state.” 

Applicants include: 

(a) West Nebraska General Hospital, 
sponsoring the Scottsbluff Home Health Care 
Service — asking $13,000 to develop a pro- 
gram to provide visiting nurses and physical 
therapy assistance. 

(b) Tabitha Home, sponsor for the Lincoln 
Home Health Care Service — asking $15,000 
to develop physical therapy service in addi- 
tion to a visiting nurses program. 

(c) Omaha - Douglas County — asking 
$34,000 to expand its visiting nurses pro- 
gram to cover physical therapy, a medical 
social worker and the development of an oc- 
cupational therapy program. 

Vitamins K and D Dangerous for 
Expectant Mothers — 

In a recent interview Doctor Donald Hart- 
ing of the National Institutes of Health em- 
phasized that an excess of Vitamin K, when 
given to expectant mothers, sometimes causes 
jaundice, damage of the central nervous sys- 
tem, and mental retardation. 

Also there is enough evidence to satisfy 
some very responsible investigators that ex- 
cess vitamin D during pregnancy can cause 
hypercalcemia in the offspring. This con- 
dition, in turn, seems to be associated with 
mental retardation and defects above the 
aortic valves of the heart in the baby. Scien- 
tists accept normal needs at about 400 units 
a day, and there is little to justify the use 
of vitamin D at much over that amount. 


NOTICE TO ALL CONTRIBUTORS 
The deadline for items to appear in the fol- 
lowing issue of the JOURNAL is the 8th of the 
month. The JOURNAL goes to press on the 10th. 


Intrauterine Contraceptive Devices — C. L. 

Lay (Lakeland General Hosp, Lakeland, 

Fla), Amer J Obstet Gynec 93:330-334 

(Oct 1) 1965. 

Eight different intrauterine contraceptive 
devices were evaluated for use in a public 
health clinic for population control in in- 
digent, poorly educated patients who have 
failed with other methods of contraception. 
Since 1959 a total of 119 women have been 
involved in this program. The nylon coil 
modification of the Grafenberg ring was 
found unsatisfactory because of the high 
expulsion rate (18 cases) and the number 
of unwanted pregnancies (10%). Margulies 
spirals gave satisfactory contraception, but 
annoying side effects. The Birnberg bow 
No. 3 had a low rate of spontaneous expul- 
sion but the number of pregnancies was con- 
sidered excessive. The larger Birnberg bow 
No. 5 has been found to be the most satis- 
factory device to date with a minimum of 
spontaneous expulsions and pain or bleeding. 
Other types of intrauterine devices were 
found to have various disadvantages. 

Coronary Heart Disease in the Aged — A. 

K. Thould (University College Hosp, Lon- 
don), Brit Med J 2:1089 (Nov 6) 1965. 

The findings of a three-year retrospective 
study of patients, aged 65 years or more, 
admitted to an acute geriatric department 
because of acute coronary heart disease are 
analyzed. These patients formed only 3% 
of 1,300 admissions, and 33 of 42 (79%) 
died. The prognosis was somewhat better 
for females than for males but worsened 
sharply with age. Over half did not com- 
plain of pain. Heart failure was noted in 
23 but this factor did not materially worsen 
the outlook. A high systolic blood pressure 
was associated with a very poor prognosis. 
The electrocardiogram proved surprisingly 
accurate. At autopsy, coronary artery oc- 
clusion without evidence of a recent myo- 
cardial infarction occurred in 6 of 29, but 
recent myocardial infarction was observed in 
the rest. A history of previous strokes 
seemed to have no bearing on the prognosis. 
Grave prognostic symptoms and signs ap- 
peared to be confusion, sudden collapse, ar- 
rythmia, cyanosis, and emphysema. 


78 


Nebraska S. M. J. 


ARTICLES 


Abnormal Bleeding Conditions 
In Urologic Patients* 


E xcessive bleeding following 

surgery or certain manipula- 
tive procedures on the genito- 
urinary tract always has been a serious fac- 
tor in a significant number of cases. In ad- 
dition to the special problem of control in- 
herent in hemorrhage occurring internally, 
widespread bleeding from all mucous mem- 
branes (as well as from cut surfaces) may 
result from prostatic or urinary bladder 
cancer or surgery of the prostate gland. 

Consideration of the known factors in- 
volved in the mechanism of the clotting of 
blood is necessary for adequate control of 
these conditions. In order to demonstrate 
the position of the various factors in blood 
clotting, a brief and contracted review of 
normal hemostasis is presented. 

Normal hemostasis depends upon: 

1. Normal vascular system (and plate- 
lets) 


JON T. WILLIAMS, MD 
and 

H. V. MUNGER, MD 

From the Departments of Internal Medicine 
and Urology. Lincoln General Hospital 
Lincoln, Nebraska 


2. Normal coagulation mechanism (and 
platelets) 

3. Normal fibrinolytic system 

Only the hemorrhagic disorders likely to 
be encountered and of significance in rela- 
tion to the trauma of surgery will be dis- 
cussed here. In the great majority of these 
conditions, there is no permanent cure, but 
the measures outlined will provide temporary 
control, allowing major surgery to be per- 
formed in most cases. 

*Supported in part by a grant from the Blood Disease 
Research and Education Foundation, Lincoln, Nebraska. 


BLOOD COAGULATION 


Prothrombin 


Heparin 


Antithromboplastins 
Other Inhibitors 


Calcium ion.s 
Thromboplastin 
Platelet derivatives 

Plasma (V) 
Ac — globulin ^ 

Serum (VI) 


Accelerators 


Stable factor (Serum) (V II) 

Antihemophilic globulin (VIII) 

Plasma Thromboplastin Component (PTC) (IX) 
Stuart-Prower Factor (X) ( ? Accelerator) 

Plasma Thromboplastin Antecedent (PTA) (XI) 
Hageman Factor (XII) 

> r Other activators 


Antithrombin — Thrombin 
Fibrinogen. — ^ Fibrin 


March, 1966 


79 



The vascular system may be deficient as 
in a congenital disease known as “vascular 
pseudohemophilia.” In this condition there 
is a prolonged bleeding time with all other-, 
factors normal. Distorted capillaries and 
failure of capillary contraction following in- 
jury may be observed under the capillary mi- 
croscope. Surgical trauma may result in 
serious bleeding for which there is no good 
treatment, although ACTH and cortisone in 
large doses may be of some help. 

Another vascular defect is demonstrated 
in the developmental dysplasia of mesen- 
chymal tissues known as the Ehlers-Danlos 
syndrome. This syndrome presents hyper- 
elasticity of the skin and joint ligaments 
with pseudotumors under the skin and fra- 
gile blood vessels. Bleeding time is pro- 
longed and wound healing is unusually slow. 
No known treatment is of value. 

A prolonged bleeding time is also pro- 
duced by a defective condition of the plate- 
lets in which, although the platelet count 
is within normal range, platelet function is 
defective resulting in conditions known as 
thrombocytasthenia or thrombocytopathia. 
The resultant deficient prothrombin utiliza- 
tion and poor clot retraction is the cause of 
severe post-operative bleeding in these cases. 
In addition to a bleeding time and platelet 
count, clot retraction tests and a tourniquet 
test for capillary fragility will usually diag- 
nose this state. Transfusions of normal 
platelets and the use of adrenal steroids are 
recommended as prophylactic measures pri- 
or to surgery.^ 

Chronic idiopathic thrombocytopenic pur- 
pura can be treated prior to surgery with 
high dosages of ACTH or cortisone, and if 
time permits, splenectomy may be decided 
upon before other elective surgery is done. 
This results in approximately an 85% cure 
rate. If prior splenectomy is impossible 
or has not resulted in a cure, temporary help 
can be obtained by the transfusion of plate- 
lets immediately prior to, and during sur- 
gery. The benefit is not nearly so long in 
duration (0-1 day) as in thrombocytas- 
thenia or thrombocytopenia resulting from 
aplasia of the marrow (3-5 days). 

Within the blood clotting mechanism it- 


self, the lack of calcium per se has never 
been recognized as a cause of excessive 
bleeding. However, lack of utilization of 
calcium which is present in normal 
amounts in the blood may result in abnormal 
bleeding in the dysproteinemias (i.e. multi- 
ple myeloma, macroglobulinemia, etc.). This 
is because of the unusual degi’ee of binding 
of calcium by the abnormal protein. At 
times, beneficial effects maj^ result in these 
conditions by the intravenous administration 
of calcium gluconate. This is seldom the 
sole factor causing excessive bleeding in the 
dysproteinemias however, since thrombo- 
cytopenia is usually the most important sin- 
gle cause, and hyperazotemia, hypoprothrom- 
binemia and fibrinogenopenia are frequent- 
ly contributing factors.^ 

In “true hemophilia” there is an antihemo- 
philic globulin (factor VIII) deficiency. It 
has long been known to be best corrected by 
the administration of fresh blood or plasma, 
or fresh frozen plasma. Preparation for ma- 
jor surgery should include plans for the ad- 
ministration of plasma prior to, during, and 
after surgery. 

The defect in PTC (Christmas factor, or 
factor IX) deficiency can be treated tem- 
porarily by administering stored (twenty- 
one day old) plasma or fresh or stored se- 
rum. In our experience, the use of serum 
has been much more effective than plasma. 
The serum from one unit of clotted com- 
patible blood given the day prior to surgery 
may be all that is necessary, although the 
use of one or two additional serum infusions 
may occasionally be needed following sur- 
gery. 

Stuart-Prower factor (factor X) deficien- 
cy is again a condition best treated with 
stored plasma or serum. Treatment may be 
carried out in the same manner as men- 
tioned above. A prolonged Russell’s viper 
venom test differentiates this condition 
from a deficiency of factor VII. 

Although a PTA (factor XI) deficiency 
may be corrected by fresh or stored plasma 
or by serum, best results seem to be obtained 
by the use of fresh plasma. The plasma 
should be administered before, and if neces- 
sary, after surgery. 


80 


Nebraska S. M. J. 


The accelerator factors, V (labile) and 
VII (stable), are important in relation to 
surgery in that a deficiency of either re- 
sults in a prolonged rate of blood clotting 
which can lead to severe postoperative hem- 
orrhage. It is also important to distin- 
guish between these defects since treatment 
is different in each. Factor V deficiency is 
treated by fresh whole blood or plasma given 
promptly after collection. The factor VII 
defect is temporarily corrected by stored 
plasma or fresh or stored serum. In our 
hands, serum has been most effective. 

In the past several years, we have become 
interested in a previously little recognized 
condition which may result in serious post- 
operative hemorrhage. This is a partially 
inherited (heterozygous) deficit in factor 
VII.® In order to demonstrate this, the fol- 
lowing case is presented. 

P.S., a 33 year old white male was admit- 
ted to the hospital on Ma.rch 15, 1959 with a 
history of a persistent urinary tract infec- 
tion. Urine culture demonstrated a pseudo- 
monas infection. His B.U.N. was 32 mgm 
per cent. X rays demonstrated a urinary 
bladder diverticulum and about 25% reten- 
tion in the urinary bladder. Cystoscopy 
demonstrated bladder neck obstruction due 
to a prostatic bar. On March 19, a trans- 
urethral prostatic resection and resection of 
the neck of the vesical diverticulum was 
performed. Bleeding was well controlled 
and the patient was dismissed March 24th. 
On March 30, gross hematuria developed and 
he was readmitted to the hospital for study. 
At that time his prothrombin time varied 
from 49% to 55% of normal and further 
studies demonstrated a deficiency in factor 
VII only. The administration of serum from 
one unit of clotted blood stopped the bleeding 
within 15 minutes. He was dismissed April 
8th. Gross hematuria recurred on April 12, 
and he was again treated with serum which 
resulted in prompt control of the bleeding. 
No further abnormal bleeding occurred. 

It is of interest that this patient gave no 
history of unusual bleeding before surgery, 
but after the above complications he con- 
sulted his mother who stated that she had 
“always known he was a bleeder.” Upon 


questioning him closely, he stated that he 
had daily cut his face with a safety razor 
from the first day he began to shave. The 
resultant bleeding usually lasted from one 
to two hours. Of further interest is the fact 
that for four days after each instance of re- 
ceiving serum, he did not bleed while shav- 
ing. 

Polycythemia vera and the secondary poly- 
cythemias present a bleeding problem fol- 
lowing surgery due to diminished fibrino- 
gen levels. In the former condition, platelet 
counts in the range of above one million may 
interfere with coagulation to the same de- 
gree that very low platelet levels do.^ The 
best management of these cases requires 
phlebotomy to reduce excess red cell mass 
and replacement of the fluid volume by nor- 
mal plasma prior to surgery. Occasionally, 
chemotherapeutic measures may be used to 
reduce the abnormally high platelet count of 
polycythemia vera. 

Fibrinogenopenia also occurs due to can- 
cer of the urinary bladder or of the prostate 
with metastasis to the liver. If bleeding 
occurs, this is best treated with plasma or 
fibrinogen. If a fibrinolytic agent is also 
present, it may result in a striking and 
often frightening degree of bleeding. The 
prostatic proteolytic enzyme produced by 
cancer of the prostate digests the fibrin clot 
in the same manner as does plasma fibrin- 
olysin.® This can frequently be brought under 
rapid control by applying judicious combin- 
ations of ACTH or cortisone, fibrinogen, 
estrogens and orchiectomy where indicated. 

It is suggested that the following screen- 
ing procedures be done prior to surgery: 

1. A careful history regarding personal 
or familial bleeding. 

2. Complete blood count. 

3. Platelet count or estimation. 

4. Prothrombin time. 

5. Hicks-Pitney Test.® 

If tests indicate an abnormal clotting 
mechanism, complete studies should be per- 
formed including a thromboplastin genera- 
tion tesU and tests for factors V and VIP 
a Russell’s viper venom test for factor X® 


March, 1966 


81 


as well as a tourniquet (capillary fragility) 
test if indicated. It may also be necessary 
to test for spontaneous lysis of the blood 
clot and in rare instances for the fibrin sta- 
bilizing factor.!® 

References 

1. Stefanini, M., and Dameshek, W. : The Hem- 

orrhagic Disorders; 2nd Edition, p. 246, 1962. Grune 
and Stratton. 

2. James, T. N.; Monto, R. W., and Rebuck, 

J. W.: Complex pathogenesis of the bleeding ten- 

dency in multiple myeloma. Ann Intern Med 39: 
1281) 1953. 

3. Williams, J. T. and Morgan, H. S.: Occult 
hemophilia as a cause of postoperative and post- 
partum hemorrhage. Amer J Obstet Gynec 83: 
1046-1050, 1962. 

4. Miale, J. B., and Garrett, V. R. : The effects 

of varying platelet concentration on the generation 


of plasma thromboplastin. Amer J Clin Path 27: 
701, 1957. 

5. Tagnon, H. J.; Whitmore, W. F., Jr., and 

Schulman, N. R.: Fibrinolysis in metastatic can- 

cer of the prostate. Cancer 5:9-12, 1952. 

6. Hicks, N. D., and Pitney, W. R.: A rapid 

screening test for disorders of thromboplastin gen- 
eration. Brit J Haemat 3:227-237, 1957. 

7. Biggs, R. G., and Douglas, A. S.: The throm- 
boplastin generation test. J Clin Path 6:23-29, 
1953. 

8. Biggs, R., and Macfarlane, R. G.: Human 

Blood Coagulation and Its Disorders. Oxford, 1953, 
Blackwell Scientific Publications, p. 352. 

9. Hougie, C.; Barrow, E. M., and Graham, 

J. B.: Stuart clotting defect. I. Segregation of an 

hereditary hemorrhagic state from the hetero- 
geneous group heretofore called “stable factor” 
(SPCA) proconvertin; factor VII deficiency. J 
Clin Invest 36:485, 1957. 

10. Lorand, L., and Dickenman, R. C.: Assay 

method for the “fibrin stabilizing factor.” Proc 
Soc Exp Biol Med 89:45-48, 1955. 


Because of new drugs, methods of treatment and a changed 
public attitude, many of our huge mental hospitals may be emptied 
of their patients within the next 20 years, according to Dr. Luther 
L. Terry, Surgeon General of the United States. 


82 


Nebraska S. M. J. 


Management of Crushed Chest Injuries 


T rauma to the chest is increas- 
ing in frequency with the in- 
crease in the number of cars 
and the increase in the speed of automobile 
traffic. Hudson reported that 25 per cent 
of all traffic deaths were due to chest in- 
juries. ^ With our ever expanding system of 
highways and superhighways, many of 
these injuries occur at sites distant from 
medical centers. At the present time, most 
people in the state of Nebraska are within 
50 miles of a community hospital and with- 
in 300 miles of a medical center. 

It therefore seems important for all physi- 
cians to familiarize themselves with the 
emergency treatment of patients with crush- 
ing injuries of the chest. The purpose of 
this paper is to stress the basic fundamentals 
of the treatment of patients with such an 
injury, and to emphasize the importance of 
the use of internal pneumatic stabilization 
in the treatment of patients with severe 
crushing injuries of the chest. 

Clinical Picture 

The initial symptoms of these patients 
vary according to the nature and the extent 
of the injury. The symptoms vary from 
mild thoracic pain to cough, dyspnea, hemop- 
tysis, cyanosis, shock, and unconsciousness. 
Physical examination should clarify the gen- 
eral condition of the patient. Special note 
should be taken of the presence of subcu- 
taneous emphysema and of the location of 
paradoxic motion of the chest wall. The lo- 
cation of the trachea and the severity of the 
dyspnea should be noted. One should look 
for the signs of air or fluid in the pleural 
cavity. The ability to cough effectively as 
well as the presence of blood, mucus, and 
other foreign material (vomitus) in the tra- 
cheobronchial tree should be checked. 

Initial Measures 

Treatment is critical in the cyanotic, 
shocky patient who has a large flail seg- 
ment. Institution of intennittent positive 
pressure breathing, decompression of hemo- 
pneumothoraces, treatment of shock, and 
careful tracheobronchial toilet are essential. 


STEPHEN W. CARVETH, MD 
Lincoln, Nebraska 
and 

KAI REHDER, MD 

Anesthesia Department, Surgical Hospital, 
University of Wurzburg 
Wurzburg, Germany 

and must be accomplished simultaneously in 
the emergency room. 

In the less severely injured person, minor 
flail segments can be managed by sandbag 
compression. Intercostal nerve blocks re- 
lieve thoracic pain and improve the ability 
of the patient to cough effectively. The ade- 
quacy of pulmonary ventilation should al- 
ways be periodically evaluated. Trache- 
ostomy should be performed when the pul- 
monary gas exchange is inadequate, or when 
the patient threatens to drown in his own 
secretions. Sandbag compression, chest 
drainage, intercostal blocks, oxygen ther- 
apy, and tracheostomy can and should be 
easily carried out in any community hos- 
pital which participates in the practice of 
surgery. Once the tracheostomy has been 
accomplished, the patient can remain in the 
community hospital, or can be transferred 
to a larger hospital if the nursing staff is 
not able to provide 24-hour tracheostomy 
care. Most tracheostomized patients should 
have the benefit of intensive care for the 
first 24 to 36 hours. 

In spite of the above measures, an element 
of dyspnea, cyanosis, and paradoxic motion 
of the chest wall may persist. Definite indi- 
cations for artificial ventilation are the ele- 
vation of a pCO, above the level of 60 mm 
Hg, and a steadily rising value of arterial 
pCOo. Actually, a patient with a normal 
pCOg value may need artificial ventilation, 
since it does not indicate how the ventilation 
was achieved. Controlled intermittent posi- 
tive pressure breathing promotes internal 
pneumatic stabilization, and thus produces 
external stabilization. It helps to relieve any 
significant atelectasis, and to reduce the ef- 
fect of traumatic wet lung. It appears to be 


March, 1966 


83 


the best currently available method of sta- 
bilization of a flail thoracic segment. Flail 
segments which cause the most trouble are 
located anteriorly and are the result of^ 
double rib fractures or a fracture of the 
sternum. 

Artificial respiration with intermittent 
positive pressure breathing (IPPB) can be 
accomplished with the use of a Bird Mark 
8, a Bennett PR-2, a Morch Respirator, and 
many other machines. The first two men- 
tioned respirators require the use of a cuffed 
tracheostomy tube. Controlled respiration 
is preferred and the patient will not attempt 
to override the machine as long as the ar- 
terial pCOa is 5-10 mm Hg lower than 
normal. This is accomplished by mild hy- 
perventilation, which maintains the arterial 
CO,-tension at approximately 30 mm Hg. 
Voluntary respiratory efforts are eliminat- 
ed, the patient requires less sedation and will 
usually appear more relaxed. The IPPB 
can be continued for one to 20 or 30 days, 
if this is deemed necessary. 

After the life-threatening complications 
are corrected, the method of care of the 
tracheostomy becomes very important. 
Sterile precautions are taken to prevent un- 
necessary contamination of the airway. The 
nursing staff, as well as the house staff, 
must be instructed to use sterile gloves and 
sterile catheters during each aspiration. Cul- 
tures with sensitivity tests of tracheal se- 
cretions are obtained at regular intervals 
and appropriate systemic antibiotics are 
given. 

In the early phases of treatment, trache- 
ostomized patients should be placed in an en- 
riched atmosphere of highly humidified oxy- 
gen. Patients who need prolonged artifi- 
cial ventilation require special humidifica- 
tion of the inspired gas. A heated Puritan 
Nebulizer may be used on the Bird or the 
Bennett machines, and an unheated Nebu- 
lizer is part of the Morch and Bird Respir- 
ator. A system of humidification prevents 
crusting of bronchial secretions. Nebuliza- 
tion of bronchodilators and mucolytic agents 
are used when indicated. 

Discussion 

In the past, ventilatoiy insufficiency ac- 


counted for the high mortality rate of pa- 
tients with severe crushed injuries of the 
chest. It was previously noted that no pa- 
tient with intact lungs, who sustained a 
crushed chest injury, and who arrived in the 
emergency room of a hospital alive, should 
die from respiratory insufficiency.^ Artifi- 
cial ventilation with IPPB will correct ven- 
tilatory insufficiency and produce internal 
pneumatic stabilization. This form of treat- 
ment of a patient with a severe crushed 
chest injury was first introduced by Avery, 
Morch, and Benson in 1956.® This method of 
treatment impedes paradoxic movements of 
the flail segment, may assist in the expan- 
sion of the atelectatic segments of the lung, 
and reduces the effect of traumatic wet lung. 

It is important to emphasize that oxygen 
therapy, intercostal nerve blocks, sandbags, 
chest drainage, and tracheostomy, can be the 
initial and only treatment necessary for pa- 
tients with a mild crushed chest injury. 
Certainly, most of the patients with such 
an injury can be cared for in a community 
hospital. The more severely injured pa- 
tients who require tracheostomy and artifi- 
cial ventilation with intermittent positive 
pressure breathing can best be managed in 
a hospital which frequently uses these facil- 
ities and has an intensive care unit. Arti- 
ficial ventilation should be employed either 
when ventilation is insufficient or when the 
work of respiration is too great for the pa- 
tient. 

Summary 

Specific requirements in the therapy of 
chest injuries should allow the patient to 
breathe easily and cough efficiently. The 
routine method of management of mild 
crushed injuries as well as recent more re- 
fined techniques are emphasized. The indi- 
cations for tracheostomy and artificial ven- 
tilation with intermittent positive pressure 
breathing are explained. 

References 

1. Hudson, T. R. ; McElvenny, R. T., and Head, 

J. R.: Chest wall stabilization by soft tissue trac- 

tion. JAMA 156:768-769, 1954. 

2. Rehder, K.; Hessler, O.; Carveth, S. W., and 

Viereck, H. J.: Crushed chest injury and artificial 

respiration. Amer J Surg (in print). 

3. Avery, E. E.; Morch, E. T., and Benson, D. 

W.: Critically crushed chests. J Thor Surg 32: 

291-309, 1956. 


84 


Nebraska S. M. J. 


Gas Gangrene Infection: Combined 
Treatment Including 3,432,000 
International Units of Polyvalent 
Gas Gangrene Antitoxin 


T he present day treatment of 
compound fractures by imme- 
diate debridement of the wound, 
followed by heavy antibiotic administration, 
has resulted in primary soft tissue healing 
in the vast majority of cases. Despite these 
expectations, however, every compound in- 
jury must be considered as a^ potentially 
septic problem. It is not unusual to note a 
mild suppurative process for several weeks 
without serious disturbance of either bone 
or of soft tissue healing. Infection of a 
compound wound by one of the gas form- 
ing anerobes, an unexpected complication in 
civilian practice, is a harrowing experience 
for both patient and physician. One imme- 
diately wonders what the most recent devel- 
opments in treatment of this entity may be; 
on noting the literature, one is then aware 
of the paucity of any recent information on 
the subject. The opportunity of treating 
a fulminating gas-gangrene infection, com- 
plicating a compound fracture, treated by 
all modalities applicable, particularly an ex- 
tremely large total dosage of gas gangrene 
antitoxin, suggested this report. 

C. C., a 23-year-old farmer, was seen on 
February 10, 1954, following an automo- 
bile accident, in which he was thrown into 
a roadside farm yard, receiving a trans- 
verse fracture of the middle third of the left 
femur, compounded anteriorly through a 
two-inch transverse laceration. Following 
X-ray study, the patient was anesthetized, 
the wound was cleansed, inspected, and ir- 
rigated (Fig. 1). One loose silk suture ap- 
proximated the skin edges. Fifteen pounds 
of skeletal traction were applied to a tibial 
tuberosity pin, with the leg resting in a 
hinged Pearson attachment Thomas leg 
splint. In addition to intramuscularly in- 
jected 600,000 units of Pencillin, the patient 


W. R. HAMSA, MD 
and 

DWIGHT W. BURNEY, JR., MD 
From the Department of Orthopedics at the 
Bishop Clarkson Memorial Hospital and the 
University of Nebraska College of Medicine 
Omaha, Nebraska 


was immediately given one vial of prophy- 
lactic Tetanus-Gas-Gangrene Antitoxin. The 
former was repeated daily. 

Progress for four days was uneventful. 
On the fifth day, some increase in thigh 
pain was noted, with definite increase in 
pain and mild elevation of temperature and 
pulse curves on the sixth day. On the eve- 
ning of this day, a sudden fever of 103° 
orally and pulse rate of 128 were associated 
with slight crepitus of soft tissues of the 
thigh, and X-ray evidence of discrete gas 
formation about the fracture site, (Fig. 2). 
Immediate wide open anterior and lateral 
drainage of the middle of the thigh under 
general anesthesia released considerable gas 
and thin, purulent drainage with very foul 
odor. The wound was packed with vaseline 
gauze and the patient was placed on isolation 
technique. Penicillin administered was in- 
creased to 4,000,000 units Penicillin G Solu- 
ble and 2 grams Dihydro-streptomycin was 
added pending return of culture studies. 

The laboratory demonstration of a Clo- 
stridium Welchii culture in twenty-four 
hours, associated with crepitus subcutane- 
ously over buttock and low back, a leuko- 
cytosis of 22,300, fever of 104° orally, and 
pulse rate of 126 prompted the use of anti- 
toxin therapy. During the following eight 
days, from twelve to twenty vials of poly- 
valent gas gangrene antitoxin daily were ad- 


March, 1966 


85 


ministered intravenously in 10 per cent 
glucose in water for a total of 132 vials. 
Contents of each vial are listed as “10,000 
units Cl. Welchii antitoxin, 10,000 units Vi^ 
brion Septique antitoxin, 30,000 units B. 
Histolyticus antitoxin, 1,500 units B. Oede- 
matiens antitoxin, 1,500 units B. Sordellii 
antitoxin.” The dailj" administration of 
4,000,000 units of Penicillin B Soluble and 
2 grams of Dihydrostreptomycin was con- 
tinued. Three 500 cubic ml of whole blood 
transfusions were given at seventy-two hour 


intervals. Roentgen therapy was added on 
four successive days. 

Under this routine a temperature drop to 
100°, pulse rate to 85, and leukocyte records 
suggested discontinuing the heavy antitoxin 
administration. Following sensitivity studies 
of the cultured organisms, the patient was 
placed on a 500 mg Achromycin every four 
hours. Thirty-four daj^s after original ad- 
mission, the fracture and wounds were im- 
mobilized by an Orr vaseline dressing plus 


Figure 1 



86 


Nebraska S. M. J. 


a double spica cast, incorporating the tibial 
pin. Note was subsequently made of the 
presence of a positive Clostridium Welchii 
culture taken from the depths of the wound. 
The patient was discharged on the thirty- 
ninth day. Redressment and new cast fixa- 
tion was necessary at the end of the third and 
fifth months. At the latter date, the wounds 
were healed, and the fracture was not united ; 
hence, a long-leg walking caliper brace was 
added. 

The persistent nonunion at the end of ten 


months following injury, with absence of 
any drainage for three and one half months, 
suggested direct fixation of the fracture. 
Intramedullary Hansen-Street nail fixation, 
supplemented with iliac grafts, was followed 
by an uneventful course (Fig. 3). The frac- 
ture site became progressively more solid 
on X-ray studies, and the intramedullary nail 
was removed on July 19, 1959. Presently, 
the knee ranges from 115° to 180° positions. 

The acute stage of this infection illus- 
trates the “dry type” of gas gangrene due 


Figure 2 



March, 1966 


87 


to Clostridium Welchiid Pain was of sud- 
den onset. The high fever was associated 
with an unusually high pulse rate. Early ap- 
prehension developed into a mild delirium, 
Anemia was not unusual and responded sat- 
isfactorily. Wound drainage was scanty and 
with typical putrefactive or “meat market” 
odor. Gas formation was a prominent fea- 
ture. This is in definite contrast to the “wet 
type” of gas gangrene as of Bacillus Oede- 
matiens infection; features here include 
milder pain, lower fever, elevated pulse rate, 
an apathetic rather than an apprehensive 


patient, profuse serous drainage, and little 
gas formations. 

Therapy in a fully developed infection of 
either type of gas gangrene must be consid- 
ered primarily as an acute toxic suppurative 
process. Immediate wide open drainage is 
necessary; the attending surgeon may ques- 
tion the advisability of the length of inci- 
sion necesary to expose adequately the 
depths of the infection. Devitalized tissue, 
as demonstrated by muscle segments that 
appear gray and lifeless, or failing to react 


Figure 3 



88 


Nebraska S. M. J. 


to pinching-, or muscles that appear darker 
than normal, must be excised. This involve- 
ment usually includes the entire muscle mass, 
illustrating the need for incisions of adequate 
length. Fascial compartment boundaries 
must be released by longitudinal section for 
circulatory improvement. If resection of all 
devitalized tissue appears impossible, serious 
consideration should be given to guillotine 
amputation. Palpable crepitus proximal to 
the compound wound suggests wide open in- 
cision of these areas as well, according to 
some authorities. 

The antibiotic preparations available are 
very numerous. Penicillin is universally sug- 
gested, as is streptomycin or its variations. 
Sensitivity tests would appear to be the most 
logical means of determining the ' antibiotic 
most suitable for a specific organism. Obvi- 
ously, the most rapidly absorbed prepara- 
tions are preferred despite the necessity for 
frequent administration. 

Antitoxin therapy begins with the prophy- 
lactic dose of combined tetanus-gas gangrene 
antitoxin administered subcutaneously. Once 
gas gangi’ene is diagnosed, a polyvalent type 
of antitoxin should be given immediately by 
intravenous route in high dosage. Drug 
periodicals recommend four vials, repeated 
every two hours until improvement is noted, 
with total requirement up to 20 vials. Dos- 
age limitations are not definitely known. A 
recent discussion of gas gangrene advised 
the maximum amount that could be given 
safely was 150,000 international units. ^ In 
our case, a total of 132 vials was given on 
the advice of and under the supervision of 
our consulting internist. During antitoxin 
administration, a syringe containing 1 cc of 
epinephrine hydrochloride (1:1000) should 
be available if respiratory difficulty or other 
signs of allergic reaction occur. 

Summary 

Every compound fracture must be con- 
sidered as an infectious process regardless 
of the thoroughness of the surgical debride- 
ment. Routine administration of tetanus 


antitoxin for prophylaxis is necessary unless 
the patient has had prior immunization, in 
which event a “booster” injection of one ml 
tetanus toxoid is adequate. The routine use 
of Penicillin as an additional safeguard is 
logical unless a history of sensitivity is ob- 
tained; in the latter event. Achromycin or 
Terramycin should be tried. 

The development of gas gangrene infec- 
tion, as evidenced by fever, high pulse rate, 
apprehension, local swelling, crepitus and 
pain, creates an acute emergency. Immedi- 
ate adequate wide surgical drainage is neces- 
sary. Of the additional modalities avail- 
ble, the antitoxin appears most logical and 
should be given in adequate doses as suggest- 
ed by the manufacturer’s circular. Uncer- 
tainty will arise as to how long this admin- 
istration is necessary. In our case, the total 
of 132 vials of antitoxin probably represents 
an extreme; in this severe infection the per- 
sistence of a positive anerobic culture sug- 
gested continuation of antitoxin. However, 
attention is called to the marked improve- 
ment in this case, as evidenced by the tem- 
perature of 100°, pulse rate of 85, and leuko- 
cyte count of 9,400 on the third day after 
drainage. The persistence of a positive cul- 
ture 28 days after drainage is also of ex- 
treme interest, as all systemic signs of infec- 
tion were then absent. One may assume, 
therefore, that antitoxin therapy may quite 
safely be discontinued when the acute signs 
of infection have subsided. A positive cul- 
ture is often present in compound wounds 
without systemic evidence of gas gangrene. 

The effectiveness of roentgen therapy can- 
not be evaluated in this case. Whenever it 
is available, however, its use should be en- 
couraged. 

Administration of whole blood transfu- 
sions affects the quickest control of the ac- 
companying anemia. 

References 

1. Snyder, Howard E.: Surgery in prophylaxis, 

diagnosis, and treatment of gas gangrene. Amer 
J Surg 87:479-48 (Mar) 1954. 

2. Aldrete, Joaquim S., and Judd, Edward S. : 
Gas gangrene. AMA Arch Surg 90:745-755 (May) 
1965. 


Americans will buy about .$60 million worth of appetite control 
drugs this year. 


March, 1966 


89 


Brachial Artery Puncture: An Oft 
Neglected Clinical Tool In The Evaluation 

Of Hypertension 


T he diagnosis of “hypertension” 
carries with it implications for 
the patient and physician 
which cannot be viewed with indifference. 
For the conscientious practitioner, the diag- 
nosis is not an end, but rather the beginning 
of a detailed, expensive investigation which 
is not entirely without risk.^ For the pa- 
tient, the finding of an elevated blood pres- 
sure may mean major vascular surgery or 
years of therapy with costly medications well 
known for their unpleasant and even dan- 
gerous side-effects. The decision to start 
down this long road of diagnosis and therapy 
is often based solely on blood pressure deter- 
minations measured indirectly with a sphyg- 
momanometer. The accuracy of this meth- 
od has been challenged by numerous work- 
ers.2. 3. 4. 5 Although some discrepancies be- 
tween the indirect and direct pressures do 
occur in any large series, by and large, the 
indirect method is amazingly accurate.^- ® 
There are, however, certain situations in 
which the cuff pressure is more likely to be 
in error.® Ordinarily, these discrepancies 
are of no clinical significance, but when the 
indirect reading indicates hypertension in 
these situations, it behooves the physician to 
determine the true blood pressure before ini- 
tiating the diagnostic and therapeutic proce- 
dures alluded to above. 

For this reason we began performing 
brachial artery puncture for direct pressure 
determination on selected patients in whom 
cuff pressure had indicated hypertension. 
Initially, we included obese patients with 
normal fundi, heart size, and kidney func- 
tion ; and elderly patients with poorly com- 
pressible brachial arteries due to Moncke- 
berg’s sclerosis. Subsequently we extended 
the technique to the performance of Regitine, 
cold pressor, benzodioxane, histamine, and 
angiotensin tests, since many of these proce- 
dures performed in the conventional manner 


HUGH S. LEVIN, MD; 

ANTHONY I. CARNAZZO, MD; 

VINCENT RUNCO. JR., MD, 
and 

RICHARD W. BOOTH, MD 
From the Department of Medicine, 

Division of Cardiology, Creighton University 
School of Medicine 
Omaha, Nebraska 

seemed to us unsatisfactory. In many cases, 
inadequate attention had been paid to tim- 
ing the blood pressure readings, which were 
frequently sporadic, variable, and difficult 
to interpret. Accounting in part for this dif- 
ficulty are the facts that hurried, repetitive 
determination of rapidly changing blood 
pressure is likely to lack accuracy,"^ and that 
pressure changes in some cases may be so 
transient that they are missed by the indirect 
method. 

Methods and Materials 

Thus far, thirty patients with hyperten- 
sion have been subjected to direct arterial 
puncture. All studies were performed in the 
Cardiac Laboratory. For comparison of di- 
rect and indirect pressures, it was decided 
that the indirect pressure in one arm should 
be compared to direct pressure in the oppo- 
site brachial artery for two reasons; (1) it 
seemed possible that the arteriospasm 
caused by an indwelling brachial arteiy 
needle might alter the indirect reading, and 
(2) it was feared that compression of a 
traumatized, spastic brachial artery contain- 
ing a foreign object might increase the inci- 
dence of thrombotic occlusion of the vessel. 
Thus, indirect pressure was determined in 
both arms by means of a mercury manometer 
with the patient supine. After bilateral 
equality of the indirect pressure was as- 
sured a #18 Cournand needle was placed in 

Reprint requests to St. Joseph's Hospital Cardiac Center, 
Omaha, Nebraska. (Dr. Levin). 


90 


Nebraska S. M. J. 


one brachial artery while the cuff was left 
on the opposite arm. The needle was then 
attached through sterile, large bore, poly- 
ethylene tubing and stopcocks to a Statham 
P23Db strain gauge* filled with heparin- 
ized 5 per cent glucose in water and connect- 
ed to an Electronics for Medicine oscillo- 
graphic recorder.f The antecubital fossae 
of both arms were maintained at the same 
level and were used as the zero reference. 
The gauge was calibrated before each pro- 
cedure against the same mercury mano- 
meter used to measure the indirect pres- 
sure. Heparinized 5 per cent glucose in 
water, contained in a pressurized poly- 
ethylene bag connected to the system through 
one of the stopcocks, was used to flush the 
indwelling needle periodically. Direct ar- 
terial pressure was registered on the record- 
er while simultaneous indirect pressures 
were determined. For the performance of 
cold pressor, Regitine, benzodioxane, hista- 
mine and angiotensin tests, essentially the 
same procedure was followed, with the ex- 
ception that an indwelling needle was placed 
in a vein in the same arm as the arterial 
needle, and its patency was maintained with 
a slow drip of 5 per cent glucose in water. 
Except for brief periods necessary to flush 
the ai’terial needle, the pressure was mon- 
itored continuously on the oscilloscope and 
recorded at a slow paper speed (2.5 or 5 
mm/sec). Once a stable baseline was as- 
sured, the patient’s other hand was im- 
mersed in cold water or the appropriate drug 
was injected into the intravenous tubing, 
unbeknown to the patient. A marker on the 
recorder indicated the exact onset of the 
test. The recording was continued until 
control pressures were regained. 

Results 

Obesity 

Direct arterial pressure measurement in 
the majority of obese patients studied con- 
firmed the existence of hypertension. The 
diagnostic work-up was completed and ap- 
jiropriate therapy was initiated. A few pa- 
tients, however, were found to have def- 
initely normal direct arterial pressure while 

*Statham Transducers, Inc., Hatorey, Puerto Rico. 

fElectronics for Medicine, Inc., White Plains, N.Y. 


simultaneously recorded indirect pressure in- 
dicated hypertension. These patients were 
spared the expense and risk of further study 
and therapy. 

Elderly Patients With Monckeberg’s 
Sclerosis of the Brachial Arteries 

Our interest in this type of patient was 
stimulated by an 81 year old man with 
congestive heart failure and medial arteri- 
osclerosis whose Korotkoff sounds were au- 
dible between 180 and 110 mm Hg. Direct 
arterial pressure was 131/57 mm Hg and 
the admitting diagnosis of hypertensive 
heart disease was abandoned. It occurred 
to us that systolic hypertension with or with- 
out diastolic hypertension in elderly patients 
might in some cases be due to artifactual ele- 
vation of the indirect pressure because of 
incompressibility of the sclerotic brachial 
arteries. A small pilot study has shown that 
the indirect pressure is accurate in many 
elderly patients with systolic or diastolic hy- 
pertension or both, but in some patients there 
is indeed a significant discrepancy. (A 
more complete study is under way and will 
be reported later). Because of the in- 
creased incidence of renal vascular hyperten- 
sion due to arteriosclerotic narrowing of the 
renal arteries in older patients and the fav- 
orable surgical cure rate of this type of hy- 
pertension,® it is essential that an attempt 
be made to establish the correct etiologic 
diagnosis. Our experience would suggest 
that in patients with Monckeberg’s sclerosis, 
an apparent elevation of diastolic pressure 
should be documented by direct arterial punc- 
ture before a diagnostic work-up is initiated. 

Cold Pressor, Regitine, Benzodioxane, 
Histamine and Angiotensin Tests 

Direct arterial pressure monitoring proved 
such a valuable modification for the per- 
formance of these tests that at the present 
time we use this method almost exclusively. 
(Fig. 1). An adequate baseline pressure is 
indicated by stability of the systolic and 
diastolic levels on the monitor, and the 
blood pressure response to the test procedure 
is immediately apparent. Control and ex- 
perimental pressures are recorded perma- 
nently without interruption. Both the exact 
degree of pressure change and the exact 


March, 1966 


91 



Figure 1. Direct arterial pressure recordings showing a histamine test (A) and a Regitine test (B). An 
adequate dose of histamine is signified by the initial drop in pressure. The test is negative because the rise in 
pressure did not exceed that observed during a previously performed cold pressor test. The fall in pressure 
of 20/12 mm Hg after Regitine injection also represents a negative test. (Paper speed: .5 mm/second). 


time relationships are apparent on the re- 
cordings. Close observation of the monitor 
frequently gives evidence concerning the 
adequacy of the test. For example, an ade- 
quate dose of histamine is confirmed by an 
initial fall in pressure easily detected on 
the oscilloscope. (Fig. lA). If several tests 
are indicated, (for example, cold pressor, 
histamine and angiotensin tests), they are 
performed at one sitting, thus avoiding 
multiple arterial punctures. In the event of 
an unforeseen reaction, the blood pressure 
can be continuously monitored while cor- 
rective measures are being taken. The 
performance of the tests in the Cardiac Lab- 
oratory, where emergency drugs as well as 
special resuscitative equipment are kept, 
provides an added safeguard not available on 
the usual hospital ward. 

A case illustrating the benefits of this tech- 
nique is that of a 42-year-old moderately 
obese negro female with hypertension of 
one year’s duration. Although antihyperten- 
sive drugs had been discontinued several 
months previously, the patient had continued 
to take amitriptyline hydrochloride*, a cen- 
trally acting antidepressant.® Other than 
a blood pressure of 170/104 mm Hg, there 
were no pertinent physical findings. A 
complete laboratory investigation of her 
hypertension was negative except for evi- 
dence of mild diabetes mellitus. Direct ar- 
terial puncture for the purpose of perform- 
ing a regitine test revealed an intra-arterial 
pressure of 171/104. Four minutes after the 
intravenous injection of 5 mg of phentola- 
mine methanesulfonite,** the blood pres- 


sure had dropped to 61/47 and the patient 
complained of dyspnea, chest pain, and ap- 
prehension. Oxygen was administered and 
an infusion of levarterenol bitartrate,*** 4 
mg in 500 ml of glucose in water was begun. 
Almost immediately the pressure rose to 
250/152 mm Hg and the patient complained 
of headache. Intravenous injection of an 
additional 5 mg of phentolamine methane- 
sulfonate lowered the pressure to control 
levels where it remained during an hour of 
observation. Subsequently, a presacral pneu- 
mogram and analysis of four 24 hour urine 
collections for vanillyl mandelic acid failed 
to confirm the existence of a catechol-produc- 
ing tumor. Aortography was suggested but 
was refused by the patient. 

Whether the positive response to Regitine 
was due to a pheochromocytoma or to ami- 
triptyline therapy thus remains undeter- 
mined. It is clear, however, that the per- 
formance of the test as described above al- 
lowed immediate recognition of the fall in 
blood pressure and prompt institution of ap- 
propriate measures. The dramatic response 
to levarterenol was at once obvious and treat- 
ed without delay. Throughout this entire 
period, arterial pressure was permanently 
and accurately recorded without interrup- 
tion. If the test had been performed in the 
conventional manner at the bedside, it is 
doubtful that the untoward reaction would 
have been managed as efficiently or that the 
blood pressure response would have been 

•Elavilg HCL ; Merck, Sharpe & Dohme 

**Regitine@ methanesulfonate : Ciba Pharmaceutical Co. 

***Levophedg bitartrate; Winthrop Laboratories 


92 


Nebraska S. M. J. 


recorded accurately in the excitement which 
followed its initial precipitous drop. 

Complications 

No complications or untoward reactions 
have been encountered in the thirty pa- 
tients included in this study. Post-puncture 
bleeding has been avoided by careful atten- 
tion to hemostasis before the patients leave 
the laboratory and arterial thrombosis has 
not occurred. 

Summary and Conclusions 

Although conventional clinical blood pres- 
sure readings closely approximate true ar- 
terial pressure in the majority of cases, 
there are notable exceptions. Indirect blood 
pressure determination is less likely to be 
accurate in extremely obese individuals; in 
those with severe Monckeberg’s sclerosis; 
and when hurried, repetitive readings are 
performed to monitor rapid changes in pres- 
sure. Since an erroneous diagnosis of hyper- 
tension may lead to unnecessary and even 
hazardous diagnostic and therapeutic pro- 
grams, it behooves the physician to verify 
the accuracy of the indirect readings if, for 
any reason, their validity is in doubt. To- 
ward this end, we would recommend brachial 
artery puncture as a simple, safe and reli- 
able tool for the determination of direct ar- 
terial pressure when the sphygmomano- 
metric diagnosis of hypertension is in ques- 


tion. By this means, we have been able to 
disprove the clinical diagnosis of hyperten- 
sion in a small but significant number of 
selected patients who otherwise would have 
been unnecessarily subjected to extensive 
laboratory evaluation and prolonged ther- 
apy. In addition, we have found direct pres- 
sure monitoring a helpful adjunct to the per- 
formance of Regitine, histamine, benzodiox- 
ine, cold pressor and angiotensin tests and 
would recommend its use for the refined 
execution of these procedures. 

References 

1. Brest, A. N., and Moyer, J. H.; Hyperten- 
sion: Recent Advances. Lea & Febiger, Philadel- 
phia, 1961, p 23. 

2. Ragan, C., and Bordley, J.: The accuracy of 

clinical measurements of arterial blood pressure. 
Bull Johns Hopkins Hosp 69:504, 1941. 

3. Steele, J. M.: Comparison of simultaneous 

indirect (auscultatory) and direct (intra-arterial) 
measurements of arterial pressure in man. J Mount 
Sinai Hosp 8:1042, 1941-42. 

4. Roberts, L. N; Smiley, J. R., and Manning, 

G. W.: A comparison of direct and indirect blood 

pressure determinations. Circulation 8:232, 1953. 

5. Van Bergen, F. H. ; Weatherhead, D. S.; Tre- 
loar, A. E.; Dobkin, A. B., and Buckley, J. J.: Com- 
parison of indirect and direct methods of measuring 
arterial blood pressure. Circulation 10:481, 1954. 

6. Berliner, K.; Fujiy, H.; Lee, D. H.; Yildiz, 

M., and Gamier, B.: Blood pressure measurements 

in obese persons: Comparison of intraarterial and 
asculatory measurements. Amer J Cardiol 8:10, 
1961. 

7. King, G. E.: Influence of rate of cuff infla- 

tion and deflation on observed blood pressure by 
sphygmomanometry. Amer Heart J 65:303, 1963. 

8. Brest, A. N., and Moyer, J. H.: p 181. 

9. 1963 Physicians Desk Reference to Pharma- 
ceutical Specialties and Biologicals, 17 ed Medical 
Economics, Inc., Oradell, N.J., 1962, p 757. 


Only four other countries besides the United States made a 
significant number of drug discoveries from 1941 to 1964, and 
all four — Switzerland, Germany, United Kingdom and France — 
have patent systems similar to that in the U. S. 


March, 1966 


93 


Carcinoma of the Tongue: 
The Role of Chronic Irritation 


C hronic irritation of tissue has 
been considered a contributing 
factor in cancer since the re- 
port of Yamagiva and Ichikawa^ in 1916. 
Presumed oral irritants are excessive use of 
tobacco and alcohol, poorly fitted dentures, 
neglected oral hygiene, syphilis, and condi- 
tions associated -with deficient iron in the 
serum. Passalacqua^ mentioned excessive 
use of tobacco, ingestion of hot drinks, nu- 
tritional deficiencies, and poor oral hygiene 
as possible causes of cancer. Shedd and as- 
sociates® considered the heavy-smoking cir- 
rhotic patient a likely candidate for oral 
carcinoma. Martin and Koop'* discussed ex- 
tensively the effect of avitaminosis B on 
the health of the tongue and its relation to 
precancerous and cancerous lesions. 

Records of patients with malignant neo- 
plasms of the tongue at Charity Hospital of 
Louisiana at New Orleans have been exam- 
ined for possible predisposing factors. Un- 
fortunately, information about personal hab- 
its of patients is not always recorded in hos- 
pital charts, and sometimes even an accurate 
description of the lesion is omitted. Lack 
of data prevented analysis of familial his- 
tory of carcinoma, dietary habits, or pres- 
ence of viral infections. 

Clinical Material 

Records of 220 patients with cancer of the 
tongue were reviewed among 773,356 total 
admissions to Charity Hospital of Louisiana 
at New Orleans from January, 1952 through 
December, 1962. Extrinsic lesions were dis- 
carded even when they involved the tongue, 
because their origin was identified as the 
alveolar ridge on the floor of the mouth, 
with extension to the tongue. Selected for 
analysis were records of 197 consecutive pa- 
tients with intrinsic carcinoma of the tongue. 

Distribution by Age, Sex, and Race 

The largest number of patients for each 
category of race and sex was in the seventh 
decade of life (Table 1). No significant 


DONOVAN B. FOOTE, MD; 

THOMAS A. GRAVES, MD, 
and 

HAROLD G. TABB, MD 
From the Department of Otolaryngology. 
Tulone University School of Medicine, and 
Charity Hospital of Louisiana at New Orleans 


difference in distribution by age was found 
between patients with carcinoma of the an- 
terior two thirds of the tongue and carcinoma 
of the base of the tongue. Jacobson® report- 
ed an average age of 63 years for women and 
59 years for men in a series of 227 patients, 
and Martin and associates® found the aver- 
age age of 556 patients to be 58 years. The 
ratio of white men to white women in the 
present study was 6 to 1, of white men to 
Negro women 3.3 to 1, of white men to Negro 
men was 2.3 to 1, and of Negro women to 
white women, 2 to 1. In the general hos- 
pital population, admissions of white men, 
white women, and Negro men are about the 
same, but Negro women are admitted three 
times more often than any of the other 
groups. 

Site of Lesion 

Lesions from the tip to the vallecula of 
the tongue and on the undersurface and floor 
of the mouth have been described as cancer 
of the tongue. Martin and associates® con- 
sidered the general term, cancer of the 

Table 1 

CARCINOMA OF THE TONGUE 
DISTRIBUTION BY SEX 
(Charity Hospital of Louisiana at New 
Orleans, 1952-1962) 


White Negro 


(yrs) 

Male 

Female 

Male 

Female 

Total 

31-40 

0 

2 

0 

0 

2 

41-50 

17 

2 

8 

5 

32 

51-60 

24 

4 

13 

6 

47 

61-70 

38 

6 

14 

11 

69 

71-80 

- __ 22 

1 

9 

7 

39 

80 

3 

1 

1 

3 

8 

Total 

104 

16 

45 

32 

197 


94 


Nebraska S. M. J. 


tongue, inadvisable because the floor of the 
mouth, as a separate anatomic structure, has 
distinctive clinical and anatomic charac- 
teristics. Only early lesions, before exten- 
sion, can be divided into those of the floor 
of the mouth and those of the undersurface 
of the tongue. 

The present study is confined to lesions 
of the tongue from the tip to the vallecula, 
excluding those which originated in the 
mouth and extended to the tongue. Sites of 
lesions were divided into the anterior two 
thirds and the posterior one third of the 
tongue, on the basis of the position of the 
lesion in relation to the lingual V formed by 
the circumvallate papillae. The initial sites 
of extensive tumors are difficult to classify. 

In the present study, 67 per cent of the 
lesions were on the anterior two thirds of the 
tongue, 30 per cent were on the posterior one 
third, and the other 3 per cent affected both 
parts of the tongue. This distribution agrees 
closely with that of Martin and associates,® 
who observed 67 per cent of lesions in the 
anterior two thirds of the tongue and 33 
per cent on the base of the tongue. Marcial,'^ 
however, found that 38 per cent of lesions 
affected the anterior two thirds of the 
tongue; 55 per cent, the base; and 7 per 
cent, the entire tongue. The reason for the 
the discrepancy is not clear, especially since 
the anatomic classification was similar, but 
difficulty in examination may be partly 
responsible. From diagrams and descrip- 
tions in records in the present series, some 
anterior lesions seem to be erroneously 
classified as posterior lesions when the ob- 
server neglected anatomic classification. 
Since little of the posterior one third of the 
tongue is visible, the patient who complains 
of a sore on the tongue probably has an 
anterior lesion, although it may be far back 
on the visible surface of the tongue. 

Histopathologic Characteristics 

Cancer of the tongue usually begins in the 
surface epithelium. The most common path- 
ologic diagnosis in the series was squamous 
cell or epidermoid carcinoma. Squamous cell 
carcinoma was reported in about 97 per cent 
of patients, an incidence congruous with that 
found by others.'^- ® Martin and associates® re- 


ported an incidence of 90 per cent. Other tu- 
mors in present study included one lympho- 
epithelioma, one mucoepidermoid carcinoma, 
one lymphosarcoma, and two undifferen- 
tiated neoplasms, probable sarcoma. Many 
tumors are poorly differentiated, but most 
of those that were classified were grade II. 
Both ulcerative and exophytic tumors wei’e 
identified. 

Symptoms 

Symptoms of early cancer of the tongue 
were rarely distressing to the patient. Even 
after discovery of a lesion, the patient may 
not seek treatment because he has no dis- 
comfort and the lesions grow slowly. Martin 
and associates® attributed lack of pain in 
patients with malignant lesions to the cover- 
ing of the base of the ulcer by epithelium. 
Moreover, symptoms vary with the position 
of the lesion on the tongue. MacFee® em- 
phasized that pain is not likely to be an 
early symptom if the site of the lesion is the 
less sensitive posterior third of the tongue, 
but in this series pain, most frequently de- 
scribed as sore throat, was the most common 
complaint of patients with lesions of the pos- 
terior one third of the tongue. 

Few patients had a single complaint. In 
patients with lesions of the anterior two 
thirds of the tongue, a sore on the tongue was 
the most frequent symptom (Table 2). Pain, 
the next commonest complaint, was described 
by patients with advanced lesions. Lesions 
of the posterior third of the tongue, which 
are not visible on the patient’s or physician’s 
casual inspection, are usually discovered at 
a later stage, sometimes after metastatic 

Table 2 

SYMPTOMS IN CARCINOMA OF THE TONGUE 
(133 Patients at Charity Hospital of 
Louisiana at New Orleans, 1952-1962) 

No Patients With 
Carcinoma of Tongue 
Anterior Posterior 
two thirds one third 


SYMPTOMS 

Sore in mouth 52* 9 

Pain 30 19 

Growth in mouth 19* 2 

Lump in neck 8 13 

Dysphagia 4 7 

Bleeding from mouth 3 3 

Asymptomatic lesion 1 0 

Hoarseness 0 1 

None listed 16 4 

* — Tongue 


March, 1966 


95 


nodes appear. Of the six patients with le- 
sions that affected the entire tongue, three 
had sores on their tongue, two had difficulty 
swallowing, and one had pain in the jaw... 
The average duration of symptoms was five 
and one half months. 

Irritants 

Apparently several irritants in the oral 
cavity combine to reduce mucosal resistance. 

Tobacco. The relation of tobacco to neo- 
plasms of the mouth and respiratory tract 
has been debated for many years. The 
form of tobacco used, amount of daily ex- 
posure, and duration of exposure all seem to 
be significant. Obviously, in nonsmoking 
patients, other causes must be sought. 

Table 3 shows the type of tobacco used by 
patients in the present study, according to 
site of lesion. When patients used several 
forms of tobacco, the commonest form used 
was recorded. Plug tobacco, for example. 

Table 3 

CARCINOMA OF THE TONGUE 
TYPE OF TOBACCO USED 
(Charity Hospital of Louisiana at New 
Orleans, 1952-1962) 


TYPE OF TOBACCO USED 
Cigarettes — 

Site of Lingual Lesion 
Anterior Posterior 

two thirds one third 

Total 

light _ _ 

13 

5 

18 

moderate 

10 

9 

19 

heavy 

5 

2 

7 

amount unknown _ 

___ 7 

2 

9 

Pipe 

18 

3 

21 

Cigars 

3 

3 

6 

None . 

8 

1 

9 

Unrecorded . 

68 

34 

102 

Total _ 

132 

59 

191 


was generally used with another form. One 
patient with an anterior lesion suggested a 
source of irritation when he stated that he 
held his plug on the same side as the lesion. 

Of the nine patients who did not use tobac- 
co, three wore dentures, and one of these 
thought the sore became smaller when she 
stopped wearing her dentures. Three pa- 
tients had poor oral hygiene, two were 
edentulous but no mention was made of 
dentures or state of hygiene, and one had no 
further information listed. 


Alcohol. Chronic ingestion of alcohol is 
irritating to the oral mucosa and would seem 
to be a specific cause of carcinoma of the 
tongue, but the associated poor nutrition in 
alcoholic patients also affects the health of 
the tongue. Moreover, heavy drinkers are 
often heavy smokers and have poor oral hy- 
giene and dental caries. Difficulty in obtain- 
ing accurate information about use of al- 
cohol may explain apparent lack of corre- 
lation between use of alcohol and presence 
of lesions in our study. Recorded data about 
use of alcohol by patients in the present 
study are classified in Table 4. 

Table 4 

CARCINOMA OF THE TONGUE 
AMOUNT OF ALCOHOL USED 
(Charity Hospital of Lousiana at New 
Orleans, 1952-1962) 


Site of Lingual 
Anterior Posterior 

two thirds one third 

Lesion 

Entire 

tongue 

Total 

AMOUNT OF 
ALCOHOL USED 
None _ 

. 20 

8 

0 

28 

Light 

. 6 

4 

0 

10 

Moderate _ _ __ 

12 

6 

1 

19 

Heavy 

. 10 

8 

1 

19 

Known alcoholic- 

. 3 

2 

0 

5 

Unrecorded 

. 82 

36 

4 

122 

Total 

133 

64 

6 

203 


Oral and Dental Hygiene. The health of 
the oral cavity is largely dependent on oral 
hygiene, although peridontal disease some- 
times occurs despite good care. The oral 
mucosa of patients with neoplasms of the 
tongue often appears to have been chronical- 
ly irritated; it is extremely erythematous 
and atrophic, and the vasculature is prom- 
inent. Carious snags with edematous perio- 
dontal tissue are sometimes evident. Den- 
tures change the color and appearance of 
the mucosa beneath them, and ill-fitting den- 
tures cause specific mucosal ulceration. 

Oral hygiene and dental disease seem to 
be contributing causes only in lesions of 
the anterior two thirds of the tongue. In 
the patients in the present study with ade- 
quate records, 39 had poor oral hygiene, and 
three had fair oral hygiene. Eight patients 
had carious teeth, pyorrhea, or periodontal 
disease; four mentioned specific teeth as 
causes of sores on their tongues; and five 


96 


Nebraska S. M. J. 


had dentures that were ill-fitting or caused 
pain. 

Syphilis. Syphilis is more common in pa- 
tients with carcinoma of the tongue than 
in the general hospital population. In pre- 
vious studies, neoplasms were believed to 
originate in syphilitic gummas. Jacobson® 
found a positive correlation between syphilis 
and lingual cancer. Table 5 shows the fre- 

Table 5 

CARCINOMA OF THE TONGUE 
INCIDENCE OF SYPHILIS 
(Charity Hospital of Louisiana at New 



Orleans, 

1952-1962) 



SYPHILIS 

No. Patients 
Anterior 
two thirds 

With Lineal 
Posterior 
one third 

Cancer 

Entire 

ton^e 

Total 

Present 

19 

8 

2 

' 29 

Absent _ 

88 

38 

3 

129 

Unknown _ 

26 

12 

1 

39 

Total 

133 

58 

6 

197 

quency of 

positive 

serologic 

evidence of 


syphilis in our patients. 

Summary and Conclusions 
Records of 197 patients with cancer of the 
tongue, treated at Charity Hospital of New 


Orleans, have been reviewed for possible pre- 
disposing factors of lingual cancer. Present 
knowledge does not identify a single specific 
cause for carcinoma of the tongue. Our 
study suggests that contributing factors in- 
clude (1) chronic irritation of mucosa of 
the oral cavity by specific agents, such as 
tobacco and alcohol, (2) poor nutritional 
status, and (3) poor oral hygiene. 

References 

1. Yamagiva, K., and Ichikawa, K., cited hy 
Sarnat, B. G., and Schour, L: Oral and Facial Can- 
cer, second edition The Yearbook published 1959, pp 
24-25. 

2. Passalacqua, L. A.: Carcinoma of base of 

the tongue. Bol Asoc Med P Rico 48:268, 1957. 

3. Shedd, D. P.; Klingerman, M. M.; Gowen, 
G. F. : Multifocal carcinogenesis in the oral cavity. 
Amer J Surg 104-682, 1962. 

4. Martin, H. E.; Koop, C. E.: The precancerous 
mouth lesions of avitaminosis B . Amer J Surg 57 : 
195, 1942. 

5. Jacobsson, F.: Carcinoma of tongue; clinical 
study of 227 cases treated at Radiumhemmet, 1931- 
1942. Acta Radiol Supp 68:1948. 

6. Martin, H. E.; Munster, H. ; Sugarbaker, 
E. D.: Cancer of the tongue. AM A Arch Surg 41: 
888, 1940. 

7. Marcial, V. A.: Carcinoma of the base of the 

tongue. Amer J Roentgenol 81 :420, 1959. 

8. Gibbel, M. L; Cross, J. H.; Ariel, I. M.: 
Cancer of the tongue; review of 330 cases. Cancer 
1949, 2:411-423. 

9. MacFee, W. F.: Concealed cancer of the 

tongue. Ann Surg 93:481, 1931. 


Manufacturers of narcotic preparations must periodically re- 
port to the federal government about every grain of narcotic sub- 
stance received, produced, consumed, sold, ti'ansferred or given 
away and for all stocks of those drugs and preparations on hand. 


March, 1966 


97 


ORGANIZATION SECTION 


Welcome, New Members 


Egan, William P., MD Omaha 

Hadley, Richard A., MD Omaha 

Hadvorsen, H. C., MD Lincoln 

Hamsa, William R., Jr., MD Omaha 

Hermanson, Eugene, MD Coleridge 

Hohn, W. F., MD Lincoln 

McGreer, John T. Ill, MD Lincoln 

Moss, R. A., MD : Lincoln 

Mundt, Willis, MD Omaha 

Olney, Richard C., MD ..Lincoln 

Rigby, Perry, MD .....Omaha 

Schenken, Jerold R., MD ..Omaha 

Scott, John W., MD Omaha 

Smith, Edgar H., MD Omaha 


Coming Meetings 

CRIPPLED CHILDREN’S CLINICS— 
March 5 — Hastings, Elks Club 
March 19 — Broken Bow, Elks Club 
April 2 — Alliance, Central High School 
Building 

April 23 — McCook, St. Catherine’s Hos- 
pital 

CONTINUING EDUCATION COURSES 
FOR PHYSICIANS — Sponsored by the 
University of Nebraska College of Medi- 
cine’s Office of Continuing Education: 
March 7 — “Closed Chest Cardian Resus- 
citation (Omaha Campus) 

March 24 — “Newer Concepts of Hyper- 
tension” (Omaha Campus) 

April 20-21 — “Disorders of Growth” 
(Pediatrics) (Omaha Campus) 

May 5 — “Infectious Disease” (Omaha 
Campus) 

May 6 — “Current Concepts of Diabetes” 
(Omaha Campus) 

May 19-20 — “Surgery and Trauma” 
(Omaha Campus) 

ETV PROGRAMS FOR REGISTERED 
NURSES— 

March 1 — Nursing Care of the Hemi- 
plegic (1 p.m.) 


March 8 — The Nursing Care of a Patient 
Requiring a Bird Respirator (1 p.m.) 
March 15 — Nursing Care of a Patient 
Requiring a Pacemaker (1 p.m.) 

THE BIG HEART, Cardiac Work and Car- 
diac Hypertrophy ; Clinical Appraisals, 
Therapeutic Considerations and Pathologic 
Correlations — Baylor University College 
of Medicine, Houston, Texas; Raymond D. 
Pruitt, MD, FACP, Director. March 7-11, 
1966. 

DIABETES INSTITUTE — The Colorado 
Diabetes Association presents the third 
annual Diabetes Institute, at Aspen, Colo- 
rado, March 9-13, 1966. Fee: $50. Write 
to : Aspen Reservation Bureau, Community 
Service, Aspen, Colorado. 

CURRENT CONCEPTS OF RENAL, GAS- 
TROINTESTINAL AND CIRCULATION 
PHYSIOLOGY — Co-sponsored by the 
American Physiological Society, Barbizon- 
Plaza Hotel, New York, N.Y. ; Daniel H. 
Simmons, MD, FACP, and Charles Klee- 
man, MD, FACP, Co-Directors. 

RURAL HEALTH CONFERENCE — Farm 
and health leaders are to meet March 18- 
19, 1966 at Colorado Springs, in the 
Broadmoor Hotel, for the 19th National 
Conference on Rural Health, sponsored by 
the Council on Rural Health of the AMA 
in association with state medical associa- 
tions; and farm, educational, and allied 
health organizations. 

CONTINUING EDUCATION — Closed 
Chest Resuscitation ; University of Nebras- 
ka College of Medicine, at Eppley Research 
Institute, March 8, 1966 (for physicians, 
9th for dentists, and 10th for nurses). 
Info : Continuing Education, University of 
Nebraska College of Medicine, 42nd and 
Dewey, Omaha 5. 

MICROCIRCULATION — Microcirculation 
is to be the topic of discussion at the 
Heart Association of Southeastern Penn- 
sylvania’s Fifth National Symposium to 
be held at the Philadelphia’s Sheraton 
Hotel on March 10 and 11, 1966. Write 


98 


Nebraska S. M. J. 



to Lyle L. Perry, Heart Association of 
Southeastern Pennsylvania, 318 S. 19th 
Street, Philadelphia, Pa. 19103. 

NATIONAL SOCIETY FOR THE PRE- 
VENTION OF BLINDNESS — “Vision 
for the Space Age Houston, Texas, Rice 
Hotel, March 24-26, 1966. Info: Director 
of Information John D. Coleman, 16 East 
40th Street, New York 10016. 

BASIC MECHANISMS IN INTERNAL 
MEDICINE, University of Toronto, Tor- 
onto, Ontario, Canada; K. J. R. Wight- 
man, MD, FACP, Director. March 28- 
April 1, 1966. 

THIRD AMA CONGRESS ON ENVIRON- 
MENTAL HEALTH PROBLEMS — 
Drake Hotel, Chicago, April 4-5, 1966. 
Write to AMA, 535 North Dearborn 
Street, Chicago, Illinois 60610; Depart- 
ment of Environmental Health. 

MAYO CLINIC AND FOUNDATION — 
Clinical Reviews, a program of lectures 
and discussions on problems of general 
interest in medicine and surgery, will be 
presented on March 28, 29 and 30, 1966, 
and will be repeated (they will be iden- 
tical sessions) on April 4, 5, and 6, 1966. 
Write to M. G. Brataas (Secretary, Clini- 
cal Reviews Committee), Mayo Clinic, 
Rochester, Minnesota. 

Future Meetings of the American 

College of Surgeons — 

CLEVELAND, OHIO, March 14-17. Annual 
4-Day Sectional Meeting for Doctors and 
Graduate Nurses. Sheraton-Cleveland and 
nearby hotels. 

ANNUAL CLINICAL CONGRESS, Octo- 
ber 10-14, 1966. San Francisco, Cali- 
fornia. 

For any advance information address: 

Secretary, American College of Surgeons, 55 

East Erie Street, Chicago, Illinois 60611. 

SOUTHWEST SURGICAL CONGRESS — 
18th Annual Meeting, Flamingo Hotel, Las 
Vegas, Nevada, April 18, 19, 20, and 21, 
1966. 

March, 1966 


SIGHT -SAVING CONFERENCE — The 
1966 annual Sight-Saving Conference of 
the National Society for the Prevention of 
Blindness, Inc., will take place from March 
30 through April 1, 1966, at the Hotel 
Roosevelt, New York, N.Y. Write to John 
D. Coleman, Director of Information, Na- 
tional Society for the Prevention of Blind- 
ness, Inc., 16 East 40th St., N.Y.C. 

ENVIRONMENTAL HEALTH — The Third 
Congress on Environmental Health Prob- 
lems of the AMA will be held April 4-5 
at the Drake Hotel in Chicago. Write to 
EHC, Department of Environmental 
Health, AMA, 535 N. Dearborn St., Chi- 
cago, Illinois 60610. 

TERATOLOGY WORKSHOP — The Third 
Teratology Workshop will be held April 
4-8, 1966 at Boulder, Colorado; it is spon- 
sored jointly by the AMA, the Teratology 
Society, and the University of Colorado, 
with the support of the National Academy 
of Sciences - National Research Council. 
Write to William Kitto, MD, Associate Di- 
rector, Department of Drugs, AMA, 535 
North Dearborn Street, Chicago, Illinois 
60610. 

INDUSTRIAL HEALTH — The 1966 Amer- 
ican Industrial Health Conference will 
take place April 25-28 in Detroit, Mich- 
igan. Headquarters will be at the Sher- 
aton Cadillac Hotel, meetings in Cobo Hall. 
Write to : American Industrial Health 

Conference, 55 East Washington Street, 
Chicago, Illinois 60602. 

ANESTHESIOLOGY — Third Annual Mid- 
west Conference on Anesthesiology. Con- 
tinental Plaza Hotel, Chicago, Illinois, 
April 28-30, 1966. Write to T. L. Ash- 
craft, M.D., 33 East Cedar Street, Chi- 
cago, Illinois 60611. 

POSTGRADUATE COURSE IN LARYN- 
GOLOGY AND BRONCHOESOPHA- 
GOLOGY — A postgraduate course in 
laryngology and bronchoesophagology will 
be conducted by the Department of 
Otolaryngology of the Illinois Eye and 
Ear Infirmary and the College of Medi- 

99 


cine of the University of Illinois at the 
Medical Center, Chicago, from March 21 
through April 2, 1966. Write to the De- 
partment of Otolaryngology, College of. 
Medicine of the University of Illinois at 
the Medical Center, Postoffice Box 6998, 
Chicago, Illinois 60680. 

THE HAHNEMAN MEDICAL COLLEGE 
AND HOSPITAL of Philadelphia offers 
the following Postgraduate Education 
Courses during 1965 and 1966: 

— April 20-23, 1966: 16th Hahneman 

Symposium, Arterial Occlusive Disease; 
Dr. Albert N. Brest; Marriott Motor 
Hotel. 

— December, 1966: 17th Hahneman Sym- 
posium, Nutritional Dysfunction; Dr. 
Donald Berkowitz ; S h e ra ton Hotel, 
Philadelphia. 

NEBRASKA STATE MEDICAL ASSOCIA- 
TION — 98th Annual Session, May 2-5, 
inclusive, Cornhusker Hotel, Lincoln. 

THE THIRTEENTH ANNUAL MEET- 
ING OF THE MID-CENTRAL STATES 
ORTHOPAEDIC SOCIETY — Will be 
held May 5-7, 1966, at the Hotel Cornhusk- 
er, Lincoln. Write to Dr. Webster for fur- 
ther details. 

ARTHRITIS FOUNDATION — A two-day 
Postgraduate Seminar on Rheumatic Dis- 
eases will be held May 6 and 7, 1966 at the 
A. B. Dick Auditorium of Presbyterian- 
St. Luke’s Hospital, 1753 West Congress 
Parkway, Chicago, Illinois. The Seminar 
is sponsored by The Illinois Chapter, The 
Arthritis Foundation, 159 North Dear- 
born, Chicago. There will be a registra- 
tion fee of $20. 

FIRST INTERNATIONAL CONGRESS ON 
SMOKING AND HEALTH — June 5 to 
8, 1966, at the New York Hilton Hotel in 
New York City. Write to the Congress 
office: Overseas Press Club, 54 West 

40th Street, New York, N.Y. 

NEBRASKA RHEUMATISM ASSOCIA- 
TION TO MEET — Creighton University 
School of Medicine in Omaha, Auditorium 


of the Eppley School of Business, May 12, 
1966, at 1 p.m. 

FIRST ANNUAL BIOMEDICAL LASER 
CONFERENCE — June 17-18, Sheraton- 
Boston Hotel, Boston, Massachusetts. 

TENTH WORLD CONGRESS OF THE IN- 
TERNATIONAL SOCIETY FOR RE- 
HABILITATION OF THE DISABLED 
— September 11-17, 1966, Rhein-Main- 

Hall, Wiesbaden, Germany. 

NEBRASKA CHAPTER OF THE AMERI- 
CAN ACADEMY OF GENERAL PRAC- 
TICE — Scientific Meeting; September 15 
and 16, 1966, Hotel Cornhusker, Lincoln, 
Nebraska. 

INTERNATIONAL CANCER CONGRESS 
— The IX International Cancer Congress 
will be held in Tokyo, Japan, from October 
23-29, 1966. Write to Hirsch Marks, MD, 
435 East 57th St., New York 22, N.Y. 

The Military Dependents' 
Medical Care 

Basis for Payment Under Trimester 
Calculation — 

Payment for obstetrical delivery including 
complete prepartum and post partum care 
is authorized under Code 4821 of the Medi- 
care Manual and Schedule of Procedures, 
only when the physician has rendered care 
for a minimum of 29 weeks before delivery. 
When the patient is treated for less than 29 
weeks, an allowance is made under Code 
4829 for delivery and 4831 for the ante- 
partum care. This allowance is based on a 
trimester calculation, the first trimester be- 
ing the first 14 weeks of pregnancy. A maxi- 
mum of two visits is authorized, plus a 
physical and history under Code 4830. The 
second trimester is to include the following 
13 weeks, and a maximum of three visits are 
authorized for payment. The third tri- 
mester consists of the remaining weeks until 
delivery and, four visits are authorized. 
However, if a doctor has not seen the pa- 
tient until the third trimester, he may bill 
for a complete physical examination. Code 


100 


Nebraska S. M. J. 


4830, thus making a maximum of five vis- 
its during the third trimester. All post- 
partum care is considered to be included with 
the delivery fee. 

Treatment for complications arising dur- 
ing pregnancy is authorized for both ante- 
partum and postpartum care. When a 
Cesarean operation is performed, pajmient 
for antepartum care will be allowed under 
Code 4831. 

Injections are authorized; however, the 
physician must state on the report that this 
charge is “at actual cost to physician.” Oral 
medications and creams are not covered un- 
der the program and are the responsibility 
of the patient or sponsor. 

If a patient should change physicians for 
any reason, the physician may bill for any 
care rendered until that time, but should 
state the reason for partial care on the 
claim form. 


THE MONTH IN WASHINGTON 

Washington, D.C. — President Johnson 
has put a price tag of about $4.5 billion on 
his fiscal 1967 health programs, both do- 
mestic and international. 

The President’s fiscal 1967 budget, for the 
year beginning next July 1, calls for spend- 
ing about $4.3 billion on domestic health 
programs under the Department of Health, 
Education and Welfare. Cost of medicare 
benefits will be in addition to this total be- 
cause they will be paid for by Social Se- 
curity taxes. 

Spending on domestic health programs 
would have been greater if some — such 
as the new heart disease, cancer and stroke 
program — had not been cut back because 
of increased costs of the Vietnam war. The 
cutbacks mainly were effected by request- 
ing smaller appropriations than Congress 
had approved. The appropriation requested 
for the heart disease, cancer and stroke 
program was only half of the $90 million 
authorized by Congress. 

Johnson told Congress he would submit 
international health legislation to: 


— create an International Career Service 
in Health ; 

— help meet health manpower needs in de- 
veloping nations; 

— combat malnutrition; 

— control and eradicate disease; 

— cooperate in worldwide efforts to deal 
with population problems. 

Johnson said the United States must be 
prepared to help developing countries that 
ask for aid in controlling population expan- 
sion. He said: 

“. . . population growth now consumes 
about two thirds of economic growth in the 
less developed world. As death rates are 
steadily driven down, the individual miracle 
of birth becomes a collective tragedy of 
want.” 

Two federal reports — by the President’s 
Council of Economic Advisers and the So- 
cial Security Administration — covered med- 
ical costs and overall national spending for 
health care. 

The annual report of the economic council 
conceded that the “true” increase in medi- 
cal costs may have been less than the dollar 
increase. The report said: 

“In the most recent five years, medical 
costs have risen less rapidly than during the 
nineteen-fifties. This has been due primar- 
ily to the fact that prices of prescriptions 
and drugs have been declining. Also, the 
increase in charges for medical services — 
including doctors’ and dentists’ fees, eye 
examinations and eyeglasses, and hospital 
rates — has slowed down in comparison with 
the earlier period. 

“The higher hospital and doctor charges 
reflected in the consumer price index may 
overstate the true increase in the cost of 
medical care when account is taken of the 
rising effectiveness of the care received. 
With the dramatic improvements in medical 
technology that have taken place over the 
postwar period, many patients get more real 
“services” from each day’s stay in the hos- 
pital, or each visit to the doctor, than before.” 

The Social Security Administration re- 
ported that the nation spent $36.8 billion in 


March, 1966 


101 


1964 for health care, almost tripling the 
$12.9 billion spent in 1950. Per capita ex- 
penditures more than doubled in the 15 
year period, rising from $84 to $191 per 
person. 

Over 90 per cent of the 1964 expenditures 
were for health services and supplies. The 
balance was spent for medical research and 
construction of medical facilities. 

There was a considerable shift in method 
of pajTnent for personal health services from 
direct out-of-pocket payments to third- 
party payments. Payments by third parties 
which include insurance benefits, govern- 
ment payments and philanthropic payments, 
met slightly over one-third of the personal 
health care expenditures in 1950 and almost 
half of these expenditures in 1964. 

Government payments continued to pro- 
vide about 22 per cent of the funds for all 
personal health services. 

The Justice Department has ordered co- 
ordination of federal procedures to assure 
that medical facilities and institutions of 
higher learning which receive government 
funds do not practice racial discrimination. 

The Department of Health, Education and 
Welfare was assigned the main responsibili- 
ties, including: 

— Preparing and distributing a compliance 
form to be submitted by all medical fa- 
cilities and institutions of higher learn- 
ing which receive federal money, and 
evaluating the submitted forms. 

— Conducting periodic reviews of recipients 
and investigating any discrimination 
complaints against them. 

— Attempting to secure voluntary compli- 
ance and notifying other departments 
and agencies when any such effort fails. 

Both the American Medical Association 
and the Food and Drug Administration have 
warned the public against interpreting the 
acquittal of the promoters of krebiozen as 
meaning it is effective in the treatment of 
cancer. 

A federal court jury in Chicago found the 
promoters not guilty of fraud. 


“The results of a criminal proceeding 
should not be interpreted as establishing 
efficacy of the alleged new drug called krebi- 
ozen by its promoters,” the AMA said. Can- 
cer sufferers should consult with their physi- 
cians and not try to determine for themselves 
what is the best course of treatment in their 
own individual cases.” 

“As far back as 1963, krebiozen was 
proved to be nothing more than mineral oil 
and creatine, a common laboratory chemical,” 
the FDA said. “That scientific judgment 
still stands. The FDA will carry out its re- 
sponsibility to the public by doing what- 
ever will be necessary to keep krebiozen out 
of interstate commerce. We will do this as 
a life-saving activity. Each day a person 
with treatable cancer relies upon krebiozen 
is a day that brings him closer to death.” 


Drug Abuse Control Amendments 

Drug Abuse Regulations Are Now in Effect; 

Impact on Most Physicians Will Be Small — 

Chicago — The Drug Abuse Control 
Amendments of 1965, providing for federal 
regulation of the manufacture, distribution, 
and possession of depressant and stimulant 
drugs, went into effect February 1. 

Its provisions, which have chiefly to do 
with maintaining records, have little effect 
on most practicing physicians. Record-keep- 
ing is required only of the small minority of 
practitioners who “regularly dispense” to 
their patients drugs, named in the law and 
the implementing regulations, for which the 
patients are charged either separately or to- 
gether with charges for other professional 
seiwices. Physicians who occasionally dis- 
pense such drugs in emergency or special 
situations are not required to maintain spe- 
cial records. Restrictions on the issuing and 
renewal of prescriptions for controlled drugs 
apply to all doctors. 

Drugs covered by the law include barbitu- 
rates, amphetamines, and others which have 
a potential for abuse because of their de- 
pressant or stimulant effect on the central 
nervous system or because of their hallucino- 
genic effect. Not covered are narcotic drugs 


102 


Nebraska S. M. J. 


— opium, morphine, marijuana, etc. — which 
are regulated under another statute. 

The purpose of the law is accomplished 
primarily by monitoring the distribution of 
the drugs from raw bulk supplies held by 
manufacturers. 

The responsibility for maintaining the 
records which permit such monitoring falls 
chiefly upon drug manufacturers and pro- 
cessors and their suppliers, wholesale drug- 
gists, licensed pharmacists, hospitals, clinics, 
public health agencies, research laboratories 
and educational institutions that use the 
drugs in research, teaching, and analysis. 

Physicians who must establish and main- 
tain records are specifically identified by 
Food and Drug Administration (FDA) regu- 
lations. They are: 

“Practitioners . . . who regularly en- 
gage in dispensing any such drug or 
drugs to their patients for which the 
patients are charged, either separately 
or together with charges for other pro- 
fessional services.” 

The regulations exempt most practition- 
ers from record-keeping by stating: 

“The maintaining of small supplies 
of these drugs for dispensing or ad- 
ministering in the course of professional 
practice in emergency or special situa- 
tions (for example, as a stopgap meas- 
ure to tide patients over until a regu- 
lar supply of drugs can be obtained by 
prescription from a pharmacy, or dis- 
pensing as trial doses to patients), will 
not be considered as regularly engaged 
in dispensing for a fee.” 

Thus, the physician who maintains a small 
supply of the controlled drugs, for dispens- 
ing in conjunction with house calls or emer- 
gency office visits, does not have to keep 
records of the drugs if the drugs are dis- 
pensed only in emergency or stopgap situa- 
tions. Neither does the physician have to 
maintain records of samples distributed by 
detailmen if the samples are disposed of by 
dispensing “occasionally” (for example, as 
starter doses). The detailman, as a repre- 
sentative of the manufacturer, must keep a 
record of all samples distributed. 


Those physicians who “regularly dispense” 
controlled drugs, and thus must keep rec- 
ords, are required to : 

— Prepare a complete and accurate inven- 
tory of stocks on hand as of February 1, 
1966, and keep this record for at least three 
years. 

— From February 1, 1966, onward, pre- 
pare and keep a record of all depressant and 
stimulant drugs defined in the law which 
are received and dispensed. In the record 
must be included : for stimulant and depres- 
sant drugs received — the kind and quan- 
tity of the drug, the name, address, and the 
FDA registration number of the person from 
whom it was received, and the date of the 
transaction ; for stimulant and depressant 
drugs dispensed — the kind and quantity of 
the drug dispensed or otherwise disposed of, 
the name and address of the person obtaining 
the drug, and the date of the transaction. The 
records must be kept at least three years 
unless state laws require a longer period. 
In most instances the wholesaler or manu- 
facturer invoice is adequate for a receipt rec- 
ord, provided the necessary information is 
included. 

— Maintain all records open to inspection 
at reasonable times by properly identified 
FDA inspectors. 

Provisions of the law which all physicians 
must observe are those involving prescrip- 
tions : 

— Prescription orders for stimulant and 
depressant drugs must bear the name and 
address of the patient and the date of issue. 
It also must be signed by the prescriber; the 
physician may give the prescription order 
by telephone or by direct oral instructions 
if the oral order is followed by a written, 
signed order. 

— No prescription order can be renewed 
more than five times, and no prescription 
order can be dispensed or renewed more than 
six months after the date of issue. After 
five renewals or six months, the physician 
may issue a new prescription but cannot 
give authorization for refilling the old order. 
These requirements apply to all prescriptions 


March, 1966 


103 


as of February 1, 1966, regardless of the 
date of issue. 

Penalties for failure to comply with the 
Drug Abuse Control Amendments of 1965, 
otherwise known as Public Law 89-74, in- 
clude both fine and imprisonment. 


Announcemen+s 

Pregnancy and Childbirth on TV — 

The story of pregnancy and childbirth 
from preconception through infant care is 
told in a 12-part television series soon to be- 
gin appearing on the Nebraska Education 
Television Network. 

“Nine to Get Ready” is the title of the 
series, which was filmed in the University 
of Nebraska Medical Center in Omaha, and 
eventually will be shown on National Educa- 
tion Television stations. 

The series will premier March 1 at 9 p.m., 
and also will be shown each Thursday at 
1 p.m., on KUON-TV, Channel 12, Lincoln, 
and KLNE-TV, Channel 3, Lexington, Nebr. 

Two actual births, one vaginal and one 
cesarean, are shown in the series. 

The scripts were prepared by members 
of the Department of Obstetrics and Gyne- 
cology* at the University of Nebraska Col- 
lege of Medicine. The KUON-TV staff 
filmed and produced the series under a 14- 
thousand-dollar grant from the Nebraska 
State Health Department’s Division of Ma- 
ternal and Child Health. 

Conference on Narcotic Addiction — 

A conference on the growing problem of 
narcotic addiction will be held March 24-25 
at the Sherman House in Chicago, Illinois. 
It is sponsored by the Illinois State Medical 
Society, with cooperating organizations in- 
cluding the AMA, Chicago Medical Society, 
Illinois Pharmaceutical Association, Illinois 
Department of Mental Health, Chicago De- 
partment of IMental Health, U. S. Bureau 
of Narcotics, Illinois Division of Narcotics 
Control, and the Council on the Understand- 
ing and Rehabilitation of Addicts. The con- 
ference is open on a reservation only basis; 


write to Paul Swarta, Coordinator, Confer- 
ence on Narcotic Addiction, c/o Illinois State 
Medical Society, 360 North Michigan, Chica- 
go, Illinois 60601. 

Nebraska Rheumatism Association to Meet — 

The Nebraska Rheumatism Association 
will hold its annual scientific program at the 
Creighton University School of Medicine in 
Omaha, on May 12, 1966, at 1 :00 p.m., in 
the auditorium of the Eppley School of Busi- 
ness. 

Dr. \"ernon Ward of Keaimey is president 
of the organization this year. Dr. Lee Hol- 
lander of the University of Pennsylvania will 
discuss inflammation; Dr. William Robin- 
son of the University of Michigan will speak 
on joint manifestations of systemic diseases; 
Dr. -James Walch of Creighton University 
will talk on metabolic aspects of rheumatoid 
arthritis, and Dr. Walt Weaver of the Uni- 
versity of Nebraska College of Medicine 
will present and discuss patients with clas- 
sical rheumatoid spondjditis. 

Mid-West Elects — 

At the annual business meeting of the 
Omaha Mid-West Clinical Society, newly 
elected officers were as follows : 

President — Dr. Harry H. McCarthy 

President-Elect — Dr. Henry J. Lehnhoff, 
Jr. 

Secretaiy - Treasurer — Dr. William J. 
Reedy 

Director of Clinics — Dr. John D. Coe 

Assistant Director of Clinics — Dr. Theo- 
dore L. Perrin 

New Appointments at Lederle — 

Pearl River, N.Y. — Dr. Earl H. Dear- 
born has been appointed Assistant Director 
of Research and five other scientists have 
been named to new research posts at Lederle 
Laboratories, a Division of American Cyana- 
mid Company. 

Dr. Dearborn previously headed Lederle’s 
experimental therapeutics research section. 
He has been affiliated with the company since 
1956. He was formerly professor and chair- 
man of the department of pharmacologj' at 


104 


Nebraska S. M. J. 


Boston University Medical School and later 
served as assistant professor of pharma- 
cology at Johns Hopkins University. 

Other appointees are: Dr. Brian Hutch- 
ings, Dr. Ira Ringler, Dr. Karl Benitz, Dr. 
Harold White, and Dr. James Smith, Jr. 

Medical Officer Wanted — 

The Minneapolis Post Office has an- 
nounced a vacancy for the position of Medical 
Officer. 

The duties of the position are to operate 
the Medical Facility and provide employee 
health services in the Minneapolis Post Of- 
fice. 

The beginning salary ranges from $11,599 
to $14,632 per annum. 

This position carries all the benefits of 
the Federal Civil Service — periodic pay in- 
creases, 21/2 to 5 weeks paid vacation each 
year, generous sick leave provisions, low- 
cost life insurance and health plans, and an 
excellent retirement program. 

Applicants must be citizens of the United 
States and graduates of an approved medical 
school, with a degree of doctor of medicine, 
and must be licensed to practice. 

Application forms may be obtained from 
the Board of Examiners, U.S. Civil Service 
Commission, Room 432, Main Post Office, 
Minneapolis, Minnesota 55401. 

Hypertension — 

Omaha — Dr. Carlos R. Ayers of the Uni- 
versity of Virginia School of Medicine is 
guest lecturer for a physicians’ continuing 
education course on the “Newer Concepts of 
Hypertension.” The course, scheduled on 
Thursday, March 24, will be at the Univer- 
sity of Nebraska College of Medicine. 

An assistant professor of medicine at the 
University of Virginia, Dr. Ayers will con- 
sider “the use of plasma renin in the diag- 
nosis of hypertension” and “the use of uni- 
lateral renal excretory function in the diag- 
nosis of hypertension.” Other sessions dur- 
ing the course will be given by College of 
Medicine faculty members. 


Dr. Albert Carr, instructor in internal 
medicine, is course coordinator. The course 
is offered by the Office of Continuing Edu- 
cation and the Department of Internal Medi- 
cine at the medical college. 

Course participants are eligible for six 
hours of Category I Credit with the Ameri- 
can Academy of General Practice. Fee is 
$ 20 . 

Inquiries and registrations may be made 
through the Office of Continuing Education, 
University of Nebraska College of Medicine, 
42nd and Dewey Ave., Omaha, Nebr. 68105. 

Nebraska Internists Schedule Scientific Meeting — 

The American College of Physicians 
(ACP) will hold a regional meeting for in- 
ternists in Nebraska on March 5. 

The meeting will be held in Lincoln, Nebr., 
at the Cornhusker Hotel, with scientific pre- 
sentations on various aspects of internal 
medicine, including new concepts in heart 
disease and cancer. 

The regional meeting is one of 29 scien- 
tific seminars sponsored each year by the 
ACP throughout the United States and 
Canada. It serves to help keep College mem- 
bers in Nebraska abreast of developments in 
the basic sciences and clinical medicine. The 
ACP represents nearly 13,000 specialists in 
internal medicine. 

Edward C. Rosenow, Jr., MD, Philadel- 
phia, Pa., ACP Executive Director, will be 
the special guest. 

The meeting is under the direction of Hen- 
ry J. Lehnhoff, Jr., MD, Omaha, Nebr., ACP 
Governor for Nebraska and Professor of In- 
ternal Medicine at the University of Ne- 
braska School of Medicine. 

Write to Henry J. Lehnhoff, Jr., MD, 720 
Doctors Building, Omaha, Nebraska. 

Pediatrics Course — 

Omaha — Cancers and other disorders in 
growth in children will be discussed at a 
pediatrics course for physicians April 20-21, 
at the University of Nebraska College of 
Medicine. 


March, 196t 


105 


Dr. Allan L. Drash, assistant professor of 
pediatrics at Johns Hopkins School of Medi- 
cine, and Dr. Robert M. McAllister, associate 
professor of pediatrics at the University of-- 
California, will be the guest lecturers at 
the course in the Eppley Cancer Institute. 

Dr. Drash will discuss “differential diag- 
nosis of the child with short stature” and 
“medical management of the short child.” 

Dr. McAllister will discuss “present 
status of possibility of viral etiologj’ in 
childhood malignancies” and “diagnosis and 
treatment of malignancies at Los Angeles 
Childrens Hospital.” He will also partici- 
pate in two panel discussions. 

The “Disorders of Growth” course is spon- 
sored by the University of Nebraska College 
of Medicine and the Division of Maternal 
and Child Health, Nebraska State Depart- 
ment of Health. Course coordinators are 
Dr. Gordon E. Gibbs, professor and chairman 
of the department of pediatrics at the Col- 
lege of Medicine, and Dr. Henry M. Lemon, 
director of the Eppley Cancer Institute. 

Fee for the two-day course is $40. Regis- 
trations may be made through the Office of 
Continuing Education, University of Ne- 
braska College of Medicine, 42nd and Dewey 
Ave., Omaha, Nebr. 68105. 

Vascular Disease — 

The Albert Einstein Medical Center of 
Philadelphia will hold a three day symposium 
on vascular disease March 28-30, 1966, at 
the Bellvue-Stratford Hotel in Philadelphia. 
Five hundred physicians are expected to at- 
tend ; 38 papers will be presented ; there will 
be 35 participants. Topics to be discussed 
will include diagnostic procedures, obstruc- 
tive and inflammatory diseases of venous 
and lymphatic systems, aneurysm, arterial 
embolism, coagulation and biophysical as- 
pects of vascular disease, renovascular hy- 
pertension, and extracranial cerebrovascular 
disease. Moderators will include Doctors 
Michael DeBakey, Paul Owren, Irvine Page, 
Charles Rob, Israel Steinberg, and Travis 
Winsor. 

The registration fee is $30. Write to 
Aaron D. Bennett, MD, Symposium Office, 


Albert Einstein Medical Center, York and 
Tabor Rds., Philadelphia, Pa. 19141. 

Grants for Geriatric Study — 

New York, N.Y. — The American Geri- 
atrics Society recently announced the re- 
newal of three $1800 grants to encourage 
resident physicians to devote more time to 
the study of the medical problems of the 
aging. 

The grants will supplement the salaries 
paid to resident physicians while they con- 
tinue their medical education, and are made 
possible by Lederle Laboratories, a Division 
of American Cyanamid Company. 

The Lederle Residency Supplements will 
cover the period between July 1966 to June 
1967. They were inaugurated in 1962. 

Application for the grants should be ad- 
dressed to the Chaii*man, Fellowship Com- 
mittee, Am.erican Geriatrics Society, 10 Co- 
lumbus Circle, New York, N.Y. 10019. Dead- 
line for applications is June 1, 1966. An- 
nouncement of the awardees will be made 
at the AGS annual meeting June 23-24 at 
Chicago. 

All About Us 

Doctor G. A. Harris has joined Doctors 
Morgan and Gross in Cambridge. 

Doctor A. E. Mailliard, Osmond, has an- 
nounced plans to construct a new clinic 
building. 

Doctor William T. Hughes, Gretna, has 
announced that he will retire from practice 
due to ill health. 

Doctors Kenneth Dalton and Robert Bass, 
Genoa, are the co-owners of a new nursing 
home in Fullerton. 

Doctor Robert Osborne, Norfolk, has been 
elected chairman of the Governor’s Advisory 
Committee on Aging. 

Doctor Tatsumi Nakamura, formerly of 
Hastings, has become associated with Doc- 
tor Ben Bishop at the Crawford Clinic. 

Doctor John Calvert, Pierce, was elected 


106 


Nebraska S. M. J. 


President of the Madison Six County Medi- health programs being carried out overseas 
cal Society at the group’s January meeting. by the Volunteers. 


Doctor Leo T. Heywood, Omaha, was re- 
cently elected Chief of the Medical Staff at 
Creighton Memorial St. Joseph’s Hospital. 

Doctor Paul Hoff, Seward, was elected 
President of the Seward County Medical 
Society at the January meeting of the group. 

Doctor H. C. Stewart, Pawnee City, was 
guest speaker at the annual Chamber of 
Commerce banquet held in January at Hum- 
boldt. 

Doctor F. W. Wanek, Gordon, attended 
the 12th Annual General Practice Review at 
the University of Colorado Medical Center 
in January. 

Doctor Robert H. Mclntire, Hastings, was 
elected President of the Adams County Medi- 
cal Society at the group’s annual dinner 
meeting held in January. 

Doctor Carl J. Potthoff, Omaha, received 
a distinguished writing award from the Ne- 
braska Chapter, American Medical Writers 
Association at the group’s January meeting. 

Doctor Harold S. Morgan, Lincoln, has 
accepted the appointment as part-time con- 
sultant and medical liaison officer in the 
State Health Department for the Medicare 
program. 

Doctor Richard A. Pirotte, Omaha, was 
named recipient of the Home of the Good 
Shepherd Outstanding Service Award at a 
Good Shepherd Junior Auxiliary luncheon 
held in January. 

News and Views 

New Peace Corps Medical Division Head — 

Dr. Ralph L. Morris, a 31-year-old gradu- 
ate of the University of Washington Medical 
School, Seattle, has been named Director of 
the Peace Corps Medical Program Division, 
Director Sargent Shriver announced recent- 
ly. 

Dr. Morris will be in charge of a staff of 
81 physicians assigned to handle the health 
needs of some 10,200 Volunteers serving 
in 46 nations. The doctors also advise on 


He served his internship at University 
Hospitals at the University of Wisconsin, 
Madison, where he did post-doctoral work at 
the Institute for Enzyme Research before 
joining the Peace Corps. 

Dr. Morris and his wife, the former Janet 
Nelsen of Prosser, Washington, have two 
sons and two daughters. They live at 239 
G Street, S.W., Washington, D.C. 

New Ultrasonic Device — 

We note that a light, portable ultrasonic 
device for detecting space-occupying lesions 
in the head is now available from the Smith 
Kline Instrument Company. It sends brief 
sound impulses into the head, and echoes 
are shown on a cathode ray tube screen along 
a trace. 

Blood Donor Brochure — 

Eight major health agencies have joined 
in fostering the volunteer blood donor con- 
cept by endorsing the newly released “Sup- 
ply, Demand and Human Life’’ brochure de- 
veloped by the National Committee on Clear- 
inghouse Program of the American Associa- 
tion of Blood Banks. The agencies are the 
A.A.B.B., the American Hospital Association, 
the AMA, the American National Red Cross, 
Blue Cross Association, Health Insurance 
Council, National Association of Blue Shield 
Plans, and Public Health Service, U.S. De- 
partment of HEW. To obtain copies of the 
brochure, write to the American Association 
of Blood Banks, Central Office, Suite 1322, 
30 North Michigan, Chicago, Illinois 60602. 

Nursing Home Accreditation Administrator 
Appointed — 

Chicago — Harris B. Jones has been ap- 
pointed assistant director of the Joint Com- 
mission on Accreditation of Hospitals in 
charge of the Joint Commission’s new ac- 
creditation program for extended care fa- 
cilities. 

Jones has been on the staff of the National 
Council for the Accreditation of Nursing 
Homes since 1963, serving as its executive 
director for the past year. 


March, 1966 


107 


The appointment, which is effective imme- 
diately, was announced by John D. Porter- 
field, MD, director of the Joint Commis- 
sion which since 1953 has conducted an ac- 
creditation program for hospitals. 

The new accreditation program for extend- 
ed care facilities, under the auspices of the 
Joint Commission, merges the approval pro- 
gram of the American Hospital Association, 
the accreditation program of the National 
Council for the Accreditation of Nursing 
Homes, and the certifying program of the 
California Commission on Accreditation of 
Nursing Homes and Related Facilities. 

HOPE in Nicaragua — 

Washington, DC — Some 130 American 
doctors, nurses and technologists recently 
started Project HOPE’S fifth medical-educa- 
tion program in Corinto, Nicaragua, accord- 
ing to HOPE headquarters here. 

Details of the new mission were relayed 
to Washington from the hospital ship S.S. 
HOPE via the Project’s ship-to-shore radio 
system. 

A 21-gun salute, government officials and 
thousands of Nicaraguans greeted the float- 
ing medical center when it arrived. 

Earlier voyages of the vessel in the last 
six years have been to Indonesia, and South 
Viet-Nam, Peru, Ecuador and last year to 
Guinea. 

On Medical Students — 

Two AMA studies concerning medical stu- 
dents have reached these conclusions : 

1. A 207-member medical school class 
contained 2i/o times as many eldest sons as 
youngest sons. Perhaps fathers influence 
first-born sons more than others, perhaps 
sons accept influence according to their order 
in the family, and it may be that fathers 
run out of money after sending first-born 
sons to medical school. 

2. Traits essential for a medical student’s 
success are intelligence, scientific curiosity, 
self-discipline, and physical and emotional 


strength. But only 13 per cent of freshmen 
medical students in the past five years had 
an “A” average in college. 

3. Basic costs of medical school study are 
about $2600 a year at privately owned medi- 
cal schools and $1600 at tax-supported medi- 
cal schools. 




Doctor Everett E. Angle is a Harvard 
man; he is a or an urologist, and a very 
good one. He has for ten years been an 
artist as well as a physician; his avocation 
is sculpture. It all started, he says, when 
the church burned down, but we have seen 
his work, and his talent and artistic ability 
were surely there long before that. He did 
church furniture, then a prie-dieu, then the 
head of his preacher. After that, he went 
on to his family, and has since then done 
friends, and doctors; doctors can be friends, 
too. He has been a sculptor for ten years; 
he has had no lessons. He works in wood; 
he says wood has advantages of its own, it 
has the beauty of grain and texture that 
other substances lack; he has used walnut, 
elm, ash, mahogany, and even monkeypot. 
We have seen his work and we have visited 
his workshop, which is immense and includes 
four large rooms. He has “always” done 
photography, he says, and still does it. One 
of these pictures shows a small corner of 
his workshop; it includes some of his heads 
and a curious photograph. The other 
picture is of three heads, which were ex- 
hibited in Japan; you will see Dr. Angle’s 
daughter, his son, and an exchange student. 
We were greatly impressed by the amount 
of sculpture Dr. Angle has accomplished, 
but more so by the obvious quality of his 
work; he has his “boards” in sculpture. We 
are none of us born without a sense of, and 
a feeling for beauty, but too few of us do 
anything about it ; Doctor Angle did. 

— F.C. 



108 


Nebraska S. M. J. 




March, 1966 


109 


Our Medical Schools 

Scholarship Awards — 

Omaha — Three incoming freshmen at the 
University of Nebraska College of Medicine 
have been awarded scholarships for the 
forthcoming academic j'ear by the University 
of Nebraska College of Medicine Alumni As- 
sociation. Announcement of their selection 
was made by Dr. George B. McMurtrey, 
president of the alumni group. 

The recipients are Martin Daniel McDer- 
mott, 316 W. 2nd St., North Platte, Nebr. ; 
Joseph Steven Unis, 2775 Mill St., Aliquippa, 
Pa., and William Frederick Willner, III, 2724 
27th St., Columbus, Nebraska. 

All are students at the University of Ne- 
braska, Lincoln. Each will receive a check 
in the amount of $650. 

Selection was made by the College of Medi- 
cine’s Committee on Scholarships and 
Awards, of which Dr. Violet M. Wilder is 
chairman. 

Conference on Poisons and Toxins — 

Omaha — Three University of Nebraska 
College of Medicine faculty members have 
been invited to assist in the initial planning 
for a 1967 International Conference on Poi- 
sons and Toxins as Etiological Agents in 
Mental Retardation. 

The Conference is sponsored by the Na- 
tional Institute of Neurological Diseases and 
Blindness. 

Planners from the medical college include 
Dr. John A. Aita, associate professor of neu- 
rology and psychiatry; Dr. Carol Angle, as- 
sistant professor of pediatrics, and Dr. Ma- 
tilda Mclntire, assistant research professor 
of neurology and psychiatry and assistant 
professor of pediatrics. 

Team Nursing — 

Omaha — A continuing education course 
for professional nurses on April 13 and 14 
will explore the “Philosophy of Team Nurs- 
ing.” The course, sponsored by the Univer- 
sity of Nebraska School of Nursing and Of- 
fice of Continuing Education, will be given 


in the auditorium of the Eppley Cancer In- 
stitute on the University of Nebraska Col- 
lege of Medicine campus. 

Mrs. Thora Kron of Floodwood, Minn., is 
guest lecturer for the sessions. She has 
worked in many phases of medical-surgical 
nursing and was nurse-director of the prac- 
tical nursing program for the Grand Rapids, 
Minn. Area Vocational-Technical School. 

She is author of a book on Nursing Team 
Leadership published by the W. B. Saun- 
ders Co. in 1961. A second edition will be 
out this spring. In addition, Mrs. Kron has 
written several articles for leading nursing 
publications. 

Sessions during the two-day course are 
“team nursing: why, when, where, who and 
how;” “team leader works with people;” 
“nursing care : assessment, diagnosis and 
therapy;” “team conference;” “demonstra- 
tion on development of a nursing care plan” 
and a summation on the “five steps to work- 
able nursing care plans.” 

A $20 fee will be charged to registrants 
for the “Philosophy of Team Nursing” 
course. Registration will be limited to 75. 

Cardiovascular Disease Course — 

Omaha — Physicians attending a con- 
tinuing education course at University of 
Nebraska College of Medicine not only heard 
actual heart murmurs, but simultaneously 
viewed them on two large television screens. 

The auditory-visual teaching method was 
used for the first time at the medical col- 
lege during a postgraduate session on the 
“Current Status of Cardiovascular Disease.” 
The course was offered on February 3 
and 4 in the auditorium of the Eppley Cancer 
Institute. 

Forty of the seats were equipped with 
stethophones which are electronic stetho- 
scopes. Enrollees heard heart murmurs 
on the stethophones and viewed the murmurs 
projected simultaneously on the television 
screens. These oscilloscope tracings, or the 
visual portion of the instruction, can be 
halted through “stop action” so that the 
speaker can elaborate on any one part of 
the tracing. 


110 


Nebraska S. M. J. 


On Friday, Dr. Gene Stollerman, professor 
and chairman of internal medicine at the 
University of Tennessee considered “strep- 
tococci and rheumatic fever” and “acute 
rheumatic fever: treatment and prognosis.” 
He was just named chairman of the Council 
of Rheumatic Fever and Congenital Heart 
Disease of the American Heart Association. 

Auscultation is just one of the tools a 
physician has in diagnosing heart defects, 
explained Dr. Paul K. Mooring, coordinator 
of the “cardiovascular disease” course. He 
is an associate professor of pediatrics at the 
Nebraska College of Medicine and pediatric 
cardiologist for University Hospital. 

Along with auscultation, the physician 
uses the patient’s physical history, the chest 
X ray and the electrocardiogram to deter- 
mine what’s going on within the patient’s 
heart. Dr. Mooring pointed out. 

Listening to sounds within the heart is 
one of the most difficult techniques that a 
medical student has to learn. Dr. Mooring 
said. “A normal person has about 100 heart 
beats per minute and each beat is timed at 
about two-thirds of a second. The student 
has to disceiTi four different time intervals 
within each heart beat or within this two- 
thirds of a second. 

In the teaching method most commonly 
used the instructor listens to the heart beat 
with his stethoscope. Then the medical stu- 
dent listens. Notes are compared. The 
physician then tells the student what he 
should have heard. “It’s extremely diffi- 
cult,” Dr. Mooring said. 

The modern method of teaching ausculta- 
tion is by the phonocardiogram and stetho- 
phones. Sounds are heard through the 
stethophone and these are simultaneously re- 
corded visually on an oscilloscope. 

The physician with his stethoscope is still 
the best man to do heart screening, despite 
the advent of modern electronic equipment. 

The “Current Status of Cardiovascular 
Disease” course was co-sponsored by the Ne- 
braska Heart Association and the Douglas 
County Heart Association. 


Omaha — Published in Nm'sing Forum 
was an article written by Mrs. Marilyn John- 
son, assistant professor of public health 
nursing at the University of Nebraska School 
of Nursing and assistant professor of pre- 
ventive medicine and public health at the 
University of Nebraska College of Medicine. 

The article, “Nurses Speak Out on Alco- 
holism,” appears in Vol. 4, No. 4, pp. 16-22. 
It is based on a portion of a research proj- 
ect conducted by Mrs. Johnson and two 
other professional nurses on the “Use of 
Selected Informants as a Method of Iden- 
tifying the Behavior of Female Alcoholics.” 

Research was supported by the Licensed 
Beverage Industries. In the survey, 160 
physicians, 71 nurses, and 35 alcoholic wom- 
en in the Omaha area were interviewed. 

The July 1965 Nebraska State Medical 
JouvTial published the report on physicians’ 
views. 

Omaha — Three faculty members from 
the University of Nebraska College of Medi- 
cine have been invited to assist in the; (ini- 
tial planning for a 1967 International Con- 
ference on Poisons and Toxins as Etio- 
logical Agents in Mental Retardation. The 
conference is sponsored by the National In- 
stitute of Neurological Diseases and Blind- 
ness. 

Planning committeemen from the College 
of Medicine are: Dr. John A. Aita, asso- 
ciate professor of neurology and psychiatry 
and associate in physical medicine and re- 
habilitation; Dr. Carol Angle, assistant pro- 
fessor of pediatrics ; Dr. Matilda Mclntire, 
assistant research professor of neurology 
and psychiatry and assistant professor of 
pediatrics. 

The committee, composed of 32 members 
selected nationally met at the National 
Institutes of Health in Bethesda, Md., on 
February 18 to discuss objectives, structure 
of the Conference, participants and possible 
dates. 

Dr. Lemon Speaker — 

Omaha — Dr. Henry M. Lemon was a par- 
ticipant in the National Science Foundation 


March, 1966 


111 


Teacher Development Seminar Conference 
in Biological Sciences on February 21. He 
is Director of the Eppley Cancer Institute at 
the University of Nebraska College of Medi? 
cine. 

Dr. Lemon discussed the “Inhibition of 
Carcinogenesis” at 7 :30 p.m. 

The Conference was scheduled at the Ne- 
braska Center for Continuing Education in 
Lincoln. Dr. Lemon was one of three invit- 
ed guest speakers. 

Dr. Robert E. Kuttner, faculty member 
from the Creighton University School of 
Medicine, attended two sessions on chroma- 
tography, a method on chemical analysis. 

He attended a course February 1 - 4 on 
gas chromatography at Roosevelt University 
in Chicago, 111. He was in Madison, Wis., 
February 8-9 for a symposium on “Modern 
Applications of Column Chromatography.” 

Dr. Heaney Conducted Session — 

Dr. Robert P. Heaney, Chairman of the 
Department of Medicine at the Creighton 
University School of Medicine, was chair- 
man of a session at a Chicago meeting Fri- 
day and Saturday, Jan. 21-22. 

He headed the session, “Symposium on 
Osteoporosis,” at the meeting of the Ortho- 
pedic Research Society. Also attending were 
Dr. Thomas G. Skillman, Professor of Medi- 
cine, and Dr. J. J. Walch, a trainee in Creigh- 
ton University’s Metabolic Unit at Creigh- 
ton Memorial - St. Joseph’s Hospital. Dr. 
Walch also attended a meeting of the Amer- 
ican Academy of Orthopedic Surgeons in Chi- 
cago, Sunday, Jan. 23. 

Dr. Grissom Appointed to Research Committee — 

Omaha — Appointed to a three-year term 
on the Great Plains Regional Research Com- 
mittee of the American Heart Association’s 
Research Council was Dr. Robert L. Gris- 
som, professor and chairman of the depart- 
ment of internal medicine at the University 
of Nebraska College of Medicine. 

As a committee member. Dr. Grissom at- 
tended a meeting in Minneapolis February 
18 through February 20. 


Dr. Aita Authors Book — 

Omaha — Dr. John A. Aita, an associate 
professor of neurology and psychiatry at 
the University of Nebraska College of Medi- 
cine, has written a new book, N eurocutxme- 
ous Disease, which was just published by 
the Charles C. Thomas Co. 

Dr. Aita prefaced his new publication 
with an appreciative note to Mrs. Bernice 
Hetzner, professor of library science and 
medical librarian at the College of Medicine, 
and her library staff for the “prompt, pro- 
fessional librarianship at every turn.” 

Dr. Dunlop Spoke in Canada — 

Omaha — Dr. Donald Dunlop, assistant 
instructor in obstetrics and gynecology at the 
University of Nebraska College of Medicine, 
presented a paper before the 35th annual 
meeting of the Royal College of Physicians 
and Surgeons of Canada. 

Entitled “Peptides of Amniotic Fluid and 
Serum,” the paper was co-authored by Dr. 
Dunlop and Dr. Wayne Ryan, associate pro- 
fessor of biochemistry and research asso- 
ciate professor of obstetrics and gjmecology. 

The meeting was held at the Queen 
Elizabeth Hotel in Montreal, Quebec, Canada 
January 20 through 22. 

Dr. Lynch to Speak at ACP Session — 

Omaha — A paper by Dr. Henry T. Lynch 
has been accepted for presentation before 
the 47th annual session of the American Col- 
lege of Physicians. He is an assistant in- 
structor in internal medicine at the Univer- 
sity of Nebraska College of Medicine. 

Dr. Lynch will present “A Study of Five 
Cancer Families” during the clinical session 
on neoplastic diseases. 

The annual meeting is scheduled April 18 
through April 22 at the Americana Hotel 
in New York City. 

Two Grants at Creighton — 

Creighton University has received two 
United States Public Health Service grants 
totaling $91,471. 

The School of Medicine received $65,971 


112 


Nebraska S. M. J. 


and the Boyne School of Dental Sciences 
was awarded $25,500. Both grants will be 
used to support general research. 

Operation Headstart — 

Omaha — Over five hundred Omaha young- 
sters participating in “Operation Headstart” 
received physical examinations at the Uni- 
versity of Nebraska College of Medicine 
Clinics on Saturday morning, Jan. 22. 

Dr. Dorothy Smith, assistant professor of 
pediatrics, and other pediatrics staff mem- 
bers and about 20 senior medical students 
conducted the examinations. 

These four-year-olds were given a com- 
plete physical examination, a urinalysis, the 
Tine test, a test for anemia and immuniza- 
tions, either initial or boosters, for diph- 
theria, whooping cough, tetanus and small- 
pox. 

“At a later date they will be given the 
trivalent Sabin orally,” Dr. Smith said. 

Omaha’s “Operation Headstart” is one of 
three nationally to receive continued Fed- 
eral support. One hundred and fifty Oma- 
ha youngsters participated in the July 1965 
program. 

Omaha — Seven University of Nebraska 
College of Medicine staff members are co- 
authors of three scientific articles recently 
published. 

“Etiology of Carcinoma: Genetic Deter- 
minisms” by Drs. Henry T. Lynch, assistant 
instructor in internal medicine ; Perry G. 
Rigby, assistant professor of internal medi- 
cine; C. W. Magnuson, assistant professor 
of internal medicine; and Arthur L. Larsen, 
assistant professor of pathology; and Mrs. 
Anne J. Krush, social worker in the section 
on heredity, growth and development at the 
Eppley Cancer Institute ; Nebmska State 
Medical Jour-nal, 51 :8-10, 1966. 

“Psycho-Social Factors in a Family with 
a Genetic Fault” by Mrs. Krush, the late Dr. 
Thaddeus P. Krush and Dr. Lynch; Psycho- 
somatics, 6 :391-95, 1965. 

“Phenotypic Variations in Hereditary Dis- 
eases with Implications for Genetic Coun- 


seling: A Family with Congenital Heart and 
Skeletal Anomalies” by Drs. Lynch; Robert 
L. Grissom, professor and chairman of the 
department of internal medicine; Robert L. 
Tips from Baylor Medical Center; and Mrs. 
Krush, Medical Times, 24:9-19, 1966. 

Distinguished Writing Awards — 

Omaha — Two Omahans received distin- 
guished Writing Awards from the Lincoln- 
Omaha chapter of the American Medical As- 
sociation Thursday night. 

The recipients were Dr. Carl J. Potthoff, 
professor of preventive medicine and public 
l>ealth of the University of Nebraska Col- 
lege of Medicine; and Dr. Donal Magee, 
chairman of the department of physiology 
and pharmacology of the Creighton Univer- 
sity School of Medicine. 

The citation for Dr. Potthoff, in part: 

“Dr. Potthoff has distinguished himself 
not only as a writer for professional and lay 
publications but also as a teacher and chair- 
man of the department of preventive medi- 
cine of the University of Nebraska College 
of Medicine. He is currently a regular col- 
umnist for Today’s Health, a publication of 
the American Medical Association, and 
writes a column in the American Journal of 
Public Health, the official publication of 
the American Public Health Association. 

“Because of his prolific writing in the 
field of medicine and his interest in better 
communication, the members of the Execu- 
tive Committee of the Lincoln-Omaha Chap- 
ter of the American Medical Writer’s Asso- 
ciation now make this presentation.” 

The citation for Dr. Magee, in part: 

“Dr. Magee has written nearly 50 papers 
for publication in the scientific and profes- 
sional journals in his field of special interest. 
He is the author of a book entitled ‘Gastro- 
intestinal physiology,’ and has contributed 
much to the text, ‘Surgery of the Stomach 
and Duodenum.’ 

“Because of his long interest in writing 
in the field of medicine and his continuing 
interest m better communication, the Execu- 
tive Committee and Members of this Chapter 
wish to honor him in this manner.” 


March, 1966 


113 


Expansion of University of Nebraska 
College of Medicine — 

Omaha — A 15-million-dollar moderniza- 
tion and expansion of the University of Ne- 
braska College of Medicine was assured re- 
cently with the announcement in Washing- 
ton, D.C., that the Surgeon General has ap- 
proved a Federal grant of $8,079,924. 

The University was informed of the ap- 
proval by the office of Congressman Clair 
Callan (Dem., Neb.). 

Last summer the State Legislature appro- 
priated $7,650,000 as its share of the Col- 
lege of Medicine building program. 

The College of Medicine developed a three- 
phase building program. The matching 
money is for Phase I. 

In the first phase, the University will 
build 189 new hospital beds, two new floors 
to its clinics wing and a new Basic Sciences 
Building. Older areas of the hospital will 
be remodeled and renovated. 


The first contracts are expected to be 
awarded in February. The construction pro- 
gram should be completed in about two 
years. Dr. Cecil L. Wittson, Dean of the 
College, said. 

The grant from the United States Pub- 
lic Health Service under the Health Profes- 
sions Assistance Act program is the largest 
ever received for medical construction in Ne- 
braska. 

The expansion and modernization not only 
will update teaching, laboratory and patient 
care facilities, but it will also enable the 
College of Medicine to increase its enter- 
ing freshman medical class by about 20 per 
cent. This is in direct response to the seri- 
ous shortage of physicians in Nebraska. 

Older units of the hospital will be re- 
modeled to carry out a pledge by the College 
of Medicine to build a compact, efficient 
hospital, blending the old with the new 
and using every foot of existing space. 



PROPOSED BASIC SCIENCE AND LIBRARY OF MEDICINE 



114 


Nebraska S. M. J. 




The new hospital will be built atop and 
around the newest section (Unit III) of 
University Hospital. 

The Basic Sciences Building will face 
Forty-Second Street on the east side of the 
campus between the North and South Lab- 
oratory Building and in front of the east 
entrance to the hospital. 

The new hospital will contain seven levels. 
Two levels will be added atop the clinics 
wing. The Basic Sciences Building will 
contain two stories above ground and one 
below, and be connected both above-ground 
and below-ground to the North and South 
Laboratoiy Buildings. 


Administrator at University of Nebraska 
College of Medicine — 

Omaha — The appointment of Richard C. 
Schripsema as administrator of the Univer- 
sity of Nebraska College of Medicine Hos- 
pital in Omaha was approved by Univer- 
sity Regents in Lincoln, Saturday. 

Mr. Schripsema, who has been assistant 
administrator for two years, succeeds Ed- 
win F. Ross, who resigned to accept a posi- 
tion in Cleveland, Ohio. 

Mr. Scripsema is a native of Grand Rap- 
ids, Mich., and a graduate of Calvin College 
in that city. 

He received two Master’s Degrees from 
the University of Michigan, one in Business 
Administration and the other in Hospital 
Administration. 


The February meeting of the Lancaster 
Society Medical Auxiliary was held at the 
home of Mrs. William F. Nye in Lincoln. 
A sandwich luncheon for approximately 65 
members was followed by a program and 
business meeting, with auxiliary president 
Mrs. Jon Williams presiding. 

A delightful glimpse of “An Afternoon 
on Broadway” was given by Mr. Ronald E. 
Hull, program director, Nebraska Educa- 



tional Television network. Mr. Hull touched 
upon authors and plays, past and present, 
and specifically gave an entertaining review 
of Nebraska’s own Henry Fonda and Sandy 
Dennis in their recent Broadway successes. 

Mrs. Stephen Carveth informed the medi- 
cal wives of an innovation for the Heart 
Association Fund drive in the area. With 
articles donated by local firms, and time giv- 
en by KOLN-TV, a “Heart Auction” was 
held on February 15 during the 9-10 p.m. 
viewing time, with proceeds going to the 
Heart Fund. 

Results of a drive for drugs and supplies 
fbr the “Vietnam Holiday Train” were told. 
Plans for a Dinner Dance at the Lincoln 
Country Club in March were given by Mrs. 
George Lewis, Jr., and the meeting adjourned 
on a gala note. 

Mrs. Harlan L. Papenfuss, 
Publicity. 


Know Your 
Blue Shield Plan 

Most Claims Paid-in-Full: Test of 
Performance Study — 

Blue Shield Plans’ best group certificate 
pays in full more than four out of every 
five surgery and in-hospital medical claims, 
and nearly three out of every four anesthesia 
claims, according to the National Association 
of Blue Shield Plans. 

Under all certificates studied, the Plans 
pay in full at least two out of every three 
surgery and in-hospital medical claims, and 
nearly one of two ansthesia claims. 

PROJECT-WIDE RESULTS 

Project-wide results of the Test of Per- 
formance survey, the largest single study in 
the history of medical economics, show that 
the over-all ratio of Blue Shield payments to 
reported patient costs for all certificates 
studied was 75 per cent or higher for each 
type of service. 

Fifty-four United States Blue Shield Plans, 



March, 1966 


115 


with an enrollment of nearly 42 million, pai’- 
ticipated in the survey. These Plans account 
for 83 per cent of Blue Shield’s United States 
membership. 

The survey results were analyzed in terms 
of the type of physician’s service involved — 
surgery, anesthesia, and in-hospital medical 
care. 

SURGICAL CARE 

Surgical care represented 795,000 of the 
1,219,000 claims studied. Seventy per cent 
of these claims were paid-in-full. Over-all, 
Blue Shield payments of $3.8 million amount- 
ed to 77 per cent of total patient cost. 

In-patient surgery claims showed 74 per 
cent of patient costs covered, while services 
outside the hospital had an average of 88 
per cent of total patient cost covered by 
Blue Shield benefits. 

ANESTHESIA SERVICES 

Anesthesia services accounted for 116,200 


of the claims studied. Here, over-all. Blue 
Shield paid more than $3.8 million, against 
total patient costs of nearly $5.1 million. 

This 75 per cent ratio is slightly lower 
than that for surgery or medical care. Near- 
ly half, 47 per cent, of the anesthesia claims 
had the full cost met by the Blue Shield pay- 
ment. 

MEDICAL SERVICES 

Medical seiwices were involved in nearly 
278,000 claims. Blue Shield’s $13.7 million 
in payments for these services covered an 
average of 79 per cent of patient costs. Two 
thirds of the claims had their full cost cov- 
ered by Blue Shield. 

Blue Shield’s performance varied by the 
level of contract held. In the best group cer- 
tificates for all participating plans. Blue 
Shield paid 84 per cent of patients’ surgical 
costs, 88 per cent of anesthesia costs, and 90 
per cent of in-hospital medical costs. 


100 ° 


75 °c 


50% - 


25°/ 


BEST GROUP CERTIFICATES 
PER CENT OF CLAIMS PAID IN FULL 



Total 


Surgery Anesthesia 


Medical 


BEST GROUP CERTIFICATES 

average per cent of patient cost coverage 



116 


Nebraska S. M. J. 



Books 




L£L_1 


Rare Diseases in Internal Medicine by Neuton S. 
Stern, MD. Published January 15, 1966 by 

Charles C. Thomas of Springfield, Illinois. 572 
pages (6" by 9'/2")- Price $18.50. 

The author of this book is Clinical Professor of 
Medicine, Emeritus, at the University of Tennessee 
College of Medicine in Memphis. He has collected, 
from the litei’ature of the past thirteen years, 
1089 case reports which he has condensed and ar- 
ranged according to the primary system involved. 
Only diseases with less than 100 reported cases are 
considered. Many are unique. The point of view 
for the selection of material is that of clinician and 
diagnostician. For those who wish more than the 
condensed information provided in the summaries, 
reference is made to the original articles where 
there is often extensive discussion as well as a 
pertinent bibliography to facilitate further study. 
The indexes are important and extensive. The 
reader will find this volume a book primarily to 
be used rather than merely read. 


Drugs of Choice, 1966-1967, edited by Walter Mo- 
dell, MD. Published 1 February 1966 by the 
C. V. Mosby Company of St. Louis, Missouri. 
969 pages 7" by 10"). Price $16.75. 

This is the fifth biennial edition of what has 
become a “standard” textbook in many medical 
schools and colleges of pharmacy as well as a 
popular “working reference book” on the desks of 
many practicing physicians. The editor is an Asso- 
ciate Professor of Pharmacology at the Cornell Uni- 
versity Medical College in New York City. He 
also is the Chairman of the Advisory Committee on 
New Drugs to the Food and Drag Administration; 
a member of the Executive Committee, United 
States Pharmacopeia XVII; and the editor of Clin- 
ical Pharmacology and Therapeutics. He has en- 
listed the aid of 45 other equally prominent and 
knowledgeable medical authorities in the prepai’- 
ation of this book. 

In this edition all chapters have been extensively 
revised; seven of them have been completely re- 
written. 


Pediatric Therapy, 1966-1967, edited by Harry C. 
Shirkey, MD. Published January 3, 1966 by 
the C. V. Mosby Company of St. Louis, Mi.ssouri. 
1223 pages (7" by 10") with 353 illustrations. 
Price $18.50. 

This is the second biennial edition of another 
“standard” textbook that has found great popu- 
larity among practicing physicians. The editor is 
the Director of The Children’s Hospital of Birming- 
ham, Alabama; Associate Professor of Pediatrics 
at the Medical College of Alabama; Professor and 
Chairman of the Department of Pharmacology of 
Howard College; and Chairman of the Committee 
on Drugs of the American Academy of Pediatrics. 


He has enlisted the aid of 83 other equally promi- 
ment and knowledgeable medical authorities in the 
preparation of this book. 

The emphasis in this volume is on treatment. 
However, precise diagnosis is stressed throughout 
and is further supported by photographs that re- 
late the treatment less to the printed page and 
more to the infants and children whose care is 
the primary concern of the authors. 


PiH)gnosis — a Guide to the Study and Practice 
of Medicine, by Leslie A. Osborn, MD. Published 
December 15, 1965 by Charles C. Thomas of 
Springfield, Illinois. 286 pages (6" by 9"). Price 
$ 10 . 00 . 

The author of this book is one of our own Ne- 
braska physicians; he is a Professor in the De- 
partment of Neurology and Psychiatry at the Uni- 
versity of Nebraska College of Medicine in Omaha. 
He has written this book as a guide for medical 
students in their preclinical years and for other 
students in related health fields. Part One follows in 
slow motion the sequence of clinical procedures 
from initial contact to completion of treatment. 
Part Two deals with practical problems of learning 
and applying clinical methods . . . with the personal 
basis of treatment and principles which are helpful 
in learning by direct care of patients. In Part 
Three the author is concerned with inter-personal 
reactions in medicine . . . interviewing, the doctor- 
patient relationship, the doctors relationship with 
relatives of the patient, other medical colleagues, 
and the public. 


Civil War Medicine, by Stewart Brooks. Published 
December 15, 1965 by Charles C. Thomas of 
Springfield, Illinois. 148 pages (6" by 9") with 
21 illustrations. Price $6.00. 

The author of this book is a graduate pharmacist 
who has written 14 textbooks in basic medical 
science and has now turned his pen to the area of 
historical medicine, combining a keen knowledge 
of the subject with an unbridled enthusiasm for 
American history. 

In the flood of literature which followed the Civil 
War, this book is the first to present the overall 
medical picture of the period. It is the true story 
of four agonizing years told in a story form that 
will fascinate both layman and physician. 

Congestive Heart Failure by Raymond T. Benack, 
MD. Published January 1, 1966 by Charles C. 
Thomas of Springfield, Illinois. 117 pages (6" 
by 9"). Price $5.50. 

The author of this book is a Clinical Instructor in 
Medicine at Georgetown University Medical School 
in Washington, D.C. He was formerly Chief of the 
Congestive Heart Failure Section of the Heart Dis- 


March, 1966 


117 



1 


in diarrhea 

I associated with 
Gastroenteritis 
Spastic bowel 

Influenza-like 

infections 

Antibiotic 

administration 


I 


i 



normal activity... 


promptly... 



117-A 


Nebraska S. M. J. 


In children with diarrhea prompt symptomatic control is usually 
urgently indicated to relieve cramping and to prevent dehydration. 

Lomotil halts precipitous progress through the intestines and 
controls diarrhea with notable promptness, safety and effectiveness. 

Experimental evidence^ has shown that Lomotil is more efficient 
in this regard than morphine without the latter’s manifest disad- 
vantages. In roentgenographic study- Lomotil slowed gastrointesti- 
nal propulsion within two hours. 

At the same time, by diminishing overstimulation of the intestines, 
Lomotil relieves the abdominal cramps' and discomfort so distress- 
ing to youngsters. 

Lomotil gets children off toast and tea and back to normal diets 
and normal activity with gratifying celerity. 


with 


LOMOTIL 


liquid/tablets 


Each tablet and each 5 cc. of liquid contains: 

diphenoxylate hydrochloride 2.5 mg. 

(Warning: may be habit forming) 
atropine sulfate 0.025 mg. 


Dosage: For full therapeutic effect— Rx full 
therapveutic dosage. The recommended ini- 
tial daily dosages, given in divided doses, 
until diarrhea is controlled, are: 

Children: 

3 to 6 months— 3 mg. 

(Vi tsp* t.i.d.) 

6 to 12 months— 4 mg. 

(Vi tsp. q.i.d.) 

1 to 2 years— 5 mg. 

(Vi tsp. 5 times daily) 

2 to 5 years— 6 mg. 

(1 tsp. t.i.d.) 

5 to 8 years— 8 mg. 

(1 tsp. q.i.d.) 

8 to 12 years— 10 mg. 

(1 tsp. 5 times daily) 

Adults: 20 mg. (2 tsp. 5 times daily or 2 
tablets 4 times daily) 

*Based on 4 cc. per teaspoonful. 
Maintenance dosage may be as low as one 
fourth the therapeutic dose. 

Precautions: Lomotil, brand of diphenoxy- 
late hydrochloride with atropine sulfate, 
is an exempt narcotic preparation of very 
low addictive potential. Recommended 


dosages should not be exceeded. Lomotil 
should be used with caution in patients 
with impaired liver function and in pa- 
tients taking addicting drugs or barbitu- 
rates. The subtherapeutic amount of 
atropine is added to discourage deliberate 
overdosage. 

Side Effects: Side effects are relatively un- 
common but among those reported are 
gastrointestinal irritation, sedation, dizzi- 
ness, cutaneous manifestations, restlessness 
and insomnia. 

1. Janssen, P. A. J., and Jageneau, A. H.: A 
New Series of Potent Analgesics: Dextro 
2:2-Diphenyl-3-Methyl-4-Morpholinobutyryl- 
pyrrolidine and Related Amides. Part 1: 
Chemical Structure and Pharmacological 
Activity, J. Pharm. Pharmacol. 9:381-400 
(June) 1957. 

2. Demeulenaere, L.: Action du R 1132 sur 
le transit gastro-intestinal, Acta Gastroent. 
Belg. 27:674-680 (Sept.-Oct.) 1958. 


SEARLE 


Research in the Service of Medicine 


March, 1966 


117-B 



ease Control Program of the U.S. Public Health 
Ser\nce. He has written a book useful for the 
medical student, the practicing physician, and allied 
medical personnel who are concerned with the care 
of the patient with congestive heart failure. He 
writes of past and recent developments in the 
diagnosis and treatment of congestive heart failure, 
the role of public health and community services, 
and he presents the patient as an individual with 
multiple problems and not just problems of the 
heart. 

Areas discussed include the following: 

a. an organized follow-up program for the pre- 
vention of recurrences 

b. the effective use of diuretic agents 

c. diet therapy 

d. rehabilitation 

e. the role of patient education. 

Current Diagnosis and Treatment, 1966, by Henry 

Brainerd, MD; Sheldon Margen, MD, and Milton 

J. Chatton, MD, and thirty-one associate authors. 

Published January 10, 1966 by Lange Medical 

Publications by Los Altos, California. 916 pages 

(7" by 10"). Price $9.50. 

Doctor Brainerd is Professor of Clinical Medicine 
at the University of California School of Medicine 
in San Francisco; also Chief of the University of 
California Medical Sendees at the San Francisco 
General Hospital. Doctor Margen is Professor of 
Human Nutrition at the University of California 
in Berkeley. Doctor Chatton is a Clinical Associate 
Professor of Medicine at the Stanford University 
School of Medicine in Palo Alto, California. As- 
sisted by thirty-one other eminent authorities they 
have written a book intended to sen-e the practicing 
physician as a useful desk reference on the most 
widely accepted technics currently available for 
diagnosis and treatment. The wide acceptance of 
this book bears testimony as to its merit. It is 
currently used as a textbook in many medical 
schools. 


Serologic Response of Infants to Combined 
Inactivated Measles-Poliomyelitis Vaccine 
— G. C. Brown and P. L. Kendrick (De- 
partment of Epidemiology, University of 
Michigan School of Public Health, Ann 
Arbor). Amer J Pub Health 55:1813- 
1819 (Nov) 1965. 

The serologic response of young infants to 
three injections of combined, inactivated 
measles-poliomyelitis vaccine administered at 
intervals of two months is described. Ma- 
ternal antibodies to both viruses were pres- 
ent in over half the children at the age 
of three months; in some they were found 
at five months, and when present the pri- 
mary i-esponse to vaccine was suppressed. 


Infants without maternal antibodies respond- 
ed to each vaccine component. Postprimary 
measles antibodies persisted until the age 
of 18 months in over half the infants. Boost- 
er injections of vaccine at the age of 18 
months were successful in stimulating anti- 
bodies to both the measles and poliomyelitis 
components in 96% of all the children, re- 
gardless of the primary response. Injection 
of live, attenuated measles virus vaccine was 
followed by antibody titers roughly com- 
parable to those obtained with the inactivat- 
ed preparation. Clinical reactions following 
these injections were either absent or mini- 
mal. Antibodies persisted with only a two- 
fold loss in titer six months after both the 
live and killed booster stimulus. 

Limitations of Footprinting as Means of 
Infant Identification — K. S. Shepard 
(USAF Hosp, Travis AFB, Calif), T. Erick- 
son, and H. Fromm. Pediatrics 37:107 
(Jan) 1966. 

A carefully done footprinting of new- 
born infants was compared with a carefully 
done printing of the same infants at five to 
six weeks of age. From the results, expert 
fingerprint technicians were only able to 
identify ten, demonstrating only about 20% 
identifiable. Of these ten correctly identi- 
fied, it was felt that the majority could not 
stand up under legal scrutiny in the courts. 
It may then be safely stated that this proce- 
dure, which seems to be standard in so 
many of our hospitals, is essentially without 
value. It seems to the authors that, if 
effort is made to band the infants properly 
in the delivery room, this should be sufficient 
identification and that standard footprinting 
is a needless expense. 

Protection From Ticks, Fleas, Chiggers, and 
Leeches — H. K. Gouck (Agricultural Re- 
search Service, US Department of Agri- 
culture, Gainesville, Fla). Arch Derm 93: 
112 (Jan) 1966. 

Protection from these acarids, insects, and 
annelids is achieved mainly by treatment of 
the clothing with repellents. When properly 
used, they will provide a high degree of com- 
fort in the presence of large numbers of 


118 


Nebraska S. M. J. 


blood-sucking arthropods. None of our pres- 
ent repellents is completely satisfactory, but 
the better repellents are for ticks — DEET 
(N,N-diethyl-m-toluamide) , butapyronoxyl 
(butyl-3, 4-dihydro-2, 2 - dimethyl - 4 - oxo - 2H- 
pyran-6-carboxylate), dimethyl carbate, and 
benzyl benzoate; for fleas — DEET and ben- 
zyl benzoate; for chiggers (larvae of Trom- 
biculid mites) — dimethyl phthalate, ethyl 
hexanediol, or any of the tick repellents ; for 
leeches — DEET and benzyl benzoate. The 
only chigger repellent remaining effective 
after rinsing and washing in water is benzyl 
benzoate. 

Anginal Pain and Depression — G. C. Grif- 
fith (1136 W 6th St, Los Angeles), and 
Harry Kaye. Dis Chest 48:584 (Dec) 
1965. 

Twelve patients with angina pectoris who 
clinically did not appear to be depressed, 
were tested with the Minnesota Multiphasic 
Personality Index (MMPI), initially, and five 
weeks after taking the energizer, nialamide. 
In the dosage used, nialamide did not appre- 


ciably affect anginal pain of depression. On 
both testings, all 12 patients were shown to 
be significantly more depressed than the 
normal population by their T score measure- 
ments on the D scale of the MMPI. Depres- 
sion may be a factor determining which 
patients with atherosclerotic heart disease 
manifest angina pectoris. 


Treatment of Intractable Asthma With Die- 
thylcarbamazine Citrate — M. S. Mallen 
(General Hosp, Mexico City, Mexico). Ann 
Allergy 23:534-537 (Nov) 1965. 

The administration of diethylcarbamazine 
citrate in daily doses of 10 mg/kg is effective 
in the symptomatic treatment of intractable 
asthma. The drug is well tolerated and, ac- 
cording to test experience, can advantageous- 
ly substitute the use of corticoids in some 
cases. It is expected that further studies 
will serve to impart knowledge upon the 
mode of action and the place of this sub- 
stance in the management of bronchial 
asthma. 


ORGANIZATIONS, NATIONAL 

American Academy of General Practice 
Mr. Mac F. Cahal 
Volker at Brookside 
Kansas City 12, Missouri 

American Academy of Pediatrics 
E. H. Christopherson, Secy. 

1801 Hinman Ave. 

Evanston, Illinois 

American College of Legal Medicine 
Glenn W. Bricker, M.D., F.C.L.M., Secretary 
1003-06 Medical Tower 
Philadelphia 3, Pennsylvania 
American College of Obstetricians & Gynecologists 
Craig W. Muckle, M.D. 

1806 Garrett Road 
Lansdowne, Pa. 

American College of Physicians 

Edward C. Rosenow, Jr., M.D., F.A.C.P., Secy. 
4200 Pine St. 

Philadelphia 4, Pennsylvania 
American College of Radiology 
Mr. W. C. Stronach 
20 North Wacker Drive 
Chicago 6, Illinois 
American College of Surgeons 
John P. North 
40 East Erie Street 
Chicago 11, Illinois 

American Diabetes Association 
Laurentius 0. Underdahl, M.D. 

1 East 45 Street 

New York 17, New York 


American Heart Association 
Mr. Rome A. Betts, Secy. 

44 East 23rd Street, New York 10, New York 
National Hemophilia Foundation 

25 West 39th St., New York, N.Y. 10018 
American Hospital Association 
Edwin L. Crosby, M.D., Director 
840 Lake Shore Drive, Chicago 11, Illinois 
American Society of Anesthesiology 
Mr. J. W. Andes 

515 Busse Hy., Park Ridge, Illinois 
American Society of Internal Medicine 
Mr. Albert V. Whitehall, Executive Secy. 

3410 Geary Boulevard 
San Francisco 18, California 
The American Society of Clinical Pathologists 
Miss Eleanor F. Larson 
445 Lake Shore Drive, Chicago 11, Illinois 
American Medical Association 

F. J. L. Blasingame, Executive Vice Pres. 

535 North Dearbon St., Chicago 10, Illinois 
American Urological Association 
Rubin Flocks, M.D., Secretary 
State University of Iowa Hospitals, 

Iowa City, Iowa 

Arthritis and Rheumatism Foundation 
Floyd B. Odium, Chairman 
10 Columbus Circle, New York 19, New York 

International College of Surgeons 
John B. O’Donoghue, M.D. 

1516 North Lake Shore Dr., Chicago 10, Illinois 
National Multiple Sclerosis Society 

257 Park Avenue South, New York 10, N.Y. 
V^ocational Rehabilitation Administration 

Mary E. Switzer, Commissioner, Washington, D.C. 


March, 1966 


119 


ORGANIZATIONS, STATE = 

Alcoholics Anonymous 
1346 N Street, Lincoln 
American Red Cross 
W. J. Frenzel, State Representative 
2631 Garfield, Lincoln 
Cerebral Palsy Association of Nebraska 
Mrs. Ben H. Cosdery 
201 South Elmwood Road, Omaha 
Creighton University School of Medicine 
Richard Egan, Dean 
302 North 14th, Omaha, Nebraska 
International College of Surgeons 
James J. O’Neil, M.D., Regent for Nebraska 
612 Medical Arts Building, Omaha 2, Nebraska 
Multiple Sclerosis Society 

Mrs. Harold Stoehr, Executive Secretary 
3648 Folsom Street, Lincoln, Nebraska 
Muscular Dystrophy Society 
Mrs. Maiwin Traeger, President 
Fairbury, Nebraska 
National Foundation, Inc. 

Clinton Belknap 
State House Station 
Post Office Box 4813, Lincoln, Nebraska 
Nebraska Chapter, 

Arthritis and Rheumatism Foundation 
Lloyd E. Skinner, President 
Box 2, Elmwood Station, Omaha 6, Nebraska 
Nebraska Association of Pathologists 
Dr. Robert A. Brooks, Secy-Treas. 

1403 Sharp Building, Lincoln, Nebraska 
Nebraska Blue Cross-Blue Shield 
Wm. H. Heavey, Executive Director 
518 Kilpatrick Building, Omaha, Nebraska 
Nebraska Chapter 

American Academy of General Practice 
John A. Brown, M.D., Secy. 

1620 M Street, Lincoln, Nebr. 

Nebraska Chapter 

American College of Physicians 

Henry J. Lehnhoff, Jr., MD, Governor for Nebr. 
720 Doctors Building, Omaha, Nebraska 69131 
Nebraska Chapter 
American College of Surgeons 
Robert W. Gillespie, MD, Secy.-Treas. 

500 South 17th St., Lincoln, Nebraska 

Nebraska Chapters 

National Cystic Fibrosis Research Foundation 
Greater Omaha Chapter 

Miss Betty Seibert, 510 South 42nd St., Omaha 
Lancaster County Chapter 
Mr. and Mrs. Gayle Voller, 530 North 75th St., 
Lincoln 

Nebraska Dental Association 
D. W. Edwards, D.D.S., Secy. 

1220 Federal Securities Bldg., Lincoln, Nebraska 
Nebraska Diabetes Association 
Mrs. E. H. Reitan, Executive Secretary 
530 N. 86th St., Omaha, Nebr. 

7611 Lawndale Drive, Omaha, Nebraska 
Nebraska Dietetic Association 
Hazel M. Fox, Ph.D., President 
Foods & Nutrition Bldg., East Campus, Lincoln 
Nebraska Division American Cancer Society 
Ray E. Achelpohl, Executive Director 
4201 Dodge, Omaha, Nebraska 
Nebraska Heart Association 

Paul S. Archambault, Executive Director 
514 South 40th Street, Omaha 5, Nebraska 
Nebraska Hospital Association 
Stuart Mount, Executive Director 
1335 “H” Street, Lincoln, Nebraska 


Nebr. Academy of Ophthalmology & Otolaryngology 
C. Rex Latta, MD, Secretary 
710 Doctors Building, Omaha, Nebraska 68131 
Nebraska Pediatric Society 
Otto G. Rath, Secretary 
3929 Harney, Omaha 
Nebraska Pharmaceutical Association 
Miss Cora Mae Briggs, Executive Secretary 
1001 Anderson Building, Lincoln 8, Nebraska 
.Nebraska Psychiatric Institute 
602 South 44th Avenue, Omaha 
Nebraska Public Health Association 
George R. Underwood, M.D., President 
935 “R” Street, Lincoln, Nebraska 

Nebraska Radiological Society 
Jack Zastera, M.D., Secy.-Treas. 

816 Medical Arts Bldg., Omaha, Nebraska 

Nebraska Rheumatism Association 
Vernon G. Ward, President 
5 West 31st Street, Kearney, Nebraska 

Nebraska Society for Crippled Children 
S. Orson Perkins, Director 
402 South 17th, Omaha, Nebraska 

Nebraska Society for Internal Medicine 
Robert S. Long, M.D., President 
8721 Shamrock Road, Omaha, Nebraska 
Nebraska Society of Anesthesiologists 
Frank Cole, M.D., President 
2430 Lake St., Lincoln, Nebraska 
Nebraska Society of Medical Technologists 
Gladys Jeurink, MT, ASCP, 4600 Spruce, Lincoln 
Nebraska State Department of Health 
E. A. Rogers,M.D., Director 
State Capitol Building, Lincoln, Nebraska 
Nebraska State Medical Association 
Ken Neff, Executive Secy. 

1315 Sharp Building, Lincoln 8, Nebraska 
Nebraska State Nurses Association 
Zelda Nelson, Executive Director 
307 Baird Bldg., Omaha, Nebraska 
Nebraska State Obstetric and Gynecologic Society 
W. Riley Kovar, M.D., Secretary-Treasurer 
3610 Dodge Street, Omaha 31 
Nebraska State Orthopedic Society 
Harold Horn, MD, Secretary 
3145 “0” Street, Lincoln, Nebraska 
Nebraska State Pediatric Society 
Otto Rath, M.D., Secretary-Treasurer 
3929 Harney, Omaha, Nebraska 
Nebraska, South Dakota, North Dakota District 
Branch of the American Psychiatric Association 
Harry C. Henderson, M.D., President 
105 South 49th St., Omaha, Nebraska 68132 
Nebraska Tuberculosis Association 
Delmer Serafy, Executive Secy. 

406 W.O.W. Building, Omaha, Nebi'aska 
Nebraska Urological Association 

Louis W. Gilbert, MD, Secretary-Treasurer 
903 Sharp Building, Lincoln 8, Nebraska 
Omaha Mid-West Clinical Society 
1040 Medical Arts Building (68102) 

Rita M. Crowell, Executive Secretary 
POISON CONTROL CENTER 
Children’s Memorial Hospital 
502 South 44th, Omaha, Nebraska 
Rehabilitation Services Division 

Fred A. Novak, Assistant Commissioner 
707 Lincoln Bldg., 1001 0 St., Lincoln 68508 
University of Nebraska College of Medicine 
Cecil L. Wittson, MD, Dean 
42nd and Dewey, Omaha, Nebraska 
(Please help us keep these addresses correct, by 
notifying the Editor of any changes). 


120 


Nebraska S. M. J. 



one mid-morning 


one mid-evening 


New 300 mg tablet 

It’s made for b.i.d. 


ForAdults-2tablets provide a full 24 hours of therapy... with all the extra 
benefits of DECLOMYCIN... lower mg intake per day. ..proven potency... 
1-2 days’ "extra” activity to protect against relapse or secondary infection. 


DECLOMYCIIV 

DEMETHYLCHLOKTETRACYCLINE 
300mg‘ FILM COATED TABLE I S 


Effective in a wide range of everyday infections 
—respiratory, urinary tract and others— in the 
young and aged— the acutely or chronically ill— 
when the offending organisms are tetracycline- 
sensitive. 

Warning — In renal Impairment, usual doses 
may lead to excessive systemic accumulation 
and liver toxicity. Under such conditions, lower 
than usual doses are indicated and, if therapy 
is prolonged, serum level determinations may 
be advisable. A photodynamic reaction to nat- 
ural or artificial sunlight has been observed. 
Small amounts of drug and short exposure 
may produce an exaggerated sunburn reaction 
which may range from erythema to severe skin 
manifestations. In a smaller proportion, photo- 
allergic reactions have been reported. Patients 


should avoid direct exposure to sunlight and 
discontinue drug at the first evidence of dis- 
comfort. 

Precautions and Side Effects — Overgrowth of 
nonsusceptible organisms may occur. Constant 
observation is essential. If new infections 
appear, appropriate measures should be taken. 
Use of demethylchlortetracycline during tooth 
development (last trimester of pregnancy, 
neonatal period and early childhood) may 
cause discoloration of the teeth (yellow-grey- 
brownish). This effect occurs mostly during 
long-term use but has also been observed in 
short treatment courses. In infants, increased 
intracranial pressure with bulging fontanels 
has been observed. All signs and symptoms 
have disappeared rapidly upon cessation of 


treatment. Side reactions include glossitis, 
stomatitis, proctitis, nausea, diarrhea, vaginitis 
and dermatitis. If adverse reaction or idiosyn- 
cracy occurs, discontinue medication and insti- 
tute appropriate therapy. Anaphylactoid reac- 
tions have been reported. 

Average Adult Daily Dosage: 150 mg q.i.d. or 
300 mg b.i.d. should be given 1 hour before or 
2 hours after meals, since absorption is 
impaired by the concomitant administration of 
high calcium content drugs, foods and some 
dairy products. 

Capsules: 150 mg of demethylchlortetracycline 
HCI. 

Tablets: film coated, 300 mg, 150 mg, and 
75 mg of demethylchlortetracycline HCI. 


LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 


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Comparison of the Thoracic and Abdominal 
Approaches to the Repair of Esophageal 
Hiatus Hernia: Long-Term Results — R. 
M. Keltner, Jr., et al (Barnes Hosp, St. 
Louis). Amer J Surg 110:910-917 (Dec) 
1965. 

In this series of 146 cases of hiatus 
hernia repair, 92 patients were asymptomatic 
and considered the result of their operation 
satisfactory wdien followed up for more than 
15 months after the operation. Eighty-eight 
hernias were repaired by an abdominal ap- 
proach, 56 by a thoracic approach, and 2 by 
a thoracoabdominal approach. There w'as 
practically no difference in the results ob- 
tained with the two approaches. The mor- 
tality for all the cases was 2.7%. Thirty-six 
per cent of the patients required celiotomy 
for surgical treatment of concomitant gas- 
trointestinal lesions. For isolated hiatus her- 
nia, equally satisfactory results may be 
achieved with either surgical approach. 
Treatment of concomitant gastrointestinal 
lesions by the abdominal approach does not 
increase the risk to the patient. 

20-A 


Immediate or Later Feeding for Premature 
Babies — B. D. Bower and B. A. Wharton 
(Children’s Hosp, Birmingham, England), 
Lancet 2:969-972 (Nov 13) 1965. 

A controlled trial was carried out in 239 
premature babies to compare immediate feed- 
ing (usually within two to three hours of 
birth, using large volumes of milk) with 
later feeding (usually at 12 hours, using 
smaller volumes). The mortality in the im- 
mediate group was 17% and in the later 
group 6%. The difference is significant; 
however, detailed analysis has produced no 
explanation for the difference other than the 
difference in feeding methods. Aspiration 
of vomit was a disturbingly frequent ne- 
cropsy finding in the immediate group. Hy- 
perbilirubinemia and hypoglycemia were less 
common in the immediate group. Although 
there are some good reasons for immediate 
feeding, it is not without some danger and 
the policies of feeding premature babies 
should be re-evaluated. 


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k 


TOPICAL TYPICAL 

TREATMENT RESULTS 



PRIMARY PYODERMA AFTER TREATMENT WITH 

■NEOSPORIN' ANTIBIOTIC OINTMENT 
AND SALINE COMPRESSES 


‘NEOSPORIN’. 


Polymyxin B- Neomycin -Bacitracin 


ANTIBIOTIC OINTMENT 


Each gram contains: 
‘Aerosporin'® brand Polymyxin B 


Sulfate 5,000 Units 

Zinc Bacitracin 400 Units 

Neomycin Sulfate (equivalent to 
3.5 mg. Neomycin Base) ..5 mg. 


Tubes of Vj oz. and 1 oz. 

■ clinically effective 

■ comprehensive bactericidal action against most 
Gram-negative and Gram-positive organisms, in- 
cluding Pseudomonas 

■ rarely sensitizes 


ecthyma, pyodermas, sycosis vulgaris, paronychia, 
traumatic lesions, eczema, herpes and seborrheic 
dermatitis. Prophylactically, for protection against 
bacterial contamination in burns, skin grafts, inci- 
sions and other clean lesions, abrasions and minor 
cuts and wounds. 

Caution: As with other antibiotic preparations, pro- 
longed use may result in overgrowth of nonsus- 
ceptible organisms and/or fungi. Appropriate 
measures should be taken if this occurs. 

Contraindication: This product is contraindicated 
in those individuals who have shown hypersensi- 
tivity to any of its components. 


For the eradication of infectious organisms in a Complete literature available on request from 
wide range of dermatologic disorders: impetigo. Professional Services Dept. PML 



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21-A 




Butazolidin'alka 

phenylbutazone 100 mg. 

dried aluminum 

hydroxide gel 100 mg. 

magnesium trisilicate 150 mg. 
homatropine 

methylbromide 1.25 mg. 


Usually works within 3 to 4 days 
in osteoarthritis 


The trial period need not exceed 1 week. In 
contrast, the recommended trial period for 
indomethacin is at least 1 month. 

That's why it’s logical to start therapy with 
Butazolidin alka — you'll know quickly whether 
or not it works. And usually, it will. 

A large number of investigators have re- 
ported major improvement in about 75% of 
cases. Some patients have gone into remis- 
sion. Relief of stiffness and pain may be fol- 
lowed quickly by improved function and res- 
olution of other signs of inflammation. And 
Butazolidin alka is well tolerated, especially 
since it contains antacids and an antispas- 
modic to minimize gastric upset. 

Contraindications 

Edema, danger of cardiac decompensation; 
history or symptoms of peptic ulcer; renal, 
hepatic or cardiac damage; history of drug 
allergy; history of blood dyscrasia. The drug 
should not be given when the patient is se- 
nile, or when other potent drugs are given 
concurrently. Large doses are contraindi- 
cated in patients with glaucoma. 

Precautions 

Obtain a detailed history and a complete 
physical and laboratory examination, includ- 


ing a blood count. The patient should be 
closely supervised and should be warned to 
report immediately fever, sore throat, or 
mouth lesions (symptoms of blood dyscrasia); 
sudden weight gain (water retention); skin 
reactions; black or tarry stools. Make regular 
blood counts. Use greater care in the elderly. 

Warning 

If coumarin-type anticoagulants are given 
simultaneously, watch for excessive increase 
in prothrombin time. Pyrazole compounds 
may potentiate the pharmacologic action of 
sulfonylurea, sulfonamide-type agents and 
insulin. Carefully observe patients receiving 
such therapy. 

Adverse Reactions 

The most common are nausea, edema and 
drug rash. Hemodilution may cause mod- 
erate fall in red cell count. The drug may 
reactivate a latent peptic ulcer. Infrequently, 
agranulocytosis, generalized allergic reac- 
tion, stomatitis, salivary gland enlargement, 
vertigo and languor may occur. Leukemia 
and leukemoid reactions have been re- 
ported but cannot definitely be attributed to 
the drug. Thrombocytopenic purpura and 
aplastic anemia may occur. Confusional 
states, agitation, headache, blurred vision, 
optic neuritis and transient hearing loss 


have been reported, as have hepatitis, 
jaundice, and several cases of anuria and 
hematuria. With long-term use, reversible 
thyroid hyperplasia may occur infrequently. 

Dosage 

The initial daily dosage in adults is 300-600 
mg. daily in divided doses. In most in- 
stances, 400 mg. daily is sufficient. When 
improvement occurs, dosage should be de- 
creased to the minimum effective level: this 
should not exceed 400 mg. daily, and is 
often achieved with only 100-200 mg. daily. 

Also available: Butazolidin®, 
brand of phenylbutazone 
Tablets of 100 mg. 

Geigy Pharmaceuticals 

Division of Geigy Chemical Corporation 

Ardsley, New York BU-3804 p 


Geigy 




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Blueprint for dealing with tension due to stress — Prolixin — once-a-day 

For the patient who must be on the job mentally as well as physically, prescribe 
Prolixin. The prolonged tranquilizing action of as little as one or two mg. helps 
him cope with tension ail day long. Markedly- low in toxicity and virtually free 
from usual sedative effects, Prolixin is effective in controlling both anxiety 
associated with somatic disorders and anxiety due to environmental 
or emotional stress. Patient acceptance is good — because Prolixin 
is low in cost, low in dosage and low in sedative activity. Prescribe 
Prolixin. 

Side Effects, Precautions, Contraindications: As used for anxiety and tension, side 
effects are unlikely. Reversible extrapyramidal reactions may develop occasionally. In 
higher doses for psychotic disorders, patients may experience excessive drowsiness, visual 
blurring, dizziness, insomnia (rare), allergic skin reactions, nausea, anorexia, salivation, 
edema, perspiration, dry mouth, polyuria, hypotension. Jaundice has been exceedingly rare. 
Photosensitivity has not been reported. Blood dyscrasias occur with phenothiazines; routine 
blood counts are recommended. If symptoms of upper respiratory infection occur, discon- 
tinue the drug and institute appropriate treatment. Do not use epinephrine for hypotension 
which may appear in patients on large doses undergoing surgery. Effects of atropine may 
be potentiated. Do not use with high doses of hypnotics or in patients with subcortical 
brain damage. Use cautiously in convulsive disorders. Available: 1 mg. tablets. Bottles of 
50 and 500. For full information, see Product Brief. 


Squibb 



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24-A 


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In anxiety | 
states: I 

B and C I 
vitamins 
are therapy 


Stress formula vitamins are an important supportive measure in main- 
taining the nutritional status of the emotionally disturbed patient. With 
STRESSCAPS, B and C vitamins are present in therapeutic amounts to meet 
increased metabolic demands. Patients with anxiety, and many others under- 
going physiologic stress, may benefit from vitamin therapy with STRESSCAPS. 

STRESSCAPS 

Stress Formula Vitamins Lederle 



Each capsule contains: 


Vitamin B i (asThiamine Mononitrate) 10 mg. 

Vitamin B? (Riboflavin) 

10 mg. 

Niacinamide 

100 mg. 

Vitamin C (Ascorbic Acid) 

300 mg. 

Vitamin 65 (Pyridoxine HCI] 

2 mg. 

Vitamin B12 Crystalline 

4 mcgm. | 

Calcium Pantothenate 

20 mg. 

Recommended intake: Adu 

ts, 1 capsule 

daily, for the treatment of 

vitamin defi- 

ciencies. Supplied in decorative “re- 

minder” jars of 30 and 100; 

Dottles of 500. 



LEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, N. Y. 

' 8241-4 









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Mailing Address: Elmwood Station, Box 6076, Omaha 68106 






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We Invite Your Inquiries 
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C. C. Kimball Company 

MANAGING AGENTS 
Sharp Building 




“If you want water, Sir, just ring for it!” 


26-A 


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Medical Journal 



among the most significant drugs in use tod^ 

CHLOROMYCETlI 

(CHLORAMPHENICOL) 

I PARKE-DAVIS | 

PARK£. DAVIS A COMPANY. Detroit. M<h,gtn 48732 

Complete information for usage available to physicians upon reaut 




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THE NEBRASKA STATE 
MEDICAL JOURNAL 


APRIL, 1966 VOL. 51, NO. 4 


EDITOR- 
FRANK COLE. MD 
2430 Lake St., Lincoln 2 


2430 Lake Street, Lincoln 2, Nebraska 


CONTENTS: 


EDITORIALS- 

The Distaff Side - 121 

P K and You - 121 

Why Grade Patients? 122 

Medical Assistance for the Needy 122 

The President's Page - 124 

ORIGINAL SECTION- 

Family Practice Teaching in Scotland 125 

Fay Smith, MD 

Diagnostic Considerations in Management of 

Penetrating Abdominal Wounds -- 127 

Hans Rath, MD 

The Management of Gunshot Wounds 

of the Extremities - 132 

Carlyle E. Wilson, MD 


A Report of Three Cases of Acute Lymphocytic 
Leukemia in Children in a Small Nebraska 


Community 137 

V. Franklin Colon, MD 

Neurological Phenomena of Leukemia - 141 

John A. Aita, MD 


ASSOCIATE EDITORS— 

FREDERICK M. NEBE. MD 
Review Editor 

943 Stuart Building, Lincoln 8 

C. R. HANKINS, MD 

822 The Doctors Building. Omaha 31 

J. MARSHALL NEELY. MD 
4201 Calvert, Lincoln 6 

W. MAX GENTRY, MD 
1720 Tenth Street, Gering 

GEORGE E. STAFFORD, MD 
800 South 13th St.. Lincoln 8 

B. R. BANCROFT, MD 

Kearney Medical Arts Building, Kearne.v 

JAMES J. O’NEIL. MD 

612 Medical Arts Building, Omaha 2 

FRANK P. STONE, MD 
2300 South 13th, Lincoln 2 

ROBERT J. STEIN, MD 

930 Stuart Building. Lincoln 8 

J. H. BARTHELL. MD 

1012 Sharp Building, Lincoln 8 

HAROLD E. HARVEY, MD 
140 South 27th Street, Lincoln 6 

H. V. MONGER, MD 
3705 South Street, Lincoln 

BERNARD F. WENDT, MD 

735 South 56th Street, Lincoln 6 

FRANK H. TANNER. M.D. 

1835 South Pershing Road, Lincoln 2 

K. D. ROSE. MD 

University Health Service. Lincoln 8 

KEN NEFF, Business Manager 
1315 Sharp Building, Lincoln 
Telephone HEmlock 2-7585 


ORGANIZATION SECTION- 

Welcome, Ne’ov Members 146 

Hobby Shop - - 146 

Woman's Auxiliary 147 

Our Medical Schools - 148 

Proceedings, Board of Councilors -- 149 

Proceedings, House of Delegates 150 

1965 Annual Audit and Committee Reports 157 

1966 Roster of Delegates 179 

Program, Nebraska State Medical Association . 181 

All About Us 1 95 

Deaths - 1 95 

Announcements 196 

News and Views 197 

Know Your Blue Shield Plan 197 

The Military Dependents' Medical Care _ 197 

Coming Meetings .. 198 

Books - - - 201 

Organizations, National 203 

Organizations, State - - 204 


SUBSCRIPTION RATE 

$5.00 Per Year Single Copies 50c Each 


The Editor of this Journal assumes no re- 
sponsibility for opinions and claims ex- 
pressed in the articles published herein. 

Manuscripts to be presented for publica- 
tion in the JOURNAL should be typewritten, 
double-spaced, on one side only of firm (not 
onion skin or flimsy), standard letter sized 
(8*^ by 11 in.) white paper. Wide margins 
(at least IH in. on left) should be left free 
of typing. On the first or title-page should 
be sh,.wn the title of the article, the name 
(or names) of the author, his degree and 
other significant credits. Pages should be 
numbered consecutively, the page number 
being shown in the right upper corner along 
with the surname of the author. 

Illusti-ations should be numbered and their 
locations shown in the text. Each should be 
identified by placing on its back the author’s 
name, its number and an indication of its 
“top.’" Drawings and charts intended for 
cuts should be in black (India ink) on pure 
white. Photographs should be on glossy 
paper and minimum of about 5 by 7 in. in 
size. A legend should be provided for each 
illustration and, preferably, attached to iu 

Manuscripts (original, not a carbon) should 
be sent directly to the Editor at the JoumaPs 
address. 

Reprints should be ordered fi*om the print- 
er, NEWS Printing Company, Norfolk, Nebr. 

Copyright 1964 by The Nebraska State 
Medical Association. 

Published monthly and postage paid at the 
Post Office at Norfolk, Nebraska, as second 
class matter. 


4-A 


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In the management of mild to moderate pain, give your patients comprehensive relief. 
TRANCO-GESIC extends the range of usefulness of aspirin by dimming pain perception- 
and also reducing mental and muscle tension. 


TRANCO-GESIC* 


tablets 


chlormezanone 100 mg. with aspirin 300 mg. 

subdues the major 
contributors to pain: 

• pain perception 

• mental tension 

• muscle tension-spasm 


In/nffyrop 


TRANCO-GESIC is so well tolerated it can be 
prescribed for anyone who can take aspirin. It 
is non-narcotic, and free from dangers of 
addiction, habituation, or dependence. 
TRANCO-GESIC is effective in all types of mild 
and moderate pain. Of 862 patients who were 
treated with chlormezanone and aspirin for 
various disorders, 88% reported excellent or 
good pain relief.’ 

s/de effects have been minor. Occasionally gastric distress, 
weakness, sedation or dizziness occur. Reversible cholestatic 
jaundice has been reported on rare occasions. However, in 
4,653 patients treated with chlormezanone, 97.7“/o had no side 
effects.' Contraindication: just one: sensitivity to aspirin. 
Dosage: Adults, usually 2 tablets three or four times daily. 
Children (from 5 to 12 years), 1 tablet three or four times daily. 
1. Collective studies. Department of Medical Research, 
Winthrop Laboratories. 


WINTHROP LABORATORIES, NEW YORK, N. Y. 10016 




In Fractures: B and C vitamins are therapy 

Stress formula vitamins are a key factor in bone and tissue regeneration. To 
increased metabolic demands, STRESSCAPS offers therapeutic amounts o 
vitamins as an aid to smoother convalescence and earlier rehabilitation. In 
as in many other conditions of physiologic stress, STRESSCAPS vitamins ar( 

STRESSCAPS 

Stress Formula Vitamins Lederle 


I meet ine 
if B and C 
fractures, 
e therapy. 



Each capsule contains: 


Vitamin Bi (ThiamineMononitrate) 10 mg. 

Vitamin Bq (Riboflavin) 

10 mg. 

Niacinamide 

100 mg. 

Vitamin C (Ascorbic Acid) 

300 mg. 

Vitamin B^, (Pyridoxine HCI) 

2 mg. 

Vitamin B 12 Crystalline 

4 mcgm. 

Calcium Pantothenate 

20 mg. 

Recommended intake: Adults, 

1 capsule 

daily, for the treatment of vitamin de- 

ficiencies. Supplied in decorative “re- 

minder” jars of 30 and 100; bottles of 500. 


ILEDERLE LABORATORIES, A Division of AMERICAN CYANAMID COMPANY, Pearl River, N. Y. 

^ 7283-4 


1 




''All Interns are Alike" 


It stands to reason. They all go through the same 
training; they all have to pass the same tests; they 
all have to measure up to the same standards; they 
all are underpaid, too. Therefore, all interns are 
alike. 

That's utter nonsense, of course. But it's no 
more nonsensical than what some people say 
about aspirin. Namely: since all aspirin is at least 
supposed to come up to certain required stand- 
ards, then all aspirin tablets must be alike. 

Bayer's standards are far more demanding. In 
fact, there are at least nine specific differences in- 


volving purity, potency and speed of tablet disinte- 
gration. These Bayer® standards result in significant 
product benefits including gentleness to the stom- 
ach, and product stability that enables Bayer tab- 
lets to stay strong and gentle until they are taken. 

So next time you hear someone say that all 
aspirin tablets are alike, you can say, with confi- 
dence, that it just isn't so. 

You might also say that all interns aren't alike, 
either. 



You can enhance the value of your own Journal by patronizing its advertisers 


7-A 


When uncontrolled 
diarrhea brings 
a call for help 



gamut of home remedies without success, 
pleasant-tasting CREMOMYCIN can answer 
the call for help. It can be counted on to 
consolidate fluid stools, soothe intestinal 
inflammation, inhibit enteric pathogens, 
and detoxify putrefactive materials — usu- 
ally within a few hours. 

CREMOMYCIN combines the bacteriostatic 
agents, succinylsulfathiazole and neomy- 
cin, with the adsorbent and protective de- 
mulcents, kaolin and pectin, for compre- 
hensive control of diarrhea. 

Indications: Diarrhea. Contraindications: Kaolin: 
Withhold if diverticulosis is present or suspected. 
Precautions: Sulfonamide: Continued use requires 
supplementary administration of thiamine and vita- 


your for 
Cremomycin 
can provide relief 




min K. Neomycin: Patient should be observed for 
new infections due to bacteria or fungi. Side Effects: 
Sulfonamide: Sensitivity reactions may occur (e.g., 
skin rashes, anemia, polyneuritis, fever; agranulo- 
cytosis with a fatal outcome has been reported). 
Reduction of thiamine output in the feces and of 
vitamin K synthesis has been observed. Neomycin: 
Nausea, loose stools possible. 

Before prescribing or administering, read product 
circular with package or available on request. 


promptly relieves diarrheal distress 

Cremomycin 

ANTIDIARRHEAL ^ 

Composition: Each 30 cc. contains neomycin sulfate 
300 mg. (equivalent to 210 mg. of neomycin base), 
succinylsulfathiazole 3.0 Gm., colloidal kaolin 3.0 
Gm., pectin 0,27 Gm. 

@MERCK SHARP & DOHME Division of Merck & Co-, Inc.. West Point. Pa. 

Where today’s theory is tomorrow’s therapy 




Current Comment 

Omaha Doctors Send Medical Gifts — 

About $6,000 in equipment and supplies 
has been sent by the Omaha Chapter of the 
Catholic Physicians’ Guild to the Catholic 
Medical Missionary Service for use by mis- 
sionary doctors throughout the world. St. 
Joseph’s Hospital in Omaha contributed much 
of the equipment, and the Creighton Uni- 
versity School of Pharmacy was also a “prime 
mover’’ in sptearheading the collection drive, 
according to Albert B. Lorincz, M.D., Presi- 
dent of the Omaha Chapter. The DC - Red 
Ball Express Company donated its time and 
charges shipping the material to New York 
City from where it will be sent directly to 
the missions. 

Nebraska Centennial Health Fair; 

Progress Report — 

Doctor E. D. Zeman, Chairman of the Ne- 
braska Centennial Health Fair Committee 
of the Lancaster County Medical Societj', re- 
ports that information concerning the Health 
Fair will soon be reaching the officers of 


county medical societies throughout the 
state. The Lancaster County doctors hope to 
enlist the aid of their colleagues throughout 
Nebraska in co-sponsoring this ambitious 
and worth-while project. The dates for the 
Health Fair are April 29, 1967 through May 
5, 1967. 

Physicians Assured of Hearing — 

All state-employed physicians, including 
those at Nebraska’s mental hospitals, can 
call on the Nebraska State Medical Associa- 
tion’s top policy committee for a hearing if 
they are discharged, transferred, or demoted. 

Findings and recommendations from the 
policy committee will be reported at once to 
the Governor who is administratively re- 
sponsible for state institutions employing 
doctors. 

The policy committee includes Doctor Dan 
Nye of Kearney, Doctor Willis Wright of 
Omaha, Doctor Richard E. Garlinghouse of 
Lincoln, Doctor Rudy Sievers of Blair, and 
Doctor Otto Kostal of Hastings. 

(Continued on page 22- A) 


10-A 


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NOTHING, THAT IS, 

EXCEPT THE SEDATIVE-ANTISPASMODIC 
BENEFITS OF 


DONNATAL 


There’s nothing quite like a vacation to ease the pressures of 
the modern, “workingday” world. And for the patient who can’t 
get away from it all, there’s nothing quite like Donnatal to relax 
stress-induced smooth muscle spasm. For 31 years it has been 
the antispasmodic-sedative most often prescribed for relieving 
functional disturbances of tone and motility of the gastrointes- 
tinal tract. 

belladonna alkaloids in optimally balanced ratio 

In Donnatal, natural belladonna alkaloids are rationally balanced 
in a specific, fixed ratio that provides “the greatest efficacy with 
the smallest possible dose.”’ They avoid the clinical uncertain- 
ties of the variable tincture and extract of belladonna, and are 
considered superior in range of action to atropine alone. ^ 
Furthermore, they are generally recognized as being more effec- 
tive than the synthetics for relieving visceral spasm. 

phenobarbital for sedation 

Years of clinical use have established phenobarbital as one of 
the most efficient and highly regarded sedatives. In fact, for 
general sedation it is the drug of choice.” In Donnatal, pheno- 
barbital potentiates the spasmolytic effects of the belladonna 
alkaloids, lessening emotional tensions and checking the neuro- 
genic impulses that trigger Gl disorders. 

more than 24 indications in PDR 

Donnatal has withstood the test of time to become the classic 
sedative-antispasmodic because of its unsurpassed effective- 
ness, safety, economy, uniformity of composition, and dosage 
convenience. Its widespread acceptance and usage by the pro- 
fession can also be attributed to its versatility in treating dis- 
orders characterized by smooth muscle spasm. There are more 
than two dozen distinct and separate indications for Donnatal 
listed in the current PDR. 


IN EACH TABLET, CAPSULE, OR 
(5 cc.) OF ELIXIR 

hyoscyamine sulfate 0.1037 mg. 

atropine sulfate 0.0194 mg. 

hyoscine hydrobromide . . . 0.0065 mg. 

phenobarbital ('A gr.) 16.2 mg. 

(warning: may be habit forming) 


IN EACH EXTENTAB 

hyoscyamine sulfate 0.3111 mg. 

atropine sulfate 0.0582 mg. 

hyoscine hydrobromide . . . 0.0195 mg. 

phenobarbital gr.) 48.6 mg. 

(warning: may be habit forming) 


BRIEF SUMMARY: Blurring of vision, 
dry mouth, difficult urination, and flush- 
ing or dryness of the skin may occur 
on higher dosage levels, rarely on 
usual dosage. Administer with caution 
to patients with incipient glaucoma, 
or urinary bladder neck obstruction. 
Contraindicated in acute glaucoma, 
advanced renal or hepatic disease, or 
a hypersensitivity to any of the ingre- 
dients. 


REFERENCES: 1. Vollmer, H.: Arch. Neurol, 
and Psychiat., 43:1057, 1940. 2. Morrissey, 
J.H.: J. Urology, 57:635, 1947. 3. Krantz, J.C., 
Jr., and Carr, C.J.: Pharmacological Prin- 
ciples of Medical Practice, 2nd ed., Balti- 
more (1954), 552. 


‘This one at Westover, elegant Colonial Vir- 
ginia plantation, located on the James River 
near Richmond. Built in the early 1730's by 
William Byrd II, founder of Richmond, it is 
now the home of Mrs. Bruce Crane Fisher. 


A. H. ROBINS COMPANY, INC., RICHMOND, VA. 


First aid for a button popper 



Second aid for a button popper 



Kim »♦ su\ 

^frfTTTiT 





• AVlt»Lit t < 


SEQUELS* 



By providing combined anorexigenic-tranquilizing action, 
BAMADEX SEQUELS Capsules help your nonshrinking 
patients to establish new patterns of eating less. The am- 
phetamine component suppresses the appetite, while the 
meprobamate helps allay nervousness and tension. And for 
most patients, the sustained release of the active ingredients 
provides convenient one-capsule-a-day dosage. 

Side Effects commonly associated with either compo- 
nent are possible but, to the extent these are dose-related, 
they should normally be mild and infrequent, since the 
total dosage of each component on the usual one-capsule- 
daily regimen is quite low. Also, the sedating effect of 
meprobamate and the stimulating eflfeet of d-amphetamine 
sulfate tend, to some extent, to cancel each other out. Ad- 
verse effects not peculiar to either component have not 
been reported. Side effects associated with d-amphetamine 
sulfate include: insomnia, excitability, increased motor 
activity, confusion, anxiety, aggressiveness, increased li- 
bido, hallucinations, rebound fatigue, depression, dry 
mouth, anorexia, nausea, vomiting, diarrhea and increased 
cardiovascular reactivity. Effects associated with meproba- 


mate include: skin rash, nonthrombocytopenic purpura 
with petechiae, ecchymoses, peripheral edema, fever and 
transient leukopenia; also, very rarely, fainting spells, angi- 
oneurotic edema, bronchial spasm, hypotensive crisis, 
anuria, stomatitis, proctitis and anaphylaxis. Other serious 
effects have occurred after concomitant administration of 
meprobamate and other drugs. Massive overdosage may 
produce grave effects. 

Precautions: BAMADEX SEQUELS should be given 
only under close supervision to patients hypersensitive to 
sympathomimetic drugs, with cardiovascular or coronary 
disease or who are severely hypertensive; to emotionally 
unstable persons and to epileptics. Patients should be 
cautioned not to drink alcoholic beverages while on the 
drug, and not to drive vehicles if they become drowsy. In 
all patients kept on the drug for long periods, the drug 
should be withdrawn gradually to avoid possible serious 
reactions. 

Contraindications: Hyperexcitability, agitated prepsy- 
chotic states and a history of previous reactions to mepro- 
bamate. 


Bamadex' Sequels* 

d-amphetamine sulfate ( 1 5 mg. ) Sustained Release Capsules 
and meprobamate (300 mg.) 

LEDERLE LABORATORIES • A Division of American Cyanamid Company, Pearl River, New York 


6655 






Elastic Stockings so sheer they look 
like support hose. Both Ultreer and 
support hose are sheer, shapely, cool 
and comfortable. But that's where 
the similarities end. New Ultreer fits 
firmly and evenly over the entire leg. 
Gives true therapeutic compression 
necessary to relieve varicose veins and 
other leg disorders. They provide 
the therapy you prescribe. The fashion 
and economy she demands. 

Ultreer stockings have a new low price. 
So low, she can afford two pairs of 
Ultreer instead of one pair of regular 
elastic stockings. There'll be no 
disagreements there. Ultreer stockings 
are as comforting to her purse as 
they are to her 
legs. New Ultreer 
are the elastic 
stockings doctors 
and women can 
agree on. 



KenoALL 



BAUCR h 9U>^K SU^ATS OfVISiON 


14A 


You can enhance the value of your own Journal by patronizing its advertisers 











The human spine is not engineered for 
prolonged sitting at desks, pianos, type- 
writers and drafting boards. The stresses 
set up by the heavy, forward-tilted head 
and trunk, balanced precariously on an 
insufficient base, result in strain of the 
dorsal musculature, particularly at the 
low lumbar level. 

The unusual nnuscle-relaxant and anal- 
gesic properties of ‘Soma’ make it espe- 
cially useful in the treatment of low back 
sprains and strains. ‘Soma’ is widely 
prescribed □ to relieve pain □ to relax 
muscles □ to restore mobility. 

Indications: ‘Soma’ is useful for management of 
muscle spasm, pain, and stiffness in a variety of 
inflammatory, traumatic, and degenerative muscu- 
loskeletal conditions. It also may act to normalize 
motor activity in certain neurologic disturbances. 


Contraindications: Allergic or idiosyncratic reac- 
tions to carisoprodol. 

Precautions: ‘Soma’, like other central nervous 
system depressants, should be used with caution 
in patients with known propensity for taking ex- 
cessive quantities of drugs and in patients with 
known sensitivity to compounds of similar chemi- 
cal structure, e.g., meprobamate. 

Side Effects: The only side effect reported with any 
frequency is sleepiness, usually on higher than 
recommended doses. An occasional patient may 
not tolerate carisoprodol because of an individual 
reaction, such as a sensation of weakness. Other 
rarely observed reactions have included dizziness, 
ataxia, tremor, agitation, irritability, headache, in- 
crease in eosinophil count, flushing of face, and 
gastrointestinal symptoms. 

One instance each of pancytopenia and leuko- 
penia, occurring when carisoprodol was admin- 
istered with other drugs, has been reported, as has 
an instance of fixed drug eruption with carisoprodol 
and subsequent cross reaction to meprobamate. 
Rare allergic reactions, usually mild, have included 
one case each of anaphylactoid reaction with mild 
shock and angioneurotic edema with respiratory 
difficulty, both reversed with appropriate therapy. 
In cases of allergic or hypersensitivity reactions, 
carisoprodol should be discontinued and appropri- 
ate therapy initiated. Suicidal attempts may pro- 
duce coma and/or mild shock and respiratory 
depression. 

Dosage: Usual adult dose is one 350 mg. tablet 
three times daily and at bedtime. 

Supplied: Two Strengths : 350 mg. white tablets 
and 250 mg. orange, two-piece capsules. 

Before prescribing, consult package circular. 


for the relief 
of low back 
sprains and strains 

SOMA 

(CARISOPRODOL) 


Wallace Laboratories, Cranbury, N.J. 

26S01J 



now... introducing a new high-strength dosage form 

SIGNEM 


A 'MAXIMUM SECURITY’ ANTIBIOTIC* 


^ THE BROAD RANGE DEPENDABILITY OF TETRACYCLINE 

long established as the broad-spectrum agent of first choice in a wide 
variety of infections 

^ WITH THE ADDED SECURITY OF MEDIUM-SPECTRUM REINFORCEMENT 
triacetyloleandomycin is highly active against the common ‘coccal’ 
pathogens, including certain strains of staphylococci resistant to penicillin 
and tetracycline 

^ ESPECIALLY VALUABLE IN U.R.I. 
provides decisive therapy in acute respiratory infections and other 
conditions in which staphylococci, streptococci or mixed flora are 
frequently encountered 

^ NOW AVAILABLE IN NEW STRENGTH FOR NEW CONVENIENCE AND 
ECONOMY 

Signemycin 375 — high-potency capsules for simpler administration, 
greater patient economy 


VCir 375 

(tetracycline 250 mg. 
triacetyloleandomycin 125 mg.) 


Indications: Indicated in the therapy of acute severe infec- 
tions caused by susceptible organisms and primarily by 
bacteria more sensitive to the combination than to either 
component alone. In any infection in which the patient can 
be expected to respond to a single antibiotic, the combina- 
tion is not recommended. Signemycin should not be used 
where a bacteriologically more effective or less toxic 
agent is available. Triacetyloleandomycin, a constituent of 
Signemycin, has been associated with deleterious changes 
in liver function. See precautions and adverse reactions. 
Contraindications: Contraindicated in individuals who have 
shown hypersensitivity to any of its components. Not recom- 
mended for prophylaxis or in the management of infectious 
processes which may require more than 10 days of con- 
tinuous therapy. If clinical judgement dictates therapy for 
longer periods, serial monitoring of liver function is recom- 
mended. Not recommended for subjects who have shown 
abnormal liver function tests, or hepatotoxic reactions to 
triacetyloleandomycin. 

Precautions and Adverse Reactions: Triacetyloleandomycin, 
administered to adults in daily ora! doses of 1.0 gm. for 10 
or more days, may produce hepatic dysfunction and jaun- 
dice. Adults requiring 3 gm. of Signemycin initially should 
have liver function followed carefully and the dosage should 
be reduced as promptly as possible to the usual recom- 
mended range of 1.0 to 2.0 gm. per day. Present clinical 
experience indicates that the observed changes in liver 


function are reversible after discontinuation of the drug. 

Use with caution in lower than usual doses in cases with 
renal impairment to avoid accumulation of tetracycline and 
possible liver toxicity, if therapy is prolonged under such 
circumstances, tetracycline serum levels may be advisable, 
in long term therapy or with intensive treatment or in known 
or suspected renal dysfunction, periodic laboratory evalua- 
tion of the hematopoietic, renal and hepatic systems should 
be done. Formation of an apparently harmless calcium com- 
plex with tetracycline in any bone forming tissue may occur. 
Use of tetracycline during tooth development (3rd trimester 
of pregnancy, infancy and early childhood) may cause dis- 
coloration of the teeth. Reversible increased intracranial 
pressure due to an unknown mechanism has been observed 
occasionally in infants receiving tetracycline. Glossitis, sto- 
matitis, proctitis, nausea, diarrhea, vaginitis and definite 
allergic reactions occur rarely. Severe anaphylactoid reac- 
tions have been reported as due to triacetyloleandomycin. 
Photosensitivity and photoallergic reactions (due to the 
tetracycline) occur rarely. Medication should be discon- 
tinued when evidence of significant adverse side effects or 
reaction is present. Patients should be carefully observed 
for evidence of overgrowth of nonsusceptible organisms 
including fungi, which occurs occasionally, and which in- 
dicates this drug should be discontinued and appropriate 
therapy instituted. Steps should be taken to avoid masking 
syphilis when treating gonorrhea. 



J. B. ROERIG AND COMPANY 
Division, Chas. Pfizer & Co., Inc. 
Science for the World’s Well-being'* 
New York, N.Y. 10017 


• Section 3 
Lost and Found 

chihuahua — Lost-fern. Tan and 
white R e watd Irving-Callf IR 8-034 1 

Lost 

THE BITTER TASTE OF 
ORAL PENICILLIN. 

See V-Cillin K® 
for full details. 


DOG found— Black Pekc. temale. 
10-76 Lincoln Park 9J3-0794 

DOBERMAN losf — brown. 

Children ^^'0- 

C. 

GER 


_ 8-0698 ^ — 

^eoherd. 'Oj;J' ^°side 

'fTrown Vic, Eu- 
w- - '-I — ^ liQor, oor- 

r^clls. old. Reward. 

y marked- 6 

w "P'k * , 

RlTTEN-LOSt on 4j7-5:45 

**1,1, «7th-ClcefO . _gg:- 


Found' 

k more PLUSMIl 'KW 
UHtO«kLPEI«C"-U*^ 

Check V-CilUn K 
for the facts. 




A 

mdior 1 
mdnuTdl 

vst wl i 

dlyidud 

fTtinUtr 

« trat 


Patients won’t complain about 
bitter penicillin taste when you 
specify V-Cillin K. Here’s why: It 
has a special coating, only one and 
a half thousandths of an inch thick. 
Because it is designed to dissolve 
after approximately six seconds, this 
barrier to bitterness remains on the 
tablet as it slides past the tongue. 
When the tablet reaches the 
stomach, however, the coating has 
dissolved, and the penicillin is ready 
for immediate absorption into 
the bloodstream. 

Result? The proved efficacy of 
potassium penicillin V without the 
penalty of bitter taste. 

Indications: V-Cillin K is an antibiotic 
useful in the treatment of streptococcus, 
pneumococcus, and gonococcus infections and 
infections caused by sensitive strains 
of staphylococci. 

Contraindications and Precautions: 
Although sensitivity reactions are much less 
common after oral than after parenteral 
administration, V-Cillin K should not be 
administered to patients with a history 
of allergy to penicillin. As with any antibiotic, 
observation for overgrowth of nonsusceptible 
organisms during treatment is important. 

Usual Dosage Range: 125 mg. (200,000 
units) three times a day to 250 mg. every 
four hours. 

Supplied: Tablets V-Cillin K, 125 or 250 mg., 
and V-Cillin K, Pediatric, 125 mg. per 5-cc. 
teaspoonful, in 40, 80, and 150-cc.-size packages. 




V-Cillin K‘ 

Potassium Phenoxymethyl Penicillin 


Additional information 
available to physicians 
upon request. 
Eli Lilly and Company, 
Indianapolis, Indiana. 

60(X)50 


18-A 


Vou can enhance the value of your own Journal by patronizing its advertisers 



EDITORIALS 


THE NEBRASKA STATE MEDICAL JOURNAL 


THE DISTAFF SIDE 

The Woman’s Auxiliary to the American 
Medical Association was organized some 44 
years ago, growing out of regional groups 
already existing in Texas, South Dakota, Ok- 
lahoma, Maine, Minnesota, and Montana. A 
resolution advocating a Woman’s Auxiliary 
was adopted on May 26, 1922 by the House 
of Delegates of the AMA at its meeting in 
St. Louis, Missouri; 24 women from nine 
states attended the first meeting. Our own 
Woman’s Auxiliary was started only three 
years later. On May 13, 1925, at the time 
of the annual meeting of the Nebraska State 
Medical Association, Mrs. F. A. Long, of 
Madison, Nebraska, suggested to a small 
group of doctors’ wives (there were 12 ladies 
present, and the meeting was under the 
chairmanship of Mrs. J. E. M. Thomson of 
Lincoln) the formation of a medical aux- 
iliary. The first annual meeting was held 
in Omaha, on May 10, 1926. When last 
counted, in 1965, Nebraska had 16 com- 
ponent auxiliaries and 825 members. The 
ladies have four executive board meetings, 
and one annual meeting which coincides with 
the annual meeting of the NSMA. The Wom- 
an’s Auxiliary to the AMA numbered 13,000 
members in 1932, 53,000 in 1950, 80,000 in 
1960, and now thei*e are almost 90,000 mem- 
bers and nearly 1200 local auxiliaries in the 
50 states and the District of Columbia. 

It has seemed to us for some time that we 
none of us realize the vast amount of good 
the ladies do, and that few, if any of us, 
know, with any degree of exactness, how 
all of this is done. It appears that the 
Woman’s Auxiliary has some eight differ- 
ent kinds of activities. There is the AMA- 
ERF and our own Nebraska Medical Foun- 
dation, and here funds are raised for stu- 
dent loans and for medical schools. The 
ladies help to mold public opinion; they are 
our own public relations ambassadors of 
good will. They encourage safety education. 
The Auxiliary has, as many of us know, an 
important and delightful social function. 
One of its activities is educational ; here the 
ladies help the lay public to prepare for dis- 


aster. There is a community service, where 
the girls help people to understand the 
policies, functions, and aims of the medical 
profession. There is a sort of miscellaneous 
group of activities, at both national and 
county levels, consisting of such things as 
scholarships for camps, fund-raising efforts 
for the AMA, school “Career Day” pro- 
grams, buying dolls for distribution by the 
community service, and even paramedical 
recruitment teas. And there is WASAMA, 
the Woman’s Auxiliary to the Student AMA. 
Nebraska has two WASAMA chapters, 
Creighton, started in 1959; and the Univer- 
sity of Nebraska, begun in 1964. This is 
indeed good ; these young women are the 
future doctors’ wives of America. 

We owe a great deal to the ladies, it 
seems, and it is fitting that we acknowledge 
our debt. If they redouble their efforts, and 
they may, and if we do less, we may even 
become their auxiliary. This is pure fancy. 
We only say: here’s to the ladies, God bless 
them. 

— F.C. 


P K AND YOU 

The concept of phenylketonuria and mental 
impaiiTnent seems to be firmly established. 
The incidence of PKU is one in approximate- 
ly 15,000 births, or 0.007% (1/150 of 1%). 
It has been shown that phenylketonuria is a 
cause of one kind of mental impairment; 
large amounts of phenylpyruvic acid appear 
in the urine. The cause of PKU is prob- 
ably lack or deficiency of phenylalanine hy- 
droxylase. Diagnosis consists at this time 
of the Guthrie test, on blood obtained by 
heel puncture (followed, if positive, by blood 
testing for phenylalanine concentration), and 
ferric chloride tests on wet diapers and dip- 
stick tests on urine. Of some 130 Nebraska 
hospitals, 94 do it, 13 do not, 6 did not reply 
to a questionnaire, 11 are not affected, and 
it is left up to the doctor in 6 towns (which 
may represent 6 hospitals). 

It is reported that we have said that test- 


April, 1966 


121 



ing can be achieved on a voluntary basis. 
Perhaps there has been over-emphasis, as 
approximately 21/2 children would be in- 
volved each year in Nebraska; there may- 
be false positives; mothers may themselves 
be uncooperative; other and possibly better 
tests may appear; confusion may be present 
at high levels; but would it not be well to 
raise the percentage of hospitals, cities, and 
patients to 100% ? 

All we need is 100% of the doctors. 

— F.C. 


WHY GRADE PATIENTS? 

Evaluation of a patient’s physical condi- 
tion and risk before subjecting him to anes- 
thesia and surgery has been a common pro- 
cedure at different times and in various 
places. It has been the custom to divide 
patients into four risk groups. Even if we 
refuse to believe that we think mathematical- 
ly, we cannot escape it; we use a two-group 
system when we consider a patient to be 
a good risk or a poor one. I remember hear- 
ing a surgeon say, “He’s a grade two risk, 
one for me and one for you.’’ A refinement 
of this system has been the adoption of a 
seven-place table. 

The motivation underlying the use of such 
a system may be more meaningful than its 
application. It is certainly improper to in- 
flict the rigors of the operating theater on 
a patient who has little to gain and more to 
lose. But the hazard has become small, while 
the rewards of surgeiy have become great. 
The two-group system appears often in the 
statement that the patient is an acceptable 
risk, implying the existence of a group of 
patients whose risks are not acceptable. But 
to whom is the risk acceptable? And who is 
not an acceptable risk? Anyone whose life 
depends on immediate surgery is an accept- 
able risk. 

It is perhaps important in studying mor- 
tality statistics to grade patients in large 
study centers, but evaluation is too often 
done without precision and too often has the 
one purpose of defense when the situation 
is critical. It has been said; give lots of 


oxygen, don’t let the blood pressure fall, 
and be careful in this case. The presence 
of the patient on the operating table is 
proof that we have all of us, surgeon, anes- 
thesiologist, patient, internist, and family, 
accepted the situation. 

—F.C. 


MEDICAL ASSISTANCE FOR 
THE NEEDY 

Public law 89-97 of the Social Security 
amendments of 1965 adds two new titles to 
the Social Security Act. The “Medicare” 
portion (title XVIII public law 89-97) has re- 
ceived most of the publicity, however, it is 
possible that title XIX of this law, which 
provides for medical care for the needy may 
be of more concern to the medical profes- 
sion. 

Title XIX of the Social Security Act, 
Medical Assistance, is a federal grant-in-aid 
program to assist states in financing medical 
and remedial care for the needy. Care will 
be provided through a single program in each 
state, providing equal benefits to all those 
eligible. 

At present there are five public assistance 
titles of the Social Security Act independent 
programs with different fonnulas for de- 
termining the federal share of expenditures. 
They may be administered at the state level 
by different agencies using different cri- 
teria to determine who is eligible. The re- 
sult is great diversity in medical care for 
the needy even within a single state. Title 
XIX seeks to eliminate this diversity by 
establishing a single program which makes 
the same medical care available to all the 
state’s needy and medically needy. 

The program is effective January 1, 1966, 
and is optional with the states. However, 
after 1969, no federal matching funds for 
medical care of the needy will be available 
through other assistance programs. By 1975, 
all needy and medically needy, of all ages, 
are to have comprehensive care and services 
available through this program. 

The states will administer the program. 


122 


Nebraska S. M. J. 


through the agencies of their choice. Each 
state can set its own eligibility standard to 
determine need for assistance, but may not 
establish income ceilings or residence re- 
quirements. Medical personnel will be re- 
quired in the state agency and at the local 
level to administer the program. The fed- 
eral share of the cost will range from 50% 
to 83% with the highest matching to low- 
est-income states. There is no ceiling on 
the amount of federal reimbursement. 

Title XIX in many ways follows the rec- 
ommendations of the AMA. It is hoped that 
other suggestions of the AMA will be in- 
corporated into regulations which are cur- 
rently being developed. The importance of 
cooperation between the federal government 
and organized medicine is quite evident. 

The medical profession has always recog- 
nized and supported locally administered 
programs providing assistance to the needy. 
While it is difficult for the profession to ac- 
cept the title XVIII providing care for those 
who are able and willing to do it themselves, 
title XIX, while not perfect, may, in time, 
be a solution to this problem of providing 
health care for the needy. Few questions can 
be answered with a simple “yes” or “no.” 
Few problems are black or white. While 
many of our profession feel that we have 
had a bad deal, we should try to forget the 
deal and play our cards the best we can. Gov- 
ernment acceptance and use of advice from 
our profession will be a major factor in the 
success or failure of this program. 

— B. R. Bancroft, M.D 


Current Comment 

Vaporizer-type Bug-killers Are “Dangerous 
Devices” — 

The Lincoln-Lancaster County Board of 
Health has issued a warning to potential 
users of vaporizer-type bug-killing devices 
following the death of a Lincoln child due to 
inhalation of poisonous fumes emanating 
from such a device. 

The apparatus, sold under various brand 
names, controls insects by electrically vapor- 
izing insecticide tablets and thus spreading 


poisonous fumes. Legally, all that the health 
board can do is to warn the public of the 
dangers. The public is often careless about 
reading warnings on labels when they do 
exist, and misleading advertisements can 
easily compound that carelessness into tragic 
circumstances. Dr. Underwood noted. 

Also condemning the use of such devices 
in the home are the American Medical As- 
sociation, the U.S. Public Health Service, 
and the interdepartmental committee of the 
Departments of Agriculture, Interior, Army, 
Navy, Air Force, and the Federal Security 
Agency. 


Castration in the Treatment of Advanced 
Breast Cancer — E. F. Lewison (Johns 
Hopkins Hosp, Baltimore), Cancer 18: 
1558 (Dec) 1965. 

Ovarian hormones have a profound effect 
upon the natural history of some hormone- 
sensitive breast cancers. In premenopausal 
patients with advanced, recurrent or meta- 
static breast cancer the response to thera- 
peutic castration is between 25% to 35%. 
Prophylactic castration may lengthen the 
free-interval but not the total survival time 
or survival rate. Thus, in this dilemma of 
therapeutic versus prophylactic castration 
the decision is difficult and the data doubt- 
ful. Prophylactic castration is recommend- 
ed in premenopausal patients having an ad- 
vanced stage II cancer at the time of mas- 
tectomy. For all other patients castration 
is reserved for therapeutic purposes. All pre- 
menopausal patients with breast cancer are 
urged to avoid pregnancy and oral contracep- 
tives containing estrogens. 

The Washing Machine and Fiberglass — R. 
R. Abel (619 Westminster Ave, Elizabeth, 
NJ). Ai'ch Derm 93:78 (Jan) 1966. 

A very pruritic, widespread eruption ap- 
peared simultaneously in five members of 
one family. The pruritis and the eruption 
were in covered areas of the body. An in- 
vestigation showed that the mother had 
washed a fiberglass curtain and the family 
underwear in the same washing machine load 
on the day before the outbreak occurred. 


April, 1966 


123 


COMMENTS FROM 

The Staff of the National Association of 
Blue Shield Plans is promoting, with vigor, 
their “PREVAILING FEE PROGRAM” that 
was developed in October of 1964. The “pre- 
vailing fee survey” has been devised to pro- 
vide a list of the costs of services doctors 
offer, individually filed, but collectively re- 
trievable, as a coding and nomenclature for 
all services. This “PREVAILING FEE 
PROGRAIM” is a new look in fee schedules 
and is a distinct departure from Blue Shield’s 
present programs. It is Blue Shield’s an- 
swer to market demands, increasing its 
ability to compete in the insurance market 
for the major producers such as autos, farm 
tools, steel, communications, and others. This 
is not for i\Irs. Jones, widowed, with two de- 
pendent daughters. It assures the purchaser 
of each contract that all medical and surgical 
care, without reference to income, is paid in 
full. Under this concept it is “theoretically 
possible” to pay all physicians in an area 
their usual and customary charges. 

On December 10, 1965, the Executive 
Committee of the Nebraska Blue Shield 
unanimously adopted a resolution urging 
the Policy Committee of the Nebraska State 
INIedical Association to approve the proposal 
of the “Prevailing Fee” concept. At the 
final meeting of the Policy Committee, held 
January 12, 1966, representatives of the Ne- 
braska Blue Shield were present to discuss 
the matter. In view of the immensity and 
the far reaching effects of this concept it was 
felt by the Policy Committee that this mat- 
ter should be brought to the House of Dele- 
gates for their action and decision. 

At the meeting of the House of Delegates 
held in Kearney, February 12th and 13th, 
1966, i\Ir. James Kneble, Director of Re- 
search and Statistics of the N.A.B.S.P. dis- 
cussed and explained the “prevailing fee.” 
Dr. Otis Wolfe of Marshalltown, Iowa, Past- 
President of the Iowa State IMedical Associa- 
tion, was invited to discuss the relative mer- 
its of the “usual and customary fee” concept. 


YOUR PRESIDENT 

As of to date, we are back where we start- 
ed. The House of Delegates adopted the 
Reference Committee’s report that referred 
this matter back to the Policy Committee. 
The Policy Committee was instructed to ask 
the two A.M.A. delegates to join them in the 
study of the prevailing fee and report back 
to the House of Delegates during the May 
1966 meeting. 

At present there are 22 states where inde- 
pendent insurance companies have been ap- 
pointed as a fiscal agent for Part B of Medi- 
care. All of these private carriers will use 
the “usual and customary” fee concept in 
participation in the government program. 
In five states there are independent insur- 
ance companies and Blue Shield combined, 
and in 23 states Blue Shield has been ap- 
pointed as a carrier. At present the number 
of Blue Shield Plans in these states using 
the “customary and usual” fee and the “pre- 
vailing fee” concept cannot be recorded. 
This will be available at a later date.” 

With the increase in business complexity, 
pressure from politicians, practical prob- 
lems of the market, what is the best way of 
offering to consumers the desired combina- 
tion of paid in full benefits, while permit- 
ting the physician his customary charges? 
Will this new concept produce a distortion of 
the fee patterns? There are also questions 
about the inflationary effects, possible ex- 
clusion of 10% of participating physicians, 
the status of nonparticipants, and the method 
of determining an economic geogi'aphic area. 
Along with this, there is no question that 
this country today is faced with the likeli- 
hood of complete, total socialization of medi- 
cine. Decisions on just what is right are 
certainly difficult to make. 

There will continue to be a commanding 
role for Blue Shield as health insurance car- 
rier now and in the future. However, is the 
“Prevailing Fee Program” the best answer? 

— W. D. Wright, M.D., 
President. 


124 


Nebraska S. M. J. 


ARTICLES 


Family Practice Teaching In Scotland 


T here is a growing shortage of 
family physicians throughout 
the United States. This criti- 
cal situation is especially true in Nebraska. 
Over a year ago, Dr. Cecil L. Wittson, Dean 
of the College of Medicine, recognized this 
problem and proposed action to combat it. 
Thirty years ago, 75 per cent of physicians 
entered general practice; now only 18 per 
cent choose this field of medicine. This 
percentage is decreasing two per cent per 
year. The general public forcefully ex- 
presses its desire for family physicians, and 
and quite possibly will demand them from 
the medical schools in the future. 

In response to this public need, the Col- 
lege of Medicine of the University of Ne- 
braska established a chair of general prac- 
tice. I was asked to help with this program 
as Professor of General Practice attached 
to the Dean’s Office. 

We learned that the first Professor of 
General Practice using family practice clin- 
ics for teaching in a medical school was Dr. 
Robert Scott of Edinburgh, Scotland. It 
was decided that I should visit these clinics 
and determine whether or not his experi- 
ence would be of value to us. This was done 
during last September. 

Dr. Scott is a man in his mid-fifties, 
friendly, cooperative, well-trained, and not 
only enthused over this type of teaching, 
but convinced it is a vital part of the train- 
ing of physicians. The learning experience 
in a family practice clinic has a continuing 
and beneficial effect on the entire profes- 
sional service rendered by a physician, re- 
gardless of his field of medicine. 

Dr. Scott is a graduate of the University 
of Edinburgh and specialized in Public 
Health and Preventive Medicine. His intro- 
duction to his present activities began with 
an ecology study in Edinburgh financed by 
the Rockefeller Foundatin. With the advent 
of Nationalized Medicine, and especially be- 
cause of the depletion of Family Physicians 
he acquired a Family Practice Clinic in Edin- 


FAY SMITH, MD 
Professor of General Practice, 
University of Nebraska College of Medicine 
Omaha, Nebraska 


burgh. This was to be a service and teach- 
ing activity of the University of Edinburgh. 
While the Clinic started as a purely charity 
service, all patients who wish to come are 
now accepted. 

The economic level of patients has changed 
very little, however, and all fees are now 
paid by the National Health Service. 

Dr. Scott has two such clinics in operation 
in economically depressed areas in Edin- 
burgh, with five full-time Family Physicians 
assisting him. His first clinic was estab- 
lished in 1946 following pilot studies. In 
addition to the six full-time physicians in the 
Family Practice Teaching Program there are 
eight private Family Physicians in other 
areas of the city. These are paid 150 pounds 
per year to cover some of their expenses, 
and are carefully selected by Dr. Scott. He 
emphasized that they must be competent men 
and have a real desire to work and teach. 

The Family Practice Teaching is carried 
on in the third year. The school year is di- 
vided into three parts and the student is 
required to participate in the program for 
one third of the year. His mornings are 
spent in the hospital, and two to three hours 
are spent in the Family Practice Clinics 
three afternoons each week. The supervis- 
ing physician has only one student at a time 
or three per week. Dr. Scott explained that 
cases are not selected for teaching. The stu- 
dent sees them just as they come. It was 
stressed that even those patients who come 
with “nothing wrong with them” do actually 
come for some reason. The student finds 
that this is a large segment of any practice 
and learns how to deal with them as well 
as with organic illnesses. The student mav 
see 10 to 15 patients a day. He may also 
make calls to the home after the case has 
been seen by the supervising physician. The 


April, 1966 


125 



student writes a report only on those cases 
he sees by himself in the clinic or in the 
home. He follows his patients to the hos- 
pital if they are hospitalized. The Family 
Physician may also follow the patient to the 
hospital but only on a “social basis,” as he 
never works in the hospital. 

Once a week a number of seminars are 
held with all full-time and part-time physi- 
cians participating with the students. They 
are divided into small groups of six to nine, 
and the same subject is discussed by all on 
the same day. The students are also given 
reading assignments. The students have ac- 
cepted the program with enthusiasm. No 
studies have been made to determine how 
many students have been influenced to enter 
Family Practice by this program. 

The six full-time physicians are respon- 
sible for the service available as well as the 
teaching program. They are on call one 
night a week and every fifth week-end. 
Though they are obliged to make night calls, 
they average less than two calls per week. 
They also give prenatal care, although the 
deliveries are by mid-wives in the hospital 
or in the home. Many deliveries are in the 
home. Usually the obstetrician sees the pa- 
tient only if a complication of labor exists. 
There is considerable competition between 
the medical students and the student mid- 
wives for cases, as the student mid-wife must 
have a total of 20 deliveries before she is 
qualified to practice. The Family Physician 
who has given the prenatal care may go to 
the hospital for the delivery only on a “social 
basis,” as he has no hospital beds assigned 
to him. The exceptions to this are in the 
remote areas of the country. 

Payment for the care of the patient in the 
clinics is made by the government, but this 


money goes to the school when care is ren- 
dered by the full-time physicians. 

The clinics are housed in very old stone 
buildings that do not easily adapt themselves 
to modernization. The building now used 
by Dr. Scott for his first clinic was built 
in 1776. This setting demonstrates so well 
that fine teaching can be done regardless 
of adequacy of brick and mortar. 

Much valuable service is rendered in the 
areas of Edinburgh using Dr. Scott’s fa- 
cilities. The average year will bring 5,500 
patients to the clinics for 30,000 calls, re- 
sulting in about five calls per person on their 
list. The visiting nurses make possible good 
follow-up on the patients. 

Dr. Scott feels they have such a success- 
ful service because the patients in that area 
of the city formed the habit of coming 
to him when they were all charity, and be- 
cause of the excellence of care given to the 
patients. Of course, under the National 
Health Plan, there are no “charity” patients. 

In all medical teaching he feels the three 
most important factors are; 

1. The patient as the real teacher. 

2. The physician-student relationship. 

3. The seminars. 

Much social orientation is given to the 
student with emphasis on solving the family 
problems. 

The Family Clinics of the University of 
Edinburg have been in operation 20 years. 
They have proven successful and the stu- 
dents are enthusiastic about them. The clin- 
ics are of value to the student regardless 
of his ultimate goal in medicine and un- 
doubtedly create a greater interest in the 
field of Family Practice. 


The American Medical Association has found that “all di’ugs 
containing the same active ingredients are not identical; drags 
having the same active ingredients and subject to the same standards 
may vary in more than 24 different respects and still be entitled 
to share the same generic name.” 


126 


Nebraska S. M. J. 


Diagnostic Considerations in Management 
of Penetrating Abdominal Wounds 


P ENETRATING abdominal 
wounds are actually an enor- 
mous variety of wounds rang- 
ing, for example, from a mere skin or 
musculo-aponeurotic laceration without peri- 
toneal penetration to innocent appearing 
wounds associated, iceberg-like, with lethal 
visceral injury. Careful evaluation and di- 
agnosis are important since the treatment 
that these injuries demand ranges from a 
skin stitch and a tetanus booster to a 
lengthy, difficult surgical operation. 

Reports of mortality rates for this hetero- 
genous group of patients range from 2.5 to 11 
per cent in various series. 

In civilian series stab wounds are far more 
common than gunshot wounds, accounting 
for 60 to 90 per cent of penetrating abdom- 
inal injuries. Pistol and rifle bullet wounds 
of the abdomen are less common and shot- 
gun wounds are least common. This is for- 
tunate because stab wounds carry the low- 
est mortality and shotgun injuries carry the 
highest mortality, pistol and rifle bullet in- 
juries having an intermediate mortality.^ A 
recent report, for example, details the mor- 
tality rate of abdominal injury with vari- 
ous weapons as follows : pocket knife 
wounds — 0 per cent mortality ; switch blade 
knife wounds — 6 per cent ; butcher knife 
wounds — 13 per cent; pistol bullet wounds 
— 17 per cent; shotgun wounds — 20 per 
cent.^^ In shotgun injuries the range of the 
blast has a great effect on the mortality. 
The point-blank range blasts are exceeding- 
ly lethal but the injuriousness of this weapon 
drops off markedly with a small increase in 
range. The energy of the bullet has an im- 
portant bearing on its injuriousness. The 
energy, in turn, varies directly with the 
mass of the bullet and the square of its velo- 
city. For example, the mass of a .38 caliber 
pistol bullet and an M-1 .30 caliber military 
rifle bullet are approximately equal ; the 
velocity of the latter missile, however, is 
roughly four times that of the .38 caliber 
pistol bullet and its energy thus approxi- 


HANS RATH, MD 

Department of Surgery University of 
Nebraska College of Medicine 
Omaha, Nebraska 

mately sixteen times as great.® The high 
velocity military missiles, therefore, are 
generally far more injurious than the weap- 
ons usually used by civilians. The nature 
of the weapon undoubtedly plays an im- 
portant role in the frequency with which an 
abdominal penetrating wound is actually an 
intra - abdominal visceral wound. In Ko- 
rean War patients with abdominal penetrat- 
ing injuries treated by celiotomy Bonwell 
reported a 91 per cent incidence of visceral 
injury.! In various World War II series 
this figure ranged from 83 to 92 per 
cent.®- In civilian patients, however, 

the frequency with which an abdominal pene- 
trating injury is associated with visceral in- 
j ury is far lower.®- 

In civilian patients treated by routine celi- 
otomy this figure is as low as 59 per cent.!! 
Restated, the incidence of “negative” opera- 
tions in civilian series ranges up to 41 per 
cent. 

In spite of this high incidence of “negative” 
celiotomy in civilian patients with abdom- 
inal stab and gunshot wounds many authors, 
citing the possibility of overlooking visceral 
injury, advise routine operative exploration 
in every one of these patients.®- ®- !®- !!- !®- !® 
MacKenzie and MacBeth, in Christopher’s 
Textbook of Surgery, are quoted as follows: 
“The patient with a penetrating injury to 
the abdomen will almost always require ex- 
ploration. In this regard. Sir Gordon-Tay- 
lor stated ‘A penetrating wound in the ab- 
domen probably means a penetrating wound 
of the bowel or other abdominal viscus and 
demands the earliest surgical intervention, 
unless a wisdom of prescience born of great 
experience justifies restraint.’ The only 
two instances when laparotomy may be de- 
ferred are when a patient is moribund and 


April, 1966 


127 


in the occasional instances in which thor- 
ough and repeated examination of the pa- 
tient reveals no abnormality whatsoever.”* 
Yet Jarvis, reporting on World War II ab- 
dominal wounds, advised laparotomy when 
the contents of the abdominal cavity were 
injured and urged against needless lapar- 
otomy;® and Rob, a British military sur- 
geon, pointed out that some of the “nega- 
tive” laparotomies might have been avoid- 
ed by closer attention to the diagnostic cri- 
teria of intra-abdominal injury.^^ The ques- 
tion, really, is this — can one, on the basis 
of clinical evidence, determine which of these 
patients have intra-abdominal injury and 
need surgical exploration? By way of com- 
parison, patients with blunt abdominal trau- 
ma pose the same question. Of course, only 
those with clinical evidence of injuiy are 
explored, and no one suggests routine explor- 
ation in this group. The studies of Shaftan 
at Kings County Hospital in Brooklyn have 
shown that one can, indeed, on the basis of 
clinical evidence accurately determine which 
of the patients with gunshot and stab wounds 
of the abdomen have intra-abdominal injury 
and need surgical exploration.^®- 

In general the signs of peritoneal irrita- 
tion are the prime indications for operation. 
Regional or generalized abdominal tender- 
ness is the most sensitive sign of peritoneal 
irritation. This is usually easy to distinguish 
from the slight local tenderness of the skin 
wound, although, most emphatically, one 
should explore if in doubt. Guarding, rig- 
idity, and rebound tenderness are signs of 
more severe peritoneal irritation. Loss of 
bowel sounds is another excellent indication 
of intra-abdominal injury. Vaso-constric- 
tive shock and evisceration are obvious indi- 
cations for operation. A peritoneal tap is 
very useful in these patients, and the return 
of blood or gastro-intestinal tract contents 
demands an operation. Paracentesis should 
be done if the other signs are negative, since, 
rarely, a bloody tap may precede the onset 
of abdominal tenderness. The presence of 
gastro-intestinal bleeding — hemetemesis 
or bleeding from the rectum — and blood in 
the urine denote injuiy and demand explor- 
ation. Probing the abdominal wound is not 
reliable in diagnosing either peritoneal pene- 
tration or visceral injur y. Laboratory 


studies are helpful if they are abnormal. 
However, laboratory studies are abnormal 
in less than half of patients i\dth intra-ab- 
dominal injury and the X rays are even less 
accurate. Laboratory studies and X rays 
of the chest and abdomen should, of course, 
be routinely done. Rarely, free air may be 
seen on X-ray examination. In gunshot in- 
juries, antero-posterior and lateral X rays 
of the abdomen may locate the bullet. This, 
plus the wound of entry, gives a hint of its 
course and the organs possibly injured. The 
chest X ray is quite valuable by showing 
presence or absence of associated intra- 
thoracic injury. With visceral injury these 
signs are present on admission almost in- 
variably; rarely they appear in a number 
of hours.®- 1® The patient judged not to have 
intra-abdominal injury must, therefore, re- 
main under close observation, a small price 
to pay in avoiding a needless operation. 

In 1955, Spreng reviewed 133 patients with 
stab and gunshot wounds of the abdomen 
seen at Kings County Hospital in Brooklyn. 
He noted that 33 patients were not explored 
and 100 patients were explored. Of those 
who were explored 83 had intra-abdominal 
injury and the remaining 17 had no peri- 
toneal penetration or no intra-abdominal in- 
jury. One of these 17 patients died of sur- 
gical complications. Spreng concluded that 
“more precise diagnosis would have averted 
laparotomy’” in this last group. 

In 1960 Shaftan reported on 112 patients 
with abdominal stab and gunshot wounds 
seen at Kings County Hospital who were 
managed by selectively exploring only those 
patients who had clinical evidence of intra- 
abdominal injury.^® Exploration was neces- 
sary in only one third of those patients. The 
mortality in the remaining two thirds, who 
were judged not to have intra-abdominal 
injury and who were not explored, was zero, 
proving that one can diagnose the absence of 
intra-abdominal injury correctly. Subse- 
quently Mason reported on two groups of 
patients, the first, and earlier group, being 
treated by routine exploration and a second 
group treated by selective operation.® He 
agreed that selection for operation could be 
made accurately and with no deaths in those 
who were judged not to have intra-abdominal 


128 


Nebraska S. M. J. 


injury and who were not explored. More re- 
cently Shaftan and his associates have re- 
viewed 535 patients managed by operation 
on only those patients who presented signs 
of abdominal injury. They have again con- 
cluded that one can very reliably determine 
whether a patient with an abdominal stab or 
gunshot wound has intra-abdominal injury 
and thus requires exploratory operation. 
There were no signs or evidence of intra- 
abdominal injury in 383 patients, 71 per cent, 
and none of these patients were explored. 
None of these died. One patient with stab 
wounds of the chest and abdomen presented 
evidence of intra-abdominal injury — pro- 
truding omentum, blood on paracentesis, and 
a falling hemoglobin — but was not ex- 
plored and died. Autopsy showed a hemo- 
peritoneum, hemothorax, and a lacerated 
spleen. He clearly does not represent a fail- 
ure in diagnosing intra-abdominal injury 
but a failure to proceed with an obviously 
indicated operation. One mortally injured 
patient had no vital signs on admission and 
could not be resuscitated for operation. 
Most of the remaining 150 operative pa- 
tients had signs of injury. Ten patients 
had no signs of injury and were explored 
without regard to the previously mentioned 
criteria. None of these ten patients had 
intra-abdominal injury. A positive peri- 
toneal tap was obtained in 25 patients. In 
9 of these patients this was the sole cri- 
terion for operation, but most of these de- 
veloped peritoneal signs in the interval be- 
tween initial examination and operation. 
The presence of free air was seen on X ray 
of the abdomen in only three instances. 
This was the only sign of injury in one pa- 
tient. However, in the interval between 
initial examination and operation he also 
developed signs of peritoneal irritation. The 
presence of herniated omentum was an indi- 
cation for operation. There were 25 patients 
with herniated omentum. Six of these had 
signs of peritoneal irritation and all of these 


had intra-abdominal injury on exploration. 
Eleven of these 25 patients were explored 
with omental herniation as the only sign; 
none of these 11 had an intra-abdominal in- 
jury. The eight remaining patients with 
omental protrusion also had no signs of peri- 
toneal irritation; these eight had no opera- 
tion except ligation and excision of the pro- 
truding omentum. They all did well. A 
total of 11 patients in the operative group 
died: seven of the 115 stab wound patients, 
6 per cent ; and four of the 33 gunshot wound 
patients, 12 per cent. The overall mortality 
was 2.4 per cent in the entire group of 535 
patients.' 

In the last four years, 49 patients with 
abdominal stab and gunshot wounds came 
to Douglas County Hospital for treatment. 
They were treated by the resident and at- 
tending staffs of the University of Nebras- 
ka College of Medicine and Creighton Uni- 
versity College of Medicine as well as by 
private physicians in the community. Most 
of the surgeons treating these patients man- 
aged them according to the principle above 
— namely exploring only those who appeared 
on examination to have visceral injury. Sev- 
enteen of these patients were judged not to 
have intra-abdominal injury and were not 
explored. All did well. These patients, of 
course, usually remained in the hospital un- 
der close observation for one or two days. 
There were 32 patients who were explored. 
Four of these patients had either no pene- 
tration of the peritoneum or no intra-ab- 
dominal injury. Three of these four patients 
had abdominal tenderness and, of course, re- 
quired surgical exploration. The other pa- 
tient, who had peritoneal penetration but no 
intra -abdominal injury, was explored as a 
routine. There were four patients in the 
operative group with evisceration. The re- 
maining operative patients had a wide va- 
riety of intra-abdominal injury. All patients 
who had intra-abdominal injury presented 
signs of this before operation. Table 1 cor- 


Table 1 

CORRELATION OF DEATHS FROM WEAPONS WITH 
OPERATION AND NO OPERATION 


Exploratory No 

Weapon Total Operation Died Operation Died 

Knives 33 23 2 10 0 

Pistols and Rifles 10 5 3 5 0 

Shotguns 6 4 3 2 0 

Total 49 32 8* 17 0 


♦ — 16 per cent 


April, 1966 


129 


relates the performance of exploratoiy op- 
eration, mortality, and the assaulting weap- 
on. Table 2 correlates the type and extent 

Table 2 

COERELATION OF TYPE AND EXTENT 
OF INJURY, MORTALITY AND 


WEAPON 

Pistols and Shot- 

Surgrical Findings and Injuries Knives Rifles gun 

No penetration of peritoneum _ 1 

Penetration only 3 _ _ 

Penetration and evisceration, 

no perforation of viscera 4 _ _ 

Liver 4 _ _ 

Mesenteiy 2 _ _ 

Colon 2 _ _ 

Gallbladder 1 _ _ 

Stomach 1 _ _ 

Small bowel 1 1 _ 

Liver and bladder 1 _ _ 

Liver and pancreas _ 1* 

Spleen and diaphragm 1 _ _ 

Spleen, diaphragm and left lung 1 _ _ 

Spleen, diaphragm and 

both lungs 1* _ _ 

Small bowel and bladder _ 1 _ 

Small bowel and retro- 
peritoneal vessels 1* _ _ 

Liver, portal triad, vena cava 1* 

Liver, stomach, pancreas _ 1* _ 

Liver, Vena cava, kidney _ _ 1* 

Colon, small bowel, stomach, 
ureter, pancreas, retroperi- 
toneal vessels _ _ 1* 

Small bowel, pancreas, liver, 
kidney, retroperitoneal 

vessels _ • _ 1* 

* — died 


of injury, mortality, and the asaulting weap- 
on. It is noted that there were no deaths 
when only a single organ was injured. 
Three of the eight deaths resulted from mas- 
sive injury caused by short range shotgun 
blasts. One patient died of associated 
thoracic trauma. The remaining deaths re- 
sulted from multiple organ injuries in the 
upper abdomen which included injuiy to the 
liver, pancreas, or vena cava. The marked 
increase in mortality with multiple organ 
injury is well known. The relatively high 
mortality in this small series is related to 
the high incidence of massive abdominal in- 
jury in this group. 

Summary 

1. Mortality of penetrating abdominal 
injuries is related to the extent of the 
intra-abdominal injury, and in series 
of patients this is related to the 
weapon used in the assault. 

2. Should every patient with an abdom- 
inal penetrating wound be routinely 


explored surgically? Large numbers 
of these patients either have no pene- 
tration of the peritoneal cavity or no 
visceral injury, and such a policy re- 
results in much needless surgery. Pa- 
tients with intra-abdominal visceral 
injuiy invariably will have clinical 
evidence thereof, either on admission 
or shortly thereafter, making the di- 
agnosis of intra-abdominal injury pos- 
sible and guiding the accurate selec- 
tion of patients for operation. 

3. In the last four years 49 such patients 
came to Douglas County Hospital. 
Seventeen were judged not to have 
intra-abdominal injury and were not 
explored. All did well. The remain- 
ing 32 patients were operated upon. 
Those in whom intra-abdominal injury 
was found invariably showed clinical 
signs of intra-abdominal injuiy before 
operation. 

References 

1. Bronwell, A. W.; Artz, C. P., and Sako, Y.: 
Abdominal and thoraco-abdominal wounds in Re- 
cent Advances in Medicine and Surgery, 19-30 
April 1954; Based on Pi’ofessional Medical Experi- 
ences in Japan and Korea 1950-1953, Washington, 
D.C., U.S. Ai-my Medical Seiwice Graduate School, 
Medical Science Publication No. 4, 1954, Vol. 1, 
pp 419-431. 

2. Bowers, W. F. : Priority of treatment in multi- 
ple injuries and summation of surgery for acute 
trauma. AMA Arch Surg 75:743-745 (Nov) 1957. 

3. Dziemian, A. J.; Mendelson, J. A., and Lind- 
sey, D.; Comparison of the wounding character- 
istics of some commonly encountered bullets. J. 
Trauma 1:341-353 (July) 1961. 

4. Fitzgerald, J. B., et al.: Surgical experience 
with 103 truncal shotgun wounds. J Trauma 5:72- 
84 (Jan) 1965. 

5. Goldman, L. I.: De Laurentis, D. A., and 

Rosemond, G. P.: Penetrating abdominal wounds 

in a civilian population. Amer J Surg 104:46-51 
(July) 1962. 

6. Jaiwis, F. J.; Byers, W. L., and Platt, E. V.: 
Experience in the management of the abdominal 
wounds of warfare. Surg Gynec Obstet 82:174- 
193 (Feb) 1946. 

7. Klickstein, G. D.; Edmunds, R. T., and Allen, 
P. D. : Immediate laparotomy in penetrating wounds 
of the abdomen. New York J Med 62:3923-3926 
(15 Dec) 1962. 

8. MacKenzie, W. C., and MacBeth, R. A.: The 
abdominal wall and peritoneum, in Christopher F.: 
Textbook of Surgery, ed 8, Philadelphia, W. B. 
Saunders Co., 1964, chap 15, p 513. 

9. Mason, J. H.: The expectant management 

of abdominal stab wounds. J Trauma 4:210-218 
(Mar) 1964. 

10. McComb, A. R., et al.: Penetrating wounds 
of the abdomen. Amer Surg 24:123-131 (Feb) 
1958. 

11. Moss, L. K.; Schmidt, F. E., and Creech, 


130 


Nebraska S. M. J. 


O., Jr.: Analysis of 550 stab wounds of the ab- 
domen. Amer Surg 28:483-489 (July) 1962. 

12. Pearson, R. W.; Tuhy, J. E., and Welch, C. S.: 
Abdominal surgery in the evacuation hospital. 
Surg 21:1-23 (Jan) 1947. 

13. Peiry, J. F., Jr.: A five-year survey of 

152 acute abdominal injuries. J Trauma 5:53-61 
(Jan) 1965. 

14. Rob, C. G.: The diagnosis of abdominal 

trauma in warfare. Surg Gynec Obstet 85:147-154 
(July) 1947. 

15. Shaftan, G. W.: Indications for operation in 


abdominal trauma. Amer J Surg 99:657-664 (May) 
1960. 

16. Shaftan, G. W., and Ryzoff, R. : To be pub- 

lished. 

17. Sherman, R. T., and Parrish, R. A.: Man- 

agement of shotgun injuries. A review of 152 
cases. J Trauma 3:76-87 (Jan) 1963. 

18. Spreng, D. S.: Unpublished data, 1955. 

19. Wilson H., and Sherman, R.: Civilian penetrat- 
ing wounds of the abdomen. I. Factors in mor- 
tality and differences from military wounds in 494 
cases. Ann Surg 153:639-649 (May) 1961. 


MALIGNED AND MISUNDERSTOOD 
In a publication issued recently. Empire Trust Company, New 
York, points out that lack of understanding of the pharmaceutical 
industry’s contributions to the national welfare and prevailing anti- 
pathetic attitudes in legislative circles jeopardize both the public 
interest and the pharmaceutical industry’s future. 

As the bank’s Newsletter says, “The U. S. pharmaceutical 
industry has become the subject of attack and rebuttal, claim and 
counter-claim, to an extent perhaps unparalleled in the recent 
history of any other American industi-y. As a result, the industry’s 
magnificent achievements, its monumental role in the prevention, 
cure and alleviation of disease, have become obscured in the public 
mind.” 


April, 1966 


131 


The Management of Gunshot Wounds 
of the Extremities* 


Introduction 

T he proper management of gun- 
shot wounds of the extremities 
requires some working knowl- 
edge of wound ballistics, as well as an 
understanding of the basic principles of 
wound surgery. IMost of the knowledge in 
this field has been gained from military 
experience, inasmuch as approximately 75 
to 80 per cent of the suiwiving wounded in 
a Korean conflict suffered extremity wounds. 
During the increasingly short periods be- 
tween these so-called armed conflicts, missile 
wounds of the extremities are seen on occa- 
sion by all physicians and surgeons who 
deal with trauma. 

Ballistic Principles 

A primary missile is an object such as a 
bullet or a shell fragment, while a secondaiy 
missile is any object set in motion by energj- 
transmitted from the primary missile. All 
shotgun missiles produce devastating wounds 
at close range, but the wounds are dissimilar 
beyond twenty yards. The bullet from a 
rifle, chambering .22 long-rifles, may pass 
through an extremity producing little dam- 
age beyond the bullet tract, while a bullet 
from a .22 high-power rifle causes consid- 
erable injury at a distance from its path- 
way. This is due to the explosive force, 
producing cavitation. There is naturally a 
tremendous variance in the character of gun- 
shot wounds produced by the variety of 
sporting arms and loads available in the 
United States today. A missile may produce 
penetrating, perforating, contused, or avuls- 
ing wounds. The effect produced by a mis- 
sile striking tissue depends upon its size, 
weight, composition, configuration, and 
velocity, as well as the character of the tis- 
sue which it strikes. 

A bullet is not a bodj’ moving straight 
ahead without other motion, but spins, 
twists, yaws, and often tumbles after strik- 
ing strong resistance, such as bone. As the 


CARLYLE E. WILSON, MD 
Omaha, Nebraska 


bullet passes through tissue, it imparts mo- 
tion to the particles in its track, causing 
them to suddenly move at right angles from 
the bullet tract, and to impart momentum 
to other particles in their path. The total 
of these motions produces the so-called ex- 
plosive effect. A low-velocity bullet, re- 
gardless of size, may well pass through an 
extremity and produce little damage other 
than that which would occur by passing a 
blunt probe through the limb. On the other 
hand, a .300 magnum sporting rifle with a 
soft-nosed bullet may cause widespread 
damage several inches beyond the actual 
line of passage, and can easily produce a 
comminuted shaft fracture without actually 
touching bone. Perforating missiles, either 
bullet or shell fragments, tend to produce 
small wounds of entrance and large wounds 
of exits. This characteristic is largely due 
to the effect of secondary missiles and cavi- 
tation. Rarely, a bullet fired at point-blank 
range with a very high initial velocity may 
produce a large “blasted out” wound of en- 
trance, and a relatively small exit wound. 
The surgeon cannot in every instance deter- 
mine the degree of tissue injury by inspect- 
ing the skin wounds. 

The .22 caliber bullet, at short range, is 
apt to pass cleanly through an extremity 
in a perforating fashion. A penetrating 
wound may be produced when the bullet 
strikes bone. The low velocity eliminates 
cavitation, and consequently, tissue necrosis 
at a distance from the missile tract is not 
gi’eat. Target pistols and revolvers of small 
caliber are more prone to produce a pene- 
trating wound, since their muzzle velocity 
is less than that of a .22 rifle, for example. 
A .38 caliber bullet, employed primarily by 

’Presented April 26. 1965 at Trauma Day Program. Univer- 
sity of Nebraska College of Medicine, Omaha. Nebraska. 


132 


Nebraska S. M. J. 


police officers, has an effect on an extrem- 
ity similar to that of a .22 rifle at close 
range, in that there is no cavitation. The 
total damage is considerably greater, due to 
the increased energy. The wound of exit is 
quite likely to be larger than that of entrance, 
and this is especially true if secondary mis- 
siles of fragmented bone are present. The 
.45 automatic has a wounding effect similar 
to that of the .38. The low velocity elim- 
inates the explosive effect of cavitation. 
Perforation is usual. The “30-06” sporting 
rifle is a most popular big game hunting 
rifle. It has a high muzzle velocity and the 
bullet is jacketed with an open point de- 
signed to mushroom or erupt the jacket, 
thereby increasing its lethal power. The 
high velocity of this bullet produces the 
characteristic explosive effect with produc- 
tion of secondary missiles. Tissue damage 
is extensive. Severe comminution can occur 
even if the bullet does not actually strike 
the bone. In ranges up to 500 yards, the 
wound is perforating, with the wound of exit 
usually much larger than the wound of en- 
trance. Shotguns at close range, regard- 
less of the gauge or size of the shot, pro- 
duce devasating and mutilating wounds. At 
a few feet, a 12-gauge shotgun will produce 
a cylindrical defect measuring about one 
inch in diameter, completely through an 
extremity. All tissues are destroyed in the 
path. At this distance, clothing and shot- 
gun wadding may be blown entirely through 
the extremity or may be retained deeply im- 
bedded. As the range increases up to a 
few yards, the wounding effect continues to 
be mutilating, with a proportionately great- 
er number of retained shot and a less clear 
cut blasting out of a cylindrical pathway. 
Beyond twenty yards, few, if any shots per- 
forate an extremity. Beyond forty yards, 
the shot pattern is widely dispersed and 
there is only superficial wounding by each 
pellet. 

First Aid Management 

Surgical management of gunshot wounds 
of the extremities ideally is begun at the 
site and time of wounding. In civilian and 
military environments the effectiveness of 
this care depends upon the availability of 
trained personnel, first-aid equipment, and 


transportation facilities. These wounds on 
the battlefield are often more favorably situ- 
ated to receive adequate care than those in 
the civilian status. 

First-aid for extremity wounds should be 
kept simple : application of a sterile dress- 
ing, control of bleeding, splinting, adminis- 
tration of morphine for relief of pain, and 
if necessary administration of a plasma 
volume expander, whole blood, or electro- 
lyte solution. Initiation of antibiotic ther- 
apy and injection of tetanus toxoid may be 
considered first-aid measures under certain 
circumstances. After the dressing is in 
place, it should not be removed, unless 
alarming bleeding or displacement occurs, 
until the patient has reached a point or hos- 
pital where definitive surgery can be start- 
ed. Only in rare instances should a tourni- 
quet be applied. A tourniquet may be left 
in situ until blood volume can be restored 
to a safe level. The practice of releasing a 
tourniquet at regular intervals is no longer 
advised. This change in practice is based 
on the assumption that the patient has al- 
ready lost a considerable volume of blood, and 
the loss of a few ounces more may be fatal. 
Certainly a tourniquet on a patient in shock 
or impending shock should not be released. 
It has been estimated that it is safe to 
allow a tourniquet to remain in place from 
three to six hours, varying somewhat with 
environmental factors, the safe period being 
extended during cool or cold weather and 
shortened in warmer weather. With im- 
proved air and ground emergency transpor- 
tation facilities in Nebraska, such cases can 
now be evacuated to the proper hospital 
within this time limit. 

The value of splinting has been well estab- 
lished. Traction is seldom indicated dur- 
ing the initial phase. Complicated surgical 
procedures must not be undertaken if shock 
is not controlled. Prior to anesthesia, and 
upon admission to the hospital for definitive 
surgery, the surgeon may quickly examine 
the wound, to determine possible vascular, 
nerve, tendon, bone, and skin injury. This 
can be assessed quite rapidly and the 
dressing replaced without touching anything. 
Depending upon the particular wound and 


April, 1966 


133 


area involved, the surgeon maj’ enlist the 
cooperation of the patient in movement of 
fingers and toes, to help him further plan 
his procedure, before beginning the anes- 
thesia. 

In some instances, the indicated procedure 
will be obvious. The wound may be mutilat- 
ing to such an extent that amputation is the 
only procedure possible. On the other hand, 
there may be an isolated traversing wound 
of the extremity calling unquestionably for 
debridement. In many instances the deci- 
sion will not be easy. At this time, consid- 
eration must be given to the time required 
and the possibility of producing an irre- 
versible state of shock. Again the sur- 
geon’s judgment will be gi’eatly taxed, where 
there are multiple small wounds, which may 
indicate potential serious internal damage. 
Experience alone will finally teach him to 
recognize the severity of individual wounds ; 
such a wound as seen in the shotgun wound 
of the range of 20 yards or more. Attempted 
debridement of these small wounds will be 
fruitless. , All high velocity bullet wounds 
should be debrided. Debridement should be 
carried out under general anesthesia if the 
patient has not eaten or drunk recently, and 
in some instances upper extremity wounds 
may be easih’ managed under brachial or 
axillary block, and in some instances spinal 
anesthesia may be used in wounds of the 
lower extremities. Some feel that spinal 
anesthesia is not advisable. I believe this 
depends upon the experience of the physician 
administering an anesthetic. 

The wounded extremity should be cleaned 
and when necessary shaved over a wide 
area. A detergent with hexachlorophene 
should be used for skin preparation. In ex- 
tensive wounds, especially those involving 
bone, shaving and cleansing of the skin 
should be performed after administration of 
the anesthetic. In many instances it should 
also follow the application of a pneumatic 
tourniquet. Extremity wounds most fre- 
quently involve all of the component tissues 
of the extremity. Initial management of 
these wounds must envision the final func- 
tioning result, as well as the immediate re- 
quirement of saving the life and the limb. 


General Principles of Initial Surgery 

1. Adequately incise in the long axis of 
the extremity. The natural skin line 
should be followed, especially in the 
hand and foot. 

2. Conserve as much skin as possible. 

3. Excise all devitalized tissue. 

4. Remove readily accessible foreign 
bodies. 

5. Remove dirty and detached segments 
of bone. Spare clean bone fragments 
^^'ith apparent existing bony supply. 

6. Establish dependent drainage by coun- 
ter-incisions when dead space indicates 
the need for drainage. 

7. Irrigate wounds with copious amounts 
of sterile saline throughout the oper- 
ative procedure. 

8. Handle tissues gently and use fine 
absorbable surgical catgut for sutures 
and ligature. 

9. Wounds are left open with the excep- 
tion of those of the hands and sjm- 
ovial membranes of the joints. In 
hands, skin wounds are closed loosely, 
and the sjTiovial membrane is su- 
tured after a careful debridement of 
the joints. 

10. Dress the wounds with fine mesh 
gauze, pack lightly, and avoid con- 
stricting bandages. 

11. Immobilize the extremity, preferably 
with plaster. If circular, bivalve 
plaster immediately after application. 

12. Keep the patient for observation until 
his condition is stabilized with assur- 
ance of continuation of the circulatory 
stability. 

Early Management of Specific Tissues 

Eveiy effort is made not to excise noi-mal 
skin, as the efficacy of delayed primary 
skin closure depends upon having sufficient 
skin to permit approximation of edges with- 
out tension. Otherwise, skin tabs from con- 
tiguous or distal sides will have to be em- 
ployed. All devitalized or contaminated 


134 


Nebraska S. M. J. 


adipose and fascial tissue must be removed. 
Strong encircling fascial bands, such as 
fascia lata in the thigh, should be widely 
opened to prevent constriction and later 
contracture. Muscle must always be split 
in the direction of its fibers. As a general 
working principle, all muscle which con- 
tracts on pinching with a hemostat is prob- 
ably alive. If the muscle bleeds freely when 
cut, it is probably viable. Lacerated and 
dirty muscle should be sacrificed, even 
though bleeding is present. All other muscle 
tissue which does not fulfil these criteria, 
and obviously appears devitalized and use- 
less, should be excised. 

Excision of bone fragments should not be 
too liberal. Only dirty and obviously de- 
tached and nonviable bone should be removed. 
Stabilization can be effected usually at the 
time of secondary closure. However, on oc- 
casion, intramedullary fixation at the time 
of delayed primary closure rather than sec- 
ondary closure, is indicated. 

The management of blood vessel injuries 
is most important for salvage of a limb. A 
trained vascular surgeon is the consultant 
of choice. The disruption of the peripheral 
nerves from gunshot wounds of the extrem- 
ities rarely, if ever, presents a primary re- 
pair potential. If the wound is relatively 
clean and the defect short and surrounding 
well vascularized tissue, primary repair can 
be considered. Otherwise it is best to de- 
lay nerve repair for several weeks. The 
time interval again depends upon the par- 
ticular situation. 

Following debridement, the simple anchor- 
ing of the cut nerves to adjacent uninvolved 
fascia is often helpful, in order to prevent 
retraction. Where there are exposed nerve 
ends, great care must be taken to cover 
these with healthy tissue. Damaged ten- 
dons, like damaged nerves, do not survive 
if left exposed in the depths of open wounds. 
Tendons injured by missiles should there- 
fore have their frayed, torn, and apparent- 
ly devitalized ends excised. No attempt 
should be made to repair tendons at the time 
of the initial surgery. Cut ends should be 
buried beneath viable soft tissues whereever 


possible. When extensive damage to ten- 
dons has occurred, the primary aim is to 
convert the wound into a clean, dry wound 
with a minimum of scar tissue, followed by 
delayed closure, usually by pedicle graft, 
and later transplantation of suitable tendon 
grafts into a good bed. 

Hand Wounds 

The hand is the most important functional 
part of the upper extremity and obviously 
much more important than the foot, and 
therefore is worthy of some special consid- 
eration.- Probably the most common gun- 
shot injury of the hand is the shotgun blast 
seen in duck hunters, particularly where the 
hand has been resting over the muzzle of 
the gun. The point of entrance is small com- 
pared with the point of exit. The charge 
fans out, spreading soft tissue, fragmenting 
bones, and dividing arteries. In the typical 
case, the wound is debrided thoroughly under 
brachial or axillary block and dressed. There 
is danger of tetanus infection from the 
horse-hair wadding often shot into the 
wound. After quickly evaluating the wound 
of the hand by the position of fingers and 
gentle manipulation, X rays are taken. A 
touimiquet is then placed about the upper 
arm and the three cardinal C’s begun — 
clean, cover, correctly position. Thoroughly 
clean, irrigate, and then a discriminatory 
and orderly debridement is carried out. Nev- 
er debride nerves. Leave all major tendons 
that are not devitalized. One may sacrifice 
the palmaris longus and the extensor of the 
index and little fingers, and probably wrist 
flexors and sublimis tendons. The distal 
end of the ulna may be sacrificed. Save all 
viable skin. Except for skin coverage, little 
repair is attempted at this time. Kirschner 
wires are used to restore bony architecture. 
Repair nerves only if they can be covered by 
well vascularized tissue. Use local rota- 
tion flap for small areas, an abdominal flap 
for large area, for if not adequately cov- 
ered with skin and subcutaneous tissues, 
hand function may never be restored. 
Wounds of the upper arms and legs do not 
require this immediate coverage and may 
do better with delayed coverage. Dress 
hand in position of function, leave finger 


April, 1966 


135 


tips exposed, splint with plaster, remove 
dressings daily, and inspect. 

Summary 

The proper management of gunshot 
wounds is based upon three principles: 

1. The basic knowledge of ballistics. 

2. Judicious first aid treatment. 


3. Adequate definitive surgery includ- 
ing secondary closures and orderly re- 
constructive surgery. 


Bibliography 

1. Carr, Capt. Chalmers R., MC, USN and Steven- 
son, Comm. Clifford A., MC, USN, Bethesda, Md. : 
The treatment of missile wounds of the extrem- 
ities. Am Acad Ortho Surgeons Instr Lectures, Vol. 
XI, 1954, 189-209. 


CURTIS SEES MEDICARE GROWTH TO ULTIMATE 
“SOCIALIZED” STAGE 

“The basic issue in the administration’s medicare proposal is 
whether everyone’s social security tax should be increased to pay 
hospital bills for those who are able to pay for themselves,” Sen. 
Carl Curtis told the Fremont Rotary Club. 

He predicted that if the bill is enacted it “ultimately would be 
expanded to include all medical and hospital care for everyone.” 
(The Norfolk Daily News, Jan. 23, 1965). 


136 


Nebraska S. M. J. 


A Report of Three Cases of 
Acute Lymphocytic Leukemia in 
Children in a Small Nebraska Community^ 


T he epidemiology of any disease 
and the etiologic agent or 
agents involved are intrinsical- 
ly related. The study of any disease or 
physical condition requires that the area 
in which the study is made be considered 
as well as the etiological agents. An epidemi- 
ological study should be correlative in na- 
ture. It should be of aid both to the re- 
searcher and the clinician. In this brief 
report of three cases of acute lymphocytic 
leukemia we will include a few of the essen- 
tials of an epidemiological study and ask 
some unanswered questions. 

The etiology of that group of diseases 
known as the leukemias is obscure to say 
the least. There are multiple theories as 
to the etiology of these dread diseases, and 
there is great diversity in the emphasis put 
on various factors which are believed to be 
causative or at least contributory. The 
theories range from that of viral causation^ 
and genetically predispositioned growth dis- 
turbances of the blood elements, 2- ^ to the 
theories of irradiation injury in utero'* and 
chemical and drug causation.® In view of 
the many theories, it is probable that mul- 
tible causes exist for this group of diseases. 

In this report we are particularly inter- 
ested in the incidence of acute lymphocytic 
leukemia in pre-school children in a small 
rural area in south central Nebraska. In the 
past eighteen months there have been three 
cases of this disease discovered in the re- 
gion. The three patients have all been sub- 
sequently cared for by a pediatrician and 
hematologist in a nearby city. Our informa- 
tion was derived from the physicians in- 
volved, hospital records, and interviews of 
some of the parents. 

The fact that three cases of acute lympho- 
cytic leukemia were discovered in a rather 


V. FRANKLIN COLON, MD 
Friend, Nebraska 


small rural area and within a rather short 
span of time is reminiscent of the “outbreak” 
of leukemia reported from the Niles area 
of Illinois and other similar “outbreaks” 
among families and closely associated groups. 
These reports have led to speculation as to 
a common factor involved in each of these 
cases. No definite factor has thus far, to 
our knowledge, been implicated. 

Our first case is that of a 21-month-old 
boy who was seen by a local physician for 
a cold on 11-9-62. The child developed a 
severe nosebleed on 11-16-62 and was re- 
ferred to a pediatrician because the local 
physician thought that the child may have 
possibly had a foreign body in his nose. 
Physical examination did not support that 
supposition. The mother stated that the 
child bruised quite easily and that he picked 
his nose frequently. Other history, in gen- 
eral, was non-contributory, but the age of 
the parents should be noted; his father was 
52 years old and his mother was 39. 

Physical examination revealed a well- 
developed, well nourished, white male who 
was irritable and bleeding from the right 
nostril. He had petechiae over his lower 
extremities and numerous ecchymoses over 
his body. He had some hemorrhages on his 
conjunctiva and upper right lid. Other 
physical findings were compatible with an 
upper respiratory infection. A diagnosis 
of upper respiratory infection and epistaxis 
was made, and it was suggested that leu- 
kemia be ruled out. For this reason a local 
hematologist was called into the case and 

‘Supported by a grant from the Blood Disease Research and 
Education Foundation, Lincoln, Nebraska. 


April. 1966 


137 


was able to palpate the liver and spleen. At 
that time he tentatively made the diagnosis 
of acute lymphocji;ic leukemia. 

On 11-18-62, blood studies revealed that 
the child had 4.5 grams of hemoglobin per 
100 ml, with 1,910,000 red cells and 16,000 
white cells per cubic mm, with a differen- 
tial of 91% lymphocytes, 3% segmented 
granulocytes, 3% staphs, 1% metamyelo- 
cytes and 2% monocytes. At this time there 
were 97,000 platelets per cubic mm. A bone 
marrow study showed a marked degree of 
lymphocytosis with immaturity and rever- 
sion to young lymph forms, which was com- 
patible with acute lymphocjdic leukemia. 

The child was then treated with blood 
transfusions, antibiotics. Prednisone and 
Methotrexate. He did fairly well until 7-20- 
63 when he was readmitted to the hospital 
with bronchopneumonia, for which he was 
treated and released. On 9-9-63 he was re- 
admitted for a transfusion. At that time 
it was noted that the patient was moon-faced 
and pale. On 10-20-63 he was readmitted 
for further transfusions, as he was again 
on 11-7-63 and 3-2-64. His last admission 
was on 3-11-64. He had a marked downhill 
course with bleeding from almost all orifices, 
and heart failure. He died on 3-25-64, just 
sixteen months after the original diagnosis 
was made. This child had a febrile course 
throughout the disease until his death. 

Our second case was that of a 3-year-old 
white male who was seen by the local physi- 
cian for an upper respiratory infection a 
few days prior to his admission to the hos- 
pital on 12-6-62. The local physician had 
found the child to be quite anemic and re- 
ferred him to a pediatrician. Again we 
note the parents’ ages. The father was 45 
years old and the mother, 40. 

The child had been asymptomatic other 
than refusing to walk long distances for a 
few weeks prior to his admission. On physi- 
cal examination the child was found to be 
pale. No bruising or petechiae were noted. 
He did have some shotty posterior and an- 
terior cervical nodes, and a grade H/VI 
blowing systolic murmur. His liver was not 
palpaole, but his spleen was about 8 cm 
b^i‘»w the left costal margin. It was firm. 


but not tender. He had many shotty in- 
guinal nodes. At that time a tentative diag- 
nosis of lymphocytic leukemia was made. 
The initial blood smear showed that the 
child had 3.2 grams of hemoglobin per 100 
ml, 1,270,000 red cells and 4,300 white cells 
per cubic mm. He had 83% lymphocytes, 
15% segmented granulocjTes, 2% monocytes 
with some poikilocytosis and anisocytosis 
and some polychromasia. There were 30,000 
platelets per cubic mm at that time. A spe- 
cial hematologj' report noted that the blood 
showed lymphocytosis with suggestion of 
immature forms. Bone - marrow study 
showed replacement by leukemic cells con- 
sistent with lymphoblastic leukemia. An 
X-ray report indicated that the child had 
findings compatible with mild peribronchitis. 
The child was exposed to chicken pox a few 
days prior to his admission, so steroids were 
withheld, and he was given gamma globulin 
in hope of preventing the disease. Treat- 
ment with blood transfusions and Methotrex- 
ate were begun. 

The child was readmitted on 1-4-63 for a 
transfusion and to start on steroid therapy. 
Physical examination was essentially the 
same as on the previous admission. He was 
readmitted on 9-10-63 once again for trans- 
fusions alone. At that time it was reported 
that he was moon-faced, and it was noted 
that he had petechiae over his legs and was 
slightly icteric. His spleen was firm and 
down to the iliac crest, but no other masses 
were noted. He was admitted for the last 
time on 9-27-63. He seemed to have failed 
on his medication since the prior admission 
and was quite “Cushingoid” and lethargic. 
He had ecchymotic areas on his legs, arms, 
and back. His liver was down 2 cm, and 
his spleen was down to his iliac crest. 

The terminal event seemed to be congestive 
heart failure, and he died on 10-11-63, ten 
months after his disease was diagnosed. It 
is interesting to observe that this child, in 
general, had an afebrile course with only a 
few episodes of fever right up to the time 
of the last two admissions, which were just 
slightly over two weeks apart. 

The third case was that of a 3-year-old boy 
originally seen by the local doctor in Janu- 


138 


Nebraska S. M. J. 


ary, 1963 for an upper respiratory infec- 
tion. At that time his hemoglobin was 12 
grams per 100 ml, and he was placed on 
hematinic therapy. He was much better 
when seen in April, 1963. He was well un- 
til Thanksgiving when his mother observed 
that the child had episodes of transient fever. 
He was seen again in January, 1964 with a 
temperature elevation and a mild sore 
throat and was treated with antibiotics. His 
hemoglobin at that time was found to be 
8 grams per 100 ml. He was placed on 
hematinic therapy again. He apparently did 
well for a short time, and he was noted to 
have a fever once again on January 31. He 
was treated with antibiotics and vitamins. 
He was seen again during the third week in 
February when he apparently felt somewhat 
better. 

He was admitted to a hospital on 2-11-64. 
That morning he had been seen in the office 
of the local physician who had found his 
temperature to be 101° F and his hemo- 
globin to be 6 grams per 100 ml. He had 
been lethargic most of the month, and his 
appetite had been poor, except for a week 
after he had received penicillin and B-12 
injections. The child had complained of 
aching pain in his right leg and appeared to 
drag it somewhat while walking the day 
prior to admission. 

The child’s past history and development 
were quite normal. Family history revealed 
a grandmother with a chronic anemic condi- 
tion, a paternal cousin who had a mongoloid 
child, and a maternal great aunt with leu- 
kemia. The ages of the parents were 48, 
father; and 46, mother. 

On physical examination it was found that 
this boy was very pale and thin. No adeno- 
pathy was found and the spleen and liver 
were not palpable. There was a grade IV- 
VI systolic bruit heard over the right neck 
and over the entire head, but there were no 
murmurs heard over the heart. Neurologic- 
ally it was found that there was a slight 
degree of weakness of the right lower ex- 
tremity. Blood studies done on admission 
revealed that he had a hemoglobin of 4.9 
grams per 100 ml, with 1,600,000 red cells 
and 20,250 white cells per cubic mm. He 


also had 20,000 platelets per cubic mm, and 
the differential was 26% lymphocytes, 70% 
prolymphocytes, 3% lymphoblasts with 1% 
progranulocytes, with 1% rubricyte and 
2% metarubricytes per 100 white cells. 

A special hematology report showed a 
peripheral blood smear exhibiting a severe 
degree of anemia, thrombocytopenia and 
lymphocytosis with immaturity of the lym- 
phocytes, which was highly suggestive of an 
acute lymphocytic leukemic process. The 
bone-marrow evaluation revealed marked re- 
placement of the marrow material by lym- 
phocytic-type cells with approximately 15% 
blast forms, highly suggestive of acute lym- 
phocytic leukemia. 

A local hematologist was asked to see the 
child. After examination of the blood 
smears and bone marrow, he concurred with 
the diagnosis of acute lymphocytic leukemia. 
The child was then treated with antibiotics, 
steroids, and Methrotrexate as well as trans- 
fusions. He died in December, 1964. 

From our short report of three cases we 
do not pretend to draw conclusions or to 
label etiologic agents, but there are several 
points worthy of mention. The ages of the 
patients and their history of upper respira- 
tory infections just prior to the discovery 
of their diseases makes us feel that there 
is a similar pattern in each. 

The ages of their parents brings a ques- 
tion to mind. Since the incidence of mon- 
golism is higher in the children of older 
parents, and mongoloid children have a 
higher rate of leukemia,® may there be a 
relationship between the ages of parents and 
leukemia in children? It is a question that 
we do not try to answer because of our 
very small study which will not allow a valid 
conclusion. It is a question that we are 
sure someone has asked and has probably 
reported on, but which we have not come 
across in our search through the more re- 
cent literature. 

An interview with parents in this study 
revealed that there was no known contact 
between any of these children prior to the 
onset of disease other than rare brief en- 
counters in town. These families live sev- 


April, 1966 


139 


eral miles from each other and even have 
different water sources. A common factor 
involving these three cases is difficult, if 
not impossible, to point out. Therefore we 
simply conclude that we have investigated 
three seemingly unrelated spontaneous cases 
of acute lymphocjdic leukemia in a relatively 
small rural area. 

References 

1. Southam, C. M. : The role of viruses in neo- 

plasia, with emphasis on human leukemia. J Fed 
63:138-57, 1963. 


2. Stewart, A.: Aetiology of childhood malig- 

nancies: congenitally determined leukemias. Brit 
Med J 1:452-460, 1961. 

3. Berhard, W. F. ; Gore, T., and Kilby, R. A.: 
Congenital leukemia. Blood 6:990-1001, 1951. 

4. Stewart, A.; Webb, J.; Giles, D., and Hewitt, 

D. : Malignant disease in childhood and diagnostic 

irradiation in utero. Lancet 2:447, 1956. 

5. Bean, R. H. : Phenylbutazone and leukemia. 

A possible association. Brit Med J 52 12:1552-5, 
1960. 

6. Stewart, A.; Webb, J., and Hewitt, D.: A 

suiwey of childhood malignancies. Brit Med J 1: 
1495-, 1958. 


THE AMERICAN WAY 

When George Merck brought Dr. Molitor to this countiy to 
set up a research institute in 1932, the total operating budget 
for this project was $10,000. It did not permit the hiring of 
trained assistants, so Dr. Molitor resorted to high school graduates 
from the local school, most of whom had no particular plans for 
higher education. 

The first six boys were hired at $18 per week. Today their 
combined yearly salaries are in six figures, and they have published 
several hundred professional papers and have obtained important 
patents. (From an Editorial in New York State J Med, Jan. 15, 
1965, p. 234). 


140 


Nebraska S. M. J. 


NEUROLOGIC PHENOMENA of 

Leukemia 

A pproximately so per cent 

of patients dying of leukemia 
disclose histopathologic changes 
in the nervous system. These include leu- 
kemic infiltration of brain and meninges 
as well as petechial hemorrhages. 

However, less than 50 per cent of pa- 
tients with acute leukemia demonstrate clin- 
ical neurologic phenomena if followed care- 
fully through their courses. 

In an occasional patient, post - mortem 
findings do not explain the clinical neuro- 
logic features. 

Many of the clinical neurologic manifesta- 
tions of leukemia are standard and often re- 
ported. 

The general clinical neurologic problems 
presented by leukemia are these: 

1. Patient demonstrates a neurologic syndrome. 
A subleukemic or aleukemic blood count is 
reported, misinterpreted as normal or indicat- 
ing infection. What neurologic syndromes 
should alert the diagnostician to order bone 
marrow study and more concerted hematologic 
survey? 

2. The patient with known leukemia reveals a 
neurologic syndrome. Does he have two un- 
related diseases? (He may!) 

3. The patient with known leukemia develops a 
related neurologic syndrome. What does this 
imply in therapy? 

Most neurologic antics in leukemia appear 
with acute forms. In chronic leukemias, 
neurologic manifestations will be regarded 
more critically. In chronic leukemia one 
may expect neurologic manifestations in 
late or terminal stages as anemia, infection 
and hemorrhage take over. The neurologic 
syndromes of acute leukemia, namely infil- 
tration of meninges and nerve roots, may oc- 
cur but do in much reduced incidence in 
chronic leukemia. 

Leukemia may present early, or even first, 
with the following common syndromes : 

1. Pain. 

2. Increased intracranial pressure with meningeal 
infiltration. 


JOHN A. AITA, MD 

Assistant Professor, Neurology and Psychiatry 

University of Nebraska College of Medicine 
Omaha, Nebraska 

3. Cranial nerve paralysis. 

4. Spinal nerve root involvement. 

9 . Epidural spinal mass. 

Later in the course of leukemia, infection 
and hemorrhage in the nervous system are 
well known concomitants. 

Pain 

The neurologist is often asked to see at 
least four presentations of pain: headache, 
backache, nerve root pain, and pain (any- 
where) of obscure origin. Leukemia may 
cause any of these problems. 

Headache is not a rare symptom in leu- 
kemia and is due to one or more of the fol- 
lowing : 

Increased intracranial pressure. 

Cranial bone involvement. 

Cranial nerve (sensory) infiltration. 

Intracranial infection. 

Intracranial bleeding. 

Epidural nodular mass (rare), 57. «5 

Backache in leukemia is due to: 

Nerve root infiltration. 

Epidural mass. 

Vertebral involvement. 

Infection (rare). 

Intraspinal bleeding (rare). 

Bone, joint or chest (rib, sternum) pain 
is a prominent feature in 5-10 per cent of 
patients with leukemia, particularly chil- 
dren with acute lymphoblastic leukemia. In 
one series, onset of present illness with 
bone pain was noted in 25 per cent of chil- 
dren with acute leukemia and 5 per cent of 
adults. Children described pain especially 
in limbs, adults in ribs and back. Vertebral 
compression and collapse have been described 
uncommonly.®®’ 

Meningeal Infiltration and Increased 
Intracranial Pressure 

(References: 1, 3, 6. 7, 9-12, 18. 22, 23, 26, 29-31, 35a, 
38, 45. 51, 52, 58, 60. 65, 67, 69, 71. 72, 73, 76, 77, 81, 
83, 85, 87, 90, 93, 94, 96, 98, 101, 103, 105, 108, 109). 

Diffuse infiltration of leptomeninges com- 


April, 1966 


141 


monly produces internal hydrocephalus, in- 
creased intracranial pressure and cranial 
nerve paralysis. Less commonly spinal nerve 
root paralyses, hypothalamic and posterior-, 
pituitaiy disturbances appear. 

The syndrome of leukemic leptomeningeal 
infiltration was described in less than 10 per 
cent of patients with acute leukemia before 
1953. It now appears in as high as 40 per 
cent of same series, due to modern chemo- 
therapies which prolong life of these patients 
(as well as improved recognition). It is now 
one of the most frequent neurologic syn- 
dromes of leukemia, commonly appearing 
well in the course of the disease and during 
hematologic remission. Exceptions are not 
rare and it does appear at onset of the ill- 
ness, during hematologic relapse or term- 
inally. 

Its highest incidence appears in male chil- 
dren with acute lymphoblastic leukemia. It 
may appear recurrently following treatment 
several times through the course of the dis- 
ease. 

The clinical features of leukemic lepto- 
meningeal infiltration may be outlined: 

Increased intracranial pressure. 

Diffuse cerebral symptoms. 

“Meningitis.” 

Cranial nerve paralysis. 

Spinal nerve root paralysis. 

Thalamic-pituitary disturbance. 

Spinal fluid changes. 

Increased intracranial pressure is disclosed 
by its usual manifestations: 

Headache. 

Nausea, vomiting. 

Papilledema. 

Elevated spinal fluid pressure. 

Separation cranial sutures in children. 

Increasing circumference of head in children. 

Diffuse cerebral sijmptoms include, in ap- 
proximate order of their frequency: 

Irritability, lethargy. 

Confusional state. 

Convulsions (focal or generalized, especially in 
children). 

Stupor, coma. 

Cerebellar deficit. 

Generalized tremor. Rarely flapping tremor. 

Chorea. 

Plegias. 


“Meningitis” is often a diagnostic con- 
sideration with these patients because of the 
symptoms and spinal fluid cell count. Most 
patients, however, are afebrile and menin- 
gism is usunlly (not invariably) absent or 
not prominent. 

Cranial nerve paralysis appears in 40-50 
per cent of these patients. The order of fre- 
quency of involvement runs thus: VII, VI, 
VIII, III, V, II, IX. One or more nerves 
may be involved and bilateral involvement is 
not rare. 

Spinal leptomeningeal and nerve root in- 
volvement is less common clinically. It pre- 
sents with pain, paresthesia, then more ob- 
jective sensory and motor loss in one or 
several nerve roots (commonly in lower 
extremities). It may remain localized or it 
may spread to produce a flaccid paraplegia. 
Rarely the syndrome of extensive acute poly- 
radiculitis appears, mimicking Guillain- 
Barre syndrome or ascending in the classical 
manner described by Landry. 

Thalamic disturbances appear in small but 
regular incidence, almost invariably mani- 
fested by polyphagia and great weight gain. 
Although pituitary infiltration is not un- 
usual on pathologic study, clinical manifesta- 
tions are rare and usually confined to dia- 
betes insipidus. 

Spinal fluid changes are commensurate 
with clinical severity of leptomeningeal in- 
filtration. Increased cell count and pres- 
sure are the most consistent findings. Cell 
counts in all ranges of elevation appear, 
even as high as 8000 per cubic mm. These 
cells are morphologically the same as those 
found in the bloodstream. Protein elevation 
appears in approximately 50 per cent of 
these patients and is seldom over 120 mg 
per 100 ml. A sugar level below 40 mg per 
100 ml occurs in 50-60 per cent of patients. 
These spinal fluid findings in a patient with- 
out clinical neurologic manifestations usual- 
ly herald impending neurologic symptoms. 

Palliative treatment with intrathecal 
aminopterin or methotrexate usually pro- 
duces significant clinical improvement in the 
leukemic leptomeningeal infiltration syn- 
drome.'^®- 


142 


Nebraska S. M. J. 


One recalls here that increased intra- 
cranial pressure may be caused also by sub- 
dural hematoma which appears in 1-2 per 
cent of patients with acute leukemia. Addi- 
tional considerations in differential diag- 
nosis of leukemic leptomeningeal infiltration 
syndrome include 

Intracranial infection (including infectious 
mononucleosis). 

Uremia. 

Electrolyte, pH, or hydration disturbances. 

Hypercalcemia due to extensive bone involve- 
ment. 5ft 

Nodular or Tumor-forming Leukemia 

(References: 21, 24, 40, 46, 49, 55, 58, 72, 72a, 93, 104, 105). 

Nodular or tumor-forming leukemia is not 
common. It may overlap much with the 
diffuse leptomeningeal infiltration syn- 
drome just described. Lymphosarcomatous 
masses may appear in lymphoblastic leu- 
kemia. Chloroma (green tumor) is a spe- 
cial feature of acute myeloblastic leukemia, 
although not all nodular masses of acute 
myeloblastic leukemia are chloromatous. In 
the neurologic realm, most of these tumors 
appear in the spinal epidural spaces. Most 
of these patients are under 20 years of age, 
males, with acute myeloblastic leukemia. It 
appears not uncommonly as a presenting or 
early manifestation of leukemia with the 
syndrome of leukemic paraplegia. This may 
be variously flaccid, spastic or mixed, de- 
pending on what spinal root and cord in- 
volvement occurs. Spinal fluid examination 
often discloses elevated protein and mano- 
metric block. Myelography usually demon- 
strates the mass-lesion. The picture of rap- 
idly evolving, severe, transecting myelopathy 
commonly indicates that the epidural mass 
has impaired circulation sufficiently to pro- 
duce myelomalacia. 

Several series cite that 25-50 per 
cent of these tumor masses are chloro- 
mas.^’ 1'^’ These are green, 

invasive tumor masses (of myeloblastic 
cells), growing in subperiosteum and mar- 
row in single or multiple sites, commonly or- 
bit, skull (including sphenoid, mastoid), ribs 
and vertebrae ; less often sternum, pelvis and 
sacrum. Spinal epidural and cranial nerve 
syndromes represent the most usual neuro- 
logic manifestations. Occasional cerebral in- 


volvement has been described. Most pa- 
tients are children. 

Intracranial Hemorrhage 

(References: 9, 11, 14. 28a, 36, 37, 39, 41, 44, 46, 47, 
52. 53, 65. 68, 70, 71a, 72, 80, 82. 92, 97. 103, 105). 

In patients with intracranial hemorrhage 
due to a hematologic (“hemorrhagic”) dis- 
ease, leukemia is the most common of these 
diseases. 

Many factors are involved in hemor- 
rhagic aspects of leukemia (most of which 
are incompletely disceraed or understood) : 
Thrombopenia, impaction of vascular walls 
by leukemic cells, increased viscosity of blood 
with leucocytosis over 50,000 cubic mm. In 
some there have been found also increased 
fibrinolysin as well as deficiency or defect 
of fibrinogen, factor V, and prothrombin. 
Less commonly reported are hypergamma- 
globulinemia, macroglobulinemia and cryo- 
globulinemia. 35 

Intracranial hemorrhage is usually a fea- 
ture of advanced leukemia although occasion- 
ally it occurs early in the course. It is a com- 
mon terminal event and an important cause 
of death in leukemic patients. In occasional 
patients, the clinical impression of intra- 
cranial hemorrhage is not borne out by 
pathologic study. Usually, then, arterial or 
venous (including large dural sinus) throm- 
bosis has occurred from infiltrative vascular 
damage. 

Sites of intracerebral hemorrhage are as 
follows in approximate order of frequency: 

Intracerebral (including intracerebellar). 

Subarachnoid. 

Subdural. 

Mixed sites. 

Epidural. 

Rarely, significant spinal (epidural, intra- 
medullary, subarachnoid) and peripheral 
nerve hemorrhages occur. 

Among 20-30 per cent of patients with 
acute leukemia, intracranial hemorrhage is 
a major factor in death. In post mortem ex- 
aminations 5-8 per cent incidence of sub- 
arachnoid and 1-2 per cent subdural hemor- 
rhage is noted. 

Acute leukemia reveals more patients with 
severe intracranial hemorrhage than does 


April, 1966 


143 


chronic leukemia. Myeloblastic forms result 
in greater incidence of important intra- 
cranial hemorrhages than do lymphoblastic 
leukemias, whether acute or chronic. 

Markedly elevated white blood counts 
(over 50,000 per cubic mm according to one 
report, over 100,000 according to others) are 
associated with a remarkably increased in- 
cidence of major intracerebral hemon-hage. 
Thrombopenia appears more significantly 
related to subarachnoid and subdural hem- 
orrhages. 

Infection 

(References; 5, 19, 25. 33, 34, 35a, 42, 52, 62. 63, 71a, 
72, 84, 86, 102, 103, 105). 

Although infection appears as a primary 
cause of death in 35 per cent of patients 
with leukemia, most of these infections are 
generalized, gastrointestinal and pulmonary 
in location. In approximately 1-2 per cent 
of deaths infection of central nervous sys- 
tem is the primary or important contribut- 
ing cause of death. One-half of these pa- 
tients had chronic leukemia. 

Infection is most likely to appear during 
periods of hematologic relapse and late in 
the course of the disease. The risk of infec- 
tion appears greater with granulocytopenia 
and following strenuous therapies with ste- 
roids, antimetabolite drugs, and radiation. 
Hypogammaglobulinemia (often progressive 
during the course of chronic lymphatic leu- 
kemia) also lowers immunity to many patho- 
gens. 

In order of frequency, the following neu- 
rologic infections appear: 

Herpes zoster. 

Meningitis (occasionally accompanied by ar- 
teritis). 

Brain abscess. 

Epidural spinal abscess. 

Encephalitis, viral. 

Pathogens are commonly: 

Staphylococcus. 

Pneumococcus. 

Gram-negative bacilli. 

Fungus. 

Mixed (bacteria-fungus). 

Virus (herpes zoster). 

Among fungal pathogens, mucor (rhizo- 
pus), cryptococcus and Candida are most 


frequent. Involvement by aspergillus and 
blastomyces of the nervous system in leu- 
kemia are reported rarely. 

Herpes zoster is most likely to appear with 
chronic leukemia, especially lymphoblastic. 

Ocular and II Cranial Nerve 
Involvement 

(References: 2, 8. 18. 20, 21, 25, 49, 55, 57, 59, 107). 

The eye and II cranial nerve disclose his- 
topathologic and fundascopic findings more 
often than clinical impairment in leukemia. 
A greater incidence of microscopic changes 
appear with acute lymphatic leukemia than 
with other forais. B o n e y orbit, retina, 
choroid, and optic nerve are particularly in- 
volved with infiltration, hemorrhage, and 
edema. Two to three per cent of patients 
with leukemia present early with proptosis 
from orbital infiltrates (more common in 
children). 

Fifty to 65 per cent of patients with leu- 
kemia disclose ocular-fundus-changes in- 
cluding leukemic infiltrates, distended veins, 
small hemorrhages, exudates, papilledema or 
rentinal edema.®® 

Sudden loss of vision may occur with suf- 
ficient infiltration or hemorrhage of any of 
these optic structures. 

Progressive Multifocal 
Leukoencephalopathy 

(References: 4, 11, 20, 74, 89). 

This is an uncommon cerebral demyelini- 
zation syndrome which appears in small but 
regular incidence with chronic leukemia, 
more so in the lymphoblastic fonn. It is re- 
ported also in Hodgkin’s disease and rarely 
in pulmonary tuberculosis and carcinoma. It 
develops as a late to terminal event, com- 
monly in the last four to six months of life. 
Most patients are adult (expected with 
chronic leukemia) presenting progressive 
focal or asymmetrical cerebral deficits with- 
out increased intracranial pressure or out- 
standing spinal fluid changes. Common are 
dementia, central vision loss (hemianopsias), 
cranial nerve defects and pyramidal tract 
deficits. Histopathologic study discloses 
widely disseminated, small, perivascular foci 


144 


Nebraska S. M. J. 


of demyelinization which become confluent; 
gigantic hypertrophic astrocytes. 

Rarities 

Rare neurologic manifestations accom- 
panying leukemia have been reported as fol- 
lows : 

Spinal lesions. 

Hemorrhage2'4. 44. i«4 

Epidural, subdural, subarachnoid, intra- 
medullary. 

Diffuse infiltrationi. ^3, 105 
Intramedullary 
Polyradicular, ascending 
Nodular (mass) lesions. 

Intradural, intramedullary. 

Demyelinization (posterolateral col- 
umns24. 56, 73, 105 

Peripheral neuropathyis, 24, 25, 27, 28, 73, 105 
Hemorrhages 

Infiltrative: proximal, distal. 

Cerebral lesions. 48, 44, 49, 57, 65, i03, 105 

Thrombosis (arterial, venous, venous sinus) 
Nodular mass lesion 

Epidural or intradural, compressing cortex. 
Dermatomyositis4i 
Hypercalcemia®# 

Vertebral compression, collapse.39, 44, 54 
Priapism.48 

Due to infiltration of corpus cavernosus. 
Toxicity of chemotherapy.!# 

Artefactual hypoglycemia.43, 6i 
Complicating, unrelated neoplasmsH. 43, 79 

Significance of Certain Neurologic 
Symptoms in Leukemia 

Focal cerebral syndrome (not cranial nerve 
involvement) commonly signifies one of the 


following, in approximate order of fre- 
quency : 

Acute intracranial hemorrhage. 

Acute cerebral thrombosis (arterial or venous). 

Epidural or intradural nodular mass compressing 
cortex. 

Infectious meningitis with arteritis causing 
thrombosis. 

Leucoencephalopathy (demyelinization). 

Convulsive seizures commonly suggest; 

Leptomeningeal infiltration with increased in- 
tracranial pressure. 

Acute hemorrhage, usually intracerebral, less 
often subarachnoid. 

Acute venous sinus thrombosis. 

Epidural or intradural nodular mass compressing 
cortex. 

Intracranial infection. 

Early recognition of leukemia as the cause 
of a neurologic syndrome is suggested by 
several of the following features (when 
white blood count does not alert the diag- 
nostician), particularly in a child or young 
adult; 

1. Pain. 

2. Increased intracranial pressure. 

3. Cranial nerve paralysis (especially VII, extra- 
ocular muscles, VIII). 

4. Spinal nerve root irritation, paralysis. 

5. Spinal cord compression. 

6. Spinal fluid changes (increased pressure, 
cells, protein). 

7. Less frequently, intracranial hemorrhage and 
other cerebral symptoms. 

(References are available from the author). 


“There may be billions for buildings, billions to disrupt and 
change the course of medical practice, billions to subvert medical 
education as well as to control the direction of medical research, 
but when it comes to the aged the President proposes limited hospital 
benefits to be paid for, not from general revenues, but by employers 
and employees, and the self employed.” From Challenge to Social- 
ism, January 14, 1965). 


April, 1966 


145 


ORGANIZATION SECTION 


Welcome, New Members 


Ford, Edward, M.D Omaha 

Giegerich, W. F., M.D. Omaha 

Haag, Robert L., ]\I.D. Lincoln 

Hahn, Robert E., M.D. Omaha 

Hammes, Donald L., M.D .Omaha 

Keilly, John E., M.D. Lincoln 

Laird, Thomas R., M.D. ...Blue Hill 

Landers, R. R., M.D. Norfolk 

iMardis, Hal, i\I.D. Omaha 

Pavelka, Donald, i\LD. Omaha 

Schabauer, E. A., M.D. Plainview 

Storter, Barry, M.D. Omaha 

M’aite, Chas., M.D. Norfolk 

Yost, John F., M.D. Lincoln 





Doctor Lloyd Kunkel practices medicine in 
Weeping Water. We have looked up Weep- 
ing Water; its creek was called L’eau qui 
pleure, but the Indians, it seems, really meant 
rustling water. No matter, the name, what- 
ever its origin, is vivid and colorful and 
rich in history. We visited with Doctor and 
iMrs. Kunkel one sunny afternoon recently 
and came away impressed. Doctor Kunkel’s 
hobby is violin making. He has been do- 
ing this for a long time and has made more 
than a hundred violins and violas, and even 
a guitar. We saw the guitar, and some sev- 
enty violins. Doctor Kunkel is a serious 
student of the violin and its history. He was 



146 


Nebraska S. M. J. 




at one time a professional musician. He is 
one of a very few American violin makers 
listed in the “Dictionnaire Universal Lu- 
thiers,” published in Brussels, Belgium. He 
has made reproductions of Stradivarius (3 
periods), Jos. Guarnerius (3 periods), Ama- 
ti. Huger, Maggini, di Salvo, and Camilli, 
and has developed an original model. He 
has made copies of the Stradivarius and 
Tertis violas. Our picture shows Doctor 
Kunkel in his workshop; the large instru- 
ment you see is the Tertis model viola, built, 
of course, by Doctor Kunkel. 

His workshop is very large, and we saw 
hundreds of tools, some of which appear in 
the picture, especially designed for this work, 
some quite small, some very old, many im- 
ported. Wood for this work is obtained 
from Switzerland. The doctor makes his 
own varnish, and showed us a wailful of 
jars used in varnish making. He is now 
working on a copy of a sixteenth century 
dancing master’s kit, a small narrow instru- 
ment which the teacher carried from place 
to place in a pocket of his long-tailed coat. 

Doctor Kunkel is also quite an archaeologist, 
and we saw hundreds of Indian artefacts he 
personally found, and picture after picture 
of Indian homes he has discovered ; several of 
these pictures have been reproduced else- 
where. But his champion hobby is the mak- 
ing of violins. It seems strange to us to 
call what we think is a second and wonder- 
ful artistic career a hobby, but it is that, 
and we came away from Weeping Water 
with a great deal of admiration, and of 
knowledge, and a very real pleasure in, how- 
ever vicariously, sharing for a while the 
joy of violin making. 

— F.C. 


oooooooooooooooooooooooooooooooooooo 

DOCTOR — Please take each copy of 
your Journal home. The wives complain 
that they never get to read the Aux- 
iliary column. 

oooooooooooooooooooooooooooooooooooo 


FORTY-FIRST ANNUAL MEETING OF 
THE WOMAN’S AUXILIARY 
to the 

NEBRASKA STATE MEDICAL 
ASSOCIATION 

The State Medical Convention to be held 
May 3, 4, 5, 1966, marks the forty-first an- 
nual meeting of the Woman’s Auxiliary to 
the Nebraska State Medical Association. A 
very cordial invitation is extended to all 
doctors’ wives in the State — whether or not 
you are an Auxiliary member. 

Following are the highlights of the Aux- 
iliary activities for the three-day period, 
which will be held at the Hotel Cornhusker, 
Lincoln, Nebraska. ALL meetings are open 
to all Auxiliary members; your Executive 
Board urges everyone to “sit in” on the 
meetings. 

Monday, May 2, 1966 

Registration desk will be open at 12:00 noon. 

Tuesday, May 3, 1966 
■ — ■ Morning — 

7 :45 No-host Breakfast 

8 :15 Pre - convention Executive Board 
Meeting. Reports of State Offi- 
cers, State Chairmen, and a report 
of the nominating committee. 

11:00 Keynote Address: James Z. Appel, 
M.D., President, American Medical 
Association 

12:00 Combined Luncheon for Auxiliary 
and Medical Association. Presen- 
tation of AMA-ERF Checks. Guest 
Speaker: Senator Carl Curtis 

— Afternoon • — 

2:30 Annual Business Meeting. Reports of 
County Presidents. Memorial Serv- 
ice. Election and installation of 
Officers. 

FUN NIGHT 

6:30 Fun Night (Lancaster County Medi- 
cal Society). A gala evening of 
dancing and entertainment. 



April, 1966 


147 


Wednesday, May 4, 1966 
— Afternoon — 

12:30 Fashion Show Luncheon, Lincoln 
Country Club 

Honored Guest Speaker: Mrs. Asher 
Yaguda, Newark, N.J. Mrs. Ya- 
guda is the President-Elect of the 
Woman’s Auxiliary to the AMA. 

— Evening — 

6:00 Social Hour (honoring the president 
and president-elect of the Nebras- 
ka State Medical Association and 
the Auxiliary). 

7:00 Annual Banquet; Presentation of the 
50 Year Pins; Entertainment — 
organ music throughout the din- 
ner. 

Guest Speaker: Kenneth McFarland, 
Ph.D., Topeka, Kansas 

Thursday, May 5, 1966 
— Morning — 

9:00 No Host Breakfast 

9:30 Post-Convention Executive Board 
Meeting 

12:30 Meeting and Convention Adjourned 


Attention All State Officers and State 
Chairmen and County Presidents — 

A written report of three minutes duration 
will be presented on Tuesday, May 4, 1966. 

May I personally urge you to submit all 
necessary reports as early as possible, in 
order that your State Organization can meet 
its deadline with the National Organization. 
I can’t emphasize this too strongly, it is ex- 
tremely difficult to send reports to the Na- 
tional office if the reports aren’t sent to 
your State President. 

Mrs. J. MTiitney Kelley, 

President, 

Nebr. St. Med. Aux. 

County Auxiliary news items should be 
sent to the Publicity Chairman of the Wom- 
an’s Auxiliary to the Nebraska State Medical 
Association for inclusion in the Nebraska 
State Medical Journal. 


Our Medical Schools 

Biochemistry Professors to Visit — 

Omaha — Two visiting professors of bio- 
chemistry will give seminars at the Univer- 
sity of Nebraska College of Medicine during 
the spring quarter. These seminars are spon- 
sored by the Merck Sharp and Dohme Post- 
graduate Program. 

Dr. Helmut Beinert will speak on Thurs- 
day, March 24. He is professor of biochem- 
istry at the Institute for Enzyme Research 
at the University of Wisconsin and is group 
chairman for the biological oxidation sec- 
tion. 

Dr. Beinert will discuss “The Intramole- 
cular Interactions of Electron Carriers in 
Metal Flavoproteins Studied by EPR Spec- 
troscopy.” The seminar will be conducted 
in the South Amphitheater at 4 p.m. 

On Tuesday, May 17, Dr. Esmond E. Snell 
will give a seminar on “The Role of Vitamin 
Bg in Catalysis of Enzymatic Alpha, Beta- 
Elimination Reactions.” He is professor of 
biochemistry at the University of California, 
Berkeley, and was chairman of the depart- 
ment from 1956 through 1962. 

Dr. Snell’s seminar is scheduled at 4 p.m. 
in the Eppley Institute’s auditorium. 

Dr. Musselman Speaker — 

Omaha — Dr. Merle M. Musselman was 
the visiting lecturer in surgery for the 
16th annual meeting of the Society of Gradu- 
ate Surgeons of Los Angeles County Hospital 
in March. He is professor and chairman of 
the department of surgery at the University 
of Nebraska College of Medicine. 

Scholarships Awarded — 

Omaha — Three freshman medical stu- 
dents at the University of Nebraska College 
of Medicine have received Avalon Foundation 
scholarships for the second half of the aca- 
demic year. They are: 

Kanchan L. Lodhia, 504 So. 41st St., Oma- 
ha (hometown: 716 Hancock Way, El Cer- 
rito, Calif.) ; Orrin Douglas Osterholm, 4502 
No. 49th St., Omaha (hometown: 5140 
Spruce, Lincoln) ; and Richard G. Patton, 


148 


Nebraska S. M. J. 


4120 Dewey Ave., Omaha (hometown: 1120 
No. Locust, Wahoo, Nebr.). 

Infant Study — 

Omaha — Dr. Robert J. Ellingson has re- 
ceived a $127,875 grant from the National In- 
stitute of Neurological Diseases and Blind- 
ness for a project entitled “Development of 
Brain Electrical Activity of Infants.” He is 
professor of neurology and psychiatry at the 
University of Nebraska College of Medicine. 

Closed Chest Resuscitation — 

Omaha — Techniques of closed chest car- 
diopulmonary resuscitation were taught at 
continuing educational courses for three pro- 
fessional groups during March of 1966. 

F or the second consecutive year, the 
course, “Closed Chest Cardiac Resuscitation,” 
was offered by the University of Nebraska 
College of Medicine in its Eppley Cancer In- 
stitute. Scheduled on March 7 for physi- 
cians, March 8 for dentists, and March 9 for 
nurses, the course offered an identical pro- 
gram for each professional group. 


PROCEEDINGS 
BOARD OF COUNCILORS 

February 11, 1966 

The Mid-Winter Meeting of the Board of Coun- 
cilors was held at the Holiday Inn, Kearney, Ne- 
braska on February 11, 1966. The meeting was 
called to order by the Chairman, Dr. W. W. Waddell. 

Members present were Drs. Leroy Lee, Omaha; 
John T. McGreer, Jr., Lincoln; W. W. Waddell, 
Beatrice; J. T. Keown, Pender; H. D. Kuper, Colum- 
bus; C. L. Anderson, Stromsburg; C. F. Ashby, 
Geneva; Rex Wilson, O’Neill; Harold V. Smith, 
Kearney; L. D. McNeill, Hastings; Max Raines, 
North Platte, and C. J. Cornelius, Sidney. 

The Chairman called for nominations for Chair- 
man of the Board of Councilors. Dr. McGreer 
moved that Dr. Waddell be re-elected. This mo- 
tion was seconded and carried. 

Nominations were called for Secretary of the 
Board of Councilors. Dr. Ashby moved that Dr. 
Raines be re-elected. The motion was seconded and 
carried. 

The Chairman introduced Dr. Charles Carignan, 
President of the Buffalo County Medical Society 
who welcomed the Board of Councilors to Kearney. 

Dr. Waddell then asked for oral reports, and 
the following were presented: 

Mr. Neff, Executive Secretary, commented on 
Legislation which was possible in the coming 1967 
Legislature. 


Dr. Raines, new Chairman of the Nebraska 
MEDPAC, explained the function of this organiza- 
tion, and stated that with the coming elections, the 
Nebraska MEDPAC should be supported by physi- 
cians in the State of Nebraska. 

Dr. Cole, Editor of the Nebraska State Medical 
Journal, was granted permission of the floor and 
stated that the Journal would be happy to help 
this organization by spreading information through 
the Journal. Dr. Anderson moved that articles be 
written by Dr. Cole for the Journal relative to this 
matter. This was approved by the Board of Coun- 
cilors. 

Dr. Gilligan, Chairman of the Medicolegal Ad- 
vice Committee, presented his oral report to the 
Councilors. In this report, a resolution was pre- 
sented relative to the establishment of a Sub-Com- 
mittee for the purpose of arranging for witnesses 
to appear in behalf of the defendant physician. 

The motion was made by Dr. Cornelius that this 
resolution be accepted, and this was approved. 

There being no other oral reports at this time, 
the Chairman called for approval of the reports 
as they appeared in the Handbook. 

The financial report as prepared by the Auditor 
was considered. Dr. McGreer moved that this be 
accepted. This was seconded and carried. 

Dr. McNeill moved that the report of the Execu- 
tive Secretary be accepted, and the motion was sec- 
onded and carried. 

Dr. McGreer moved that the report of the Board 
of Trustees be accepted and the motion was seconded 
and carried. 

The report of the Editor was considered and Dr. 
McGreer moved that this be accepted. This was 
seconded and carried. 

The report of the Delegate to the A.M.A. was con- 
sidered, and Dr. McNeill moved that this be accepted. 
The motion was seconded and carried. 

The report of the Delegate to the North Central 
Conference was considered, and Dr. McNeill moved 
that this be accepted. This was seconded and car- 
ried. 

The report of the 10th National Conference on 
Physicians and Schools was considered, and Dr. 
Ashby moved that this report be accepted. This 
was seconded and carried. 

The report of the Blood and Blood Products Com- 
mittee was considered, and Dr. Raines moved that 
this be accepted. This was seconded and carried. 

It was moved and seconded to accept the report 
of the Continuing Committee on Medical Practice. 
The motion carried. 

The I’eport of the Maternal and Child Health 
Committee was considered, and Dr. Bosley, Chair- 
man, reported on the PKU survey which had been 
conducted in the state. It was moved and seconded 
to accept this report, and the motion carried. 

Dr. Bancroft, Chairman of the Council on Profes- 
sional Ethics, was asked to present his oral report 
to the Councilors. Dr. Bancroft stated that the 
Governor had expressed concern to him that there 
was no body of professional persons who could 
deal with complaints against professional people 
in the employ of the state. He stated that the 
Governor had designated a committee of the Lan- 
caster County Medical Society as the official agency 


April, 1966 


149 


to hear and investigate any complaints regarding 
the pi’ofessional staffs of all state agencies. Dr. 
Bancroft stated that the Governor’s idea was sound; 
however, he questioned the wisdom of the designa- 
tion of a committee of any single county medical 
society to deal with this state wide problem. 

Dr. Bancroft recommended that the Board of 
Councilors consider suggesting to the Governor the 
designation of a committee appointed by the Ne- 
braska State Medical Association to deal with these 
problems of state wide significance. 

Dr. Bancroft stated that he had been approached 
by the Bar Association about the concern of that 
organization with the ethical consideration which 
the legal profession is apprehensive about in connec- 
tion with malpractice cases. They feel that if a 
reputable attorney declines a malpractice suit, the 
complainant frequently secures a less reputable at- 
torney to pursue the legal action. They requested 
some competent body representing the Nebraska 
State Medical Association to meet with their repre- 
sentatives to explore this problem. Dr. Bancroft 
recommended that some action be taken by this 
body to implement a cooperative effort to deal with 
this concern of the Nebraska State Bar Association. 

Dr. Cornelius moved that these suggestions be re- 
ferred to the House of Delegates for their recom- 
mendations. Following considerable discussion. Dr. 
McGreer suggested that the motion of Dr. Cornelius 
be amended, and that the matter of the Governor’s 
request for a committee to deal with complaints re- 
garding the professional staffs of all state agencies 
be handled by the Council on Professional Ethics; 
and that the request of the Bar Association for a 
body representing this Association to meet with 
representatives of that organization to explore the 
problem of malpractice suits, be handled by the 
Medicolegal Advice Committee. Dr. Anderson moved 
that this motion be accepted as amended. This was 
seconded and carried. 

The report of the Psychiatry Committee was con- 
sidered. Attention was called to the No. 2 recom- 
mendation concerning establishment of a review 
or appeal board. Following considerable discussion, 
it was moved by Dr. McGreer that the report of 
this committee be accepted with the exception of this 
No. 2 recommendation, and that this be excluded 
from the report. This was seconded and carried. 

It was moved by Dr. McGreer that the report 
of the Hospital and Professional Relations Commit- 
tee be accepted. This was seconded and carried. 

It was moved by Dr. McGreer and seconded that 
the report of the Diabetes Committee be accepted. 
Motion carried. 

It was moved and seconded to accept the report of 
the Medicine and Religion Committee. Motion car- 
ried. 

It was moved by Dr. McGreer that the report of 
the Joint Commission for the Improvement of the 
Care of the Patient be accepted. TTiis was seconded 
and carried. 

Dr. McGreer moved that the report of the Prepay- 
ment Medical Care committee be accepted. The 
motion was seconded and carried. 

Dr. Anderson moved that the report of the Rela- 
tive Value Study committee be accepted. Motion 
was seconded and carried. 

It was moved by Dr. Kuper and seconded that 


the report of the Sub-Committee on Athletic In- 
juries be accepted. This was carried. 

Dr. McGreer moved that the report of the Re- 
habilitation committee be accepted. This was sec- 
onded and carried. 

It was moved and seconded to accept the report 
of the Health Education in Schools and Colleges 
Committee. Motion carried. 

Dr. Andei'son moved that the report of the Rural 
Medical Service Committee be accepted. The mo- 
tion was seconded and carried. 

Dr. Wright was asked to present the report of 
the Policy Committee. There was considerable dis- 
cussion on the subject of Payment by Blue Shield- 
Blue Cross in Non-Federal Hospitals. It was moved 
by Dr. Kuper that the words “Blue Shield’’ be 
deleted from this entire portion of the report. This 
was seconded and carried. 

Dr. Wright stated that the Policy Committee had 
another item to bring before the council and that 
was the recommendation made by Dr. Grier at the 
Annual Session that compulsory A.M.A. dues be 
dropped. Dr. Wright stated that the Policy Com- 
mittee felt that this should not be accepted and 
that compulsory A.M.A. dues should be retained. 
It was moved by Dr. Ashby that the stand of the 
Policy Committee be accepted. This was seconded 
and carried. 

Dr. Anderson moved that the Policy Committee 
report as amended be accepted. This was seconded 
and carried. 

Dr. Waddell read the requests for Life Member- 
ships and the list of 50-year practitioners. It was 
moved and seconded to accept these as read. Mo- 
tion carried. 

Mr. Neff read a letter regarding the quitclaim 
deed on the property of the American Cancer So- 
ciety in Omaha, in which we have been asked to 
relinquish our interest in the title. Dr. Kuper 
moved that approval be given in this matter, and 
this was approved. 

Dr. Waddell stated that the Board of Councilors 
had been asked to study the resolution from Adams 
County relative to the reorganization of the N.S.M.A. 
so as to achieve a more representative body in 
the Board of Councilors and the House of Delegates. 
It was moved by Dr. Smith that this body approve 
the present status of the Councilor Districts. Fol- 
lowing considerable discussion, it was moved that 
the Board of Councilors prepare a i-esolution to be 
presented to the House of Delegates at their first 
session tomorrow asking that a committee be formed 
to study the problem of representation of small 
medical societies with a total number of less than 
five members. This was seconded and carried. 

There being no further business, the meeting was 
adjourned. 


HOUSE OF DELEGATES 

FIRST SESSION 
February 12, 1966 

The first session of the Mid-Winter Meeting of 
the House of Delegates was held at the Holiday Inn, 
Kearney, Nebraska, on Febiaiary 12, 1966. 

Dr. Nutzman, Speaker of the House, called the 


150 


Nebraska S. M. J. 


meeting to older and asked that all present stand 
for the invocation by Dr. McFadden. 

Dr. Charles Carignan, President of the Buffalo 
County Medical Society, was introduced and wel- 
comed the House of Delegates to Kearney. 

The Speaker called for a report of the Credentials 
Committee; and Dr. R. E. Garlinghouse, who had 
been appointed to act as Sergeant-at-Arms, reported 
44 duly elected delegates present. A quorum be- 
ing present, the report of the Credentials Com- 
mittee was approved. 

Dr. Wright, President, was asked to introduce 
distinguished visitors who were present. Dr. Dono- 
van Ward, Immediate Past President of the A.M.A., 
and Dr. Otis Wolfe, Past President of the Iowa 
State Medical Society, were introduced to the House. 

Dr. Nutzman gave a brief outline of the pro- 
cedure of the meeting and reference committees. 

Approval of the minutes of the House for the 
Annual Session, as printed in the July, 1965 issue 
of the Nebraska State Medical Journal, was called 
for and these were approved. 

Oral reports were presented to the House of Dele- 
gates as follows: 

Council on Professional Ethics — Dr. Paul Ban- 
croft, Chairman — 

Following this oral report. Dr. Bancroft made 
the following recommendations: 

1. Recommend that consideration be given to 
suggesting to the Governor the designation 
of a committee appointed by the Nebraska 
State Medical Association to deal with prob- 
lems of state-wide significance. 

2. Recommend that action be taken to implement 
a cooperative effort to deal with malpractice 
suits as they concern the legal profession. 

Medical Service Committee — Dr. L. J. Gogela, 
Chairman 

Dr. Gogela gave a brief report on legislative 
matters, mainly concerning legislation which is 
anticipated in 1967 relative to medicine. 

Mr. Neff was asked to introduce the A.M.A. guests 
who were present, and Mr. Arthur Seeds, new Field 
Representative of the A.M.A. for Nebraska, and 
Mr. Bill Alexander, Field Representative of AMPAC, 
were introduced to the House. 

Dr. Max Raines, new Chairman of the Nebraska 
MEDPAC, outlined the purpose of this organiza- 
tion, and urged that physicians in the state sup- 
port this organization. 

Committee appointments for 1966-1967 were read 
by Dr. Dan Nye, President-Elect. These appoint- 
ments will become official on May 3, 1966, when 
Dr. Nye takes office as President. 

Dr. E. A. Rogers, Director of State Department 
of Health, and Dr. Harold Morgan, Medical Con- 
sultant for Medicare in Nebraska, were asked to 
discuss the aspects of Medicare and Certification 
in Nebraska, and Utilization Review Committees. 

The Speaker stated that the next item on the 
agenda would be the subject of physicians’ fees. He 
said that the Policy Committee felt this subject 
should be brought before the House of Delegates 
for its action, and for this reason two discussants 
were present to present both concepts. 


Following preliminary remarks by Dr. Wright, 
Chairman of the Policy Committee, Dr. Offerman in- 
troduced Mr. James Knebel, Statistician for National 
Blue Shield in Chicago, who discussed the “Prevail- 
ing Fee” concept. 

Dr. Wright introduced Dr. Otis Wolfe of Mar- 
shalltown, Iowa, Past President of the Iowa Medical 
Society, who discussed the “Usual and Customary 
Fee” concept. 

Following remarks by Dr. Schenken, Delegates 
to the A.M.A., the House was recessed for lunch, 
at which time Dr. Donovan Ward was the guest 
speaker. 

Upon reconvening, the Speaker read his selec- 
tion of Reference Committee members, and the 
room assignments for these committees. The selec- 
tion of members was approved by the House. 

Dr. McFadden read the Reference Committee 
assignments of the reports that appeared in the 
Delegates Handbook. 

The reports of the Allied Professions Committee, 
which did not appear in the Handbook, was pre- 
sented and referred to Reference Committee No. 4. 
The following is this report: 

ALLIED PROFESSIONS COMMITTEE 

Otis W. Miller, M.D., Ord, Chairman ; Loyd Wagner, M.D., 
Hastings ; R. Pitsch, M.D., Seward : Kenneth R. Dalton. M.D., 
Genoa ; E. G. Brillhart. M.D., Columbus ; Wallace E. Engdahl, 
M.D., Omaha. 

The Allied Professions Committee met with the 
Nebraska State Nurses Association in regard to 
duties of nurses in hospitals. The committee tried 
to impress on the nurses that for a state committee 
to set up a set of rules regarding duties would be 
difficult if not impossible as each hospital staff 
would have a different criterion depending on size 
and location of a hospital. The criterion for duties 
w'ould have to be an individual thing with each 
hospital. The duties would also depend on the 
nurses ability to carry them out. 

The Allied Profession Committee met twice dur- 
ing the year with the Interprofessional Council 
last September, 1965, and again February 10, 1966 
at Columbus, Nebraska. Discussion of state legisla- 
tion related to all professions w'as covered. The 
program to make pamphlets and other material 
available to all high school students interested in 
the professions was continued by rechecking with 
each High School Guidance Counselor to make 
sure the Interprofessional folder was on hand with 
the allied professions pamphlets. 

In the meeting on February 10, 1966, our com- 
mittee explained AMPAC and NEBPAC to the 
council and a motion was made by the council giv- 
ing myself permission to meet with the NEBPAC 
Board of Directors to request that information be 
sent to all the allied state societies in the council 
for their officers and delegates to read and invite 
them to recommend to their individual members that 
they join AMPAC and NEBPAC in order to 
strengthen the allied professions political effective- 
ness. The comments by the other professions were 
very much in favor of the program. The combined 
effort of new members could strengthen our political 
efforts. 

Dr. Kenneth R. Dalton, M.D., Genoa, Nebraska, 


April, 1966 


151 


was nominated for secretary-treasurer of the Inter- 
professional Council. 

Respectfully submitted, 

Otis W. Miller, M.D., 
Chairman. 

The following resolutions, which were received 
prior to the meeting, were read and referred to the 
appropriate Reference Committee. 

Resolution No. 1 — From Dr. J. P. Gilligan, Chair- 
man, Medicolegal Advise Committee. 

WHEREAS: The marked increase in the num- 
ber of malpractice threats filed and the increas- 
ing complexity of those cases and at times the 
distance of travel required; 

WHEREAS: It is more difficult to get medi- 
cal witnesses to appear in behalf of the defend- 
ant physician; 

BE IT THEREFORE RESOLVED: A sub- 

medicolegal committee be formed in each coun- 
cilor district with the councilor of each dis- 
trict seiwing as chairman of said sub-commit- 
tee, to function under the Nebraska State Medi- 
cal Legal Committee for the purpose of ar- 
ranging for witnesses to appear in behalf of de- 
fendant physician. 

The sub-committee in each district to be ap- 
pointed by the President of the Nebraska State 
Medical Association on recommendation of the 
councilor of the individual district. 

This resolution was referred to Reference Com- 
mittee No. 3. 

Resolution No. 2 — From Lancaster County Medical 
Society 

W'HEREAS, the Nebraska Centennial will be 
celebrated throughout the State of Nebraska 
during the year of 1967, and 

WHEREAS, medicine and all of the healing 
arts and health agencies have a golden oppor- 
tunity to promote the cause of good health and 
family health at this time, and 

WHEREAS, the Lancaster County Medical 
Society agrees to co-sponsor the Nebraska Cen- 
tennial Health Fair, a state-wide public service, 
educational health fair to be held at the Per- 
shing Memorial Auditorium in Lincoln, Ne- 
braska from April 29th thi’ough May 5th, 1967. 

BE IT HEREBY RESOL\^D, that the Lan- 
caster County Medical Society requests the Ne- 
braska State Medical Association to co-sponsor 
the Nebraska Centennial Health Fair. 

This resolution was referred to Reference Com- 
mittee No. 4. 

Resolution No. 3 — From the Board of Councilors 

WHEREAS, the matter of reorganization of 
the County Medical Societies of the Nebraska 
State Medical Association has been in the 
Board of Councilors and the House of Dele- 
gates for several years with no definitive ac- 
tion being taken, and 

WHEREAS, there is a need to study such re- 
organization so as to continue the propagation 
or organized medicine and promote a more 
equitable representation to the House of Dele- 
gates; 


THEREFORE BE IT RESOLVED, that the 
House of Delegates submit this matter to the 
appropriate committee of the Association for 
immediate study as to the size of societies rela- 
tive to delegate representation, and that said 
committee make a report to the Annual Session 
in May. 

This resolution was referred to Reference Com- 
mittee No. 5. 

The Speaker called for resolutions from the floor, 
and the following were presented: 

Resolution No. 4 — From Gage County Medical 
Society, introduced by Dr. Elias on the subject of 
physicians’ fees. This was referred to Reference 
Committee No. 7. 

Resolution No. 5 — Fi’om Hamilton County Medi- 
cal Society, introduced by Dr. Houtz Steenburg, on 
the subject of physicians’ fees. This was referred 
to Reference Committee No. 7. 

Resolution No. 6 — From Omaha-Douglas County 
Medical Society, introduced by Dr. W. J. McMartin, 
as follows: 

Upon the recommendation of the Insurance 
Committee and the Executive Board of the 
Omaha-Douglas County Medical Society, the rec- 
ommendation was approved that Blue Cross 
make payment for their insured to the Univer- 
sity of Nebraska Hospital. 

This was referred to Reference Committee No. 6. 

Resolution No. 7 — Introduced by Dr. McMartin. 

In October of 1965, the A.M.A. House of 
Delegates passed the following resolution: 

“Hospital based medical specialists are en- 
gaged in the practice of medicine. The fees 
for the ser\'ices for such specialists should not 
be merged with hospital charges. The charges 
for the seiwices of such specialists should be 
established, billed and collected by the medical 
specialist in the same manner as are the fees 
of other physicians. The A.M.A. intends to 
continue vigorously its efforts to prevent in- 
clusion in the future, the specialists services 
and the hospital services under any health care 
legislation. 

“Be it resolved, that the Nebraska State 
Medical Association House of Delegates endorse 
and support this action. 

“Be it further resolved, that this action be 
immediately distributed to all members of the 
Nebraska State Medical Association and the 
Nebraska Hospital Association.” 

This was referred to Reference Committee No. 6. 

Resolution No. 8 — Introduced by Dr. Nutzman, 
Chairman of Tuberculosis Committee. 

RESOLVED, that approval be given to change 
the name of the Tuberculosis Committee to 
Committee on Tuberculosis and Other Respira- 
tory Diseases. 

This was referred to Reference Committee No. 6. 

Resolution No. 9 — Introduced by Dr. McMartin 
on the subject of physicians’ fees. This was re- 
ferred to Reference Committee No. 7. 

The Speaker called on Mr. Neff to present any 
correspondence which had been received in the head- 


152 


Nebraska S. M. J. 


quarters office, and a letter was read to the House 
relative to a quit claim deed on the property of 
the American Cancer Society, in which we were 
asked to relinquish our interest in the title. This 
was referred to Reference Committee No. 3. 

The following requests for Life Membership were 
read and referred to Reference Committee No. 4. 
Clarence F. Bantin, M.D., Omaha 
Waldron A. Cassidy, M.D., Omaha 
Maurice E. Grier, M.D., Omaha 
Julius A. Johnson, M.D., Omaha 
Ralph Luikart, M.D., Omaha 

J. Harry Murphy, M.D., Omaha 
A. S. Rubnitz, M.D., Omaha 
Earl B. Brooks, M.D., Lincoln 
George W. Covey, M.D., Lincoln 
Frederick D. Coleman, M.D., Lincoln 
Harry E. Flansburg, M.D., Lincoln 

K. S. J. Hohlen, M.D., Lincoln 
D. D. Sanderson, M.D., Lincoln 
Sidney O. Reese, M.D., Lincoln 

The following list of 50-year practitioners was 
read and referred to Reference Committee No. 4; 
Wilmar D. McGrath, M.D., Grand Island 
Geo. W. Hoffmeister^ M.D., Mesa, Arizona 
Carl Gouldman, M.D., Ingleside 
Raymond S. Johnston, M.D., Kearney 
Sidney Reese, M.D., Lincoln 
Ruth A. Warner, M.D., Lincoln 
A. H. Webb, M.D., Lincoln 
Chas. Zimmerer, M.D., Nebraska City 
Arthur C. Brown, M.D., Omaha 
Lyman J. Cook, M.D., Omaha 
J. D. McCarthy, M.D., Omaha 
Friedrich D. Niehaus, M.D., Omaha 
A. J. Offerman, M.D., Omaha 
J. J. O’Hearn, M.D., Omaha 
A. C. Pi’uner, M.D., Omaha 
A. S. Rubnitz, M.D., Omaha 
Wm. L. Shearer, M.D., St. Paul, Minn. 

Lyle J. Roberts, M.D., Omaha 
Marcia Young, M.D., Omaha 

L. Morrow, M.D., Tekamah 

Dr. Nutzman read portions of the minutes of the 
Board of Councilors as they pertained to the House 
of Delegates. Dr. Landgraf moved that these be 
accepted and this was approved. These minutes were 
referred to Reference Committee No. 2. 

There being no further business, the House was 
adjourned until 9:00 a.m. Sunday morning. 

SECOND SESSION 
HOUSE OF DELEGATES 
February 13, 1966 

The second session of the Mid-Winter Meeting 
of the House of Delegates was called to order by 
the Speaker, Dr. Nutzman. 

The report of the Credentials Committee showed 
33 delegates present, and the House was declared 
in session. 

Dr. McFadden, Vice Speaker, read the minutes of 
the first session, and these were approved as read. 

Dr. Wright, President, was granted permission 
of the floor and recommended the formation of a 
Cardio-Vascular Committee. He stated that since 
over one-half of the deaths in Nebraska are due 
to cardiovascular diseases, it was appropriate that 


a committee be formed to study advances in cardio- 
vascular research and to follow and work with the 
voluntary health agencies and the medical schools 
in Nebraska and report to the Nebraska State 
Medical Association. Dr. Wright recommended that 
this be a standing committee of the Association. 
The Speaker called for suspension of the rules 
so that this recommendation could be discussed at 
this time. Following approval of the House to 
suspend the rules, the motion was made to accept 
this recommendation and that it be referred to the 
Constitution and By-Laws Committee so that proper 
changes may be made. This was seconded and 
carried. 

Dr. Nutzman called for the reports of the Ref- 
erence Committees, and they were given as fol- 
lows: 

Reference Committee No. 1 

Members of Reference Committee No. 1 were 
Drs. Vein Steffens, Chairman; Otis Miller, and 
Frank Tanner. 

Your Reference Committee recommends approval 
of the report of the Editor, Dr. Cole, as given 
on page 24 of the Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report by Dr. Sorensen, Chairman of the 
Board of Trustees, as given on pages 22-23 of the 
Handbook. The committee calls attention to the 
last sentence in the report: “We may be assured 
any future dues increases will be made necessary 
by the added activities we must undertake in order 
to maintain our position in a modern complex so- 
ciety.” 

Mr. Speaker, I move the adoption of this sec- 
tion of our report. This motion was seconded 
and carried. 

Your Reference Committee recommends approval 
of the report of our Delegate to the A.M. A., Dr. 
Schenken, as given on pages 25-27 of our Handbook. 
The committee wishes to call attention to five of 
the statements which are to be used as a guide ir- 
respective of whether such fees are paid by the 
patient or paid or reimbursed in whole or in part 
under Public Law 89-97 or any other third-party 
plan. 

1. No interposition of a third-party carrier. 

2. It is the patient’s responsibility to deal 
with third-party carriers in the area of fi- 
nancial assistance. 

3. Advance understanding between doctor and 
patient regarding payment of the fees is 
highly desirable. Physician may choose 
manner in which he is to be compensated. 

4. A.M. A. disapproves of any program which 
promotes charging excessive fees. 

5. A.M. A. opposes any program of dictation, 
interference, or coercion affecting freedom 
of choice of the physician to detennine for 
himself the extent and manner of participa- 
tion or financial arrangement under which 
he shall provide medical care to patients 
under Public Law 89-97, or other third-party 
plans. 


April, 1966 


153 


Mr. Speaker, I move the adoption of this sec- 
tion of our report. This was seconded and carried. 

Your Reference Committee recommends approval 
of the report of the Executive Secretaiy, Mr. Ken 
Neff, as given on pages 16-21 of the Handbook. 
Special attention is called to his summaiy of Title 
XIX of the Medicare Bill: “This bill brings under 
one roof all the cuiTent welfare programs which 
are in existence such as the Old Age Assistance 
Program, Kerr-Mills, Aid to Dependent Children 
and Aid to the Blind. A committee of the Nebraska 
State Medical Association has been designated to 
follow the implementation of Title XIX very closely 
in Nebraska.” 

Mr. Speaker, I move the adoption of this sec- 
tion of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report of our Delegate to the North Central 
Conference, Dr. Paul Maxwell, as printed in the 
Handbook on pages 28-31. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee wishes to call atten- 
tion to the recommendation of the Board of Coun- 
cilors that the matter of the Governor’s request 
for a committee to deal with complaints regarding 
professional staffs of all state agencies be handled 
by the Council on Professional Ethics. Our com- 
mittee recommends that this recommendation be 
adopted by the House of Delegates. 

Mr. Speaker, I move the adoption of this 
section of our report. However, it was noted 
that Reference Committees No. 2 and No. 4 
had also considered this recommendation, and 
Dr. Steffens requested that this portion of his 
Reference Committee report be withdrawn. This 
request was approved. 

Your Reference Committee also calls attention to 
the recommendation by the Board of Councilors 
that the request of the Nebraska Bar Association 
for a body representing the Association meet with 
representatives of that organization to explore the 
problem of malpractice suits be handled by the 
Medicolegal Advice Committee. Our committee rec- 
ommends that this recommendation be adopted by 
the House of Delegates. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee would also like to call 
attention to the fact that there were more than 
six complaints coming before grievance committees 
during the year, but most of these were handled 
at a local level. 

Dr. Steffens stated that it was felt that 
the osteopath should be removed from the 
Board of Medical Examiners and asked that 
this problem be considered at this time. The 
motion to suspend the rules to consider this 
matter was approved. Dr. Tanner, a member 
of the Board of Examiners, stated that this 
Board felt that in view of the fact that the 
osteopath had been placed on this Board for 
the pui-pose of inspecting the osteopathic schools 
and that this had been accomplished, it was 
no longer necessary to retain this member on 


the Board of Examiners. Dr. Tanner said it 
was their recommendation that the Medical 
Seiwice Committee take immediate steps with 
our legal counsel to prepare this for introduc- 
tion into the Legislature. It was moved and 
seconded that this recommendation be accepted. 
Motion carried. 

Mr. Speaker, I move the adoption of the re- 
port of your Reference Committee No. 1 as a 
whole. This was seconded and cai’ried. 

Reference Committee No. 2 

Members of Reference Committee No. 2 were 
Drs. J. Whitney Kelley, Chairman; Ivan French, 
and P. B. Olsson. 

Your Reference Committee recommends approval 
of the Audit as carried on pages 2-16 of the Hand- 
book. Exhibit A was approved and a loss of 
$917.62 was noted. Exhibit B and its sub-sections, 
B-1, B-2, B-3 and B-4 were all approved. A loss 
of $1,650.12 in B-1 was noted, as was a loss of 
$115.22 in B-3. A gain of $590.71 was noted in 
B-4. Exhibit C was approved and a loss of $71.07 
was noted. Exhibit D was approved. Attention 
of the House is called to these losses in order to 
accentuate the need for an increase in state dues. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded 
and carried. 

Your Reference Committee recommends approval 
of the report on Health Education in Schools and 
Colleges as earned on pages 53-55 of the Hand- 
book. Much progress has been made, but there 
is room for a great deal more. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded 
and canned. 

Your Reference Committee recommends the ap- 
proval of the report of the Sub-Committee on Ath- 
letic Injuries as carried on pages 49-50 of the Hand- 
book. We wish also to highly commend the activ- 
ities of this committee for the excellent work 
that they have done. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Refei’ence Committee recommends the ap- 
proval of the report of the Tenth National Confer- 
ence on Physicians and Schools as carried on pages 
32-33 of the Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee was assigned the Coun- 
cilors report which recommended the deletion of 
part 2 in the report of the Psychiatry Committee. 
We met with Reference Committee No. 4 on this 
matter because they were directly interested in 
Psychiatiy. We heartily commend their solution 
to the problem. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Mr. Speaker, I move the adoption of the 
report of your Reference Committee No. 2 as 
a whole. This was seconded and carried. 


154 


Nebraska S. M. J. 


Reference Committee No. 3 

Members of Reference Committee No. 3 were 
Drs. Arnold Lempka, Chairanan, Hull Cook, and 
A. J. Alderman. 

Your Reference Committee recommends approval 
of the report of the Civil Defense and Disaster Com- 
mittee as carried on pages 36-40 of the Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report of the Joint Commission for the Care 
of the Patient as carried on page 43 of the Hand- 
book. " 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report of the Council on Hospital and Pro- 
fessional Relations as carried on page 40 of the 
Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report of the Continuing Committee on Medi- 
cal Practice as carried on page 35 of the Hand- 
book. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee reviewed the letter 
requesting release of the quit claim deed of the 
property on 42nd and Dodge belonging to the 
American Cancer Society and recommends approval 
of this action. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee reviewed the Reso- 
lution No. 1 as submitted by Dr. Gilligan, but did 
not recommend its approval at this time because 
of considerable controversy regarding the exact 
function of the subcommittees suggested and the 
advisability of having 12 subcommittees. Your Ref- 
erence Committee recommends that Resolution No. 
1 as submitted by Dr. Gilligan be returned for 

clarification and be resubmitted at the Annual 
Meeting. 

Mr. Speaker, I move the adoption of this 

section of our report. This was seconded and 
carried. 

Mr. Speaker, I move the adoption of the 

report of your Reference Committee No. 3 as 
a whole. This was seconded and carried. 

Reference Committee No. 4 

Members of Reference Committee No. 4 were 
Drs. James Ramsey, Chairman; Roy J. Smith, and 
Robert Sorensen. 

Your Reference Committee recommends approval 
of the report of the Committee on Pre-Payroent of 
Medical Care, as carried on pages 44-45 of the 
Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
canned. 


Your Reference Committee recommends the ap- 
proval of the report of the Committee on Psy- 
chiatry, as carried on pages 46-47 of the Hand- 
book, with the exception of the second recommenda- 
tion in concurrence with the recommendation of the 
Board of Councilors. We recommend the substi- 
tution of the following recommendation: “The 

Policy Committee shall be obliged to review the 
discharge transfer or demotion of any state em- 
ployed physician upon written request of the in- 
volved individual. Their recommendations shall be 
reported to the governor of the State. Any such 
action should become a part of their report to the 
House of Delegates.” Mr. Speaker, I move the 
adoption of the substitute recommendation. This was 
approved. 

Mr. Speaker, I move the adoption of this 
section of our report as amended. This was 
seconded and carried. 

Your Reference Committee recommends the ap- 
proval of the report of Life Members. 

This was seconded and carried. 

Your Reference Committee recommends the ap- 
proval of the report on 50-year practitioners. 

This was seconded and carried. 

Your Reference Committee recommends the ap- 
proval of the report of the Committee on Allied 
Professions. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends the ap- 
proval of Resolution No. 2 from Lancaster County, 
except for the last paragraph. We recommend this 
change to read, “Be it hereby resolved that the 
Lancaster County Medical Society requests the Ne- 
braska State Medical Association to sponsor with 
other allied health fields the Nebraska Centennial 
Fair.” 

Mr. Speaker, I move the adoption of this 
resolution as amended. This was seconded and 
carried. 

Mr. Speaker, I move the adoption of the 
report of your Reference Committee No. 4 as 
a whole. This was seconded and carried. 

Reference Committee No. 5 

Members of Reference Committee No. 5 were 
Drs. H. V. Nuss, Chairman; Donald Purvis, and 
T. L. Weekes. 

Your Reference Committee recommends the ap- 
proval of the report of the Committee on Blood 
and Blood Products, as carried on pages 34-35 of 
the Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
earned. 

Your Reference Committee recommends the ap- 
proval of the report of the Committee on Diabetes, 
as carried on pages 41-42 of the Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends the ap- 
proval of the report of the Committee on Medicine 


April, 1966 


155 


and Religion, as carried on page 42 of the Hand- 
book. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends the ap- 
proval of the report of the Committee on Rural 
Medical Service, as canded on pages 56-57 of the 
Handbook. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Rehabilitation Committee had no meeting, but 
they anticipate this committee’s activity during 
1966 will be greater with the advent of the multi- 
ple types of Federal programs being put into effect 
this coming year, many of which will involve the 
sphere of Rehabilitation Medicine. 

Resolution No. 3 from the Board of Councilors, 
was referred to this Reference Committee and after 
due consideration of this resolution, we the Com- 
mittee in turn submit this matter to the Planning 
Committee of the Association, to report back to the 
House at the May meeting. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
caiTied. 

Ml'. Speaker, I move the adoption of the 
report of your Reference Committee No. 5 as 
a whole. This was seconded and carried. 

Reference Committee No. 6 

Members of Reference Committee No. 6 were 
Drs. Charles Landgraf, Chairman; Bmce Claussen, 
and Jerry Tamisiea. 

Your Reference Committee considered the report 
of the Policy Committee and recommends the ap- 
proval of that committee with the exception of 
the following; 

That portion of the report dealing with the pro- 
posed Blue . Shield Series 90 Plan. Is this an 
ordinal'^' “se^•^’ice benefit” plan or will the “pre- 
vailing fee” apply ? 

That portion dealing with Medicare negotiations. 
The House of Delegates of the N.S.M.A. directed 
the Policy Committee and Relative Value Study 
to negotiate a “usual and customary fee” based 
upon a 5 conversion factor across the board in the 
1965 Relative Value Study for all future contracts. 
The office of Dependents Medical Care did not ac- 
cept the conversion factor of 5 and proposed a 
conversion factor of 4.25 for medicine and surgery 
and a factor of 5 for radiology and pathology in 
the 1965 Relative Value Study and indicated that 
it wishes to meet with the Policy Committee again 
after the matter has been brought to the House 
of Delegates of the N.S.M.A. The Policy Com- 
mittee wishes a discussion by the House of Dele- 
gates to determine whether the House still directed 
that committee to follow the “usual and customary 
fee” of a 5 conversion factor across the board. As 
of this date, no other programs have been nego- 
tiated as the Policy Committee felt that this mat- 
ter should be settled prior to going into other 
negotiations. 

A letter from Fritz Teal, M.D., President, Ne- 
braska Association of Orthopedic Surgeons, Inc., 


requested “that in negotiations with various agen- 
cies concerning the 1965 Relative Value Study, 
the conversion factor of five (5) continue to be 
applied for all orthopedic procedures.” This letter 
is dated February 4, 1966. 

Your Reference Committee recommends that the 
House of Delegates direct the Policy Committee to 
continue to negotiate the conversion factor of 5 
for all medical and surgical services. 

Mr. Speaker, I move the adoption of this sec- 
tion of our report. This was seconded; how- 
ever discussion followed relative to the portion 
relative to the Blue Shield Series 90 Plan. It 
was pointed out that this had been taken 
care of at the 1965 Annual Meeting in May; 
and the House approved the deletion of this 
portion. 

There was also discussion on the last para- 
graph concerning the recommendation that the 
Policy Committee continue to negotiate for 
medical and surgical sei'sdces, and it was moved 
and seconded to amend this to read, “the Policy 
Committee and the Relative Value Study Com- 
mittee to continue to negotiate.” This was ap- 
proved. 

Your Reference Committee recommends the ap- 
proval of the report of the Maternal and Child 
Health Committee. It is reported that 92% of the 
newborn infants in Nebraska are being examined in 
the newborn period for phenylketonuria. Of those 
individuals of the United States confined to in- 
stitutions for the retarded, 1% suffered from 
phenylketonuria. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of the report of the Relative Value Study Commit- 
tee. 

Mr. Speaker, I move the adoption of this 
section of our repoi't. This was seconded and 
carried. 

Your Reference Committee recommends the ap- 
proval of Resolution No. 6 of the Omaha-Douglas 
County Medical Society which recommends Nebraska 
Blue Cross make payment for their insured to the 
University of Nebraska Hospital. 

Support of this resolution points out that Legis- 
lative Bill 911 permits acceptance to University Hos- 
pital of patients insured by Blue Cross and all 
other third party carriers; University Hospital is 
the only University Hospital in the United States 
not approved for Blue Cross payments; Nebraska 
Blue Cross now pays University Hospitals in other- 
states and makes reciprocal payments in Nebraska; 
University Hospital now cares for some Blue Cross 
insured patients who are denied benefits of their 
policy by Nebraska Blue Cross. 

Mr. Speaker, I move the adoption of this 
section of our repoi't. This was seconded and 
carried. 

Your Reference Committee recommends approval 
of Resolution No. 7 of the Omaha-Douglas County 
Medical Society in which it is requested that the 
N.S.M.A. endorse and suppoi-t the resolutions of 
the A.M.A. concerning the practice of medicine by 
hospitals based medical specialists in which it 
is further requested that report of such action be 


156 


Nebraska S. M. J. 


immediately distributed to the members of the 
N.S.M.A. and the Nebraska Hospital Association. 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Your Keference Committee recommends approval 
of the request of the Committee on Tuberculosis 
to change the name of that committee to the “Com- 
mittee on Tuberculosis and Other Respiratory Dis- 
eases.” 

Mr. Speaker, I move the adoption of this 
section of our report. This was seconded and 
carried. 

Mr. Speaker, I recommend the adoption of 
the report of your Reference Committee No. 
6 as a whole. This was seconded and carried. 

Reference Committee No. 7 

Members of Reference Committee No. 7 were 
Drs. Louis J. Gogela, Chairman; Robert Morgan, 
Warren Bosley, Dwaine Peetz, Houtz Steenburg, 
Dwight Burney, and W. J. McMartin. 

Your Reference Committee heard and considered 
the arguments advanced by the delegation relating 
to the “prevailing fee” and the “usual and cus- 
tomary fee” concept of payment for medical serv- 
ices. 

The committee wishes to thank the participants 
for the orderly and cordial manner in which the 
hearing was conducted. We believe the decision at 
which we arrive was obtained openmindedly. It 
was our opinion that the consideration of the two 
concepts revolved about negotiating mechanisms and 
philosophical ideals. 

The committee wishes to go on record as acknowl- 
edging the direction and service provided to the pro- 
fession by Nebraska Medical Services. At the same 
time, we realize the debt we owe other carriers. 

Upon conclusion of the hearing, the committee 
cast a ballot. However, some members of the com- 
mittee were of the opinion that not all the facts 
were presented. Accordingly, wishing to be as 
thorough, honest, and impartial as possible, addi- 
tional information was sought by the committee 
regarding the facts surrounding both the “usual 
and customary” concept and the “prevailing fee” 
program concept. The committee members present 
were aware of the opinion that the facts were better 
“balanced” after obtaining this infoi-mation. The 
decision of the committee regarding the two concepts 
then vacillated considerably. 

Lest the committee be judged to be dishonest or 
partial by reconsidering and casting a second 
ballot, we are recommending that this matter be 
referred to the Policy Committee for further con- 
sideration. It is recommended also that the two 
A.M.A. Delegates be members of this committee. 

It is with apology that this incomplete report 
is rendered. We believe you understand the com- 
plexity of the problem. We regret we do not have 
a ciystalized decision. 

Mr. Speaker, I move the adoption of this 
report. This was seconded, and considerable 
discussion followed. It was suggested that Ref- 
erence Committee No. 7 continue to study 
this and bring back their report to the House 
of Delegates at the May, 1966 meeting. How- 
ever, Dr. Gogela stated that this Reference 


Committee did not feel equipped or qualified 
to handle this situation, and it was for this 
reason they recommended that this be handled 
by the Policy Committee. 

The motion was made that the recommenda- 
tion of Reference Committee No. 7 be accepted, 
that the Policy Committee study this further 
and also that they report back to the House 
of Delegates in May as to the results of their 
study. This was seconded and carried. 

The Speaker called for unfinished business, and 
Dr. Gogela presented the following resolution: 

Resolution: Re — Mr. Frank Woolley 

WHEREAS, Mr. Frank Woolley has been 
Field Representative of the American Medical 
Association to Nebraska for the past five years, 
and 

WHEREAS, he has most ably served our As- 
sociation and its members during this period 
in a most efficient and prompt manner; there- 
fore be it 

RESOLVED, that the House of Delegates go 
on record as extending their sincere thanks 
to Mr. Woolley for a job well done; and be 
it further 

RESOLVED, that a copy of this resolution 
be sent to Mr. Woolley and the American 

Medical Association. 

This resolution was approved by the House of 
Delegates. 

Dr. Wittson, Dean of the University of Ne- 

braska College of Medicine, was asked for his com- 
ments on the construction program at the Uni- 
versity and any other information he w'ould like 
to convey to the House. 

Dr. Steffens was granted permission of the 

floor and extended an invitation to the House of 
Delegates to hold their 1967 Mid-Winter Meeting 
in Kearney, Nebraska, and this was approved. 

The Speaker asked that a letter of appreciation 
be written to Mr. Hutchins, of the Holiday Inn of 
Kearney. 

There w'as discussion relative to the negotiating 
committee for governmental programs, and Dr. 

Ramsey moved that the Policy Committee, in con- 
sultation with the Relative Value Study Committee, 
be the negotiating committee for all governmental 
agencies and compensation courts on fees. 

The House approved the suspension of the rules 
to consider the motion by Dr. Ramsey, and the 
motion was seconded and carried. 

There being no further business, the House was 
adjourned. 

1965 Annua! Audit and 
Committee Reports, 
Nebraska State Medical Association 

January 17, 1966 

Nebraska State Medical Association 
Lincoln, Nebraska 

We have examined the books and records of the 
Nebraska State Medical Association for the year 


April, 1966 


157 


1965, and submit herewith our report. Included 
with the report are the following exhibits and 
schedules : 

Exhibit A — Analysis of Fund Balances 

Exhibit B — Statement of Receipts and Disbui'se- 
ments, General Fund 

Schedule B-1 — Statement of Receipts and 
Disbursements, Annual Session 
Schedule B-2 — Compai-ison of General Ex- 
pense with Budget 

Schedule B-3 — Statement of Receipts and 
Disbursements, Hall of Health 
Schedule B-4 — Statement of Receipts and 
Disbursements, Athletic Confei’ence 

Exhibit C — Statement of Receipts and Disburse- 
ments, Journal Fund 

Exhibit D — Statement of Investments 

Schedule D-1 — Statement of Investment 
Balances 

Exhibit E — Journal Accounts Receivable, Decem- 
ber 31, 1965 

EXHIBIT A 

Exhibit A is the analysis of fund balances. During 
the year 1965 there was a decrease in the bal- 
ances amounting to $917.62. Total fund balance on 
December 31, 1965 was $74,500.00, and was repre- 
sented by cash in the General Fund account of 
$165.41, cash in the Journal Fund account of $4.33, 
investments of $71,330.26, and notes receivable from 
Nebraska Medical Foundation of $3,000.00. Both of 
the above cash accounts are maintained at the Na- 
tional Bank of Commerce Timst and Savings Asso- 
ciation, Lincoln, Nebraska. 

EXHIBIT B 

The details of the changes in the General Fund 
cash balances are shown in Exhibit B. In this 
statement the receipts and disbursements have been 
divided into two classifications. Under the head- 
ing of General, the principal items are membership 
dues of $67,622.50, interest collected of $707.20, 
trust account income of $1,979.27, income from the 
Annual Session of $7,022.95, and the American Medi- 
cal Membership expense rebate of $538.65. 

Other receipts include cash received for the Ameri- 
can Medical Association dues of $54,067.50. This 
amount was i-emitted to the American Medical As- 
sociation, as shown under Other Disbursements in 
this statement. 

The General Fund disbursements of the Associa- 
tion are divided into the same classifications as the 
receipts. The total amount of general disbursements 
was $78,032.88. A comparison of these items with 
the budget items approved for 1965 is shown in 
Schedule B-2. Other disbursements were $55,008.54. 
This amount included American Medical Association 
dues of $54,067.50. Other items classified as Other 
Disbursements were $626.46 for miscellaneous ex- 
penditures not budgeted for 1965 and net funds 
transferred to a separate bank account to be used 
exclusively for the Athletic Conference activities 
in the amount of $314.58. The total General Fund 
disbursements during the year were $133,041.42. The 
excess of disbursements over receipts for 1965 Gen- 
eral Fund operations amounted to $972.62. 

During the year 1965, the Association established 
the Athletic Conference Fund as a separate account 


to be used exclusively for Athletic Conference ac- 
tivities. The amount of funds transferred to the 
separate account (net) during 1965 is shown on 
Schedule B-4, together with an accounting of Ath- 
letic Conference receipts and disbursements will 
be accounted for as a separate fund and not as a 
part of the General Fund. 

EXHIBIT C 

A separate Journal Fund account was established 
on Januaiy 1, 1963 for handling receipts and dis- 
bursements in connection with publication of the 
Association Journal. The details of the Journal Fund 
receipts and disbursements are presented as Ex- 
hibit C. Journal receipts during 1965 amounted 
to $25,361.71 and total disbursements were $25,432.78. 
The excess of disbursements over receipts for 1965 
was $71.07. 

EXHIBIT D 

The changes which occurred in the Investment ac- 
count during the year are shown in Exhibit D. The 
total of investments at the beginning of the year 
was $71,204.19. There was a net increase in the 
U. S. Government Bonds, Series J, held by the 
Association of $161.00. There was a net loss in- 
curred on the redemption of Sears-Roebuck bonds 
called in 1965 in the amount of $34.93. The resulting 
net increase in investments for 1965 was $126.07. 
The total amount of investments at cost value at 
December 31, 1965, was $71,330.26. A detailed list 
of the investments at the beginning and close of 
the year is shown in Schedule B-1. 

EXHIBIT E 

Exhibit E is a list of the Journal accounts receiv- 
able. Our examination of the accounts receivable 
records indicated that the major portion of these ac- 
counts are receivable for Journal advertising dur- 
ing the months of November and December, 1965. 
The records also indicated that these accounts are 
being paid currently. Because the Association oper- 
ates on a cash basis, these items are not taken into 
income until cash is received. We did not confirm 
the balances of the accounts by independent corre- 
spondence. 

SCOPE OF EXAMINATION AND 
GENERAL COMMENTS 

Receipts for the year were traced through the 
books and into the bank accounts. Tests were made 
of letters of transmittal tracing the detail items 
to the individual members’ accounts. An inspection 
of the members’ cards in connection with our exam- 
ination of the receipts indicated that all cards issued 
to members during the year were accounted for on 
the books of the Association. The records also in- 
dicated that during the year 1965, cards were issued 
to 101 Life Members, for which no dues were col- 
lected. Cancelled checks for the year were in- 
spected and compared to the items in the check regi- 
ster. Invoices and creditors’ statements were ex- 
amined covering a major portion of the disburse- 
ments. Minutes of the timstees’ meetings during the 
year were examined with regard to authorization of 
salaries, budgets and other disbursements. 'The 
balances shown as cash in bank were confirmed by 
direct correspondence with the depository. Our ex- 
amination also included an inspection of securities 
owned by the Association at the close of the year. 


158 


Nebraska S. M. J. 


Funds in investment accounts were confirmed by 
correspondence. 

Subject to the foregoing comments it is our 
opinion that the attached statement of fund bal- 
ances at December 31, 1965, and the related state- 
ments of receipts and disbursements for the year 
then ended present fairly the financial position 
of the Nebraska State Medical Association at Decem- 
ber 31, 1965 and the results of its operations for the 
year then ended, on the basis of cash receipts and 
disbursements, in a manner consistent with the 
preceding year. 


Officers’ Expense 2,875.07 

A.M.A. Expense (Dele- 
gate. Alternate) 3,353.86 

Committee Expense and 

Travel 3,428.31 

Senior Medical Day 1,056.50 

Dues, Share to Journal 5,998.50 

Office Equipment and 

Furniture 501.37 

General Fund Expense 1,379.00 

Public Relations 6,338.20 


Other : 

A.M.A. Dues Forward- 
ed to A.M.A. 54,067.50 

Other Disbursements 

from General Fund 626.46 

Athletic Conf. (note) 314.58 


78,032.88 


55,008.54 


DANA F. COLE AND COMPANY 


TOTAL DISBURSEMENTS $133,041.42 

EXCESS OF DISBURSEMENTS OVER RECEIPTS 972.62 


EXHIBIT A: 

NEBRASKA STATE MEDICAL ASSOCIATION 
ANALYSIS OF FUND BALANCES 


YEAR 1965 

Total Fund Balance, January 1, 1965 $75,417.62 

Represented by : 

Cash — National Bank of Commerce, 

General Fund $ 446.37 

Cash — National Bank of Commerce, 

Trust Account. Investment Fund 691.66 

Cash — National Bank of Commerce, 

Journal Fund 75.40 

Investments — Exhibit D 71,204.19 

Notes Receivable — Nebraska Medical 

Foundation 3,000.00 


CASH BALANCE, National Bank of Commerce, 

Lincoln, Nebr., December 31, 1966 $ 165.41 

NOTE: This amount is a transfer of funds to a separate 
bank account to be used exclusively for Athletic 
Conference activities. In the future. Athletic Con- 
ference fund receipts and disbursements will be 
accounted for as a separate fund and not as part 
of the Association account. 


SCHEDULE B-1: 

NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF RECEIPTS AND DISBURSEMENTS 
ANNUAL SESSION 


Decrease in Fund Balances: 
Excess of Disbursements over 

Receipts, General Fund 

Excess of Disbursements over 
Receipts, Journal Fund 


$75,417.62 

.$ 972.62 

71.07 


Less Increase in Investments, 
Exhibit D 


1,043.69 

126.07 917.62 


TOTAL FUND BALANCES. 

December 31, 1965 $74,500.00 

Represented by : 

Cash — National Bank of Commerce, 

General Fund $ 165.41 

Cash — National Bank of Commerce, 

Journal Fund 4.33 

Investments — Exhibit D 71,330.26 

Notes Receivable — Nebraska Medical Foundation 3,000.00 


$74,500.00 


EXHIBIT B: 


YEAR 1965 


RECEIPTS: 

Exhibits $6,105.93 

Banquet 852.00 

Miscellaneous 65.00 


TOTAL RECEIPTS $7,022.93 

DISBURSEMENTS: 

Badges $ 61,77 

Exhibitors’ Party 130.00 

Booths 592.50 

Courtesy Room 37.75 

Banquet 1,379.45 

Guest Speakers 4,199.27 

Employees’ Expense 387.10 

Past Presidents’ Breakfast 25.30 

Entertainment and Gratuities 255.00 

Miscellaneous 117.47 

50-Year Pins 61.14 

Printing 5.15 

Presidents* Reception 580.00 

Plaques, Engraving 47.05 

Projectionists, Camera, Film 456.70 

Special Programs 337.40 


NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF RECEIPTS AND DISBURSEMENTS 
GENERAL FUND 
YEAR 1965 

Cash Balance, National Bank of Commerce, 

Lincoln, Nebr., Jan. 1, 1965 $ 446.37 

Cash Balance, National Bank of Commerce, 

Trust Account. Lincoln, Nebr., 

Jan. 1. 1965 691.66 1,138.03 


RECEIPTS: 

General : 

Membership Dues 

Interest Collected 

Trust Acct. Income _ 
Annual Session. 1965 
A.M.A. Membei*ship 

Expense Rebate 

Relative Value Studies 


Other Receipts : 

A.M.A. Dues 54,067.50 


TOTAL RECEIPTS $132,068.80 

DISBURSEMENTS: 

General : 


Salaries - $ 

29,770.23 

Payroll Taxes 

800.08 

Travel Expense 

2,598.42 

Office Expense: 
Rent 

4,105.09 

Postage 

1,445.99 

Telephone & Telegraph 

1,894.10 

Supplies and Misc. 
Contracts 

712.93 

Annual Session 

8,673.05 

Professional Fees 

840.00 

Dues in Other 
Organizations . 

690.00 

Insurance Expense 

95.78 

Printing, Supplies and 
Publications 

1,476.40 


67,622.50 

707.20 

1,979.27 

7,022.93 

538.65 

130.75 78,001.30 


TOTAL DISBURSEMENTS $8,673.05 

EXCESS OF DISBURSEMENTS OVER RECEIPTS __$1,650.12 


SCHEDULE B-2: 

NEBRASKA STATE MEDICAL ASSOCIATION 
COMPARISON OF GENERAL EXPENSE WITH BUDGET 
YEAR 1965 

Actual 
(Over) or 
Actual Under 

Budget Expense Budget 

Salaries $29,776.00 $29,770.23 $ 5.77 

Payroll Taxes 900.00 800.08 99.92 


Travel Expense (employees) — 
Office : 

Rent 

Postage 

Telephone and Telegraph 

Supplies and Miscellaneous 

Contracts 

Annual Session 

Professional Fees 

Dues in Other Organizations— 

Insurance Expense 

Printing, Supplies and 

Publications 

Officers’ Expense 

A.M.A. Expense (Delegate, 

Alternate) 

Committee Expense and Travel 

Senior Medical Day 

Dues, Share to Journal 

Office Equipment and 

Furniture 

General Fund Expense 

Public Relations 


2,600.00 

2,598.42 

1.58 

4,093.00 

4,105.09 

(12.09) 

1,400.00 

1,445.99 

(45.99) 

1,600.00 

1,894.10 

(294.10) 

475.00 

712.93 

(237.93) 

6,800.00 

8,673.05 

(1,873.05) 

1,800.00 

840.00 

960.00 

640.00 

690.00 

(50.00) 

130.00 

95.78 

34.22 

1,500.00 

1,476.40 

23.60 

2,200.00 

2,875.07 

(675.07) 

2,100.00 

3,353.86 

(1,253.86) 

3,000.00 

3,428.31 

(428.31) 

575.00 

1,056.50 

(481.60) 

6.000.00 

5,998.50 

1.50 

500.00 

501.37 

(1.37) 

1,200.00 

1,379.00 

(179.00) 

6,800.00 

6,338.20 

461.80 


[,089.00 $78,032.88 ($3,943.88) 


April, 1966 


159 


SCHEDULE B-3: 

NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF RECEIPTS AND DISBURSEMENTS 
HALL OF HEALTH 
YEAR 1965 

Unexpended Balance, Bank Balance, National 


Bank of Commerce. Lincoln, Nebr., 

January 1, 1965 $ 209.95 

RECEIPTS : 

American Cancer Society $ 100.00 

Nebraska Dental Association 100.00 

Nebraska Tuberculosis Association 100.00 

Nebraska Society of Radiologic 

Technologists 100.00 

Nebraska Heart Association 100.00 

Nebraska Diabetes Association 100.00 

Nebraska Nursing Home Association 100.00 

Nebraska Chapter, Arthritis and 

Rheumatism Foundation 100.00 

Nebraska Psychiatric Institute 100.00 

Nebraska Society of Medical 

Technologists 100.00 

Nebraska Sertoma Clubs 100.00 

Nebraska Lions Sight Conservation 100.00 

Nebraska State Department of Health 300.00 

Nebraska State Medical Association 200.00 1,700.00 


$1,909.95 

DISBURSEMENTS: 

Nebraska State Fair and Exposition 600.00 

Fred McDaniel. Labor and Supplies 160.14 

Jerrold Copley. Labor 85.00 

Bill Schellpeper, Labor and Supplies 50.00 

Gorham Photo 41.00 

Electricity 74.40 

Baker Hardware. Supplies 3.54 

M. G. Lehman Co.. Service, Air Conditioner 28.00 

United Rent-Alls, Chairs 35.00 

Earl Carter Co., Supplies 2.55 

Davison Display 595.00 

A.M.A. Exhibit 120.10 1,794.73 

Unexpended Balance, Bank Balance, National 
Bank of Commerce, Lincoln, Nebr., 

December 31, 1965 $ 115.22 


NOTE: The Hall of Health is jointly sponsored by the 
above organizations, and the records are kept by 
the Nebraska State Medical Association. How- 
ever, funds for this project are not properly a 
part of the Association funds and are kept in a 
separate bank account. 


SCHEDULE B-4: 


NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF RECEIPTS AND DISBURSEMENTS 
ATHLETIC CONFERENCE 
YEAR 1965 


RECEIPTS: 

Transferred from General Fund $ 314.58 

Sponsors : 

Nebraska Dental Association $ 150.00 

Nebraska Academy of G.P. 150.00 

Nebraska School Activities 150.00 450.00 

Exhibits : 

Brunswick 100.00 

Rawlings 100.00 200.00 

Grant : 

Merck, Sharp & Dohme 400.00 

Registration Fees and Banquet 296.00 


$ 75.00 

66.00 
451.57 
27.50 
261.35 
11.45 
177.00 


Unexpended Balance, Bank Balance, National 
Bank of Commerce, Lincoln, Nebraska. 

December 31. 1965 $ 590.71 

EXHIBIT C: 

NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF RECEIPTS AND DISBURSEMENTS 


JOURNAL FUND 
YEAR 1965 

Cash in Bank, January 1, 1965 $ 75.40 

RECEIPTS: 

Advertising $17,939.28 

Subscriptions 427.93 

Copies Sold 3.00 

Dues, Share to Journal 5,998.50 

Associate Members’ Subscriptions 155.00 

Journal Publication 813.00 

Miscellaneous 25.00 


TOTAL RECEIPTS $25,361.71 

DISBURSEMENTS : 

Salaries $ 2.188.00 

Editor’s Expense 1,247.65 

Printing of Journal: 

Publication Expense $15,110.45 


DISBURSEMENTS: 
Freeman Decorating 

Lincoln City Lines 

Hotel Cornhusker 

Gratuities 

Mr. Bobby Gunn 

Reprints 

Dr. Irvin Hendi*yson 


1,346.00 

$1,660.58 


1,069.87 


Color 

2,784.87 

9d 

Cuts, Engraving and 


Art Work 

499.96 

Press Clipping Expense 

204.20 

Cartoons - _ _ 

391.00 

Single Wrapping _ 

117.24 

Cover - 

926.98 

Reprints _ _ . 

. - 174.89 

Miscellaneous _ 

1.025.30 


TOTAL DISBURSEMENTS $25,432.78 

EXCESS OF DISBURSEMENTS OVER RECEIPTS „$ 71.07 


CASH BALANCE. December 31, 1965 $ 4.33 

Represented by : 

Cash Balance, National Bank of Commerce, 

Lincoln, Nebr., Dec. 31, 1965 $ 4.33 

EXHIBIT D: 

NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF INVESTMENTS 


YEAR 1965 

Total Investments, January 1, 1965 

(Schedule D-1) $71,204.19 

Increased by: 

Increase in Value, U.S. Savings Bonds, 

Series J 161.00 


$71,365.19 

Decreased by : 

Loss on Redemption of Seal's Roebuck 

Bonds (called) 34.93 


TOTAL INVESTMENTS. December 31, 1965 

(Schedule D-1) $71,330.26 


SCHEDULE D-1 : 

NEBRASKA STATE MEDICAL ASSOCIATION 
STATEMENT OF INVESTMENT BALANCES 
DECEMBER 31. 1964 and 1965 

12-31-1964 12-31-1965 

TRUST ACCOUNT: (Securities and Cash 
at Cost Value in Hands of National 
Bank of Commerce Trust and Savings 
Association) 

Central and Southwestern Coi*p., 


100 Shares Common $ 1,358.44 $ 1,358.44 

General Electric Company, 

120 Shares Common 3,623.35 3,623.35 

Houston Lighting and Power Company, 

363 Shares Common 3,898.08 3,898.08 

Standard Oil Company (N.J.), 

100 Shares Common 6,441.40 6,441.40 

U, S. Steel, 60 Shares Common 6,118.08 6,118.08 

Sears & Roebuck Bonds, 

4%^c due 8-15-83 5,179.36 4,134.99 

U. S. Steel Bonds. 4</f. due 7-15-83 4,962.50 4,962.50 

U. S. Treasury Bonds, 

3%<7f. due 1-15-71 1,992.50 1,992.50 

U. S. Treasury Notes, 

due 11-15-73 13,901.56 13,901.56 

Principal Cash Account 281.17 1,290.61 


TOTAL TRUST ACCOUNT $47,756.44 $47,721.51 

U. S. GOVERNMENT BONDS: 

U. S. Savings Bonds, Series H $11,000.00 $11,000.00 

U. S. Savings Bonds, Series J, 

(Cost $4,122 : Maturity Value $5,725) 

at Redemption Value 4,959.00 5,120.00 

U. S. Savings Bonds, Series K 3,000.00 3,000.00 

U. S. 'Treasury Bonds. 4%> due 2-15-72, 

(Maturity Value $4,500), at Cost 4,488.75 4,488.75 


TOTAL U. S. GOVERNMENT BONDS,— $23,447.75 $23,608.75 


GRAND TOTAL OF TRUST ACCOUNT 
AND U. S. GOVERNMENT 

BONDS ACCOUNT $71,204.19 $71,330.26 


EXHIBIT E: 

NEBRASKA STATE MEDICAL ASSOCIATION 
JOURNAL ACCOUNTS RECEIVABLE 
DECEMBER 31, 1965 


News Printing Company $ 18.00 

Chem-Plastics and Paint Coi*p. 30.00 

R. T. Satterfield, M. D. 2.00 

Mrs. H. B. Rae 4.00 

R. C. Thompson 2.00 

State Medical Journal Advertising Bureau 2,732.38 


$2,788.38 

REPORT OF EXECUTIVE SECRETARY 
The year 1965 will go down in the annals of 
medical history as one of the most significant and 
monumental years ever for organized medicine. 
In the report that follows I will capsule the events 
that have taken place on the national and state level 


160 


Nebraska S. M. J 


as they reflect and affect Nebraska medicine. 
Throughout the book there will be more detailed 
reports on specific activities by the various chair- 
men and officers. 

NATIONAL LEGISLATION 

Two major pieces of legislation passed in the 
1965 Congress are now law and will have far 
reaching effects upon the practice of medicine. 
They are Public Law 89-97, more commonly known 
as “Medicare,” and Public Law 89-239, the Heart 
Disease, Cancer and Stroke Amendments of 1965. 
I am sure that everyone is familiar with this legis- 
lation and also aware of the tremendous battle 
which was fought by organized medicine and its 
allies to stop this legislation from being passed. 
However, our efforts were not successful and we 
are now faced with making the laws work to 
the best of our ability. Much activity has taken 
place since the passage of these two laws with nu- 
merous national and regional meetings being car- 
ried out to inform physicians and to work on the 
regulations by which these programs will be im- 
plemented. Representatives of the American Medi- 
cal Association have been appointed to all task 
forces w'hich are working with the Department of 
Health, Education and Welfare preparing the regu- 
lations which will tell the real story of what “Medi- 
care” is going to be. Likewise an advisory commit- 
tee has been set up to implement the Heart Dis- 
ease, Cancer and Stroke law. In addition to this, 
the Nebraska State Medical Association called a 
meeting late in 1965, and formally organized an ad- 
visory study council to look into the program of 
Heart Disease, Cancer and Stroke in the State of 
Nebraska. The Policy Committee is representing 
the Nebraska State Medical Association on this 
matter and the President of the State Medical As- 
sociation will seiwe as permanent chairman of this 
organization. Under the “Medicare” law, the State 
Department of Health has been named the admin- 
istrator for the Title XVIII portion. This division 
will have the responsibility for certification of hos- 
pital and long term care facilities as they apply 
to the “Medicare” program. Another very im- 
portant section of the “Medicare” Bill is Title XIX, 
w^hich possibly has greater potentiality for the 
eventual federal control over the practice of medi- 
cine than does Title XVIII. This bill brings under 
one roof all the current welfare programs w^hich are 
in existence such as the Old Age Assistance Pro- 
gram, Kerr-Mills, Aid to Dependent Children and 
Aid to the Blind. A committee of the Nebraska 
State Medical Association has been designated to 
follow' the implementation of Title XIX very closely 
in Nebraska. From time to time w'e will make re- 
ports to the membership regarding the progress on 
Title XVII portion of “Medicare” as well as Title 
XIX. 

The passage of this legislation by the 1965 Con- 
gress w'ill necessitate greater activity on the part 
of the Association and its members in order to fully 
protect the rights of the physicians to the greatest 
possible extent. 

STATE LEGISLATION 

The Nebraska Unicameral met in 1965 and this 
group was also very active in the health field. A 
number of pieces of important legislation w'ere con- 


sidered by this body and I will make a brief report 
regarding the final status of this legislation. 

Approximately 45 pieces of legislation affecting 
public health and medicine were followed and acted 
on appropriately by the Nebraska State Medical 
Association. I am pleased to say that the Associa- 
tion enjoyed a very fine relationship with the Legis- 
lature during this session. It was extremely help- 
ful to have a physician in the Unicameral for the 
first time in many years. Each bill on which we 
testified, either for or against, was handled in a 
manner satisfactory to the Association and there- 
fore contributed to a successful legislative session 
in our behalf. Listed below' are some of the major 
bills and the action taken by the Legislature. The 
follow'ing bills w'ere killed in committee; 

1. Allow'ance for counting of pills by other than 
a pharmacist. 

2. Prohibiting doctor ownership of a pharmacy. 

3. Creating a board of registration for X-ray 
technicians. 

4. Revising the procedures for admission and re- 
lease of mentally ill persons from hospitals. 

5. Compulsory testing of new'-born infants for 
metabolic diseases and PKU. 

6. The addition of chiropractic sei-vices as pay- 
able under health insurance policies. 

7. Law's relating to the repeal of the compulsory 
sterilization of inmates at the Beatrice State 
Home. 

The following bills were supported by the State 
Medical Association and passed by the Legislature: 

1. The repoi-ting of w'ounds or injuries w'hich ap- 
pear to have been the result of criminal of- 
fense. 

2. Increasing the annual license fees for physi- 
cians. 

3. Provision for suspension of a physician’s li- 
cense by reason of mental illness. 

4. Increase in per diem allowance of the Board 
of Examiners in Medicine and Surgery. 

5. The expansion of the Keir-Mills program 
through liberalizing income limitations and 
removal of relative responsibility. This bill 
has been neutralized to a large degree by the 
passage of the Medicare Bill w'hich incorpor- 
ated the Kerr-Mills law' into the overall w'el- 
fare program. Kerr-Mills, as such, w'ill not 
be an individual program from here on out. 

6. Making certain changes in the reciprocity pro- 
cedure for physicians. 

7. Reporting of suspected cases of the Battered 
Child Law' and w'aiving of privileged communi- 
cations in the case of the battered child. 

8. The removal of the ceiling of the annual 
salary of the State Health Director. 

9. The final and most significant bill in the 
1965 Legislature as far as w'e w'ere con- 
cerned w'as the passage of the law' providing 
that Osteopathic Schools meet certain stand- 
ards before applying to the Board of Exam- 
iners for inspection. During late 1964 and 
early 1965, the Board of Examiners in Medi- 
cine' and Surgery in Nebraska visited all five 
Osteopathic Schools and inspected their fa- 
cilities. A comprehensive report was pre- 


April, 1966 


161 


pared by the committee which also included 
Uvo osteopaths and Deans of both medical 
schools. These reports were made to the 
Board of Health and subsequently made kno\\Ti 
to the Legislature in the form of L.B. 624. 
In their report, the Board of Examiners felt 
that none of the schools examined reached 
the minimum requirements as required of 
the medical schools. There has been na- 
tional interest in the findings of the Board 
of Examiners, and many states have requested 
copies of the report which was prepared by 
this body. The passage of this bill ends a 
number of years of activity and considerable 
controversy on this subject; and we feel that 
it has been solved to the best interest of all 
persons involved. 

The Legislature introduced nearly 1,000 bills in 
1965 and it is my estimation they will probably 
exceed this figure in 1967. For this reason we 
can expect an increase in the number of bills affect- 
ing public health and medicine. The year 1967 will 
undoubtedly see us involved in another year of con- 
siderable activity at the State Legislature. 

We do appreciate all the help the members have 
given us, and especially the contact men in the 
Legislative Districts. We will be calling on you 
again to assist us in our contact with the 1967 
Legislature. 

1966 ANNUAL SESSION 

The 1965 Session climaxed another successful ef- 
fort by the Scientific Sessions Committee to pre- 
sent an interesting and dynamic program. It was 
well received and well attended by physicians. Aux- 
iliary and other guests. 

The 1966 Annual Session will again prove to be a 
very informative and active meeting for members 
of the Nebraska State Medical Association. The 
Scientific Sessions Committee has worked diligently 
to add new features and insure that a top-notch sci- 
entific program will be presented. I am sui’e each 
of you will agree once you see the finished program. 

The 1966 meeting will be held the week of May 
2 - 5, 1966, at the Hotel Corahusker, Lincoln. 

The Auxiliary will join us for the Keynote Speech 
on Tuesday morning by Dr. James E. Appel, Presi- 
dent of the American Medical Association. 

A new item introduced in 1966, will be the First 
Annual Distinguished President’s lecture and will 
be given by Dr. Isidore S. Ravdin of Philadelphia, 
world-renowned physician. This will be the begin- 
ning of an annual Presidential Lectureship. The 
committee feels this will add considerably to the 
quality of the Annual Session. 

Another feature to be held on the last day, is a 
combined meeting on medicine and the law. A 
number of well known speakers in both fields will 
be present to discuss this subject. The Nebraska 
Bar Association is also planning a continuation of 
this meeting in the afternoon. All members of the 
Nebraska Bar Association as well as the State 
Medical Association, will be invited to attend this 
most important conference. 

NEBRASKA STATE MEDICAL JOURNAL 

During the year 1965, the Nebraska State Medical 
Journal has been able to hold its own financially, 
and we have reason to believe that possibly the 


bottom has been reached. We hope that 1966 will 
see a gradual upturn in the income producing ability 
of this publication. 

At the October Journal Conference in Chicago, 
our representatives of the State Medical Journal 
Advertising Bureau felt optimistic about the possi- 
bility of additional income from new ads and ex- 
pansion of the advertising progi’am of some of our 
long-time advertisers. 

This is still an extremely competitive field and 
we cannot expect a significant increase in our in- 
come; however, the Journal is not a profit-making 
enterprise for this Association. As long as it car- 
ries its own expenses, we feel that it is a profit 
carrier of scientific and socio-economic information 
to the membership. 

The Journal has been in the hands of a new Editor 
since June, Dr. Frank Cole of Lincoln. He has done 
a very excellent job in carrying on the high quality 
and content of the Journal which has been one of its 
main features for many years. 

With the December publication, 1965, the Journal 
has ended 50 years of publication, and it has been 
a significant part of organized medicine in Ne- 
braska and we feel it will continue to play an ever- 
increasing role in this area. 

We are always pleased to receive any recommenda- 
tion or comments which you may have concerning 
the Journal so that we may print a publication which 
is of value to you in your practice and information 
to you as well. 

ANNUAL OFFICERS CONFERENCE 

Due to a second unprecedented special meeting of 
the House of Delegates of the A.M.A. in October, 
1965, the Second Annual Conference which was 
planned for the exact dates of the special session, 
had to be cancelled in order for the representatives 
of the Association to attend this most important 
meeting in Chicago. Due to extreme activity since 
this meeting, we did not call the Second Annual 
Conference; however, it will definitely be sched- 
uled for 1966. It is a veiy worthwhile conference 
and all those who attended felt that it was a most 
worthwhile and productive meeting. 

Some of the subjects which would have been pre- 
sented at the 1965 Conference will be discussed at 
the 1966 Mid-Winter Meeting of the House of Dele- 
gates and the Board of Councilors. 

It would be helpful to the officers of this Asso- 
ciation to receive ideas or topics for presentation 
at the conference which will be held late in Septem- 
ber or early October, 1966. 

NEBRASKA MEDICAL FOUNDATION 

Last year I made a report on the Nebraska Medi- 
cal Foundation as I felt it was of significant inter- 
est and of value to the Association. 

Since the program became effective on May 1, 

1964, we have made a total of 131 loans amounting 
to $134,180.00. These loans have been made pre- 
dominantly to the medical students at the Univer- 
sity of Nebraska College of Medicine and the 
Creighton University School of Medicine, with four 
loans being made to Interns and three to Resi- 
dents. Of the above amount, $119,180.00 was loaned 
in 1965. Total receipts for the Foundation for 

1965, including donations and repayment of old 
loans, totals $13,552.00. At the present time, we 


162 


Nebraska S. M. J. 


have $56,946.00 in the resei-ve account which will 
give us a loaning capacity of $711,000.00. 

As indicated by these figures, the amount of 
loans each year is increasing and the number of 
students being seiwed is also increasing, which indi- 
cates that the Foundation is cariying out a most 
worthwhile program. We will, however, need the 
continued support of organized medicine and the 
Auxiliaiy, as well as friends of the Foundation, to 
keep the program operating at maximum capacity. 

If you know of any individuals who are consider- 
ing giving donations to particular programs, we 
hope that you would mention the Nebraska Medical 
Foundation and the excellent job it is doing in 
assisting the students and other para-medical fields 
to secure their education. 

PUBLIC RELATIONS 

The Public Relations activities carried on by the 
Association this year were primarily concerned with 
the educational campaign carried on in relation to 
the Eldercare proposal and the anti-Medicare cam- 
paign. This activity took place from early January 
until the middle of April. The project included the 
use of radio and television, new'spapers across the 
state, pamphlet and material preparation, postage 
and freight. 

Other Public Relations projects carried on in- 
cluded the visitation of TV stations across the state 
as well as contacts made wdth the radio and tele- 
vision representatives in the state while in attend- 
ance at the annual convention of the Nebraska 
Broadcasters Association. The Code of Cooperation 
prepared by the Association and adopted by our 
House of Delegates in February of 1965, was also 
adopted by the Nebraska Broadcasters Association 
at its annual meeting in September. 

Numerous news releases were sent out in addi- 
tion to large amounts of health education material. 

The film, “Gravity of Death” was again shown 
extensively both in Nebraska and in numerous other 
states; and various other films and taped messages 
were provided for media use. 

The Association played a dominant role in the 
recently completed Diabetes Week and provided ma- 
terials and information for Community Health Week 
which took place the first week in November. Much 
greater use of our Speaker’s Bureau by the public 
was evident in 1965. As the Association member- 
ship became more aware of the speech and informa- 
tion file in the headquarters office, much greater 
use was made of this facility. 

Approximately 50,000 people visited the Hall of 
Health at the Nebraska State Fair this past year. 
Through an expansion of the program by the in- 
clusion of more allied health groups in the exhibit, 
we are working toward a much larger percentage 
of those attending the Fair spending part of their 
time in our exhibit. 

Even though the State Association has carried on 
an active public relations program during the past 
year, it cannot equal or have the same effect that 
the 30 seconds a physician spends talking with a 
patient can accomplish in improving the image of 
medicine. 

MEETINGS — HEADQUARTERS 
OFFICE 

Meetings over the past year have continued at a 


rapid pace as they have for the last several years. 
There were a total number of 117 miscellaneous. 
County Medical Society and National meetings. The 
National meetings were especially heavy during 
1965, with a total of 14 being attended, requiring 
39 days of time in attendance. Total miles traveled 
on Association business for 1965, exceeded 30,000 
miles. These statistics are a fair barometer of 
the activities carried on by the headquarters staff, 
in addition to their regular work of administration 
in the office. The Board of Tnistees approved the 
addition of one girl to the staff and also approved 
the expansion of the cuiTent office space. The 
additional staff and space will certainly help us to 
function more effectively in the years to come. 

In looking ahead to 1966, it is quite apparent 
that there will be a fui’ther acceleration of activ- 
ity which must be absorbed by the Association head- 
quarters. Your staff stands ready to carry out the 
various assignments of this Association in the most 
equitable and efficient manner possible. 


MEMBERSHIP 

Active Members 1,233 

Life Members 101 

Service Members 1 


Total 1,335 

Less: Suspended Member 1 

Deceased Members 10 


Total 1,324 

A.M.A. Membei’ship 1,206 

Potential Members 38 

New Members 55 


Total New Doctors Moved 

Into State in 1965 93 

CORRESPONDENCE 

Incoming Mail 9,569 

Outgoing Mail 35,933 


Respectfully submitted, 
KENNETH NEFF, 

Executive Secretai’y. 

REPORT OF BOARD OF TRUSTEES 

C. N. Sorensen. M.D., Scottsbluff. Chairman ; R. Russell 
Best, M.D., Omaha ; George Salter, M.D., Norfolk ; H. V. Nuss, 
M.D., Sutton : Horace V. Munger, M.D., Lincoln. 

The Board of Trustees is the duly elected body 
of this Association responsible for all financial 
operations of the Headquarters Office, personnel 
and the Journal. 

We felt that at this time it would be a good idea 
to make a detailed report to the membership in 
order that they may become cognizant of our fi- 
nancial status; and what may be our financial needs 
in the future. 

The Board meets four times a year — at the Mid- 
Winter Meeting, the Annual Session, a Fall Meeting 
in September, and the Budget meeting in December. 

During the past year, the Association has lived 
within its actual income for 1965, of $78,693.00. 
We were not able to stay within the 1965 budget 
of $74,089.00. However, the additional income over 
expenditures allowed us to remain in the black, 
with a sui’plus of $165.41. 

During the year, the Board of Trustees approved 


April, 1966 


163 


a Public Relations Program to support the Elder- 
care Medical Care Program of the A.M.A. in oppo- 
sition to the “Medicare” Bill. Funds for this were 
taken from the Public Relations Portion of our 
budget. 

Our investments continue to realize a good re- 
turn, although we have not purchased additional 
stocks for several years. Investments as of De- 
cember 1, 1965, totaled $71,895.85. 

The Nebraska State Medical Jouimal, which for 
many years provided additional income to this As- 
sociation, is no longer producing additional income 
due to the rapid decrease in advertising. At this 
time, the Association is supporting the publication 
of the Journal with $5.00 of every member’s dues. 
The Journal income has plateaued during 1965 and 
there is some reason to believe that a possible in- 
crease in advertising income may be expected in the 
next year. However, we do not anticipate a re- 
turn to the amount of advertising realized in the 
late ’50’s. We have received veiy excellent coopera- 
tion from Mr. Dave Powell of News Printing Com- 
pany in Norfolk who has printed the Journal for 
the past 50 years. 

There has been some interest in the past year in 
the North Central Conference States, of which 
Nebraska is a member, to give consideration to the 
amalgamation of the medical journals in these 
states into a regional journal. Several meetings 
have taken place and some interest has been shown 
by the states. We do not anticipate any further 
action on this subject in the immediate future. If 
such action is contemplated at any time in the future, 
the Board would bring this matter to the attention 
of the House of Delegates. 

The Board of Trustees, during the past year, has 
given approval to the Executive Secretary to ex- 
pand the office space and to add one girl to the staff. 
This is the first increase in staff since 1949, and 
now brings the total number to 5. The increased 
space was vitally needed as the Headquarters Office 
had less than 1,000 square feet of operation space. 
The new contract for additional space has been 
signed and will allow for greater flexibility in 
operation efficiency and storage capability of the 
Association Headquarters Office. The lessor has 
assumed the cost of the reconstruction and decora- 
tion of the Headquarters Office at no cost to this 
Association; and we have a guaranteed no increase 
in rent clause for the term of the new contract. 
We feel that this expansion will fulfill the needs 
of the Association for the immediate future. The 
increase in rent for the extra space is ver>' nominal 
and well within our ability to pay. 

In September of 1965, the Executive Secretary 
presented to the Board a comprehensive analysis of 
activities and financial condition of this Associa- 
tion. Through the use of charts, the Executive 
Secretary presented a graphic picture of our income 
and expenditures, both from the Association and the 
Journal, for the past 20 years. He indicated that 
during that time the average increase operation 
costs of the Association on a yearly basis has been 
from 5% to 7% per year. The income for this 
period, with the dues increase of $10.00 per mem- 
ber, approved in 1964, has matched expenditures, 
but there is an indication of costs exceeding the 
income in the not too distant future. 

Also presented was a projection chart for the 


next 10 years based upon the activities at this 
time and the anticipated increase in activities. The 
chart shows a gradual increase in the expenditures 
of this Association, primarily due to the increased 
activities. With such a projection, it is quite cer- 
tain that the Association will have to give consid- 
eration to additional income in the future. The 
activities of the Association since 1945, have in- 
creased five or six times. We have much more 
activity in committee and more work in the legis- 
lative field, and with the passing of the Medi- 
care Bill and the Heart Disease, Cancer and Stroke 
Bill, there is every reason to believe that with in- 
creased activity it is going to be necessary to recom- 
mend a dues increase to keep the Association in a 
financially stable position. 

During the past two years, we have been able 
to maintain a less than 5 % increase in the budget. 
The 1965 budget was 4.3% increase over the 1964, 
and we have a 4.1% increase in the 1966 budget 
over 1965. 

Another increased cost absorbed temporarily by 
the Association in 1965, was the printing of the 
Relative Value Study. The cost was $4,364.22, and 
it was the Board’s opinion that the Association 
membership should be willing to pay for this publi- 
cation. Therefore, when the copies of the 1965 
Relative Value Study were mailed out, the individual 
physicians and members were charged $5.00 each. 

The Board has also given direction to the Head- 
quarters Staff that all persons wishing a copy of 
this book will also pay the same fee. This in- 
come will go to pay for the cost of printing and 
mailing the Relative Value Study. 

Members of the Board of Tnastees have an oppor- 
tunity to become acquainted with the business 
transactions of the Society and with the general 
operation of the Headquarters Office. From this 
opportunity, we conclude that your Nebraska State 
Medical Society Headquarters Office is operated 
with efficiency, without waste, and with excellent 
performance records on the part of each employee. 
We may be assured any future dues increase will 
be made necessary by the added activities we must 
undertake in order to maintain our position in mod- 
ern complex society. 

Respectfully submitted, 

C. N. SORENSEN, M.D., 
Chairman. 

REPORT OF THE EDITOR, 
NEBRASKA STATE MEDICAL JOURNAL 

Volume 50 of the Nebraska State Medical Joumal 
was issued during 1965. It is 662 pages long; it 
includes 56 articles by 86 authors, 51 editorials, and 
eight President’s Pages. The format of the Jouimal 
has been changed. The cover picture shows the 
beauty of Nebraska in different areas, from time 
to time, with editorial comment. Tuberculosis ab- 
stracts are not being continued. We plan a “Wel- 
come, New Members” department (this has been 
accomplished) and an artistic touch for the Woman’s 
Auxiliary reports. We are about to begin a “Doctor’s 
Hobby” column. We plan a series of cover pictures 
of Nebraska hospitals. At least four of our edi- 
torials have been reprinted in other journals, which 
is flattering, but also shows that the Journal is 
being widely read. 


164 


Nebraska S. M. J. 


There has been no shortage of articles, and we 
have been pleased to encourage Nebraska talent. 
We have been able to publish the remarks of two 
A.M.A. Presidents and of the legal counsel of the 
A.M.A. during the recent Medicare episode, and 
so to keep our readers well infoiTned. We have dis- 
cussed, in editorials and in related articles, current 
medical legislation, dealing with injuries of violence 
and with the “Battered Child.” Different articles 
discussing a single subject are now being published 
simultaneously, with editorial discussions relating to 
each problem. 

A personal sampling leads us to the conclusion 
that the Journal is widely read by our own mem- 
bers (and by their wives); editorials are well re- 
ceived; advertising, we are told, is up; articles 
keep coming in; we are on sure footing. 

Respectfully submitted, 

FRANK COLE, M.D., Editor 

DELEGATE’S REPORT 

PROCEEDINGS OF THE HOUSE OF DELEGATES 
American Medical Association 
19th Annual Clinical Meeting 

James Z. Appel, President of the American Medi- 
cal Association, described organized medicine’s ef- 
forts “to guide in the best possible direction the 
action that government agencies are now taking to 
activate existing law (PL 89-97).” He described the 
activities of the committees which have met with 
the government and stated “Their suggestions have 
been received favorably in most instances, and we 
are hopeful that they will be translated into the 
final published regulations . . . (but) we know 
that in certain significant instances this will not 
be true.” 

The House rejected the concept of the prevailing 
fee program as proposed by the Board of Trustees 
and the National Association of Blue Shield Plans 
and reaffirmed its support of the “usual and cus- 
tomary” concept as a basis of reimbursing physician 
participating in government - supported programs 
should be on the basis of ‘usual and customary’ 
fees.” 

Billing and payment for medical services were 
carefully studied by the House, which adopted 8 
statements as a guide which are applicable “irre- 
spective of whether such fees are paid by the 
patient, or paid or reimbursed in whole or in part 
under Public Law 89-97, or any other third party 
plan.” The statements are as follows; (in sum- 
maiy form) 

1. No interposition of a third-party carrier. 

2. It is the patient’s responsibility to deal with 
third-party carriers in the area of financial assist- 
ance. 

3. Advance understanding between doctor and 
patient regarding payment of the fees is highly 
desirable. Physician may choose manner in which 
he is to be compensated. 

4. AMA disapproves of any program which pro- 
motes charging excessive fees. 

5. AMA opposes any program of dictation, inter- 
ference, or coercion affecting freedom of choice of 
the physician to determine for himself the extent 
and manner of participation or financial arrange- 
ment under which he shall provide medical care 


to patients under Public Law 89-97, or other third- 
party plans. 

6. Insurance should not be an excuse to revise 
professional fees upward. 

7. Charging of excessive fees is unethical. 

8. Physician may consider patient’s ability to 
pay if he fixes his fee within reasonable limits. 

Federal health care laws were reviewed and the 
following specific actions were taken: 

1. Amend Public Law 89-97, Part B, Title XVIII, 
by deleting the word “receipted” from Section 1842, 
Part 3, Item B, line (ii), and substituting “such 
payment will be made on the basis of a method of 
payment so arranged to preserve and continue the 
profession’s current practice of billing.” 

2. Authorize a study of the constitutionality of 
PL 89-97 by calling on the Board of Trustees to 
“take such action as may be necessary and appro- 
pi-iate to provide for the study and investigation of 
all aspects of PL 89-97 for the purpose of deter- 
mining possible court action to test the legality and 
constitutionality of any provision or regulation 
issued under the law.” 

3. Recommend “that the state and local medical 
societies be urged at this time to assume leadership 
in the establishment of local advisory committees” 
under the Heart Disease, Cancer and Stroke Amend- 
ments of 1965. 

4. Urge that the AMA Advisory Committee on 
PL 89-97 and 89-239 should persist in its efforts to 
achieve “practical recognition” by HEW of the 
differences between Utilization Review and Claims 
Review. This statement was predicated on the 
basis that the Council on Medical Service reported 
that there was “widespread confusion between the 
Utilization Review function and the Claims Review 
function.” 

5. Criticism of the Coggeshall report, entitled 
“Planning for Medical Progress through Educa- 
tion.” This report was made to the Association 
of American Medical Colleges and recommended 
that the AAMC “serve as spokesman for organi- 
zations concerned with education for health and 
medical sciences” and that “the professional aspects 
of education for health and medical sciences should 
be regarded as an essential function and fully inte- 
grated component of university organization, with 
decreasing dependence upon or control by organized 
professions and their related associations.” The 
House took issue with these two statements in par- 
ticular and several other important statements which 
were in the report. 

6. Federal aid to medical education. The House 
urged that the policies of the AMA should be such 
that control of medical school functions is invested 
in their own institutional governing bodies and 
“the AMA should foster diverse source of support 
for medical schools under circumstances which would 
prevent any extramual source from exercising a 
controlling influence. 

7. Miscellaneous actions: 

a. Defeated a proposal to set more stringent re- 
quirements for calling a special session of the 
House. 

b. Approved a resolution to achieve a separation 
of billing and payments for professional fees from 


April, 1966 


165 


hospital charges under insurance contracts written 
by the health insurance industiy. 

c. Agreed to a re-writing of two sections of a 
model agreement between hospitals and physicians 
pro%'iding professional sendees in hospital emer- 
gency departments to conform to principles estab- 
lished by the House. 

d. Requested state medical associations to act 
to assure that the physicians are properly repre- 
sented on state Hill-Bui-ton hospital adrisoiy coun- 
cils. 

e. Instructed the Council on Medical Sendee to 
develop for the AMA its definition and principles 
for determination of medical indigency. 

f. Urged creation of a separate post in the Cabinet 
of the President of the U.S. for a Secretary of Health. 

g. Commended past president Edward R. Annis, 
M.D., for his leadership, his dedication, and his tre- 
mendous contribution to medicine’s campaign to pre- 
seiwe the world’s finest system of medical care. 

h. Listened with approval to the report of the 
Executive Vice President, Doctor Blasingame, who 
outlined the progi'ams, facilities and acthdties of 
the AMA headquaiders. 

There were many other actions and the complete 
report will be available on or before the next meet- 
ing of the House of Delegates of the AMA. 

Respectfully submitted, 

JOHN R. SCHEXKEX, M.D., 
Delegate. 

REPORT OF DELEGATE TO THE XORTH 
CEXTRAL MEDICAL COXFEREXCE 

It was both a pleasure and a privilege for your 
delegate to be the presiding officer for the Xorth 
Central Medical Conference held in Minneapolis, 
Minnesota on Xovember 7, 1965. 

A roundup on new legislation as it affects the 
medical profession was discussed by representatives 
from Xorth Dakota, Xebraska, Minnesota, South Da- 
kota and Iowa. 

Mr. Jule M. Hannaford of Minneapolis, Minnesota, 
a perennial speaker at the Xorth Central Medical 
Conference, reviewed the highlights out of a total 
of 2000 bills introduced in 1965 in the two houses of 
the Minnesota legislature. He said that distribution 
of contraceptives and information about them had 
been a misdemeanor in 1886 in Minnesota and noth- 
ing had been done to change the situation until the 
1965 legislature decreed that contraceptive informa- 
tion can be given by organizations or peraons asso- 
ciated with health or welfare agencies. Bills which 
would require all coroners to be physicians had 
been introduced during several sessions but had 
not been adopted, largely because of the expense 
involved. However, a bill which had been introduced 
by morticians was passed in the 1965 legislature and 
this would require all new coroners to be physicians. 
Mr. Hannaford stated that PKU tests had been made 
mandatory in 1965 and again failed of passage. 

Doctor Earlin Larson, Jr., of Davenport, Iowa 
reviewed the legislation for his state. He reported 
that more bills had been introduced and passed 
than had been any previous session. Of those 
bills which had medical impact, Doctor Larson dis- 
cussed the following: 

A bill was enacted to license physical therapists, 


and a new board of physical therapy examiners was 
created, including one M.D. and three physical 
therapists. With regard to PKU testing, the bill 
finally enacted merely stated that PKU tests for 
all newboi-n babies was to be a matter of state 
policy. A law was passed requiring protective 
glasses for all children participating in chemistry 
classes, shop and comparable training. Another 
bill had to do with the free choice of physician under 
workmen’s compensation. As originally introduced, 
the law would provide a complete free choice but 
a compromise bill passed as a result of strong op- 
position of employers permits an injured employee 
to I'etain a physician of his own choice and at the 
employer’s expense to evaluate his claim for per- 
manent disability, if he should disagree with the 
determination made by the employer’s physician. 
A bill was passed, creating an Iowa Mental Health 
authority for the pui-pose of accepting Federal 
funds. A bill was also passed forcing Blue Shield 
to make base pajnnents to podiatrists who render a 
covered seiwice to subscribers. This bill was en- 
acted over the opposition of the Iowa Medical So- 
ciety and Blue Shield. Counsel for Blue Shield feels 
that this bill is unconstitutional and will be re- 
jected by the courts. 

Mr. W’illiam Darner of Bismarck, Xorth Dakota, 
reported on 35 bills and two resolutions which came 
before the Xorth Dakota Assembly which were of 
direct interest to the Xorth Dakota Medical Associa- 
tion. The more interesting of these bills are noted 
in the following: 

A bill amending medical center loan law by pro- 
viding forgiveness of loans to interns and to 
physicians who practice in towns of 5,000 persons 
or fewer. Another bill proriding for the licensing 
and operation of clinics for alcoholism and addic- 
tion. Still another bill would permit expert wit- 
ness fees in the amount of $50 per day for time 
expended in preparation for trial. The “battered 
child” bill was adopted. The Xorth Dakota Medical 
Association opposed an amendment to the State’s 
chiropractice licensing act, particularly opposing 
the use of the term “chiropractic physician.” This 
term was removed before the bill became law. The 
Society also introduced and supported an amend- 
ment to the 1963 cancer quackeiy law which would 
permit dentists to diagnose and treat cancer. A 
bill which would include the ser%*ices of podiatrists 
in Blue Shield was vigorously opposed by the 
Xorth Dakota Association and was indefinitely post- 
poned in the House. A bill designed to give doctors 
of osteopathy full medical, surgical and drug priv- 
ileges under the authority of their own licensing 
board was strongly opposed and indefinitely post- 
poned in the House. A bill supported by the Asso- 
ciation and adopted by the Assembly directed to 
members of the 39th legislative assembly together 
with two members of the State Board of Medical 
Examiners and two members of the State Board 
of Osteopathic Examiners to study the feasibility 
of a single licensing board for physicians and osteo- 
paths. 

Doctor Richard E. Garlinghouse gave the report 
for the Xebraska legislature and reported that our 
batting average was 100%. Doctor Garlinghouse 
gave a great deal of credit to our executive secre- 
tary, Mr. Kenneth Xeff, and to his assistant, Mr. 
Bill Schellpeper, for their part in assistance to the 
Medical Service Committee. 


166 


Nebraska S. M. J. 


Doctor Paul H. Hohm of Huron, South Dakota, 
reported on legislature from his state. He indicated 
that the following bills, sponsored by the medical 
association, were passed by their legislature: 

1. Maximum hospital surgical medical benefit 
under Workmen’s Compensation was raised from 
$2,900 to $21,700. 

2. Tuberculosis was included under occupational 
diseases section of Workmen’s Compensation law. 

3. The Kerr Mills program was revised by rais- 
ing income limits from $1,500 single and $1,800 
family to $2,100 single and $2,700 family. 

4. A bill was passed increasing the size of the 
State Hill-Burton Advisory Council specifying that 
a licensed physician be a member of that council. 

5. The 1919 version of the Insanity Hearing 
Forum was revised and brought up to date and the 
new foiTnat was accepted by the legislature. 

6. A bill dealing with the sale and possession 
of amphetamines and setting up tighter controls 
was passed. 

A panel which discussed the Gunderson report 
was moderated by Doctor J. N. Stickney of Rochester, 
Minnesota. Doctor Gunnar Gundersen of LaCrosse, 
Wisconsin, gave an introductory talk on his com- 
mittee report. 

Doctor Stickney then reviewed the highlights of 
the recommendations and suggestions made by this 
committee. Following Doctor Stickney were discus- 
sions by Doctor Thomas E. Pederson of Jamestown, 
North Dakota; Doctor Christian E. Radcliffe of 
Iowa City, Iowa; Doctor Arthur T. Reding of Marion, 
South Dakota; Doctor A. 0. Swenson of Duluth, 
Minnesota, and Doctor Willis D. Wright of Omaha, 
Nebraska. 

The Gundersen report is obviously too complex 
to include in the report of your delegate but is of 
sufficient importance and interest to the members 
of the association that the report as published 
in the Journal should be read in its entirety. Brief- 
ly, the Gundersen report has to do with several 
facets of the committees and stimcture of the AMA. 
The first part of the report has to do with reference 
committees of the House of Delegates and also to 
do with resolutions and the time in which resolutions 
must begin, etc. The next portion of the Gundersen 
report deals at considerable length with the coun- 
cils and committees and the structure of the AMA. 
A large section of the report deals with the tenure 
of office. Another portion of the report considers 
the size of the House of Delegates, pointing out 
that the number has been growing rather rapidly, 
and there was a feeling that the House was becom- 
ing rather unwieldy on that account. Another sec- 
tion of the report dealt with what constitutes the 
policy of the AMA. In addition, there were a good 
many comments about the council on medical educa- 
tion. 

An extremely interesting panel discussed “Tooling 
up for Medicare” and this panel was moderated 
by Mr. Robert B. Throckmorton of Des Moines, Iowa, 
formerly with the legal department of the AMA. 
According to Mr. Throckmorton, some 20 million 
people will be affected by the new amendments to 
the Social Security law. It was his feeling that 
the big problem would be to keep people satisfied 
within the framework of a free economy. He said 
further that it had been his privilege to work 


closely with the Board of Tnastees of the AMA 
and that he had been greatly impressed with the 
high calibre of its members. He felt the physicians 
were much better represented on this Board than 
most people have any idea of. 

Doctor L. 0. Simenstadt of Osceola, Wisconsin 
discussed “Physician Reimbursement” and presented 
the various plans that had been proposed for physi- 
cian payment. Doctor J. M. Stickney of Rochester, 
Minnesota discussed “Physician Participation.” A 
good deal of Doctor Stickney’s discussion was spent 
on pointing out the certification of the need for 
hospital care and the utilization committees which 
will be necessai-y in hospitals for performing 30- 
day reviews on all Medicare cases. Doctor Elmer 
Smith of Des Moines, Iowa discussed “Provider 
Participation.” He pointed out that the over-all 
control is vested in the Social Security Administra- 
tion, though some contracts will remain with the 
Public Health Service; and the provider may select 
his own carrier. Of further importance, he pointed 
out the need for nursing homes to be accredited 
in order to be eligible for Medicare participation. 
Doctor Donovan F. Ward of Dubuque, Iowa, imme- 
diate past president of the American Medical Asso- 
ciation, discussed “Administrative Agents.” He 
pointed out that government agencies are merely 
dealing with glittering generalities now. They are 
simply setting up guidelines. He indicated that the 
final decision would still be up to HEW. He indi- 
cated that Blue Shield was a strong contender in 
the administration of this program. He felt that 
the state medical societies were obligated to par- 
ticipate in negotiations in the hope of holding third 
party functions to a minimum, and to leave no roads 
open for HEW to bypass medical organizations 
entirely. 

Doctor John R. Schenken of Omaha, Nebraska dis- 
cussed “Specialist Services in Hospitals.” He point- 
ed out that there were several questions which were 
inadequately satisfied by the terminology of the 
Medicare bill. He indicated that no diagnostic pro- 
cedures would be permitted in hospitals or doctors’ 
office except by licensed personnel. He felt that 
that would mean that every person in the office 
must be licensed. Just how private laboratories 
were to be licensed, was not clear. At the present 
time the physician who maintains a laboratory for 
his own patients is exempt from special licensure, 
but Doctor Schenken felt it would be only a ques- 
tion of time before a specialty license would be 
superimposed on the general license from the state. 
Doctor Hugh T. Carmichael of Chicago, Illinois, dis- 
cuseed “Psychiatric Services.” In connection with 
psychiatric seiwices under the program. Doctor Car- 
michael called attention to two special problems. 
One was the participation of psychiatric services in 
the hospital. He indicated that various meetings 
were then in progress to try and define these pi’ob- 
lems, but no report had yet been made available as 
to the outcome of the work of these special groups. 

Following the noon luncheon Mrs. Sue Boe of 
Chicago, Illinois, representing the AMA as a field 
representative for women’s oi-ganizations, gave an 
interesting paper titled “The Gold-headed Cane.” 

Doctor Charles R. Hudson, president-elect of the 
American Medical Association from Cleveland, Ohio, 
gave a report entitled, “The White House and the 
AMA.” 


April, 1966 


167 


In addition to your delegate, the North Central 
Conference was attended by Doctor Willis D. 
Wright, Doctor Dan A. Nye, and Doctor Richard 
E. Garlinghouse. While this is a very small group 
from the state of Nebraska, it still represents the 
largest group from Nebraska to attend this confer- 
ence in the past several years that I have been 
privileged to be the delegate. This was an especial- 
ly well-prepared and timely conference in view of 
the problems confronting organized medicine today. 
I would again encourage more Nebraska physicians 
to attend these meetings in the future. 

Respectfully submitted, 

PAUL J. MAXWELL, M.D., 
Delegate 

REPORT OF THE TENTH NATIONAL 
CONFERENCE ON PHYSICIANS 
AND SCHOOLS 
September 23 to 25, 1965 
Chicago, Illinois 

PURPOSES OF THESE NATIONAL 
CONFERENCES: 

1. To evaluate the progress in health and fitness 
of youth in relation to the National Confer- 
ence on Physicians and Schools. 

2. To discover effective methods of working to- 
gether for the improvement of school health 
and physical education programs. 

3. To exploi-e in our present pattern of living 
the basic factors that influence the total health 
and fitness of youth. 

4. To agree on policies for joint action by public 
health, education, and medicine that will lead 
to the development of essential seiwices for 
health and fitness. 

5. To point up and emphasize the fundamental 
responsibility of each family in promoting 
health and fitness of youth. 

Doctor Fred Hein, Director of the Department 
of Community Health and Health Education, stated 
that in his opinion the main accomplishment of 
these conferences has been to help bring about inter- 
professional agreement on school health policies 
and practices as these evoke and develop. 

The conference theme: “Seeking Solutions to Cur- 
rent Health Problems.” 

PLAN OF CONFERENCE: 

There were two major objectives for this con- 
ference. One was the evaluation of the recommen- 
dations of the past nine conferences and second 
a discussion of current health problems, namely sex 
education programs and consideration of related 
problems such as the VD, promiscuity and illegiti- 
macy; the other, improving instructions in the area 
of haiTnful substances. 

There was an attempt made at this conference 
to have a meeting of the physicians representing 
various state medical societies for the purpose of 
becoming acquainted with each other and to share 
their experiences. The conference participants were 
predominantly other than physicians, mostly edu- 
cators. 

One of the chief weaknesses of these conferences 
is the fact that the physicians have been in a 
minority and have not had an opportunity to dis- 


cuss their problems with those that have an under- 
standing of their situations. The other weakness 
of this conference is that the principles that are 
established are always in generalities. In a multi- 
disciplinary group, it has not been possible to dis- 
cuss school health problems in depth and to ai-rive 
at definitive standards for the present day. 

It was of real interest to note that in one of the 
major presentations that dealt with a new approach 
to health education, that of a unified health con- 
cept, that there were large numbers of participants, 
both physicians and educators, that were not suffi- 
ciently knowledgeable regarding curriculum and cur- 
riculum planning to have the appreciation or even 
understanding of the unified health concept ap- 
proach in health education. 

Several reports were made available and these 
are as follows: 

1. Survey report of School Health Activities in 
State Medical Association. 

2. Why Health Education?, a publication of the 
Joint Committee on Health Problems in Edu- 
cation of the National Education Association 
and the AMA. 

3. Mental and School Health Services, a Joint 
Committee report on Health Problems in Edu- 
cation of the National Education Association 
and the AMA. 

4. Report of the Committee on Exercise and 
Physical Fitness of the AMA on Health Prob- 
lems Revealed During Physical Activity. 

All of these are available for distribution. 

Respectfully submitted, 

S. I. FUENNING, M.D. 

REPORT OF BLOOD AND BLOOD 
PRODUCTS COMMITTEE 

Theodore L. Perrin, M.D., Omaha. Chairman : George J. 
Millett, M.D., Fremont ; Morton Kulesh, M.D.. Omaha ; Harlan 
Papenfuss, M.D.. Lincoln ; Donald P. Skoog, M.D., Omaha ; 
Frank T. Herhahn, M.D., Scottsbluff. 

The 1964-1965 Blood and Blood Products Com- 
mittee included in its report to the Board of Coun- 
cilors and House of Delegates of the Nebraska 
State Medical Association a recommendation that, 
“The Blood and Blood Products Committee undertake 
a study of blood procurement, blood processing and 
compatibility testing in the State of Nebraska.” 

The recommendation of the 1964-1965 committee 
was discussed in detail at a recent meeting of the 
present committee. All members present agreed 
that blood procurement, blood processing and com- 
patibility testing are matters of significant interest 
and concern to the Nebraska State Medical Associa- 
tion. However, current developments affecting medi- 
cal practice in our state will include surveys which 
in all probability will embrace facets of blood pro- 
curement, processing and compatibility testing. Ac- 
cordingly, we recommend that such a study by this 
committee be held in abeyance at this time. 

The American Association of Blood Banks, the 
American Society of Clinical Pathologists and many 
other medical groups have been encouraging state 
legislation to define the provision of blood and other 
human tissues as a service rather than a sale. Your 
committee favors such action and has reviewed sec- 
tions of several state laws relating to this subject. 
We believe that a Wisconsin law passed in 1965 
embodies the desirable features of such legislation: 


168 


Nebraska S. M. J. 


WISCONSIN 

Senate Bill 218 — An Act to Create 146.31 
of the statutes, relating to procurement, pro- 
cessing, distribution and use of blood, blood 
products and other tissues. 

Blood or Tissue Transfer Services 

The procurement, processing, distribution 
or use of whole blood, plasma, blood prod- 
ucts, blood derivatives and other human 
tissues such as corneas, bones or organs 
for the purpose of injecting, transfusing or 
transplanting any of them into the human 
body is declared to be, for all purposes, the 
rendition of a service by every person par- 
ticipating therein and, whether or not any 
remuneration is paid therefor, is declared 
not to be a sale of such whole blood, plasma, 
blood products, blood derivatives or other 
tissues, for any purpose, subsequent to en- 
actment of this section. 

The committee recommends consideration of such 
legislation for Nebraska by the Board of Councilors 
and House of Delegates. 

In addition to the specific matters presented above, 
other problems relating to blood transfusion were 
discussed at length by committee members and guest 
Horace K. Giffen, M.D., Medical Director of the 
Omaha-Douglas County Red Cross Blood Center. 

It was the consensus of the group that there Is 
great need for an educational program for physi- 
cians on several aspects of the procurement, process- 
ing and utilization of blood and blood products. The 
committee recommends such a program to the Board 
of Councilors and House of Delegates. If approved, 
the committee will be glad to prepare appropriate 
material to cany out such a recommendation. 

Respectfully submitted, 
THEODORE L. PERRIN, M.D., 
Chairman 

REPORT OF CONTINUING COMMITTEE 
ON MEDICAL PRACTICE 

W. R. Miller, M.D., Columbus, Chairman ; David Weeks, 
M.D., Omaha; Robert W. Herpolsheimer, M.D.. Seward; Bryce 
Shopp, M.D., Imperial ; Richard DeMay, M.D., Grand Island ; 
W. J. Jensen, M.D., Omaha. 

The Continuing Committee on Medical Practice 
has had no meetings and no business transacted. 

Apparently the Preceptorship program for the 
University of Nebraska is meeting with excellent 
response on the part of the practitioners throughout 
the state and also is well accepted by the students 
of the University of Nebraska. Most of whom I 
have talked to personally feel that this is a most 
worthwhile part of their medical education. We 
hope that this program will continue to have the 
support of the Nebraska State Medical Association. 

Respectfully submitted, 

W. R. MILLER, M.D., 
Chairman 

REPORT OF CIVIL DEFENSE AND 
DISASTER COMMITTEE 

George N. Johnson, M.D.. Omaha, Chairman : Joe T. Hanna. 
M.D., Scottsbluff : John G. Wiedman, M.D., Lincoln ; I. M. 
French, M.D., Wahoo; Max M. Raines, M.D., North Platte; 
C. T. Mason, M.D., Superior. 

The Civil Defense and Disaster Committee met 
at the Sheraton-Fontenelle Hotel on May 26, 1965. 


Present were Doctors George N. Johnson, Chair- 
man, Omaha; Willis D. Wright, President, Omaha; 
H. M. Hepperlen, Beatrice; Horace K. Giffen, Omaha; 
E. A. Rogers, Lincoln; Kenneth Neff, Executive Sec- 
retary, and Bill Schellpeper, Executive Assistant. 
Guests present were Major General Lyle A. Welch, 
Lincoln; Lt. Colonel Burl Johnson, Lincoln; Miss 
Betty Wiley, Lincoln; Mrs. Ethelyn Templin, Hast- 
ings; Annabelle Abbott, Omaha; Milton Parker, 
Lincoln; Harold McGrew, Lincoln; and Larry Smith, 
Lincoln. 

Doctor Johnson opened the meeting by welcoming 
eveiybody in attendance, and stai'ted the discussion 
by stating that in his estimation, someone from this 
group should be placed on the Hospital Association’s 
Convention Program to discuss the objectives of 
this Committee and the State’s Civil Defense Pro- 
gram in general. He stated that he feels it is of 
utmost importance that the hospital personnel are 
allied very closely in any disaster program which 
is undertaken. 

Doctor Rogers stated that the Hospital Association 
did not participate in the formation of the pro- 
gram for the Nebraska Health Mobilization State- 
line Training Seminar entitled, “Health and Medical 
Sei'vices in Disasters” which was held in Omaha on 
May 26-27, 1965. The Hospital Association was sent 
notices for mailing to all their members of the 
Stateline Seminar but evidently they were not sent 
as representatives of this group present did not 
receive any notice of the meeting. All present felt 
that there must be closer liaison between the hos- 
pitals in the state and the other allied health groups 
repi’esented in the over-all Civil Defense Program in 
Nebraska. 

The question of what approach might be used to 
obtain more adequate participation was discussed. 
Doctor Best felt that all Omaha hospitals have an 
organized program in case of any disaster. Doctor 
Johnson stated that a numerical break down of the 
attendance in the Stateline Training Seminar, ac- 
cording to Para-Medical Field, should be published 
in the State Medical Association’s Bulletin. 

Mr. McGrew stated that the communications be- 
tween Para-Medical Health groups in every com- 
munity across the state are unsatisfactory. All 
Para-Medical groups in a town should be notified 
of a project or exercise but unfortunately, this is 
not done at present. He stated that perhaps each 
group through an individual could be requested to 
participate in the program. 

Mr. Neff stated that possibly the President of 
the Hospital Association should be contacted and a 
request made through him that representatives of 
the Hospital Association be chosen to participate in 
any future programming. 

Doctor Wright felt that the physicians and nurses 
should participate in any program or seminar pre- 
sented to the Hospital Association at their conven- 
tion. 

Mr. Neff felt that possibly requests should go out 
to all Para-Medical groups across the state and to 
all parent organizations for any information they 
may have regarding the programs presently in oper- 
ation or in what specific ways they would be able 
to participate should a disaster strike. 

Doctor Johnson stated that the State Medical As- 
sociation’s Board of Councilors might be designated 


April. 1966 


169 


as the contact person for informational purposes 
should a disaster occur in their particular district. 

Doctor Best felt that there is no need for these 
contact physicians, as in a disaster any member of 
the Association may need to be called. 

Doctor Rogers stated that the Medical Directors 
of the Civil Defense Emergency Hospitals might be 
used in this capacity. Those present decided that 
the Medical Director be used as the contact person 
and the state be divided into areas according to the 
location of the emergency hospitals. 

General Welch felt that the contact person would 
be responsible for assessing any disaster situation, 
and to report immediately to the headquarters in 
Lincoln the extent of the disaster and what is needed 
to help remedy the situation. The information re- 
ferred to the Emergency Operating Center would 
seiwe to both secure aid and to help inform the news 
media and other groups as to the actual extent of 
any disaster. 

Doctor Johnson stated that each Civil Defense 
Emergency Hospital Director must of necessity 
have a local committee comprised of pai-a-medical 
repi'esentatives in his area. 

Colonel Johnson stated that each emergency hos- 
pital iMedical Director must work closely with the 
local hospital administrator in this program. 

Doctor Rogers suggested that Colonel Johnson be 
directed to compile information on the items dis- 
cussed and to specify what the needs are and draft 
information to be sent to all Civil Defense Emei'- 
gency Hospital Directore. This portfolio would 
contain all the information such as the resources 
available, the area to be covered, personnel to be 
contacted, etc. 

General Welch stated that this infomiation can 
be compiled and the direction for such planning must 
come from Doctor Rogers and Doctor Johnson. He 
went on to say that correct facts in a disaster are 
difficult to obtain and at times the facts are not 
correct and possibly the Medical Director is the 
individual to relate the exact facts to the head- 
quarters office. 

Red Cross Regional representatives as well as 
all para-medical representatives in a particular area 
must work with the Medical Director and form an 
efficient workable program. 

Mr. Smith stated that the Pharmaceutical Asso- 
ciation would be happy to designate a representative 
in each area for such an arrangement. 

Mr. Xeff stated that any ideas to be sent out 
should be compiled by each para-medical group 
and then a combined meeting be held in the fall 
for final decision and implementation. 

Doctor Best felt that each Medical Director should 
be instructed to form the group of representatives 
in his area. This instimction will be given each 
Medical Director along with a port-folio of ma- 
terial regarding the entire over-all program. 

Doctor Giffen stated that a Red Cross Civil De- 
fense representative should be requested to par- 
ticipate in this group. He then reviewed the Red 
Cross Blood Center operation as it functions from 
the headquartere in Omaha. He stated how blood 
is moved from state to state in order to insm-e that 
no shortage exists. He felt that the Red Cross plays 
a ver>- important part in the over-all Civil Defense 
Program should any disaster occur. 


Projects to be enacted: (1) Try to develop better 
cooperation from the Hospital Association by re- 
questing that a panel be included at their Annual 
Convention. (2) Set up the Program of Communica- 
tion on the local level as proposed above. 

Meeting adjoumed. 

During the year of 1965 the following Packaged 
Disaster Hospitals have been established in the 
following communities: 

Alliance 

Aurora 

Chadi'on 

Lincoln 

Omaha 

O’Neill 

Valentine 

The following are the Medical Directors and Alter- 
nates of the Packaged Disaster Hospitals in Ne- 
braska : 

Alliance — Robert J. Morgan, M.D. 

Aurora — Houtz G. Steenburg, M.D., (P. J. Mad- 
den, M.D.) 

Beatrice — Harry Hepperlen, M.D., (C. T. Frer- 
ichs, M.D.) 

Blair — Leslie I. Grace, M.D., (R. F. Sievere, 
M.D.) 

Broken Bow — T. H. Koefoot, M.D., (R. B. Koe- 
foot, M.D.) 

Chadron — R. H. Rasmussen, M.D. 

Fremont — Robert Sorenson, M.D., (Harold 
Smith, M.D.) 

Grand Island — Robert Koefoot, M.D., (D. P. Wat- 
son, M.D.) 

Hastings — Robert C. Smith, M.D. 

Kearney — Robert Rosenlof, M.D., (John Mc- 
Cammond, M.D.) 

Kimball — Alfred Shamberg, M.D. 

Lincoln — Russell C. Brauer, M.D., (C. D. Bell, 
M.D.) 

Norfolk — James H. Dunlap, M.D., (Harold Dahl- 
heim, M.D.) 

North Platte — Max McCoy Raines, M.D. 

Ogallala — Donald E. Eberle, M.D. 

Omaha — Richard Svehla, M.D., (Gerald Ries, 
M.D.) 

O’Neill — Rex W. Wilson, M.D., (R. W. Water's, 
M.D.) 

Schuyler — Henr>' Dey Myers, M.D., (Howard 
Feud, M.D.) 

Scottsbluff — John Paul Heinke, M.D., (Lawrence 
Gridley, M.D.) 

St. Paul — Maurice Mathews, M.D., (Richard 
Hanisech, M.D.) 

Superior — Claude T. Mason, M.D., (T. Kiekhaefer, 
M.D.) 

Valentine — Thomas Deakin, M.D. 

Wahoo — John E. Hansen, M.D., (Ivan French, 
M.D.) 

West Point — Louis Erickson, M.D. 

York — James D. Bell, M.D., (Harold Mordlund, 
M.D.) 

The application for a Packaged Disaster Hospital 
for Ogallala has been approved by the Federal 
Government and it is expected to be delivered on 


170 


Nebraska S. M. J. 


December 23. The application for Kimball has not 
yet been accepted because of tbe proximity of missile 
bases. Further information on the storage site 
is being obtained and the application will again be 
submitted in the near future. Dr. Quick of Crete 
has expressed an interest in a Packaged Disaster 
Hospital for that ai’ea. In the meantime, we are 
looking for a suitable storage location in Crete. 
No other requests have been received so far. It is 
not expected that any more of these Packaged Dis- 
aster Hospitals will be available after January 1, 
1966. 

Of the 16 hospitals originally located in Nebraska 
the only one that is not receiving supply additions 
at the present time is that of Blair because of the 
lack of storage space. However, the city of Blair 
is in the process of constructing a new building for 
the pui^pose of storing this hospital and it is ex- 
pected that these additional supplies can be ordered 
soon after the first of the year. 

During the present year Packaged Disaster Hos- 
pital training exercises were held in the follow- 
ing locations: 

Wahoo — January 24; attendance 200; 4 physi- 
cians 

West Point — March 27-28; attendance 318; 2 
physicians 

O’Neill — July 23-24; attendance 146; 3 physi- 
cians 

Norfolk — July 17; attendance 180; 7 physicians 

In November a meeting was held in each of the 
communities of Valentine, Chadron, Alliance, Scotts- 
bluff, and Superior. This was for the purpose of 
providing orientations for an exercise to be held 
about April 1966 in each of these localities. It is 
planned at that time to haul the training unit from 
one community to the other in the western part 
of the State in order to have all these exercises 
w'ithin about a ten-day period. 

Medical Self Help. As of November 30, 1965 
the total number of persons in Nebraska trained 
in Medical Self-Help according to our records is 
12,706. Of these 5,201 were students in school. 
Approximately 290 schools in Nebraska, public and 
parochial, are now providing instimction in Medical 
Self-Help, at least they have requested and received 
supplies for teaching it. Beginning April 1, 1965 
a man was employed for three months to call on 
schools in the interest of Medical Self-Help. He 
visited 240 schools at that time with very encour- 
aging results although we have not yet begun to 
receive their reports where Medical Self-Help has 
been taught in schools so far this year. On De- 
cember 1, 1965 a person again was employed on a 
temporary basis to work full time in Medical Self- 
Help and at the present time he is working mainly 
with schools but also extension clubs and other 
industrial and civic groups which are in a position 
to further this program. In a few instances we 
have been informed that there is difficulty in 
finding instructors in Medical Self-Help. The pub- 
lication of the State Nurses Association has carried 
an appeal to nurses to volunteer their services for 
Medical Self-Help when requested and we hope that 
time will better the situation. 

On May 26 and 27, 1965, a Stateline Course on 
Health Mobilization was held at the Sheraton-Fon- 
tenelle Hotel, Omaha, with 229 in attendance. This 


included members of the Medical and Allied profes- 
sions as well as Civil Defense and Civic groups with 
special emphasis on the representation by the State 
organizations. Since that time the Pharmaceutical 
Association has promoted Packaged Disaster Hos- 
pitals and in their five Regional meetings held last 
month the Packaged Disaster Hospital film was 
shown and a presentation of this subject made to 
the pharmacists in each case. 

Respectfully submitted, 

GEORGE N. JOHNSON, M.D., 
Chairman 

REPORT OF HOSPITAL 
AND PROFESSIONAL RELATIONS 

Russell Brauer. M.D., Lincoln, Chairman ; John Brush, M.D., 
Omaha ; L. H. Hoevet, M.D., Chadron ; Howard Yost, M.D., 
Fremont; E. J. Loeffel, M.D., Mitchell; L. I. Grace, M.D., Blair. 

The Hospital and Professional Relations Commit- 
tee in 1965 had one problem referred to it by a 
physician. The committee met with him and re- 
viewed the problems he presented. Certain com- 
mittee recommendations were made, primarily em- 
phasizing the importance of more unity of physi- 
cian relations in the community. 

Respectfully submitted, 

RUSSELL BRAUER, M.D., 
Chairman 

REPORT OF DIABETES COMMITTEE 

The Diabetes Committee again prepared a state 
wide program for Diabetes Detection Week in 1965. 
Included are reports of results of that program 
plus the program at the State Fair and results 
from several county projects. 

STATE FAIR 

Dextrostix 

(Blood 

Sugars) 


Total number of tests 1,527 

Number of positives 75 

Number of positives previously 

known 12 

Number of positives previously 

unknown 63 


FRONTIER COUNTY HEALTH COUNCIL 

Clinistix 

(Urine 

Sugars) 


Total number of tests 749 

Total number of positives 2 

Total number of positives 

previously known 2 

Total number of positives 

previously unknown 0 


RICHARDSON COUNTY 

Clinistix 

(Unne 

Sugars) 


Total number of tests 319 

Total number of positives 5 

Total number of positives 

previously known 3 

Total number of positives 

previously unknown 2 


April, 1966 


171 


PHYSICIANS’ OFFICES 


( U rine 
Sugars) 

Number of physicians report 165 

Total number of tests 7,659 

Total number of positives 316 

Positives previously known 213 

Positives previously unknown 103 

Total tests 10,254 

Positives 398 

Positives previously known 230 

Positives previously unknown 168 


Respectfully submitted, 

MORRIS MARGOLIN, M.D., 
Chairman 

REPORT OF MEDICINE AND RELIGION 

Horace Giffen, M.D., Omaha. Chairman : Ray Sundell, M.D., 
Omaha : John Campbell. M.D.. Central City ; J. J. Hanigan, 
M.D.. Lincoln ; Dwaine J. Peetz. M.D., Neligh. 

This committee met repeatedly last year prior to 
the State Medical Association meeting and directed 
the initiation of medicine and religion discussions 
with a special meeting in the Civic Auditorium with 
provision of literature for follow-up in County Medi- 
cal Societies. The initial meeting was moderately 
attended and seemed to be stimulating to those 
there. It is to be hoped that County Medical groups 
will continue to be conscious of the needs for doc- 
toi’s and ministers working together in many problem 
areas of medical cases. 

Respectfully submitted, 

HORACE K. GIFFEN, M.D., 
Chairman 

REPORT OF JOINT COMMITTEE FOR THE 
IMPROVEMENT OF THE CARE 
OF THE PATIENT 

\V. C. Kenner, M.D., Nebraska City. Chairman : M. P. 

Brolsma, M.D., Lincoln. 

The Joint Committee for the Improvement of the 
Care of the Patient met with representatives of 
the Nebraska Hospital Association and of Blue 
Cross and Blue Shield on several occasions the past 
year. 

The establishment and functioning of Utilization 
Committees in various hospitals in Omaha, Lincoln, 
Kearney and vaidous other cities of the State was 
reported and discussed. This experience over the 
past two years is proving to be valuable not only 
to the hospitals in making better use of their staff 
and facilities but also in making it easier to meet 
the requirements of the Joint Accreditation Com- 
mittee. 

As you all know, the establishment and proper 
functioning of a Utilization Committee has been 
made a requirement if a hospital is to continue to 
be accredited after its next examination following 
January 1, 1966. 

It will also be a requirement of any hospital wish- 
ing to be eligible to care for patients under the new 
Medicare law. If the Staff does not form its own 
Committee the law provides for the establishment 
of a Committee by tbe regional director. 

Hence it seems only logical that a Utilization 
Committee should be established by each hospital 
even though the Staff Doctors themselves may not 


have made up their minds as to whether to partici- 
pate in the Medicare program or not. 

Respectfully submitted, 

W. C. KENNER, M.D., 
Chair-man 

REPORT OF PREPAYMENT MEDICAL 
CARE COMMITTEE 

Lee Stover, M.D., Lincoln, Chainnan : John J. Grier. M.D., 
Omaha : James D. Hayhurst, M.D., Scottsbluff : Clyde Kleager, 
M.D., Hastings ; Vincent S. Lynn, M.D., Geneva ; Orvis A. 
Neely, M.D.. Lincoln. 

1965 was a year of momentous change in the field 
of prepayment. No one knows for sure the im- 
pact Medicare will make on prepajment, the free 
practice of medicine, nor the quality of medical 
care. However, positive action must be taken to 
favorably influence its effect so that none suffer, 
neither the patient, the doctor, his practice, the 
quality of his care nor the traditional physician- 
patient relationship. 

Nebraska Blue Shield has again proved its in- 
valuble woi-th to doctors of medicine by taking 
immediate and positive action to try and forestall 
any further deterioration of any phase of Ameri- 
can medical care. 

Special coverage is being developed and will be 
offered by Nebraska Blue Shield to compensate for 
many of the deductibles, co-insurance and other 
open areas of Medicare so that no further legisla- 
tion will be necessary for prepaying the costs of 
medical care. 

Unless American medicine can show government 
and the American public that low overhead, reason- 
able cost, voluntaiy methods of prepaying the costs 
of medical care will work — then the present P.L. 
89-97 (Medicare) will only be the forerunner of ad- 
ditional, if not complete, federalization of medical 
care. 

It was necessai-y for Nebraska Blue Cross-Blue 
Shield to increase rates the past year. They avoid 
doing this as long as fiscally possible, but when- 
ever the cost of patient care exceeds income over 
a period of time, it is the only recourse they have. 
There just isn’t any magical solution to this prob- 
lem. It takes members’ premium dollars to pay for 
members’ medical care. 

New schedules were developed for anesthesia, 
radiological diagnosis and pathological examina- 
tions. Revised manual pages were mailed to all 
participating physicians. 

Prevailing Fees is the predominant current dis- 
cussion topic in the search for an equitable and 
fair means of paying for medical sei-vices. In all 
areas where this program has been tried it has 
met with ovei-whelming acceptance by participating 
physicians. 

As of December 17, 1965, there were 1,242 par- 
ticipating physicians in Nebraska. Tbis is an 
increase of 24 since January 1st. 

376 doctors’ offices were visited and sei-\’iced 
by Plan personnel during the year. This included 
the employees of 762 physicians as some offices 
house several doctors. 

Exhibits and displays were installed and manned 
at the State Medical Association’s Annual Meeting 
and the Midwest Clinical Society Meeting. Litera- 
ture and reprints were fumished prestamped and ad- 


172 


Nebraska S. M. J. 


dressed to the Blue Shield Committee of the Wom- 
an’s Auxiliary to the Nebraska State Medical Asso- 
ciation for mailing with a covering letter to all 
County Medical Society Auxiliary Blue Shield Com- 
mittees. Newsletters and informational material 
are also mailed to the various health disciplines. 

Members of your Prepayment Medical Care Com- 
mittee have attended all regular and special Ne- 
braska Blue Shield Board Meetings during 1965. 
Several other meetings pertaining to prepayment 
were also attended by one or more of your Commit- 
tee Members during the year, including the National 
Blue Shield Meeting held in Chicago, Illinois, on 
October 25, 26 and 27. 

If American Doctors of Medicine are to halt the 
advance of government medicine, they must band 
together and provide a positive answer to the 
demand for an adequate means of prepaying for 
medical care. Right or wrong, just or unjust, the 
demand is there — by government — by unions — 
by management — and even by our own patients. 
We can no longer hide our heads in the sand and 
hope the specter goes away. If we sincerely want 
to continue the free practice of medicine as our 
fathers and their fathers knew it, we have to provide 
an answer and then be sure that we make the 
answer work. 

The Prepayment Medical Care Committee recom- 
mends continued approval and support of the Ne- 
braska Blue Shield Plan by the Nebraska State 
Medical Association. 

Respectfully submitted, 

LEE STOVER, M.D., 
Chairman 

REPORT OF PSYCHIATRY COMMITTEE 

The Committee on Psychiatry met five times in 
1965 and once in 1966. The Committee has continued 
to represent the Nebraska Medical Association at 
various state and national meetings: 

1. Mental Health Conference in Washington, D.C. 

2. Regional Conference on Community Workshop 
sponsored by the AAGP in Omaha. 

3. National Conference on Community Mental 
Health Program in Chicago. 

4. Second Nebraska Congress on Mental Health 
in Lincoln. 

The Committee designed and displayed an ex- 
hibit at the annual state meeting showing the 
trends in psychiatric treatment, the progress of 
private psychiatric-treatment, the contributions of 
the family physician and private psychiatrist, the 
contributions of State Government organizations, and 
the availability of psychiatric care in Nebraska. 

The Committee has held much discussion on the 
trends and the future of mental health, especially 
in this state now that the Federal Government plans 
a bigger role. The private practice sector of psy- 
chiatry is much concerned with the community 
treatment aspects of mental health care, and with 
the federal funding and control being exerted at 
the present. In the past the Nebraska Legislature 
has taken the responsibility in caring for Nebras- 
ka’s mentally ill and will probably continue to do 
so. The proposed community health centers should 
be under control of the community and/or State, 
and should be financed as much as possible by the 


community, since in years to come the Federal 
funds would probably not be available in large 
amounts after the initial facility and program is 
organized. We believe the Nebraska State Medical 
Association in conjunction with other organizations 
in this area, should start a program telling what 
facilities, manpower, etc., are available now; what 
is the ultimate goal for adequate treatment; and 
what is going to be available in the future as 
things now stand. An adequate plan should be 
drawn up, put into action, and information be pro- 
vided to the professions and public. The pro- 
gram should include: (1) Evaluation of the psychi- 
atric system in Nebraska; (2) Have an educational 
campaign directed at the physicians explaining what 
we expect in years to come and what can and should 
be done. 

The Committee has been much concenied with 
the present policy of giving one man complete au- 
thority in the appointment, dismissal, demotion, 
and the involuntary transfer of psychiatrists within 
the state hospitals. We also noted that the legis- 
lature has seen fit to budget for lay administrators, 
and the budget committee determines the policy 
within the state hospitals. The fact that the lay 
administrator is a political appointee is considered 
very dangerous, but we concede that in any hos- 
pital, an assistant administrator of a business man- 
ager type is of great importance. 

After considerable discussion, it was decided by 
the committee to present the following items to the 
House of Delegates for adoption and proper dissem- 
ination: 

1. The Nebraska State Medical Association is in 
favor of the Chief Administrative Officer of a State 
Mental Institution being a Medical Doctor in the 
Psychiatric Branch of Medicine. 

2. Recommended establishment of a review or 
appeal board for deliberation and consultation, re- 
porting to the Governor, when a state institution 
medical director or other medical personnel are faced 
with involuntary release, transfer, or dismissal and 
that this board have membership consisting of the 
President of the County Medical Society having a 
state mental hospital at the time in question, the 
President of the Nebraska State Medical Association, 
the Chairman of the Committee on Psychiatry, (or 
their designates), a Nebraska representative of the 
Executive Committee of the District Branch of the 
American Psychiatric Association, the President of 
the Nebraska Academy of the Private Practice of 
Psychiatry, or his designate, and a representative 
of another State Mental Hospital. 

The Committee makes the following recommenda- 
tions: 

1. A study committee be named to review the 
problems involved with State Federal Funding of the 
State Mental Institutions. 

2. We request the House of Delegates to change 
the name of this Committee to “The Committee on 
Mental Health and Retardation.” 

3. Change page 48 in the Constitution and By- 
Laws relating to the description of the activities 
of this committee. We recommend that this section 
be changed to read, “The Committee on Mental 
Health and Retardation shall keep in touch with 
current progress in their field. It shall bring be- 
fore the members of the Nebraska State Medical 


April, 1966 


173 


Association such activities as may be of interest 
in this part of medical practice.” 

4. The House of Delegates is requested to en- 
dorse the principles, implementation and activi- 
ties of the Omaha Community Mental Health Center, 
which was brought into existence by the efforts 
of the Eastern Nebraska Mental Health Association 
upon the recommendations of the Region 6 of the 
Govemor’s Nebraska Long Range Mental Health 
Plan. 

As Chairman of the Committee on Psychiatiy, 

I wish to express my gratitude to the members of 
the committee, the Executive Secretaiy and Assist- 
ant Executive Secretary and to the Nebraska 
Branch of the American Psychiatric Association for 
their help and consultation during the past year. 

Respectfully submitted, 

LESLIE I. GRACE, JR., M.D., 
Chairman 

REPORT OF RELATIVE VALUE 
STUDY COMMITTEE 

B. R. Bancroft. M.D.. Kearney. Chairman : J. E. Courtney, 
M.D.. Omaha ; H. E. Mitchell. M.D., Lincoln ; Robert Long. 
M.D., Omaha; Harlan Papenfuss, M.D., Lincoln; James E. 
Ramsey, M.D., Atkinson. 

Since the progress report given to the House of 
Delegates at the annual meeting in 1965, your com- 
mittee has been occupied largely with the revision 
and upgrading of the Relative Value Study origin- 
ally compiled in 1961. After more than a year of 
preparation this Study is now in the hands of the 
members of the Nebraska State Medical Association. 
Your committee sincerely appreciates the coopera- 
tion of the representatives of the various specialty 
groups without which this work would have been 
impossible. 

Negotiation with the military Medicare, with the 
chairman of this committee as consultant, is now 
underway and will be reported by the Policy Com- 
mittee. Negotiations with welfare, old age assist- 
ance, Kerr-Mills and compensation court, by this 
committee, are yet to come. Your Policy Commit- 
tee has been designated as a negotiating committee 
for social security amendments of 1965, with the 
chairman of this committee as a consultant. 

Progress report of the activities of this com- 
mittee will be given to the House of Delegates at the 
annual meeting in 1966. 

The Chairman of your committee wishes to ex- 
press his appreciation of the hard work and faith- 
ful attendance of the members of this committee and 
the association office. 

Respectfully submitted, 

B. R. BANCROFT, M.D., 
Chairman 

REPORT OF SUB-COMMITTEE ON 
ATHLETIC INJURIES 

H. W. Shreck. M.D., Hastings. Chairman : Paul Goetowski. 
M.D.. Lincoln : John G. Yost. M.D.. Hastingrs ; S. I. Fuenning, 
M.D., Lincoln ; Bruce F. Claussen. M.D.. North Platte : Otis 
Miller. M.D.. Ord ; Mr. George Sullivan. Lincoln. 

During the year 1965 your Sub-Committee on 
Athletic Injuries has continued its progress in the 
alleviation of injuries to our Nebraska school ath- 
letes. In addition, significant developments are in 
the making which will tie school administrators. 


coaches, and the State Medical Association in a 
closer working relationship. 

Your Sub-Committee had four meetings during the 
year 1965, plus the Third Annual Seminar. Three 
meetings were held prior to the Seminar to prepare 
the program and to arrange the meeting, and one 
following. 

The Third Annual Seminar was held at the Hotel 
Cornhusker August 20-21, 1965. The program fea- 
tured injuries and treatment to the lower extrem- 
ities. Two National figures in diagnosis and treat- 
ment were featured throughout the program. Addi- 
tional fonims were held including a discussion from 
school administrators and insurance men. Our usual 
feature of taping and treatment demonstrations was 
given on the last morning. 

Attendance to the Seminar by medical personnel 
was good, and the increase of coach attendance, 
especially the last morning, over last year was 
gratifying. In fact, there were so many that the 
question was immediately forthcoming: Where might 
we find more room. 

Our efforts in financially supporting the Sem- 
inar has come from a number of sources, including 
the School Activities Association, Medical Groups, 
Sporting Goods Manufacturers, Tape and Bandage 
Manufacturers, and Book Publishers. 

Looking fonvard to next year and our Fourth 
Annual Seminar, there are new developments prog- 
ressing. We hope to combine our place of meeting 
with the Coaching School, which is always held 
at the same time as our meeting. This will have, 
the committee feels, a number of beneficial effects 
for both meetings. It will provide more room, as 
the Pershing Auditorium basement is to be used. 
Displayers that support both programs will have 
a better display area and better attendance. Both 
meetings will be adjacently held, providing easier 
access of coaches to our meetings. Costs will be 
more easily covered. Progress of this phase is 
well along and it looks very favorable for the 1966 
Seminar. 

The other development is the request of the Ne- 
braska State School Administrators to join with our 
committee in establishing an additional set of guide 
lines for physical education in Public Schools in Ne- 
braska. We will be holding meetings on this mat- 
ter and also will discuss Health and Education for 
Schools in more detail during 1966. 

Our committee feels that this last development is a 
significant break-thru in aligning Nebraska School 
Administrators and the Nebraska State Medical As- 
sociation. 

We think our Committee is gaining in its objec- 
tives and hope our progress will continue. 

Respectfully submitted, 

H. W. SHRECK, M.D., 
Chairman 

REPORT OF REHABILITATION COMMITTEE 

D M. Frost. M.D., Omaha. Chairman: F. S. Webster. M.D., 
Lincoln : Frank Stone. M.D., Lincoln : R. M. House. M.D., 
Grand Island : J. G. Yost, M.D., Hastings ; John M. Thomas, 
M.D.. Omaha. 

The Rehabilitation Committee had no foi-mal meet- 
ings during 1965 since no issues were presented or 
arose for this committee’s attention. 

Although there is nothing to report for the corn- 


174 


Nebraska S. M. J. 


mittee for 1965, it is fully anticipated that this 
committee’s activity during 1966 will be greater 
with the advent of the multiple types of Federal 
programs being put into effect during this coming 
year, many of which will involve the sphere of re- 
habilitation medicine. 

Respectfully submitted, 

D. M. FROST, M.D., 
Chairman 

REPORT OF MATERNAL AND CHILD 
HEALTH COMMITTEE 

Warren Bosley, M.D., Grand Island. Chairman ; Hodsen 
Hansen. M.D., Lincoln; Otto Rath, M.D.. Omaha; Theo. J. 
Lemke, M.D., Columbus ; Theo. Koefoot, M.D., Broken Bow ; 
William Rumbolz, M.D., Omaha ; Harold S. Morgan, M.D., 
Lincoln ; Robert F. Getty, M.D., North Platte ; R. Fischer, M.D., 
Columbus. 

The last meeting of the Maternal and Child Health 
Committee was held on January 5, 1966, at the Hotel 
Cornhusker in Lincoln. Present were Doctors War- 
ren Bosley, Grand Island, Chainnan; Hodson Han- 
sen, Lincoln; William Rumbolz, Omaha; Harold S. 
Morgan, Lincoln; Robert F. Getty, North Platte; 
Willis D. Wright, Omaha, President; Dan A. Nye, 
Kearney, President-Elect; Mr. Kenneth Neff, Execu- 
tive Secretary, and Bill Schellpeper, Executive As- 
sistant. 

The programs sponsored and carried out by the 
MCH Committee were then reviewed. The Chair- 
man reported that in the three years since the re- 
vised maternal mortality forms were adopted, 24 
of these have been sent out and 17 have been re- 
turned. It was agreed that this was a good re- 
sponse. The Committee agreed that three additional 
questions should be added to the form to make it 
more informative and to increase its teaching value. 
Copies of these revised forms will be made avail- 
able to the House of Delegates as soon as they 
are printed. The death certificates in Nebraska 
now carry a question asking that if the deceased 
is a woman, whether or not she was pregnant dur- 
ing the 9 months prior to death. The Committee 
generally agreed that the maternal mortality studies 
were proceeding well and that some thought 
might now be given to considering a tabulation 
or study of perinatal deaths. 

The matter of testing newborn infants for phenyl- 
ketonuria was then discussed. The House will recall 
that legislation requiring this was introduced in 
the State Legislature at the last session, but this 
bill was killed in committee through the efforts 
of the MCH Committee and other groups. There 
is ample evidence that efforts to pass this legisla- 
tion are still quite vigorous. The Secretary of the 
Association has carried out a survey of Nebraska 
Hospitals. 94 reported that they do PKU testing 
on a routine basis, 9 hospitals reported that they 
do not do such testing, and 5 hospitals stated they 
contemplated setting up a testing program. 7 re- 
ported that testing is carried out in the local physi- 
cians’ offices. Only 4 hospitals questioned did not 
reply. 

From this study, it would appear that over 90% 
of newborn infants in Nebraska are being examined 
in the newborn period for phenylketonuria. The 
Committee discussed the problem of phenylketonuria 
at some length. Because there are many unsettled 
questions at the investigative level, the Committee 
makes no recommendations regarding the type of 


tests that should be performed. The Committee will 
prepare and send to each physician of Nebraska a 
summary of the present state of knowledge of this 
disease in order that the members of the Associa- 
tion may be as well-informed as present knowledge 
permits. According to the presently accepted inci- 
dence of phenylketonuria — 1 in 10,000 births — 
one might expect that 3 babies per year to be born 
in Nebraska with phenylketonuria. 

In September, the Chairman of the MCH Commit- 
tee participated in an Institute for the home care 
and management for the physically-handicapped and 
mentally-retarded child. This Institute was spon- 
sored jointly by the Iowa and Nebraska State Medi- 
cal Associations, the Iowa and Nebraska Associa- 
tions for Retarded Children and the Iowa and Ne- 
braska United Cerebral Palsy Associations. This 
was a well-conducted meeting, and it provided a fine 
opportunity to develop good relationships with these 
organizations of laymen. The Chainnan has also 
been active in representing the Nebraska State 
Medical Association on the Nebraska Committee for 
Children and Youth and the Governor’s Committee 
on Mental Retardation. It may be possible to at- 
tend the next annual meeting of the Nebraska As- 
sociation for Retarded Children and to appear on 
the program. This is a most active lay group in 
the area of mental retardation, and it is certainly 
to their and our advantage to improve our com- 
munication with them.. 

Respectfully submitted, 

WARREN BOSLEY, M.D., 
Chairman 

REPORT OF HEALTH EDUCATION IN 
SCHOOLS AND COLLEGES 
COMMITTEE 

S I Fuenning, M.D.. Lincoln. Chairman ; Paul Bancroft, 
M.D., Lincoln : H. W. Shreck, M.D.. Hastings : R. C. Rosenlof, 
M.D., Kearney ; J. P. Heinke, M.D.. Scottsbluff ; H. V. Smith, 
M.D., Kearney; S. M. Rathbun. M.D., Beatrice: Ray Hill, M.D., 
Seward ; W. P. Jensen, M.D., Omaha. 

The chief project of the Health Education Com- 
mittee has been the continuation of the Health Educa- 
tion Suiwey project that was established in 1964. 
The study of health education in the Class C Schools 
in Nebraska was completed in 1965. Enclosed is a 
summary of this health education survey. As a 
result of this very significant study, the following 
action and recommendations have been made: 

1. Disposition of Summary of Health Education 
Study: 

Summary of report to be sent to all physi- 
cians, principals, and superintendents with a 
cover letter signed by the President of the 
N.S.M.A., Floyd Miller, Commissioner of Edu- 
cation, and Mr. Ted Dappen, Chairman of the 
Department of Health Education, State Depart- 
ment of Health. A similar procedure was used 
at the time the study was initiated. 

2. The Development of a Curriculum in Health 
Education for Elementary and Secondary 
Schools : 

Mr. Floyd Miller has indicated that he will 
appoint a committee in the Department of 
Public Instruction to work with the Health 
Education Department State Department of 
Health, to establish a suggested curriculum for 
health education. 


April, 1966 


175 


Question: What do the physicians expect of 

elementarj- school students, high school stu- 
dents and community citizens in the area 
of health knowledge and understanding? 

3. The Employment of a Health Educator in the .. 
State Department of Education: 

Several years ago the State Department of 
Education did have a specialist on their staff 
to promote health education in the schools 
in the State of Nebraska. This was as a re- 
sult of a Kellogg Foundation Project on School 
Community Health Education in the early 
1950’s. Several years after the completion of 
this Kellogg Project, the specialist resigned 
and this position has never been filled. 

Funds from Washington are now becoming 
available to employ assistants in specialized 
areas. The general orientation in the Ele- 
mentary and Secondary Education Act of 1965 
provides assistance in the area of health and 
physical education and recreation. This fol- 
lows the presently established patterns of 
associating health education with physical edu- 
cation. 

Since there has been precedence for the 
State Department of Health to loan person- 
nel to the State Department of Education in 
specialized areas, the Health Education Com- 
mittee recommends the following: 

It is recommended that a full time Profes- 
sional Health Educator be employed by the 
State Department of Health in the Department 
of Health Education and loaned to the State 
Department of Education to assist the schools 
in the further development of health education 
programs in the elementary and secondary 
schools. 

4. Nebraska State-Wide Conference on Health 
Education: 

The Nebraska Health Education Survey and 
the Nation-Wide Study of Health Instimction 
in the Public Schools sponsored by the Bronf- 
man Foundation has indicated the great need 
for health education in elementaiy and sec- 
ondary schools. The lack of health education 
in our schools not only in the State of Ne- 
braska but throughout the United States, is 
as a result of many factors, situations, and 
philosophical influences, and these are briefly 
as follows: 

a. The lack of concern and interest by physi- 
cians. 

b. The cleavage between physicians and edu- 
cators. The field of health education by 
default has become the concem of physical 
educators. The physical educators are pri- 
marily trained in physical education with 
very little training in health education. 
This has resulted in the development of 
veiy poor health education programs. 

c. The recent rapid development of the Pupil 
Personnel Movement (guidance and coun- 
seling) which has as its objective the in- 
clusion of health ser\dce and education as 
part of its puiwiew in providing a new 
direction and orientation, and is detri- 
mental to the development of a sound 
program in health education. 


d. The cleavage between public health edu- 
cators and health educators. This is grad- 
ually being resolved. 

In order to provide leadership to the de- 
velopment of health education in the State 
of Nebraska and to further implement the 
desired results of the health education survey, 
it has been proposed by the Health Education 
Committee that a State- Wide Conference on 
Health Education be held. 

Specifically, the State- Wide Conference on 
Health Education will emphasize the im- 
portance of a sound health education pro- 
gram in our schools and colleges, mobilize our 
health resources in the State of Nebraska 
for a concerted effort to help establish sound 
health education programs not only in our 
schools and colleges but in our communities, 
and will provide further guidelines for the 
continued development of health education 
curriculum and programs in schools, colleges 
and communities. The Health Education 
Committee has recommended the following 
resolution : 

“The Nebraska State Medical Association to 
sponsor a State- Wide Conference on Health 
Education. Interested professional health agen- 
cies, voluntary health agencies, and official 
health agencies will be invited to co-sponsor such 
a conference.” 

STATE INTER-AGENCY HEALTH 
COUNCIL 

In the past several years the U.S.P.H.S. has been 
aware of the fragmentation of health services in 
communities. As a result, the U.S.P.H.S. has estab- 
lished a Division of Community Health Services to 
promote coordination of health facilities and agen- 
cies within a community. The National Health Coun- 
cil through a nation-wide commission on health 
services, has made an intensive study on this prob- 
lem of coordination of health activities with com- 
munities. This study has further emphasized the 
need for concerted action on our major health prob- 
lems. 

As a result of the Surgeon General’s Report on 
Smoking and Health, a National Inter-Agency Coun- 
cil on Smoking and Health has been established. 
This National Inter-Agency Council on Smoking and 
Health is now stimulating the development of State 
Inter-Agency Councils on Smoking and Health. 
Other states have established a State Inter-Agency 
Council with a Sub-Committee on Smoking and 
Health. In the State of Nebraska, an Intei'-Agency 
Council on Smoking and Health is being proposed. 
The Health Education Committee recommends that 
a State Inter-Agency Council be established with 
official representatives from professional health 
agencies, voluntary health agencies, official health 
agencies and educational agencies. The function of 
such a council would be to mobilize, coordinate, and 
integrate health education efforts in the State of 
Nebraska and to study community health education 
needs and how best to meet these needs. 

It is recommended that the N.S.M.A. assume the 
leadership in the development of such a State Inter- 
Agency Health Council and to initially provide the 
necessary secretarial seiwices. It would be anti- 
cipated that after the State Inter-Agency Health 


176 


Nebraska S. M. J. 


Council has been established, that each participat- 
ing health organization would contribute towards 
the expenses of the State Inter-Agency Health 
Council. Following the establishment of a Nebraska 
State Inter-Agency Council, a Sub-Committee on 
Smoking and Health would be established. 

PROPOSED COOPERATIVE STUDY ON 
ESTABLISHING PHYSICAL AND 
MENTAL HEALTH STANDARDS 
FOR TEACHERS 

A request was received from Mr. Floyd Miller, 
State Commissioner of Health for this committee 
to study this problem. After considerable discussion 
and consultation with Mr. Leonard Skov, Director 
of Certification in the State Department of Educa- 
tion and appropriate educational agencies to study 
this problem of health standards for teachers. The 
various discussions that have been held indicate 
that such a study will materialize. 

Respectfully submitted, 

S. I. FUENNING, M.D., 
Chairman 

REPORT OF RURAL MEDICAL 
SERVICE COMMITTEE 

R. L. Tollefson, M.D., Wausa, Chairman ; Lyle Nelson, 
M.D., Crete ; Robert L. Heins, M.D., Falls City : Otis Miller, 
M.D., Ord ; F. A. Mountford, M.D., Davenport ; James E. 
Rogers, M.D., Ord. 

The Rural Medical Service Committee sponsored 
the 15th annual Senior Medical Day, October 14, 
1965 at the Indian Hills Inn in Omaha. The fol- 
lowing program was presented: 

Presiding — Willis D. Wright, M.D., Omaha 
President, Nebraska State Medical Association 
“You Will Soon Be a Doctor” 

Fay Smith, M.D., Omaha 
Professor of General Practice, 

University of Nebraska College of Medicine 
“Why I Chose a Community Practice” 

Lyle Nelson, M.D., Crete 
Member, Rural Medical Service Committee 
“The Doctor’s Obligation to His Community” 
Richard L. Tollefson, M.D., Wausa 
Chairman, Rural Medical Service Committee 
“The Role of General Practice in Modern Medicine” 
R. F. Sievers, M.D., Blair 

Past President, Nebraska State Medical Assn. 
“The Role of the Professional Service Represent- 
ative” 

Mr. C. E. Purdy, Omaha 
Mead Johnson and Company 
Panel: “The Socio-Economic Aspects of Your 

Practice” 

Mr. Charles J. Marshall, Verdigre 

Vice President and Cashier, Bank of Verdigre 
Mr. Wallace A. Richardson, Lincoln 

Mason, Knudsen, Berkheimer & Endacott 
Law Firm 

Mr. M. K. Mills, Waterloo, Iowa 
General Manager, Professional Management 
Midwest 

“Medical Ethics — The Doctor’s Golden Rule” 
George B. Salter, M.D., Norfolk 
Member, Board of Trustees 
Nebraska State Medical Association 


Banquet Speaker — Edward R. A n n i s, M.D., 
Miami, Florida 
Past President 

American Medical Association 

Respectfully submitted, 

R. L. TOLLEFSON, M.D., 
Chairman 

REPORT OF POLICY COMMITTEE 

Willis D. Wright, M.D., Omaha, Chairman : Dan A. Nye, 
M.D., Kearney; R. F. Sievers, M.D., Blair; R. E. Garlinghouse, 
M.D., Lincoln ; O. A. Kostal, M.D., Hastings 

The year 1965 proved to be a most active and 
busy year for the Policy Committee since its 
origination by the House of Delegates. This Com- 
mittee consists of the President, President-elect, and 
the three immediate past presidents of the Nebraska 
State Medical Association and is given the respon- 
sibility of making policy in behalf of this organiza- 
tion between meetings of the House of Delegates. 
I wish to mention at this time that all decisions 
regarding policy made by this Committee are given 
thorough and careful study before any decisions 
are made as the House also directed that any 
decisions regarding policy which this Committee 
made would have to be finally approved by the 
House of Delegates itself. The follov/ing is a 
summary of activities and recommendations of the 
Policy Committee for 1965. 

Liaison with the Governor’s Office: On several 

occasions in 1965, comments and actions by the 
Governor of the State of Nebraska regarding health 
issues, reflected the lack of communication between 
his office and the State Medical Association. 
In reviewing this situation, the Policy Commit- 
tee approved the sending of a letter over the 
signature of the President to offer the assistance 
of the Policy Committee as the official body of the 
Nebraska State Medical Association to discuss any 
health matters with the Governor’s office. No 
meetings between the Governor and this Committee 
have been called; however, we are on record as 
expressing our willingness to serve in this ca- 
pacity. At this time, we would ask approval of 
the House of Delegates for the Policy Committee 
to continue in this advisory capacity until such 
other body has been duly organized to take over 
this function. 

Committee on Aging: With the passage of Medi- 
care the Governor of the State of Nebraska indicat- 
ed his desire to create a Committee on Aging. 
In response to this, the Policy Committee recom- 
mended that Doctors W. W. Waddell of Beatrice, 
Meyer Beber and F. F. Paustian of Omaha be con- 
sidered to sit on this Committee representing Ne- 
braska State Medical Association. The recommen- 
dations of the Committee, however, were not fol- 
lowed by the Governor as none of these three men 
appeared on the Committee named by the Gov- 
ernor. At this time, the physician on the Committee 
is Doctor Robert Osborne of the State Hospital 
in Norfolk. 

State Board of Health: In September of 1965, 

Doctor E. F. Leininger completed his second three- 
year term as a member of the State Board of Health. 
As Board members are limited to two such terms, 
the State Medical Association recommended Dr. 
Fay Smith for appointment to the Board by the 


April, 1966 


177 


Governor, and this appointment also took place in 
the month of September. 

Establishment of a State Advisory Health Com- 
mittee: During the past year, there has been con- 

siderable interest expressed by the Association, 
Voluntary Health Agencies and other interested 
individuals in setting up a state-wide Advisory 
Health Council. The Nebraska State Medical As- 
sociation should be the active leader in this pro- 
gram and the Policy Committee in reviewing this 
matter with the Committee on Health Education 
in Schools has asked this Committee to provide the 
leadership and represent the Nebraska State Medical 
Association in this endeavor. The Health Education 
Committee will make specific recommendations 
relative to this subject in its own report. At this 
point, the Policy Committee would request approval 
of the House of Delegates by approving the Com- 
mittee on Health Education in Schools and Col- 
leges to represent Nebraska State Medical Associa- 
tion in the establishment of a state-wide Advisoiw 
Health Council. 

Blue Shield Series 90: In October, Doctor A. J. 

Offennan met with the Policy Committee and pre- 
sented details regarding the establishment of a new 
Series 90 Blue Shield Policy which has been placed 
on the market. At this meeting the Policy Com- 
mittee approved the creation of the Series 90 Policy 
and at this point would ask the House of Dele- 
gates to approve the action by this Committee 
of the establishment of a Blue Shield Series 90 
contract. 

Veterans Administration Fee .Schedule: The Ne- 

bi’aska State Medical Association was contacted in 
the fall of last year by the Veterans Administration 
indicating an interest in establishing a fee schedule 
for home health seiwices for veterans on an out- 
patient basis. In discussions with the representa- 
tives there was indication that they were not will- 
ing to pay the going schedule for the seiwices as 
indicated in our 1961 Relative Value Study. Here- 
tofore there has never been established a fee sched- 
ule for out-patient care for veterans home services 
in Nebraska or any other state. Checking into the 
matter, we found that all other states were also 
being contacted, .\fter receiving all information 
the Policy Committee recommended that a schedule 
would have to be negotiated for this seiwice with 
the Relative Value Study Committee. As of this 
date, the Veterans Administration has made no 
further proposal or indicated no further interest 
in establishing such a fee schedule. 

Governor’s Advisory Committee on Medicare: 
The Governor of Nebraska has established a Gov- 
ernor’s Advisory Committee to Medicare in Ne- 
braska on which the President of this Association 
is seiwing at this time. The purpose of the Com- 
mittee is to retain as much as possible in the State 
of Nebraska the prerogatives for setting up cri- 
teria for the establishment of this program. It 
was anticipated that the Committee would meet 
on a regular basis and funds have been set aside 
by the Legislature for the use of this Committee. In 
view of the potential time required for a representa- 
tive to sit on the Committee from the Nebraska 
State Medical Association, the committee approved 
the selection of Doctor R. E. Garlinghouse, who 
lives in Lincoln, the site of all the meetings, to be 
the official representative from the Nebraska State 


Medical Association in place of the President. It 
was the feeling of the Committee at that time 
that a permanent representative should be on the 
organization representing medicine as opposed to 
having a new man each year on the Committee. 
At this time, the Policy Committee would ask ap- 
proval of the House of Delegates to place Doctor 
Garlinghouse on as a continuing representative of 
this organization. 

Payment by Blue Shield ■ Blue Cross in Non- 
Federal Hospitals: It was brought to the attention 

of the Policy Committee that the hospitals at the 
College of Medicine, Creighton University, and 
Douglas County Hospital cannot receive payments 
for patients who have Blue Cross - Blue Shield poli- 
cies and are receiving care in those institutions. 
It was requested that Blue Cross - Blue Shield in- 
stitute the payment of claims for patients who 
receive care in such institutions as the College of 
Medicine, Creighton University and Douglas County 
Hospital. Following the discussion of the matter, 
it was felt by the Policy Committee that the Omaha 
Douglas County Medical Society, if they' approve 
such a move, should bring a resolution to the 
House of Delegates at this time requesting change 
in the current policy of the Blue Cross - Blue Shield. 
At this time, the Policy Committee would recom- 
mend the payment of claims at these three institu- 
tions and recommend the House of Delegates to 
support the payment of such claims. 

^ledicare Negotiations (ODMC) : One of the most 
important meetings of the Policy Committee in 1965 
was the re-negotiation of the Medicare contract for 
seiwicemen and their dependents held on December 
7th. Four representatives of the ODMC office 
from Denver, Colorado, came to Lincoln to meet 
with the Policy Committee and its advisors, the 
President of Blue Shield and the Chairman of the 
Relative Value Study Committee. A day long 
meeting was held with these representatives; how- 
ever, at the end of the day we were not able to 
come to a satisfactoiy agreement to which both 
of us could mutually subscribe. The position of the 
Nebraska State Medical Association was pi-esented 
by the Policy Committee and its advisors relative 
to the fact that a new contract had not been nego- 
tiated with this program since its inception in 1957, 
and we felt that we were duly justified in asking 
for a fee program as represented by the 1965 Rela- 
tive Value Study. The ODMC officials argued 
that the average income of their personnel was 
$6,000. They further argued that the Blue Shield 
Series 60 Policy which represented incomes up to 
$6,000, did not represent the payment of fees as 
listed in the 1965 Relative Value Study. Because 
of this, they did not feel obligated to pay the con- 
version factor of 5 in the 1965 Relative Value Study. 
This was the critical point of discussion which 
could not be resolved and this is where the Policy 
Committee concluded its discussions with the ODMC 
officials. At the close of the meeting, ODMC offi- 
cials made a counter proposal offer of 4 25 for 
medicine and surgery and 5 for radiology and path- 
ology in the 1965 Relative Value Study and indi- 
cated they wanted to meet with the Policy Com- 
mittee again after the matter had been brought 
to the House of Delegates. In view of the fact 
that the House has directed the Policy Commit- 
tee and Relative Value Study Committee to nego- 
tiate a usual and customary fee based upon a 5 con- 


178 


Nebraska S. M. J. 


version factor across the board in the 1965 Rela- 
tive Value Study for all future contracts, the Policy 
Committee has brought this matter back to the 
House of Delegates for further direction. At this 
point we would like a discussion by the House 
of Delegates to determine whether or not we should 
accept the proposal of ODMC or whether the House 
still directs us to follow the usual and customary 
fee of a 5 conversion factor across the board 
for this program. As of this date, no other pro- 
grams have been negotiated as the Policy Com- 
mittee felt that this matter should be settled prior 
to going into other negotiations. 

Heart Disease, Cancer and Stroke: On Decem- 

ber 28th, the Policy Committee invited our two 
medical schools, the Heart Association, the Cancer 
Society, the Department of Health, and two repre- 
sentatives of the public to meet and discuss the 
implementation of an Advisory Council on Heart 
Disease, Cancer and Stroke in the State of Ne- 
braska. All representatives of the invited organ- 
izations and individuals appeared at this meeting 
and a very fruitful discussion was carried out re- 
garding the future plans and needs of Nebraska in 
this particular area. As this was an exploratory and 
oi’ganizational meeting, the following actions were 
taken. 

The President of the Nebraska State Medical As- 
sociation on a continuing basis shall he the perma- 
nent chairman of the Advisory Committee on Heart 
Disease, Cancer and Stroke in the State of Ne- 
braska. An executive Committee was appointed 
consisting of Doctor Egan, Doctor Wittson and Doc- 
tor Nye, with Doctor Nye being named Chairman. 
This Committee will be responsible for making the 
content up of the next program and providing some 
guidelines for the Committee to follow. Also other 
surrounding states will be contacted to indicate 
whether or not they are interested in participating 
as a region under this new program. There was 
some feeling at the time of the meeting that funds 
would not be forthcoming from the administration 
for this; however, no definite knowledge of this 
freezing of funds has yet been received. The Policy 
Committee has accepted responsibility for repre- 
senting our state in this particular project and 
we would at this time ask for the approval for the 
Policy Committee to continue to be the official 
committee of representatives for this program in 
the State of Nebraska as organized. 

At the final meeting of the Policy Committee 
held in January, representatives of the Nebraska 
Blue Shield were present to discuss the matter 
of the prevailing fee concept which has been sug- 
gested by National Blue Shield and recommended 
by the Nebraska Blue Shield. Much discussion has 
insued since the announcement of the “prevailing 
fee concept” and the “usual and customary fee con- 
cept” which constituted considerable discussion by 
the House of Delegates of the American Medical 
Association at their meeting in Philadelphia. At 
the meeting of the House of Delegates in Philadel- 
phia, they reaffirmed their adoption of the “usual 
and customary fee” concept and recognized the 
“prevailing fee” concept of Blue Shield in those 
states which approve such a program. In view 
of the immensity and far reaching effects of 
these two new concepts, it was felt by the Policy 
Committee that this matter should be brought to 


the House of Delegates for their action and deci- 
sion. Therefore in line with this, the Policy Com- 
mittee has prepaied a program at which the “usual 
and customary” fee concept and the “prevailing” 
fee concept will be presented by the respective indi- 
viduals of those two programs and allow an open 
discussion by the House of Delegates. It will be 
sent to reference committee for recommendation 
and action by the House of Delegates at its final 
session. We trust that everyone will express his 
opinion and ask questions so that he will thoroughly 
understand these two concepts of which are vitally 
important to the medical profession. At this point 
we would ask for the approval for the repoi’t as a 
whole by the House of Delegates. 

“Medicare” Cases: During the year, the Policy 

Committee adjudicated 103 “Medicare” cases. 

Respectfully submitted, 

WILLIS D. WRIGHT, M.D., 
Chairman 


1966 Roster of Deleqates, 
Nebraska State Medical Association 

Sat. Sun. 
Feb. 12 Feb. 13 


ADAMS— 

Chas. Landgraf. Hastings (D) P P 

Lloyd Wagner, Hastings (.A) P 

ANTELOPE— 

Dwaine Peetz, Neligh (D) P P 

Frank McClanahan, Jr., Neligh (A) 

BOONE— 

Roy J. Smith. Albion (D) P P 

Gerald J. Spethman, Albion (A) 

BOX BUTTE— 

Robert Morgan. Alliance (Dl P P 

J. J. Ruffing. Hemingford (A) 

BUFFALO— 

L. C. Steffens, Kearney (D) P P 

F. L. Richards, Keai-ney (A) 

BURT— 

Isaiah Lukens, Tekamah (D) 

L. Morrow. Tekamah (A) P P 

BUTLER— 

J. E. Kaufmann, David City (D) 

Wm. C. Neihaus, David City (A) 

CASS ■ 

R. R. Andersen. Nehawka (D) P P 

L. N. Kunkel, Weeping Water (A) 

CHEYENNE-KIMBALL-DEUEL— 

C. B. Dorwart. Sidney (D) P 

Hull Cook, Sidney (A) P P 


COLFAX— 

H. D. Myers, Schuyler (D) 

Howard L. Fend. Schuyler (A) 

CUMING— 

L. L. Ericson, West Point (D) 

L. J. Chadek, West Point (A) 

CUSTER— 

Theo Koefoot. Jr., Broken Bow (Dl 

Ralph Blair, Broken Bow (A) 

DAWSON— 

P. B. Olsson. Lexington (D) P P 

Victor Norall, Lexington (A) 

DODGE— 

Robert Sorensen, Fremont (D) P P 

FILLMORE— 

V. S. Lynn, Geneva (D) 

A. A. Ashby, Geneva (A) 

FIVE— 

Robert B. Benthack, Wayne (D) 

Chas. Muffly. Pender (A) 

C. M. Coe. Wakefield (D) 

Wm. Reynolds. So. Sioux City (A) 

C. J. Vlach, Hartington (D) 

Henry Billerbeck, Randolph (A) __ 

FOUR— 

Roy Cram, Burwell (D) 

Otis Miller, Ord (A) P P 


P P 

P 


April, 1966 


179 


FRANKLIN— 

W. A. Doering. . Franklin (D) P P 

C. J. Thomas, Franklin 

GAGE— 

H. F. Elias, Beatrice (D) P P 

John Chapp, Beatrice (A) 

GARDEN-KEITH-PERKINS— 

E. E. Colglazier, Grant (D) P P 

Berl Spencer. Ogallala (A) 

HALI^ 

Warren Bosley, Grand Island (D) P 

P. T. Sloss, Grand Island (A) 

HAMILTON— 

H. G. Steenburg, Aurora (D) P P 


J. M. Woodard, Aurora (A) 

HARLAN— 

J. S. Long, Alma (D) 

K. C. McGrew, Orleans (A) 

HOLT AND NORTHWEST— 

James Ramsey, Atkinson (D) P P 

Floyd Shiffermiller, Ainsworth (A) 

HOWARD— 

M. D. Mathews, St. Paul (D) 

R. W. Hanisch, St. Paul (A) 

JEFFERSON— 

K. J. Kenney, Fairbury (D) 

F. W. Falloon. Fairbury (A) 

JOHNSON— 

Michael Sorrell, Tecumseh (D) 

John Schutz, Tecumseh (A) 

KNOX— 

R. L. Tollefson. Wausa (D) 


Stanley Neil, Niobrara (A) P P 

LANCASTER— 

D. F. Purvis, Lincoln (D) P P 

R. F. Station, Lincoln (A) 

B. F. Wendt. Lincoln (D) 

P. Goetowski, Lincoln (A) 

L. J. Gogela, Lincoln (D) P P 

D. Matthews. Lincoln (A) 

A. L. Smith, Lincoln (D) 

F. H. Hathaway, Lincoln (A) P 

F. H. Tanner, Lincoln (D) P P 

G. E. Lewis, Jr„ Lincoln (A) 

LINCOLN— 

Bruce F. Claussen, North Platte (D) P P 


Gordon Sawyers, North Platte (A) 
MADISON— 

J. H. Dunlap. Norfolk (D) 

J. D. Pollack. Norfolk (A) 

MERRICK— 

E. T. Zikmund, Central City (Dl _ 
John A. Campbell. Central City (A) 


NEMAHA— 

Paul M. Scott. Auburn (D) 

J. J. Bence, Auburn (A) 

N.W'. NEBRASKA— 

A. J. Alderman, Cbadron (D) P P 

H. V. Crum, Rushville (A) 

NUCKOLLS— 

C. T. Mason, Superior (D) P P 

OMAHA-DOUGLAS— 

Geo. B. McMurtrey. Omaha (D) 

Gilbert C. Schreiner. Omaha (A) 

W. J. McMartin, Omaha (D) P P 

Wm. C. Jensen, Omaha (A) 

Maurice Stoner, Omaha (D) 

J. Whitney Kelley. Omaha (A) P P 

Dwight Burney, Omaha (D) P P 

Joseph Pleiss, Omaha (A) 

Arnold Lempka. Omaha (D) P P 

J. J. O’Neill, Omaha (A) 

Thomas J. Gurnett, Omaha (D) P P 

J. J. Grier, Omaha (A) 

Richard Egan, Omaha (D) 

W. E. Kelley. Omaha (A) P P 

John D. Coe, Omaha (Dl 

Jerry Tamisiea, Omaha (A) P P 

T. 'T. Smith. Omaha (D) P 

S. M. Truhlsen, Omaha (A) 

C. A. McWhorter. Omaha (D) 

A. W. Abts, Omaha (A) P P 

OTOE— 

T. L. Weekes, Nebraska City (D) P P 

C. J. Formanack, Syracuse (A) 


PAWNEE— 

H. C. Stewart. Pawnee City (D) _ 
A. B. Anderson, Pawnee City (A) 


PHELPS— 

H. A. McConahay, Holdrege (D) P P 

Walter Reiner, Holdrege (A) 

PIERCE— 

W. I. Devers, Pierce (D) P 

A. E. Mailliard, Osmond (A) 


PLATTE— 

Robert Bums, Columbus (D) 
H. D. Kuper, Columbus (A) 


POLK— 

C. L. Anderson, Stromsburg (D) P 

R. Bierbower, Shelby (A) P 

RICHARDSON— 

R. L. Heins, Falls City (D) P 

W. V. Glenn. Falls City (A) 

SALINE— 

Clarence Zimmer, Friend (D) 

V. Franklin Colon, Friend (A) P 

SAUNDERS— 

Ivan French. Wahoo (D) P P 


E. J. Hinrichs, Wahoo (A) 

SCOTTS BLUFF— 

Edwin J. Loeffel, Mitchell (D) 

Carl Frank, Scottsbluff (A) 

SEWARD— 

W. Ray Hill, Seward (D) P P 

Robt. Herpolsheimer, Seward (A) 

S.W. NEBRASKA— 

F. M. Karrer, McCook (D) 


THAYER— 

L. G. Bunting, Hebron (D) P P 

R. E. Penry, Hebron (A) 

WASHINGTON— 

R. F. Sievers, Blair (D) P P 

C. D. Howard, Blair (A) 

YORK— 

R. E. Harry, York (D) 


Harold Friesen, Henderson (A) 


Adrenal Hemorrhage During Anticoagulant 
Therapy: A Clinical and Pathological 

Study of Ten Cases — E. Amador (Peter 
Bent Brigham Hosp., 721 Huntington Ave., 
Boston). Ann Intern Med 63:559-571 
(Oct.) 1965. 

The records of 4,325 autopsies performed 
on adults since the adoption of anticoagulant 
therapy in 1949 were searched for cases of 
adrenal hemorrhage. In nine cases (plus one 
personal case) adrenal hemorrhage occurred 
during anticoagulant therapy for thrombo- 
embolism or myocardial infarction. Five pa- 
tients received heparin, and five heparin plus 
bishydroxycoumarin (Dicumarol). Adrenal 
hemorrhage occurred after two to ten days 
of therapy. Localizing manifestations were 
steady pain of sudden onset, located to the 
upper abdomen or flanks, accompanied by 
tenderness and guarding. Anorexia, nau- 
sea, and vomiting also occurred. Manifesta- 
tions of adrenal crisis were listlessness and 
weakness, progressing to lethargy. Tachy- 
cardia, hypotension, fever, and cyanosis were 
late signs. Death occurred in two to eight 
days. A direct eosinophil count above 50 
cells/cu mm may be the most helpful labora- 
tory test for detecting an adrenal crisis. 
None of the present cases was diagnosed clin- 
ically. However, the diagnosis was made in 
three cases reported previously, and in all 
three prompt and intensive corticosteroid 
therapy was life-saving. 


180 


Nebraska S. M. J. 


Nebraska State Medical Association 

Ninety-Eighth Annual Session 
Hotel Cornhusker, Lincoln 
May 2, 3, 4, 5, 1966 


THINGS YOU SHOULD KNOW 


This program is acceptable for 16 credit 
hours by the American Academy of General 
Practice. 


REGISTRATION — Mezzanine, Hotel Cornhusker, 
8:30 a.m., Tuesday, Wednesday and Thursday, 
May 3, 4, 5, 1966. 

GENERAL SESSIONS — Ballroom and State 
Suites 1, 2 and 3. 

POSTGRADUATE COURSES — Two Courses will 
be conducted each moiming at 8:00 a.m. These 
Courses are an hour in length and should 
be very infonnative. The Registration fee is 
$1.00 and a Continental Breakfast will be 
seiwed. Attendance is limited to 25, so if you 
plan to attend register at the Registration Desk. 

SEMINARS — The Seminars or Workshops have 
been veiy popular in past years, and are once 
again included in the program. The guest 
faculty will be in attendance at these informal 
question and answer periods. 

OF SPECIAL INTEREST 

PAST PRESIDENT’S BREAKFAST — Wednesday, 
7:00 a.m.. May 4th, Room 200. 

SOCIAL HOUR — Honoring the President and the 
President of the Woman’s Auxiliaiy, State 
Suites, Hotel Cornhusker, 6:00 p.m., Wednesday, 
May 4, 1966. 

BANQUET — Ballroom, Hotel Cornhusker, 7:00 
p.m., Wednesday, May 4, 1966. Presentation 
of 50-year pins. Kenneth McFarland, Ph.D., 
Topeka, Kansas; Guest Lecturer, General Mo- 
tors Corporation. 

MEDICAL-LEGAL SYMPOSIUM — The Nebraska 
State Medical Association and the Nebraska 
State Bar Association are pleased to sponsor 
a Symposium on Medical-Legal Problems and a 
Trial Demonstration on Thursday, May 5. A 
joint luncheon will also be held with Judge John 
R. Brown, Fifth Circuit Court of Appeals, Hous- 
ton, Texas, as guest speaker. 


FUN NIGHT — Tuesday, May 3rd, beginning at 
6:30 p.m. A gala evening of dining, dancing 
and entertainment. Tickets will be available at 
the Registration Desk all day Tuesday, at $7.50 
per person; J. W. Ballew, M.D., and George 
E. Lewis, Jr., M.D., Chairmen. 

GOLF TOURNAMENT — Hillcrest Country Club, 
Monday, May 2nd, 1:00 p.m.; John G. Wiedman, 
M.D., and Francis Neumayer, M.D., Chairmen. 

TRAP SHOOT — Lincoln Gun Club, Monday, May 
2, 1:00 p.m.; Hariy Flansburg, M.D., Chaimian. 

BOWLING — Parkway Lanes, Monday, May 2nd, 
1:00 p.m.; L. Palmer Johnson, M.D., Chairman. 

SPORTSMAN’S DINNER — Hillcrest Country Club, 
Monday, May 2nd, 7:00 p.m. Dinner, $5.00 per 
person; I. E. Weston, M.D., Chairman. 


ANCILLARY MEETINGS 

ANNUAL BUSINESS MEETING — Nebraska 
Chapter, American College of Surgeons, Sunday, 
May 1st, 5:00 p.m.. Room 901, Hotel Com- 
husker. 

NEBRASKA CHAPTER, AMERICAN MEDICAL 
WRITERS ASSOCIATION — Meeting and 
Workshop, Monday, May 2nd, 2:00 p.m.. State 
Suites, Hotel Cornhusker. 


AMPAC BREAKFAST — 7:30 a.m., Tuesday, May 
3rd, Lancaster Room, Hotel Cornhusker. 

BREAKFAST MEETING — Nebraska State Ob- 
stetric and Gynecological Society, Tuesday, 
May 3rd, 7:30 a.m., Room 921, Hotel Cornhusker. 

ALUMNI MEETING AND SOCIAL HOUR — Uni- 
versity of Nebraska College of Medicine, Tues- 
day, May 3rd, 5:00-6:30 p.m., Lancaster Room, 
Hotel Cornhusker. 


UNIVERSITY OF NEBRASKA PRECEPTOR 
BREAKFAST — Wednesday, May 4th, 7:30 
a.m., State Suites, Hotel Cornhusker. 


April, 1966 


181 


Officers 


} 



WILLIS D. WRIGHT, M.D. 
President 1965-1966 


Dan A. Nye, M.D. 


President 


Kearney 


Vice President 


H. V. Nuss, M.D. 


Sutton 


Secretarj'-Treasurer 

Horace V. Monger, M.D. Lincoln 


Executive Secretary 

Kenneth Neff Lincoln 


Board of Councilors 

District Term Expires 

1. Leroy W. Lee, M.D., Omaha 1966 

2. John T. McGreer, Jr., M.D., Lincoln 1966 

3. W. W. Waddell, M.D., Beatrice 1966 

4. J. T. Keown, M.D., Pender 1966 

5. H. D. Kuper, M.D., Columbus 1967 

6. C. L. Anderson, M.D., Stromsburg 1967 

7. C. F. Ashbv, M.D., Geneva 1967 

8. Rex Wilson^ M.D., O’Neill 1967 

9. H. V. Smith, M.D., Kearney 1968 

10. L. S. McNeill, M.D., Hastings 1968 

11. Max M. Raines, M.D., North Platte 1968 

12. C. J. Cornelius, M.D., Sidney 1968 



DAN A. NYE, M.D. 
President 1966-1967 


Chairman, Board of Councilors 


W. W. Waddell, M.D., Beatrice 1966 

Speaker, House of Delegates 
Wm. E. Nutzman, M.D., Kearney 1968 


Vice Speaker, House of Delegates 
Harry W. McFadden, Jr., M.D., Omaha 1968 

Delegates to A.iM.A. 

Earl F. Leininger, M.D., McCook 1967 

John R. Schenken, M.D., Omaha 1966 

Alternate Delegates to A.M.A. 

W. C. Kenner, M.D., Nebraska City 1967 

Harold S. Morgan, M.D., Lincoln 1966 

Board of Trustees 

C. N. Sorensen, M.D., Scottsbluff, Chairman __ 1967 

R. Russell Best, M.D., Omaha 1969 

H. V. Nuss, M.D., Sutton 1968 

George Salter, M.D., Norfolk 1966 

Horace V. Munger, M.D., Lincoln 


182 


Nebraska S. M. J. 


GUEST SPEAKERS 



David R. Akers, M.D. 

Denver, Colorado 

Graduated from the Univer- 
sity of Colorado School of 
Medicine in 1936. Following 
some time in general practice 
and Militaiy Service, he re- 
ceived his residency training in 
surgery at Colorado General, 
Denver General and Children’s 
Hospitals. His private practice 
is limited to Pediatric Surgery. 
He is currently serving as As- 
sociate Clinical Professor of 
Surgery, Univei*sity of Colorado 
Medical Center: and Chief, Sur- 
gical Service, Children’s Hos- 
pital of Denver. 


Robert J. Booher, M.D. 

New York, New York 

Graduated from Creighton 
University School of Medicine in 
1938. Since 1945, he has been 
on the Staff of the Memorial 
Cancer Center where he is As- 
sociate Attending Surgeon on 
the Gastric and Mixed Tumor 
Services ; Assistant Professor of 
Clinical Surgery, Cornell Uni- 
versity Medical College, and 
Associate Clinician. Sloan-Ket- 
tering Institute for cancer re- 
search. His primary interests 
have been the tumors of the 
soft somatic parts, the manage- 
ment of neoplasms of the skin, 
especially melanoma, and can- 
cer of the stomach, duodenum 
and pancreas. 


James Z. Appel, M.D. 

Lancaster, Pennsylvania 

Graduated from the Univer- 
sity of Pennsylvania School of 
Medicine in 1932. Doctor Ap- 
pel became a surgeon and gen- 
eral practitioner. He was born 
in Lancaster in the house 
where he now has his office. 
He assumed the position of 
I20th President of the Ameri- 
can Medical Association in 
June, 1965. He became a dele- 
gate to the Amertcan Medical 
Association in 1945 and mem- 
ber of the Board of Trustees in 
1957. Doctor Appel had been 
vice chairman of the Board of 
Trustees since 1962, a position 
he relinquished upon being 
elected President-elect of the 
American Medical Association. 
Doctor Appel is a member of 
the World Medical Association 
and for the last two years has 
been a United States delegate 
to this organization. 




No 

Photo 

Available 


Hon. Reginald I. Bander 

Los Angeles, California 

Graduated from Creighton 
Univei*sity Law School in 1927. 
Served as a member of the 
Legal Department, Pacific In- 
demnity Company, Los Angeles. 
California and as lecturer for 
the University of California Ex- 
tension, in Legal Medicine. He 
is presently serving as Judge 
of the Superior Court of Los 
Angeles County. 


Henry A. Buchtel, M.D. 

Denver, Colorado 

Graduated from Harvard 
Medical School in 1931. His 
Urological training consisted of 
four years at the Mayo Clinic 
with two years as the first as- 
sistant in Urology. Is cur- 
rently serving as Associate Pro- 
fessor of Urology. Colorado 
University School of Medicine. 
Is Past President. Denver Medi- 
cal Society. Rocky Mountain 
Urological Society, South Cen- 
tral Section and is currently 
serving on the American Board 
of Urology. Has numerous pub- 
lications on Urology. 



Hon. John R. Brown 

Houston, Texas 

Graduated from the Univer- 
sity of Michigan School of Law 
in 1932. Was appointed by 
President Eisenhower to serve 
as Circuit Judge of the United 
States Court of Appeals for the 
Fifth Circuit in April of 1955. 
He has served as Moderator of 
the University of Texas Law 
School Tax Institute for the 
past nine years. 



April, 1966 


183 





GUEST SPEAKERS 


▼ 



Philip H. Corboy, Esq. 

Chicagro, Illinois 

Graduated cum laude, Loyola 
University Law School, in 1948. 
Received his preparatory edu- 
cation, St. Ambrose College and 
Notre Dame University. Mem- 
ber of the Illinois Supreme 
Court Committee on Jury In- 
structions and is a Fellow of 
the American College of Trial 
Lawyers. He is a Past Presi- 
dent of t he Association of 
Plaintiffs’ Lawyers of Illinois. 
Has served as past member of 
the Board of Governoi’s, former 
state committeeman, and Asso- 
ciate Editor of the NACCA 
Law Journal of the American 
Trial Law'>’ers Association. He 
has appeared on American Bar 
Association Convention pro- 
grams in 1963, 1964 and 1965, 
and on State Bar Association 
programs of 20 different states : 
he has also lectured in excess 
of 50 cities throughout the 

counti*y- 


William T. Dobbins, M.D. 

Denver. Colorado 

Graduated from the Univer- 
sity of Tennessee College of 
M^icine in 1956. Has served 
as Instructor. Department of 
Pediatrics, University of Ten- 
nessee : Director. Research Lab- 
oratory and Endocrine-Metabolic 
Unit. Denver Children’s Hos- 
pital : and Chairman, Advisory 
Committee for the Medical As- 
pects of Project Head Start for 
the State of Colorado. He is 
currently serving as Associate 
Professor of Pediatrics. Univer- 
sity of Colorado Medical Center 
and Coordinator of Graduate 
Education. The Children’s Hos- 
pital. Doctor Dobbins has au- 
thored numerous articles relat- 
ing to Pediatnc Medicine. 



Hon. Carl T. Curti.s 

w ashington. D.C. 

Senator Carl T. Curtis of 
Minden. Nebraska, entered the 
United States Senate on Janu- 
ary 1, 1955. His present term 
will expire on January 3. 1967. 
Prior to his service in the 
Senate, he was elected to the 
United States House of Repre- 
sentatives for eight consecutive 
terms. He was born near Min- 
den, Nebraska, on March 15, 
1905, and he and his fam ly al- 
ways have lived there. He at- 
tended Nebraska Wesleyan Uni- 
versity : he is Dean of the Ne- 
braska Delegation, having 
served in Congress continuous- 
ly since January 3, 1939. He 
is a member of Masonic bodies, 
the Shrine, the Nebraska Bar 
Association, Rotary, Elks, and 
Odd Fellows. 




Robert W. Goltz, M.D. 

Denver. Colorado 

Graduated from the Univer- 
sity of Minnesota Medical 
School in 1945. Former Clini- 
cal Associate Professor, Derma- 
tology. University of Minnesota : 
and is presently Professor and 
Director of the Division of 
Dermatology, Univei'sity of Colo- 
rado Medical School and Center. 
His professional interests cen- 
ter in the histopathology and 
hi.stochemistr>’ of the skin. 



John R. Dixon, Esq. 

St. Louis, Missouri 

Graduated from Missouri State 
College and Vanderbilt Univer- 
sity, receiving L.L.B. degree in 
1937. Has practiced law in 
Missouri since 1937, with most 
( f his practice being devoted 
to damage suits and those in- 
volving medical-legal work. Cur- 
rently serving as General Chair- 
man. Section of Insurance. 
Negligence and Compensation, 
of the American Bar Associa- 
tion. 


Fred H. Hartshorn, M.D. 

Denver. Colorado 

Graduated from the Univer- 
sity of Colorado School of Medi- 
cine in 1927. Is currently serv- 
ing as Clinical Professor of 
Orthopedic Surgei-y. University 
of Colorado Department of 
Medicine : is a Fellow of the 
American College of Surgeons : 
a Fellow of the American 
Academy of Orthopedic Sur- 
geons ; Past-President of WeU- 
ern Orthopedic Association : and 
a former member of the Colo- 
rado State Board of Health. 



184 


Nebraska S. M. J. 



GUEST SPEAKERS 



George M. Horner, M.D. 

Denver, Colorado 

Graduated from the Univer- 
sity of Nebraska College of 
Medicine in 1946. Has served 
as Consultant in Obstetrics and 
Gynecology, Veterans Adminis- 
tration Hospital. Albuquerque, 
New Mexico; Chief, Depart- 
ment of Obstetrics and Gyne- 
cology, St. Luke's Hospital, 
Denver ; and is presently serv- 
ing as Clinical Assistant Pro- 
fessor, Obstetrics and Gyne- 
cology, University of Colorado 
School of Medicine. Has been 
named Clinical Associate Pro- 
fessor, Obstetrics and Gyne- 
cology, University of Colorado 
School of Medicine becoming ef- 
fective in July. 


M. Eugene Lahey, M.D. 

Salt Lake City, Utah 

Graduated from the St. Louis 
University School of Medicine 
in 1943. Served as Assi.stant 
Professor of Pediatrics. Univer- 
sity of Utah ; Assistant and As- 
sociate Professor of Pediatries, 
University of Cincinnati : Pro- 
fessor and Head, Department of 
Pediatrics, University of Utah : 
Research Director, Children's 
Hospital of the East Ray, Oak- 
land, California, and is current- 
ly serving as Professor and 
Head, Department of Pediatrics, 
University of Utah, Salt Lake 
City, Also currently serving on 
the Editorial Board, The Journal 
of Pediatrics : and the Resi- 

dency Review Committee for 
Pediatrics, American Medical 
Association. Doctor Lahey has 
authored numerous publications 
concerning Pediatric problems. 



Arthur P. Klotz, M.D. 

Kansas City, Kansas 

Graduated from the Univer- 
sity of Chicago School of Medi- 
cine in 1938. Has served as 
Assistant Professor of Medicine 
and Associate Professor of 
Medicine at the University of 
Kansas Medical Center. Is 
presently seiwing as Professor 
of Medicine and Chief. Section 
of Gastroenterology at the Uni- 
versity of Kansas Medical Cen- 
ter, and Director of Gastro- 
intestinal Laboratories. He also 
serves on the Editorial Board, 
American Journal of Digestive 
Diseases ; and as a consultant 
in Gastroenterology, Question 
and Answer Section, of Journal 
to the American Medical Asso- 
ciation. Doctor Klotz has au- 
thored over 50 articles. 




Kenneth McFarland, Ph.D. 

Topeka, Kansas 

Doctor McFarland is a grad- 
uate of Pittsburg State College 
in Kansas ; he earned graduate 
degrees from Columbia Univer- 
sity and Stanford University. 
For nearly a quarter of a cen- 
tury Doctor McFarland was an 
outstanding school leader in 
America. The modern McFar- 
land Trade School, which he 
designe<i and built at Coffey- 
ville, Kansas, was named in his 
honor. His work in selling 
America to Americans caused 
the National Sales Executives 
Clubs, in 1957, to name Doctor 
McFarland as America’s Out- 
standing Salesman for the 
year. When the nation’s trade 
associations were requested by 
the United States Chamber of 
Commerce to name the speak- 
ers who had addressed their an- 
nual meetings or conventions. 
Doctor McFarland’s name head- 
ed the list of the ten most 
fre<iuently mentioned. 



Robert M. Kretzschmar, 
M.D. 

Iowa City, Iowa 

Graduated from the Univer- 
sity of Michigan Medical School 
in 1957. Has served as Instruc- 
tor. University of Michigan 
Medical School, Department of 
Obstetrics and Gynecology ; and 
is presently serving on the 
Medical School Postgraduate 
Piducation Committee and the 
Formulai-y and Therapeutics 
Committee. He is currently As- 
sociate Professor in Obstetrics 
and Gynecology at the Univer- 
sity of Iowa College of Medicine. 


Frank E. Meelhuysen, 

M.D. 

Minneapolis, Minnesota 

Graduated from the Medical 
School Utrecht, State Univer- 
sity of Utrecht, The Nether- 
lands in 1957. Has served as 
Medical Staff member of the 
Pediatric Unit, St. Joseph Hos- 
pital. Heerlen and Medical Su- 
pervisor Respiratory Center. 
Municipal Hospital. The Hague, 
both in the Netherlands : and 

Instructor in Physical Medi- 
cine and Rehabilitation. Loma 
Linda University. Loma Linda, 
California. He is presently 
serving as Assistant Professor 
in Physical Medicine and Re- 
habilitation. University of Min- 
nesota School of Medicine. 
Areas of major interests are in 
the fields of Pilectroneuromy- 
ography. Neuromuscular Disease 
and Biomechanics for which ad- 
ditional training has been re- 
ceived at noted University cen- 
ters in London. Kopenhagen. 
Birmingham and Pavia. 



April, 1966 


185 



GUEST SPEAKERS 



Harry Meyer, M.D. 

New Orleans, Louisiana 

Graduated from Tulane Uni- 
versity School of Medicine in 
1932. Has served as Chief, 
Department of Obstetrics, Touro 
Infirmary' : Senior. Department 

of Obstetncs and Gynecology, 
Touro Infirmary, and Charity 
Hospital : on the Grievance 

Committee of Orleans Parish 
Medical Society ; and was a 
member of the Founders Group 
of the New Orleans Graduate 
Medical Assembly. Is presently 
serving at Tulane • University 
School of Medicine as Assistant 
Professor, Clinical Obstetrics 
and Gynecology. Doctor Meyer 
has authored 22 articles on Ob- 
stetrics and Gynecology*. 


I. S. Ravdin, M.D. 

Philadelphia, Pennsylvania 

Doctor Ravdin has been iden- 
tified with the University of 
Pennsylvania School of Medicine 
since receiving his medical de- 
gree there in 1918. From 1945 
until 1959, he was John Rhea 
Barton Professor of Surgery 
and Director of Harrison De- 
partment of Surgical Research 
of School of Medicine and Sur- 
geon-in-Chief of Hospital of 
University of Pennsylvania. In 
1959, he was appointed Vice 
President for Medical Affairs of 
University of Pennsylvania. 
Currently ser\*ing as Emeritus 
Professor of Surgery, School 
of Medicine, University of 
Pennsylvania. Also serving 
as Executive Vice Chairman, 
Medical Campaign Executive 
Committee. University* of Penn- 
sylvania. Holds numerous aca- 
demic degrees and has been 
named an Honorary Fellow in 
Royal College of Surgeons of 
England. Royal College of 
Physicians and Surgeons of 
Canada. Royal College of Sur- 
geons of Edinburgh and Royal 
College of Ireland. 



Alan K. Moritz, M.D. 

Cleveland, Ohio 

Graduated from University of 
Nebraska College of Medicine 
in 1923. Currently serving as 
Professor of Pathology and 
Provost of Western Reserve Uni- 
versity. Has served as Director 
of the Institute of Pathology, 
Western Reserve University* ; 
Director of Pathology. Univeisity 
Hospital of Cleveland ; and Vice 
President of W'estern Reserve 
University. Received prelimin- 
ary education in Hastings Pub- 
lic School system and Univer- 
sity* of Nebraska. Has served as 
a lecturer in legal medicine at 
Boston University, Tufts Col- 
lege Medical School and Univer- 
sity* of Southern California. Has 
served as consultant and official 
investigator. National Defense 
Research Committee. Office of 
Scientific Research and Develop- 
ment, National Research Coun- 
cil. Has been named Honorary* 
Consultant. Army Medical Li- 
brary, and has written numerous 
books and publications. 



Wayne B. Slaughter, M.D. 

Chicagro, Illinois 

Graduated from the Univer- 
sity of Nebraska College of 
Medicine in 1935. Currently 
serving as Professor of Sur- 
geiT (Clinical) Loyola Univer- 
sity. Stritch School of Medicine 
and Chairman of the Depart- 
ment of Plastic Surgery. He is 
Chief of Service, Mercy Hos- 
pital. Chicago : and Chief, De- 
partment of Plastic Surgery, St. 
Francis Hospital. Evanston, The 
Cradle, Evanston and St. Vin- 
cent's Hospital, Chicago. 



Richmond S. I’aine, M.D. 

Washington, D.C. 

Graduated from Harvard Med- 
ical School in 1944. Has served 
as Clinical Assistant, National 
Hospital of Nervous Diseases, 
London ; and Instructor in Pedi- 
atrics, and Associate Instructor 
at Harvard Medical School. 
Presently serving as Professor 
of Pediatric Neurology. George 
Washington University School 
of Medicine and Consultant 
Neurologist, Children’s Conval- 
escent Hospital of the District 
of Columbia. 


E. Thurston Thieme, M.D. 

Ann Arbor, Michigan 

Graduated from Harvard Med- 
ical College in 1933. He served 
as Instructor in Surgei*y until 
1963 at the University* of Michi- 
gan and is currently serving as 
Clinical Associate Professor of 
Surgery* at that Medical School. 
He also served as Chief. De- 
partment of General Surgery* 
from 1940 until 1965. He has 
written 22 articles on medical 
and surgical subjects and served 
as Founder and Secretary- 
Treasurer of the Frederick A. 
Coller Surgical Society. 



186 


Nebraska S. M. J 




GUEST SPEAKERS 


Technical Exhibitors 




Austin L. Vickery, Jr., 
M.D. 

Boston, Massachusetts 

Graduated from the Univer- 
sity of Nebraska College of 
Medicine in 1943. Is currently 
serving as Associate Clinical 
Professor of Pathology, Har- 
vard Medical School ; Patholo- 
gist, Massachusetts General Hos- 
pital ; Consulting Pathologist, 
Massachusetts Eye and Ear In- 
firmary ; and member of the 
Thyroid and Tumor Clinics of 
the Massachusetts General Hos- 
pital. He is currently engaged 
in experimental and clinical re- 
search projects, with his major 
hospital interest being surgical 
pathology. He served in the 
Far East Theater General Lab- 
oratory from 1952 to 1954. 


Abbott Laboratories, North Chicago, Illinois 

Blue Cross - Blue Shield, Omaha, Nebraska 

Ciba Phai’maceutical Products, Inc., Summit, New 
Jersey 

Coca-Cola Company, Atlanta, Georgia 
Daily Council of Lincoln, Lincoln, Nebraska 
Des Moines Flying Service, Des Moines, Iowa 
Dictaphone Corporation, Omaha, Nebraska 
Donley Medical Supply Company, Lincoln, Nebraska 


Laurens Williams, Esq. 

Washington, D.C. 

Graduated from Cornell Law 
School in 1931. Is a partner 
in Washington, D.C., Law Firm 
of Sutherland, Asbill and Bren- 
nan. Has served as Assistant 
to the Secretary of the Treas- 
ury and Head, Legal Advisory 
Staff, for which he earned the 
Alexander Hamilton Award for 
distinguished leadership. Mr. 
Williams has also served as 
President of the Nebraska Bar 
Association and as Chairman 
of various Section Committees 
of the American Bar Associa- 
tion. He has also authored va- 
rious legal articles on taxation 
and served as a member on 
various Advisory Groups to the 
Committee on Ways and Means. 



Dorsey Laboratories, Lincoln, Nebraska 

Encyclopaedia Britannica, Chicago, Illinois 

International Business Machines, Lincoln, Nebraska 

Mead Johnson Laboratories, Evansville, Indiana 

Medco Products Company, Inc., Waterloo, Iowa 

Medical Protective Company, Fort Wayne, Indiana 

Merck, Sharp & Dohme, West Point, Pennsylvania 

Monarch Life Insurance Company, Omaha, Nebraska 

Physicians & Hospitals Supply Company, Minne- 
apolis, Minnesota 

Professional Credit Control, Inc., Lincoln, Nebraska 
A. H. Robins Company, Inc., Richmond, Virginia 


Roche Laboratories, Nutley, New Jersey 
Sandoz Pharmaceuticals, Hanover, New Jersey 


W. B. Saunders Company, Philadelphia, Pennsylvania 
Schering Corporation, Union, New Jersey 
G. D. Searle & Company, Chicago, Illinois 
E. R. Squibb & Sons, New York, New York 
Ulmer Pharmacal Company, Minneapolis, Minnesota 


Upjohn Company, Kalamazoo, Michigan 
Warren-Teed Pharmaceuticals, Inc., Columbus, Ohio 


Woodmen Accident and Life Company, Lincoln, Ne- 
braska 


April, 1966 


187 






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Nebraska S. M. J. 


188 


Acknowledgements 


PROGRAM 


The Nebraska State Medical Association wishes to 
take this opportunity to recognize and express its 
appreciation for the grants received from the follow- 
ing organizations: 

Nebraska Division, American Cancer Society 
Eli Lilly and Company 

Merck, Sharp & Dohme Postgraduate Program 
Smith Kline & French Laboratories 


Scientific Sessions Committee 


R. 0. Garlinghouse, M.D., Chairman Lincoln 

C. R. Brott, M.D. Beatrice 

Bruce F. Claussen, M.D. North Platte 

Russell L. Gorthey, M.D. Lincoln 

M. M. Musselman, M.D. Omaha 

Harold N. Neu, M.D. Omaha 

H. V. Munger, M.D. Lincoln 


Announcements 

House of Delegates 

1st Session: Monday, May 2, 1966, 9:00 a.m., Lan- 

caster Room 

2nd Session: Wednesday, May 4, 1966, 8:00 a.m., 
Lancaster Room 

3rd Session: Thursday, May 5, 1966, 8:00 a.m., Lan- 
caster Room 

Board of Councilors 

1st Session: Tuesday, May 3, 1966, 4:00 p.m.. Room 
933 

2nd Session: Wednesday, May 4, 1966, 9:00 a.m., 

Lancaster Room 

3rd Session: Thursday, May 5, 1966, 9:00 a.m., 

Lancaster Room 

Board of Trustees 

Wednesday, May 4, 1966, 3:45 p.m., Lancaster 
Room 


Nebraska State Medical Association 
98th Annual Session 

TUESDAY, MAY 3, 1966 
8:30 Exhibits Open 
9:30 Film 

“The Different Drum” 


OPENING CEREMONIES — Ballroom 

R. E. Garlinghouse, M.D., Lincoln, 
Presiding 

10:00 Welcome 

- — Willis D. Wright, M.D., President, Omaha 
10:05 Invocation 

— Reverend Lawrence L. Stanton, Lincoln 

10:10 Presidential Address 

— Willis D. Wright, M.D., Omaha 

10:20 Installation of Incoming President 
- — Dan A. Nye, M.D., Kearney 

10:30 Necrology 

— George B. Salter, M.D., Norfolk 
10:40 VISIT THE EXHIBITS 

11:00 Keynote Address 

“Federal Health Care Laws: A Major 
Challenge” 

— James Z. Appel, M.D., Lancaster, Pennsyl- 
vania 

President, American Medical Association 

12:00 Noon Luncheon, Ballroom 

— Dan A. Nye, M.D., President, Presiding 

Guest Speaker: 

— The Honorable Carl T. Curtis, United 
States Senate 

VISIT THE EXHIBITS 


April, 1966 


189 


PROGRAM 


PROGRAM 


TUESDAY AFTERNOON, MAY 3, 1966 
LECTURES — SECTION A 
Ballroom 

SURGERY LECTURES 

— John P. Heinke, M.D., Scottsbluff, Mod- 
erator 

2:30 “Chronic Thyroiditis” 

— Austin L. Vickery, Jr., M.D., Boston, Mas- 
sachusetts 

2:50 “The Plastic Repair of Accidental Wounds” 

— Wayne B. Slaughter, M.D., Chicago, Illinois 

3:10 “Melanoma” 

— Robert J. Booher, M.D., New York, New 
York 

3:30 VISIT THE EXHIBITS 

OBSTETRICS and GYNECOLOGY LECTURES 

— Rex Fischer, M.D., Columbus, Moderator 

4:00 “The Maturation Index and Cyclic Hor- 
mone Therapy (Limitation of the Aging 
Process)” 

— Harry Meyer, M.D., New Orleans, Louis- 
iana 

4:20 “Endometriosis” 

— George M. Horner, M.D., Denver, Colorado 

4:40 “The Pre-Marital Examination: A Doctor’s 
Responsibility” 

— Robert M. Kretzschmar, M.D., Iowa City, 
Iowa 

VISIT THE EXHIBITS 

5:00 SExMINARS FOR ABOVE LECTURES 

Surgery, Room 921 

— John P. Heinke, M.D., Scottsbluff, Mod- 
erator 

Drs. Vickery, Slaughter and Booher 

Obstetrics and Gynecology, Room 901 

— Rex Fischer, M.D., Columbus, Moderator 
Drs. Meyer, Horner, and Kretzschmar 

— FUN NIGHT — 


TUESDAY AFTERNOON, MAY 3, 1966 
LECTURES — SECTION B 
State Suites 

PEDIATRICS LECTURES 

— Robert Sorensen, M.D., Fremont, Moder- 
ator 

2:30 “Obesity in Childhood” 

— William T. Dobbins, M.D., Denver, Colo- 
rado 

2:50 “Management of Convulsive Disorders in 
Children” 

— Richmond S. Paine, M.D., Washington, 
D.C. 

3:10 “Changing Concepts of the Ediology of Iron 
Deficiency Anemia in Infants” 

— M. Eugene Lahey, M.D., Salt Lake City, 
Utah 

3:30 VISIT THE EXHIBITS 

MEDICINE LECTURES 

— John D. Hartigan, M.D., Omaha, Moderator 

4:00 “Rehabilitation of the Stroke Patient” 

— Frank Meelhuysen, M.D., Minneapolis, Min- 
nesota 

4:20 “Ulcerative Colitis” 

— Arthur P. Klotz, M.D., Kansas City, Kansas 

4:40 “Cutaneous Signs of Internal Disease” 

— Robert W. Goltz, M.D., Denver, Colorado 

VISIT THE EXHIBITS 

5:00 SEMINARS FOR ABOVE LECTURES 

Pediatrics, State Suite 1 

— Robert Sorensen, M.D., Fremont, Moderator 
Drs. Dobbins, Paine, and Lahey 

Medicine, State Suites 2 and 3 

— John D. Hartigan, M.D., Omaha, Moderator 
Drs. Meelhuysen, Klotz, and Goltz 

FUN NIGHT — 


190 


Nebraska S. M. J, 


PROGRAM 


PROGRAM 


WEDNESDAY MORNING, MAY 4, 1966 

8:00 Course in Medicine, Room 901 

— O. A. Kostal, M.D., Hastings, Moderator 
(Continental Breakfast — $1.00 per par- 
ticipant, limit of 25) 

“The Diagnosis and Management of Pan- 
creatic Disease” 

— Arthur P. Klotz, M.D., Kansas City, Kan- 
sas 

GENERAL SESSION 
Ballroom 

9:30 SYMPOSIUM ON CONGENITAL ANO- 
MALIES* 

— Horace Munger, M.D., Lincoln, Moderator 

“Imperforate Anus” 

— David R. Akers, M.D., Denver, Colorado 

“Cryptorchidisih and Hypospadias” 

— Heniy A. Buchtel, M.D., Denver, Colo- 
rado 

“Congenital Dislocation of the Hip” 

— Fred H. Hartshorn, M.D., Denver, Colo- 
rado 

“Sex Differentiation” 

— William T. Dobbins, M.D., Denver, Colo- 
rado 

10:30 VISIT THE EXHIBITS 

11:00 ANNUAL DISTINGUISHED NEBRASKA 
LECTURE, Ballroom 

— Dan A. Nye, M.D., Kearney, Presiding 

Guest Lecturer 

— Isidor S. Ravdin, M.D., Philadelphia, Penn- 
sylvania 

12:00 VISIT THE EXHIBITS 

12:30 Noon Luncheon, Ballroom 

“Your Association Reports” 

— Willis D. Wright, M.D., Omaha, Presiding 

♦Supported in part by a grant from Merck, Sharp 

& Dohme 


WEDNESDAY MORNING, MAY 4, 1966 

8:00 Course in Obstetrics and Gynecology, Room 
921 

— Russell L. Gorthey, M.D., Lincoln, Mod- 
erator 

(Continental Breakfast — $1.00 per par- 
ticipant, limit of 25) 

“Contraceptives” 

— George M. Horner, M.D., Denver, Colorado 

— Robert Kretzschmar, M.D., Iowa City, 
Iowa 


SYMPOSIUM ON CONGENITAL 
ANOMALIES 

(See Opposite Page) 


10:30 VISIT THE EXHIBITS 

11:00 ANNUAL DISTINGUISHED NEBRASKA 
LECTURE, Ballroom 

— Dan A. Nye, M.D., Kearney, Presiding 

Guest Lecturer 

— Isidor S. Ravdin, M.D., Philadelphia, 
Pennsylvania 

12:00 VISIT THE EXHIBITS 

12:30 Noon Luncheon, Ballroom 

‘Your Association Reports” 

-Willis D. Wright, M.D., Omaha, Presiding 


April, 1966 


191 


PROGRAM 


PROGRAM 


WEDNESDAY AFTERNOON, MAY 4, 1966 
LECTURES — SECTION A 
Ballroom 

SURGERY LECTURES 

— William Glenn, M.D., Falls City, Moderator 

2:00 “The Solitary Nodule and Thyroid Cancer” 

— Austin L. Vickei-y, Jr., M.D., Boston, Mas- 
sachusetts 

2:20 “The Treatment of Hemang-iomas” 

— Wayne B. Slaughter, M.D., Chicago, Illinois 

2 :40 “Gastric Cancer” 

— Robert J. Booher, M.D., New York, New 
York 

3:00 VISIT THE EXHIBITS 

OBSTETRICS and GYNECOLOGY LECTURES 

— Howard Yost, M.D., Fremont, Moderator 

3:30 “Oxytocic Infusion for Induction or Aug- 
mentation of Labor” 

— Harry Meyer, M.D., New Orleans, Louis- 
iana 

3:50 “Causes and Means of Preventing Maternal 
Deaths” 

— George M. Homer, M.D., Denver, Colorado 

4:10 “Third Trimester Bleeding: Pitfalls of Man- 
agement” 

— Robert M. Kretzschmar, M.D., Iowa City, 
Iowa 

VISIT THE EXHIBITS 

4:30 SEMINARS FOR ABOVE LECTURES 

Surgery, Room 921 

— William Glenn, M.D., Falls City, Moderator 
Drs. Vickery, Slaughter, and Booher 

Obstetrics and Gynecology, Room 901 

— Howard Yost, M.D., Fremont, Moderator 
Drs. Meyer, Horner, and Kretzschmar 

6:00 Social Hour, State Suites 

7 :00 Annual Banquet, Ballroom 

— L. J. Gogela, M.D., President, Lancaster 
County Medical Society, Presiding 

Presentation of 50- Year Pins 

Banquet Speaker, Kenneth McFarland, Ph.D., 
Guest Lecturer, General Motors Corpora- 
tion 


WEDNESDAY AFTERNOON, MAY 4, 1966 
LECTURES — SECTION B 
State Suites 

PEDIATRICS LECTURES 

— ^\Varren Bosley, M.D., Grand Island, Mod- 
erator 

2:00 “Short Boys and Tall Girls: Is There a 
Need for Endocrine Therapy?” 

— William T. Dobbins, M.D., Denver, Colo- 
I’ado 

2:20 “Evaluation of Neurologic Abnormalities in 
the Newborn Period” 

— Richmond S. Paine, M.D., Washington, 
D.C. 

2:40 “The Choice of Iron Compounds for the 
Treatment of Iron Deficiency Anemia” 

■ — M. Eugene Lahev, M.D., Salt Lake City, 
Utah 

3:00 VISIT THE EXHIBITS 

MEDICINE LECTURES 

— W. W. Waddell, M.D., Beatrice, Moderator 

3:30 “Hiatus Hernia and Esophagitis” 

— Arthur P. Klotz, M.D., Kansas City, Kansas 

3:50 “General Management of Spasticity” 

— Frank Meelhuysen, M.D., Minneapolis, Min- 
nesota 

4:10 “W’hat’s New in Dennatologic Therapy?” 

— Robert W. Goltz, M.D., Denver, Colorado 

VISIT THE EXHIBITS 

4:30 SEMINARS FOR ABOVE LECTURES 
Pediatrics, State Suites 2 and 3 

— Warren Bosley, M.D., Grand Island, Mod- 
erator 

Drs. Dobbins, Paine and Lahey 
Medicine, State Suite 1 

— W. W. Waddell, M.D., Beatrice, Moderator 
Drs. Klotz, Meelhuysen, and Goltz 

6:00 Social Hour, State Suites 

7 :00 Annual Banquet, Ballroom 

— L. J. Gogela, M.D., President, Lancaster 
County Medical Society, Presiding 

Presentation of 50- Year Pins 

Banquet Speaker, Kenneth McFarland, Ph.D., 
Guest Lecturer, General Motors Corpora- 
tion 


192 


Nebraska S. M. J. 


PROGRAM 

THURSDAY MORNING, MAY 5, 1966 

8:00 Course in Pediatrics, Room 901 

- — Paul Bancroft, M.D., Lincoln, Moderator 
(Continental Breakfast — $1.00 per par- 
ticipant, limit of 25) 

“The Diagnostic Evaluation of Mental Re- 
tardation” 

— Richmond S. Paine, M.D., Washington, 
D.C. 

8:00 Course in Surgery, Room 921 

— M. M. Musselman, M.D., Omaha, Moderator 
(Continental Breakfast — $1.00 per par- 
ticipant, limit of 25) 

“When, Why and How I Biopsy the Breast” 
— E. Thurston Thieme, M.D., Ann Arbor, 
Michigan 

9:00 VISIT THE EXHIBITS 

9:30 SYMPOSIUM ON TRAUMA IN CHIL- 
DREN, Ballroom 

— R. W. Gillespie, M.D., Lincoln, Moderator 
“Blunt Abdominal Trauma in Children” 
—David R. Akers, M.D., Denver, Colorado 
“Fractures of the Spine and Pelvis” 

— Fred H. Hartshorn, M.D., Denver, Colorado 
“Urinary Tract Trauma” 

— Henry A. Buchtel, M.D., Denver, Colorado 

10:30 SYMPOSIUM ON MEDICAL-LEGAL PROB- 
LEMS, Ballroom 

— R. E. Garlinghouse, M.D., Lincoln, Mod- 
erator 

“Tax Problems of the Professional Man” 

— Laurens Williams, Esq., Washington, D.C. 
“Unexpected Death from Unsuspected 
Trauma” 

— Alan R. Moritz, M.D., Cleveland, Ohio 
“Professionalism in the Courtroom” 

— Honorable Reginald I. Bauder, Judge, Su- 
perior Court, Los Angeles, California 

12:30 Noon Luncheon 

— R. E. Garlinghouse, M.D., Lincoln, Moder- 
ator 

“The Rat Race, The Human Race, The Court 
House Race — Medico-Legal Variations on 
An Explosive Theme” 

— Honorable John R. Brown, Judge, Fifth 
Circuit Court of Appeals, Houston, Texas 

2:00 TRIAL DEMONSTRATION, Ballroom 

— Flavel A. Wright, Esq., Lincoln, Moderator 

VIGNETTE — “Trauma and Heart Disease” 
A graphic demonstration of some problems 
in this important area. 

Judge — Hon. Reginald I. Bauder, Los An- 
geles, California 

Witness — Alan R. Moritz, M.D., Cleveland, 
Ohio 

Attorney — Philip H. Corboy, Esq., Chica- 
go, Illinois 

Attorney — John R. Dixon, Esq., St. Louis, 
Missouri 

4:00 Meeting Adjourned 


Scientific Film Program 

C. R. Brott, M.D., Coordinator 
Room 901 

TUESDAY, MAY 3, 1966 
Morning Program 

9:00 “Modei-n Concepts of Epilepsy” 

9:30 “An Otological Seminar” 

10:00 “Clinical Application Tonometry” 

10:30 “A Clinic on Chronic Otitic Purulencies” 

Afternoon Program 

1:00 “Peutz-Jeghers Syndrome” 

1:30 “Frontiers on Allergy” 

2:00 “Hemostasis: The Effect of Estrogens” 
2:30 “Atherosclerosis: The Role of Estrogens” 
3:00 “Nose and Paianasal Sinuses” 

3:30 “Cinegastroscopy with the Fiberscope and 
Aid to Diagnosis of Gastric Lesions” 

4:00 “Anorectal Applied Anatomy” 

WEDNESDAY, MAY 4, 1966 
Morning Program 

9:00 “Basic Principles in Management of the 
Local Burn Wound” 

9:30 “Functional Anatomy of the Hand” 

10:00 “Major Amputations for Arteriosclerosis, 
Technic and Rehabilitation” 

10:30 “Transmetatai’sal Amputation” 

11:00 “Thrombectomy for Ileofemoral and Ax- 
illary Vein Thrombosis” 

11:30 “Adrenolectomy” 

Afternoon Program 

1:00 “Cholelithiasis and Choledocholithiasis” 

1:30 “Pitfalls in Biliary Surgery” 

2:00 “Subphrenic Abscess” 

2:30 “Complications of Acute Appendicitis” 

3:00 “Management of Advanced and Neglected 
Surgical Lesions” 

3:30 “Acute Head Injury” 

4:00 “Thyroidectomy: A Half Centui-y of Ex- 

perience” 

THURSDAY, MAY 5, 1966 
Morning Program 
9:00 “Pyloric Stenosis” 

9:30 “Pathophysiology and Surgical Management 
of Achalasia of the Esophagus” 

10:00 “Gastrectomy: The Place of Conservative 

Resection in the Management of Duodenal 
Ulcer” 

10:30 “Vagotomy and Pyloroplasty for Bleeding and 
Perforated Duodenal Ulcer” 

11:00 “Treatment of Carcinoma of the Stomach 
in Elderly Patients” 

11:30 “Achalasia and Hiatal Insufficiency” 


April, 1966 


193 


Woman's Auxiliary 



MRS. J. MHITNEY 
KELLEY 

Omaha, Nebraska 

President, 1965-1966 


MRS. FAY SMITH 

Omaha. Nebraska 

President, 1966-1967 




MRS. ASHER 
YAGUDA 

Newark. New Jersey 

Honored Guest Speaker 
M'oman’s Auxiliary 

President - Elect 
\Yoman’s Auxiliary 
to the 

American Medical 
Association 


MRS. RICHARD A. 
SUTTER 

St. Louis. Missouri 

President 

IVoman’s Auxiliary 
to the 

American Medical 
Association 



Woman's Auxiliary 

41st ANNUAL MEETING 
OF THE 

WOMAN’S AUXILIARY TO THE 
NEBRASKA STATE MEDICAL ASSOCIATION 

A registration desk will be open on the Mezzanine 
of the Hotel Comhusker on Tuesday, May 3 and on 
Wednesday, May 4, until 12 p.m. 


CONVENTION COMMITTEES 

General Chairman — 

Mrs. Jon T. Williams 

Social Chairmen — 

Mrs. George Lewis, Jr. 

Mrs. Keith Sehnert 

Program Chairmen (Style Show) — 

Mrs. E. S. Maness 
Mrs. E. D. Zeman 

Registration — - 

Mrs. Frank Cole 

Tickets and Finance — 

Mrs. C. D. Bell 

Hospitality — 

Mrs. R. A. Hillyer 

Flowers — 

Mrs. W. Q. Bradley 

Transportation — 

Mrs. M. P. Brolsma 

Reservations — 

Mrs. Robert Jones 

Publicity — 

Mrs. H. L. Papenfuss 

Hostess Auxiliary — 

Lancaster County Medical Auxiliary 

A cordial invitation is extended to all doctors’ 
wives of Nebraska whether or not you are an aux- 
iliaiy member. 

AUXILIARY PLEDGE 

I pledge my loyalty and devotion to the Wom- 
an’s Auxiliary to the American Medical Association. 
I will support its activities, protect its reputation, 
and ever sustain its high ideals. 

WHO IS EXPECTED TO ATTEND 
Officers 

Chairmen of Committees 
Presidents of County Auxiliaries 
District Councilors 

New officers and chairmen, either on the state 
or local levels, will benefit from attending the ses- 
sions. 


194 


Nebraska S. M. J. 



Woman's Auxiliary 
PROGRAM 

A registration desk will be open on the Mez- 
zanine of the Hotel Comhusker on Tuesday, May 

3 and on Wednesday, May 4, until 12 p.m. 

MONDAY, MAY 2, 1966 

12:30-3:00 Registration, Mezzanine, Hotel Corn- 
husker 

TUESDAY, MAY 3, 1966 

8:00 Registration, Mezzanine, Hotel Comhusker 

8:15 Pre-Convention Executive Board Meeting, 
State Suites 
No-Host Breakfast 
Mrs. J. Whitney Kelley, Presiding 
Reports of Officers and State Chairmen 

11:00 Keynote Address, Ballroom 

James Z. Appel, M.D., President, American 
Medical Association 

12:00 Combined Auxiliary and Association Lunch- 
eon, Ballroom 

Guest Speaker: The Honorable Carl T. Curtis 
Presentation of AMA-ERF Checks 
(Tickets available at Ballroom) 

2:30 Annual Business Meeting, Lancaster Room 
Mrs. J. Whitney Kelley, Presiding 
Reports of County Presidents 
Memorial Sei-vice 
Election of Officers 
Installation of New Officers 

6:30 FUN NIGHT (Lancaster County Medical 
Society) 

WEDNESDAY, MAY 4, 1966 

12:30 Luncheon, Lincoln Country Club 

Tickets and transportation infonnation to 
the Country Club available at the Regis- 
tration Desk, Hotel Comhusker 
Mrs. Asher Yaguda, President-elect, Wom- 
an’s Auxiliary to the American Medical 
Association 
Fashion Show 

6:00 Social Hour, State Suites 

(To honor the Presidents of the Nebraska 
State Medical Association and the Wom- 
an’s Auxiliary) 

7--0 Annual Banquet, Ballroom 

Presentation of Fifty Year Pins 
Guest Speaker: Dr. Kenneth McFarland, To- 
peka, Kansas 

THURSDAY, MAY 5, 1966 

9:00 Post-Convention Executive Board Meeting, 
State Suites 

Mrs. Fay Smith, Presiding 
No-Host Breakfast 


All About Us 

Doctor John A. Aita, Omaha, has written 
a book entitled, “Neurocutaneous Disease.” 

Doctor L. Thomas Hood, Omaha, is presi- 
dent of the Immanuel Hospital medical staff 
for the year 1966. 

Doctor Albert S. Black, Jr., Omaha, has 
been elected president of the Clarkson Hos- 
pital medical staff. 

Doctor Robert Gillespie, Lincoln, has been 
named to the American College of Surgeons 
Trauma Committe. 

Doctor Theodore Pfundt, Houston, has 
been appointed Medical Director of Chil- 
drens Hospital in Omaha. 

Doctor John D. Coe, Omaha, has been 
named president of the Nebraska Metho- 
dist Hospital medical staff. 

Doctor R. E. Garlinghouse, Lincoln, ad- 
dressed the Executive Club of Lincoln on the 
subject of Medicare in January. 

Doctor John H. Krickbaum, Auburn, has 
been elected to active membership in the 
American Academy of General Practice. 

Doctor C. L. Anderson was recently hon- 
ored by the Stromsburg Sertoma Club, be- 
ing given a “Service to Mankind” award. 

Doctor Lawrence Morrow was recently hon- 
ored by the Tekamah Chamber of Commerce 
for the 50 years of medical service he has 
provided that community. 

Doctor L. W. Forney, Crete, has been 
named the nominee of the Southern Nebraska 
Sertoma Clubs for their Service to Mankind 
Award. He is one of two Nebraskans to re- 
ceive this honor this year. 


Deaths 

SMITH — Eldon J. Smith, M.D., died De- 
cember 21, 1965, at the age of 88. Bom in 
Iowa, Dr. Smith graduated from the Univer- 
sity of Nebraska College of Medicine, and 
then located in Burwell, Nebraska where he 
was in practice for sixty years. During the 
1950’s Doctor Smith served as mayor of Bur- 


April, 1966 


195 


well. His election to the office of mayor 
was sjTnbolic of the high esteem in which 
he was held by his patients and friends in 
Bunvell. 


Announcements 

Nebraskan Named Top Winner in 1966 
SAM A Scientific Forum — 

Chicago — A sophomore medical student 
from the University of Nebraska College of 
Medicine, Dennis F. Landers, has been named 
as the Grand Award winner in the 1966 ver- 
sion of the SAMA-Mead Johnson Scientific 
Forum of the Student American Medical As- 
sociation. 

Mr. Landers won a check for $500 and 
expense-paid trips to deliver his paper at the 
SAMA meeting in Los Angeles in May and 
the June meeting of the American Medical 
Association in Chicago. His winning paper 
is entitled: “Observations on Location and 
Ultrastructure of Duodenal Liunphocytes ; a 
Light and Electron Microscopic Study.” 

Annual Meeting of the Nebraska 
Rheumatism Association — 

THURSDAY, MAY 12, 1966 
Creighton University Auditorium, 

Eugene C. Eppley 
College of Business Administration 
26th and California, Omaha, Nebraska 

PROGRAM 

VERNON G. WARD, M.D., Presiding 

Fb'esident, Nebraska Rheumatism Association; 
Assistant Professor, Department of 
Internal Medicine, 

College of Medicine, University of Nebraska 

1:00 Registration 

1:30 Rheumatoid Spondylitis — Case Pre- 
sentation 

Walt Weaver, iMD, Instructor, De- 
partment of Internal i\Iedicine, 
College of Medicine, University of 
Nebraska 

2:00 Assessment of Periarticular Osteo- 
porosis in Rheumatoid Arthritis 
J. James Walch, i\ID, Trainee in Hard 
Tissue Metabolism, Metabolic Re- 
search Unit, School of Medicine, 
Creighton University 


2:30 The Immunopathogenesis of Rheu- 
matoid Arthritis 

*Joseph L. Hollander, MD, Professor 
of iMedicine, School of Medicine, 
University of Pennsylvania; Edi- 
tor-in-Chief of the Textbook, “Ar- 
thritis and Allied Conditions Past 
President, American Rheumatism 
Association 

3:30 Break 

3:45 Arthritic Manifestations of Systemic 
Diseases 

William D. Robinson, MD, Professor 
and Chairman, Department of In- 
ternal iMedicine, University of 
^Michigan iMedical School ; Past 
President, American Rheumatism 
Association 

4:45 Discussion 

5:00 Business Meeting and Election of Of- 
ficers 

♦ — Supported by a grant from the Merck, Sharp and Dohme 
Postgraduate Program. 

Emergency Care and Transportation — 

The first 3^ o day advanced practical course 
for ambulance attendants, firemen, police- 
men, emergency squads, safety engineers, 
public health and civil defense personnel, on 
Initial Emergency Care and Transportation 
of the Sick and Injured, will be held March 
28 through 31, 1966, at the Jung Hotel, New 
Orleans, Louisiana. It is sponsored by the 
Committee on Injuries of t h e American 
Academy of Orthopaedic Surgeons, in cooper- 
ation with Tulane University School of Medi- 
cine and the New Orleans health, police, and 
fire departments, under the direction of Dr. 
Jack Wickstrom. Tlie registration fee is $25 ; 
write to Dr. Paul R. Mej'er, Jr., Department 
of Orthopaedic Surgery, Tulane University 
Medical School, 1430 Tulane Avenue, New 
Orleans, Louisiana 70112. 

Evaluation of Permanent Impairment — 

“Guides to the evaluation of permanent 
impairment — the respiratory system,” the 
eighth guide in a permanent impairment 
evaluation series, and developed by the AiMA 
Committee on Rating of Mental and Physi- 
cal Impairment,” is available. Previously 
published guides were concerned with the 


196 


Nebraska S. M. J. 


extremities and back ; the visual system ; the 
cardiovascular system ; ear, nose, and throat, 
and related structures; the central nervous 
system ; the digestive system ; and the per- 
ipheral spinal nerves. A limited number of 
copies of this guide may be obtained, without 
charge, by writing to the above committee at 
535 North Dearborn Street, Chicago, Illinois 
60610. 


News and Views 

-Massive Screening for Breast Cancer — 

One half of 60,000 women between 40 and 
64 years old will receive regular medical care 
and will constitute the control group, while 
the other 30,000 are to have medical check- 
ups and breast X rays three times a year. 
In the first 10,000 women examined, 23 
breast cancers were found ; 16 of these can- 
cers were detected before they had spread 
to nearby lymph nodes. 


Nobel Laureate to Biomedical Institute — 

Sir John C. Eccles, PhD, whose research of 
nerve function won for him the Nobel Prize 
in Physiology and Medicine, has been ap- 
pointed to the Institute for Biomedical Re- 
search of the AMA Education and Research 
Foundation. 


Know Your 
Blue Shield Plan 

Progress Report: 98% Paid-in-Full in Louisville — 
Some 98 per cent of claims filed during the 
first six months of Kentucky Blue Shield’s 
Prevailing Fees Program has been paid-in- 
full, according to Avil McKinney, director of 
hospital, physician, and public relations for 
the Plan. 

Speaking at the Prevailing Fees Work- 
shop January 19 and 20 at the Sheraton Hotel 
in Chicago, McKinney said, “Utilization and 
cost of the program have both been below' 
our estimates. We are quite pleased with 
the results and are planning to expand the 
program to other accounts.” 



Minnesota and Kansas — 

It was also brought out at the workshop 
that Minnesota Blue Shield has implemented 
a Prevailing Fees-type program and the Kan- 
sas Medical Society has given virtually 
unanimous approval to a Prevailing Fees Pro- 
gram in that state. 

The day and a half meeting was devoted to 
a review of the Blue Shield Prevailing Fees 
Program Handbook and a discussion of va- 
rious aspects of the program by representa- 
tives of the four Plans with prevailing fees 
contracts in effect. 

Prevailing Fees Plans — 

In addition to McKinney, Leonard Davis of 
Delaware, William Love of Rockford, 111., and 
Dr. Sydney E. Sinclair of Pennsylvania were 
on hand to answer questions of the delegates 
concerning the Prevailing Fees Programs im- 
plemented in their areas. 


The Military Dependents' 
Medical Care 

Anesthesia Fees Fnder the Military Dependents 
Medical Care Program 

Amounts payable for anesthesia services 
on a procedure, time, or percentage of sur- 
gical fee basis or any basis, provide com- 
pensation for the customary preoperative and 
postoperative visits, the administration of 
the anesthetic and the administration of 
fluids, including blood, incident to the anes- 
thesia or surgery. 

Anesthesia fees may be negotiated under 
any one of the methods outlined below, but 
only one method may be negotiated for each 
contract. 

Those anesthesia fees based on time are 
calculated from the beginning of the actual 
anesthetic until the anesthesiologist or anes- 
thetist is no longer in professional attend- 
ance (when the patient may be safely placed 
under customary postoperative supervision). 

Listed anesthesia fees are payable only to 
physicians or surgeons (holding unlimited li- 
censes) who personally administer the anes- 
thesia and who remain in constant attend- 
ance during the procedure for the sole pur- 
pose of rendering the anesthesia service. 


April, 1966 


197 


No additional amount is allowable to the 
physician or surgeon w'ho furnishes his own 
anesthetic equipment or materials. 

When the anesthesia is administered by 
the operating surgeon, or his surgical assist- 
ant, only 50% of the listed anesthesia fee 
may be allowed. For this payment the as- 
sistant must be a licensed physician and one 
who is not in a training status. 

Fifty per cent of obstetrical anesthesia fee 
is allowable to the attending physician or 
surgeon who administers the anesthetic to a 
patient upon whom he performs delivery. 
The administration of intermittent analgesia 
will not be construed to constitute anesthesia. 

No anesthesia fee is allowable to an at- 
tending physician or surgeon who admin- 
isters a local anesthetic to a patient upon 
whom he performs a surgical procedure. 

Physicians who have agreements, contrac- 
tual arrangements, or who othei’wise receive 
remuneration from the hospital for anes- 
thesia service, are not eligible to submit 
charges for services rendered under this sec- 
tion. Hospitals include an amount for this 
service from these individuals in their nor- 
mal hospital charges. 

Nurses, dentists, or Doctors of Osteopathy 
(with limited licenses) who render anes- 
thesia service on a “free lance” basis are 
entitled to direct remuneration from the fis- 
cal administrator paying hospitals in an 
amount equal to no more than their usual 
public charges to patients with an income of 
$4500 per year. 


Coming Meetings 

CRIPPLED CHILDREN’S CLINICS— 

April 2 — Alliance, Central High School 
Building 

April 23 — IMcCook, St. Catherine’s Hos- 
pital 

j\lay 7 — Kearney, Good Samaritan Hos- 
pital 

IMay 21 — Falls City, Elks Club 

THIRD AMA CONGRESS ON ENVIRON- 
MENTAL HEALTH PROBLEMS — 
Drake Hotel, Chicago, April 4-5, 1966. 


Write to AMA, 535 North Dearborn 
Street, Chicago, Illinois 60610; Depart- 
ment of Environmental Health. 

Future Meetings of the American 

College of Surgeons — 

ANNUAL CLINICAL CONGRESS, Octo- 
ber 10-14, 1966. San Francisco, Cali- 
fornia. 

For any advance information address: 

Secretary, American College of Surgeons, 55 

East Erie Street, Chicago, Illinois 60611. 

SOUTHWEST SURGICAL CONGRESS — 
18th Annual Meeting, Flamingo Hotel, Las 
Vegas, Nevada, April 18, 19, 20, and 21, 
1966. 

ENVIRONklENTAL HEALTH — The Third 
Congress on Environmental Health Prob- 
lems of the AMA will be held April 4-5 
at the Drake Hotel in Chicago. Write to 
EHC, Department of Environmental 
Health, AMA, 535 N. Dearborn St., Chi- 
cago, Illinois 60610. 

TERATOLOGY WORKSHOP — The Third 
Teratology Workshop will be held April 
4-8, 1966 at Boulder, Colorado; it is spon- 
sored jointly by the AMA, the Teratology 
Society, and the University of Colorado, 
with the support of the National Academy 
of Sciences - National Research Council. 
Write to William Kitto, MD, Associate Di- 
rector, Department of Drugs, AMA, 535 
North Dearborn Street, Chicago, Illinois 
60610. 

ANNUAL SCIENTIFIC SEMINAR — Of the 
Adams County Medical Society. The an- 
nual Scientific Seminar this year devoted 
to gastrointestinal disorders will be held 
in Hastings, Nebraska, on Wednesday, 
April 13, 1966. The Seminar will be held 
in the Conference Room of the Hastings 
Public Library, starting at 9:00 a.m. 

COURSE IN TRAUMA — April 20 through 
23, 1966; Tenth postgraduate course in 
trauma, announced by the Chicago Com- 
mittee on Trauma of the American College 


198 


Nebraska S. M. J. 


of Surgeons. Write to James P. Ahstrom, 
Jr., M.D., Chairman, Tenth Postgraduate 
Course, American College of Surgeons, 55 
East Erie Street, Chicago, Illinois 60611. 

AMERICAN ACADEMY OF PEDIATRICS 
— The annual spring session of the AAP 
(1801 Hinman Avenue, Evanston, Illinois) 
will be held April 25-27, 1966 in Montreal, 
in the Queen Elizabeth Hotel, and will 
include closed circuit television clinical pre- 
sentations from Montreal Children’s Hos- 
pital, a diversified scientific program, and 
more than 90 scientific and technical ex- 
hibits. 

INDUSTRIAL HEALTH— April 25-28, 1966; 
American Industrial Health Conference, 
Sheraton-Cadillac Hotel and Cobo Hall, De- 
troit, Michigan. Address: 55 E. Washing- 
ton Street, Chicago, Illinois 60602. 

ANESTHESIOLOGY — Third Annual Mid- 
west Conference on Anesthesiology. Con- 
tinental Plaza Hotel, Chicago, Illinois, 
April 28-30, 1966. Write to T. L. Ash- 
craft, M.D., 33 East Cedar Street, Chi- 
cago, Illinois 60611. 

CONTINUING EDUCATION COURSES — 
For physicians sponsored by the University 
of Nebraska College of Medicine’s Office 
of Continuing Education: 

April 20-21 — “Disorders of Growth” (Pe- 
diatrics), (Omaha Campus) 

May 5 — “Infectious Disease” (Omaha 
Campus) 

May 6 — “Current Concepts of Diabetes” 
(Omaha Campus) 

May 19-20 — “Surgery and Trauma” 
(Omaha Campus) 

THE HAHNEMAN MEDICAL COLLEGE 
AND HOSPITAL of Philadelphia offers 
the following Postgraduate Education 
Courses during 1965 and 1966: 

— April 20-23, 1966: 16th Hahneman 

Symposium, Arterial Occlusive Disease; 
Dr. Albert N. Brest; Marriott Motor 
Hotel. 

— December, 1966: 17th Hahneman Sym- 


posium, Nutritional Dysfunction; Dr. 
Donald Berkowitz ; S h e ra ton Hotel, 
Philadelphia. 

NEBRASKA STATE MEDICAL ASSOCIA- 
TION — 98th Annual Session, May 2-5, 
inclusive. Hotel Cornhusker, Lincoln. 

AMERICAN COLLEGE OF OBSTETRI- 
CIANS AND GYNECOLOGISTS — The 
ACOG (79 West Monroe Street, Chicago, 
Illinois 60603) will hold its 14th Annual 
Clinical Meeting May 2-5, 1966, at the 
Palmer House in Chicago. 

MID-CENTRAL STATES ORTHOPAEDIC 
SOCIETY — The 13th Annual Meeting of 
this group will be held May 5-7, 1966, at 
the Hotel Cornhusker, Lincoln. Contact 
Dr. Fred Webster for further details. 

RHEUMATIC DISEASE SEMINAR — May 
6 and 7 ; Postgraduate seminar on rheu- 
matic diseases, at the Sheraton-Blackstone 
Hotel in Chicago, under the sponsorship of 
the Illinois Chapter of the Arthritis Foun- 
dation; registration $25; write to the Illi- 
nois Arthritis Foundation, 159 North 
Dearborn Street, Chicago, Illinois. 

FIRST INTERNATIONAL CONGRESS ON 
SMOKING AND HEALTH — June 5 to 
8, 1966, at the New York Hilton Hotel in 
New York City. Write to the Congress 
office: Overseas Press Club, 54 West 

40th Street, New York, N.Y. 

NEBRASKA RHEUMATISM ASSOCIA- 
TION TO MEET — Creighton University 
School of Medicine in Omaha, Auditorium 
of the Eppley School of Business, May 12, 
1966, at 1 p.m. 

FIRST ANNUAL BIOMEDICAL LASER 
CONFERENCE — June 17-18, Sheraton- 
Boston Hotel, Boston, Massachusetts. 

AMA ANNUAL CONVENTION — 115th 
Annual Convention, Chicago, June 26-30, 
1966; Scientific Program in McCormick 
Place, House of Delegates in the Palmer 
House. 


April, 1966 


199 


TENTH WORLD CONGRESS OF THE IN- 
TERNATIONAL SOCIETY FOR RE- 
HABILITATION OF THE DISABLED 
— September 11-17, 1966, Rhein-Main- 

Hall, Wiesbaden, Gennany. 

NEBRASKA CHAPTER OF THE AMERI- 
CAN ACADEMY OF GENERAL PRAC- 
TICE — Scientific Meeting; September 15 
and 16, 1966, Hotel Cornhusker, Lincoln, 
Nebraska. 

ENDOCRINE SOCIETY — October 3rd 
through 7th, 1966; Eighteenth Postgradu- 
ate Assembly of the Endocrine Society, in 
Oklahoma City, Oklahoma ; co-sponsored 
by the University of Oklahoma Medical 
Center at the Skirvin Hotel. Registration 
fee: $100; write to Dr. Henry H. Turner, 
1200 North Walker, Oklahoma City. 

INTERNATIONAL CANCER CONGRESS 
— The IX International Cancer Congress 
will be held in Tokyo, Japan, from October 
23-29, 1966. Write to Hirsch Marks, MD, 
435 East 57th St., New York 22, N.Y. 

Effects of Acetylsalicylic Acid, Phenacetin, 
Paracetamol, and Caffeine on Renal Tu- 
bular Epithelium — L. F. Prescott (Uni- 
versity of Aberdeen iMedical Bldg, Forest- 
erhill, Aberdeen, Scotland). Lancet 2:91- 
95 (July 17) 1965. 

The excretion of renal tubular cells, ery- 
throcytes, and leukocytes was measured in 
70 healthy volunteers before and during the 
administration of aspirin, the combination 
of aspirin, phenacetin, and caffeine (APC), 
phenacetin, n-acetyl-p-aminophenol (Para- 
cetamol), caffeine, or placebo. Ten volun- 
teers receiving 3.6 gm of aspirin daily, all 
showed a striking increase in the output of 
renal tubular cells and erythrocytes. Similar 
but less notable changes were seen in five 
of ten volunteers given APC (1.8 gm aspirin, 
1.8 gm phenacetin, and 1.2 gm caffeine). 
For the first time, the nephrotoxic effects of 
phenacetin and caffeine were demonstrated 
in healthy volunteers. Two of ten volunteers 
taking 3.6 gm phenacetin daily showed a 
great increase in renal-tubular cell excretion, 
while the administration of 2.4 gm caffeine 


citrate daily resulted in a moderate increase 
in mean renal tubular cells and erythrocytes 
in another 10. There was only a slight in- 
crease in mean renal-tubular cell excretion 
in 21 volunteers given 3.6 gm n-acetyl-p- 
aminophenol daily. No significant change 
occurred in 10 given placebo tablets. None 
of the drugs tested seemed to influence the 
output of leukocytes or urinary protein. It 
is suggested that nephritis following the use 
of analgesics is caused by the abuse of several 
different drugs and not by phenacetin alone. 

New Screening Test for Cystic Fibrosis — 
R. H. Gregg (5224 St. Antoine St, Detroit) 
and R. E. Boucher, Pediatrics 36:700 
(Nov) 1965. 

An inexpensive, disposable indicator of 
chloride ion concentration has been used in 
an attempt to develop an office test for 
cystic fibrosis. The indicator consists of a 
paper-like wick impregnated wdth silver 
chromate and encapsulated in plastic. Sweat- 
ing was locally induced by subcutaneous in- 
jection of methacholine chloride. Analyses 
of tests done simultaneous^’ on 85 subjects 
by two methods demonstrate clinical useful- 
ness of the new method. 

Sudden Illness as a Cause of Motor Vehicle 
Accidents — B. Herner, B. Smedby, and 
L. Ysander (Lasarettet, Varberg, Sweden). 
Brit J Industr Med 23:37 (Jan) 1966. 

Forty-one of the 44,255 road accidents re- 
ported to the police in one region of Sweden 
from 1959 to 1963 were, or probably were, 
caused by sudden illness in the driver of a 
motor vehicle. All 41 were males, and the 
illness was most often due to epilepsy or myo- 
cardial infarction. Eight drivers died at the 
wheel from their disease, but no other per- 
sons were killed in the 41 accidents. Only 
in 19 out of the 41 cases was there any pos- 
sibility of a previous medical examination 
having indicated that the man was unfit to 
drive. In view of this, and the extremely 
small proportion (about 1 in 1,000) of acci- 
dents caused by sudden illness at the wheel, 
there is little point in providing for general 
measures such as periodic medical examin- 
ation to prevent these accidents. 


200 


Nebraska S. M. J. 



Books 



Medical Pharmacology — Principles and Concepts 
(3rd edition) by Andres Goth, MD. Published 
Jan. 25, 1966 by the C. V. Mosby Company of 
St. Louis, Missouri. 668 pages (7" by 10") with 
66 figures and 23 tables. Price $12.50. 

The author of this popular book is Chairman of 
the Department of Pharmacology at the University 
of Texas Southwestern Medical School in Dallas, 
Texas. This current edition, although somewhat 
larger than the previous editions in 1961 and 1964, 
provides a concise, selective, and usable textbook 
for medical students and practicing physicians. In- 
formation of interest to the pharmacologist only has 
been eliminated. 

Emphasis has been placed particularly on the 
mode of action of drugs in terms of interactions with 
physiologic and biochemical mechanisms. Documen- 
tation is more complete than in previous editions. 
A new feature has been added to the bibliography, 
namely, a separate grouping of recent reviews at 
the end of chapters. This feature should make it 
possible for the reader to get much additional in- 
formation and many more references whenever 
they are needed. 


Respiratory Care by H. H. Bendixen, MD; L. D. 

Egbert, MD; J. Hedley - Whyte, MD; M. B. 

Laver, MD, and H. Pontoppidan, MD. Published 

November 26, 1965 by the C. V. Mosby Company 

of St. Louis. 252 pages (7" by 10") with numer- 
ous illustrations. Price $15.00. 

This book has been written by staff members of 
the Respiratory Unit and the Anesthesia Labora- 
tory of the Harvard Medical School at the Massa- 
chusetts General Hospital in Boston, Massachusetts. 
It represents an excellent example of the ways in 
which basic knowledge developed through science 
and technology can be applied to the real prob- 
lems of disease. The remarkable alteration of mor- 
tality and morbidity rates in diseases affecting the 
respiratory function is testimony to the success 
of such work at the Massachusetts General Hos- 
pital, as well as numerous other centers in this 
countiy and abroad. 

Chapter headings include the following: 

a. Physiological disturbances in respiratory in- 
sufficiency 

b. Manifestations of acute respiratory insuffi- 
ciency 

c. Blood-gas measurements and acid-base balance 

d. Prevention of respiiatory complications 

e. Chest physical therapy and humidificatioii 

f. Problems in oxygen therapy 

g. Management of patients undergoing prolonged 
artificial ventilation 

h. Respiratory management in special cases 


1. Chest injuries 

2. Intracranial lesions 

3. Myasthenia gravis 

i. Respiratory management of acute poisoning 

j. Respiratory management in thoracic and car- 
diac surgery 

k. Respiratory management of obstructive pul- 
monary disease. 


Diagnosis and Therapy of the Glaucomas (2nd edi- 
tion) by Bernard Becker, MD, and Robert N. Shaf- 
fer, MD. Published November 29, 1965 by the 
C. V. Mosby Company of St. Louis. 443 pages 
(7" by 10") with 233 illustrations including 5 
color plates. Price $18.50. 

Doctor Becker is Head of the Department of 
Ophthalmology at the Washington University School 
of Medicine in St. Louis, Missouri. Doctor Shaffer 
is a Clinical Professor of Ophthalmology at the Uni- 
versity of California School of Medicine in San 
Francisco, California. 

The purpose of this book is to make available in 
one brief volume much of the current thinking on the 
pathogenesis, diagnosis, and management of the 
glaucomas. The authors have expressed conclusions 
based on a review of the literature but interpreted 
in the light of their own personal experiences. 

Section headings include the following: 

1. Classification of the glaucomas 

2. Gonioscopy — methods and inteipretation 

3. Tonometry and tonography 

4. Ophthalmology and perimetry 

5. Diagnosis and therapy 

6. Medical techniques 

7. Surgical techniques. 

Vitreoretinal Pathology and Surgery in Retinal De- 
tachment by Paul A. Cibis, MD. Published No- 
vember 8’, 1965 by the C. V. Mosby Company of 
St. Louis. 292 pages (7" by 10") with 227 figures. 
Price $20.00. 

The author of this book was a staff member of the 
Department of Ophthalmology and the Oscar John- 
son Institute of the Washington University School 
of Medicine in St. Louis. He devoted the last five 
years of his remarkably productive life to new ap- 
proaches to the therapy of those retainal detach- 
ments not amenable to cure by currently accepted 
methods. For such studies he had available not 
only an enormous wealth of clinical material but 
also his own remarkable ingenuity and unique tech- 
nical skill. His amazing results with the referred 
“hopeless” case were known to many. 

The present monograph provides the fundamental 
pathophysiological background, elementary instru- 
mentation, and early primitive techniques for sur- 


April, 1966 


201 


In Cardiovascular 


Increased 

intrathoracic 

and 

intra-abdominal 

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April, 1966 


201-B 




gery within the vitreous cavity. These were the foun- 
dations upon which Cibis planned to build and de- 
velop this bold new approach to retinal detach- 
ments. His untimely death so soon after com- 
pleting the manuscript left little time for this de- 
velopment, but already he was in the process of 
setting up a new operating room with special in- 
strumentation for intravitreal surgery. This book 
will introduce the concepts of intravitreal surgery 
to its readers, and hopefully it may stimulate some 
of them to experiment with and further develop 
this exciting field. 


Cardiac Resuscitation: A One- Year Study of 
Survival of Patients Resuscitated Within 
a University Hospital — E. J. Stemmier 
(Hosp. of the University of Pennsylvania, 
3400 Spruce St., Philadelphia). Ann Intern 
Med 63:613-618 (Oct.) 1965. 

Excluding patients whose cardiac arrest oc- 
curred in the operating room or cardiac 
catheterization laboratory, 103 patients re- 
ceived external cardiac massage in the hos- 
pital from July 1, 1963, to June 30, 1964. 
Since the chief attribute of external cardiac 
massage is its potential success under disad- 
vantageous circumstances, this study is con- 
cerned with the factors which diminish the 
chances of success. Thirty-six patients were 
successfully resuscitated for longer than one 
hour, 13 of these survived 24 hours, and 5 
were discharged from the hospital alive. The 
chance of surviving a cardiac arrest is dis- 
tinctly less for a patient with serious under- 
lying illness than for patients with unexpect- 
ed cadiac arrest who were well and in no ap- 
parent jeopardy from a mortal illness. The 
immediate application of external cardiac 
massage and effective ventilation had the 
most important influence on survival rate. 
Survival may be improved by closer observa- 
tion. Nursing personnel should probably be 
taught the techniques of external cardiac 
massage, but the decision to initiate therapy 
should be made by a physician, and he should 
supervise the procedui e if possible. 

What Constitutes An Adequate Operation for 
Carcinoma of the Thyroid? — R. L. Clark 
(6723 Bertner Ave., Houston). Arch Surg 
92:23 (Jan) 1966. 

Total thyroidectomy, with oi' without neck 
dissection as indicated by pathology, con- 


stitutes the adequate operation for thyroid 
carcinoma. “Compartmental” dissection is 
performed when the positive nodes occur 
only high along the recurrent nerve; radical 
neck dissection is done when other meta- 
static nodes are present. Enlarged contra- 
lateral nodes should be removed. If the 
larynx and the trachea are invaded, they 
should then be removed. Extensive radio- 
active iodine therapy is used in superficial 
laryngeal or tracheal infiltration ; external 
irradiation is utilized in poor metastatic 
radioactive iodine uptake. In distant meta- 
stases, total thyroidectomy reduces seed- 
ing and prevents terminal tracheal or vas- 
cular obstruction. Carefully planned and 
executed surgical procedures by surgeons 
specifically trained in this procedure will 
reduce the postoperative morbidity. 

New Device (Diagnostotube) for the Local- 
ization of Upper Gastrointestinal Bleed- 
ing — G. Nissenbaum et al (V. W. Grois- 
ser. New Jersey College of Medicine, Jer- 
sey City), Gastroenterology 49:662 (Dec) 
1965. 

A new device (Diagnostotube) for local- 
ization of upper gastrointestinal bleeding is 
described. The device consists of a flex- 
ible plastic polyvinyl tube with 50 intra- 
luminal numbers one inch apart and an outer 
absorbent disposable cotton sheath. It is 
introduced orally and is used in conjunc- 
tion with intravenous fluorescein. Ninety- 
two patients were studied, of whom 71 pre- 
sented with evidence of gastrointestinal 
bleeding. Forty-two patients were actively 
bleeding at the time of the test and their 
bleeding sites were accurately localized with 
the device. 

Abdominal Surgery Without Gastrointestinal 
Suction — I. F. Stein, Jr. and H. S. Lans 
(625 Roger Williams Ave., Highland Park, 
111.). Arch Surg 92:35 (Jan) 1966. 

A series of 539 consecutive cases of major 
abdominal surgery in whom gastric suction 
was not used revealed that these patients 
had a smoother convalescence, fewer respir- 
atory comi)lications, easier nursing care, and 
easiei- management of fluid and electrolytes 


202 


Nebraska S. M. J. 


than patients in whom gastric suction was 
used. Since the use of gastrostomy or naso- 
gastric intubation is conducive to such com- 
plications, the use of suction should not be 
a routine measure but should only be used 
in cases with indications for suction. In 
properly selected cases the use of suction is 
valuable, namely, in patients with gastro- 
intestinal bleeding or abdominal trauma to 
determine the presence of bleeding in those 
with perforated peptic ulcers, in patients 
who ingested food or fluids shortly prior to 
requiring emergency surgery, in surgical 
procedures necessitating manipulation of the 
possibly full stomach, and in those patients 
who are “air swallowers.” The majority of 
patients do not require suction and do better 
without it, either pre- or postoperatively. 

Early and Late Course of Patients With Ul- 
cerative Colitis After Ileostomy and Colec- 
tomy — J. B. Rhodes and J. B. Kirsner 
(University of Chicago Department of 
Medicine, Chicago). Surg Gynec Obstet 
121:1303-1314 (Dec) 1965. 


ORGANIZATIONS, NATIONAL 

American Academy of General Practice 
Mr. Mac F. Cahal 
Volker at Brookside 
Kansas City 12, Missouri 

American Academy of Pediatrics 
E. H. Christopherson, Secy. 

1801 Hinman Ave. 

Evanston, Illinois 

American College of Legal Medicine 

Glenn W. Bricker, M.D., F.C.L.M., Secretary 
1003-06 Medical Tower 
Philadelphia 3, Pennsylvania 
American College of Obstetricians & Gynecologists 
Craig W. Muckle, M.D. 

1806 Garrett Road 
Lansdowne, Pa. 

American College of Physicians 

Edward C. Rosenow, Jr., M.D., F.A.C.P., Secy. 
4200 Pine St. 

Philadelphia 4, Pennsylvania 
American College of Radiology 
Mr. W. C. Stronach 
20 North Wacker Drive 
Chicago 6, Illinois 
American College of Surgeons 
John P. North 
40 East Erie Street 
Chicago 11, Illinois 

American Diabetes Association 
Laurentius O. Underdahl, M.D. 

1 East 45 Street 

New York 17, New York 


Among patients with ulcerative colitis re- 
quiring surgery, one fourth present a serious 
complication such as toxic megacolon, mas- 
sive hemorrhage, or perforation of intestine ; 
and three fourths will have failed to respond 
to intensive medical management. The inci- 
dence of perforation of colon has not increased 
despite the administration of adrenal corticos- 
teroids. Adrenal corticosteroids do not im- 
pede the surgical management of ulcerative 
colitis, but necesitate meticulous preoperative 
stabilization of blood volume, plasma pro- 
teins, electrolyte and fluid balance, and post- 
operatively, a delay in the removal of sutures. 
Except in patients with localized segmental 
disease and in poor risk patients, ileostomy 
with proctocolectomy is the operation of 
choice for ulcerative colitis. Ileostomy prob- 
lems occur in about two thirds of the pa- 
tients; and additional surgery for ileostomy 
dysfunction, intestinal obstruction, and per- 
ineal repair may be required in approximate- 
ly 50% of the patients. These problems 
should not interfere with the choice of thera- 
peutic method, if surgery seems unavoidable. 


American Heart Association 
Mr. Rome A. Betts, Secy. 

44 East 23rd Street, New York 10, New York 
National Hemophilia Foundation 

25 West 39th St., New York, N.Y. 10018 
American Hospital Association 
Edwin L. Crosby, M.D., Director 
840 Lake Shore Drive, Chicago 11, Illinois 
American Society of Anesthesiology 
Mr. J. W. Andes 

515 Busse Hy., Park Ridge, Illinois 
American Society of Internal Medicine 
Mr. Albert V. Whitehall, Executive Secy. 

3410 Geary Boulevard 
San Francisco 18, California 
The American Society of Clinical Pathologists 
Miss Eleanor F. Larson 
445 Lake Shore Drive, Chicago 11, Illinois 
American Medical Association 

F. J. L. Blasingame, Executive Vice Pres. 

535 North Dearbon St., Chicago 10, Illinois 
American Urological Association 
Rubin Flocks, M.D., Secretary 
State University of Iowa Hospitals, 

Iowa City, Iowa 

Arthritis and Rheumatism Foundation 
Floyd B. Odium, Chairman 
10 Columbus Circle, New York 19, New York 

International College of Surgeons 
John B. O’Donoghue, M.D. 

1516 North Lake Shore Dr., Chicago 10, Illinois 
National Multiple Sclerosis Society 

257 Park Avenue South, New York 10, N.Y. 
V^ocational Rehabilitation Administration 

Mary E. Switzer, Commissioner, Washington, D.C. 


April, 1966 


203 


ORGANIZATIONS. STATE = 

Alcoholics Anonymous 
1345 N Street, Lincoln 
American Red Cross 

W. J. Frenzel, State Representative 
2631 Garfield, Lincoln 
Cerebral Palsy Association of Nebraska 
Mrs. Ben H. Cosdery 
201 South Elmwood Road, Omaha 
Creighton University School of Medicine 
Richard Egan, Dean 
302 North 14th, Omaha, Nebraska 
International College of Surgeons 
James J. O’Neil, M.D., Regent for Nebraska 
612 Medical Arts Building, Omaha 2, Nebraska 
Multiple Sclerosis Society 

Mrs. Harold Stoehr, Executive Secretary 
3648 Folsom Street, Lincoln, Nebraska 
Muscular Dystrophy Society 

Mrs. Marvin Traeger, President 
Fairbuiy, Nebraska 
National Foundation, Inc. 

Clinton Belknap 
State House Station 

Post Office Box 4813, Lincoln, Nebraska 
Nebraska Chapter, 

Arthritis and Rheumatism Foundation 
Lloyd E. Skinner, President 
Box 2, Elmwood Station, Omaha 6, Nebraska 
Nebraska Association of Pathologists 
Dr. Robert A. Brooks, Secy-Treas. 

1403 Sharp Building, Lincoln, Nebraska 
Nebraska Blue Cross-Blue Shield 
Wm. H. Heavey, Executive Director 
518 Kilpatrick Building, Omaha, Nebraska 
Nebraska Chapter 

American Academy of General Practice 
John A. Brown, M.D., Secy. 

1620 M Street, Lincoln, Nebr. 

Nebraska Chapter 

American College of Physicians 

Henry J. Lehnhoff, Jr., IMD, Governor for Nebr. 
720 Doctors Building, Omaha, Nebraska 69131 

Nebraska Chapter 
American College of Surgeons 

Robert W. Gillespie, MD, Secy.-Treas. 

500 South 17th St., Lincoln, Nebraska 

Nebraska Chapters 

National Cystic Fibrosis Research Foundation 
Greater Omaha Chapter 

Miss Betty Seibert, 510 South 42nd St., Omaha 
Lancaster County Chapter 

Mr. and Mrs. Gayle Voller, 530 North 75th St., 
Lincoln 

Nebraska Dental Association 
D. W. Edwards, D.D.S., Secy. 

1220 Federal Securities Bldg., Lincoln, Nebraska 
Nebraska Diabetes A.ssociation 

Mrs. E. H. Reitan, Executive Secretary 
530 N. 86th St., Omaha, Nebr. 

7611 Lawndale Drive, Omaha, Nebraska 
Nebraska Dietetic Association 
Hazel M. Fox, Ph.D., President 
Foods & Nutrition Bldg., East Campus, Lincoln 
Nebraska Division American Cancer Society 
Ray E. Achelpohl, Executive Director 
4201 Dodge, Omaha, Nebraska 
Nebraska Heart Association 
Paul S. Archambault, Executive Director 
514 South 40th Street, Omaha 5, Nebraska 
Nebraska Hospital Association 
Stuart Mount, Executive Director 
1335 “H” Street, Lincoln, Nebraska 


Nebr. Academy of Ophthalmology & Otolaryngology 
C. Rex Latta, MD, Secretary 
710 Doctors Building, Omaha, Nebraska 68131 
Nebraska Pediatric Society 
Otto G. Rath, Secretaiy 
3929 Harney, Omaha 
Nebraska Pharmaceutical Association 
Miss Cora Mae Briggs, Executive Secretary 
1001 Andei'son Building, Lincoln 8, Nebraska 
Nebraska Psychiatric Institute 
602 South 44th Avenue, Omaha 
Nebraska Public Health Association 
George R. Underwood, M.D., President 
935 “R” Street, Lincoln, Nebraska 

Nebraska Radiological Society 
Jack Zastera, M.D., Secy.-Treas. 

816 Medical Arts Bldg., Omaha, Nebraska 

Nebraska Rheumatism Association 
Vernon G. Ward, President 
5 West 31st Street, Kearney, Nebraska 

Nebraska Society for Crippled Children 
S. Orson Perkins, Director 
402 South 17th, Omaha, Nebraska 

Nebraska Society for Internal Medicine 
Robert S. Long, M.D., President 
8721 Shamrock Road, Omaha, Nebraska 
Nebraska Society of Anesthesiologists 
Frank Cole, M.D., President 
2430 Lake St., Lincoln, Nebraska 
Nebraska Society of Medical Technologists 

Gladys Jeurink, MT, ASCP, 4600 Spruce, Lincoln 
Nebraska State Department of Health 
E. A. Rogers, M.D., Director 
State Capitol Building, Lincoln, Nebraska 
Nebraska State Medical Association 
Ken Neff, Executive Secy. 

1315 Sharp Building, Lincoln 8, Nebraska 
Nebraska State Nurses Association 
Zelda Nelson, Executive Director 
307 Baird Bldg., Omaha, Nebraska 
Nebraska State Obstetric and Gynecologic Society 
W. Riley Kovar, M.D., Secretary-Treasurer 
3610 Dodge Street, Omaha 31 
Nebraska State Orthopedic Society 
Harold Horn, MD, Secretary 
3145 “O” Street, Lincoln, Nebraska 
Nebraska State Pediatric Society 

Otto Rath, M.D., Secretary-Treasurer 
3929 Harney, Omaha, Nebraska 
Nebraska, South Dakota, North Dakota District 
Branch of the American Psychiatric Association 
Harry C. Henderson, M.D., President 
105 South 49th St., Omaha, Nebraska 68132 
Nebraska Tuberculosis Association 
Delmer Serafy, Executive Secy. 

406 W.O.W. Building, Omaha, Nebraska 
Nebraska Urological Association 

Louis W. Gilbert, MD, Secretary-Treasurer 
903 Sharp Building, Lincoln 8, Nebraska 
Omaha Mid-West Clinical Society 
1040 Medical Arts Building (68102) 

Rita M. Crowell, Executive Secretary 
POISON CONTROL CENTER 
Children’s Memorial Hospital 
502 South 44th, Omaha, Nebraska 
Rehabilitation Services Division 

Fred A. Novak, Assistant Commissioner 
707 Lincoln Bldg., 1001 0 St., Lincoln 68508 
University of Nebraska College of Medicine 
Cecil L. Wittson, MD, Dean 
42nd and Dewey, Omaha, Nebraska 
(Please help us keep these addresses correct, by 
notifying the Editor of any changes). 


204 


Nebraska S. M. J. 



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fosters normal sleep through both its anti- 
anxiety and muscle-relaxant properties. 
Contraindications: Previous allergic or idio- 
syncratic reactions to meprobamate or 
meprobamate-containing drugs. 
Precautions: Careful supervision of dose 
and amounts prescribed is advised. Consider 
possibility of dependence, particularly in pa- 
tients with history of drug or alcohol addic- 
tion; withdraw gradually after use for weeks 
or months at excessive dosage. Abrupt with- 
drawal may precipitate recurrence of pre- 
existing symptoms, or withdrawal reactions 
including, rarely, epileptiform seizures. 
Should meprobamate cause drowsiness or 
visual disturbances, the dose should be re- 
duced and operation of motor vehicles or 
machinery or other activity requiring alert- 
ness should be avoided if these symptoms 
are present. Effects of excessive alcohol may 


An eminent role in 
medical practice 

Clinicians throughout the world con- 
sider meprobamate a therapeutic 
standard in the management of anxi- 
ety and tension. 

The high safety-efficacy ratio of 
‘Miltown’ has been demonstrated by 
more than a decade of clinical use. 

Miltowir 

(meprobamate) 

possibly be increased by meprobamate. 
Grand mal seizures may be precipitated in 
persons suffering from both grand and petit 
mal. Prescribe cautiously and in small quan- 
tities to patients with suicidal tendencies. 

Side effects: Drowsiness may occur and. 
rarely, ataxia, usually controlled by decreas- 
ing the dose. Allergic or idiosyncratic re- 
actions are rare, generally developing after 
one to four doses. Mild reactions are char- 
acterized by an urticarial or erythematous, 
maculopapular rash. Acute nonthrombocy- 
topenic purpura with peripheral edema and 
fever, transient leukopenia, and a single 
case of fatal bullous dermatitis after admin- 
istration of meprobamate and prednisolone 
have been reported. More severe and very 


rare cases of hypersensitivity may produce 
fever, chills, fainting spells, angioneurotic 
edema, bronchial spasms, hypotensive crises 
(1 fatal case), anuria, anaphylaxis, stoma- 
titis and proctitis. Treatment should be 
symptomatic in such cases, and the drug 
should not be reinstituted. Isolated cases of 
agranulocytosis, thrombocytopenic purpura, 
and a single fatal instance of aplastic ane- 
mia have been reported, but only when other 
drugs known to elicit these conditions were 
given concomitantly. Fast EEG activity has 
been reported, usually after excessive me- 
probamate dosage. Suicidal attempts may 
produce lethargy, stupor, ataxia, coma, 
shock, vasomotor and respiratory collapse. 
Usual adult dosage: One or two 400 mg. 
tablets three times daily. Doses above 2400 
mg. daily are not recommended. 

Supplied: In two strengths: 400 mg. scored 
tablets and 200 mg. coated tablets. 

Before prescribing, consult package circular, 
WALLACE LABORATORIES 
\£r,Cranbury, N.J. cM-s^ei 


I 


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Physicians Assured of Hearing — 

(Continued from page 10- A) 

Doctor Nye, who succeeds Doctor Wright 
as President of the Nebraska State Medical 
Association this spring, said that insecurity 
among state-employed doctors working under 
a Department of Institutions headed by a 
nonmedical director makes it difficult for Ne- 
braska to attract and to keep qualified doc- 
tors. He looks for the further action on the 
part of the Nebraska State Medical Associa- 
tion to encourage the Governor to place 
mental hospitals in a separate state division 
under a full-time qualified medical director. 


New Help for Alcoholic.s? — 

DPN, short for diphosphoryridine nucleo- 
tide, an enzyme treatment developed by Doc- 
tor Paul O’Hollaren at the Shadel Hospital 
in Seattle, Washington, is being tested on 
ten volunteers from the Open Door Mission 
in Omaha. According to Doctor Maurice 
Stoner, an Omaha physician who is super- 
vising the experiments in Omaha, the results 
of tests performed locally will be compared 
with results of similar experiments being 
conducted in New Orleans, "S'ancouver, Se- 
attle, and Paris. 



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PHYStChl 
TODAY 
ONLY' 

rm DOCTORS 

TO SERVE 
YOU.. 

NO WAITING 






22-A 


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I 



she can say "No thank you" 
to the crepe suzette. 


'Dexamyl' does more than most anorectics. Be- 
cause it curbs appetite and lifts mood, 'Dexamyl' 
can encourage the discouraged dieter to stay 
on her diet. 

The mood lift with 'Dexamyl' can make the dif- 
ference between the success or failure of her 
diet plan. 

Formulas: Each 'Dexamyl' Spansule® Capsule (brand of sustained 
release capsule) No. 1 contains 10 mg. of Dexedrine® (brand of 
dextroamphetamine sulfate) and 1 gr. of amobarbital, derivative of 
barbituric acid (Warning, may be habit forming]. Each 'Dexamyl' 
Spansule capsule No. 2 contains 15 mg. of Dexedrine (brand of 
dextroamphetamine sulfate) and iVj gr. of amobarbital (Warning, 
may be habit forming). 

Principal cautions and side effects: Use with caution in patients 

hypersensitive to sympathomimetics or barbiturates and in coronary 
or cardiovascular disease or severe hypertension. Insomnia, excit- 
ability and increased motor activity are infrequent and ordinarily 
mild. 

Before prescribing, see SK&F product Prescribing Information. 

Smith Kline & French Laboratories 




I 


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23-A 



The T^am Is Qone 

Despite introduction of synthetic substitutes, efficacy of 
‘Empirin’ Compound with Codeine remains unchallenged. 


‘Empirin’®Compound with Codeine Phosphate gr.1/2 No. 3 

Each tablet contains: Codeine Phosphate gr. Vi (Warning— May be habit forming), Phenacetin gr. 2Vi, 
Aspirin gr. 3Vi, Caffeine gr. Vi. 


Keeps the Promise oi Pain Relief 

U BURROUGHS WELLCOME & CO. (U.S.A.) INC., TUCKAHOE, N.Y. 


24-A 


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Doctor...two important 
Lederle products for 

routine office procedures 





A 

single-dose vials 
for convenient 
and economical 
polio 

immunization 


ORiMUNE 


POLIOVIRUS VACCINE.LIVE, ORAL 

TRIVALENT 

SABIN STRAINS, TYPES 1,2 and 3 

Fast, simple administration— and economy for the 
patient — make the new 0.5 cc single-dose vial of 
ORIMUNE Trivalent ideal for private practice. {Packaged 
5 to a box with 5 sterilized disposable droppers for your 
convenience). 

(Also available in 2 cc and 2 drop dosage forms). 

Only 2 doses required for complete, initial immunization 
for patients more than a year old. 


Effectiveness — may be expected to confer active immu- 
nity against all three types of poliovirus infection in at 
least ninety percent of susceptibles only if given at full 
dosage, as directed. No characteristic side effects have 
been reported. There are, however, certain contraindica- 
tions . These are, broadly: acute illness, conditions which 
may adversely affect immune response, and advanced 
debilitated states. In these, vaccination should be post- 
poned until after recovery. 

In infants vaccination should not be commenced before 
the sixth week of life. Do not give to patients with viral 
disease, or if there is persistent diarrhea or vomiting. 
ORIMUNE and live virus measles vaccine should be given 
separately. 

Dosage — initial immunization: two doses each given 
orally at least 8 weeks apart. (Give a third dose to 
infants at 10-12 months). Booster immunization: one 
dose, given orally. See package literature for full 
directions. 





simplifies routine screening 

TURERCUUN, 
TINE TEST 

(Rosenthal) Lederle 

Swab* Uncap • Press • Discard 

Comparable in accuracy and reliability to older standard 
intradermal tests*, but faster and easier to use. Since 
TINE TEST is relatively painless it should receive greater 
patient acceptance. Results are read at 48-72 hours. The 
self-contained, completely disposable unit requires no 
refrigeration and is stable for two years. 

Side effects are possible but rare: vesiculation, ulcera- 
tion or necrosis at test site. Contraindications, none; 
but use with caution in active tuberculosis. Available in 
boxes of 5 (new individually-capped unit); cartons of 25. 
‘Rosenthal, S. R., Nikurs, L., Yordy, E., and Williams, W.: 
Scientific Exhibit Presented at the Annual Meeting of 
the National Tuberculosis Association, Chicago, Illinois, 
May 30-June 2, 1965. 



LEDERLE LABORATORIES, A Division of American Cyanamid Company, Pearl River, New York 


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at Merck Sharp & Dohme... 



understanding... 


precedes development 


The development of chlorothiazide and probene- 
cid were events of major importance, but perhaps 
even more important for the future was the Renal 
Research Program by which they were developed. 
When Merck Sharp & Dohme organized this pro- 
gram in 1943, it was expressing in action some of 
its basic beliefs about research: 

• Many problems connected with renal structure 
and function were still undefined or unsolved. The 
Renal Research Program would begin its basic 
research in some of these problem areas. 

• From knowledge thusacquired might comeclues 
to the development of new therapeutic agents of 
significant value to the physician. 


For example, the Renal Research Program put 
fifteen years into this search before chlorothiazide 
became available. But because these years had 
first led to a greater understanding of basic 
problems, the desired criteria for chlorothiazide 
existed before the drug was developed. 

Along with other research teams at Merck Sharp 
& Dohme, the Renal Research Program continues 
to add new understanding of basic problems — 
understanding which will lead to important new 
therapeutic agents. 

^MERCKSHARP& DOHME D'viS'On ol Meet* & Co . Kc . Wcs* Pomt. Pa 

where today’s theory is tomorrow's therapy 


26-A 


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Blueprint for dealing with tension due to stress — Prolixin — once-a-day 

For the patient who must be on the job mentally as well as physically, prescribe 
Prolixin. The prolonged tranquilizing action of as little as one or two mg. helps 
him cope with tension all day long. Markedly low in toxicity and virtually free 
from usual sedative effects, Prol