Skip to main content

Full text of "North Carolina medical journal [serial]"

See other formats


if 






Digitized by tine Internet Arclnive 

in 2011 witln funding from 

North Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project 



http://www.archive.org/details/ncarolinamed371976medi 



North Carolina Medical Journal 

Owned and Published by 
NORTH CAROLINA MEDICAL SOCIETY 



Under the Direction of Its 
EDITORIAL BOARD 



CHARLES W. STYRON, M.D. 
Raleigh, Chairman 

JOHN S. RHODES. M.D. 
Raleigh, Associate Editor 

ROSE PULLY, M.D. 
Kinston 



ROBERT W. PRICHARD, M.D. 
Winston-Salem 

LOUIS deS. SHAFFNER, M.D. 
Winston-Salem 

GEORGE JOHNSON, JR., M.D. 
Chapel Hill 



ROBERT E. WHALEN, M.D. 
Durham 



JOHN H. FELTS, M.D. 
Winston-Salem, Editor 



MR. WILLIAM N. HILLIARD 
Raleigh, Business Manager 



Volume 37 

January-December, 1976 



500 South Hawthorne Road 



EDITORIAL OFFICE 



Winston-Salem, N.C. 27103 



1821 North Boulevard 



Press of 

Edwards & Broughton Company 

P. O. Box 27286 



Raleigh, N.C. 27611 



December 1976, NCMJ 



685 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY 



January 1976, Vol. 37, No. 1 



NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: Management of Pulmonary Embolism, Francis Robicsek, M.D., Harry K. Daugherty, M.D., Donald C. 
Mullen, M.D., Norris B. Harbold, Jr., M.D., Donald G. Hall, M.D., and Robert D. Jackson, M.D.; Assets and Liabilities of 
Helicopter Evacuation in Support of Emergency Medical Services, H. J. Proctor, M.D., F.A,C.S., and Stephen A. Acai, Jr.; 
Anton Chekhov: A Physician-Genius in Spite of Himself, Part IV, Richard E. Cytowic. 



Il =^ 




BECOTIN® 

Vitamin B Complex 

BECOTIN With VITAMIN C 

Vitamin B Complex with Vitamin C 

BECOTIN ^-T 

Vitamin B Complex with Vitamin C, Therapeutic 

MI-CEBRIN® 

Vitamins-Minerals 

MI-CEBRIN T® 

Vitamin-Minerals Therapeutic 

AND A WIDE VARIETY OF OTHER PHARMACEUTICALS 




.pDISTA 


DISTA PRODUCTS COMPANY 1 
Division of Eli Lilly and Company ^| 
Indianapolis, Indiana 46206 H| 






400944 ^H 


U^^Hm^^H^^^^^^H 







1976 Leadership Conference 
January 30-31, 1976— Raleigh 



1976 ANNUAL SESSIONS 
May 6-9— Pinehurst 



Both often 




Predominant 
• psychoneurotic 
anxiety 



Associated 

• depressive 

symptoms 



Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints wliich are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adiunctively in skeletal mi'scle 
spasm due to reflex spasm to loca, pathol- 
ogy, spasticity caused by upper motor 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 
therapy). 

Contraindicated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



orders, possibility of increase in frequency 
and/ or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 




ond to (y^ 



According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feelings, part of the problem 
may sound like depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two. although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 




-".-.- »'--^'»^-*.fiKt*v^*J 



Wium(g 

(diazepam) ^ 

2-mg,5-mg, lO-mg scored tablets 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to tiabituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
skin rash, ataxia, constipation, headache, 
incontinence, changes In salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug. Iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 



Roche Laboratories 
■ Division of Hoftmann-La Roche Inc 
Nutley. New Jersey 07110 



TREATMENT AND LEARNING CENTER For 

ALCOHOL RELATED PROBLEMS 




I 






( 



FELLOWSHIP HALL 

THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit 
Tax-Exempt • A Controlled and Pleasant Psychological Atmosphere 

• Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



coi 






Member of: 

• The American Hospital Association 
• The N. C. Hospital Association 

• Accredited by the Joint Commission 

on the Accreditation of Hospitals 



Individual Counseling • Group Therapy 

Nature Trail • Indoor/Outdoor Recreation 

Relaxation and Sleep Therapy 

Audio-Video Therapy 






FOR ADMITTANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



FELLOWSHIP HALL 

p. 0. BOX 6929 • GREENSBORO, N. C. 27405 

Located off U.S. Hwy. No. 29 at Hicone Road Exit, 

6V2 miles north of downtown Greensboro, N. C. 

Convenient to 1-85, 1-40, U.S. 421, U.S. 220, 

and the Greensboro Regional Airport. 



INC. 



FOR MEDICAL INFORMATION CALL 

J. W. WELBORN, JR., M.D. 

MEDICAL DIRECTOR 

919-275-6328 





trc 



Facility, program and en- 
vironment allows the indi- 
vidual to maintain or re- 
gain respect and recover 
with dignity. 



Films, tapes, lectures, 
group discussions and in- 
dividual counseling are 
used with emphasis on 
reality therapy. 



Medical examination 
admission. 



Modern, motel-like accom- 
modations with private bath 
and individual temperature 
control. 



A therapeutic nature trail 
to encourage physical ex- 
ercise, and arouse objec- 
tive interest in the miracle 
of nature. 



FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 



Fewer than 200 doctors 
can become Navy 
physicians this year. 

Are you one of them? 



If you're interested in a practice that 
'lombines high-quality medicine with a 

unique life- 
style, Navy 
medicine 
could be right 
for you. You'll 
get the 
chance to 
practice med- 
icine instead 
of paperwork. 
Practice al- 
most anywhere 
in the world And earn between $30,000 
and $40,000 a year. 

Right now, the Navy needs General 
Medical officers, plus those specialties 
listed in the coupon. You may also receive 
training to become a Navy Flight Surgeon, 
Dr a specialist in Undersea Medicine. 




But the number of 
doctors needed is limit- 
ed. For more details, fill 
in and mail the 
coupon, or call collect 
919-872-2005, and ask 
for the Medical Re- 
cruiter, David L Powell. 

Out of statecall 

800-841-8000 




It pays to look into Navy Medicine. 



I Commanding Officer, Navy Recruiting District, Raleigh 
I Pinewood Building, P. 0. Box 18568 
1001 Navaho Drive, Raleigh, N. C. 27609 



(0M) 



I 



NAME 
STREET_ 



(Please Print or Type) 
CITY 



STATE_ 



_ZIP_ 



_PHONE_ 



MEDICAL SCHOOL 



(Area Code & No.) 



YEAR GRADUATED 



DATEOFBIRTH^ 



I AM INTERESTED IN (CHECK ONE): 




•Z FLIGHTSURGEON 
'Z UNDERSEA MEDICINE 
MY SPECIALTY (IF ANY) IS: 

D ANESTHESIOLOGY 
D FAMILY PRACTICE 
D PSYCHIATRY 
n INTERNAL MEDICINE 

I STATUS (CHECK ONE): 

Z: PRIVATE PRACTICE 
D HOSPITAL STAFF 



1 GENERAL MEDICAL OFFICER 
:: PRACTICING MY SPECIALTY 

: NEUROLOGY 
Z RADIOLOGY 
:: PATHOLOGY 
:: PEDIATRICS 

r INTERN 
i: RESIDENT 



John H. Felts, M.D. 
Winston-Salem 

EDITOR 

John S. Rhodes. M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Milliard 
Raleigh 

BUSINESS MANAGER 



NORTH CAROLINA 
MEDICAL JOURNAL 

Published Monthly as the Official Organ of 

The North Carolina 

Medical Society 



January 1976, Vol. 37, No. 1 



EDITORIAL BOARD 

Charles W. Styron, M.D. 

Raleigh ORIGINAL ARTICLES 

Management of Pulmonary Embolism 21 

George Johnson, Jr., M.D. Francis Robicsek, M.D., Harry K. Daugherty, M.D.. 

Chapel Hill Donald C. Mullen, M.D., Norris B. Harbold, Jr., M.D., 

Donald G. Hall. M.D., and Robert D. Jackson, M.D. 

Robert w Prichard. M.D. ^^^^j^ ^^j Liabilities of Helicopter Evacuation in Support of 

Wmston-Salem ,^ »« j- i c- • ic 

Emergency Medical Services 25 

Rose Pully M D H.J. Proctor, M.D., F.A.C.S., and Stephen A. Acai, Jr. 

Kinston Anton Chekhov: A Physician-Genius in Spite of Himself 

Part IV 29 

John S. Rhodes, M.D. Richard E. Cytowic 

Raleigh 

I c-u w »» T-, Editorial 

Louis Shaffner, M.D. 

Winston-Salem Suggestions for Authors 34 

Of Sex and Science 34 

Robert E. Whalen, M.D. 

Durham BULLETIN BOARD 

New Members of the State Society 35 

What? When? Where? 35 

Auxiliary to the North Carolina Medical Society 38 

News Notes from the University of North Carolina 

Division of Health Affairs 40 

News Notes from the Duke University Medical Center ... 42 
News Notes from the Bowman Gray School of Medicine of 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. \i; l r- . I I • •* AS 

HawlhorneRd.Wmslon-Saiem.N.C. 27103, isowned Wake FOreSt UulVCrSlty 45 

and published by The North Carolina Medical Society . . y— < n c t-»i - • a'^ 

under Ihe direction of Its Editorial Board. Copyright ■ AmCriCan College Ot PhySlCianS 47 

The North Carolina Medical Society IQTS. Address 

manuscripts and communications regarding editorial Disability Determination Under Social Security and the 

mattertothisWinslon-Salem address. Quesliom; relat- v , <-, i i r, • i ¥-. 

ing to subscription rales, advertising, etc . should be Ncw Supplemental Security Incomc Program — 

addressed to the Business Manager. Box 27167, ^^ j o- -i ■ ■ a'^ 

Raleigh, N C. 27611. All advertisemenis are accepted COUtraStS aUd Similarities 47 

subject to the approval Ota screening cymmilteeot the Wilov; VI Pn^art \A V\ 

state Medical Journal Advertising Bureau, 711 South WllCy IVl . V_OZ.dIl, IM . U . 

Blvd., Oak Park. Illinois 60302 and/or by a Committee \\j- . c- i ii i*u /-^ rt\ i ac\ 

oi the Editorial Board oi the North Carolina Medical Winston-Salcm Health Carc Plan, Inc 49 

Journal in respect to sTrtctly local advertising, instruc- 
tions to authors appear in Ihe January and July issues. 

Annual Subscription, S.'i. 00. .Single copies, $1,00. Hub- \/f/-,vi-rii iki \A/ a ci iiKi*---r/~,Ki <f\ 

lication office: Edwards & Broughlon Co., P,0, Box MONTH IN WASHINGTON ISU 

27286, Raleigh, N.C. 2761 I. Sfci>nd-cUis.\ posragt' paid 
at RciL'igh. North Camliiui 27611. 

In Memoriam 58 

Classified Ads 61 

Index to Advertisers 62 

Contents listed in Current Contents/Clinical Practice 





fTlondolo Center 



A fully accredited private multi-disciplin- 
ary psychiatric hospital, partial care and 
out-patient clinic for the acutely ill to the 
mildly distressed. Children, young people, 
adults, couples or entire families may enter 
the treatment programs. 

A modified form of the therapeutic com- 
munity, a full spectrum of treatment mo- 



dalities are used. The services consist of 
individual, couple, group and family psycho- 
therapies; sexual and marriage counseling; 
pastoral counseling; vocational guidance and 
rehabilitation; alcohol and drug counseling; 
psychological testing, chemotherapy, elec- 
trotherapy and other somatic therapy ser- 
vices. 




Blue Cross participating hospital 

JCAH Accredited 

Richard B. Boren, M.D. Glenn N. Burgess, M.D. 

Psychiatrist-in-Chief Psychiatry 

For information Call Collect (919) 724-9236 or Write: 
741 Highland Avenue • Winston-Salem, N. C. 27101 

Towards Wholeness 



North Carolina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy — 
75 percent — 25 percent Co-Insurance 



PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 
60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$205.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50.00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 
40-49 
50-59 
50-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age 60. 

"Integrates with Medicare at age 65. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus 50 cents. 



Term Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


655 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-59 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 

The above plans quality for use in the Professional Association. 



For Full Information — Write or Call 

Golc'en-Brabham Insurance Agency, Inc. 

Ralph J. Golden Van Brabham III 

108 E. Northwood St., Phone: BRoadway 5-3400, Box 6395, Greensboro, N. C. 27405 





Saint Albans 
Psychiatric Hospital 

Pi 



A fully accredited private 

psychiatric hospital for the 

treatment of all major 

psychiatric illnesses 

including alcoholism and 

drug abuse problems of 

adolescents and adults. 



Radford, Virginia 24141 
Telephone 703 639 2481 




! I 




Here's a North Carolina resource 
you can depend on. 

Name a more valuable asset than the health of the people. 

We can't. 

And we've spent over 40 years paying this state's health bills. 
Keeping up with the progress of medicine and helping to make its many 
benefits available to our subscribers. 

It's the reason we have 25 Blue Cross and Blue Shield offices across 
the state. To cover the health care needs of the more than 2 million 
people we serve. To stay constantly in touch with the 302 hospitals, 
nursing homes, home health agencies and 5,355 doctors our subscribers 
depend on. 

It's the reason we publish and distribute thousands of booklets on 
diet and exercise, immunization, alcoholism, stress and other health 
subjects. To encourage North Carolina people to take better care of 
their health. 

In these and many other ways your Blue Cross and Blue Shield Plan 
is constantly working to protect your health. When you're in the health 
business you have to be ahead of the times just to keep up. 

Your Blue Cross and Blue Shield Plan. A North Carolina resource you 
can depend on. 




Blue Cross 
Blue Shield 

of North Carolina 



ifiRegistered Marks Blue Cross Association ""'Regisleted Service Marks ol the National Association ol Blue Shield Plans 




'ound useful m the management of vertigo" associated v\ath 

^ases affecting the vestibular system. 

Can relieve nausea and vomiting often associated with vertigo" 

Jsual adult dosage for Antivert/25 for x'ertigo:" one tablet t.i.d. 

ilso available as Antivert (meclizine HCl) 12.5 mg. scored 

iets, for dosage convenience and flexibilit>^ 

\ntivert/25 (meclizine HCl) 25 mg. Chewable Tablets for 

isea. \'omiting and dizziness associated with motion sickness. 

•F SUMMARY OF PRESCRIBING INFORMATION 



NDICATIONS Based on a renew oi this drug hv the Naaonal Academy of 
liences — National Research Qiuncil and/or other mformanon, FDA has dasstfied 
e indications as follows: 

E//ecni't*: Management of nausea and \omidng and dizziness assoaated with 
ptton sickness. 

tPossihh Effective: Management of verngo assoaated with diseases affecting the 
stibular system- 
Final classificanon ot the less than eftecn\'e indications requires further 
vesttgation. 



Big Balanced Rock, Chincahua Mountains. Arizona (approx i. 000 tons) 

CONTRAINDICATIONS Adnunistrauon oi Anovert (meclizine HQ) during preg- 
nancy or to women who may become pregnant is contraindicated in \iew of the 
teratogenic effect of the drug in rats 

The adn-uni strati on of meclizine to pregnant rats during the 12-15 day of gestanon 
has prLxiucedcletc palate in the oftspnng Limited studies using doses of over 100 mg/ 
kg. /day in rabbits and 10 mg./kg./day in pigs and monkeys did not show cleft palate. 
Congeners of meclizine have caused cleft palate in species other than the rat. 

Meclizine HCl is contraindicated in indniduals who have shown a pre\ious h>per- 
sensia\at>' to it. 

WARNINGS Since drowsiness may, on occasion, occur with use oi this drug, patients 
should be warned of this possibility and cautioned against dn\ing a car or operating 
dangerous machinery. 

Usage in Children: Clinical studies establishing safety and effectiveness in children 
ha\'e not been done; therefore, usage is not recommended in the pediatric age group 

L'sa^L' inPrcgnancy: See "Contraindications" 
ADX'ERSE REACTIONS Drowsiness, dry mouth and, on rare txrcasions, blurred 
vision have been reported 

More detailed professional informanon a\'ailable on 
request 



ROeRIG 



Antivert/^25 

(meclizine HCl) 25 nig.Tablets 

for vertigo* 



A division of Pfizer Pharmaceuticals 
New York. New York 10017 



'4 



Documented bioavailability.. 
Regimen flexibility 

q.i.d. or q 6h immediately after or between meals 








E-Myciii 

erythromycin enteric -coated tablets, Upjohn 

250 mg 

Formulated for quality... 
Priced for economy. 



See facing page for brief summary of prescribing information. 



1 



[-lYCIN' TABLETS — 250 mg — For Oral Administration (ery- 
hirmycin enteric-coated tablets, Upjotin) 

:-|y'cin Tablets (erythromycin enteric-coated tablets) are spe- 
ijy coated to protect the contents from, the inactivating effects 
f astric acidity and to permit efficient absorption when ad- 
liistered either immediately after meals or when given be- 
7v;n meals o.n an empty stomach. 

11'cations: Streptococcus pyogenes (group A beta-hemolytic 
tiotococci): Upper and lower respiratory-tract, skin, and soft- 
SJe infections of mild to moderate severity. Parenteral benza- 
i,e penicillin G is considered by the American Heart Associa- 
te to be the drug of choice in the treatment and prevention 
f ;treptococcal pharyngitis and in long-terrii prophylaxis of 
hijmatic fever. When oral medication is necessary (because 
■> parenteral route is contraindicated) or if there is known 
|-gy to penicillin, the following recommendations made by 
II American Heart Association apply: 1) Oral penicillin G or V 
mere no allergy exists)— This Is the drug of choice. Give for 
. inimum of 10 days; 2) Erythromycin— Give for a minimum 
days. A few strains of streptococci resistant to erythro- 
n have been reported. 

<a-hemolytic streptococci (virdans group): Short-term pro- 
laxls against bacterial endocarditis prior to dental or other 
ative procedures in patients with a history of rheumatic 
!r or congenital heart disease who are hypersensitive to 
liclllin. (Erythromycin Is not suitable prior to genitourinary 
gery where the organisms likely to lead to bacteremia are 
Ti-negative bacilli or the enterococcus group of streptococci.) 
Dhylococcus aureus: Acute infections of skin and soft tissue 
nild to moderate severity. Resistance may develop during 
tment. 

lococcus pneumoniae: Upper respiratory-tract infections 
., otitis media, pharyngitis) and lower respiratory-tract in- 
ions (e.g., pneumonia) of mild to moderate degree. 
:oplasma pneumoniae (Eaton agent, PPLO): In the treatment 
jrimary atypical pneumonia, when due to this organism. 
oonema paliidum: Infections due to this organism. 



Corynebacterium dipiittieriae and Corynebacterium minutissi- 
mum: As an adjunct to antitoxin, to prevent establishment of 
carriers, and to eradicate the organism in carriers. In the treat- 
ment of erythrasma. 

Entamoeba liistolytica: In the treatment of Intestinal amebiasis 
only. Extra-enteric amebiasis requires treatment with other agents. 
Listeria monocytogenes: Infections due to this organism. 
Contraindication: Contraindicated in patients with known hyper- 
sensitivity to erythromycin. 

Warning: Safety for use in pregnancy has not been established. 
Precautions: Erythromycin is principally excreted by the liver. 
Caution should be exercised In administering the antibiotic to 
patients with Impaired hepatic function. Surgical procedures 
should be performed when indicated. 

Adverse reactions: The most frequent side effects of erythro- 
mycin preparations are gastrointestinal, such as abdominal 
cramping and discomfort, and are dose-related. Nausea, vomit- 
ing, and diarrhea occur infrequently with usual oral doses. 
During prolonged or repeated therapy, there is a possibility of 
overgrowth of non-susceptible bacteria or fungi. If such infec- 
tions occur, the drug should be discontinued and appropriate 
therapy instituted. Mild allergic reactions such as urticaria and 
other skin rashes have occurred. Serious allergic reactions, in- 
cluding anaphylaxis, have been reported. 

Treatment of overdosage: The drug is virtually nontoxic, though 
some individuals may exhibit gastric Intolerance to even thera- 
peutic amounts. Allergic reactions associated with acute over- 
dosage should be handled in the usual manner— that is, by the 
administration of adrenalin, corticosteroids, and antihistamines 
as indicated and the prompt elimination of unabsorbed drug, 
in addition to all needed supportive measures. 
How supplied: 250 mg— in bottles of 100 and in unit-dose pack- 
ages of 100 enteric-coated tablets. Caution: Federal law pro- 
hibits dispensing without prescription. 

For additional product information, consult the package insert 
or see your Upjohn Representative. 



'monstrated bioequivalence of E-Mycin taken immediately after meals or between meals. 




\ m 


3rcl 


Day 




\/\ 


A 


^ 


ffi 


V 


V ^ 


^ 


^f 


1 1 1 1 1 


1 ; 


1 1 ! 1 1 





J U \ I \ ! I I : ! ' : I I I I I 1 I I I I : ' I i i ! i i 

10 1112 13 14 15 16 17 18 19 20 2122 23 24 4849 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 
AA ▲▲ AA AA aA AA 

A A 



67 68 69 70 7172 



Time After Administration of First Dose (flours) 

Regimen A (after meals)— One 250 mg E-Mycin® tablet admin- 
istered q.i.d. Immediately after breakfast, lunch, and dinner, 
and at bedtime with a snack. 

!■ Regimen B (between meals)— One 250 mg E-Mycin tablet 
administered q 5h at least two hours after meals. 

) statistically significant difference in area under 
e curve was observed from 0-24 hours or 48-72 
jurs at the 95% confidence level (p>.05). 

,ie data clearly demonstrate that E-Mycin, when 
Iministered q.i.d. immediately after meals, pro- 
iced average serum levels equivalent to those 
itained when the drug was administered q 6h at 
ast two hours after meals. 



Lq.i.d. Drug/Food 



q 6h Drug 



E-Mycin Study CS076 on file at The Upjohn Company. The study 
was performed with twenty-two normal male adult volunteers 
utilizing a randomized two-way complete crossover design. 



E-Mycin 

erythromycin enteric-coated tablets, Upjohn 

250 mg 

Formulated for quality . . . priced for economy 



Tfie Upjohn Company, Kalamazoo, Micfiigan 49001, U.S.A. 
.1975 Ttie Upjofin Company mcd b ? ^. 



Should a 
specially prepared 
pacmge insert 
be made available to 
patiertts? 




Dr. Alexander M. Schmidt 
Commissioner, 
Food and Drug 
Administration 



Dr. James H. Sammons 

Executive Vice President 

of the American 

Medical Association 






alo^e 



I3li 
XII 
1> 

■he 
jfir 

ion. 



teoi 




The idea of a so-called patie* 
package insert has been around for 
a long time. Many physicians already 
use written instruction sheets to 
provide patients with information 
about the drugs they are taking. And 
some physicians give verbal instruc- 
tions; but in too many instances 
these are what I call eye-glazing ex- 
ercises. I have seen patients sit with 
glazed eyes listening to a rapid-fire 
lecture by a hurried physician who 
has 20 people out in his waiting 
room. These patients aren't given 
sufficient understanding and there- 
fore do not follow instructions. Sol 
think the idea of an official package 
insert for patients is a good one. 
Perhaps we should really think of 
this kind of information simply as ar 
extension of drug labeling. 

The benefits of patient involvement i '1^ 

Many physicians may not real- -'3' 
ize how frequently a patient obtains 
his drug information from Aunt l^- 
Tillie or the next door neighbor. Andp' 
this information is almost always p 
bad or irrelevant to the case at hand ■- 
Furthermore, the incentive to go ~; 
along with a prescribed program is "'^ 
slim if the only reading matter the ^P 
patient receives, along with his pre-' 'i'' 
scription, is a bill. * 

As an educator I am impressec' "'"' 
by the principle that the best way to: *' 
get someone to do something is to -' 
involve him in the process. So the ''^'• 



I think there are advantages asl' 
well as some real disadvantages in fl' 
a patient package insert. When you 
begin to use semi-medical or medi-iiil 
cal terms to describe complications' * 
or possible sequelae of disease or sk 
treatment, you may frighten the pa-' ml 
tient— particularly since the more w 
highly sophisticated patient is not ;ii 
the one who is going to read the in- ■ neii 
serf. The patient who will read it is 
the one most susceptible to fright hii 
and confusion by the language. xk 

On the positive side, a packagfH 
insert will probably give the patient ja 
better insight into why he is being ptit 
treated the way he is, and it may J* 
give the physician a little bit more ijw, 
time. But it does not remove from J 
the physician the need or obligatiorj* 
to explain the insert. ^ ''I" 



Some pitfalls in the inclusion of 
side effects 

Certainly a patient should be 
warned of the possibility of serious 
side reactions— to know what the 
real dangers are. But it doesn't do a 
bit of good to indicate that a patient 
on oral penicillin may develop a 
rash, itching, or a drop in blood 
pressure. Or that he may faint. I 
think the real danger is that fright 
engendered by the insert may poS' 
sibly outweigh the potential good. 



cook 



::C'- 



H* 



ain purpose of drug information 
rthe patient is to get tiiscoopera- 
bn in followinga drug regimen. 

reparation and distribution of 
jtient drug information 

We would hope to amass infor- 
lation from physicians, medical 
icieties, the pharmaceutical indus- 
yand centersof medical learning. 
16 ultimate responsibility for uni- 
irm labeling must, however, rest 
ith the Food and Drug Administra- 
an. There is nothing wrong with 
lis agency saying, "this informa- 
Dn is generally agreed upon and 
lerefore it should be used," as long 
; our process for getting the infor- 
liation is sound. 

Distribution of the information 
a problem. In great measure it 
ould depend on the medication in 
jestion. For example, in the case 
fan injectable long-acting proges- 
rone, we would thinl< it mandatory 
j) issue two separate leaflets— a 
lort one for the patient to read be- 
)re getting the first shot and a long 
ne to tal<;e home in order to mal<e a 
ecision about continuing therapy. 
[1 this case, the information might 
e put directly on the package and 
|ot removable at all. But for a medi- 
lation lil<e an antihistamine this 
hformation might be issued sepa- 
3tely, thus giving the physician the 
ption of distribution. This could 
reserve the placebo use, etc. 



It is in the distribution of pa- 
tient information that the pharma- 
cist may get involved. As profession- 
als and members of the health-care 
team and asa most important source 
of drug information to patients, 
pharmacists should be responsible 
for l<eeping medical and drug rec- 
ordson patients. It isalso logical 
that they should distribute drug in- 
formation to them. 

Realistic problems must be 
considered 

We have to expect that the in- 
troduction of an information device 
will also create new problems. First, 
how can we communicate complex 
and sophisticated information to 
people of widely divergent socio- 
economic and ethnic groups? Sec- 
ond, what will we say? And third, 
how can we counteract the negative 
attitude of many physicians toward 
anyoutside influenceor input? Hope- 
fully the medical profession will re- 
spond by anticipating the problems 
and helping to solve them. Assum- 
ing we can also solve the difficulty 
of communicating information to di- 
verse groups throughout the United 
States, our remaining tasl< will be 
the inclusion of appropriate material. 

What information is appropriate? 

In my opinion, technical, chem- 
ical and such types of material 
should not be included. And there is 



no point in the routine listing of side 
effects like nausea and vomiting 
which seem to apply to practically 
all drugs, unless it is common with 
the drug. However, serious side ef- 
fects should be listed, as should in- 
formation about a medication that 
is potentially risky for other reasons. 

Other pertinent information 
might consist of drug interactions, 
the need for laboratory follow-up, 
and special storage requirements. 
What we want to include is informa- 
tion that will help increase patient 
compliance with the therapy. 

Positive aspects of patient drug 
information 

Labeling medication for the 
patient would accomplish a number 
of good things: the patient could be 
on the lookout for possible serious 
side effects; his compliance would 
increase through greater under- 
standing; the pnysician would be a 
better source of information since 
he would be freer to use his time 
more effectively; other members of 
the health-care team would benefit 
through patient understanding and 
cooperation; and, finally, the physi- 
cian-patient relationship would prob- 
ably be enhanced by the greater 
understanding on the part of the pa- 
tient of what the physician is doing 
for him. 



/nly the doctor can remove that fear 
y 20 or 30 minutes of conversation. 

I'm not suggesting that we 
'ithhold any information from the 
atient because, first of all, it would 
e totally dishonest and secondly, it 
'ould defeat the very purpose of the 
psert. I do think that a patient on the 
irth control pill should know about 
he incidence of phlebothrombosis. 

If you're going to tell a patient 
he incidence of serious adverse re- 
ctions, then you have to tell him 
(lata concerned medical decision 
/as made to use a particular medi- 
ation in his situation after careful 
;onsideration of the incidence of 
complications or side effects. 

imotionally unstable patients pose 
I special problem 

There are patients who, be- 
:ause of severe emotional problems, 
;ould not handle the information 
;ontained in a patient package in- 
sert. Yet if we are going to have a 
package insert at all, we just can't 
nave two inserts. I think we might 
;imply have to tell the families of 
hese patients to remove the insert 
rom the package. 

Legal implications of the patient 
oackage insert 

Just what effect would a pa- 



tient package insert have on mal- 
practice? We could try to avoid any 
legal implications by pointing out 
that the physician has selected a 
particular medication because, in 
his professional judgment, it is the 
treatment of choice. For instance, 
you can't tell everyonetaking anti- 
histamines not to work just because 
a few patients develop extreme 
drowsiness which can lead to acci- 
dents. And what about the very small 
incidence of aplastic anemia rarely 
associated with chloramphenicol? 
If, based on sensitivity studies and 
other criteria, we decide to employ 
this particular antibiotic, we do so 
in full knowledge of this serious po- 
tential side effect. It's not a simple 
problem. 

How do we handle an insert for medi- 
cation used for a placebo effect? 

With rare exceptions, physi- 
cians no longer use medications for 
a placebo effect. This question does 
raise the issue of how a patient may 
react to receiving a medication 
without a package insert. 

Preparation of the package insert 

The development of the insert 
ought to be a joint operation be- 
tween physicians, the pharmaceuti- 
cal industry, the A.M. A. and the F.D. A. 



I view the A.IVI.A.'s role as a co- 
ordinator or catalyst. It is the only 
organization through which the pro- 
fession as a whole, irrespective of 
specialty, can speak. It has relatively 
instant access to all the medical ex- 
pertise in this country. And it can 
bring that professional expertise to- 
gether to ensure a better package 
insert. The A.M. A. can work in con- 
junction with the industry that has 
produced the product and which is 
ultimately going to supply the insert. 

I don't think we should rely, or 
expect to rely, on legislative com- 
mittees and their nonprofessional 
staffs to make these decisions when 
it is perfectly within the power of 
the two groups to resolve the issues 
in the very best American tradition— 
without the government forcing us 
to do it. I think the F.D. A. has to be 
involved, but I'd like them to become 
involved because they were asked 
to become involved. 



Pharmaceutical 
Manufacturers Association 
1155 Fifteenth Street, N.W. 
Washington, D.C. 20005 




There's something special about children vomitiiii 



■"^ *fc 



The risk of dehydration . . . plus the psychological f' 
stress on both mother and child . . . 
greatly increases the urgency in controlling vomitinfi' 
in children. In addition, there is, of course, need to 
avoid the extrapyramidal problems associated with . 
phenothiazine medications. 



' -i..^.- 



'% 



//7y^-s ^ 






/■ V ^ 



■^ -^ 



?v 



In 



\ 




■ ,s--:~sPi^0m 





fat's why special medication is preferred 



fS® CHILDREN SUPPRETTES™ are specially 
ilated to stop vomiting and nausea in children - 
oily and with minimal complications. 

\\NS are administered rectally— often the best 
Lit in the vomiting patient. 

Fe exclusive WANS formula provides both 
'iimine maleate and sodium pentobarbital for 
e iveness . . . contains no phenothiazines or local 
fihetics. 

Fe unique Supprette delivery system rapidly 
ieses effective levels of medication . . . with no 
3 r fatty acids to affect absorption or cause local 
ittion. 

\^\NS SUPPRETTES require no refrigeration . . . 
Ibrication other than water . . . and dissolve 
"E'letely, with virtually no leakage. 

'or children over 12 years of age and adults 
%ingfrom nausea and vomiting, consider higher- 
th WANS® No. 1 or WANS® No. 2. 



A special favorite*of 
North Carolina physicians 
in controlling 
childhood vomiting 



WANS 




CHILDREN 

SUPPRETTES™ 

rectal antinauseant/antiemetic 

pynlamine maleate 25 nig; sodium pentobarbital 30 mg 
Warning: may be habit forming 

*Based on usage by dosage form: data gathered by independent research 
organization. 



■RIPTION: WANS" ChildieMi: (Blue) pyrilaniine maleate 
=; and peiilobarbiral sodium* Yz gr (30 mg) scored for 
sage. WANS" No. 1: (Piuk) pyrilamine maleate 50 mg 
entobarbital sodium* V, gr (fiO mg) .scored for 1/2 dosage. 
IS" No. 2; (Yellow) pyrilamine maleate 50 mg and 
'barbital sodium* I'/i gr (100 mg) scored for 'A dosage. 

KNING: may be habit forming. 

TRAINDICATIONS: Infants under 6 months. Acute 
nitlenl porphyria, known hypersensitivity to barbiturates 
lihistamines. known j^revious barbiturate addiction, 
e hepatic imi)airment. CNS injury, senility, and presence 
;controlled pain. 

JNINGS: Barbiturates may be habit forming. Pre-existing 
lologic disturbances may be aggravated. Idiosyncratic 
ions may occur. Acquired sensitivity may result in allergic 
lions. Safety in pregnancy has not been established. 



."AUTI()NS: lJ.se cauliously with other sedative, hypnotic 
rcolic agents. Use with caution in patients with acute or 
lie hepatic dise.ise. fever, hyperthyroidism, diabetes 
lu.s. .severe anemia, congestive heart failure, or a history 
iig deiH'iidence or suicidal tendencies. May impair 



ADVEF^SE REACTIONS: Drowsiness, fatigue, vertigo, 
incoordination, tremor, muscle weakness, ataxia, hypotension, 
respiratory depression, delirium and coma. Dryness of nose, 
mouth, and throat, pupillary dilatation or blurred vision, urinary 
retention, abdominal pain, nausea, vomiting, diarrhea, and 
hypersensitivity reactions. Overdose may result in hallucina- 
tions, excitement, ataxia, incoordination, athetosis, convulsions, 
and death. .■-■«^^. 

DOSAGE AND ADMINISTRATION: Rectally, children 2-12 
years of age. one WANS" CHILDREN every (>8 hours as 
required. Children under 2 years of age may receive Vi 
the above dosage. Adults: Rectally, one WANS" No.l Supprette' 
to inhibit mild nausea and/or vomiting; one WANS* No. 2 
Supprette to control pernicious vomiting. Repeat doses for 
adults should be A to 6 hours apart, not to exceed four doses in 
24 hours. Moisten finger and Supprette with water before 
inserting. Optimum dosage must be deteiiiiined in each case by 
the clinical response. 



WEBCON 



Webcon Pharmaceutical Division 
' Alcon Laboratories, Inc. 
Fori Worth. Texas 7(il01 



Officers 
1974-1975 



NORTH CAROLINA MEDICAL 
SOCIETY 



President James E. Davis. M.D. 

1200 Broad St., Durham 27705 

President-Elcct Jesse Caldwell. Jr., M.D. 

1 14 W. 3rd Ave.. Gastonia 280.S2 

Fir.sl Vice-President John L. McCain, M.D. 

Wilson Clinic, Wilson 27893 

Second Vice-President T. Reginald Harris, M.D, 

808 N. DeKalb St.. Shelby 28150 

Secretary E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Durham 27710 (1976) 

Speaker Chalmers R. Carr, M.D. 

1822 Brunswick Ave., Charlotte 28207 

\'ice-Spcaker Henry J. Carr. Jr., M.D. 

603 Beamon St., Clinton 28328 

Pasi-Prcsident Frank R. Reynolds. M.D. 

1613 Dock St., Wilmington 28401 

Executive Director William N. Hilliard 

222 N. Person St., Raleigh 2761 1 

Councilors and Vice-Councilors 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor Joseph A. Gill, M.D. 

1202 Carolina Ave., Elizabeth City 27909 (1977) 

Second District J. Ben.iamin Warren, M.D. 

Box 1465. New Bern 28560 (1976) 

Vice-Councilor Charles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1976) 

Third District E. Thomas Marshburn, Jr., M.D. 

1515 Doctors Circle, Wilmington 28401 ( 1976) 

Vice-Councilor Edward L. Boyette, M.D. 

Chinquapin 28521 (1976) 

Fourth District Harry H. Weathers, M.D. 

Central Medical Clinic, Roanoke Rapids 27870 (1977) 

\'ice-Councilor ...Robert H. Shackleford, M.D. 

115 W. Main St.. Mt. Olive 28365 (1977) 

Fifth District August M. Oelrich, M.D. 

Box 1169, Sanford 27330 (1978) 

\' ice-Councilor Bruce B. Blackmon, M.D. 

P. O. Box 8, Buies Creek 27506 (1978) 

Sixth District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd., Chapel Hill 27514 (1977) 

\' ice-Councilor W. Beverly Tucker, M.D. 

Box 988, Henderson 27536 (1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Road, Charlotte 28207 (1978) 

Vice-Councilor J. Dewey Dorsett, Jr. 

1851 E. Third St., Charlotte 28204 ( 1 978 ) 

Eighth District ERNEST B. Spangler, M.D. 

Drawer X3, Greensboro 27402 (1976) 

Vice-Councilor James F. Reinhardt, M.D. 

Cone Hospital, Greensboro 27402 (1976) 

Ninth District _ Verne H. Blackwelder, M.D. 

Box 1470, Lenoir 28645 (1976) 

Vice-Councilor Jack C. Evans, M.D. 

244 Fairview Dr., Lexington 27292 (1976) 

Tenth District Kenneth E. Cosgrove, M.D. 

510 7th Ave., W.. Hendersonville 28739 (1978) 

Vice-Councilor Otis B. Michael, M.D. 

Suite 208, Doctors Bldg., Asheville 28801 ( 1978) 

16 



Section Chairmen — 1975-76 

Anesthesiology Jack H. Welch, M.D. 

Physicians Quadrangle, Greenville 27834 

Dermatologv George W. Crane, Jr., M.D. 

1200 Broad St., Durham 27705 

Familv Physicians William W. Hedrick, M.D. 

331 1 N. Boulevard, Raleigh 27604 

Internal Medicine James H. Black, M.D. 

1351 Durwood Dr., Charlotte 28204 

N'curoloq\ & Psvchiatrv Hervy W. Mead, M.D. 

1900 Randolph Rd., Suite 900, Charlotte 28207 

Neurological Surgery M. Stephen Mahaley, Jr., M.D. 

3940 Nottaway Rd., Durham 27707 

Obstetrics & Gynecology C. T. Daniel, Jr., M.D. 

1641 Owen Dr., Fayetteville 28304 

Ophthalmology E. R. Wilkerson, Jr., M.D. 

1012 Kings Drive, Charlotte 28207 

Orthopaedics Frank C. Wilson. M.D. 

N. C. Memorial Hospital, Chapel Hill 27514 

OiolarvnQolosx N. L. Sparrow, M.D. 

3614 Haworth Dr., Raleigh 27609 

Pathology R. Page Hudson, M.D. 

P. O. Box 2488, Chapel Hill 27514 

Pediatrics Gerard Marder, M.D. 

224 New Hope Rd., Gastonia 28052 

Public Health & Education J. N. MacCormack, M.D. 

Box 2091, Raleigh 27602 

Radioloqy R. W. McConnell, M.D. 

1711 W. 6th Street, Greenville 27834 

Surgery Robert C. Moffatt, M.D. 

309 Doctors Bldg., Asheville 28801 

Urology Robert Dale Ensor, M.D. 

1333 Romany Road, Charlotte 28204 
Students. Medical 

Delegates to the .'Vmerican Medical Association 

James E. Davis. M.D 1200 Broad St., Durham 27705 

(December 31, 1976) 
John Glasson. M.D 306 S. Gregson St.. Durham 27701 

(December 31, 1976) 
David G. Welton, M.D. 

3535 Randolph Road. Charlotte 28211 

(December 31. 1977) 
Edgar T. Beddingmeld, Jr., M.D. 

Wilson Clinic. Wilson 27893 

(December 31, 1977) 

Alternates to the American Medical Association 

George G. Gilbert, M.D. 

1 Doctor's Park, Asheville 28801 
(December 31, 1976) 

Louis deS. Shaffner. M.D. 

Bowman Gray, Winston-Salem 27103 
(December 31, 1976) 

Charles W. Styron, M.D. 

615 St. Marys St., Raleigh 27605 
(December 31, 1977) 
D E. Ward, Jr., M.D.. . 2604 N. Elm St., Lumberton 28358 
(December 31, 1977) 

Vol. 37, No. 



NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 

Now Pays Up To 

WEEKLY INCOME 
($2^66.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 




GUARANTEED RENEWABLE 



You are guaranteed the privi- 
lege of renewing $300-week to 
age 70. The other $200 per week 
renewable to age 60. This is an 
exclusive and most important 
feature. 



DIRECT PERSONAL SERVICE 

Since 1939, it has been our 
privilege to administer your pro- 
gram from Durham, N. C. includ- 
ing payment of all claims! 



J. L. & J. SLADE CRUMPTON, INC. 

GENE GREER 
Office Manager 

'. 0. Drawer 1 767— Durliani. N. C. 27702. Telephone: 919 682-5497 
Underwritten by The Continental Insurance Cos. of New York 

JACK FEATHERSTON, Field Representative 

P. 0. Box 17824. Charlotte. N. C. 28211. Telephone: 704 366-9359 

North Carolina F'rofessional Group Administiators for: 

NORTH CAROLINA MEDICAL SOCIETY • NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI- 
NEERS ■ NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A.'S AND BAR GROUPS 




Even Chicago Stadium 
couldn't hold all 
the physicians the AMA 
helped put through school. 




Every year, thousands of young men and women struggle 
to scrape up the funds to pay for their medical educa- 
tion and training. Many, though highly qualified, simply 
can't swing it alone. 

Where can they turn for financial assistance? One 
important source is the American Medical Association 
Education and Research Foundation (ERF). It was set 
up in 1962 to help just such qualified individuals 
complete their training. 

Through its Loan Guarantee Program, AMA-ERF 
has arranged for over $57 million in loans to more 
than 26,000 medical students, interns and residents 
in the last 1 1 years. 

Physicians often ask what the AMA really does. 
Helping to increase the number of doctors is just one 
of many things. Find out more about the AMA, how 
it serves the profession, how it serves the public. 
Just send us the completed coupon. 



Join us. 

We can do much more together. 

Dept. DW 

Amencan Medical Association 
535 N. Dearborn St. 
Chicago, 111. 60610 

Please send me more information on 
the AMA and AMA membership. 

Name 



Address - 




City/State/Zip- 




It's what you do. It's what you are. It's 
what you, as a physician, strive to 
give every patient. In every way. 

Sometimes, a patient's needs 
require specialized help. When the 
need arises. Tidewater Psychiatric 
Institute stands ready to augment 
your care. 

AtTPI, help takes many forms, 
through a comprehensive program of 
patient-oriented diagnostic, con- 
sultative and psychiatric treatment 
services within a therapeutic setting. 
Individually designed treatment 
programs meet the particular needs 
of both adult and adolescent patients. 
Our hospital's school allows adoles- 
cents to continue their education 
while at TPI. A special program 
exists forthe detoxification and 
rehabilitation of the individual with 
alcohol or drug-related problems. 

You are invited to investigate 
personally, by telephone orthrough 




correspondence, the avenues of 
specialized help available to your 
patient at ourfacilities in Norfolk and 
Virginia Beach. 



tali 



TIDEWATER 
PSYCHIATRIC INSTITUTE 



1701 Will-0-Wisp Dr., Va. Beach, Va. 23454 
CALL COLLECT (804) 481-1211 
1005 Hampton Blvd., Norfolk, Va. 23507 
CALL COLLECT (804) 622-2341 



Accredited by The Joint Commission on the Accreditation of Hospitals. 
Approved for Blue Cross, Champus, [Medicare and other health coverage. 







if%^ 




Entrapped gas. 



Silent ^ 
partner of 

GI spasm 

Painful GI spasm in the presence of entrapped 
gas causes even more pain and more discomfort. Yet, 
while spasm is relieved, entrapped gas often goes 
untreated. 

Not so when you prescribe Sidonna. Sidonna 
helps release entrapped gas with specially activated 
simethicone, a nonsystemic antiflatulent, while also 
helping to relieve spasm with a traditional combina- 
tion of belladonna alkaloids. And Sidonna provides 
mild sedation with butabarbital. 

Sidonna. The therapeutic partnership approach 
to functional or organic GI disturbances including 
spastic colon, irritable bowel syndrome, gastroenteri- 
tis, gastritis, peptic ulcer and nervous indigestion. 

Contraindications : hypersensitivity to barbiturates or bella- 
donna alkaloids; plaucoma, prostatic hy'pertrophy. pyloric 
obstruction. SUlv Kffrcts: dry mouth, blurred vision, dysuria, 
skin rash, constipation or drowsiness. Dosage: one or two tablets 
preferably before meals and at bedtime. 

Reed & Carnrick/Kenilworth, N.J. 07033 ^ 

Sidonna 

Each scored tablet contains: specially activated simethicone 

25 mg., hyoscyamine sulfate 0.1037 mg., atropine sulfate 

0.0194 mg., hyoscine hydrobromide 0.0065 mg. (equivalent to 

belladonna alkaloids [as bases] 0.1049 mg. ) and butabarbital 

sodium N.F. 16 mg. (Warning: may be habit forming.) 

A working partnership 

against the 
pain of gas and spasm 



I 



Management of Pulmonary Embolism 



Francis Robicsek, M.D., Harry K. Daugherty, M.D., 

Donald C. Mullen, M.D., Norris B. Harbold, Jr., M.D., 

Donald G. Hall, M.D., and Robert D. Jackson, M.D. 



'T has been estimated that half a 
. milhon patients suffer pulmo- 
ary emboHzation every year and 
40,000 die as a consequence of 
heirdisease.' That these figures are 
onsiderably higher than those pre- 
iousiy reported indicates two 
hings: (1) the medical profession is 
ncreasingly aware of this problem. 
nd (2) the introduction of pulmo- 
lary angiography and pulmonary 
canning shed the light of accurate 
iagnosis on cases previously un- 
ecognized. 

While most physicians have re- 
;arded this disease, which often oc- 
curs as a dreaded complication of an 
therwise successful surgical pro- 
edure. with a somewhat fatalis- 
ic attitude, some have recom- 
nended preventive measures. 
Veight reduction before elective 
urgery. elevation of the lower 
imbs. galvanic stimulation of the 
j:alf muscles during the operation. 
farly postoperative mobilization 
|ind pharmacological treatment 
ave been advocated to reduce the 
hances of phlebothrombosis and 
onsequential pulmonary em- 
x)lism. Unfortunately, these mea- 
;ures have been only partially suc- 
essful. Pulmonary embolism still 



From ihe Depanmeni ot Thoracic and Cardiovascular 
.•)urger\ . Charlotte Mc-monal Hospital. Charlotte. Nonh 
Carohna, 28201 

Repntll requests to Dr Robicsek 



occurs in a significant number of pa- 
tients and treatment is hindered by a 
number of persisting problems. 

PATHOPHYSIOLOGY NOT 
UNDERSTOOD 

The first such problem is that 
even after a century of experimental 
and clinical research, the patho- 
physiology of pulmonary embolism 
is not completely understood.^ Con- 
troversy continues between propo- 
nents of mechanical blockade and 
proponents of humoral and retlex 
vasoconstriction. Almost every 
year, theories emphasizing the role 
of histamine, serotonine and other 
bioactive substances are set forth, 
only to be questioned and later dis- 
proved. The situation is further 
obscured by the great diversity with 
which different patients react to dif- 
ferent embolic insults to the lung. 
Some reactions are but mildly 
symptomatic of massive emboli 
while others bring about a deep 
shock following occlusion of secon- 
dary branches. The fact that some 
embolic occlusions result in infarc- 
tions and others do not remains an 
enigma. Although research has shed 
considerable light on the impact of 
pulmonary embolism on the heart, 
particularly the right ventricle and 
its prognostical significance of pul- 
monary embolism, it has left un- 
touched our ignorance about the ef- 



;Ia.nl.\rv 1976, NCMJ 



fects of pulmonary embolism on the 
coronary circulation and the in- 
tramyocardial distribution of blood 
flow. 

UNDER-DIAGNOSIS 

The second problem is under- 
diagnosis. Even in institutional care 
of patients, a large number of pul- 
monary emboli — probably the 
majority of them — go undetected. It 
is evident that the disease must be 
suspected more frequently.^ 

The main reason for under- 
diagnosis is the non-specificity of 
the clinical picture in both small and 
massive pulmonary embolism. Clin- 
ical evidence of thrombophlebitis is 
present in only a third of the patients 
with manifest pulmonary embolism. 
When the emboli are small enough 
to reach the periphery of the lung, 
the patient usually presents himself 
with pleuritic pain and friction rub, 
and later with occasional hemopty- 
sis and, in about half of the cases, 
with consolidation of the infarcted 
area and pleural effusion. Involve- 
ment of secondary major branches 
usually leads to tachypnea, rales, 
tachycardia, fever and loud pulmo- 
nary second sound. If the pulmo- 
nary embolus is massive, it is usu- 
ally associated with shock, severe 
dyspnea and dull mid-chest pain, 
greatly accentuated P2 and the de- 
velopment of S3 or Sj gallop sounds. 



21 



While the development of the com- 
bination of these symptoms may be 
characteristic of pulmonary em- 
bolism, they also may mimic other 
life-threatening conditions, primar- 
ily myocardial infarction. 

The other reason for under- 
diagnosing pulmonary embolism is 
the continuing lack of specific 
laboratory tests. Enzyme studies, 
once promising, have not proved to 
be specific. The only way to avoid 
the serious, sometimes deadly mis- 
take of under-diagnosis of pulmo- 
nary embolization is to consider it a 
possibility in every challenging 
diagnostic situation, especially if 
the patient has symptoms of phle- 
bothrombosis, heart failure, is on 
bed-rest or has recently undergone 
surgery. The old 19th Century med- 
ical saying should be rephrased 
from "If it is young, and the 
symptoms don't make sense, think 
of tuberculosis"' to "If it is lung, and 
the symptoms don't make sense. 
think of pulmonary embolism." 

OVER-DIAGNOSIS 

It should also be mentioned, how- 
ever, that some physicians, trying 
to avoid the sandtrap of under- 
diagnosing, have fallen into the trap 
of over-diagnosing. We can recall 
several instances in which patients 
with nondescript chest pain, cor 
pulmonale or even a simple nose- 
bleed have been diagnosed as 
having pulmonary emboli, been 
placed on anticoagulants or. worse, 
have had their cava ligated. 

ASSESSMENT OF DIAGNOSTIC 
TESTS 

Closely associated with the prob- 
lem of under- and over-emphasis is 
the problem of proper assessment of 
diagnostic tests. 

Enzyme studies 

The unreliability of enzyme 
studies has already been men- 
tioned. While the lactic acid dehy- 
drogenase (LDH) is elevated in 
50-70% of the cases, the glutamic 
oxalacetic transaminase (GOT) 
shows an abnormally high value 
only in 20-30% and creatinine phos- 
phokinase only in 1-'^%. The triad 
thought to be typical of pulmonary 
embolism, namely elevated LDH, 



22 



normal GOT and elevated bilirubin, 
occurs only in 10-15% of patients 
with pulmonary emboli. 

Arterial oxygen tension measure- 
ments 

Recent studies contribute path- 
ognostic significance to arterial 
oxygen tension measurements. It 
has been found that in most patients 
with significant pulmonary emboli, 
the oxygen tension of the arterial 
blood was below 80; only in 11.5% 
was it above 80 and particularly 
never above 90 mmHg. This test, 
however, also lacks specificity be- 
cause in other shock-stages, such as 
in massive myocardial infarction, 
low oxygen tensions are also com- 
mon.^ 

Radiogram of the chest 

While these biochemical tests 
have been downgraded, the conven- 
tional radiogram of the chest has 
gained value. This, however, can be 
appreciated only in institutions 
where there is a close exchange of 
clinical information between the 
physician in charge of the patient 
and an experienced radiologist 
aware that pulmonary embolization 
may lurk in the background of the 
clinical picture. According to the 
National Heart and Lung Institute 
trial study, the two most common 
features on the radiogram are high 
diaphragm on the embolized side 
and pulmonary consolidation. It has 
to be noted, however, that this 
study included only patients with 
large pulmonary emboli and high 
diaphragm and pulmonary consoli- 
dation, together with pleural effu- 
sion usually signified either as a well 
developed infarction or infarction in 
progress. Other x-ray signs which 
may call attention to the presence of 
a massive pulmonary embolus are: 
dilatation of the pulmonary artery, 
or to the contrary an abnormally 
small hilus. hypovascularity. cutoff 
of the peripheral vessels and secon- 
dary cardiac enlargement.'^ 

Electrocardiogram 

The value of the electrocardio- 
gram has been a controversial issue. 
Both left and right ventricular 
changes have been described, and 
the electrocardiographic picture of 



pulmonary embolism may be con- 
fused with those of myocardial in- 
farction. The typical EKG picture 
of an acute cor pulmonale occurs in 
only 31% of the patients and only if 
about 60% of the pulmonary arterial 
tree is obstructed. The recent con- 
sensus on EKG appears to be that it 
is a very sensitive test in pulmonary 
embolism but it is not very specific. 
Its main value lies not so much in 
the verification of pulmonary em- j 
bolization but rather in its distinc- | 
tion of a massive myocardial infarc- 
tion. I 

Other diagnostic tests 

There are a number of diagnostic i 
tests which are not aimed to dem- i| 
onstrate the presence of blood clots ' 
in the pulmonary vasculature but to j 
establish the clinical diagnosis of 
phlebothrombosis of the lower ex- 
tremities: radioactive fibrinogen 
test, impedance phlebography, 
Doppler ultrasound and contrast 
phlebography. The diagnostic yield 
of these tests could be quite high in 
experienced hands. Naturally, be- 
cause of the close association be- 
tween deep vein thrombosis and 
pulmonary embolism, if the pres- 
ence of phlebothrombosis is proven 
in a patient suspected of pulmonary 
embolism, the likelihood of the lat- 
ter is quite convincing. 

While the diagnostic studies here- 
tofore listed are largely nonspecific, 
there are two tests which are con- 
sidered to be virtually specific in the 
diagnosis of pulmonary embolism: 
perfusion lung-scanning and pul- 
monary angiography. 






Bll 



\P 



Lung-scanning j 

It is generally recognized that if a' 
patient has a strong possibility of 
pulmonary embolism, multiple- 
view lung-scanning should be per- 
formed immediately. This examina- 
tion provides useful information on 
both the regional and quantitative 
pulmonary flow. It is simple and 
safe, even for patients in poor gen- 
eral condition. Most isotopic 
studies use iodine-131 tagged alba 
min macroaggregates or micro- 
spheres of albumin tagged witli 
technetium. On the scanogram per- 
fusion deficits are clearly outlined^ 
and pulmonary emboli of mod 



1^) 

St 

el 

iiit 

hie 



ft 
it 

to 

itSt 



ills 



Vol. 37. No. 1 



II 



erate-to-large sizes are easily rec- 
ognized. The specificity of pulmo- 
nary perfusion scanning has been 
recently further improved by com- 
bining it with radioactive gas-wash- 
out. This is done by making the pa- 
tient inhale radioactive gas (Xenon 

i 133) in a closed breathing system. 

i Pulmonary embolus will produce 
perfusion deficit only; parenchymal 
lung disease will result in both per- 
fusion and ventilation defect. •* 
Pulmonary angiography 

The "last word" in the laboratory 
diagnosis of pulmonary embolism is 
undoubtedly pulmonary angiogra- 
phy. While even this examination 
is not absolutely free of diagnostic 
mishaps — abnormalities associated 
with tumors, emphysema and bron- 
chiectasis may cause difficulties in 
the interpretation — this examina- 
tion is the most specific tool avail- 
able for verification of pulmonary 
embolism. Done by experienced 
hands in a well prepared laboratory, 
the risk of this examination does not 
exceed that of pulmonary scanning, 
and, while the scan outlines the per- 
fusion deficit of the pulmonary 
parenchyma, the angiogram vis- 
ualizes the anatomy of the pulmo- 
nary vasculature. Another advan- 
tage of angiography is the feasibility 
of added hemodynamic studies 
using the same catheter and the pos- 
sibility of continued monitoring of 
the pulmonary arterial pressure by 
an indwelling catheter. In our ex- 
perience, normal pulmonary arte- 
rial pressure excludes life-threat- 
ening pulmonary embolism, and 
gradual increase of the pulmonary 
pressure, if embolism is diagnosed, 
indicates progression of the throm- 
bus and/or deterioration of the cir- 
culation. 

OPTIMAL THERAPY 

The last problem to be mentioned 
is the optimal therapy for pulmo- 
nary emboli. 

Most physicians agree that the 
treatment for acute, not very se- 
vere, pulmonary embolization is 
medical. Controversy, however, 
exists about the management of pa- 
tients with major embolization .with 
j recurrent embolization and/or with 
contraindications to anticoagula- 
tion. 



Intravenous heparin therapy 

As a rule, intravenous heparin 
therapy should be initiated as soon 
as the diagnosis of pulmonary em- 
bolus is made or strongly suspected. 
The administration of heparin may 
be every four hours through an in- 
dwelling catheter or by continuous 
infusion. A large dose of 10,000 lU 
should be given initially followed by 
4,000-8,000 lU maintenance doses 
to maintain the clotting time 30-40 
minutes. It is mandatory that the 
Lee-White clotting time be deter- 
mined daily, reported without delay 
and acted upon immediately. 
Therapeutic regimens in which the 
first clotting time is taken 24 hours 
after the initiation of the therapy, 
reported on the following morning 
and acted upon a day later are with- 
out clinical value.' 

Thrombolytic therapy 

There have been recent clinical 
trials to combine intravenous hepa- 
rin with thrombolytic therapy. 
Urokinase or streptokinase have 
been given for an initial period of 12 
hours with promising clinical re- 
sults. The disadvantages of throm- 
bolytic therapy are the relatively 
high occurrence of complications 
and the scarcity of thrombolytic 
agents. 

If the embolization is not severe 
and the episode does not recur, the 
patient should remain on intraven- 
ous heparin therapy for not less than 
seven days and probably not ex- 
ceeding two weeks. He should be 
ambulatory and wearing elastic 
stockings from the third day unless 
symptoms of phlebothrombosis 
exist. If they do, the phlebitis 
should be treated concomitantly 
with bed-rest, elevation of the in- 
volved extremity and warm soaks. 

Oral anticoagulants 

If the patient's condition does not 
deteriorate and embolization does 
not recur, heparin is gradually sub- 
stituted by oral anticoagulants, 
preferably by sodium warfarin. In- 
travenous heparin is discontinued, 
however, only after the patient's 
prothrombin time reaches double 
that of the control in seconds. He 
should be maintained on a well 
supervised oral anticoagulant for 
four to six months.* 



Supportive management 

If the initial episode of pulmonary 
embolization was severe, the pa- 
tient is in need of active and con- 
scientious supportive management. 
He should be transferred to the in- 
tensive care unit where heart rate, 
electrocardiogram, respiration, 
arterial, central venous and pulmo- 
nary arterial pressures are continu- 
ously monitored. The diagnosis of 
the embolization should be con- 
firmed and its extent determined not 
only by lung scan but by angio- 
graphy. Oxygen should be adminis- 
tered throughout the critical period 
to maintain arterial p02 above 60. If 
oxygen delivered by mask is not ef- 
fective enough, consideration 
should be given to tracheostomy 
and assisted respiration. We 
strongly believe that adequate dig- 
italization is essential in the man- 
agement of acute cor pulmonale 
secondary to pulmonary embolism. 

Pulmonary embolectomy 

If continued deterioration of vital 
signs indicates that the above mea- 
sures are not sufficient, if arterial 
p02 remains unacceptably low, 
pulmonary hypertension worsens, 
heart rate increases, etc., pulmo- 
nary embolectomy should be per- 
formed without delay. Early con- 
sideration should also be given to 
pulmonary embolectomy if the an- 
giogram shows massive occlusive 
changes involving both pulmonary 
arteries. Under no circumstances 
should the patient be prepared for 
pulmonary embolectomy unless the 
diagnosis is confirmed by angio- 
graphy.^ 

While pulmonary embolectomy is 
the only recourse in certain other- 
wise hopeless situations, it is a mea- 
sure which could and should be 
applied infrequently. It is a heroic 
operation with an operative mortal- 
ity rate of 40-50% and should be 
chosen with utmost consideration 
and intelligent evaluation. Experi- 
ences indicate that if the patient 
survives the first 30 minutes of em- 
bolization, which is long enough to 
institute adequate supportive man- 
agement and anticoagulant therapy, 
he will most likely recover without 
operative intervention. Naturally, if 
the patient has a massive embolus. 



January 1976, NCMJ 



23 



1 



which leaves only a lobe or less 
functioning, and if his condition 
continues to deteriorate on ener- 
getic supportive therapy, there is no 
alternative but a speedy embolec- 
tomy on cardio-pulmonary bypass. 

Caval interruption 

The other surgical procedure 
applied in patients with pulmonary 
embolization is interruption of the 
inferior caval vein. This operation is 
not aimed to treat pulmonary em- 
boli but to prevent their recurrence. 
As in pulmonary embolectomy, the 
surgical indication of caval interrup- 
tion has narrowed considerably in 
the past few years. The reason is the 
high morbidity rate — the venous 
stasis in the lower extremities in- 
creases in 30-40% of the patients. 
Ten years ago the indication for 
cava ligation was simply the suspi- 
cion of pulmonary embolism. The 
most frequent question concerned 
method: with simple ligation, dif- 
ferent ways of plication or clamping 
devices; that is, how to do it? This 
matter now is fairly well settled. It 
has been shown that plication pro- 
cedures, extra- and intra-caval de- 
vices designed to reduce postopera- 
tive stasis, offer little or no advan- 
tage over simple ligation, and they 



may be associated with a slight in- 
crease in recurrent embolization.'" 

Nowadays the most frequent 
question concerns timing and cir- 
cumstances for ligating the inferior 
vena cava; that is, when to do it? 

Patients who have repeated em- 
bolization while adequately an- 
ticoagulated are obvious candidates 
for vena cava ligation. Another pos- 
sible candidate is the patient whose 
initial pulmonary embolus was mas- 
sive and whose cardiopulmonary 
status remains in such a precarious 
condition that a second embolus 
probably would be fatal. Cava liga- 
tion should also be considered after 
pulmonary embolectomy. Cava li- 
gation should be avoided, if possi- 
ble, in patients with chronic indu- 
rated edema and skin discoloration 
due to lymphatic and venous stasis. 
Such patients respond to caval in- 
terruption with further severe de- 
terioration of their circulatory 
stasis. The diagnosis of pulmonary 
embolism should always be con- 
firmed by lung scan and/or (prefera- 
bly) by pulmonary angiography be- 
fore cava ligation is recommended. 

SUMMARY 

Pulmonary embolization should 
be suspected even when "typical" 



symptoms of this disease are ab- 
sent. The diagnosis of pulmonary 
embolization should be confirmed 
by lung scan and/or pulmonary an- 
giography. Initial episodes of pul- 
monary embolus should be treated 
with anticoagulant therapy and gen- 
eral supportive measures; only rare 
cases of massive embolization re- 
quire pulmonary embolectomy. 
Vena cava ligation is recommended 
for repeated cases of pulmonary 
embolization in patients who are 
adequately anticoagulated. 

References 

i. Hume M. Sevitt S, Thomas DP: Venous Thrombosis 
and Pulmonary Embohsm- Cambridge: Harvard Uni- 
versity Press, p 4, 1970- 

2- Stem M, Levy ST: Reflex and humoral responses to 
pulmonary embolism. Progress in Cardiovascular Dis- 
eases. Vol. 17, No, }. pp I6K-I71. 1974, 

3, Urokmase Pulmonary Embolism Trial, A National 
Cooperative Study, Circulation (Suppl, II) 47: 11-61, 
1973, 

4, Szucs MC, Brooks HL. Grossman W, et al: Diagnostic 
sensitivity of laboratory findings in acute pulmonary 
embolism- Ann Intern Med 74: 161-166, 1971, 

-*i, Fleischner FG: Observations on the Radiologic 
Changes in Pulmonary Embolism, in Sasahara AA, 
Stem M (eds): Pulmonary Embolic Disease, New York: 
Grune & StraClon. p 206. 1965, 

6, Sasahara AA: Current problems in pulmonary em- 
bolism: Introduction, Progress in Cardiovascular Dis- 
eases. Vol, 17, No, 3, 1974, 

7- Genton E. Hirsh J: Observations in anticoagulant and 
thrombolytic therapy in pulmonary embolism. Progress 
in Cardiovascular Diseases. Vol, 17, No. 5. pp 335-343. 
1975, 

8, Genton E, Hirsh J: Observations in anticoagulant and 
thrombolytic therapy in pulmonary embolism. Progress 
in Cardiovascular Diseases, Vol. 17. No, 5. pp 335-343, 
1975 

9, Sautter RD, Myers WO, Jerrerson FR, Wenzel FJ: 
Pulmonary embolectomy: review and current status. 
Progress in Cardiovascular Diseases, Vol, 17, No, 5, pp 
371-385, 1975, 

10- Crane C: Venous interruption tor pulmonary embolism: 
present status- Progress in Cardiovascular Diseases, 
Vol. 17, No. 5, pp 329-334. 1975. 



It is highly probable that different portions of the ahmentary canal are endued with different kinds of 
sensibility or rather excitability. The sensibility of the stomach is in accordance with the presence of 
undigested food, when first swallowed, which would and does occasion much inconvenience in the 
duodenum and other intestines; while we know that the presence of bile in the duodenum produces no 
unpleasant effect there; whereas, if it regurgitate into the stomach, it disorders the whole system. The 
organic sensibility of the large intestines is very different in kind from that of the small. The presence of 
faecal matters in the colon and rectum produces no sensation; but if substances pass down undigested 
from the stomach, the whole line of the intestines is irritated — although the effects are often not felt 
there, but in various other parts of the body from sympathy. Onions, chestnuts, and a hundred other 
things, eaten in the evening, will disturb the organic or special sensibility of the stomach and bowels, 
producing what is called the fidgets, restlessness, incubus, and sundry other disagreeable effects, in 
parts of the body far remote from the actual seat of irritation. — An Essay on Indigestion; or Morbid 
Sensibility of the Stomach & Bowels. James Johnson, 1836, p 4, 



24 



Vol, 37, No, 1 



Assets and Liabilities of Helicopter Evacuation in 
Support of Emergency Medical Services 



H. J. Proctor, M.D., F.A.C.S.t, and 
Stephen A. Acai, Jr.* 



INTRODUCTION 

STIMULATED by the reduction 
in mortality and morbidity 
through helicopter evacuation of 
battle casualties, the civilian com- 
munity has frequently envisioned a 
parallel achievement in civilian 
emergencies. 

The MAST (Military Assistance 
to Safety and Traffic) helicopter 
program of North Carolina offers an 
opportunity to assess the helicop- 
ter's role in these areas, since the 
medical aspects of all cases 
evacuated are reviewed by a physi- 
cian. 

Previous studies of civilian dem- 
onstration projects'' have dealt 
with the technical aspects of avia- 
tion and the cost of operation. Al- 
though these are important aspects 
for study, data vary from one lo- 



tHead. Trauma Section. Depanmeni of Surgery. Univer- 
sity of North Carolina School of Medicine and the North 
Carohna Memonal Hospital. Chapel Hill. North Carolina 
27.SI4; Chairman. MAST Advisory Committee. State of 
North Carolina 

"Transportation Specialist. North Carolina Department 
of Human Resources. Division of Facility Services. Office 
of Emergency Medical Services. Raleigh. North Carolina 
27605: Coordinator. North Carolina M.AST Program 

North Carolina M.^ST Program supported by the North 
Carolina Department of Human Resources. Division of 
Facility Services. Office of Emergency Medical Services. 
North Carolina Regional Medical Program. Department of 
Suigery, Lni^ersity of North Carolina School of Medicine 
and the North Carolina Memonal Hospital; North Carolina 
Department ofTransportation. Governor's Highway Safety 
Program; and 57th Medical Detachment. Ft Bragg. North 
Carolina. 

Reprinted by permission of the Journal of the American 
College of Emergency Physicians 



cale to another. Moreover, these re- 
ports fail to address themselves to 
the major aspect of the problem — 
"What was the benefit to the pa- 
tient?" 

The following report analyzes a 
year's missions by the North Caro- 
lina MAST program. Excluded are 
missions involving military person- 
nel and their dependents as well as 
"practice" missions prior to formal 
inauguration of MAST in Novem- 
ber, 1973. 

OPERATION PLAN 

The 57th Medical Detachment 
(RA), Ft. Bragg, North Carolina, 
supports the North Carolina MAST 
program. Federal guidelines limit 
MAST coverage to a 100 nautical 
mile radius of Ft. Bragg. Five large 
receiving hospitals have been des- 
ignated at the periphery of the area 
(Fig. 1). Helicopters fly from Ft. 
Bragg to the pickup area, then to the 
closest receiving hospital. 

Since the MAST area includes 89 
community hospitals and 240 ambu- 
lance providers, the patient is first 
taken by ground vehicle to a local 
hospital for initial care. This system 
allows a physician to make the ini- 
tial assessment of the need for air 
evacuation. If air evacuation is de- 
sired, the referring physician calls 
the MAST coordinating physician. 
Only after the medical aspects of 



the case have been reviewed does 
the MAST physician request a 
Medevac. Arrival times at the refer- 
ring and receiving hospitals with de- 
tails of the patient's condition are 
related by telephone, supplemented 
by radio (155.340 mhz, 155.280 
nihz), allowing helicopters to com- 
municate directly with hospitals and 
ambulance providers. 

DATA ANALYSIS 

The period from November, 
1973, to November, 1974, was 
selected for study. Evaluation in- 
cluded a review of the medic's in- 
flight patient log and tijnes of mis- 
sion request, liftoff, arrival at the 
referring hospital, airborne with the 
patient and arrival at the receiving 
hospital. 

The total time of the mission 
(mission request to arrival at receiv- 
ing hospital) and patient transfer 
time (time from referring to receiv- 
ing hospital) were compared with 
known driving times for ground am- 
bulances between referring and re- 
ceiving hospitals. 

The patient's medical status was 
assessed in terms of the etiology of 
the emergency, major area of body 
or organ system affected and 
whether in the authors' estimation 
the helicopter evacuation affected 
patient morbidity or mortality. 

Morbidity and mortality determi- 



Ianuary 1976, NCMJ 



25 




Geographic area covered by the North Carolina MAST Program. CMH = Charlotte Memo- 
rial Hospital, NCBH = North Carolina Baptist HospiUl and the Bowman Gray School of 
Medicine, DUH = Duke University Hospital and the Duke University School of Medicine, 
NCMH = North Carolina Memorial Hospital and the University of North Carolina School of 
Medicine, HNMH = New Hanover Memorial Hospital. 



nations were based on data from the 
medic's record of the patient's con- 
dition in flight, a review of the pa- 
tient's hospital chart at the receiv- 
ing hospital and, where further 
clarification was necessary, a re- 
view of the patient's hospital chart 
at the referring hospital. Whenever 
possible, physicians who actually 
cared for a patient were inter- 
viewed. 

Mortality and morbidity were 
said to be lessened if any of the fol- 
lowing were present: 

A. A rapidly deteriorating or un- 
stable patient who probably would 
have died during the known driving 
time to the receiving hospital. For 
example, a patient with a proven 
epidural hematoma with a dilated 
pupil 1.5 hours from the receiving 
hospital. 

B. A patient requiring in-transit 
care capable of being rendered by 
the Army medic but not possible in 
North Carolina under the present 
statutes governing emergency med- 
ical technicians (EMTs). For exam- 
ple, the necessity to regulate, inde- 
pendent of a physician's direction, 
an isoproterenol drip to maintain 
heart rate in cases of complete heart 
block. 

C. Inadequacy of ground vehi- 
cles. For example, roads impass- 
able due to inclement weather, 
multiple patients exceeding local 
vehicle capacity or cumbersome 
medical equipment physically im- 
possible to fit into a conventional 
ambulance. 

If a patient subsequently expired 



26 



for any reason, he was counted as a 
mortality with no credit for reduc- 
tion in morbidity despite the possi- 
ble presence of one or more of the 
above criteria. 

Employing a scale of (poor) to 
10 (excellent), patient data were 
further examined for accuracy of 
the initial diagnosis and appro- 
priateness of initial treatment be- 
fore evacuation. 

The appropriateness of the re- 
ceiving hospital selected by the re- 
ferring physician in terms of patient 
transit time was also noted. 

RESULTS 

During the study period, 116 re- 
quests for helicopter evacuation 
were made. Six were refused by the 
MAST coordinating physician, who 
concluded the medical condition 
was not severe enough to warrant a 
helicopter. Four requests were ap- 
proved but could not be flown due 
to weather. Two missions were 
canceled when the patients expired 
before the helicopter arrived. One 
of these patients had sustained mas- 
sive thoracic and cranial trauma 
after a vehicle accident; the second 
was in septic shock after a criminal 
abortion. Both were moribund at 
the time a helicopter was requested. 
One request accomplished the 
transfer of frozen blood for kidney 
transplantation and was not consid- 
ered further. 

The remaining 103 missions 
evacuated 110 patients. Complete 
data concerning time and distance 
traveled were available in 100 (91 



percent). Documentation of the 
medical condition was complete for 
93 (85 percent). 

With the exception of the six re- 
quests refused by the MAST physi- 
cian, all requests seemed valid on 
the basis of telephone information. 
Subsequent review of patient rec- 
ords revealed six additional cases 
clearly not severe enough to war- 
rant helicopter evacuation. Two of 
these patients, a hysterical conver- 
sion reaction presenting as a rapidly 
progressive quadriplegia and a 
strangulating cryptorchid testicle 
diagnosed as myocardial infarction, 
were clearly the result of misdiag- 
nosis. In the other four cases, the 
diagnosis was correct but did not 
appear to be as severe as initially 
described. 

The diagnostic accuracy on the 
part of the referring physicians was 
generally correct and in 83 percent 
of the cases either all or a significant 
portion of the referring diagnosis 
was supported by the findings at the 
receiving hospital. 

Only 55 percent of patients, how- 
ever, had been appropriately 
treated to minimize morbidity and 
mortality during transfer. Chest 
tubes and intravenous infusions 
were most frequently correct; im- 
mobilization of fractures and 
adequate provision for an airway 
were most frequently neglected. 

In 32 percent of the evacuations, 
the receiving hospital selected by 
the referring physician was not the 
closest and mission time was pro- 
longed. 

For ease of analysis, the 87 pa- 
tients judged to be valid helicopter , 
evacuations were arbitrarily di- 
vided into four groups (Tables 
I-IV). Traumatic cases were further 
analyzed in terms of the most seri- 
ous of their various diagnoses (Ta- 
ble V). 

A review of the medic's in-flight 
record of the patient's condition and 
the treatment he rendered indicated 
10 patients improved in transit, four 
deteriorated and the remainder did 
not appear to change. Improvement 
in condition was most often the re- 
sult of intravenous infusion of fluid 
to elevate blood pressure. Deterio- 
ration of the four patients resulted! 
from conditions beyond the con- 

VOL. 37, No. 1 



rol of the medic. Three of the pa- 
ients had sustained severe cranial 
rauma. One was pronounced dead 
m arrival despite intubation and 
nanual ventilation by the medic and 
he othertwo subsequently expired, 
rhe fourth patient was also dead on 
irrival with a massive hemothorax 
ind a traumatic rupture of the tho- 
acic aorta. 

It is apparent from Tables II and 
/ that 13 of the 23 mortalities were 
issociated with central nervous sys- 
em problems. The two deaths in the 
;astrointestinal bleeding group (Ta- 
ile IV) were cirrhotics with bleed- 
ng esophageal varices. Both died in 
lepatic coma after bleeding had 
)een controlled. 

Three lives were thought to have 
)een saved as a result of helicopter 
■vacuation: a gastrointestinal 
)leeder transported in shock who 
eceived four units of blood during 
ier50-minute evacuation; atrauma- 
ized patient with a depressed skull 
racture and an epidural hematoma 
vith uncal herniation following a 
'5-minute evacuation; and a patient 
vith preinfarction angina and ven- 
ricular premature beats who un- 
lerwent coronary angiography and 
■mergency coronary artery bypass 
urgery upon arrival at the receiving 
lospital. 

The greatest reduction in morbid- 
ty was clearly in the cardiac group 
Table 11). Morbidity was reduced 
in the embolus (Table II) and 
eimplantation groups (Table I) due 
o the average (77-minute) reduc- 
ion in ischemia time (comparing the 
otal helicopter time to the driving 
ime). 

Despite an average response time 
■)f 25 ± 15 minutes, the mean total 
ime consumed by helicopter 
:vacuation from request to arrival 
it the receiving hospital of 1 19 ± 43 
ninutes was significantly less than 
he calculated driving time of 162 ± 
jl minutes. The mean time from re- 
erring to receiving hospital of 53 ± 
£4 minutes was faster than the driv- 
ng time for obvious reasons. In 
mly 19 instances was the total 
lelicopter time longer than the es- 
ated driving time. 

Ten of these 19 patients (53 per- 
-ent) expired, compared to a mor- 
ality of 20 percent for the 66 pa- 



ria 
T( 



Table I 
Distribution of Trauma Cases According to Etiology 



Etiology 

Vehicle accident 

Gunshot wound 

Stab wound 

Blunt instrument 

Falls 

Traumatic amputation 

(re-impiantation) 
Operative mishap 
Spons 
Tetanus 
Burns 

Total 



Number 


Mortality 


Morbidity 
Reduced 


Morbidity 
Increased 


Morbidity 
Indefinite 


22 


7 


7 


1 


7 


7 


2 


2 





3 


1 











1 


1 











1 


4 


2 








2 


2 





2 








2 


1 








1 


1 











1 


1 








1 





4 





2 





2 


45 


12 


13 


2 


18 


— 


27% 


29% 


4% 


40% 



Table II 
Distribution of Cases Considered Cardiovascular 



Etiology 

Mvocardial infarct 

Stokes-Adams 

Embolus 

Ruptured abdominal 

aneurysm 
Dissecting thoracic 

aneurysm 
Subarachnoid bleeding 
Arteritis 

Total 



Number 


Mortality 


M 
R 


orbldity 
educed 


Morbidity 
Increased 


Morbidity 
Indefinite 


6 







6 








5 







5 








2 







2 








2 


2 













2 


1 




1 








3 


2 










1 


1 







1 








21 


5 




15 





1 


— 


24% 




71% 


0% 


5% 



Table III 
Distribution of Illness in Newborn Infants 



Etkilogy 

Respiratory distress 

syndrome 
Cyanotic heart 

disease 

Total 



Number 


Mortality 


Morbidity 
Reduced 


Morbidity 
Increased 


Morbidity 
Indefinite 


5 


1 




2 





2 


1 


1 













6 


2 




2 





2 


— 


33% 




33% 


0% 


33% 



Table IV 
Miscellaneous Illnesses 



Etkilogy 

Renal failure 
G-l bleeding 
Pneumonia 
Status eprlepticus 
fvletastatic cancer 
PAM inhalation 
Septic shock 

Total 



Number 


Mortality 


Morbidity 
Reduced 


Morbidity 
Increased 


Morbidity 
Indefinite 


3 











3 


5 


2 


1 





2 


2 





1 





1 


1 











1 


2 


1 








1 


1 


1 











1 





1 








15 


4 


3 





8 


— 


27% 


20% 


0°/o 


53°'o 



0, ANUARY 1976, NCMJ 



27 



Table V 
Distribution of Trauma Cases According to Major Diagnosis 



Diagnosis 

Acute subdural or 
epidural hematoma 

Cerebral or bram 
stem contusion 

Spinal cord injury 

Penetrating abdomma! 

Blunt abdominal 

Penetrating thoracic 

Blunt thoracic 

Multiple fractures 

Burns 

Re-implanted 
extremity 

Tetanus p laceration 

Total 



Morbidity Morbidity Morbidity 

Number Mortality Reduced Co) Increased (°o( Indefinite 



3 


7 


2 





4 


5 


2 








3 


3 





1 





2 


3 





1 


1 


1 


2 





2 








5 


1 


1 





3 


3 











3 


4 





2 





2 


2 





2 








1 








1 





5 


12 


13 


2 


18 


- 


27% 


29% 


4% 


40 



tients evacuated in a reduced time. 
Four of the 10 fatalities might have 
been prevented by faster evacua- 
tion. The remaining six patients, all 
with severe brain stem contusions, 
probably had fatal injuries and 
would have died regardless of 
evacuation time. 

In two cases (Table I and V) it was 
judged that helicopter evacuation 
increased morbidity. Both con- 
sumed more time in helicopter 
evacuation than the estimated driv- 
ing time. 

DISCUSSION 

We have presented a simple, reli- 
able system of helicopter evacua- 
tion which functions well in a rural 
area such as North Carolina. Physi- 
cian cooperation was excellent; in- 
appropriate utilization was rare; 
and the mission completion rate 
was high despite adverse weather. 

At the inception of the MAST 
program in North Carolina, the 
majority of ambulance attendants 
possessed only basic American Red 
Cross first aid skills (26 hours) and 
ambulance vehicles were poorly 
equipped. It was evident that, in ad- 
dition to speed, evacuation by 
helicopter had the possible added 
advantages of better patient care en 
route and a better equipped vehicle. 
As a result of efforts by the Office of 
Emergency Medical Services, 
nearly 2,000 ambulance attendants 
were certified at the 81 -hour EMT 
level during 1974 and ambulance 



28 



equipment was upgraded to stan- 
dards set by the American College 
of Surgeons Committee on Trauma. 
Thus, comparing the helicopter to 
the existing ground capability in 
North Carolina, morbidity was re- 
duced in only 10 cases (six cardiac, 
four traumatic) as a result of in- 
flight care; whereas, in the majority 
of instances in which morbidity and 
mortality were favorably affected, 
speed was either the sole or major 
factor. Further efforts appear to be 
warranted to reduce both total mis- 
sion time (faster response) and pa- 
tient transport time (referral to a 
closer hospital). 

From the inception of the pro- 
gram it has been emphasized to 
physicians that although the total 
time involved in a helicopter evacu- 
ation might exceed the driving time 
for a given transfer, the period of 
time in which the patient was not 
under a doctor's care in a favorable 
environment would be greatly re- 
duced. Such is the case when one 
compares the 53-minute helicopter 
time to the 162-minute estimated 
mean driving time. It is interesting 
to note that despite the added dis- 
tance from Ft. Bragg to the referring 
hospital, the total mission time was 
still less than the estimated driving 
time in the majority of patient trans- 
fers. 

The 71 percent reduction in mor- 
bidity in cardiac cases indicates that 
helicopter evacuation should be 
emphasized for patients of this type 



and that consideration should be 
given to additional training of 
medics and to more sophisticated 
equipment such as cardiac moni- 
tors, defibrillators and electronic 
blood pressure monitors. On the 
basis of these data, it is impossible 
to single out any other category of 
patient as being particularly appro- 
priate for helicopter evacuation. 

Lack of speed probably contri- 
buted to four of the deaths. Al- 
though this was obviously a judg- 
ment decision by the reviewer, the 
possibility of error was no greater 
than in the three judgments in which 
it was claimed the helicopter saved 
a life. In this study, therefore, there 
did not appear to be any effect by 
the helicopter on patient mortality. 
The overall mortality of 28 percent 
reflects the severity of illness in the 
patients evacuated. 

The criteria for reduction in pa- 
tient morbidity, although rigorously 
applied, were still subjective and 
are thus open to criticism. The 38 
percent overall reduction in morbid- 
ity claimed for the helicopter, while 
not the panacea expected by some,| 
appears realistic, is possibly a min-' 
imal figure and compares favorably' 
with other therapeutic modalities, 
accepted by the medical community 
and the public. It should be remem-j 
bered that this report compares the 
helicopter to existing ground trans- 
portation in a given geographic 
locale; extrapolation to other 
locales should be done cautiously. 

ACKNOWLEDGMENTS j 

The authors wish to acknowledge the ef-| 
forts of Major Robert Rose, commanding of- 
ficer. Captain Terrance Muldoon, Warrant! 
Officer Joseph McDonald and the pilots and! 
crews of the 57th Medical Detachment, Ft., 
Bragg. North Carolina; Colonel Robert E.' 
Mathias, Commanding Officer. 44th Medical 
Brigade; and Colonel Albert L. Gore. Com- 
manding Officer, Womack Army Hospital, 
Ft. Bragg. North Carolina. Our appreciation 
also is extended to Noel B. McDevitt. M.D.. 
George Johnson. Jr., M.D., and Stanley R. 
Mandel. M.D., for their services as MAST 
coordinating physicians. 

References 

1 United States Department of Transportation 
Emergency .Medical Service for an Urban Area (Am 
Arbor: University of Michigan. 19701. 

2 United States Department of Transportation. Air Medi 
cal Evacuation System (Tempe; Arizona State Univer 
sily, 1970). 






P 



3i 



fa:)' 



■■Jbi 



Vol. 37. No. 1, 









Anton Chekhov: A Physician-Genius 
in Spite of Himself 



Part IV 

— Conclusion — 

Richard E. Cytowic 



Chekhov's Doctors 

IT is interesting that Anton Chek- 
hov, whom history has shown to 
X a literary genius, accomplished 
physician and a famous personality 
during his own era, should look 
jpon himself as a failure. The con- 
nection between Chekhov and his 
fictional physicians is a deprecatory 
self-image. Common to his doctors 
is an acceptance of the tedium based 
on the belief that nothing can 
change the way things are. 

One such person is Dr. Ragin of 
'Palata No. 6" ("Ward No. 6," 
1892). He is the ineffective director 
of the insane ward in a provincial 
hospital, a haven of filth, inade- 
quacy and generalized misery. 
Eager in his early career to institute 
reform and improve efficiency and 
treatment. Dr. Ragin grows content 
to leave patients to a degrading exis- 
tence among the vermin, disease 
and beatings of the cruel guard 
Nikita, who also steals what little 
allowance they have. 

Dr. Ragin consoles himself by 
rationalizing that "there is nothing 
on earth so fine that it has not had 
some filth at its origin." He is 
:aught in a circle of specious logic, 
arguing that doctors should not 
keep people from dying since death 



Bowman Gray School ol Medicine, \\'inslon-Salem, 
North Carolina 27103 



is the normal, legitimate end for 
everyone, and that "suffering is 
said to lead man to perfection." He 
gradually withdraws from his 
duties, seeking solace in vodka and 
the reading of philosophy. 

His only medical journal is 
Vratch {The Physician), which he 
reads backwards. He is amazed at 
the transformation that medicine 
has undergone in 25 years. Regard- 
ing it as little more than alchemy or 
metaphysics as a student. Dr. Ragin 
is now aroused with wonder and en- 
thusiasm. "What unexpected bril- 
liance, what a revolution!" He mar- 
vels at modern anesthesia with 
which one can perform operations 
that even the great Pirogov once 
considered impossible. A cure for 
syphilis, theories of heredity, hyp- 
notism, the discoveries of Pasteur 
and Koch, modern humane treat- 
ment of psychotics — it is all a new 
world to Ragin. Still, he cannot ac- 
cept it, cannot believe anything has 
changed: 

There's antiseptics and Koch and Pas- 
teur, but the essence of the work 
hasn't changed a hit. Illness and mor- 
tality exist just the same. . . . It's all 
rubbish and bustle, and the difference 
between the best Viennese clinic and 
my hospital is, m effect, nonexistent. 

He befriends one of the patients, 
a paranoid schizophrenic, who is in- 
telligent enough to recognize and 
point out Dr. Ragin's foibles. "My 



illness," he says, "is that in twenty 
years I've found only one intelligent 
person in the whole town, and he's a 
lunatic." His ambitious assistants 
(one of whom owns a single book, 
"New Prescriptions of the Vienna 
Clinic") slowly undermine his posi- 
tion, force his resignation and ob- 
serve his financial demise. Ulti- 
mately, he is judged insane and 
committed to Ward No. 6. where he 
dies of a stroke after being brutally 
beaten by Nikita. 

Dr. Startsev, in "lonych" (1898), 
succumbs to bourgeoise material- 
ism rather than allowing himself a 
demise such as Dr. Ragin's. He is a 
sycophant of the Turkin family, the 
pompous pseudointellectuals of 
their small provincial town. 
Startsev proposes to their daughter. 
Katerina, although she is more in- 
terested in her career as a concert 
pianist and wants nothing to do with 
him. Rejected, he sublimates his de- 
sire and builds up a large practice 
despite his inadequacy as a physi- 
cian. He accumulates much wealth 
and gains prominence among the 
local intelligentsia, although, deep 
down, he detests the provincial res- 
idents and his life among them. 
When Katerina returns from the 
conservatory, having insufficient 
talent to launch a career, she 
suggests marriage to Startsev. The 
old bachelor has lost his original vis- 



January 1976, NCMJ 



29 



ion and, instead of accepting the 
idea of marriage, he throws a bucket 
of cold water on Katerina. He is 
resigned not to change his way of 
life since he is already established 
among the citizenry. 

In "Siipruga" ("The Compan- 
ion," 1895) one finds a nameless 
physician already married to a ca- 
pricious, adulterous wife. Working 
long hours to support her and her 
tastes, he becomes exhausted and 
contracts tuberculosis. He suggests 
divorce in order to live his last few 
years alone in peace. He even 
agrees to appear the guilty party and 
provide alimony. But the wife re- 
fuses because she is afraid of losing 
her social position. Typically, the 
doctor accepts his fate without ar- 
gument and continues to work him- 
self to death. 

Chekhov practiced no sex dis- 
crimination when creating his mel- 
ancholy characters. "KIwroshyie 
Lyudi" ("Excellent People." 1886) 
shows Doctoress Semionova slav- 
ing through a medical practice that 
she finds distasteful. The solution 
enabling her to tolerate this predic- 
ament is to detach all emotion from 
her clinical practice, and. in fact, 
from her personal life as well. She is 
cold, disinterested, and calmly ac- 
cepts her boring life. She shows no 
emotion as she watches her brother 
die of an acute illness. Chekhov 
aptly compares her to an ill animal 
warming itself in the sun. 

Many of Chekhov's fictitious 
physicians tind escape from their 
ennui and sense of futility in death. 
Such is the case of Dr. Dymov in 
"La Linotte" (1891). He works 
hard as an assistant physician in one 
hospital and as an autopsy prosec- 
tor in another. Since he has few pri- 
vate patients, these jobs are neces- 
sary to support himself and his 
frivolous wife. She is unfaithful and 
serves as a constant source of criti- 
cism. When Dymov becomes seri- 
ously ill. one of his colleagues tells 
her that he has aspirated the 
diphtheric membrane from a young 
boy with that disease. Dymov con- 
tracts diphtheria in his nose and 
lapses into cardiac failure. After he 
dies, his wife realize^ what a won- 
derful husband he had been and 
blames herself for his death. 



Dr. Sergievich provides a student 
with another type of escape, this 
time drugs, in "Strokh" ("Terror." 
1892). After visiting the Moscow 
brothels with some friends, the law 
student Vassilev is overcome with 
both disgust and empathy for the 
women he has seen. He feels sick 
for living in a world where human 
beings can be driven to such low. 
vile levels of existence. The 
psychiatrist obtains a complete per- 
sonal history and tests his tactile 
sensibility with a bizarre instru- 
ment. Vassilev sinks to the floor, 
crying because he can do nothing to 
change the way things are, for him- 
self or the prostitutes. Dr. Ser- 
gievich understands and sends Vas- 
silev home with prescriptions for 
bromides and morphine. 

The doctors of Chekhov's stories 
are discontented men, seeing the 
need for change in their lives and the 
lives of those about them. But they 
lack any vision of how that change 
can be brought about construc- 
tively. Their impotence is mirrored 
by the doctors who appear as key 
characters in all but one of 
Chekhov's plays. 

In Chayka (The Sea Gull. 1896), 
the elderly Dr. Dorn is shown as an 
impotent, ineffective hanger-on in 
the Sorin household. A 55-year-old 
bachelor, Dorn used to be the 
ladies' favorite, mainly because of 
his skill as a physician. Now all he 
can do is prescribe valerian drops 
and quinine for any ailment about 
which his attention is sought. He 
regrets his life, but realizes that it is 
too late for him to change anything: 

l.ife has to be taken seriously, but 
when it comes to taking cures at sixty, 
and regretting that you don't get 
enough enjoyment out of life when 
you were young — all that, forgive me. 
is just futile (11, i). 

He is an empathetic observer of 
Trepilov's love affair with Masha 
but more fascinated by Trepilov's 
play. He admits that although he has 
lived a varied and discriminating 
life, he would like to have been an 
artist and experience the true joy 
and excitement of creativity. Dorn 
has never been a man of vision or 
imagination, though, and his prob- 
lem is not that of teaching an old dog 
new tricks — simply knowing what 
tricks to learn. He would gladly help 



the disconsolate Masha. and 
everyone else, but is paralyzed with 
ignorance: "What can I do. my 
child? Tell me what can I do? 
Whaf]"" (I.i). 

This same sense of futility ap- 
pears again in Dxadva Vanva (Un- 
cle Vanya. 1890'. revised 1898). In 
this play. Chekhov's answer to 
boredom and depression is 
"work!" Although the play takes its 
title from Ivan (Vanya) Voinitsky, 
its main protagonist is clearly Dr. 
Astrov. who believes that "only 
God knows what our real vocation' 
is" (I.i). Astrov is a prototype 
ecologist who plants forests and 
manages wildlife and wonders what 
will become of them in future years. 
He is one of the few people left who 
can appreciate the simplicity and 
beauty of life around him: 

.Anyone who can bum up all that 
beauty in a stove, who can destroy 
something that we cannot create, 
must be a barbarian incapable of 
reason. . . . When 1 hear the rustling 
of the young trees 1 planted with my 
own hands, I'm conscious of the fact 
that if mankind is happy in a thousand 
years' time, I'll be responsible for it 
even though only to a very minute ex- 
tent (I.i). 

Astrov receives no satisfaction or 
recognition for his work, and is not 
solaced by Nanny's consolation: 
"If people won't remember. God 
will" (I.i). He hopes to make a bet- 
ter world for future generations, 
even though his is personally one of 
misery and self-deprecation: 

As for my own life. God knows 1 can 
tlnd nothing good m it at all. . . . I 
work harder than anyone in the 
district — you know that — fate batters 
me continuously, at times 1 suffer un- 
bearably. I'm not expecting anything 
for myself any longer (II. i). 

He visits in a household of un- 
happy people that is set into com- 
motion by the return of Professor 
Serebriakov and his new wife 
Yelena. who is young, beautiful 
and bored. She is too weak to resisi 
the advances of Dr. Astrov. whc 
fawns on her beautiful emptiness 
and she alone realizes him as a vis- 
ionary: 

He has breadth of outlook. He plants a 
tree and wt>nders what will come of it 
in a thousand years" time, and specu- 
lates on the future happiness of man- 
kind. Such people are rare, and we 

must love them \ talented man 

can't stay free from blemishes m Rus- 
sia (11.1).' 



t 



30 



Vol. 37, No. f 



This vision is lost to Sonya. who 
in her love for Astrov can only mar- 
vel: "He's so clever. He can do any- 
thing. He treats the sick and plants 
forests too!'" (11. i). Vanya admires 
Dr. Astrov too. who is able to dis- 
suade him from suicide but can offer 
no reason for living. "What can 1 
do? What can I do?" asks Vanya; 
"Nothing," is Dr. Astrov's only 
reply (IV, i). This exchange is cru- 
cial because it shows Astrov as a 
pathetic person who can see nothing 
positive other than trees. As for 
himself, Astrov is reduced to the 
vague hope "that when we're at rest 
in our graves we may see visions — 
perhaps even pleasant ones" (IV. i). 

In Tri Syostiy (The Three Sisters, 
1901), the last of Chekhov's stage 
doctors. Chebutykin, transcends il- 
lusions to attain nonexistence. At 
60, he admits to being "a lonely, 
utterly unimportant old man" (I.i). 
He is a permanent "guest" on the 
sisters' estate. A good doctor 25 
years ago, Chebutykin has forgot- 



ten everything he once knew. He 
curses the other characters because 
they expect that he can treat any 
ailment just because he is a physi- 
cian. He counteracts his ignorance 
and insecurity with vodka and, like 
a true existentialist, wails over his 
very being: 

I've forgotten everything I used to 
knovw I remember nothing, nothing. 
. . . Perhaps I'm not a man at all, hut I 
just imagine that I've got hands and 
feet and a head. Perhaps I don't exist 
at all, and I only imagine that I'm 
walking about and eating and sleep- 
ing. [Cries. \ Oh, if only I could simply 
stop existing! (Ill.i). 

This article has given a new 
perspective to Chekhov, showing 
him as a doctor who was a writer 
rather than a writer who was a doc- 
tor. Hopefully, it sheds some light 
on the doctors he created and shows 
how they are, in part, projections of 
Chekhov's own concerns of the 
weaknesses of his own world and 
his inability to change anything 
about it. Even his concern as a 
playwright was. through his doc- 



tors, a curing of the ills he saw in the 

society around him. 

All 1 wanted to say honestly to people 
was: 'Have a look at yourselves and 
see how bad and dreary your lives 
are!" It is important that people realize 
this, for when they do, they w. ill most 
certainly create another and better life 
forthemselves. I will not live to see it. 
but 1 know that it will be quite differ- 
ent, quite unlike our present life. And 
so long as this different life does not 
exist. I go on saying to people again 
and again: 'Please, understand that 
your life is bad and dreary!'," 

References 

1 >armolinsk\ .A (ed): LtUirs nj Anton Chfkhov New 
York Viking Press. 1973 .All quolalions are laken from 
here I unless otherw. ise noted I and are daled according lo 
the Old Style Calendar, 

2 Duclos HB.Antone Tcliekhov, ie medecm el lecnvain. 
these pour Ie doctoral en medectne. Paris: Grasset. 
19:7 

3 Pergusson F: 7^1*- /Je(j oy « r/iffl/e'r Princeton Prince- 
ton Liniversitv Press, 1960 

4. Gilles D: Chekhov. Observer Without IHuium. tr. C. L. 
Markmann New York: Funk and Wagnalls. 196S. 

-^. Gorky M, el al: Remintscence.s of Anton Chekhov, tr, S. 
S. Kolehansky and L. Woir New York: n.p , 1921 

fi Kolehansky SS.n. Notebook.-, ot Anton Chekhov Lon- 
don: n.p., 1921, 

7 Magarshack D: Chekhov. A Lile New York: Grove 
Press, 19.^2 

8 Simmons EJ: Chekhov. A Bioiirapiiw Boston: Little, 
Brown, 1962 

9 Toumano^a PnncessNA:y4n/*>n C/iei/«)i', Tfie VoiceoJ 
Twtlii^ht in Russia. New York: Columbia University 
Press, 1960. 

Ml Fen E, tr. Chekhow Plays, introduction Baltimore 

Penguin Classics. 1973. 
I I Briistein R The Theater o) Re\olt. New York. Little. 

Brown & Company, 1964 



The physiological action of food and drink on the stomach is shown more on other organs and parts 
than in the stomach itself. When the quantity is moderate and the quality simple, there is nothing more 
experienced than a general sense of refreshment, and the restitution of vigour, if some degree of 
e.xhaustion have been previously induced. We are then fit for either mental or corporeal exertion,* But 
let a full meal be made, and let a certain quantity of wine or other stimulating liquor be taken; — we still 
feel no distinct sensation in the stomach; but we experience a degree of general excitement or exhilara- 
tion. The circulation is quickened — the face shews an increase of colour — the countenance becomes 
more animated — the ideas more fluent, — 

*1 should, perhaps, except the dinner meal, which is always followed by some degree of mental and 
corporeal inaptitude for exercise, however temperate the repast, especially in civilized, or artificial 
modes of life, — An Essay on Indigestion: or Morbid Sensibility of the Stomach & Bowels. James 
Johnson, 1836, p 5, 



January 1976. NCMJ 



31 










;^*«. 



lUr fUin (dyphylline) 

Before prescribing, please review complete prod- 
uct information, a summary of which follows: 

Indications: For relief of acute bronchial asthma 
and for reversible bronchospasm associated with 
chronic bronchitis and emphysema ■■::•>■'": 



Precautions: 

"presence of severe 
natih malfun( 



peptic ulcer, 
thine-contaimVi 
ulating drugs* 



^mBm«.»IWHfll.ilB: 



Adverse Reactior^: May cause nausea, headasnl 
cardiac palpitation and CNS stimulation. Posi 
prandial administration may help to avoid gastril 
discomfort. ■*, » ._, i 



iac disease^ 

lucoma, hypl 
cicomitant use of other xan-| 
tions or other CNS stim- 



. jb i^ ^£l. 



i-hg., Tablets^ NBC^^-RSZiij 
tR521-97, bottleiW 100^^ 
'mC 19-R515-68, pint bajf* 
^allon bottle. -*>• ._ _ 
tion: NDC 19-R537-X2, box^o 



w 



For relief of acute bronchial asthma and for reversible bronchospasm 
associated with chronic bronchitis and emphysema. 



UU\J...a basic need for the 
Cdyphyllino) J»nchospastic patif lit., 



blets: 200mgdyphylline 
ixir: per15ml:dyphylline100mg, 
alcohol 20% v/v 



iS bronchodilator with a difference... dyphylline. 



A NEED FOR YOUR PATIENT 
BECAUSE 

1 . Therapeutically effective 

2. Little to no CNS stimulation 

3. Little to no gastric upset 

4. Effective during long-term therapy 

5. Only 1/5 the toxicity of 
theophylline or aminophylllne '^^ 
(based on animal studies) 



111 ! REFERENCES 

Poi 1. McColl, J. D., et al; J. Pharm. & Exp. Therap. 

fill 116:343, 1956 



I 2. Quevauville 




Mallinckrodt 



Pharmaceuticals, 



-ouis, Missouri 63147 




Editorials 



SUGGESTIONS FOR AUTHORS 

The North Carolina Medical Journal wel- 
comes original contributions to its scientific pages, 
expecting only that they be under review solely by this 
Journal at a given time, and that they follow a few 
simple guidelines. The guidelines are as follows: 

1. Subject Matter 

Educational articles, especially those in which particular applica- 
tions to the practice of medicine in North Carolina are developed, 
are one of the main objectives of this Journal. 

Articles reporting original work by North Carolina physicians are 
invited, whether the work is done in a clinic, a laboratory, or both. 
The editor and his consultants will evaluate the work by the usual 
criteria, including a proper discussion of previous work, control 
observations, and statistical tests where indicated. 

Historical articles, especially those dealing with local history, are 
considered of real value and interest. 

2. Manuscripts 

An original and a carbon copy of the manuscript should be sub- 
mitted, one for review by the editorial staff, the other by referees. 
The manuscript should be typed on standard-size paper, double- 
spaced, with wide margins (one inch on each side). 

3. Bibliographic References 

References to books and articles should be indicated by consecu- 
tive numerals throughout the text and then typed, double-spaced, 
on a separate page at the end of the manuscript. Books and articles 
not indicated by numerals in the paper should not be included. 

References will be much more valuable to the reader if they are 
given in a proper form and contain the full information necessary to 
locate them easily. The North C.arolin,^ Medic.\l Journal fol- 
lows the form used in the journals of the American Medical Associa- 
tion and the Index Meduus. giving the author's surname and ini- 
tials, title of the article, name of the periodical, volume, inclusive 
page numbers, and ihe date of publication. It is believed that this 
style makes it easier for the reader to judge w hether the reference is 
likely to prove useful to him. and enables him to locate it more 
quickly. 

4. Tables and Illustrations 

Tables and legends for illustrations should be typed on separate 
sheets of paper. The illustrations should be glossy black-and-white 
prints or line drawings. It is necessary to obtain permission from the 
author or publisher to reproduce illustrations which have been 
published elsewhere. Costs in excess of $15.00 for illustrations are 
borne by the author. Costs for setting of tables are also borne by the 
author as are charges for art work which might be needed for proper 
printing of figures. 

5. Style 

The style followed by this Journal will be. in general, that 
outlined in the Style Book issued by the Scientific Publications 
Division of the American Medical Association. John H. Talbot. 
M.D.. director. All manuscripts are subject to editorial revision for 
such matters as spelling, grammar, and the like. 

By following the above suggestions, writers will greatly expedite 
the publication of papers accepted by the North Carolina Medi- 
cal Journal. 



OF SEX AND SCIENCE 

Sometimes it is a relief to turn from the animal 
world (R and X-rated movies, television shows about 

34 



prostitutes with hearts of gold, the underwhelming 
novels of Harold Robbins, and surveys about premari- 
tal intercourse in mixed college dormitories) to the 
plant kingdom where such matters are so neatly or- 
dered as not to be responsive to manipulation of the 
media. On closer examination we find that plants have 
had to cooperate with animals to ensure survival of the 
species just as a man sometimes has to "say it with 
flowers." 

Recently, the Journal has seen fit to comment on the 
intimate relationship between milkweed and monarch 
butterfly which allows the animal to protect itself from 
predators by feeding in its larval stage on the plant 
from which it sequesters cardenolides. Danaids con- 
tinue their dependence on plants during later life feed- 
ing on some containing pyrrolizadionone or related 
heterocyclic compounds which are chemicals related^ 
to the male sex attractants — pheromones. A similar 
association has now been observed between black oak 
leaves from which pheromones in complex combina- 
tion have been identified chromatographically and the 
destructive male oak leaf roller moth who may ever 
try to copulate with leaves damaged by feeding larvae 
which, if to be females of the species, might be extract- 
ing the attractant compounds from the leaves.' Some 
21 isomeric tetradecenylacetates have been found ir 
the sexual attractant fraction of the female moth; ac 
tivity is confirmed by using the antennae of the maid 
moth as a test organ and measuring its response. Ap 
pie leaves contain similar compounds and the frui 
tree tortix moth cannot be reared in the laboratorj 
without apple leaves — experimental confirmation o 
an ancient Near Eastern myth. 

These findings have extensive ecological implica 
tions. If synthetic sex pheromones can be made avaif 
able, specific plant pests can be controlled withou 
harm to the innocent. For example, the Douglas-fi 
tussock moth recently returned to the Northwest am 
DDT was used, despite protests, to eradicate the pest 
although it appears that moth populations were al 
ready declining when it was applied. A synthetic / 
isomer, seemingly much more effective than tb 
synthetic E isomer of the pheromone of this moth, i 
now available and may be the means of preventing tb 
periodic drastic defoliations caused when they ge 
hungry. - 

The emergence of behavioral endocrinology'' wit 
its promising antipollutional potential can only b 
welcomed, particularly if it will allow us to abando' 
dangerous pesticides and herbicides. There is littl 
likelihood that we need worry about trying to contrc 



|.ibi 

ii 



'j,i 



-lif 



Vol. 37. No. 



li 



the human population with synthetic sex attractants 
but we may have more effective, safer and cheaper 
jcontraceptive agents as a resuh. Still we must be 
cautious. That the Food and Drug Administration has 
enough to do and enough undone probably won't pre- 
vent congressional attempts to assign it control of 
perfumes, colognes and pheromones. Still it might be 



bettertoleaveittothe FDA, than to the Pentagon or to 
the CIA. 

References 

1, Hendry LB. Wichmann JK. Hindentong DM. Mumma RO, Anderson ME: Evidence 
(orongin of insect sex pheromones: presence in food plants. Science I8K: 59-63. 1975 

2 Smith RG. Daterman GE. Daves GD Jr: Douglas-t~ir tussock moth: sex pheromone 
idenlitlcation and synthesis Science 188: 63-64. 1975 

1 Beach FA: Behavioral endocrinology: an emerging dtsciphne American Scientist 63 
17S-187. 1975. 



Bulletin Board 



NEW MEMBERS 

of the State Society 



Allen. Robert Wilson, Jr., MD (PD). 124 Foye Drive, Rocky Mount 

27801 
Almond, Charles Malcolm, MD (FP). P.O. Box 40, Tarboro 27886 
Bynum, Robert Willia. IV (STUDENT), 201-D Bolinwood Apts., 

Chapel Hill 27514 
Chaney, Nancy Elizabeth (STUDENT), Fidelity Ct.. Apt. 52, 
, Carrboro 27510 

Chung, II Whan, MD (U), Medical Building, Sylva 28779 
Clark, Terence Peter. MD (EM). P.O. Box 622. Cullowhee 28723 
Credle. William Frontis, Jr.. MD (IM), 1202 Medical Center Dr.. 

Wilmington 28401 
Drake, James Edwin. MD (R). 2921 Round Hill Rd., Greensboro 

27405 

■ Dudley, Robert Edward, MD (P), 837 Cherokee PI. SW. Lenoir 

28645 
Eagle, Elizabeth Anne (STUDENT), 353 Craige Hall. UNC, 
. Chapel Hill 27514 
■Elkins, Wilson Oliver, MD (FP), 1607 Efland Dr.. Greensboro 

■ ■ 27408 

1 :Green, Ray Lyman, MD (DBG), 2024 Westover Terrace, flur- 
ry ' lington 27215 

Hawes, Samuel Pinckney, 111, MD (U). 2019 Colwyn PI. Charlotte 

" • 28211 

! Hinds, Caria Jean (STUDENT), 17-G Booker Creek Apts, Chapel 
Hill 27514 
Hunter. Rosemary Sundborg. MD(CHP), UNC, Div. of Child Psy., 

i: Chapel Hill 27514 

, Kendrick, Paul Wayne, MD (IM), 1705 W. Sixth St., Greenville 
27834 
Kim, Yong Kie, MD (NS), 201 W. McDowell St., Morganton 28655 

y: Krohn, John Ramon, MD (PS). 1125 Medical Center Dr.. Wil- 
mington 28401 

- Leppert, Phyllis Carolyn, MD (INTERN-RESlDENT). 200 Seven 

<■ ' Oaks Rd.. Durham 27704 

■ Lonchyna. Vassyl Andrey. MD (INTERN-RESIDENT), 1315 

Morreene Rd.. Apt. 7G. Durham 27705 

■ Malekpour. Bahman. MD (INTERN-RESIDENT). Box 74. Cherry 
t I Hospital. Goldsboro 27530 

|, Mancusi-Ungaro, Peter Curt. MD (HEM). 2131 S. 17th St., Wil- 
mington 28401 

b- ^IcLear, Ronald Kent, MD (INTERN-RESIDENT), 17 Balmoray 
; ; Ct. #18, Durham 27707 
McRee, Jean Douglas, MD (P), Dorothea Dix Hosp.. Station B, 
Raleigh 27602 

a: Miller, John Noel. MD (AN). Box 3094, Duke Med. Ctr., Durham 

, i I 27710 

• ' Neale, Wirt Thomas, MD (PD), Ste. 1018, 1900 Randolph Rd., 

C* ' Charlotte 28207 

llll jPike, Isadore Murray, MD (HEM), 160 Country Club Rd.. 

,„ I Asheville 28804 



Plimpton, Herbert Wheatley, Jr. (STUDENT), Apt. 2-C. Booker 
Creek Apts.. Chapel Hill 27514 

Robinson. Stephen Carey, MD (NS), 3701 Mossborough Dr.. 
Greensboro 27401 

Saad. Maged Hanna. MD (INTERN-RESIDENT), 1512 Kennon 
Rd.. Gamer 27526 

Stewart. George Terry, MD (OBG), 16 Forest Hills Dr.. Wil- 
mington 28401 

Stiegel. Robert Mark (STUDENT), 215-B Vance St., Chapel Hill 
27514 

Tasher. Jacob. MD (INTERN-RESIDENT), 304 Anderson St.. 
Durham 27705 

Trought, William Stanlev,MD(R), 402 1 Bristol Rd., Durham 27707 

Vaught. William Wayne. Jr., MD (ENT), 1610 Vaughn Rd., Bur- 
lington 27215 



WHAT? WHEN? WHERE? 

In Continuing Education 



Ianuary 1976, NCMJ 



Please note: I. The Continuing Medical Education Programs of the 
Bowman Gray. Duke and UNC Schools of Medicine art accredited 
by the American Medical Association. Therefore CME programs 
sponsored or co-sponsored by these schools automatically qualify 
for AMA Category 1 credit toward the AMA Physician's Recogni- 
tion Award, and for North Carolina Medical Society Category "A" 
credit. Where AAFP credit has been requested or obtained, this 
also is indicated. 

2. The "place" and "sponsor" are indicated for a program only 
when these differ from the place and source to write "for informa- 
tion." 

PROGRAMS IN NORTH CAROLINA 
February 7-8 

Endoscopy Workshop (re-scheduled from December 6-7. 1975) 

Place; Berry hill Hall 

Sponsors: Department of Medicine and the Office of Continuing 

Education. UNC School of Medicine 
Fee: $75; enrollment limited to 100 
Credit: AAFP credit applied for 
For Information: Oscar L. Sapp, 111, M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine. Chapel Hill 

27514 

February 11 

Wingate M. Johnson Memorial Lecture 

Place and time: Babcock Auditorium. 11:00 a.m. 

Speaker; Dr. Grant Liddle. Professorand Chairman. Department of 

Medicine. Vanderbilt University School of Medicine 
Credit; 2 hours 
For Information: Emery C. Miller. M.D.. Associate Dean for Con- 



35 



tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 

February 21-22 

Clinical Application of Biochemical Determination in Drug Treat- 
ment of Affective Disorders 

For Information: Joseph Parker, M.D., Department of Psychiatry. 
Box 3837. Duke University Medical Center. Durham 27710 

February 23-27 
The Management of Craniofacial Pam 
Sponsors: UNC School of Dentistry. School of Medicine. Dental 

Research Center and School of Nursing. F*resented by UNC Pain 

Clinic 
Fee: $200; enrollment limited to 80 participants 
Credit: 29 hours; AAFP credit applied for 
For Information: Oscar L. Sapp. 111. M.D., Associate Dean for 

Continuing Education. UNC School of Medicine. Chapel Hill 

27514 

February 26 

Cosmetic Surgery 

Place: Country Club of Southern Pines (Elks Club) 
Sponsors: Moore Memorial Hospital & UNC School of Medicine 
Fee: $11.50 

Credit: 2 hours: AMA Category I and AAFP approved 
For Information: C. H. Steffe. M.D., P.O. Box 3000, Pinehurst 
28374 

March 5-6 

General Diagnostic Radiology Updated 

Fee: $100 

Credit: 9 hours; AAFP credit applied for 

For Information: Emery C. Miller, M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 

March 19-20 

E. C. Hamblen Symposium in Reproductive Biology and Family 

Planning 
For Information: Charles B. Hammond, M.D.. Box 3143, Duke 

University Medical Center. Durham 27710 

March 22-26 

Radiology of the Urinary Tract — A Tutorial Postgraduate Course 

Program: Emphasis on personalized small group tutorial type teach- 
ing. Subject matter will cover all facets of urinary tract disease, 
including comprehensive coverage of diagnostic techniques 

Fee: $300 

Credit: 30 hours 

For Information: Robert McLelland. M.D.. Radiology. Box 3808. 
Duke University Medical Center. Durham 27710 

March 25-26 

Medical Alumni Day and Scientific Meetings 

Place: Berryhill Hall 

Sponsor: Office of Continuing Education and Alumni Affairs 

Credit: To be announced 

For Information: Oscar L. Sapp, III, M.D., Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 

March 26 

Symposium on Alcoholism 

Fee: $25 

Credit: 6 hours; AAFP credit applied for 

For Information: Emery C. Miller, M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine, 
Winston-Salem 27103 

March 29-30 

Obstetrics and Gynecology Postgraduate Course 

Fee: $35 

Credit: 9 hours; AAFP credit applied for 

For Information: Emery C. Miller, M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 

April 9-10 
(note change of date) 

Annual Arthritis Symposium 

For Information: Oscar i^. Sapp. III. M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 



36 



April 9-10 

Practical Pediatrics 

Fee: $35 

Credit: 9 hours; AAFP credit applied for 

For Information: Emery C. Miller. M.D., Associate Dean forCon- 

tinuing Education, Bowman Gray School of Medicine 

Winston-Salem 27103 

April 16-17 

Practical Nuclear Medicine: Emphasis Oncology 

Fee: $75 

Credit; 9 hours; AAFP credit applied for 

For Information: Emery C. Miller. M.D., Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine, 
Winston-Salem 27103 

April 22 ' 

New Bern Annual Medical Symposium — 1976, "Pulmonan 

Medicine" 
Place: Ramada Inn, New Bern 

Sponsor: Craven - Pamlico - Jones County Medical Society 
Credit: 5 hours; AAFP credit applied for 
ForInformation:Zack J. Waters. M.D.. Box 1089, New Bern 2856(t 

AprU 23-24 

Perinatology Post-Graduate Course 

For Information: Oscar L. Sapp. III. M.D.. Associate Dean foi 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 

April 23-30 j 

Medical Symposium — Cruise to Bermuda i 

Sponsors: Bowman Gray School of Medicine and the Medical Uni- 
versity of South Carolina 
For Information: Emery C. Miller, M.D.. Associate Dean for Con 
tinuing Education, Bowman Gray School of Medicinei 
Winston-Salem 27103 , 

April 30-May 1 ! 

(note change in date) i 

Diving Deafness and Related Physiology j 

Fee: $35 j 

Credit: 9 hours; AAFP credit applied for 

For Information: Emery C. Miller. M.D.. Associate Dean for Con 
tinuing Education. Bowman Gray School of Medicine 
Winston-Salem 27103 

May 6-9 

122nd Annual Session of the North Carolina Medical Society 
Place: Pinehurst Hotel and Country Club. Pinehurst 
For Information: William N. Hilliard. Executive Director. Nortl 
Carolina Medical Society. Box 27167. Raleigh 27611 

May 7-9 

Pulmonary Infections in Pediatric Patients 
Place: Quail Roost Conference Center. Rougemont 
Registration: Limited to 50 participants 
Credit: 11 hours; A.AFP credit applied for 
For Information: Alexander Spock. M.D.. P.O. Box 2994. Duki, 
University Medical Center. Durham 27710 i_ 

May 12-13 

Breath of Spring "76: Respiratory Care Symposium 

Fee: $25 

Credit: 12 hours; AAFP credit applied for 

For Information: Emery C. Miller, M.D., Associate Dean for Con 

tinuing Education, Bowman Gray School of Medicine 

Winston-Salem 27103 

May 27-28 
The 27th Scientific Session and Annual Meeting of the Nort 

Carolina Heart Association 
Place: Benton Convention Center and the Winston-Salem Hyat 

House, Winston-Salem 
Sponsors: The North Carolina Chapter of the American College o 

Cardiology will be one of the co-sponsors of the sessions, and wil 

hold its sessions, which are open to all physicians, on May 28 

Special concurrent sessions will be held for nurses, emergenc; 

medical technicians, and cardiology technologists 
For Information: Thomas R. Griggs. M.D., North Carolina Hear 

Association, P.O. Box 2408. Chapel Hill 27514 

Vol. 37, No, 



^:is 



ITEMS OK SPECIAL INTEREST 
Series of Postgraduate Medical Programs 

The First Medical District, in cooperation svith the UNC Medical 

School's Office of Continuing Education, will sponsor a series of 

continuing medical education meetings, with dates and places as 

follows: 
February 4 Elizabeth City 
February 1 1 Edenton 
Presentations will be from 4 to 5 p.m. and from 7:.^0 to 8:30 p.m.. 

with dinner served in the interim. 
Credit (for the series) is 12 hours: AAFP credit applied for 
For information contact Oscar L. Sapp. ill. M.D.. .Associate 

Dean for Continuing Education. UNC School of Medicine. Chapel 

Hill 27514 

Continuing Education for Nurses 

(The meetings listed below will be held in Carrington Hall. UNC 

School of Nursing. Chapel Hill, unless otherwise indicated. The 

numbers in parantheses indicate the number of course contact 

hours.) 

February 4-13: Preparation for Implementing the Problem- 
Oriented Medical Record System (30) 

February 24-25: Nursing .Audit (12) 

'February 25-26: A New Look At Patient Teaching (13) 

February 25-26: (at Hickory); Oncology and Enterostomal 
Therapy 

April 21-22: (at Salisbury): Oncology and Enterostomal 

Therapy 

April 5-9: Practical .Approaches to Diabetic Care (35) 

April 20-21: Primary Care Nursing (12) 

April 26-30: Nursing Process (30)" 

.April 29: Toward More Effective Diabetic Teaching (6) 

April 29: (at Boone): Neonatal Workshop — Immediate 

Care of the High Risk Infant 

July 12-15: (at the Blue Ridge .Assembly. Black Mountain): 

Challenge and Change in Lung Disease 

For Information on the above programs contact the Continuing 
Education Program. UNC School of Nursing. Chapel Hill: for 
programs number 4. 5 and 10 contact Mrs. Judy Soper. Nursing 
Education Director. Northwest .AHEC. Bowman Gray School of 
Medicine. Winston-Salem 27103. For the last program contact C. 
Scott Venable. Executive Director. North Carolina Lung .As- 
sociation. 916 West Morgan St.. Box 127. Raleigh 27602 

Cancer Seminars 

"Principles in Clinical Oncology." a series of seminars on 
patient-care related topics in cancer research and treatment, is 
being presented as part of the Clinical Cancer Education Program 
:CCEP) at the UNC School of Medicine. Chapel Hill. Topics range 
from carcinogenic factors to the clinician's relationship with the 
:ancer patient and the patient's family. 
. , Seminar dates are January 13. 20 & 27. and February 3. Meeting 
:ime is 7:30 p.m. in the Board Room of the North Carolina Me- 
■norial Hospital. Chapel Hill. Meetings are open to all interested 
Undents, staff, faculty and practicing physicians. 

For further information contact Dr. James F. Newsome or Dr. 
lames Lea, UNC School of Medicine. Chapel Hill 27514 

I! Hypertension Seminars for Dentists 

The North Carolina Regional Medical Program, the North 

. Carolina Heart Association, the North Carolina Medical Society 

ind the UNC School of Dentistry are cosponsonng a series of 

hypertension seminars to be held throughout the state of North 

Carolina. Dates and places of the remaining seminars are as follows: 

February 7 Charlotte 

February 28 Greenville 

March 20 Wilmington 

For Information: North Carolina Heart Association, P.O. Box 
fli 2408. Chapel Hill 27514 

I niversitv of Maryland CME 

The Program of Continuing Education of the University of Mary- 
and School of Medicine has a broad range of two and three day 
"ME courses available to interested physicians. The schedule 
hrough the 1975-1976 academic year includes such topics as 
leuropathology, dermatology, gastroenterology, blood diseases, 
lulmonary conditions, psychiatry for the family physician, internal 
Tiedicine. sexual abuse, obstetrics, child development, drug abuse 
ind a family practice review course. 
, fOr Information: Steven L. Barber, Educational Coordinator, 
Program of Continuing Education, University of Maryland 
School of Medicine, 29 South Greene Street, Baltimore, .Mary- 
land 21201 



PROGRAMS IN CONTIGUOUS STATES 
February 5-6 

Symposium on Recent Advances in Bacterial & 'Viral Gastroen- 
teritis 

Sponsors: Department of Continuing Education and the Depart- 
ment of Microbiology 

Fee: $50 

Credit: 12'2 hours: AMA Category 1: AAFP credit applied for 

For Information: Department of Continuing Education. School of 
Medicine. Medical Collece of Virginia. Box 91. Richmond. Vir- 
ginia 23298 

February 15-21 

Seventh Annual Family Practice Refresher Course 

Place: Mills Hyatt House Hotel. Charleston. S.C.. with visits to 

various units of the Medical University complex for tours and 

demonstrations 
Program: Topics covered will include internal medicine, pediatrics. 

surgery, psychiatry and community health 
Fee: SI 50 payable on or before February 1 : fee includes social hour 

and banquet to which spouses are cordially invited. Participant 

enrollment is limited to 75 
Credit: 40 hours: .A.AFP approved 

For Information: Dr. Vince Moseley. Director. Division of Continu- 
ing Education. Medical University of South Carolina. SO Barte 

Street. Charieston. S.C. 29401 

May 10-13 

The Frontiers in Cardiology 

Place: Royal Coach Motor Hotel. Atlanta, Georgia 

Sponsors: Council on Clinical Cardiology, American Heart Associ- 
ation: Department of Medicine, Emory University School of 
Medicine in cooperation with the Georgia Heart .Association 

Fee: ACC members $125; non-members $175 

Credit: .AMA Category I 

For Information: Miss Mary .Anne Mclnemy. Director. Depart- 
ment of Continuing Education Programs, American College of 
Cardiology, 9650 Rockville Pike, Bethesda. Maryland 20014 

Medical College of Virginia 

The number in parenthesis, following the title, indicates the 
number of hours for that particular course. 
February 5-6 Symposium on Recent .Advances in Bacterial and 

Viral Gastroenteritis (12' 2) 
February 18 Pediatric Menatology — Oncology for the Practic- 
ing Physician (4) 
February 29- Radiology of the G. U. Tract (24) 
March 4 (This program will be held in Williamsburg. 

Virginia) 
March 18 Neonatology for the Practicing Physician (4) 

March 25-26 29th .Annual Stoneburner Lecture Series — 

Neurology for Primary Care Physicians (12) 
April 1 Pediatric Cardiology for the Practicing Physician 

(4) 
Apnl 22 Medico-Legal Workshop (5) 

(Place: Virginia Baptist Hospital, Lynchburg. 

Virginia) 
May 17-18 EEG Symposium (14) 

May 21 Annual Spring Forum for Child Psychiatry (4) 

June 2 Pediatric Nephrology for Practicing Physicians (4) 

For further information on the above CME opportunities write to 
the Department of Continuing Education. School of Medicine. 
Medical College of Virginia. Box 91. Richmond. Virginia 23298 



The items listed in this column are for the six months immediately 
following the month of publication. Requests for listing should be 
received by WHAT'.' WHEN' WHERE?. P.O. Box 15249. 
Durham. N.C. 27704. by the 10th of the month prior to the month in 
which they are to appear. ,A "Request for Listing" form is available 
on request. 



Janu.a>ry 1976. NCMJ 



37 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



In September the state auxiliary president, Mrs. 
Charles Herring, made her report to the executive 
council of the North Carolina Medical Society. The 
highlights of her report deserve repetition. 

MEMBERSHIP 

Auxiliary membership is at an all-time high of 2,890. 
with 2,867 also members of the auxiliary of the Ameri- 
can Medical Association. Sixty-nine of North Caroli- 
na's 100 counties are organized into 51 auxiliaries. 

The year's activities began in May with a leaders' 
workshop emphasizing legislation, family and com- 
munity health and health education. Additional work- 
shops were held in September — in Kinston for the 
eastern counties and in Winston-Salem for the rest of 
the counties — with 150 auxiliary leaders attending. 

LOANS, GRANTS AND DONATIONS 

Five student loans of $500 each were made by the 
auxiliary last year. Three more have been given since 
June 1975, and another is being processed. None of 
the auxiliary's outstanding 60 loans is past due. Since 
June of 1964, 28 loans in the amount of $13,450 have 
been repaid. 

This year's interest of $1 ,350. 76 from the auxiliary's 
$20,000 Mental Health Research Endowment Fund 
was given to the Department of Psychiatry at the 
University of North Carolina at Chapel Hill for use in 
the area of child mental health. 

The auxiliary is striving to improve cooperation and 
communication between old and new members so that 
projects such as the AMA-ERF can be more effective. 
Last year the state auxiliary gave $23,950.71 to 
AMA-ERF, small in comparison to donations by other 
state auxiliaries. 

LEGISLATION AND EDUCATION 

The auxiliary's state legislation chairman, Mrs. 
Charles Hoffman, is working closely with the medical 
society's Steve Morrisette on all legislative matters 
and keeping the auxiliary informed as to what action to 
take. 

The auxiliary is working in school systems to im- 
prove the caliber of health education. A committee of 
five auxiliary members is working with five represen- 
tatives of the medical society and the Department of 
Public Instruction in this area. 

The auxiliary is promoting a new film series, "Self 
Incorporated," along the same lines as last year's 
"Inside/Out" series carried by public broadcasting. 

In keeping with th^ celebration of the bicentennial, 
the auxiliary is collecting the histories of medicine in 
counties throughout the state. 



38 



PRESCRIBING INFORMATION 
Antiminth (pyrantel pamoate) Oral 
Suspension 

Actions. Antiminth (pyrantel pamo- 
ate) has demonstrated anthelmintic 
activity against Enterobtus vermicu- 
laris (pinworm) and Ascaris lumbri- 
coides (roundworm). The anthelmin- 
tic action is probably due to the 
neuromuscular blocking property of 
the drug. 

Antiminth is partially absorbed 
after an oral dose. Plasma levels of 
unchanged drug are low. Peak levels 
(0.05-0.I3;iig/ml.) are reached in 1-3 
hours. Quantities greater than 50% 
of administered drug are excreted in 
feces as the unchanged form, whereas 
only 7% or less of the dose is found 
in urine as the unchanged form of 
the drug and its metabolites. 
Indications. For the treatment of 
ascariasis (roundworm infection) and 
enterobiasis (pinworm infection). 
Warnings. Usage in Pregnancy: Re- 
production studies have been per- 
formed in animals and there was no 
evidence of propensity for harm to 
the fetus. The relevance to the hu- 
man is not known. 

There is no experience in preg- 
nant women who have received this 
drug. 

Precautions. Minor transient eleva- 
tions of SCOT have occurred in a 
small percentage of patients. There- 
fore, this drug should be used with 
caution in patients with pre-existing 
liver dysfunction. 

Adverse Reactions. The most fre- 
quently encountered adverse reac- 
tions are related to the gastrointes- 
tinal system. 

Gastrointestinal and hepatic reac- 
tions: anorexia, nausea, vomiting, 
gastralgia, abdominal cramps, diar- 
rhea and tenesmus, transient eleva- 
tion of SGOT 

CNS reactions: headache, dizzi- 
ness, drowsiness, and insomnia. Skin 
reactions: rashes. 

Dosage and Administration. Chil- 
dren and Adults: .Antiminth Oral 
Suspension (50 mg. of pyrantel base/ 
ml.) should be administered in a 
single dose of 1 1 mg. of pyrantel base 
per kg. of body weight (or 5 mg./lb.); 
maximum total dose 1 gram. This 
corresponds to a simplified dosage 
regimen of 1 cc. of Antiminth per 10 
lb. of body weight. (One teaspoonful 
= 5 cc.) 

Antiminth (pyrantel pamoate) 
Oral Suspension may be adminis- 
tered without regard to ingestion of 
food or time of day, and purging is 
not necessary prior to, during, or 
after therapy. It may be taken with 
milk or fruit juices. 
How Supplied. Antiminth is avail- 
able as a pleasant tasting caramel- 
flavored suspension which contains 
the equivalent of 50 mg. pyrantel 
base per ml., supplied in 60 cc. bot- 
tles and Unitcups'^" of 5 cc. in pack- 
ages of 12. 

ROeRIG<0 

A division of Pfizer Pharmaceuticals 
New York, New York 10017 



VIORNS BLITZED 




A single dose of Antiminth 
( 1 cc per 10 lbs. of body 
weight, 1 tsp 750 lbs— max- 
imum dose, 4 tsp=20 cc ) 
offers highly effective control 
of both pmworms and 
roundworms - 

AntimLith has been shown 
to be extremely well tolerated 
by children and adults alike 
in clinical studies* Pleasantly 
caramel-flavored, it is 
non-staining to teeth and oral 
mucosa on ingestion,,, 
doesn't stam stools, linen or 
clothing. 

One prescnption can 
economically treat the entire 
family 

ROGRIG <0 

A division of Pfizer Pharmaceuticals 
New York New York 10017 



NSN 6505-00-148-6967 



Pinworms, roundworms controlled 
with a single, non-staining dose of 

ANTIMINTH 

(pyrantel pamoate) 



, 'Dala on file at Roeng. 



equi\alcnt to oO ni^ p\ rai-vtcl/ml. 

ORAL SUSPENSION 



Please see prescribing information on facing page 



I[ 



News Notes from the— 

UNIVERSITY OF NORTH CAROLINA 

DIVISION OF HEALTH AFFAIRS 



Dr. Thomas L. Hall has been named director of the 
Carohna Population Center (CPC) at the University of 
North Carolina at Chapel Hill. He has served as acting 
director of the Carolina Population Center (CPC) 
since early 1974. 

Dr. Hall came to Chapel Hill in 1971 from the Johns 
Hopkins School of Hygiene and Public Health. He 
joined the UNC faculty as an associate professor in 
the department of health administration in the School 
of Public Health and as deputy director of the CPC. In 
1974 he was promoted to professor. 

As an interdisciplinary unit within the University of 
North Carolina at Chapel Hill, the Carolina Popula- 
tion Center supports a comprehensive program of re- 
search, education and service in the population and 
family planning fields. CPC began operations in July, 
1966. Currently it supports and gives cohesion to the 
participation in population activities of more than 150 
faculty associates in a number of schools, depart- 
ments and institutions on the UNC-CH campus. 

The center is one of the largest and most diverse 
university-based population programs in the world. 



Dr. Ralph H. Boatman of the University of North 
Carolina at Chapel Hill is the new president-elect of 
the American Society of Allied Health Professions 
( AS AHP), an umbrella organization for over 200 allied 
health professions. 

Boatman is director of the Office of Continuing 
Education in Health Sciences and administrative dean 
and director of the Office of Allied Health Sciences at 
UNC. 

Boatman was elected in the Society's first general 
election at its eighth annual meeting. He will serve on 
the board as president-elect until November, 1976, 
when he will be installed as the Society's 10th presi- 
dent at the annual meeting in San Francisco. 



Two new departmental chairmen have been ap- 
pointed at the University of North Carolina School of 
Medicine at Chapel Hilll. 

Dr. James Neil Hayward, who comes to Chapel Hill 
July 1 from the Reed Neurological Research Center of 
the University of California at Los Angeles, will direct 
the department of neurology. 

Dr. Edward J. Shahady heads the department of 
family medicine. Formerly director of the family prac- 
tice residency program at Akron City Hospitals and 
chairman of family medicine at the College of 
Medicine of Northeastern Ohio Universities, he 
joined the UNC faculty on Jan. 1. 



The University of North Carolina School of 
Medicine at Chapel Hill has been awarded seed money 
for a new scholarship fund. 

Called the Carolina Country Family Medicine 
Scholarship Fund, it has been established through the' 
efforts of James A. Chaney, former editor of Carolina ' 
Country magazine. 

According to Chaney, the fund was started "to' 
stimulate among North Carolinians a willingness to' 
contribute whatever they can towards scholarships or' 
financial assistance for medical students interested in, 
going into family practice in rural North Carolina." i 

In addition to individual contributions, seed money 
for the fund will come from sales of the book 
"Carolina Country Reader," a collection of articles' 
Chaney wrote during his eight-year editorship of the 
magazine. 

Dr. William L. Fleming of the University of North 
Carolina School of Medicine at Chapel Hill has been 
presented the William Freeman Snow Award by the 
American Social Health Association (ASHA). 

The award, named after a founder of ASHA, recog- 
nizes those men and women who have made outstand- 
ing contributions to humanity. Since 1938, the associ- 
ation has recognized 34 individuals and one corpora- 
tion. 

Fleming and Dr. Bruce P. Webster of New York 
received the 1975 awards. Each was honored as "a 
man who devoted decades to lessening the fierce, 
onslaught of venereal disease against man- and 
woman-kind." 



Dr. Frank C. Wilson, chief of orthopaedic surgerj 
at the University of North Carolina School o1 
Medicine at Chapel Hill, has been installed as presi- 
dent of the N.C. Orthopaedic Association. 

Dr. Edward C. Cumen Jr., first chairman o 
pediatrics at the University of North Carolina Schoo 
of Medicine at Chapel Hill, was honored here Nov 
14-15. 

Curnen's colleagues and former students anc 
housestaff gathered in Chapel Hill for the dedicatior 
of the Edward C. Curnen Pediatric Library and Con- 
ference Room at The North Carolina Memorial Hospi- 
tal. 

The program in Curnen's honor was the highligh; 
of a two-day pediatric scientific meeting. 

New Faculty 

Curtis Harper, associate professor, department o 
pharmacology. School of Medicine, has been a senioli 
staff fellow in the pharmacology branch of the Nal 
tional Institute of Environmental Health Sciences ii 
the Research Triangle Park since 1972. He has been ; 
adjunct associate professor at UNC since 1973. HJ 
holds the B.S. and M.S. degrees from Tuskegee Insti 
tute, the M.S. degree from Iowa State University an(| 
the Ph.D. degree from the University of Missouri. 

Ramon U. Florenzano, assistant professor, del 
partment of psychiatry, School of Medicine, also wil| 



40 



Vol. 37. No. 



oe chief of the Alcoholism Program at the Orange- 
.^erson-Chatham Mental Health Center. A native of 
Chile, he earned his B.A. and M.D. from the Univer- 
sity of Chile and his M.P.H. from UNC-CH this year. 
Since 1973 he has been a part-time staff psychiatrist at 
the Orange-Person-Chatham Mental Health Center. 

North Carolina physicians with epileptic patients 
inder their care now have access to the only state- 
;upported anticonvulsant drug analytical laboratory 
n the country. 

Funded by the Department of Human Resources, 
he Epilepsy and Anticonvulsant Drug Research 
^boratory (EADRL) at the University of North 
^'arolina at Chapel Hill offers inexpensive drug level 
leterminations and free consultations to any physi- 
ian in the state. It is directed by Drs. Kenneth H. 
Dudley and Larry W. Boyles. 

An epilepsy workshop was held Dec. 13 to inform 
ihysicians of the latest techniques for managing 
pilepsy and to introduce the laboratory's facilities 
ind services. 



Dr. Joseph S. Haas, a widely known expert on 
Jaucoma, delivered the 14th annual McPherson Lec- 
ure Dec, 13 at the University of North Carolina 
school of Medicine at Chapel Hill, 
i The lecture was named in honor of the late Dr. 



Samuel Dave McPherson Sr., founder of McPherson 
Hospital in Durham. 



Twelve of Africa's most distinguished medical 
educators were in Ch«ipel Hill in December for a 
two-week workshop on curriculum planning in family 
health. 

The workshop is part of the African Health Training 
Institutions Project, a tlve-year, $3 milliori program 
administered by the Office of Medical Studies at the 
University of North Carolina School of Medicine at 
Chapel Hill and the Carolina Population Center. 

Funded by the U.S. Agency for International De- 
velopment, the project was established two years ago 
to give African mothers and children better health care 
by enhancing teaching programs in African medical, 
nursing and midwifery schools. 

Participants in the workshop will design curricula to 
meet their countries' needs. These curricula will cover 
such aspects of family health as preventive pediatrics, 
nutrition, infectious diseases, family planning, mater- 
nal and child health and health care delivery. 



The William N. Creasy Memorial Lecture on Clini- 
cal Pharmacology was presented Nov. 19 at the Uni- 
versity of North Carolina School of Medicine at 




Ifoiir son 
isn't thinking 

about grad school 
yet. 

But you should be. 

Ciratluato school is the farthest thiiifi from a xouiig ho\ s niinti — 
but in onl\ a few years it may be uppermost \'ou should be planning 
educational opportunities for your son now that w ill keep ojxmt for 
hiin every option, 

.\ strong academic foundation is essential to successful higher 



ucation Will his educational needs be met localli'!* 



ha\'t 



an\ doubts, and man\ parents do, we invite \ou to consider 
a hoarding school .Ashexille School pro\ides an atmo- 
sphere in which academic excellence is expectetl — 
and respectetl We can help \our son fulfill his 
ilieams — aiul \our tlreams foi him loi infoinia- 
tion write 

The Asheville School 

,/j,. E\erett F Gourle\ 

/ Director of ,-\dn'\issions 



\shovi 



\ C l'H«(«i 



\NUARY 1976, NCMJ 



41 



Chapel Hill. Dr., Rubin Bresslerof the University of 
Arizona Medical Center is the Creasy Visiting Profes- 
sor in Clinical Pharmacology. While in Chapel Hill, 
Bressler met with students, faculty and housestaff for 
informal teaching sessions. 

Sponsored by The Burroughs Wellcome Fund, the 
visiting professorship is one of 10 awarded to medical 
schools across the country. 



Dr. Frank C. Wilson, chairman of orthopaedic 
surgery at the University of North Carolina School of 
Medicine at Chapel Hill, was a guest speaker Nov. 
12-16 at the 1975 convention of the New Jersey Or- 
thopaedic Association held at Paradise Island in the 
Bahamas. Dr. Wilson spoke on "The Pathogenesis 
and Treatment of Ankle Injuries'" and "Replacement 
of the Knee Joint." 

Three facuhy members of the University of North 
Carolina School of Medicine at Chapel Hill were key 
participants Nov. 2-7 at the national meeting of the 
Association of American Medical Colleges in 
Washington, D.C. 

Dr. Merrel Flair, Director of the Office of Medical 
Studies, is chairman of the Group on Medical Educa- 
tion which is made up of five representatives from 
each member medical school. 

C. N. Stover Jr., associate dean for administration 
at the medical school, is chairman-elect of the Group 
on Business Affairs (GBA). Stover will assume chair- 
manship of the group in November 1976. 

Dr. Kenneth Sugioka, chairman of anesthesiology, 
is president of the Society of Academic Anesthesia 
Chairmen, a group ofanesthesia department chairmen 
from all AAMC member schools. 



Dr. Ernest Craig, Henry A. Foscue Distinguished 
Professor of Cardiology at the University of North 
Carolina at Chapel Hill , gave a paper Dec . 1 2- 1 3 at the 
"Symposium on Newer Diagnostic Methods in Heart 
Disease" in Belgium. 

He discussed "Genesis of Heart Sounds: 
Echophonocardiographic Studies." 

Dr. Colin G. Thomas Jr. , professor and chairman of 
surgery, presented a paper entitled "Evaluation of 
Dominant Thyroid Masses" at the Dec. 8-10 meeting 
of the Southern Surgical Association in Hot Springs, 
Va. 



Dr. D. Gordon Sharp, professor of bacteriology and 
immunology, gave a lecture on "The Effects of Virus 
Particle Aggregation on the Disinfection of Water by 
Halogens" at the Third Annual Water Quality 
Technology Conference Dec. 7-9 in Atlanta. 

Daniel A. Okun of the University of North Carolina 
at Chapel Hill was honored Dec. 3 by the New York 
Academy of Science for his outstanding contribu- 
tions in environmental sciences. 

Okun, Kenan Professor of Environmental En- 



42 



gineering, received the Gordon Y. Billard Award dur- 
ing the annual banquet meeting of the Society in New 
York. The citation read: 

"The Gordon Y. Billard Award for Research in 
Environmental Sciences: $500 and a Certificate of 
Citation for outstanding contributions embodying 
original work for research in Environmental Sci- 
ences." 

Okun's 38-year career has spanned education, re- 
search and consulting on environmental problems on 
every continent. 



Dr. Sidney Shaw Chipman, retired public health 
professor at the University of North Carolina at 
Chapel Hill, received the Martha May Eliot Award 
Tuesday (Nov. 18) at the annual meeting of the Ameri- 
can Public Health Association in Chicago. 

He was cited for his leadership in the maternal and 
child health field. Chipman received a $1,000 hon- 
orarium and a bronze plaque bearing the likeness of 
Dr. Eliot. 

Chipman, founder of UNC's department of mater- 
nal and child health in the School of Public Health, 
retired in 1970 after 20 years on the UNC faculty. He 
also has been a clinical professor of pediatrics at the 
UNC School of Medicine 



Harriet H. Barr of the University of North Carolina 
at Chapel Hill is the newly elected vice-president of 
the national Society for Public Health Education, Inc. 

Barr, an assistant professor and director of public 
relations for the School of Public Health, will serve a 
one-year term. For the past two years, Barr has served 
on the society's executive committee representing the : 
North Carolina Chapter. 



News Notes from the — 

DUKE UNIVERSITY MEDICAL CENTER 



Dr. C. Edward Buckley III, an associate professor 
of medicine and assistant professor of immunology, 
has been named to a four-year term as an advisor to 
the National Institute of Allergy and Infectious Dis- 
eases. 

He is one of five new appointees whose selection 
was announced by Donald S. Fredrickson, director of: 
the National Institutes of Health, a division of thci 
Department of Health, Education and Welfare. I 

The advisory council is made up of 15 leaders in the 
fields of biomedical science, education, health care 
and public affairs. 



A heart specialist here says artificial pacemakers 
may be able to protect some heart attack survivors 
against later, fatal attacks. 

Vol. 37, No. 1 



Preventive Medicine 
Makes Sense... 

Disability Income Protection Does Too! 




Just as preventive medicine can help you 
avoid disasters to your health, Disability inconne 
Protection can help you avoid financial 
disasters. A long-term disability, for example, 
without adequate insurance protection could 
mean weeks or even years without an income. 

For this reason alone, you cannot afford 
to be without the proper protection. 

That's why we have especially designed a 
Disability Income Protection Plan for younger 
doctors. A plan of protection to help make sure 
your family continues to live in the manner to 



which they are accustomed should you become 
disabled and unable to practice medicine. 

These benefits are paid directly to you to use 
as you see fit whether you are confined in 
a hospital or recovering at home. Furthermore, 
these benefits are tax free under present 
federal income tax laws. 

If you are under 55 years of age, just fill out 
the coupon below and mail it today. Mutual of 
Omaha will provide personal service in 
furnishing all of the details. Of course, 
there is no obligation. 



siiEfiWRiITtS 




Mutual 
^maha 

People you cao couot on... 

Life Insurance Affiliate; United of Omaha 

MUTUAL OF OMAHA INSURANCE COMPANY 
HOME OFFICE: OMAHA, NEBRASKA 



Mutual of Omaha Insurance Company 

Dodge at 33rd Street • Omaha, Nebraska 68131 

I am interested in learning more about the program of Disability Income 
Protection available to me. 

Name — 



Address 
City 



. State 



ZIP code 



I J 



The specialist is Pr. James J. Morris, an associate 
professor of cardiology. He has received a $22,000 
contract from Medtronic, Inc., of Minneapolis to test 
his theory. 

"We're going to see if we can predict which heart 
attack patients are at very high risk of sudden death 
from cardiac arrest and could be benefitted by a 
pacemaker,"" Morris said in an interview. 



Plans to construct a $6-million cancer treatment 
building at the medical center were announced by Dr. 
William W. Shingleton, director of the Comprehen- 
sive Cancer Center. 

The building is expected to be completed by the end 
of 1977 and will be the last of three new buildings 
which will comprise the regional cancer center. 

The National Cancer Institute granted up to $4.24 
million for the building. The medical center will make 
up the remaining costs. 

Bringing together most of Duke's clinical cancer 
specialists under one roof, the structure "will make 
the latest methods of cancer detection and treatment 
available to more individuals," Shingleton said. As 
yet unnamed, the building will be added onto the 
northwest wing of the existing Duke Hospital and will 
contain more than an acre of usable space. 



Cancer clinics are now scattered throughout the 
medical center, often in cramped quarters. This limits 
the number of outpatients who can be treated, Shin- 
gleton said. 

More than 1,000 cancer outpatient treatments a 
week will be possible in the new facility, up from the 
nearly 650 treatments now given every week at Duke. 



Arrangements have been made to provide chartered 
airplane service to Washington, D.C.. and to areas 
around North Carolina frequently visited by physi- 
cians and other university personnel. 

The charter service has been initiated to facilitate 
and to speed transportation to the selected destina- 
tions. 

All flights are in twin-engine aircraft with two qual- 
ified pilots in accordance with the highest FAA "Air 
Taxi, Commercial Operator" standards. 






* 



Three Distinguished Teaching Awards and four Dis- 
tinguished Alumni Awards were presented during 
Medical Alumni Weekend. 

The teaching awards, presented by the alumni, went 
to the late Dr. Elijah Eugene Menefee Jr., who died 
last May in Arizona; Dr. Thomas D. Kinney, former 



A unique hospital specializing in treatment of . . 

ALCOHOLISM 
DRUG ADDICTION 



In this restful setting away from pressures 
and free from distractions, the Willingway 
staff, with understanding and compassion, 
carries out an intensive program of 
therapy based on honesty and responsi- 
bility. The concepts and methods are ori- 
ginal, different and have been highly suc- 
cessful for fifteen years. 

John Mooney, Jr.. M D . Director 
Dorothy R. Mooney, Associate Director 



(JUiXXi*%c^*>*>tMM^ l^TO^^>*taJ^ 



311 JONES MILL RC ., STATESBORO. GA. 30458 TEL. (912) 764-6236 

ACCREDITEDBYTHEJ.C.A.H. 




44 



\MaL.a7,f*to. II 



n' 



chairman of the Department of Pathology who 
stepped down last year as associate provost of the 
university and director of medical and allied health 
education; and Dr. Edward S. Orgain, professor of 
medicine and director of the cardiovascular disease 
Iservice. 

Distinguished Alumni Awards went to Dr. Rubin 
Bressler, chairman of pharmacology, professor of 
medicine and chief of clinical pharmacology at the 
University of Arizona; Dr. Nathan Kaufman, chair- 
man of pathology at Queen's College in Kingston, 
Canada; Dr. Arthur H. London Jr.. a Durham pedia- 
trician; and Dr. Jack D. Myers, professor of medicine 
at the University of Pittsburgh. 



A Duke physician has become the first North 
Carolinian ever elected to the Board of Regents of the 
American College of Surgeons. 

He is Dr. David C. Sabiston, chairman of the De- 
partment of Surgery. 

The 18-member Board of Regents directs the affairs 
of the professional scientific organization. 

Sabiston is James B. Duke Professorof Surgery. He 
also has served as chairman of the Board of Governors 
of the American College of Surgeons, chairman of the 
American Board of Surgery and president of the 
Southern Surgical Association. 



News Notes from the — 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



Initial results of a study at the Bowman Gray- 
Baptist Hospital Medical Center indicate that when 
early treatment of acute myloblastic leukemia in- 
cludes transfusions of blood cells matched to the pa- 
tient's blood, the patient has far fewer problems with 
internal bleeding and infections. 

Infections are the major killer of leukemia patients. 
Internal bleeding, once the major killer, is still a seri- 
ous problem. 

Sixty-tlve percent of the 50 patients in the medical 
center study also experienced complete remissions of 
their disease after receiving both chemotherapy and 
the early transfusions. That compares with only 27 per 
cent among patients receiving chemotherapy and 
transfusions of non-matched blood cells. 

Physicians in the study believe that the matched 
transfusions strengthen the patient so that more 
chemotherapy can be given over a longer period of 
time. Remissions are the direct result of chemo- 
therapy and not the transfusions. 

Transfusions given as part of the medical center 
study contain platelets and leukocytes which are 
matched to the patient's blood in exactly the same way 



that tissue is matched for kidney or heart transplants. 

The matching greatly reduces the chance that the 
patient will have an adverse reaction to the transfused 
blood. 

The donated blood cells are used to counter the 
suppression of the body's production of platelets and 
leukocytes. That suppression is due to the effects of 
the leukemia and the adverse effects of the chemo- 
therapy. 

The transfused leukocytes do not provide complete 
protection from infection, but work with powerful 
antibiotics if infection develops. 

The process of using matched platelets and leuko- 
cytes potentially can be beneficial to patients being 
treated for other kinds of cancer and for other kinds of 
diseases which suppress production of those blood 
cells. 



Surgeons at the medical center have performed 
their tlrst transplant of parathyroid glands. 

The surgeons removed all four of the parathyroid 
glands from a Forsyth County woman, sliced up one of 
the glands into 20 pieces less than an eighth of an inch 
in size and transplanted the pieces in the muscle of the 
woman's lower left arm. 

Kidney disease, which required the woman to have 
a kidney transplant at Baptist Hospital over a year 
ago, caused an overactive condition of the woman's 
parathyroids. 

The new procedure, only recently described in med- 
ical literature, involves just one operation on the 
throat and permits easy access to the transplanted 
tissue if some of that tissue has to be removed. Suc- 
cess with the procedure also relieves the patient of a 
life time of having to take calcium and vitamin D pills. 

The operation is of potential benefit to recipients of 
new kidneys who have overactive parathyroids which 
do not return to normal and to those with overactive 
parathyroids resulting from other medical problems. 



Dr. James A. Chappell. associate professor of 
community medicine, has been reappointed by the 
Forsyth County Commissioners to a three-year term 
as a member of the Forsyth-Stokes Area Mental 
Health Board. 



Dr. William D. Wagner, assistant professor of 
neurosurgery, has been appointed to a four-year term 
on the Research Review Sub-Committee of the Medi- 
cal and Community Program Committee of the North 
Carolina Heart Association. 



Dr. Richard C. Proctor, professor and chairman of 
the Department of Psychiatry, has been appointed to 
the editorial board of the World Journal of Psychosyn- 
thesis. He also was appointed chairman of the Board 
of Census for the North Carolina Neuropsychiatric 



January 1976. NCMJ 



45 



BE A PHYSICIAN 

AND A FAMILY MAN... 

THERE'S TIME FOR BOTH ! 

Time to relax with your family - and still enjoy the professional 
advantages of modern facilities and a highly trained technical staff. 
You'll have the standing of an officer AND a professional. Yet, there's 
challenge, too. Air Force medicine ranges from research to every con- 
ceivable type of clinical practice, in every conceivable location you can 
imagine. Off-duty, you and your family can enjoy the excellent recrea- 
tional facilities of the Air Force Base of your choice. Free travel. One 
months paid vacation every year. And many other extras. 

Find yourself —and your family— in the Air Force. 




Look up. Be looked up to. Air Force 



Mail the coupon below for all the information. 

310 New Bern Ave , Rm 303. Raleigh. N C 27611. Call: 919/755-4134 

Name Social Security No. 

Address _^ 

City 

State 



Zip 



Phone 



Specialty _ 
Dale of Birth 



AIR FORCE. Health) Care At Its Best. 



Association and has been named to the North Carolina 
District Board of the American Psychiatric Associa- 
tion. 

AMERICAN COLLEGE OF PHYSICIANS 

Ten North Carohnians are among 325 new fellows 
jf the American College of Physicians, a 60-year-old 
ntemational society representing specialists in in- 
emal medicine and related fields. 

They are Victor L. Stotka. M.D.,ofCamp Lejeune; 
lames F. Alexander, M.D., of Charlotte; Harvey J. 
Tohen, M.D., John D. Hamilton, M.D., John P. Tin- 
lall, M.D., and Malcolm P. Tyor, M.D., of Durham; 
lohn A. Lusk III, M.D., of Greensboro; Charles M. 
^msdell, M.D., of Greenville; William B. Kremer, 
vl.D., of Lakeland; and Robert S. Brice Jr., M.D.,of 
A'inston-Salem. 

The new fellows were elected at a recent meeting of 
he Board of Regents. Robert G. Petersdorf, M.D..of 
Seattle, president of the American College of Physi- 
:ians and chairman of the department of medicine at 
he University of Washington School of Medicine, 
;aid the new fellows have earned the honor through 
.cientific accomplishments and through acceptance 
)y fellow practitioners as leaders in their specialty. 

In addition to Petersdorf, college officers who will 
erve until the 57th annual session in Philadelphia 
Kpril 5-8 are Jack D. Myers, M.D., of Pittsburgh, 
)resident elect, and Maxwell G. Berry. M.D., of 
Cansas City, vice president. Serving five-year terms 
ire Edward J. Stemmler. M.D., of Philadelphia, trea- 
urer, and Richard W. Vilter, M.D., of Cincinnati, 
ecretary general. Edward C. Rosenow Jr., M.D., of 
Philadelphia is executive vice president. 

DISABILITY DETERMINATION 

UNDER 

SOCIAL SECURITY 

AND 

HE NEW SUPPLEMENTAL SECURITY INCOME 

PROGRAM 

CONTRASTS AND SIMILARITIES 

Wiley M. Cozart, M.D. 

On January 1, 1974, a nationwide program of direct 
ederal payments to aged, blind or disabled persons 
vith limited income and resources went into effect. 
Cnown as "Supplemental Security Income" (SSI), 
he new program has uniform eligibility requirements 
or such persons to replace the multiplicity of re- 
luirements existing under the old federal-state public 
ssistance programs. The title of the program indi- 
ates that benefits are expected in most cases to sup- 
ilement income from other sources, including Social 
Security benefits. 

The Supplemental Security Income Program is 
/holly financed from federal general tax revenues. 



Responsibility for administering the program has been 
given to the Social Security Administration (SSA) not 
only because of their experience in managing a 
monthly benefit payment program and the existing 
SSA advanced data processing system, but also be- 
cause of the well-established nationwide network of 
SSA offices and program centers. 

The SSI program generally uses the same defini- 
tions of disability and blindness used in the social 
security disability insurance program for determining 
eligibility in new claims. To help simplify and speed 
the processing of disability decisions and to insure 
uniform treatment of all applicants, no matter where 
they live, the medical evaluation criteria developed 
for the Title II disability insurance program (Social 
Security) with the aid of practicing physicians, medi- 
cal organizations and the Medical Advisory Commit- 
tee to the Social Security Administration have been 
generally adopted for the SSI program. In terms of 
symptoms, signs and laboratory findings, the evalua- 
tion criteria describe impairments that reflect the level 
of severity that would prevent most people from work- 
ing for a year or longer. These criteria are constantly 
being refined to reflect advances in medicine and to 
take into account disability program experience. 

If an applicant has an impairment or a combination 
of impairments that meets or equals the criteria, and 
he is not working, he would generally be considered 



"om the Division of Social Services. Department of Human Resources. Raieigfi. Nortft 
arolina 27602 




Marcia Mills, M.A., R.D. 

Consulting Nutritionist 

Normal Nutrition, Weight Control, 

Therapeutic Dietetics 

Serving Physicians and Medical Groups 

Through: Private Physician Referral 

and Hospital Follow-up. 

CDC COMMUNITY 
DIET COUNSELING SERVICE, inc. 

100 EASTOWNE DRIVE • EASTOWNE OFFICE PARK 

CHAPEL HILL, NORTH CAROLINA 27514 

CHAPEL HILL 967-9400 * DURHAM 489-3751 



ANUARY 1976. NCMJ 



47 



I 



disabled. Most allowances are based on medical con- 
siderations alone — that is, the claimant's impairment 
meets or equals the level of medical severity in the 
criteria. It is also possible for an impairment to be 
slight or minimal, thereby resulting in a denial strictly 
on a medical basis. However, for workers who have 
impairments which fall short of the listed level of 
severity but which prevent them from doing their pre- 
vious or customary work, consideration is given to 
their ability to do any other work in light of their 
remaining capacity and of their age, education, train- 
ing and work experience. In these cases, the indi- 
vidual must not only have an impairment which pre- 
vents him from doing his usual work, or work he has 
done previously, but also other kinds of work for 
which he is reasonably suited. In the situation where 
an older worker with a marginal education and long 
history of arduous unskilled physical labor has an 
impairment which prevents him from doing his usual 
work, he may be considered under a disability. 

Since the criteria for evaluation of disability under 
Social Security presupposes a work history and, since 
many SSI applicants have never worked or the past 
work has no current vocational relevance due to being 
too remote, too brief or not substantially gainful, the 
applicant's ability to work must be evaluated consid- 
ering both his medical and vocational circumstances. 
To be allowed, the claimant must first have an im- 
pairment of significant severity to prevent him from 
performing his customary activity and secondly, con- 
sidering his impairment and vocational cir- 
cumstances, there must be no substantial activity 
available to him in the national economy that he can 
do. For example, a claimant retaining the ability to do 
a wide range of light work, not of advanced age, and 
able to speak, read and write at the elementary level, 
may be considered in the competitive labor market 
even if he doesn't have special experience or skills. He 
would have the residual functional capacity to per- 
form a wide range of light work for which he could be 
trained. A claimant who is of advanced age, or ap- 
proaching advanced age, is illiterate and unskilled 
would not generally be expected to achieve a voca- 
tional accommodation even though he retains the ca- 
pacity for light or sedentary work. The primary reason 
for an individual being unable to work under both Title 
II claims and Title XVI claims remains his medically 
demonstrable impairment. Secondary consideration 
is given to vocational factors. Title II claimants, hav- 
ing contributed of their wages to the program and 
having thereby earned insured status by virtue of their 
past work, are evaluated from the standpoint of both 
their medical impairment and their work history. Title 
XVI (SSI) claimants, having, in most instances, no 
work history are evaluated from a standpoint of their 
medical demonstrable impairment and their ability to 
work. All persons whose applications for determina- 
tions of disability are adjudicated in a state disability 
determination unit a-e considered for referral to the 
State Vocational Renabilitation Agency. 

Although generally the same guides apply under 

48 



Title II and Title XVI there are some differences. Fo 
example: 

1. No Waiting Period Under Title XVI (SSI)— Af 
individual who is determined to be blind or disablec 
will be eligible for payment for the first month in whici; 
he has filed an application and is disabled. (Unde 
Title II, a five-month waiting period must be servec] 
after the onset of disability). i 

2. Presumptive Disability — The law provides thai 
an applicant for disability benefits who is found to b( 
"presumptively disabled' may be paid, under certaii 
conditions, for as many as three months while forma 
determination of his disability is being made. 

3. Childhood Disability — With the implementatioi 
of the SSI program, the Social Security Administra, 
tion will, for the first time, be responsible for disabilit; 
evaluations and payments for children who are unde^ 
the age 18. A child of a family with limited income anc] 
resources will be found disabled if the child has ; 
medically determinable physical or mental impair, 
ment which can be expected to result in death or whicl 
has lasted or can be expected to last for at least Ki 
consecutive months and is of comparable severity tcj 
that which would prevent an adult from engaging ii) 
substantial gainful activity. The question of vocationa 
assessment and concomitant ability to engage in subi 
stantial gainful activity is generally not relevant i'' 
evaluating disability during childhood because, ii 
most situations, the child will not be of age where he 
could reasonably be expected to enter the workinj, 
population. Thus, in childhood cases, a finding ol 
disability will be made solely on the basis of medica 
considerations. There are, for example, severe im 
pairments unique to childhood cases which are no 
now specifically described in the Social Security List 
ing of Impairments. Because of their effect on th(| 
child's growth and development, these are usuall; 
easily identified and can be fairly equated with aij 
expected capacity for work. 

4. Blindness — The criteria for establishing blindj 
ness under SSI are identical to those required to estab 
lish statutory blindness under the Social Security DiS' 
ability Insurance Program. Unlike Title II, however 
engagement in substantial gainful activity will not pre 
elude SSI payments if the statutory definition o 
blindness is met, although the SSI payments may b 
reduced under the income test. Also, since there is n(| 
duration requirement for blindness under SSI, then 
can be a favorable decision based on temporary blind 
ness. 

Since the implementation of this program oi 
January 1, 1974, there has been an unprecedenteC( 
influx of applications requiring the development o 
medical evidence for their adjudication. While th< 
Disability Determination Section is not allowed to paj 
for existing medical evidence in processing Title I 
claims, we are allowed to pay up to $10 for evidence o: 
record on SSI claims. The claimant will continue t( 
furnish, at his expense, initial medical evidence unde; 
the regular disability program. Please note that oiii 
letters of inquiry under both programs are requests foi 

Vol. 37, No. ; 



lA 



vailable evidence of record. Often, it appears that the 
attending physician interprets our inquiry as a request 
br current examination and study. 
I We have found that many of the SSI apphcants have 
ever had continuing treatment or in-depth medical 
tudies. Some have not seen a physician for several 
'ears. For these patients, available medical evidence 
imply does not exist. We have, therefore, developed 
review examination, less extensive in its scope than 
ur usual comprehensive consultative examination, 
et thorough enough to enable us to make a disability 
•ecision or to direct further study of the applicant. A 
at fee of $30 has been established in keeping with 
udgetary limitations as a reasonable reimbursement 
)r this service. 

There has been no significant decrease in our need 
)r comprehensive examinations requiring complete 
arrative reports. We welcome inquiries from those of 
ou who have the time and facilities to provide us with 
lese. 

, In summary, the Disability Determination Section 
f the North Carolina Department of Social Services, 
hich administers the disability provisions of the Se- 
al Security Act in this state, has been since January 
1974, responsible for the administration of the 
upplementary Security Income (SSI) Program (Title 
VI). Similarities and variations in the two programs. 



Title II and Title XVI, are reviewed. A plea is voiced 
for the assistance of the practicing physicians of the 
state in obtaining medical evidence on which sound 
decisions can be based. Three areas of need are out- 
lined: (1) the provision of existing medical evidence, 
when available, (2) the performance of screening 
examinations on applicants with little or no existing 
medical evidence and, (3) the performance of com- 
prehensive consultative examinations where indi- 
cated. 

With implementation of the SSI program, new areas 
of concern with respect to the medical community are 
constantly surfacing. Your inquiries and comments 
are invited. Please contact Dr. Byron D. Casteel. 
Chief Medical Consultant, Disability Determination 
Section, Post Office Box 243, Raleigh, North Carolina 
27602, or telephone (919) 829-7613. station-to-station, 
collect. 

WINSTON-SALEM HEALTH CARE PLAN, INC. 

Dr. E. Reid Bahnson. a Winston-Salem physician 
since 1948, has been named medical director of the 
Winston-Salem Health Care Plan, Inc. The an- 
nouncement was made by the organization's board of 
directors. 

The Winston-Salem Health Care Plan. Inc.. is a 
nonprofit organization which will begin administering 



[MNSCO, sole North Carolina dealer for Rolls-Royce Motor Cars, 
invites you to an adventure in England. 




Special arrangements have been made with Rolls-Royce, Ltd. 
to enable a select few to visit their factories in England and 
see the world's ultimate motor car being built. 
You'll tour the Rolls-Royce assembly plant in Crewe, Eng- 
land, where skilled craftsmen contribute the patience and 
refinement that makes Rolls-Royce the best car in the world. 
You'll also visit H. ]. Mulliner — Park Ward in London, 
where centuries-old coachbuilding techniques are still used 
to build special Rolls-Royce bodies. 

Arrangements have also been made for you to visit Lord 
Montague's famed antique car collection at his family home, 
Beaulieu, as well as places of historic interest. 
Departing April 22 for London, you will spend seven days in 
England. While in London, accommodations will be at the 
Savoy. Bookings are now being accepted. Further informa- 
tion regarding this unique opportunity is available from : 



ROLLS 



ROYCL 



TRANSCO, INC. 

1800 N. Main Street 
High Point, North Carolina 27262 
Telephone: (919) 882-9647 
(919)288-7581 — Evenings 



For literature and test drive, contact Geof Eade, General Manager 
Travel and accommodations through Lucas Travel Agency 



>v J^UARV 1976. NCMJ 



49 



a group health care plan for Winston-Salem-area 
employees of R. J. Reynolds Industries, Inc. and its 
subsidiaries in the spring of 1976. Under the plan, 
participating R. J. Reynolds employees will receive 
primary medical care through Winston-Salem Health 
Care Plan physicians located in the organization's 
facility in Stratford Executive Park. 

In his new position. Dr. Bahnson, who is also an 
assistant professor of clinical internal medicine at 
Bowman Gray School of Medicine, will supervise the 
organization's medical staff. 

"We feel very fortunate to have a man of Dr. 
Bahnson's caliber as medical director," said Rodney 
Austin, a member of the board of directors of 
Winston-Salem Health Care Plan, Inc. "He is a highly 
skilled physician who is dedicated to insuring the 
finest in medical care." 

A 1934 graduate of R. J. Reynolds High School, 
Bahnson received his A.B. degree from the University 



of North Carolina at Chapel Hill and his M.D. degree! 
from the University of Pennsylvania School of| 
Medicine. 

He is a past president of both the Forsyth County I 
Medical Society and the medical staff of City Memo- 
rial Hospital (replaced by Forsyth Memorial Hospital) | 
and a former chief of the division of medicine at For- 
syth Memorial Hospital. His professional member- 
ships include the American Medical Association, thai 
Forsyth County and North Carolina Medical Societies | 
and the American Society of Internal Medicine. 

Bahnson is also a member of Home MoravianI 
Church and the Board of World Mission, Moravian! 
Church of North America. 

In addition to Bahnson, two other local physicians,! 
Dr. Henry L. Valk and Dr. Benjamin F. Huntley, arej 
members of the board of directors of the Winston- 
Salem Health Care Plan, Inc. 



Month in 
Washington 



The continual improvement in our health system, 
with its ever-increasing responsiveness to the 
people's needs, must not be stifled by adopting 
foreign-flavored elements into a national health insur- 
ance plan, the American Medical Association has told 
the Congress. 

"When considering a national plan for this country, 
it is necessary to take cognizance of the strengths of 
our own method of health care delivery. . . this will 
assure that our excellent system will continue to im- 
prove and will not suffer the stifling effects experi- 
enced in other countries," AMA president Max H. 
Parrott, M.D., testified before a subcommittee of the 
House Ways and Means Committee. 

Pointing to the large problems involved in creating a 
national health insurance program. Dr. Parrott, a Port- 
land, Ore., practitioner, said that the public attitudes 
toward it are changing steadily. 

"These problems have been brought into better 
focus as a result of evidence of the effects of gov- 
emmentally administered and controlled programs 
both here and abroad. 

"Our national priorities have also shifted because of 
the effects of the changing economy, and the devastat- 
ing effects of inflation on all segmentsof our society. 

"The public has expressed among its major 
priorities aconcem with inflation, with the state of the 
economy, and with :rime. National polls have indi- 
cated that national health insurance is of low concern. 

"During this same period of time significant 



50 



changes have taken place in our health system througl 
increased manpower programs, increased facilitiesi 
construction, increased levels of private health insur- 
ance coverage, and a variety of other programs. There! 
is fuller realization and acknowledgment that thisj 
country's health system — under attack by many in thi 
course of the NHI debate — is indeed superior to an; 
other in the world," Dr. Parrott said. 

Dr. Parrott and Richard E. Palmer, M.D., oil 
Alexandria, Va., and Chairman of the AMA Board ol| 
Trustees, reminded the subcommittee members of th( 
medical profession's national health insurance plai 
(H.R. 6222) which builds on the structure of the pres 
ent system of employer-employee group health insur 
ance plans, mandating each employer to provide com' 
prehensive and catastrophic benefit coverage with thi 
employer picking up at least 65 percent of the cost. 

Dr. Palmer pointed out that in pressing for the adoj 
tion of any particular NHI proposal, sincerity musll 
not be confused with objectivity — "We cannot afforc| 
to have a program of such importance fail! 

"We must avoid the mistake inherent in proposal!.! 
such as H.R. 21 (Kennedy-Corman) which would loci 
medicine into a rigid, monolithic, no-choice bureau! 
cratic system. Such a creation would be impossible tc| 
reverse. It would be an undertaking full of promise buj 
empty of fultlllment. Establishment of cost control 
through fixed budgets including arbitrary fee|; 
schedules would result in curtailment of care and disi 
courage participation by providers. A look at the cur 

Vol. 37, No. 



,t 



■>:si 



No.3 __ 

(Vs potent as the pain ft relieves, 



S* e.3. the pain oF 
J sprains and strains 




lOT TOO LITTLE 

as potent as the pain you need to relieve in patients 
witii fractures, sprains, strains, wounds, contusions, 
and the pain of surgical convalescence 
unhide acetaminophen/codeine combinations, it 
does not sacrifice anti-inflammatory action 

40T TOO MUCH 

i potent— yet not excessive ■ addiction liability low 



NOT TOO EXPENSIVE 

■ brand-name quality, yet reasonable in cost 

■ readily available in both hospital and local pharmacies 

a CONVENIENCE 

■ telephone Rx in most states, up to 5 refills in 

6 months at your discretion (where state law permits) 



^ 



EDWIiUN COMi>OUND 
MITH CODEiNE NO. 3 

adeine phosphate*(32 4 mgl gr '.; 

ach tablet also contains aspinngrS':. phenacetin gr 2'-,, caffeine gr '2 "Warning -may be habit-form ing 



ft 

Wellcome 



Burroughs Wellcome Co. 

Research Triangle Park 
North Carolina 27709' 



Effectiveness across 
the spectrum of most 
common forms 
of insomnia 



Awake too long, awake too often, 
awake too early. . . 

These ate the most common forms of insomnia, 
and may occur singh' or in any combination. 
The night of troubled sleep depicted here 
comprises all three types. As the night 
progresses from left to right, each 
sleep stage is identifiable by its own 
shade of gray. Blue represents "Awake!" 



As you can see, this hypothetical "patient" 
takes well over an hour to fall asleep, awakens 
several times during the middle of the night 
and awakens too early in the morning. 

Sleep Stages 




Awake too long 



Awake too often during the night 



i 



The insomnias most often 
occurring in young and older adults 

For patients with trouble Falling asleep 
(common in young adult insomnia patients), 
Dalmane (flurazepam HCl) 30 mg provides sleep 
within 17 minutes, on average. For those with 
trouble staying asleep or sleeping long 
lenough (common in those over 50), Dalmane 
ioffers increased total sleep time with fewer 
nocturnal awakenings. These clinical results 
were demonstrated in studies conducted in 
four geographically separated sleep 
research laboratories?-^ 



The relative safety of Dalmane 
(flurazepam HCl) is well documented 

Dalmane (flurazepam HCl) is relatively safe 
and well tolerated; morning "hang-over" has 
been infrequent. The usual adult dosage is 30 
mg; in elderly or debilitated patients, limit 
initial dosage to 15 mg to preclude over- 
sedation, dizziness or ata.xia. Caution patients 
about possible combined effects with 
alcohol and other CNS depressants. 



Hours 




Broad-Spectrum 
medication for the 
most common forms 
ofinsomnia 

Dalmane 

(flurazepam HCl) ^ 

One 30-mg capsule h.s.— usual aduii dosage 

( I 5 mg may sutf ice in some patients). 
One 15-mg capsule h.s.— initial dosage for 
elderly or debilitated patients. 

D induces sleep rapidly 

n reduces nighttime awakenings 

n lengthens total sleep time 




<^ROci^ 



Awake too early 



Please see following page for a 

summary of complete product information. 



Broad-spectrum medication for 
the most common forms of insomnia 

Dalmane 

(f lurazepam HCI ) (3 




Objectively proved in the 

sleep research laboratory, 

Dalmane 

n induces sleep within 
17 minutes, on average 

n reduces nighttime 
awakenings 

D provides 7 to 8 hours 
sleep, on average, with- 
out repeating dosage 

Before prescribing Dalmane (flurazepam 
HCI), please consult complete product 
information, a summary of which follows: 
Indications: Effective in all types ot insomnia 
cfiaracterized by difficulty in falling asleep, 
frequent nocturnal awakenings and/or early 
morningawakening; in patients with recurring 
insomnia or poor sleeping habits: and in 
acute or chronic medical situations requiring 
restful sleep. Since insomnia is often transient 
and intermittent, prolo:iged administration is 
generally not necessary or recommended. 
Contraindications: Known hypersensitivity 
to flurazepam HCI. 

Warnings: Caution patients about possible 
combined effects wnlh alcohol and other 
CNS depressants. Caution against hazardous 
occupations requiring complete mental alert- 
ness (eg-, operating machinery, dri\'ing). 
Use in women who are or may become preg- 
nant only when potential benefits have been 
weighed against possible hazards Not 



recommended for use in persons under 15 
years of age. Though physical and psycho- 
logical dependence have not been reported 
on recommended doses, use caution in 
administering to addiction-prone individuals 
or those who might increase dosage. 
Precautions: In elderly and debilitated, initial 
dosage should be limited to 15 mg to preclude 
oversedation, dizziness and/or ataxia. If 
combined with other drugs having hypnotic 
or CNS-depressant effects, consider potential 
additive effects. Employ usual precautions 
in patients who are severely depressed, or 
with latent depression or suicidal tendencies. 
Periodic blood counts and liver and kidne\' 
function tests are advised during repeated 
therapy Observe usual precautions in 
presence of impaired renal or hepatic function. 
Adverse Reactions: Dizziness, drowsiness, 
lightheadedness, staggering, ataxia and 
falling have occurred, particularly in elderly 
or debilitated patients. Severe sedation, 
lethargy, disorientation and coma, probably 
indicative of drug intolerance or overdosage, 
have been reported. Also reported were 
headache, heartburn, upset stomach, nausea, 
vomiting, diarrhea, constipation, Gl pain, 
nervousness, talkativeness, apprehension, 
irritability, weakness, palpitations, chest 
pains, body and joint pains and GU com- 
plaints. There have also been rare occurrences 
of leukopenia, granulocytopenia, sweating, 
flushes, difficulty in focusing, blurred 
vision, burning eyes, faintness, hypotension, 
shortness of breath, pruritus, skin rash, dry 
mouth, bitter taste, excessive salivation, 
anorexia, euphoria, depression, slurred 
speech, confusion, restlessness, hallucina- 
tions, and elevated SGOT, SGPT, total and 
direct bilirubins and alkaline phosphatase. 
Paradoxical reactions, e.g., excitement. 



stimulation and hyperactivity. ha\e also 
been reported in rare instances. 

Dosage: Individualize for maximum bene :ial 
effect. Adults: 30 mg usual dosage; 15 mg 
may suffice in some patients. Elderly or . 
debilitated patients: 15 mg initially until ij 
response is determined. ! 

Supplied: Capsules containing 15 mg or 
30 mg flurazepam HCl. 

I 

REFERENCES: 

1. Karacan I. Williams RL, Smith JR:Th( 
sleep laboratory in the investigation of 
sleep and sleep disturbances. Scientific ' 
exhibit at the 124th annual meeting of thl 
American Psychiatric Association. 
Washington DC, IVIay 3-7, 1971 

2. Frost JD Jr: A system for automatical!; 
analyzing sleep. Scientific exhibit at the 
24th Clinical Convention of the Americar 
Medical Association, Boston, Nov 29- ' 
Dec 2, 1970; and at the 42nd annual ! 
scientific meeting of the Aerospace Mediiil 
Association. Houston, Apr 26-29, 1971 i 

3. Vogel G\V: Data on file. Medical 
Department. Hoffmann-La Roche Inc., 
Nutle\- NJ ' 

4. Dement WC: Data on file. Medical 
Department, Hoffmann-La Roche fnc 
Nutley NJ 



,'-'" 



.,-*^' 




ROCHE LABORATORIES 
Division of Hoffmann-La Rocfie I 
Nutley, New Jersey 07110 



ki 



rent trouble of the British health care system impels a 
close re-examination of the alleged need for such dras- 
tic action, as is embodied in H.R. 21. In our opinion 
justification for such a program is totally lacking!" 

Alluding to other measures aimed at providing 
catastrophic health insurance alone. Dr. Palmer ob- 
served that 135 million Americans under 65 carried 
major medical insurance in 1974. 

"This is the most rapidly growing form of health 
insurance in the nation, and the trend for such added 
coverage is fostered by an increasing public aware- 
ness. Consequently, we must question the need to 
impose on the American taxpayer and consumer a 
costly universal federal program of free-standing 
catastrophic insurance." 



The National Health Insurance hearings on Capitol 
Hill have been marked so far by a notable lack of 
excitement or sense of urgency. The national news 
media has ignored the first legislative hearings of the 
year on NHI, underscoring contentions by many wit- 
nesses that the public doesn't rate NHI high on its 
scale of worries or interests. 

Nonetheless, the recently announced decision that 
the House Interstate and Foreign Commerce Commit- 
tee's Subcommittee on Health will conduct NHI hear- 
ings, brings into the open anew the odd jurisdictional 
dilemma that perplexes Congress in its quest for ac- 
tion on NHI. Rep. Paul Rogers (D-Fla.) has an- 
nounced his House Commerce Subcommittee on 
Health will start NHI hearings. He plans to call first 
the chief Congressional sponsors of the major NHI 
bills to testify. Rogers is telling the House Ways and 
Means Committee in unmistakable terms that he 
wants a piece of the NHI action, perhaps the big piece. 

The Ways and Means Subcommittee on Health, 
headed by Rep. Dan Rostenkowski (D-Ill.), will end 
six weeks of hearings on NHI just as Rogers gets 
started. Relations between the rival panels and their 
staff members are strained. 

Since Ways and Means traditionally has had prime 
jurisdiction, the chief sponsors of the NHI bills in the 
House are for the most part members of the Ways and 
Means Committee. Examples include Ways and 
Means Chairman Al Ullman (D-Ore.), sponsor of the 
American Hospital Association's plan. Rep. John 
Duncan (R-Tenn.) a chief sponsor of the American 
Medical Association's NHI proposal. Rep. Omar 
Burleson (D-Texas), foremost House backer of the 
Health Insurance Companies" measure, and Rep. 
James Corman (D-Calif.), sponsor of Labor's Health 
Security Act. 

None are anxious to go before the Rogers" Sub- 
committee in behalfof their bills, thus lending support 
to Rogers" jurisdictional claim. 

The way health jurisdiction has been parcelled out 
in the House this year, Rogers can lay valid claim to 
much of the benefit and structural side of NHI legisla- 
tion while Ways and Means has acknowledged hold on 
ill tax financing aspects. But the question remains: 



Can these be separated? Most believe they can't and 
some special joint-committee setup will have to be 
formed to avoid a divisive squabble in the House 
pitting one major committee against another. 



A Congressional committee trying to ascertain the 
causes of a large hike in premium costs for the huge 
Federal Employees Health Benefits Program (FEHB) 
has been told by the American Medical Association 
that physicians" long-run prices have paralleled price 
changes elsewhere in the economy. 

Williams C. Felch, M.D.,of Rye, N.Y., a member 
of the AMA Council on Legislation, told the House 
Civil Service Subcommittee that professional liability 
expense "has increased far beyond any other 
economic indicator." 

Dr. Felch said "this skyrocketing of professional 
liability premiums is of necessity reflected by higher 
fees."" He continued: 

"The most recent premium increases are stagger- 
ing. Increases of 100 percent are frequent, with in- 
creases ranging up to 600 percent."' 

Premiums of $10,000 are not unusual today. Dr. 
Felch told the lawmakers. "Amounts in the range of 
$25,000 to $30,000 in the high risk speciahies are not 
rare, as compared with $6,000-$7,000 a year ago. 
Some premiums have been reported as high as $45,000 
annually."" 

The other major factors in medical fee rises are the 
lingering effects of the economic stabilization program 
and economy-wide inflation, the physician said. 
Physicians" fees were under price controls from Au- 
gust, 1971, through April, 1974. he noted. 

Consumer price figures for 1975 show that the per- 
centage increase in physicians" fees has been lower 
than the price increases in the hospital industry but 
higher than the price increases in the economy in 
general, according to Dr. Felch. 

"During the tlrst nine months in 1975, physicians" 
fees increased 8.4 percent. In the same time period 
other health care costs were as follows: hospital ser- 
vice charges up 10.2 percent, semi-private room 
charges up 12.0 percent and operating room charges 
up 10.4 percent."" 

Dr. Felch also said utilization of physician services 
has risen with progress of medical technology, rising 
incomes, increased insurance coverage, and a rising 
proportion of elderly in the population. "These fac- 
tors no doubt have combined to increase the costs in 
the Federal Employees" Benefit Program. We under- 
stand that the FEHB as well as other plans have ex- 
perienced sharp rises in utilization." 

Another reason for increased utilization may be 
more extensive tests and services as a result of threats 
of liability lawsuits, he said. 

Dr. Felch said the AMA has recently approved the 
creation of a high level commission to study the prob- 
lem of rising health care costs. This Commission on 
the Cost of Medical Care will include top level rep- 
resentatives of health care providers and of the public. 



January 1976, NCMJ 



55 



reflecting a broad spectrum of interest in health care. 
"It is our desire that through the joint efforts of all 
members of the Commission, the causes for health 
care cost increases will be better understood." 



The Administration has had a change of mind and 
now backs legislation that would bar unions from re- 
quiring members to join federally-subsidized Health 
Maintenance Organizations (HMO's). 

Referring to a provision in the HMO bill recently 
passed by the House, Theodore Cooper, M.D., Assis- 
tant HEW Secretary for Health, said, "This amend- 
ment would assure that each individual employee 
would have the right to choose to participate before 
joining." 

Dr. Cooper's statement before the Senate Health 
Subcommittee represented a switch in Administration 
policy. Only a month ago, the HEW Department is- 
sued regulations on HMO's that allowed unions at the 
collective bargaining table to choose an HMO or regu- 
lar private health insurance on behalf of the entire 
union membership. 

The original HMO measure approved by Congress 
specified that all employers with more than 25 workers 
had to offer the "dual option" of HMO or regular 
insurance to their employees in areas where HMO's 
were situated and sought this option. However, this 
clause caused confusion and was viewed by labor — 
backed by the Labor Department — as interfering with 



Labor's present collective bargaining rights to pick i, 
single health benefit package. In issuing final regulaj 
tions on HMO's last month, HEW went along witi 
Labor's viewpoint. 

As the Senate Health Subcommittee headed by Sen. 
Edward Kennedy (D-Mass.) opened hearings on th( 
House-passed amendments to the HMO law, Dr 
Cooper said, "We endorse the clarification of existing 
law which provides that an employer offer an HMC 
option under 'dual choice' first to the employees' rep; 
resentative, if any, and, if accepted by the representa; 
tive. then to the individual employees." 

The House measure retained Labor's collective 
bargaining opportunity to select a regular private 
health insurance program as the sole health benefits 
program, but said that employees could not be forcec 
to accept an HMO. 

The problem with the Labor Relations Act and the 
"dual option" may eventually have to be settled b> 
the courts. A key issue is whether union membership 
can be required in total to join a plan that is federally 
subsidized. A non-subsidized HMO or pre-paid group 
practice plan may, of course, be selected by Labor foi 
all members without question. 

* * * 

i 

Federal controls dictating where medical graduate!; 

practice, rationing of residencies, and federal licen 

sure and re-licensure of physicians have been strongly 

opposed by the American Medical Association. 



"WHEN YOUR BACK FEELS GOOD YOU'LL FEEL GOOD ' 

SEALY POSTUREPEDIC 

A Unique Back Support System 

Designed in cooperation witli lead- 
ing orthopedic surgeons for comfort- 
ably firm support-"no morning 
bactcaclie from sleeping on a too-soft 
mattress." 




$10095 

FRO.M J. V/ \J 



SEALY OF THE CAROLINAS, INC. 

(a division of the 12-year old Peerless Mattress Co.) 

Asheville - Charlotte - Lexington - High Point - Greenville - Columbia 

"Sleeping on a Sealy is like sleeping on a cloud" 



56 




Twin Size 
ea. pc. 



Further governmental regulations may "have ad- 
iverse effects on the forces which are bringing about 
desired changes without regulatory intervention," 
said Tom Nesbitt, M.D., speakerofthe AMA's House 
of Delegates. 

Dr. Nesbitt told the Senate Health Subcommittee 
headed by Sen. Edward Kennedy (D-Mass.) that the 
AMA supports continued capitation and other aid for 
medical schools, but provisions requiring students to 
repay the government in money or in shortage area 
service in return for the capitation aid are "coercive 
jnd unprecedented." 

"Such requirements would place an unconsciona- 
ble burden on students." Dr. Nesbitt declared. 

The Senate Subcommittee is finishing hearings on 
nealth manpower legislation and is expected to draft 
egislation shortly. The House last fall approved a 
lealth manpower bill extending federal aid for medical 
schools but imposing the compulsory payback on all 
itudents. A provision mandating allocation of res- 
dencies. however, was defeated on the House floor. 

From the standpoint of the medical school finances, 
he battle over whether federal capitation support will 
:ontinue has already been won. with the pro-support 
TEW Department finally getting the upper hand in an 
ntra-administration dispute with the Office of Man- 
igement and Budget which wanted to end federal sub- 
.idies for medical schools. 

Dr. Nesbitt told Kennedy's Subcommittee that fed- 
;ral scholarships should continue, not only those tied 
o service in the Public Health Service and National 
health Service Corps, but scholarships with no strings 
ittached for students in severe financial need from the 
locio-economic disadvantaged. Funds for student 
cans also are needed, he said. 

' Proposals to regulate the total numbers of first year 
'esidency provisions, their geographic location, and 
heir distribution by specialty were labelled "un- 
■ necessary and unwise" by the AMA official. 

i The number of residency positions is declining at 

, .he same time the number of medical school graduates 

• ^ increasing. Dr. Nesbitt noted. "It is a particularly 

nappropriate time to establish arbitrary legislative 

eilings on total residency positions." 

The goal of such allocations is to increase the 

Iumberof "primary care" physicians. However, Dr. 
lesbitt pointed out that last year 58 percent of 
raduate students entered "primary care" specialties, 
inore than the 50 percent goal set by the AMA previ- 
')usly. What Congress is seeking is already being ac- 
omplished without legislation, he said. 

^1 * * * 

The House Ways and Means Committee has ap- 
iroved four technical amendments to the Medicare 
iw including one which would forestall rollbacks in 
ome physicians' Medicare reimbursement. 



An unintended effect of the HEW Department's 
new Medicare reimbursement index tying physicians' 
Medicare fees to a cost-of-living-type formula was to 
cause some reimbursement levels to be less this year 
than last despite rises in the cost of living. The Ways 
and Means amendment would prevent any reim- 
bursement to be less this fiscal year than allowed 
previously. 

The AMA had urged this change. The other 
amendments dealt with reimbursement for teaching 
hospitals, the Federal Employees Health Benefits 
Program, and extension of an exemption for certain 
nurse staffing requirements in rural hospitals. 



Two broad philosophical principles — the right of 
privacy and the public's right to know — are colliding 
in Federal health programs. The dilemma was pointed 
up recently when the Federal Medicaid program de- 
cided the Freedom of Information Act required it to 
release upon request the names of physicians who 
collected more than $100,000 yearly from Medicaid 
payments. 

The HEW Department said 207 physicians last year 
received more than $100,000 from Medicaid. The 
names of 13 New Jersey physicians were released 
immediately and all other names will be made public, 
HEW officials said. The names were requested by the 
New York Daily News and other newspapers on the 
basis of the Freedom of Information Statute designed 
toopenup the workings of the Federal Government to 
public scrutiny. 

Medicaid officials made clear that the figures were 
gross receipts and that there was no suggestion of any 
abuse or impropriety. Dr. Keith Weikel, Federal 
Medicaid Director, told a small group of newsmen that 
he was concerned that disclosure of the physicians' 
names might discourage some physicians from treat- 
ing Medicaid patients, but he added that the Agency 
felt the information law required release. 



The military medical school is still in jeopardy. The 
school, to be located on the Bethesda, Md., grounds of 
the Naval Medical Center, was opposed last year by a 
special White House task force that concluded tax- 
payers would save $100 million without it. The House 
recently approved funds for the school, but the Senate 
asked the General Accounting Office to make a study 
of the cost effectiveness of the Uniformed Services 
University of the Health Sciences compared with the 
present military medical scholarship program. Sen. 
William Proxmire (D-Wis. ) told the Senate $15 million 
has already been spent on the school and Congress 
should allow it to go ahead. The AMA has opposed the 
establishment of the school since its conception a 
number of years ago. 



ANLARY 1976, NCMJ 



57 



in Mtmarmm 



T. C. BOST, M.D. 

Dr. T. C. Bost was a master surgeon, financier and 
philanthropist. 

Born in Midland, a suburb of Charlotte, in 1886, he 
received his medical degree from George Washington 
University. After completing his internship and resi- 
dency in the Washington area, he volunteered for 
military service. This was before the United States 
entered World War I. An appointment signed by King 
George V granted Dr. Bost a commission as captain in 
the Royal Army and he was assigned to Dartford Hos- 
pital. It was there that while operating on a young 
officer with multiple wounds the patient suffered car- 
diac arrest. Dr. Bost opened the chest and by heart 
massage ("cardiac compression," he called it) the 
heart started beating and the officer was restored to 
life. Lancet, the oldest English language m.edical jour- 
nal, reported this case as the first of its kind. Dr. Bost 
later practiced at Dartford and in London. 

When he returned to Charlotte, he was appointed 
chief of surgery for life at Mercy Hospital, and al- 
though he worked at all of Charlotte's hospitals, 
Mercy was his first love. He probably operated on 
more doctors and their families and on more Catholic 
sisters than any surgeon. His unusual dexterity and 
profound surgical judgment made him a very fast sur- 
geon and his fame spread quickly. 

Dr. Bost wrote extensively in surgical journals. 
There was a young man brought to Mercy Hospital 
from a traffic accident. He had a good-sized piece of 
timber through his abdomen. Dr. Bost removed the 
timber and after a series of operations (there were no 
antibiotics in those days) the man not only recovered 
but served in the military in World War II. 

Dr. Bost had an inherent ability of knowing just 
what the stock market was doing and what it was going 
to do. He invested heavily and very successfully. Just 
a few years ago he gave Duke University a trust fund 
of a million dollars to be used for medical research and 
student loans. He said, "If a person is going to give, 
give enough to do some good." 

Dr. Bost operated on many charity patients, both 
adult and children, and gave freely of his time to them. 
He was especially active in the Scottish Rite and was 
advanced to KCCH and later awarded the 33d degree. 
He was the most noble of the nobility of the Shrine. 

With all this, his life-style was simple and unpreten- 
tious. He cut red tape to the bone and went directly to 
the point, losing very few words, and very little time 
and energy. His conversation was sprinkled with a dry 



58 



wit which endeared him to his many friends and pa 
tients. 

When a man reaches 89 years of age, he has ven' 
few friends left to mourn his passing, but Dr. Thoma; 
C. Bost must go down in the annals of Charlotte anc 
Mecklenburg County as one of our most distinguished 
citizens and a beloved and leading surgeon. 

Mecklenburg County Medical Society 

I 
ALLYN BLYTHE CHOATE, M.D. I 

AUyn Blythe Choate, M.D., died on October 2.j 
1975, after serving Charlotte. Mecklenburg County 
and the state of North Carolina long and well, not only 
as a physician but as the organizer of several social 
services that have made invaluable contributions tc 
the whole community. The mental health programs 
and the heart programs are only two examples of his 
farsightedness. Therefore, Bob Choate will be missed' 
not only by his medical colleagues, his patients, and' 
his friends, but by the many people associated with 
him in these endeavors. 

Bom in Huntersville on April 12. 1903. Allyn Blythe 
Choate was the son of Joseph Lee and Harriet Blythe 
Choate. He was educated in the Huntersville schools! 
and attended Davidson College for two years. He was 
graduated with an A.B. degree from the University oli 
Richmond in 1925. | 

His medical education was obtained at the Medical 
College of Virginia where he was granted the M.D. 
degree in 1929. His postgraduate training included an 
internship at Memorial Hospital in Richmond and res- 
idencies at Baltimore City Hospital and Church Home| 
and Infirmary in Baltimore, Maryland. i 

He then came to Charlotte where he began the prac-i 
tice of internal medicine and became a member of the 
Mecklenburg County Medical Society, the North 
Carolina Medical Society and the American Medical 
Association in 1932. He later became a Fellow of the 
American College of Physicians. He served as the 
chief of staff of Mercy Hospital. On the state level, he 
served on the North Carolina Medical Society's 
Committee on Mental Health from 1950-1973 and was} 
chairman of this committee from 1950 to 1962. 

Soon after returning to Charlotte. Dr. Choate met 
Sarah Glover and they were married in 1939. They had! 
two sons. Allyn Blythe Choate Jr., and Fred Glover 
Choate. The whole family became interested in horses; 
and every summer while the boys were growing up,: 
the Choates spent their weekends at horse shows. Boo 
was not only a dedicated physician, an active partici-i 

Vol. 37. No. 1 



)ant in many community projects, but a devoted hus- 
band and father. 

Dr. Choate was a pioneer in the field of mental 
lealth and actively served in this area throughout his 
nedical career. In the early 1930s he was active in 
organizing the first mental health program in North 
Carolina, known as the Charlotte Mental Hygiene 
society, serving as one of its first presidents. He also 
lelped organize the North Carolina Mental Health 
\ssociation and served a term as president. He was a 
brmer chairman of the North Carolina Mental Health 
Touncil. a state-appointed board of coordinating 
netal health organizations. 

In the 1940s. Dr. Choate started the first heart pro- 
;ram in Charlotte and served as volunteer director of 
ji outpatient heart clinic at Charlotte Memorial Hos- 
lital. In 1955 he was president of the first Charlotte 
ieart Association, known then as Heart Services, 
vhich became The Community Health Association in 
%7. He died on the day following the 20th anniver- 
ary of the opening of the first Heart Services office in 
he Doctors Building on October 1, 1955. He was also 

trustee of the Augusta M. Wray Heart Services 
^und. 

Among other social welfare programs with which he 
vas associated was the Social Planning Council, 
vhich he served as president. Dr. Choate also was 
:hairman of the budget committee of the United 
Community Chest and a member of the board of direc- 
,ors of the Family Service Association. The most per- 
bnally rewarding position Dr. Choate held was the 
iresidency of the North Carolina Conference for So- 
ial Service. 

Dr. Choate was a deacon of the old Second Pres- 
lyterian Church, a member of Covenant Presbyterian 
"hurch, a Mason and a member of the Charlotte 
Tountry Club. 

Allyn Blythe Choate will be remembered not only as 
I respected physician but as a doctor whose concern 

- 'or his fellow man went beyond the realm of the physi- 
cal into all facets of life. He performed this service 
vith quiet dedication, a sense of humor and great 
liplomacy. His contributions have made Charlotte a 
)etter community and we are grateful for his life of 

■> '.ervice here. 

' ' Mecklenburg County Medical Society 



ERNEST WASHINGTON FRANKLIN, JR., M.D. 

Dr. Ernest Washington Franklin. Jr., 70. died in a 
local hospital October 25, 1975. after a prolonged ill- 
ness. Dr. Franklin was born in Raleigh on April 13. 
1905, the son of Emest.Washington Franklin and Ettie 
Williams Franklin. He received hiselementary educa- 
tion in Raleigh and a bachelor of science in medicine 
from the University of North Carolina in 1928. He re- 
ceived his M.D. degree from the University of Penn- 
sylvania in 1930. He served an internship at the Chest- 
nut Hill Hospital in Philadelphia from 1930 to 1931 and 
a residency in obstetrics and gynecology at Kings 
County Hospital in 1933. 

Dr. Franklin married Miss Tempie Williams of 
Louisburg, North Carolina, in 1930, and he began the 
practice of obstetrics and gynecology in Charlotte in 
1933. He was certified by the American Board of 
Obstetrics and Gynecology in 1930. He was a member 
of the staffs of Charlotte Memorial, Presbyterian and 
Mercy Hospitals, and was president of the visiting 
staff of Charlotte Memorial Hospital in 1956 and 1957. 
He served as president of the Mecklenburg County 
Medical Society in 1960. He was an active member of 
the Myers Park United Methodist Church, the Dil- 
worth Rotary Club and the Charlotte Country Club. 
He was also a member of the North Carolina Medical 
Society, the South Atlantic Association of Obstetri- 
cians and Gynecologists, the American College of 
Obstetrics and Gynecology, the Southern Gynecolog- 
ical and Obstetrical Society and the Southern Medical 
Association. 

Dr. Franklin is survived by his son. Dr. Ernest W. 
Franklin. Ill, of Atlanta; a daughter. Mrs. Allen O. 
Maxwell. Jr., of Charlotte, and two brothers. Dr. Roy 
Franklin of Croydon on the Hudson, New York, and 
Worth Franklin of Raleigh. 

Dr. Franklin was a genteel, kind and understanding 
person and was loved and admired by his patients and 
friends. His main professional interest was gynecolog- 
ical surgery with special emphasis on procedures for 
the correction of urinary incontinence. He was very 
much interested in art and occasionally did some sci- 
entific paintings as a hobby in his leisure time. 

Dr. Franklin will be greatly missed by the medical 
community and will be long remembered by his many 
friends and associates. 

Mecklenburg County Medical Society 



AVAILABLE FOR IMMEDIATE SHIPMENT Standard Approved Forms for 

Billing to Commercial Insurance Companies - Blue Cross - Medicare 

G 33P FOR PHYSICIANS G 34D FOR DENTISTS 2 Part Carbon Interleaved Snap-A-Part Sets 

500 FORMS FOR ONLY $19.50 1000 FORMS FOR ONLY 834.45 

Forms may be imprinted with Doctor's Name, Address, Registry number, I.D. Number, etc. 
IMPRINT CHARGES: $12.50 per 1000 jorms (Minimum Imprint Charge is $12.50) Orders for 
forms NOT imprinted are shipped same day received. For imprinted orders please allow 2 
weeks. All orders FOB Durham. North Carolina. 



L^aCaLei ^ale^ i^oibo'iation 



p. 0. DRAWER 15130 



DURHAM, NORTH CAROLINA 27704 



Telephone: 919 477-7397 



Monday through Friday 9:00 A.M. - 1:00 P.M. 



ANUARY 1976, NCMJ 



59 



COMPREHENSIVE 

GROUP 

HEALTH CARE 

PLAN 



(Winston-Salem, N. C. 



A new prepaid group health plan (Multi-specialty) is being de- 
veloped for employees of R. J. Reynolds Industries, Inc., and the 
following board-qualified specialists are needed. 



INTERNISTS 

PEDIATRICIANS 

OB/GYN 



This represents an opportunity to practice under ideal conditions 
in modern new facilities and excellent hospitals in a unique con- 
cept in the Southeast. 

Winston-Salem is located in the Piedmont section of North Caro- 
lina and is within reasonable driving distances to the Atlantic 
Ocean and Blue Ridge Mountains. The city is noted for its cul- 
tural, recreational and college environments. 

Salary commensurate with experience. Liberal fringe benefits in- 
cluding paid vacation, CME, retirement, life insurance and health 
coverage. Relocation expenses paid. 



Send curriculum vitae including salary requirements, to: 
Reid Bahnson, M.D., Medical Director 

W-S Health Care Plan, Inc. 

P. 0. Box 2959 
Winston-Salem, N.C. 27102 

An Equal Opportunity Employer, m/f 



Classified Ads 



jTAFF psychiatrists, located in Piedmont, N.C., young mental 
health staff serving 180,000 residents in three county area. No re- 
strictions on private practice after hours. Good fringe benefits. 
Contact Larry Parrish, Area Director. Tri County Mental Health 
Complex, 165 Mahalev Avenue, Salisburv. N.C. 28144. Telephone 
collect (704( 633-3616". 



)FFICE SPACE FOR RENT: 1300 sq. ft. Erdman building in front 
of Pardee Hospital. Excellent parking facilities. Former tenant 
after two years had to take two associates and needed more footage. 
Contact: 704-692-2115 or 704-692-2321. 



•HYSICIAN'S ASSOCIATE— Duke Graduatis-Strong background 
in pediatrics and surgery. Interested in relocating to Central or 



Staff Psychiatrists, located in Piedmont, N. C, young mental health 
staff serving 180,000 residents in three county area. No restrictions 
on private practice after hours. Good fringe benefits. Contact 
Larry Parrish, Area Director, Tri County Mental Health Complex, 
165 Mahaley Avenue, Salisburv, N. C. 28144. Telephone collect 
(704) 633-3616. 



Eastern North Carolina. Reply to: NCMJ-10, P. O. Box 27167, 
Raleigh, N. C. 27611. 



EMERGENCY MEDICINE: Northeastern North CaroUna; four, 
12-hour evening rotations per week. Paid malpractice, vacation, 
professional dues. $45,000 annual remuneration. Contact Drs. 
Cooper or Spurgeon toll free 1-800-325-3982. 

PHYSICIANS NEEDED: M.D.'s with completed internships or resi- 
dencies for hospital/clinics/flight surgeon duties — worldwide 
placement available! Relocation fees paid, 30 days paid vacation 
each year. 40 hour work week. Contact Dave Powell, Nav^ Medical 
Representative, Navy Recruiting District, P.O. Box 18568, Ra- 
leigh, N.C. 27609. Call Collect: 782-2005. 



TUCKER HOSPITAL, Inc. 



212 West Franklin Street 
Richmond, Virginia 



A private hospital for diagnosis and treatment of psychiatric and 
neurological disorders. Hospital and out-patient services. 

(Visiting hours 2:00 p.m. -8:00 p.m. daily) 



James Asa Shield, M.D. 
James Asa Shield, Jr., VI. D, 
Graenum R. Schife, M.D. 



Weir M. Tucker. M.D. 

George S. Flltz. Jr., M.D. 

Catherine T. Ray, M.D. 



William D. Kernodle, M.D. 



\nuary 1976, NCMJ 



61 



Index to 
Advertisers 



Asheville School 41 

Blue Cross & Blue Shield of N.C 8 

Burroughs Wellcome Company 51 

Cavalier Sales Corporation 59 

Community Diet Counseling Service, Inc 47 

Crumpton. J. L. & J. Slade, Inc 17 

Fellowship Hall 2 

Golden-Brabham Insurance Agency 6 

Lilly, Eli & Company Cover 1 

Mallinckrodt, Inc 32, 33 

Mandala Center 5 

Mutual of Omaha 43 

Pharmaceutical Manufacturers Association .12, 13 

Reed & Carnrick 20 

Reynolds, R. J. Industries 60 



Roche Laboratories Cover 2. 1, 52, 53, 5!, 

Cover 3, Cover i 
Roerig, A Division of Pfizer 

Pharmaceuticals 9, 38, * 

Saint Albans Psychiatric Hospital 

Sealy of the Carolinas, Inc j 

Tidewater Psychiatric Institute 

Transco, Inc '< 

Tucker Hospital ( 

United States Air Force < 

United States Navy 

Upjohn Company 10, 

Webcon Pharmaceuticals 14, 

Willingway, Inc <■ 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company ' 



I 



WINCHESTER 

"CAROLINAS' HOUSE OF SERVICE" 

Winchester Surgical Supply Company 

200 South Torrence St. Charlotte, N. C. 28204 
Phone No. 704-372-2240 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N. C. 27401 
Phone No. 919-272-5656 

Serving the MEDICAL PROFESSION of NORTH CAROLINA 
and SOUTH CAROLINA $ince 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N. C. State Medical Society Meeting since 1921, and, 
advertiser CONTINUOUSLY in the N. C. Journal since January 1940 issue. 



62 



Vol. 37. No. 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 



• prompt and specific action 

• documented benefit-to-risk ratio 

• three dosage strengths to meet most therapeutic needs 




Before prescribing, please consult 
complete product information, a summary 
of which follows: 

Indications: Relief of anxiety and tension 

occurring alone or accompanying various 

disease states. 

Contraindications: Patients witfi known 

hypersensitivity to tfie drug. 

Warnings: Caution patients about possible 

combined effects witti alcohol and other 

CNS depressants. As with all CNS-acting 

drugs, caution patients against hazardous 

occupations requiring complete mental 



alertness (e.g., operating machinery, driv- 
ing). Though physical and psychological 
dependence have rarely been reported on 
recommended doses, use caution in ad- 
mmistering to addiction-prone individuals 
or those who might increase dosage; with- 
drawal symptoms (including convulsions), 
following discontinuation of the drug and 
similar to those seen wilh barbiturates, 
have been reported. Use of any drug in 
pregnancy, lactation or in women of child- 
bearing age requires that its potential 
benefits be weighed against its possible 
hazards. 

Precautions: In the elderly and debilitated, 
and in children over six, limit to smallest 
effective dosage (initially 10 mg or less per 
day) to preclude ataxia or oversedation, 
increasing gradually as needed and tol- 
erated. Not recommended in children 
under six. Though generally not recom- 
mended, if combination therapy with other 
psychotropics seems indicated, carefully 
consider individual pharmacologic effects, 
particularly in use of potentiating drugs 
such as IVIAO inhibitors and phenothia- 
zines. Observe usual precautions in pres- 
ence of impaired renal or hepatic function. 
Paradoxical reactions (e.g., excitement, 
slimulation and acute rage) have been 
reported in psychiatric patients and hy- 
peractive aggressive children. Employ 
usual precautions in treatment of anxiety 
states with evidence of impending depres- 
sion; suicidal tendencies may be present 
and protective measures necessary. Vari- 
able effects on blood coagulation have 
been reported very rarely in patients re- 
ceiving the drug and oral anticoagulants; 
causal relationship has not been estab- 
lished clinically. 



Adverse Reactions: Drowsiness, ataxia 
and confusion may occur, especially in the 
elderly and debilitated. These are revers- 
ible in most instances by proper dosage 
adjustment, but are also occasionally ob- 
sen/ed at the lower dosage ranges. In a 
few instances syncope has been reported. 
Also encountered are isolated instances of 
skin eruptions, edema, minor menstrual 
irregularities, nausea and constipation, 
extrapyramidal symptoms, increased and 
decreased libido— all infrequent and gen- 
erally controlled with dosage reduction; 
changes in EEG patterns (low-voltage fast 
activity) may appear during and after treat- 
ment; blood dyscrasias (including agranu- 
locytosis), jaundice and hepatic dysfunction 
have been reported occasionally, making 
periodic blood counts and liver function 
tests advisable during protracted therapy. 
Usual Daily Dosage: Individualize for 
maximum beneficial effects. Oral— Adults: 
Mild and moderate anxiety and tension, 
5 orlO mg t.i.d. or q./.d.; severe states, 20 
or 25 mg t.i.d. or q.i.d. Geriatric patients: 
5 mg b.i.d. to q.i.d. {See Precautions.) 
Supplied: Librium'5' (chlordiazepoxide HCI) 
Capsules, 5 mg, 10 mg and 25 mg — bottles 
of 100 and 500; Tel-E-Dose'S' packages of 
100, available in trays of 4 reverse-num- 
bered boxes of 25, and in boxes contain- 
ing 10 strips of 10; Prescription Paks 
of 50, available singly and in trays of 10. 
Libritabs?' (chlordiazepoxide) Tablets. 
5 mg, 10mg and 25 mg — bottles of 100 and 
500. With respect to clinical activity, cap- 
sules and tablets are indistinguishable. 



Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nut ley. New Jersey 07110 



Please see following page. 



LIBRIUM 

chlordiazepoxide HCI/Roclie 
5mg,10mg, 25 mg capsules 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 

Yesterday's decision to use Librium for a clinically anxious 
patient was based on several good reasons. Safety. Effectiveness. 
Versatility. And the reasons you chose it yesterday are as valid today. 

Librium has accumulated an unsurpassed clinical record. A 
record validated in several thousand papers published both here 
and abroad. 

Librium, when used in proper dosage, rarely interferes with a 
patients mental acuity or ability to perform. However, as with all CNS' 
acting agents, good medical practice suggests that patients be cautioned 
against hazardous activities requiring complete mental alertness. 

Librium has an established safety record and a documented 
benefit'to-risk ratio. And Librium is used concomitantly with such drugs 
as cardiac glycosides, diuretics, anticholinergics and antacids. 

So when you consider antianxiety therapy, consider Librium. 

It's a good choice. For today. And tomorrow. 




ROCHE 




PROVEN ADJUNCT FOR CLINICAL ANXIETY 

UBRIUM ' 

chlordiazepoxide HCI/Roche 

Please see preceding page for summary of product informatioa 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY 



February 1976, Vol. 37, No. 2 



NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: Medical Management of Rheumatoid Arthritis, Nortin M. Hadler, M.D.; Surgery of the Lower Limb in 
Rheumatoid Arthritis, Frank D. Wilson, M.D.; Medicine-During the Great War of 1914-1918, Adrian M. Griffin 



BECOTIN® 

Vitamin B Complex 




1976 ANNUAL SESSIONS 
May 6-9— Pinehurst 



1976 Committee Conclave 
Sept. 22-26— Southern Pines 



Both often 




Predominant 
• psychoneurotic 
anxiety 



Associated 

• depressive 

symptoms 



Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints which are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adjunctively in skeletal r.iuscle 
spasm due to reflex spasm to local pathol- 
ogy, spasticity caused by upper motor 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 
therapy). 

Contraindicated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



orders, possibility of increase in frequency 
and/ or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 



reso 



According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feelings, part of the problem 
may sound like depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two. although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 




Wium(g 

(diazepam) ^ 

2-mg, 5-mg, 10-nig scored tablets 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to tnabituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
skin rash, ataxia, constipation, headache, 
incontinence, changes in salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug. Iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 



\. / Nutley, t 



Laboratories 
of Hoffmann-La Roche Inc. 
New Jersey 07110 



North Car6lina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy- 
75 percent — 25 percent Co-Insurance 



PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 

60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$206.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50.00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 

40-49 
50-59 
60-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age GO. 

**lntegrates with Medicare at age 65. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus 50 cents. 



Term Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


655 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-69 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 

The above plans quality for use in the Professional Association. 



For Full Information — Write or Call 

Golden-Brabhann Insurance Agency, Inc. 

Ralph J. Golden Van Brabham III 

108 E. Northwood St., Phone; BRoadway 5-3400, Box 6395, Greensboro, N. C. 27405 



physician: 

COULD YOU 1AKE 
SOIM^UACAnON 
AYEAR AWAY FROM 
YOUR PRESENT PRACTICE? 

You can as a United States 
Air Force Officer! 

In addition to the good salary, a very 
comprehensive benefits list, and the full 
scope to practice your specialty, the Air 
Force offers you the position and prestige 
due your profession. Weigh the confine- 
ment of your present practice against the 
travel and professional freedom you'll en- 
joy as a commissioned officer. If you're a 
fully qualified physician, osteopathic 
physician, dentist, veterinarian or opto- 
metrist, isn't it worth a few minutes of 
your time to investigate the opportunities 
your United States Air Force can extend to 
you? You may find your private practice \n 
the Air Force. 



Mail the coupon below (or all the Information. 

310 New Bern Ave , Rm 303 
Raleigh. N C 27611 
Call 919/755-4134 




Name 

Address 

City 

Slate 



Social Security No 



Zip 



Phone 



Specially _ 
Dale of Birth 

AIR FORCE. Health Care At Its Best. 



_ .-•■■1 I vii'wi.. iicaiiii y^aiv «i iia oesi. _ 



John H, Felts, M.D. 
Winston-Salem 

EDITOR 

John S. Rhodes. M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Hilliard 
Raleigh 

BUSINESS MANAGER 



NORTH CAROLINA 
MEDICAL JOURNAL! 

Published Monthly us the Official Organ of 

The North Carolina 

Medical Society 

February 1976, Vol. 37, No. 2l 



EDITORIAL BOARD 

Charles W. Styron. M.D. 
Raleigh 

CHAIRMAN 

George Johnson. Jr.. M.D. 
Chapel Hill 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Fully. M.D. 
Kinston 

John S. Rhodes, M.D. 
Raleigh 

Louis Shaffner, M.D. 
Winston-Salem 

Robert E. Whalen. M.D. 
Durham 



NORTH CAROLINA MEDICAL JOLRNAL. .100 S. 
Hawthorne Rd., Wmslon-Saiem. N. C. 2710.1. is owned 
and published by The Nonh Carolina Medjeal Soeiely 
under the direction of its Editorial Board. Copyright ' 
The Nonh Carolina Medical Society 1975. Address 
manuscripts and communications regarding editorial 
matter to this Winston-Salem address. Questions relat- 
ing to subscription rates, advenising, etc.. should be 
addressed to the Business Manager. Bo.x 27167. 
Raleigh. N. C. 2761 1. All advertisements are accepted 
subiect to the approval ofa screening committee ol the 
state Medical .lournal Advenising Bureau. 711 South 
Blvd.. Oak Hark, Illinois 60.102 and or bv a Committee 
of the Editorial Board otthc Nonh Carolina Medical 
Journal in respect to strictly local advenising. Instruc- 
tions to authors appear in the January and July issues. 
.Annual Subscription, SiO.tX). Single copies, SI 'OO. Hub- 
healion ollice: Edwards ,.^i Broughton Co.. P.O. Box 
272S6. Raleigh, N.C. IKsW-SecimJ-class lyoslaac puiJ 
tuRiilfigh. Ni:nh Cariilinu 27611. 



Original Articles 

Medical Management of Rheumatoid Artliritis 85| 

Nortin M. Hadier, M.D. 

Surgery of tlie Lower Limb in Rheumatoid Arthritis 92| 

Frank b. Wilson, M.D. 

Medicine During the Great War of 1914-1918 96| 

Adrian M. Griffin 



Editorials 

Young Dr. Fogy 

Poke Saiit: A Success Story 



Bulletin Board 

New Members of the State Society 

What? When? Where? 

Auxiliary to the North Carolina Medical Society 

News Notes from the Duke University Medical Center . . 

News Notes from the Bowman Gray School of Medicine 
Wake Forest University 

Controlled Therapeutic Trial of Corticosteroids in 

Fulminant Hepatic Failure 



991 
lOOl 



1021 

IO2I 

IO4I 

IO4I 

of 
109 



Month in Washington 



Book Reviews 



II 



In Memoriam 1 Ulf 



Classified Ads 115 



Index to Advertisers 



Contents listed in Current Contents/Clinical Practice 




lund useful in the management of vertigo"" associated with 

s ses affecting the \'estibular system. 

i n relieve nausea and vomiting often associated with \'errigo" 

lual adult dosage for Antivert/25 for vertigo:* one tablet t.i.d. 

/50 available as Antivert (meclizine HCl) 12.5 mg. scored 

b ts, for dosage convenience and flexibility. 

/itivert/25 (meclizine HCl) 25 mg. Cheuable Tablets for 

U5a, \'omiting and dizziness associated with motion sickness. 

'J SLMNWRV OF PRESCRIBING INFORMATION 



*1 ^IC.-\T10NS Based on a reuew ot this drug bv the Naaonal .Academv of 
S( ices — NanonaJ Research G^uncil and/or other mtormaQon, FDA has classified 
cr ndications as follows: 

fecnic. Management of nausea and \'omiting and dizriness associated with 
:n on sickness. 

■ssib/v Effective. Management of \-erngo assoaated wnth diseases affecting the 
•'t bular system. 

lal classificanon oi the less than effecn\'e indicanons requires further 
n ^tl'^anon 



,i.^'-iV 7*-*"3!*' - 

Big Balanced Rock. Chincatiua Mountains, Arizona (approx 1,000 tons) 

CONTRAIKDICATIONS. Administration of Antivert (meclizine HQ) during preg- 
nancv or to women who may become pregnant is conrraindicated in \-ie\v of the 
teratogenic effect of the drug in rats. 

The administranon of meclinne to pregnant rats during the 12-15 day of gestanon 
has ptoduced cleft palate in the offspnng. Limited studies using doses of over ICVO mg./ 
kg./day in rabbits and 10 mg.Ag./day in pigs and monkeys did not show cleft palate 
Congeners of meclizine have catjsed cleft palate in species other than the rat. 

Meclizine HCl is conrraindicated in indmduals who ha\-e shown a previous h\per- 
sensio\ir>* to it. 

WARNINGS Since drowsiness may. on occasion, occur with use of this drug, paaents 
should be warned of this possibilir\' and caunoned against dn\ing a car or operating 
dangerous machinery 

LMgf m Children Clinical studies establishing safety and effectiveness in children 
have not been done, therefore, usage is not recommended in the pediatnc age group 

L'sage in Pregruinc^v See "Contraindicanons'' 
ADVERSE REACTIONS. Drowsiness, dry mouth and, i-'n rare occasions, blurred 
\'ision has'e been reported. 

More detailed professional intormanon a\-ailable on 
request 



Antivert/^25 

(meclizine HCl) 25 mg,Tablets 

for vertigo* 



ROeRIG <9 

A division o1 Pf'zer Pharmaceuticals 
New York, New York 10017 



VISU/IL FOCUS 

ON 

/lOUTE GOUTY/IRTHRITIS 



I 




Foot of patient with acute gouty arttiritis Scintiphotogram of same foot reflects 
as seen by conventional x-ray. inflammatory process. 

The scintiphotograph on the right shows increased joint of the great toe of a patient with acute gout 
uptake of radiotechnetium polyphosphate in the meta- arthritis. This increased uptake probably results fror 
tarsophalangeal jointand the proximal interphalangeal increased vascularity in the affected areas. 

For a more detailed description of scintipiiotography, 
see "addendum" at right. 



THEf^PEUTIC FOCUS 

ON 



CAPSULES, 25 mg and 50 mg 




INDIMETHACIN I MSD) 



helps relieve pain 

and other symptoms 

of Inflammation 

in acute 

gouty arthritis 

in selected patients 

INDOCIN is a potent drug with anti-inflammatory, 
antipyretic, and analgesic properties. It should not be 
used in conditions other than those recommended. Al- 
though INDOCIN does notalterthe progressive course 
of the underlying disease, in selected patients with 
acute gouty arthritis it has been found MSD 

highly effective in relieving pain and in merck 

reducing fever, swelling, and tenderness. dohme 



For a brief summary of prescribing information, 
please see following page. 




Facts about 
Scintiphotography 




In recent years a variety of 
radiopharmaceuticals have 
been employed to aid in the 
diagnosis of bone and joint 
disorders. The joint-imaging 
technique consists of inject- 
ing technetium polyphos- 
phate intravenously, and 
imaging is performed with 
the scintillation camera two 
hours after the administra- 
tion of the radionuclide. In 
general, for joint surveying, 
the shoulders, elbows, hands, 
wrists, knees, ankles, feet, 
and vertebral column are 
mapped. The entire scanning 
process takes approximately 
one hour. The criterion for a 
positive image is a higher 
concentration of radioactivity 
in a joint region than in ad- 
jacent nonarticular bone. In 
effect, each patient serves 
as his own control. 




(INDOMETHACIN I MSD) 




helps relieve pain 
and other symptoms 
of inflammation 
in acute 
gouty arthritis 
in selected patients 



IMPORTANT NOTE: INDOCIN (Indomethacin, MSD) cannot be consider! 
a simple analgesic and should not be used in conditions other than tho; 
recommended. The drug should not be prescribed for children becau: 
safe conditions for use have not been established. 

Because of the high potency of the drug and the variability of its potent! 
to cause adverse reactions, the following are strongly recommende 
1) the lowest possible effective dose for the individual patient should t. 
prescribed. Increased dosage tends to increase adverse effects, parti 
ularly in doses over 150-200 mg per day, without corresponding clinic; 
benefits; 2) careful instructions to, and observations of, the individu; 
patient are essential to the prevention of serious and irreversible, I 
eluding fatal, adverse reactions, especially in the aging patient. 
Contraindications: Children 14 years of age and under; pregnant wome' 
and nursing mothers; active gastrointestinal lesions or history of recurre 
gastrointestinal lesions; allergy to aspirin or indomethacin. 
Warnings: Gastrointestinal Effects: Because of the occurrence and, 
times, severity of gastrointestinal reactions, be continuously alert for ar 
sign or symptom signaling a possible gastrointestinal reaction. The risi 
of continuing therapy with INDOCIN in the face of such symptoms mu 
be weighed against the possible benefits to the individual patient. Gastr 
intestinal effects may be reduced by giving the drug immediately aft 
meals, with food, or with antacids. Use greater care in aging patients. 
Ocular Effects: Corneal deposits and retinal disturbances, including tho; 
of the macula, have been observed in some patients on prolonged therap 
Discontinue therapy if such changes are observed. Ophthalmologic exar 
ination at periodic intervals is desirable in patients on prolonged therap 
Central Nervous System Effects: INDOCIN may aggravate psychiatr 
disturbances, epilepsy, and parkinsonism, and should be used with co 
siderable caution in patients with these conditions. If severe CNS adver; 
reactions develop, discontinue the drug. 

Precautions: Blurred vision may be a significant symptom that warrants 
thorough ophthalmologic examination. Patients should be cautioned aboi 
engaging in activities requiring mental alertness and motor coordinatio 
as driving a car. Headache which persists despite dosage reduction r 
quires complete cessation of the drug. May mask the usual signs ai 
symptoms of infection; therefore, the physician must be continually c 
the alert for this and should use the drug with extra care in the presenc 
of existing controlled infection. After the acute phase of the disease 
under control, an attempt to reduce the daily dose should be made r 
peatedly until the patient is off entirely. 

Adverse Reactions: Gastrointestinal Reactions: Single or multiple ulcer 
tions of the esophagus, stomach, duodenum, or small intestine, includir 
perforation and hemorrhage, with fatalities in some instances; rarely, inte 
tinal ulceration has been associated with stenosis and obstruction; gastr 
intestinal bleeding without obvious ulcer formation; perforation of pr 
existing sigmoid lesions (diverticulum, carcinoma, etc.); rarely, increase 
abdominal pain in ulcerative colitis patients or development of ulcerati' 
colitis and regional ileitis; gastritis, which may persist after the cessatic 
of the drug; nausea, vomiting, anorexia, epigastric distress, abdomin 
pain, and diarrhea. 

fye Reactions: Corneal deposits and retinal disturbances, Including tho: 
of the macula, have been observed on prolonged therapy; blurring 
vision. 

l-fepatic Reactions: Rarely, toxic hepatitis and jaundice, including son 
fatal cases. 

l-fematologic Reactions: Aplastic anemia, hemolytic anemia, bone marrc 
depression, agranulocytosis, leukopenia, and thrombocytopenic purpur 
Since some patients manifest anemia secondary to obvious or occult ga 
trointestinal bleeding, appropriate blood determinations are recommende 
Hypersensitivity Reactions: Acute respiratory distress, including dyspne 
and asthma; angiitis; pruritus; urticaria; angioedema; skin rashes; purpur 
Ear Reactions: Hearing disturbances, deafness, tinnitus. 
Central Nervous System Reactions: Psychic disturbances including ps 
chotic episodes, depersonalization, depression, and mental confusioi 
coma; convulsions; peripheral neuropathy; drowsiness; lightheadednes 
dizziness; syncope; headache. 

Cardiovascular-Renal Reactions: Edema, elevation of blood pressur 
hematuria. 

Dermatologic Reactions: Loss of hair, erythema nodosum. 
Miscellaneous: Rarely, vaginal bleeding, hyperglycemia, glycosuria, ulce. 
ative stomatitis, and epistaxis. 

Note: In patients receiving probenecid, plasma levels of indomethacin ai 
likely to be increased. 

Supplied: Capsules containing 25 mg indomethacin each, in single-ur 
packages of 100 and bottles of 100 and 1000; capsules containir 
50 mg indomethacin each, in single-unit packages of 100 and bottif 
of 100. 

For more detailed information, consult your MSD representative or si 
full prescribing information. Mercl< Sharp & Dotime, Division of Merc 
&Co., Inc., West Point, Pa. 19486 n/ict 

MERC 
SHARP 
DOHM 






Preventive Medicine 
Makes Sense ... 

Disability Income Protection Does Too! 



1. / 



\ 




H J ^: 



Just as preventive medicine can help you 
avoid disasters to your health, Disability Income 
Protection can help you avoid financial 
disasters. A long-term disability, for example, 
without adequate insurance protection could 
mean weeks or even years without an income. 

For this reason alone, you cannot afford 
to be without the proper protection. 

That's why we have especially designed a 
Disability Income Protection Plan for younger 
doctors. A plan of protection to help make sure 
your family continues to live in the manner to 



which they are accustomed should you become 
disabled and unable to practice medicine. 

These benefits are paid directly to you to use 
as you see fit whether you are confined in 
a hospital or recovering at home. Furthermore, 
these benefits are tax free under present 
federal income tax laws. 

If you are under 55 years of age. just fill out 
the coupon below and mail it today. Mutual of 
Omaha will provide personal service in 
furnishing all of the details. Of course, 
there is no obligation. 



L MJtR\\RnT(S 




Mutual 
^maha 

People ifou can count on... 

Life Insurance Affiliate; United of Omaha 

MUTUAL OF OMAHA INSURANCE COMPANY 
HOME OFFICE: OMAHA, NEBRASKA 



Mutual of Omaha Insurance Company 

Dodge at 33rd Street • Omaha. [Nebraska 68131 

I am interested in learning more about the program of Disability Income 
Protection available to me. 

Mame 



Address 
City 



. State 



.ZIP code 



-»<s»^ 




■*'$, 



* !(.=■. 



luting in Humans: 
Who,Where & When. 



weight of ethical opinion: 

Few would disagree that the effective- 

and safet}' of any therapeutic agent 

;vice must be determined thtough 

cal research. 

3ut now the practice of clinical re- 
h is under appraisal by Congress, the 

; and the general public. Who shall 

inister it? On whom are the products 
tested.-' Under what circumstances? 
how shall results be evaluated and 

:ed? 

"he Pharmaceutical Manuficturers 
ciation represents firms that are sig- 
ntly engaged in the discovery and 

I opment of new medicines, medical 
es and diagnostic products. Clinical 
rch is essential to their efforts. Con- 

j :-ntly, PMA formulated positions 
1 it submitted on July 1 1, 1975, to 
ibcommittee on Health ot the Sen- 
bor and Public Welfare Committee, 
official policy recommendations. 
are the essentials of PM A's current 
ing in this vital area. 
.PMA supports the mandate and 
)n of the National Commission tor 

J-Qtcction of Human Subjects of 
edical and Behavioral Research and 
establish a special committee 
n jscd of experts of appropriate 
nes fimiliar with the industry's 
ch methodology to volunteer its 
'e to the Commission. 
PMA supports the formation of an 
ndent, expert, broadly based and 
lentative panel to assess the current 
f drug innovation and the impact 
tof existing laws, regulations and 
ures. 

When FDA proposes regulations, 
Id prepare and publish in the Fed- 
■gister a detailed statement assess- 
impact of those regulations on 
nd device innovation. 
PMA proposes that an appropri- 
lualified medical organization be 
aged to undertake a comprehen- 
idy of the optimum roles and 
sibilities of the sponsor and physi- 
len company-sponsored clinical 
h is performed by independent 
investigators. 



5» PMA recognizes that the physician- 
investigator has, and should have, the 
ultimate responsibility tor deciding the 
substance and form of the informed con- 
sent to be obtained. However, PMA 
recommends that the sponsor of the ex- 
periment aid the investigator in dis- 
charging this important responsibility by 
providing (1) a document detailing the 
investigator's responsibilities under FDA 
regulations witiitegard to patient consent, 
and (2) a written description of the 
relevant tacts about the investigational 
item to be studied, in comprehensible 
la\' language. 

O.In the case of children, the sponsor 
must require that informed consent be 
obtained from a legally appropriate rep- 
resentative of the participant. Voluntary 
consent of an older child, who may be 
capable of understanding, in addition to 
that of a parent, guardian or other legally 
responsible person, is advisable. Safety of 
the drug or device shall have been assessed 
in adult populations prior to use in 
children. 

7»PMA endorses the general prin- 
ciple that, in the case of the mentally 
infirm, consent should be sought from 
both an understanding subject and trom 
a parent or guardian, or in their absence, 
another legally responsible person. 

8. Pharmaceutical manufacturers 
sponsoring investigations in prisons must 
take all reasonable care to assure that the 
ftcilities and personnel used in the con- 
duct of the investigations are suitable for 
the protection of participants, and for the 
avoidance of coercion, with a respect tor 
basic humanitarian principles. 

9'Sponsors intending to conduct non- 
therapeutic clinical trials through the 
participation of employee volunteers 
should expand the membership and scope 
of its existing Medical Research Commit- 
tee, or establish such an internal Medical 
Research Committee, with responsibility 
to approve the consent torms of all 
volunteers, designs, protocols and the 
scope of the trial. The Committee should 
also bear responsibility to ensure full 
compliance with ail procedures intended 
to protect employee volunteers' rights. 

10. Where the sponsor obtains medi- 
cal inf( irmation or data on individuals, it 
shall be accorded the same conhdential 



status as provided in codes of ethics gov- 
erning health care professionals. 

11. PMA and its member firms accept 
responsibility to aid and encourage ap- 
propriate tollow-up of human subjects 
who have received investigational prod- 
ucts that cause latent toxicity in animals 
or, during their use in clinical investiga- 
tion, are found to cause unexpected and 
serious adverse effects. 

U.PMA supports the exploration 
and development by its member compa- 
nies ot more systematic surveillance pro- 
cedures for newly marketed products. 

13. When a pharmaceutical manu- 
facturer concludes, on the basis of early 
clinical trials of a basic new agent, that a 
new drug application is likely to be sub- 
mitted, a proposed development plan 
accompanied by a summar}' of existing 
data, would be submitted to the FDA. 
Following a review of this submission, 
the FDA, and its Advisory Committee 
where appropriate, would meet with the 
sponsor to discuss the development plan. 
No formal FDA approval should be re- 
quired at this stage. Rather, the emphasis 
should be on identification of potential 
problems and questions for the sponsor's 
further study and resolution as the pro- 
gram develops. 

The PMA belie\cs that health profes- 
sionals as well as the public at large 
should be made aware of these 13 points 
in its Policy on Clinical Research. For 
these recommendations envisage con- 
structive, cooperative action by industry, 
research institutions, the health profes- 
sions and government to encourage crea- 
ti\ e and workable responses to issues 
involved in the clinical investigation of 
new products. 

Pharmaceutical Manuficturers 

Association 
jl 1 155 Fifteenth Streer.N.W 
™ Washington, D. C. 20005 



OFFICIAL CALL 
HOUSE OF DELEGATES 

pursuant to the Bylaws, Chapter IV, Section 1: 

HOUSE OF DELEGATES 
Meetings scheduled 

lyiotice to: Delegates, Alternate Delegates, Officials 
of the IVortli Carolina Medical Society, and Presidents 
and Secretaries of county medical societies. 

Sessions of the HOUSE OF DELEGATES will convene in 
the Cardinal Ballroom. Pinehiirst Hotel. Pinehurst. North 
Carolina, at the lollowing times: 

Thursday, May 6, 1976 — 2:00 p.m. — Opening Session 
Saturday, May 8. 1976 — 2:00 p.m. — Second Session 

A member of the CREDENTIALS COMMITTEE will be present at 
the Desk in the Hotel Lobby, Thursday, May 6, 1976, from 8:30 
a.m. to 12:30 p.m. to certify Delegates. Delegates are urged to bring 
their Credential Cards for presentation at the Registration Desk. 
Delegate Badges must be worn to be seated in the HOUSE OF 
DELEGATES. 



REFERENCE COMMITTEE 
HEARINGS 

Reference Committee hearings are scheduled to begin Friday. May 7. 1976. at 2:00 p.m. 



James E. Davis. M.D.. President 
Chalmers R. Carr, M.D., Speaker 
E. Harvey Estes, Jr., M.D., Secretary 
William N. Hilliard, Executive Director 



74 



Vol. 37. No. 



"Kid,this shifF^ 
Is the bananas! 



mt^ 



A;f«^v 



'^iw 





Experts agree: when it 




comes to good-tasting 


4:-M% 


banana flavor— without 


' ' V 


J»4 jpm 


the unpleasant taste of 


' >jil' 


•%mm V'Wl 


'I'AWI 


• «> W 


K paregoric— the makers 


4 


jkM '^' 


■ of Donnagel'^-PG really 


4.^ 


BHJ 


S know their stuff! 

"il For diarrhea 


r 


I^T 


► -. ^'^ 


D()nnaqel-PG (v 


^^■T^^^^^^^^^HB 


Donnagel with paregoric equivalent 


|Oonn.g«^ 


Eacti 30 cc. contains: 


ff"TiiiM y 


Kaolin 6.0 g. 


■ §;■: .11 


Pectin 142.8 mg. 


l="-"^,_ i 


1 Hyoscyamine sulfate 0.1037 mg. 


'iH 


\ Atropine sulfate 0.0194 mg. 


'■'^1 


V^ Hyoscine 


.^H^hk 


f_ ^N tiydrobromide 0.0065 mg. 


■v1^ 


Mu Powdered opium, USP 24.0 mg. 


- >v^-.^-^' 


'( I i-tj ui Vein. Ill to [jiirt;cn.>r ic o mi / 
(warninc) may be hobit formincj) 




^tj^ Sodium benzoate 60.0 mg. 




' Alcotiol, 5% . " • •. 




V Now witti ctiild-proof closure . -; ' 




/l-H'[^BINS 


1 iii^n 


AH. Robins Company . O 


^ %%^i % 


Rictimond, Virginia 23220 



.*«^', 

,,:;^:_ 




i. ^ 



THE I RELIABLE ROBITUSSINS can really help clear the respiratory 
tract. All contain guaifenesin* the expectorant that works system- 
cally to help stimulate the output of lower respiratory tract fluid. 
This enhanced flow of less viscid secretions promotes ciliary action and 
makes thick, inspissated mucus less viscid and easier to raise. 

•formerly named Glyceryl Guaiacolate 



U 



For productive and unproductive coughs 

ROBITUSSIN 

Each 5 mi teaspoonful contains 

Guaifenesin, NF 1 00 mg 

Alcohol 3 5% 

For severe coughs 

ROBITUSSIN A-C (V 

Each 5 ml teaspoonful contains 

Guaifenesin. NF 1 00 mg 

Codeine Phosphate, USP 10 mg 

[warning: may be habit forming] 
Alcohol, 3 5% 

Non narcotic for 6-8-hr. cough control 

ROBITUSSIN-DM 

Each 5 ml teaspoonful contains: 

Guaifenesin, NF 1 00 mg 

Dextromethorphan Hydrobromide, NF 15mg 

Alcohol, 1,4% 



Decongests nasal passages and sinus 
openings as it helps relieve coughs 

ROBITUSSIN-PE 

Each 5 mi teaspoonfui contains 

Guaifenesin, NF lOOmg 

Pseudoephednne** Hydrochloride, NF 30 mg 

Alcohol, 1 4% 

**Formerly contained Phenylephrine Hydrochloride 1 mg 

Decongestant action helps control cough and 
clear stuffy nose and sinuses. Non narcotic. 

ROBITUSSIN-CF 

Each 5 ml teaspoonful contains 

Guaifenesin, NF 50 mg 

Phenylpropanolamine Hydrochloride, NF 1 2 5 mg 

Dextromethorphan Hydrobromide, NF 10 mg 

Alcohol, 1 4% 

All Robitussin formulations available on your 
Rx or Recommendation. 

A. H Robins Company, Richmond, Va 23220 /I'H'DOBI NS 



For many years Robins has spotlighted the expectorant action of the Robitussin cough formulations by featuring 
action photographs of steam engines. In keeping with this tradition, the company recently commissioned a well-known 
illustrator to render full-color drawings of several classic locomotives ... accurate to the minutest detail. The first of the 
series is now available. To order your print suitable for framing, write "Robitussin Clear-Tract Engine # 1" on your Rx pad 
and mail to "Vintage Locomotives," Dept. T4, A. H. Robins Company, 1407 Cummings Drive, Richmond, Va. 23220. 





,-j^ — #s=»\ 



P-' fe^^lc'O ^«! 



I .',f 



1^ 



The William Mason (1856) 



Officers 
1974-1975 



NORTH CAROLINA MEDICAL 
SOCIETY 



President James E. Davis, M.D. 

1200 Broad St., Durham 27705 

President-Elect Jesse Caldwell, Jr., M.D. 

114 W. 3rd Ave.. Gastonia 28052 

First Vice-President John L. McCain, M.D. 

Wilson Clinic, Wilson 27893 

Second Vice-President T. Reginald Harris, M.D. 

808 N. DeKalb St., Shelby 28150 

Secretary E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Durham 27710 (1976) 

Speaker Chalmers R. Carr, M.D. 

1822 Brunswick Ave., Charlotte 28207 

Vice-Speaker Henry J. Carr, Jr., M.D. 

603 Beamon St., Clinton 28328 

Past-President Frank R. REYNOLDS, M.D. 

1613 Dock St., Wilmington 28401 

Executive Director William N. Hilliard 

222 N. Person St.. Raleigh 2761 1 

Councilors and Vice-Councilors 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor Joseph A. Gill, M.D. 

1202 Carolina Ave., Elizabeth City 27909 (1977) 

Second District J. Ben.iamin Warren, M.D. 

Box 1465, New Bern 28560 (1976) 

Vice-Councilor (Tharles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1976) 

Third District E. Thomas Marshburn, Jr.. M.D. 

1515 Doctors Circle, Wilmington 28401 (1976) 

\'ice-Councilor Edward L. Boyette. M.D. 

Chinquapin 28521 (1976) 

Fourth District Harry H. Weathers, M.D. 

Central Medical Clinic, Roanoke Rapids 27870 (1977) 

Vice-Counciior Robert H. Shackleford, M.D. 

1 15 W. Main St., Mt. Olive 28365 ( 1977) 

Fifth District August M. Oelrich, M.D. 

Box 1 169, Sanford 27330 ( 1978 ) 

\' ice-Councilor Bruce B. Blackmon, M.D. 

P. O. Box 8, Buies Creek 27506 (1978) 

Sixth District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd., Chapel Hiil 27514 (19771 

Vice-Councilor ..W. Beverly Tucker, M.D. 

Box 988, Henderson 27536 ( 1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Road, Charlotte 28207 (1978) 

\'ice-Councilor J. Dewey Dorsett, Jr. 

1851 E. Third St., Charlotte 28204 ( 1978) 

Eighth District ERNEST B. Spangler, M.D. 

Drawer X3, Greensboro 27402 ( 1976) 

Vice-Councilor James F. Reinhardt, M.D. 

Cone Hospital, Greensboro 27402 (1976) 

Ninth District Verne H. Blackwelder, M.D. 

Box 1470, Lenoir 28645 (1976) 

Vice-Councilor Jack C. Evans, M.D. 

244 Fairview Dr.. Lexington 27292 (1976) 

Tenth District Kenneth E. Cosorove, M.D. 

510 7th Ave., W., Hendersonville 28739 (1978) 

Vice-Councilor Otis B. Michael, M.D. 

Suite 208, Doctors Bldg., Asheville 28801 (1978) 

78 



Section Chairmen— 1975-76 

Anesthesiology Jack H. Welch, M.D. 

Physicians Quadrangle, Greenville 27834 

Dermatology George W. Crane, Jr., M.D. 

1200 Broad St., Durham 27705 

Family Physicians William W. Hedrick, M.D. 

33 1 1 N. Boulevard, Raleigh 27604 

Internal Medicine James H. Black, M.D. 

1351 Durwood Dr., Charlotte 28204 

Neurology & Psychiatry Hervy W. Mead, M.D. 

1900 Randolph Rd., Suite 900, Charlotte 28207 

Neurological Surgery M. STEPHEN Mahaley, Jr., M.D. 

394t') Nottaway Rd., Durham 27707 

Obstetrics & Gvnecolovy C. T. Daniel, Jr., M.D. 

1641 Owen Dr., Fayetteville 28304 

Ophthalmology E. R. WilkersoN, Jr., M.D. 

1012 Kings Drive, Charlotte 28207 

Orthopaedics Frank C. Wilson, M.D. 

N. C. Memorial Hospital, Chapel Hill 27514 

Otolaryngology N. L. Sparrow, M.D. 

3614 Haworth Dr., Raleigh 27609 

Pathology R. Page Hudson, M.D. 

P. O. Box 2488, Chapel Hill 27514 

Pediatrics Gerard Marder, M.D. 

224 New Hope Rd., Gastonia 28052 

Public Health & Education J. N. MacCormack, M.D. 

Box 2091, Raleigh 27602 

Radiology R. W. McConnell, M.D. 

1711 W. 6th Street, Greenville 27834 

Surgery Robert C. Moffatt, M.D. 

309 Doctors Bldg., Asheville 28801 

Urology Robert Dale Ensor, M.D. 

1333 Romany Road, Charlotte 28204 
Students. Medical 

Delegates to the American Medical Association 

James E. Davis. M.D 1200 Broad St., Durham 27705 

(December 31, 1976) 

John Glasson, M.D.... 306 S. Gregson St., Durham 27701 

(December 31, 1976) 
Frank R. Rlvnolds, M.D. 

1613 Dock Street. Wilmington 28401 
(December 3 1, 1976) 
David G. Welton, M.D. 

3535 Randolph Road. Charlotte 2821 1 
(December 31, 1977) 
Edgar T. Beddingfield, Jr., M.D. 

Wilson Clinic, Wilson 27893 
(December 31, 1977) 

Alternates to the American Medical Association 

George G. Gilbert, M.D. 

1 Doctor's Park, .Asheville 28801 
(December 31, 1976) 
Louis dfS. Shaffner, M.D. 

Bowman Gray, Winston-Salem 27103 
(December 31. 1976) 
Jesse Caldwell. Jr.. M.D. 

114 W. 3rd Ave., Gastonia 28052 
(December 31. 1976) 
Charles W. Styron, M.D. 

615 St. Marys St., Raleigh 27605 
(December 31. 1977) 

D. E. Ward, Jr., M.D 2604 N. Elm St., Lumberton 28358 

(December 31, 1977) 

Vol. 37. No 



NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 

Now Pays Up To 

$500 -4 

WEEKLY INCOAAE 
($2,166.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 




GUARANTEED RENEWABLE 



You are guaranteed the privi- 
lege of renewing $300-week to 
age 70. The other $200 per week 
renewable to age 60. This is an 
exclusive and most important 
feature. 



DIRECT PERSONAL SERVICE 



Since 1939, it has been our 
privilege to administer your pro- 
gram from Durham, N. C. includ- 
ing payment of all claims! 




J. L & J. SLADE CRUMPTON, INC. 

GENE GREER 

Office Manager 

0. Drawer 1 767— Durham. N. C. 27702. Telephone: 919 682-5497 
Underwritten by The Continental Insurance Cos, of New York 

JACK FE.4THERSTOi>. Field Representative 

l\ 0. Box 17824, Charlotte. N. C. 28211, Telephone: 704 .366-93.59 



North C, 



irolina 



Professional Group Aiiniinistrators for: 



NORTH CAROLINA MEDICAL SOCIETY • NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI- 
NEERS • NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A.'S AND BAR GROUPS 



I 





fnondolo Center 



A fully accredited private multi-disciplin- 
ary psychiatric hospital, partial care and 
out-patient clinic for the acutely ill to the 
mildly distressed. Children, young people, 
adults, couples or entire families may enter 
the treatment programs. 

A modified form of the therapeutic com- 
munity, a full spectrum of treatment mo- 



dalities are used. The services consist of 
individual, couple, group and family psycho- 
therapies; sexual and marriage counseling; 
pastoral counseling; vocational guidance and 
rehabilitation; alcohol and drug counseling; 
psychological testing, chemotherapy, elec- 
trotherapy and other somatic therapy ser- 
vices. 




Blue Cross participating hospital 

JCAH Accredited 

Richard B. Boren, M.D. Glenn N. Burgess, M.D. 

Psychiatrist-in-Chief Psychiatry 

For Information Call Collect (919) 724-9236 or Write: 
741 Highland Avenue • Winston-Salem, N. C. 27101 



Towards Wholeness 



Fewer than 200 doctors 
can become Navy 
physicians this year. 

^re you one of them? 



If you're interested in a practice that 
inbines high-quality medicine with a 

^ _^___ unique life- 

^ ■v^B^^^SIl^KSS style, Navy 

medicine 
could be right 
for you. You'll 
get the 
chance to 
practice med- 
icine instead 
of paperwork. 
Practice al- 
most anywhere 
^■^he world. And earn between $30 000 
I $40,000 a year. 

''ight now, the Navy needs General 

;'dical officers, plus those specialties 

*S5d in the coupon. You may also receive 

'ming to become a Navy Flight Surgeon, 

' specialist in Undersea Medicine. 




i^'y^s i, v**-- *#^ '^^■'*=i( 3^ ' 



I 



But the number of 
doctors needed is limit- 
ed. For more details, fill 
in and mail the 
coupon, or call collect 
919-872-2005, and ask 
for the Medical Re- 
cruiter, David L. Powell. 

Out of state call 
800-841-8000 




It pays to look Into Navy Medicine. 



H, 



Commanding Officer, Navy Recruiting District, Raleigh 
Pinewood Building, P. 0. Box 18568 
1001 Navaho Drive, Raleigh, N. C. 27609 



(0M) 



NAML 



STREET.^ 

STATE_ 



(Please Print or Type) 
CITY 



_ZIP^ 



^PHONE_ 



MEDICAL SCHOOL . 
YEAR GRADUATED 



(Area Code & No.) 



_DATEOFBIRTH^ 



I AM INTERESTED IN (CHECK ONE): 




FLIGHT SURGEON 
UNDERSEA MEDICINE 
MY SPECIALTY (IF ANY) IS: 

D ANESTHESIOLOGY 
D FAMILY PRACTICE 
D PSYCHIATRY 
n INTERNAL MEDICINE 

STATUS (CHECK ONE): 

Z PRIVATE PRACTICE 
:: HOSPITAL STAFF 



C GENERAL MEDICAL OFFICER 
D PRACTICING MY SPECIALTY 

C NEUROLOGY 
D RADIOLOGY 
:Z PATHOLOGY 
:: PEDIATRICS 



n INTERN 
C RESIDENT 



.a basic need for life support. 





"^-^•""Stf'" 



r 



«►**»* 



rrff 



r 



^i^'^y' 



■8^ . .-^^ 



;^ 



•«»'** 

*#■•*" 



fei*l 



(dyphylline) 

Before prescribing, please review complete prod- 
uct information, a summary of which follows: 

Indications: For relief of acute bronchial asthma 
and for reversible bronchospasm associated with 
chronic bronchitis and emphysema. _ 



Precautions: E) 

presence of severe cardiac disease, re., 



peptic ulcer, < 
thine-containTf 
ulating drugs. 



lomltant use of other xan 
ations or other CNS stim 



Adverse Reactions: May cause nausea, headac 
cardiac palpitation and CNS stiniulation. Pc 
prandial administration may help to avoid gas 
discomfort. ^ » - 



ig.. Tablets! NL- 

■^«R521-97, bottle:.. , 

I^I^DC 19-R515-68, pint bo|' 
''a Ion bottle. -«^' 



tipn: NDC 19-R537-X2. box' of 




For relief oT acute bronchial asthma and for reversible bronchospasm 
associate^jadtb chronic bronchitis and emphysema. 





UU\J...a basic need for the ^ 
Cdyphy ine) ^^nchospastlc patient. 



blets: 200mgdyphylline 

xir: per15ml:dyphylline100mg, 

t alcohol 20% v/v 



ie bronchodilator with a differi^^^cl^phylline. 






*' H .* J 



A NEED FOR YOUR PATIENT 
BECAuSE 

1. Therapeutically effective 

2. Little to no CNS stimulation 

3. Little to no gastric upset 

4. Effective during long-term therapy 

5. Only 1/5 the toxicity of 
theophylline or aminophylline^^'^ 
(based on animal studies) 



REFERENCES 

1 WIcColl, J. D., et al : J. Pharm. & Exp. Therap. 

I 116:343,1956 

'2. Quevauv/iller, Par An''--— -' • " "' 

fe -fti -1-180-1482, 1953 ? 



I', P. v., et al : J. Am. Pharm. Assoc 
1-272, 1946 



S^^Bfej^'« ^K>.' I 



Mallinckrodt 



Pharmaceuticals^' Unking Cti&l 

jnckrodtrirfc, 
illin«;krod*'Pharmaceutical Divisiorii 
uOuis, Missouri 63147 , :*^ 




SSHK' "^1.- -I,.. 



Famous Fighters 




NEOSPORIN* Omtmciit 

(polymyxin B-bacitracin-neomycin) 

is a famous fighter, too. 

Provides overlapping, broad-spectrum antibacterial action to help combat 
infection caused by common susceptible pathogens (including staph and strep). 



Each gram contains: Aerosporin* brand Polymyxin B Sulfate 5,000 units; zinc 
bacitracin 400 units; neomycin sulfate 5 mg (equivalent to 3.5 mg neomycin base); 
special white petrolatum qs in tubes of 1 oz and 1/2 oz and 1/32 oz (approx.) 
foil packets, 

INDICATIONS: Therapeutically (as an adjunct to systemic therapy when indicated) 
for topical infections, primary or secondary, due to susceptible organisms, as in: 
• infected burns, skin grafts, surgical incisions, otitis externa • primary 
pyodermas (impetigo, ecthyma, sycosis vulgaris, paronychia) • secondarily 
infected dermatoses (eczema, herpes, and seborrheic dermatitis) • traumatic 
lesions, inflamed cr suppurating as a result of bacterial infection. 
Prophylactically , the ointment may be used to prevent bacterial contamination in 
burns, skin grafts, incisions, and other clean lesions. For abrasions, minor cuts 
and wounds accidentally incurred, its use may prevent the development of infec- 
tion and permit wound healing. CONTRAINDICATIONS: Not for use in the eyes or 
external ear canal if the eardrum is perforated. This product is contraindicated in 
those individuals who have shown hypersensitivity to any of the components. 
WARNING: Because of the potential hazard of nephrotoxicity and ototoxicity due to 




neomycin, care should be exercised when using this product in treating extensive 
burns, trophic ulceration and other extensive conditions where absorption of 
neomycin is possible. In burns where more than 20 percent of the body surface is 
affected, especially if the patient has impaired renal function or is receiving other 
aminoglycoside antibiotics concurrently, not more than one application a day is 
recommended. PRECAUTIONS: As with other antibacterial preparations, prolonged 
use may result in overgrowth of nonsusceptible organisms, including fungi. 
Appropriate measures should be taken if this occurs. ADVERSE REACTIONS: 
Neomycin is a not uncommon cutaneous sensitizer. Articles in the current litera- 
ture indicate an increase in the prevalence of persons allergic to neomycin. Oto- 
toxicity and nephrotoxicity have been reported (see Warning section). 
Complete literature available on request from Professional Services Dept. PML. 



i^ / Burroughs Wellcome Co. 

. ^'m / Researcti Triangle Park 
eJ WBlcome / Nortti Carolina 27709 



iff 
llO 

m 
nvee 
,te 
iiona 
iiido 
tfiE 

;lil, 

will 

k\i 

shal 

Tt 

;opi 
isai' 
;oiir 
mhi 
sns 






Medical Management 
of Rheumatoid Arthritis 



Nortin M. Hadler, M.D. 



INTRODUCTION 

THE atmosphere surrounding the 
medical management of rheu- 
matoid arthritis was summarized in 
an exchange some 20 years ago be- 
tween two giants of 20th Century 
American medicine:' After a na- 
tional meeting. Fuller Albright, the 
endocrinologist, approached Wal- 
ter Bauer, the pioneer rheumatolo- 
gist. with the remark that soon he 
would know all there was to know 
about rheumatoid arthritis except 
what causes it and how to cure it. 
This condemnation has lingered 
to provide a challenge to the inves- 
tigator. To the clinician, it can be 
counter-productive. Rheumatoid 
arthritis is a common affliction with 
considerable morbidity. Yet we 
know that the majority of patients 
with rheumatoid complaints do not 
seek medical advice.- Could it be 
that the medical community is not 
only non-aggressive in seeking out 
such patients but is less than recep- 
tive to their collective suffering? 
The thesis I will attempt to develop 
in this discussion is this: Medicine 
has available to it today an ar- 
mamentarium capable of significant 



Department ol Medicine 

Division ol Rheumatology and (.Imie.il Immunology 

University ot North Carohna School ol Medicine 

Chapel Hill. North Carolina 27514 

Reprint requests to Dr Hadler 



modulation in the pattern and the 
impact of this disease. 

CONSERVATIVE 
MANAGEMENT 

Scientific definitions will not suf- 
fice in discussing the management 
of rheumatoid arthritis. The social 
ramifications of an affliction which 
includes malaise, morning stiffness, 
intense articular pain and deformity 
and a variety of extra-articular man- 
ifestations are enormous. The dis- 
ease tries the emotional strength, 
patience and ingenuity of the suf- 
ferer in every aspect of his daily life. 
These elements demand attention in 
any attempt to formulate a program 
of management. The primary physi- 
cian should assume a pivotal role in 
helping his patient restructure his 
life consummate with the patient's 
functional capacity. In many com- 
munities a considerable degree of 
expertise is available from the allied 
health professions of social service 
and occupational therapy. The 
awareness of long-handled combs 
or specially designed kitchen uten- 
sils can make a considerable differ- 
ence in the daily life of a patient w ith 
rheumatoid arthritis. Maneuvers 
such as these can modulate the im- 
pact of this disease. Is it possible to 
modulate the course of the disease? 
Answering this question requires 



some grasp of the natural history. 
The classic studies attempting to de- 
fine the prognosis from the time of 
onset in patients managed conser- 
vatively are now almost 30 years old 
and are still relevant.' It is clear 
from these studies that most pa- 
tients do not deteriorate over five 
years of conservative management. 
Furthermore, there are few features 
that distinguish those patients who 
are at greatest risk. 

Several lessons can be gleaned 
from data such as these. The future 
need not be bleak if the patient is 
afforded conservative therapy 
alone. The pattern of remissions 
and relapses — as well as their 
severity — is extraordinarily vari- 
able and unpredictable. 1 should 
point out that with conservative 
therapy, a remission implies dra- 
matic improvement, as total ab- 
sence of inflammation rarely 
occurs.^ This variability and unpre- 
dictability create a considerable 
challenge when trying to formulate 
a program of pharmacologic mter- 
vention. The challenge is com- 
pounded when we examine the 
available drugs. The obvious impli- 
cation is that the essence of inter- 
vention is to minimize the psycho- 
social impact, alleviate pain and 
preserve function. That is what is 
meant by conservative manage- 



Febrl AR\ 1976. NCMJ 



8.^ 



ment. Management beyond that is 
not dictated by the diagnosis itself 
but by the course of the individual 
patient. 

What are the elements of a pro- 
gram of "conservative manage- 
ment"? Clinical experience and 
corroborative data support a num- 
ber of maneuvers as effective inter- 
vention with minima! side effects. 
These include rest, exercise and 
agents with analgesic and anti- 
inflammatory effects. ' 

The rest-exercise paradox has 
caused confusion for years. Total 
immobilization of the limbs by pro- 
longed splinting results in only a 
transient decrease in range of mo- 
tion and muscle strength; yet it is 
associated with a decrease in signs 
of inflammation." Such a maneuver 
is impractical. An attempt to com- 
pare complete bed rest with limited 
activity documented no such ef- 
fect." Furthermore. I can find no 
convincing evidence that splinting 
in the adult impedes the progression 
of deformity or joint destruction. 
From observations such as these, a 
rather empirical approach has 
evolved. The patient with 
rheumatoid arthritis suffers both 
from pain on use of an inflamed joint 
and from a number of systemic man- 
ifestations including malaise. 
Periods of rest during the course of 
daily activities are palliative. The 
use of simple splinting devices such 
as resting splints for wrist and knee 
at night and "cock-up" wrist splints 
during activity can reduce the pa- 
tient's discomfort. On the other 
hand, muscle atrophy about in- 
flamed joints occurs early in 
rheumatoid arthritis and these 
para-articular structures are inte- 
gral to the biomechanical integrity 
of the joints with which they are 
associated. It follows that preserva- 
tion of this mechanism should spare 
the inflamed, particularly weight- 
bearing, joint additional trauma. 
Simple exercises — particularly 
non-weight-bearing exercises — are 
essential to the therapeutic milieu. 
These can be expedited by consult- 
ing physical and occupational 
therapists with reference to several 
standard textbooks."-^ Patient and 
family education, rest, maintenance 
of muscle bulk and tone, palliative 



86 



TABLE 1 
DRUGS DISCUSSED 



Generic Name 

Acetaminophen 

Phenacetin 

Phenylbutazone 

Oxyphenbutazone 

Indomethacin 

Hydroxychloroquine 

Metenamic Acid 

Ibuprofen 

Gold Salts 

Cyclophosphamide 



Proprietary Name(s) 

Tylenol Tempra 

Acetophenetidin 

Butazolidin 

Tandearil 

Indocin 

Plaquenil 

Ponstel 

Motrin 

Soiganai, Myochrysine 

Cytoxan 



splinting and psychosocial support 
comprise the foundation of man- 
agement in all patients with 
rheumatoid arthritis. These cannot 
be overemphasized and are not 
supplanted by the available drugs. 
However, a cornerstone of con- 
servative therapy is to use drugs to 
ameliorate pain, if not reduce in- 
flammation. Furthermore, in man- 
aging a chronic disease which alters 
life expectancy so little, consider- 
able thought should be given to 
choosing agents with "side effects" 
considerably less than the potential 
ravages of the disease. This red flag 
should be raised when considering 
any agent where clinical experience 
is limited compared to the indi- 
vidual patient's life expectancy. Of- 
ten, the issue is not clearcut, so that 
it is worth our while to consider 
several categories of new and old 
drugs in detail. Table I lists the 
generic name as well as some pro- 
prietary names of some of these 
agents. 

Aspirin 

Aspirin has withstood the test of 
time in spite of precious little scien- 
tific documentation. Synthetic as- 
pirin, acetylsalicylic acid, was in- 
troduced in li<99 and rapidly found 
its way into the life style of the 
civilized world. Some 30 tons are 
consumed in the United States 
daily. Taken sporadically, and in 
low doses, it is antipyretic and 
analgesic. It is the experience of as- 
tute clinicians for almost a century 
that in patients who take high doses 
only, one can observe an anti- 
inflammatory effect in rheumatoid 
arthritis. Short-term controlled clin- 
ical trials document this result.'" 
There are no long-term controlled 
trials, nor does any study examine 



:3>' 
-J IB 

ll« 

ilis. 
liias' 

sis oi 



optdii 



the rate of progression of erosions -'" 
during aspirin therapy. Nonethe- 
less, the clinical utility of high-dose 
aspirin therapy is established. In 
many patients this intervention re- 
sults in dramatic relief from pain 
and stiffness and permits consider- 
able functional improvement. 

Several aspects of the phar- 
macology of aspirin are worth atten- 
tion. The drug is uncharged in the 
acid environment of the stomach 
and readily traverses the mucosal 
membranes. Renal clearance is 
markedly enhanced when the urine 
is alkaline, so that the use of ab- 
sorbable antacids prevents attaining 
the sustained high serum salicylate 
level necessary for anti-intlam- 
matory effect. 

The half-life of salicylate in the! 
blood is quite variable, ranging be-' ss 
tween 3 and 8.5 hours. Thus, state- 
ments that one needs 5 g/D divided 
in four-hourly doses are approxima- 
tions. It is necessary to increase the 
dose gradually and decrease the in- 
terval of administration until one 
sees either an effect or toxicity as 
manifest by tinnitus or decreased 
auditory acuity. The serum salicy- 
late level is useful in monitoring 
therapy and in assessing patient 
compliance and it certainly should 
be checked before the patient is 
considered unresponsive. Because 
of the variability in half-life, it is 
difficult to justify the increased ex- 
pense of timed-release preparations 
of aspirin." 

Another relevant aspect of aspi- 
rin pharmacology is that the half-life 
increases as the serum level in- 
creases.''' Thus, it may take a small 
increment in dose to help a patient 
who is taking many grams daily 
without relief. Likewise, a small de- 
crease can often eliminate tinnitus. 
For the past several decades em- 
phasis on the side effects of aspirin 
has eroded understanding of its use- 
fulness. Serious side effects cer- 
tainly should be considered by 
physicians prescribing high-dose 
aspirin therapy but they are com- 
mon because of the ubiquitous use 
of aspirin. Let me state my strong 
personal bias: There is no anti- 
inflammatory agent currently avail- 
able that compares favorably with 
aspirin in terms of cost, effective- 



liS 



M 

slai 



k 



OK 



Vol. 37. No. 2 



1 



less and side effects. Newer agents 
lave a role, hut they have not re- 
)laced aspirin as the drugof choice. 

The dose-related complications 
ind toxicity of aspirin are well 
;nown.''' In addition to true 
diosyncratic reactions, there is a 
are'^''' syndrome of aspirin intol- 
:rance marked by angioedema. 
■hinitis. nasal polyposis and bron- 
;hial asthma. Because of this syn- 
Irome and some pharmacologic ef- 
ects of aspirin such as histamine 
■elease. 1 am cautious in the use of 
ispirin in asthmatics. 

Symptomatic gastritis is the usual 
mpediment to aspirin therapy. 
\cetylsalicylic acid, on contact 
A'ith the mucosa, promptly induces 
erythema and in large doses \\ ill in- 
:rease daily gastrointestinal blood 
OSS from 0.2 to 1.6 ml to 1.2 to 8.4 
nl."''' This hazard can be di- 
Tiinished by giving aspirin with 
:'(.xid. by manipulating the diet, by 
increasing the dose slowly and by 
avoiding other gastric irritants. In 
;he face of peptic ulcer or gastritis, 
aspirin is contraindicated. Almost 
ill anti-intlammatory agents — 
glucocorticoids for example — must 
be tried with caution because of 
their ulcerogenic potential. 

Attempts to modify the structure 
of aspirin to lessen gastrointestinal 
toxicity uhile retaining adequate 
anti-intlammatory potency have 
been futile. The intriguing compari- 
son is between aspirin (acetyl- 
s;ilicylic acid) which is absorbed m- 
tact and sodium salicylate. How- 
ever, there are circulating hy- 
drolases so that within 15 minutes. 
75 percent of circulating salicylate is 
no longer acetylated"" so that aspi- 
rin is rapidK con\erted to sodium 
i salicylate. Despite this, therapeutic 
potency of aspirin is considerably 
greater than sodium salicylate. Sev- 
eral clues suggest that the acetyl 
group of aspirin is essential to its 
greater anti-intlammatory potency. 
During the course of high-dose aspi- 
rin therapy, human serum albumin 
is acetylated''' and antigenically al- 
tered. Aspirin, but not sodium 
salicylate, can interfere with the 
complement system. In low doses, 
aspirin, but not sodium salicylate, 
prolongs the bleeding time, though 
this difference is not apparent at 



high doses. These observations-" 
lessen the likelihood of anti- 
inflammatory effectiveness of 
salicv'lates that are niit esters of ace- 
tic acid. This is unfortunate, since 
sodium salicylates can be adminis- 
tered intraveiioKsly without gas- 
trointestinal toxicity."' One other 
salic\iate deserves note. Choline 
salicylate lacks the acetyl group, 
has fewer gastrointestinal side ef- 
fects and may have some anti- 
inflammatory action. In my opinion 
its cost-effectiveness offers little 
over low-dose aspirin or 
acetaminophen. 

Para-aminophenols 

Many para-aminophenols were 
introduced before the turn of the 
century but only two have survived: 
acetaminophen and phenacetin. 
The principal metabolic pathway 
for phenacetin leads to conversion 
to acetaminophen, the active 
metabolite. Because prolonged 
high-dose phenacetin administra- 
tion, usually in combination v\ith 
aspirin and caffein, is associated 
with chronic interstitial nephritis or 
pyelonephritis and a high incidence 
of papillary necrosis,-'-- 1 do not 
use phenacetin, particularly not in 
the long-term management of 
rheumatoid arthritis. 

The same does not hold for 
acetaminophen, vshich is not a gas- 
trointestinal irritant and does not in- 
terfere with clotting. It is antipyretic 
and analgesic — perhaps half as po- 
tent as aspirin, but neither clinical 
experience nor laboratory e\ idence 
supports any anti-inflammatory or 
antirheumatic effect. This is a "bet- 
ter than nothing"" drug. From per- 



sonal clinical experience, and from 
a review of the clinical drug trials, 
one must be impressed by the effect 
of the "placebo."" This is not to ad- 
vocate sham treatment, but to point 
out that a physician" s positive at- 
titude can do much to encourage the 
patient to follow conservative regi- 
mens faithfully and to persist in 
the activities of daily living. 
Acetaminophen can offer some re- 
lief in treating the aspirin-intolerant 
patient and can be incorporated into 
the conser\ati\e regimen. 

Phenylbutazone 

Like the para-aminophenols. 
pyrazolon derivatives were intro- 
duced before the turn of the cen- 
tury. The congener in use today — 
phenylbutazone — was introduced 
in 1949. The structLire iif this agent 
tolerates little modification v\ithout 
loss of potency — the exception 
being the hydroxy derivative, 
oxyphenbutazone, which works 
like phenylbutazone with the possi- 
ble exception o\' less gastric irrita- 
tion. 

Phenylbutazone is a poor an- 
tipyretic and analgesic when com- 
pared w ith aspirin and should not be 
used for these actions. Experimen- 
tally, it is as potent as glucocor- 
ticoids as an anti-intlammatory 
agent although many clinicians feel 
it is less effective than aspirin in 
treating classic rheumatoid ar- 
thritis. Furthermore, what is the 
price of this anti-inflammator\ ben- 
efit? The relative contraindications 
are legion (Table 2). Sodium reten- 
tion can be quite signillcant and the 
dmg is contraindicated in conges- 
tive heart failure. The eastrointesti- 



TABLE 2 
Side-Effects of Phenylbutazone 





Target 






Mechan 


:ism 


Relevant CImical State 


1 


Kidney 


Na- retention 
Uncosuna 






Congestive Heart Failure 

Glaucoma 

Sultmpyrazone is used as a 2nrj-tine agent in 

management of gout 


2 


Thyroid 


Red 


!uces 1 


uptake 




Borderline myxedema 


3 


Gl 


irrtlant 








Hepatitis 

Nausea, vom;t.-.i3 riiarrhfta 

Peptic ulcer diasmesis 


4 


CN S 


? 










Vertigo, insomnia 
Nervousness, euphoria 


5 


Mucoculaneous 












Ulcerative stomatitis 
Rashes 


6 


Bone marrow 

Drug-Drug Interactions 
Coumadin 
Sulfonureas 


9 

Competes for 
Competes for 


binding -(-9 

binding-t-'? 


Cytopenias including aplastic anemia, agranulocytosis 

Bleeding diasthesis 
Prolonged hypoglycemia 



, FLBRLAR'i 1976. NCMJ 



87 



nal side effects are at least as fre- 
quent and severe as those of aspirin. 
Central nervous system symptoms 
are common (particularly in the el- 
derly) as are mucocutaneous side 
effects. Bone marrow toxicity is not 
uncommon but is usually slow, 
dose-related and reversible. How- 
ever, perhaps 1/50.000 patients 
suddenly develops the most feared 
complication, agranulocytosis or 
aplastic anemia.--' Finally, let me 
emphasize two highly significant in- 
teractions: The drug can potentiate 
coumarin in a dramatic fashion so 
that it is contraindicated in a patient 
taking these anticoagulants. Even 
more dramatic is the hypoglycemia 
induced by the interaction w ith oral 
hypoglycemics, sometimes lasting 
for days and perhaps reflecting the 
72-hour biological half-life of 
phenylbutazone. 

Nonetheless, attempts have been 
made to use phenylbutazone in 
the long-term management of 
rheumatoid arthritis. In one study-^ 
315 patients uith rheumatoid ar- 
thritis received an average of 300 
mg/D of phenylbutazone. Most 
stopped the drug within two years 
generally because of intolerance 
(usually gastrointestinal) or because 
the drug was ineffective. The remis- 
sion rate after four years was similar 
to that observed in the trials of con- 
servative therapy alone. Phenyl- 
butazone has no role to play in the 
management of rheumatoid ar- 
thritis. 

Indomethacin 

Introduced slightly over ten years 
ago. after intensive experimental 
pharmacological screening, in- 
domethacin is structurally a unique 
agent — an indole derivative. This is 
a useful and important drug,-'' al- 
most totally supplanting phenyl- 
butazone in my practice. It is a po- 
tent antipyretic that can be effective 
in patients unresponsive to aspirin 
and is an effective anti- 
inflammatory agent more potent in 
some- 'animal models Lhu'.i glucocor- 
ticoids. It is a highly effective agent 
for treating the symptoms of acute 
gout and is worth trying in patients 
with osteoarthritis and rheumatoid 
variants such as spon<\litis w ho are 
unresponsive to aspirin. The same 



88 



applies for rheumatoid arthritis; in- 
domethacin is worthy of trial in pa- 
tients unresponsive to full-dose as- 
pirin therapy. Yet no controlled 
study has show n indomethacin to be 
superior to aspirin in rheumatoid ar- 
thritis. Therefore, because of its ex- 
pense and our relatively short ex- 
perience with it. 1 feel it is a second- 
line drug. 

Some 35 percent of patients w ill 
experience side effects and as high 
as 20 percent will be forced to dis- 
continue indomethacin. most com- 
monly because of gastrointestinal 
difficulties: nausea, symptomatic 
gastritis, peptic ulcers. Central 
nervous system side effects are next 
in frequency, particularly in the el- 
derly: headaches, dizziness, som- 
nolence, confusion. Bone marrow 
and liver toxicity is rare in con- 
tradistinction to phenylbutazone. 

As with aspirin, gastrointestinal 
side effects may be avoided by 
gradually increasing dose and by 
utilizing the buffer capacity of meals 
and sometimes antacids. Particu- 
larly in the elderly, bedtime doses 
alone are often well tolerated and 
may relieve morning stiffness. 

Anti-malarials 

There is an anti-intlammatory 
agent that is not an irritant to the 
intestinal mucosa. The drug is 
chloroquine. or its currently avail- 
able analogue, hydroxychloro- 
quine. These antimalarial drugs 
have been used to treat rheumatoid 
arthritis since 1951 — with great en- 
thusiasm until their ocular toxicity 
was appreciated. A number of con- 
trolled trials demonstrate the anti- 
intlammatory effectiveness of these 
drugs in rheumatoid arthritis. In- 
terestingly, it takes a month or so 
for this effect to occur and it may 
not be apparent for several 
months.-'" Often the drug will in- 
duce diarrhea which is usually 
transient. Hydroxychloroquine can 
cause patients with psoriasis to ex- 
foliate. A rare neuromyopathy has 
been described v\ith chloroquine. 

The principal deterrent to the use 
of hydroxychloroquine is ocular 
toxicity. The drug accumulates in 
tissues, notably pigmented tissues 
including the retina. Associated 
with this are bilateral, symmetric. 



slam 
i»i 

sal 
ireli 



progressive degenerative changes 
principally in the macula. Then 
slowly develops patchy depigmen 
tation of the center of the macula 
surrounded by a concentric clea 
zone and then a ring of pigment 
Patchy skin pigmentation and los: 
of hair color may accompany thes( ^^ 
changes. Discontinuation o 
therapy may arrest and even re 
verse these changes — but not in- 
variably.-' 

Fortunately, the ocular toxicity ii 
related to dose and time. Most case; 
have received considerably highei 
doses for prolonged periods tharl 
are currently employed for anti-j 
inflammatory effect. Ocular toxicJ 
ity is quite infrequent in patients 
using hydroxychloroquine at a dose 
of 200 mg once or twice a day, bu^ 
ophthalmologic examination by 
physician familiar with this drug'^ 
toxicity should be performed at 
least every six months. There is 
some reason to think that avoiding 
direct sunlight will reduce the risk of 
ocular toxicity. One other precau- 
tion: these drugs in low doses pre- 
sent a major cardiac-toxic threat tC 
children and care must be taken tc 
avoid accidental ingestion in the 
home. 

There is a role for hydroxy- 
chloroquine in the management ol 
rheumatoid arthritis. Only in pa- 
tients with active ulcer disease do I 
consider hydroxychloroquine as a 
sole agent. However, it is available 
as a useful adjunct therapy. 



'Mi 

lie 

*l 
9 

% 

m 

It! 

re 

,eiir 
.ten 



eavi 
jani 



Steroids 

Let us turn our attention tci 
glucocorticoids, the most potent jjjj 
anti-intlammatory agents available. 
The use of these agents in 
rheumatoid arthritis and other 
rheumatoid diseases is a very 
thorny issue. It is clear that they are 
a very effective anti-intlammatory 
agent, a fact which in combination 
with their mood-elevating potential 
can result in dramatic palliation. 
Several passages from a letter-" to 
five prominent rheumatologists 
from Dr. Philip Hench dated Feb-, 
ruary 24, 1949, illustrate this: 
"As you may recall, we have been trying for 
twenty years to njentil'y the 'substance X' 
which is responsible lor the striking remis- 
sions induced in rheumatoid arthritis by 
jaundice and pregnancy. At last we think we 



Vol. 37. No. 2 



ik 



, have identified it as a rare chemical, very 
small amounts of uhich have been prepared 

.- and made available to us. Since last Sep- 
tember, ue have been studying intensively 
its physiological action and have adminis- 
tered It to about tuelve patients with severe 
or moderatelv severe rheumatoid arthritis. 
The material has striking effects v\hich pro- 
vide relief almost as dramatically, if not as 
dramatically, as the effects ofjaundice . . .in 
all patients, within a few days, there is a 
notable reduction of symptoms and im- 
provement of function of muscles and 
joints." 

The rest is history — Dr. Hench's 
, iNobel Prize and the v\ idespread use 
'of steroids in the management of 
, rheumatoid arthritis. The short- 
term improvement in symptoms and 
function was indeed dramatic. But. 
with time, the medical world came 
to realize that one disease, 
rheumatoid arthritis, was being 
superseded by an equally debilitat- 
ing and devastating disease — 
exogenous Gushing" s syndrome. 

The death-knell for steroids was 
sounded with the realization that in 
spite of the dramatic reduction in 
: inflammation, no evidence was 
forthcoming that destruction of 
joints was halted. Withdrawal of the 
agent was met with tremendous pa- 
tient resistance. It meant with- 
drawal of pain relief and mood ele- 
vation, and finally, withdrawal itself 
may provoke arthralgias. 

It is difficult to discard the most 
reliable and effective anti- 
inflammatory agent available. What 
has evolved is a consensus that 
there are "special cases"" for whom 
systemic steroid therapy is 
indicated — but the criteria are not 
uniformly defined. To state my bias, 
i leaving aside such extra-articular 
i manifestations of rheumatoid ar- 
thritis as pericarditis with restric- 
tion, these "special cases" are ex- 
ceedingly rare. In the relatively 
young patient with severe active 
disease, I aggressively pursue other 
options, including combinations of 
some of the agents we have already 
discussed, periods of hospitaliza- 
tion for rehabilitation and other op- 
tions we will come to shortly. Only 
with the rare active rheumatoid ar- 
thritis patient well into the sixth de- 
cade of life do I feel systemic 
steroids is an option. Even here, I 
use the lowest effective dose and 
can usually convince the patient to 
accept the compromise in relief re- 
sulting from alternate day therapy. 

February 1976. NCMJ 



My negativism toward steroids is 
only slightly less sanguine when we 
come to discuss intra-articular 
steroids in rheumatoid arthritis. 
There is good data that intra- 
articular steroids themselves are 
disruptive to the integrity of the ar- 
ticular cartilage.-" Therefore, 1 will 
not inject the same joint more than 
once. Furthermore, in classic sym- 
metric disease, intra-articular injec- 
tions are impractical. 1 reserve 
intra-articular injections for the ex- 
ceedingly unusual patient whose 
disease pattern is both highly 
asymmetric and intermittent. 

Newer non-steroidal 
anti-inflammatory agents 

As is apparent from the highly ef- 
fective advertising campaigns that 
are blanketing our journals, filling 
our mailboxes and even reaching 
our patients ahead of us, a number 
of new non-steroidal anti- 
inflammatory agents have recently 
been released. This is just the be- 
ginning, for many more are cur- 
rently at various levels of investiga- 
tion. Having just reviewed the sad 
saga of systemic steroids, we should 
be cautious in our approach to using 
these agents. On the other hand, it is 
all too clear that we currently have 
no potent agent without disadvan- 
tages. Therefore, both the mag- 
nitude of the need and of the market 
are obvious. Nonetheless, clini- 
cians have the difficult task of inter- 
preting the carefully worded claims 
of the marketing teams and of sifting 
through the statistical exercises 
provided in the literature. 

I want to consider the two new 
non-steroidal anti-inflammatory 
agents that are on the market in the 
U.S. today. Each represents a new 
class of agents: anthranilic acid 
congeners, often referred to as the 
fenamates, have been under study 
since the early 1960s as anti- 
inflammatory agents. Several are 
considerably more potent in some 
animal models than phenylbutazone 
or aspirin. One of the agents, 
mefenamic acid, was released by 
the FDA in 1966. It is a potent 
analgesic, but dose-related tox- 
icities include ulcers, hemolytic 
anemia and bone marrow hypo- 
plasia.^" For these reasons, its use is 



restricted to one week as an 
analgesic agent and it has neither 
been aggressively marketed nor 
widely used. It has no role in 
rheumatoid arthritis. 

The phenylalkanoic acids have 
exploded on the clinical scene in the 
form of ibuprofen. The parent com- 
pound, ibufenac, was introduced in 
1968 after extensive clinical trials 
demonstrating a predictable anti- 
inflammatory effect similar to that 
of aspirin. The parent compound 
was released for commercial mar- 
keting, then quickly withdrawn 
when it was recognized that it could 
cause jaundice and even death from 
hepatocellular necrosis. 

Before this parent compound had 
completed its life cycle, the engines 
of clinical pharmacology were into 
production and evaluation of a 
number of congeners. Ibuprofen 
has been sufficiently studied to 
satisfy the FDA and is now aggres- 
sively marketed. It is intriguing that 
the only structural modification in 
the toxic parent compound neces- 
sary to produce ibuprofen is the in- 
troduction of a methyl group on the 
organic acid side chain. Neverthe- 
less, no hepatotoxicity or major 
organ damage has been ascribed to 
this drug. 

Ibuprofen, in animal experi- 
ments, is a potent anti-inflamma- 
tory agent. The clinical data are less 
clear, probably because of uncer- 
tainty as to the effective dose. It is a 
fair overview that this drug has a 
potency similar to that of aspirin, 
only when used in high doses rang- 
ing from 1600 to 2400 mg/day.^' 

Like its parent compound, ibup- 
rofen has the potential for peptic 
ulcer formation. Nonetheless, it is 
considerably better tolerated in 
terms of gastrointestinal toxicity 
than aspirin — as asserted in the 
advertising. Perhaps as many as half 
of the patients intolerant to aspirin 
will be tolerant to ibuprofen. This 
drug does not interfere with the clot- 
ting mechanism. The agent proba- 
bly has a role in conservative man- 
agement, but 1 will use it sparingly 
until greater clinical experience is 
available. 

In reviewing the available 
analgesic and anti-inflammatory 
agents, 1 have frequently alluded to 



89 



cost-effectiveness. To illustrate my 
point. 1 phoned my corner drugstore 
to obtain prices for a patient. It is 
clear that maintenance therapy with 
aspirin wins hands down, costing 
some $30 per year while the others 
approach $180. 

Gold salts and cyclophosphamide 

It is important to emphasize that 
none of the anti-intlammatory 
agents discussed has been shou n to 
be truly antirheumatic: they do not 
impede or stop the erosive, destruc- 
tive component of rheumatoid ar- 
thritis. There are only two agents 
currently available that may do 
this — gold salts and cyclophos- 
phamide. 

Organic salts of gold were widely 
used in the treatment of tuber- 
culosis early in this century. By 
1930. following the observations of 
many clinicians, notably Fores- 
tier.''- it was used in the manage- 
ment of rheumatoid arthritis. There 
was considerable controversy both 
to the anti-intlammatory effective- 
ness of this parenteral medication 
and the incidence of side effects, 
which was clearly significant. The 
definitive study addressing these is- 
sues was a multicenter. double- 
blind, controlled trial sponsored by 
the Empire Rheumatism Council in 
Great Britain and published in 
1%0.-'-' Only severe dermatitis, in- 
cluding exfoliative dermatitis, was 
unique to the gold group. Al- 
buminuria occurred with similar 
frequency in both groups (about 3 
percent) but during gold salt treat- 
ment this can rarely progress to the 
nephrotic syndrome. Bone marrow 
toxicity manifest as cytopenia did 
not occur in this trial, although it is a 
well described complication. The 
study supports the summary that 
while side effects are significant and 
not infrequent, the drug can be used 
relatively safely. 

Did it work? Using a large 
number of subjective and objective 
measures of function and intlamma- 
tion. the study shows that gold salt 
treated patients improved to agreat- 
er degree than controls. This dif- 
ference was apparent at three 
months and persisted through 12 
months. It is to be emphasized that 
the control group also improved — 



but we have previously discussed 
the utility of the ""placebo effect. "" 
This differential effect was gone at 
30 months. 

The Empire Rheumatism Council 
study could demonstrate no differ- 
ence in the rate of progression in 
radiographic joint damage. How- 
ever, in 1974. a study group by the 
rheumatology divisions at Baylor 
and the Henry Eord Hospital'^ gave 
20 weekly injections of either gold 
salt or placebo followed by monthly 
injections for two years and dem- 
onstrated that the rate of joint de- 
struction by disease was signifi- 
cantly slower for the population 
given gold. 

Based on such studies. I tell my 
patients: In most patients with 
rheumatoid arthritis, gold salts have 
nothing to offer except nuisance, 
expense and the potential for side 
elTects; but a significant minority of 
treated patients can anticipate an 
anti-inflammatory effect if not an 
antirheumatic effect after at least 
two months of therapy. Further- 
more, if there is no major improve- 
ment after a total dose of I g ad- 
ministered as 50 mg l.M. weekly for 
20 weeks, such an event is unlikely 
and the drug should be discon- 
tinued. Finally, in the responsive 
patient. 1 continue the drug injecting 
.sO mg at monthly intervals until a 
better agent is developed. 

Who is candidate for gold salt 
therapy? 1 must be certain that my 
patient has rheumatoid or psoriatic 
arthritis since the drug has nothing 
to offer in osteoarthritis and such 
rheumatoid variants as ankylosing 
spondylitis and may be hazardous if 
not useless in systemic lupus 
erythematosus. The patient must 
have persistent disease activity in 
the face of conservative therapy for 
a prolonged period — at least six 
months. And I must see radiologic 
documentation of progressive ero- 
sive disease — though I will accept 
very subtle changes. 

Finally the physician employing 
this agent must detect side effects 
early, most of which will reverse if 
the course of therapy is terminated. 
1 still employ the 10 mg "test dose"" 
to identify the rare patient with an 
idiosyncratic or immediate hyper- 
sensitivity response. Prior to each 



of the 50 mg weekly injections, and 
each injection on the long-term 
monthly maintenance schedule, the 
patient is questioned about pruritus, 
rash, stomatitis, and complete 
blood count and urinalysis are ob- 
tained. It is noteworthy that 
eosinophilia can be a harbinger of 
the dermatitis. In the Arthritis 
Clinic at the North Carolina Memo- 
rial Hospital, these procedures are 
executed by a specially trained reg- 
istered nurse and barring obvious 
complications the patient is 
evaluated by a rheumatologist only 
once a month. 

If there is a rationale for the use of 
cyclophosphamide, it was stated by 
Hamlet: ""Diseases, desperate 
grown, by desperate appliances are 
relieved."" This drug, in high doses 
only, has been demonstrated to be 
anti-inflammatory and to slow the 
progression of erosive disease. Its 
side effects are numerous: bone 
marrow toxicity, alopecia, cystitis 
as well as bladder fibrosis and 
dysplasia, and sterility. In theory it 
is oncogenic and clearly it impairs 
host defense mechanisms creating a 
target for serious sepsis. In short, 
cyclophosphamide and not 
rheumatoid arthritis threatens the 
life expectancy of the patient. The 
use of cyclophosphamide in articu- 
lar rheumatoid arthritis is more than 
heroic. Furthermore the drug is not 
released by the FDA for this pur- 
pose and guidelines for its usage 
published by the American 
Rheumatism Association'*' include 
the mandate for therapeutic pro- 
tocols approved by peer group re- 
view. 

STATE OF THE ART 

Rheumatoid arthritis is the calling 
of the generalist at the bedside — 
\\here the exactness of the clinical 
laboratory in no way supplants the 
judgment, compassion and common 
sense of the physician. 

The state of the art forces us to 
individualize treatment using all the 
tcKils we have. Dr. Charley Smyth 
of Denver has described a pyramid 
of interventions-'" in the case of the 
patient v\ith rheumatoid arthritis 
similar in form to that illustrated in 
Figure 1 . This is a useful conceptual 
tool. However, different clinicians 



l- 



Sich 
± 
krt 

sy; 
s [ 
p 
(ars 
ilio 

?( 
am 
ait I 
i} 



90 



Vol. 37. No. 2 



PROTOCOL 
THERAPY 



GOLD 
SALTS 



ANTI- 
MALARIAL 



NONSTEROIDAL ANT! - INFLAMMTORY DRUGS 



CONSERVATIVE MANAGEMENT 



•ig. 1. A pyramidal scheme for the sequential management ol rheumatoid arthritis. 




I-J. l-lKv.x.d PM 
and Rchahililation. 



Handbook 
1>)7I, W 1 



_ fill these boxes somev\hat differ- 
ently. More important, the pyramid 
builds seqiientialh during the 
course of the individual patient's 
. illness. It may grov\ truncated or 
. lopsided. These are issues of judg- 
ment. 

Finally, there is an issue of reality 
in the concept of conservative man- 
agement I have tried to develop. 
Such management is extraordinar- 
ily demanding of a physician's time. 
There is considerable aid available 
I from the allied health professions if 
they are called upon. Furthermore, 
the need for implementing man- 
agement programs in arthritis ap- 
pears to be gaining long overdue 
nationwide recognition. The fund- 
ing of the Regional Medical Pro- 
gram has greatly facilitated our cur- 
; rent efforts at UNCand a substan- 
' tial National Arthritis .Act has just 
passed Congress and awaits ap- 



propriation of funds. The future is 
bright. 

ACKNOWLEDGEMENTS 

This paper was presented at the First An- 
niKil .Arthritis .Symposium held in Chapel 
Hill. North Carolina. April 12-13. 1475, and 
spiinsored b\ the North Carolina Chapter ol 
the .Arthritis Foundation. North Carolina 
Regional Medical Program ( U.S. 1\H.S.) and 
the Office of Continuing Education of the 
University of North Carolina School of 
Medicine. The advice, encouragement and 
assistance of Dr. Oscar Sapp. Ms. Margaret 
Honeycuttand Mrs. Betty Neilson are grate- 
fully acknowledged. 

Rt^KRtStK.S 

1 Willjams. RV Rhcumaloid Anhnli'. as a Svslemit Dis- 
ease. IS)74, W B Saunders. Phila . PreLice 

2 Rudd t. Robinson HS- Public education in rheunialie 
diseases J Rheum 1:34.1-147. l'<74 

.1 Shod CI.. Bauer W: The course ol rheumatoid arthritis 
in patients recei\ing simple medical and orthopedic 
measures N KngI J Med U.S. 14:-14S. IM4S 

4 Shon CI Long remissions in rheumatoid arthritis 
Medicine 4.': 401-41)6, I^M 

.s Ropes MW ; C onservatise treatment m rheumatoid ar- 
thritis Med CIm N ,a.mer 4.';- 1147.1207, I%1. 

fi. Panridge REH, DuthicJJR Controlled Inalot the etiect 
ol complete immobilization ol the joints in rheumatoid 
arthritis. .Ann Rheum I)is 22: 91-99. 196.V 

7 Mills J A. Pinals RS. Ropes MW, Short CL. Sutclille J: 
Value ol bed rest in patients uith rheumatoid arthritis 
N Engl J Med 2.S4 4,V1-45«, 1971 

s Phrlich Cil:: 1 otal Management o! the .Arthritic Patient, 
197V J H Lippincott, Phila 



Krusen PH, Koltke 
i'hysical Medicine 
Sjundcrs, Phila, 

Boardman PI., Han ED: Clinical measurement ol the 
anti-inllammalorv ellecis ol salicylates in rheumatoid 
arthritis Brit Med J 4 264-26S. 1967 
Hollister LE: Measuring measurin; Problems ol oral 
prolonged-action medications. Clin Pharmacol Ther 1,V 
l-,V 1972, 

Paulus HE, Siegel M, Mongan E, (Ikun R, Calahro JJ: 
Variations ol serum CLincenlrations and hall-lile ol 
salicylate in patients with rheumatoid arthritis .Anhntis 
Rheum 14 527->}2. 1971, 

Ba\les 7B Salicylate therapy tor rheumatoid arthritis. 
In. Arthritis and Allied Conditions, 1972, Hollander ti- 
led I, Lea and Eebiger, Phila,, pp. 44S-4,S4 
Samler M, Beers RE: Intolerance to aspirin Ann Intern 
Med fiS 97,s-9s,1, 196,s 

t.iraldo B, Blumenlhal MN. Spink WW Aspirin intol- 
erance and a ,'hma Ann Intern Med 71 479-49f>, 1969. 
Leonards JR, Le . > G -Aspii .n-mduced occult gastroin- 
testmal blood loss: Local versus systemic ettects J 
Pharm Sci 59: 1511-1512. 1970, 

Leonards JR, Le\y 0, Niemczura R; Gastrointestinal 
hlood kiss during proUineed aspirin administration, N 
Engl J Med 290: 1020-1021, I97,">, 
Ba\les TB: Salicylates and rheumatic disease Arthritis 
Rheum 9 ,'>42-,147, 1966 

Hawkins 15, Pinckard RN, Craw lord IP, EarrRS: Struc- 
tural changes in human serum albumin induced b\ in- 
gestion ol acetylsalic\lic acid J t.'lin ln\cst 4;s: 536-542. 
1969 

Samter M: The acetNl- in aspirin. .Ann Intern Med 71: 
20»-209, 1969 

Kincaid-Smith P- -Analgesic nephropath\ 
Med 6S, 949-953, 1 i6,S 
Gault MH, Blennerhassett ,1, 
nephropathy .Am J Med 51 

Mills J, A Nonsteroidal anti-inllammatorv drugs, N Engl 
J Med 291. 7KI-7S4, 1002-1005, 1974 
Mason RM, Steinberg V L, Long-term use ol phenyl- 
butazone in rheumatoid arlhritis^Brit Med J 2 ^2}<-S30. 
I960 

Sm\th l, J Indomethacin — its righttui place in treat- 
ment Ann Intern Med 72: 430-432, 1970 
Mackenzie, AH An appraisal ol chloroquine Arthritis 
Rheum 13 2.S0-291, 1970 

Carr RE, Henkind P, Rothtield N, Siegel IM: llcular 
toxicity ol antimalarial drugs: Long-term tollow-up Am 
J Ophthal 66, 73S.744, 196)i 

Hench PS: L elter to W' Bauer in the historical collec- 
tion ol the ,Arthrilis L nit ^tl Mass General Hospital 
Salter RB, Gross A, Hall JH Hydrocortisone ar- 
thrvipalhy: .An espenmental investigation Can Med 
Assoc J 97 374-377. 1967 

W:ilkcns RE, tfBrien WM New nonsteroidal anti- 
inllammatory drugs Bull Rheum Dis24 770-777, 1974 
Godlrey RG, de laCruzS, E-llectol ibuproten dosage on 
patient response in rheumatoid arthritis Arthritis 
Rheum IS- I35-13S, 1975. 

Eorestier MJ: Laurotherope dans jes rheumatismes 
Chroniques. J Bull Mem Soc Med d'Hosp, de Pans, 53: 
323-327, 1929 

Research Sub-Committee ot the Empire Rheumatism 
Council: Gold therapy in rheumatoid anhntis, ,Ann 
Rheum Dis 19: 95-1 17, 1960, 

SiglcrJW, BluhmGB, Duncan H, Sharp JT, Ensign DC, 
McCrum WR Ciold salts in the treatment ol rheumatoid 
anhntis Ann Intern Med SO 21-26, 1974 
Schuanz RS, Gowans J DC: Guidelines lor the use ol 
cytoloyic drugs in rheumatic diseases, ,Arthritis Rheum 
14: 1,34, 1971 

Sm\th (,"J: Therapy ol rheumatoid arthritis A pyrami- 
dal plan Postgrad'Med 51: 23-36, 1972 



nn Intern 



, Muehrcke RC: Analgesic 
740-756. 1971. 



Thus, let some tartar-emetic he secretly introduced with the wine which a man drinks after dinner. 
Instead ot the pleasant sensations usually produced by this beverage, he soon begins to perceive a 
langtnirof mindand body — the face grows pale instead of red — the mind is unsteady and depressed — the 
muscular power is diminished — the head aches or becomes contused — the heart beats slowly or 
intermits — in short, there is a prostration of all the corporeal and intellectual powers — and all this, in 
many cases, before any disagreeable sensation is felt in the stomach. At length, nausea and vomiting take 
place, it the dose be sutTicient — the contents of the stomach are ejected — reaction succeeds — and the 
mental and corporeal energy is once more restored. — An Essay mi JnJii;cstioii- or Morbid Sciuihilitx of 
the Slomach A Bowels. James Johnson. IS,16. p 6. 



Febri ari IV7h. NCMJ 



91 



I 



Surgery of the Lower Limb 
in Rheumatoid Arthritis 



Frank C. Wilson, M.D. 



INTRODUCTION 

SINCE the primary function of 
the upper limb is mobility and 
that of the lower limb stability, it 
would seem that the surgical ap- 
proaches to each might differ, in- 
clining toward arthroplasty in the 
upper limb and fusion in the lower. 
However, because of the tendency 
of rheumatoid arthritis to produce 
spontaneous fusion, procedures 
that preserve motion are preferred 
in both areas. 

DETERMINANTS OF SURGERY 

In general, surgery should be 
considered for any rheumatoid pa- 
tient persistently disabled by joint 
pain, deformity or instability. 

The contraindications to surgery 
include: 

1. Florid disease, i.e., patients 
who are systemically ill: however, 
neither elevation of the sedimenta- 
tion rate alone nor local joint in- 
flammation is necessarily a deter- 
rent. 

2. Any focus of infection. 

3. Significant medical or psychi- 
atric problems, which increase the 
risk of failure. 

4. Poor motivation. Active par- 



Diviston ol Orthopaedic Surgery 
Universilv ot North Carolina School 
Chapel Hill. North Carolina :75U 
Repnnl reqiiesls to Dr Wilson 



ticipation by the patient is often 
necessary to insure successful joint 
surgery. While motivation cannot 
be consistently predicted, a patient 
who did not perform well after a 
previous operation will probably be 
a poor performer after a second one . 
5. Unrealistic expectation, e.g.. 
the patient with extensive disease 
who expects significant overall im- 
provement from one operation. 

TYPES OF SURGERY 

The decision on what type of 
surgery should be performed is 
based largely on findings in the 
joint. The procedures available are: 

1. Synovectomy 

2. Osteotomy 

3. Arthroplasty 

a. resection 

b. interposition 

c. replacement 

(1) partial 

(2) total 

4. Arthrodesis 

To be of value, synovectomy 
must be done before the joint sur- 
faces are damaged. If significant de- 
formity is also present, it may be 
corrected by the release of con- 
tracted soft tissues (tendon, cap- 
sule, etc.) or osteotomy. Where 
there is significant destruction of ar- 
ticular cartilage, it is unlikely that 
any procedure short of replacement 
or fusion of the joint will provide 



long lasting relief of pain or correct 
deformity. 

Any of the joints in the lower limb I 
may be sufficiently painful, de- 
formed or unstable to produce dis- 
ability: however, the knee most fre- 
quently forces patients to a bed- 
chair type of existence. Next most 
frequent is the hip and, much less 
often, the foot and ankle. 

The Knee 

Synovectomy of the knee is indi- 
cated with persistent synovitis, 
usually manifested by pain and 
swelling. The fact that synovec- 
tomy is carried out in the knee more 
frequently than in other joints of the 
lower limb reflects both the greater 
disability produced by knee in- 
volvement and the greater visibility 
of an effusion in the knee as com- 
pared to the hip. 

Contraindications to synovec- 
tomy of the knee include: 

1. A fixed flexion deformity of 
greater than 15 degrees, 

2. Over 15 degrees of mediolat- 
eral instability, 

3. Less than 90 degrees of knee 
motion, or 

4. Appreciable loss of articular 
cartilage. 

The surgical technique of 
synovectomy is beyond the scope of 
this paper: however, it is unneces- 
sary to remove all of the synovium 

Vol. 37. No. 2 



— M 
tie. 
n 

J Ills 

Posi 





liiC 

ikiei 
;iie. 

In 

;ikr 

s: 

I, 



to obtain benetlt from the proce- 
dure. Most synovectomies of the 
knee remove less than 75 percent of 
the diseased tissue. 

Postoperatively, patients are kept 
in a compression dressing for about 
three days, folknving which range of 
motion and quadriceps strengthen- 
ing exercises are begun. Weight- 
bearing is usually deferred until ac- 
tive control of the knee has been 
achieved and wound healing is se- 
cure. These usually take about 
three weeks. 

In general, the degree of im- 
provement after synovectomy of 
the knee is inversely proportional to 
the: 

1. Severity of the systemic dis- 
ease. 

2. Stage of the joint disease at the 
time of synovectomy. 

3. Length of follow-up. 
The synovium regenerates within 

a few months and eventually re- 
sembles the original rheumatoid 
synovium, although it shows more 
scarring. It is possible that this in- 
creased collagenous tissue forms at 
least a partial barrier to the infiltra- 
tion of rheumatoid inflammatory 
cells, preventing the new synovium 
from becoming as acutely inflamed 
as it was before synovectomy. 

With careful selection of patients, 
about three-fourths of them may be 
expected to have sufficiently long 
lasting results to justify the proce- 
dure. Poor results are usually recur- 
rent synovitis with progressive loss 
of cartilage space and deformity. 

If the cartilage space in either 
compartment of the knee is pre- 
served, consideration may be given 
to femoral or tibial osteotomy to 
shift weight-bearing forces toward 
the normal compartment; however, 
this procedure has little effect on the 
rheumatoid process itself and is use- 
ful only to correct associated de- 
formity. As a rule, valgus defor- 
mities are treated by distal femoral 
osteotomies while varus is better 
corrected by osteotomy through the 
proximal tibia. The procedure 
should not be done if there is a flex- 
ion contracture of greater than 15 
degrees or a range of motion less 
than 90 degrees. 

Excisional and interpositional ar- 
throplasties of the knee have been 

»,: Febrl .\ri 1976. NCM,1 
I 




Fig. 1-A. .\ stabilizing knee prosthesis 
(Walldiu S.I 



largely abandoned because of the 
difficulties encountered in achiev- 
ing a proper balance between mobil- 
ity and stability. 

If persistent disabling arthritis is 
present with destruction of articular 
cartilage, replacement of the knee is 
usually the procedure of choice. In 
general, replacement of only one 
side of the jomt. as with tibial 
plateau or femoral mold prostheses, 
has not proved as satisfactory as re- 
placement of both joint surfaces be- 
cause the disease is not confined to 
one side of the joint. 




Fig. l-B. A condylar replacement knee pros- 
thesis (geometric.) 



The indications for total knee re- 
placement are the same as those for 
fusion. It is an end-of-the-road 
procedure that should be reserved 
for patients with sufficient joint de- 
struction to make them unsuitable 
for synovectomy or osteotomy. 

Total knee replacement should 
not be carried out in the presence of: 

1. Local or systemic sepsis. 

2. Inadequate muscle power, 
e.g.. a non-functional quadriceps 
muscle. 

3. Claudication. The increased 
activity made possible by joint re- 
placement may lead to increased is- 
chemia and loss of limb. 

4. Extensive generalized joint 
disease — not a definite contraindi- 
cation but should be carefully con- 
sidered, since the replacement of 
any one joint in this kind of case 
may produce minimal overall im- 
provement. 

Although some three hundred dif- 
ferent knee joint prostheses have 
been used throughout the world, 
there are basically two types: the 
stabilizing prosthesis, in which sta- 
bility is inherent in the prosthesis 
itself (Fig. 1 - A ) and the condylar re- 
placement prosthesis (Fig. l-B) in 
which stability depends on 
ligamentous integrity. If a flexion 
contracture of over 45 degrees or 
over 30 degrees of mediolateral in- 
stability exists, a stabilizing pros- 
thesis is preferable. The primary 
theoretical objection to this type of 
prosthesis is that it does not allow 
movement other than fiexion and 
extension; however, the impor- 
tance of other prosthetic motions in 
the rheumatoid knee has yet to be 
determined. 

Unless instability or deformity 
are major problems, a condylar re- 
placement prosthesis, requiring less 
bone resection, is generally pre- 
ferred. These prostheses are avail- 
able in many models. Unlike some 
stabilizing prostheses, all condylar 
replacement devices require the use 
of cement. 

With either knee prosthesis, the 
most striking result is pain relief. 
About 90 percent of the patients 
having knee replacement will report 
either no pain or mild pain (defined 
as insufficient to produce limitation 
of normal activities). Adequate sta- 



93 



bility (defined as mediolateral mo- 
tion of less than 10 degrees) is also 
achieved in over 90 percent of the 
patients. The range of motion is im- 
proved in about 50 percent: more 
important, in patients with a flexion 
contracture whatever motion is 
achieved is put into a more func- 
tional range by elimination of the 
contracture. 

Failure of knee replacement may 
be defined as any complication re- 
sulting in removal of the prosthesis. 
Infection is the most frequent com- 
plication, although loosening and 
technical errors have also led to 
failure. Peroneal nerve palsies and 
patellar tendon ruptures have also 
been worrisome complications. 
Settling of the prosthesis has not 
been a problem when cement was 
used. 

About the only indication for fu- 
sion of the knee is a failed pros- 
thesis. In unusual circumstances, 
e.g., a young laborer with long 
standing monarticular disease, fu- 
sion may be considered initially, 
but in general the progressive, ca- 
pricious, ankylosing polyarticular 
nature of the disease makes fusion a 
poor choice. 

The Hip 

Surgical approaches to the 
rheumatoid hip are synovectomy 
and arthroplasty. There are few re- 
ports in medical literature on the re- 
sults of synovectomy of the hip; 
nevertheless, it should be consid- 
ered in cases where the pain is un- 
responsive to drug therapy and the 
architecture of the joint is pre- 
served. 

The types of hip arthroplasty are 
interposition (cup), replacement (of 
the femoral head or the entire joint) 
and excision. The more complete 
pain relief and earlier return to nor- 
mal activities following total hip re- 
placement have all but eliminated 
other arthroplasties from considera- 
tion. 

Because of the constraints the 
disease imposes on activity, age is 
not a significant contraindication to 
total joint replacement, although in 
borderline decisions between 
synovectomy and replacement, 
synovectomy is fa' ored in the 
younger patient. 



94 



Unless severe and bilateral, lim- 
ited motion is not usually an indica- 
tion for total replacement of the hip. 

As with other forms of total joint 
replacement, pain relief has been 
the most gratifying aspect in over 
90 percent of the patients. Most 
patients also have improved mo- 
tion, with the greatest improve- 
ment in those patients having the 
greatest preoperative restriction. 

Hip replacement involves use of a 
metallic femoral component and an 
acetabulum of high density poly- 
ethylene, both cemented in place 
with methylmethacrylate (Fig. 2). 

No discussion of total hip re- 
placement would be complete with- 
out mention of the complications. 
Depending upon the length of 
follow-up and the care in reporting, 
at least 25 percent of the patients 
undergoing this operation develop 
one or more complications. Infec- 
tion or loosening are the complica- 
tions that most frequently necessi- 
tate removal of the prosthesis. The 
patient is left with what is es- 
sentially ajoint resection; however, 
resection of the joint is not as dis- 



I 



:Jer 






Kig. 2. t'harnlej-Meuller Hip Prosthesis. Note 
metallic femoral component and polyethylene 
acetabulum. 



JlXlll 

pi 

-eii 
;cial 



abling as one might imagine. In fact 
it is sometimes used as a primary 
procedure in patients with exten '^ 
sive joint involvement or ankylosis 
of the hips in positions that make 
perineal care or body posturing difj 
ficult. 

The Ankle 

The rheumatoid ankle has re 
ceived relatively little emphasis ir 
comparison to the hip and knee, bul 
it will undoubtedly receive more at' 
tention as the problems of the hip 
and knee are solved. Synovectomy 
is infrequently used, partly because 
of technical difficulties; however, 
these objections are not prohibitive, 
and the procedure probably should 
be done more often. Where signifi- 
cant cartilage destruction has oc- 
curred, fusion may be necessary, 
but total replacement of the ankle 
is now under investigation. Since it 
is technically one of the simplest ot 
the major joints to replace, it is 
likely that prostheses will replace 
fusion in the ankle as they have ir 
other joints. 



The Foot 

Rheumatoid arthritis of the foo 
may produce deformity either in the 
hindfoot. forefoot, or both. 
Hindfoot deformities usually occui 
as varus or valgus displacement re- 
sulting from a combination of joini 
destruction, weight-bearing and 
muscle contracture or spasm. II 
shoe modifications do not control 
pain and deformity and spontane- 
ous fusion does not occur, triple ar- 
throdesis (in which the joints con- 
trolling varus and valgus are fused; 
may be expected to reduce pain and 
improve abulation. 

Forefoot deformities most com- 
monly involve the metatar- 
sophalangeal joints. The usual de- 
formities are hallux valgus and 
clawtoes, which, like other 
rheumatoid deformities, are pro- 
duced by a combination of synovitis, 
and mechanical forces. The 
synovitis causes stretching of the 
ligaments and capsule, allowing 
normal weight-bearing and muscle 
action to displace the joint. As pro-; 
gressive clawing occurs, the 
metatarsophalangeal joints undergo 
dorsal displacement, which draw^ 
the cushioning fat pad forward from 

Vol. .^7, No. 2 



I 



under the metatarsal heads and 
forces the matatarsal heads down- 
ward as a result of shoe pressure on 
the dorsally prominent proximal 
phalanx. These effects combine to 
produce the painful callouses often 
encountered under the metatarsal 
heads in rheumatoid feet. If the ap- 
plication of metatarsal bars does not 
relieve symptoms, surgery may be 
useful. Hallux valgus and clawtoes 
j are treated by resection of the joints 
- either the proximal phalanges, 
(metatarsal heads or both. Resection 
1 of the joints allows the plantar fat 



pad to be returned to a more normal 
position in relation to the metatar- 
sals, thereby reducing symptoms 
and making shoes fit better. Trans- 
metatarsal amputation has been 
employed for severe clawing; how- 
ever, this procedure seems un- 
necessarily mutilating to most sur- 
geons (and to their patients). 

In summary, surgical correction 
of hindfoot deformities usually re- 
quires triple arthrodesis; forefoot 
procedures include metatar- 
sophalangeal joint resection, or, 
rarely, amputation of the toes. 



SUMMARY 

Having discussed the joints of the 
lower limb individually, it should be 
pointed out that treatment is rarely 
so simple because the disease is not 
often monarticular. When disability 
results from multiple joint involve- 
ment, surgery must be carefully and 
individually planned. Joint preser- 
vation by synovectomy should re- 
ceive tlrst priority, followed by the 
staging of reconstructive proce- 
dures according to the greatest total 
gain to be derived by the patient. 



In proportion as we have excited the ganghonic s\stom ot nerves, or. in other words, the involuniary 
or vital organs (stomach, heart, cv; o. wedisqualitv the \oliintar\ muscles tor act ion. and the mtellectual 
system for deep thought and other mental operations. In tact, we are then onl\ lit to sit and talk very 
comfortably over our wine — and ultimately go to sleep. Whether this habit, which is that of civilized life 
in general, be that which is best adapted tor preser\ing or regaining health, is a question which I shall 
presently discuss; but. in the mean time, it will be sufficientK evident that pleasurable sensations are 
ditfused over mind and body, by the presence of food and w ine in the stomach, nnlinut the existence of 
liny iii\!int r .\cn.\iitiiin or sensible exeitemem in the sinimu li ilsell. This is an obvious truth, and it is of 
great importance to remember it; for if the nerves of the stomach. ;/; ii slate ot lieiiltli. be capable of 
exciting pleasurable emotions in the mind, and comfortable sensations in the body, on the application of 
gixid food and generous wine, we shall Imd that the same nerves, when in a disordered stale, are equalK 
capable of excitingthe most gloomy thoughts m the mind, and the most painful sensations in the body, on 
the application of the very same speciesof refection, either with or »i;/i(i/(f an unpleasant sensation in the 
stomach itself. — An Essay on Indigestion: or Morbid Sensibility of the Stoinueh & Bonels. James 
Johnson. IS?f>. pp y-h. 



FEBRL.A.R1 1976. NCMJ 



95 



Medicine During the Great War 
of 1914-1918 



Adrian M. Griffin 



oFroi 

to 
sase: 

iSBK 



ame 
tote 

ill 
iid 
iaiioi 
Kan 
m 
ilar 



THE Great War of 1914-1918 
brought far-reaching advances 
to the field of medicine. The nature 
of combat itself was transformed 
and Europeans were caught unpre- 
pared for the naval and military tac- 
tics developed during the American 
Civil War. For more than 40 years 
the British and French armies had 
fought only colonial wars, and only 
a small contingent of the German 
army had ever fired a shot in 
anger — and that was in China.' 

A major characteristic of the new 
warfare was its unprecedented 
mobilization of scientific and tech- 
nical skills.- And one of the out- 
standing benefits was improvement 
in medical services. 

The British Empire had only 
14.000 hospital beds at the begin- 
ning of the war, which left six mil- 
lion sick and two million wounded 
in Great Britain alone. ^ At war's 
end the number of beds had in- 
creased to 637,746.^ Despite gross 
oversights such as the failure to 
send any denfists with the British 
Expeditionary Force to France in 
1914, the response of volunteers 
from the medical profession was 



Bowman Gray School ol Medicine 
Winslon-Salem. North Carolina 27103 

Reprint requests to Mr GntTin 



96 



such that no compulsory enlistment 
of doctors was required until 1916.'' 
Women volunteers formed Volun- 
tary Aid Detachments (VADs) 
under the auspices of the War Office 
and the British Red Cross Society 
and the Women's Imperial Service 
League under the Belgian. French 
and Serbian Red Crosses. 

"It was not until Spring of 1915 that medi- 
cal women undertook the lull charge of 
British wounded in England, although in 
1914. Dr. Louisia Garrett Anderson estab- 
lished under the French Red Cross a small 
hospital in Paris which received some British 
wounded.'"" 

Wounds often became infected 
with gas gangrene and tetanus, 
probably due to the severity of high 
velocity projectiles or shrapnel and 
the filth, lice, mud and damp of the 
Western Front. After two years it 
became apparent that the best 
treatment for tetanus-infected 
wounds was quick removal of 
casualties to a hospital for extensive 
wound debridement.' This was 
often impossible because of the dif- 
ficulty of retrieving wounded men 
from "no-man's land" and the 
Germans' habit of bombarding hos- 
pital convoys. 

"In 1914 few men received prophylactic 
antitoxin after being wounded, and the high- 
est monthly incidence was 9.0 cases of 
tetanus per 1.000 wounded. From 1915 until 
the end of the war practically every wounded 
man received antitoxin, and by I91S the inci- 
dence of tetanus had been reduced to about 
0.6 per 1.000 wounded. There was also a 



marked decrease of case mortality in 
wounded men who developed tetanus." 

X-rays of bones became com- 
monplace.'* And the increased skill 
in bone surgery'" led to the founding 
of the British Orthopedic Society in 
1918. Surgery of the eye, face, ear, 
nose, throat and brain as well as 
plastic surgery developed because 
10 per cent of all injuries were to the 
head despite the use of steel hel- 
mets." Abdominal surgery did not 
advance, however, probably be- 
cause no blood transfusion service 
was evolved and the wounded often 
could be evacuated to a hospital 
only with great difficulty. Their 
wounds became contaminated and 
they often died of acute sepsis. 

"Al first we were influenced by the experi- 
ence of the African War. w hich seemed to 
prove conclusively that opium, starvation, 
and rest in the Fow ler position yielded better 
results in gunshot injuries of the abdomen 
than treatment by operation. "'- 

The concept of healing by third 
intention had not been evolved; 
hence, despite surgery and drain- 
age, the majority of men with ab- 
dominal wounds died.'^ 

Disease produced more casual- 
ties than the enemy. But the military 
axiom from earlier wars that the 
chance of a soldier's dying from dis- 
ease was always greater than his 
chance of being killed by his enemy 
was to be challenged. For example, 
in the South African War (1899- 

VoL. 37, No. 2 



t^as( 
idile 



M 

:\K 

aa 
Ike 
Ign; 

spit 

•idle 

Si 



m 
h 

mi 



;i!ix 
adii 

aei 

h] 

^';oD 



ISii 



902) there were 15 non-battle 
;asualties per wounded man in far 
nilder conditions than on the West- 
ern Front of World War 1. in which 
here were two non-battle casualties 
or each wounded man.'-* This was 
lue to the control of waterborne 
liseases (cholera, typhoid and 
lysentery) by chlorination of drink- 
ng water.'"' Typhoid immunization 
vas begun at the same time and full 
jse made of the principles of the 
"carrier" as explained by Sir John 
"harles Grant Ledingham and Sir 
loseph Arkwright in The Carrier 
"^roblcm in Infectious Diseases. 
^ter James Glover found a positive 
elationship between the carrier- 
•ate and the case-rate in infectious 
liseases. By spacing the beds in 
nilitary hospitals more than three 
eet apart Glover was able to reduce 
X)th the carrier-rate and the case- 
ate."' Nevertheless, insect-borne 
diseases remained important in the 
Vlediterranean and tropical thea- 
ers. A million deaths in the Balkans 
A-ere attributed to typhus and in 
jerman East Africa more than half 
■ he troops were kept out of action 
3y malaria. 

The public in Great Britain was 
ndignant and horrified to learn that 
jne soldier in 20 was admitted to the 
;aospital for treatment of venereal 
disease. (Incidentally, this was no 
greater than the general population. 
and it is stated that half the cases 
vvere infected before leaving En- 
igland.) By 1918 public sentiment 
forced the closing of the "maisons 
de tolerance"" (officially recognized 
,French brothels). One story is that 
in Le Havre 171.000 men were 
known to have visited the "houses"" 
in one street in one year.'" The 
treatment of venereal disease was 
primitive and hepatitis was often 
transmitted when unsterile needles 
were used. A consequence was the 
introduction of the venereal disease 
sradication programs in the United 
States shortly after the war.'^ 
Psychiatric disorders were 
., jamong the new medical problems 
; vvhich arose during the war. Stress 
.and exhaustion in the trenches pro- 
duced '"shell shock. ■■ It was found 
that while all soldiers suffering from 
"shell shock" had been under 
heavy bombardment, only a fifth 

i 
: 'February 1976, NCMJ 



were involved in the explosions. By 
the end of the first year of war 10 per 
cent of the officers and five percent 
of the soldiers admitted to a hospital 
in Boulogne were sent back to Brit- 
ain suffering from "shell shock." 
Psychiatrists were enlisted to help 
the British and French armies and in 
1917, 91 percent of those patients 
who had been sent home returned to 
duty. This contributed to the gen- 
eral recognition of psychiatry as a 
specialty. 

Deserters were subject to death 
by firing squad. It was found that 89 
percent of those sentenced to death 
were diagnosed as suffering from 
""shell shock" and they joined 
others for psychiatric treatment in 
special institutions or hospitals. In 
1921. 65,000 men were still receiv- 
ing pensions as victims of ""shell 
shock." '^ 

Another new disease was trench 
fever, 

■' . . . first described by John Henry Por- 
teus Graham in 191? as 'a relapsing febrile 
illness ot unknown origin' in troops on the 
British Front . . . .Allan Coats Rankm called 
it 'trench lever'. By early 1916 it had been 
comprehensively studied by Sir John William 
McNee. ... In German troops it was de- 
scnbed by H. Werner, and by William His in 
Volhynia on the Russian front. v\ ho hence 
called It Volhynian lever. Werner called it 
two-dav lever. It was shown bv McNee that 
the disease could be produced b\ inoculation 
with blood from a patient, and it was proved 
experimentally that lice could transmit the 
disease. Many points regarding the infection 
from the louse were cleared up by the War 
Office Committee, and the causative organ- 
ism — named Rickettsia quintana — was de- 
scribed by Hans Willi Topfer in 1916." -" 

British troops had been in- 
structed well in cleanliness and 
were aware of the problems of 
lice.'-' It is likely that such instruc- 
tion, despite the conditions in the 
trenches, helped to control the 
epidemic of "trench fever. "' 

Gas warfare accounted for some 
185,000 casualties. On April 22, 
1915, the Germans used chlorine 
gas north of Ypres and the Allies, 
though warned, were so surprised 
that two divisions broke: fortu- 
nately the Germans did not press 
their advantage. Five months later 
the British, who had protested the 
illegality and inhumanity of gas, 
used it themselves at Loos and 
added to its effect by mixing ii with 
smoke. Three months later the 
Germans replied with Phosgene, a 
product easily made from their large 



dye industry. Diphosgene, 
chloropicrin and hydrocyanic acid, 
which attacked the central nervous 
system, were used by the Germans, 
who scored a second surprise in 
1917 with the use of mustard gas 
uhich injured by contact as well as 
by ingestion. The treatment of 
gassed soldiers sparked much con- 
troversy. Some favored preventing 
chemical poisoning by having a lib- 
eral supply of oxygen available in 
the trenches for the troops to 
breathe when subjected to a gas at- 
tack.-- Others tried methods of 
stimulating expectoration by the 
gassed, as well as ""compression of 
the thorax, emetics, administration 
of oxygen, administration of com- 
pressed air, and the administration 
of atropine to diminish secre- 
tions." -■' Another routine treat- 
ment of gassed soldiers w as 

"... to ensure an abundant supply of air 
and warmth, give an emetic of salt and water 
if the patient was cyanosed and had not al- 
ready vomited, followed by the administra- 
tion of ammonium carbonate and vinum 
ipecacuanliac. If there was a marked case of 
syanosis and dyspnea, oxygen inhalation was 
given, opium was added for restless cases to 
allav the mental strain and pituitary extract 
and brandy was (sic) added when the heart 
threatened to fail."-' 

Of the 185,706 British gas casual- 
ties in World War 1, 5,899 died 
(these figures do not include British 
Dominion or Empire dead)-' be- 
cause of the blistering and burning 
action of the gas on the skin or of 
severe bronchitis resulting in acute 
congestion and edema of the lungs. 
The air passages were affected ap- 
proximately an hour after the gases 
had been inhaled. The misery and 
suffering of the gassed were vividly 
described: 

"The hospital is very heavy now — as 
heavy as v\ hen 1 came; the fighting is continu- 
ing very long this year, and the convoys keep 
coming down, two or three a night. . . . 
Sometimes in the middle of the night we have 
to turn people out ol bed and make them 
sleep on the floor to make room for the more 
senousK ill ones that have come down from 
the line. We have heaps of gassed cases pres- 
ent who came in a day ortv\oago. there are 10 
in this ward alone . . . the poor things are 
burnt and blistered all over with great mus- 
tard coloured suppurating blisters, w ith blind 
eves — sometimes temporally (sic). some- 
times permanentK — all sticky and stuck to- 
gether, and aK\a\s fighting for breath, with 
voices a mere whisper, saving that their 
throats are closing and they know they will 
choke. The only thing one can say is that such 
severe cases don't last long; either they die 
si.xin or else improve — usualU the former; 
they certainly never reach England in the 



state we have them here. 



97 



The chemical warfare stimulated 
a tremendous amount of research in 
biochemistry and pharmacology 
and several new drugs were discov- 
ered, such as emetine bismuth 
iodide which today is one of the bet- 
ter agents for treatment of amoebic 
dysentery. 

In the I9th Century, Germany 
had been the leader in medicine and 
surgery but she lost momentum as a 
result of the war. The disillusion of 
defeat and the financial attraction of 
private practice delayed the recov- 
ery of German medicine, which was 
further slowed by emigration of 
physicians, in Great Britain 
"specialists" gave a new direction 
of medicine while in the United 
States group medical practices were 
set up because of the success of 
such units in the war. 



Above all, the war introduced 
new and dramatic medical problems 
which could be solved only by sus- 
tained scientific effort, a fusion of 
science with medicine which was to 
transform life in the next 60 years. 

Reterences 

I Buchan J A Historvot the Great War. London- Thomas 

Nelson and Sons, Ltd.. 19::. chlV. 
: Osier W: An address on science and war. Lancet 

U:79s-S0l, I9[f 
^ Charman TC; Department ol Printed Books, Imperial 

War Musuem, London Personal communication 
4 Charman TC Department ol Printed Books, Imperial 

War Museiim, London Personal communication 
.s C harman TC Department ^il Printed Books, Imperial 

V\'ar Museum, London Personal communication 

6 Lens MHI- The part played bv British medical women 
in the war Br Med J ll:20.V:6s, 1917, 

7 Makins GH The de\elopment ol British surgery in the 
hospitals on the lines ol communication in Prance Br 
Med J l,7s')-SUh, 1917, 

.s Singer C Underwood EA: A Shon History ol 

Medicine New York and Oxiord ttxlord L nuersity 

Press, 1962, p 443, 
9 Caldwell JR: The X-rav theatre in war hospitals Lancet 

l:,s,S4, I9LS 
HI Mackenzie NC, Military orthopaedic hospitals Br Med 

J LM.9.679, 1917 
I I Addinsell AW He.id iniuriesin war Br MedJ ll-9,s-l(i:, 

I9lh 
i: Mayo-Rohson ,^VV: Treatment ol gunshot wounds ol 



the abdomen Br Med J IL,»0.^, 191,s | 

Lockwood AL, Kennedy CM etal: tthservations on II 

treatment ol gunshot wounds Br Med J l:3l7-.320, |9i' 

Charman TC; Department ol Printed Books, Impeii 

W'ar Museum, London Personal communication, 

t^astellani ,A: Enteric and cholera inoculations w 

mixed vaccine, Br Med J ll:S14. 1914, 

Singer C, Lnderwood EA: A Short History . 

Medicine New >ork and Oxiord: Oxiord Univers 

Press. 196:, p, 409 

Spry C: Medicine at war, in Taylor AJP. Roberts J 

History ol the Twentieth Century, Vol, :, Bristol. E 

gland Pumell. I96«. p, 7."^-^, 

Spry C: Medicine at war, in Taylor AJP, Roberts Jl 

History ol the Twentieth Century, Vol, :, Bristol. E, 

gland Purnell. I96S, p, 7_Ss. 

Spry C: Medicine at war. in Taylor AJP, Roberts Jl, 

History ol the Twentieth Century. Vol, 2, Bristol, E- 

gland: Pumell, I9hs. p 7-S,s, 

Singer C, Underwood E,\: A Short Hi.story 

Medicine, New York and Oxiord: Oxford Universi 

Press. 196:. pp, 4.SI-45:, ( 

Copeman SM: Notes on a successlul method tor t 

extermination ol sermin infecting troops, Br Med' 

1:247. 19LS 

Horwood JG The pretention ol gas poisoning, Br M. 

J 11:161, 19LS 

Hill L: Gas poistinmg. pathological symptoms andclii 

cal treatment Br Med J 11:K0I-S04, 191,'i- 

Black JE, Glenny ET, McNee JW: Observations on 6 

cases ol poisoning by noxious gases used by the enem 

with a note by Sir William Herringham Br Med J 

16.S-I67, I9I.S 

Charman Tt.": Department ol Printed Books, Imperi 

War Museum, London Personal communication. 

Bntlain V " Working in a hospital in Erance. alter t 

battle ol Camhrai, quoted b\ Roberts J M in The N< 

Warlare in Taylor AJP, Roberts JM: History ol t 

Twentieth Century, Vol 2 Bristol, England: Purne 

I96,s, p 729 



It leads us to divide into two great classes, those symptomatic or sympathetic affections of various 
organs in the body, dependent on a morbid condition of the stomach and bowels — \ iz, into that yvhich is 
accompanied by itmscidii.s sen.saiion, irritation, pain, or obviously disordered function of the organs of 
digestion — and. into that w hich is not accompanied by any sensihlf disorder of the suid organs or their 
functions. Contrary to the general opinion. I venture to maintain, from very long and attentive observa- 
tion of phenomena, in others as well as in my own person, that this larier class of human afflictions is 
infinitely more prevalent, more distressing and more obstinate, than the former. — An Essiiy on Indii;L's- 
lion: or Morbid ScnsihiUly of the Stomach & Bowels. James Johnson, 1836. p 7. 



lolc 

llW 



ijiei 
as 11 

'itiii 

Firs 

(Slll 

i»' 

lev: 



SIM 
»Sl 

nil 

;jt 
lip 

SSI 



Wi 



98 



Vol. 37. No. 



Editorials 



YOUNG DR. FOGY 



Told that he is a dirty old man, a senior citizen or 
two will smile proudly and admit it as a reasonable 
m sequel to his career as a dirty young man. BlU Tve yet 
to meet someone who will admit being an old tbgy. 
"^ Since medicine spends a lot ottime and money nowa- 
days trying to predict w hose coronaries will close up. 
jlood pressure rise, car crash or marriage fail, maybe 
it's time to look at the dread t'ogyism. 

First, what is it? Consensus "old fogies" in this 
neighborhood seem to share being over 40, slowness 
of movement and speech, and resistance to new ideas. 
They are notorious for slow, middle-of-the-road driv- 
ing. Most fall back on predictable formulas w hen re- 
sponding to any proposal that would change the way 
they conduct their personal or business affairs. Al- 
most all are ill-informed about current events and 
uninterested in any of the arts. Some are so fogied up 
that their total response pattern consists of 
complaint — usually complaints so unoriginal that only 
the subcategory of bitching applies. As far as lean tell, 
the obsolete sense of "fogy" associating the pattern 
with obesity doesn't apply. Our local fogies come in all 
sizes and shapes, both sexes and all races. One could 
argue that social groups that rel\ much on tradition 
produce what we consider fogies by their very nature. 
Maybe that is why the Maoists are running aroimd 
burying Confucius deeper all the time. 

Fogyism certainly differs from senility. It is plain 
old prejudice that places "old" in front of "fogy." 
That prejudice has been around a long time. I've run 
into the phrase in George Eliot's /l</«/?; Bede . Fliot's 
character, hovsever. gives one reason that hanging 
"old" in front of fog\ became routine. He said. "My 
part ... is always that of the old fogy who sees noth- 
ing to admire in the young folks." 

If that were all that defined fogy, "old" would be 
essential, but lots of old people have nothing against 
young folks, and lots of the young consider their own 
generation rotten. My 80-year-old mother says there is 
nothing fogyish about her and points out to me what a 
fog\ I am. since 1 am more conser\ati\e than she. 

I hope I've separated old and fogy w idel\ enough to 
show that young fogies can be "identified." as our 
social-science types like to say. A while back I de- 
scribed local consensus fogies as beyond 40. but that's 
because of the prejudicial view of fogyism. vshich is 
what I'd like to change. 

Little kids are pretty fogyish about age two. in many 
cases. Manv of them are slow as the mischief, and 



their outstanding feature is resistance to new ideas. 
The predictable formulas that fogies rely on for their 
reactions are never more predictable than in early 
childhood. This nonspecific orneriness of the "terri- 
ble two" is succeeded in most cases by a latent period. 
Then fogyism sproLits again with pubic hair. What is 
usually called teenage rebellion isn't very different 
from acknowledged old fogyism. though not generally 
recognized under that gerontophobic heading. Start 
with a favorite teenage subject, "their" music: can 
you imagine a more infie.xible stance than the one most 
kids take against an> music other than top-forty glitter 
rock? What archetypal old fogy sitting in the Union 
League club windov^ could harrumph more resolutely 
than a blasted-ears young fogy on the subject of 
music? 

Moving on to the later teen years, one finds a variety 
of young fogyisms. Some young folks are so con- 
vinced that the older generation has so poisoned the 
soil with fertilizer and insecticides that they desper- 
ately seek a plot of ground to manure so they can grow 
food fit for them to eat. .And the idea that one must 
work at something that might be found in a dictionary 
becomes anathema — even though they would accept a 
discretely ottered allowance to help them along while 
they gather rosebuds. Most of these young people are 
ill-informed, uninterested in points of view other than 
theirs, and as intolerant of older people as George 
Fliot's old fogy was of the young. To me it is a general 
dullness that is the essence of the fogy, and I agree 
wholeheartedly with physician and novelist Walker 
Percy when, in Love in the Ruins, he says. "Nothing is 
drearier than the ideology of students, left or right." 1 
would add. however, that Dr. Percy is probably de- 
scribing only the young fogies among the students. 
This general dullness gradually intensifies, and by the 
time the afflicted reach the 40s. they emerge as fully 
developed old fogies. 

Specifics about young medical fogies? Our medical 
center has its share, and they come from all over this 
and other countries. Some habitually order a certain 
group of lab tests no matter w hat newer methods have 
been developed and brought to their attention. Eccen- 
tricities of hair and costume are cherished as lov ingly 
as any old fogy's carpet slippers or sway-backed 
chair. Virtually to a person they are as protective of 
their parking places as a total old fogv of his favorite 
seat for the evening's TV shows. Whatever little tricks 
of technique they learned during medical school or an 
earlier house staff post, even if thev're hand-me- 



FbBRi AR'i I47h. NCMJ 



yy 



downs from Hippocrates, are treated like revealed 
truth by the nascent fogies in the crowd. A cir- 
cumscribed group of abbreviations and cliches in the 
histories and physicals, recurring references to a small 
selection of journals or texts (especially texts) — all 
show the young fogy moving along the groove that 
circumscribes the fogy's beat. 

I hate to close without considering possible good 
aspects of being a fogy, of whatever age. One thing 
that comes immediately to mind is the traditional 
military use of the unmodified word fogy — a raise in 
pay without a raise in rank. If you can't get promoted, 
at least you can be happy over a little more money , or a 
"fogy." Besides, fogyism may well be a protective 
mechanism; to do away with fogyism may be as 
dangerous as doing away with people's illusions. And 
then, what would we bright, energetic types do with- 
out a few fogies to sneer at? 

R.W.P. 



POKE SALIT: A SUCCESS STORY 

"1 don't care if you live in a shotgun shack and eat 

poke salit if you love it there, you're all right." 

Thus a radio evangelist commenting on the state of the 
world. Unfortunately many have not had the advan- 
tage of eating poke salit in season and even more don't 
know what it is. For those so grievously uninformed, 
or who have heard poke is poison, a 3'/2 ounce (100 g) 
serving of boiled, drained poke shoots contains 20 
calories. 2.3 g protein, 8.700 International units (lU) 
Vitamin A. 82 mg Vitamin C and some B vitamins. 
Botanically. pokeweed, also known as garget, 
pokeberry, inkberry or pigeonberry, is Phytolacca 
americana whose tender leaves may be cooked as 
greens (hence poke salit. or salad) and whose berries, 
according to Hardin and Arena,' are edible if baked in 
apie. When leaves and berries are eaten raw, and if the 
highly poisonous roots are ingested, severe gastroin- 
testinal symptoms, impaired breathing, seizures and 
even death may result. 

The root contains a plant lectin with the capacity for 
incomplete panhemagglutination as well as incom- 
plete panleukagglutination. More interesting medi- 
cally is the presence of mitogen activity which induces 
transformation of 50 to 60 percent of human peripheral 
lymphocytes in culture to a type resembling early 
plasma cells.- Pokeweed mitogen (PWM) and 
phytohemagglutinin (PHA) from the red kidney bean. 
Phaseoliis vuli^aris. possess similar characteristics al- 
though the latter provokes complete hemagglutination 
and leukagglutination and 80 to 90 percent transforma- 
tion of peripheral lymphocytes in culture. Hence poke 
has escaped from the category of weed, a plant of no 
value, and deserves to be promoted if poke salit and 
PWM are of worth. 



, Hardin JW. Arena JM: Human r*uisoning from Nalure and Cultivated Plants 2n(j 
edition- Duke Lniversitv. Durham, iy'^4 
Borieson J, Reisteld R , Chessin LN et al J tvpr Med i:4' S59. 1966 



100 



PRESCRIBING INFORMATION j 
Antiminth (pyrantel pamoate) Orai' 
Suspension ' 

Actions, .■\ntiminth (pyrantel pamo 
ate) has demonstrated anthelmintic 
activity against Enterobius vermicu- 
laris (pinworni) and Ascaris lumbri 
coides (roundworm). The anthelmin- 
tic action is probably due to the 
neuromuscular blocking property of 
the drug. 

Antiminth is partially absorbed 
after an oral dose. Plasma levels of 
unchanged drug are low. Peak levels 
(0.05-0. i3;ig/ ml.) are reached in 1-3 
hours. Quantities greater than 50% 
of administered drug are excreted in 
feces as the unchanged form, whereas 
only 7% or less of the dose is found 
in urine as the unchanged form of 
the drug and its metabolites. 
Indications. For the treatment of 
ascariasis (roundworm infection) and 
enterobiasis (pinworm infection). 
Warnings. Usui^c in Pregriancy: Re- 
production studies have been per- 
formed in animals and there was no 
evidence of propensity for harm to 
the fetus. The relevance to the hu- 
man is not known. 

There is no experience in preg- 
nant women who have received this 
drug. 

Precautions. Minor transient eleva- 
tions of SCOT have occurred in a 
small percentage of patients. There- 
lore, this drug should be used with 
caution in patients with pre-existing 
liver dysfunction. 

Adverse Reactions. The most fre- 
quently encountered adverse reac- 
tions are related to the gastrointes- 
tinal system. 

Gastrointestinal and hepatic reac- 
tions: anorexia, nausea, vomiting, 
gastralgia, abdominal cramps, diar- 
rhea and tenesmus, transient eleva- 
tion of SGOT 

CNS reactions: headache, dizzi- 
ness, drowsiness, and insomnia. Skin 
reactions: rashes. 

Dosage and Administration. Chil- 
dren and Adults: .\ntiminth Oral 
Suspension (50 mg. of pyrantel base/ 
ml.) should be administered in a 
single dose of 1 1 mg. of pyrantel base 
per kg. of body weight (or 5 mg./lb.); 
maximum total dose 1 gram. This 
corresponds to a simplified dosage 
regimen of 1 cc. of Antiminth per 10 
lb. of body weight. (One teaspoonful 
= 5 cc.) 

Antiminth (pyrantel pamoate) 
Oral Suspension may be adminis- 
tered without regard to ingestion of 
food or time of day, and purging is 
not necessary prior to, during, or 
after therapy. It may be taken with 
milk or fruit juices. 
How Supplied, Antiminth is avail- 
able as a pleasant tasting caramel- 
flavored suspension which contains 
the equivalent of 50 mg. pyrantel 
base per ml., supplied in 60 cc. bot- 
tles and Unitcups"' of 5 cc. in pack- 
ages of 12. 

ROeRIG<^ 

A division of Ptizer Pharmaceuticals 
New York. New York 10017 



WORMS BUTZED 




A single dose of Antiminth 
( 1 CO, per 10 lbs. of body 
weight, 1 tspy 50 lbs.— max- 
imum dose, 4 tsp =20 cc. ) 
offers highly effective control 
of both pinworms and 
roundworms. 

Antiminth has been shown 
to be exti-emely well tolerated 
by children and adults alike 
m clinical studies* Pleasantly 
caramel-flavored, it is 
non-stammg to teeth and oral 
mucosa on ingestion... 
doesn't stain stools, linen or 
clothing. 

One prescnption can 
economically ti:^eat the entire 
family 

ROeRIG <o 

A division ot Pfizer Pharmaceuticals 
New York New York 10017 



NSM 6505-00-M8-6967 



Pinworms, roundworms controlled 
with a single, non-staining dose of 

ANTIMINTH 

(pyrantel pamoate) 



'Data on file at Roerig 



cqui\c^ont to ;5() nig p\Taj"\tcl/inl, 

ORAL SUSPENSION 



Please see prescnbing information on facing page 



Bulletin Board 



NEW MEMBERS 

of the State Society 



Anderson. Robert William, MD (TS). Box 30S4, Duke Med. Ctr.. 

Durham 27710 
Avis. Kredcnck Patterson. MD. Univ. ofN.C. Chapel Hill 27.^14 
Bartelt, Curtis Frederick. MD(FP). .'?.'i35 Randolph Rd.. Charlotte 

2S21I 
Burroughs. Frederick Douglas. MD (PD). 510 S. Person St.. 

Raleigh 27602 
Conrad, Cvnthia Dale (STUDFNT). 23K McCauley St.. Chapel Hill 

27514 
Cook. Joseph Wm.. MD (TS». XIO Edgehill Rd.. Charlotte 2X207 
Davis. Guy Claude. .Ir,. MD (AN). Box .M)94. Duke Med. Ctr., 

Durham 27710 
Eakms. Joey Wm.. MD (IM). .15.^9 Kirbv Smith Dr.. Wilmington 

2S401 
Gordon. John Bennett. Ill (STLIDFNT). 1617 Old Oxford Road. 

Chapel Hill 27514 
Karis. Joannes Hubertus. MD (AN). Box 3094. Duke Med. Ctr.. 

Durham 27710 
King. Joseph Aanm. MD (AN). 4224 Wild Partridge St.. Charlotte 

2S21I 
Kramer. Jeane Ann Grisso (STUDENT). 31 Oakwood Dr.. Chapel 

Hill 27514 
Lane. Jerald Paul. MD (P), 5913 Gatepost Rd.. Charlotte 28211 
Minor. Walter Nathan. MD (GP). 320 N. Ransom St.. Fuquay- 

Varina 
Musselwhite.Ncill Hector. 111. MD(lntcrn-Resident). 3846Gillette 

Dr.. Wilmington 2K401 
Patterson. Robert William (STUDENT). Route 3. Box .347. Chapel 

Hill 27514 
Rhvne. James Moody. MD (IM). 1 lO-M Stockton St.. Statesville 

28677 
Robinson. Stephen Carey. MD. 3701 Mossborough Dr.. 

Greensboro 27401 
Scott, Samuel Edwin. MD (RENEWAL). Route 2. Burhngtcm 

27215 
Seabrook, Paul Dewitt. Jr.. MD (AN). 2035 Clematis Dr.. Charlotte 

28211 
Tse. Alex Yu-Cho\v, MD (PD), 120 Memorial Drive, Jacksonville 

28540 
Ward. James Singleton. MD(FP). 41! Walnut St.. Statesville 28677 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: I. The Continuing Medical Education Programs of 
the Bowman Gray. Duke and UNC Schools of Medicine are accred- 
ited by the American Medical Association. Therefore CME pro- 
grams sponsored or co-sponsored by these schools automatically 
qualify for AMA Category 1 credit toward the AMA Physician's 
Recognition Award, and for North Carolina Medical Society 
Category "A" credit. Where AAFP credit has been requested or 
obtained, this also is indicated. 

2. The "place" and "sponsor" are indicated for a program only 
when these difler from the place and source to write "for informa- 
tion." 



102 



■liliim 



IreaUi 



PROGRAMS IN NORTH CAROLINA 
.March 5-5 

General Diagnostic Radiology Updated 

Fee: $I0<) 

Credit: 9 hours; AAFP credit applied for 

For information: Emmery C. Miller. M.D.. Associate Dean for ConJ 

tinuing Education. Bowman Gray School of Medicine 

Winston-Salem 27103 

March 6-7 

Establishing Yourself in Medical Practice — a Practice Management 

Workshop for Senior Residents 
Place: Charlotte Memorial Hospital 
For Information: David S. Citron, M.D.. or Carl B. Lyle. M.D. 

P. O. Box 2554. Charlotte 28207 

March 19-20 

Twelfth Annual F~. C. Hamblen .Symposium in Reproductive Biol-j nsS' 



ogy and Perinatal Medicine 



Program: Designed for practitioners and residents in Obstetrics ancj icCi 



Gynecology. Two basic themes: "The Effect of Metabolic Dis 
eases Upon Pregnancy" and "Teratogenicity" 

Fee: $60: no charge for residents or students 

Credit: 9 hours; AAFP credit applied lor 

For information: Charles B. Hammond. M.D,. P. O, Box 3143 
Duke University Medical Center. Durham 27710 



March 21-24 

Conference on Maternal and Child Health. Family Planning and' 

Crippled Children Services 
Fee: "Travel costs are tun available but a per diem supplement of 

$16 for registrants is provided through a grant from the Bureau ol '"m 

Community Health Services. Office of Maternal and Child 

Health" 
For Information: Continuing FAlucation, UNC School of Public 

Health, Chapel Hill 27514 

March 22-26 

Radiology of the Urinary Tract — a Tutorial Postgraduate Course 



Program: Emphasis on personalized small group tutorial type teach-j 
ing. Subject matter will cover all facets ^■l'i urinary tract disease" 
including comprehensive coverage of diagnostic techniques 

Fee: $300 

Credit: 30 hours 

For Information: Robert McLelland. M.D.. Radiology. Box 3808 
Duke University Medical Center. Durham 27710 

March 25 

Greensboro Academy of Medicine Symposium 
Jefferson Standard Country Club. Greensboro 
Program: General areas of nutrition and metabolism 
For Information: Ronald Garber. M.D.. 1904 N. Church Street 
Greensboro 27401 

March 25-26 

Medical Alumni Dav and Scientific Meetings 
Place: Berryhill Hall 

Sponsor: OtTice of Continuing Education and Alumni Affairs 
Credit: To be announced 

For Inlbrmalion: Oscar L. Sapp. 111. M.D.. Associate Dean for 
Continuing Education. LINC School of Medicine. Chapel Hill 

-■'-''I'* March 27 

Southern Regional LMtrasound Meeting 
Place: Berryhill Hall, UNC. Chapel Hill 
Spiinsors: UNC Office of Continuing Education and the .American 

Institute of Ultrasound in Medicine 
Fee: SIO 
For Information: Oscar L. Sapp. Ill, M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 



Vol. 37. No. 2 



iPii 

llW 



:«al 

Si) 



lliSi 



MSOP 

.ten 
N( 
•jilei 
■ill: I 
ilnlii 
(mill 
liJH 



»il 



rJl: 
li(c 
(oilii 



alua 
d!: 



Ifiisl 



ke:( 



!(infii 



tit 

ulufi 

t«li 
ISM 

»lnli 



a:( 
'I* 
alil: 



iBlUj 



March 29-30 

bstetrics and Gynecology Postgraduate Course 
je: $35 

redit: 9 hours: AAFP credit applied tor 

or information: Hmery C. Miller. M.D.. Associate Dean for Con- 
tinuing Education. Bouman Grav School of Medicine. 
Winston-Salem 27103 

March 31 

iflammatory Bowel Disease — The Challenge of Diagnosis and 
Treatment 

xjnsors: Moore Memorial Hospital: Office of Continuing Educa- 
tion. b'NC School of Medicine 

ace: tllks" ClubtCountrv Cluhof Southern Pines). Southern Pines 
ee: SI 1.50 

redit: 2 hours: .\M.\ Category I; AAFP approved 
or Information: C. Harold Steffee, M.D.. Moore Memorial Hospi- 
tal. Pinehurst 2S374 

.\pri! 1 

Cd Wilson Memorial Hospital Symposium — Carcinoma of the Breast 
or Informatum: M. A. Pittman. Jr.. M.D.. Wilson Memorial Hos- 
pital, Wilson 27X93 

April 2-3 

inAactical Nuclear Medicine: Emphasis Oncology 
ee: $75 

'redit: 9 hours: ,AAKP credit applied for 

or Information: Emery C, Miller. M.D., Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 

April 2-4 

)ring Symposium for Radiologists: Radiology and Images of the 

Chest ' 
iiiBace: Carolina Inn. Chapel Hill 

ponsors: L'NC School of Medicine and the N. C. Chapter ol the 

American College of Radiology 
ee: NCCACR members $20: non-members $30: registration 

limited to 150 
redit: 15 hours 
or Information: Oscar L. Sapp. HI. M.D.. Associate Dean for 

Continuing Education. L NC School of Medicine. Chapel Hill 

27514 

April 9-10 
(Note change of date) 
econd .Annual .Arthritis S\mposium 
ee: $50 

:'redit: II hours: .AAFP credit applied for 
or Information: Oscar L. Sapp. III. M.D.. Associate Dean for 

Continuing Education. UNC School of Medicine. Chapel Hill 
: 27514 

April 9-10 

tactical Pediatrics 

■ee: $35 

I'redit: 9 hours; AAFP credit applied for 

■or Information: Emery C. Miller. M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 

April 22 

lew Bern Annual Medical Symposium — 1976. "Pulmonary 
Medicine" 
'lace: Ramada Inn. New Bern 

Sponsor: Craven-Pamlico-Jones County Medical Society 
'redit: 5 hours ."^.AFP credit applied for 
■or Information: Zack J. Waters. M.D.. Box KW9. New Bern 2X560 



April 23-24 

iecond Postgratuate Course in Perinatology 

■ee: $25: registration limited to 200 

'redit: S hours: AAFP credit applied for 

■or Information: Oscar L. Sapp, 111, M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine. Chapel Hill 

27514 

May 6-9 

22nd Annual Session of the North Carolina Medical Society 
'lace: Pinehurst Hotel and Country Club. Pinehurst 
■or Information: William N. Hilliard. E.xecutive Director, North 
Carolina Medical Society. Box 27167, Raleigh 27611 

May 7-9 

*ulmonary Infections in Pediatric Patients 

'lace: Quail Roost Conference Center, Rougemont 

Registration: Limited to 50 participants 

>edit: II hours: .AAFP credit applied for 

■FBRL ARI 1976. NCMJ 



For Information: Alexander Spock. M.D,, P. O. Box 2994, Duke 
University Medical Center. Durham 27710 

May 12-13 

Breath of Spring '76: Respiratory Care Symposium 

Fee: $25 

Credit: 12 hours: .AAFP credit applied for 

For Information: Emery C. Miller. M.D.. Associate Dean for Con- 
tinuing Flducation. Bowman Gray School of Medicine, 
Winston-Salem 27103 

May 27-28 
The 27th Scientific Sessions and .Annual Meeting of the North 

Carolina Heart Association 
Place: Benton Convention Center and the Wmston-Salem Hyatt 

House, Winston-Salem 
Sponsors: The North Carolina Chapter of the .American College of 

Cardiology vmII be one of the co-sponsors of the sessions, and will 

hold Its sessions, which are open to all physicians, on May 28. 

Special concurrent sessions will be held for nurses, emergency 

medical technicians, and cardiology technologists 
For Information: Thomas R. Griggs. M.D.. North Carolina Heart 

Association. P. O. Box 2408, Chapel Hill 27514 

1TP:MS of SPECIAL INTEREST 

Continuing Education for Nurses 
The following courses are being offered through the School of 
Nursing, UNC-Chapel Hill, during the Spring 1976 session: 
March 3 Intravenous Therapy Complications. Monitor- 

ing, and Surveillance 
March 4-5 .A Practical Approach to Drug Interactions 

March 9-10 Family Centered Maternity Care (F.C.M.C.) 
March 22-26 Planning Education for Quality Care (This pro- 
gram will be repeated on .April 12-16) 
March 23-24 Management by Objectives 
.April 5-9 Practical .Approaches to Diabetic Care 

.April 20-21 Primary Nursing 

April 26-30 Nursing Process 

April 29 Toward More Effective Diabetic Teaching 

May 25-26 Results-Oriented Perlormance-Evaluation 

James M. Johnston .Awards are available to help with tuition. Credit 
will be offered for each course. .All of Ine courses listed above will 
be held in Carnngton Hall. School of Nursing, UNC-CH. 
For additional information write: Continuing Education Program. 
School of Nursing, University of North Carolina. Chapel Hill 275 14 

PROGRAMS IN CONTlGLOl S STATES 
March 11-13 

Gynecologic Endocrinology 

Sponsor: The Department of Obstetrics and Gynecology. Univer- 
sity of Tennessee Center For The Health Sciences. Memphis. 
Tennessee 

Place: Hilton Inn — Memphis Airport 

For Information: James R. Givens. M.D.. 800 Madison .Avenue. 
Memphis. Tennessee 38163 

March 25-26 

29th .Annual Stoneburner Lecture Series — Neurology for Primary 
Care Physicians 

Sponsors: Department of Neurology and Department of Continuing 
Medical Education 

Fee: $105 

Credit: 1 1-'4 hours: AM.A Category I; AAFP credit applied for 

For Information: Department of Continuing Education. School of 
Medicine. Medical College of Vircmia. P.O. Box 91 . Richmond. 
Virginia 23298 

May 3-5 

The 1976 Southeast Emergency Medicine Congress 

Place: Fairmont Colony Square Hotel. .Atlanta. Georgia 

Sponsors: The Southeast Chapters of the .American College of 
Emergency Physicians. School of Medicine Medical College of 
Georgia (sic), and in conjunction with the F^mergency Depart- 
ment Nurses Association 

Fees: $100 (ACEP). $125 (Non-ACEP Physician). $40 (EDNA), $50 
(Non-EDNA Nurse). $40 (Registered FMT). $50 (Non- 
Registered EMF). $25 (Residents. Interns. Medical &. Nursing 
Students with Letter from department chief), $100 (EMS Ad- 
ministrators with letter on EMS System stationery), $125 
(Others). 

For Information: Registrar. 1976 Southeast Emergency Medicine 
Congress. 1919 Beachwav Road. Suite 5C. Jacksonville, Florida 
32207 



103 



May 10-13 

The Frontiers in Cardiology 

Place: Royal Coach Motor Hotel, Atlanta, Georgia 

Sponsors: Council on Clinical Cardiology, American Heart Associ- 
ation; Department ot Medicine. Emory University School of 
Medicine in cooperation with the Georgia Heart Association 

Fee: ACC members $125; non-members $175 

Credit: AMA Category 1 

For Information: Miss Mary Anne Mclnemy, Director, Depart- 
ment of Continuing Education Programs. American College of 
Cardiology, %50 Rockville Pike, Bethesda, Maryland 20014 

May 21-22 

Clinical Rheumatology for the Practicing Physician 

Place: Bonhomme Richard Inn, 500 Merrimac Trail, Route 143, 

Williamsburg, Virginia 
SpKinsors: Virginia Chapter of The Arthritis Foundation; Virginia 
Regional Medical Program; Medical College of Virginia — 
Virginia Commonwealth University; University of Virginia 
School of Medicine; Eastern Virginia Medical School 
Fee: $25 

Credit: 8'4 hours; AMA Category I; AAFP credit applied for 
For Information: Department of Continuing Education, School of 
Medicine, Medical College of Virginia. P.O. Box 91, Richmond, 
Virginia 23298 

Medical College of Virginia 

The number in parenthesis, following the title, indicates the 
number of hours for that particular course. 



Neonatology for the Practicing Physician (4) 
29th Annual Stoneburner Lecture Series — 
Neurology for Prinary Care Physicians (12) 
Pediatric Cardiology for the Practicing Physi- 
cian (4) 

Medico-Legal Workshop (5) 
(Place: Virginia Baptist Hospital, Lynchburg, 
Virginia) 

EEG Symposium (14) 

Annual Spring Forum for Child Psychiatry (4) 
Pediatric Nephrology for Practicing Physicians 
(4) 
For further information on the above CME opportunities write to 
the Department of Continuing Education, School of Medicine, 
Medical College of Virginia, Box 91, Richmond, Virginia 2329K 



March 18 
March 25- 
March 26 
April 1 

April 22 



May 17-18 
May 21 
June 2 



The items listed in this column are for the six months immediately 
following the month of publication. Requests for listing should be 
received by WHAT' WHEN'' WHERE^ P.O. Box 15249, 
Durham, N.C. 27704, by the 10th of the month prior to the month in 
which they are to appear. A "Request for Listing" form is available 
on request. 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



Dr. Rene Dubos, author and professor emeritus of 
Rockefeller University, expressed optimism that the 
world can reverse the doomsday forecast of starvation 
during a speech, "Science and Ideals in a Hungry 
World" at ajoint meeting of the Auxiliary and AMA in 
Atlantic City. 

Two immediate problems are the acidic rain and the 
significantly cooler climate. Norway and Sweden 
have reported malfunctions in fish caused by oxides in 
the fogs from Great Britain, France and Germany 
along with decreased ability of crops to engage in 
photosynthesis. The cooler temperature of the past 
three years simulates the "little ice age" of 17th Cen- 
tury Central Europe and means that large areas of 
Canada and China cannot continue to produce the 
same kinds of crops. 



104 



However, Dr. Dubos is optimistic because histor 
ically mankind does not stand placid before events am 
forewarned can control his destiny with scientific in 
vestigation and subsequent production. 

"Today we are still using the same species of plants 
animals and techniques of 2.000 years ago. Al 
growth — including human — is modified. Much of th< 
deficit in food production comes from bad social struc 
ture with land ownership preventing effective agricul 
tore. 

"India a few years ago was self sufficient; then tht 
government shifted its priority to heavy industry am 
hunger resulted. One of today's miracles is that main 
land China is not only self sufficient but is exporting 
rice and has California rice growers worried." 

Man's adaptability is shown in his changing fooc 
habits. After World War I Dr. Dubos' home village ir 
France was dismayed to receive from the U.S. a gift o 
com which they had always considered food only foi 
pigs. Today this section of France is a big com pro 
ducer. 

Already the efforts of human intervention have pro 
duced results in the environmental movement witJ 
once polluted rivers and lakes such as the Thames ir 
England and Lake Washington in Washington state 
again teeming with fish. 

In conclusion Dr. Dubos warns, "You in your tun 
must take a stand to manipulate public opinion. This ; 
will do if I have any strength left in me the few years I 
have left. It can be done if you elect to do it." 



News Notes from the— 
DUKE UNIVERSITY MEDICAL CENTER 



Alpha Omega Alpha, honor medical society, ha 
tapped new members. 

The newly elected members from the class of 197' 
include Steven P. Honickman, Richard Klausner 
David Ling, Michael K. Magill, Gary R. Moellef 
Peter K. Smith, Linda C. Terry and Neil W. Trasl 
III. 

Those chosen from the graduating class were Car 
E. Arentzen, Barbara Blaylock, David D. Collins 
Eric H. Conn, Barbara J. Grain, Arnold M. Epstein 
Paul G. Galentine, James R. Gavin, III, John Mar- 
quardt, David Schlossman, Diana J. Schultz, Bemarc 
P. Scoggins, Robert B. Stanley Jr. and Robert E 
Ziegler. 

Dr. J. David Robertson was elected from the facult5| 
and Drs. John Tindall and Charles Styron were hon- 
ored as alumni selections. 

Robertson is chairman of the Department o 
Anatomy and is widely published in the field of mem- 
brane biology. 

Tindall is professor of medicine in the Division o: 
Dermatology and also widely published in his disci- 
pline. 

Styron is in private practice in Raleigh and has beei 

Vol. 37. No. 2 



TR 

f 
10 

K 
01 



,® Each capsule contains 50 mg. 
of Dyrenium* (triamterene, SK&F) 
and 25 mg. of hydrochlorothiazide. 



uaaux. 

_ _ Trademark 

MAKES SENSE 

TRIAMTERENE CONSERVES POTASSIUM 
WHILE HYDROCHLOROTHIAZIDE 
LOWERS BLOOD PRESSURE 

FOR LONG-TERM CONTROL 

OF HYPERTENSION^ serum K+ and BUN should be checked periodicaUy. (See Warnings Section.; 




Before prescribing, see complete prescribing in- 
formation in SK&F literature or PDR The fol- 
lowing is a brief summary. 



Warning 

This fixed combination drug is not indi- 
cated for initial therapy of edema or hyper- 
tension. Edema or n/pertension requires 
therapy titrated to the individual patient. If 
the fixed combination represents the dosage 
so determined, its use may be more convenient 
in patient management. The treatment of 
hypertension and edema is not static, but 
must be reevaluated as conditions in each 
patient warrant. 



* Indications: Edema. That associated with con- 
gestive heart failure, cirrhosis of the liver, the 
nephrotic syndrome; steroid-induced and idio- 
pathic edema; edema resistant to other diuretic 
therapy. Mild to moderate hypertension. Useful- 
ness of the triamterene component is limited to 
its potassium-sparing effect. 

Contraindications: Pre-existing elevated serum 
potassium. Hypersensitivity to either component. 
Continued use in progressive renal or nepatic 
dysfunction or developing hyperkalemia. 
Warnings: Do not use dietary potassium supple- 
ments or potassium salts unless hypokalemia 
develops or dietary potassium intake is markedly 
impaired. Enteric-coated potassium salts may 
cause small bowei stenosis with or without 
ulceration. Hyperkalemia (>5.4 mEq/L) has 



been reported in 4% of patients under 60 years. 
in 12% of patients over 60 years, and in less than 
8% of patients overall. Rarely, cases have been 
associated with cardiac irregularities. Accord- 
ingl\', check serum potassium during therapy, 
particularly in patients with suspected or con- 
firmed renal insufficiency {e.g.. elderly or dia- 
betics). If hyperkalemia develops, substitute a 
thiazide alone, [f spironolactone is used con- 
comitantly with 'Dyazide'. check serum potas- 
sium frequently —both can cause potassium 
retention and sometimes hyperkalemia. Two 
deaths have been reported in patients on such 
combined therapy {in one. recommended dosage 
was exceeded; in the other, serum electrolytes 
were not properly monitored). Observe patients 
on "Dyazide" regularly for possible blood 
dyscrasias, liver damage or other idiosyncratic 
reactions- Blood dyscrasias have been reported 
in patients receiving Dyrenium (triamterene, 
SK>SiF). Rarely, leukopenia, thrombocytopenia, 
agranulocytosis, and aplastic anemia have been 
reported with the thiazides. Watch for signs of 
impending, coma in acutely ill cirrhotics. Thia- 
zides are reported to cross the placental barrier 
and appear in breast milk This may result in 
fetal or neonatal hyperbilirubinemia, thrombo- 
cytopenia, altered carbohydrate metabolism and 
possibly other adverse reactions that have oc- 
curred in the adult. When used durin g preg nanc y 
or in women who mi g ht bear children , weigh 
potential benefits against possible hazards to 
fetus. 
Precautions: Do periodic serum electrolyte and 



BUN determinations. Do periodic hematologic 
studies in cirrhotics with splenomegaly. Anti- 
hypertensive effects may be enhanced in post- 
sympathectomy patients. The following may 
occur: hyperuricemia and gout, reversible nitrogen 
retention, decreasing alkali reserve with possible 
metabolic acidosis, hyperglycemia and glycosuria 
(diabetic insulin requirements may be altered), 
digitalis intoxication (in hypokalemia). Use 
cautiously in surgical patients. Concomitant use 
with antihypertensive agents may result in an 
additive hypotensive effect. "Dyazide' interferes 
with fluorescent measurement of qumidine. 
Adverse Reactions: Muscle cramps, weakness, 
dizziness, headache, dry mouth; anaphylaxis; 
rash, urticaria, photosensitivity, purpura, other 
dermatological conditions; nausea and vomiting 
(may indicate electrolyte imbalance), diarrhea, 
constipation, other gastrointestinal disturbances. 
Necrotizing vasculitis, paresthesias, icterus, 
pancreatitis, xanthopsia and, rarely, allergic 
pneumonitis have occurred with thiazides alone. 
Supplied: Bottles of 100 capsules; in Single Unit 
Packages of 100 (intended for institutional use 
only). 

SK&F Co., Carolina, P.R. 00630 

Subsidiary of SmithKlme Corporation 



Effectiveness across 
the spectrum of most 
common forms 
of insomnia 



Tl 



IfflM 



Awake too long, awake too often, 
awake too early. . . 

These are the most common forms of insomnia, 
and may occur singly or in any combination. 
The night of troubled sleep depicted here 
comprises all three types. As the night 
progresses from left to right, each 
sleep stage is identifiable by its own 
shade of gray. Blue represents "Awake!' 



t0 

sete 



As you can see, this hypothetical "patient" 
takes well over an hour to fall asleep, awakens 
several times during the middle of the night 
and awakens too earl\- in the morning. 



Sleep Stages 




Awake v,..«J .Slace ? 






RFM bI 


H Stage 3 






Stage 1 H 


H Stage 4 




Awake too long 




Awake too often during the night 



The insomnias most often 
occurring in young and older adults 

For patients u'ith trouble falling asleep 
(common in young adult insomnia patients), 
Dalmane (flurazepam HCI) 30 mg provides sleep 
within 17 minutes, on a\'erage. For those with 
trouble sta\ing asleep or sleeping long 
enough (common in those over 50), Dalmane 
offers increased total sleep time with fewer 
nocturnal awakenings. These clinical results 
were demonstrated in studies conducted in 
four geographically separated sleep 
research laboratories.'"^ 



The relative safety of Dalmane 
(flurazepam HCI) is well documented 

Dalmane (flurazepam HCI) is relatively safe 
and well tolerated: morning "hang-over" has 
been infrequent. The usual adult dosage is 30 
mg: in elderly or debilitated patients, limit 
initial dosage to 15 mg to preclude over- 
sedation, dizziness or ataxia. Caution patients 
about possible combined effects with 
alcohol and other CNS depressants. 



Hours 




Broad-Spectrum 
medication for the 
mpst common forms 
ofinsomnia 

Dalmane 

(flurazepam HCI) 

One 30-mg capsule h.s.— usual adult dosage 

( 1 5 mg may suttice in some patients). 
One 15-mg capsule h.s.— initial dosage for 
elderly or debilitated patients. 

D induces sleep rapidly 

□ reduces nighttime awakenings 

n lengthens total sleep time 




<^ 




l^fSWfTi « <?!^3j» 



Awake too early 



Please see following page for a 

summary of complete product information. 



Broad-spectrum medication for 
the most common forms of insomnia 

Dalmane 

(flurazepamHCI) 



(S 



areei 



teH( 
4f«i 



iliose 

fc50 

iorv 




Objectively proved in the 

sleep research laboratory, 

Dalmane 

n induces sleep within 
17 minutes, on average 

n reduces nighttime 
awakenings 

n provides 7 to 8 hours 
sleep, on average, with- 
out repeating dosage 

Before prescribing Dalmane (flurazepam 
HCl), please consult complete product 
information, a summary of which follows: 
Indications: Effective in all types of insomnia 
characterized by difficulty in falling asleep, 
frequent nocturnal awakenings and/or early 
morning awakening, inpatients with recurring 
insomnia or poor sleeping habits; and in 
acute or chronic medical situations requirmg 
restful sleep. Since insomnia is often transient 
and intermittent, prolonged administration is 
generally not necessary or recommended. 
Contraindications: Known hypersensitivity 
tu llura/.epam HCl. 

Warnings: Caution patients about possible 
combmed effects uith alcohol and other 
CNS depressants. Caution against hazardous 
occupations requiring complete mental alert- 
ness (e-g., operating machinery, driving). 
Use in women \\ ho are or ma\' become preg- 
nant onh' u hen potential beneiits have been 
weighed against possible hazards. Not 



recommended for use in persons under 15 
vears of age. Though physical and psycho- 
logical dependence ha\ e not been reported 
on recommended doses, use caution in 
administering to addiction-prone individuals 
or those who might increase dosage 
Precautions: In elderly and debilitated, initial 
dosage should be limited to 15 mg to preclude 
o\ersedation. dizziness and/or ataxia. II 
combined with other drugs having hypnotic 
or CNS-depressant effects, consider potential 
additive effects. Employ usual precautions 
in patients who are severely depressed, or 
with latent depression or suicidal tendencies. 
Periodic blood counts and liver and kidney 
function tests are advised during repeated 
therap\'. Observe usual precautions in 
presence of impaired renal or hepatic function. 
Adverse Reactions: Dizziness, drowsiness, 
lightheadedness, staggering, ataxia and 
falling have occurred, particularly in elderly 
or debilitated patients. Severe sedation, 
lethargv, disorientation and coma, probably 
indicative of drug intolerance or overdosage, 
ha\e been reported. Also reported were 
headache, heartburn, upset stomach, nausea, 
vomiting, diarrhea, constipation, Gl pain, 
nervousness, talkativeness, apprehension, 
irritability weakness, palpitations, chest 
pains, body and joint pains and GU com- 
plaints. There have also been rare occurrences 
of leukopenia, granulocytopenia, sweating, 
flushes, difficulty in focusing, blurred 
vision, burning eyes, faintness, hypotension, 
shortness of breath, pruritus, skin rash, dry 
mouth, bitter taste, excessive salivation, 
anorexia, euphoria, depression, slurred 
speech, confusion, restlessness, hallucina- 
tions, and elevated SCOT, SGPT, total and 
direct bilirubins and alkaline phosphatase. 
Paradoxical reactions, e.g., excitement. 



stimulation and hyperactivity ha\e also 
been reported in rare instances. 
Dosage: Individualize for maximum benefi 
effect. Adults: 30 mg usual dosage: 15 mg 
mav suffice in some patients. Elderly or 
debilitalcd patients: 15 mg initially until 
response is determined. 
Supplied: Capsules containing 15 mgor 
30 mg llurazepam HCl 



REFERENCES: 

1. Karacan I, Williams RL, Smith JR: The 
sleep laboratory in the investigation of 
sleep and sleep disturbances. Scientilic 
exhibit at the 124th annual meeting ol the 
American Psvchiatric Association, 
Washington DC, May 3-7, 1971 

2. Frost JD Jr: A svstem for automatically 
analvzing sleep. Scientific exhibit at the 
24th Clinical Convention of the American 
Medical Association, Boston, Nov 29- 
Dec 2, 1970; and at the 42nd annual 
scientific meeting of the Aerospace Medica 
Association, Houston, Apr 26-29, 1971 

3. Vogel GW: Data on file. Medical 
Department, Hoffmann-La Roche Inc., 
Nutley NJ 

4. Dement WC: Data on file. Medical 
Department, Hollmann-l.a Roche Inc., 
Nutlev NJ 



■jBir! 



lOL 



Line 



:iip 

'k 

:m 

it 

t 

Sil 

■;e 



..'^•^" 




ROCHE LABORATORIES 
Division of Hoffmann-La Rocfie Inc 
Nulley, New Jersey 071 10 



;tive in both ci\ ic and medical societies thnnighout 
IS career" as well as maintaining a special interest and 
icpertise on the subject of diabetes mellitus. 



While a search is under uay for a neu director oi' 
aike Hospitals, an assistant vice president is ser\ ing 
> director pro tern. 

John D. Shytle, assistant vice president to Dr. Wil- 
am G. Aniyan. vice president for health affairs, will 
II the post until a successor to Dr. Stuart M . Sessoms 
. chosen. 

Sessoms. director since 1968. resigned to become 
;nior vice president of Blue Cross and Blue Shield of 
lorth Carolina the first of the year. 

Shytle is a former controller of the Veterans Ad- 
linistration in Washington, serving in that position 
om l%3-72. The Shelby native was director of the 
'A Hospital in Richmond immediately prior to com- 
ig to Duke in the fall of 1974. 

Duke hospitals include Duke University Hospital in 
>urham. Highland Hospital in .'\she\ille and Sea 
~ J2vel Hospital in Carteret County. 



11 F 



Fred L. Winsor has been named administrator of 

ighland Hospital, according to Dr. Jack W. Boner. 
' [1. medical director. Winsor succeeds James Carter, 
ow assistant director at Duke Hospital. 

A native of Oneonta. N.Y.. Winsor received his 
I. A. degree at Duke, served two years with the U.S. 
larine Corps, and then returned to complete a two 
ear program in hospital administration at Duke. 

He began his health career as assistant adminis- 
-ator of Southeastern General Hospital in Lumberton 
jr two years, then served as administrative director 
f Presbyterian Hospital in Knoxville. Tenn.. for over 
ight years. He was executive director of McNabb 
'enter also in Knoxville and had been administrator 
f Sibley Memorial Hospital in Washington. D.C. 
ince May. 1973. 



/ 



News Notes from the — 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



Dr. Marvin B. Sussman. former Selah Chamberlain 
rofessor of sociology and director of the Institute on 
le Family and Bureaucratic Society at Case Western 
Leserve University, has been appointed professor of 
ociology at the Bowman Gray School of Medicine. 

His appointment is in the medical school's Depart- 
lent of Medical Social Sciences and Marital Health. 
i An internationally recognized sociologist. Dr. 
iussman's fields of special interest include family 
lieory and research; sociology of medicine; sociology 



of rehabilitation and human service systems; and 
gerontology. 

He is a past president of the Groves Conference on 
Marriage and the Family, and now serves that organi- 
zation as a memberofthe executive board. He also is a 
past president of the Ohio Council on Family Rela- 
tions and the Society for the Study of Social Problems. 

Presently a member of the council of the Section on 
Social Psychology of the American Sociological As- 
sociation, he has twice served the ASA as chairman of 
the Family Section and round table seminars for the 
annual meeting. 

Most recently, Sussman was co-director for the 
1975 International Workshop on Changing Sex Roles 
in Family and Society, and a section chairman for the 
fourth International Conference on the Linity of the 
Sciences. 

Dr. Sussman is a graduate of New York University, 
and received the M.S. degree from George 'Williams 
College. He also holds the M.A. and Ph.D. degrees in 
sociology from Yale University, and has completed 
postgraduate study at the University of Chicago. 



Other recent appointments to the Bowman Gray 
faculty include Dr. David W. Gelfand. associate pro- 
fessor of radiology (gastrointestinal); Louisa P. 
Branscomb. instructor in biomedical communica- 
tions; Dr. James P. Caldwell, instructor in medicine; 
and Peggy Wills, instructor in community medicine 
(Allied Health Sciences). 

Appointed to the school's part-time faculty were 
Dr. Amon L. Funderburk, clinical instructor in 
medicine (endocrinology); Dr. George E. Hamilton 
Jr., clinical assistant professor of psychiatry; Dr. 
Leroy Barden Lamm, clinical associate professor of 
psychiatry; and Dr. Thomas GardinerThurston. clini- 
cal instructor in radiology (nuclear medicine). 



Dr. R. F. Smith Jr.. pastor of the First Baptist 
Church in Hickory, has been elected chairman of the 
Medical Center Joint Administrative Board of the 
medical school and North Carolina Baptist Hospital. 

He succeeds Francis E. Garvin of Wilkesboro. 

The joint administrative board was formed in early 
1974 to provide a better means of coordinating the 
work of Baptist Hospital and the Bowman Gray 
School of Medicine. The board consists of trustees of 
Wake Forest University and the hospital and a 
member of the medical center professional staff. It is 
responsible for the overall supervision of the medical 
center. 

Smith was appointed to the Wake Forest Board of 
Trustees in 1974. He is a member of that board's 
Executive Committee and is chairman of its Student 
Life Committee. 

He also is a member of the Board of Trustees of 
Southeastern Baptist Theological Seminary and is 
chairman of that board's Long-Range Planning Steer- 
ing Committee. 



IHRL A,R>, I^Th. NC \l,l 



109 



Dr. Harold O. Goodman, professor of medical ge- 
netics, has been named associate dean for biomedical 
graduate studies at Bowman Gray. The graduate 
studies program offers course work leading to the 
M.S. and Ph.D. degrees in anatomy, biochemistry, 
comparative and experimental pathology, microbiol- 
ogy and immunology, pharmacology and physiology. 



Dr. James C. Leist has been appointed assistant 
dean for continuing education at Bowman Gray. 
Leist. an instructor in community medicine, is deputy 
director of the Northwest Area Health Education 
Center Program in North Carolina. 

The memory of Dr. Robert A. Moore, a pioneer 
orthopedic surgeon in Forsyth County, was honored 
during a full day of activities at Bowman Gray in 
December. Dr. Moore died in 1970. 

Dr. Moore, who retired in 1964 after 45 years of 
orthopedic practice in Winston-Salem and 23 years of 
service to the Medical Center, was one of the 12 char- 
ter members of the medical school's private Diagnos- 
tic Clinic and was, for seven years, director of Section 
on Orthopedics. 

Scientific sessions and the dedication of a room at 
the medical center in memory of Dr. Moore high- 
lighted the day. 

Dr. Frank C. Greiss Jr., professor and chairman of 



the Department of Obstetrics and Gynecology 
Bowman Gray, has been elected president-elect of th 
Southern Gynecological and Obstetrical Association 

He will be installed as president in Nov. 1976, atth 
Society's Annual meeting in New Orleans. 

D. Ted George and John Mustol, third-year sti 
dents at Bowman Gray, have been awarded Medic; 
Assistance programs-Reader's Digest Internation; 
Fellowships. The program provides three-month a; 
signments to rural mission hospitals in remote parts c 
the world. 



leraei 



Dr. I 

iorosu 



Dr. Eben Alexander Jr., professor of neurosurgeni 
has been elected second vice president of the Amen 
can College of Surgeons. He has been re-appointed t in 
the Interspecialty Council of the American Medicj 
Association as a representative from the America 
Association of Neurological Surgeons 

Dr. William A. Brady, instructor in neurology, ha 
been appointed Stroke Work-Up chairman of th 
North Carolina Heart Association. 

Dr. Courtland H. Davis Jr., professor c 
neurosurgery, has been elected chairman of the Medi 
cal Care Evaluation (Audit) Committee of the Pied 
mont Medical Foundation, Inc 

Dr. Frederick W. Glass, assistant professor c|« 
surgery, has been appointed to the Undergraduati 

jlici 
mi 

sib' 



A unique hospital specializinfi in treatment of 

ALCOHOLISM 
DRUG ADDICTION 



In this restful setting away from pressures 
and free from distractions, the Wlllingway 
staff, with understanding and compassion, 
carries out an intensive program of 
therapy based on honesty and responsi- 
bility. The concepts and methods are ori- 
ginal, different and have been highly suc- 
cessful for fifteen years. 

John Mooney, Jr , M D , Director 
Dorothy R Mooney, Associate Director 



vX^«XlX*«cp%vaLM^ yr^^^fy^Xa*^ 



311 JONES MILL RD., STATESBORO. GA. 30458 TEL. (912) 764-6236 

IHIHBHHHHaHBHH^HHH ACCREDITEDBYTHE J.C. A.H. 

110 Vor. 37. 




yica 



CO 



m 



No. 



Inns 



(TTt 



1 



ducation Committee of the American College of 
mergency Physicians for a three-year period. 

Dr. Donald M. Hayes, professor and chairman of 
le Department of Community Medicine, has been 
.'lected as a charter member of the Health Systems 
gency for Region G. the 13-county sector which 
icludes Forsyth County. 

Dr. David L. Kelly Jr.. associate professor of 
;urosurgery. has been elected to membership in the 
..cademy of Neurological Surgery. 



Dr. Richard C. Proctor, professor and chairman of 
r?ei|ie Department of Psychiatry, has been elected to 
iDii lembership in the Academy of Psychosomatic 
ItJiledicine. 

Dr. C. Glenn Sawyer, professor of medicine, has 
:ricieen elected vice president of the Forsyth County 
ledical Society. 



CONTROLLED THERAPEUTIC TRIAL OF 

CORTICOSTEROIDS IN FULMINANT 

HEP,4TIC FAILURE 

When hepatic decompensation supervenes in viral 
epatitis and drug-induced hepatitis and is sufficiently 
;vere to produce hepatic coma, the patient's prog- 
osis becomes one of the poorest in present day 
ledicine. Estimates of case fatality rate in this situa- 
lon range from 60 to 97 percent. This level of fatality is 
articularly frustrating because complete recovery is 
ossible if the patient survives the immediate injury. 



It is not surprising that for such patients the clinician 
quickly adopts any measure reputed to be of benbfit. 
Since the 1950s, hydrocortisone (corticosteroids) has 
been used in fulminant hepatic failure with varying 
results. If you were to poll different physicians 
throughout the country, you would probably come up 
with 50 percent who use corticosteroids always in 
hepatic failure and another 50 percent or thereabouts 
who do not use it because of the increased risk to the 
patient. Because there have been no controlled 
therapeutic trials in the use of corticosteroids in this 
situation, the Committee on Hepatic Failure of the 
American Association for the Study of Liver Diseases 
has begun a controlled therapeutic trial on the use of 
corticosteroids in fulminant hepatic failure from viral 
or drug-induced liver disease. Approximately 20 cen- 
ters are participating, allowing for a larger number of 
subjects to be studied and thereby obtaining signifi- 
cant results more quickly. One of those centers w ill be 
The University of North Carolina School of Medicine 
under the direction of Dr. Henry R. Lesesne. Patients 
who are referred to our institution will be randomly 
given corticosteroid therapy or placebo therapy when 
hepatic coma has supervened in the process of viral or 
drug-induced liver disease within 6 weeks of onset and 
after complete informed consent has been obtained 
from the nearest relative. 

Physicians are requested to refer these patients to 
Dr. Henry R. Lesesne. Department of Medicine. 
North Carolina Memorial Hospital, Chapel Hill, 
North Carolina 27514; or a phone call may be made on 
a WATS line— 800-672-8271. 



Month in 
Washington 



The public interest would be better served if the 

'[lation examined the goals of a national health insur- 

.'ince program within the context of the existing health 

' ;are system and directed its energies toward the per- 

ection of that system, the American Medical Associa- 

ion said in testimony before a subcommittee of the 

House Interstate and Foreign Commerce Commil- 

ee. 

"It is unnecessary to gamble on a whole new medi- 
;al health system in order to meet the health care 
needs of all Americans. "" AMA president Max H. 
Parrott told the Public Health and Environment Sub- 
;ommittee. 

Pointing to the large problems invoKed in creating a 
national health insurance program. Dr. Parrott. a Port- 
land. Ore., practitioner, said that public attitudes to- 
I ward it are changing steadily. 



"These problems have been brought into better 
focus as a result of evidence of the effects of gov- 
emmentally administered and controlled programs 
both here and abroad. 

"Our national priorities have also shifted because of 
the effects of the changing economy, and the devastat- 
ing effects of inflation on all segments of our society. 

"Significant changes have taken place in our health 
system through increased manpower programs, in- 
creased facilities construction, increased levels of pri- 
vate health insurance coverage, and a variety of other 
programs. There is fuller realization and acknow- 
ledgment that this country's health system — under 
attack by many in the course of the NHI debate — is 
indeed superiortoany other in the world." Dr. Parrott 
said. 

Dr. Parrott told the subcommittee members of the 



February 1976. NCMJ 



III 



medical profession's national health insurance plan 
(H.R. 6222) which builds on the structure of the pres- 
ent system of employer-employee group health insur- 
ance plans, mandating each employer to provide com- 
prehensive and catastrophic benefit coverage with the 
employer picking up at least 65 percent of the cost. 

Employees, according to the AMA spokesmen, 
would not be compelled to participate. The self- 
employed as well as the non-employed could purchase 
qualified private health insurance, through pools if 
needed, at a cost not more than 125 percent of the cost 
of group plans. And, after a certain level of co- 
insurance is reached, depending upon income, the 
insurance would cover all remaining costs as a com- 
plete protection against catastrophic costs. 

Dr. Parrott pointed out that in pressing for the adop- 
tion of any particular NHl proposal, sincerity must 
not be confused with objectivity — ""We cannot afford 
to have a program of such importance fail. " 

"We must avoid the mistake inherent in those pro- 
posals which would lock medicine into a rigid, 
monolithic, no-choice bureaucratic system. Such a 
creation would be impossible to reverse. It would be 



an undertaking full of promise but empty of fulfi 
ment. Establishment of cost control through tlx( 
budgets including arbitrary fee schedules would resi 
in curtailment of care and discourage participation \ 
providers. 

'"A look at the current trouble of the British heal 
care system impels a close re-examination of the 
leged need for such drastic action, "" Dr. Parrott sai 






er 
wl 



The Senate Finance Committee also approved wi 
few changes Medicare Amendments adopted earli 
by the House. The major one assures that no preva 
ing Medicare fee for this fiscal year is less than for tl 
previous fiscal year. An unintended effect of the ne 
law tying physicians" Medicare reimbursement in wit 
acost-of-living-type index was to roll back some fee 
HEW didn't want to do anything about it. but tl 
House at the urging of the AMA and other group 
agreed to prevent the rollback. 

The Senate Committee added language to t\ 
House provision to indicate that in calculating th 
controversial fee index HEW should include to th 



Kan 



jther 



ireas 
fall 



tev 
ffiie 



ieve 




Facility, program and environment 

allows ttie individual to maintain 

or regain respect and recover with 
dignity. 





Medical examination upon admis- 
sion. 




FELLOWSHIP HALL 

THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

TREATMENT AND LEARNING CENTER FOR ALCOHOL RELATED PROBLEMS 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit Tax-Exempt 
• A Controlled and Pleasant Psychological Atmosphere • Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



Individual counseling 

Group Therapy 

Nature Trail 

Indoor Outdoor Recreation 



FOR ADMITTANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



Recognized by: 

Jlue Cross S Blue Shield • Life Assurance Co of Carolina 

• Pilot Life Ins Co • Aetna Lite & Casualty 

• Jofin Hancock Mutual Life Ins Co • Kemper Ins, 

Metropolitan Life ins. Co • United Benefit Life Ins Co 

• Security Lite & Trust Co 

FELLOWSHIP HALL mc 

p. BOX 6928 • GREENSBORO, N. C. 27405 



Member of: 

• N C Hospital Association 

The Alcotiohc & Drug Problemi 

Assn ot Nortri America 

' Anencan Hospital Association 



FOR tVIEDICAL INFORMATION C 
J W WELBORN, JR , M,D 
MEDICAL DIRECTOR 
919-275-6328 



Modern, motel-hke accommodations 
with private bath and individual 
temperature control. 



Located off U.S. Hwy. No. 29 at Hicone Road Exit 
6V2 miles north of downtown Greensboro, N, C. 



Convenient to 1-85, 1-40, U.S. 421, U.S. 220. 
and the Greensboro Regional Airport. 

FELLOWSHIP HAIL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 



Vol. 37, No. 



'4i 

tf, 



Ike 



extent feasible "factors related to any increases in 
costs of malpractice insurance and that index calcula- 
resi tions should be prepared on a regional rather than a 
national basis."" 
The other Medicare changes include: 
**A one-year extension of authority to grant waiv- 
ers of nursing staff requirements in rural areas 
where nurses are in short supply. The House had 
approved a three-year extention. 
**Repeal of a present provision which would make 
the Federal Employees Health Program rather 
than Medicare the primary payer of benefits for 
••al older or retired U.S. workers. The amendment 
iofti specifies that Medicare be the primary payer for 

fit people eligible for both programs. 

«i 

■'« * * * 

Physicians in some larger states containing more 

llthan one Professional Standards Review Organization 

Ij area may have a chance to choose a single, statewide 

tl plan under legislation approved by the Senate Finance 

Committee. Texas. Louisiana and possibly some 

other states would qualifv'. the Health. Education and 

Welfare Department said. 

The amendment by Sen. Lloyd Bensten (D-Texas) 
applies to states that have been divided into PSRO 
areas, and w here no conditional PSROs have yet been 
designated. The HEW Department would poll the 
physicians in the areas to determine their preference 
for a local or a state-wide PSRO. If a majority of 
physicians in each area approve the state-wide plan, 
the verdict would have to be accepted b\ HEW. 

The Texas Medical Association and other state 
societies, as well as the AMA. have fought for the 
rights of larger states to become single PSRO areas. 
but the HEW Department turned dow n the appeals on 
grounds PSROs were intended to be primarily local. 
As a result, large population states were divided into 
several PSRO areas. 



The Medical Liability Commission has urged Con- 
gress not to employ National Health Insurance as a 
vehicle for forcing a federal solution to the profes- 
sional liability problem. 

Gale Richardson. M.D.. a member of the Liability 
Commission, told the House Ways and Means Sub- 
committee on Health that the causes of the liability 
crisis "vary in kind and in relative emphasis from state 
to state. This is one reason that the remedies should be 
sought within the individual states."" 

"We are particularly opposed to linking of this prob- 
lem in any way with national health insurance."" said 
Dr. Richardson. 

The Commission is composed of 20 national medi- 
cal specialty and institutional provider groups, includ- 
ing the AMA. the American Hospital Association and 
major specialty associations. 

Dr. Richardson noted that there have been sugges- 
tions that under NHI the government pay the liability 
premium for physicians who accept assignment. He 
cited speculation that physicians may be willing to 
accept government control of medicine in return for 
having the burden of liability premiums lifted. 

"We do not believe that limiting the rights of pa- 
tients or the rights of any class of citizens is a proper 
approach to the solution of this problem — nor do we 
beheve that granting by Congress of immunity to 
physicians or any other group at any time is a proper 
approach."" Dr. Richardson declared. 

Dr. Richardson said "both the immediate and 
longer range remedies can be more responsive to the 
needs of all concerned if approached at the most prac- 
tical local level — state legislatures when legislative 
remedies are required."" 

Dr. Richardson said the liability problem should be 
corrected by innovative changes which should be 
evolutionary and not revolutionary. 

"We strongly oppose those who believe that the 
answer to the weaknesses in our system is a controlled 
economy and a gov ernment w hich is more important 
than those it governs."" he asserted. 



Book Review 



CORRECTION: 

Review of Medical Microbioloijy. 1 Ith edition, was 
reviewed in the March. 1975. issue oi' the Joiinuil. We 
inadvertently listed this as a CRC Press publication, 
when credit should have been given to Lange Medical 
Publications. Los Altos, California. 

The Journal regrets the error. 



Febrl \r> 1976. NCMJ 



113 



In mpmoriam 



Edmund S. Boice, M.D. 

Dr. Boice was born in 1X83 in the mountains of 
western North CaroHna. grew up in Abingdon. Vir- 
ginia, received his B.A. degree from Washington and 
Lee in 1905 and his M.D. from the University of 
Pennsylvania in 1909. He was president of his class in 
medicine and is a "Distinguished Senior Alumnus of 
the University of Pennsylvania School of Medicine." 

He interned at Union Memorial Hospital in Balti- 
more from 1909to 1910. For the next four years he was 
on the surgical staff of the Johnston-Willis Hospital in 
Richmond and instructing in anatomy, pathology and 
surgery at the Medical College of Virginia. 

He became the first surgeon at Park View Hospital 



in 1914 and was joined by Dr. B. C. Willis in 1915. The 
partnership formed by these two grew to a clinic of 
specialists now numbering 12. 

Dr. Boice was a diplomate of the American Board of 
Surgeons, a Fellow of the American College of Sur- 
geons, president of the Seaboard Medical Society, a 
charter member of the Edgecombe-Nash Medical So- 
ciety and director of the Edgecombe-Nash Cancer 
Center from 1948 until 1970. 

Most of all, he was a great human being, respected 
and loved by all of us who had the privilege of knowing 
him. 

The Edgecombe-Nash Medical Society 



. 



TRANSCO, sole North Carolina dealer for Rolls-Royce Motor Car, 
invites you to an adventure in England. 




ROLLS 



ROYCE 



Special arrangements have been made with Rolls-Royce, Lt 
to enable a select few to visit their factories in England ai 
see the world's ultimate motor car being built. 
You'll tour the Rolls-Royce assembly plant in Crewe, En 
land, where skilled craftsmen contribute the patience ar 
refinement that makes Rolls-Royce the best car in the world. 
You'll also visit H. J. Mulliner — Park Ward in Londo 
where centuries-old coachbuilding techniques are still us< 
to build special Rolls-Royce bodies. 
Arrangements have also been made for you to visit Loij 
Montague's famed antique car collection at his family homj 
Beaulieu, as well as places of historic interest. 
Departing April 22 for London, you will spend seven days 
England. While in London, accommodations will be at tl 
Savoy. Bookings are now being accepted. Further inform;, 
tion regarding this unique opportunity is available from : 



TRANSCO, INC. 

1800 N. Main Street 
High Point, North Carolina 27262 
Telephone: (919)882-9647 
(919)288-7581 — Evenings 



For literature and test drive, contact Geof Eade, General Manager 
Travel and accommodations through Lucas Travel Agency 



114 



Vol . 37. No. 2 



Classified Ads 



ASSOCIATE INTKRMST WANTED— Resort arta in Wtstirn 
North Carolina. (Juaranteed salary first M-ar: $30, (KM) plus percen- 
tage: thereafter, increased income leadin)> to partnership. Profes- 
sional t orporation «ith fringe benefits. Excellent otllce facilities 
located near ne» modern hospital. Write: NCM.I-J, P. O. Box 
27167, Raleigh, N.C. 27611. 

DIKE PHYSICIAN'S ASSOCIATE STl DENT graduating May 
I'*76 seeks position in Eastern N.C. Background and training in 
Internal Medicine and Eamily Practice. Call Collect (919) 286-3031 
e>enlngs, or write Miss T. Gardner, 506 Elf St.. #16. Durham, 
N.C. 27705. 

STAEE PSYCHIATRISTS, located in Piedmont N,C., young mental 
health stall ser>ing 1X0,000 residents in three county area. No 
restrictions on pri\ate practice after hours, (iood fringe benefits. 
Contact Larry Parrish, Area Director, Tri County Mental Health 
Complex, 165 Mahalev Avenue, Salisbury, N,C. 28144. Telephone 
collect (704) 633-3616. 



OEFICE SPACE EOR RENT: 1300 sq. ft. Erdman building in front 
of Pardee Hospital. F^xcellent parking facilities. Former tenant 



after two years had to take t«o associates and needed more footage. 
Contact: 704-692-2115 or 704-692-2321. 



PH\ SICIANS ASSOCIATE— Duke (Iraduate— Strong background 
in pediatrics and surgery. Interested in relocating to Central or 
Eastern North C arolina. Reply to: NCM,I-10. P. O. Box 27167. 
Raleigh, N. C. 27611. 

EMERGENCE MEDICINE: Northeastern North Carolina: four, 
12-hour e\ening rotations per week Paid malpractice, \acation, 
professional dues. $45,000 annual remuneration. C<mtact Drs. 
Cooper or Spurgeon loll free 1-800-325-3982. 

PHYSICIANS NEEDED: M.D.'s with completed internships or resi- 
dencies for hospital clinics flight surgeon duties — worldwide 
placement a\ailable! Relocation fees paid, 30 days paid vacation 
each year. 40 hour work week. Ccmtact Daye Powell. Na\y Medical 
Representative. Nayy Recruiting District, P.O. Box 18568, Ra- 
leigh, N.C. 27609. Call Collect: 782-2005. 



TUCKER HOSPITAL, Inc. 



212 West Franklin Street 
Richmond. Virginia 



A private ho.-pilal tor iliagiio?!- and IfeatiiKMit oi p>vcliialri(' and 
nriindcigical diMir(ltM>. Hospital and out-patient ^er\ ices. 

(Visiting hours 2:00 p.m. -8:00 p.m. daily) 



James .Asa Shilld, MU. 
James Asa Shield. Jr., MI). 
Graenum R. ScHif 1-, M.D. 



Weir M. Tucker. M.D. 

CiEORGE S. FCLTZ, JR., M.D. 

Caeherine T, Ra>', M.D. 



\\IELI\.\I D. Kl RXOOEE, M,D, 



Ekbrl XR-i 147(1. N(. \1.| 



115 



Index to 
Advertisers 



Burroughs Wellcome Company 84 

Crumpton. J. L. and J. Slade. Inc 79 

Fellowship Hall 112 

Golden-Brabham Insurance Agency 64 

Lilly. Eli & Company Cover 1 

Mallinckrodt. Inc 82. 83 

Mandala Center 80 

Merck Sharp & Dohme 68. 69. 70 

Mutual of Omaha 71 

Pharmaceutical Manufacturers Association . . .72. 73 
Robins, A. H. Company 75. 76. 77 



Roche Laboratories Cover 2. 63. 106, 107, 

108. Cover 3. Cover 4 
Roerig. A Division of Pfizer 

Pharmaceuticals 67. 100. 101 

Smith Kline & French 105 

Transco. Inc 1 14 

Tucker Hospital 115 

United States Air Force 65 

United States Navy 81 

Willingway, Inc 110 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company 116 



WINCHESTER 

"CAROLIISAS' HOUSE OF SERVICE" 

Winchester Surgical Supply Company 

200 South Torrence St. Charlotte, N. C. 28204 
Phone No. 704-372-2240 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N. C. 27401 
Phone No. 919-272-5655 

Serving the MEDICAL PROFESSIO^ of ^ORTH CAROLINA 
and SOUTH CAROLI^A since 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N. C. State Medical Society Meeting since 1921, and 
advertised CONTIM'OUSLY in the N. C. Journal since January 1940 issue. 



116 



Vol. 37. No. 



10-day Bactrim therapy 
outperforms 10-day ampicillin therapy 



^>^>^ 



--V--'- 



v^^ 




In a multicenter, double- 
blind study of patients with 
chronic orfrequently recurrent 
urinary tract infection, Bactrim 1 0- 
day therapy outperformed ampi- 
cillin 10-day therapy by 27.2%, 
when comparing patients 
who maintained clear cultures 
for eight weeks. Criterion for "clear culture" was 
1000 or fewer organisms/ ml of urine. 

While adverse reactions were mild {e.g.. nausea, 
rash), more serious reactions can occur with these 
drugs. See manufacturers' product information 
forcomplete listing, 

Wo;e, Bactrim single strength tablets were used in these clinical 
trials. However, studies have established the bioequivalency of 
Bactrim DS with the single strength tablets 



"Bactrim DS 

60 mgtrimethoprim and 800 mg sulfamethoxazole) 

ciouble strength tablets 
Just 1 tablet B.I.D. 



Bactrim 

(80 mg trimethoprim and 400 mg sulfamethoxazole) 

2 tablets B.LD. 

For chronic or frequently recurrent c> stitis 
and p\ elonephritis due to susceptible organisms. 



Before prescribing, please consult complete product information, a 
summary of which follows: 

Indications: Chronic urinary tract infections evidenced by persistent 
bacteriuria (symptomatic or asymptomatic), frequently recurrent infec- 
tions (relapse or reinfection), or infections associated with urinary 
tract complications, such as obstruction. Primarily for cystitis, pyelo- 
nephritis or pyelitis due to susceptible strains of E. coli, Klebsiella- 
Enterooacter, Proteus mirabilis, Proteus vulgaris and Proteus 
morganii. 

W07f.- The increasing frequency of resistant organisms limits the use- 
fulness of antibacterials, especially in these urinary tract infections. 
The recommended quantitative disc susceptibility method {Federal 
Register. 37:20527-20529, 1972) may be used to estimate bacterial 
susceptibility to Bactrim, A laboratory report of "Susceptible to tri- 
methoprim-sulfamethoxazole" indicatesan infection likely to respond 
to Bactrim therapy. If infection is confined to the urine, "Intermedi- 
ate susceptibility" also indicates a likely response, "Resistant" indi- 
cates that response is unlikely. 

Contraindications: Hypersensitivity to trimethoprim or sulfonamides; 
pregnancy; nursing mothers- 
Warnings: Deaths from hypersensitivity reactions, agranulocytosis, 
aplastic anemia and other blood dyscrasias have been associated 
with sulfonamides. Experience with trimethoprim is much more 
limited but occasional interference with hematopoiesis has been re- 
ported as well as an increased incidence of thrombopenia with pur- 
pura in elderly patients on certain diuretics, primarily thiazides. 
Sore throat, fever, pallor, purpura or jaundice may be early signs of 
serious blood disorders. Frequent CBC's are recommended; therapy 
should be discontinued if a significantly reduced count of any formed 
blood element is noted. Data are insufficient to recommend use in in- 
fants and children under 12. 

Precautions: Use cautiously in patients with impaired renal or hepatic 
function, possible folate deficiency, severe allergy or bronchial 
asthma. In patients with glucose-6-phosphate dehydrogenase defi- 
ciency, hemolysis, frequently dose-related, may occur. During ther- 
apy, maintain adequate fluid intake and perform frequent urinalyses, 
with careful microscopic examination, and renal function tests, par- 
ticularly where there is impaired renal function. 

Adverse Reactions: All major reactions to sulfonamides and trimeth- 
oprim are included, even if not reported with Bactrim, Blood dys- 
crasias: Agranulocytosis, aplastic anemia, megaloblastic anemia, 
thrombopenia, leukopenia, hemolytic anemia, purpura, hypopro- 
thrombinemiaand methemoglobinemia. /4/;erg/creac(/ons; erythema 
multiforme, Stevens-Johnson syndrome, generalized skin eruptions. 



epidermal necrolysis, urticaria, serum sickness, pruritus, exfolia- 
tive dermatitis, anaphylactoid reactions, periorbital edema, con- 
junctival and scleral injection, photosensitization, arthralgia and 
allergic myocarditis. Gastrointestinal reactions: Glossitis, stomati- 
tis, nausea, emesis, abdominal pains, hepatitis, diarrhea and pan- 
creatitis. CNS reactions: Headache, peripheral neuritis, mental de- 
pression, convulsions, ataxia, hallucinations, tinnitus, vertigo, in- 
somnia, apathy, fatigue, muscle weakness and nervousness. Miscel- 
laneous reactions: Drug fever, chills, toxic nephrosis with oliguria 
and anuria, periarteritis nodosa and L, E, phenomenon. Due to cer- 
tain chemical similarities to some goitrogens, diuretics (acetazola- 
mide, thiazides) and oral hypoglycemic agents, sulfonamides have 
caused rare instances of goiter production, diuresis and hypoglyce- 
mia in patients; cross-sensitivity with these agents may exist. In 
rats, long-term therapy with sulfonamides has produced thyroid 
malignancies. 

Dosage: Not recommended for children under 12. Usual adult dos- 
age: 1 DS tablet (double strength), 2 tablets (single strength) or 
4 teasp, (20 ml) b,i.d, for 10-14 days. 

For patients with renal impairment: 



Creatinine 
Clearance (ml/m 


in) 


Recommended 
Dosage Regimen 


Above 30 




Usual standard regimen 


15-30 




1 DS tablet (double strength), 

2 tablets (single strength) 

or 4 teasp, (20 ml) every 24 hours 


Below 15 




Use not recommended 



Supplied: Double Strength (DS) tablets, each containing 160 mg tri- 
methoprim and 800 mg sulfamethoxazole, bottles of 100; Tel-E-Dose® 
packages of 100, Tablets, each containing 80 mg trimethoprim and 
400 mg sulfamethoxazole — bottles of 100 and 500; Tel-E-Dose® 
packages of 100; Prescription Paks of 40, available singly and in 
trays of 10. 

Oral suspension, containing in each teaspoonful (5 ml) the equiva- 
lent of 40 mg trimethoprim and 200 mg sulfamethoxazole; fruit- 
licorice flavored — bottles of 16 oz (1 pint). 



<nftf«iir\. '^°^'^'^ '- 
ROCHE > Division 
/ Nutley, I 



Laboratories 
of Hoffmann-La Roche Inc. 
New Jersey 07110 



In a multicenter study of patients with chronic or frequenth' recurrent urinary- tract infections 

Bactrim was 27.2% more 

effective tlian ampicillin in 

keeping patients 

infection-free for 8 weeks. 



% of patients infection-free at 8 weeks 



Bactrim 
70.5% of 
78 patients 



ampicillin 

55.4% of 
74 patients 



1 1 1 1 1 1 1 1 r— 

%0 10 20 30 40 50 60 70 80 90 

*This percentage is arrived at by the statistical mettiod of 
dividing ttie difference between Bactrim and ampicillin results 
(15.1 %) by tfie percent of ampicillin results (55,4%) 

tData on file, Hoffmann-La Rocfie Inc., Nutley, N.J. 071 10 




Bactrirri DS Bactrirri 



(160 mg trimetfioprim and 800 mg suifametfioxazoie) 

double strength tablets 
Just 1 tablet B.I.D. 



Please see summary of product information 
on preceding page. 



(80 mg trimethoprim and 400 mg sulfametfioxazoie) 

2 tablets B.I.D. 



<^OCHE 



NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: High Mortality in North Carolina, Kathryn B. Surles, M.Ed., and Charles J. Rothwell, M.B.A., M.S.; Pseu- 
domembranous Colitis Following Clindamycin Therapy, Robert D. Stratton, M.D., James L Lapis, M.D., and Eugene M. 
Bozymski, M.D.; Benign Strictures of the Anus and the Rectum, Harold F. Hamit, M.D., F.A.C.S. 









BECOTIN® 

Vitamin B Complex 




BECOTIN^ with VITAMIN C 

Vitamin B Complex with Vitamin C 




BECOTIN = -T 

Vitamin B Complex with Vitamm C. Ttierapeutic 




MI-CEBRIN® 

Vitamins-Minerals 




MI-CEBRIN T® 

Vitamin-Minerals Therapeutic 






AND A WIDE VARIETY OF OTHER PHARMACEUTICALS 1 






-IDdista 


DISTA PRODUCTS COMPANY H 
Division of Eli Lilly and Company ^| 
Indianapolis, Indiana 46206 H 


1 






400944 ^H 


1976 
Mc 


ANNUAL SESSIONS 
y 6-9— Pinehurst 




1976 Committee Conclave 
Sept. 22-26— Southern Pines 



Both often 




Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints which are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adiunctively in skeletal muscle 
spasm due to reflex spasm to loc? pathol- 
ogy, spasticity caused by upper motor 



' 



Predominant 
• psychoneurotic 
anxiety 



Associated 

• depressive 

symptoms 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 
therapy). 

Contraindicated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



orders, possibility of increase in frequency 
and/ or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 



respond to r^^ 



According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feehngs, part of the problem 
may sound hke depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two. although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 




Wium;(g 

(diazepam) ^ 

2-mg,5-mg, lO-mg scored tabids 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to habituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
skin rash, ataxia, constipation, headache, 
incontinence, changes in salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug. Iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 



<„„„,,.\ Roche L 
ROCHE) 0-s,on 



Laboratories 
of Hoffmann-La Roche Inc. 
New Jersey 07110 



TO tne 

full-fledged physician 

whose practice needs 

new perspective. 



Look into fiir Force 
fierospace Medicine. 

Aerospace Medicine is nothing new to 
us — but it's something you're not likely 
to encounter in your civilian practice. As 
an Air Force Flight Surgeon, you will 
have atruly general practice on the 
ground.whileintheairyouwillflywith 
and observe aircrew members — adding 
a new perspective to your medical career 
The Air Force gives you the respect of 
your profession and the prestige of an 
Air Force officer. In addition to the 
numerous benefits of an Air Force career, 
you will also have the opportunity to com- 

Mail the coupon below forall the information. 

Name 




p^te with other 
physicians for an 
outstanding educa- 
tion program. It's the 
way to pull your entire 
life into perspective — time 
for your family, time foryour- 
;: self, and time to advance in your 

profession. 

Examine your opportunities now 



Or write for more information. 




AIR FORCE. Health Care At Its Best. 



310 New Bern Ave,, Rm, 
Raleigh, N.C. 27611 
Call: 919/755-4134 



303 



Social Security No, 



Address 

City 

State 

Specialty 



Zip 



Phone 



No.3 
As potent as the pain it relieves. 



e.3. the pain of 
surgical convalescence 




M 



HOT TOO LITTLE 

■ as potent as the pain you need to relieve in patients 
with fractures, sprains, strains, wounds, contusions, 
and the pain of surgical convalescence 

■ unlike acetaminophen/codeine combinations, it 
does not sacrifice anti-inflammatory action 

NOT TOO MUCH 

■ potent— yet not excessive ■ addiction liability low 



NOT TOO EXPENSIVE 

■ brand-name quality yet reasonable m cost 

■ readily available in both hospital and local pharmacies 

(^ CONVENIENCE 

■ telephone Rx in most states, up to 5 refills in 

6 months at your discretion (where state law permits) 



EMPIRIN COMPOUND 
WITH CODEiNE NO. 3 

codeine phosphate' (32 4 mg) gr '■? 

Each tablet also contains aspiringrSlJ, phenacetin gr 2':., caffeine gr '^ 'Warning- may be habit-form mg 



ft 

Wellcome 



Burroughs Wellcome Co. 

Research Triangle Park 
North Carolina 27709 



John H. Felts, M.D, 
Winston-Salem 

EDITOR 

John S. Rhodes, M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Milliard 
Raleigh 

BUSINESS MANAGER 



EDITORIAL BOARD 

Charles W. Styron, M.D. 
Raleigh 

CHAIRMAN 

George Johnson, Jr., M.D. 
Chapel Hill 

Robert W. Prichard, M.D, 
Winston-Salem 

Rose Pully, M.D. 
Kinston 

John S. Rhodes, M.D. 
Raleigh 

Louis Shaffner, M.D. 
Winston-Salem 

Robert E. Whalen, M.D. 
Durham 



NORTH CAROLINA MEDICAL JOURNAL. 300 S. 
Hawthorne Rd., Winston-Salem. N. C. 27103. is owned 
and published by The North Carohna Medical Society 
under the direction ol its Editorial Board, Copyright 
The North Carolina Medical Society 1975. Address 
manuscripts and communicalions regarding editorial 
matter to this Wmslon-Salem address. Questions relat- 
ing to subscription rates, advertising, etc.. should be 
addressed to the Business Manager. Box 27167. 
Raleigh. N. C, 2761 1 , All advertisements are accepted 
subject to the approval ol'a screening committee olthe 
state Medical Journal Advertising Bureau. 711 South 
Blvd.. Oak Park. Illinois 60302 and;or by a Committee 
ol the Editorial Board ot the North Carolina Medical 
Journal in respect to strictly local advenising. Instruc- 
tions to authors appear in the January and July issues. 
Annual Subscription. $10.00. Single copies. SI. 00. Pub- 
lication oltlce: Edwards & Broughton Co.. P. (J. Box 
27286. Ralei3h, N.C. 2761 1 . Secimd-clas.t poslat:r paid 
alKaleish. Norlli Carolina 2761 1 . 



NORTH CAROLINA 
MEDICAL JOURNAL 

Published Monthly as the Official Organ of 

The North Carolina 

Medical Society 

March 1976, Vol. 37, No. 3 



Original Articles 

High Mortality in North Carolina 135 

Kathryn B. Surles, M.Ed., and Charles J. Rothwell, 
M.B.A., M.S. 

Pseudomembranous Colitis Following Clindamycin Therapy 1 4 1 

Robert D, Stratton, M,D,, James L. Lapis, M.D,, and 
Eugene M. Bozymski, M.D. 

Benign Strictures of the Anus and the Rectum 144 

Harold F. Hamit, M.D., F.A.C.S. 



Editorials 

High Mortality in North Carolina 149 

The Nineteenth Hole 149 



Committees & Organizations 
The North Carolina Medical Care Commission 



Bulletin Board 

New Members of the State Society 

What? When? Where? 

News Notes from the Bowman Gray School of Medicine 
of Wake Forest University 

News Notes from the University of North Carolina 
Division of Health Affairs 

News Notes from the Duke University Medical Center . . 

Alpha Epsilon Delta 

North Carolina Academy of Family Physicians 

Piedmont Ob-Gyn Society 



150 



151 
151 

154 

155 

156 1 
158 

158 
158 i 



Month in Washington 159 



In Memoriam 163 



Program 165 



Classified Ads 171 



1 Index to Advertisers 

Contents listed in Current Contents/Clinical Practice 



172 



Of all menthols : 



Nobody^ 
lower dian 



Cailton 




Look at the latest U.S. Government 

figures for other menthols 

that call themselves low in t^u; 



tar nicotine, 
mg/cig mg/cig 



* Av per cigarette by FTC mettiod 



Warning: The Surgeon General Has Determined 
That Cigarette Smoking Is Dangerous to Your Health. 




Brand DCMenthol] 13 1.0 

Brand KM [Menthol} 13 0.7 

Brand T [Menthol] 11 6 

Brand V [Menthol} 11 0.7 

Carlton Menthol — 

•2 mg. tar, 0.2 mg. nicotine. 

Carlton 70s (lowest ot all brandsj- ^^ ^^^^ ^^ 

= 1 mg, tar 0.1 mg. nicotine "^^[^trfr^^^^ ^m-^ Carlton 

Menthol 
2mg.- 
newly 
reduced. 

Menthol. 2 mg. "tar", 0.2 mg. nicotme av. per cigarette, by FTC method. 





>"^ 




Testing in Humans: 
Who,Wheni & When. 



^he weight of ethical opinion: 

Few would disagree that the efFective- 
less and safety of any therapeutic agent 
Dr device must be determined through 
linical research. 

But now the practice of cHnical re- 
search is under appraisal by Congress, the 
3ress and the general public. Who shall 
[administer it.' On whom are the products 
|to be tested? Under what circumstances? 
\.nd how shall results be evaluated and 
jtilized? 

The Pharmaceutical Manufacturers 
Association represents iirms that are sig- 
Inificantly engaged in the discovery and 
development ot new medicines, medical 
devices and diagnostic products. Clinical 
Iresearch is essential to their eftbrts. Con- 
sequently, PMA formulated positions 
Iwhich it submitted on July 1 1, 1975, to 
Ithe Subcommittee on Health of the Sen- 
ate Labor and Public Welfare Committee, 
las its official policy recommendations. 
iHere are the essentials of PM As current 
[thinking in this vital area. 

l.PMA supports the mandate and 
[mission of the National Commission tor 
Ithe Protection of Human Subjects of 
iBiomedical and Behavioral Research and 
loffers to establish a special committee 
[composed of experts of appropriate 
Idisciplines familiar with the industry's 
[research methodology to volunteer its 
Iservice to the Commission. 

2* PMA supports the formation of an 
I independent, expert, broadly based and 
Irepresentative panel to assess the current 
I state of drug innovation and the impact 
I upon it of existing laws, regulations and 
[procedures. 

3«When FDA proposes regulations, 
I it should prepare and publish in the Fed- 
eral Register a detailed statement assess- 
I ing the impact of those regulations on 
[drug and device innovation. 

4«PJMA proposes that an appropri- 
ately qualified medical organization be 
encouraged to undertake a comprehen- 
sive study of the optimum roles and 
responsibilities of the sponsor and physi- 
cian when company-sponsored clinical 
research is performed by independent 
clinical investicators. 



5» PMA recognizes that the physician- 
investigator has, and should have, the 
ultimate responsibility for deciding the 
substance and form of the inlormed con- 
sent to be obtained. However, PMA 
recommends that the sponsor of the ex- 
periment aid the investigator in dis- 
charging this impottant responsibility by 
providing ( 1 ) a document detailing the 
investigator's responsibilities under FDA 
regulations with regard to patient consent, 
and ( 2) a written description of the 
relevant facts about the investigational 
item to be studied, in comprehensible 
la\- language. 

€».In the case of children, the sponsor 
must require that informed consent be 
obtained from a legally appropriate rep- 
resentative of the participant. Voluntary 
consent of an older child, who may be 
capable of understanding, in addition to 
that of a parent, guardian or other legally 
responsible person, is advisable. Safety of 
the drug or device shall have been assessed 
in adult populations prior to use in 
children. 

7»PMA endorses the general prin- 
ciple that, in the case of the mentally 
infirm, consent should be sought from 
both an understanding subject and from 
a parent or guardian, or in their absence, 
anotlier legally responsible person. 

8. Pharmaceutical manufacturers 
sponsoring in\estigations in prisons must 
take all reasonable care to assure that the 
facilities and personnel used in the con- 
duct of the investigations are suitable tor 
the protection of participants, and for the 
avoidance of coercion, with a respect for 
basic humanitarian principles. 

9* Sponsors intending to conduct non- 
therapeutic clinical trials through the 
participation of employee volunteers 
should expand the membetship and scope 
of Its existing Medical Research Commit- 
tee, or establish such an internal Medical 
Research Committee, with responsibility 
to approve the consent forms of all 
volunteers, designs, protocols and the 
scope of the trial. The Committee should 
also bear responsibility to ensure tuU 
compliance with all procedures intended 
to protect employee volunteers' rights. 

lO.Where the sponsor obtains medi- 
cal information or data on individuals, it 
shall be accorded the same confidential 



status as pro\'ided in codes of ethics gov- 
erning health care professionals. 

11. PMA and its member firms accept 
responsibility to aid and encourage ap- 
propriate follow-up of human subjects 
who have received investigational prod- 
ucts that cause latent toxicity in animals 
or, during their use in clinical investiga- 
tion, are found to cause unexpected and 
serious adverse effects. 

IZ.PMA supports the exploration 
and development by its member compa- 
n ies of more sysrematic surveillance pro- 
cedures for newly marketed products. 

13.\^'hen a pharmaceutical manu- 
facturer concludes, on the basis of early 
clinical trials of a basic new agent, that a 
new drug application is likely to be sub- 
mitted, a proposed development plan 
accompanied by a summar)' of existing 
data, would be submitted to the FDA. 
Following a review of this submission, 
the FDA, and its Advisoty Committee 
where appropriate, would meet with the 
sponsor to discuss the development plan. 
No formal FDA approval should be re- 
quired at this stage. Rather, the emphasis 
should be on identification of potential 
problems and questions for the sponsor's 
further study and resolution as the pro- 
gram develops. 

The PMA believes that health profes- 
sionals as well as the public at large 
should be made aware of these 13 points 
in its Policy on Clinical Research. For 
these recommendations envisage con- 
structive, cooperative action by industry, 
research institutions, the health profes- 
sions and government to encourage crea- 
tive and workable responses to issues 
involved in the clinical investigation of 
new products. 

Pharmaceutical Manufacturers 

Association 
«l 1155 Fifteenth Street, N.W 
■• Washington, D. C. 20005 




North Carblina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy — 
75 percent — 25 percent Co-Insurance 


PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 
60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$206.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50.00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age 60. 

'^Integrates with Medicare at age 6S. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus SO cents. 



Term Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


555 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-69 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 



The above plans quality for use in the Professional Association. 



:,v;wKSis;^SiX- 



For Full Information — Write or Call 

Golden-Brabhann Insurance Agency, Inc. 

Ralph J. Golden Van Brabham III 

108 E. Northwood St.. Phone: BRoadway 5-3400, Box 6395, Greensboro, N. C. 27405 



Ih 




4-a» •*j--wil^ 









AGoU€las§i€, 
wilhouf 
an audience. 

Enjoy a weekend of 
classic golf on a private 18- 
hole Championship course 
designed by George Cobb, 
and played by only a few in 
uncrowded leisure. 
I Why uncrowded? We 
planned it that way. Because 
Fripp Island isn't really a 
commercial resort. When we 
found Fripp. it was unspoiled, 
filled with subtropical vege- 
tation and wildlife, an expanse 
of southern beach that hadn't 
seen development, and we've 
kept it that way 

For the few who will 
come for a special visit, we've 
added amenities to part of the 



island, and left the rest alone. 
You'll find professional island 
security, tennis courts, an 
Olympic sized pool, and bi- 
cycle trails. You'll also enjoy 
activities nature alone can 
provide — crabbing, fishing, 
swimming and beachcombing 
along four and a half miles of 
sandy white beach. 

The course itself, with 
four holes bordering the 
blue Atlantic, winds through 
palmetto trees and natural 
lagoons, and offers a challenge 
to all who play it. 

Our simplified golf pack- 
age for S72.50 includes three 
days and two nights of accom- 
modations, breakfast each 
morning, two evening meals, 
unlimited golf and tennis, and 
the use of an electric golf cart. 

After golf, you may want 
to try some sight-seeing on 
your own in nearby historic 
Beaufort, or visit fine exam- 
ples of ante-bellum homes in 
Charleston or Savannah. 




Either way. a golf weekend 
at Fripp Island is a weekend for 
the golfer who enjoys more 
than his game, 

CalUSOS) 838-2131 or 
mail in the coupon below for 
more information on our 
golf packages. 




Fripp Island 






Saint Albans 
Psychiatric Hospital 



A fully accredited private 

psychiatric hospital for the 

treatment of all major 

psychiatric illnesses 

including alcoholism and 

drug abuse problems of 

adolescents and adults. 



Radford, Virginia 24141 
Telephone 703 639 2481 





■F 



IK 




Entrapped gas... 

Silent 
partner of 

GI spasm 

Painful GI spasm in the presence of entrapped 
gas causes even more pain and more discomfort. Yet, 
while spasm is relieved, entrapped gas often goes 
untreated. 

Not so when you prescribe Sidonna. Sidorma 
helps release entrapped gas with specially activated 
simethicone, a nonsystemic antiflatulent, while also 
helping to relieve spasm with a traditional combina- 
tion of belladonna alkaloids. And Sidonna provides 
mild sedation with butabarbital. 

Sidonna. The therapeutic partnership approach 
to functional or organic GI disturbances including 
spastic colon, irritable bowel syndrome, gastroenteri- 
tis, gastritis, peptic ulcer and nervous indigestion. 

Contraindications: hypeisensitivity to barbiturates or bella- 
donna alkaloids; glaucoma, prostatic hypertrophy, pyloric 
obstruction. Side EiTccIs: dry mouth, blurred vision, dysuria, 
skin rash, constipation or drowsiness. Dosage: one or two tablets 
preferably before meals and at bedtime. ^^ 

Reed & Camrick/Kenilworth, N.J. 07033 [^ 

Sidonna 

Each scored tablet contains: specially activated simethicone 

25 mg., hyoscvamine sulfate 0.1037 mg.. atropine sulfate 

0.0194 mg., hvoscine hvdrobromide 0.0065 mg. ( equivalent to 

belladonna alkaloids [as bases] 0.1049 mg. ) and butabarbital 

sodium N.F. 16 mg. (Warning: may be habit forming.) 

A worldng partnership 

against the 
pain ofgas and spasm 



■3.. 



Officers 
1974-1975 



NORTH CAROLINA MEDICAL 
SOCIETY 



President James E. Davis, M.D. 

1200 Broad St., Durham 27705 

President-Elcct jEssE Caldwell, Jr., M.D. 

114 W. 3rd Ave., Gastonia 28052 

First Vice-President John L. McCain, M.D. 

Wilson Clinic, Wilson 27893 

Second Vice-President T. Reginald Harris, M.D. 

808 N. DeKalb St., Shelby 28150 

Secretary E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Durham 27710 (1976) 

Speaker Chalmers R. Carr, M.D. 

1822 Brunswick Ave., Charlotte 28207 

Vice-Speaker Henry J. Carr, Jr., M.D. 

603 Beamon St., Clinton 28328 

Past-President Frank R. Reynolds, M.D. 

1613 Dock St., Wilmington 28401 

Executive Director William N. Hilliard 

222 N. Person St.. Raleigh 2761 1 

Councilors and Vice-Councilors 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor JOSEPH A. GiLL, M.D. 

1202 Carolina Ave., Elizabeth City 27909 (1977) 

Second District J. Ben.iamin Warren, M.D. 

Box 1465, New Bern 28560 (1976) 

Vice-Councilor Charles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1976) 

Third District E. Thomas Marshburn, Jr., M.D. 

1515 Doctors Circle, Wilmington 28401 (1976) 

Vice-Councilor Edward L. Boyette. M.D. 

Chinquapin 28521 (1976) 

Fourth District Harry H. Weathers, M.D. 

Central Medical Clinic, Roanoke Rapids 27870 (1977) 

\'ice-Councilor Robert H. Shackleford. M.D. 

115 W. Main St., Mt. Olive 28365 (1977) 

Fifth District AUGUST M. Oelrich, M.D. 

Box 1169, Sanford 27330 (1978) 

Vice-Councilor Bruce B. Blackmon, M.D. 

P. O. Box 8, Buies Creek 27506 (1978) 

Si.Mh District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd., Chapel Hill 27514 (1977) 

Vice-Councilor .W. Beverly Tucker, M.D. 

Box 988, Henderson 27536 ( 1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Road, Charlotte 28207 (1978) 

Vice-Councilor J. Dewey Dorsett, Jr 

1851 E. Third St., Charlotte 28204 (1978) 

Eighth District Ernest B. Spangler, M.D. 

Drawer X3, Greensboro 27402 (1976) 

Vice-Councilor James F. Reinhardt, M.D. 

Cone Hospital, Greensboro 27402 (1976) 

Ninth District Verne H. Blackwelder, M.D. 

Box 1470, Lenoir 28645 (1976) 

Vice-Councilor Jack C. Evans, M.D. 

244 Fairview Dr., Lexington 27292 (1976) 

Tenth District Kenneth E. Cosgrove, M.D. 

510 7th Ave., W, Hendersonville 28739 (1978) 

Vice-Councilor Otis B. Michael, M.D. 

Suite 208, Doctors Bldg., Asheville 28801 ( 1978) 

128 



Section Chairmen — 1975-76 

Anesthesiology Jack H. Welch, M.E 

Physicians Quadrangle, Greenville 27834 

Derniaiolovv George W. Crane, Jr., M.E 

1200 Broad St., Durham 27705 

Family Phxsicians William W. Hedrick, M.E 

3311 N. Boulevard, Raleigh 27604 

Internal Medicine James H. Black, M.D 

1351 Durwood Dr., Charlotte 28204 

Neurology & Psychiatry Hervy W. Mead, M.D 

1900 Randolph Rd., Suite 900, Charlotte 28207 

Neurological Suriiery M. Stephen Mahaley, Jr., M.D 

394() Noltaway Rd., Durham 27707 

Obstetrics A Gynecology C. T. Daniel, Jr., M.D 

1641 Owen Dr., Fayetteville 28304 

Ophthalmology E. R. Wilkerson, Jr., M.D 

1012 Kings Drive, Charlotte 28207 

Orthopaedics Frank C. Wilson, M.D 

N. C. Memorial Hospital, Chapel Hill 27514 

Otolaryngology N. L. SPARROW, M.D 

3614 Haworth Dr., Raleigh 27609 

Pathology R. Page Hudson, M.D 

P. O. Box 2488, Chapel Hill 27514 

Pediatrics Gerard Marder, ?/f.D 

224 New Hope Rd., Gastonia 28052 

Public Health & Education J. N. MacCormack, M.D 

Box 2091, Raleigh 27602 

Radiology R. W. McCoNNELL, M.D 

1711 W. 6th Street, Greenville 27834 

Surgery ROBERT C. MoFFATT, M.D 

309 Doctors Bldg., Asheville 28801 

Urology Robert Dale Ensor, M.D 

1333 Romany Road, Charlotte 28204 
Students, Medical i 



Delegates to the American Medical Association 

James E. Davis. M.D 1200 Broad St., Durham 2770.' 

(December 31, 1976) 

John Gi asson, M.D 306 S. Gregson St., Durham 27701 

(December 31, 1976) 
Frank R. Ri;"iNOLDs, M.D. 

1613 Dock Street. Wilmington 28401 
(December 31, 1976) 
David G. Wflton, M.D. 

3535 Randolph Road, Charlotte 28211 
(December 31. 1977) 
Edgar T. Beddingfiei d, Jr.. M.D. 

Wilson Clinic, Wilson 27893 
(December 31, 1977) 

Alternates to the American Medical Association | 

I 

George G. Gilbert, M.D. 

1 Doctor's Park. Asheville 28801 

(December 31, 1976) j 

Louis deS. Shaffner, M.D. | 

Bowman Gray, Winston-Salem 27103 

(December 31, 1976) 

Jesse Caldwell. Jr.. M.D. 

114 W. 3rd Ave., Gastonia 28052; 
(December 31, 1976) 
Charles W. Styron, M.D. 

615 St. Marys St., Raleigh 276051 
(December 31, 1977) 

D. E. Ward, Jr., M.D 2604 N. Elm St., Lumberton 28358; 

(December 31, 1977) 

Vol. 37. No. 



NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 

Now Pays Up To 

$500 -4 

WEEKLY INCOME 
($2,166.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 




GUARANTEE D RENEWABLE 

You are guaranteed the privi- 
lege of renewing $300-week to 
age 70. The other $200 per week 
renewable to age 60. This is an 
exclusive and most important 
feature. 



DIRECT PERSONAL SERVICE 

Since 1939, it has been our 
privilege to administer your pro- 
gram from Durham, N. C. includ- 
ing payment of all claims! 



J. L. & J. SLADE CRUMPTON, INC. 

GENE GREER 

Office Manager 

U. Drawer 1767^Durliani. N. C. 27702, Telephone: 919 682-5497 
Underwritten by The Continental Insurance Cos. of New York 

JACK FEATHERSTON, Field Representative 

P. 0. Box 17824, Charlotte. N. C. 28211, Telephone: 704 366-9359 



North Carolina Professional Group Administrators for: 



'^.r.l^s .-.M%^/o?IS^.^c^°.^pV^.V o> Sgc^jrTE?Tl-'KS.?^H^\%o!?.TILoc7.°Tro^. g^^Ts f.Tll.^nl'^uVs 






fTlandQlo Center 



A fully accredited private multi-disciplin- 
ary psychiatric hospital, partial care and 
out-patient clinic for the acutely ill to the 
mildly distressed. Children, young people, 
adults, couples or entire families may enter 
the treatment programs. 

A modified form of the therapeutic com- 
munity, a full spectrum of treatment mo- 



dalities are used. The services consist of 
individual, couple, group and family psycho- 
therapies; sexual and marriage counseling; 
pastoral counseling; vocational guidance and 
rehabilitation; alcohol and drug counseling; 
psychological testing, chemotherapy, elec- 
trotherapy and other somatic therapy ser- 
vices. 




Blue Cross participating hospital 

JCAH Accredited 

Richard B. Boren, M.D. Glenn N. Burgess, M.D. 

Psychiatrist-in-Chief Psychiatry 

For Information Call Collect (919) 724-9236 or Write: 
741 Highland Avenue • Winston-Salem, N. C. 27101 

Towards Wholeness 



Preventive Medicine 
Makes Sense... 

Disability Income Protection Does Too! 




Just as preventive medicine can help you 
avoid disasters to your inealth. Disability Income 
Protection can help you avoid financial 
disasters. A long-term disability, for example, 
without adequate insurance protection could 
mean weeks or even years without an income. 

For this reason alone, you cannot afford 
to be without the proper protection. 

That's why we have especially designed a 
Disability Income Protection Plan for younger 
doctors. A plan of protection to help make sure 
your family continues to live in the manner to 



which they are accustomed should you become 
disabled and unable to practice medicine. 

These benefits are paid directly to you to use 
as you see fit whether you are confined in 
a hospital or recovering at home. Furthermore, 
these benefits are tax free under present 
federal income tax laws. 

If you are under 55 years of age, just fill out 
the coupon below and mail it today. Mutual of 
Omaha will provide personal service in 
furnishing all of the details. Of course, 
there is no obligation. 



I SnfRURITTtS \i\ 




Mutual 
^maha 

People ifou can count on... 

Life Insurance Affiliate: United of Omaha 

MUTUAL OF OMAHA INSURANCE COMPANY 
HOME OFFICE OMAHA, NEBRASKA 



Mutual of Omaha Insurance Company 

Dodge at 33rd Street • Omaha, Nebraska 68131 

I am interested in learning more about the program of Disability Income 
Protection available to me. 

Name 



Address 
City 



. State 



. ZIP code 



I . „_J 




It's what you do. It's what you are. It's 
what you, as a physician, strive to 
give every patient. In every way. 

Sometimes, a patient's needs 
require specialized help. When the 
need arises. Tidewater Psychiatric 
Institute stands ready to augment 
your care. 

At TPI, help takes many forms, 
through a comprehensive program of 
patient-oriented diagnostic, con- 
sultative and psychiatric treatment 
services within atherapeutic setting. 
Individually designed treatment 
programs meet the particular needs 
of both adult and adolescent patients. 
Our hospital's school allows adoles- 
cents to continue their education 
whileatTPI. Aspecial program 
exists forthe detoxification and 
rehabilitation of the individual with 
alcohol or drug-related problems. 

You are invited to investigate 
personally, by telephone orthrough 




correspondence, the avenues of 
specialized helpavailabletoyour 
patient at our facilities in Norfolk and 
Virginia Beach. 



i 



mbif 



i 



tpj 



TIDEWATER 
PSYCHIATRIC INSTITUTE 



1 701 Will-0-Wisp Dr., Va. Beach, Va. 23454 
CALL COLLECT (804) 481-1211 
1005 Hampton Blvd., Norfolk, Va. 23507 
CALL COLLECT (804) 622-2341 



iinir 



Accredited by The Joint Commission on ttie Accreditation of Hospitals. 
Approved for Blue Cross, Champus, Medicare and other health coverage. 



^ewer than 200 doctors 
i:an become Navy 
physicians this year. 

'IVre you one of them? 



If you're interested in a practice that 
:nnbines high-quality medicine with a 

unique life- 
^'v^^^l^^^ style, Navy 

medicine 
could be right 
for you. You'll 
get the 
chance to 
practice med- 
icine instead 
of paperwork. 
Practice al- 
most anywhere 
II the world. And earn between $30,000 
:d $40,000 a year 

Right now, the Navy needs General 
Radical officers, plus those specialties 
ited in the coupon. You may also receive 
Mining to become a Navy Flight Surgeon, 
Da specialist in Undersea Medicine. 




But the number of 
doctors needed is limit- 
ed For more details, fill 
in and mail the 
coupon, or call collect 
919-872-2005, and ask 
for the Medical Re- 
cruiter, David L Powell. 

Out of state call 
800-841-8000 




It pays to look into Navy Medicine. 



ro 



Commanding Officer, Navy Recruiting District, Raleigh 
Pinewood Building, P. 0. Box 18568 
1001 Navaho Drive, Raleigh, N. C. 27609 



(0M) 



STREET 
STATE 



(Please Print or Type) 
CITY 



„ZIP_ 



_PHONE_ 



MEDICAL SCHOOL 



(Area Code & No.) 



YEARGRADUATED_ 



I AM INTERESTED IN (CHECK ONE): 



_DATEOFBIRTH_ 




FLIGHT SURGEON 
UNDERSEA MEDICINE 
r MY SPECIALTY (IF ANY) IS: 

C ANESTHESIOLOGY 
D FAMILY PRACTICE 
n PSYCHIATRY 
□ INTERNAL MEDICINE 

STATUS (CHECK ONE): 

~ PRIVATE PRACTICE 
12 HOSPITAL STAFF 



Z GENERAL MEDICAL OFFICER 
J PRACTICING MY SPECIALTY 

:Z NEUROLOGY 
D RADIOLOGY 
n PATHOLOGY 
□ PEDIATRICS 



G INTERN 
n RESIDENT 



Communicating with Professionals 



Effective, two-way communication between 
physicians' offices and tlie internal 
management and operating departments of 
Blue Cross and Blue Shield of North 
Carolina is the function of our Professional 
Relations Department. 

Our eight specially trained Professional 
Relations representatives are responsible 
for personal liaison between doctors and 
their office staffs and the Plan. 



The Professional Relations Representative 
assigned to your area is listed below. Your 
representative is ready to provide Blue 
Cross and Blue Shield benefit information 
and to assist with any problems that may 
arise. Please call on your representative 
anytime. 



W 



NORTH WEST CENTRAL NORTH EAST CENTRAL NORTHEASTERN 

NORTHWESTERN REGION ^ REGION \ REGION /REGION 



WESTERN REGION 



SOUTH WEST CENTRAL REGION 




NORTHWESTERN REGION 

R. Stuart Veach 
P. O. Box 195 

Winston-Salem, N. C. 27102 
919/722-4141 

NORTH WEST CENTRAL REGION 

James D. Webb 
P. O. Box 6746 
Greensboro, N. C. 27405 
919/272-8123 

NORTH EAST CENTRAL REGION 

Larry W. Moss 
P. O. Box 27884 
Raleigh, N. C. 27611 
919/834-0376 

SOUTH WEST CENTRAL REGION 

Sam W. Pridgen 
P. O. Box 4470 
Charlotte, N. C. 28204 
704/333-5106 



SOUTHEASTERN REGION 

Hilda C. Muse 
P. O. Box 1018 
Wilmington, N. C. 28401 
919/763-4684 

SOUTH EAST CENTRAL REGION 

Walter T. O'Berry 
Drawer A 

Fayetteville, N. C. 28302 
919/483-1322 

WESTERN REGION 

Daniel P. Mclntyre 
P. O. Box 371 
Asheville, N. C. 28801 
704/ 253-6844 



Blue Cross 
Blue Shield 

of North Carolina 



fel;a 
tola' 
'tool 
bin 



fcurs 



High Mortality in North Carolina 



Kathryn B. Surles. M.Ed.,* and 
Charles J. Rothwell, M.B.A., M.S. 



A STUDY of leading causes of 
mortality in North Carolina' 
1 revealed some disturbing trends for 
the period 1960 through 1973. The 
" purpose of this paper is ( 1 ) to add 
, data from 1974 to that study and (2) 
to take a close look at geographical 
I areas of the state in which current 
/ mortality levels are high. 

STATEWIDE MORTALITY 
TRENDS SINCE 1960 

After an increase of 4.8 percent 
between 1960 and 1971. the North 
Carolina death rate increased an 
additional 4.6 percent between 1971 
» land 1972 to a level of 9. 1 deaths per 
1.000 population. This rate, the 
highest recorded in the state since 
1938.- remained unchanged in 1973. 
Even more sharply than it rose in 
1972. however, the rate dropped .*>.5 
percent in 1974 to a level of 8.6, 
the lowest since 1967. While this 
improvement is encouraging, the 
situation u ith respect to some popu- 
lation groups and to certain causes 
of death continues to evoke con- 
cern. 

Age-Specific Mortality 

Altogether, the state's death rate 
increased 3.6 percent between 1960 



"Btostalislician. Public Health Statistics Branch. Nonh 
t arotma Division of Health Services. Raleigh. North 
t arohna :760; 

tHead ol the Public Health Statistics Branch. North Car- 
olina Division ol Health SerMces. Raleigh. North Carolina 
27(10: 
Reprint requests to Mrs Surles. 



and 1974. most of the increase re- 
flecting a higher ""risk ofdeath"" due 
to North Carolina's changing age 
structure — more people at older 
high-risk ages and fewer at young 
low-risk ages. However, for young 
people ages 15-24. the rate in- 
creased 4.3 percent, from 122..^ per 
100.000 population in 1960 to 127.8 
in 1974. 

Race- and Sex-Specific Mortality 

Race differentials in North Caro- 
lina's mortality remained high in 
1974. but the gap has narrowed. 
While the white death rate in- 
creased six percent, from 7.7 per 
1.000 population in 1960 to 8.2 in 
1974. the nonwhite rate decreased 
three percent, from 10.2 to 9.9. On 
the other hand, sex differentials re- 
mained high and reductions in ex- 
cessive male mortality have not oc- 
curred. Between 1960 and 1974. the 
male death rate rose from 9.8 to 10. 1 
while the female death rate in- 
creased from 6.9 to 7.2. 

The 1974 death rates for race-sex 
groups were 9.9 for white males, 7.0 
for white females. 12.3 for nonwhite 
males and 8.5 for nonwhite females. 
These rates reflect reductions of be- 
tween 5 and 8 percent during 1974 
with each of the race-sex groups 
showing reductions in most age- 
specific rates. Exceptions were 
white females ages 20-24 and non- 



white females between the ages of 
15 and 24. 

Cause-Specific Mortality 

The most significant changes in 
North Carolina's mortality since 
1960 involve the causes of death. 
While rates for infant mortality and 
several other leading causes of 
death have been reduced, these im- 
provements have been counterbal- 
anced by deterioration with respect 
to other causes. The death rates for 
Ixith lung cancer and emphysema 
have nearly tripled and the rate for 
cirrhosis of the liver has more than 
doubled. Rates for non-medical 
causes have also risen appreciably 
— homicide by 57 percent and 
suicide by 40 percent. Before 1974. 
the rate for accidents had also in- 
creased appreciably, but improve- 
ments during the past year resulted 
in a net rate increase of only 1 1 per- 
cent since 1960. 

For North Carolinians ages 15-24, 
the rate increase of 4 percent largely 
reflects increases in non-medical 
deaths. The suicide rate for this 
group has risen 124 percent while 
the rate for homicide is up 85 per- 
cent from 1960. The death rate for 
accidents has also risen, but the 
motor vehicle death rate for these 
young people dropped 18 percent 
between 1973 and 1974. 

Coupled with the improvements 



M.ARCH lyVh, NCMJ 



135 



GENERAL MORTALITY 
NORTH CAROLINA 1972-1974 




,. „„ ..,. ^ ...„..,. ^, ,, ,.,„, j^ f^ irans!! . ; "••••=•••■1! 



r-lwssjJiraR::!!!, 



::::;\ 'X;::; iH;ii!:''''!ii:| "Ijjiiii!!!:!!;'' 
"■'■■■■ — ^ ^> ■ "'';ii!i!;i„ 



'^r^^: 



Mortality Rates 
per 1,000 Population 

D 4.58-e,12 m 9.I3-11.32 

n 8.13-3.72 m 11.33-14.63 




Resident Data 



ll:;m;:;;;i|j, ^J,ni;||H:!, — 'i '- 



1. 

! 



FIGURE 1 



already noted lor accidents were 
improvements in the rates for heart 
disease and stroke during 1974. De- 
creases in these three areas ac- 
counted lor about 80 percent of the 
total annual decline. 

Rates for several other leading 
causes of death also decreased in 
1974. but the diabetes rate rose by 
10 percent and rates for hyperten- 
sion as well as nephritis and ne- 
phrosis remained unchanged. The 
1974 rate for cancer also reflected 
negligible improvement over 1973. 

COUNTY MORTALITY LEVELS 
DURING 1972-74 

The previously cited study of 
North Carolina's mortality' in- 
volved the mapping of county death 
rates for total mortality, infant mor- 
tality and 25 specific causes of death 
for the period 1971-73. For each 
map. four levels of death rates were 
used to group counties that were 
"like each other"" with respect to 
the particular cause of death.* 

Using methods described above, 
the 1972-74 county rates for total 
mortality are depicted in Figure 1. 

'The tour levels ot dealh rates were determined by ttie death 

rate distributions such that the tollowing properties apphed: 

a) The middle two levels = x± (Mt (SO) where x the 

mean or average county death rale, M = a multiple less 

than or equal to 1.00: 

bl M IS chosen such that rates in each interval are 

homogeneous, 
c) X is the lower limit ot level three, considering level one 
the lowest rate interval and level lour the highest 

136 



Computed as average resident 
deaths per 1 .000 average popula- 
tion, these rates show a county"s 
status with respect to the actual in- 
cidence of mortality during the 
three-year period. The rates of Fig- 
ure 2. on the other hand, are age- 
race-sex-adjusted rates. Computed 
by the direct method.-' these rates 
are those which would be expected 
if the average annual age. race and 
sex composition of each county"s 
population were the same as that 
projected for the state. In other 
words, these rates are free of the 
efl'ects of age. race and sex and thus 
demonstrate a county's status with 
respect to other determinants of 
mortality. 

As shown in Figure 1. the actual 
mortality rates ranged from 4.6 per 
1 .000 population to 14.6 with higher 
rates occurring in the south central 
and northeastern portions of the 
state. To some extent, the high rates 
would appear to reflect unfavorable 
age. race and sex composition of the 
county populations; for example, 
among counties with level-four ac- 
tual rates (Figure 1). Gates. Hyde. 
Perquimans. Polk and Warren had 
level-two or level-one adjusted 
rates (Figure 2). Also, several coun- 
ties had level-three actual rates cor- 
responding to level-one adjusted 
rates. On the other hand, some 



counties with low (level-one) actual 
rates had notably higher (level- 
three) adjusted rates. This was true 
for Catawba. Craven. Cumberland 
and Onslow, indicating that low 
mortality in these counties reflected 
favorable age. race, and sex factors 
and other conditions were not so 
favorable during 1972-74. 

Altogether, adjustment for age, 
race and sex resulted in the identifi- 
cation of 17 counties where mortal- 
ity was significantly high during 
1972-74: a band of six contiguous 
south central counties extending 
from Montgomery to Columbus and 
including Bladen; a band of 10 con- 
tiguous counties extending from 
Lee in the center of the state to Tyr- 
rell on the coast; and Carteret 
County, also on the coast. These 
counties with level-four adjusted 
rates, as well as those with upper 
level-three rates, should investigate 
the determinants of their death 
rates. Although not explained by 
age, race and sex factors, high mor- 
tality may be due to other demo- 
graphic correlates, such as poverty 
or rurality. or may be due to some 
other set of local conditions which 
invite remedy. 

Cause-Specific Mortality 
in 17 Counties 

As an aid to investigating the par- 

VoL. 37, No. 3 



m 



ker 
-jiise- 



stk 
iem 

;:Jllt 
J»! 
M 

:m 
itre 

JllOt 

ilea 
fcve 
Job 



3p 
bet 



l«ll 



l«ci 



GENERAL MORTALITY 
NORTH CAROLINA 1972-1974 




f 



£!;;i,=,7;;r S' '■';'. il'^'p : 



Age-Race-Sei Adjusted 

Mortality Rates 
per 1,000 Population 

D 5.47-8.10 D 9.02-9.92 

n 8.11-9.01 m 9.93-11.04 



icular causes of death contributing 
!iO high mortality. Table 1 shows the 
;972-74 cause-specific death rates 
■adjusted) for the 17 counties iden- 
ified in Figure 2 as having overall 
jigh and unexplained mortality. 
Other counties may assess their 
;ause-specitlc mortality by consult- 
ng published data.'^ 

Heart disease was a major con- 
iributorto high mortality with all 17 
;ounties experiencing above aver- 
age rates for acute myocardial in- 
arction and/or other forms of is- 
;hemic heart disease. All but 
Beaufort and Tyrrell had higher 
han average rates for all forms of 
leart disease combined. Rates for 
)ther major cardiovascular diseases 
vere also high in many of the 17 
;ounties: the hypertension death 
"ate and the stroke death rate were 
ibove average in most counties with 
stroke mortality especially prev- 
ilent in the south central counties. 
The rate for arteriosclerosis was 
ligh in several counties but was 
ower than average in the seven 
easternmost counties. 

All 1 7 counties had above average 
Tiortality from some form of cancer. 
In 11, rates for lung cancer were 



-[■IT all causes examined, Ihe average or mean rate tor all 
(M) counties was equal to or sligtitK greater than eenain 
iliier measures ot central tendency, i e .( II the median rate 
or all too counties and 12) the mean and median rates tor 
ounties uhere mortalits was not considered signiticanlK 
ugh or low Thus, the estimates ot excessive mortality may 
)e considered slightly conservati\'e. 





FIGURE 2 

above average, with the higher rates 
occurring in Harnett and several 
eastern counties. Excessive mortal- 
ity from ovarian cancer was ob- 
served in the northeast. For all 
cancer sites combined. 14 of the 17 
counties had higher than average 
rates with highest rates occurring in 
Beaufort. Bertie and Tyrrell. 

All 17 counties also experienced 
excessive mortality from other 
causes of death with accidents, 
homicide, emphysema and cirrhosis 
of the liver the most prevalent prob- 
lems. Rates for motor vehicle acci- 
dents and homicide were notably 
high in the south central counties 
and rates for all four external causes 
of death were above average in six 
counties — Robeson. Columbus, 
Lee. Johnston, Wilson and 
Beaufort. 

In order to assess the relative im- 
pact of various causes of death in 
the 17 counties, we computed 
"synthetic rates"" which represent 
the 1972-74 adjusted mortality rates 
that each county might have ex- 
pected had it not experienced ex- 
cessive mortality from particular 
causes. In other words, while hold- 
ing the adjusted death rates for 
other causes constant, we have as- 
sumed that a county could achieve a 
particular cause-specific adjusted 
rate not exceeding the average for 
all 100 counties.*' In the case of 



Resident Data 



Montgomery, for example, we re- 
placed the excessive heart disease 
rate of 412.5 with the average 
county rate of 325.8 (see Table !). 
The county's adjusted rate with ex- 
cessive heart mortality removed is 
then 9.3 compared to its observed 
rate of 10.1. 

Results of the foregoing exercise 
are presented in Table 2 where lead- 
ing causes of death are ranked ac- 
cording to their relative contribu- 
tions to excessive mortality. A low 
rank (small number) represents a 
low synthetic rate and hence a rela- 
tively high contribution. Ties are 
assigned the average of the tied 
ranks. A blank indicates that the 
county's cause-specific mortality 
was not excessive. 

As a whole, heart disease, stroke 
and cancer (in that order) figured 
prominently in the excessive mor- 
tality experienced by most coun- 
ties. Heart disease was the leading 
contributor in 12 counties and 
stroke in the remaining five. Cancer 
was the second or third leading con- 
tributor in eight counties. 

In Figure 3, each county's ob- 
served adjusted rate is compared to 
its synthetic adjusted rates resulting 
from (a) removal of excessive heart 
disease mortality, (b) removal of 
excessive heart and stroke mortal- 
ity and (c) removal of excessive 
heart, stroke and cancer mortality. 



March 1976. NCMJ 



137 



TirLE 1 

C»USE-SPECIfIC MOCTILITY IM NORTH CABOLPJ* COUNTIES 
1172-1974 



Cajse of Death 


Average 
County Rate* 
(100 Countieo) 










BATES 


■ FOn SFVtWTEEN COOiTIES 














u 

I 

i 


-0 
c 




C 



c 




c 


i 

E 

S 


~i 


c 
u 

5 


1 
1 


c 



i 




c 
i 




■rt 
L 


c 

s 


U 
>> 


• 
3 




All Cou'-es 


9.0 


10.1 


11.0 


11.0 


10.. 1 


10. n 


10.2 


10.0 


10.2 


10.5 


10.4 


10.0 


10.1 


10.2 


10.6 


10.0 


10.4 


10.0 




Hrart OigtfB^e 


325-8 


412.5 


408.5 


379.6 


\}f..K 


14fl.7 


195.4 


380.4 


"05.7 


133.9 


312.6 


401.1 


314.8 


391.2 


421.1 


119.2 


280.6 


108. 9' 


^ 


Acute Myocardial 








































Infarctioo 


172.3 


268.1 


229.3 


180.4 


159.? 


203.9 


170.2 


220.1 


115.5 


151.1 


19S.6 


203-5 


le^i.i 


157.9 


238.9 


159.7 


106.5 


210.8 




Other Ischeflilc 








































Heart Oi5ea<;e 


121.5 


116.9 


143.7 


156.9 


161.1 


1^5.9 


128.7 


140.9 


171.3 


251.1 


121.3 


IW.O 


91.4 


176.9 


140.0 


166.3 


166.7 


162.3 


:s 


Hyperteosion 


".5 


1.5 


5.5 


11. B 


9.1 


4.4 


2.8 


13.0 


10.2 


3.2 


9.7 


5.5 


5.7 


1.3 


8.7 


10.8 


9.3 


6.0 


St'ole 


109.2 


in. 2 


169-5 


150.1 


139.9 


152.2 


135.2 


106.8 


92.6 


109.2 


136.1 


127.4 


117.2 


106.0 


133.2 


101.0 


165.3 


92.9 




A-- terio^clerosi^ 


12.7 


13.1 


8.6 


37.2 


33.4 


15.7 


7.8 


15.3 


14.6 


21.1 


21.7 


10.6 


9.0 


7.0 


5.9 


11.4 


0.0 


3.2 




Taoce^ 


I'lO.O 


142.6 


150.9 


155.8 


141.9 


126.4 


190.1 


152.9 


148.7 


111.3 


151.8 


153.6 


166.2 


136.2 


171.7 


146.0 


191.7 


161.0 




Stomach 


5.7 


e.o 


7.0 


10.9 


4.7 


1.4 


3.7 


'6.3 


8.1 


9.0 


3.9 


1.9 


6.8 


4.0 


12.6 


1-3 


3.1 


7.0 




Colon/Rectum 


15.1 


16.8 


10.7 


7.8 


18.4 


20.5 


11.7 


19.2 


20.7 


12.7 


13.8 


11.7 


14.1 


13.9 


20.5 


9-5 


23.7 


15.2 




Pancreas 


8.3 


8.7 


6.6 


7.8 


5.7 


6-9 


1.7 


7.9 


5.1 


6.6 


U.O 


8.2 


8.7 


2-3 


7.8 


2-9 


3.7 


10.6 


-:A 


Lung 


28.9 


29.3 


29.9 


27.8 


29.5 


26.5 


26.0 


31.1 


37-0 


26.8 


28.9 


38.5 


13.8 


33-9 


40.7 


32.6 


^..9 


31.9, 


,.,.f 


Female Breast 


23.1 


30.5 


33.0 


53.4 


20.3 


15.8 


21.2 


19.5 


22.5 


17.1 


29.1 


21.5 


28.2 


24.2 


21.1 


21.8 


11.7 


17.1 


.M 


Csrvi, Uteri 


6.4 


3.5 


7.0 


9." 


8.6 


2-5 


7.5 


11-3 


8.9 


6.0 


11.5 


4.0 


10.9 


9.3 


0.0 


6.0 


0.0 


8.7 


'■■■'.'(1 


Ovary 


1.0 


6.5 


3.6 


3.3 


B.3 


9.6 


8.1 


6.0 


3.7 


1.7 


5.'' 


6.9 


9.4 


13.9 


18.2 


13.7 


25.5 


6.5 




Prostate 


17.9 


22.7 


20,4 


24.4 


21. b 


16.2 


23.5 


27-2 


18.9 


18.8 


18.7 


16.1 


17.0 


8.3 


24.3 


17.3 


20.5 


16.2 


"'X 


Leuken-ia 


5.9 


_4.6 


10-3 


2.0 


8.9 


7.3 


7.9 


7-6 


6.7 


6.0 


2.0 


1.9 


1.9 


5.9 


5.6 


11.9 


6.2 


11.2 




Diabetes Mellitua 


20.1 


31.1 


19.9 


31.7 


2-1.5 


20.4 


20.6 


18.2 


26.9 


11.7 


21,4 


15.6 


14.6 


17.1 


15. B 


18. 9 


30.4 


18.1 


".i\ 


In rluenz a/Pneumonia 


28.2 


44.0 


21.4 


26. B 


27.0 


31. 8 


27.4 


19.2 


24.8 


24.4 


38.9 


26.2 


33.1 


56.1 


28.9 


28.2 


6.8 


2?-7 


;:e 


Eronchltis, 






































Emphysema/Asthma 


11.7 


10.3 


7.0 


18.8 


11.9 


14.4 


13-9 


13-3 


6.0 


13.6 


19-1 


17.1 


16.8 


12.9 


22.4 


11.0 


8.7 


10.1 


■■■'a 


Cirrhosia of Liver 


14.1 


■1.7 


?0.0 


11.6 


16.7 


10.8 


11.4 


17-8 


11.0 


17.2 


19.9 


15.1 


20.0 


7.0 


10.7 


21.9 


22.9 


16.5 


Nephritis/Neohrcsif 


4.4 


1.4 


11.6 


B.l 


<1.<1 


2.1 


8.1 


1-3 


5.2 


3.5 


8.5 


5.9 


1.0 


1.8 


3.5 


6.6 


8.2 


7.9 




Motor Vehicle 








































Accidents 


38.3 


44.7 


47.9 


52.0 


61.9 


67.8 


58.1 


40.7 


62.9 


16.5 


15.7 


38.2 


52.5 


37.2 


40.1 


26.3 


6.3 


36.8: 


■fii'i 


Al 1 Other Accidents 


34.8 


37.5 


31.5 


24. B 


41. e 


41.4 


38.5 


40.0 


48.4 


37.0 


37.0 


30.2 


49.8 


39-1 


31.1 


39.1 


77.9 


39.1; 


spkr 


Suicide 


13. 1 


9.7 


12.3 


U.O 


16.3 


7.7 


15.7 


15.6 


17.8 


14.1 


15.0 


12.5 


22.7 


13-1 


10.1 


9.1 


0.0 


9.7I 


"oricide 


12.7 


17.2 


20.4 


19.2 


25.7 


22.3 


18.9 


16.3 


12.7 


15.9 


15-7 


11.5 


16.7 


in.l 


6.3 


4.4 


0.0 


13.5; 


'!tor 


•Age-Race-5ex-Ad]u 


ted by the Oire 


ct Melh< 


d.5 T 


ie rate 


Tor AH Causes is e- 


pressed 


as dea 


the per 


1 ,000 pcpula 


ion; th 


e cause«-speclf ic rates are c 


eaths f 


!18 


100, CWO populatio 






































'iiri 



The horizontal Mne at 9.0 indicates 
the average adjusted rate observed 
for all 100 counties. 

By comparing its four death rate 
bars against the average rate, each 
county may assess the extent to 
which removal of excessive heart, 
stroke and/or cancer mortality 
might have affected the excess in its 
overall adjusted rate, in the case of 
Washington County, for example, 
removal of excessive heart mortal- 
ity alone serves to eliminate the 
county's entire excess above the 
average county rate of 9.0. Removal 
of excessive heart mortality also re- 
duces by at least one-half the overall 
excess observed for nine other 
counties. Removal of excessive 
stroke mortality substantially re- 
duces the overall excess in a num- 
ber of counties, notably Richmond, 
Bladen, Beaufort and Tyrrell, and 
removal of excessive cancer mortal- 
ity further reduces the overall ex- 

138 



cess in most counties, especially 
Beaufort. Bertie and Tyrrell. As a 
Vk-hole, however, excessive heart, 
stroke and/or cancer mortality 
could account for a county's entire 
excess only in the case of Pitt, 
Washington and Carteret. Thus, 
counties should be sensitive to 
other diseases and conditions 
contributing to high mortality. This 
is particularly true for four counties 
— Scotland, Robeson, Wilson, and 
Martin — where excessive heart, 
stroke and cancer mortality could 
account for only one-third to one- 
half of the county's overall excess 
during 1972-74. 

COMMENTS 

Statistical procedures applied to 
the 1972-74 death rates for North 
Carolina's 100 counties have re- 
sulted in the identification of 17 
counties where overall mortality 
levels were considered high after 



adjustment for the age, race and sexi 
composition of county populations 
(Figure 2). This means that un- 
favorable conditions other than age. 
race and sex distributions need to be 
identified. Additionally, Figure 1 
shows that all but one of the 17 
counties also experienced above 
average actual mortality during 
1972-74, indicating that existing 
health care resources may need to 
be evaluated. 

With respect to local conditions 
which may be contributing to high 
adjusted mortality, it is noteworthy 
that all 17 counties except Wilson 
and Pitt were predominantly rural 
in 1970 and all except Carteret 
and Lee included a disproportion- 
ately high number of people living 
below the poverty level, when com- 
pared to the state as a whole.' In 
addition to these demographic cor- 
relates of disease and mortality , cer- 
tain environmental factors may also 

Vol. 37. No. 3 



llii 



TABLE 2 

RANKS OF SYNTHETIC ADJUSTED DEATH RATES> FOR SEVENTEEN COUNTIES 

NORTH CAROLINA, 1972-1974 

















County 


and 


Rank2 












































c 






Cause of Death 


E 
O 
cn 
+-> 
c 
o 
s: 


c 
o 
E 

u 


-o 
cz 

U 


o 

OJ 
O 

cc: 


QJ 
5 


on 

=3 
_Q 
E 

'o 


OJ 
OJ 

— 1 


+-1 

0) 

c 
s_ 

in 


c 
o 
+-) 

c 

o 


c 
o 

3 


4-> 


4-> 

o 

=3 
CO 


fT3 


+J 
s- 

0) 
CQ 


o 

en 
c 

3 


OJ 

1- 
s- 

1- 


HI 

1- 

QJ 
S- 


ieart Disease 


1 


1 


1 


5 


3 


1 


1 


1 


1 


2 


1 




1 


1 


1 




1 


^ypertension 




8 


7 


7 






3 


6 




9 


7 


10 




5 


3 


6 


6.5 


itroke 


6 


2 


2 


1 


1 


2 








1 


2 


1 




3 




1 




Arteriosclerosis 


9 




3 


3 


7 




7 


8 


2 


5 
















lancer 


8 


3 


4 


11 






2 


4 


8 


3 


3 


2 




2 


4 


2 


2 


Diabetes Mellitus 


3 




6 


8 


9 


9 




5 




14 












4 




Influenza/Pneumonia 


2 








6 










4 




7 


2 


7 






6.5 


Emphysema ^ 






8 


12 


8 


8 


10 




7 


6.5 


4 


8 


4 


4 








Cirrhosis of the Liver 




7 




10 






5 




5 


8 


6 


6 






2 


5 


5 


Nephri tis/Nephrosis 




6 


10 






5.5 




9 




10 


5 








6 


7 


4 


"lotor Vehicle Accidents 


4 


4 


5 


2 


2 


3 


9 


2 


3 


6.5 




4 




5 








Ml Other Accidents 


7 






6 


5 


5.5 


4 


3 


6 


12 




3 


3 




5 


3 


3 


Suicide 








9 




7 


8 


7 


9 


13 




5 












Homi cide 


5 


5 


9 


4 


4 


4 


6 




4 


11 




9 










8 



2Adjusted rate after removal of excessive cause-specific mortality. 

Synthetic adjusted rates ranked from low to high with a low rank (small number) indicating that the 
3 cause of death was a relatively heavy contributor to excessive mortality. 

The category includes bronchitis and asthma but is predominantly emphysema. 



■ March 1976, NCMJ 



139 



FIGURE 3 
OBSERVED AND SYNTHETIC ADJUSTED DEATH RATES FOR SEVENTEEN COUNTIES 
NORTH CAROLINA. 1972-1974 



Rate 

Per 1,000 

Population 

12.0 



10.0 



8.0 



6.0 



-l.O 



2.0 




*Age-race-sex adjusted by the direct me 



underlie excessive mortality in 
these and other counties. The litera- 
ture abounds, for example, with 
studies relating health — heart dis- 
ease in particular — to the mineral 
content and hardness of local water 
supplies," and certain forms of 
cancer have been related to atmo- 
spheric agents.^ These environmen- 
tal elements need to be investigated 
in North Carolina. 

It is, of course, difficult to assess 
the adequacy of a county's health 
care resources, because counties 
vary widely with respect to specific 
disease proneness and thus with re- 
spect to health care needs. One can, 
however, examine the availability 
of resources in terms ol broad quan- 
titative measures such as the ratios 

140 



of county populations to the number 
of non-federal primary care physi- 
cians practicing in the county, the 
number of active registered nurses 
residing in the county and the 
number of short-term general hospi- 
tal beds licensed in the county. 

Assuming that high adjusted mor- 
tality is indicative of high disease 
proneness, it is interesting to note 
that only six of the 17 counties ap- 
pear average or better with respect 
to the three resources named above. 
Compared to ratios for all 100 coun- 
ties, the other 1 1 counties are found 
to be worse than average with re- 
spect to one or more resources as 
follows: Columbus, physicians and 
hospital beds: Bertie and Martin, 
nurses and hospital beds; Carteret, 



Richmond, Harnett, and Tyrrell, 
physicians: Bladen. Johnston. Pitt, 
and Washington, hospital beds.' 



Re Terences 

Nunh Carolina Depanmcnl ol Human Resources. Divi- 
sion ot Health SerMces. Administrative Services Sec- 
tion. Public Health Statistics Branch North Carolina 
Vital Statistics 1471-73, Volume 2: Leadmg Causes of | 
Mortality. Raleigh. North Carolina. April. 1975, 

North Carolina State Board ol Health. Public Health 
Statistics Section North Carolina Vital Statistics 1969. 
Raleigh, North Carolina. 1970 

Grove RD. Hctzel AM Vital Statistics Rates m the 
Lnited States 19-10-1960 Public Health Ser\ icc Publica- 
tion Number 1677. L.S. Government Printing OlVice, 
Washington. D, C. 196.S, 

North Carolina Depailment ol Human Resources. Divi- 
sion ol Health Services, Administrative Services Sec- 
tion, Public Health Statistics Branch North Carolina 
\ ital Statistics 1972-74. Volume 2: Leading Causes of 
Mortality Raleigh, North Carolina. May. 1975. 

Southern Regional Council, Inc. Health Care in the 
South: A Statistical Profile. Atlanta. Georgia. June. 
1974 

Neri LC HcMit D, Schreiber GB, Reviews and com- 
mentarv can epidemiology elucidate the water story? 
Am J Epidemiol: \ ol 99, No. :. Pebruary. 1974. 

SiKerberg PI. Holleb AL: Cancer Statistics. 1974. 
Worldwide Hpidemiology. CA; Cancer Journal lor Clini- 
cians: Vol 24. No I American Cancer Society. New 
'I'ork, New York. January-Pebruary . 1^74 



Vol. .^7, No. 3 



;ist 



m 



■k 



Pseudomembranous Colitis Following 
Clindamycin Therapy 



Robert D. Stratton, M.D.. 
James L. Lapis, M.D., and 
Eugene M. Bozymski, M.D. 



INTRODUCTION 

THE introduction of clindamycin 
(Cleocin") brought with it the 
hope that this more readily ab- 
sorbed derivative of lincomycin 
would have fewer side effects than 
the parent drug. In early clinical 
trials, clindamycin was effective 
against most penicillin-resistant 
staphylococci and skin rash was the 
most common side effect. Diarrhea 
was reported in only one of 50 
cases.' Recently, there have been 
many reports of gastrointestinal 
complications ranging from mild 
diarrhea to pseudomembranous co- 
litis with bloody diarrhea, fever, 
hypoproteinemia and leuko- 
cytosis.'"" The following four 
cases seen at North Carolina 
Memorial Hospital during a 14- 
month period illustrate our experi- 
ence with this complication of clin- 
damycin therapy. 

CASE REPORTS 

Case I 

A 21 -year-old female college stu- 
dent was treated for endometritis 
with a 10-day course of oral clin- 



Depanment ol Medicine 

Lniversilv o\ Nonh Carolina School ol Medicine 

Chapel HilL N C Z7f\i 

Supponed in pan b\ G I Training Gram #1-0-1^^-4228- 
GM04ft 

Repnnl requests to Dr Bozvmski 



damycin. The initial symptoms of 
lower abdominal pam cleared, but 
on the eighth day of treatment she 
developed diarrhea and fever to 
104° F. The diarrhea persisted de- 
spite antidiarrheal medications, and 
four days after completing the 
10-day course of clindamycin she 
was admitted to the student intlr- 
mary complaining of fever, nausea, 
vomiting and cramping lower ab- 
dominal pain along with the 
diarrhea. She denied tenesmus, 
melena and hematochezia. Her 
temperature was 102" F. Bowel 
sounds were hypoactive and the 
lower abdomen was tender with 
minimal rebound. The stool was 
benzidine positive. The white cell 
count was 10.700/mm^ with 65 per- 
cent polymorphonuclear leuko- 
cytes (PMN), and 3 percent bands. 
The hematocrit was 38 percent. The 
serum sodium was 141 mEq/1. 
potassium 2.8 mEq/1. and the urea 
nitrogen was 6 mg/'dl. No ova. para- 
sites or pathogenic bacteria were 
found in the stool. An upper gas- 
trointestmal series was within nor- 
mal limits. On the fifth hospital day 
proctoscopy to 8 cm revealed spotty 
cream-colored plaques, some of 
which could be remov ed revealing a 
friable base. She responded to sup- 
portive therapy, including in- 
travenous tluids and metamucil. 



and was discharged on the 13th hos- 
pital day. A barium enema was 
normal and she was well on follow- 
up two weeks later. 

Case 2 

A 26-year-old woman had the 
onset of an erythematous tender 
swelling in the left axilla, thought to 
be hidradenitis. She was treated 
with a 10-day course of clindamycin 
(150 mgq.i.d. orally I. On the eighth 
day she developed nausea, vomit- 
ing, cramping abdominal pain and 
diarrhea consisting of 4-5 watery, 
bloodless stools per 24 hours. The 
symptoms continued mtermittently 
for three weeks and were unrelieved 
by tincture of opium, lactobacillus 
acidophilus and kaopectate. When 
seen at the hospital the patient was 
dehydrated and had a temperature 
of 102° F which spiked to 104° F on 
the first day. Hypoactive bowel 
sounds and minimal diffuse abdom- 
inal tenderness were noted and the 
stool contained occult blood. The 
white cell count was 30.000/mm^ (77 
percent PMN, 12 percent bands) 
and the hematocrit was 50 percent. 
The serum sodium was 136 mEq/1, 
potassium 3.5 mEq/1. albumin 2.1 
gi'dl. Alkaline phosphatase. SCOT 
and SGPT were normal. Sig- 
moidoscopy to 16 cm revealed a 
patchy, raised, cream-colored 



March 1976. N'CMJ 



141 



pseudomembrane throughout the 
rectum and distal sigmoid colon. A 
gram stain of the membrane re- 
vealed many bacterial forms includ- 
ing a few gram positive cocci. A 
culture of the material obtained at 
sigmoidoscopy grew out normal 
flora. She was rehydrated and given 
albumin and lactobacillus acid- 
ophilus. The symptoms abated and 
she was discharged on the eighth 
hospital day. One week later she 
was well and sigmoidoscopic exam 
was normal. 

Case 3 

A previously healthy 32-year-old 
woman developed Vincent's angina 
after extraction of a molar and v\ as 
treated with one week of oral clin- 
damycin (600 mg per day) and tet- 
racycline (1 g per day). The clin- 
damycin was continued for another 
tw/o weeks and on the last day of 
therapy she noted diffuse lower ab- 
dominal pain with watery, bloodless 
diarrhea and fever. She received 
clindamycin for another week and 
then was admitted to her local hos- 
pital because of persisting com- 
plaints. Sigmoidoscopy revealed 
erythematous friable mucosa and 
the upper Gl series and barium 
enema were normal. One week la- 
ter, the colonic mucosa was cov- 



ered by creamy, yellow plaques. 
Treatment was begun with methyl- 
prednisolone (80 mg IV per day). 
She continued to do poorly and de- 
veloped ascites and bilateral pleural 
effusions resulting in her transfer to 
North Carolina Memorial Hospital. 
On arrival she was febrile to 101.6° 
F with evidence of volume deple- 
tion, bilateral pleural effusions, as- 
cites and lower abdominal tender- 
ness with rebound. Bowel sounds 
were present. Sigmoidoscopy re- 
vealed diffusely scattered cream- 
colored plaques and edematous red 
mucosa (Fig. 1). Plam film of the 
abdomen demonstrated thumb- 
printing of the transverse colon. 
The stool was positive for occult 
blood. The white cell count was 
23,000/mm^ with 78 percent PMN 
and 15 percent bands. Gram stain 
and culture of the stool demon- 
strated normal tlora. The serum al- 
bumin was 2.8 g/dl, the SGOT 143 
U. the SGPT 86 U and the alkaline 
phosphatase 23 NP units (normal 
2-6). 

After treatment v» ith intravenous 
fluids, prednisone (10 mg q.i.d.). al- 
bumin (75 gperday), and lactobacil- 
lus acidophilus, she became afebrile 
with a normal white cell count but 
continued to have 15 stools per day 
and abdominal pain. She recovered 




slowly and was discharged on the! •' 
24th hospital day. Her total in-lfci" 
hospital time was seven weeks. She 
was well, with a normal sigmoidos- *' 
copy and liver function tests, one ii'''' 
week after discharge. ife' 

Ike! 



Case 4 



iocyi 



ipe 



Fig. 1. Photograph of mucosa seen through sigmoidoscope. Case # 3. Note the raised cream- 
color plaques on the edematous mucosa. 

142 



A 35-year-old woman with glom- 
erulonephritis and chronic renal 
failure underwent bilateral nephrec- 
tomy in October, 1972. She was 
maintained on home dialysis until ai 
renal transplant was performed! a 
IVlarch, 1973. She remained oliguric 
for the ensuing two months and in 
May. 1973, the transplant was re- 
moved after a needle biopsy dem- 
onstrated acute rejection. A wound 
infection developed from which 
streptococci, staphylococci and 

E. coli were cultured and the pa- 
tient was treated with clindamycin 
and kanamycin. Steroids were ta- 
pered and hemodialysis was con- 
tinued. On the fifth day of treatment 
she was afebrile and the wound in- 
fection was improving. On the ninth 
day of therapy, her temperature 
went to 100.8° F and she developed 
nausea, and later, severe abdominal 
pain along with episodes of hypo- 
tension. On the 13th day of antibiot- 
ic therapy she had a period of apnea 
and hypotension during hemodialy- 
sis, with a temperature spike to 102° |§:l 

F. Nausea, vomiting and severe ab- 
dominal pain continued, and on 
successive days the w hite cell count 
rose to 13.8, 28.9, 47. and 74.4 x 
10^/mm^. Massive ascites de- 
veloped which did not respond to 
albumin administration. Abdominal 
exploration revealed no evidence of 
abscess. She died during an episode 
of apnea and hypotension on the 
17th day of treatment. Autopsy re- 
vealed previously unsuspected 
pseudomembranous colitis involv- 
ing the entire colon (Fig. 2). Other 
findings were fibrinous pericarditis 
and wound infection. 

DISCUSSION 

Pseudomembranous colitis can 
occur in a variety of clinical situa- 
tions and is often associated with 
the use of broad spectrum antibiot- 
ics. The diagnosis should be sus- 
pected when a patient taking a 
broad spectrum antibiotic develops 

Vol. 37. No. 3 



m 



m 
iiiiij 

aire, 
(sA 
a 01 
aa 
ii 
;iis 
of 






am 
i!( 



m 



iPI 

>ii 
)ev 

Ml 



iver. diarrhea, abdominal pain or 
istention. It is confirmed by sig- 
loidoscopy with the finding of 
■ eam-colored tenacious plaques 
ith the intervening mucosa being 
ythematous and edematous. 
The patients presented abo\e 
ere seriously ill with high fever, 
ukocytosis and immature forms in 
e peripheral blood. In the 20 cases 
ported in detail in the literature, 
hite cell counts \ aried from 1 1 .500 
34.000 with all but two greater 
an 16.000/mm-'. Fever in all but 

JO of the 20 was greater than lOT 

2.a..)-i 1 

Protracted disability in otherw ise 
;althy young people was a striking 
ature. both in our patients and in 

: lose described by others. It ranged 
om one week to several months, 
ith a median and mean of five 
eeks. That this can be a serious 
ness is demonstrated by the fact 
lat of these 24 patients, two died 
id two others required extended 
3spital stays. Ages ranged from 9 
) 74. w ith a mean of 46. One-third 
f the patients were under 35. A 
Dtable feature is that the majority 
f patients (19 of 24) were women. 
The most consistent chemical ab- 
Drmality in our cases was the low 
;rum albumin primarily from pro- 
;in loss via the gastrointestinal 

' "act. As demonstrated by Case 3. 
scites and pleural effusions may 
isult from the hypoalbuminemia 
nd the requirement for albumin re- 
lacement may be extensive. In two 
four patients, elevated SCOT and 
Ikaline phosphatase levels were 
oted, returning to normal with re- 
overy. Mild transient elevation of 
GPT and SCOT, or alkaline phos- 
hatase was noted in 8 of 19 patients 
iven clindamycin in one study.'- 
Jo evidence of colitis was reported. 
-Imore and colleagues reported a 
larked rise in SGOT and an ab- 
ormal liver biopsy following in- 
ravenous clindamycin therapy 









■ 








-^ 










-'^ 




,,.-, ,^. ^ ^ 








,; 


1 






?* ■ 


. ,. ■.-'■^■'■v 


V 








■%.' y 


■ X 




\ 






^^^^, t' 


■% 








f ■■ ■■- 



Fig. 2. Gross appearance of colon from Case # 4. Note the diffuse and extensive involvement. 



which quickly resolved after cessa- 
tion of therapy.'^ The nature of this 
defect in hepatic function and its re- 
lation to colitis remains obscure. 

In view of these experiences, we 
believe the use of clindamycin 
should be reserved for those 
specific clinical situations in which 
it is clearly the antibiotic of choice. 
The potential significance of 
diarrhea, fever or abdominal pain in 
a patient receiving clindamycin 
therapy is evident. Continued fever, 
diarrhea, marked leukocytosis or 
hypoalbuminemia should be 
watched for and viewed with suspi- 
cion. Detection of this complication 
by a high index of suspicion and by 
early sigmoidoscopy may decrease 
the severity and length of debility. 
Treatment is non-specitlc and in- 
cludes discontinuance of the an- 
tibiotic, supportive care, albumin 
replacement and lactobacillus 
acidophilus. Burbige and Milligan 
have recently reported prompt re- 



mission of symptoms in this entity 
with cholestyramine in one pa- 
tient. '■' 



Retertnces 

Geddes AM. Bndg«aler HA. Williams DN. el al; Clini- 
cal and baclenological studies with ciindamvcin Bnl 
Vkd J : 703-7114. 1970 

Cohen LE. McNeill CJ, Wells Rh: Clindamvcin- 
associaled colitis JAMA 2:3:1379-1380. 1973 
Shimkin FM. Link RJ: Pseudomembranous colitis: a 
consideration in the barium enema dillerential diag- 
nosis ol acute generalized ulceratue colitis Brit J 
Radiol 46 437-439. 1973 

Tedesco 1-J, Banon RW , Alpers DH Diagnostic lea- 
tures ol clindam\cin-associated pseudomembranous 
colitis. N EngJ Med :»0»43, 1974 
Slroehlein JR. Sedlack RE. Hollman HN Znd 
Clindamvcin-associated colitis Mayo Clin Froc 
49-;40-:43. 1974 

V iteri ,AL. Paxton HH D>ck W P: The spectrum ol 
linci>m\cin-clindamvcin colitis Gastroenterology 
b6 1137-1144. 1974 

DePord JW\ Molinaro JR. Daly JJ: Lincomycin- and 
clindamvcin-associated colitis Gastrointest Endosc 

:i-i9-:i. 1974 

Hunter PG: Clindamycin-associated colitis J Maine 
Med Assoc (j.\30:-.303. 30.\ 1974. 
Daws JS Severe colitis lolloping lincomycin and clin- 
damycin therap\ .-^m J Gastroenterol 62:16-23. 1974. 
Wolle MS JAMA 229:266-267. 1974. 
Pastore RA kadair RG: Hypoalbuminemia. ascites and 
pseudomembranous colitis alter clindamycin therap\ 
South Med J h7:S6.<-»6S. 1974 

Pass RJ, Scholand JP. Hodges GR. Saslav^ S: Clin- 
damycin in the treatment ol serious anaerobic i 
lions Ann Intern Med 7s:S.svs.s9. 1973 
Klmore M, Rissing JP. Rink L. Brooks 
Clindamycin-associated hepatoloxicity. Am J 
.s7:627-6.30. 1974 

Burbige EJ. Milligan PD: Pseudomembranous colitis: 
association with antibiotics and therapy vwth choles- 
tyramine JAMA 231:ll57-ll."iS. 197.s, 



inlec 



GP 

Med 



... 1 am convinced the great majority ofthose complaints which are considered purely mental, such 
asirntability and irascibility ot'temper. gloomy melancholy, timidity and irresolution, despondency. &c. 
might be greatly remedied, if not entirely removed, by a proper system of temperance, and with very 
little medicine. On this account, medical men often have it in their power to confer an immense boon of 
happiness on many valuable members of societv. whose lives are rendered wretched by morbid 
sensitiveness of the mind, having its unsuspected source in morbid sensibility of the stomach, bowels, or 
nervous system. — An Essay on Indigestion: or Morbid Sensihilily of the Stomach & Boh els. James 
Johnson. 1836. p 8. 



.Iarch 1976. NCMJ 



143 



Benign Strictures of the Anus and the Rectum 



avera 



cures' 
ionsai 
laiy.ii 



Harold F. Hamit, M.D.. F.A.C.S. 



dill 



ijrac 
iissioi 
ilker 
iminei 



the 

[U 

ireas 
izaii 
iS in 1 
lays 
ipilaii 
ipri 
jver! 
Th( 
iciurt 



BENIGN strictures of the anus 
and the rectum apparently are 
considered so insignificant that they 
are scarcely mentioned in several 
current textbooks on surgery and 
gastroenterology. These lesions 
occur in a variety of degrees, result 
from a variety of causes and re- 
spond to a variety of treatments. 
Among the causes are anal and rec- 
tal surgery, fissures and fistulas //; 
ano. chronic colitis and proctitis, 
diverticulitis and diverticulosis. 
lymphogranuloma venereum and 
ionizing radiation. Among any 
group of patienis with these lesions 
will be several for whom the lesion 
must be termed idiopathic since its 
cause cannot be traced to any rec- 
ognized injury or disease. Because 
this subject has been neglected in 
current literature, we reviewed our 
recent experience with this prob- 
lem. 

METHODS AND MATERIALS 

We asked our Department of 
Medical Records to collect the clin- 
ical records of patients discharged 
from the hospital from 197! through 
1974 with any diagnosis associated 
with a stricture of the anus or the 



Associiile Director. DL-partmenI ol General Surgery 

Charlulle Memorial Hospilal and Medical Center 

I'D Bo\ ^^iJ 

C'harlolle. North Carolina 2fi234 

Reprint requests \o Dr Hamit 



144 



rectum, whether benign or malig- 
nant and v\ hether the stricture was 
the primary cause for hospitaliza- 
tion or an incidental or secondary 
diagnosis. This request produced 
186 charts for review. We elimi- 
nated cases in which the patient had 
fistulae. polyps, villous adenomas 
and other conditions not associated 
with actual strictures and cases of 
malignant disease of the anus or the 
rectum. We were left with 27 clini- 
cal records of patients with bona 
fide strictures not associated with 
malignant disease. The one excep- 
tion was a patient with a history of 
local excisions over a period of 20 
years for polyps of the rectum, 
some of which contained carcinoma 
in situ. This patient apparently had 
developed a stricture as a result of 
these repeated local excisions. The 
complete records of these 27 pa- 
tients, including all admissions to 
this hospital for any cause, were 
studied in detail. In an attempt to 
assess the results of the treatments 
these patients had undergone for 
stricture, we requested follow-up 
information from their physicians. 

RESULTS 

Age, Race and Sex 

Five of the 27 patients were men 
(three white, one black and one 
American Indian). Of the 22 wom- 



en. 16 were white and three blacl 
The race of the other three could m 
be determined from clinical re 
ords. The ages of these patients o, 
their first admission to the hospiti 
ranged from 26 to 84 years with bot 
a mean and a median age of 56. / 
the final admissions, their age p 
ranged from 30 to 85 years with 
mean of 56 and a median of 57. (Th 
ages of two black women were ui 
certain; the youngest ages of seven 
ages recorded for them were used 
The ages of the men ranged from 2' 
to 60 on first admission with a mea 
of 37 and a median of 34; on fim 
admission the men ranged from 3 
to 63 with a mean of 38 and a media 
of 37. The ages of the women rangci 
from 4 1 to 84 with a mean age of 60. 
and a median age of 56 on first ad 
mission; on final admission tht 
women ranged from 44 to 85 with 
mean of 64 and a median of 67. 



pita! 
'sof 
tlivt 



an 
lomi 
ved 
io 

01 

inre 
idii 
Jet 
•M 
iir 

01 

lied 



Marital and Social Status 

The three white men and the Iri 
dian were married. The marita| '^t 
status of the black man was not in ™ 
dicated in his record. All the womerfpli 
except one were or had been mar 
ried. All of the patients except threJ 
were private. 

Hospitalizations 

The 27 patients were hospitalize* 
73 times, the number of hospitaliza 



110 
■.IV 

ed 
iz 
ion 



Vol. 37. No. 3 



tins ranging from one to eight \\ ith 
a average of 2.7 per patient. 
1 enty-five hospitalizations were 
pmariiy because of anal or rectal 
sictLires: the others uere for other 
r'lsons and the stricture was a sec- 
cdary, incidental or unmentioned 
ciditioned. During nine hospitaii- 
j mns. examination of the rectum 
v.s '"deferred"" and apparently 
rver accomplished; for 13 other 
amissions there was no indication 
\iether the rectum had been 
eamined. Seventeen patients were 
fspitalized primariK for stricture; 
I of them uere hospitalized once. 
tjr twice and two three times for 
is reason. During these 25 hos- 
falizations, the patients spent 223 
cys in the hospital (an average of 
1 days per patient or ti.9 days per 
tspitalization). Those hospitalized 
(ce primarily for strictures spent 
i average of 6.6 days in the hospi- 
t . Those hospitalized tw ice for 
ricture spent an a\erage of 5.2 
lys in the hospital the first time 
;dy.3 days the second time. Those 
1 spitalized three times spent aver- 
;es of 17.5. 12.5. and 15 days, re- 
•ectively. in the hospital. 

'. agno.sis 

The s\ mptoms included constipa- 

)n and obstipation, rectal pain. 

,'dominal pain and cramping re- 

ved in some cases by laxatives. 

. lall or ribbon-like stools, "steno- 
i"" or "stricture." hemorrhoids, 
isures and fistulae and rectal 
eeding. Diagnosis usually was 
ade b\ digital examination. In five 
itients the diagnosis by digital 
.amination was not evaluated by 
ly other means and was never 
;ated. in 12 patients the problem 
as further evaluated by procto- 
opic examination, barium enema 
a consultant; none of these was 
;ated for stricture during the ini- 
al admission, but eight sub- 
quently were treated, in two. rec- 
1 examination was reported as 
.■gative during a subsequent ad- 
ission. and in two rectal examina- 
'n was either not reported or ""de- 
rred"' during subsequent hos- 
talizations. In four, rectal exami- 
ition either was not reported or 
as "deferred"' during hospitaliza- 

{pns preceding the hospitalization 



during w hich the diagnosis of stric- 
ture was made. A Frei test was 
negative in the only patient upon 
whom It was performed. It appar- 
ently was not done upon another 
patient who gave a history of sup- 
purative inguinal lymphaden- 
opathy. Tuberculosis was never 
mentioned as a possible cause of the 
stricture and was not diagnosed in 
any of these patients. 

For the 17 patients eventually 
treated for anal or rectal strictures, 
rectal examinations were reported 
as "negative"" in two diiring earlier 
hospitalizations. Rectal examina- 
tion was either not reported or "de- 
ferred"" during the 18 preceding ad- 
missions of these patients for other 
ailments. Certain treated patients 
subsequently were hospitalized i 1 
times for one reason or another; 
during three of these hospitaliza- 
tions rectal examination was either 
not reported or was "deferred,"" but 
the\ v\ere reported as negative dur- 
ing eight hospitalizations. 

Cause of Stricture 

The probable causes associated 
with anal or rectal stenosis are 
shown in Table F 

Treatment 

The manner by which these pa- 
tients were treated is shown in 
Table IF Dilation and incision in- 
cluded combinations of dilation and 
biopsy in one patient, with hemor- 
rhoidectomy and fissurectomy in 
two. with fissurectomy and 
sphincterotomy in two (one of the 
last subsequently required a 
sphincteroplasty because of persis- 
tent fecal incontinence). One of the 
patients who underwent dilation 
and hemorrhoidectomy also re- 
quired a sphincteroplasty. One pa- 



TABLE I 

Causes Associated with Anal or Rectal 

Strictures 

Unknown 8 

Post-hemorrhoidectomv 12 months 10 15 years) 7 

Fistula or fissure in ano 3 

Post ionizing radiation to pelvic organs 2 

Associated with hemorrhoids (preoperattveW) 2 

Associated with diverticular disease 2 
Post-rectal surgery (other than 

hemorrhoidectomy) 2 

Ulcerative colitis 1 



TABLE II 

Treatment of Patients with Anal or Rectal 

Strictures 

None — Stricture apparently ignored after 

diagnosis 7 

None — Stricture evaluated but not treated 3 

Dilation and incision 6 

Dilated only (under anesthesia) 3 
Excision or incision of fissure or fistula and 

hemorrhoidectomy 3 

Colostomy 2 

Resection of stenosis 2 

Dilation bv patient (after instruction) 1 



TOTAL 



27 



TOTAL 



27 



tient was treated by elective colos- 
tomy which preceded a resection 
from a posterior approach oi the 
stenotic rectum which in turn was 
followed by a closure of the colos- 
tomy. Another patient hospitalized 
twice in two years at this hospital 
first for suspected subdural hema- 
toma and later for a urinary tract 
infection with septicemia, was 
treated by colostomy at another 
hospital for a rectal stricture "at 
seven centimeters"" and returned 
here for closure of his colostomy. 
During this procedure the stricture 
was "dilated from above and be- 
low" but not resected. Six days af- 
ter his discharge he returned with a 
wound infection which was incised 
and drained of a '"tremendous 
amount of ascitic fluid."" which on 
culture grew out a Proteus microor- 
ganism. The patient then made a 
'"remarkable recovery." A colosto- 
my, intended to be permanent, was 
performed on a patient who had 
been treated by ionizing radiation 
for cancer of the cervix and had de- 
veloped proctitis and rectal stric- 
ture. A patient treated repeatedly 
over a period of 20 years by local 
excision of rectal polyps, several of 
which contained carcinoma /// situ. 
e\entually developed a stricture 
w hich was treated by anterior resec- 
tion of the rectosigmoid and a simi- 
lar resection was performed on a 
stricture associated with diverticu- 
lardisease. Incisions of the stricture 
or the anal sphincter ranged from 
four-quadrant incisions to simple 
fissurotomy and anal sphincter- 
otomy. One elderly woman m 
whom a tight anal stenosis had been 
noted but not treated eventuallv 
was admitted with a diagnosis of 
""large bowel obstriiction."" which 



Iarch 1976, NCMJ 



TABLE III 
Follow-Up Results on Patients 

Discharged with a 
Diagnosis of Rectal Stricture 



Result 


Number 


Cured, No furlher treatmenl necessary 


1 1 


Apparent Asvmplomatic, Not Evaluated 


3 


Improved, Still has a problem 


5 


Performing self-dilalions satisfactorily 


1 


Not seen since discharge 


1 


TOTAL 


21 



was relieved by incision of an anal 
stenosis "so tight that an opening 
could hardly be found"" and delivery 
of a fecal impaction. Three patients 
were treated by dilation under anes- 
thesia and one patient was taught to 
perform dilations at home with 
graduated plastic dilators. One pa- 
tient whose pelvic organs had been 
irradiated and upon whom digital di- 
lation had been performed was ad- 
vised to continue self-dilations at 
home. 

Follow-Up 

Thirteen physicians returned 21 
follow-ups. Except for one patient 
who was not seen after discharge, 
the follow-up periods ranged from 
three weeks to more than three and 
one-half years (see Table 111). 

One patient who required a 
sphincteroplasty to correct an 
over-correction of her stenosis was 
having a slight problem with fecal 
incontinence at last follow-up. Two 



patients, who apparently were in- 
structed to perform self-dilations 
without this being noted in the hos- 
pital record, have been able to dis- 
continue these treatments. Two pa- 
tients who required further dilations 
by the physician in his office now 
are apparently doing well. One pa- 
tient died of unrelated causes, but 
none has died from any cause as- 
sociated with rectal or anal stric- 
ture. 

CONCLUSION 

Benign anal and rectal strictures 
are rare and accounted for only 73 
(27 patients, or .06 percent) of the 
114.229 hospitalizations at Char- 
lotte Memorial Hospital and Medi- 
cal Center during the period of this 
study. Only 25 (or .02 percent) of 
these hospitalizations were due to 
anal and rectal stricture. 

From this review it appears that a 
high percentage of benign anal or 
rectal strictures are iatrogenic. 
Eleven of 27 (41 percent) were as- 
sociated with some kind of medical 
treatment. Hemorrhoidectomy was 
the greatest single cause of stricture 
(7 out of 27, or 26 percent). Al- 
though there was no recorded his- 
tory of rectal surgery for eight (30 
percent) of the patients for whom 
the cause of stricture was unknown, 
one might reasonably suspect that 
some of these may have had a 
hemorrhoidectomy or other rectal 



I 



surgery in the past and that this fac! 
simply was not mentioned in thei! 
histories. The next most importan 
cause appears to be intlammatori i 
disease. : 

Whatever the cause, the treal i 
ment or non-treatment of thes» | 
strictures appears to have beei I 
satisfactory. Although five patient 1 
of the 21 followed still were havin; 
problems, only one of these coulo 
be said not to be under satisfactor 
control at last follow-up. From thi 
study it appears that benign recti 
and anal strictures are rather un| 
common, that most are readil 
amenable to appropriate treatment] 
and therefore are, indeed, benign] 
Probably the most important fac 
disclosed by this study is that doc| 
tors may not be as diligent as the; 
should be in taking advantage of op| 
portunities to perform routine recta] 
examinations on their patients an 
may be missing the opportunity I 
detect more serious lesions, i.e. 
malignancies, as well as benig 
strictures. It is especially disturbin; 
to find that rectal examinations an| 
"deferred,"" "not done" or not re 
corded for patients known to hav' 
had and to have been treated fo 
rectal problems. 

ACKNOWLEDGEMENT 

Dr. Isaac isaiah. lormerly a resident i 
general surgery, pertbrmed the initial screen] 
ing ol the clinical records. 



Thus, aman in perfect health, and with an excellent appetite, is allured by variety of dishes, agreeable 
company, provocative liquors, and pressing invitations, to take food more in accordance with the relish 
of appetite than the power of digestion. No inconvenience occurs for an hour or two; hut then the food 
appears to, and actually does, swell in the stomach, occasioning a sense of distention there, not quite so 
pleasant as the sensations attendant on the various changes of dishes, and bumpers of wine, or other 
dnnk. He unbuttons his waistcoat, to give more room to the labouring organ underneath: but that affords 
only temporary relief. There is a struggle in the stomach between the vital and the chemicat laws, and 
eructations of air or acid proclaim the ascendancy of the latter. — An Essay on Indigestion: or Morbid 
Sensibility of the Stomach & Bowels. James Johnson. 1836, p 22. 



146 



Vol. 37, No. 3 




h 



land useful in the management oi \"ertigo" associated 
IS ses affectmg the \-estibular system. 

I ( n relieve nausea and vomiting often associated with \'ertigo" 
i lual adult dosage for Anti vert/2 5 for vertigo;" one tablet t.i.d. 

/50 available as Antn-ert (meclizine HCl) 12.5 mg. scored 
it ts, for dosage convenience and flexibility'. 

/.tivert/25 (meclizine HCl) 25 mg. Cheuable Tablets for 
ai sa, vomiting and dizziness associated w'ith motion sickness. 

ai SL'MMARY OF PRESCRIBING INFORMATION 



*l DICATIONS Based on a re\ie\v of this drug by the Naoonal Academy of 
S" ices — National Research Q^unci! and/or other intormanon, FDA has classified 
tr ndicanons as follows 

ietuve: Management ot nausea and \-ominng and di::iness associated wnth 
rr on sickness. 

)ssibly Effective: Management ot verngo associated with diseases aftecnng the 
V' bular system. 

nal classificanon ot the less than effective indicatkins requires turther 
ir stitjation 



B;g Balanced Rock, Chincahua Mountains. Arizona (approx 1,000 tons) 

CONTFLAIN'DICATIONS. Adminiscranon of Ann vert Imechzme HCll during preg- 
nancy or to women who n^y become pregnant is ccintraindicated m \iew ot the 
teratogenic effect oi the drug in rats 

The administraoon of meclizine to pregnant rats durmg the 12-15 day of gestanon 
has produced cleft palate in the oftspnng Limited studies using doses of over lOC mg./ 
kg, /day in rabbits and 10 mg./kg./day in pigs and monkeys did not show cleft palate 
Congeners of meclizine have caused cleft palate in species other than the rat. 

Meclizine HCl is contra indicated m mdmduals who have shown a presious h\per- 
sensia\iry to it. 

WARNINGS. Since drowsiness maw on «.'Ccasion. occur wTth use of this drug, patients 
should be warned of this possibilio,- and cautioned against dn\ing a car ot operaong 
dangerous machinery. 

L'sugt: in Children Clinical studies establishing safet\' and effecfi\'eness m children 
ha\-e not been done; therefore, usage is not recommended in the pediatric age group 

L'sage mPregniincy: See "Contraindications. 
ADVERSE REACTIONS. Drowsiness, dry mouth and, on rare ivcasions. blurred 
vision have been reported 

More detailed professional information a\'ailable on 
request. 



I 



Antivert/^25 

(meclizine HCl) 25 nig.Tablets 

for vertigo* 



ROeRIG<9 

A divtsion of Pfizer Pharmaceuticals 
New York, New York 10017 




^ A. ^^^ ^^^ .^^ ^^^ k. .^ - ^^_. Trademark 



MAKES SENSE 

TRIAMTERENE CONSERVES POTASSIUM 
WHILE HYDROCHLOROTHIAZIDE 
LOWERS BLOOD PRESSURE 

FOR LONG-TERM CONTROL 



® Each capsule contains 50 mg. 
of Dyrenium® (triamterene, SK&F) 
and 25 mg. of hydrochlorothiazide. 



OF HYPERTENSION 



Serum K+ and BUN should be checked periodically. (See Warnings Section.) 




Before prescribing, see complete prescribing in- 
formation in SK&F literature or PDR. The fol- 
lowing is a brief summary. 



Warning 

This fixed combination drug is not indi- 
cated for initial therapy of edema or hyper* 
tension. Edema or n/pertension requires 
therapy titrated to the individual patient. If 
the fixed combination represents the dosage 
so determined, its use may be more convenient 
in patient management. The treatment of 
hypertension and edema is not static, but 
must be reevaluated as conditions in each 
patient warrant. 



T*^ Indications: Edema: That associated with con- 
gestive heart failure, cirrhosis of the liver, the 
nephrotic syndrome; steroid-induced and idio- 
pathic edema; edema resistant to other diuretic 
therapy. Mild to moderate hypertension: Useful- 
ness of the triamterene component is limited to 
its potassium-sparing effect. 

Contraindications: Pre-existing levated serum 
potassium. Hypersensitivity to eittier component. 
Continued use in progressive renal or nepatic 
dysfunction or developing hyperkalemia. 
Warnings: Do not use dietary potassium supple- 
ments or potassium salts unless hypokalemia 
develops or dietary potassium intake is markedly 
impaired. Enteric-coated potassium salts may 
cause small bowel stenosis with or without 
ulceration. Hyperkalemia { > 5.4 mEq/L) has 



been reported in 4% of patients under 60 years, 
in 12% of patients over 60 years, and in less than 
8% of patients overall. Rarely, cases have been 
associated with cardiac irregularities. Accord- 
ingly, check serum potassium during therapy, 
particularly in patients with suspected or con- 
firmed renal insufficiency (e.g.. elderly or dia- 
betics). If hyperkalemia develops, substitute a 
thiazide alone. If spironolactone is used con- 
comitantly with 'Dyazide'. check serum potas- 
sium frequently —both can cause potassium 
retention and sometimes hyperkalemia. Two 
deaths have been reported m patients on such 
combined therapy (in one. recommended dosage 
was exceeded: in the other, serum electrolytes 
were not properly monitored). Observe patients 
on "Dyazide' regularly for possible blood 
dyscrasias, liver damage or other idiosyncratic 
reactions. Blood dyscrasias have been reported 
in patients receiving Dyrenium (triamterene. 
SK&F). Rarely, leukopenia, thrombocytopenia, 
agranulocytosis, and aplastic anemia have been 
reported with the thiazides. Watch for signs of 
impending coma in acutely ill cirrhotics. Thia- 
zides are reported to cross the placental barrier 
and appear in breast milk. This may result in 
fetal or neonatal hyperbihrubinemia. thrombo- 
cytopenia, altered carbohydrate metabolism and 
possibly other adverse reactions that have oc- 
curred in the adult. When used durin g preg nanc y 
or in women who mi g ht bea r ch ildren , weigh 
potential benefits against possible hazards to 
fetus. 
Precautions: Do periodic serum electrolyte and 



BUN determinations. Do periodic hematologic! 
studies in cirrhotics with splenomegaly. Anti- 
hypertensive effects may be enhanced in post- 
sympathectomy patients. The following may 
occur: hyperuricemia and gout, reversible nitrogen 
retention, decreasing alkali reserve with possible 
metabolic acidosis, hyperglycemia and glycosuria 
(diabetic insulin requirements may be altered), 
digitalis intoxication (in hypokalemia). Use 
cautiously in surgical patients. Concomitant use 
with antihypertensive agents may result in an 
additive hypotensive effect. 'Dyazide' interferes' 
with fluorescent measurement of quinidine. | 

Adverse Reactions: Muscle cramps, weakness, 
dizziness, headache, dry mouth; anaphylaxis; 
rash, urticaria, photosensitivity, purpura, otheri 
dermatological conditions; nausea and vomiting 
(may indicate electrolyte imbalance), diarrhea, i 
constipation, other gastrointestinal disturbances. 
Necrotizing vasculitis, paresthesias, icterus, 
pancreatitis, xanthopsia and. rarely, allergic 
pneumonitis have occurred with thiazides alone, 
Supplied: Bottles of 100 capsules; in Single Unit 
Packages of 100 (intended for institutional use 
only). 

SK&F Co., Carohna, P.R. 00630 

Subsidiary of SmithKline Corporation 



Editorials 



HIGH MORTALITY IN NORTH CAROLINA 

As the United States was settled, geographic and 
iconomic considerations helped define county lines 
vhich have remained virtually unchanged despite 
hifts in population, changes in resources and varia- 
ions in productivity. The transition of our country 
irom a primarily rural and agricultural to a predomi- 
lantly urban and industrial society has concentrated 
)opulation and has often left smaller counties tlnan- 
;ially unable to provide minimal health and other ser- 
aces without state or federal assistance, a dilemma 
eading some to advocate extensive county consolida- 
ion and regionalization of medical and other service 
acilities. Since minimum populations appear neces- 
ary to support certain specialists, data about varia- 
ions in age. disease incidence and prevalence and 
!thnic susceptibility might be helpful in planning and 
n allocation of funds if maximal benefit is to be 
ichieved from the resources available. Such expecta- 
ions might be important in deciding where to establish 
:enters for categorical care as dialysis, coronary care, 
leonatal intensive care and radiation therapy 
acilities. 

Such planning to bear fruit requires epidemiologic 
tudy of a number of variables. As Surles and 
lothwell suggest in this issue of the Journal, there is 
ignificant unexplained variation in mortality from 
ertain specific diseases among our hundred counties. 
!he explanation of which might require investigation 
)f a number of factors including mineral content and 
lardness of water supplies and variations in atmo- 
jpheric agents. To these might be added efforts to 
•3 dentify industrial determinants, genetic influences 
ind dietary factors which might be susceptible to so- 
ial action. Recent studies of cancer mortality by 
;ounties. 1950-69. by the epidemiology branch of the 
National Cancer Institute may be instructive.' - Risk 
)f bladder cancer in white males, for example, appears 
inked to industrial exposure whereas excessive mor- 
ality for stomach cancer in white males is greatest in 
he upper midwest where people of northern Euro- 
)ean descent are clustered. Cancer mortality, all 
Primary sites combined in white males and females, is 
lignificantly lower in most of North Carolina, a more 
igricultural state with less concentrated heavy indus- 
ry than the rest of the United States and probably 
Inore homogenous in the ethnic derivation of its 
i)eople. Even so. mortality from nasopharyngeal and 
)ther cancers of the mouth and throat among white 
nales. malignant melanomas and other skin cancers 

March 1976. NCMJ 



among whites of both sexes, eye cancer and bone 
tumors is significantly greater in many counties in 
North Carolina than the rest of the nation. Both en- 
vironmental and genetic factors have been linked to 
the appearance of melanomas so that more extensive 
investigation might lead to the identification of un- 
favorable factors which might be remediable. As 
Hoover et al indicated and Surles and Rothwell con- 
firm, counties are "small enough to be homogenous 
for demographic and environmental characteristics 
that might influence . . . risk and yet large enough for 
stable estimates of . . . mortality. "" 

References 

1. Hoo\cr R. Mason TJ. McKay hW, hraumeni JR Jr: Science 189:1005. 1975 

2. Mason TJ. McKav FW, Hoover R. Blot WJ. hraumeni Jh Jr: Atlas of Cancer Mortality 
lor US. Counties: 1950-1969 Government Printing Ollice, Washington. 1975. 103 pp. 

THE NINETEENTH HOLE 

No figures are available to tell us how many doctors 
play golf on Wednesday afternoons, but patients seem 
to have accepted this as a secular ritual seldom chal- 
lenged, except by the weather. Not as rigidly stylized 
as bullfighting, golf nevertheless has its fixed aspects, 
including the nineteenth hole with its endless discus- 
sions of hooking and slicing and other abstruse mat- 
ters. Yet the medical mind, so geared to problem- 
solving at the bedside, has provided no lasting solution 
for the obstacles of a pleasant golfing afternoon, 
perhaps because without complaints and difficulties 
play would be less fun and conversation more mun- 
dane. 

Still, such is the drive for perfection that the source 
of greatest anguish on the links has been identified: the 
ball. It. at least, can be changed — perhaps made to 
self-correct in its flight, similar to more advanced tools 
in the Pentagon's armamentarium. Since only three 
requirements must be met for a modem golf ball to be 
legitimate — a weight of no more than 1 .62 ounces, a 
diameter of at least 1 .68 inches and a maximal velocity 
on standard impact of 250 feet per second — variations 
seem almost infinite. Working within these restric- 
tions, two California scientists have produced a ball 
which, it is said, reduces hooking and slicing by 75 to 
80 percent, with modest compensatory decrease in 
length of the drive, all by applying simple principles of 
physics and spending about $2.75 for raw material.' 

No longer should the surface of the ball be totally 
dimpled, but only at its equator; such cosmetic 
surgery reduces the ball's tendency to stray but sac- 
rifices distance. The ball's mass is increased at its 
poles because rigidly connected weights tend to spin 



149 



in only one axis, rather like a drum majorette's baton, 
hence hooking and slicing are inhibited. Unfortu- 
nately, putting won't improve. 

We wish the American Tentative Society (yes, there 
is an American Tentative Society dedicated to the 
proposition that all knowledge is tentative and thus 
scientific principles must be constantly evaluated as to 
their validity-) could be enticed into identifying and 



validating the principles of the Department of Health 
Education and Welfare, as well as the significance o 
redesigned golf balls. Hooking and slicing, whetheroi 
the golf course or in Washington, demand carefu 
examination. 



1 Science 1X7. >J41. 1V75 

:. Wall Screel Journal, Sepl, 5, W74, 



Committees and 
Organizations 



THE NORTH CAROLINA MEDICAL CARE 
COMMISSION 

At the December 11-12. 1975, meeting ofThe North 
Carolina Medical Care Commission, resolutions of 
appreciation for retiring members were unanimously 
approved. The retiring members were Drs. Harold B. 
Kemodle and William Raney Stanford. 

Resolved: Whereas. Dr. Harold B. Kemodle of Bur- 
lington. Alamance County, has served as a member of 
The North Carolina Medical Care Commission since 
1%7 and during that time has served as a member of 
the Student Loan Committee; and 

Whereas. Dr. Kemodle has served the people of 
North Carolina in these endeavors with a devotion and 
interest beyond the call of duty with highest integrity, 
graciousness and efficiency: and 

Whereas, during Dr. Kernodle's tenure, the Com- 
mission assisted local communities throughout the 
State in providing new. enlarged and modernized hos- 
pital facilities, nursing homes, health centers, 
facilities for the mentally retarded, and community 
mental health centers: and, in addition, administered 
funds to assist in the education of physicians, dentists, 
pharmacists, nurses and other health personnel for 
medically deprived areas of North Carolina: and 

Whereas, North Carolina's accomplishments in 
these fields have been recognized throughout the na- 
tion: 

Now. Therefore. Be It Resolved that The North 



150 



tto 

'0 

Blil 

ib. 

m 

At 
* 
111 
iir, 
M 
fe 

m. 

i: 

Carolina Medical Care Commission does herebyf?"; 
record its appreciation of the unselfish, highly m-; -jli, 
telligent and friendly services of Dr. Harold B. Ker- -'^i 
nodle over a period of eight years: 

Resolved: Whereas. Dr. William Raney Stanford ol: 
Durham. Durham County, has served as a member ol 
The North Carolina Medical Care Commission since 
1949. a period of 26 years: and 

Whereas. Dr. Stanford has served the people ol 
North Carolina with a devotion and interest beyond 
the call of duty with highest integrity, graciousness 
and efficiency: and 

W7(t'/-c'rt.s. during Dr. Stanford's tenure, the Com- 
mission assisted local communities throughout the 
State in providing new. enlarged and modernized hos- 
pital facilities, nursing homes, health centers, 
facilities for the mentally retarded, and community 
health centers: and. in addition, administered funds to! 
assist in the education of physicians, dentists, phar- 
macists, nurses and other health personnel for medi- 
cally deprived areas of North Carolina: and 

Whereas. North Carolina's accomplishments in 
these fields have been recognized throughout the na- 
tion: 

Now. Therefore. Be It Resolved that The North 
Carolina Medical Care Commission does hereby 
record its appreciation of the unselfish, highly in- 
telligent and friendly services of Dr. William Raney jli 
Stanford over a period of 26 years. *" 



')2II1 

U 



Vol. 37. No. 3 



h 



Bulletin Board 



NEW MEMBERS 

of the State Society 



Anderson, Larrv Glenn, M.D. (ORS). SOX-B N. Dekalb St.. Shelbv 

2« 1 50 
)aniel. Walter Eugene. Jr. (STUDENT). 304 Woodhaven Road. 

Chapel Hill 21^\A 
idden. Stanley Harry. M.D. (GP). Box 307. Mam Street. Beulaville 

28.^ I S 
rlardeman. Riehard A.. M.D. (EP). Box 45. Grover 2X073 
rlundley. James Da\enport, M.D. (ORS). 315 N. 17th Street. Wil- 

mmgton 2X401 
.auer. Thomas Eucene (STUDENT). I9IX Halifax Court. High 

Point 27262 
klcCrearv. Jeremv .Alan (STUDENT). Route #3. Box 1 10. Hills- 
borough 2727X 
Vliller. Robert Michael. M.D. (EP). X04 N. Eafavette Street. Shelbv 

2X 1 50 
Dsbera. .Arthur Guyer (STUDENT). B-IO Camelot Apartments. 

Chapel Hill 27514 
Pope. Thomas Lee. Jr. (STUDENT). 47 Davie Circle. Chapel Hill 

27514 
^per, David Rav (STUDENT). #47 Tarheel Trailer Park. Chapel 

Hill 27514 

ilRozier. John Charles. Jr.. M.D. (OBG). 4300 Eavetteville Road. 
■ Lumherton 2X35X 



Smith. Ronnie D. (STUDENT). 704-A Hibbard Drive. Chapel Hill 
27514 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: 1. The Continuing Medical Education Programs of 
the Bowman Gray. Dukeand UNC Schoolsof Medicine are accred- 

,rited by the Amencan Medical Association. Therefore CME pro- 
grams sponsored or co-sponsored by these schools automatically 

! qualify for AMA Category I credit toward the AMA Physician's 

,,. Recognition Award, and for North Carolina Medical Society 
Category "A" credit. Where AAEP credit has been requested or 
obtained, this also is indicated. 
2. The "place" and "sponsor" are indicated for a program only 

. when these differ from the place and source to write "tor inlorma- 
tion . " 

PROGRAMS IN NORTH CAROLINA 
April 1 

Cancer of the Breast — Wilson Memorial Hospital Symposium 
Credit: 7 hours: AAEP credit applied for 

For Information: M. A. Pittman. Jr.. M.D.. Wilson Memorial Hos- 
pital. Wilson 27X93 

April 2-3 

, Practical Nuclear Medicine: Emphasis Oncology 

Fee: S75 
' Credit: 4 hours; AAEP credit applied for 
For Inlormation: Emery C. Miller. M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine, 
W'inston-Salem 27103 



April 2-4 

Spring Symposium for Radiologists: Radiology and Imaging of the 

Chest 
Place: Carolina Inn. Chapel Hill 
Sponsors: UNC School of Medicine and the N.C. Chapter of the 

American College of Radiology 
Fee: NCCACR members $20; non-members and out of state $30. 

registration limited to 150 
Credit: 15 hours 
For Inlormation: Oscar L. Sapp. 111. M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 

April 5-9 

Practical Approaches to Diabetic Care: Unit 1 — Diabetes and Its 
Management; Unit II — Teaching the Diabetic Patient 

Fee: $125; James M. Johnston awards available to partially cover 
cost of tuition 

Credit: 35 contact hours. CERP 

For Information: Patricia Lawrence. R.N.. UNC-CH School of 
Nursing, Chapel Hill 27514 

April 9 

Gastroduodenal Ulcerations — Joseph W. Hooper Memorial Lec- 
tures 

Sponsors: North Carolina Chapter of the American College of Sur- 
geons and the Joseph W. Hooper Memorial Tmst 

Place: Blockade Runner. Wrightsville Beach 

For Information: J. S. Mitchener. Jr.. M.D.. P. (J. Box 1599, 
Laurinburg 2X352 

April 9-10 

Second Annual Arthntis Symposium 

Fee: $50 

Credit: 11 hours; AAEP credit applied for 

For Information: Oscar L. Sapp. Ill, M.D.. Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 

April 910 

Practical Pediatrics 

Fee: $35 

Credit: 9 hours; AAEP credit applied for 

For Information: Emery C. Miller. M.D.. Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine. 
Winston-Salem 27103 



1976. "Pulmonary 



April 22 

New Bern Annual Medical Symposium 

Medicine" 
Place: Ramada Inn. New Bern 

Sponsor: Craven - Pamlico - Jones County Medical Society 
Credit: 5 hours; AAEP credit applied for 
For Information: Zack J. Waters. M.D.. Box 10X9. New Bern 2X560 

April 22-24 

Behavioral Approaches to Medical Practice 

Place: Governor's Inn. Research Triangle Park. Durham 

Program: Focus on "the use of behavioral techniques in treating 
obesity, fecal incontinence, insomnia, headaches, pain, al- 
coholism, urinary disorders, smoking, hypertension, asthma. 
Type-A personality, and compliance with medical regimen" 

Sponsor; Department of Psychiatry 

Fee: $200; registration limited 

Credit: 13 hours; AAEP credit applied for 

For Information: W. D.Gentry. Ph.D. or R. B, Williams. Jr.. M.D., 
Box 3264, Duke University Medical Center, Durham 27710 



M,»lRch 1976. NCMJ 



151 



April 23-24 

Second Postgraduate Course in Perinatology 

Fee: $25; registration limited to 200 

Credit: 8 hours; AAFP credit applied for 

For Information: Oscar L. Sapp, HI, M.D., Associate Dean for 

Continuing Education, UNC School of Medicine, Chapel Hill 

27514 

April 29 

Modem Management of Rheumatoid Arthritis 

Place & Time: Elks' Club, Southern Pines (Country Club of South- 
em Pines); 6:30 p.m. 

Fee: $11.50 

Credit: 2 hours; AMA Category 1; AAFP approved 

For Information: C. Harold Steffee, M.D., Moore Memorial Hospi- 
tal, Pinehurst 28374 

May 6-9 

122nd Annual Session of the North Carolina Medical Society 
Place: Pinehurst Hotel and Country Club, Pinehurst 
For Information: William N. Hilliard. Executive Director, North 
Carolina Medical Society, Box 27167, Raleigh 27611 

May 7-9 

Pulmonary Infections in Pediatric Patients 
Place: Quail Roost Conference Center, Rougemont 
Registration: Limited to 50 participants 
Credit: 1 1 hours; AAFP credit applied for 

For Information: Alexander Spock, M.D., P.O. Box 2994. Duke 
University Medical Center, Durham 27710 

May 12-13 

Breath of Spring '76: Respiratory Care Symposium 

Fee: $25 

Credit: 12 hours; AAFP credit applied for 

For Information: Emery C. Miller, M.D., Associate Dean for Con- 
tinuing Education, Bowman Gray School of Medicine, 
Winston-Salem 27103 

May 20-22 

National Conference — Daycare for Older Adults: The New Mo- 
dality 

Sponsor: Older American Resources and Services Program. Center 
for the Study of Aging and Human Development 

Credit: AAFP credit applied for 

For Information: Dorothy Heyman, Executive Secretary. Box 
3003, Duke University Medical Center, Durham 27710 

May 26 

Recent Trends in Therapy of Myocardial Infarction Including Ef- 
forts to Limit the Size of Myocardial Infarction 

Place and time: Elks' Club. Southern Pines, (Country Club of 
Southern Pines); 6:30 p.m. 

Fee: $11.50 

Credit: 2 hours; AMA Category 1; AAFP approved 

For Information: C. Harold Steffee, M.D.. Moore Memorial Hospi- 
tal, Pinehurst 28374 

May 27-28 
The 27th Scientific Sessions and Annual Meeting of the North 

Carolina Heart Association 
Place: Benton Convention Center and the Winston-Salem Hyatt 

House, Winston-Salem 
Sponsors: The North Carolina Chapter of the American College of 

Cardiology will be one of the co-sponsors of the sessions, and will 

hold its sessions, which are open to all physicians, on May 28. 

Special concurrent sessions will be held for nurses, emergency 

medical technicians, and cardiology technologists 
For Information: Thomas R. Griggs, M.D., North Carolina Heart 

Association. P.O. Box 2408. Chapel Hill 27514 

ITEMS OF SPECIAL INTEREST 
Continuing Education for Nurses 

The following are among the courses being offered through the 
School of Nursing, UNC-Chapel Hill, during the Spring 1976 ses- 
sion: 

April 5-9 Practical Approaches to Diabetic Care 

April 20-21 Primary Nursing 

April 26-30 Nursing Process 

April 29 Toward More Effective Diabetic Teaching 

May 25-26 Results-C'riented Pert'ormance-Evaluation 
James M. Johnston Awards are available to help with tuition. Credit 
will be offered for each course. All of the courses listed above will 



152 



BRIEF SUMMARY OF \ 

PRESCRIBING INFORMATION 
ANTIMINTH " (pyrantel pamoate) 
ORAL SUSPENSION 

Actions. Antimmth (pyrantel pamoate) has 
demonstrated anthelmintic activity against 
En'.erobius vermiculaTis (pin worm) and As- 
cans lumbricoides (roundworm). The anthel- 
mintic action is probably due to the neuro- 
muscular blocking property of the drug. 

Antimmth is partially absorbed after an oral 
dose. Plasma levels of unchanged drug are 
low. Peak levels (0.05-0. 13/xg/ml) are reached 
in 1-3 hours. Quantities greater than 50% of 
administered drug are excreted m feces as 
the unchanged form, whereas only 7% or less 
of the dose is found in urine as the unchanged 
form of the drug and its metabolites. 
Indications. For the treatment of ascariasis 
(roundworm infection) and enterobiasis (pin- 
worm infection). 

Warnings. Usage in Pregnancy: Reproduction 
studies have been performed in animals and 
there was no evidence of propensity for harm 
to the fetus. The relevance to the human is not 
known. 

There is no experience in pregnant women 
who have received this drug. 

The drug has not been extensively studied 
in children under two years; therefore, in the 
treatment of children under the age of two 
years, the relative benefit/risk should be con- 
sidered. 

Precautions. Minor transient elevations of 
SGOT have occurred in a small percentage of 
patients. Therefore, this drug should be used 
with caution m patients with preexisting liver 
dyslunction. 

Adverse Reactions. The most frequently en- 
countered adverse reactions are related to the 
gastrointestinal system. 

Gastrointestinal and hepatic reactions: an- 
orexia, nausea, vomiting, gastralgia, abdomi- 
nal cramps, diarrhea and tenesmus, transient 
elevation of SGOT. 

CNS reactions: headache, dizziness, drowsi- 
ness, and insomnia. Skin reactions: rashes. 
Dosage and Administration. Children and 
Adults: Antimmth Oral Suspension (50 mg of 
pyrantel base/ml) should be administered in a 
single dose of 11 mg of pyrantel base per kg 
of body weight (or 5 mg/lb.); maximum total 
dose 1 gram. This corresponds to a simplified 
dosage regimen of 1 ml of Antimmth per 10 lb. 
of body weight. (One teaspoonful=5 ml.) 

Antimmth (pyrantel pamoate) Oral Suspen- 
sion may be administered without regard to 
ingestion of food or time of day, and purging 
is not necessary prior to, during, or after ther- 
apy. It may be taken with milk or fruit )uices. 
How Supplied. Antiminth Oral Suspension is 
available as a pleasant tasting caramel- 
flavored suspension which contains the equiv- 
alent of 50 mg pyrantel base per ml supplied 
in 60 ml bottles and Unitcups'" of 5 ml in pack- 
ages of 12, 

ROGRIG <S^ 

A division of Pfizer Pfiarmaceuticais 
New York, New Yorl< 10017 



Vol. 37, No. 3 






eliminates Pi nworms and Roundworms with a single dose 



■ Single dose effectiveness against 
both pinworms and roundworms— 

The only single-dose anthelmintio effective 
against pinworms and roundworms. 

■ Nonstaining— to oral mucosa, 
stomach contents, stools, clothing or linen. 

■ Well tolerated — the most frequently 
encountered adverse reactions are related 
to the gastrointestinal tract. 



■ Economical — a single prescription 
will treat the whole family. 

■ Highly acceptable - pleasant tasting 
caramel flavor. 

■ Convenient — just 1 tsp. for every 

50 lbs. of body weight. May be taken with- 
out regard to meals R09RIG #g> 

or lime OI aay. ^ division of Rizer Pharmaceuticals 

New York, New York 10017 
Please see prescribing mtoimation on lacmg page. NSN 6505-00- 143-6967 



Antiminth 



ORAL 
SUSPENSION 



(pyrantel pamoate) equivalent to DUn^g pyrantel/ml 



be held in Carrmgton Hall, School of Nursing, UNC-CH. 

For additional intormation write; Continuing Education Program. 

School of Nursing. University of North Carolina, Chapel Hill 27514 

PROGRAMS IN CONTIGUOUS STATES 
May 3-5 

The 1976 Southeast Emergency Medicine Congress 
Place: Fairmont Colony Square Hotel. Atlanta. Georgia 
Sponsors: The Southeast Chapters of the American College of 
Emergency Physicians; Medical College of Georgia School of 
Medicine in conjunction with the Emergency Department Nurses 
Association 
Fees; $100(ACEP), $12.5 (Non-ACEP Physician). $40(EDNA). $50 
(Non-EDNA Nurse), $40 (Registered EMT). $50 (Non- 
Registered EMT). $25 (Residents. Interns. Medical & Nursing 
Students with Letter from department chief). $100 (EMS Ad- 
ministrators with letter on EMS System stationery), $125 
(Others). 
For Information: Registrar, 1976 Southeast Emergency Medicine 
Congress, 1919 Beachway Road. Suite 5C, Jacksonville, Florida 
32207 

May 10-13 

The Frontiers in Cardiology 

Place: Royal Coach Motor Hotel, Atlanta. Georgia 

Sponsors: Council on Clinical Cardiology, American Heart Associ- 
ation; Department o{' Medicine. Emory University School of 
Medicine in cooperation with the Georgia Heart Association 

Fee; ACC members $125; non-members $175 

Credit: AMA Category 1 

For Information: Miss Mary Anne Mcinemy. Director. Depart- 
ment of Continuing Education Programs. American College of 
Cardiology, 9650 Rockville Pike. Bethesda. Maryland 20014 

May 21-22 

Clinical Rheumatology for the Practicing Physician 

Place: Bonhomme Richard Inn. 5(K) Merrimac Trail. Route 143. 

Williamsburg. Virginia 
SfKinsors: Virginia Chapter of The Arthritis Foundation; Virginia 
Regional Medical Program; Medical College of Virginia — Vir- 
ginia Commonwealth University; University of Virginia School 
of Medicine; Eastern Virginia Medical School 
Fee: $25 

Credit: 8'/4 hours; AMA Category I; AAFP credit applied for 
For Information; Department of Continuing F^ducation. School of 
Medicine. Medical College of Virginia. P.O. Box 91. Richmond. 
Virginia 2329X 

Medical College of Virginia 

The number in parenthesis, following the title, indicates the 
number of hours for that particular course. 

April 1 Pediatric Cardiology for the Practicing Physician 

(4) 
April 22 Medico-Legal Workshop (5) 

(Place: Virginia Baptist Hospital. Lynchburg. 
Virginia) 
May 17-lS EFIG Symposium ( 14) 

May 21 Annual Spring Forum for Child Psychiatry (4) 

June 2 Pediatric Nephrology for Practicing Physicians (4) 

For further information on the above CME opportunities write to 
the Department of Continuing Education. School of Medicine. 
Medical College of Virginia, Box 91, Richmond. Virginia 23298 



The Items listed in this column are for the six months immediately 
following the month of publication. Requests for listing should be 
received by WHAT? WHEN'' WHERE'. P.O. Box 15249. 
Durham. N.C. 27704. by t'le 10th of the month prior to the month in 
which they are to appear, A "Request for Listing" form is available 
on request. 



154 



News Notes from the — 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



lisel' 



tee 



Of.Tt 






Dr. E, Ted Chandler, an internal medicine specialis 
in Hickory, has been selected as the medical directo 
for the Reynolds Health Center in Winston-Salem. 

The Bowman Gray School of Medicine has a| 8«'l 
agreement with the Forsyth County Commissioners t 
be responsible for professional services at th 
Reynolds Health Center. 

Chandler is a 195 1 graduate of Wake Forest College 
and holds the M.D. degree from the University o 
North Carolina School of Medicine. He took internifcfcii 
ship and residency training at Norlh Carolina Baptisi 
Hospital. 

He is a member of the Board of Trustees of Nortl 
Carolina Baptist Children's Home and the Board o 
Advisors of Mars Hill College. 



Dr. Zelma A. Kalnins. directorof the Bowman Gra 
Cytotechnology Program, has retired after 20 years oi 
the medical school faculty. 

She has served as director of the Clinical Cytolog; 
Laboratories at the medical center and director of the 
Cytotechnology Program since 1969. 

Dr. Kalnins. an associate professor of patholog; 
and an associate professor of community medicine 
(allied health), was honored during a January dinne 
by her colleagues, friends and former students. 

A native of Riga. Latvia, Dr. Kalnins received thd 
M.D. degree from the University of Latvia. She camf't'A 
to the United States in 1951 and was appointed to th(J»e 
Bowman Gray faculty in 1955 following three years o! w 
fellowship training in cytology. ; Piii 

nilf 
in 

Dr. Charles A. Duckett, associate professor of famj ife 
ily medicine, has been elected president-elect of tha !1( 
Nonh Carolina Academy of Family Physicians 



Dr. Donald M. Hayes, professor and chairman o1 
the Department of Community Medicine, has beerj 
appointed chairman of a new Advisory Committee oil 
Childhood Cancer being formed by the North Caroline 
Division of the American Cancer Society. 



Dr. Cornelius F. Strittmatter, professor and chair 
man of the Department of Biochemistry, has beer 
appointed to the Council of Academic Societies of the 
Association of American Medical Colleges as a rep 
resentative of the Association of Medical School De 
partments of Biochemistry. 

Vol. 37. No. 3 



liiti 



Dr. Thomas H. Clark, associate professor of sociol- 
gy. has been elected president-elect for 1976 of the 
Jorth Carolina Association of Marriage and Family 
ounselors. 



Dr. James F. Martin, professor of medical sonics. 
as been re-elected secretary for the American 
Roentgen Ray Society. 



Dr. Jesse H. Meredith, professor of surgery, has 
een elected vice chairman of the Committee for 
!ommission on Health Services for the State of North 
larolina. 



Helen P. Vos. assistant professor of community 
ledicine. has been re-elected chairman of the Ameri- 
an Association of Nurse Anesthetists Council on 
tactice. 



News Notes from the— 

UNIVERSITY OF NORTH CAROLINA 

DIVISION OF HEALTH AFFAIRS 



ipp<>intnu'nts 

Wiley M. Sams Jr.. professor of the department of 
ermatology. will join the faculty after heading the 
ivision of dermatology at the University of Colorado 
ledical Center. He holds the B.S. degree from the 
Jniversity of Michigan and the M.D. degree from 
imory University. 

Peter Curtis, assistant professor, department of 
amily medicine, has been in general practice in Win- 
hester. Hants. England since 1963. He was a visiting 
irofessor at UNC in 1973. He holds the M.B. and 
4.R.C.P. from the University of London. 

Connie J. Evashwick, assistant professor, depart- 
nent of hospital administration, spent the past year as 
I program specialist in medical care for the Mas- 
achusetts Department of Public Health m Boston, 
ihe holds the A.B. and M.A. from Stanford Univer- 
.it\ and the M.Sc. and D.Sc. from Harvard School of 
\jblic Health. 

Gary B. Mesibov. assistant professor of psychol- 
ogy, department of psychiatry, also will be clinical 
.cientist inthe Biological Sciences Research Center of 
he Child Development Institute. A graduate of Stan- 
brd University, he received the M.A. from the Uni- 
/ersity of Michigan and the Ph.D. from Brandeis Uni- 
/ersity. Since 1974 he has been a postdoctoral fellow 
n the UNC division for disorders of development and 
earning. 



Fnmiofion 

Archie T. Johnson Jr. and Martha K. Sharpless. 
department of pediatrics, have been promoted to the 
rank of associate professor. 



Leaves of Absence 

Richard V. Wolfenden. professor, department of 
biochemistry and nutrition, will do experimental work 
at Oxford University and the University of Lund 
while on leave from Jan. 1-June 30. 1976. 

Marshall H. Fldgell. associate professor, depart- 
ment of bacteriology, began a one-year leave Feb. 1 to 
pursue studies in the laboratory of Dr. Philip Leder. 
Laboratory of Molecular Genetics. National Institute 
of Health and Human Development, in Bethesda. Md. 

George M. Himadi. associate professor, depart- 
ment of radiology, began a si.x-month leave Jan. 1. 
The first three months he studied fungus diseases of 
the Southwest at the University of Arizona and was 
involved in medical student teaching and the evalua- 
tion of teaching methods. In April he will be at the 
University of Washington in Seattle to observe 
radiological teaching approaches for medical stu- 
dents. 

Mohammad R. Habibian. assistant professor, de- 
pailment of radiologv . School of Medicine, is on leave 




EMERGENCY ROOM 
PHYSICIANS 

Richland Memorial Hospital, a 650 bed gen- 
eral hospital and regional emergency care 
facility serving the Midlands, offers full time 
physicians eligible for S.C. licensure: 

• excellent salary and fringe benefits 

• professional growth opportunity through 
continued education 

• top flight specialty support in family prac- 
tice, general surgery and sub specialties, in- 
ternal medicine, and pediatrics 

• modern facilities and equipment 

• medical university affiliation 

Contact: 

Daniel Love, M.D. 

Director, Emergency Services 

(803) 76S-6861 
Richland Memorial Hospital 



'Iarch 1976. NCMJ 



155 



until Aug. 1, 1976, to establish a nuclear medicine 
facility at a university in Iran, his native country. 



Joseph J. Bonanno. assistant professor, department 
of radiology. School of Medicine, resigned Dec. 31 to 
enter private practice in Phoenix, Ariz. 



The North Carolina National Bank recently pre- 
sented a $2,500 check for the N.C. Jaycee Burn 
Center, to be built at N.C. Memorial Hospital in 
Chapel Hill. 

Charles Roupas, city executive of NCNB in Chapel 
Hill, presented the check, which is part of the bank's 
$10,000 pledge. 

When completed, the Burn Center will be the only 
major center of its kind in the Carolinas. It will offer a 
full range of treatment and services for seriously 
burned patients, which now number about 500 each 
year in North Carolina alone. Plans call for a 24-bed 
center with nursing facilities, supporting laboratories, 
physical therapy areas, social service space and teach- 
ing and conference rooms. 



Dr. John K. Spitznagel of the University of North 
Carolina School of Medicine at Chapel Hill has been 
elected chairman of the division of immunology of the 
American Society of Microbiology. Spitznagel, pro- 
fessor of bacteriology and immunology at UNC-CH, 
will begin his one-year term on July 1. 



Dr. Donal Dunphy of the University of North 
Carolina School of Medicine at Chapel Hill has been 
named to the Board of Directors of the American 
Board of Family Practice (ABFP). Dunphy, acting 
chairman of family practice and professor of pediat- 
rics, will represent the American Board of Pediatrics 
during his five-year term on the ABFP board. 



LeRoy D. Werley Jr. has been named acting dean of 
the University of North Carolina at Chapel Hill School 
of Pharmacy. 

Werley has served as assistant dean since 1967. 

Dean Werley is a graduate of the University of 
Maryland School of Pharmacy and holds a master's 
degree in hospital administration from the University 
of Minnesota. 



A series of workshops on public and mental health 
law was presented throughout the state in January and 
February by the University of North Carolina at 
Chapel Hill. 

Sponsored by the UNC School of Public Health and 
Institute of Government, the course introduced public 
and mental health personnel to the legal system and 
current legal issues in the health field. Areas cov- 



ered included consent to treatment, access to publi iiil'P'^ 
and client records and public officials" liability. fc^ 

llie';l 

ional 



Dr. Naomi Morris, professor and chairman of tf 
maternal and child health department at the UNi, 
School of Public Health, participated in a series cl'^' 
workshops at the Greater Baltimore Medical Centei *^J 
She was invited to be on the resources panel for t 
workshops which studied the ambulatory care of chi 
dren. 



h *"i 



ibec 
jorci 



News Notes from the— 

DUKE UNIVERSITY MEDICAL CENTER 



Over the past 18 months. 10,000 women have bee 
checked at the Breast Cancer Project, ajoint ventur 



lew 



iluce 

of Duke, the National Cancer Institute and the Ameri ujs 
can Cancer Society. i.'\' 

Of that number, 33 women were discovered to havfiss. 
cancer 

In only five of the 33 had the disease spread beyom 
the breast, according to Dr. Josephine Newell, projec' 
coordinator. That means that 28 women — 85 per cen 
— had their cancer detected at a stage when "it 
highly curable," Dr. Newell said. 



A research team at Duke has identified the firs 
known lipid (fat) molecule that serves as a trigger tt 
attract disease-fighting white blood cells to the site o 
body injury. 

It is a small molecule called HETE (L2-hydrox; 
eicosotetraenoic acid). The identification of it 
makeup and behavior could have far-reaching benefit: 
in the understanding and control of human disease. 

The discovery came as a result of research into thi 
process known as chemotaxis, which is the reaction o 
living cells being either attracted to or repelled by ; 
chemical stimulus. 

The reaction — or message — sets in motion th 
body's initial response to injury, and is critical in tht 
defense against infection. White blood cells are sum 
moned to the point of injury where they attack an(^ 
destroy intruding bacteria. 

The team, headed by Dr. William S. Lynn, profes 
sor of medicine and associate professor of biochemis 
try, reported the discovery in "Nature," an English 
scientific journal with international circulation. 



If heart disease among aggressive, highly competii 
tive, easy-to-anger persons is to be reduced, they musj 
learn how to relax. 

That is the conclusion reached by a Duke psychial 
trist who is the chief investigator in a continuing re-( 



156 



Vol. 37. No. J, ' 



;arch program into the effects of a person's beha\ ior 
ii his heart. 

The ""Type A"' — oraggressive — personality is the 
cus of the investigation because it is he — or she — 
ho is most likely to suffer a heart attack. 
"What v\e"ve got to do nov\ is show that Type A 
■rsonality can be changed. And then we've got to 
1 ahead and change it." said the investigator. Dr. 
:dford B. Williams Jr.. associate professor of 
.ychiatry. 

Williams believes that if a person's behavioral traits 
in be changed, that will be proof that behavior is a 
ajor contributor to the problem. 
The principal method to be empKned in the effort is 
ofeedback training, a technique b\ \s hich a patient is 
ught to monitor the electronic impulses of his brain 
id heart. Through sensors attached to his body he is 
)le to pinpoint muscle tension. 
■"Basically." Williams said, "vse want to teach 
;ople to relax. Through biofeedback we can shov\ 
em where the tension is. and if the\ can learn to 
duce it — perhaps by thinking about pleasant 
ings — then they can learn to do the same thing in real 
e." when they are confronted with problems of 
ress. 



With the opening of a new inpatient unit of Duke 



Hospital, located in the Durham Rehabilitation Center 
building at .^100 Hrwin Road. Duke's total bed capac- 
ity stands at 895. 

The new unit has no connection with the rehabilita- 
tion center, which is a private nursing home, but space 
is leased there. 

The Duke portion includes an annex of the Surgical 
Private Diagnostic Clinic, housing the offices of or- 
thopaedic surgeons Drs. Frank Bassett and Frank 
Clippinger; a surgical inpatient unit; the Inpatient Re- 
habilitation L'nit; and the Sports Medicine Program. 

The new complex is being called Duke Hospital 
West. 



The Fannie E. Rippel Foundation has awarded a 
second S50. 000 grant to Duke in support of the "Com- 
puterized Textbook of Medicine" project. 

Researchers here are computerizing detailed diag- 
nostic and treatment information of cases involving 
coronary heart disease. As a result, they can identify 
from the computer patients whose case profiles most 
nearly match the particular case at hand. 

An initial S5(). 000 grant from the Rippel Foundation 
in 1974 helped to establish a special coronary follow- 
up clinic, the major source of information being com- 
piled in the "textbook." 




Ifoiir son 
isn't thinking 

about grad school 
yet. 

But you should be. 



Cjiculuato school is the farthest thing t'roiii a uuin^; ho\ s mind — 
)ut in only a few \ears It may be uppermost \'ou should be planning 
etlucational o|j|)ortunities for \our son now that w ill kee|j open for 
hinA eveiA' o[)tlon 

A strong academic foundation is essential to successful higher 
tlucatlon Will his educational needs be met localK''' If \ou haw 
an\ doubts, and man\ parents do. we in\ Ite you to consider 
a l)oarding school .Asheville School provides an atmo- 
sphere in which academic excellence is expected — 
and respected We can help \our son fulfill his 
i-lreams — and your dreams for him For informa- 
tion write 

The Asheville School 

ti\ort;[t 1 Ciourle\ 
' Director of Admissions 
Asheville. N C 2««nfi 



Urch 1976. NCMJ 



1.^7 



Dr. Robert E. Fellows of Duke will become head of 
the Department of Physiology and Biophysics in the 
Universtiv of Iowa College of Medicine, effective 
July 1. 

A native of Syracuse, N.Y., the 42-year-old Fellows 
earned A.B., M.D. and Ph.D. degrees at Hamilton 
College, McGill and Duke Universities, respectively; 
held an internship and residency in internal medicine 
at The New York Hospital, and a second residency at 
Royal Victoria Hospital in Montreal. 

He has taught and directed research as a full-time 
faculty member here since 1966. He is an associate 
professor of physiology and pharmacology. 



The American Cancer Society has granted $135,000 
to help a Comprehensive Cancer Center scientist 
search for human cancer viruses. 

The scientist. Dr. Dani P. Bolognesi, heads the 
Cancer Center's Surgical Tumor Virus Laboratory 
and is an associate professor of surgery at the medical 
center. The award will support his salary for five 
years. 

ALPHA EPSILON DELTA 

Robert L. Garrard, M.D.. of Greensboro and Chris- 
topher D. Fordham, 111, M.D., dean of the University 
of North Carolina School of Medicine, will be on the 
program when Alpha Fpsilon Delta holds its national 
convention March 31-April 3, at the University of 
Alabama, Tuscaloosa. The honor society was founded 
on the Alabama campus 50 years ago. 

Dr. Garrard, a founding member and the second 
national president, will speak at a Founders Lun- 
cheon. Dr. Fordham will participate on a panel with 
David Mathews, Secretary of Health, Education and 
Welfare, and others discussing "Health Care in the 
Next Decade." 

The honor society for students interested in careers 



in the health professions has 1 12 college and unive 
sity chapters. About 350 students, faculty advisoi 
and alumni are expected at the convention. 

NORTH CAROLINA ACADEMY OF 
FAMILY PHYSICIANS 

The North Carolina Academy of Family Physician 
has named Edwin P. Davis of Raleigh as executiv 
director. 

Davis, 43, is a native of Roanoke, Va., and bnngst 
the academy some 15 years' experience in profesj 
sional association management. His last post in Nortl|„^jj 
Carolina was as executive director of Professiona 1 ^ 
Engineers of North Carolina. Before moving U n ^,, 
Raleigh in 1965, Davis managed three local chamber 
of commerce in Virginia and served as director o 
public affairs and legislative research for the Virgini; 
State Chamber of Commerce for three years, 

Davis is a 1955 graduate of Virginia Polytechnii "n 
Institute with a degree in business administration am 
is married to the former Mildred Smith, a registerec 
nurse who is operating room supervisor at Wake Med 
ical Center in Raleigh. They have two children. 



(iieir 
Hilves 



PIEDMONT OB-GYN SOCIETY 



The first quarterly meeting of 1976 of the Piedmoii 
Ob-Gyn Society was held at the Catawba Countr 
Club on January 13. Twenty members and their wive, 
attended. The scientific program was presented by Dr 
Ernest Franklin, a specialist in gynecologic cancer a 
Crawford Long Hospital in Atlanta. A yoga demon 
stration was presented for the wives. Dr. Pau 
Kearnes of Statesville, president, welcomed th 
guests: Dr. Alan Huffman. Jr.. of Hickory, and Dr 
Norman Cohen of Winston-Salem. A new memberi 
Dr. Tom Thurston of Salisbury, was presented to th^ 
group. j 



Met 
tl 
Ike 
it; 
sspli 
'ord 

:lid 

leas 



■I 
IF 

!i;al: 



Instead ot sound sleep, the Gourmand experiences much restlessness, and what is called //</i,'('r,v. 
through the night — or, if he sleeps, alarms his neighbours with the stifled groans of the night-mare. In the 
morning, we perceive some of those sympathetic effects on other parts of the system, which, at a later 
period of the career of intemperance, play a more important part in the drama. The head aches — the 
intellect is not clear or energetic — the eyes are muddy — the nerves are unstrung — the tongue is furred — 
there is more inclination for drink than food — the urinary secreation is turbid, or high-coloured — and the 
bowels very frequently disordered, in consequence of the irritating materials which have passed into the 
intestinal canal impertectly digested. This can hardly be called a fit of indigestion, though, even here, we 
find many of the leading phenomena which afterwards harass the individual w ithout such provocation. It 
is a fit of repletion, or tnlcmperance. . . . — An Essay on IndiKfslion: or Morbid Si'nsihility oj the 
Stomach rf; Bowels. James Johnson, 1836, p 23. 



MS 



lie 



(pula 
'Sei 



ik 



w 

ill! 
lii 
iOl: 



158 



Vol. 37, No. 3 



tii 



Month in 
Washington 



: 



President Ford's all-out attack against rising gov- 
■nment spending sustained a major blow with the 
ongressional override of his \eto ot" a S4s biihon 

lalth. v\elfare and labor bill. 

The vetoed bill called tor SI b:llion more than the 
dministration"s budget request and required hiring 
' 8.000 more Health. Education. Welfare Depart- 
ent employees. Almost S800 million ot the mcrease 
volves health programs \v hich would receive a total 
■ $3.9 billion for the fiscal \ear that ends September 
). 

Both houses of Congress exceeded the two-thirds 
)te necessary to override a veto. The tally v\as 310 to 
13 in the House: 10 to 24 in the Senate. 

The .Administration defeat came despite a last- 
linute administration offer to compromise by more or 
ss splitting the difference fora S.^00 million increase. 

Ford had said in his veto message the bill was "a 
assic example of unchecked spending." But Demo- 
ats charged the money measure would cut spending 
slow last year's level and not meet intlation-caused 
icreases. 

The bill provides more funds for such programs as 
!ommunity Mental Health Services, Maternal and 
!hild Health, medical research. Alcoholism and Drug 
.buse Facilities. Emergency Medical Services, and 
iucation of health professionals. 

The Congressional vote was preceded by all-out 
•"fforts on both sides to line up votes and by vigorous 
)bbying from affected outside groups. 

The HEW money bill is considered the hardest to 
ote against in Congress because of the multitude of 
opular programs funded. Asked how the House was 
ble to muster such a vote to override including dissi- 
ent Republicans. House Majority Leader. Thomas 
)"Neill. Jr.. (D-Mass.) replied simply, '"the coming 
lection."" 

House Majority Whip. Representative Robert 
lichel. (R-lll.) told the house in the debate that it 
ould be ""setting the spending tone for the session."" 



Officials of the .American Medical Association have 
let with President Ford and his top health officers to 
iscuss a wide range of health topics including the 
idministration's new health proposals and federal 
egulation problems worrying the physicians of the 
ountry. 

The 45-minute meeting in the Cabinet Room at the 
Vhite House was described by participants as 
'iendlv. ""The President listened w ith interest to w hat 



v\e had to say and his attitude seemed to be sympathet- 
ic."" said .AMA President. Max H. Parrott. M.D. 

Dr. Parrott said President Ford noted the pressures 
he is facing to take positions that might disturb some 
physicians. The Chief Executive made a point of urg- 
ing the AM.A and members of his Administratiitn and 
White House staff to confer often to resolve differ- 
ences. 

Among the subjects discussed were the President's 
State of the Union and Budget Health Proposals, gov- 
ernment regLilations affecting physicians, the Federal 
Trade Commission move toallov\ physicians to adver- 
tise, costs of medical care, and medical manpower. 

Present for the AMA. in addition to Dr. Parrott. 
were Raymond T. Holden. M.D.. Chairman of the 
.AM.A Board of Trustees: Richard E. Palmer. M.D.. 
AMA President-Elect: .lames H. Sammons. M.D.. 
Executive Vice President of the AMA: and Joe Miller. 
Deputy Assistant Executive Vice President. 

President Ford was told that his recommended an- 
nual four percent limit on physician reimbursement 
increases under Medicare poses real problems with 
the medical profession which must adjust to higher 
costs of doing business yearly as well as the ever- 
climbing costs of professional liability insurance. 

Ford indicated he understood the viewpoint of the 
profession on the matter and proposed that .Adminis- 
tration officials and .AMA representatives meet fur- 
ther on the issue. 

The AMA delegation told Ford about the AMA's 
National Commission on the Cost of Medical Care and 
invited the President to appoint a representative of his 
Administration to serve as a member. 

There was considerable talk about the supply of 
physicians, with President Ford evincing special in- 
terest in the Foreign Medical Graduate situation and 
the problems of .Americans studying medicine abroad. 
The AMA officials described the increasing numbers 
of young physicians entering primary care, now 5S 
percent. 

The AMA's support of the National Health Service 
Corps as a principal means of helping physician-shoil 
areas was outlined. The voluntary incentives in this 
program were compared with the ""indentured ser- 
vice" aspects of health manpower legislation before 
Congress that would compel young physicians to 
serve or to repay the government for federal aid 
received by medical schools. 

In reply to a question from Ford, the AMA dele- 
gates noted the organization's support of federal med- 
ical scholarships. 



/Urch 1976. NCMJ 



159 



The controversial Utilization Review Regulations 
were talked about. HEW Secretary Mathews was 
complimented by the delegation for his reasonable 
approach and w illingness to work with the profession 
to reach agreement on these rules. 

President Ford was told that the AM A could find no 
scientific basis for the disputed Maximum Allowable 
Cost proposals for Medicare-Medicaid outpatient 
drugs. The MAC plan could lead to interference in the 
practice of medicine by restricting the physicians" 
prescribing scope and could hurt the quality of health 
care, the AMA officers said. 

The FTC suit to overturn the AMA ban on physician 
advertising will be contested in court, the AMA as- 
serted. The AMA was founded in part to do away with 
abuses of charlatans and advertising of physicians" 
services, the Chief Executive heard. 

The President sought support for his health pro- 
grams and expressed confidence the Administration 
and the representatives of the medical profession 
could work together to iron out differences and reach 
accommodations. 



Mandatory second professional opinions have been 
urged for elective or non-emergency surgery under 
Medicare and Medicaid by a House Commerce Sub- 
committee. 



The Subcommittee on Investigations and OverL>'f- 
sight, which held hearings last fall on unnecessante 
surgery, charged in a report that there were an esti .icf 
mated 2.4 million unnecessary surgeries performed ii 
1974 at a cost to the public of almost S4 billion. Thi 
procedures led to an estimated 700 deaths, the repor ugis 



said. 



jiizali 



Contending that second consultations could cu 
down "significantly"" on unneeded surgery, the Sublif 



Edga 
JlVs 

;jiit 



committee, headed by Representative John Mos; 
(D-Calif. ) said "such a program would save the gov 
emment millions of dollars." 

Arguments that second opinions would cost mone;^ 
and not necessarily provide a solution and expert as 
sertions that it is difficult to determine what consti; :\' 
tutes unnecessary surgery were brushed aside by th( Ihe- 
Subcommittee in its strongly-worded report. . -Min 

The report said the lawmakers were impressed witlj «jiiia 
evidence "that prepayment plans for consumers anc -S 
salaried surgeons help reduce surgery in equivoca 
situations." , 

"Evidence was compiled in the Subcommittee": 
investigation that the fee-for-service mechanism o; 
surgical payment encourages surgery in questionabit 
situations,"" the report said. '"An in-depth study of this 
should be undertaken" by the HEW Department. 

The Subcommittee recommended that HEV, 
immediately undertake a studv to determine the dif 



iei 
Or.: 



A unique hospital specializing in treatment of . 

ALCOHOLISM 
DRUG ADDICTION 



In this restful setting away from pressures 
and free from distractions, the Willingway 
staff, with understanding and compassion, 
carries out an intensive program of 
therapy based on honesty and responsi- 
bility. The concepts and methods are ori- 
ginal, different and have been highly suc- 
cessful for fifteen years. 

John Mooney, Jr.. M D., Director 
Dorothy R Mooney, Associate Director 



CAi/iiltMC|^vau|^ iTTo^*>*taX 



311 JONES MILL RD. STATESBORO, GA. 30458 TEL. (912) 764-6236 

■■■^■IHHBHHHHHHHI ACCREDITED BY THE J. C. A. H. 

160 Vol. 37. No. ^ 




ijiil 



Ml 



■rences in health indices, costs and the surgical pro- 
jdure rates between salaried surgeons and tee-for- 
,'r\ ice surgeons. 



. Legislation to amend the Health Maintenance Or- 
anization (HMO) program ■■v\ould effectively gut the 
IMC) concept and subvert the original intent of the 
rogram.'" the .AMA has told the Senate. 

EdgarT. Beddingfield. M.D.. Vice-C'hau-man of the 
,MA's Council on Legislation, said the House passed 
IMO amendments "remove imponant comprehen- 
ive services and eliminate characteristics which dis- 
nguish the HMO from other prepaid group prac- 
ces." 

The .A.\LA \\ itness testified on the final day of hear- 
:gs on changes in the HMO program. The House bill 
iliminates many of the benefits stipulated in the origi- 
'al HMO bill and makes other changes designed to 
lake it easier to set up and operate such pre-paid 
ealth systems. 

Dr. Beddingfield said the House bill in effect con- 
erts a demonstration health delivery program into a 



mechanism for the federal funding of ordinary prepaid 
groups. 

■"if in fact the HMO is to be no different from 
prepaid groups which have existed without federal 
funding, then we submit there is no Justification for 
federal funding under the guise of experimentation or 
otherwise."" 



Congress has buttressed the medical and hospital 
professions" case against the Utilization Revievs Regu- 
lations originalh promulgated by HEW. 

The lawmakers approved with no dissent a provi- 
sion making it clear that Congress never intended to 
require 100 percent review of all Medicare-Medicaid 
hospital admissions, a key part of the controversial 
LiR Regulations issued by HEW. 

The AMA has challenged successfully the LR Reg- 
ulations in court. The HEW Department is slated soon 
to issue revised regulations after court-ordered 
negotiations with the AMA. 

One of the major arguments against the Regulations 
was that HEW had reached bevond Congress" intent 




Facility, program and environment 
allows the individual to maintain 
or regain respect and recover with 
dignity. 




Medical examination upon admis- 
sion. 




Modern, motel-like accommodations 
with private bath and individua 
temperature control. 




FELLOWSHIP HALL 

THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

TREATMENT AND LEARNING CENTER FOR ALCOHOL RELATED PROBLEMS 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit Tax-Exempt 
• A Controlled and Pleasant Psychological Atmoophere • Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



Member of; 

•The American Hospital Association 

• The l\l. C. Hospital Association 

•Accredited by the Joint Commission 

on the Accreditation of Hospitals 



individual Counseling • Group Therapy 

Nature Trail • Indoor/Outdoor Recreation 

Relaxation and Sleep Therapy 

Audio-\/ideo Therapy 



FOR ADMITFANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



FELLOWSHIP HALL mc. 

p. 0. BOX 6929 • GREENSBORO, N. C. 27405 



FOR MEDICAL INFORMATION CALL 

J. W. WELBORN. JR., M.D. 

MEDICAL DIRECTOR 

919-275-5328 



Located off U.S. Hwy. No. 29 at Hicone Road Exit 
51/2 miles north of downtown Greensboro, N. C. 



Convenient to 1-85, 1-40, U.S. 421, U.S. 220, 
and the Greensboro Regional Airport. 

FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 



M,\RCH 1976. NCMJ 



161 



in carrying out the review program. Congress" vote on 
the amendment to the Medicare-Medicaid laws ap- 
peared to back up the protests of the AMA and the 
American Hospital Association. 

Sen. Paul Fannin (R-Ariz.) told the Senate that the 
original regulations calling for direct review of each 
Medicare-Medicaid admission "is beyond the scope 
of what we intended . . ."" 

Chairman Russell Long (D-La.) of the Senate Fi- 
nance Committee said '"the idea of requiring that ev- 
erything in a claim be reviewed is not what we had in 
mind when we passed the law . It is a technical error 
that should be corrected, otherwise, there would be 
needless cost and a great deal of unnecessary paper- 
work." 



The Administration has opposed a specific exten- 
sion of the program of federal aid to states and 
localities to demonstrate ways of improving emer- 
gency medical services. 

Testifying before the Senate Health Subcommittee. 
Theodore Cooper. M.D.. Assistant Secretary for 
Health, said such assistance could be handled in the 
future under the Administration's proposed block 
grant plan to consolidate 16 existing categorical pro- 
grams. 

The so-called "Financial Assistance For Health 
Care Act" will give states and localities "the discre- 



■'Con 



tion to continue funding according to individual state 
priorities." Dr. Cooper testified. 

Legislation before the Senate to extend the prograir 
at costs ranging from $270 million to S4I6 million are 
"far in excess" of what is required to demonstrate 
effective systems for emergency medical services, 
said Dr. Cooper. 

He told the Subcommittee, headed by Senator Edi '""'O 
ward Kennedy (D-Mass.). that the HFW Departmenli "''f* 
already has ample research authority to carry out im 
provements in emergency services. 



»eilie 



^la or 
^rc£< 



Americans" health continues to improve. Lower in- 
fant death rates and longer life expectancy are shownl 
in a State of the Union's Health Report for 1975 sub-l 
mitted to Congress and President Ford by the HEW 
Department. 

Rates of infant deaths in the U.S. declined from 29. 2 
per 1.000 live births in 1950 to an estimated 16.5 im 
1974. Over the same period, life expectancy at birthi 
increased by nearly four years. The death rate for' 
heart disease is decreasing. 

"The report shows considerable achievement asi 
well as need for improvement." Theodore Cooper. 
M.D.. Assistant Secretary for Health, said. "As a 
people we are receiving more medical care now than 
10 years ago. We have made considerable progress in 



s san 
iiosi 
aisa 

"Thi 

\ipei 

.ills! 

■lid 
■iff 



"WHEN YOUR BACK FEELS GOOD YOU'LL FEEL GOOD ' 

SEALY POSTUREPEDIC 

A Unique Back Support System 

Designed in cooperation with lead- 
ing ortliopedic surgeons for comfort- 
ably firm support-"no morning 
haclvache from sleeping on a too-soft 
mattress." 




^109 

FROM MVr %^ 



95 




Twin Size 
ea. pc. 



SEALY OF THE CAROLINAS, INC. 



(a division of the 72-year old Peerless Mattress Co.) 

Asheville - Charlotte - Lexington - High Point - Greenville - Columbia 

"Sleeping on a Sealr is like sleeping on a cloud'' 



111 

318 



ssi 



162 



Vol. .^7. No. 3 



Dwering the income harrier to care. Most of lis de- 
;ribe our health as good or excellent. 

""Conversely, we may well have a higher prevalence 
f chronic diseases.'" Dr. Cooper said. "People are 
\ing to the older ages w here the\ de\elop conditions 
jch as arthritis and diabetes, and we can better man- 
ge these conditions medically. Many areas of the 
ountry appear to lack adequate supplies of health 
lanpower. and costs remain a biirden for many."" 

The report. Health. United States. 1975. includes 
ata on health care costs and tlnancing, health re- 
ources and utilization, and health status. The death 
ate for heart disease among persons aged 55-64 
ropped almost 15 percent over the past six \ears. In 
ne same age group, the death rate from cancer rose 
Imost four percent. Among younger people, acci- 
ents and homicide are major causes of death. 

"'7 he data suggest that much improvement in health 
tatus could come from individual action." Dr. 
"ooper said. ""Most death and disability from acci- 
ents are preventable, so are health conditions which 
re aggravated by excessive use of alcohol and to- 
bacco and bv lack of exercise and proper diet. The\ 
.re preventable primarily by changes in individual 
lehavior. Medical care alone can do relativelv little."' 



Representative Thomas Morgan. M.D.. Chairman 
of the House Foreign Affairs Committee, announced 
he w ill retire at the end of this session of Congress. Dr. 
Morgan, a Pennsylvania Democrat, is one of three 
physicians in Congress. Despite his Congressional 
duties. Dr. Morgan has maintained a continuous but 
small practice in his home town of Fredericktown. 
The 69-year-old physician has served in Congress for 
32 years and as Chairman of the Foreign Affairs 
Committee for IS years — longest service as Chair- 
man of any current Committee Chairman in the 
House. Dr. Morgan focused his legislative interest 
almost exclusively on foreign affairs. He seldom be- 
came involved in legislative health matters. The other 
physician-Congressmen are Representative Tim Lee 
Carter (R-Ky.) and Larry McDonald (D-Ga.). 



Out-of-town hearings on National Health Insurance 
have been slated tentatively by the House Ways and 
Means Health Subcommittee for: 

San Francisco — March 18-19: Knoxville. Tenn. 
— March 25-26: Salem, Oregon — May 6-7 and New 
Orleans — Mav 20-21. 



In iHf moriam 



Jerome Otis Williams, M.D. 

Whereas. Dr. Jerome Otis Williams has distin- 
^ished himself as pathologist and director of clinical 
aboratories at Cabarrus Memorial Hospital, as a gen- 
leman and scholar, as a master of the written as well 
is the spoken word, as a friend, teacher and investi- 
gator, as a husband and father, and 

Whereas. Dr. Williams' love of "The Arts"" and all 
things beautiful endeared him to everyone, even many 
who did not know him personally, and 

Wlwreas. Dr. Williams" leadership in medical fields 
has touched untold thousands of lives and especially 

March 1976. NCMJ 



those who have benefited from his pioneer leadership 
in the development of cancer screening for women in 
this state, and 

Whereas, all persons, young and old, w ho came in 
contact with Dr. Williams benefited from his gracious 
charm, his encouraging smile, and unselfish advice. 

Now. Therefore, he it Resolved, that the Cabarrus 
County Medical Society wishes to acknowledge the 
leadership of this man not only in the field of his 
profession, but in ""The Arts'" as well. 

Cabarrus County Medical Society 

163 



OFFICIAL CALL 
HOUSE OF DELEGATES 

pursuant to the Bylaws, Chapter IV, Section 1: 

HOUSE OF DELEGATES 
Meetings scheduled 

Dlotice to: Delegates, Alternate Delegates, Officials 
of the IVorth Carolina Uledieal Society, and Presidents 
and Secretaries of county medical societies. 

Sessions of the HOUSE OF DELEGATES will convene in 
the Cardinal Ballroom, Pinehurst Hotel, Pinehurst, North 
Carolina, at the iollowing times: 

Thursday, May 6, 1976 — 2:00 p.m. — Opening Session 
Saturday, May 8, 1976 — 2:00 p.m. — Second Session 

A member of the CREDENTIALS COMMITTEE will be present at 
the Desk in the Hotel Lobby. Thursday. May 6. 1976, from 8:30 
a.m. to 12:30 p.m. to certify Delegates. Delegates are urged to bring 
their Credential Cards for presentation at the Registration Desk. 
Delegate Badges must be worn to be seated in the HOUSE OF 
DELEGATES. 

REFERENCE COMMITTEE 
HEARINGS 

Reference Committee hearings are sche(Ude(l to begin Friday. May 7. 1976. at 2:00 p.m. 



James E. Davis. M.D.. President 
Chalmers R. Carr, M.D., Speaker 
E. Harvey Estes. Jr.. M.D., Secretary 
William N. Hilliard. Executive Director 

164 Vol. 37. No. 3 , \k 



Program 



122nd ANNUAL SESSION 

May 6-9, 1976 

NORTH CAROLINA MEDICAL SOCIETY 

PINEHLRST HOTEL 

PINEHURST. NORTH CAROLINA 

Thursday, Mav 6, 1976 

9:00 a.m.-vOO p.m. — AUDIO-VISUAL PRO- 
GRAM — (HMS Bounty) 

0:00 a.m.- 1:00 p.m. — Section on Urology Meeting 
— (Disco Room) 

2 Noon-l:45 p.m. — Section on Ophthalmology 
Luncheon — (Crystal Room) 

2:00 p.m. — Section on Ophthalmology Meeting — 
(Disco Room) 

2:00 p.m. — HOUSE OF DELEGATES- 
OPENING SESSION — (Cardinal 
Ballroom) 

4:30 p.m.— MEMBERSHIP OPEN MEETING — 
(Cardinal Ballroom) 

6:00 p.m.— SOCIAL HOUR — NCSIM — ( Augusta 
Cottage) 

6:(X1 p.m. — Reception — Mecklenburg County 
Medical Society (Crystal Room) 



Friday, May 7, 1976 

7:30 a.m.— MEDICINE & RELIGION BREAK- 
FAST — (Crystal Room) 
9:00 a.m.— FIRST GENERAL SESSION — (Car- 
dinal Ballroom) 
9:00 a.m.— AUDIO-VISUAL PROGRAM — (HMS 

Bounty) 

9:00 a.m.- 12 Noon — Section on Otolaryngology 

Meeting — (Dutch Room. Holly Inn) 

9:00 a.m.- 1 2 Noon — Auxiliary Program Planning 

Workshop — (Ballroom. Holly Inn) 

12:30 p.m. — Luncheon — Section on Surgery — 

(Crystal Room) 
12:30 p.m. — Luncheon — Auxiliary President-Elect 

— (Dining Room. HolK Inn) 
2:00 p.m.— REFERENCE COMMITTEE Meet- 
ings: 

I — Cardinal Ballroom 
II — Disco Room 
2:00 p.m. — Section on Public Health & Education 
Meeting — (Dutch Room. Holly Inn) 
2:00 p.m. — Cardio-Pulmonary Resuscitation — 
Auxiliary & N.C. Heart Association — 
(Society members welcomed) — (Din- 
ing Room — HOLLY INN) 



5:30 p.m. — Bov,man Gray Medical .Alumni Social 

Hour — (Disco Room) 
6:00 p.m. — Exhibitors" Party — (Land Sales Office) 
6:30 p.m. — UNC Medical Alumni Social Hour — 

(HMS Bounty) 
6:30 p.m. — Duke Medical Alumni — Social Hour & 

Dinner — (Pinehurst Country Club) 
6:30 p.m. — Medical College of Virginia Medical 

Alumni — Social Hour & Dinner — 

(Crystal Room) 
7:00 p.m.— MEDPAC Dinner — (Cardinal Ball- 
room) 
9:00 p.m. — Auxiliary Board of Directors Meeting — 

(Presidential Cottage Suite) 



8:30 

9:00 
9:00 

9:00 
9:00 



Saturday, May 8, 1976 

a.m. -9:30 a.m. — Section on Neurology & 
Psychiatry Executiye Committee 
Meeting — (Disco Room) 

a.m.— SECOND GENERAL SESSION — 
(Cardinal Ballroom) 

a.m.- 11:00 a.m. — Informal Meeting — Nu- 
clear Medicine — (HMS Bounty 
Room) 

a.m.- 12 Noon — Section on Anesthesiology 
Meeting — (Parlor #129) 

a.m.- 1:00 p.m. — Breakfast & Scientific Meet- 
ing — Section on Neurological 
Surgery — (Crystal Room) 
9:30 a.m. -12:30 p.m. — Section on Neurology & 
Psychiatry Scientific Session — 
(Disco Room) 
12:00 Noon— PICNIC Lunch — Section on Der- 
matology & Pediatrics — (Poolside) 
12:00 Noon — North Carolina Pediatric Society — 
Luncheon Meeting — (Pinehurst 
Country Club) 

Noon-2:30 p.m. — Section on Orthopaedics 
(Dining Room. Holly Inn) 

p.m. — Luncheon — Section on Neurology & 
Psychiatry (East End-Main Dining 
Room) 

p.m. — Section on Radiology Meeting — (HMS 
Bounty ) 

p.m. -3:00 p.m. — Section on Neurology & 
Psychiatry Business Meeting — 
(Disco Room) 

p.m. — Commission for Health Seryices — 
(Crystal Room) 



12:00 
12:30 

1:30 
1:30 

2:00 



March 1976. NCMJ 



165 



2:00 p.m. — Sections on Dermatology & Pediatrics 

Scientific Session (Ballroom. Holly 

Inn) 
2:00 p.m.— HOUSE OF DELEGATES — Second 

Session — (Cardinal Ballroom) 
6:30 p.m.— PRESIDENT'S RECEPTION— (Land 

Sales Office) 
7:30 p.m.— PRESIDENT'S DINNER — (Main 

Dining Room) 
9:00 p.m.— PRESIDENT'S BALL — (Cardinal 

Ballroom) 



8:00 a.m.- 



8:30 a.m.- 



9:00 a.m. 



Sunday, May 9, 1976 

-Breakfast Meeting — Auxiliary Board of 
Directors — (Crystal Room) 

1:00 p.m. — Section on Family Physicians 
Scientific Meeting & North (Carolina 
Academy of Family Physicians 
Board of Directors Meeting — (Disco 
Room) 

-THIRD GENERAL SESSION — (Car- 
dinal Ballroom) 



GENERAL SESSIONS 

FIRST GENERAL SESSION 

Friday, May 7, 1976 Cardinal Ballroom 

9:00 a.m. -12:00 Noon 

Convene Session 

Presiding: James E. Davis. M.D., President 

Durham 
Invocation: 

Surgical Session 

Department of Surgery. Bowman Gray School of 
Medicine-North Carolina Baptist Hospital Medi- 
cal Center. Winston-Salem 
MODERATOR: Richard T. Myers. M.D., Profes- 
sor and Chairman. Department of Surgery 
9:00 a.m.— OPENING REMARKS 

Richard Janeway, M.D.. Dean 
Bowman Gray School of Medicine 
9:10 a.m.— SURGERY FOR OBSTRUCTIVE 
JAUNDICE IN INFANTS 
Louis deS. Shaffner, M.D. 
9:20 a.m.— EXPERIENCES WITH TOTAL 
KNEE REPLACEMENT 
George D. Rovere, M.D. 
9:30 a.m.— MODERN MANAGEMENT OF AB- 
DOMINAL AORTIC ANEURYSMS 
Frank R. Johnston. M.D. 
9:40 a.m.— REVIEW OF STAGING LAPAROT- 
OMIES PERFORMED FOR LYM- 
PHOMAS AT THE NORTH CAR- 
OLINA BAPTIST HOSPITAL 
John Michael Sterchi. M.D. 
9:50 a.m.— MANAGEMENT OF PRE-MALIG- 
NANT LESIONS OF THE CERVIX 
Howard D. Homesley. M.D. 



166 



10:00 a.m.— LESS RADICAL APPROACHES TC 
SOLITARY THYROID NODULES 

Timothy C. Pennell. M.D. 
DISCUSSION 
BREAK 
GASTRIC BYPASS FOR OBESITY 

Jesse H. Meredith, M.D. 
MANAGEMENT OF MINOR FA- 
CIAL TRAUMA 

Julius A. Howell. M.D. 
-ULTRASONOGRAPHY OF THE 
PROSTATE AND BLADDER 



10:10 


a 


m. 


10:20 


a 


m. 


10:40 


a 


m. 


10:50 


a 


m. 


11:00 


a 


.m 


11:10 


a 


m. 


11:20 


a 


m. 



1:30 a.m.- 



11: 
12: 



40 a.m.- 
00 Noon 



Martin I. Resnick, M.D. 
-THE STATUS OF PACEMAKERS— |* 
1976 

Robert Cordell. M.D. 

-COMBINED USE OF 'SUPER 

PEEP" — (Positive End Expiratory 

Pressure) and "IVM" — (Intermittent 

Mandatory Ventilation) IN THE 

TREATMENT OF POST-SURGICAL 

RESPIRATORY FAILURE 

Robert L. Gibson. M.D. 

-RECENT ADVANCES IN CATA 

RACT SURGERY 

John Allen Stanley, M.D. 
-Discussion 

-ANNOUNCEMENTS 
ADJOURN 



SECOND GENERAL SESSION 

Saturday, May 8, 1976 Cardinal Ballroon 

9:00 a.m. -12:30 p.m. 

Convene Session 

Presiding: John L. McCain, M.D., Wilson 
First Vice-President 

Medical Session 

Department of Medicine. Duke University Medica 
Center, Durham 
MODERATOR: 



9:00 


a.m.— OPENING REMARKS 


9:10 


a.m. — 


9:20 


a.m. — 


9:30 


a.m. — (to be announced) 


9:40 


a.m. — 


9:50 


a.m. — 


10:00 


a.m. — 


10:10 


a.m.— DISCUSSION 


10:30 


a.m.— BREAK 


10:40 


a.m. — 


10:50 


a.m. — 


11:00 


a.m. — 


11:10 


a.m. — (to be announced) 


11:20 


a.m. — 


11:30 


a.m. — 


11:40 


a.m. — 



iwn 



M)i 



H) 



Vol. 37. No. 3 



lin 

it 
!:| 

!:!5 
!:!« 



F.1 



IH 



12:00 Noon— ANNUAL ADDRESS OF THE 

PRESIDENT 

James E. Davis. M.D.. President 

Durham 

2:30 p.m.— ANNOUNCEMENTS 
ADJOURN 



:^ 



THIRD GENERAL SESSION 

unday. May 9. 1976 Cardinal Ballroom 

9:00 a.m. -12:30 p.m. 

!onvene Session 

SS- tesiding: T. Reginald Harris. M.D.. Shelby 
Second Vice-President 

ocio-Economic Session 

9:00 a.m.— CONJOINT SESSION 

North Carolina Medical Society and 

North Carolina Division of Health 

Services 

Jacob Koomen. M.D.. State Health 

Director. Raleigh 

a.m. — (to be announced) 

a.m. — Address: Richard E. Palmer. M.D.. 
President-Elect. American Medical 
Association. Alexandria. Virginia 

a.m. — Address: Jesse Caldwell, M.D., Presi- 
dent. North Carolina Medical Soci- 
ety. Gastonia 
2:30 p.m. — Awarding of Prizes 

Josephine E. Newell. M.D., Chair- 
man 

Annual Convention Commission 
ADJOURN SINE DIE 



9:30 
1:00 



1:45 



POSTGRADUATE AUDIO-VISUAL PROGRAM 



J. Patrick 
Pinehurst 



Henderson, Jr., M.D.. Chairman. 



^HURSDAY. May 6, 1976— HMS Bounty Room 
►lorning Session — 9:00 a.m. -12 Noon 

tloderator: Paul Abernethy, M.D.. Burlington 

9:00 a.m.— PULMONARY COMPLICATION IN 
SHOCK 

9:20 a.m.— DIZZINESS 
I 9:45 a.m.— THE THERAPEUTIC ASSESSMENT 
I OF HYPERTENSION AND EDEMA 

0:15 a.m.— NUTRITION IN THE INJURED PA- 
TIENT 

0:30 a.m.— ABSORPTION 

0:50 a.m.— RECURRENT TRACT INFECTIONS 

y'ternoon Session — 2:00 p.m. -5:00 p.m. 

Vloderator: Thornton R. Cleek. M.D., Asheboro 
2:00 p.m.— PHYSIOLOGY AND THE EMO- 
TIONS IN THE MATURE WOMAN 
2:35 p.m.— THE LONG RANGE PROBLEMS 
OFTHE POSTMENOPAUSAL WOM- 
AN 
3:20 p.m.— A LIFE IN YOUR HANDS 

^RCH 1976, NCMJ 



3:35 p.m.— CORONARY ARTERY DISEASE, 
REAL OR IMAGINARY? 

4:00 p.m.— HEART IN JEOPARDY 

4:30 p.m.— SIMPLIFIED ABDOMINAL HYS- 
TERECTOMY 

FRIDAY. May 7. 1975— HMS BOUNTY ROOM 
Morning Session — 9:00 a.m.- 12 Noon 

Moderator: Jack C. Evans. M.D.. Lexington 



00 

25 
5s 



10:15 



10:35 



11:00 



a.m.— Rx FOR FLIGHT 

a.m.— Gl ROUNDS 

a.m.— LAPAROSCOPY, THE VIEW WITH- 
IN 

a.m.— CARDIOPULMONARY RESUSCI- 
TATION 

a.m. — RECOGNITION AND MANAGE- 
MENT OF SKIN LESIONS 

a.m.— HOW TO AVOID YOUR DAY IN 
COURT 



Afternoon Session — 2:00 p.m. -5:00 p.m. 

Moderator: J. Benjamin Warren. M.D., New Bern 

2:00 p.m.— FORENSIC MEDICAL PROBLEMS 
IN INFANCY AND CHILDHOOD 

3:00 p.m.— THE TECHNIQUES OF INTRAAR- 
TICULAR AND PERIARTICULAR 
INJECTION 

3:20 p.m.— PROSTAGLANDINS: TOMOR- 
ROWS PHYSIOLOGY':- 

3:45 p.m.— DIABETES: SPECIAL PROBLEMS 
IN THE OLDER PATIENT 

4:10 p.m.— NEXT WITNESS 



SPECIALITY SECTIONS 
SECTION ON UROLOGY 

Thursday, May 6. 1976 
10:00 a.m. -1:00 p.m Disco Room 

Chairman: Robert Dale Ensor. M.D., Charlotte 
Scientific Session 
Business Session: 

Election of Officers. Delegate and Alternate 
Delegate for 1976-77 



SECTION ON OPHTHALMOLOGY 

Thursday. May 6. 1976 
Luncheon and Business Meeting 

12:00 Noon— 1:45 p.m Crystal Room 

Chairman: E. R. Wiikerson. Jr., M.D., Charlotte 
Program Chairman: Harold N. Jacklin. M.D., 
Greensboro 

SCIENTIFIC MEETING 

2:00 p.m Disco Room 

2:00 p.m.— INTRODUCTION: E. R. Wiikerson. 

Jr., M.D.. Chairman 

Harold N. Jacklin, M.D., Program 

Chairman 

I— GENERAL PAPERS 

-PSEUDOEPIBULBAR MELANOMA 
David W. White. M.D., Greenville 



167 



2:05 p.m. 



II_CATARACT SURGERY IN NORTH CAROLINA 

A. CONVENTIONAL INTRACAPSULAR CATA- 
RACT EXTRACTION 

2:L^ p.m.— GOOD OLD FASHION CATARACT 
SURGERY— A Review of 500 Cases 

Arthur C. Chandler, Jr., M.D., 

Durham 
2:25 p.m.— EVOLUTION OF MICROSURGERY 

Samuel D. McPherson, Jr., M.D., 

Durham 

B. PHACOEMULSIFICATION EXTRACAPSU- 
LAR EXTRACTION 

2:35 p.m.— INDICATIONS FOR PHACEOMUL- 
SIFICATION 

Paul Simel. M.D., Greensboro 
2:45 p.m.— SURGICAL TECHNIQUE 

E. Reed Gaskin, M.D., Charlotte 
2:55 p.m.— ROLE OF THE PHYSICIAN'S AS- 
SISTANT 

Wayne Stirewalt, C.R.O.T., Char- 
lotte 
3:00 p.m.— MANAGEMENT OF POSTERIOR 
CAPSULE 

Steven M. White, M.D., Greenville 
3:10 p.m. — PHACOEMULSIFICATION IN A 
COMMUNITY HOSPITAL 
L. Byerly Holt. M.D., Winston- 
Salem 
3:20 p.m.— CONGENITAL CATARACT PHA- 
COEMULSIFICATION 

Hampton Lefler, M.D., Hickory 
3:30 p.m.— PHACOEMULSIFICATION RE- 
SULTS 
William R. Harris, M.D., Hickory 
3:40 p.m.— COFFEE BREAK (10 minutes) 

in— CONTACT LENSES AND INTRAOCULAR 
LENSES 

A. CONTACT LENSES 
3:50 p.m.— SOFT CONTACT LENSES IN 
APHAKIA 
Edward K. Isbey. Jr., M.D., 
Asheville 
4:00 p.m.— SOFT CONTACT LENSES 

Joe H. Woody, M.D., Charlotte 
B. INTRAOCULAR LENSES 
4:10 p.m.— INTROCULAR LENSES (Movie) 

Charles W. Tillett, Jr.. M.D.. 
Charlotte 

rv_VITREOUS SURGERY IN NORTH CAROLINA 

4:20 p.m.— INSTRUMENTATION 

Scot Brower, M.D., Durham 

4:30 p.m.— INDICATIONS 

M. Madison Slusher, M.D., Win- 
ston-Salem 

4:40 p.m.— SURGICAL TECHNIQUE 

Harold N. Jacklin, M.D., Greens- 
boro 



4:50 p.m.— COMPLICATIONS AND RESULTS 
Maurice B. Landers, III. M.D 
Durham 

5:00 p.m.— ADJOURNMENT 



Hi i 



SECTION ON OTOLARYNGOLOGY I) a 

Friday, May 7, 1976 

9:00 a.m.— 12 Noon Dutch Room. Holly In 

Chairman: N. L. Sparrow, M.D., Raleigh 

Scientific Session 

METASTATIC CARCINOMA OF THE PAROTII 

John R. Mountjoy, M.D., Winston-Salem 
TUBERCULOUS MASTOIDITIS 

John R. Emmett. M.D.. Dept. ENT, 

N.C. Memorial Hospital, Chapel Hill 
SINONASAL SURGERY WITHOUT PACKING 

Thad H. Pope, Jr.. M.D.. McPherson Hospital 

Durham 
DISPENSING OF HEARING AIDS lH 
OTOLARYNGOLOGY 

B. Ray Olinger, M.D.. 
Business Session 
Election of Chairman. 
Delegate for 1976-77 



Ashevil 



Delegate and Altemat 



SECTION ON SURGERY 

Friday, May 7, 1976 

12:30 p.m Crystal Roon; 

Chairman: Robert C. Moffatt, M.D., Asheville 
Luncheon and Business Meeting 



SECTION ON PUBLIC HEALTH & EDUCATION 

Friday. May 7, 1976 

2:00 p.m Dutch Room. Holly Inr 

Chairman: J. N. MacCormack, M.D., Raleigh 
2:00 p.m.— SMALLPOX — GOING, GOING 
GONE? 

J. Michael Lane, M.D., Director 
Bureau of Smallpox Eradication 
Center for Disease Control, Atlanta 
Georgia 
3:00 p.m.— OCCUPATIONAL LUNG DISEASI 
IN NORTH CAROLINA INDUS- 
TRIES 

Carl Shy. M.D., Director 
Institute for Environmental Studies 
University of North Carolina, Chape 
Hill 
4:00 p.m. — Short Business Meeting 



SEI 



bir 



m 



Sl'( 



SECTION ON NEUROLOGICAL SURGERY 

Saturday, May 8, 1976 

8:00 a.m.- 1:00 p.m Crystal Room 

Chairman: M. S. Mahaley. Jr., M.D., Durham 
8:00 a.m.— BREAKFAST— go thru Buffet Line and 
on into Crystal Room 






168 



Vol. 37, No. 3 



OT 



cientific Session 

9:00 a.m.— INTACT ARCH LUMBAR SPON- 
DYLOLISTHESIS 

William Brown. M.D., Resident in 
Neurosurgery, Bowman Gray School 
of Medicine. Winston-Salem 

9:15 a.m.— POSTERIOR CERVICAL FUSION IN 
CHILDREN 

J. M. McWhorter. M.D.. Resident in 
Neurosurgery. Bow man Gray School 
of Medicine. Winston-Salem 

9:45 a.m.— CSF RHINORRHEA: CONTROVER- 
SIES IN MANAGEMENT 

Courtland H. Davis, M.D.. Professor 
of Neurosurgery. Bowman Gray 
School of Medicine, Winston-Salem 

0:00 a.m.— ROLE OF NEUROSURGEON IN 
ORGAN PROCUREMENT 

Stanley Mandel. M.D.. UNC and 
John Weinerth. M.D., Duke 

0:20 a.m.— SPECIAL COMMITTEE REPORTS: 
Liaison: Neurosurgical Manpower 
Discussion 

Courtland H. Davis. M.D.. Mod- 
erator 

Legal & Professional Liability: Mal- 
practice Discussion 
Ira Hardy. M.D.. Moderator 

2:00 Noon — Other Committee Reports 

2:15 p.m. — Minutes of last meeting: Walter Lock- 
hard. M.D., Secretary 

2:20 p.m. — Report of Officers 

2:30 p.m.— UNFINISHED BUSINESS: 

Election of Officers: President-Elect, 
Vice-President, Board of Directors 
Neurosurgical Nurses Training: Eben 

Alexander, M.D. 
Other Business 

1:00 p.m.— ADJOURNMENT 



a 



SECTION ON NEUROLOGY & PSYCHIATRY 

Saturday. May 8. 1976 

8:30 a.m Disco Room 

Thairman: Hervey W. Mead. M.D.. Charlotte 
8:30 a.m. -9:30 a.m. — Executive Committee Meet- 
ng 
, Scientific Session 

^ 9:30 a.m. -12:30 p.m.— CLINICAL ASPECTS OF 
CHRONIC PAIN 
PSYCHIATRIC ASPECTS OF CHRONIC PAIN 

(Jeffrey L. Houpt. M.D.. Assistant Professor of 
I Psychiatry. Duke University Medical Center. 

Durham 
BEHAVIORAL TREATMENT OF CHRONIC 
,[ iPAIN — A Status Report 

W. Doyle Gentry. Ph.D.. Associate Professor & 
Head of Division of Medical Psychology, Duke 
University Medical Center. Durham 



APPLICATION OF NERVE BLOCKS IN TREAT- 
ING CHRONIC PAIN 

Bruno J. Urban, M.D.. Associate Professor of 
Anesthesiology and Assistant Professor of 
Neurosurgery; Co-Director. Pain Clinic, Duke 
University Medical Center. Durham 
Discussion of Papers 
Jerry H. Greenhoot. M.D., Private Practice of 
Neurosurgery. Charlotte Neurosurgical As- 
sociates. P. A.. Charlotte 

Formerly: Director. Pain Clinic. University of 
California, San Diego, California 
12:30 p.m. -1:30 p.m.— LUNCH — East End. Main 

Dining Room (Reserved tables) 
1:30 p.m. -3:00 p.m.— BUSINESS MEETING in 
conjunction with North Carolina 
Neuro-Psychiatric Association 



SECTION ON FAMILY PHYSICIANS 

& 

NORTH CAROLINA ACADEMY OF FAMILY 

PRACTICE 

BOARD OF DIRECTORS MEETING 

Saturday. May 8, 1976 

8:30 a.m.- 1:00 p.m Disco Room 

Chairman: William W. Hedrick. M.D.. Raleigh 
Program Chairman: Robert S. Cline, M.D., Sanford 
THE FUTURE AND GOALS OF FAMILY 
MEDICINE AT UNC-CHAPEL HILL 
Edward J. Shahady. M.D.. Chairman 
Department of Family Medicine. UNC. Chapel Hill 
BUSINESS SESSION: 

Election of Chairman. Delegate and Alternate 
Delegate for 1976-77 



SECTION ON ANESTHESIOLOGY 

Saturday, May 8, 1976 

9:00 a.m Parlor #129 

Chairman: Jack H. Welch. M.D.. Greenville 
Program Chairman: Merel H. Harmel, M.D. .Durham 
9:00-9:20 a.m.— DEVELOPMENT OF A LARGE 
OB-GYN SERVICE CENTER 

Francis M. James, M.D.. Bowman 
Gray 
9:25-9:45 a.m.— ANESTHESIA FOR THE PRE- 
MATURE INFANT 

Kenneth J. Levin. M.D., UNC 
9:50-10:10 a.m.— STUDIES OF THE EFFECT OF 
ANESTHESIA ON THE PULMO- 
NARY CIRCULATION 
Guv C. Davis. M.D.. Duke 
10:10-10:35 a.m.— DRUG EFFECTS ON RENAL 
BLOOD FLOW 

Alexander A. Birch. M.D., Bowman 

Gray 

10:40-11:00 a.m.— THE ELECTROENCEPHA- 

LOMYOGRAM — A PRACTICAL 

METHOD OF NEUROMUSCULAR 



March 1476. NCMJ 



169 



EVALUATION DURING ANES- 
THESIA 

David A. Davis. M.D.. Duke 
11:05-11:25 a.m.— RECENT ADVANCES IN 
BLOOD-GAS MEASUREMENT 
Kenneth Sugioka. M.D., UNC 
Noon — Business Meeting 

Jack H. Welch, M.D.. Section 
Chairman 



11:30- 



Informal Meeting— NUCLEAR MEDICINE 

Saturday. May 8, 1976 

9:00 a.m.- 11:00 a.m... Dutch Room. HOLLY INN 

Presiding: Edward V. Staab. M.D. 
Department of Radiology, 
N.C. Memorial Hospital, Chapel Hill 



NORTH CAROLINA PEDIATRIC SOCIETY 

& 
NORTH CAROLINA CHAPTER OF THE 
AMERICAN ACADEMY OF PEDIATRICS 

Saturday, May 8. 1976 

12 Noon Pinehurst Country Club 

Presiding: Archie T. Johnson. Jr.. M.D.. Raleigh 

Chapter Chairman 
Executive and Liaison Committees — Luncheon 
Meeting 



Informal Discussion 

of 

Forming a Section on Nuclear Medicine 

Saturday. May 8. 1976—9 a.m. -11 a.m. 
HMS BOUNTY ROOM— Pinehurst Hotel 

Presiding: Edward V. Staab. M.D. 
Department of Radiology 
N.C. Memorial Hospital 
Chapel Hill 



SECTION ON PATHOLOGY 

Saturday. May 8. 1976 
9:30 a.m. -4:00 p.m. . . .Dutch Room. HOLLY INN 
Chairman: Charles M. Hassell, Jr., M.D., Greensboro 
9:30 a.m. — Registration 
10:00 a.m. — Scientific Session 

(program to be announced) 
12:30 p.m. — Lunch — (on your own) 
2:00 p.m. -3:30 p.m. — Scientific Session 

(program to be announced) 
3:30 p.m. -4:00 p.m. — Business Session 

Election of Chairman. Delegate and 
Alternate Delegate for 1976-77 



SECTION ON ORTHOPAEDICS 

Saturday, May 8, 1976 

12:00 Noon Dining Room, HOLLY IN> 

12 Noon — Executive Committee Meeting Luncheon 
1:30 p.m. — Business Meeting 

Scientific Session — 2:30 p.m. 

PANEL: THE MANAGEMENT OF HIP FRAG 

TURES 

Moderator: Frank Clippinger. M.D.. Durham 
THE TREATMENT OF FEMORAL NECK FRAC 
TURES BY INTERNAL FIXATION 

Edwin T. Preston, M.D., Chapel Hill 
THE TREATMENT OF FEMORAL NECK FRAC 
TURES BY PRIMARY PROSTHETIC REPLACE 
MENT j 

Donald B. Reibel. M.D.. Raleigh 
FRACTURES IN THE INTERTROCHANTERIC 
REGION 

Everett I. Bugg. Jr.. M.D., Durham 
FRACTURES IN THE SUBTROCHANTERIC 
REGION 

Phillip J. Bach. M.D.. Charlotte 
Judging Committee: J. Stuart Gaul. M.D.. Anthony 
G. Gristina. M.D.. John L 
Wooten. M.D. 



SECTION ON RADIOLOGY 

Saturday. May 8. 1976 

1:30 p.m HMS BOUNTY ROOM 

Chairman: R. W. McConnell. M.D., Greenville 



JIKS 

•\1,llf 
sl:H 

■S 

ۥ( 

s 1)1 

k- 

am 






»CI 
U 



SECTION ON DERMATOLOGY & 
SECTION ON PEDIATRICS 

Saturday. May 8. 1976 

2:00 p.m Ballroom, HOLLY INN 

Chairmen: George W. Crane, Jr.. M.D.. Durham — 
Dermatology 
Gerard Marder. M.D.. Gastonia — 
Pediatrics 
SYMPOSIUM ON RECENT ADVANCES IN IM 
MUNOLOGY 

Robert E. Jordon, M.D.. Assistant Professor, 
Dermatology and Immunology 
Mayo Medical School 
Rochester, Minnesota 
Rebecca H. Buckley, M.D.. 

Associate Professor of Pediatrics and Chief 
Division of Allergy & Immunology 
Duke University Medical Center, Durham 
4:30-5:(X) p.m. — Business Session 

Election of Chairman, Delegate and Al- 
ternate Delegate for 1976-77 — (ead 
Section) 



170 



Vol. 37, No. 



«c« 



Classified Ads 



)FFICE SPACE FOR SALE OR RF:NT: Ample parking, Tri-Citv 
area. Piedmont North Carolina. Multispace Medical Complex, t»o 
: spaces available. Solo practice or small group. Area needs: inter- 
nist, hematologist oncologist, psvchiatrist or general practice. Con- 
tact: HKiH POINT MEDICAL CENTER, INC., 919-882-1725 or 
919-882-1524. 

lOME-OFFICE FOR SALE OR LEASE: Greensboro, N.C. Spaci- 
ous brick home. Main floor — 3,000 sq. ft.. 8 rooms. Second 
floor — 2,000 sq. ft.. 5 rooms including second kitchen, suitable 
inlaw setup. Basement — 2,000 sq. ft,. 8 room office with separate 
entrance appraised at $130,000 or lease with option to buv , \\ rite: 
NC\U-9. P.O. Box 27167. Raleigh, N.C. 27611. 

VIMEDIATE OPENING FOR C HILD PSVCHIATRIST. $15-$20 
thousand for approximately half time. To head up medical 
psychiatric staff in community Child Guidance Clinic. Metropoli- 
tan area population 500,000 plus. Opportunity for private practice 
available. Liberal fringe benefits. Equal Opportunity Employer 
with Affirmative Action Plan. \N rite or call Betty Reames, Memo- 
I rial Guidance Clinic. 2319 East Broad Street, Richmond, \ irginia 
23223—804 648-1605. 

SSOCIATE INTERNIST WANTED— Resort area in Western 
North Carolina. Guaranteed salary first year: $30,000 plus percen- 
tage; thereafter, increased income leading to partnership. Profes- 
sional Corporation with fringe benefits. Excellent office facilities 



l(Kated near new modern hospital. Write: NCMJ-3, P, O. Box 
27167, Raleigh. N.C. 27611. 

DLTvE PH\SK lAN'S ASSOCIATE STCDENT graduating May 
1976 seeks position in Eastern N.C. Background and training in 
Internal Medicine and Family Practice. Call Collect (919) 286-3031 
evenings, or write Miss T. Gardner. 506 Elf St., #16, Durham, 
N.C. 27705. 

STAFF PSYCHIATRISTS, located in Piedmont, N,C,, young mental 
health staff serving 180,000 residents in three county area. No 
restrictions on private practice after hours. Good fringe benefits. 
Contact Larry Parrish, Area Director, Tri County Mental Health 
Complex, 165 Mahalev Avenue, Salisburv, N.C . 28144. Teleph<me 
collect (704) 633-3616". 

EMERGENCY .MEDICINE: Northeastern North Carolina: four, 
12-hour evening rotations per week. Paid malpractice, vacation, 
professional dues. $45,000 annual remuneration. Contact Drs. 
Cooper or Spurgeon toll free 1-800-325-3982. 

PHYSICIANS NEEDED: M.D.'s with completed internships or resi- 
dencies for hospital clinics night surgeon duties — worldwide 
placement available! Relocation fees paid, 30 days paid vacation 
each year. 40 hour work week. Contact Dave Powell, Navy Medical 
Representative, Navv Recruiting District, P.O. Box 18568, Ra- 
leigh, N.C. 27609. Call C ollect: 782-2005. 



TUCKER HOSPITAL, Inc. 



212 West Franklin Street 
Richmond, Virginia 



A private hospital for diagnosis and treatment of psvrhiatrie aiul 
neurological di-dnlei--. Hospital and out-patient services. 

(\ isiting hours 2:00 p.m. -8:00 p.m. (daily) 



James Asa Shield, M.D. 
James Asa Shield, Jr,, M.D. 
Graenum R. Schuf, M,D, 



Weir M, Tucker, M.D, 

George S. Fultz, Jr,, M,D. 

Catherine T, Ray, M.D. 



William D. Kernodle, M.D, 



vl-kRCH 1976. NCMJ 



171 



Index to 
Advertisers 



American Tobacco Company 121 

Asheville School 157 

Blue Cross & Blue Shield of N.C 134 

Burroughs Wellcome Company 119 

Crumpton, J. L. and J. Slade. Inc 129 

Fellowship Hall 161 

Fripp Island 125 

Golden-Brabham Insurance Company 124 

Lilly, Eli & Company Cover 1 

Mandala Center 130 

Mutual of Omaha 131 

Pharmaceutical Manufacturers Association . 122, 123 

Reed & Carnrick 127 

Richland Memorial Hospital 155 



Roche Laboratories Cover 2, 1 17, Cover 3. Cover 4'| 
Roerig & Company (A Division j 

of Pfizer Pharmaceuticals) 147. 152. 153 

Saint Albans Psychiatric Hospital 126 

Sealy of the Carolinas, Inc 162 

Smith Kline & French 143 

Tidewater Psychiatric Institute 132 

Tucker Hospital 171 

U.S. Air Force 1 ig 

United States Navy 133 

Willingway, Inc 16O 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company 172 



WINCHESTER 

"CAROLINAS' HOUSE OF SERVICE" 

Winchester Surgical Supply Company 

200 South Torrence St. Charlotte, N. C. 28204 
Phone No. 704-372-2240 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N. C. 27401 
Phone No. 919-272-5656 

Serring the MEDICAL PROFESSIO^ of ISORTH CAROLINA 
and SOUTH CAROLINA since 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N. C. State Medical Society Meeting since 1921, and 
advertised CONTINUOUSLY in the N. C. Journal since January 1940 issue. 



172 



Vol. 37, No. 3 



J 



I® 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 



i prompt and specific action 

documented benefit-to-risk ratio 

' three dosage strengths to meet most therapeutic needs 




Before prescribing, please consult 
complete product information, a summary 
of which follows: 

Indications: Relief of anxiety and tension 

occurring alone or accompanying various 

disease states. 

Contraindications: Patients withi known 

hypersensitivity to the drug. 

Warnings: Caution patients about possible 

combined effects with alcohol and other 

CNS depressants. As with all CNS-acting 

drugs, caution patients against hazardous 

occupations requiring complete mental 



alertness [e.g., operating machinery, driv- 
ing). Though physical and psychological 
dependence have rarely been reported on 
recommended doses, use caution in ad- 
mmistering to addiction-prone individuals 
or those who might increase dosage; with- 
drawal symptoms (including convulsions), 
following discontinuation of the drug and 
similar to those seen wilh barbiturates, 
have been reported. Use of any drug in 
pregnancy, lactation or in women of child- 
bearing age requires that its potential 
benefits be weighed against its possible 
hazards. 

Precautions: In the elderly and debilitated, 
and in children over six, limit to smallest 
effective dosage (initially 10 mg or less per 
day) to preclude ataxia or oversedation, 
increasing gradually as needed and tol- 
erated. Not recommended in children 
under six. Though generally not recom- 
mended, if combination therapy with other 
psychotropics seems indicated, carefully 
consider individual pharmacologic effects, 
particularly m use of potentiating drugs 
such as IvIAO inhibitors and phenothia- 
zines. Observe usual precautions in pres- 
ence of impaired renal or hepatic function. 
Paradoxical reactions (e.g., excitement, 
stimulation and acute rage) have been 
reported in psychiatric patients and hy- 
peractive aggressive children. Employ 
usual precautions in treatment of anxiety 
states with evidence of impending depres- 
sion; suicidal tendencies may be present 
and protective measures necessary. Vari- 
able effects on blood coagulation have 
been reported very rarely in patients re- 
ceiving the drug and oral anticoagulants; 
causal relationship has not been estab- 
lished clinically. 



Adverse Reactions: Drowsiness, ataxia 
and confusion may occur, especially in the 
elderly and debilitated. These are revers- 
ible in most instances by proper dosage 
adjustment, but are also occasionally ob- 
served at the lower dosage ranges. In a 
few instances syncope has been reported. 
Also encountered are isolated instances of 
skin eruptions, edema, minor menstrual 
irregularities, nausea and constipation, 
extrapyramidal symptoms, increased and 
decreased libido— all infrequent and gen- 
erally controlled with dosage reduction; 
changes in EEG patterns (low-voltage fast 
activity) may appear during and after treat- 
ment; blood dyscrasias (including agranu-, 
locytosis), jaundice and hepatic dysfunction 
have been reported occasionally, making 
periodic blood counts and liver function 
tests advisable during protracted therapy. 
Usual Dally Dosage: Individualize for 
maximum beneficial effects. Oral— Adults: 
Mild and moderate anxiety and tension, 
5 orlO mg t.Ld. or q.i.d.: severe states, 20 
or 25 mg t.i.d. or q.i.d. Geriatric patierits: 
5 mg b.i.d. to q.i.d. (See Precautions.) 
Supplied: Librium? (chlordiazepoxideHCI) 
Capsules, 5 mg, 10 mg and 25 mg — bottles 
of 100 and 500; Tel-E-Dose'5 packages of 
100, available in trays of 4 reverse-num- 
bered boxes of 25, and in boxes contain- 
ing 10 strips of 10; Prescription Paks 
of 50, available singly and in trays of 1 0. 
Libritabs-' (chlordiazepoxide) Tablets. 
5 mg, lOmg and 25 mg — bottles of 100 and 
500 With respect to clinical activity, cap- 
sules and tablets are indistinguishable. 



Roche Laboratories 

Division of Hoff mann-ka Roche Inc. ■ 

Nutley, New Jersey 07110 



Please see following page. 



LIBRIUM 

chlordiazepoxide HCI Roche 
5mg,10mg, 25 mg capsules 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 

Yesterday's decision to use Librium for a clinically anxious 
patient was based on several good reasons. Safety. Effectiveness. 
Versatility. And the reasons you chose it yesterday are as valid today. 

Librium has accumulated an unsurpassed clinical record. A 
record validated in several thousand papers published both here 
and abroad. 

Librium, when used in proper dosage, rarely interferes with a 
patients mental acuity or ability to perform. However, as with all CNS- 
acting agents, good medical practice suggests that patients be cautioned 
against hazardous activities requiring complete mental alertness. 

Librium has an established safety record and a documented 
benefit'to-risk ratio. And Librium is used concomitantly with such drugs 
as cardiac glycosides, diuretics, anticholinergics and antacids. 

So when you consider antianxiety therapy, consider Librium. 

It's a good choice. For today. And tomorrow. 



I 



m 




ROCHE 




PROVEN ADJUNCT FOR CLINICAL ANXIETY 

UBRIUM ' 

chlordiazepoxide HCI/Roche 

Please see preceding page for summary of product information. 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY 



April 1976, Vol. 37, No. 4 



NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: Training the Internist to Provide Primary Care— Are We? Carl B. Lyie, Jr., M.D., David S. Citron, M.D., 
and Marvin M. McCall, III, M.D.; Training in North Carolina for Family Practice, William B. Herring, M.D.; Ethical Implica- 
tions of Professional Standards Review Organizations, James F. Toole, M.D. 





, 


a 




^ 




BECOTIN® 

Vitamin B Complex 

BECOTIN^ with VITAMIN C 

Vitamin B Complex with Vitamin C 

BECOTIN -T 

Vitamin B Complex with Vitamin C, Therapeutic 

MI-CEBRIN® 

Vitamins-Minerals 

MI-CEBRIN J® 

Vitamin-Minerals Therapeutic 

AND A WIDE VARIETY OF OTHER PHARiVIACEUTICALS 




I-Ddista 


DISTA PRODUCTS COMPANY 1 
Division of Eli Lilly and Company ■ 
Indianapolis, Indiana 46206 ■ 






400944 ^1 





1976 ANNUAL SESSIONS 
May 6-9— Pinehurst 



1976 Committee Conclave 
Sept, 22-26— Southern Pines 



Both often 




Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints which are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adjunctively in skeletal n jscle 
spasm due to reflex spasm to local pathol- 
ogy, spasticity caused by upper motor 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 
therapy). 

Contralndlcated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



Predominant 
• psychoneurotic 



anxiety 



Associated 

• depressive 

symptoms 



orders, possibility of increase in frequency 
and/ or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 



respond to 




According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feehngs, part of the problem 
may sound hke depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two, although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 



Wium(g 

(diazepam) ^ 

2-mg, 5-mg, 10-mg scored lableis 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to habituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
skin rash, ataxia, constipation, headache, 
incontinence, changes in salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug. Iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 



<S>E 



Roche Laboratories 

sion of Hoffmann-La Roche Inc. 
tley, New Jersey 07110 



TREATMENT AND LEARNING CENTER For 

ALCOHOL RELATED PROBLEMS 




\ 



FELLOWSHIP HALL 



THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit 
Tax-Exempt • A Controlled and Pleasant Psychological Atmosphere 

• Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



mt) 



Member of: 

• The American Hospital Association 
• The N. C. Hospital Association 

• Accredited by the Joint Commission 

on the Accreditation of Hospitals 



Individual Counseling • Group Therapy 

Nature Trail • Indoor/Outdoor Recreation 

Relaxation and Sleep Therapy 

Audio-Video Therapy 



FOR ADMITTANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



FELLOWSHIP HALL 



INC. 



P. 0. BOX 6929 



GREENSBORO, N. C. 27405 



Located off U.S. Hwy. No. 29 at Hicone Road Exit, 

6V2 miles north of downtown Greensboro, N. C. 

Convenient to 1-85, 1-40, U.S. 421, U.S. 220, 

and the Greensboro Regional Airport. 



FOR MEDICAL INFORMATION CALL 

J. W. WELBORN, JR., M.D. 

MEDICAL DIRECTOR 

919-275-6328 




Facility, program and en- 
vironment allows the indi- 
vidual to maintain or re- 
gain respect and recover 
with dignity. 



Films, tapes, lectures, 
group discussions and in- 
dividual counseling are 
used with emphasis on 
reality therapy. 



Medical examination 
admission. 



Modern, motel-like accom- 
modations with private bath 
and individual temperature 

controL 



A therapeutic nature trail 
to encourage physical ex- 
ercise, and arouse objec- 
tive interest in the miracle 
of nature. 



FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 



Fewer than 200 doctors 
can become Navy 
physicians this year. 

Are you one of them? 



J« If you're interested in a practice that 
Dmbines high-quality medicine with a 

unique life- 



style, Navy 
medicine 
could be right 
for you. You'll 
get the 
chance to 
practice med- 
icine instead 
of paperwork 
Practice al- 
most anywhere 
1 the world And earn between $30,000 
nd $40,000 a year. 

Right now, the Navy needs General 
ledical officers, plus those specialties 
sted in the coupon. You may also receive 
'aining to become a Navy Flight Surgeon, 
r a specialist in Undersea Medicine. 




But the number of 
doctors needed is limit- 
ed. For more details, fill 
in and mail the 
coupon, or call collect 
919-872-2005, and ask 
for the Medical Re- 
cruiter, David L Powell. 

Out of state call 
800-841-8000 




It pays to look into Navy Medicine. 



^'is. 



I Commanding Officer, Navy Recruiting District, Raleigh 

I Pinewood Building, P. 0. Box 18568 

I 1001 Navaho Drive, Raleigh, N. C. 27609 

I 



(0M) 



NAME_ 



STREET 
STATE 



(Please Print or Type) 
CITY ._. . 



_ZIP^ 



_PHONE_ 



(Area Code & No.) 



MEDICAL SCHOOL 



YEARGRADUATED_ 



DATE OF BIRTH 



■;?«;.',.V-=^:i^sS 



I AM INTERESTED IN (CHECK ONE): 




FLIGHT SURGEON 
UNDERSEA MEDICINE 
MY SPECIALTY (IF ANY) IS: 

_ ANESTHESIOLOGY 
n FAMILY PRACTICE 
G PSYCHIATRY 
Z INTERNAL MEDICINE 

STATUS (CHECK ONE): 

□ PRIVATE PRACTICE 

□ HOSPITAL STAFF 



GENERAL MEDICAL OFFICER 
PRACTICING MY SPECIALTY 

: NEUROLOGY 
RADIOLOGY 
PATHOLOGY 
PEDIATRICS 



INTERN 
RESIDENT 



John H. Felts. M.D. 
Winston-Salem 

EDITOR 

John S. Rhodes, M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Hilliard 
Raleigh 

BUSINESS MANAGER 



NORTH CAROLINA 
MEDICAL JOURNAL 

Published Monthly as the Official Organ of 

The North Carolina 

Medical Society 

April 1976, Vol. 37, No. 4 



EDITORIAL BOARD 

Charles W. Styron. M.D. 
Raleigh 

CHAIRMAN 

George Johnson. Jr.. M.D. 
Chapel Hill 

Robert W. Pilchard. M.D. 
Winston-Salem 

Rose Pully, M.D. 
Kinston 

John S. Rhodes. M.D. 
Raleigh 

Louis Shaffner, M.D. 
Winston-Salem 

Robert E. Whalen, M.D. 
Durham 



NORTH CAROLINA MEDICAL JOURNAL. 300 S. 
Hawthome Rd,, Winston-Salem. N- C. 27103, is owned 
and published by The North Carolina Medical Society 
under the direction of its Editorial Board. Copyright " 
The North Carolina Medical Society 1976. Address 
manuscripts and communications regarding editorial 
matter to this Winston-Salem address. Questions relat- 
ing to subscription rates, advertising, etc., should be 
addressed to the Business Manager, Box 27167, 
Raleigh, N. C. 276! 1, All advertisements are accepted 
subiect to the approval of a screening committee of the 
state Medical Journal Advertising Bureau. 71 1 South 
Blvd.. Oak Park. Illinois 60302 and/or by a Committee 
of the Editorial Board of the North Carolina Medical 
journal in respect to strictly local advertising, instruc- 
tions to authors appear in the January and July issues. 
Annual Subscnption, SI 0,00. Single copies, $1.00, Pub- 
lication office: Edwards & Broughton Co,. P.O. Box 
27286, Raleigh, N.C. 2761 1 . Second-class postage paid 
at Raleigh. Nfirth Carolina 27611. 



Original Articles 

Training the Internist to Provide Primary Care — Are We? 193 

Carl B. Lyie. Jr.. M.D., David S. Citron, M.D., and 
Marvin M. McCall, III, M.D. 

Training in North Carolina for Family Practice 197 

William B. Herring, M.D. 

Ethical Implications of Professional Standards Review 

Organizations 201 

James F. Toole, M.D. 



Editorials 

An Audience for a Discourse 205 

Ethical Obligations of Physicians to Peer Review 206 

Midwinter Meeting of the Executive Council of the North 
Carolina Medical Society 208 

Bulletin Board 

New Members of the State Society 209 

What? When? Where? 209 

Auxiliary to the North Carolina Medical Society 211 

News Notes from the Duke University Medical Center . . 211 

News Notes from the Bowman Gray School of Medicine of 
Wake Forest University 214 

American Academy of Family Physicians 215 

Month in Washington 216 

Book Reviews 218 

In Memoriam 219 

Classified Ads 221 

Index to Advertisers 222 

Contents listed in Current Contents/Clinical Practice 




lund useful in the management of vertigo" associated with 

ases affecting the vestibular system. 

an relieve nausea and vomiting often associated with vertigo!" 

sual adult dosage for Antivert/25 for vertigo:" one tablet t.i.d. 

Iso available as Antivert (meclizine HCl) 12.5 mg. scored 

ets, tor dosage convenience and flexibilirv'. 

ntivert/25 (meclizine HCl) 25 mg. Chewable Tablets for 

^ea, voniitmg and dizziness associated with motion sickness. 

-I ■MN'L'\RY OF PRESCRIBING INFORMATION 



(DICATIOKS. Based on a re\ie\v of this drug by the National Academy of 

ences— National Research Council and/or other informa don, FDA has classified 

, indications as follows. 

Effective. N4anagement oi nausea and \-omiting and dizziness associated with 

I tion sickness. 

'ossi6l\ Effective: Management of \'erdgo assoaated \nth diseases affecting the 

tibular system. 

inal classification ot the less than effecrive indications requires further 

esngarion. 



Big Balanced Rock, Chincahua Mountains, Arizona (approx 1,000 tons) 

CONTRAINDICATIONS. Administradon of AnDvert (meclizine HQ) during preg- 
nancy or to women who may becc^me pregnant is contraindicated in \iew of the 
teratogenic effect of the drug in rats. 

The administration of meclizine to pregnant rats during the 12-15 day of gestanon 
has produced cleft palate in the offspnng. Limited studies using doses of over 100 mg,/ 
kg. /day m rabbits and 10 mg./kg./dav in pigs and monkeys did not show cleft palate. 
Congeners of meclizine have caused cleft palate in speaes other than the rat. 

Meclizine HCl is contraindicated m indmduals who have shown a pre\ious h>per- 
sensiti\Tt>' to it. 

WARNINGS. Since drowsiness may, on occasion, occur with use of this drug, panents 
should be warned of this possibilit\' and cautioned against driving a car or operaang 
dangerous machinery. 

L'sdge in Children Clinical studies establishing safef\' and effectiveness in children 
have not been done; therefore, usage is not recommended in the pediatric age group. 

L'sagt; m Pregnancy: See "Contraindications ' 
ADXTRSE REACTIONS. Drowsiness, dry mouth and, on rare occasions, blurred 
vision have been reported. r^^NANr^l/^ J'^BUtk. 

More detailed professional information a\'ailable on ri^^^^ltl^l \j^^^^ 
request. A division ot Fiizer Pnarmaceuticais 






Antivert/^25 

(meclizine HCl) 25 nig,Tablets 

for vertigo* 



New York, New York 10017 



Effectiveness across 
the spectrum of most 
common forms 
of insomnia 



Awake too long, awake too often, 
awake too early. . . 

These are the most common forms of insomnia, 
and may occur singly or in any combination. 
The night of troubled sleep depicted here 
comprises all three types. As the night 
progresses from left to right, each 
sleep stage is identifiable by its own 
shade of gray. Blue represents "Awake" 



As you can see, this hypothetical "patient" 
takes well over an hour to fall asleep, awakens 
several times during the middle of the night 
and awakens too early in the morning. 



for 

DIM 
*1 



lers 
xtm 

seal 



Sleep Stages 




Awake 


.Stage 7 






RF.M H 


H Stage 3 






Stage 1 H 


H Stage 4 



rs^' 




Awake too long 



Awake too often during the night 



The insomnias most often 
accurring in young and older adults 

For patients with trouble tailing asleep 
(common in \oung adult insomnia patients), 
Dalmane (flurazepam HCl) 30 mg provides sleep 
within 17 minutes, on a\'erage. For those with 
trouble staying asleep or sleeping long 
enough (common in those over 50). Dalmane 
Dffers increased total sleep time with fewer 
nocturnal awakenings. These clinical results 
were demonstrated in studies conducted in 
four geographically separated sleep 
research laboratoriesH 



The relative safety of Dalmane 
(flurazepam HCl) is well documented 

Dalmane (tlurazepam HCl) is relati\ely safe 
and well tolerated: morning "hang-o\'er" has 
been infrequent. The usual adult dosage is 30 
mg: in elderl\- or debilitated patients, limit 
initial dosage to 15 mg to preclude over- 
sedation, dizziness or ata.xia. Caution patients 
about possible combined effects with 
alcohol and other CNS depressants. 



Hours 




Broad-Spectrum 
medication for the 
most common forms 
ofinsomnia 

Dalmane 

(flurazepam HCl) 

One 30-nig capsule h.s.— usual adult dosage 

( 1 5 nig may suttice m some patients). 
One 15-mg capsule h.s.— initial dosage for 
elderly or debilitated patients. 

n induces sleep rapidly 

D reduces nighttime awakenings 

D lengthens total sleep time 




<s> 



Awake too early 



Please see follouing page for a 

summary of complete product information. 



Broad-spectrum medication for 
the most common forms of insomnia 

Dalmane 

(flurazepamHCI) © 




Objectively proved in the 
sleep research laboratory, 
Dalmane 

□ induces sleep within 
17 minutes, on average 

□ reduces nighttime 
awakenings 

□ provides 7 to 8 hours 
sleep, on average, with- 
out repeating dosage 

Before prescribing Dalmane (flurazepam 
HCI), please consult complete product 
information, a summary of which follows: 
Indications: Eliective in ail tvpes ot insomnia 
characterized by difficulty in falling asleep, 
frequent nocturnal awakenings and'or early 
morning awakening; in patients with recurring 
insomnia or poor sleeping habits: and in 
acute or chronic medical situations requiring 
restful sleep. Since insomnia is often transient 
and intermittent, prolonged administration is 
generall\' not necessary or recommended. 

Contraindications: Known hypersensitivity 
to llurazepam HCI. 

Warnings: Caution patients about possible 
combined effects with alcohol and other 
CNS depressants. Caution against hazardous 
occupations requiring complete mental alert- 
ness (t-.g., operating machinery driving). 
Use in women who are or iiav become preg- 
nant only when potential benefits have been 
weighed against possible hazards. Not 



recommended for use in persons under 15 
years of age. Though physical and ps\'cho- 
logical dependence have not been reported 
on recommended doses, use caution in 
administering to addiction-prone individuals 
or those who might increase dosage. 
Precautions: In elderly and debilitated, initial 
dosage should be limited to 15 mg to preclude 
oversedation, dizziness and/or ata.xia. If 
combined with other drugs having hvpnotic 
or CNS-depressant effects, consider potential 
additive effects. Employ usual precautions 
in patients who are severely depressed, or 
with latent depression or suicidal tendencies. 
Periodic blood counts and liver and kidney 
function tests are advised during repeated 
therapy Observe usual precautions in 
presence of impaired renal or hepatic function. 
Adverse Reactions: Dizziness, drowsiness, 
lightheadedness, staggering, ata.via and 
falling have occurred, particulariy in elderly 
or debilitated patients. Severe sedation, 
lethargy, disorientation and coma, probably 
indicative of drug intolerance or overdosage, 
have been reported. Also reported were 
headache, heartburn, upset stomach, nausea, 
vomiting, diarrhea, constipation, GI pain, 
nervousness, talkativeness, apprehension, 
irritability weakness, palpitations, chest 
pains, body and joint pains and GU com- 
plaints. There have also been rare occurrences 
of leukopenia, granulocytopenia, sweating, 
flushes, difficulty in focusing, blurred 
vision, burning eyes, faintness, hypotension, 
shortness of breath, pruritus, skin rash, dry 
mouth, bitter taste, excessive salivation, 
anorexia, euphoria, depression, slurred 
speech, confusion, restlessness, hallucina- 
tions, and elevated SCOT SGPT. total and 
direct bilirubins and alkaline phosphatase. 
Paradoxical reactions, e.g.. excitement. 



stimulation and hyperactivity, have also 
been reported in rare instances. 
Dosage: Indi\idualize for maximum bene 
effect. Adults: 30 mg usual dosage; 15 mg 
may suffice in some patients. Elderlv or 
debilitated palients: 15 mg initially until 
response is determined. 
Supplied: Capsules containing 15 mg or 
30 mg flurazepam HCI. 



REFERENCES: 

1. Karacan I, Williams RL, Smith JR:Th 
sleep laboratory in the investigation of 
sleep and sleep disturbances. Scientific 
exhibit at the 124th annual meeting of th* 
American Psychiatric Association, 
Washington DC, May 3-7. 1971 

2. Frost JD Jr: A system for automatical! 
analyzing sleep. Scientific e.xhibit at the 
24th Clinical Convention of the Americar 
Medical Association, Boston, Nov 29- 
Dec 2, 1970; and at the 42nd annual 
scientific meeting of the Aerospace Medic 
Association, Houston, Apr 26-29, 1971 

3. Vogel GW: Data on file, Medical 
Department, Hoffmann-La Roche Inc i 
Nutley NJ ' ' 

4. Dement WC: Data on file. Medical 
Department, Hoffmann-La Roche Inc 
Nutley NJ 






.«-'" 



.^■ 



.f*'" 




ROCHE LABORATORIES 
Division of Hoffmann-La Roche Inc 
Nullev. New Jerspv 071 in 



mountain 

vallev 



bti 



10( 







gonf 

Mountain valley golf is a 
Sapphire Valley speciality . . . 
played on a championship 
course designed by George W. 
Cobb (he called it one of his 
finest). The nearly level course 
rolls gently through our vast, 
quiet valley — surrounded by the 
cool North Carolina mountains. 

A complete family resort. 
Sapphire Valley has much to 
offer, including 12 tennis courts, 
Blue Ridge scenery, lakes, 
trips to gem fields, and 
accommodations at the stately 
1896 Fairfield Inn or our 
luxury Villas. And it's all 
about 3 hours' drive from 
Atlanta, Charlotte and Knoxville. 

Come up for a day, or a 
lifetime. Call 704-743-3441 or 
write Sapphire Valley, Star 
Route 70, Box 80, Sapphire, 
N. C. 28774 

Attn: N. M. Wright 



Sapphire Valley 




Brown Bag Permit No. 2265 



North Carolina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy — 
75 percent — 25 percent Co-Insurance 



PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 
60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$206.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50,00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age EO. 

''Integrates with Medicare at age 65. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus 50 cents. 



erni 



Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


655 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-69 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 
The above plans quality for use in the Professional Association. 



For Full Information — Write or Call 

Go!den-Brabham Insurance Agency, Inc. 

Ralph J. Golden Van Brabham III 

108 E. Northwood St., Phone: BRoadway 5-3400, Box 5395, Greensboro, N. C. 27405 








,... <^^^" 



^00 ,^e 



VxSV' 



P.\ea 



.%« 



o<°^°' 



,o<5*= 



,^^^^' 



,t«' 



.i^o^'^^.s^.e^o' 






.^»' 



.0^^' 



^^'<CX^■ 



^'-,.°-.,ve- 



o<^ „o\e^ 



no^^ 



,\e>' 



,a^^' 



P.(^^^ 



.^^<^":o.*- 



e^a" 



^o\^<^;;"^x^e«^^o^^^ 



,as^>' 



,<e^' 



<>.- 



ctv°' 



,ov«^'^v;e--^^'^ 



e^- >.«5^ 






>^^reS>t,.o. 



CC^^ 









VM« 



.\X^« 



,a'?■^ 












,,s.e' 



^cv>' 



,ve 



,ce*",v^e<o^^ 



aoV" 



=.ve' 









-";;>!::'-•::>"" 






...^;>:;.!^!:<s::^':..:.. 



>o<^^ 



."^^ 



„\e>^ 



,\e^ 



.e^^ 



^^>^ 



o'' 



,e9^' 



,3'*= 



rtvc«' 



v^ 



0*r>e-- 









, v<^ 



vH" 



,\a<^ 






.^'^ ' n<i 'S^ 



oco' 



%e 



o^ \'': ovo° 



PC«^ 






^'^^^V^' 



,^oH-,^<i^^";^S^%ee^' 









>-^.»5;c-^'° «,,„. 



,cS' 



. 6^' 



,ee 



3^"= 



\vM>= 



.0^<« 









v^^';oo^^^^,^c' 



-->'°" 



At^" 



,ce'- 



9-.1 ^^^^' ' „va<i°>^; ,,>e'^''^,V°'^'t*^o*^^*' 



..oQ^ 












cO^>!:...-^^:<s-^'"^ .apO^^^^rTe^-^-oO^ 



,oe'^^l.vo<5" 



.A*'*^ 



.^O^o<» 



,evs :.--'=:-.5,o.e' ^^^ ^^,, 



■^*'^.e»-.„vs-^^9S- V' 



, <^* 









,aV«'' 






.o-t:>'' 






e9^^" 



.av" 



<ea^ 



=,X^V 



.o^S 



<i«''-,f^^e^^ 






<^-:.,aO-'„ 0^*= ■ ^.»6-,-x.,r;,9°^-:„,e< S^°-^.> 






as^<' 



,vf^^' 



uO-^ 



r^ea' 



(ia<^ 



ne 






v'pe' 



ai^' 



sV-^^° a*-^^ 



,'»":.<ee 



,^<i'' 



''''' -*^^ V^' 



Q=^>.^'^' 






,^\e^ 



^\^<« 






^o 









at><^' 



p<'' 



xxSV" 



.xO< 






°°^,%o,:<^°^^^' 






AaS 







lasting in Humans: 
Who,Whei« & When. 



le weight of ethical opinion: 

Few would disagree that the efFective- 
pss and safety of any therapeutic agent 
: device must be determined through 
linical research. 

But now the practice of cHnical re- 
larch is under appraisal by Congress, the 
Tress and the general public. Who shall 
iminister it.' On whom are the products 
) be tested? Under what circumstances? 
Ind how shall results be evaluated and 
filized? 

The Pharmaceutical Manufacturers 
Issociarion represents firms that are sig- 
lificantly engaged in the discovery and 
evelopment of new medicines, medical 
svices and diagnostic products. Clinical 
bsearch is essential to their eft'orts. Con- 
equently, PMA formulated positions 
thich it submitted on July 1 1, 1975, to 
}ie Subcommittee on Health of the Sen- 
Ire Labor and Public Welfare Committee, 
; its official policy recommendations, 
^ere are the essentials of PMA's current 
linking in this vital area. 

I. PMA supports the mandate and 
iiission of the National Commission for 
lie Protection of Human Subjects of 
liomedical and Behavioral Research and 
Ters to establish a special committee 
Dmposed of experts of appropriate 
lisciplines familiar with the industry's 
psearch methodology to volunteer its 
prvice to the Commission. 

I, PMA supports the formation of an 
fidependent, expert, broadly based and 
bpresentative panel to assess the current 
late of drug innovation and the impact 
Ipon it of existing laws, regulations and 
Irocedures. 

3«W'hen FDA proposes regulations, 
J: should prepare and publish in the Fed- 
tral Register a detailed statement assess- 
pg the impact of those regulations on 
Irug and device innovation. 

4«PMA proposes that an appropri- 
Itely qualified medical organization be 
Incouraged to undertake a comprehen- 
Tve study of the optimum roles and 
bsponsibilities of the sponsor and physi- 
lian when company-sponsored clinical 
psearch is performed by independent 
.inical investigators. 



5. PMA recognizes that the physician- 
investigator has, and should have, the 
ultimate responsibility for deciding the 
substance and form of the informed con- 
sent to be obtained. However, PMA 
recommends that the sponsor of the ex- 
periment aid the investigator in dis- 
charging this important responsibility by 
providing (1) a document detailing the 
investigator's responsibilities under FDA 
regulations with regard to patient consent, 
and (2) a written description of the 
relevant facts about the investigational 
item to be studied, in comprehensible 
la\' language. 

6. In the case of children, the sponsor 
must require that informed consent be 
obtained from a legally appropriate rep- 
resentative of the participant. Voluntary 
consent of an older child, who may be 
capable of understanding, in addition to 
that of a parent, guardian or other legally 
responsible person, is advisable. Safety of 
the drug or device shall have been assessed 
in adult populations prior to use in 
children. 

7«PMA endorses the general prin- 
ciple that, in the case of the mentally 
infirm, consent should be sought from 
both an understanding subject and from 
a parent or guardian, or in their absence, 
another legally responsible person. 

8. Pharmaceutical manufacturers 
sponsoring investigations in prisons must 
take all reasonable care to assure that the 
facilities and personnel used in the con- 
duct of the investigations are suitable for 
the protection ol participants, and for the 
avoidance of coercion, with a respect for 
basic humanitarian principles. 

9« Sponsors intending to conduct non- 
therapeutic clinical trials through the 
participation of employee volunteers 
should expand the membership and scope 
of its existing Medical Research Commit- 
tee, or establish such an internal Medical 
Research Committee, with responsibility 
to approve the consent tonus ot all 
volunteers, designs, protocols and the 
scope of the trial. The Committee should 
also bear responsibility to ensure full 
compliance with all procedures intended 
to protect employee volunteers' rights. 

10. Where the sponsor obtains medi- 
cal information or data on individuals, it 
shall be accorded the same confidential 



status as provided in codes of ethics gov- 
erning health care professionals. 

11. PMA and its member firms accept 
responsibility to aid and encourage ap- 
propriate follow-up of human subjects 
who have received investigational prod- 
ucts that cause latent toxicity in animals 
or, during their use in clinical investiga- 
tion, are tound to cause unexpected and 
serious adverse efitects. 

IZ.PMA supports the exploration 
and development by its member compa- 
nies of more systematic surveillance pro- 
cedures lor newly marketed products. 

13.When a pharmaceutical manu- 
facturer concludes, on the basis of early 
clinical trials of a basic new agent, that a 
new drug application is likely to be sub- 
mitted, a proposed develop.Tient plan 
accompanied by a summar}' of existing 
data, would be submitted to the FDA. 
Following a reviev.' of this submission, 
the FDA, and its Advisory Committee 
where appropriate, would meet with the 
sponsor to discuss the development plan. 
No fornidl FDA approval should be re- 
quired at this stage. Rather, the emphasis 
should be on identification of potential 
problems and questions for the sponsor's 
further study and resolution as the pro- 
gram develops. 

The PMA believes that health profes- 
sionals as well as the public at large 
should be made aware of these 13 points 
in its Policy on Clinical Research. For 
these recommendations envisage con- 
structi\'e, cooperative action by industry, 
research institutions, the health profes- 
sions and government to encourage crea- 
tive and workable responses to issues 
involved in the clinical investigation of 
new products. 



Pharmaceutical Manufacturers 

Association 

1155 Fifteenth Street, N.W 



Washington, D. C. 20005 



Officers 
1975-1976 



NORTH CAROLINA MEDICAL 
SOCIETY 



President James E. Davis, M.D. 

1 ;00 Broad St., Durham 27705 

Prcsident-Elcct Jesse Caldwell, Jr., M.D. 

1 14 W. 3rd Ave., Gastonia 28052 

First \'icc-Prcsidcnt John L. McCain, M.D. 

Wilson Clinic, Wilson 27893 

Second Vice-President T. Reginald Harris, M.D. 

808 N. DeKalb St., Shelby 28150 

Secretary E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Durham 27710 (1976) 

Speaker Chalmers R. Carr, M.D. 

1822 Brunswick Ave., Charlotte 28207 

Vice-Speaker Henry J. Carr, Jr., M.D. 

603 Beamon St., Clinton 28328 

Past-President FRANK R. REYNOLDS, M.D. 

1613 Dock St., Wilmington 28401 

Executive Director William N. Milliard 

222 N. Person St., Raleigh 276 II 

Councilors and Vice-Councilors 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor Joseph A. Gill, M.D. 

1202 Carolina Ave.. Elizabeth City 27909 (1977) 

Second District J. Ben.iamin Warren, M.D. 

Box 1465, New Bern 28560 ( 1976) 

Vice-Councilor Charles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1976) 

Third District E. Thomas Marshburn, Jr., M.D. 

1515 Doctors Circle, Wilmington 28401 (1976) 

\'icc-Councilor Edward L. Boyeite. M.D. 

Chinquapin 28521 (1976) 

Fourth District Harry H. Weathers, M.D. 

Central Medical Clinic, Roanoke Rapids 27870 (1977) 

}'icc-Councilor Robert H. Shackleford, M.D. 

115 W. Main St., Mt. Olive 28365 (1977) 

Fifth District August M. Oelrich, M.D. 

Box 1169. Sanford 27330 (1978) 

Vice-Councilor Bruce B. Blackmon, M.D. 

P. O. Box 8, Buies Creek 27506 (1978) 

Sixth District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd., Chapel Hill 27514 (1977 I 

Vice-Councilor W. Beverly Tucker, M.D. 

Box 988, Henderson 27536 (1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Road, Charlotte 28207 (1978) 

\'ice-CounciIor J. Dewey Dorsett, Jr 

1851 E. Third St., Charlotte 28204 (1978) 

Eighth District Ernest B. Spangler, M.D. 

Drawer X3, Greensboro 27402 (1976) 

Vice-Councilor James F. Reinhardt, M.D. 

Cone Hospital, Greensboro 27402 (1976) 

Ninth District Verne H. Blackwelder, M.D. 

Box 1470, Lenoir 28645 (1976) 

Vice-Councilor Jack C. Evans, M.D 

244 Fairview Dr., Lexington 27292 (1976) 

Tenth District Kenneth E. Cosgrove, M.D. 

510 7th Ave., W., Hendersonville 28739 (1978) 

Vice-Councilor Otis B. Michael, M.D. 

Suite 208, Doctors Bldg., Asheville 28801 (1978) 

186 



Section CJiaimien — 1975-76 

Anesthesiology Jack H. Welch, M.D. 

Physicians Quadrangle, Greenville 27834 

Derniatologv George W. Crane, Jr., M.D. 

1200 Broad St.. Durham 27705 

Family Physicians William W. Hedrick, M.D. 

331 1 N. Boulevard, Raleigh 27604 

Internal Medicine James H. Black, M.D. 

1351 Durwood Dr., Charlotte 28204 

Neurology & Psychiatry Hervy W. Mead, M.D. 

1900 Randolph Rd., Suite 900, Charlotte 28207 

Neurological Surgery M. Stephen Mahaley, Jr., M.D. 

394() Nottaway Rd., Durham 27707 

Obstetrics & Gynecology C. T. Daniel, Jr., M.D. 

1641 Owen Dr., Fayetteville 28304 

Ophthalmology E. R. Wilkerson, Jr., M.D. 

1012 Kings Drive, Charlotte 28207 

Orthopaedics Frank C. Wilson, M.D. 

N. C. Memorial Hospital, Chapel Hill 27514 

Otolaryngology N. L. SPARROW, M.D. 

3614 Haworth Dr., Raleigh 27609 

Pathology R. Page Hudson, M.D. 

P. O. Box 2488, Chapel Hill 27514 

Pediatrics Gerard Marder, M.D. 

224 New Hope Rd., Gastonia 28052 

Public Health & Education J. N. MacCormack, M.D. 

Box 2091, Raleigh 27602 

Radiology R. W. McConnell, M.D. 

1711 W. 6th Street, Greenville 27834 

Surgery Robert C. Moffatt, M.D. 

309 Doctors Bldg., Asheville 28801 

Urology Robert Dale Ensor, M.D. 

1333 Romany Road, Charlotte 28204 

Students. Medical 

j 
Delegates to the American Medical Association 

James E. Davis, M.D 1200 Broad St., Durham 27705 

(December 31, 1976) 

John Gi asson, M.D 306 S. Gregson St., Durham 27701 \ 

(December 31, 1976) ■ 

Frank R. Reynolds, M.D. 

1613 Dock Street, Wilmington 28401 I 
(December 31, 1976) 
David G. Welton, M.D. 

3535 Randolph Road, Charlotte 28211 
(December 31, 1977) 
Edgar T. Beddingmei d, Jr.. M.D. 

Wilson Clinic, Wilson 27893 
(December 31, 1977) 

Alternates to the American Medical Association 

George G. Gilbert, M.D. 

1 Doctor's Park, Asheville 28801 
(December 31, 1976) 
Louis dfS. Shaffner. M.D. 

Bowman Gray, Winston-Salem 27103 
(December 31. 1976) 
Jessk Caldwell. Jr.. M.D. 

114 W. 3rd Ave., Gastonia 28052 
(December 31, 1976) 
Charles W. Styron, M.D. 

615 St. Marys St., Raleigh 27605 
(December 31, 1977) 

D. E. Ward, Jr., M.D 2604 N. Elm St., Lumberton 28358 

(December 31, 1977) 

Vol. 37, No. 



NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 

Now Pays Up To 

$500 4 

WEEKLY INCOME 
($2,166.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 




GUARANTEED RENEWABLE 



You are guaranteed the privi- 
lege of renewing $300-week to 
age 70. The other $200 per week 
renewable to age 60. This is an 
exclusive and most important 
feature. 



DIRECT PERSONAL SERVICE 



Since 1939, it has been our 
privilege to administer your pro- 
gram from Durham, N. C. includ- 
ing payment of all claims! 



J. L. & J. SLADE CRUMPTON, INC. 

GENE GREER 

Office Manager 

. (). Drawer ] 767— Durham. \. C. 27702. Telephone: 919 682-5497 
Underwritten by The Continental Insurance Cos. of New York 

JACK FEATHERSTON, Field Representative 

P. 0. Box 17824. Charlotte. N. C. 28211. Telephone: 704 366-9359 

INorth Carolina Professional Group Administrators for: 

NORTH CAROLINA MEDICAL SOCIETY . NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI 
NEERS • NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A/S AND BAR GROUPS 




Physician... 




your 

rgeneral practice" 

couldrit be 
more general 

tfiantiie Air Force 



Our doctors run into everything - and have the modern facilities and highly 
trained support staff to deal with it. A medical career in the Air Force 
offers other advantages, too - reasonable hours with time to spend with 
your family around the outstanding Air Force Base facilities. Administra- 
tive support. Patient treatment without regard for ability to pay. An 
excellent program of education if you wish to specialize in one of the many 
areas of medicine. 

Find '*the perfect practice" 

in the Air Force. 

Mail the coupon below for all the information. 

310 New Bern Ave , Rm 303 
Raleigh, NO. 27611 
Call. 919/755-4134 

AIR FORCE. Health Care At Its Best. 

Social Security No. 




Name 

Address 

City 

state 



Zip. 



Phone . 



Specially „ 
Date of Birth 



® Each capsule contains 50 mg. 
of Dyrenium* (triamterene, SK&F) 
and 25 mg. of hydrocUorothiazide. 



'makes SENSE 

TRIAMTERENE CONSERVES POTASSIUM 
9(^ILE HYDROCHLOROTHIAZIDE 
JOWinS BLOOD PRESSURE 

FOR LONG-TERM CONTROL 

3F HtPERTENSION Serum K"*" and BUN should be checked periodically. (See Warnings Section.) 




tefore prescribing, see complete prescribing in- 
>rmation in SK&F literature or PDR. The fol- 
iwing is a brief summary. 



Warning 

This fixed combmation drug is not indi- 
icated for initial therapy of edema or hyper- 
tension. Edema or nVpertension requires 
therapy titrated to the individual patient. If 
the fixed combination represents the dosage 
so determined, its use may be more convenient 
in patient management. The treatment of 
hypertension and edema is not static, but 
must be reevaluated as conditions in each 
patient warrant. 



■'idications: Edema: That associated with con- 
,^stive heart failure, cirrhosis of the liver, the 
?phrotic syndrome: steroid-induced and idio- 
athic edema; edema resistant to other diuretic 
lerapy. Mild to moderate hypertension: Useful- 
^ss of the triamterene component is limited to 
s potassium^sparing effect. 

ontraindications: Pre-existing elevated serum 
Dtassium. Hypersensitivity to either component, 
ontinued use in progressive renal or hepatic 
^sfunction or developing hyperkalemia, 
/arnings: Do not use dietary potassium supple- 
ents or potassium salts unless hypokalemia 
ivelops or dietary potassium intake is markedly 
ipaired. Enteric-coated potassium salts may 
i luse small bowel stenosis with or without 
k ceration. Hyperkalemia t>5.4 mEq/L) has 



been reported in 4% of patients under 60 years. 
in 12% of patients over 60 years, and in less than 
8% of patients overall. Rarely, cases have been 
associated with cardiac irregularities. Accord- 
ingly, check serum potassium during therapy, 
particularly in patients with suspected or con- 
firmed renal insufficiency (e.g.. elderly or dia- 
betics). If hyperkalemia develops, substitute a 
thiazide alone. If spironolactone is used con- 
comitantly with "Dyazide". check serum potas- 
sium frequently —both can cause potassium 
retention and sometimes hyperkalemia. Two 
deaths have been reported in patients on such 
combined therapy {in one, recommended dosage 
was exceeded; m the other, serum electrolytes 
were not properly monitored). Observe patients 
on 'Dyazide' regularly for possible blood 
dyscrasias. liver damage or other idiosyncratic 
reactions. Blood dyscrasias have been reported 
in patients receiving Dyrenium (triamterene. 
SKu^F). Rarely, leukopenia, thrombocytopenia, 
agranulocytosis, and aplastic anemia have been 
reported with the thiazides. Watch for signs of 
impending coma in acutely ill cirrhotics. Thia- 
zides are reported to cross the placental barrier 
and appear in breast milk. This may result in 
fetal or neonatal hyperbilirubinemia, thrombo- 
cytopenia, altered carbohydrate metabolism and 
possibly other adverse reactions that have oc- 
curred in the adult. When used durin g preg nanc y 
or in women who mi g ht bear children , weigh 
potential benefits against possible hazards to 
fetus. 
Precautions: Do periodic serum electrolyte and 



BUN determinations. Do periodic hematologic 
studies in cirrhotics with splenomegaly. Anti- 
hypertensive effects may be enhanced m post- 
sympathectomy patients. The following may 
occur: hyperuricemia and gout, reversible nitrogen 
retention, decreasing alkali reserve with possible 
metabolic acidosis, hyperglycemia and glycosuria 
(diabetic insulin requirements may be altered). 
digitalis intoxication (in hypokalemia). Use 
cautiously in surgical patients. Concomitant use 
with antihypertensive agents may result m an 
additive hypotensive effect. "Dyazide" interferes 
with fluorescent measurement of quinidine. 
Adverse Reactions: Muscle cramps, weakness, 
dizziness, headache, dry mouth; anaphylaxis; 
rash, urticaria, photosensitivity, purpura, other 
dermatological conditions: nausea and vomiting 
(may indicate electrolyte imbalance), diarrhea, 
constipation, other gastrointestinal disturbances. 
Necrotizing vasculitis, paresthesias, icterus. 
pancreatitis, xanthopsia and. rarely, allergic 
pneumonitis have occurred with thiazides alone. 
Supplied: Bottles of 100 capsules: in Single Unit 
Packages of 100 (intended for institutional use 
only). 

SK&F Co., Carolina, P.R. 00630 

Subsidiarv' of SmithKline Corporation 



f !^^^;>:-.-, 





'%. 



HELP 
STOP TH 
TEARS 

of colic, diarrhoi 
or similar malad 

USE LOMA LINDi 
i-SOYALAC 

i-Soyalac and regular Soyalac are 
palatable, readily digestible and 
assimilated. It simulates human mill 
appearance, taste and texture. It is 
complete with vitamins and mineral 
It is suitable for all infants and child 
Soyalac is especially recommende 
physicians for children who are ser 
five to or cannot tolerate cow's mill< 

For nearly a quarter of a century, 
Soyalac has proven its value in pro- 
moting growth and development -a 
shown by extensive clinical data. 

Available without carrageenan in: 
SOYALAC Liquid Concentrate, 
SOYALAC Powder and i-SOYALAC 
Liquid Concentrate. 



^6w in 32 oz. size. Ready-to-Serve 



Send to: Loma Linda Foods 

Medical Products Division 
Riverside, Calif. 92505 

Please send me free sample and literature. 
Name 



Address. 



City_ 



State- 



_Zip_ 



SJ-4 



Or a simple note on your prescription form will do. 




i-SOYALAC contains no corn products. 



Preventive Medicine 
Makes Sense •.. 

Disability Income Protection Does Too! 



! / 



\ 




;/■ 



i\ 



w / A; 



Just as preventive medicine can help you 
avoid disasters to your health. Disability Income 
Protection can help you avoid financial 
disasters. A long-term disability, for example, 
without adequate insurance protection could 
mean weeks or even years without an income. 

For this reason alone, you cannot afford 
to be without the proper protection. 

That's why we have especially designed a 
Disability Income Protection Plan for younger 
doctors. A plan of protection to help make sure 
your family continues to live in the manner to 



which they are accustomed should you become 
disabled and unable to practice medicine. 

These benefits are paid directly to you to use 
as you see fit whether you are confined in 
a hospital or recovering at home. Furthermore, 
these benefits are tax free under present 
federal income tax laws. 

If you are under 55 years of age. just fill out 
the coupon below and mail it today. Mutual of 
Omaha will provide personal service in 
furnishing all of the details. Of course, 
there is no obligation. 



L SIHHWRrlltS a\ 




Mutual 
9lOmaha 

People ifou can count on... 

Life Insurance Affiliate: United of Omaha 

MUTUAL OF OMAHA rNSURANCE COMPANV 
HOME OFFICE; OMAHA, NEBRASKA 



Mutual of Omaha Insurance Company 

Dodge at 33rd Street • Omaha, Nebraska 68131 

I am interested in learning more about the program of Disability Income 
Protection available to me. 

Name 



Address 
City 



. State 



ZIP code 



I .. J 



Famous Fighters 




NEOSPORIN^ Ointment 

( polymyxin B-bacitracin-neomycin) 

is a fam^ous fighter, too. 

Provides overlapping, broad-spectrum antibacterial action to help combat 
infection caused by common susceptible pathogens (including staph and strep). 



Each gram contains Aerosporm" brand Polymyxin B Sulfate 5,000 units, zinc 
bacitracin 400 units, neomycin sulfate 5 mg (equivalent to 3 5 mg neomycin base) 
special wtiite petrolatum qs in tubes of 1 oz and 1/? oz and 1/32 oz (approx | 
foil packets 

INDICATIONS: Therapeutically (as an adjunct to systemic therapy wfien indicated) 
for topical infections, primary or secondary, due to susceptible organisms, as in 
• infected burns, skin grafts, surgical incisions, otitis externa • primary 
pyodermas (impetigo, ecthyma, sycosis vulgaris, paronychia) • secondarily 
infected dermatoses (eczema, herpes, and seborrheic dermatitis) • traumatic 
lesions, inflamed or suppurating as a result of bacterial infecbon 
Prophylacfically , the ointment may be used to prevent bacterial contamination m 
burns, skin grafts, incisions, and othe clean lesions For abrasions, minor cuts 
and wounds accidentally incurred, its use may prevent the development of infec- 
tion and permit wound healing CONTRAINDICATIONS: Not for use in the eyes or 
external ear canal if the eardrum is perforated This product is contramdicated in 
those individuals who have shown hypersensitivity to any of the components 
WARNING: Because of the potential hazard of nephrotoxicity and ototoxicity due to 



^^rvss^ 



0I,M>1IM 



f^-. 



« 



neomycin, care should be exercised when using this product in treating extensive 
burns, trophic ulceration and other extensive conditions where absorption of 
neomycin is possible In burns where more than 20 percent of the body surface is 
affected, especially if the patient has impaired renal function or is receiving other 
aminoglycoside antibiotics concurrently, not more than one application a day is 
recommended PRECAUTIONS: As with other antibacterial preparations, prolonged 
use may result m overgrowth of nonsusceptible organisms, including fungi. 
Appropriate measures should be taken it this occurs ADVERSE REACTIONS: 
Neomycin is a not uncommon cutaneous sensitizer Articles in the current litera- 
ture indicate an increase m the prevalence of persons allergic to neomycin Oto- 
toxicity and nephrotoxicity have been reported (see Warning section) 
Complete literature available on request from Professional Services Dept PML. 



^ 



Burroughs Wellcome Co. 

Researcti Triangle Park 
Nortti Carolina 27709 



Training the Internist to Provide Primary Care- 
Are We? 



Carl B. Lyle, Jr., M.D.,* David S. Citron, M.D.,t and 
Marvin M. McCall, III, M.D.i: 



rHIS report, part of a continuing 
study of the practice of internal 
ledicine in a southern urban com- 
lunity, compares the activities of 
rivate internists with those of the 
ledical house staff in the communi- 
y's teaching hospital. Its intent is to 
lentify areas in the educational 
rogram that might be modified to 
rovide a training program more 
omparable with the requirements 
f community practice. Therefore. 
'e have attempted to describe and 
uantify the clinical activities of six 
iternists who are primary care 
hysicians in the same community. 
Over the past decade, much has 
een written about the appropriate- 
ess of the clinical exposure interns 
nd residents get during their train- 
ig programs.'"' In most programs, 
le early years are spent dealing 
'ith critical, catastrophic illness 
nd end-stage disease. Analyses of 
le patient populations of house of- 
cers usually reflect the social dep- 
vation of the populations served 
y many teaching hospitals. Dis- 
ises spawned by poverty, as well 
5end-stage cardiac, renal, hepatic, 
id central nervous system prob- 
ms predominate. In this milieu. 



"Associate Professor of Medicine. Universilv of North 
irolina. Chapel Hill, and Assistant Chairman, Department 
Medicine. Charlotte Memonal Hospital. (. harlotte, N C 
^Clinical Professor of Medicine. University of North 
irolina, and Chairman, Department of Family Practice, 
larlotte Memorial Hospital, (-'harlotte 
tClinical Professor of Medicine, University of North 
irolina, and Associate Chairman, Department of 
sdicine, Charlotte Memonal Hospital 

Reprint requests to Dr Lyle 



clinical responsibility is shared by 
the attending physician and various 
members of the house staff hierar- 
chy. Involvement of a house officer 
with a patient is measured in days or 
weeks — rarely in months, and al- 
most never in years. Moreover, the 
patient is often unable to identify by 
name any of the several house offi- 
cers responsible for his care. 

By contrast, the general internist 
in private practice spends much 
time dealing with the early sick and 
the worried well. His patients are 
upright rather than horizontal, unat- 
tached to life support systems, tube- 
less, conscious and expecting to re- 
cover. Many of them have sought 
medical advice because of ill health 
which is feared rather than real. 
Some have presented for routine 
comprehensive examinations. Of 
the problems they present, most are 
self-limited and few are critical or 
life-threatening. The physician's re- 
sponsibility for continuing care, 
though it may be shared at times 
with consultants, is implicit in his 
unwritten contract with each pa- 
tient who has identified him as "my 
doctor." 

By no means do we imply that 
house officers should not experi- 
ence a healthy dose of "blood and 
guts" medicine, for such experi- 
ences develop professional compe- 
tence in dealing with clinical crises. 
Indeed, it is imperative that the in- 
tern or resident, during his early 



postgraduate years should through 
trial and error make the transition 
from bookish recall to clinical re- 
flex. However, during these forma- 
tive years, the art of medicine is too 
often relegated to a position of sec- 
ondary importance. 

When a patient presents with a 
virtual portfolio of end-stage 
pathologic abnormalities substan- 
tiated by abnormal physical, chemi- 
cal and radiologic findings, the sci- 
entific approach to his problems 
must predominate. Evaluating fam- 
ily dynamics and psychosocial in- 
fluences on irreversible disease may 
be interesting from an epidemi- 
ologic standpoint, but it is rarely 
relevant to his immediate or long- 
term management. However, when 
a patient presents for help having 
few or minor demonstrable abnor- 
malities, it is incumbent upon the 
physician to probe more deeply, 
orienting himself not only toward 
the patient but toward his family 
and his environment. Such patients 
appear infrequently on teaching 
wards and in hospital medical 
clinics. When they do, they receive 
little priority from the house staff, 
whose time must be spent attending 
those seriously and critically ill. 

As the educational community 
responds to public and political de- 
mands for more physician man- 
power, it is inevitable that commu- 
nity hospitals will expand their roles 
in the education of internists.*'' 



PRIL 1976. NCMJ 



193 



ll 



Proponents of community hospital 
training programs anticipate that 
they will afford the resident a more 
realistic spectrum of clinical experi- 
ence and thereby better prepare him 
for community-based practice. Be- 
fore the validity of this conclusion 
can be tested, significant changes 
will have to be effected by those 
responsible for the design of such 
programs. An effort must be made 
to provide a more balanced experi- 
ence incorporating more of the 
problems seen in the private prac- 
tice of internal medicine. Serious 
pitfalls threaten community hospi- 
tal programs which only duplicate 
the ward experiences offered at 
university teaching centers. In the 
urban community, practitioners of 
the science and the art and their pa- 
tients offer a great resource for bal- 
anced educational exposure; but 
many barriers to the proper use of 
these resources exist. Unless these 
barriers can be eliminated, it seems 
unlikely that physicians training at 
community hospitals will be better 
equipped as primary care physi- 
cians than their counterparts from 
university hospital programs. That 
most general internists spend a large 
proportion of their time providing 
primary care and that their prepara- 
tion for this role has been incom- 
plete are conclusions reached in 
several recent studies.^ 

BACKGROUND AND METHODS 

Charlotte Memorial Hospital is 
an 850-bed, acute care facility serv- 
ing a county population of 400,000. 
A referral center for medical, 
pediatric and surgical subspecialties 
in a region of approximately 
1,000,000, it has an average daily 
census of 751 of whom 26 percent 
are staff (charity) patients. 

The medical teaching service has 
as its potential patient pool the adult 
indigent population of the county. 
Of the approximately 19,000 recip- 
ients of public assistance in the 
county, some 5,000 are active pa- 
tients in the adult medical clinic, ac- 
counting for 14,000 visits per year. 
Six interns on the medical service 
work in the indigent clinic nine 
hours a week and spend approxi- 
mately 60 additional hours a week 
on inpatient duties. Only those 

194 



non-indigent patients who require 
emergency admission and do not 
have a physician on the visiting 
medical staff are treated by the in- 
terns. A member of the visiting staff 
is promptly assigned to assume 
primary responsibility for their sub- 
sequent care. 

The six private physicians in this 
study practice in a clinic close to the 
hospital, which they use exclu- 
sively. This clinic, with active med- 
ical records of 18,000 patients, had a 
total of 21,000 office visits for the 
one-year study period. Most of 
these private patients were from the 
same county as the indigent popula- 
tion of the teaching service. Seeing 
patients by appointment, each prac- 
titioner averaged 28 hours a week in 
the office. He spent 12"^ hours a 
week attending inpatients and was 
"on call" every third weekend. On 
weekends, the two physicians on 
call spent an average of four and 
one-half hours each at the hospital. 

The internists are all certified by 
the American Board of Internal 
Medicine. Several have subspe- 
cialty interests: two in hematology, 
one in pulmonary disease and one in 
gastroenterology . 

During the one-year study period, 
which ended in September, 1973, 
admissions to the medical teaching 
services were not managed by the 
same six interns. A total of 18 in- 
terns were involved, each serving 
an average of four months. The ser- 
vice was divided into three teams, 
each consisting of a junior assistant 
resident, two interns, and some- 
times a senior medical student serv- 
ing an elective rotation. 

RESULTS 

Table 1 compares the number of 
admissions of the six internists in a 
private clinic with those of the three 
medical teaching services. Only 1.0 
percent of the private admissions 
were beneficiaries of Medicaid, 
while 17.0 percent of staff admis- 
sions were so covered. Of all private 
patients, 40.5 percent were covered 
by Medicare or Medicaid, as were 
37.6 percent of all staff patients. 
Almost all private patients not cov- 
ered by these two federal programs 
had hospital insurance. Most of the 
62.4 percent of staff patients not 



covered by Medicare or Medicaii & i"! 
had limited, if any, insuranc; ir;:-^"' 
coverage. |■;^^pf' 

Table 2 lists selected specifi, j Ei?!" 
primary disorders chosen to con"; 't'ensit 
pare the types of admissions of th( mi *' 
two groups. Not all patients wer-iK^er 
included in this list. Only thos jisu 
categories of illness that reflecte acser 
either a significant number of ac; a e «it 
missions or some difference be 
tween the two populations are ir 
eluded. The number of patient 
listed in Table 2 for the teachin 
services represents 64.0 percent o 
admissions to those services; 49. ,„, 
percent of the admissions of the pri pn 
vate clinic are reflected in the table ''' 
Those patients excluded from tb 
study represented a wide variety o * 
diagnoses, with few patients fallini «» 
into the same category. The teach ■* 
ing service had 24.0 percent mon * 
admissions than the private clinii ,.^ 
during the study period. The degrei 3is 

of severity of illness between thi 

two groups is reflected by the fac 
that more than 95.0 percent of thi 
staff patients were admitted on ai 
emergency basis, while only 18.1 
percent of private admissions wen 
emergencies. The staff death rat( 
was double that of private patients 
and 20.0 percent of the indigent pa 
tients required subsequent care ii 
an extended care facility as com 
pared with only 8.0 percent of th^ 
private population. 

If one looks at physical disorder 
commonly associated with alcohol 
ism — delirium tremens, seizures! 
liver disease and acute pancreatitis 
— one can see that there were l^j J* 
times as many admissions with sucl »* 
disorders on the teaching service afl *"' 
there were on the private service. 

In the realm of serious infectioui 
diseases — tuberculosis, meningiti; ; :« 
and gonococcal sepsis — there wen * 
28 times as many admissions to tht ^^'' 
teaching service. The house officer; ,« 
were exposed to almost three time; '■; 
the number of cerebrovascular ac , a. 
cidents as were the private inter] 
nists, which is not surprising in view 
of the fact that 49.0 percent of al 
visits to the indigent clinic are re 
lated to hypertensive disease as 
compared with 15.0 percent of the 
visits to the private clinic. The per 
centage of admissions for docu 

Vol. 37, No. 4^ 



iM 
Irs 

Co'l 
Lffil: 

Lymph 



'KB 

Er;«i 
Cifrho; 



^ented myocardial infarction was 
4 percent on the indigent service 
id 6. 1 percent for the private ser- 
vice. Eight patients with malignant 
.fpertension were admitted to the 
j"'' aching service and none to the 
*' ivate service. There were almost 
"' /ice as many admissions on the 
'^.^ ivate service for ischemic heart 
sease without infarction as there 



were on the teaching service. Elev- 
en cases of myoc?rditis were seen in 
the indigent population; two in the 
private population. More than twice 
as many cases of pneumonia requir- 
ing hospitalization were seen in the 
indigent population and there were 
seven lung abscesses in this group. 
Over four times as many patients 
with ulcer disease without hemor- 



TABLE 1 

Admissions of Six Internists and 
Six Interns for a One-Year Period 



Patients 
Hospital Days 
Average Stay 
Patients (Medicare) 

Hospital Days iMedicare) 

Average Stay (Medicare) 
Patients (Medicaid) 

Hospital Days (Medicaid) 

Average Stay (Medicaid) 
Deaths 



Private 


Staff 


830 


1,030 


7,662 


9,508 


9-23 days 


9,23 days 


328 
(3952%) 


212 

(20.58%) 


3.214 
(41.95%) 


1,788 
(18,81%) 


9.80 days 


8.43 days 


8 
(0,96%) 


175 
(170%) 


132 

(1.72°o) 


1,590 
(1672%) 


16 5 days 


9,09 days 


57 
(6 87°„) 


139 

(13,50%! 



TABLE 2 

Number of Hospital Admissions 

by Selected Primary Disorder 





Admissions to 


Admissions to 




Teaching Service 


Private Service 


Tuberculosis 


lb 


1 


Bacterial Meningitis 


7 





Gonococcal Arthritis 


5 





Sarcoidosis 


6 





Carcinoma 






Stomach 


2 





Lung 


14 


10 


Breast 





5 


Colon 





3 


Leukemia (all types) 


2 


11 


Multiple Myeloma 


2 


2 


Lymphosarcoma 





2 


Hodgkin s Disease 





2 


Renal Disease (Nephritis 






Nephrotic Syndrome, etc) 


31 


10 


Attempted Suicide 


19 


2 


Diabetic Ketoacidosis 


21 


4 


Diabetes without Ketoacioosis 


13 


29 


Delirium Tremens 






(acute alcoholism) 


43 





Seizures 


23 


1 


Valvular Heart Disease 


9 


7 


Malignant Hypertension 


8 





Essential Hypertension 


23 


24 


Myocardial Infarction 


66 


51 


Ischemic Heart Disease 






(without infarction) 


44 


79 


Myocarditis 


1 1 


2 


Congestive Heart Failure 


31 


8 


Cerebral Vascular Accident 


84 


31 


Dissecting Aneurysm 


4 


2 


Pneumonia 


86 


41 


Lung Abscess 


7 





Gastric or Duodenal Hemorrhage 


12 


8 


Ulcer Disease without Hemorrhage 


4 


17 


Enteritis and Colitis 


6 


31 


Cirrhosis 


30 


6 


Gallstones and or Cholecystitis 


3 


12 


Acute and Chronic Pancreatitis 


27 


' 



rhage were admitted to the private 
service, whereas upper gastro-in- 
testinal hemorrhage was only 
slightly more common in the indi- 
gent population. There were more 
than five times as many patients 
with small and large bowel disease 
admitted to the private service, and 
four times as many cases of gall- 
bladder disease. 

DISCUSSION 

The specialty of internal medicine 
has undergone a striking metamor- 
phosis during the past 40 years. The 
internist of the 1930s played the role 
of diagnostician and consultant — 
largely for patients with obscure or 
complicated illnesses beyond the 
ken of the general practitioner. Dur- 
ing the decade of the 1970s, the 
young internist who trained inten- 
sively as a specialist, and often as a 
subspecialist, has found himself as- 
suming the role of a primary physi- 
cian — a role for which his resi- 
dency training may have failed to 
prepare him completely. 

It is estimated that 72.0 percent of 
internists serve as primary prac- 
titioners for their patients.'" The 
editor of the Bulletin of the Ameri- 
can College of Physicians implies 
that such a professional lifestyle is 
encouraged by the American Col- 
lege of Physicians — that "the Col- 
lege thinks a man certified by the 
American Board of Internal 
Medicine is the ideally trained man 
for adult family practice as cur- 
rently defined.'"" Acceptance by 
the internist of the role of primary 
physician has been fostered by pub- 
lic demand.'- The number of gen- 
eral practitioners and their propor- 
tion to the total physician popula- 
tion have declined steadily since the 
1930s: the number and percentage 
of internists to the total physician 
population have increased.'^"'' In 
many urban areas, patients seeking 
a family physician find the internist 
to be more accessible than the gen- 
eral practitioner. Meanwhile, edu- 
cational campaigns by the Ameri- 
can Cancer Society, the American 
Heart Association, the USPHS, and 
articles in the lay press encouraged 
preventive medicine and periodic 
health appraisals, channeling pa- 
tients in increasing numbers to in- 



PRIL 1976, NCMJ 



195 



ternists, whose dedication to 
thorough initial workups and 
periodic re-examinations had by 
this time become well known. The 
respect, confidence and rapport 
which the internist engendered in 
each new patient at the time of the 
initial encounter established firmly 
his status as that patient's personal 
physician. Well prepared to manage 
such problems as bacterial en- 
docarditis and systemic lupus, the 
internist (as primary physician) 
soon found himself inundated with 
patients having upper respiratory 
infections, backaches and parony- 
chias He was forced to make deci- 
sions about the care of patients 
with psychiatric, gynecologic and 
traumatic illness. In many instances 
he considered himself overtrained 
for his role. In others, he felt uneasy 
and insecure because of his limited 
exposure during residency training 
to the gamut of problems encoun- 
tered by the primary care physician. 

That most internists function 
largely as primary physicians rather 
than consultants is documented by 
detailed analysis of the daily profes- 
sional activities of the internist and 
the clinical problems he encoun- 
ters."*" 

One must then ask whether the 
internist's period of training pre- 
pared him appropriately for his 
eventual role as provider of primary 
care. Is there a close parallel be- 
tween the problems managed by the 
house officer and those managed by 
the private primary care physician 
— or indeed should there be? Does 
the house officer's experience en- 
courage him to practice preventive 
and prospective medicine, give him 
an overview of the problems in- 
volved in providing continuing 
comprehensive care to each patient, 
provide adequate exposure to the 
problems of office management and 
of the economics of medical prac- 
tice, afford him an opportunity to 
acquire close rapport with most of 
his patients and to accept and feel 
the major responsibility for the ac- 
curacy of diagnosis and the effec- 
tiveness of treatment for each pa- 
tient to whom he ministers? Such 
questions are diffic.ilt to answer 
with objective data. However, the 
observations recorded in this study 

1% 



lead us to the inevitable conclusion 
that such questions suggest that 
major deficiences might exist in 
traditional residency programs in 
general internal medicine. Re- 
sponses to a survey conducted 
among internists in Monroe 
County, N.Y., indicate that many of 
them consider their postgraduate 
experience in ambulatory medicine, 
gynecology, psychiatry and other 
disciplines to have been in- 
adequate.'* 

Those educators and practicing 
physicians who have established 
guidelines for residency programs 
in family practice, keenly aware of 
the disparity between the activities 
of the hospital-based resident 
physician and the community- 
oriented family physician, have 
chosen the model family practice 
unit as a vehicle for lessening this 
difference.'" The chairman of the 
department of internal medicine at 
a leading medical school has 
suggested that the model family 
practice unit concept might profit- 
ably be introduced into residency 
programs in internal medicine.'" An 
alternative, incorporating some of 
the features of the model family 
practice unit in a medical outpatient 
teaching service, is the subject of a 
recent report.^' 

CONCLUSIONS 

It would seem reasonable to as- 
sume that many community as well 
as university training programs 
would have patient diagnostic pro- 
files and intern activities similar to 
those enumerated above. Indeed, 
this paper simply attempts to de- 
scribe objectively what many medi- 
cal educators have expressed sub- 
jectively in the past. 

A beginning has been made in the 
residency program at the study hos- 
pital to overcome some of these de- 
ficiences. During his senior assis- 
tant resident year, the house officer 
rotates through six medical sub- 
specialties, spending two months in 
each. During a rotation, he is as- 
signed to a visiting staff member for 
whose private patients he is respon- 
sible. He works them up, writes or- 
ders, makes hospital rounds with 
the private physician attending and 



in most cases works in his offic 
several days weekly. In this way h 
studies the subspecialty in depth 
More important, he acquires som 
insight into the relationships of th 
private physician and his patieni 
To a lesser extent, the first yea 
resident has a similar two month ex 
posure during an elective period. r 

How can we modify the progran | 
at the intern level so that it provide; 
not only the care of the acutely am 
seriously ill patient but the begin 
ning concepts of long term man 
agement of "his practice?" 

If training programs are t( 
change, a careful integration of am 
bulatory activities with more realis 
tic expenditure of time and energy 
on inpatients must evolve. Mode 
practice units for training the inter 
nist as well as the family prac- 
titioner would seem a logical nexi 

step. 



,a 'nii 



iview 



ACKNOWLEDGEMENTS 

We thank Mrs. Zoe Wood for technici 
assistance. 

This study was supported in part by a grar „ .t.i 
from the Commonwealth Fund of New York ' 

IllMO 

tiatk 



REFERENCES 



toved 



Bemoi 



«l;ai 



Pellegnno ED The identity cnsis of an ideal: Coi 

Iroversy in Internal Medicine II, Philadelphia. W] latr 

Saunden; Co.. 1474. pp 4l-?0. 

Young LE: The broaaly based internist as the backbon 

of medical practice: Controversy in Internal Medicin 

II Philadelphia. W. B. Saunders Co.. 1914. pp 51-63. lipCl 

. Ebert RH: Are medical schools obsolete'^ Pharo, ■, , 
M- 140- 144. W7I. I -'Xi- 

. Lord Rosenheim: The conflicts between health need| 
and health wants of society. World Med J 20:3-5. 1973.' ^'^ 
tngstrom WW; Residency training in internal medicinkj 
for what, subspecialty boards, what for? Ann InterT 
Med 70:621-633. I%9 ] 

Eben RV: Training of the internist as a primary physj 
cian Ann Intern Med 76 :653-6-'i6, 1972. 

. Bogdonoff MD: A change in the training model forth-} 
practicing internist. Arch Intern Med 126:694-697. 1970MHO: 

. Young LE: Convictions and predictions on the role o 
internists in medical education. JAMA 2 18:72-74. 1971* ^pOR 
Rosinki EF: The community hospital as a center foi ■.-I,,,, 
iraimng and education JAMA 206:1955-1957. 1968. I '^^^'^^ 
Lead article: 1973 demographic survey identifies ASIM .U,, 
member charactenstics. The Internist IV, No 8:1, 3-4 ""^^ 

''*'^^- l-ian 

Rosenow EC: Executive director's page. Bull Am Coll 
lege Phys 6:218 (Jul-Aug). 1965, f-;[ii][] 

Sixleman W A: Internist called in "when the going gel;, 
rough ■■ Int Med News 7:1. 42-43. 1974. I [hv 

Report of the National Advisory Commission on Healtl 
Manpower. Vol I., Washington. DC. Govemmen 
Printing Office. Nov. 1967 

Higher Education and the Nation's Health: Report b\ 
the Carnegie Commission. New York. McGraw Hill 
Oct. 1470, 

Annual Report of Graduate Medical Education in thQ vy 
LI S JAMA 226:935-936. 1973. ' 

Bumum J F: What one internist does in his practice. Anil 'pj 
Intern Med 78:437-444. 1973. j^'. 

Bumum J F: Pnmary care within the academic tradition WM\ 
JAMA 233:974-975. 1975, 

Young LE: Education and roles of personal physician! 
in medical practice JAMA 187:927-933. 1964. 
WillardWR (chairman): Meeting the Challenge of Fam 
ily Practice. Rept^>n of the ad hoc committee on educa 
tion for family practice. Council on medical education 
Chicago. AMA. 1966 
, Ebert RV: Proceedings of the 1973 Annual WorkshO( 
for Directors of Family Practice Programs. Kansa; 
City. American Academy of Family Physicians, pp 
73-74 



Tte 



21 Perlman LV. Kennedy BW, Kaufman J: Training foi ji,^^| 
pnmary care Arch Intern Med 133:448-451. 1974. Jf^'.\^^^\ 

Vol. 37, No. 4|Ll] 






Training in North Carolina for Family Practice 



WiUiam B. Herring, M.D. 



1 

Hi 



^INCE the first meeting in Feb- 
y ruary, 1969, of the Residency 
eview Committee for Family Prac- 
|Ce of the Council on Medical Edu- 
■ition of the American Medical As- 
jciation*. family practice resi- 
ency programs have been ap- 
roved for the Moses H. Cone 
lemorial Hospital. Greensboro; 
lorth Carolina Memorial Hospital, 
hapel Hill; Watts Hospital 
Duke-Watts Family Medicine 
rogram). Durham; Charlotte 
lemorial Hospital. Charlotte; 
/omack Army Hospital. Fayette- 
ille; and the North Carolina Bap- 
st Hospital. Winston-Salem. This 
eport summarizes the collective 
roductivity of these six programs 
) date and projects their future per- 
)nnance and its probable effect on 
le number and distribution of fam- 
y physicians in North Carolina. 

METHOD 

The director of each program 
ifovided information for a ques- 
onnaire including the numbers and 
rigins of residents enrolled, the 
umbers and locations of graduates. 



Dirt'clor of Clinical Training 
The Moses H (.'one Memonal Hospital 
Greensboro, North Carohna 27401 
Rcphnl requests to Dr. Herring 

"The Coordinating Council on Medical hducation, or- 
jiized in 1973. has the responsibility for coordination and 
rection of accreditation of medical education at all levels 



the numbers of paid faculty, and es- 
timates of the numbers of residents 
to be trained and of faculty required 
when each program reaches its pro- 
jected capacity. Five directors gave 
approximate current costs of opera- 
tion. Estimates of the costs of con- 
struction of planned facilities or of 
renovation of existing space were 
also supplied. 

RESULTS 

The first residents enrolled in the 
first program in 1969. In 1971 and in 
each subsequent year one addi- 
tional program was established. A 
total of 108 residents are now en- 
rolled in the six programs; the num- 
ber ranges from 7 to 30. Twenty-five 
(22^) attended North Carolina 
medical schools; 83 (78T-f) came 
from out-of-state schools. Only 
twenty-two (209f) list North 
Carolina as their native state. 

The first graduates, having en- 
tered residency training at the 
second-year level after internships 
elsewhere, finished the three-year 
program in 1971. Of the 22 physi- 
cians who completed the training 
requirements for examination by 
the American Board of Family Prac- 
tice in these six programs. 18 (Sl^c) 
are practicing in North Carolina. 
Figure 1 shows their distribution 
across the state. Entry into practice 



was delayed for some by military 
service obligations, but this is no 
longer a significant factor. 

When all six programs reach their 
projected capacities (a total of 150 
residents), they will be expected to 
produce 50 graduates per year. Two 
programs reached their planned 
maximum enrollments in 1975, two 
others are expected to do so in 1976 
and 1977. and two will be filled in 
1980. Figure 2 shows the number of 
graduates by year since 1 97 1 and the 
projected number through 1981. 
The projections for 1976-1978 are 
firm, since these physicians are al- 
ready enrolled. 

Seven of the 22 graduates have 
taken the examination of the 
American Board of Family Practice 
with a success rate of 100 percent. 

Paid faculty include 23 fulltime 
family physicians and six fulltime 
faculty representing other disci- 
plines. Sufficient data to estimate 
the number of "■fulltime equiva- 
lents"" is lacking, but there are 12 
part-time family physicians and 129 
■"other"" salaried part-time faculty. 
The latter figure is misleading, how- 
ever, for it includes a large number 
of full-salaried physicians whose 
individual contributions are small 
and limited to only two programs. 
When they are excluded this figure 
becomes 19 and probably more rep- 



lPRil 1976. NCMJ 



197 




Fig. I . The distribution of family practice resi- 
dency programs (open circles) and llieir 
graduates (closed circles) in North Carolina. 



resentative. The usual salaried hos- 
pital staff (radiologists, pathologists 
and emergency room physicians) 
are not included although they are 
indispensable to these programs. 
Likewise, the essential contribu- 
tions of a large number of volunteer 
part-time clinical facuhy cannot be 
adequately evaluated for lack of 
data. 

By 1980. when all six programs 
are expected to be functioning at 
capacity, 36 fulltime family physi- 
cians and 1 1 fulltime faculty in other 
disciplines will be required. An in- 
crement of five part-time faculty is 
anticipated. 

The present resident/faculty 
(fulltime) ratio averages 3.7; the 
projected average ratio is 3.2. 
Resident/faculty ratios vary widely, 
from 1.75 to 6.0. 

Crude estimates of current opera- 
tional costs for five programs were 
furnished. They average $38,000 
per resident per year. The figures 
range widely and show no consis- 
tent relationship to numbers of resi- 
dents or faculty or to resident/ 
faculty ratios. 

The sources of financial support 
for the five programs whose direc- 
tors furnished this information are 
diverse and their relative contribu- 
tions are highly variable. The pro- 
gram in Fayetteville is unique in that 
it is financed entirely as a cost of 
operation of the Womack Army 
Hospital. The remaining four show 
a pattern of sources that is too vari- 
able for meaningful quantitation but 
which permits some important 
generalizations: 

1. The State of North Carolina, 

198 



47 47,' 

f-, 44,^ 



Z7f 




I970'7I 72 '73 '74 '75 '76 
YEAR 



77 78 79 '80 



Fig. 2. Numbers of family physicians who have 
completed training (solid line) or who are ex- 
pected to (broken line) by year in six residency 
programs in North Carohna. The peak in 1978 
results from two programs having exceeded 
their complements of first-vear positions in 
1975. 



through the University of North 
Carolina and its Area Health Educa- 
tion Centers (AHEC) program is the 
largest single source of support for 
the training of family physicians in 
the state. 

2. Sponsoring hospitals contrib- 
ute a relatively small proportion of 
the total costs, ranging from none to 
35 percent. 

3. Practice income (derived from 
the model family practices) is a con- 
sistently minor source, ranging 
from 10 to 28 percent. 

In addition, federal grants have 
made important contributions to 
three programs and medical schools 
have assisted two. 

To meet the absolute requirement 
of the approving body for a model 
family practice unit, two directors 
have secured space that has been or 
will be remodeled at an approximate 
total cost of $250,000. The remain- 
ing four plan to build new facilities; 



Sales, 
''it« 

' :l! 10 

::lol 

I Hi,' 

, WW 



lipra 

win 

fal fa 

[Bins 



estimates of the costs of construe! to I 
tion total $4,700,000. I sJiiil 

DISCUSSION : , 

Since 1969, training for familj W 
practice has made rapid progress in«£ 
North Carolina, as in the rest of the wpi 
nation. Evidence for this is th« part 
number of approved programs ill li; 
the state, their success in recruit! i^U' 
ment of residents and faculty anc iir 
the establishment of departments o >'(|i 
family medicine in our medica jok 
schools. Whether the purpose o '\b 
this effort (i.e., to make uniformly 'Jie 
available throughout North Care A 
lina family-oriented primary health 
care of high quality) will be realizec 
remains to be seen, but it seems 
likely that our present position with 
respect to the numbers and distribu 
tion of family physicians will rapidly 
improve. 

The combined output of thest 
programs to date is 22 family physi 
cians. Twenty-seven residents are: 
due to complete their training ir 
June, 1976. At the present rate ol 
retention they will more than doubk 
the number of graduates of these j.ciic 
programs now practicing in North |i.\ 
Carolina. This number will rapidly wi 
increase until 1981, when curren': ;jr; 
projections of maximum output wil ' «; 
be reached (Figure 2). By 1990 peci 
these six programs may be expectec 
to have produced about 720 family 
physicians. Eighty-one percent o: 
our graduates have remained ir 
North Carolina, in accordance with 
the well-known fact that physicians 
tend to enter private practice in the 
state in which they receive their reS' 
idency training.' Assuming that at 



£\P 



Vol. 37. No. i 



k 



Jale 



i;io 



till' 



fition, including "losses" to other 
tates, does not exceed 20 percent. 
|/e may expect about 575 of these 
[hysicians to be practicing in North 
arolina in 1990, a number equiva- 
;nt to over 30 percent of our cur- 
;nt total of all primary care physi- 
ians.^ 
At the present rate of decline in 
leir numbers,' however, the 
laximum annual output of these six 
rograms will be only about half the 
lUmber required to maintain a sta- 
le primary care physician popula- 
on in North Carolina. To what ex- 
jnt family physicians from pro- 
rams yet to be established and 
: ither primary care physicians, in- 
luding immigrants, will help to 
leet or exceed this deficit is uncer- 
lin. 
While some graduates have re- 
" lained near those programs that 
1 ave produced them (Figure 1 ). this 
; partly due to their retention as 
acuity. To date. 4 of our 22 
■ raduates have taken fulltime 
; 'aching-practice positions, a rate 
: 18%) considerably higher than the 
![. ;ational average of 5.9 percent of 
: 975 graduates.' Since the number 
" f these opportunities in North 
arolina is limited, this rate might 
: e expected to diminish. 

Predictions have been offered 

; lat while the deficit of total physi- 

ians is decreasing and may have 

■i disappeared by 1980. "maldistribu- 

'on" of primary care physicians is 

kely to persist.^ This term is gen- 

; rally equated with the shortage of 

hysicians in small communities. A 

; ational survey of those physicians 

; 'ho graduated from family practice 

; ^sidencies in 1975 reveals that 14 

:- ercent and 35 percent entered 

1;; ractice in communities smaller 

•I nan 5.000 and 15.000 population. 

:; espectively.^ The distribution of 

ur graduates in North Carolina 

hows a similar trend ( 17% and 50% 

• 5spectively). suggesting that the 

istribution problem may be solved 

' 1 due course. 

The fact that 80 percent of the 
jsidents now enrolled are from 
tates other than North Carolina 
ind that 78 percent come from out- 
f-state medical schools indicates 
lat these programs are able to at- 
'act out-of-state medical gradu- 



ates. Since these are new residency 
positions, they will increase the net 
number of medical graduates enter- 
ing residency training in North Car- 
olina by up to 50 per year. 

Data that would permit an as- 
sessment of the quality of these 
programs is meager. Presumably it 
bears some relationship to the 
resident/faculty ratios, the medical 
school background and personal 
qualifications of the residents, and 
the performance of their graduates 
on examination by the American 
Board of Family Practice. 

The present overall resident/ 
faculty (fulltime) ratio is 3.7. an ac- 
ceptable figure, but it varies widely 
among the programs. While there 
are no substantiated data to indicate 
an ideal ratio, a consensus of pro- 
gram directors suggests that 3.0 is 
optimal. Resident/faculty ratios 
must be interpreted with caution, 
however, for they fail to reflect the 
highly variable but often critical 
input of volunteer faculty. This im- 
portant contribution cannot now be 
measured but it may possibly be a 
function of the numbers of residents 
and volunteer faculty where such 
faculty are available. 

Information on the background 
and personal qualifications of the 
residents was not gathered for this 
study. However, all the residents in 
the program at the author's institu- 
tion are graduates of 18 reputable, 
well-established American medical 
schools. Forty percent achieved 
overall academic honors in college 
and/or medical school, and match- 
ing through the National Intern and 
Resident Matching Plan was com- 
pleted within approximately the top 
half of the rank order preference list 
in each of the last two years. If these 
characteristics apply generally, the 
average medical graduate entering a 
residency in family medicine is at 
least as well qualified as the average 
medical graduate entering other 
training programs. 

Finally, the graduates who have 
been examined by the American 
Board of Family Practice have 
passed. 

To the extent that these indices 
apply, the quality of these programs 
must be considered acceptable. 
Other determinants, such as the 



qualifications of the faculty, the 
variety and effectiveness of teach- 
ing modalities, the quality of ad- 
ministrative support, and the kinds 
and continuity of clinical experi- 
ences, cannot be measured at this 
time. 

It is not possible to establish with 
precision the per capita costs of 
training family physicians at pres- 
ent. The estimates of current opera- 
tional costs of these programs indi- 
cate an annual figure of about 
$38,000 per resident. While national 
surveys are in progress, there are no 
hard data available with which this 
figure can be compared. Anecdotal 
data gathered from a number of fam- 
ily practice programs in 1973 
yielded an estimate of about $30,000 
per resident per year (Stern TL, 
personal communication). Consid- 
ering inflation, our current average 
figure seems fairly comparable. 
This figure must be treated with 
great caution, for the estimates from 
which it is derived are crude. Its 
lack of a discernible relationship to 
resident/faculty ratios also detracts 
from its credibility. A more precise 
analysis of per capita costs and 
comparison with the results of na- 
tional surveys now in progress 
would be of great interest. 

Although its accuracy is in doubt, 
the figure of $38,000 per family 
practice resident per year should be 
regarded as an acceptable cost, for 
there has been no alternative pro- 
fxjsed that can match the potential 
of these programs to improve the 
number and distribution of family 
physicians in so short a time. For 
this reason also, the amounts pro- 
jected for capital expenditures (for 
the construction of model family 
practice units and related education 
facilities) seem modest indeed. 

From the examination of the 
sources of financial support it is 
evident that the state of North 
Carolina has made a major com- 
mitment to the training of family 
physicians through these programs. 
While any judgment of cost- 
effectiveness must be ventured with 
caution at this point, it appears 
likely that this will prove to be a 
sound investment by the state.'' 
Pending a reliable assessment of 
needs and the contributions to 



iPRiL 1976. NCMJ 



199 



primary care from other sources, 
the state might well consider in- 
creasing its support in order to 
strengthen and expand this effort. 
AHEC is an existing mechanism 
through which increased support 
might conveniently be channeled. 

An appropriate source of anxiety 
for hospital officials is the propor- 
tion of costs that must be borne by 
the sponsoring hospital and. usu- 
ally, passed on to the patient. This 
varies with the degree of success 
each program has in finding sources 
of funds other than AHEC, such as 
training grants, but it appears to be a 
relatively small part of the total. 

It is evident that income derived 
from model family practices will 
never fully support residency pro- 
grams in family medicine, nor are 
model family practices, as compo- 



nents of residency programs, likely 
even to be self-supporting. There 
are significant time commitments 
by faculty and residents to teaching 
and learning that substantially re- 
duce the amount of service deliv- 
ered. Model family practices must 
support staff members having both 
service and teaching functions, in- 
cluding social workers, technolo- 
gists, and administrators, and 
mechanisms for quality control (of 
both patient care and teaching) that 
are not found in private practices. In 
theory an ideal model would be an 
efficient, tightly run private prac- 
tice, but since residents must par- 
ticipate in order to learn, some 
compromises with efficiency are 
unavoidable. 

Hospitals sponsoring family prac- 
tice residency programs will require 



T 



that a majority of the financial sup- 
port come from outside sources. 
Since the state, rather than the 
communities where these programs 
are located, will be the primary ben- 
eficiary, it is appropriate that the 
state provides this support. 

ACKNOWLEDGEMENT i 

I am indebted to the following for informa- 
tion about their programs and for reviewing 
the manuscript: Drs. Donal Dunphy. William 
J. Kane, David Citron. Milton Smith, 
Charles H. Duckett and George T. Wolff. 

REFKRKNCKS 

i Scheffler RM: The relalionship helween medical educa- 
tion and the stale\Mde per capita distribution of physi- 
cians J Med Educ 46:9'(5-W8, l'J7l 

2 Pnmar7 (_'are: Physicians in North Carohna. Health Ser- 
vices Research Center of North Carohna. Raleigh, N.C. 
I>)74, 

3. Graham R: Memorandum: Practice choices of family 
practice residents graduating in I47S Division of fcduca- 
tion. Amencan Academy of Family Physicians. Kansa; 
City. Mo , .Septemher 17, \<i7f 

4 Physician manpower and distribution 1 he pnmary care 
physician A report of the (oi>rdinaling Council on Med 
ical Education. JAMA 23.1:880-881. 1975. 



When the combination of liver and stomach affection is established, we have a train of well-marked 
phenomena indicative of their coexistence. The appetite is llckle, being sometimes ravenous, at others 
almost annihilated, and sometimes whimsical. Whatever is eaten produces more or less of distention, 
discomfort, or even of pain in the stomach, the duodenum, or in some portion of the alimentary canal, till 
the faecal remains have been evacuated. On this account the bilious and dyspeptic patient is very 
anxious to take aperient medicine, as temporary relief is generally experienced by free evacuations. 1 say 
temporary relief; for purgation will not remove the cause of the disease; it only dislodges irritating 
secreations, soon to be replaced by others equally offensive. Indeed the usual routine of calomel at night 
and black-draught in the morning, if too often repeated, will keep up rather than allay irritation in the 
bowels, and produce, as long as they are continued, morbid secretions from the liver and whole intestinal 
canal. — An Essax on lnJii;i\sli(iii: or Murhid Sfnsihility of the Stomach S: Binveh , James Johnson, 18.^6, 
pp 2X-29. 



200 



Vol. 37, No, 4 



Ethical Implications of Professional 
Standards Review Organizations 



James F. Toole, M.D. 



AM pleased to have the opportu- 
nity to discuss the changes in our 
ledical ethic which, I fear, the 
;wly activated Professional Stan- 
irds Review Organizations may 
ring about. In my opinion, the 
ing-range effects of PSRO and its 
andmaiden, a system of national 
salth insurance, will become key 
sues not just for physicians but for 
ur entire citizenry. Among the 
imifications of widely available 
avemment-supported health care 
re our ability to prolong the lives of 
le mentally retarded, the comatose 
nd the senile; the increased cost of 
ledical care to insure the survival 
f our aged; and the impact these 
rograms will have on our society 
nd its economics. The PSRO prog- 
im will bring equally dramatic 
hanges to the practice of medicine, 
Itering in fundamental ways the 
revision of medical care to our 
opulation. 
Up to now, a few physicians have 
'restled with these potential prob- 
:ms, but most have ignored them 
nd concentrated on their primary 
jsponsibility of providing the best 
ledical care for their patients, 
likewise, our national advisory 
ommittees have often failed to 



Professor and Chairman 
DepartmenI of Neurology 
Bowman Gray School of Medicine 
Winslon-Salem. Nonh Carolina 27103 



foresee and plan for obvious prob- 
lems attending the rapid develop- 
ment of medicine during the past 
decade. Some of my experiences 
with such committees are directly 
applicable to these potential dif- 
ficulties which I would like for you 
to consider. 

During the past 10 years I served 
on committees of the American 
Heart Association (AHA) and the 
National Institutes of Health, Na- 
tional Heart and Lung Institute 
(NHLI) and National Institute of 
Neurologic Diseases and Stroke 
(NINDS). This decade was an era of 
great excitement — human heart 
transplantation, surgery for strokes 
and development of the concept of 
brain death. To a surprising degree, 
however, researchers or scientists 
did not consider the long-term ef- 
fects of these radical developments. 
Shortsightedness was far too com- 
mon. Several personal examples il- 
lustrate this point. 

For instance, the research com- 
mittee of the AHA seldom tolerated 
a discussion of the broad implica- 
tions of a research project they were 
deliberating. We considered only 
the rigor of the scientific design and 
the validity of any data that might be 
forthcoming. The specific duty of 
the research committee is to rank in 
order of excellence projects and in- 
vestigators seeking financial sup- 



port. These multimillion-dollar de- 
cisions determine the funding and, 
therefore, the direction of the scien- 
tific effort of the AHA. 

In 1965-66, our committee had be- 
fore it applications from surgeons 
who were transplanting animal 
hearts and working on implantable 
artificial hearts. Despite what 
should have been apparent to all of 
us, our cardiovascular research es- 
tablishment was thrown into disar- 
ray when Christiaan Barnard trans- 
planted the first human heart in 
1967. This electrifying news put the 
AHA and the NHLI in the public 
eye; yet neither of these groups had 
an advance position. As best as I 
can ascertain, no one had antici- 
pated this event or its ethical, moral 
and legal dimensions. No one had 
thought through such questions as 
the availability of donor hearts, who 
should receive them, or how much 
of our national research budget 
should be devoted to this area; 
therefore, no one had formulated 
position papers on whether we as a 
nation should encourage this re- 
search. For instance, given a feasi- 
ble system for transplantation with- 
out rejection, there remains a factor 
that should have been obvious from 
the beginning ^ the limited avail- 
ability of donor hearts. Therefore, 
one might have expected questions 
such as: Is the effort worthwhile? 



iPRlL 1976. NCMJ 



201 



Where will a successful program 
lead? 

What was the result of this un- 
foreseen event — the first human 
heart transplantation? The AHA 
called an emergency meeting of our 
committee and gave us four hours to 
come up with a position statement 
the AHA could use in a release to 
the media. Because of the in- 
adequate handling of this problem, 
some of us pressured the AHA into 
forming a standing committee on 
ethics, composed of scientists, car- 
diologists, ethicists, theologians, 
philosophers, historians and others. 
The role of the committee was to be 
neither regulatory nor judgmental, 
but rather to bring to the attention of 
the lay and medical members of the 
AHA ethical issues relating to re- 
search. Those of us on the commit- 
tee debated, discussed and digested 
issues relating to artificial hearts, 
randomized studies, brain death, in- 
formed consent and other topics. 
One of our products is entitled 
"Ethical Implications of Investiga- 
tions in Seriously and Critically 111 
Patients."' Another is "Ethical 
Considerations of the Left Ven- 
tricular Assist Device."^ 

The committee met semiannually 
for four years to ponder these 
weighty subjects and attempt to 
provide insights into what might be 
logical consequences of certain 
types of research. I expected the 
deliberations of the group to be well 
received and thought of the commit- 
tee as a forward step that added a 
new dimension to science. I was 
surprised to find out that the com- 
mittee was deeply resented by some 
researchers, who finally forced it to 
cease its activities in 1974.* 

At first I thought this action might 
be an aberration. Who could be 
against flag, country, motherhood 
and ethics? I was particularly dis- 
turbed, therefore, when a proposal 
for a similarly constituted group put 
forth in the U.S. Senate and House 
was opposed by many of my fellow 
scientists, who lobbied actively for 
its defeat. As you all know, a com- 
mission was set up and is beginning 
its deliberations — over the objec- 



*The committee has been reactivated in 1976 under the 
leadership of Dr Harriet Dustan. 



202 



tions of many in the scientific com- 
munity. Why? What do we have to 
fear? Is there something threatening 
in the public consideration of scien- 
tific endeavors? What happened, I 
believe, is a result of the uneasy re- 
lationship between ethics, which is 
intrinsically subjective, and basic 
science, which is objective. The 
televised "Ascent of Man" segment 
on Galileo illustrated this point 
well.^ From the time Galileo had to 
retract his public statements that 
the earth moved around the sun 
rather than the reverse — presum- 
ably he would have gone to the 
stake had he not done so — we have 
had very uneasy relationships vis- 
a-vis academic freedom, scientific 
inquiry, and the state, whatever the 
state might be. Since Galileo, scien- 
tists have feared and resisted at- 
tempts by governments to curb their 
freedom of inquiry. I believe my col- 
leagues have an unexpressed anxi- 
ety that ethics committees may 
change from forums for exchange of 
ideas to regulatory bodies that will 
police their activities and limit their 
freedom. The former is precisely 
what our society needs and the lat- 
ter is what prevents its realization. 

One might think that what I have 
outlined does not relate to the ethics 
of PSRO, but it does. The medical 
community will face similar prob- 
lems as it adapts to the new re- 
quirements of a regulated system 
unless we recognize potential trou- 
ble areas. Some problems I foresee 
are the inhibition of new modes of 
treatment, the rating of physicians 
and institutions, the politicalization 
of the viability of any program such 
as PSRO, and regulated uniformity 
of medical treatment. 

How can PSRO inhibit the de- 
velopment of good treatment pro- 
grams? Quality care delivered in a 
timely fashion often determines the 
course of disease. Shifting patients 
from individualized attention to a 
more standard form of care will 
greatly reduce physicians' freedom 
to weigh the results of their treat- 
ments and to try improvements that 
deviate from accepted norms. It 
may eventually eliminate the inquir- 
ing attitude that has made American 
medicine the world's leader. Here 
are a few examples: 



'ii 

aali 



Both endarterectomy and long 
term anticoagulation are accepteii 
forms of treatment for cerebral vasi 
cular insufficiency. Yet the exac' 
circumstances under which one o 
the other is justified have not beei!p 
elucidated. Whether either treat J; 
ment provides an advantage is de "''"' 
batable. But PSRO standards an '!*' 
being set now. Choices must b( '''"', 
made now despite the lack of con *" 
vincing data. My medical ethic re '(*" 
quires a randomized study of a large «* 'I" 
population in order to gather valid '(*' 
data, but PSRO will tend to inhibii «* 
this. PSRO will not create the proW ^'' 
lem but will prevent its solution bjl "!P' 
impeding the use of randomized *"" 
trials to determine the best forms o: *^ ' 
therapy. ("^ 

Other treatment programs stili *sffl 
being debated are coronary arterj! *n 
bypass for angina pectoris, simple »*"{ 
vs. radical mastectomy or othe^ * 
forms of treatment for carcinoma oi W^ 
the breast, and radiation vs. surgerji '"Pi 
for pituitary tumors. Frequently! ^^iins 
we in medicine have differences oil * f 
opinion about which treatment is Bpiif 
better for a given problem. Physi~ *i 
cians must have the freedom to del'lf' 
viate from the therapeutic norm —1 
even after it is set down by th 
PSRO — long enough to accumulate 
results and to present and debate 
them in scientific form. The quest 
for truth must not be impaired. A 
system to insure the evaluation of 
new treatments must be built into 
the PSRO; it is the obligation ol 
PSRO to help determine that its' 
guidelines include the best range ol 
treatments. To do this, it must build 
these options into the requirements 
for clinical vascular programs sc' 
that these answers may be found. 

What is the best therapy foii 
malignant brain tumors? Or is nc 
treatment worth giving? What about) 
costly surgery for the severely re- 
tarded when the chances of improv- 
ing their mental capacity are nill 
These are ethical questions about 
which PSRO must make judgments 
and the system must have built into 
it, from the beginning, methods foi 
encouraging this activity. This will 
require the adoption of randomized] 
trials and the use of deception irt 
therapy — a point that will generate 
much political argument. Can 



iiy, 



■be- 



Vol. 37, No. 4 



lacebos be given in a system where 
uality care is demanded and in- 
armed consent involved? At the 
resent time, none of these, as far as 
can determine, are a part of the 
SRO system. 

Quahty care depends, in large 
art. on the training and skill of the 
hysician who administers it. 
/ithin a short time, accumulated 
. .ata will show that one institution or 
1, ihysician has a far better recovery 
ate than another institution or 
hysician. It is well known that 
jme surgeons have extraordinarily 
ood results and that others have 
ery poor results in carotid endar- 
;rectomy. 1 refer my patients to 
lose who have the good results, 
nd I assume everybody else does 
le same. Under PSRO. this infor- 
lation will become available in the 

- ase of all illnesses and all physi- 
ians. Therefore, a mechanism for 

r; topping those who do poorly and 
)T upgrading marginal physicians 
nd institutions must be planned for 
ow. Furthermore. I suspect that, 
espite all pious mouthings to the 
ontrary, information of this nature 
i/ill become public knowledge and a 

T ew form of shopping for medical 
are. in terms of price as well as 
afety. will develop. Up to this 
'oint, I have never heard a patient 
sk, "What is the percentage 
hance of my surviving or improv- 

- ig after this operation?" When I 
i- iuggest surgery for a patient. I have 
r lever had one in a true spirit of in- 
I . juiry say. "Give me my cost- 
: lenefit ratio and comparative prices 

'f different modes of treatment." 
-■ "hey may well be doing that before 
00 long. 

Now I would like to consider 
mother aspect of the ethics of 
'SRO — the ethic of initiating a 
■ nedical-care delivery system that is 
lubject to political pressures. Draw- 
• ng once more on personal experi- 
;nce, I would like you to consider 
)ur recent involvement in the soon- 
o-be-defunct Regional Medical 
'rogram (RMP). Born during a 
Democratic administration, it was 
eceived in some comers with great 
mthusiasm. Programs were con- 
.tructed. people recruited and de- 
ivery systems initiated. Then, just 
is it was beginning to run smoothly. 



a change in philosophy took place at 
the federal level and the programs 
came under attack. Political battles 
raged and finally RMP is being 
abandoned. I maintain that the ethi- 
cal considerations in starting and 
then discontinuing programs for the 
delivery of care are submerged in 
the politics and economics of these 
programs. 

This could happen to PSRO if we 
are not careful to make it apolitical 
and broadly based in all walks of 
society. As you know, it is not 
apolitical at the moment, and there 
are many walks of society, particu- 
larly in medical circles, where it is 
being resisted. Therefore, you can 
be certain that it will be attacked 
and could be abandoned just as 
RMP was if there is a change in ad- 
ministrative philosophy. 

Now let us consider where new 
therapeutic approaches may lead. 
Most of us are aware that our ex- 
traordinarily successful program to 
prevent infant and childhood deaths 
in underdeveloped countries has led 
to explosive population growth that 
threatens the societies that they 
were designed to improve. Could 
some unanticipated result of PSRO 
lead to deleterious social conse- 
quences? Consider this scenario. 
With population control and severe- 
ly limited immigration, our popula- 
tion will stabilize. As we prevent 
premature death with better medi- 
cal care, the proportion of aged citi- 
zens will increase. The require- 
ments for geriatric care will become 
an ever-increasing proportion of our 
national health-care budget. The 
burden of taxation on the shrinking 
middle-aged population will like- 
wise increase to support these 
needs. 

As a nation, we have adopted the 
moral and ethical concept that 
everybody has an equal right to high 
quality care, and PSRO is a monitor- 
ing system to guarantee that right. 
As we watch the inception of PSRO. 
the emphasis is being put on quality, 
and physicians are being asked to 
set down usual types of evaluation 
in hospitalizations. Presumably, 
this standard of care will be estab- 
lished nationally and maintained 
equally for all citizens as soon as a 
national health law is enacted. In 



the short run, PSRO will result in 
gratifying improvements in medical 
care, particularly in peripheral 
areas where physicians have been 
working alone, unaccustomed tc 
having others more knowledgeable 
than they close at hand, as is the 
case in medical centers where many 
eyes watch every act performed by 
the attending physician. In some 
outlying hospitals, care is delivered 
in private and mistakes can go un- 
recognized, ignored or be buried. 
This state of affairs will cease as 
marginal practices cease, and a 
stratification of levels of care with 
so-called major problems treated 
only in medical centers will de- 
velop. 

The ethic of equal access to care 
requires that if one institution pro- 
vides a unique form of treatment 
better than all other institutions this 
particular form of treatment be dis- 
tributed nationally so it will be 
available to all citizens. The dis- 
tribution of quality care is thus car- 
ried to its logical extension. In the 
long run. the cost of care will in- 
crease as every citizen begins to 
exercise his right. Congress will be 
forced to consider means by which 
to contain costs. At that point, the 
standard of care will become an is- 
sue. Choices currently made on an 
individual basis by a physician and 
his patient will be made on the col- 
lective basis of public policy and, 
therefore, in the political arena. The 
Congress and the courts will be- 
come the final arbiters of health care 
and. therefore, of the ethics of 
health-care delivery. 

Already, the U.S. Supreme Court 
has decided that abortion, previ- 
ously an ethical and moral issue, is a 
legal issue also. The testing of the 
concept of brain death is under con- 
sideration. As time goes on. we 
will see many more such issues — 
for example, the denial of access to 
care. Segments of our population in- 
terested in particular diseases will 
lobby for the standards and types of 
care that they desire. We will have 
economics and politics as the final 
arbiters of the ethics of who gets 
care and how much. This is already 
an issue in England in the case of 
renal dialysis. Even now. we have 
an illustration of this trend in our 



\PRIL 1976. NCMJ 



203 



own local community as our elected 
and appointed officials attempt to 
decide who has financial responsi- 
bility for the medically indi- 
gent. This concept will be elevated 
to the national level as soon as this 
type of issue is transposed to the 
health-care laws. 

CONCLUSIONS 

1) PSRO is a rational, short-term 
approach to complex problems for 
assuring quality care for all our citi- 
zens. 

2) It is a public response to prob- 
lems that the medical profession has 
been unable to resolve for itself. 

3) Resistance to the new system 
by the medical community has its 
origins in deeply rooted fears that 



bureaucratic interference in what 
has been a private enterprise would 
lead to the destruction of the system 
as we know it. 

4) Clinical investigators in 
academic medical centers have re- 
sisted public inquiry into their 
hitherto private research activities 
for fear that their freedom of inquiry 
will be limited. There are signs that 
the latter is happening, for example , 
moratoria on fetal research and on 
psychosurgery. 

5) I predict current restrictions on 
clinical investigators will, within a 
few years, be imposed on practicing 
physicians under the system of the 
PSRO. (I have lived under these re- 
strictions and I cannot say that I 
have resisted them, but I feel them.) 



6) Public inquiry will lead to 
politicalization of the system wher 
in special interest groups will se( 
to influence the delivery of ca 
through their legislation and the 
congressmen. 

7) In the long run, the delivery 
care by physicians will be dele 
mined by legislation, and the co( 
of medical ethics currently used \ 
physicians will be superseded I 
federal guidelines. 



REFERENCES 

Committee on Ethics of the Amencan Heart Associat 

(JF Toole. ChaitTnan): Ethical implicatiotis of investi 

tiofis in senously and ciiticaily ill patients- Circulat 

50;106_VI06'J, l';74. 

Committee on Ethics of the Ameincan Heart Associat 

JAMA 235: 823-825, 1976. 

Bronowski J: The Ascent of Man. Public Broadcast 

System. 1975. 



'Hie 

iiied 
spilal 
liiicia 
lost 

1S[ 
i. ■ 

ill of 



I lately saw a gentleman of brilliant talents and prolific genius, who could sit down and write 
extemporaneously, whole pages of superior poetical effusions, with scarcely an effort of the mind, and 
who would yet. from a sudden derangement of the digestive organs, be so completely and quickly 
prostrated in intellectual power, as not to be able to write three lines on the most common subject. On a 
late occasion, when he had merely to communicate an oftlcial transaction that required not more than 
hiilf a dozen lines in the plainest language, he could not put pen to paper, though the attempt was fifty 
times made in the course of two days. Al length, he was forced to throw himself into a post-chaise and 
perform a longjoumey, to deliver orally what might have been done, in one minute, by the pen. In half an 
hour after this task was performed, he sat doun and wrote an ode descriptive of his own state of nervous 
irritability, which would not have done discredit to the pen of a Byron! — An Essay on Indigestion: or 
Morbid Sensibilily of the Stomach d Bowels. James Johnson, 1836. p 31. 



SI IK 

[OM, 

Kean 
Jipul 
ihy 
lie 
a of 



slei 
(lor- 
bo 

ier 
finet 
ties; 
Idb 
lay 



IK 11 
■iCi 

so 
fresli 
inict 



irie 
'«li; 
iilogi 
Ssiii 
Ijec 
ssu 



204 



Vol, 37, No. 



III 

i 



Editorials 



AN AUDIENCE FOR A DISCOURSE 



"The primary difficulty is that instruction has to be 
arried out largely in the wards and dispensaries of 
ospitals rather than in the patient's home and the , 
hysician's office."" F. W. Peabody' 

"Justice demands that every citizen should have so 
i,„ir as possible an equal chance to develop his tai- 
nts. . . Therefore every citizen should have an equal 
ight of access to the means of good health, so far as it 
[available."" Alasdair Maclntyre- 

Despite television"s appeal to the eye. there has 
een no letup in the parade of papers describing the 
nown. the unknown and the dimly glimpsed. Our 
ccelerated specialization in all fields of business, sci- 
nce and religion has spawned so many scribes under 
ompulsion to publish that there is some danger of 
'orthy discourses forlornly seeking audiences. So 
ifolific have we become that the times cry for some 
ort of literary contraceptive. 

We have only to look at medicine"s problems today 
3 realize the near futility of recognizing, let alone 
nderstanding or adequately describing, the many 
orces in action. When such complexity confronts us. 
he temptation is to retreat, protesting that the 
octor-patient relationship is being threatened or to 
ffer overly simple suggestions or catch phrases as 
nswers to poorly posed questions. But solutions lie 
either in such generalities or in ill-conceived, poorly 
lefined. uncertainly financed federal intervention. 
^or example, since the introduction of Medicare and 
»Iedicaid. there has been a striking increase in the 
utlay of federal funds for these programs, much 
reater than earlier estimates. Part of the cost spiral 
:an perhaps be attributed to the removal of restric- 
ions imposed by poverty on the provision of adequate 
nedical care and is reflected in rising hospital costs 
ind some of the increase to the pressure, in the in- 
erest of social justice, to offer more comprehensive 
ervice to all groups, each in itself a noble course. 
>uch pressures require a careful assessment of the 
luality of care, of cost effectiveness and indeed of 
vhat the physician"s role really is. As a result, we are 
laced with a strange vocabulary; we speak now of 
lealth providers, health consumers, health screening. 
»eer review, life support, often without a clear view as 
o what we really mean. Health, instead of being a 
)iologic state, now seems to be a commodity to be 
:onsumed. aright conferred by citizenship, a category 
lubject to metaphorical abstraction if not to precise 
neasurement. Such a movement has its evangels and 



Vpril 1976. NCMJ 



its skeptics who must grapple with rising expectations 
of a public stimulated by the hope that health may 
really be delivered like merchandise from a store. 

This issue of the Journal is devoted to several as- 
pects of these problems — who is responsible for 
medical care, how is it to be provided and what is the 
acceptable cost. Lyle, Citron and McCall offer several 
cogent observations which deserve careful considera- 
tion. They have confirmed that our general hospitals 
do deal with two populations, a sicker, poorer group 
and a more prosperous segment with different dis- 
eases. This, of course, comes as no surprise and has 
previously been well-defined in similar vein by Hol- 
lingshead and his associates^ in the realm of mental 
health. Particularly noteworthy is the appreciation 
that separate hospital populations are still tended 
separately by staff and house staff physicians and that 
such division has important implications for those 
concerned with proper training for the infantry of 
medicine: internists, family practitioners and pedia- 
tricians who will eventually go out to the trenches: 
office practice. New models'* for training are being 
developed and offer great promise for the better 
equipping of doctors who care for patients. Some of 
these models suggest that conventional wisdom w hich 
makes the hospital the cathedral of medicine must be 
revised because home care may be cheaper and be- 
cause the doctor as a ""therapeutic self" may function 
better in the patient"s own environment, not in the 
hospital. ''■ Herring's observations in this regard indi- 
cate that concern is not limited to Boston but alive and 
improving in Greensboro as well as Charlotte. 

One of the great fears of the medical infantryman is 
that his colleagues at base headquarters don"t ap- 
preciate his plight and encumber him with impera- 
tives, directives, definitions v\hich have little bearing 
on the realities of the market place. As Toole points 
out. there are dangers inherent in any program which 
sets standards which may be too restrictive, perhaps 
in an effort to minimize risks, and may in the long run 
be detrimental to patients and limit the physician in the 
exercise of his mature medical judgment. 

We have long known that such concern about the 
relationship between health and medicine is not re- 
stricted to the United States and have been particu- 
larly perplexed by the nature of things in England. - 
For those who feel the need of looking beyond the 
current issue of the Journal, there is a proper dis- 
course which unfortunately will not find the medi- 
cal audience it deserves in the United States. Scott"s 



205 



paper.'' which recently summarized the state of things 
in New Zealand, has a most attractive title "Health 
and Medicine: Is There a Connection? or A White 
Paper for Politicians." Scott points out that despite 
the expansion of medical knowledge and the many 
more tools for diagnosis and treatment that we have 
today, health as general welfare has been better ap- 
proached by improving economic and social condi- 
tions. What can organized medicine do in the United 
States about environmental hazards, too much al- 
cohol, too much tobacco, handguns, fast drivers? 
Perhaps the phrase health consumer is well chosen 
because consumption does suggest the use of re- 
sources which are often irreplaceable. 

RKFKRKNtKS 

1. Peabody FW: The care of the palienl JAMA 8K:K77-K8:. Ii:7 

2, Maclntyre A: How virtues become vices Medicine and society. Hncounter XLV No 
1:11-17. (July) 1975. 

3 al Hollingshead AB, Redlich FC Social Class of Mental Illness: A Community Study 
New York. John Wiley and Sons. Inc.. |iJ58.(b) MyerJK. Bean LL: A Decade Later: A 
Follow-Up of Social Class and Mental Illness. New York. John Wiley and Sons Inc 
1968. 

4. Ooroll AH. Stoeckle JD. Goldflnger SD. et al: Residency training in primary care 
internal medicine Report of an operational program. Ann Intern Med 83:872-877.' 1975. 

5 Bnckner P\\ Duque T. Kaufman A. et al: The homebound aged. A medicallv un- 
reached group Ann Intern Med 82:1-6. 1975. 

6. Runyan JW Jr: The Memphis chronic disease program. Compansons in outcome and 
the nurses extended role JAMA 231:264-267. I9'75. 

7. Scott .AJ: Health and medicine: is there a connection? or A white paper for politicians 
N Z Med J 82:234-236. I97.s 



ETHICAL OBLIGATIONS OF PHYSICIANS 
TO PEER REVIEW 

Difficult questions about the legal and medical 
ethics of peer review are raised by Toole in this issue 
of the Journal. But the outcome he predicts — gov- 
ernment control of medical ethics and health care — 
need not occur. There is an alternative — one which 
the North Carolina Medical Peer Review Foundation 
has already begun to pursue; it will need total support 
from physicians in North Carolina if it is to be effec- 
tive. 

The foundation was established by the State Society 
to promote quality medical care and has contracted 
with the State of North Carolina to review services 
rendered Medicaid patients to determine whether 
these services are medically necessary, are rendered 
at the appropriate level and generally conform to 
professionally accepted judgments. The foundation 
will use in its reviews model screening criteria sets to 
select from a large number of cases being screened a 
small number for further review. The screening 
criteria identify those cases where medical care may 
have been substandard in quality or services improp- 
erly utilized. The criteria, which are short and based 
on easily obtainable objective data, were developed 
with help from all the major medical specialties and 
most of the subspecialties. 

It is important to note that the foundation's criteria 
do not (1) define rigid standards of quality. (2) define 
which services will be paid for as part of claims re- 
view, or (3) preclude innovation by physicians. The 
foundation is attempting to identify potential gaps in 
practioners" knowledge and capabilities and problem 
areas in facilities and support personnel operations. 
The system being used is the foundation's Hospital 

206 



V 



ermox 

mebendazole 



DESCRIPTION VERMOX (mebendazole) is methyl 5- 
benzoyIbenzimidazole-2-carbamale 

ACTIONS VERMOX exerts Its anthelmintic effect by 
blocking glucose uptake by the susceptible helminths, 
thereby depleting the energy level until it becomes 
inadeguatefor survival 

An insignificant amount of mebendazole is absorbed 
from the gastrointestinal tract. Most of this is excreted in 
the urine within three days either as metabolites or 
unchanged drug 

INDICATIONS VERMOX is indicated for the treatment of 
Trichuns tnchiura (whipworm), Enterobius vermiculans 
(pinworm). /(scans lumbricoides (roundworm). 
Ancylostoma duodenale (common hookworm), Wecator 
americanus (American hookworm) in single or mixed 
infections. 

Efficacy varies in function of such factors as pre-existing 
diarrhea and gastrointestinal transit time, degree of 
infection and helminth strains Efficacy rates derived 
from various studies are shown in the table below: 





Trichuns 


Ascans 


Hookwoim 


Pinworm 


cure rates 

mean 
(rangei 


68». 
(61-75%! 


98'i 
(91-100%! 


96". 


95% 
190-100%! 


egg reduction 

mean 

rangpi 


93% 
70-99%! 


99 7% 
(99 5-100% 


99 9% 


- 



CONTRAINDICATIONS VERMOX is contramdicated in 
pregnant women (see Pregnancy Precautions) and in 
persons who have shown hypersensitivity to the drug. 

PRECAUTIONS Pfife/V/IA/Cy VERMOX has shown 
embryotoxic and teratogenic activity in pregnant rats at 
single oral doses as low as fOmg kg Since VERMOX 
may have a risk of producing fetal damage if 
administered during pregnancy, it is contramdicated in 
pregnant women 

PEDIATRIC USE: The drug has not been extensively 
studied in children under two years: therefore, in the 
treatment of children under two years the relative 
benefit'Tisk should be considered 

ADVERSE REACTIONS Transient symptoms of abdomi- 
nal pain and diarrhea have occurred in cases of massive 
infection and expulsion of worms. 

DOSAGE AND ADMINISTRATION The same dosage 

schedule applies to children and adults 

For the control of pmworm (enterobiasis), a single tablet 

IS administered orally, one time. 

For the control of roundworm (ascariasis). whipworm 

(trichuriasis), and hookworm infection, one tablet of 

VERMOX is administered, orally, morning and evening, 

on three consecutive days 

II the patient is not cured three weeks after treatment, a 

second course of treatment is advised No special 

procedures, such as fasting or purging, are reguired. 

HOW SUPPLIED VERMOX is available as tablets each 
containing 100 mg of mebendazole, and is supplied m 
boxes of twelve tablets 

VERMOX (mebendazole) is an original product of 
Janssen Pharmaceutica, Belgium, and co-developed by 
Ortho Pharmaceutical Corporation 



t Because Vermox has not been extensively studied 
in children under 2 years of age, the relative 
benefit/risk should be considered before treating 
these children Vermox is contramdicated in 
pregnant women (see Pregnancy Precautions! and 
in persons who have shown hypersensitivity to 
the drug 

OJ 288-5R fesg.i^^^ 



Ortho Pharmaceutical Corporation 
Raritan, New Jersey 08869 



Vol. 37. No. 



The onl^ypingle^tablet 
treatment of piniwform 






i 7 >; 






u 






r:*- / 






just one 
g ' chewable tablet, 
once, usually 
eradicates pinworm 
^ in both children 

and adults! 
fei and without 
staining 




/ chewable 
tablets 




OPC 19^ 



Admission Review Program (HARP), controlled and 
administered by individuals under the direction of 
physicians. The data collected will be used by the 
foundation's Norms Committee to correct identified 
deficiencies through educational means whenever 
possible. 

An intangible benefit exists for alleviating some 
malpractice problems through having corrected some 
of the deficiencies identified. Patients have exerted 
their influence on the profession in those cases where 
they feel they have not received appropriate treatment 
and that physicians did not demonstrate accountabil- 
ity. Some patients have voiced their protest through 
the courts and this, in part, has resulted in the mal- 
practice crisis. With the kind of peer review system 
the foundation envisions, physicians will be account- 
able and will be correcting deficiencies through educa- 
tion, whenever possible. 

Physicians, generally, have been aware of their 
ethical obligations to their patients but many have 
tended to think only in terms of the private physician/ 
patient relationship. The review system being de- 
veloped by the foundation will not interfere with this 
relationship but will address some of the broader prin- 
ciples of medical ethics as developed by the American 
Medical Association "to aid physicians individually 
and collectively in maintaining a high level of ethical 
conduct."' Since these principles are consistent with 
the philosophy and approach of the foundation's peer 
review program, they warrant summation: 

"The principle objective of the medical profes- 
sion is to render service to humanity with respect 
for the dignity of man. . . 
"Physicians should strive continually to im- 
prove medical knowledge and skill. . . 
"The medical profession should safeguard the 
public and itself against physicians deficient in 
moral character or professional competence. 
Physicians should observe all laws, uphold the 
dignity and honor of the profession and accept its 
self-improved disciplines. They should expose, 
without hesitation, illegal or unethical conduct 
of fellow members of the profession. 
"A physician should seek consultation upon re- 
quest; in doubtful or difficult cases; or whenever 
it appears that the quality of medical service may 
be enhanced thereby. 

"The honored ideals of the medical profession 
imply that the responsibilities of the physician 
extend not only to the individual, but also to 
society where these responsibilities deserve his 
interest and participation in activities which 
have the purpose of improving both the health 
and the well-being of the individual and the 
community. '"- 

If physicians do not support a review system con- 
trolled and operated by their peers, then health care 
dictated by government and consumers will almost 
certainly occur — V the detriment of all concerned. 
However, physicians working together to improve 
health care, using the type of review system being 



208 



developed in North Carolina, can prevent further ii '* 
trusion by government into the practice of medicii ''"^ 
while at the same time demonstrating accountabiiii' 
to the public — M. Frank Sohmer. M.D., Presidei' 
and Medical Director, and Woodford Burnett) 
Director, Hospital Review Services and PSRO A( 
tivities, North Carolina Medical Peer Review Found 
tion. 



REFKRENCKS 

American Medical Association. Judicial Council Opinions and Reports, 1971, pages 
and VII. 

Amencan Medical Association, Judicial Council Opinions and Reports, \91\ . pages 
and VII. 



iierd 
:ilsea 
(J to 
a 
i( 
isan 

wlvei 
sac 



tSoi 



MIDWINTER MEETING OF THE EXECUTIV 

COUNCIL 
OF THE NORTH CAROLINA MEDICAL SOCIET 

February 1, 1976 

A bleak, windy, wet February day is hardly appn 
priate for a pilgrimage to Raleigh, or anywhere else f« 
that matter, but custom and need dictate that thei 
mustbeamidwinter meeting of the Executive Counc 
of the Society and so it sat February 1, 1976. To ti 
gloom of the day was added the constant concei 
about how to maintain clinical freedom in an atmo 
phere of regulation and counter-regulation and tl" 
awareness that, despite our good intentions, many ( 
our best efforts would be in vain. But February he 
forever been a gray and cheerless month. 

Still the day brought some enlightenment and with 
encouragement. Dr. Tilghman Herring, on the trail t 
the balanced budget, led the council calmly from t\ 
arcane to the understandable, not without pointing Olitiiiii 
that deficits lurked if we didn't follow his trail cart •''" 
fully. In short, while the Society still has an operatii 
surplus, demands on the dollar threaten such a happ tt 
state. But the Society now claims more than 4,0( 
AMA members and so has earned the right to sela 
another delegate to the AMA House of Delegates W *, 
cause state organizations can elect one delegate pi 
thousand members or a fraction thereof The counc 



m 

rill 



named past-president Frank Reynolds the new del J'j'' 
gate and president-elect Jesse Caldwell alternate; tl; ~'' 



House of Delegates of the State Society ordinari) 
does the selecting, but we are not notified of the frai 
tions thereof until the House has had its annual se 
sion. Dr. David Welton was recognized by the counc %l 
for his efforts to swell our roles in the AMA ar ^^' 
accepted on behalf of everyone involved. The counc fe 
also endorsed the nomination of past-president ar * 
AMA delegate, John Glasson, to a position on tl 
AMA Council on Medical Service and recognized D 
Archie Johnson for devoted services in govemmei 
and in the practice of medicine to the people of Nod 
Carolina and to the medical profession. 

The council then directed its attention to continuir 
efforts to do something about the problems of profe; 
sional liability. Dr. Shahane Taylor spoke for the Pre 
fessional Liability Legislative Action Committee an 
Dr. Ira Hardy summarized the report of the Profe; 



at. 
■-■iilei 



Vol, 37. No. 



I 



ional Liability Legislative Research Commission. 
Members of these groups have taken the place of 
esterday's postman: they seem to "post o'er land 
nd sea without rest."" To achieve an equitable solu- 
lon to the problem, it was apparent that economic, 
olitical and humanitarian impulses and aspirations 
emanded the closest attention, that vigilance, fair- 
ess and work were essential and that few could gain 
nd many suffer if a workable scheme were not 
volved with dispatch. The report of the commission 
/as accepted in principle and efforts to secure its 
doption by appropriate legislative action encour- 
ged. The Legislature meets in May and members of 
le Society have been urged to impress upon their 



representatives and senators the need to allow legisla- 
tion to be introduced and passed at that session. 

The council also heard from Dr. Rose Pully on be- 
half of the Committee on Cancer, from Dr. Louis 
ShafTner who Assured us that the revision of the con- 
stitution and bylaws was being carried out with due 
deliberation and calm contemplation and accepted in- 
formation, resolutions and comments about matters 
great and small, some of which will require action by 
the House of Delegates in annual session. After having 
assured himself that all who sought it had had the 
opportunity to speak. President Jim Davis then graci- 
ously and with good humor accepted a motion for 
adjournment. 



TF 



Bulletin Board 



NEW MEMBERS 

of the State Society 



unslie. John Durham. MD. (P). 2 16 Shoreline Dr. . New Bern 28.'i60 
lltvater. Arnold Hugh. MD. (PTHXRenewal). 205 Edgewood Dr.. 

Boone 28605 
snvndrus. Thomas Ross. Jr. (STUDENT) 103 Deblyn Ct.. Durham 

27707 
llackman. Jesse Aycock, MD, (FP) 107 S. Sycamore St.. Fremont 

27830 
iroadrick. Gary Lee. MD, (GS) 318 Wards Bridge Rd.. Warsaw 

28398 
lultman. Charles Keene. MD. (ORSi 3659 N. Patterson Ave.. 

Winston-Salem 27103 
lums, Robert Henry. III. MD. (IM) Baldwin Woods, S. W. 

Whiteville 28472 
"arter, Thaddeus Cox. MD. (U) 1001 N. Washington St.. Shelby 

28150 
:arr. John Ferguson. II. MD (P) 3411 Angus Rd.. Durham 27707 
:hudgar. Kalpana Mukesh Kumar. MD. 222 S. Main St.. Stanley 

28164 

raft, William Hugh. Jr.. (STUDENT) 500 Umstead Rd.. Apt. 

201-D Chapel Hill 27514 
'rumley. Charles Edwin. MD. (IM) 824 S. Aspen St., Lincolnton 

28092 
Xjlly. Forrest Ray. (STUDENT) 210 Henderson St.. Chapel Hill 
, 27514 

•abian. Denis. MD. (PS) 503 Owen Dr.. Favetteville 28304 
•isher. Carl Ellis. MD. (PD) 318 South St.. Gastonia 28052 
■riedland. Gerald Wilfred. MD. (R) 3421 Kirklees Rd.. Winston- 
Salem 27104 
)antt, Charles Bernard. Jr., MD, (R) Rt. 12. Box 674. Sanford 

27330 
,«ils. George Frederick, MD, (IM) 808 N. DeKalb St.. Shelby 

28150 
'irooms. Gary Allen. MD, (GS) 1501 Medical Center Dr.. Wil- 
mington 28401 
lamby. James Lawrence. MD. (U), 2 Furman St.. Boone 28607 
'larvin, Allan Brabham. MD. (ORS) 809 Simmons St., Goldsboro 
I 27530 
ames, Francis Marshall. III. MD. (AN) 2845 Fairmont Rd.. 

Winston-Salem 27106 
ones. Edward Claude. (STUDENT) P.O. Box 382. Chapel Hill 

27514 



Jones. James Marshall. Jr.. MD. (IM) 1225 E. Fifth St., Winston- 
Salem 27101 
Kahl. Frederic Ross. MD. (CD) 3.'i01-H Hvde Park. Winston-Salem 

27101 
Kim. Kvung-Hwae. MD. (OBG) P.O. Box 190. Plymouth 27962 
Marston. Charles Thomas. Jr.. (STUDENT) RED 6. Box 462. 

Chapel Hill 27514 
Maurer. Frederick Sigurd. MD. (FP) Route I. Grover 28073 
McClain. Eldon Duane. MD. (PTH) 306 W. Wilson Creek Dr.. New 

Bern 28560 
McCloud. Willard Laveme. MD. (OBG) 1334 N. Patterson Av.. 

Winston-Salem 27105 
McRee. Christine Ellis. MD. (CHP) Route I. Wake Forest 27587 
McLamb. Joseph Timothv. MD. (ORS) 809 Simmons St.. 

Goldsboro 27530 
Oneni. Gerald Vincent. MD.(R) 102 Ingleside Dr.. Concord 28025 
Park. Yong Ho. MD. (GS) 230 Hawthorne Rd.. Elkm 28621 
Parker. Michael Youne (STUDENT) 41 I N. Columbia St.. Chapel 

Hill 27514 
Ramsdell. Charles Michael. MD.(IM) 1705 W. Sixth St.. Greenville 

27834 
Reams. Calvin Joshua. MD. (Intern-Resident) 12 Ashiev Rd.. 

Durham 27704 
Smith. Ronald Steven. (STUDENT) 1902 Oueen St.. Apt. E-2. 

Winston-Salem 27103 
Walker. John Ingram. MD. (Intem-Rcsident) 4312 Samoa Ct.. 

Durham 27705 
Willis. Henry Stuart Kendall, Jr.. MD. (FP) 125 W. Central Av., 

Mount Holly 28120 
Zemp, Charles Hubert. MD. (PD) (Renewal) 328 S. Mulberry St., 

SW. Lenoir 28645 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: 1. The Continuing Medical Education Programs of 
the Bowman Gray. Duke and UNC Schoolsof Medicine are accred- 
ited by the American Medical Association. Therefore CME pro- 
grams sponsored or co-sponsored by these schools automatically 
qualify for AMA Category I credit toward the AMA Physician's 
Recognition Award, and for North Carolina Medical Society 
Category "A" credit. Where AAFP credit has been requested or 
obtained, this also is indicated. 

2. The '"place" and "sponsor" are indicated for a program only 



^RIL 1976, NCMJ 



209 



when these differ from the place and source to write "for informa- 
tion." 

PROGRAMS IN NORTH CAROLINA 

May 6-9 

122nd Annual Session of the North Carolina Medical Society 
Place: Pinehurst Hotel and Country Club, Pinehurst 
For Information: William N. Milliard. Executive Director. North 
Carolina Medical Society, Box 27167, Raleigh 27611 

May 7 

"Alternatives for the Aged" — Saint Albans Psychiatric Hospital 

Annual Spring Conference 
Place: Saint Albans Psychiatric Hospital, Radford, Va. 
For Information: George K. White, Administrator, Saint Albans 

Psychiatric Hospital, Radford, Va. 24141 Tel: 703-639-2481 

May 7-9 

Pulmonary Infections in Pediatric Patients 
Place: Quail Roost Conference Center, Rougemont 
Registration: Limited to 50 participants 
Credit: 1 1 hours; AAFP credit applied for 

For Information: Alexander Speck, M.D., P.O. Box 2994. Duke 
University Medical Center, Durham 27710 

May 12-13 

Breath of Spring '76: Respiratory Care Symposium 

Fee: $25 

Credit: 12 hours; AAFP credit applied for 

For Information: Emery C. Miller. M.D., Associate Dean for Con- 
tinuing Education. Bowman Gray School of Medicine, 
Winston-Salem 27103 

May 14-16 

1 1th Annual Meeting, North Carolina State Society. American As- 
sociation of Medical Assistants 

Place: Great Smokies Hilton. Asheville 

Fee: $25; Students $20; Saturday only $10 

For Information: Miss Shirley J. Mathis. Convention Chairman, c/o 
Jean M. Harkey, L.P.T., P.O. Box 5731. Asheville 28803 

May 20-21 

Management Dimensions of Medical Staff Leadership 

Place: Sheraton National Motor Inn. Arlington. Virginia 

For Information: American College of Hospital Administrators, 

Glen C. Irving, 450 West Broad Street, Suite 313. Falls Church. 

Virginia 22046 

May 20-22 

National Conference — Daycare for Older Adults: The New Mo- 
dality 

Sponsor: Older American Resources and Services Program, Center 
for the Study of .\ging and Human Development 

Fee: $60; enrollment limited to 200 

Credit: AAFP credit applied for 

For Information: Mrs. Dorothy K. Heyman. MSW. Executive Sec- 
retary. P.O. Box 3003, Duke University Medical Center, Durham 
27710 

May 21-23 

10th Annual Duke — McPherson Otolaryngology Symposium 
Place: McPherson Hospital, Durham 

For Information: Joseph Farmer, Jr.. M.D.. P.O. Box 3805. Duke 
University Medical Center, Durham 27710 

May 26 

Recent Trends in Therapy of Myocardial Infarction Including Ef- 
forts to Limit the Size of Myocardial Infarction 

Place and time: Elks' Club, Southern Pines, (Country Club of 
Southern Pines); 6:30 pm 

Fee: $11.50 

Credit: 2 hours; AMA Category I; AAFP approved 

For Information: C. Harold Steffee. M.D.. Moore Memorial Hospi- 
tal. Pinehurst 28374 

May 27-28 
The 27th Scientific Sessions and Annual Meeting of the North 

Carolina Heart Association 
Place: Benton Convention Center and the Winston-Salem Hyatt 

House. Winston-Salem 
Sponsors: The North Carolina Chapter of the American College of 

Cardiology will be one of the co-sponsors of the sessions, and will 

hold its sessions, which are open to all physicians, on May 28. 

210 



Special concurrent sessions will be held for nurses, emergent 
medical technicians, and cardiology technologists 
For Information: Thomas R. Griggs. M.D.. North Carolina Hea 
Association, P.O. Box 2408. Chapel Hill 27514 

June 22-24 
North Carolina Hospital Association Annual Meeting 
Place: Blockade Runner, Wrightsville Beach 
For Information: Diane Turner, NCHA, P.O. Box 10937, Raleij 
27605 

ITEMS OF SPECIAL INTEREST 
Humanities Seminars for Medical Practitioners 

The National Endowment for the Humanities will provide tuitit 
to 60 physicians and other health professionals who wish to partic 
pate in seminars to be presented during 1976 by distinguishe 
humanists from the fields of philosophy, religion, sociology ar 1 
history. "The Endowment's goal in sponsoring these seminars isl'i 



ttitM' 

IrJo* 
(jJiolof 



id 



limist 



0^' 



caCoB 



help improve the quality of leadership in the medical profession, bl 
bringing humanistic knowledge and understanding to bear on prol 
lems which arise in the practice of medicine." The date. location( 
seminar, application deadline, name and position of seminar dire<: 
tor. and address to write for additional information on respectiv, 
seminars is as follows: 

June 1-30, 1976 (applications by April 15) Write: Prof. Renee C 
Fox. Chairman. Dept. of Sociology. 128 McNeil BIdg. CR, U 
Pa., Philadelphia, Pa. 19174. 

June 28-July 23, 1976 (applications by April 15) This seminar wi 
be held at Stanford Univ.. Stanford, Calif. Write: Prof William I 
May. Chairman. Dept. of Religious Studies. Sycamore Hall 23( iWO 
Indiana Univ.. Bloomington. Indiana 47401. 

August 9-September 3. 1976 (applications by May 13) Write: Pro; 
John C. Bumham, Dept. of History, The (3hio State Univ., 23 
West 17th Avenue. Columbus. Ohio 43210. 

September 13-October 8, 1976 (applications by May 13) Writ' *™ 
Prof. H. Tristram Engelhardt, Jr., Institute for the Medici >■'' 
Humanities, Univ. of Texas Medical Branch. Galveston, Texal'''*! 
77550. 

The Endowment awards will provide free tuition, $l,2(K)to hel 
cover expenses, and travel reimbursement up to $300. 



Hi HI 
;t(iof 
Slit li- 
fe:! 

lad 



Ingi 



iiipsi 



Courses In Ultrasound 

A series of three ten-week postgraduate courses in 



Soni 



KlCC 



Medicine at Bowman Gray School of Medicine will be offered o 
the following dates: September 27-December 3. 1976, January K 
March 18. 1977. and April 11-June 17, 1977. These courses ar 
designed to provide background, techniques, experience am 
knowledge so that the individual will be able to set up both ai, 
ultrasonic laboratory and a training program. Participants may at 
tend the entire course or only those portions which are of interest t 
them. Enrollment is limited. Graduates receive 30 credit hours pej \glt- 
week in Category I. 

The program will cover acoustics, instrumentation, scanning am 
applications to obstetrics, gynecology, ophthalmology, adult ani 
pediatric cardiology, the abdomen, the breast, radiation therap; 
planning, the urinary tract and the nervous system. 

For further information, please write to: James F. Martin. M.D 
Director. Postgraduate Medical Sonics. Bowman Gray School o 
Medicine. Winston-Salem. North Carolina 27103. 



PROGRAMS IN CONTIGUOUS STATES 

May 3-5 ' 

The 1976 Southeast Emergency Medicine Congress ! 

Place: Fairmont Colony Square Hotel. Atlanta, Georgia ! 

Sfionsors: The Southeast Chapters of the American College o| 
Emergency Physicians, School of Medicine Medical College oj 
Georgia (sic), and in conjunction with the Emergency Depart 
ment Nurses Association 

Fees: $100 (ACEP). $125 (Non-ACEP Physician). $40 (EDNA), $5(1 
(Non-EDNA Nurse). $40 (Registered EMT), $50 (Non 
Registered EMT), $25 (Residents, Interns, Medical & Nursini 
Students with Letter from department chief). $100 (EMS Ad 
ministrators with letter on EMS System stationery). $12; 
(Others). 

For Information: Registrar. 1976 Southeast Emergency Medicim 
Congress. 1919 Beachwav Road. Suite 5C. Jacksonville, Florid; 
32207 

May 10-13 

The Frontiers in Cardiology 

Place: Royal Coach Motor Hotel. Atlanta. Georgia 

Sponsors: Council on Clinical Cardiology. American Heart Associ 

Vol. 37, No. 4 



tloi 

iini 

w 

Sev( 

toil 
itk 



He; 



irei 



h 
sic 
ad! 



y« 



M 



men, ition; Department of Medicine. Emory University School of 
Vledicine m cooperation with the Georgia Heart Association 
e: ACC members $125; non-members $175 
edit: AMA Category I 

r Infonnation: Miss Mary Anne Mclnemy. Director. Depart- 
nent of Continuing Education Programs, American College of 
Cardiology. 9650 Rockville Pike, Bethesda. Maryland 20014 



May 21-22 

inical Rheumatology for the FYacticing Physician 

ice: Bonhomme Richard Inn. 500 Merrimac Trail. Route 143. 

Williamsburg. Virginia 

onsors: Virginia Chapter of The Arthritis Foundation; Virginia 

Regional Medical Program; Medical College of Virginia — Vir- 
:r':-%inia Commonwealth University; University of Virginia School 

of Medicine; Eastern Virginia Medical School 

e: $25 

ioji fcdit; SVa hours; AMA Category I; AAFP credit applied for 
m\ >r Information: Department of Continuing Education. School of 

Medicine. Medical College of Virginia. P.O. Box 91. Richmond. 

Virginia 23298 

Medical College of Virginia 

The number in parenthesis, following the title, indicates the 
mber of hours for that particular course. 
May 17-18 EEG Symposium (14) 

May 21 Annual Spring Forum for Child Psychiatry (4) 

June 2 Pediatric Nephrology for Practicing Physicians (4) 

Forfurther information on the above CME opportunities write to 
i Department of Continuing Education. School of Medicine. 
edicaJ College of Virginia. Box 91. Richmond. Virginia 23298 



le:W 

IV. 



The items listed in this column are for the six months immediately 
Hewing the month of publication. Requests for listing should be 
ceived by WHAT':' WHEN'!' WHERE':'. P.O. Box 15249. 
M irham. N.C. 27704, by the lOthof the month prior to the month in 
lich they are to appear. A "Request for Listing" form is available 
I request. 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



"Busy work" is the phrase which for years has been 
he accursed nomenclature of women's auxiliaries. In 
male-dominated society, whatever the "little wom- 
in" found to do outside the house was often regarded 
IS an attempt to seem important on her own rather 
't'han working in partnership with men to accomplish 
wice as much. 

Several years ago the Auxiliary to the North 
Carolina Medical Society dropped "woman" from its 
itle because it was no longer appropriate. Today the 
iuxiliary works hand in hand with the doctors to 
ichieve the same goals for the medical profession and 
he health of the state. Thejoint effort for legislation to 
mprove the professional liability situation in the state 
s a recent example. Assuring the medical doctor an 
;ven shake requires education of the lay public as well 
is the General Assembly. The auxiliary has willingly 
:aken an active role in instructing friends and 
neighbors and assisting in letter writing campaigns to 
iielp improve climate and get legislation considered 
ind passed. 

The February 18, AM News spoke of the crisis in 
medical education. Tuitions are rising and federal fi- 
nancial aid has been severely curtailed. Even the most 
liberal members of the Senate and House say that the 
states and the private sector should take up the burden 



of financial assistance to medical students. The aux- 
iliary has been aware of this situation for some time 
and has been pushing for increased contributions to 
AMA-ERF. (As a sign of the times, well-endowed 
Stanford University Medical School, for the first time 
this year, sought $150,000 in AMA-ERF funds and 
hopes to double that next year.) Even now awareness 
of the crisis is not all it should be. These funds are 
made available to the "medical school of your choice" 
for tuition and other critical school expenses. The 
North Carolina Medical Auxiliary is stressing indi- 
vidual personal contributions of at least $15 per 
member and/or spouse as well as making available for 
sale a number of items such as a bicentennial plate 
from which $5 of the $13.50 price goes to AMA-ERF. 

Last year the auxiliary gave approximately $24,000 
to AMA-ERF. This year the auxiliary is stressing the 
need for much, much more. 

The county auxiliaries also contribute to the state 
auxiliary's Student Loan Fund, an additional source 
of aid to those who qualify for financial assistance to 
complete their education in the health sciences. Again 
the source is small compared to the need. 

The auxiliary works alongside the medical society 
in AMPAC-MEDPAC in the areas of political educa- 
tion and candidate support. Many medical crises 
could be eased if not eliminated by the election of 
well-informed, understanding representatives on the 
state and national levels. 

Another strong unifying push is afoot in health edu- 
cation. Five auxiliary members, in conjunction with 
the medical society and the Department of Public In- 
struction, are working to improve the qualifications of 
health education teachers from kindergarten through 
high school. It takes training to teach not just treat- 
ment in crisis but sanitation, safety and maintenance 
of good health. The future rewards are mind-boggling. 
What better way to fight drug addiction, obesity, ve- 
nereal disease and dangerous driving habits? 

Members of the North Carolina Medical Auxiliary 
are busy, and not even the most dyed-in-the-wool 
male chauvinist, once informed, could call what the 
auxiliary does "just busy work." 



News Notes from the— 

DUKE UNIVERSITY MEDICAL CENTER 



Dr. Herman Grossman, professor of radiology and 
pediatrics, is acting chairman of the Department of 
Radiology while a search is under way for a new 
department head. 

The absence was created by the resignation of Dr. 
Richard Lester who left to join the faculty at the Uni- 
versity of Texas Medical School in Houston. 

Grossman earned his B.A. at the University of 
North Carolina, an M.A. at Wesleyan in Connecticut 
and his M.D. at Columbia in 1953. He has been at 
Duke since 1971. 



April 1976. NCMJ 



211 



Dr. Hsioh-Shan Wang, 47, a member of the Duke 
faculty since 1964 and chief of the Day Unit in the 
Department of Psychiatry, has been promoted to full 
professor of psychiatry. 



A major research effort to determine the feasibility 
of using concentrated amounts of a natural body 
chemical to dissolve gallstones is getting under way 
here. 

Successful results could mean a considerable reduc- 
tion in the number of gallstone disease patients requir- 
ing hospitalization and surgical treatment. 

Funded by a grant from the National Institutes of 
Health, the study is to run for three years and eventu- 
ally will involve up to 900 patients nationally. As one 
of the 10 institutions chosen as treatment centers. 
Duke's share of the total grant is $499,520. 

The study involves the use of chenodeoxycholic 
acid (CDCA) which is one of the primary bile acids 
normally produced by the liver. The bile is stored in 
the gallbladder until it is needed to aid in digestion of 
fats in the diet. Stones form when there is a heavy 
concentration of cholesterol in the bile. 

Dr. Malcolm P. Tyor, head of the division of gas- 
troenterology in the Department of Medicine, said the 
study will attempt to show that by "feeding" addi- 
tional quantities of CDCA it is possible to improve the 
body's ability to cope with cholesterol buildup, thus 
preventing the formation of stones. 

In addition, he said, it is hoped that the treatment 
will make it possible to dissolve stones that already 
have solidified. 



Duke is ahead of the national average in the number 
of women being admitted to and graduating from med- 
ical school. 

There were 34 women among the 1 14 students in the 
1975 entering class. This amounted to 29.8 percent of 
the class compared to a national average of 27 percent. 

The number of women graduates from the medical 
school has risen steadily over the past 10 years. 

In 1966 Duke was slightly behind the national aver- 
age. Its five women accounted for 6.2 percent of the 
medical graduating class that year as compared with 
6.9 percent nationally. 

But by 1971 women at Duke made up 12.5 percent 
of the class while the national average was 9.2 percent. 

The gap widened slightly by last year. Duke's medi- 
cal graduates in 1975 included 21 women, or 17.2 
percent of the class, compared with 13.4 percent na- 
tionally. 

The national figures are from the American Medical 
Association's 75th Annual Report on medical educa- 
tion. 



A new program in fa nily medicine designed to make 
the family doctor a better scientist is starting here. 
Dr. E. Harvey Estes Jr., chairman of the Depart- 



212 



BRIEF SUMMARY OF 
PRESCRIBING INFORMATION 
ANTIMINTH" (pyrantel pamoate) 
ORAL SUSPENSION 

Actions. Antimmth (pyrantel pamoate) has 
demonstrated anthelmintic activity against 
Enlerobius vermiculans (pinworm) and As- 
cans lumbncoides (roundworm). The anthel- 
mintic action IS probably due to the neuro- 
muscular blocking property of the drug. 

Antiminth is partially absorbed after an oral 
dose. Plasma levels of unchanged drug are 
low. Peak levels (0.05-0. 13/xg/ml) are reached 
in 1-3 hours. Quantities greater than 50% of 
administered drug are excreted in feces as 
the unchanged form, whereas only 7% or less 
of the dose is found in urine as the unchanged 
form of the drug and its metabolites. 
Indications. For the treatment of ascanasis 
(roundworm infection) and enterobiasis (pin- 
worm infection). 

Warnings. Usage m Pregnancy: Reproduction 
studies have been performed in animals and 
there was no evidence of propensity for harm 
to the fetus. The relevance to the human is not 
known. 

There is no experience in pregnant women 
who have received this drug. 

The drug has not been extensively studied 
in children under two years; therefore, in the 
treatment of children under the age of two 
years, the relative benefit/risk should be con- 
sidered. 

Precautions. Minor transient elevations of 
SCOT have occurred in a small percentage of 
patients. Therefore, this drug should be used 
with caution m patients with preexisting liver 
dysfunction. 

Adverse Reactions. The most frequently en- 
countered adverse reactions are related to the 
gastrointestinal system. 

Gastrointestinal and hepatic reactions: an- 
orexia, nausea, vomiting, gastralgia, abdomi- 
nal cramps, diarrhea and tenesmus, transient 
elevation of SGOT. 

CNS reactions: headache, dizziness, drowsi- 
ness, and insomnia. Skin reactions: rashes. 
Dosage and Administration. Children and 
Adults: Antimmth Oral Suspension (50 mg of 
pyrantel base/ml) should be administered in a 
single dose of 1 1 mg of pyrantel base per kg 
of body weight (or 5 mg/lb.); maximum total 
dose 1 gram. This corresponds to a simplified 
dosage regimen of 1 ml of Antimmth per 10 lb. 
of body weight. (One teaspoonful=5 ml.) 

Antimmth (pyrantel pamoate) Oral Suspen- 
sion may be administered without regard to 
ingestion of food or time of day, and purging 
IS not necessary prior to, during, or after ther- 
apy. It may be taken with milk or fruit juices. 
How Supplied. Antimmth Oral Suspension is 
available as a pleasant tasting caramel- 
flavored suspension which contains the equiv- 
alent of 50 mg pyrantel base per ml, supplied 
in 60 ml bottles and Unitcups™of 5 ml in pack- 
ages of 12. ^^^ 

ROeRIG <0> 

A division of Rizer Pharmaceuticals 
New York, New York 10017 



Vol. 37, No. 4 




eliminates Pinworms and Roundworms with a single dose 



■ Single dose effectiveness against 

both pinworms and roundworms— 

The only single-dose anthelmintic effective 
against pinworms and roundworms. 

■ Nonstaining— to oral mucosa, 
stomach contents, stools, clothing or linen. 

■ Well tolerated — the most frequently 
encountered adverse reactions are related 
to the gastrointestinal tract. 



■ Economical — a single prescription 
will treat the whole family. 

■ Highly acceptable — pleasant-tasting 
caramel flavor. 

■ Convenient —just 1 tsp. for every 

50 lbs. of body weight. May be taken v/ith- 
out regard to meals ROGRIG <^ 
or time of day. ^ „„,3,„„ ,, „,_,,, p,3,™?f!^s 

New York. New York 10017 
Please see prescribing inlormation on lacing page. NSN 6505-00- 148-6967 



Antiminth 

(pyrantel pamoate) 



ORAL 
SUSPENSION 



cqui\'alent to 50mg pyrantel/ml 



«l 



merit of Community Health Sciences, reported that a 
faculty research and training grant amounting to 
$802,885 has been received from the Robert Wood 
Johnson Foundation of Princeton, N . J . , to support the 
program for three years, beginning July 1. 

Focusing on epidemiology — the basic science dis- 
cipline dealing with the cause, distribution and control 
of disease within a community — the project will 
attempt to make doctors better able to recognize the 
cause of illness among their regular patients, and to be 
more effective in drawing up plans for control of the 
illness. 

"We want to equip the family doctor with the ability 
to recognize unique phenomena, and to interpret their 
significance," Estes said. "We want him to be able to 
evaluate whether it means something. That's what 
epidemiology will teach him to do." 

"Intensive training in epidemiology hasn't been 
given to family doctors in the past," he said, "just to 
public health doctors." With such training, Estes be- 
lieves that doctors in a community setting could con- 
tribute greatly to existing knowledge within 
epidemiology, as well as improve the quality of care to 
their own patients. 

The family doctor with such training should also be 
more able to study the occurrence of illness in the 
family unit, and to distinguish between the effects of 
heredity and the effects of a common exposure in the 
home, he said. 

The new project will be a joint endeavor between 
Duke and the University of North Carolina School of 
Public Health at Chapel Hill. 



News Notes from the— 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



A four-drug therapy first proposed at the Bowman 
Gray School of Medicine is yielding promising results 
in the fight against stages three and four of Hodgkin's 
disease. 

An international evaluation of the therapy, con- 
ducted since 1972 by Acute Leukemia Group B, has 
shown that 75 per cent of patients using the therapy for 
remission induction and long-term followup mainte- 
nance are free of the disease 36 months after the 
therapy was started. 

The drug regimen proposed at Bowman Gray con- 
sists of Nitrosourea, Vinblastine, Prednisone and 
Procarbazine. The standard treatment for advanced 
Hodgkin's disease, in use since 1964, consists of ni- 
trogen mustard. Vincristine, Prednisone and Procar- 
bazine. 

The therapy which originated at Bowman Gray was 
proposed as a way »f reducing the side effects as- 
sociated with nitrogen mustard and Vincristine in the 
standard treatment for advanced Hodgkin's. 



214 



Dr. lei 



Eleciei 



(Vino 



So many people treated with the new drug therap] 
are still in complete remission that the average lengtl 
of remission has yet to be determined. And no on( In* 
knows what the median length of survival will be. 

But the new treatment is producing better result 
than the standard therapy for advanced Hodgkin's 
which produces an average length of remission of 3! 
months and a median survival time of 59 months. 

A total of 562 patients were in the comparativi 
study as of November, 1975, making it one of the larg 
est studies of treatment for Hodgkin's disease eve 
done. ^ fciliciiit 

The federal government's Indian Health Service ft L< 
has adopted an instructional program, developed a taHe 
Bowman Gray, for teaching physician assistants 

It is being used in the PA program at the Indiai 
Health Service Hospital in Gallup, New Mexico. Stu- 
dents enrolled in the program represent Indian tribeAsia, 
in New Mexico, Oklahoma, Arizona arid Soutl 
Dakota, as well as natives of Alaska 

The Bowman Gray instructional program, called s 
self-instructional/tutorial (S.I./T.) curriculum iden- 
tifies that material which is essential for the physiciaiAiosu 
assistant to learn to function effectively. The physi- i 
cian assistant program at Bowman Gray has identified n 
106 of the most common medical problems seen in i 
primary care practice. 

Learning under the S.l./T. is generally done in smal 
groups, with the first quarter of the curriculum in-l 
volved in the basic sciences and the last three-quarters 
ofthe nine-month S.I./T. curriculum placing emphasis 
on those 106 complaints. The remainder ofthe two 
year Bowman Gray PA program is taken up witl 
clinical training. 

The Indian Health Service's use ofthe S.I./T. has 
been a field test for the new curriculum and represents! 
the first "export" ofthe curriculum. Bowman Grayi 
believes that several other physician assistant pro-| 
grams will adopt the new curriculum within the next 
couple of years 



Dr. 



kfl 



Dr. 



E. Lawrence Davis, a Winston-Salem attorney anc 
a member of the North Carolina Senate, has beer| 
elected vice chairman ofthe Medical Center Board of 
the Bowman Gray School of Medicine and North 
Carolina Baptist Hospital. Dr. R. F. Smith Jr. ol 
Hickory is chairman of the board. ! 

The board was established in 1974 to provide £' 
better means of coordinating the work ofthe hospital 
and medical school. The board consists of eight trust- 
ees of Wake Forest University, eight trustees of Bap- 
tist Hospital and a member ofthe professional staff ol 
the medical center. I 

Wake Forest trustees recently appointed to two-! 
year terms on the board include Mrs. Polly Lambeth 
Blackwell of Winston-Salem; Robert R. Forney of 
Shelby; Dr. George W. Paschal Jr. of Raleigh; and 
Leon L. Rice Jr. of Winston-Salem. 

Appointed from the Baptist Hospital Board of 



:n 



?'j 



I 



Vol. 37, No. 4 sj 



■ustees were E. J. Prevatte of Southport; Dr. Ernest 

. Stines of Canton; and Miss Joyce E. Warren of 
I inton. 

Dr. Jesse Chapman of Asheville was re-appointed 
li a one-year term. 

Elected to the board's executive committee were 
. Edwin Coliette of Winston-Salem and Francis E. 
larvin of Wilkesboro. 



;Dr. James E. Leist. instructor in community 
ledicine. has been appointed assistant dean for con- 
nuing education at Bowman Gray. 
Dr. Leist also is deputy director of the Northwest 
."ea Health Education Center (AHEC). 



Dr. Paul B. Comer, assistant professor of anes- 
lesia. has been named to the editorial advisory board 
( Respirator}' Therapy. 

Dr. Courtland H. Davis Jr.. professor of 
lurosurgery. was installed as president of the South- 
n Neurosurgical Society during the organization's 
inual meeting in New Orleans. 



Dr. Frederick W. Glass, assistant professor of 
surgery, has been appointed to the Undergraduate 
Education Committee of the American College of 
Emergency Physicians. The same organization has 
appointed Dr. David S. Nelson, clinical assistant pro- 
fessor of surgery, to its Emergency Medical Services 
Committee, and Dr. George Podgomy. clinical assis- 
tant professor of surgery, as its chairman of the Sec- 
tion on Education and as chairman of the college's 
Scientific Assembly and Symposium. 

American Academy of Family Physicians 

Six North Carolina physicians were named to com- 
missions and committees of the American Academy of 
Family Physicians when its board met in December in 
Hawaii. 

James G. Jones, M.D., of Greenville was named to 
the commission on education: George T. Wolff, M.D., 
of Greensboro, chairman of the commission on health 
care services; Thornton R. Cleek, M.D.. of Asheboro 
to the finance committee; Clement C. Lucas Jr., 
M.D., of Edenton, to the publication committee; 
George W. Brown. M.D.. of Hazlewood to the com- 
mittee on scientific program; and Cranford O. Plyler 
Jr., M.D., of Thomasville to the committee on 1976 
state officers' conference. 




LCOHOLISM 
RUG ADDICTION 



In this restful setting away from pressures 
and free from distractions, the Willingway 
sfaff, with understanding and compassion, 
carries out an intensive program of 
therapy based on honesty and responsi- 
bility. The concepts and methods are ori- 
ginal, different and have been highly suc- 
cessful for fifteen years. 

'- John Mooney. Jr.. M.D.. Director 

«;■ Dorothy R. Mooney. Associate Director 

311 JONES MILL RD.. STATESBORO. GA 30458 TEL. (912) 764-6236 

: ^HlB^HBilHiHHIHBHHH ACCREDITED BY THE J. C. A. H. 

PWL 1976, NCMJ 




215 



Month in 
Washington 



Opposition to the Administration's proposals to 
change Medicare appears to be almost universal on 
Capitol Hill. The American Medical Association, the 
American Hospital Association, the AFL-CIO, the 
National Council of Senior Citizens are among many 
frequently crossed organizations that have joined in 
assailing the President's proposal. 

The Administration has asked Congress to approve 
a new catastrophic benefit for Medicare coupled with 
much higher cost-sharing, to impose percentage 
"caps" on Medicare reimbursement for hospitals and 
physicians, and to change Medicaid into a block grant 
program for the states. 

The House Ways and Means Health Subcommittee, 
headed by Rep. Dan Rostenkowski (D-IU.), chaired 
three days of hearings as the Ford proposal was in- 
tended to take effect in March and Congressional 
approval was necessary. Any illusions the Adminis- 
tration may have entertained that some important 
support might surface for the Medicare plan were 
swiftly dispelled by the parade of hostile witnesses. 

Rostenkowski chided the Administration for seek- 
ing early enactment without being able to provide 
Congress with a legislative proposal by the time hear- 
ings started. From the tone of Rostenkowski and other 
Subcommittee members in their questioning, there 
seems little chance of the proposal getting anywhere. 

Raymond T. Holden, M.D., Chairman of the 
AMA's Board of Trustees, said, "The proposed 
changes would not only be impractical, but would also 
be inherently unfair to all parties concerned. Unfortu- 
nately, the unfairness would be especially hard upon 
the beneficiaries of the Medicare program." 

Discussing the proposed four percent limitation in 
1977 on increases in Medicare physician reimburse- 
ment. Dr. Holden said, "We must point out un- 
equivocally that the percentages proposed are wholly 
unrealistic. The proposal ignores the realities occur- 
ring in our economy throughout the country. 
Moreover, inflationary conditions existing generally 
in our economy cannot justifiably be the basis for 
imposition of arbitrary and discriminatory ceilings on 
a single segment of the economy." 

"To impose such arbitrary limits on only one seg- 
ment of the economy and then to expect a continua- 
tion of beneficiary satisfaction for having benefits paid 
by Medicare (as promised by the program) is naive. 
The health care sector of our society cannot operate in 
a vacuum. It is subject to the same costs of living and 
costs of doing business as is any other segment of 
society. It cannot be expected to provide high quality 



216 



jlkatf 



S( 

Senatt 
iRep 
iseddi 



care while having reimbursememt limited to unrealis 
tic levels." 

The AMA Chairman told the Subcommittee thllfct 
proposed limitations on increases in charges are ii siieii 
reality a response to a problem created in large meaipie 
sure by government itself. "Providers and physicianijove 
cannot be subject to ever increasing regulations anwiPri 
requirements. . . and yet be expected to keep chargCj^isiro 
at less than cost levels. These special requirements ar, ijsai 
on top of the inflationary problems faced by theri;ita 
along with everyone else." :;:iiiri 

Dr. Holden noted that both physicians and hospital] i«ai 
also "are experiencing highly unusual expenses rela wii 
tive to professional liability insurance." 

"If the limitations were imposed, some healt 
facilities could face bankruptcy," Dr. Holden saicjik/ 
"The patient will pay more, and the federal goverri me 
ment will again have promised a broad program whil) jilie 
seeking to limit payment for the care received. Unde ou 
the guise of holding down costs to the federal goverr ic 
ment, the costs would, in fact, be increased to pci kh 
tients. The federal government must realize that onci.tiii 
a program is legislated the service does not becom. l^ji 
free. But that, as with services generally, paymer jijiilie 
must be provided. In this instance we believe that it i' \ojii 
unconscionable on the part of the Administration tibojl 
shift costs to the beneficiary under the pretense c: aa 
trying to limit the costs of the program to the feden- Imijs 
government." Ani 

The proposals creating the four and seven percei , 
(on hospitals) limitations "are clearly discriminator I 
and arbitrary," he said. "They should be rejecte ,;Sf 
summarily. Physicians have already been subjected tJ,iiio 
unreasonable and arbitrary controls. First the 83rj jy 
percentile formula, then the various phases und< [jj,f, 
price controls, and now the 75th percentile whic |[(„ 
itself is controlled by an arbitrary economic index, mi, 

"These inequities are further magnified by the uii ijj,. 
realistic Medicare practice which bases current pay ,||j 
ments upon data almost two years old. While phys, ^j 
cians have accepted their responsibility in meeting tb 
needs of the elderly, it is time for the government tj 
meet its responsibility of fulfilling the commitment 
made to the elderly under Medicare." 

Bert Seidman, Director of the AFL-CIO's Soci 
Security Department, said Labor was "dismayed" b 
the Administration's recommendations, which he di 
clared would "create a most serious barrier to healt 
care for the elderly." Seidman argued that the pre 
posed reimbursement controls on hospitals and physi 
cians would simply shift the financial load to nor 



Vol. 37. No. 



I: 



^edica^e patients in hospitals and result in fewer 
pysicians accepting assignment. 



The sounds of a catastrophic-only national health 
iiurance plan for this year still reverberate through 
Snate halls. 

Senate Majority Leader Mike Mansfield (Mont.) 

aJ Republican Leader Hugh Scott (Pa.) recently 

a'eed during a joint television appearance on backing 

-c:astrophic and on predicting it has a good chance of 

caring Congress this year. 

Thief Congressional sponsor of a catastrophic- 

• oented plan — Sen. Russell Long(D-La.) — said ina 

"siarate appearance that he believes Congress will 

'^orove his bill this session. Congress will go beyond 

viat President Ford recommended in the way of 

c.astrophic benefits for Medicare beneficiaries, 

Ing said, and extend the concept to all Americans. 

le Chairman of the Senate Finance Committee said 

tilt for the average working man with a long siege of 

! iiess and very high medical expenses "'we are going 

"tcprovide some help for him. too." 



The Administration has told Congress it won't 

ppose a national health insurance (NHI) program 

util the economy brightens. However. Health. Edu- 

c ion and Welfare Secretary David Mathews has 

"deeded the plan — when submitted — will be close 

t the Nixon Administration's so-called CHIP plan 

:E.ndating comprehensive private health insurance 

average to be offered by employers. 

: Mathews appeared before the House Commerce 

1 Sbcommittee on Health as it opened the 1976 hear- 

ii;s on NHI. Under questioning from Subcommittee 

-:( airman Paul Rogers (D-Fla.), Mathews said CHIP 

ufnains the basic Administration NHI plan and that 

poposing it "is a matter of timing." 



; \ Senate report charges that some clinical 

:-l! 'oratories involved in Medicaid have operated on a 

'Ikback basis with physicians and clinics. 

r Chairman Frank Moss (D-Utah) of the Senate Spe- 

cl Committee on Aging said the report "concludes 

;:'t it, at least in the states which came under investiga- 

rtn, kickbacks are widespread among labs specializ- 

'1; in Medicaid business. In fact, it appears necessary 

t give a kickback to secure the business of physicians 

. c clinics who specialize in the treatment of welfare 

p:ients." 

• The report focused on Illinois. Other states men- 
t ned were New York. New Jersey. Michigan, 
(lifomia and Pennsylvania. 

\ staff witness told the Committee at a hearing that 
t: Staff estimates that at least $45 million of the S213 
rllion Medicare-Medicaid payments to clinical 
lioratories is either fraudulent or unnecessary. Av- 
enge kickback was 30 percent of the lab's charge, the 
riort estimated. 



The report says a small number of labs control the 
Medicaid business in the involved states. In New 
York, according to the report. 17 facilities control 70 
percent of the Medicaid business: in New Jersey. 12 
labs control nearly 60 percent of Medicaid payments; 
in Illinois. 26 labs handle over 90 percent of the vol- 
ume. 

In response to numerous press queries generated by 
the Committee's report including a filmed version of 
the charges carried nationally by CBS's program 
"Sixty Minutes," Max H. Tarrott. M.D.. AMA Presi- 
dent, made the following statement: 

"I would remind physicians and the public alike that 
the AMA Code of Ethics is very clear on the matter of 
laboratory charges. 

"The physician's ethical responsibility is to provide 
his patients with high quality services. As a profes- 
sional man. the physician is entitled to fair compensa- 
tion for his services. But he is not engaged in a com- 
mercial enterprise and he should not make a markup, 
commission or profit on the services rendered by 
others. 

"If after due process a physician is found to have 
violated the Code of Ethics in this or any other re- 
spect, he is fully liable for whatever professional 
penalties may be imposed, in addition to whatever 
penalties may be imposed by law." 



The Health. Education and Welfare Department 
has been accused of attempting a shocking invasion of 
privacy in proposing to collect social security number 
identification of hospitalized patients and their physi- 
cians. 

The AMA told HEW that "In this age of great 
concern over the right of privacy on the part of all 
citizens in our country, we are shocked that a federal 
department would now formally propose to establish a 
mechanism by which most physicians and every hos- 
pitalized Medicare, Medicaid, and Title V recipient 
could be classified, identified, matched, compared, 
reviewed and computerized with the impersonal ease 
of electronic machines.'" 

The social security information uould be part of the 
data collected by the Dept. for Uniform Hospital Dis- 
charge Abstract (UHDA) for federal medical pro- 
grams. Purpose is to gather and coordinate statistical 
information which also could be used by planning 
bodies, accrediting organizations, hospitals, and pri- 
vate third-party payors. 

The form would require the names of patient and 
attending physician and operating physician as well as 
their society security numbers. 

The AMA noted in a formal comment that such use 
of social security numbers as universal identifiers has 
been criticized both by Congress and HEW in the past 
as a significant threat to peoples' right of privacy. 

"There is well founded reason to fear that universal 
identifiers might be potentially available for abuse." 
the AMA said. "If. for example, each individual is 
idenfified in all of his activities by a single number and 



N ^'RiL 1976, NCMJ 



217 



his activities are tabulated in a number of different 
record systems, all computerized, the universal iden- 
tifier tends to erode the barriers between information 
systems. The fact that the social security number is 
already in such wide use makes any further encour- 
agement for its use as contemplated by the proposed 
UHDA, highly dangerous."" 



Staff of the House Commerce Health Subcommit- 
tee has prepared a discursive dictionary designed to 
steer lawmakers through the maze of terms — medi- 
cal, legal, and federal — involved in an intelligent 
discussion of national health insurance. 

The 183-page document also will help physicians 
who have dealings with the federal government and 
Congress. It contains concise definitions of most of 
the pertinent legal and governmental terms and ac- 
ronyms ("alphabet soup expanded"") flavored with a 
touch of whimsy. 

Illustrations range from a drawing of the lower in- 
testines (see borborygmus) to a handsome full-page 
sketch of andreas vesalius and a two-page biography 
("a wonderful man""). 

In an introduction. Subcommittee Chairman Paul 
Rogers (D-Fla.) said the developing debate on NHI 
("a term not yet defined in the United States"') 
employs a "bewildering array of new and unfamiliar 



terms."" He described the discursive dictionary a 
"the first reasonably complete dictionary of term 
relevant to the consideration of NHI and health car 
available."" 

Skipping through the document one finds defini 
tions of such terms as triage, trolley car policy (benefi 
for injuries only when hit by a trolley car), slip law 
respondent superior (employers" liability for malprac 
tice of an employee), ping-ponging (passing patient 
from one physician to another), halo effect, gork 
chainside and backdoor authority. 

A typical definition — legislative history: 

the written record of the writing of an act of Congress. It 
may be used in writing rules or by courts in interpreting the 
law to ascertain or detail the intent of the Congress if the 
act is ambiguous or lacking in detail. The legislative history 
is listed in the slip law (final version) and consists of the 
House, Senate and conference reports (if any), and the 
House and Senate floor debates on the law. The history, 
particularly the committee reports, often contains the only 
available complete explanation of the meaning and intent of 
the law. 

Put together by Lee Hyde, M.D., professional stal 
member of the Commerce Heklth Subcommittee, th, 
dictionary is available in limited quantities on writte 
request to: (Please enclose a self-addressed envelope, 
Interstate and Foreign Commerce Committee, 212| 
Raybum House Office Building, Washington, D.C 
20515. 






j| 



Book Reviews 



Physician's Handbook. Eighteenth Edition. Marcus 
A. Krupp. M.D.. et al (eds). 7.M pages. Price. $8.00. 
Los Altos. California: Lange Medical Publications, 
1976. 

Current Medical Diagnosis and Treatment. Fifteenth 
Edition. Marcus A. Krupp, M.D.. and Milton J. Chat- 
ton. M.D. (eds). 1.062 pages. Price. $14.00. Los Al- 
tos. California: Lange Medical Publications, 1976. 

These perennials from Lange have long been among 
the best buys in medical books. With rare exceptions, 
each editionis up to the high standard set by its pre- 
decessor; writing is clear and to the point, the price is 
right and the contents up to date. The Handbook even 
fits the hand, no mean feat these days, and should be 
very attractive for the house officer. Current Medical 
Diagnosis and Treatment, while primarily for the gen- 
eral internist and family practitioner, is worth the at- 
tention of medical subspecialists and even surgeons 
faced by some everyday problems which can be 
solved without getting a consultant or picking up the 
knife. 

John H. Felts, M.D. 



n 



218 



Vol. 37, No. 



i 



In iUpmnrtam 



Warren Harding Grumpier, M.D. 

Warren Crumpler died on January 7. 1976, at the age 
)f 55 following a long illness. He had practiced in 
ilount Olive. North Carolina, from 1946 until his re- 
irement because of illness. 

A native of the Roseboro area in Sampson County, 
le graduated from Roseboro High School, Wake 
^orest College and the Bowman Gray School of 
viedicine. His internship was at Rex Hospital in 
Raleigh and he did a year of residency at the Duke 
Jniversity School of Medicine. During World War II 
le served in the United States Navy. 

He was a member of the Wayne County Medical 
society. North Carolina Medical Society, Southern 
viedical Association and the American Academy of 
"amily Practice. 



A long time member of the Mount Olive Volunteer 
Fire Department, he was serving as department chap- 
lain at the time of his death. He was active in church 
and civic affairs until illness curtailed his activities. 

He is survived by his wife, Adelaide, five daughters 
and three sons. 

Dr. Crumpler"s dedication to his profession and his 
patients as well as his genuine concern for people have 
marked his career since its inception. He was beloved 
by colleagues, patients and his community in general. 

Warren Crumpler was a devoted physician and will 
be sorely missed by the Society and by his patients. 
Wayne County Medical Society 



^RiL 1976, NCMJ 



219 



Index to 
Advertisers 



Burroughs Wellcome Company 192 

Crumpton, J. L. & J. Slade, Inc 187 

Fellowship Hall 174 

Golden-Brabham Insurance Agency 182 

Key Pharmaceuticals Inc 183 

Lilly, Eli & Company Cover 1 

Loma Linda Foods 190 

Mandala Center 220 

Mutual of Omaha 191 

Ortho Pharmaceuticals 206, 207 

Pharmaceutical Manufacturers Association .184, 185 



Roche Laboratories Cover 2, 173, 178, 179, 

180, Cover 3, Cover 4 

Roerig & Company 177, 212, 213 

Sapphire Valley 181 

Smith Kline & French Laboratories 189 

Tucker Hospital 221 

United States Air Force 188 

United States Navy 175 

Willingway, Inc 215 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company 222 | 



0^ 



:'cc 



WINCHESTER 

"CAROLIISAS' HOUSE OF SERVICE" 

Winchester Surgical Supply Company 

200 South Torrence St. Charlotte, N. C. 28204 
Phone No. 704-372-2240 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N. C. 27401 
Phone No. 919-272-5656 

Serving the MEDICAL PROFESSION of NORTH CAROLINA 
and SOUTH CAROLINA »ince 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N. C. State Medical Society Meeting since 1921, and 
advertised CONTINUOUSLY in the N. C. Journal since January 1940 issue. 



i>M 



Stisi 
tSli I 

;■[; 
-■ilil 

:;:(! 

■ 'iSl 
'■M 

m\ 
:bI 



'■:l; 



222 



Vol. 37. No. 4 



10-day Bactrim therapy 
outperforms 10-day ampicillin therapy 



\^,'->" 



^^li^ 




In a multicenter, double- 
blind study of patients with 
chronic or frequently recurrent ^ ■' 
urinary tract infection, Bactrim 10- r^^,^ 
day therapy outperformed annpi- \ Ti . 
cillm 10-day therapy by 27.2%, ^^Z;^^ 
when comparing patients ■L 

who maintained clear cultures *% 
for eight weeks. Criterion for "clear culture" was 
1000 or fewer organisms/ ml of urine. 

While adverse reactions were mild (e.g., nausea, 
rash), more serious reactions can occur with these 
drugs. See manufacturers' product information 
for complete listing. 

Note: Bactrim single strength tablets were used in these clinical 
trials. However, studies have established the bioequivalency of 
Bactrim DS with the smgle strength tablets. 



actrim DS 

(160 mg trimethoprim and 800 mg sulfamethoxazole) 

clouble strength tablets 
Just 1 tablet B.I.D. 

Bactrim 

(80 mg trimethoprim and 400 mg sulfamethoxazole) 

2 tablets B.LD 



For chronic or frequenth^ recurrent c\ stitis 
and p\ elonephritis due to susceptible organisms. 



Before prescribing, please consult complete product information, a 
summary of which follows: 

Indications: Chronic urinary tract infections evidenced by persistent 
bacteriuria (symptomatic or asymptomatic), frequently recurrent infec- 
tions (relapse or reinfection), or infections associated with urinary 
tract complications, such as obstruction. Primarily for cystitis, pyelo- 
nephritis or pyelitis due to susceptible strains of E. coli, Klebsiella- 
Enterobacter, Proteus mirabilis, Proteus vulgaris and Proteus 
morganii. 

NOTE: The increasing frequency of resistant organisms limits the use- 
fulness of antibacterials, especially in these urinary tract infections. 
The recommended quantitative disc susceptibility method [Federal 
Register. 37:20527-20529, 1972) may be used to estimate bacterial 
susceptibility to Bactrim. A laboratory report of "Susceptible to tri- 
methoprim-sulfamethoxazole" indicatesan infection likely to respond 
to Bactrim therapy. If infection is confined to the urine, "Intermedi- 
ate susceptibility" also indicates a likely response. "Resistant" indi- 
cates that response is unlikely. 

Contraindications: Hypersensitivity to trimethoprim or sulfonamides; 
pregnancy; nursing mothers. 

Warnings: Deaths from hypersensitivity reactions, agranulocytosis, 
aplastic anemia and other blood dyscrasias have been associated 
with sulfonamides. Experience with trimethoprim is much more 
limited but occasional interference with hematopoiesis has been re- 
ported as well as an increased incidence of thrombopenia with pur- 
pura in elderly patients on certain diuretics, primarily thiazides. 
Sore throat, fever, pallor, purpura or jaundice may be early signs of 
serious blood disorders. Frequent CBC's are recommended; therapy 
should be discontinued if a significantly reduced countof any formed 
blood element is noted. Data are insufficient to recommend use in in- 
fants and children under 12. 

Precautions: Use cautiously in patients with impaired renal or hepatic 
function, possible folate deficiency, severe allergy or bronchial 
asthma. In patients with glucose-6-phosphate dehydrogenase defi- 
ciency, hemolysis, frequently dose-related, may occur. During ther- 
apy, maintain adequate fluid intake and perform frequent urinalyses, 
with careful microscopic examination, and renal function tests, par- 
ticularly where there is impaired renal function. 
Adverse Reactions: All major reactions to sulfonamides and trimeth- 
oprim are included, even if not reported with Bactrim. 6/oocf dys- 
crasias: Agranulocytosis, aplastic anemia, megaloblastic anemia, 
thrombopenia, leukopenia, hemolytic anemia, purpura, hypopro- 
thrombinemiaand methemoglobinemia./l//erg/c/-eac(/ons.' erythema 
multiforme, Stevens-Johnson syndrome, generalized skin eruptions. 



epidermal necrolysis, urticaria, serum sickness, pruritus, exfolia- 
tive dermatitis, anaphylactoid reactions, periorbital edema, con- 
junctival and scleral injection, photosensitization, arthralgia and 
allergic myocarditis. Gastrointestinal reactions: Glossitis, stomati- 
tis, nausea, emesis, abdominal pains, hepatitis, diarrhea and pan- 
creatitis. CNS reactions: Headache, peripheral neuritis, mental de- 
pression, convulsions, ataxia, hallucinations, tinnitus, vertigo, in- 
somnia, apathy, fatigue, muscle weakness and nervousness. Miscel- 
laneous reactions: Drug fever, chills, toxic nephrosis with oliguria 
and anuria, periarteritis nodosa and L. E. phenomenon. Due to cer- 
tain chemical similarities to some goitrogens, diuretics (acetazola- 
mide, thiazides) and oral hypoglycemic agents, sulfonamides have 
caused rare instances of goiter production, diuresis and hypoglyce- 
mia in patients; cross-sensitivity with these agents may exist. In 
rats, long-term therapy with sulfonamides has produced thyroid 
malignancies. 

Dosage: Not recommended for children under 12. Usual adult dos- 
age: 1 DS tablet (double strength), 2 tablets (single strength) or 
4 teasp. (20 ml) b.i.d. for 10-14 days. 

For patients with renal impairment: 



Creatinine 

Clearance (ml/ min) 


Recommended 
Dosage Regimen 


Above 30 


Usual standard regimen 


15-30 


1 DS tablet (double strength), 

2 tablets (single strength) 

or 4 teasp. (20 ml) every 24 hours 


Below 15 


Use not recommended 



Supplied: Double Strength (DS) tablets, each containing 160 mg tri- 
methoprim and 800 mg sulfamethoxazole, bottlesof 100; Tel-E-Dose® 
packages of 100. Tablets, each containing 80 mg trimethoprim and 
400 mg sulfamethoxazole -bottles of 100 and 500; Tel-E-Dose® 
packages of 100; Prescription Paks of 40, available singly and in 
trays of 10. 

Oral suspension, containing in each teaspoonful (5 ml) the equiva- 
lent of 40 mg trimethoprim and 200 mg sulfamethoxazole; fruit- 
liconce flavored — bottles of 16 oz (1 pint). 



<(^ROCHE^ 



Roche Laboratories 

Division of Hoffmann-La Roche Inc. 

Nutley, New Jersey 07110 



In a mukicenter study of patients with chronic or frequently recurrent urinary tract infections / 

Bactrim was 27.2% more 

effective than ampicillin in 

keeping patients 

infection-free for 8 weeks. 



% of patients infection-free at 8 weeks 



Bactrim 

70.5% of 
78 patients 



ampicillin 

55.4% of 
74 patients 



1 1 1 i 1 1 1 1 r— 

%0 10 20 30 40 50 60 70 80 90 

*This percentage is arrived at by tfie statistical method of 
dividing ttie difference betw/een Bactrim and ampicillin results 
(15.1%) by the percent of ampicillin results (55.4%). 

tData on file, Hoffmann-La Roche Inc., Nutley, N.J. 071 10 




Bactrini DS Bactrini 



(160 mg trimethoprim and 800 mg sulfamethoxazole) 

double strength tablets 
Just 1 tablet B.I.D. 



Please see summary of product information 
on preceding page. 



(80 mg trimethoprim and 400 mg sulfamethoxazole) 

2 tablets B.I.D. 



<^ROCHr> 



n 



The Official Journal of the NORTH CAROLINA MEDICAL SOCIETY 



May 1976, Vol. 37, No. 5 



NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: Metachronous Quadruple Malignant Neoplasms: A Case Report and Review of the Literature, Lloyd H. 
Harrison, M.D., John M. Nordan, M.D., Martin I. Resnick, M.D., and Richard T. Myers, M.D.; Microsurgical Composite 
Tissue Transplantation: A New Horizon in Plastic and Reconstructive Surgery, Donald Serafin, M.D., and Nicholas G. 
Georgiade, M.D.; Cardiopulmonary Resuscitation (CPR) as Treatment of Cardiac Arrest (First of Three Articles), James T. 
McRae. M.D. 



r. 



New from Lilly/Dista Research 

NALFON^ 

fenoppofen calcium 



300-mg.* Pulvules"^ 



Dista Products Company 

Division of Eli Lilly and Company 
Indianapolis, Indiana 46206 

Additional information available to the profession 
on request. 

'Present as 345.9 mg of tfie calcium salt of fenoprofen dihydrate 
equivalent to 300 mg. fenoprofen. 




1976 Committee Conclave 
Sept 22-26— Southern Pines 



1977 ANNUAL SESSIONS 
May 5-8— Pinehurst 



Both often 




Predominant 
• psychoneurotic 
anxiety 



Associated 

• depressive 

symptoms 



Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints which are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adiunctively in skeletal muscle 
spasm due to reflex spasm to local pathol- 
ogy, spasticity caused by upper motor 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 
therapy). 

Contraindicated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



orders, possibility of increase in frequency 
and/or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 







According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feelings, part of the problem 
may sound like depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two, although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 




(diazepam) ^ 

2-mg, 5-mg. 10-mg scored tablets 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to habituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
skin rash, ataxia, constipation, headache, 
incontinence, changes in salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug, iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 




ROCHE 



Roche Laboratories 
> Division of Hoftmann-La Roche Inc. 
Nutley, New Jersey 07110 



TREATMENT AND LEARNING CENTER For 

ALCOHOL RELATED PROBLEMS 




FELLOWSHIP HALL 

THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit 
Tax-Exempt • A Controlled and Pleasant Psychological Atmosphere 

• Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



Member of: 

• The American Hospital Association 
• The N, C. Hospital Association 

• Accredited by the Joint Commission 

on the Accreditation of Hospitals 



Individual Counseling • Group Therapy 

[Mature Trail • Indoor/Outdoor Recreation 

Relaxation and Sleep Therapy 

Audio-Video Therapy 



FOR ADMITTANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



FELLOWSHIP HALL 



INC. 



P. 0. BOX 6929 



GREENSBORO, N. C. 27405 



Located off U.S. Hwy. No. 29 at Hicone Road Exit, 

6V2 miles north of downtown Greensboro, N. C. 

Convenient to 1-85, 1-40, U.S. 421, U.S. 220, 

and the Greensboro Regional Airport. 



FOR MEDICAL INFORMATION CALL 

J. W. WELBORN, JR., M.D. 

MEDICAL DIRECTOR 

919-275-6328 



I' 




Facility, program and en- 
vironment allows the indi- 
vidual to maintain or re- 
gain respect and recover 
with dignity. 



F ms, tapes, lectures, 
group discussions and in- 
dividual counseling are 
used with emphasis on 
reality therapy. 



Medical examination upon 
admission. 



Modern, motel-like accom- 
modations with private bath 
and individual temperature 
control. 



A therapeutic nature trail 
to encourage physical ex- 
ercise, and arouse objec- 
tive interest in the miracle 
of nature. 



FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 



Of all filter kings: 



Nobody^ 
lower dum 



Look at the latest U.S. Government figures for 
other top brands that eall themselves "low "in tai; 



tar, nicotine, 

mg/cig. mg/cig. 



Brand D (Filter) 14 1.0 

BrandDl Menthol) 13 W 



Carlton 
Filter 
2mg. 



Brand V (Filter) 11 



0.7 



Brand T (Menthol) 11 



0.6 



Brand V (Menthol) 11 

Brand T (Filter! ^Tl 

Carlton Filter 
Carlton Menthol 



0.7 



2 0.2 

2 0.2 

Carlton 70's (lowest of all brands)— 
■■^ mg. tar, 0.1 mg. nicotine 

"Av. per cigarette by FTC method 



No wonder Cculton is 
fastest grow ing of the top 25. 




Carlton 
Menthol 
2mg. 



Warning: The Surgeon General Has Determined 
That Cigarette Smoking Is Dangerous to Your Health. 



Filter and Menthol: 2 mg. "tar", 0.2 mg. nicotine av. per cigarette, by FTC method. 



John H. Felts. M.D. 
Winston-Salem 

EDITOR 

John S. Rhodes, M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Milliard 
Raleigh 

BUSINESS MANAGER 



EDITORIAL BOARD 

Charles W. Styron. M.D. 
Raleigh 

CHAIRMAN 

George Johnson. Jr.. M.D. 
Chapel Hill 

Robert W. Prichard, M.D. 
Winston-Salem 

Rose Pully, M.D. 
Kinston 

John S. Rhodes. M.D. 
Raleigh 

Louis Shaffner. M.D. 
Winston-Salem 

Robert E. Whalen, M.D. 
Durham 



NORTH CAROLINA 
MEDICAL JOURNAL 

Published Monthly as the Official Organ of 

The North Carolina 

Medical Society 

May 1976, Vol. 37, No. 5 



Original Articles 

Metachronous Quadruple Malignant Neoplasms: A Case 
Report and Review of the Literature 241 

Lloyd H. Harrison. M.D.. John M. Nordan, M.D.. Mar- 
tin 1. Resnick, M.D., and Richard T. Myers, M.D. 

Microsurgical Composite Tissue Transplantation: A New 

Horizon in Plastic and Reconstructive Surgery 246 

Donald Serafin, M.D., and Nicholas G. Georgiade, M.D. 

Cardiopulmonary Resuscitation (CPR) as Treatment of 

Cardiac Arrest (First of Three Articles) 249 

James T. McRae, M.D. 



Editorials 

Human Tissue Donations 250 

Down Home 25 1 

Talking Back: An Editorial Book Review 251 



Correspondence 

Insect Bites 

Claude A. Frazier, M.D. 



254 



Bdlletin Board 

New Members of the State Society 254 

Whaf^ When'' Where'' '>'>f\ 

NORTH CAROLINA IHEDICAL JOURNAL, 300 S. YV lldl . vv llCIl . VVJICIC _JO 

Hawthorne Rd.. Winston-Salem. N. C. 27103, is owned a -i- i vi i ^^ i- »# i- i r-> ■ '^ /- ^ 

and published by The North Carolina Medical Society Auxiliary to thc North Carolioa Medical Society 256 

under the direction of its Editorial Board, Copyright '" 

^::Z^^'c:^^.^Z^', e'lilS News Notes from the Bowman Gray School of Medicine of 

matter to thLs Winstun-Salem address. Questions retat- WfiWp PnrF**;! I Inivt^riiitv '?S8 

ing to subscnption rates, advenising, etc. should be t» ar,.»- i y.ti%^^i i^iiivcisuy ^.'O 

addressed to the Business Manager, Box 27167, vt xt ^ r ...i t-^ i i i • -^ \ m i- t r^ ^ '> m 

Raieigh.N.c. 27611. All advertisements are accepted Ncws Notes tfom thc DuKc UniveFsity Medical Center . . 259 

subject to the approval of a screening committee of the 

ofn '^A'^t^S \''",T^ '^'in',nr'"!.''"u"''v'" ^'""*' AmcricaH College of Emergency Physicians, 

Blvd.. Oak Park. Htmois 60302 andor by a Committee ,^ G J J 

of the Editorial Board of the North Carolina Medical NoPth Carolina Chapter 265 

Journal in respect to strictly local advertising. Instruc- 
tions to authors appear in the January and July issues. 
Annual Subscription. $lt).00. Single copies. $1.00. Pub- ., - ^ ^ 

licalion office: Edwards & Broughton Co.. P.O. Box MONTH IN WASHINGTON 265 

27286. Raleigh, N,C, 2761 1. Second-L-tass postage paid 
at RaUigh. North Carolina 27611. 

Book Reviews 270 

Classified Ads 271 

i „ Index to Advertisers 272 

Contents listed in Current Contents/Clinical Practice 






No.3 
As potent as the pain it relieves. 



e.3. the pain of 
surgical convalescence 



# 



>^** 





NOT TOO LITTLE 

■ as potent as the pain you need to relieve in patients 
with fractures, sprains, strains, wounds, contusions, 
and the pain of surgical convalescence 

■ unlike acetaminophen/codeine combinations, it 
does not sacrifice anti-inflammatory action 

NOT TOO MUCH 

■ potent— yet not excessive ■ addiction liability low 



NOT TOO EXPENSIVE 

■ brand-name quality yet reasonable in cost 

■ readily available in both hospital and local pharmacies 

(]> CONVENIENCE 

■ telephone Rx in most states, up to 5 refills in 

6 months at your discretion (where state law permits) 



EMPIRIN COMPOUND 
WITH CODEINE NO. 3 

codeine phosphate*, 3 2 4 mg. gr '; 

Each tablet also contains aspinngr 3'r,phenacetin gr 2 '4, caffeine gr la "Warning -may be habit-formmg 



ft 

Wellcome 



Burroughs Wellcome Co. 

Research Triangle Park 
North Carolina 27709 



North Car6lina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy- 
75 percent — 25 percent Co-Insurance 



PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 
60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$206.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50.00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age BO. 

♦'Integrates with Medicare at age 65. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus SO cents. 



Term Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


655 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-69 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 
The above plans quality for use in the Professional Association. 



For Full Information — Write or Call 

Golden-Brabham Insurance Agency, Inc. 

Ralph J Golden Van Brabham III 

108 E. Northwood St., Phone: BRoadway 5-3400, Box 5395, Greensboro, N. C. 27405 





fTlandQlQ Center 



A fully accredited private multi-disciplin- 
ary psychiatric hospital, partial care and 
out-patient clinic for the acutely ill to the 
mildly distressed. Children, young people, 
adults, couples or entire families may enter 
the treatment programs. 

A modified form of the therapeutic com- 
munity, a full spectrum of treatment mo- 



dalities are used. The services consist of 
individual, couple, group and family psycho- 
therapies; sexual and marriage counseling; 
pastoral counseling; vocational guidance and 
rehabilitation; alcohol and drug counseling; 
psychological testing, chemotherapy, elec- 
trotherapy and other somatic therapy ser- 
vices. 




Blue Cross participating hospital 

JCAH Accredited 

Richard B. Boren, M.D. Glenn N. Burgess, M.D. 

Psychiatrist-in-Chief Psychiatry 

For Information Call Collect (919) 724-9236 or Write: 
741 Highland Avenue • Winston-Salem, N. C. 27101 



Towards Wholeness 



Officers 
1975-1976 



NORTH CAROLINA MEDICAL 
SOCIETY 



President James E. Davis, M.D. 

1200 Broad St., Durham 27705 

President-Elect Jesse Caldwell, Jr., M.D. 

1 14 W. 3rd Ave., Gastonia 28052 

First J'icc-Prcsideni John L. McCain, M.D. 

Wilson Clinic, Wilson 27893 

Second Vice-President T. Reginald Harris, M.D. 

808 N. DeKalb St., Shelby 28150 

Secretary E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Durham 27710 (1976) 

Speaker Chalmers R. Carr, M.D. 

1822 Brunswick Ave., Charlotte 28207 

Vice-Speaker Henry J. Carr, Jr., M.D. 

603 Beariion St., Clinton 28328 

Past-President F^ANK R. Reynolds, M.D. 

1613 Dock St., Wilmington 28401 

Executive Director William N. Hilliard 

222 N. Person St., Raleigh 2761 1 

Councilors and Vice-Councilors 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor Joseph A. Gill, M.D. 

1202 Carolina Ave., Elizabeth City 27909 (1977) 

Second District J. Ben.)amin Warren, M.D. 

Box 1465, New Bern 28560 ( 1976) 

Vice-Councilor (Tharles P. Nicholson, Jr., M.D. 

3108 Arendell St., Morehead City 28557 (1976) 

Third District E. Thomas Marshburn, Jr., M.D. 

1515 Doctors Circle, Wilmington 28401 (1976) 

Vice-Councilor Edward L. Bovette. M.D. 

Chinquapin 28521 (1976) 

Fourth District Harry H. Weathers, M.D. 

Central Medical Clinic, Roanoke Rapids 27870 (1977) 

\'ice-Coiincilor Robert H. Shackleford, M.D. 

115 W. Main St., Mt. Olive 28365 (1977) 

Fifth District August M. Oelrich, M.D. 

Box 1169, Sanford 27330 (1978) 

Vice-Councilor Bruce B. Blackmon, M.D. 

P. O. Box 8, Buies Creek 27506 (1978) 

Sixth District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd., Chapel Hill 27514 (1977) 

Vice-Councilor W. Beverly Tucker, M.D. 

Box 988, Henderson 27536 ( 1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Road, Charlotte 28207 (1978) 

\'ice-Councilor J. Dewey Dorsett, Jr. 

1851 E. Third St., Charlotte 28204 (1978) 

Eighth District Ernest B. Spangler, M.D. 

Drawer X3, Greensboro 27402 (1976) 

Vice-Councilor James F. Reinhardt, M.D. 

Cone Hospital, Greensboro 27402 (1976) 

Ninth District Verne H. Blackwelder, M.D. 

Box 1470, Lenoir 28645 (1976) 

Vice-Councilor Jack C. Evans, M.D. 

244 FairviewDr., Lexington 27292 (1976) 

Tenth District Kenneth E. Cosgrove, M.D. 

510 7th Ave., W., Hendersonville 28739 (1978) 

Vice-Councilor Otis B. Michael, M.D. 

Suite 208, Doctors B.Jg., Asheville 28801 ( 1978) 

230 



Section Chairmen — 1975-76 

Anesthesiology Jack H. Welch, M.D. 

Physicians Quadrangle, Greenville 27834 

Dcrmatolog\ George W. Crane, Jr., M.D. 

1200 Broad St.. Durham 27705 

Family Physicians William W. Hedrick, M.D. 

33 1 1 N. Boulevard, Raleigh 27604 

Internal Medicine jAMES H. Black, M.D. 

1351 Durwood Dr., Charlotte 28204 

Meurologv & Psychiatry Hervy W. Mead, M.D. 

1900 Randolph Rd., Suite 900, Charlotte 28207 

Neurological Surgery M. Stephen Mahaley, Jr., M.D. 

3940 Nottaway Rd., Durham 27707 

Obstetrics & Gynecology C. T. Daniel, Jr., M.D. 

1641 Owen Dr., Fayetteville 28304 

Ophthalmology E. R. Wilkerson, Jr., M.D. 

1012 Kings Drive, Charlotte 28207 

Orthopaedics Frank C. Wilson, M.D. 

N. C. Memorial Hospital, Chapel Hill 27514 

Otolaryngology N. L. Sparrow, M.D. 

3614 Haworth Dr., Raleigh 27609 

Pathology R. Page Hudson, M.D. 

P. O. Box 2488, Chapel Hill 27514 

Pediatrics Gerard Marder, ?/1.D. 

224 New Hope Rd., Gastonia 28052 

Public Health & Education J. N. MacCormack, M.D. 

Box 2091, Raleigh 27602 

Radiology R. W. McConnell, M.D. 

1711 W. 6th Street, Greenville 27834 

Surgery Robert C. Moffatt, M.D. 

309 Doctors Bldg., Asheville 28801 

Urology Robert Dale Ensor, M.D. 

1333 Romany Road, Charlotte 28204 
Students, Medical 

Delegates to the American Medical Association 

James E. Davis. M.D 1200 Broad St., Durham 27705 

(December 31, 1976) 

John Glasson, M.D 306 S. Gregson St., Durham 27701 

(December 31, 1976) 
Frank R. Reynolds. M.D. 

1613 Dock Street, Wilmineton 28401 
(December 31. 1976) 
David G. Welton, M.D. 

3535 Randolph Road, Charlotte 28211 
(December 31, 1977) 
EtxiAR T. Beddingfield, Jr.. M.D. 

Wilson Clinic, Wilson 27893 
(December 31, 1977) 

Alternates to the American Medical Association 

George G. Gilbert, M.D. 

1 Doctor's Park, Asheville 28801 
(December 31, 1976) 
Louis deS. Shaffner. M.D. 

Bowman Gray, Winston-Salem 27103 
(December 31. 1976) 
Iessl Caldwell. Jr.. M.D. 

114 W. 3rd Ave., Gastonia 28052 
(December 31. 1976) 
Charles W. Styron, M.D. 

615 St. Marys St., Raleigh 27605 
(December 31, 1977) 

D. E. Ward, Jr., M.D 2604 N. Elm St., Lumberton 28358 

(December 31. 1977) 

Vol. 37, No. t 



NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 

Now Pays Up To 

$500 -4 

WEEKLY INCOAAE 
($2^66.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 

GUARANTEED RENEWABLE DIRECT PERSONAL SERVICE 

You are guaranteed the privi- Since 1939, it has been our 
lege of renewing $300-week to privilege to administer your pro- 
age 70. The other $200 per week gram from Durham, N. C. includ- 
renewabie to age 60. This is on ing payment of all claims! 
exclusive and most important 
feature. 




J. L & J. SLADE CRUMPTON, INC. 

GENE GREER 
Office Manager 

. 0. Drawer 1767— Durham. N. C. 27702. Telephone: 919 682-5497 
Underwritten by The Continental Insurance Cos. of New York 

JACK FEATHERSTON, Field Representative 

P. O. Box 17824. Charlotte. N. C. 28211. Telephone: 704 366-9359 

North Carolina Professional Group Administrators for: 

NORTH CAROLINA MEDICAL SOCIETY • NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI- 
NEERS • NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A.'S AND BAR GROUPS 





It's what you do. It's what you are. It's 
what you, as a physician, strive to 
give every patient. In every way. 

Sometimes, a patient's needs 
require specialized help. When the 
need arises. Tidewater Psychiatric 
Institute stands ready to augment 
your care. 

AtTPI, helptakes manyforms, 
through a comprehensive program of 
patient-oriented diagnostic, con- 
sultative and psychiatric treatment 
services within atherapeutic setting. 
Individually designed treatment 
programs meet the particular needs 
of both adult and adolescent patients. 
Our hospital's school allows adoles- 
cents to continue their education 
whileatTPI. Aspecial program 
exists forthe detoxification and 
rehabilitation of the individual with 
alcohol or drug-related problems. 

You are invited to investigate 
personally, bytelephoneorthrough 
correspondence, the avenues of 
specialized help available to your 
patient at our facilities in Norfolk and 
Virginia Beach. 




Efle 



Cai 
Rel 

Ou 
Rel 

for 



WEST 



ijA 



TIDEWATER 
PSYCHIATRIC INSTITUTE 



1701 Will-0-Wisp Dr., Va. Beach, Va. 23454 
CALL COLLECT (804) 481-1211 
1005 Hampton Blvd., Norfolk, Va. 23507 
CALL COLLECT (804) 622-2341 



NORTH 



PSYCHIATRY 
Stuart Ashman, M.D. 

Hospital Director, Va. Beach 
Lawrence A. Bernert, M.D. 
John H. Furr, M.D. 



James F. Griswold, M.D. 
Trafford Hill, Jr., M.D. 
David B. Kruger, M.D. 
Murray C. Miller. M.D. 
John A. Mirczak, M.D. 



Burt W. Phillips, M.D. 
Julian W. Selig, Jr., M.D. 

Hospital Director, Norfolk 
Stephen E. Slatkin, M.D, 
Duncan S. Wallace, M.D. 



Accredited by The Joint Commission on the Accreditation of Hospitals. 
Approved for Blue Gross, Champus, Medicare and other health coverage. 



James I 
P.O.Bi 
Gieensl 
91912?; 



Laiiyii 
P.O.B 



5am 'i' 



I '04/33 



Communicating with Professionals 



Effective, two-way communication between 
physicians' offices and the internal 
management and operating departments of 
Blue Cross and Blue Shield of North 
Carolina is the function of our Professional 
Relations Department. 

Our eight specially trained Professional 
Relations representatives are responsible 
for personal liaison between doctors and 
their office staffs and the Plan. 



The Professional Relations Representative 
assigned to your area is listed below. Your 
representative is ready to provide Blue 
Cross and Blue Shield benefit information 
and to assist with any problems that may 
arise. Please call on your representative 
anytime. 



NORTH WEST CENTRAL 



NORTH EAST CENTRAL 



NORTHWESTERN REGION 



WESTERN REGION 



NORTHEASTERN 
REGION 




SOUTH WEST CENTRAL REGION 



NORTHWESTERN REGION 

R. Stuart Veach 
P. O. Box 195 

Winston-Salem, N. C. 27102 
919/722-4141 



SOUTH EAST CENTRAL REGION 



NORTHEASTERN REGION 

Alton R. James 
P. O. Box 1447 
Greenville, N. C. 27834 
919/756-1175 



SOUTHEASTERN REGION 



NORTH WEST CENTRAL REGION 

James D. Webb 
P. O. Box 6746 
Greensboro, N. C. 27405 
919/272-8123 

NORTH EAST CENTRAL REGION 

Larry W. Moss 
P. O. Box 27884 
Raleigh, N. C. 27611 
919/834-0376 

SOUTH WEST CENTRAL REGION 

Sam W. Pridgen 
P. O. Box 4470 
Charlotte, N. C. 28204 
704/333-5106 



SOUTHEASTERN REGION 

Hilda C. Muse 
P. O. Box 1018 
Wilmington, N. C. 28401 
919/763-4684 

SOUTH EAST CENTRAL REGION 

Walter T. O'Berry 
Drawer A 

Fayetteville, N. C. 28302 
919/483-1322 

WESTERN REGION 

Daniel P. Mclntyre 
P. O. Box 371 
Asheville, N. C. 28801 
704/ 253-6844 




Blue Cross 
Blue Shield 

of North Carolina 



Testing in Humans: 
Who,Whens & When. 



|the weight of ethical opinion: 

Few would disagree that the efFective- 
Iness and safety of any therapeutic agent 
lor device must be determined through 
Iclinical research. 

But now the practice of clinical re- 
Isearch is under appraisal by Congress, the 
I press and the general public. Who sliall 
[administer it.' On whom are the products 
1 to be tested? Under what circumstances? 
I And how shall results be evaluated and 
[utilized? 

The Pharmaceutical Manufacturers 
I Association represents firms that are sig- 
nificantly engaged in the discovery and 
development of new medicines, medical 
devices and diagnostic products. Clinical 
research is essential to their efforts. Con- 
sequently, PMA formulated positions 
which it submitted on July 1 1, 1975, to 
the Subcommittee on Health ot the Sen- 
ate Labor and Public Welfare Committee, 
as its official policy recommendations. 
Here are the essentials of PMA's current 
thinking in this vital area. 

I, PMA supports the mandate and 
mission of the National Commission tor 
the Protection of Human Subjects of 
Biomedical and Behavioral Research and 
offers to establish a special committee 
composed of experts of appropriate 
disciplines fimiliar with the industry's 
research methodology to volunteer its 
service to the Commission. 

I. PMA supports the formation of an 
independent, expert, broadly based and 
representative panel to assess the current 
state of drug innovation and the impact 
upon it of existing laws, regulations and 
procedures. 

3. When FDA proposes regulations, 
it should prepare and publish in the Fed- 
eral Register a detailed statement assess- 
ing the impact of those regulations on 
drug and device innovation. 

4«PMA proposes that an appropri- 
ately qualiiied medical organization be 
encouraged to undertake a comprehen- 
sive study of the optimum roles and 
responsibilities of the sponsor and physi- 
cian when company-sponsored clinical 
research is performed by independent 
clinical investigators. 



5»PMA recognizes that the physician- 
investigator has, and should have, the 
ultimate responsibility lor deciding the 
substance and lorm ot the informed con- 
sent to be obtained. However, PMA 
recommends that the sponsor of the ex- 
periment aid the investigator in dis- 
charging this important responsibility by 
providing (1) a document detailing the 
investigator's responsibilities under FDA 
regulations with regard to patient consent, 
and (2) a written description ot the 
relevant tacts about the investigational 
item to be studied, in comprehensible 
la\' lanaua^e. 

O.In the case of children, the sponsor 
must require that informed consent be 
obtained from a legally appropriate rep- 
resentative of the participant. Voluntary 
consent of an older child, who may be 
capable of understanding, in addition to 
that of a parent, guardian or other legally 
responsible person, is advisable. Safety of 
the drug or device shall have been assessed 
in adult populations prior to use in 
children. 

7«PMA endorses the general prin- 
ciple that, in the case of the mentally 
infirm, consent should be sought from 
both an understanding subject and from 
a parent or guardian, or in their absence, 
another legally responsible person. 

8. Pharmaceutical manufacturers 
sponsoring investigations in prisons must 
take all reasonable care to assure that the 
facilities and personnel used in the con- 
duct of the investigations are suitable for 
the protection of participants, and tor the 
avoidance of coercion, w ith a respect for 
basic humanitarian principles. 

9» Sponsors intending to conduct non- 
therapeutic clinical trials through the 
participation of employee volunteers 
should expand the membership and scope 
of its existing Medical Research Commit- 
tee, or establish such an internal Medical 
Research Committee, with responsibility 
to approve the consent forms of all 
\olunteers, designs, protocols and the 
scope of the trial. The Committee should 
also bear responsibiliry to ensure full 
compliance with all procedures intended 
to protect employee volunteers' rights. 

XO. 'Where the sponsor obtains medi- 
cal information or data on individuals, it 
shall be accorded the same confidential 



status as provided in codes of ethics gov- 
erning health care professionals. 

II. PMA and its member firms accept 
responsibility to aid and encourage ap- 
propriate follow-up of human subjects 
who have received investigational prod- 
ucts that cause latent toxicirj' in animals 
or, during their use in clinical investiga- 
tion, are found to cause unexpected and 
serious adverse efitects. 

IX. PMA supports the exploration 
and development by its member compa- 
rt ies of more systematic surveillance pro- 
cedures for newly marketed products. 

I3«When a pharmaceutical manu- 
facturer concludes, on the basis of early 
clinical trials of a basic new agent, that a 
new drug application is likely to be sub- 
mitted, a proposed development plan 
accompanied by a summar)' of existing 
data, would be submitted to the FDA. 
Following a review of this submission, 
the FDA, and its Advisory Committee 
where appropriate, would meet with the 
sponsor to discuss the development plan. 
No formal FDA approval should be re- 
quired at this stage. Rather, the emphasis 
should be on identification of potential 
problems and questions for the sponsor's 
kirther study and resolution as the pro- 
gram develops. 

The PMA believes that health profes- 
sionals as well as the public at large 
should be made aware of these 13 points 
in its Policy on Clinical Research. For 
these recommendations envisage con- 
structive, cooperative action bv industry, 
research institutions, the health profes- 
sions and government to encourage crea- 
tive and workable responses to issues 
involved in the clinical investigation of 
new products. 



PM-A 



Pharmaceutical Manufacturers 

Association 

115^ Fifteenth Street, N.W 

Washins:ton,D.C. 20005 





Saint Albans 
Psychiatric Hospital 



A fully accredited private 

psychiatric hospital for the 

treatment of all major 

psychiatric illnesses 

including alcoholism and 

drug abuse problems of 

adolescents and adults. 

Radford, Virginia 24141 
Telephone 703 639 2481 




mountain 

vallev 







■ ii- g^ Mountain valley golf is a 
^^ Sapphire Valley speciality . . . 
played on a championship 
course designed by George W. 
Cobb (he called it one of his 
finest). The nearly level course 
rolls gently through our vast, 
quiet valley — surrounded by the 
cool North Carolina mountains. 

A complete family resort, 
Sapphire Valley has much to 
offer, including 12 tennis courts. 
Blue Ridge scenery, lakes, 
trips to gem fields, and 
accommodations at the stately 
1896 Fairfield Inn or our 
luxury Villas. And it's all 
about 3 hours' drive from 
Atlanta, Charlotte and Knoxville. 

Come up for a day, or a 
lifetime. Call 704-743-3441 or 
write Sapphire Valley, Star 
Route 70, Box 80, Sapphire, 
N. C. 28774 

Attn: N. M. Wright 



Sapphire Valley 



Brown Bag Permit No. 2265 



medicine/osteopathy 



phu/kl 




UM ImQl vou 




As an Air Force officer, you'll practice in a highily professional atnnosphere, 
supported by a team of highily qualified technical assistants. You'll treat 
patients in your specialty in new and modern health care facilities. You'll 
enjoy specialty training which is second to none in military and civilian 
hospitals. The Air Force has many opportunities for unlimited professional 
development, with a carefully individualized plan to make the best use of 
your skills, knowledge, and ambition. From research to clinical medicine, 
our centers offer a full range of available openings. For a full-time career 
without the time-consuming burdens of private practice, a minimum of 
administrative details, and a reasonable amount of leisure time - consider 
our offer . . . 

Mail the coupon below for all the information. 

310 New Bern Ave., Rm. 303, Raleigh, N.C. 27611. Call: 919/755-4134 

Name Social Security No. 

Address 

City 

State 



Zip 



Phone 



Specialty _ 
Date of Birth 



AIR FORCi£. Health Care At Its Best. 



find your perfect practice in the oir force 



AHUMl \i3MjiC Scrapbook 
of Vitamin Facts & Fallacies 





Northern and Central Europeans nnust obtain their vitamin C 
primarily from cabbage because these countries don t have 
a Florida or California as a source of citrus fruits These 
inhabitants get about twice as much ascorbic acid when they 
eat their cabbage raw as when they boil it 




People in more primitive, less commercialized 
societies often eat better balanced diets than 
affluent Americans These natives instinctively 
choose nourishing foods because their bodies tell 
them what they need The dietary habits of Ameri- 
cans are often influenced by television commer- 
cials that appeal to our wants instead of our needs 





Look for the monogram 
"AHR" on every Allbee 
with C capsule It is your 
assurance that this is the 
original and genuine 
product and not an 
imitation 



Available on your 

prescription or 

recommendation 



High Potency 

B-Complex and 

Vitamin C 

Formula 



\.ll. Robins Conipan>. Rii hnioiid. \ j. 2t:2(l /j.U, 




Allbee^withC 



°Do'ann(6.l lOmfl 

P,rao.-ne nyd'ochiorrde (6.)5 mq 
N.ac-njm.oe » mg 



30 CAPSULES 




RO 





A 




|*LTH( 

la the I 

tah' 

lijtian 

|eqiienll 

mm 

II inJiv! 

pmary 

p S) 



i:views 
Esof 
mrsi 



veactoi? 
Donnatal! 



aide 
'-li a 
inoc 



each tablet. 








capsule or 5 cc. 








teaspoonlul 


each 






of elixir 


Donnatal 




each 


(23% alcohol) 


No 2 




Extenlab 


hyoscyamine sulfate 0. 1 037 mg 


1037mg- 




31 1 1 mg. 


atropine sulfate 0.0'94mg 


0,0194 mg. 




0582mg 


hyoscine hydrobromide 0.0u65 mg 


0.0065 mg. 




0195 mg 


phenobarbital C^g'')16 2mg ( 


''i gr)32 4 mg 


C^ 


gr)48.6 mg 


[warning: may be habit forming) 









Brief summary. Adverse Reactions Blurring of vision, dry mouth, 
difficult urination, and flustimg or dryness of the sl<in may occur on 
higher dosage levels, rarely on usual dosage Contraindications: 
Glaucoma: renal or hepatic disease: obstructive uropathy (for ex- 
ample, bladder neck obstruction due to prostatic hypertrophy): or 
hypersensitivity to any of the ingredients 

/1-H-DOBINS A H Robins Company Richmond Virginia 23220 






Ul) 



Metachronous Quadruple Malignant Neoplasms: 
A Case Report and Review of the Literature 



Lloyd H. Harrison, M.D., John M. Nordon, M.D., 
Martin I. Resnick, M.D., and Richard T. Myers, M.D. 



ALTHOUGH considered rare at 
the time of the first report by 
Billroth' in 1819. multiple primary 
malignant neoplasms now occur 
frequently.- More than 200 skin 
carcinomata have been reported in 
an individuaP but three or more 
primary carcinomas in different 
organ systems remains rare. ^•^■' 
This report describes a new case of 
quadruple primary malignancy and 
reviews 26 previously reported 
cases of multiple primary malignant 
tumors in different organ systems. 

CASE REPORT 

Mrs. H. F. was first seen in this 
institution in May. 1961, at the age 
of 49. She complained of lumbar 
back pain radiating to the lateral as- 
pect of the right thigh. The pain was 
more severe when she walked, 
stood or strained. She said she had 
had a total hysterectomy for 
adenocarcinoma of the uterus and 
postoperative irradiation at another 
institution in 1955. She had been 
well until April, 1960, when she had 
a partial resection of her transverse 
colon for adenocarcinoma which on 



Department of Surgery 
Section? of Urology and General Surgery 
North Carolina Baptist Hospital and 
Bowman Gray School of Medicine 
Winslon-Salem. North Carolina 2710? 

Repnnt requests to Dr Hamson 



pathologic examination had metas- 
tasized to two of nine regional 
lymph nodes. Tissue sections of 
these tumors were reviewed and the 
diagnoses of adenocarcinoma of the 
endometrium and adenocarcinoma 
of the colon were confirmed. At this 
time she showed no evidence of 
malignancy but had a herniated in- 
tervertebral disc at L4 and L5 which 
was removed. After surgery her 
symptoms resolved. 

She returned in December, 1961, 
complaining of easy fatigability and 
dizziness. She had observed red 
blood mixed with each stool over 
the preceding week and had noted 
small amounts of blood in her stool 
intermittently for about three 
months. She was anemic with a 
hemoglobin of 9.5 gm. Chest x-ray 
showed no evidence of metastatic 
disease but barium enema revealed 
an annular constriction in the region 
of the hepatic flexure. On De- 
cember 27, 1961, the distal 3-4 
inches of ileum, cecum, and the 
colon to the mid-transverse area 
were removed. The area of previous 
anastomosis was easily identified 
and was free of tumor both grossly 
and microscopically. Five cen- 
timeters proximal to this anas- 
tomosis was a 3.0 x 3.5 cm cir- 
cumferential mass in the wall of the 
colon. In the adjacent mesentery 



was a 4.0 x 2.5 x 2.5 cm mass. These 
masses were identified as moder- 
ately differentiated adenocar- 
cinoma of the colon. 

She did well following this colon 
resection though she was seen on 
several occasions due to back pain 
from what proved to be a traumatic 
compression fracture of the T12 ver- 
tebral body. 

In April, 1973, she was readmit- 
ted for evaluation of left flank pain 
which had been present for about 
three months. Two months before 
admission her local physician had 
found some microscopic hematuria, 
and a month before admission she 
had had an episode of gross 
hematuria with passage of clots. In 
each case she was treated with anti- 
biotics and the bleeding cleared. 
But her flank pain persisted. 

At admission, her hemoglobin 
was 13.3 gm. The urine contained 
over 50 white blood cells and only 
3-4 red blood cells per high power 
field. Blood urea nitrogen was 32 
mg9f. Chest x-ray and barium 
enema showed no evidence of re- 
current or metastatic tumor, but in- 
travenous pyelography revealed 
non-visualization of the left upper 
urinary tract. Retrograde pyelo- 
ureterograms demonstrated nu- 
merous filling defects in the left ure- 
ter with pyelocaliectasis. A selec- 



May 1976. NCMJ 



241 



live renal arteriogram showed a 
small, hydronephrotic left kidney 
with no tumor vasculature. Urine 
cytology was reported as positive 
for malignant cells. 

On May 1, 1973. the patient un- 
derwent left nephroureterectomy. 
Multiple tumor masses were found 
in the left ureter. These were iden- 
tified as poorly differentiated transi- 
tional cell carcinoma. No bladder 
tumors were noted at the time of 
cystoscopy and there was no evi- 
dence of hepatic or other in- 
traperitoneal malignancy. 

The patient is presently alive with 
no evidence of recurrent disease 36 
months following her last operation. 

DISCUSSION 

Criteria of Selection 

Criteria for selection of cases of 
multiple malignant tumors were de- 
fined by Billroth' who stated that: 

(1) each tumor must have an inde- 
pendent histological appearance; 

(2) the tumors must arise in different 
situations, and (3) each tumor must 
produce its own metastases. These 
criteria proved to be too strict 
primarily because even solitary 
malignant tumors could be excluded 
if they had not yet metastasized. 

In their 1932 review, Warren and 
Gates^ proposed more liberal 
criteria on which subsequent re- 
ports including the present case 
have been based. They proposed 
that: (1) each of the tumors must 
present a definite picture of malig- 
nancy; (2) each must be disdnct, 
and (3) the probability that one is a 
metastasis of the other must be 
excluded. 

The patient described in this re- 
port had four documented separate 
malignancies; adenocarcinoma of 
the uterus, transitional cell car- 
cinoma of the ureter, adenocar- 
cinoma of the transverse colon and 
adenocarcinoma of the colon in the 
region of the hepatic flexure. Multi- 
ple colon tumors are not a rare oc- 
currence^"*'' and though one cannot 
be absolutely certain, it appears that 
each of the two bowel tumors in this 
patient represents a primary neo- 
plasm. Their distance apart and 
separate nodal metastasis point to 
different sites of origin. Other indi- 

242 



cations that each is a primary tumor 
are the lack of diffuse metastasis or 
other bowel tumors at the time of 
the second colon resection, the ab- 
sence of any evidence of tumor re- 
currence and the long tumor-free 
status of the patient. 

Due to the frequent occurrence of 
multiple primary tumors in some 
single tissues and organs, and some 
paired organs, Werthamer*' pro- 
posed more restrictive criteria stat- 
ing that: (1) the malignancies must 
be primary in different organs, (2) 
paired-organ primary malignant de- 
generations, whether synchronous 
or metachronous, should be consid- 
ered as representing one tumor, (3) 
multiple malignancies in the same 
organ should be considered as rep- 
resenting a single primary malig- 
nancy, (4) the lower intestinal tract, 
as well as the uterus, should be con- 
sidered single organs, (5) there must 
be histologic evidence of the aber- 
rant growth in the organ tissue, and 
(6) a careful histologic attempt to 
exclude metastasis should be made. 
Only 26 cases of quadruple malig- 
nant neoplasms fulfill these criteria. 

Frequency 

The frequency of multiple malig- 
nant tumors varies from less than 
1%' to 1 1%* in generalized series. If 
one considers multiple carcinomas 
in single tissues the incidence has 
been recorded as high as 21%**. 
Table 1 tabulates several series of 
carcinoma patients and the inci- 
dence of multiple primaries. These 
include clinical and autopsy series 
and show an overall incidence of 
3.4%. This agrees with the large 
cumulative series reported by Mal- 
mio^ who found an incidence of 
3.5%. 

Age and Sex 

The age at which the highest inci- 
dence of multiple cancer occurs 
varies. Goodner'" reported the 
highest incidence between 60 and 90 
years of age and others have noted 
similar findings."'^ Hanlon'^ 
states "they (multiple primary 
malignant tumors) occur among 
persons who are several years older 
than those who harbor but one car- 
cinoma." However, Warren and 
Gates^ found no difference in age 



distribution between patients with 
single and multiple carcinomas. 
More recent studies show that the 
age of highest incidence is the same 
in patients with single and multiple 
primaries though the incidence of 
carcinoma in females begins to rise 
earlier due to the earlier age of oc- 
currence of some female genital 
tumors. ^-^'^ 

There is a slight increased inci- 
dence of multiple carcinomas in 
males in most large series^'*' 
though Warren and Gates'^ initially 
reported a higher incidence in 
females. There is generally a higher 
ratio of males to females in autopsy 
series'^ '^ and a higher ratio of 
females to males in clinical 
series.'^'" Lerman and col 
leagues'^ surveyed patients with 
papilloma of the urinary bladder and 
found that about one-third of 
females and about one-seventh of 
males with papilloma developed 
later or concomitant cancers of sites 
other than the urinary tract. 






Si, nil 

1-JC»W 
IlllW 

ijlir 
lijCuW 

a en* 
rs.iB 

mi 

liJHyj 

l-,JWSt 
•r l!7 IB 

,'w 
'M 
IB, IS 

jSlSISJi 

Ml 
M 

lOiPiW 

t&ii 

ice 

'(21,W 

ISS),I1« 



|l-JbKi 



Blood Groups 

Since the initial report of an as 
sociation between carcinoma of the 
stomach and blood group A,"* in- 
vestigators have examined blood 
groups in cases of multiple car- 
cinoma for a similar association. 
While some small series have re- 
ported a relationship between blood 
group A and multiple carcinoma,"* 
larger series^"-' have reported no 
difference in blood types (ABO or 
Rh) between patients with multiple 
carcinoma and either the normal 
population or patients with single 
malignancies. 

Immunologic Factors 

Recently Dellon and colleagues^^ 
evaluated the cellular immunity and 
histocompatability antigens of 42 
patients who had had from two to 
four primary malignant neoplasms. ,* 
No pre-existing impairment in im- ate^ 
munocompetence or abnormal 
HL-A antigens were observed, 
suggesting that multiple neoplasms 
may result from an unidentified im- 
munologic defect or from repetitive 
exposure to some unknown induc- 
ing agent. 

Vol. 37, No. 5 [ |i,j|„. 









Hill 

mas 
It 4 
samf 



TABLE 1 
Incidence of Multiple Primary Malignancies 



Haddow and Boyd 

NY J Med 

63 95 1963 

Nixon 

South Med J 

65 305 1972 

Mohamad! 

Grace Hosp Bull 

48 90 1970 

Kuehn 

Am J Surg 

111 164 1966 
Schreiner 

Am J Cancer 

20 418 1934 
Bugher 

Am J Cancer 

21 808, 1934 
Hurt and Brodero 
J Lab Clin Med 
18 765 1933 
Peller 

Am J Hyg 

34 1 1941 

Thomas 

Am J Med Sci 

247 427 1964 

Wallace 

Br J Surg 

45 165 1957 

Stalker 

Surg Gynecol Obstet 

68 595. 1939 

Owen 

JAMA 

76 1329 1921 

Cameron 

J Clin Pathol 

14 574 1961 

Moertel 

Cancer 

14 221, 1961 

Warren and Ehrenreich 

Cancer Res 

4: 554 1944 

Watson 

Cancer 

6 365 1953 

Burke 

Am J Cancer 

27: 316 1936 

Yashar 

Am J Surg 

112 70 1966 
Tsukada 
Cancer 

17 1229 1964 

Goodner 

Cancer 

9: 1248 1956 

Pickren 

NY J Med 

63 95. 1963 



TOTAL 



Number of 


Nu 


mber c 


°o With 


Cancer Patients 


Multlpl 


e Primaries 


Multiple Primar 


61 288 




428 


73% 


4 260 




50 


1.17 


10 990 




249 


2.27 


19,711 




460 


2.33 


11.212 




307 


2.7 


983 




30 


3.1 


2.124 




71 


3.34 


5,876 




270 


3.9 


2.346 




99 


4.2 


3.006 




134 


4.5 


2,500 




113 


4.5 


3.000 




143 


4.7 



3.000 


143 


924 


45 


37.580 


1 909 


3 907 


234 



16626 
583 

1 470 
3.647 
1.315 
2.094 



310 
126 



TABLE 2 
Synchronous Quadruple Primary Neoplasms 



Author 

Goetze^" 

1913 

Lauda-" 

1925 

Hornback'^ 

1964 

McKee" 
1967 

Yamasaki^^ 
1970 

Average 



4.88 

5.1 

6.0 

7.11 

7.8 

8.4 

8.5 

9.5 



\qe 




Location of Primary Tumors 




Survival 


75 


Colon 


Stomach 


Rectum 


Prostate 


Autopsy 
Report 


54 


Epith Ca 
Tonsil 


Epiih Ca 
Esophagus 


Common 
Bile Duct 


Adenoca 
Rectum 


4 mos 


63 


Adenoca 
Rectum 


Leukemia 


Adenoca 
Gallbladdef 


Renal Cell 
Ca 


2 mos 


74 


Sq Cell Ca 
Esophagus 


Carcinoid 
Small Bowel 


Adenoca 
Colon 


Adenoca 
Prostate 


1 yr 3 mos 


51 


Esophageal 
Melanoma 


Stomach 


Adenoca 
Colon 


Trans 
Cell Ca 
Ur Bladder 


10 mos 



63 yr 



Susceptibility 

The prognostic significance of the 
occurrence of one malignant tumor 
with regard to the development of 
subsequent new primary malignant 
tumors has been extensively de- 
bated. Most investigators^'^"^-^^ 
agree with the theory proposed by 
Warren and Gates^ that multiple 
carcinomas occur more frequently 
than would occur by chance and 
that these individuals make up a 
group with increased susceptibility 
to malignancy. These conclusions 
have been based on series in which 
multiple tumors of single tissues or 
organs were included with multiple 
tumors of separate organ systems 
and considered as single entities. 
On this basis Warren and Ehren- 
reich^ reported susceptibility in this 
group 1 1 times that of the normal 
population. 

Various studies have shown that 
if an individual has had one malig- 
nancy he is more likely to have a 
second malignancy in the same tis- 
sue organ system than an individual 
who had never had a car- 
cinoma."^"'^'' This presumably oc- 
curs because the entire organ sys- 
tem has been exposed to the same or 
similar carcinogen. ^^ An increased 
incidence of multiple malignant 
tumors has been observed in paired 
organs. This most commonly oc- 
curs in the female breast-" but has 
also been seen in the ovary, -^ 
testes'" and lung.-'' 

SURVEY OF REPORTED CASES 

OF METACHRONOUS 
QUADRUPLE MALIGNANCIES 

We have been able to collect only 
26 cases of quadruple primary 
malignant neoplasms which fulfill 
the criteria of Werthamer.*^ In the 
over 195,000 cases reviewed this 
represents an incidence of 0.014%. 
We have been unable to confirm the 
original report in one case (Aoki, 
1967) but have included it because it 
appears to conform to the above 
criteria. 

There were tlve cases-' '-^"'^^ 
of synchronous quadruple malig- 
nancies (Table 2). These are consi- 
dered separately since their clinical 
course and prognosis differ dis- 
tinctly from those with metachro- 
nous disease. The average age of 



May 1976, NCMJ 



243 



these patients at the time of death 
was 63.4 years. All died of their first 
known mahgnant tumor or at the 
time of surgery for the tumor. The 
longest reported survival after the 
diagnosis of malignancy was 15 
months and the average survival 
was slightly over six months. 

The majority of patients with 
quadruple malignancies are in the 
group with metachronous disease 
(Table 3). There are 20 such cases 
reported with an average age of 60.0 



years at the time of their initial neo- 
plasm. Eleven of these patients had 
died at an average age of 69.2 years 
while nine were alive at an average 
age of 63.8 years. Of these nine, 
eight had no evidence of tumor at 
last report and one had marked re- 
gression of carcinoma of the pros- 
tate following orchiectomy and es- 
trogen therapy. The average length 
of survival from their first malig- 
nancy for the entire group was 10.9 
years and of those eight tumor-free 



patients the intervals since their last 
malignancy ranged from two 
months to five years. 

The eleven patients who died 
succumbed to either progression of' 
the malignancy or to complications 
of surgery for removal of the tumor. 
However, none died of their first 
malignancy and most died of their 
third or fourth. In only one case was 
evidence of the first tumor present 
at the time of death. 

It has been suggested that pa- 



igors 
iiicli as 
jirvivet 
is 
iiewed 
KBtste 
jieiinp 

Iliep 
iioneoi 
!i least 1 
ieseco 
his 
Ire, 01 
le pos! 
fiiman' 



TABLE 3 
Metachronous Quadruple Malignant Neoplasms 



Author 


Age- 


Location 
1st Tumor 


Interval 


Location 
2nd Tumor 


Interval 


Location 
3rd Tumor 


Interval 


Location 
4th Tumor 


Survival** 


Alive 

Without 

Malignancy 


Cause 
01 

Death 


BCKB 

ffss 


Leyden 

Ztschir f Krebsforsch 

7 675, 1909 


Not 
Reported 


Ca Uterus 
and Cervix 




Bilateral 
Breast Ca 




Skin Ca 




Stomach Ca 


15yr 




4th Ca 


Won 
[limary 


Luchsinger 
Frankfuil 2 Path 
40 417, 1930 


87 


Basal Cell Ca 


3yr 
6 mos 


Sq Cell Ca 
Bronchus 




Kidney 




Lung 
Osteosarcoma 


3V2 yr 




2nd Ca 


liity 
las no 


Goldman 

Am J Surg 

69 265, 1945 

Holland 

JAMA 

126 356, 1945 


47 
55 


Breast 

Adenoca 
Breast 


17 yr 
6yr 


Sq Cell Ca 
Skin 

Sq Cell Ca 
Esophagus 


1yr 


Cervix 

Basal Cell 
Skin 


1yr 

3yr 


Adenoca 
Rectum 

Adenoca 
Rectum 


19 yr 

11 yr 




■> 4th Ca Lfel, 

locarcii 


Mass Gen +Hosp 
N Engl J Med 
235 691 1946 


74 


Trans Cell 
Ur Bladder 


4V2 yrs 


Gallbladder 




Adenoca 
Prostate 




Adenoca 
Rectum 


4V2 yr 




2nd Ca 


.mi; 

acer- 
(lysom 
miiino 
Bweve 
eenin 


Goldstein 
Bull Sch Med 
Univ Maryland 
32 140, 1948 
Ettinger 
Am J Surg 
78 894, 1949 


53 
53 


Trans Cell 
Ur Bladder 

Trans Cell 
Ur Bladder 


8 mos 
4yr 


Renal Cell Ca 

Adenoca 
Jeiunum + 
Colon 


1 yr 
5 mos 

1 yr 


Adenoca 
Sig Colon 

Adenoca 
Recto- 
sigmoid 




Basal Cell Ca 
Skin 

Sq Cell Ca 
Skin 


2yr 
7yr 


-1- 


Peritonitis 


Duncan 

NY State J Med 

50 1278, 1950 


56 


Ca Vulva 


8yr 


Adenoca 
Rectum 


7yr 


Adenoca 
Uterus 


3yr 


Basal Cell 
Ca Skin 


18 yr 


+ 






Freeh 

Southern Surgeon 

16 13, 1950 


59 


Adenoca 
Breast 


1 yr 


Adenoca 
Ovary 


10 mos 


Ca 
Pancreas 




Papillary Ca 
Renal Pelvis 


1 5/6 yr 




3rd Ca 




Albrecht 
Oncology 
5 12, 1952 


60 


Adenoca 
Stomach 


4yr 


Esophagus 




Adenoca 
Prostate 




Basal Cell Ca 
Piriform Sinus 


4 yr 




2nd Ca 




Watson 

Plast Reconstr Surg 

11 183, 1953 


50 


Breast 


4yr 


Sq Cell Ca 
Skin 




Thyroid 




Fibrosarcoma 
Esophagus 


12 yr 


-1- 


1 


1 


Cameron 
J CIm Pathol 
14 574, 1961 


65 


Cecum 


2 mos 


Breast 


2yr 
2 mos 


Basal Cell 
ca Skin 


1 mos 


Adenoca 
Rectum 


2 5/12 yr 




Pulmonary 
Embolism 




Werthmer 

JAMA 

175 558 1961 


61 


Endometrial 
Ca 


2yr 
7 mos 


Adenoca 
Breast 


8 mos 


Basal Cell 
Ca Skin 


9 mos 


Adenoca 
Duodenum 


4 1/6 yr 




4th Ca 




Hankins 

JAMA 

179 896, 1962 


50 


Sq Cell Ca 
Cervix q 


6yr 


Adenoca 
Breast 


5 mos 


Sq Cell Ca 
Bronchus 


6 mos 


Trans Cell Ca 
Ur Bladder 


13 yr 


-1- 






Schapira 

J Mount Spnai Hosp NY 

30 228, 1963 


61 


Adenoca 
Stomach 


14 yr 


Renal Cell Ca 


2yr 


Basal Cell 
Ca Skin 


6yr 


Ca Prostate 


22 yr 


+ '*• 






Gracey 

Arch Intern Med 
115 217, 1965 


40 


Adenoca 
Thyroid 


13 yr 


Sq Cell Ca 
Cervix 


18 yr 


Trans Cell 
Ca Ur 
Bladder 


3yr 


Adenoca 
Stomach 


35 yr 


+ 






Baldwm 
Am J Surg 
111 230, 1966 


68 


Adenoca 
Stomach 


3yr 


Sq Cell Ca 

Tonsillar 

Pillar 


2yr 


Broncho- 
genic Ca 




Renal Cell Ca 


5yr 




3rd Ca 


.1 


Oren 

South Med J 

60 280, 1967 


50 


Trans Cell Ca 
Ur Bladder 


5yr 


Sq Cell Ca 
Larynx 


4yr 


Adenoca 
Colon 


3yr 


Sq Cell Ca 
Bronchus 


13 yr 


+ 






Aoki 

Strahlentherape 
140 275, 1970 


57 


Cecum 




Ovary 




Cervix 




Stomach 










Caselnova 
Obslet Gynecol 
32 826, 1968 


18 


Basal Cell Ca 
Scalp 


Syr 


Adenoca 
Ovary 


2yr 


Adenoca 
Colon + 
Endometrium 


5yr 


Adenoca 
Rectum 


Syr 


+ 






Nixon 

South Med J 
65 305, 1972 


56 


Adenoca 
Rectum 


13yr 


Alveolar Cell 
Ca Lung 


1 yr 


Sq Ceil Ca 

Lip 


3yr 


Osteogenic 
Sarcoma 


17 yr 




4th Ca 




Average 


56 




6yr 




2 5yr 




15 yr 




10,9 yr 









"Age - Refers to Age at Time of Diagnosis of First Tumor 
"Survival - Total Interval From Diagnosis To Time Of Case Report 
■"Alive With Regression Of Prostatic Ca 



244 



Vol. 37, No. 5 



tients who Have multiple malignant 
tumors have survived mild types, 
such as skin carcinoma, and not 
survived more aggressive tumors. 
This is not true of the patients re- 
viewed here. The nine living pa- 
tients have survived carcinomas of 
the urinary bladder, breast, colon, 
esophagus, lung and stomach. 

The patient who survives a tumor 
in one organ system appears to have 
at least as good a chance for cure of 
the second tumor as the patient who 
has his first malignancy.^ There- 

— fore, one should always consider 
the possibility of a second or third 
primary malignancy and should at- 

- tack each new primary neoplasm 
:■■ , aggressively. A patient should not 

. ; be allowed to die of a second or third 
primary neoplasm because the pos- 
sibility of multiple primary tumors 
was not considered or the patient 

• was felt to have a high susceptibility 
to carcinoma and. therefore, a poor 
prognosis for cure. 

Why these patients appear to be 
cancer-prone is not known. Possi- 

, bly some defect has occurred in the 
immunologic surveillance system: 
however, studies in this area have 
been inconclusive. Repeated expo- 



sure to a specific carcinogen, as has 
been suggested by others, could 
certainly explain the predisposition 
observed in these individuals.'^ 
Obviously further investigations are 
required to define the abnormality. 
More important, these patients 
need to be identified so that they 
may be more closely followed. 



REFERENCES 

Billroth T: General Surgen. Pathology and Therapeu- 
tics Additions bv S^inewaner Translated b\ Hacklev 
CK New York. NY: Applelon Century Crofts. 188'J. p 
76.V 

, Malmio K: Multiple pntnarv ijancer A clinical- 
statistical investigation based on 6.^0 cases. Ann Chir 
Gynaecol Fenn ISuppIl K I. 1959. 
Rappin Gaz med de nantes .August 15. 1928. Abstr by 
Cancer Renew 4 .124. 1929 

V^a^Ten S. Ehrenreich T: Multiple ptimai^ malignant 
tumors and susceptibility to cancer Cancer Res 4: 554. 
1944 

Warren S. Gates (): Multiple pnmary malignant tumors: 
A survey of the literature and a statistical study .Am J 
Cancer 16: 1.158. 1932 

Werthamer S. Jabush M. Schulman J: Multiple primary 
malignancies JAMA 175- 558. 1961 
Haddov. Al. Boyd JF Multiple pnmary neoplasms in 
the western hospital region Scotland A survey based on 
cancer registration data. Scot Med J 17: 143. 1972. 

. Pickren JW: Cancer often stnkes twice. New York J 
Med 63 95. 1963 

Bomnan R; Statistik und Cauistik uber 290 hislologisch 
unlersuchte Hautcarcmome. Deutsche Ztschr fChir 76: 
404. 1905 

Gocxiner J. Watson W: Cancer of the esophagus; Its 
association with other pnmary cancers. Cancer 9: 1248. 
1956 

Mohamadi The incidence of multiple pnmary malig- 
nant neoplasms .A study of 10.990 cancer patients from 
the Grace Hospital Grace Hosp Bull 4>K2y 90. 1970 
Stalker l,K. Phillips RB. Pembenon J dej Multiple 



pnmatv malignant lesions Surg Gynecol Obstet 68: 
S95. 19'39 
1 1 Hankin FR Multiple pnmary carcinomas. Am J Cancer 
15: 2(K)1. 1931 

14 BugherJC Probability of chance occurrence of multiple 
malignant neoplasms. Am J Cancer 21: 809, 1934. 

15 Burke M Multiple pnmary cancers. Am J Cancer 27: 
316. 1936 

16 Hun HH. Brodero AC Multiple pnmary malignant 
neoplasms J Lab Clin Med 18: 765, 1933. 

17 LeraianRI. HutterRP. WhitmoreWF: Papillomaof the 
unnary bladder Lancer 25: 333. 1970. 

18 .Aird I. Bentall HH Relationship between cancer of the 
stomach and AB( l blood groups Br Med J 1 : 799. 1953. 

19. Fadhli H.A. Dominquez R .ABO blood groups and mul- 
tiple cancers JAMA 185: 757. 1963 

20 Holley Kt. Taswell HF. Moertel CG ABO and Rh (01 
blood types in patients with multiple pnmary cancers. 
JAMA 198: 1297. 1966 

21 Tsukada Y. Moore RH. Bross IDJ. Pickren J W. Cohen 
E: Blood groups in patients with multiple cancers. 
Cancer 17: 1229. 1964 

22 Dellon AT. Chretien PB. Potvin C, Nicholas R Jr: Mul- 
tiple pnmary malignant neoplasms. A search for an 
immunogenetic basis .Arch Surg 110: 156. 1975. 

23 Goldstein AF. Rubin SW Multiple pnmary neoplasms: 
A summary of the literature and repon of a case of four 
pnmarv neoplasms with complete autopsy findings. 
Bull .Sch Med L'niv Maryland 32 140. 1948. 

24 Lockan-Mummery HE. Heald RJ. Chir M: Melachro- 
nouscancerof the large intestine Dis Colon Rectum 15: 
261, 1972 

25 Willis RA: Further studies on the mode of origin of 
carcinomas of the skin Cancer Res 5 469, 1945, 

26 Kilgore .ARJ: The incidence of cancer in the second 
breast after removal of one breast for cancer J.AM A 77: 
454. 1921 

27 Hombait H. MollerJ: Multiple tumors Report of a case 
with five histologi ally different neoplasms Dan Med 
Bull 11 67. 1964 

28 Hamilton JB. Gilbert J B: Studies in malignant tumors of 
the testis IV bilateral testicular cancer, incidence, na- 
ture and beanngsupon management of the patient with a 
single testicular cancer (.ancer Res 2 125. 1942 

29 Ryan RE, McDonald JR. Clagetl OT Histopathologic 
observations on bronchial epithelium with special refer- 
ence to carcinoma of the lung J Thorac Surg 33: 264, 
1957. 

30. Goetze O Bemerkungen uber multlplizitat primarer 
carcinome in aniehnung an einer fall von dreifachem 
carcinom. Z Krebsforsch 13: 281. 1913 

31 Lauda F Muttergewebe ausgehender pnmarkarzinome 
des verdauungstraktes Wien Med Wochenschr 75: 
1890. 1925 

32 McKee Jr WP. Cox EC Pnmary carcinoma multiplex: 
Repi^n ot a case of four simultaneously occurring pn- 
mary carcinomas Cancer 20: 1723, 1967. 

33 Yamasaki M. Higuchi M An autopsy case of synchro- 
nous quadruple cancer Strahlentherapie 140:275, 1970. 



Equally astonishing and unaccountable is the degree of timidity, terror, incapacity, or \y hate ver other 
magic-like spell it is, vy hich annihilates, for a time, the whole energ\ of the mind, and renders the victim 
of dyspepsia afraid of his oun shadow — or of things more unsubstantial (if possible) than shadows! It is 
not likely that the great men of this earth should be exempt from these visitations, any more than the lit- 
tle, and if so, ue may reasonably conclude, that there are other things besides CONSCIENCH. which 
"make cov\ards of us all" — and that, by a temporary gastric derangement, many an enterprise of "vast 
pith and moment" has had its "current turned awry." and "lost the name of action," The philosopher 
and the metaphysician, who know but little of these reciprocities of mind and matter, have drawn many a 
false conclusion from, and erected many a baseless hypothesis on, the actions of men. Many a happy and 
lucky thought has sprung from an empty stomach! Many an important undertaking has been ruined by a 
bit of undigested pickle — many a well-laid scheme has failed in execution from a drop of green bile — 
many a terrible and merciless edict has gone forth in consequence of an irritated gastric nerve! — An 
Essay on Indigestion: or Morbid Sensibility of the Stomach & Bowels. James Johnson, 1836. pp 31-32, 



May 1976, NCMJ 



245 



Microsurgical Composite Tissue Transplantation: 
A new horizon in plastic and reconstructive surgeryj /; 



Donald Serafin, M.D., and Nicholas G. Georgiade, M.D. 



THROUGHOUT the ages exten- 
sive soft tissue defects and 
losses have encouraged surgeons to 
find better methods for wound 
coverage. Local cheek flap recon- 
struction of noses was described as 
early as 600 B.C. in the Sushruta 
Veda' of India. The surgery was 
performed by the Koomas caste of 
potters to reconstruct noses ampu- 
tated for punishment. ^-^ 

The inadequacy of local tissues 
for flap reconstruction led to the 
concept of distant direct flap cover- 
age. The ravages of syphilis and 
dueling injuries of the 16th Century 
prompted Tagliacozzi^"' in 1597 to 
describe a method of total nose re- 
construction using the arm flap. 

Filatov'' in 1917 introduced the 
concept of the tubed pedicle flap. 
This concept was later popularized 
by Gillies'"'' and the idea grew to 
include the movement of large 
amounts of distant composite tissue 
on an intermediate forearm carrier 
to its new location. Moving large 
blocks of tissue required multiple 
stages and often left a significant 
secondary deformity of the flap 
donor site. 



Division of Plastic and Reconstructive Surgery 
Duke University Medical Center 
Durham. North Carolina 27710 

Presented in part to the 121st Annual Session of the North 
Carolina Medical Societv. Pinehurst Hotel and Countrv 
Club. May 1-4. 1975. 

Repnnt requests to Dr. Serafin. 



246 



McGregor in 1972'" is credited 
with making the distinction between 
an axial pattern and a random pat- 
tern flap. McGregor and Jack- 
son"'- noted that the presence of a 
predictable vascular pattern within 
a flap permits it to be raised and 
transferred without delay despite a 
significantly increased length- 
breadth ratio. 

The introduction of microsurgical 
technique by Jacobson and 
Suarez'^ in 1960 began the era of 
replantation. Digital vessels with an 
external diameter of I.O mm could 
be anastomosed with predicted pa- 
tency rates. '^"'^ Due to experience 
gained in replantation efforts and in 
the experimental laboratory, trans- 
plantation of composite tissue be- 
came a clinical reality in 1973.'" 
Since the first report by Daniel, 
other series have demonstrated an 
awakening interest. '*■"' 

CASE REPORT 

A 50-year-old man was admitted 
to the Division of Plastic and Re- 
constructive Surgery at Duke Uni- 
versity Medical Center for treat- 
ment of a close-range shotgun blast 
to the left side of his face. He un- 
derwent initial debridement of the 
extensive soft tissue injury with 
open reduction and fixation of left 
hemimandible, tracheostomy and 



cervical esophagostomy (Figure 1). 
The postoperative course was com- 
plicated by meningitis and diabetes 
insipidis which were treated 
nonoperatively with resolution of 
symptoms. 

Thirteen days later a free compos- 
ite groin flap (Figure 2) was used to 
provide soft tissue coverage to the 
left side of his face (Figure 4). The 
posterior or intra-oral portion was 
resurfaced with a split thickness 




Fig. 1. Status five days after shotgun wound 
left liemiface, debridement and open reduc- 
tion mandible. 



Vol. 37, No. 5 




A, 






i«; 








Fig. 2. Groin flap dissected from surrounding Fig. 3. Composite tissue transplantation com- Fig. 4. Approximately two weeks post compos- 
tissue preserving vascular attachment. plete with split thickness graft to resurface ite tissue transplantation. 

intra-oral portion of flap. 



graft (Figure 3). The superficial cir- 
cumflex iliac artery and vein were 
anastomosed to the external facial 
artery and vein which had not been 
damaged. The postoperative course 
was uncomplicated (Figure 5). 

Reconstruction of extensive tis- 
sue defects can now be ac- 
complished in a single operative 
procedure, without lengthy delays 
or multiple hospitalizations and 
with no significant deformity of the 
donor site. The groin flap is most 
frequently used since the ensuing 
defect can be concealed in the ""bi- 
kini line."^" 

A two-team approach is em- 
ployed. One team dissects out the 
groin flap and maintains its viability 
on the blood supply, the superficial 
circumflex iliac artery and vein. The 
other team prepares the recipient 
bed, locating and isolating the recip- 
ient vasculature. When all is in 
readiness the donor flap is sepa- 
rated and transferred to its recipient 
area. The artery and vein (1.0-3.0 
mm external diameter) are meticul- 
ously approximated using the 
Week* operating diploscope (16X 
magnification). Interrupted 10-0 
Ethicon'i" suture on a BV6 needle is 
used in the anastomosis; four to six 



•Edward Week & Co. . Inc.. 49033 3 1 st Place, Long Island 
City, New York 

tEthicon, Inc., Sommerville. New Jersey 08876 



sutures are placed in the artery and 
six to eight in the vein. The opera- 
tive procedure, which takes about 
11 hours, completes the major re- 
constructive attempt. 

Twenty-nine such procedures 
have been done at Duke to recon- 
struct areas of extensive tissue loss 
in the head, neck and extremities. 
Twenty-one cases have been com- 
pletely successful, three have been 
partially successful (flap surviving 
at least 50 percent) and five have 
failed. In unsuccessful cases, the 




V ^/- 



Fig. 5. Approximately one year after compos- 
ite tissue transplantation and flap insetting. 



older, longer method of staged flap 
transfer can still be employed. 

Two factors directly influence the 
success of microsurgical composite 
tissue transplantation: The quality 
of the recipient vasculature and the 
technical expertise of the surgeon 
performing the anastomosis. 

With increased experience, 
operative time should be signifi- 
cantly reduced. 

SUMMARY 

Microsurgical composite tissue 
transplantation is routinely em- 
ployed for the immediate recon- 
struction of extensive tissue de- 
fects. Nineteen patients with ex- 
tremity defects have had the benefit 
of this procedure and avoided pro- 
longed and expensive hospitaliza- 
tions and multiple operations. Ten 
patients with bone and soft tissue 
loss in the region of the head and 
neck have also been operated upon 
with this method. 

Refinement of microsurgical 
technique and flap viability studies 
are continuing in our microvascular 
laboratory and new applications of 
the technique are being explored 
both experimentally and clinically. 

References 

1. Sushnila: English translation of the Sushruta Samhita 
based on the onginal Sansknt text Edited and pub- 
lished by Kavirai Kunja Lai Bhishagratna Bose, Cal- 
cutta, l'J07.|'il6, 

2 McDowell F, Valoue JA, Brown JB: Bibliography and 



May 1976, NCMJ 



247 



historical note on plastic surgery of the nose Plast Re- 9. 
constr Surg 10: 149. 1952. 

3. Millard DR: Total reconstructive rhinoplasty Plast Re- 10. 
constr Surg 37: 167. 1966, 

4. Tagliacozzi G: De Curturum Chirurgia per Insitiontm 
Gasper Bindonus. Jr. Venice, \597. II. 

5 Gnudi M, Webster JP: The Life and Times of Gaspare 

Tagliacozzi Herbert Reichner. New York. 1950- |2. 

6. Filatov VP: Plastic procedure using a round pedicle (in 
Russian). Vestnik Oftalmologii 34(405): 149- 158 ( ApnI. 13 
May) 1917 (Translated Lubunka M. Gnudi MT, Web- 
ster JP: Surgical Clinics of North Amenca 39: 277. 14. 
1959) 

7. Gillies HD: The tubed pedicle in plastic surgery New 
York Med J 111: 1. 1920. 15. 

8. Gillies HD: Plastic surgery of facial burns Surg 
Gynecol Obstet 30: 121, 1920. 16 



Gillies HD: Plastic surgery of the face. London. Fronde, 
1920, 

McGregor lA: Fundamental Techniques of Plastic 17 
Surgery Fifth ed . Edinburgh and London: Churchill 
Livingslone, 1972, 

McGregor lA. Jackson IT: The extended role of the 
deltopectoral flap, Br J Plast Surg 23:173-185. 1970. 
McGregor lA. Jackson IT: The groin flap. Br J Plast 
Surg 25: 3-16, 1972, 19 

Jacobson JH. Suarez EL: Microsurgery in anastomosis 
of small vessels. Surg Forum II: 243, 1960 
Chen CW: Sixth Peoples Hospital Shanghai: Replanta- 
tion of severed fingers Clinical expenences on 162 20 
cases involving 270 severed fingers. (To be published t 
O'Bnen BM. MacLeod AM. Miller GDH: Clinical re- 
plantation of digits, Plast Reconstr Surg 52: 4SK). l'^73 
Klcincrt HK.KutzJE, Atasoy E.Neale HW.SerafinD: 



/ 

Replantation of non- viable digits: 10 years experience. J 
Bone Joint Surg (to he published) 
Daniel RK, Taylor Gl' Distant transfer of an island flapi 
by inicrovascular anastomosis Plast Reconstr Surg 52: 
III. 1973. 
8, Hani K, Kitaro <). Ohmori S: Successful clinical trans- 
fer of ten free flaps by inicrovascular anastomosis. Plast 
Reconstr Surg fi: 2.59, 1974. 

Serafin D. Villarreal-Rios A. Georgiade NG: Microsur- 
gical composite tissue transplantation: A reappraisal of 
fourteen patients. Plast Reconstr Surg (accepted for 
publication). 

Serafin D: Microsurgical composite tissue transplanta- 
tion: .An appraisal oj tiperative technique and approach, 
(to be published). 



The skin and its functions are very much affected in bilio-dyspeptic complaints. It is either di^ and 
constricted, or partially perspirable, with feelings of alternate chilliness and unpleasant heat, especially 
about the hands and feet. The skin, indeed, in these complaints, is remarkably altered from its natural 
condition; and the complexions of both males and females are so completely changed, that the patients 
themselves are constantly reminded, by their mirrors, of the derangement in the digestive organs. The 
intimate sympathy between the external surface of the body and the stomach, liver and alimentary canal, 
is now universally admitted, and explains the reciprocal influence of the one on the other. Many of the 
remote causes, indeed, of indigestion and liver-affection will be found to have made their way through 
the cutaneous surface. On the other hand, the great majority of those eruptions on the skin, which 
disfigure the countenance and cause so much irritation and suffering in various parts of the body, are now 
clearly traced to disorder in the stomach and bowels. The purely local treatment of these cutaneous 
affections, by external applications, is generally ineffectual; whereas a restoration of healthy function in 
the digestive organs, is almost sure to remove them, with the aid of a very few outward applications, — 
A,^ Essa\ on Indigestion: or Morbid Sensibility of the Stomach & Bowels. James Johnson, 1836. 
pp 33-34, 



248 



Vol. 37, No. 5 



Cardiopulmonary Resuscitation (CPR) as 
Treatment of Cardiac Arrest 



INTRODUCTION 

(First of three articles) 

James T. McRae, M.D. 



MYOCARDIAL infarction oc- 
curs in a million Americans 
each year. Of these. 650,000 die, 
350,000 of them before they reach a 
hospital.' Most of the deaths out- 
side the hospital occur within two to 
four hours after onset of symptoms, 
many within the first 15 minutes. It 
is my belief, and that of others in the 
field of emergency medical care, 
that many of those who now die 
could be saved by prompt response 
of patients to warning symptoms 
and prompt action by trained per- 
sonnel who can keep the victim 
alive until definitive care is avail- 
able. Such efforts are termed life 
support or cardiopulmonary resus- 
citation (CPR). The same resuscita- 
tive techniques are useful in the 
early stages of both primary respira- 
tory arrest and primary cardiac ar- 
rest. Both disorders have several 
causes and either, left untreated, 
leads quickly to the other. 

Three pathophysiological types 
of cardiac arrest lead to sudden 
death unless treated early and ag- 
gressively: ventricular asystole or 
cardiac standstill: ventricular fibril- 
lation; and electromechanical dis- 



Assistanl Professor 

Section on Emergency Medical Services 

Department of Surger> 

Bowman Gray School of Medicine 

Winston-Salem. North CaroUna 27103 

* Available from local Amencan Heart Association ofTices 



May 1976, NCMJ 



sociation, formerly called profound 
cardiovascular collapse. 

The two levels of cardiopulmo- 
nary resuscitation are basic and ad- 
vanced. Basic CPR is administered 
by a trained person at the site of the 
victim's collapse without any 
equipment or drugs. It is sufficient 
to maintain life in a person with ar- 
rested breathing or cardiac arrest. 
Basic CPR includes artificial respi- 
ration by a mouth-to-mouth tech- 
nique and, if needed, external car- 
diac massage. Advanced CPR is 
practiced by persons trained in the 
use of emergency medical equip- 
ment and may be done at the site of 
the victim's collapse, en route to a 
hospital or in the hospital. It adds to 
basic CPR the techniques of in- 
travenous infusion, drug therapy, 
isolation of the airway by endo- 
tracheal intubation, ventilation with 
oxygen in high concentrations, 
monitoring and treatment of cardiac 
arrhythmias, and defibrillation if 
needed. 

Both basic and advanced CPR 
training have been standardized by 
the American Heart Association 
and the National Research Council 
of the National Academy of Sci- 
ences. The American Medical As- 
sociation published the first stan- 
dardized CPR instructions in 1974 
as a supplement to the association's 
journal.'* 

The American Heart Association 
offers courses in CPR to physicians 
at national medical meetings. The 
physicians are asked to return to 
their communities and help train 
other instructors, who, in turn, can 
teach others, both laymen and 



physicians. The American Medical 
Association is offering similar 
courses to professionals and the 
American National Red Cross is 
giving courses to the lay public. 
Changes in technique are incorpo- 
rated into the training as new infor- 
mation and experience dictate. 

The success of such training de- 
pends on strict adherence to the 
standardized training procedure, 
close rapport between the Ameri- 
can Heart Association and the in- 
structors at all levels, recognition of 
the American Heart Association's 
authority in this area and the will- 
ingness of physicians to refresh 
their skills in CPR. 

This article is the first of three 
dealing with basic and advanced 
CPR. The series provides an over- 
view of the problem; it is not meant 
to be a substitute for a refresher 
course. It is intended for all in the 
medical profession who might be 
called upon to carry out CPR and is 
written with more than one level of 
education and training in mind. 

CPR is primarily for the preven- 
tion of sudden, unexpected death. 
The emphasis in these articles will 
be on resuscitation of the patient 
with cardiac arrest from myocardial 
infarction since that disease is the 
major cause of cardiac arrest in our 
society. Resuscitation of children 
and of adults with cardiac arrest 
from causes other than myocardial 
infarction will be mentioned where 
pertinent. 



REFERENCE 

Standards for C ardiopulmonary Resuscitation (CPR ) and 
Emergency Cardiac Care (ECC) JAMA 227 (Supple- 
ment): 833-868, l')74 



249 



Editorials 



HUMAN TISSUE DONATIONS 

Pursuant to a study authorized by the 1973 North 
Carohna General Assembly, the Legislative Research 
Commission in 1974 conducted a study of human 
tissue donation. Key testimony was heard from med- 
ical schools at Duke, Bowman Gray and UNC, the 
North Carolina Medical Society, the Department of 
Human Resources, the Department of Transportation 
and Highway Safety, and voluntary agencies such as 
the North Carolina Eye and Human Tissue Bank and 
the Kidney Foundation of North Carolina. 

The Legislative Research Commission found that 
despite the efforts of groups involved in procuring and 
transplanting human tissue , there is still a critical need 
within the state for more donations of human tissue. 
The commission further found that the need for such 
tissue will continue to expand in the foreseeable fu- 
ture. Citing the lack of coordinated efforts between 
the various groups interested in the area of human 
tissue utilization and the restrictive classification of 
individuals permitted by statute to enucleate eyes, the 
commission made several recommendations to the 
1975 General Assembly: 

1. Establishment of a coordinated human tissue 
program within the Department of Human Re- 
sources. 

2. Establishment of a Human Tissue Advisory 
Council to the Department of Human Resources 
comprised of representatives of all agencies and 
groups in the state involved with the acquisition 
and distribution of human tissues. 

3. Amendment of the Uniform Anatomical Gift Act 
to allow groups such as physicians assistants, 
licensed practical nurses, registered nurses and 
third- and fourth-year medical students to enu- 
cleate eyes. 

Last June 16, the General Assembly ratified House 
Bill 68 entitled, "An Act to Establish A Coordinated 
Human Tissue Donation Program . ' ' This bill amended 
Chapter 130 of the General Statutes at 130-235.1-3. 
The bill mandated the establishment of a human tissue 
program within the Department of Human Resources 
and an advisory council to the Human Tissue Pro- 
gram, and provided $50,000 to establish and conduct 
the program during the 1976-77 fiscal year. 

The human tissue bill also calls for the support and 
cooperation of other departments and agencies of the 
state, as well as public and private groups, with the 
Department of Human Resources. To this end, activ- 
ity has already begun. Even before actual funding 



250 



begins on July 1, the Drivers License Division of the 
Department of Motor Vehicles has begun distributing 
an organ donor brochure along with drivers license 
renewal notices sent to each licensed driver every four 
years. Every month approximately 70,000 citizens 
will receive an organ donor brochure along with their 
license renewal notices. Thus over a four-year period 
almost every adult in North Carolina will at least be 
apprised of the need for organ donors and have the 
opportunity to sign and carry a donor card. The 
brochure features an "Organ Donor" sticker which 
may be affixed to the reverse of the drivers license. 
This will serve as notice to emergency or hospital 
personnel that an individual has expressed a prefer- 
ence to donate tissue for transplantation after death. 
The Uniform Donor Card, signed and witnessed by 
two persons, is a legal will and is recognized by all 50 
states. 

The first meeting of the Human Tissue Advisory 
Council created by the new legislation was in Raleigh 
on February 18. The council will advise and make 
recommendations to the Secretary of Human Re- 
sources relating to the establishment and conduct of 
the Coordinated Program for Human Tissue Dona- 
tions. Perhaps input from this new and innovative 
program will decrease the deficit between tissue 
needed for transplantation and that available. Cer- 
tainly needs for transplanting tissue such as cornea 
and kidney are as yet unmet, although our techniques 
for transplanting them are quite advanced. Education 
to convince the public to become donors after death 
must go hand in hand with vigorous efforts to educate 
medical professionals to use the donors who are avail- 
able. Efforts such as this will mean the gift of life or 
sight to many who must now wait or die. 

Charles D. Lee 

Executive Director 

Kidney Foundation of North Carolina 

DOWN HOME 

Country Ham 

Southerners, particularly conservative Southerners 
and even more particularly conservative Southern 
Republicans, in public office or out, make light of 
government as an institution for human betterment 
and even tend to blame it for many of our ills. So it 
comes as something of a shock to learn that Sen. Jesse 
Helms (R-N.C.) has entered the lexicographic lists at 
the Department of Agriculture in Washington in an 
effort to get government to tell us what country ham is. 

Vol. 37, No. 5 



It seem 

Werna' 
J 
It 
iieiiii' 
t'cren'i 
ttretk 
tiignwi 
Icwal 
atiablt 
Soil 
touldn 
jays.! 
wliiius 
itieirp' 
iolerei 
iheOI 
Wasliii 
peaks 



urged 
accord 
19751, 
secreii 



Jireni 
Sen 



Prcsid 



liesrr 



Ont 



:;neri 

■jvel 
|*^ewl 

!':ose 
'iai( 
iioygl 



lajle: 



It seems that small Carolina country ham producers 
got upset in 1971 when big business in the form of 
International Telephone and Telegraph Corp., Es- 
mark. Inc., and Smithfield Foods, Inc.. brought its 
talent to the hog and asked the Agriculture Depart- 
ment to spell out what a country ham is, as if taste 
weren't the best test. Obviously the small producers 
were threatened by the big boys and were fearful that 
big money and a uniform product would drive them to 
the wall and deprive us connoisseurs of great pleasure 
at table. 

So the department proposed that a country ham 
couldn't be a country ham unless it had been aged 140 
days. This ruling didn't sit well with Virginia curers 
who use higher temperatures for as few as 55 days in 
their processing. So Rep. Robert Daniel of Virginia 
entered the linguistic tournament as the champion of 
the Old Dominion definition of country ham. 
Washington, caught in the slough between Virginia's 
peaks and North Carolina's valleys, retreated and 
withdrew the regulation. A declaration in 1972 pro- 
voked the disputants again so the department again 
turned tail. 

But late last year. North Carolina processors 
urged their champion to sally forth. So Sen. Helms, 
according to the Wall Street Journal (December 12. 
1975), asked Secretary Earl Butz to help out. The 
secretary, probably happy to be dealing with a conti- 
nental problem rather than with Russians and wheat, 
issued a call for recipes and got 200 from six states. 
After due deliberation, a ham then became a country 
ham if it were cured for at least 70 days at a tempera- 
ture no greater than 95 degrees Fahrenheit. 

Sen. Helms' constituency is pleased even though 
country ham can now be urban or rural country ham so 
long as the 70:95 formula holds. But the Mother of 
Presidents is unhappy; Rep. Daniel suggests that the 
Department of Agriculture is siding with the Tar Heel 
state. Let us hope that whatever the ultimate formula, 
the small producers will survive and even multiply to 
the greatest good of those of us who like to define 
country ham by our own fashions. 

One group of consumers must, however, feel left 
out of such delicate deliberations: those forced to eat 
no salt because of high blood pressure or heart failure. 
What are their wishes? The relationship between salt, 
hog meat and hypertension in the South is an old and 
generally honorable one. We Southerners do tend to 
salt our food before tasting and to be more likely to 
have high blood pressure, be we black or white, than 
New Englanders, Midwestemersandthe remainder of 
those unfortunate enough to be unconcerned with 
what country ham is. It is an established folk remedy 
though to leave off hog meat when hypertension is 
diagnosed, a practice preceding the appreciation of 
sodium's role in the development of hypertension. 

As usual, there is more to the urge for salt than we 
might think because high salt intake, particularly early 
in life, may be a factor leading to hypertension later. If 
this is so, a recent report' that young blacks require 
higher concentrations of salt than young whites for 



satisfactory taste suggests that we also need a low or 
no-salt country ham for those forbidden the current 
products whether Carolinian or Virginian. 

Chestnut Blight 

While we are on the subject of ham, it is worth 
recalling the great chestnut forests of North America. 
In the North Carolina mountains, these trees provided 
timber, shade, warmth and even mast for hogs allowed 
to roam and scavenge for survival until the chestnut 
blight, caused by the fungus Endothia parasitica, 
stripped the slopes and left only bare trunks for fence 
rails. Although stumps continue to sprout, shoots no 
longer reach maturity and the search for a resistant 
hybrid has been no more successful than the struggle 
of the shoots. 

It now appears that some progress toward control- 
ling the blight is being made with the demonstration 
that the virulence of the fungus can be attenuated by 
transfer in tissue culture of a cytoplasmic determi- 
nant.- This determinant acts to limit host invasion and 
to induce hypovirulence of dangerous fungal strains. 
Since it has been shown in Europe that hypoviru- 
lence can control chestnut blight in nature, there is at 
last hope that the disease can be controlled in this 
country perhaps leading to the restoration of our 
chestnut forests. 



1. Desor JA. Greene LS. Mailer O: Science IW: 686. I'JT.s 

2. Van Alfen NK. Jaynes RA. Anagnoslakis SL. Day PR: Science 189: 890. 1975 



TALKING BACK: AN EDITORIAL BOOK REVIEW 

Medicine as a social institution has survived its 
association with magic, its flirtation with astrology 
and its capture by the church in the Middle Ages 
because its ultimate concern has always been the 
well-being of the patient. But social institutions tend 
toward inertia, become bound to ritual and offer rich 
material for humorists and satirists and challenges to 
legislators intent on many things at once. The doctor 
occupies a dangerous position — he seems to preside 
over life and death — and sometimes yields to the 
temptations to speak too authoritatively. When he 
escapes such traps, he can become one with doctors 
described in one of Whitehead's dialogues with Price. ' 

W - "One of the most advanced types of human 
beings on earth today is the good American doctor." 

P - "Because in him science is devoted to the relief 
of suffering?" 

W - "I would place it on more general grounds: he 
is sceptical toward the data of his own profession, 
welcomes discoveries which upset his previous 
hypotheses, and is still animated by humane sympathy 
and understanding." 

At othertimes, frustrated by his culture, his patients 
or his colleagues, he may have trouble maintaining 
such an advanced position and retreat to negativism, 
defend the status quo or erupt into polemics. And 
most polemicists do indeed have something to say if 
their audience can be sufficiently sceptical and selec- 
five in the listening. 



May 1976. NCMJ 



251 



Medicine, the institution, the art and the science, 
then is constantly being remolded from within and 
from without — in response to our own impulses and 
compulsions and to increasing concern by patients 
about what medical care is. We deal with the sick, the 
wistful well and that intangible called public health. 
And we are faced with rising demands and shrinking 
resources; health expenditures accounted for 8.3 per- 
cent of the gross national product in 1975, an increase 
of 14 percent over 1974. 

Onto this scene steps a physician with a book with 
the imperative title Talk Back to Your Doctor. How to 
Demand (& Recognize) High Quality Health Care* 
which has been cited with approval by a New York 
Times reporter in his midwinter expose of things med- 
ical. Since this editorial reviewer does not have Dr. 
Levin as his physician, I am in no position to talk back 
to him about the quality of his book. If I were, I would 
congratulate him in recognizing that patients teach 
doctors and doctors instruct patients and in being 
aware that when this relationship is not well- 
developed, quality of care is inadequate. I would 
suggest, however, that he seems to lose his vision as 
he becomes bewitched with the trappings of technol- 
ogy and prestige; he offers us the cookbook of routine 
laboratory tests, the uncertain values of screening and 
the big city teaching hospital urging the "sophisticated 
health consumer" to seek the outpatient department 
of medical school hospitals where chances for con- 
tinuity of care — person to person — are often slim 
indeed. He cites favorably the Ladies Home Journal 
list of outstanding hospitals, published in 1967, but 
fails to note how the adequacy of medical care can be 
evaluated in terms of its animation "by humane sym- 
pathy and understanding," an inconsistency I would 
ask him to clarify. 

If restoration of trust between doctor and patient is 
one answer to some of our current problems. Dr. 
Levin hasn't been very helpful because he doesn't 
really outline the proper way for the patient to talk 
with his physician; he is more concerned about the 
patient as adversary, talking back. That is too bad; a 
really good book about the educational nature of the 
doctor-patient relationship is a must and Dr. Levin has 
offered a lot of valuable data. But seriousness and 
sincerity often lead to excess and excess to errors as 
on pages 28 and 85 where our author advises us to treat 
hypoparathyroidism with parathyroid hormone. How 
can this be considered "High Quality Care?" 

What all of us as physicians must avoid is behaving 
like Edward Lear's Jumblies who 

"went to sea in a sieve, they did 
and each of them said "How wise we are!" 
Yet we never can think we were rash or wrong 
while round in our sieve we spin." 

John H. Felts, M.D. 

REFERENCES 

1. Dialoguesof Alfred North Whitehead as Recorded by LucienPnce New York: Mentor 
Books. 1956, p 136. 



* Talk Back lo Your Doctor Hon lo Demand lA Recof^nizc) High Qualitv Hcatlh Cart- 
Arthur Levin, MD 245 pages Pnce, $7,95. Garden City, New York: Doubleday & 
Company, Inc., 1975. 



BRIEF SUMMARY OF 
PRESCRIBING INFORMATION 
ANTIMINTH • (pyrantel pamoate) 
ORAL SUSPENSION 

Actions. Antimmth (pyrantel pamoate) has 
deiTionstroted anthelmintic activity against 
Enterobius vermiculans (pinworm) and As- 
cans lumbncoides (roundworm). The anthel- 
mintic action IS probably due to the neuro- 
muscular blocking property of the drug, 

Antiminth is partially absorbed after an oral 
dose. Plasma levels of unchanged drug are 
low. Peak levels (0,05-0, IS/xg/ml) are reached 
in 1-3 hours. Quantities greater than 50% of 
administered drug are excreted in feces as 
the unchanged form, whereas only 7% or less 
of the dose is found in urine as the unchanged 
form of the drug and its metabolites. 
Indications. For the treatment of ascariasis 
(roundworm infection) and enterobiasis (pin- 
worm infection). 

Warnings. Usage m Pregnancy: Reproduction 
studies have been performed in animals and 
there was no evidence of propensity for harm 
to the fetus. The relevance to the human is not 
known. 

There is no experience in pregnant women 
who have received this drug. 

The drug has not been extensively studied 
in children under two years; therefore, in the 
treatment of children under the age of two 
years, the relative benefit/risk should be con- 
sidered. 

Precautions. Minor transient elevations of 
SGOT have occurred in a small percentage of 
patients. Therefore, this drug should be used 
with caution m patients with preexisting liver 
dysfunction. 

Adverse Reactions. The most frequently en- 
countered adverse reactions are related to the 
gastrointestinal system. 

Gastrointestinal and hepatic reactions: an- 
orexia, nausea, vomiting, gastralgia, abdomi- 
nal cramps, diarrhea and tenesmus, transient 
elevation of SGOT, 

CNS reactions: headache, dizziness, drowsi- 
ness, and insomnia. Skin reactions: rashes. 
Dosage and Administration. Children and 
Adults: Antimmth Oral Suspension (50 mg of 
pyrantel base/ml) should be administered in a 
single dose of II mg of pyrantel base per kg 
of body weight (or 5 mg/lb.); maximum total 
dose I gram. This corresponds to a simplified 
dosage regimen of 1 ml of Antimmth per 10 lb. 
of body weight, (One teaspoonful=5 ml) 

Antimmth (pyrantel pamoate) Oral Suspen- 
sion may be administered without regard to 
ingestion of food or time of day, and purging 
is not necessary prior to, during, or after ther- 
apy. It may be taken with milk or fruit juices. 
How Supplied. Antimmth Oral Suspension is 
available as a pleasant tasting caramel- 
flavored suspension which contains the equiv- 
alent of 50 mg pyrantel base per ml, supplied 
in 60 ml bottles and Unitcups™ of 5 ml in pack- 
ages of 



t 



ROeRIG <SS» 

A division of Pfizer Pharmaceuticals 
New York, New York 10017 



252 



Vol, 37. No, 5 



y 






eliminates Pinworms and Roundworms with a single dose 



■ Single dose effectiveness against 
both pinworms and roundworms— 

The only smgle-dose anthelmintic effective 
against pinworms and roundworms. 

■ Nonstaining— to oral mucosa, 
stomach contents, stools, clothing or linen. 

■ Well tolerated - the most frequently 
encountered adverse reactions are related 
to the gastrointestinal tract. 



■ Economical — a single prescription 
will treat the whole family. 

■ Highly acceptable — pleasant tasting 
caramel flavor. 

■ Convenient -just 1 tsp. for every 

50 lbs. of body weight. May be taken with- 
out regard to meals ROGRIG <S& 
or time of dav i>-^>^i "^i- -■^j^t^ 

wi Liiiicr wi vj.vj.y . A division or Ptizer Pharmaceuticals 

New York, New York 10017 
Please see prescribing tnlormation on lacing p^ge. NSN 6505-00- 148-6967 



Antiminth 



(pyrantel pamoate) 



OR.XL 
SUSPENSION 



■quivalent to5()mji pyrantel/ml 



Correspondence 



s 



INSECT BITES 

To the Editor: 

Again this year I am compiling a biting insect sum- 
mary and would appreciate any case reports of un- 
usual allergic reactions, especially systemic reactions 
(sneezing, wheezing, urticaria) to bites of insects such 
as mosquitoes, fleas, gnats, kissing bugs, bedbugs, 
chiggers, black flies, horseflies, sandflies and deer- 
flies. 

I would like physicians to send me case reports 
covering the types of reactions (immediate and de- 
layed symptoms), treatments, the age, sex, and race of 



the patient, the site of the bite(s), the season of the 
year, and other associated allergies. 

If skin tests and hyposensitization were instituted, I 
would like reports of both. Please note that it is the 
biting (not stinging) insect in which I am interested. 

If you have found any insect repellent, local treat- 
ment, or insecticides of value, I would also appreciate 
knowing about it. 

Please send this information to: 

Claude A. Frazier, M.D. 

4-C Doctors Park 

Asheville, North Carolina 28801 



■4 



f 



Bulletin Board 



NEW MEMBERS 

of the State Society 



Mi. Shamshad, MD (PD), Ste. B, 402 Fleming Ave., Marion, NC 

28752 
Anderson, Philip Allan, MD (FP), 1601 Owen Dr., Fayetteville 

28304 
Aplington, James Page, MD (ORS), 1311 N. Elm St., Greensboro 

2740! 
Banfield, William John, MD (GE), 1109 Windemere Dr., Wilson 

27893 
Bouzigard, Ray Joseph, MD (R), 2000 Greenbriar Rd.. Kinston 

28501 
Bradford, Arthur Louis, MD(FP), 507 N. Wilkinson Dr., St. Pauls 

28384 
Byrum, James Edwin, Jr.. MD (EM), 115 Staffordshire Ct., 

Winston-Salem 27103 
Caceres, Marco Antonio. MD (GS), 804 Quail Court. Roanoke 

Rapids 27870 
Clonmger, Timothy Earl. MD Craven Co. Hosp., New Bern 28560 
Cox. Stanley Cullen, 111. MD (OTO). 205 Crest Rd. Southern Pines 

28374 
Crowder, Herman Redditt. 111. MD (AN), 97 Union St., N.. Con- 
cord 28025 
Dioquino. Renato Mercado. MD (IM). 240 Morgan St.. Marion 

28752 
Drake, Wilton Rodwell, Jr., MD (FP), Vance Medical Arts Ctr., 

Henderson 27536 
Dupuy, David Norris, MD (ORS), 1708 Sterling Rd.. Charlotte 

28209 



Hamilton. George Edward. Jr.. MD (P). 908 Arbor Rd.. Winston- 
Salem 27103 
Hamrick, John Carl, Jr., MD (ORS). 809 N. Lafayette St.. Shelby 

28150 
Henley. Thomas Franklin, MD (OBG), 3109-1311 N. Elm St., 

Greensboro 27401 
Hoffman, Carl Maurice, MD (OBG), 307 Lindsay St., High Point 

27262 
Hooks, William Borden. Jr.. MD (FP). 731 N. Main St.. Mt. Airy 

27030 
Hucks-Follis. Anthony George. MD (NS). P.O. Box 2000, 

Pinehurst 28374 
Hunt, William Bryce, MD (IM), 400 Edgehill Dr., New Bern 28560 
Joyner, Raymond Edward. MD (U). 1002 Rollingwood Dr.. Wilsom 

27893 
Kim. Kyoung-Hi Park, MD (PD), Kinston Clinic, Suite 5, Kinston! 

28501 ■ 

Lee. James Gary. MD (OTO). 104 E Northwood St., Greensboro: 

27401 

Lee, Ying-Huey. MD (GS). 824 S. Aspen St., Lincolnton 28092 I 
Long, Walter N, Jr., MD(FP), (RENEWAL) Box 756, Taylorsville" 

28681 
Mattox, James Dwight, Jr.. MD (P). 1546 Overbrook Ave., 

Winston-Salem 27104 
McCormick, Carolyn Brumm, MD(GP), 123 E. Broad St., St. Pauls 

28384 
Morris, Peter Joseph, (STUDENT). 110 Purefoy Rd., Chapel Hill 

27514 
Perry, Irvin Samuel, MD (IM), 4210 Tangle Lane, Winston-Salem 

27106 
Rao, Innanje R.. MD (CD), 1900 Randolph Rd., #416. Charlotte 

28207 I 

Royster, Henry Page, MD (PS), 1507 Canterbury Rd.. Raleigh! 

27608 
Russell, Joseph Dwight, MD(IM), 1904 Stafford Dr.. Wilson 27893 



1 



254 



Vol. 37, No. 5 i 



^-#<^^^^5fiJ 






L^^ 







Seagle, Michael Brent, MD (OTO). 2507 Neuse Blvd., New Bern 
28560 

Sheppeck, Michael Louis, MD (PN). 105 Anne St., Rutherfordton 
28139 

Shull, Lonnie Newell, Jr., MD (GS), 513 Norwood St., Lenoir 
28645 

Snyder, John Michael, MD (AN), 3224 Lazy Branch Road, Mat- 
thews 28105 

Walthall, Julius Byron, Jr. (STUDENT), 215 Nature Trail Park, 
Chapel Hill 27514 

Wang, Grena, MD (PD), 824 S. Aspen St., Lincolnton 28092 

Williams, Rhoderick Thomas, Jr.. MD (DRl, 108 Daniel Dr., 
Goldsboro 27530 



I: 



WHAT? WHEN? WHERE? 

In Continuing Education 



Please note: 1. The Continuing Medical Education Programs of 
the Bowman Gray, Duke and UNC Schoolsof Medicine are accred- 
ited by the American Medical Association. Therefore CME pro- 
grams sponsored or co-sponsored by these schools automatically 
qualify for AMA Category 1 credit toward the AMA Physician's 
Recognition Award, and for North Carolina Medical Society 
Category "A" credit. Where AAFP credit has been requested or 
obtained, this also is indicated. 

2. The "place " and "sponsor" are indicated for a program only 
when these differ from the place and source to write "for informa- 
tion." 

PROGRAMS IN NORTH CAROLINA 

June 4 

Cardiovascular Problems in the Aged 
Fee: $25; James M. Johnston awards available 
Credit: 6 CERP 

For Information: Ruth J. Hams, Assistant Professor, UNC-CH 
School of Nursing. Chapel Hill 27514 

June 17-19 

Mountain Assembly 

Place: Waynesville Country Club, Waynesville 
SfHDnsor: Haywood County Medical Society 
For Information: R. Stuart Roberson. M.D.. P.O. Box 307, Hazel- 
wood 28738 

June 22-24 

North Carolina Hospital Association Annual Meeting 
Place: Blockade Runner, Wnghtsville Beach 
For Information: Diane Turner, NCHA. P.O. Box 10937. Raleigh 
27605 

July 4-6 

Sixth Annual Sports Medicine Symposium 
Place: Blockade Runner Motor Hotel. Wnghtsville Beach 
Fee: $20; physician and spouse or guest $40 
For Information: Mr. Gene L. Sauls, North Carolina Medical Soci- 
ety, P.O. Box 27167, Raleigh 27611 

September 10-11 

Annual Meeting of the North Carolina Chapter of the American 
Academy of Pediatrics and The North Carolina Pediatric Society 

Place: Pinehurst Hotel. Pinehurst 

For Information: Mrs. John McLain. Executive Secretary, 3209 
Rugby Road, Durham 27707 

September 16-19 

Invitational Assembly for Advanced Urology: The Prostate 
Place: Pinehurst Hotel & Country Club, Pinehurst 
Fee: $135; registration is limited; pre-registration required 
Credit: 18 hours 

For Information: Ms. Virginia Jordan, Assembly Secretary, P.O. 
Box 3707, Duke University Medical Center, Durham 27710 

September 17-18 

6th Walter L. Thomas Symposium 

For Information: William Creasman. M.D.. P.O. Box 3079, Duke 
University Medical Center. Durham 27710 



256 



September 22-26 

North Carolina Medical Society Annual Committee Conclave 

Place: Mid-Pines Club, Southern Pines 

Regular meetings will be scheduled for the chairman and members 
of almost all regular committees of the Medical Society. Commit- 
tee members should plan to be present if at all possible. 

For Information: Mr. William N. Hilliard, Executive Director, 
North Carolina Medical Society, P.O. Box 27167, Raleigh 2761 1 

ITEMS OF SPECIAL INTEREST 

Courses In Ultrasound 

A senes of three ten-week postgraduate courses in Sonic Medicine 
at Bowman Gray School of Medicine w ill be offered on the follow- 
ing dates: September 27-December 3, 1976, January lO-March 18. 
1977, and April ll-June 17, 1977. These courses are designed to 
provide background, techniques, experience and knowledge so that 
the individual will be able to set up both an ultrasonic laboratory and 
a training program. Participants may attend the entire course or 
only those portions which are of interest to them. Enrollment is 
limited. Graduates receive 30 credit hours per week in Category I. 
The program will cover acoustics, instrumentation, scanning and 
applications to obstetncs. gynecology, ophthalmology, adult and 
pediatnc cardiology, the abdomen, the breast, radiation therapy 
planning, the urinary tract and the nervous system. 
For further information, please write to: James F. Martin, M.D., 
Director. Postgraduate Medical Sonics. Bowman Gray School of 
Medicine. Winston-Salem, North Carolina 27103. 

October 25-29 

New Concepts in General Radiology 

Place: Southampton Princess Hotel. Bermuda 

Fee: $250 

Credit: 25 hours 

Program: The scientific program will take place from 8:00 A.M. to 
1:00 P.M. each day. and will be organized around a disease 
oriented format. Subject areas and guest faculty who will address 
these include: chest — Robert Heitzman. M.D.. Syracuse. New 
York; gastro-intestinal tract — Roscoe H. Miller. M.D., In- 
dianapolis. Ind.; genito-unnary — John A. Evans. M.D.. New 
York. N.Y.; nuclear medicine — .Alexander Gottschalk. M.D., 
New Haven. Conn.; pediatnc radiology — J. Scott Dunbar, 
M.D.. Cincinnati. Ohio; skeletal system — Elias G. Theros. 
M.D.. Washington. DC. 

For Information: Robert McLelland. M.D.. Radiology-Box 3808. 
Duke University Medical Center. Durham 27710 

PROGRAMS IN CONTIGUOUS STATES 

Note: At the time for submitting copy for the May Journal the 
WHAT? WHEN7WHERE? editor had not received information on 
any continuing medical education programs which would take place 
in Georgia. South Carolina. Tennessee or Virginia during the period 
June 1976 through November 1976. 



The items listed in this column are for the six months immediately 
following the month of publication. Requests for listing should be 
received by WHAT'' WHEN'' WHERE''. P.O. Box 15249. 
Durham. N.C. 27704. by the 10th of the month prior to the month in 
which they are to appear. A "Request for Listing" form is available 
on request. 



AUXILIARY TO THE NORTH CAROLINA 
MEDICAL SOCIETY 



"Designed as an expeinence-oiiented teaching de- 
vice, the Hall of Health is one of the most sophisti- 
cated health education facilities in the Southeast . . ." 
This is how the brochure from the Mecklenburg 
County "Hall of Health" introduces its programs to 
the school classes throughout the area. Staffed by four 
health education teachers (three are registered nurses) 
and assisted by volunteers from the Mecklenburg 
Medical Auxiliary, the "Hall of Health" presents the 

Vol. 37. No. 5 



Uii^ 



I physiology of the human body appropriately from 
kindergarten through the 12th grade. 

It all started in 1973 when the Charlotte Nature 
Museum director, Russell I. Peithman, called upon a 
member of Mecklenburg Medical Auxiliary, Freda 
Nicholson, the wife of H. H. Nicholson, M.D., to 
launch his "Hall of Health." Mrs. Nicholson accepted 
the challenge and by spring of 1975 the museum 
classes absorbed at least 15 hours a week. She sug- 
gested to the local medical auxiliary that it take on the 
"Hall of Health" as a project. The challenge was again 
accepted and auxiliary volunteers have provided the 
additional necessary womanpower to sustain the pro- 
gram. They staff the "Hall of Health," operate the 
projectors for tllm and slide presentations, operate 
the Transparent Anatomical Mannikin (TAM) and 
help with the touch-and-feel models. The hall's film 
library is available for the use of other auxiliaries on 
request. 

Program.s at the "Hall of Health" include such 
things as "The Five Senses," "The Digestive Sys- 
tem" and a skeletal and muscle project for children 
from kindergarten through the second grade. Grades 3 
and 4 learn more about the senses, heart and circula- 
tion and digestion. Ninth graders are required to at- 
tend a 1 Vi-hour program on growth and development. 
Next year, a program will be scheduled for all the 5th 



graders in the area as well. This year the "Hall of 
Health" will handle at least 20.000 students and plans 
are in the works to expand the hall to handle several 
times that many. 



Meanwhile, the Buncombe County Medical Aux- 
iliary has had an exciting year with its Asheville 
Health Education Museum, housed now in a log cabin 
on the grounds of the Memorial Mission Hospital 
Complex but moving soon to the new Mountain Area 
Health Education Center. This year 3.500 people will 
visit the Health Education Museum. A successful 
fund-raising effort by members of the auxiliary has 
enabled the museum to hire a tour guide for the late 
afternoons when the volunteer auxiliary guides are un- 
able to work. 

A community advisory board should be im- 
plemented next year, and after further fund-raising 
projects the auxiliary hopes to hire a part-time direc- 
tor. Two auxiliary members went to Chicago to seek 
the advice of Richard Rush, an expert on health 
museums, and he has helped them develop a plan for 
continued growth of the museum. 



The Greensboro Medical Auxiliary has purchased 



A unique hospital specializing in treatment of 

ALCOHOLISM 
DRUG ADDICTION 



In this restful setting away from pressures 
and free from distractions, the Willingway 
staff, with understanding and compassion, 
carries out an intensive program of 
therapy based on honesty and responsi- 
bility. The concepts and methods are ori- 
ginal, different and have been highly suc- 
cessful for fifteen years. 

John Mooney, Jr , M.D . Director 
Dorothy R Mooney, Associate Director 



(J\JiXxiwt*>%>oL*^ \TTcy^f>*talL 



311 JONES MILL RD., STATESBORO. GA. 30458 TEL. (912) 764-6236 

■^■■■■■■■I^BHaHI^HH ACCREDITEDBYTHEJ.C.A.M. 

May 1976. NCMJ 




257 



the Transparent Anatomical Mannikin (TAM) to get a 
health museum under way in that area but no final 
action has been taken on the project. 



News Notes from the — 

BOWMAN GRAY SCHOOL 
OF MEDICINE 

WAKE FOREST UNIVERSITY 



Researchers at the Bowman Gray School of 
Medicine have found that it is possible to bring about 
the regression of some forms of atherosclerosis in 
rhesus monkeys through diet control. 

Results of the research were recently presented to 
the American Association of Pathologists and Bac- 
teriologists by Dr. M. Gene Bond, instructor in com- 
parative medicine and a memberof the research team. 

The study originally involved 54 monkeys. All the 
monkeys were fed a high cholesterol diet to induce 
atherosclerosis. 

After 19 months, 18 monkeys were removed from 
the study and examined to determine the extent of 
disease and the types of atherosclerosis created by the 
original diet. 

Examination showed that the monkeys had de- 
veloped all four of the uncomplicated forms of the 
disease, believed to be the same as the early forms of 
atherosclerosis in humans. 

The remaining monkeys in the study were divided 
into two groups, with one group being fed a high 
cholesterol diet and the other group being fed a diet 
which kept serum cholesterol in a range normal for 
humans. 

After 24 months on the diet, studies showed that the 
monkeys on the lower cholesterol diet had a reduction 
in two of the four types of uncomplicated 
atherosclerosis. 

Studies are continuing on two other groups of mon- 
keys to determine how longer periods on the diets will 
affect atherosclerosis. 



Two of the 24 graduate fellowships in the medical 
sciences awarded nationwide by the National Science 
Foundation have been awarded to students at the 
Bowman Gray School of Medicine. 

The two students are Mrs. Clara R. Dodge, a first- 
year graduate student in anatomy, and Donald R. Ko- 
han. a first-year graduate student in physiology. 

Each of the fellowships carries an award of $3,900 
each year for three years of full-time study. But the 
fellowships can be used over a five-year period to 
permit students to incorporate experiences in teaching 
and research into their education. 

More than 5 ,330 students competed for a total of 550 
graduate fellowships awarded by the foundation in the 
sciences, mathematics and engineering. 



25S 



Only five of the 550 fellowships were awarded to 
graduate students attending North Carolina schools. 



Recently appointed to the medical school's full-time 
faculty are Dr. Paul Racz, visiting associate professor 
of microbiology and immunology; Dr. Janet E. Dacie, 
visiting assistant professor of radiology; Dr. Michael 
R. Adams, instructor in comparative medicine; and 
Patricia Ann Gibson, instructor in pediatric neurology 
(social work). 

Appointed to the part-time faculty are Dr. Jack S. 
Billings and Dr. Davey B. Stallings, clinical instruc- 
tors in family medicine; and Dr. Bill C. Terry, lecturer 
in plastic surgery (orthodontia). 



Dr. E. Ted Chandler has been appointed associate 
professorof medicine at Bowman Gray. Dr. Chandler 
recently was appointed medical director for the 
Reynolds Health Center in Winston-Salem. 

He is a 1951 graduate of Wake Forest College and 
holds the M.D. degree from the University of North 
Carolina School of Medicine. He took his internship 
and residency training at North Carolina Baptist Hos- 
pital. 

Bowman Gray, in a cooperative arrangement with 
the University of North Carolina School of Medicine, 
is making computer assisted instruction (CAI) avail- 
able to its medical students. 

Four computer terminals have been installed in 
Bowman Gray's library, providing students with ac- 
cess to five major categories of computer programs. 

The programs either were produced at the UNC 
medical school or were collected there after produc- 
tion elsewhere. 

The five categories of programs are CRIB (com- 
puterized random item bank), which provides a self 
assessment process in the basic sciences for students; 
CNS (central nervous system) and MPNS (muscular 
and peripheral nervous system), both of which also 
are intended for student self assessment; CASE (com- 
puter aided simulation of the clinical encounter), 
which permits students to naturally interact with "pa- 
tients" in 22 patient histories; and ACIBA (acid, base 
balance), a tutorial using slides in addition to the com- 
puter program. 

* * + 

Dr. Eugene R. Heise, associate professor of mi- 
crobiology and immunology, has been elected chair- 
man of the Committee of Histocompatibility for the 
Southeastern Organ Procurement Foundation. He 
also has been selected to serve on the Ad Hoc Con- 
tract Review Panel for the National Heart and Lung 
Institute. 



Dr. Quentin N. Myrvik, professor and chairman of 
the Department of Microbiology, has been elected a 

Vol. 37. No. .s 



I 



member of the Lung SCOR Advisory Committee and 
a member of , the Microbiology Test Committee of the 
National Board of Medical Examiners. He also has 
been elected president of the American Association of 
Microbiology Chairmen. 



News Notes from the — 

DUKE UNIVERSITY MEDICAL CENTER 



A patient area in the Medical Center has been dedi- 
cated in honor of Dr. Julian M. Ruffm, professor 
emeritus of medicine. It is known as the Julian M. 
Ruffin Clinical Suite. 

Ruffin is retired from the active faculty at Duke but 
is in private practice in Durham and serves as a consul- 
tant to both Duke and Watts hospitals. 

A member of the original Duke medical faculty, he 
is a specialist in clinical gastroenterology. 



Dr. William G. Anlyan was in Poland in March as a 
consultant to the U.S. government on medical educa- 
tion. 



Anlyan, vice president for health affairs, addressed 
a session of the five-day U.S. -Polish Medical Sym- 
posium in Warsaw on the development of medical 
education in the United States and current programs 
in various countries. 

In recent years Anlyan has studied comparative 
medical education systems on visits to countries in 
Europe, th^ Mediterranean and the Far East. 

On the Warsaw trip he was consultant to the ad- 
ministrator of the Health Resources Administration, 
Department of Health, Education and Welfare. 



Dr. Edward Orgain, professor emeritus of 
medicine, has been honored by the American College 
of Cardiology with its Gifted Teacher Award. The 
award was presented at ceremonies in New Orleans. 

Orgain has been at Duke since 1934 and formerly 
headed the cardiovascular disease service. Last 
November the Duke Medical Alumni Association 
similarly honored Orgain with a Distinguished Teach- 
ing Award. 



The Emergency Department in the new $90 million 
Duke Hospital North will benefit from a $300,000 



A serious alternative to this nonsense of trading 
in your car every three years. 



The car you are driving today is probably just a short 
step away from the used car lot. You know it. The 
manufacturer knows it. And, trade-in statistics prove it. 

Since 1904, there has been an exception to this 
improvidence. Of all the Rolls-Royce motor cars built 
since that glorious year, more than half are still cruising 
on the world's highways. 

There is no guarantee that the Rolls-Royce you buy 
today will be serving you in the year 2025. However, 
with proper maintenance and care, the chances are 
good. Very good indeed. 

And should you wish to trade, remember that no 
i ordinary luxury car holds its resale value better. 

At your leisure, take a pencil and paper and total the 
purchase prices of all the automobiles you have owned 
... or plan to own. Remember to subtract their trade- 
in values. Now, match this figure against the purchase 




price of a Rolls-Royce Silver Shadow or a Corniche. 
This remarkable value cannot go unheeded. 

You are invited to visit our showroom to see and 
drive these extraordinary motor cars. 



ROLLS 



U 



ROYCE 



TRANSCO, INC. 

1800 N. Main Street 
High Point, North Carolina 27262 
Telephone: (919) 882-9647 
(919)288-7581 — Evenings 



For literature and test drive, contact Geoff Eade. General Manager 



May 1976. NCMJ 



259 



grant from the Kate B. Reynolds Health Care Trust of 
Winston-Salem. 

The grant will assist in the construction and equip- 
ping of the emergency care facility scheduled to open 
when the new hospital is completed in the spring of 
1979. 

Duke treats 40,000 persons a year through the 
Emergency Department. The new emergency area 
will have separate entrances for walk-ins and ambu- 
lance patients with a reception-triage area between 
them. 

A helicopter landing pad will be constructed near 
the emergency entrance so patients can be taken di- 
rectly to emergency care facilities without having to 
be transferred to another means of transportation and 
handled unnecessarily. 

Duke's emergency care services are under the di- 
rection of Dr. Joseph Moylan, who came to Duke last 
year after directing the Emergency Medical Service 
Program at the University of Wisconsin. He also is a 
specialist in the treatment of bum patients. 



A policy adopted in early April prohibits smoking in 
the Medical Center except in specified areas. The 
policy was designed to recognize the rights of both 
non-smokers and smokers. 

Specific non-smoking areas include corridors and 
stairwells, examination and treatment rooms, 
elevators, nursing stations, food preparation areas, 
libraries, classrooms, conference rooms and lecture 
halls. Areas are clearly marked by signs. 

While patients are permitted to smoke in their 
rooms. Medical Center personnel are prohibited from 
smoking in patients' rooms or in the presence of pa- 
tients. 



Dr. Samuel Katz, Chairman of the Department of 
Pediatrics, is a member of the Advisory Committee on 
Immunization Practices which recommended to Pres- 
ident Ford that steps be taken to immunize Americans 
against swine flu virus. 

Katz, who heads the Committee on Infectious Dis- 
eases of the American Academy of Pediatrics, said 
some of the early research trials on the vaccine will be 
conducted at Duke later this year. 



Promotions and Appointments: 

* Dr. Dolph O. Adams and Dr. Edward H. Bossen 
promoted to associate professorship in pathology. 

* Dr. W. Allen Addison (M. D. '60, Duke) named 
assistant professor of Ob-Gyn; coming from private 
practice in Toccoa and Gainesville, Ga. 

* Dr. Albert B. Deisseroth (Ph.D. '68 and M.D. '70, 
University of Rochester), named assistant professor 
of medicine; has been fellow in medicine at Harvard. 

* Dr. Seymour Grufferman (M.D. "64, State Uni- 
versity of New York), named assistant professor of 
community health sciences (epidemiology); coming 



Before prescribing, please consult 
complete product information, a summary 
of which follows: 

Indications: in adults, urinary tract 
infections complicated by pain (primarily 
pyelonephritis, pyelitis and cystitis) due 
to susceptible organisms (usually E. coli, 
Klebsiella-Aerobacter, Staphylococcus 
aureus, Proteus mirabilis, and, less fre- 
quently, Proteus vulgaris) in the absence 
of obstructive uropathy or foreign bodies. 
Note: Carefully coordinate in vitro sulfon- 
amide sensitivity tests with bacteriologic 
and clinical response; add aminobenzoic 
acid to follow-up culture media. The increas- 
ing frequency of resistant organisms limits 
the usefulness of antibacterials including 
sulfonamides. Measure sulfonamide blood 
levels as variations may occur; 20 mg/ 
100 ml should be maximum total level. 

Contraindications: Children below age 
12; sulfonamide tiypersensitivity; preg- 
nancy at term and during nursing period; 
because Azo Gantanol contains phenazo- 
pyridine hydrochloride it is contraindicated 
in glomerulonephritis, severe hepatitis, 
uremia, and pyelonephritis of pregnancy 
with G I disturbances. 

Warnings: Safety during pregnancy not 
established. Deaths from hypersensitivity 
reactions, agranulocytosis, aplastic ane- 
mia and other blood dyscrasias have been 
reported and early clinical signs (sore 
throat, fever, pallor, purpura or jaundice) 
may indicate serious blood disorders. Fre- 
quent CBC and urinalysis with microscopic 
examination are recommended during 
sulfonamide therapy. 

Precautions: Use cautiously in patients 
with impaired renal or hepatic function, se- 
vere allergy, bronchial asthma; in glucose- 
6-phosphate dehydrogenase-deficient 
individuals in whom dose-related hemoly- 
sis may occur. Maintain adequate fluid 
intake to prevent crystalluria and stone 
formation. 

Adverse Reactions: Blood dyscrasias 
(agranulocytosis, aplastic anemia, throm- 
bocytopenia, leukopenia, hemolytic ane- 
mia, purpura, hypoprothrombinemia and 
methemoglobinemia); allergic reactions 
(erythema multiforme, skin eruptions, 
Stevens-Johnson syndrome, epidermal ne- 
crolysis, urticaria, serum sickness, pruritus, 
exfoliative dermatitis, anaphylactoid re- 
actions, periorbital edema, conjunctival 
and scleral injection, photosensitization, 
arthralgia and allergic myocarditis); G.I. 
reactions (nausea, emesis, abdominal 
pains, hepatitis, diarrhea, anorexia, pan- 
creatitis and stomatitis); CNS reactions 
(headache, peripheral neuritis, mental 
depression, convulsions, ataxia, hallucina- 
tions, tinnitus, vertigo and insomnia); 
miscellaneous reactions (drug fever, chills, 
toxic nephrosis with oliguria and anuria, 
periarteritis nodosa and L,E phenomenon). 
Due to certain chemical similarities with 
some goitrogens, diuretics (acetazoiamide, 
thiazides) and oral hypoglycemic agents, 
sulfonamides have caused rare instances 
of goiter production, diuresis and hypo- 
glycemia Cross-sensitivity with these 
agents may exist. 

Dosage: Azo Gantanol is intended for 
the acute, painful phase of urinary tract 
infections. Usual adult dosage: 2 Gm 
(4 tabs) initially, then 1 Gm (2 tabs) 
B.I.D. for up to 3 days. If pain persists, 
causes other than infection should be 
sought. After relief of pain has been ob- 
tained, continued treatment with Gantanol 
(sulfamethoxazole) may be considered. 

NOTE: Patients should be told that the 
orange-red dye (phenazopyridine HCl) will 
color the urine. 

Supplied: Tablets, red, film-coated, 
each containing 0.5 Gm sulfamethoxazole 
and 100 mg phenazopyridine HCl— bottles 
of 100 and 500, 



<' \ Roc 

ROCHE)- 



Roche Laboratories 

sion of Hoffmann-La Roche Inc. 
Nutley, New Jersey 07110 



260 



Vol. 37, No. 5 



When pain 
complicates acute cystitis 

Azo Gantatiol 

Each tablet contains 0.5 Gm sulfamethoxazole andlOO mg phenazopyridine HCI. 

for the pain for the pathogens 



n Early relief of painful symp 
toms such as burning and 
discomfort associated witin 
urgency and frequency. 

D Effective control of sus- 
ceptible pathogens sucin as 
E. coll, Klebsiella-Aerobac- 
ter, Staph, aureus, Proteus 
mirabilis and, less fre- 
quently, Proteus vulgaris. 



*nonobstructed; due to 
susceptible organisms 




n Appropriate antibacterial 

therapy: up to three days with 
Azo Gantanol, then 11 days 
with Gantanol® (sulfamethox- 
azole). 



ROCH?)> 



Each capsule contains 50 mg. 

of Dyrenium® (triamterene, SK&F) 

and 25 mg. of hydrochlorothiazide. 



Umax. 

MAKES SEKSE 

TRIAMTERENE CONSERVES POTASSIUM 
WHILE HYDROCHLDROTHIAZIDE 
LONERS BLOOD PRESSURE 

FOR LONG-TERM CONTROL 

wr H 7 rCK I ENSIwN Serum K+ and BUN should be checked periodically. (See Warnings Section.) 




Before prescribing, see complete prescribing in- 
formation in SK&F literature or PDR The fol- 
lowing is a brief summary. 



Warning 

This fixed combination drug is not indi- 
cated for initial therapy of edema or hyper- 
tension. Edema or nVpertension requires 
therapy titrated to the individual patient. If 
the fixed combination represents the dosage 
so determined, its use may be more convenient 
in patient management. The treatment of 
hypertension and edema is not static, but 
must be reevaluated as conditions in each 
patient warrant. 



* Indications: Edema That associated with con- 
gestive heart failure, cirrhosis of the liver, the 
nephrotic syndrome; steroid-induced and idio- 
pathic edema; edema resistant to other diuretic 
therapy. Mild to moderate hypertension: Useful- 
ness of the triamterene component is limited to 
its potassium-sparing effect. 

Contraindications: Pre-existing elevated serum 
potassium. Hypersensitivity to either component. 
Continued use m progressive renal or nepatic 
dysfunction or developing hyperkale'^iia. 
Warnings: Do not use dietary potassium supple- 
ments or potassium salts unless hypokalemia 
develops or dietary potassium intake is markedly 
impaired. Enteric-coated potassium salts may 
cause small bowel stenosis with or without 

ti1/-orafi(-in Htrrn=rL'al*imi a ( "> '-i A mPn/T \ Viae 



been reported in 4% of patients under 60 years, 
m 12% of patients over 60 years, and in less than 
8% of patients overall. Rarely, cases have been 
associated with cardiac irregularities. Accord- 
ingly, check serum potassium during therapy, 
particularly in patients with suspected or con- 
firmed renal insufficiency (e.g., elderly or dia- 
betics). If hyperkalemia develops, substitute a 
thiazide alone. If spironolactone is used con- 
comitantly with 'Dyazide', check serum potas- 
sium frequently —both can cause potassium 
retention and sometimes hyperkalemia. Two 
deaths have been reported in patients on such 
combined therapy (in one, recommended dosage 
was exceeded; in the other, serum electrolytes 
were not properly monitored). Observe patients 
on 'Dyazide" regularly for possible blood 
dyscrasias. liver damage or other idiosyncratic 
reactions. Blood dyscrasias have been reported 
m patients receiving Dyrenium (triamterene, 
SKN;F). Rarely, leukopenia, thrombocytopenia, 
agranulocytosis, and aplastic anemia have been 
reported with the thiazides. Watch for signs of 
impending, coma in acutely ill cirrhotics. Thia- 
zides are reported to cross the placental barrier 
and appear m breast milk. This may result in 
fetal or neonatal hyperbilirubinemia, thrombo- 
cytopenia, altered carbohydrate metabolism and 
possibly other adverse reactions that have oc- 
curred in the adult. When used durin g preg nanc y 
or in women who mi g ht bear children , weigh 
potential benefits against possible hazards to 
fetus. 



BUN determinations. Do periodic hematologic 
studies in cirrhotics with splenomegaly. Anti- 
hypertensive effects may be enhanced in post- 
sympathectomy patients. The following may 
occur: hyperuricemia and gout, reversible nitrogen 
retention, decreasing alkali reserve with possible 
metabolic acidosis, hyperglycemia and glycosuria 
(diabetic insulin requirements may be altered), 
digitalis intoxication (in hypokalemia). Use 
cautiously in surgical patients. Concomitant use 
with antihypertensive agents may result in an 
additive hypotensive effect. "Dyazide" interferes 
with fluorescent measurement of quimdine. 
Adverse Reactions: Muscle cramps, weakness, 
dizziness, headache, dry mouth; anaphylaxis; 
rash, urticaria, photosensitivity, purpura, other 
dermatological conditions; nausea and vomiting 
(may indicate electrolyte imbalance), diarrhea, 
constipation, other gastrointestinal disturbances. 
Necrotizing vasculitis, paresthesias, icterus, 
pancreatitis, xanthopsia and, rarely, allergic 
pneumonitis have occurred with thiazides alone. 
Supplied: Bottles of 100 capsules; in Single Unit 
Packages of 100 (intended for institutional use 
only). 

SK&F Co., Carolina, P.R. 00630 

Subsidiary of SmithKline Corporation 



Upjohn 

The Upjohn Company, Kalonnazoo, Michigan 49001 



AAedrd 4 mg Dosepak 

methylprednisolone, Upjohn 

The explicit printed dosage instructions that accompany each Dosepak 
make it easy for the patient to understand and follow the dosage regimen. 





g Balanced Rock, Chincahua Mountains, Arizona (approx 1,000 tons) 



;pi(leiw»l 
lamed as: 



TivoV 
sintinei 
BvidS. 
onsubC' 
nierjen 
ifEmeri 
tasbeen 
talAsso 
Podgoni! 
taiericai 
is secret! 



Theft 
K prog 
tpidemic 

Most I 
■tiihttie 
Jas a to 
'iieloDt 



larnned 
AMA 



n Found useful in the management of vertigo* associated with CONTRAINDICATIONS, Administration of Aniivert (meclizine HCl) ciuring preg-,i|i5pect 

diseases affecting the vestibular system, " '■' ' ■ ;-j;--j :- ..:— . -c -l.: . 

D Can relieve nausea and vomiting often associated with vertigo* 
D Usual adult dosage for Antivert/25 for vertigo:* one tablet t,i.d, 
n Also available as Antivert (meclizine HCl) 12.5 mg. scored 
tablets, for dosage convenience and flexibility, 
D Antivert/25 (meclizine HCl) 25 mg, Cheuub/f Tablets for 
nausea, vomiting and dizziness associated with motion sickness, 

BRIEF SUMMARY OF PRESCRIBING INFORMATION 



"INDICATIONS Based on a reMew ot thjs drug by the National Academy of 
Sciences -National Research Council and/or other information, FDA has classified 
the indications as follows: 

EjIctVive. Management of nausea and vomiting and dizziness associated with 
motion sickness. 

Possibly Effecnve: Management of vertigo associated mth diseases affecting the 
\'esnbular system 

Final classificanon of the less than effecnve indications requires further 
in\'estigation 



nancy or to women who may become pregnant is contraindicated in siew of the 
teratogenic effect of the drug in rats. 

The administration o( meclizine to pregnant rats during the 12-15 day of gestation 
has produced cleft palate in the offspnng. Limited studies using doses of over 100 mg./' 
kg. /day in rabbits and 10 mg /kg /day in pigs and monkeys did not shou' cleft palate 
Congeners of meclizine have caused cleft palate in species other than the rat 

Meclizine HCl is contraindicated in individuals who have shown a previous hyper 
sensitiNTty to it. 

WARNINGS Since drowsiness may, on occasion, occur with use of this drug, patienL' 
shotild be warned of this possibility and cautioned against driving a car or operating 
dangerous machinery. 

Usage m Children Clinical studies establishing safety and effectiveness in childrerj 
have not been done, therefore, usage is not recommended in the pediatric age group, 

Usage in Pregnancy See "Contraindications" 
ADVERSE REACTIONS, Drowsiness, dry mouth and, on rare occasions, blurre^ 
vision have been reported 

More detailed professional information available on 
request 



Antivert725 

(meclizine HCl) 25 mg.Tablets 

for vertiao* 



ROGRIG <0 

A division of Ptizer Pharmaceutical; 
New York, New York 10017 



der 
car 

vin 
h 
m 
"T 



lOl 

vac 

to I 



from Harvard where completing doctorate in 

jjspidemiology. 

I * Dr. Robert J. Ruderman (M.D. '68, Rochester), 
named assistant professor of orthopaedic surgery; has 
been chief resident in orthopaedic surgery at Duke. 

AMERICAN COLLEGE OF EMERGENCY 
PHYSICIANS 

North Carolina Chapter 

Two Winston-Salem physicians have received ap- 
pointments in emergency medical organizations. 
David S. Nelson, M.D., is chairman of the transporta- 
tion subcommittee of the Committee on Technology in 
Emergency Medical Services of the American College 
of Emergency Physicians. George Podgomy, M.D., 
has been named to the council of the American Medi- 
cal Association's Section on Emergency Medicine. 
Podgomy is president of the N.C. Chapter of the 
American College of Emergency Physicians; Nelson 
is secretary-treasurer. 



Month in 
Washington 



The American Medical Association has supported 
President Ford's decision to undertake a mass im- 
munization program against the swine influenza virus. 
The President asked Congress for $135 million for 
the program in an attempt to stave off a possible 
epidemic next fall and winter. 

Most of the medical community seemed to agree 
with the Ford decision, though many pointed out it 
was a tough one. Albert B. Sabin, a partner in the 
development of the polio vaccines, said, "It has an 
aspect of — you're damned if you do and you're 
damned if you don't." 

AMA leaders prepared to appear before the Senate 
and House in support of the Ford decision. 
The AMA statement in full: 

"The American Medical Association sup- 
ports the decision of President Ford to un- 
dertake a massive national immunization 
campaign against the swine influenza 
virus. Under the circumstances, we be- 
lieve his decision is absolutely the correct 
one. 

"The AMA stands ready to assist in the 
national campaign in any way possible, in- 
cluding organizing the medical profession 
to insure that every person who wants to be 
vaccinated will be — regardless of ability 
to pay. 

May 1976, NCMJ 



"We spealj: for the medical profession in 
committing the doctors of this nation to 
make whatever efforts are necessary to 
vaccinate the entire population. It will not 
be easy, but it can and must be done." 



A federal-state campaign to reduce Medicaid fraud 
and abuse has been launched by David Mathews, Sec- 
retary of Health, Education and Welfare. 

A team of federal and state Medicaid examiners will 
begin work in Massachusetts soon at the invitation of 
Gov. Michael Dukakis. Another team will begin oper- 
ations in June in Ohio at the request of Gov. James 
Rhodes. 

HEW said it plans to focus the joint effort on states 
with the largest Medicaid programs. Reviews in at 
least five states are planned this year. 

The examiners will have two objectives. Mathews 
said. They will identify fraud and abuse and refer 
violations for possible prosecution. They will also 
help states develop efficient program management 
and abuse detection systems. 

HEW has developed a computerized Medicaid 
management information system (MMIS) to help pro- 
cess claims. MMIS will alert a state if, for example, a 
patient was in a hospital the same day a physician 
claimed to have treated him at home, or if a pregnancy 
test was ordered on a male, HEW said. 

HEW is assembling a Medicaid fraud and abuse unit 
of 108 people in the Medical Services Administration 
and a criminal investigative branch of 74 investigators 
which will report directly to Undersecretary Marjorie 
Lynch. 

HEW said it will coordinate its Medicaid investiga- 
tions with the Department of Justice and the Internal 
Revenue Service. 

Mathews said he plans to invite representatives of 
national health services provider organizations to 
Washington shortly to solicit their ideas and to urge 
them to undertake a self-policing program. 

"We recognize that the overwhelming majority of 
health care providers are ethical and professional," 
Mathews said. "They share our desire to bring effi- 
ciency to Medicaid in its management and in the qual- 
ity of health care it offers. We want to ferret out the 
comparative few who break the law. We believe the 
health professions organizations will give us their en- 
thusiastic support in this effort." 

Heading the HEW office of investigators will be 
John J. Walsh, senior investigator for the Senate per- 
manent subcommittee on investigations and a former 
FBI agent. 



Major changes in the Medicare-Medicaid programs 
are called for in legislation introduced by Sen. Herman 
Talmadge (D-Ga.). The proposal would establish in- 
centives for physicians to accept assignment; restrict 
payment methods for hospital-based specialists; mold 
Medicare. Medicaid and the Bureau of Quality Assur- 



265 



ance into a single agency; and set up reimbursement 
incentive programs for hospitals. 

Talmadge, chairman of the finance subcommittee 
on health, said in a Senate speech, "Either we make 
Medicare and Medicaid more efficient and economical 
or we reduce benefits. We have just too many worth- 
while demands on the limited federal dollar to be able 
to allocate increasingly disproportionate amounts to 
Medicare and Medicaid." 

Hearings will be held sometime this year, Talmadge 
promised, but he set no date. He stressed that the 
proposals are not "frozen in concrete" and are subject 
to change after the hearings. 

Talmadge surprised the health field last year when 
he made a Senate speech outlining the ideas finally put 
in legislative form recently. Many of the recommenda- 
tions are controversial, especially the reorganization 
of the health activities at HEW that are expected to be 
opposed by the administration and the restrictions on 
payment of hospital-based specialists. 

Talmadge describes the specialist provision as fol- 
lows: 

"Under the legislation speciahsts — such as certain 
radiologists, pathologists, and anesthesiologists — 
would be eligible under Medicare-Medicaid for fee- 
for-service, or other reasonable fixed compensation 
agreed upon with a hospital, for services which they 
personally render or which are provided under their 
direct personal supervision. For their administrative 



and general supervision of an X-ray, laboratory or 
anesthesia department, the hospital could compensate 
them on a basis comparable to what a salaried 
radiologist, pathologist or anesthesiologist receives 
for comparable time and work. No percentage, lease, 
or direct billing arrangements would ordinarily be rec- 
ognized for Medicare or Medicaid reimbursement 
purposes." . . . 

Physicians who choose assignments, to be called 
participating physicians, would be able to submit 
simplified and fewer claims and receive a $1 per pa- 
tient bonus for most office visit charges. Medicaid 
would have to pay not less than 80 percent of the 
Medicare reasonable charge for nonsurgical care. As a 
means of encouraging physicians to move into physi- 
cian shortage areas, new physicians could establish 
customary charges at the 75th percentile of prevailing 
charges in the locality, rather than the present 50 
percent. 

A single administration for health care financing 
would contain the present Medicare, Medicaid and 
Bureau of Quality Assurance Agencies to be headed 
by an assistant HEW secretary. Within this agency a 
central fraud and abuse unit headed by an inspector 
general would monitor performance and violations. 

The bill would abolish the Health Insurance Ben 
efits Advisory Council. 

A new reimbursement system is designed to reward 




Yoiur son 
isn't thinking 
about grad school 
yet. 

But you should be 



Graduate school is the farthest thing from a young boy s mind — 
but in only a few years it may be uppermost You should be pleinning 
educational opportunities for your son now that will keep open for 
him every option 

A strong academic foundation is essential to successful higher 
education Will his educational needs be met loccdly? if you have 
any doubts, and many parents do, we invite you to consider 
a boarding school Asheville School provides an atmo- 
sphere in which academic excellence is expected — 
and respected We can help your son fulfill his 
dreams — and your dreams for him For informa- 
tion write: 

The Asheville School 

Everett F Gourley 
Director of Admissions 
Asheville. N C 28«06 



266 



Vol. 37, No. 5 



Preventive Medicine 
Makes Sense... 

Disability Income Protection Does Too! 




Just as preventive medicine can help you 
avoid disasters to your health, Disability Income 
Protection can help you avoid financial 
disasters. A long-term disability, for example, 
without adequate insurance protection could 
mean weeks or even years without an income. 

For this reason alone, you cannot afford 
to be without the proper protection. 

That's why we have especially designed a 
Disability Income Protection Plan for younger 
doctors. A plan of protection to help make sure 
your family continues to live in the manner to 



which they are accustomed should you become 
disabled and unable to practice medicine. 

These benefits are paid directly to you to use 
as you see fit whether you are confined in 
a hospital or recovering at home. Furthermore, 
these benefits are tax free under present 
federal income tax laws. 

If you are under 55 years of age, just fill out 
the coupon below and mail it today. Mutual of 
Omaha will provide personal service in 
furnishing all of the details. Of course, 
there is no obligation. 



L)\UtRV%HIIIES BY 




Mutual 
e^maha 

People ifou can count on... 

Life Insurance Affiliate: United of Omaha 

MUTUAL OF OMAHA INSURANCt COMPANY 
HOME OFFICE: OMAHA, NEBRASKA 



Mutual of Omaha Insurance Company 

Dodge at 33rd Street • Omaha. Nebraska 68131 

I am interested in learning more about the program of Disability Income 
Protection available to me. 

Name 



Address 
City 



- State 



.ZIP code 



I J 



hospitals with less than average operating costs and 
penalize those with higher costs. 



James Cowan, M.D., has resigned as assistant sec- 
retary for defense for health and environment. Among 
those reported under consideration as his successor is 
Malcolm Todd, M.D., immediate past president of the 
AMA. Cowan, former New Jersey commissioner of 
health, is understood to be contemplating an entry into 
politics in his home state, possibly running for the 
GOP nomination for the Senate. 



Now passed by both houses of Congress and await- 
ing conference, medical device legislation has made 
members of that industry predict a bullish future. 

The legislation will add $250,000 to $700,000 in costs 
to products requiring premarket approval. The hottest 
medical device will continue to be the pacemaker. 
Sales are expected to increase at an average annual 
compound rate of 9 percent. Another big item is the 
CAT scanner. Manufacturers predict 3,000 place- 
ments by 1980. The use of renal dialysis is expected to 
triple by 1980. Catastrophic or comprehensive na- 
tional health insurance will also help the industry. 
Makers of orthopedic and surgical appliances, clinical 
diagnostics, medicinais and pharmaceuticals all ex- 
pect steady growth. Drug companies predict biggest 
growth in anti-anthritics sales. 

The legislation provides three categories for devices 
— class I, general controls; class II, performance 
standards; and class 111, premarket approval. The 
general controls give FDA authority to move against 
devices that are misbranded or badly made and re- 
quire their registration as if they were drugs. FDA can 
exempt some devices from this control, such as cus- 
tom devices not intended for general sale. 

Class II devices would be required to meet certain 
manufacturing standards. 

Class III involves premarket clearance for new 
products and essentially the same type of clearance 
for existing products. The House Commerce Commit- 
tee report said it expected that intrauterine devices 
would be class III. 



The Senate Labor and Public Welfare Committee 
has approved legislation subjecting clinical 
laboratories in both intrastate and interstate com- 
merce to federal licensing and standards require- 
ments. 

The revision of the Clinical Laboratories Improve- 
ment Act (CLIA) would for the first time cover labs 
operating only within one state and give HEW a 
stronger role in supervising the nation's clinical 
laboratories. 

Physicians who perform tests solely in connection 
with treatment of their own patients could be exemp- 
ted from the law's requirements if HEW wished. 

The measure provides leeway for continuation of 



V 



ermox 

mebendazole 



DESCRIPTION VERMOX (mebendazole) is methyl 5- 
benzoylbenzimidazole-2-carbamate 

ACTIONS VERMOX exerts its anttielmmtic ettect by 
blockmq glucose uptake by ttie susceptible helminths, 
thereby depleting the energy level until it becomes 
inadequate for survival. 

An insignificant amount of mebendazole is absorbed 
from ttie gastrointestinal tract Most of this is excreted in 
the urine within three days either as metabolites or 
unchanged drug 

INDICATIONS VERMOX is indicated tor the treatment of 
Tnchuris tnchiura (whipworm), Enterobius vermicularis 
(pinworm). /Iscar/s lumbncoides (roundworm), 
Ancylostoma duodenale (common hookworm), A/ecator 
amencanus (American hookworm) in single or mixed 
infections 

Efficacy varies in function of such factors as pre-existing 
diarrhea and gastrointestinal transit time, degree of 
infection and helminth strains Efficacy rates derived 
from various studies are shown in the table below: 





Tnchuris 


Ascaris 


Hookworm 


Pinworm 


cure rates 

mean 
(range) 


68". 
I61-75'.) 


98% 
(91-100"/.) 


96"'. 


95". 
190-100". 1 


egg reduction 

mean 
irangel 


93% 
170- 99". 1 


99 7". 
199 5-100".) 


99 9°. 


- 



CONTRAINDICATIONS VERMOX is contraindicated in 
pregnant women (see: Pregnancy Precautions) and in 
persons who have shown hypersensitivity to the drug 

PRECAUTIONS PflfG/V/l,A/Cy VERMOX has shown 
embryotoxic and teratogenic activity in pregnant rats at 
single oral doses as low as 10 mg/kg Since VERMOX 
may have a risk of producing fetal damage if 
administered during pregnancy, it is contraindicated in 
pregnant women 

PEDIATRIC USE. The drug has not been extensively 
studied in children under two years: therefore, in the 
treatment of children under two years the relative 
benefit/risk should be considered 

ADVERSE REACTIONS Transient symptoms of abdomi- 
nal pain and diarrhea have occurred in cases of massive 
infection and expulsion of worms 

DOSAGE AND ADMINISTRATION The same dosage 

schedule applies to children and adults 

For the control of pinworm (enterobiasis), a single tablet 

IS administered orally, one time 

For the control of roundworm (ascariasis), whipworm 

(trichunasis), and hookworm infection, one tablet of 

VERMOX IS administered, orally, morning and evening, 

on three consecutive days 

If the patient is not cured three weeks after treatment, a 

second course of treatment is advised No special 

procedures, such as fasting or purging, are reguired. 

HOW SUPPLIED VERMOX is available as tablets, each 
containing 100 mg of mebendazole, and is supplied in 
boxes of twelve tablets 

VERMOX (mebendazole) is an original product of 
Janssen Pharmaceutica, Belgium, and co-developed by 
Ortho Pharmaceutical Corporation 



t Because Vermox has not been extensively studiec^ 
m chilcjren under 2 years of age trie relative 
benefit/risl< stiould be considered before treating 
Ihese ctiildrGn Vermox is contraindicated in 
pregnant women (see Pregnancy Precautions) and 
in persons who have shown hypersensitivity to 

the drug j 1 

OJ 288-5R r'ei=-S:.s5- 



Ortho Pharmaceutical Corporation 
Raritan, New Jersey 08869 




268 



Vol. 37, No. 5l 



The only single^tablet 
treatment of pinNMomi 




% 




just one 
chewable tablet, 
once, usually 
eradicates pinworm 
in both children 
and adultsi 
and without 
I staining 



jchewable 
f ta 



\ tablets 



llmebendcJZole^ 



© OPC1975 



i 



existing accreditation and certification programs by 
the Joint Commission on Accreditation of Hospitals 
and the College of American Pathologists (CAP). 
AMA and the CAP had urged Congress to allow these 
activities to continue. 

One provision adopted by the committee would re- 
quire disclosure of fees and contractual relationships 
between labs and physicians using their services. 



The American health care system is due for tight 
government control because costs are becoming more 
than the economy can bear. 

This was the grim message of speaker after speaker 
at a Washington conference on the economic impact 
of health care legislation. The meeting was sponsored 
by Arthur D. Little, Inc., a Cambridge, Mass., con- 
sulting and research firm. 

"The cost is becoming prohibitive," declared 
Charles Edwards, M.D., former assistant HEW sec- 
retary for health. "The U.S. health care system is 
headed toward fundamental changes that are certain 
to occur and sooner than most expect," Edwards 
warned. He predicted health care will cost $135 billion 
next year, or $600 for every person in the country. 

Declaring that this decade for physicians could be 
called the "showdown '70s" Malcolm C. Todd, M.D., 
immediate past president of the AMA, told the confer- 
ence of business and health leaders that he hoped for a 
"proper accommodation" between the medical pro- 
fession and the federal government. Unless a pluralis- 
tic system is retained, Todd warned, "federally in- 
spired chaos" could emerge. 

"There could be a vicious circle . . . with programs 
foundering on their own shortcomings and blunders 
. . . and government blaming doctors and hospitals for 



I 
the failures in order to justify even more repressive 
programs," he said. 

A study by the Arthur D. Little firm estimated that 
the passage of national catastrophic health insurance 
would add $4.5 billion to 1980 expenditures for princi- 
pal health care products and services. If no new na- 
tional health coverage becomes effective, spending 
for health care is expected to grow at an average 
annual rate of four percent over the next five years, or 
from $98.8 billion in 1975 to $112 billion in 1980, the 
study said. 

Enactment of national comprehensive health insur- 
ance, which Little said is not regarded as very likely to 
happen before 1980, would increase health care spend- 
ing by 12 percent, or $13.6 billion, for an annual total 
of $125.6 billion in five years. 

Commenting on the study, Todd said "it confirms 
that any of the national health insurance programs 
before the Congress will result in greater utilization by 
patients and thus increased expenditures." 

Lawrence Hill, executive vice president of the 
American Hospital Association, said the future holds 
"more expenditures, rising costs, concern with those 
expenditures, and costs leading to attempts to control 
by price controls and by tinkering with the delivery 
system." 

Hill foresees a collision between rising costs and 
"capped" prices. Hospitals, he said, might have little 
option but to limit services. "Lines of doctors and 
patients will form and the hospital will patrol these, 
admitting as resources allow." 

"The price-cost collision will cause some rationing 
which, in turn, will cause internal adjustments con- 
cerning how physicians use hospital facilities. The 
community relations implications in rationing are ob- 
vious, and, of course, at this point in time we simply 
do not know how to ration health care because we 
never have tried before." 



Book Reviews 



Books Received 

Modem Home Dictionary of Medical Words, by Morris Fish- 
bein, M.D.. 267 pp. $1.95, New York: Doubleday & Com- 
pany, Inc.. 1976. 

Tlie New Way to Live witli Diabetes, by Brian Boylan and 
Charles Weller, M.D., 140 pp, $2.50, New York: Doubleday 
& Company, Inc.. 1976. 



270 



Vol. 37, No. 5 



i 




Coastal N.C. — E. D. PHYSICIAN. Established primary care group 
of young physicians needs replacement for 5th man. $50,000 plus 
excellent benefits. Needed after July 1, 1976. 186 bed hospital, new 
eleven bed E. D. Career emergency physician desired, others con 
sidered. Excellent outdoor recreation, N.C.'s sailing capital near 
by. N.C. license required. E. Robert Nealy, M.D., Director 
Emergency Department, Craven County Hospital, New Bern, N.C 
28560. 

INTERNIST AND TWO FAMILY PRACTITIONERS needed. Pri 
vate practice. Year-round resort community located in western 
N.C. Office space (Rent free for one year) available in new profes 
sional building attached to 98-bed general hospital. Contact Dr 
Robert A. Chapman, Cannon Memorial Hospital, Banner Elk 
N.C. 28604, Phone: 704/898-4828. 

CLINIC FOR SALE OR RENT: Office space for 2 doctors, 6 beds 
fully-equipped facility, 3,000 sq. ft. Roseboro, N.C. is currently 
without a physician. 12 miles from 150-bed hospital. Price negotia 
ble. Write: Brewer-Starling CUnic. P.O. Box 98, Roseboro, N.C 
28382. 

40 year old Certified Allergist desires group or partnership associa 
tion in Eastern N.C. Will consider solo practice in an Eastern area 
needing Allergist. Write NCMJ #10, P.O. Box 27167, Raleigh 
N.C. 27611. 

OP/ER PHYSICIAN: Vacancy July 15. Ambulatory Center 24000 
visits, specialty backup, fee for service with $46,000 guarantee 
Pleasant associates, peaceful community near mountains, 45 min 
utes to two medical centers. Contact Administrator, Northern 
Surry Hospital, Mount Airy, N.C. 27030. 919-789-9541. 



POEMS WANTED: The North Carolina Society of Poets is compihng 
a book of poems. If you have written a poem and would like our 
selection committee to consider it for pubhcation, send your poem 
and a self-addressed stamped envelope to: THE NORTH 
CAROLINA SOCIETY OF POETS, 614 — 1st Lnion Building, 
Winston-Salem, N.C. 27101 

OFFICE SPACE FOR SALE OR RENT: Ample parking, Tri-City 
area. Piedmont North Carolina. Multispace Medical Complex, two 
spaces available. Solo practice or small group. Area needs: inter- 
nist, hematologist/oncologist, psychiatrist or general practice. Con- 
tact: HIGH POINT MEDICAL CENTER, INC., 919-882-1725 or 
919-882-1524. 

HOME-OFFICE FOR SALE OR LEASE: Greensboro, N.C. Spa- 
cious brick home. Main floor — 3,000 sq. ft., 8 rooms. Second 
floor — 2,000 sq. ft., 5 rooms including second kitchen, suitable 
inlaw setup. Basement — 2,000 sq. ft., 8 room office with separate 
entrance appraised at $130,000 or Iea3e with option to buy. Write: 
NCMJ-9, P.O. Box 27167, Raleigh, N.C. 27611. 

EMERGENCY MEDICINE: Northeastern North Carolina; four, 
12-hour evening rotations per week. Paid malpractice, vacation, 
professional dues. $45,000 annual remuneration. Contact Drs. 
Cooper or Spurgeon toll free 1-800-325-3982. 

PHYSICIANS NEEDED: M.D.'s with completed internships or resi- 
dencies for hospital/clinics/flight surgeon duties — worldwide 
placement available! Relocation fees paid, 30 days paid vacation 
each year. 40 hour work week. Contact Dave Powell, Navy Medical 
Representative, Navy Recruiting District, P.O. Box 18568, Ra- 
leigh, N.C. 27609. Call Collect: 782-2005. 



"WHEN YOUR BACK FEELS GOOD YOU'LL FEEL GOOD" 

SEALY POSTUREPEDIC 

A Unique Back Support System 




Designed in cooperation with lead- 
ing orthopedic surgeons for comfort- 
ably firm support-"no morning 
backache from sleeping on a too-soft 
mattress." 



FROM Il\J \J 




Twin Size, 
ea. pc. 



SEALY OF THE CAROLINAS, INC 



(a division of the 72-year old Peerless Mattress Co.) 

Asheville - Charlotte - Lexington - High Point - Greenville - Columbia 

"Sleeping on a Sealy is like sleeping on a cloud" 



May 1976, NCMJ 



271 



Index to 
Advertisers 



American Tobacco Company 225 

Asheville School 266 

Blue Cross & Blue Shield of N.C 233 

Burroughs Wellcome Company 227 

Crumpton. J. L. & J. Slade, Inc 231 

Fellowship Hall 224 

Golden-Brabham Insurance Agency 228 

Key Pharmaceuticals, Inc 255 

Lilly, Eli & Company Cover 1 

Mandala Center 229 

Mutual of Omaha 267 

Ortho Pharmaceuticals 268, 269 

Pharmaceutical Manufacturers Association .234, 235 
Robins, A. H. Company 239, 240 



Roche Laboratories Cover 2, 223, 260, 

261 , Cover 3, Cover 4 

Roerig & Company 252, 253, 264 

Saint Albans Psychiatric Hospital 236 

Sapphire Valley 237 

Sealy of the Carolinas, Inc 271 

Smith Kline & French Labs 262 

Tidewater Psychiatric Institute 232 

Transco, Inc 259 

United States Air Force 238 

Upjohn Company 263 

Willingway, Inc 257 

Winchester Surgical Supply Company, 

Winchester-Ritch Surgical Company 272 



WINCHESTER 

"CAROLINAS' HOUSE OF SERVICE" 



Winchester Surgical Supply Company 

200 South Torrence St. Charlotte, N. C. 28204 
Phone No. 704-372-2240 

Winchester-Ritch Surgical Company 

421 West Smith St. Greensboro, N. C. 27401 
Phone No. 919-272-5656 

Serving the MEDICAL PROFESSidS of ISORTH CAROLINA 
and SOUTH CAROLINA since 1919. 

We equip many new Doctors beginning practice each year, and invite your inquiries. 

Our salesmen are located in all parts of North Carolina 

We have DISPLAYED at every N. C. State Medical Society Meeting since 1921, and 
advertised CONTINUOUSLY in the N. C. Journal since January 1940 issue. 



272 



Vol. 37, No. 5 



ikl 



I® 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 



prompt and specific action 

documented benefit-to-risk ratio 

three dosage strengths to meet most therapeutic needs 




Before prescribing, please consult 
complete product information, a summary 
of which follows: 

Indications: Relief of anxiety and tension 

occurring alone or accompanying various 

disease states. 

Contraindications: Patients witfi known 

hypersensitivity to the drug. 

Warnings: Caution patients about possible 

combined effects with alcohol and other 

CNS depressants. As with all CNS-acting 

drugs, caution patients against hazardous 

occupations requiring complete mental 



alertness (e.g., operating machinery, driv- 
ing). Though physical and psychological 
dependence have rarely been reported on 
recommended doses, use caution in ad- 
mmistering to addiction-prone individuals 
or those who might increase dosage; with- 
drawal symptoms (mcluding convulsions), 
following discontinuation of the drug and 
similar to those seen with barbiturates, 
have been reported. Use of any drug in 
pregnancy, lactation or in women of child- 
bearing age requires that its potential 
benefits be weighed against its possible 
hazards. 

Precautions: In the elderly and debilitated, 
and in children over six, limit to smallest 
effective dosage (initially 10 mg or less per 
day) to preclude ataxia or oversedation, 
increasing gradually as needed and tol- 
erated. Not recommended in children 
under six. Though generally not recom- 
mended, if combination therapy with other 
psychotropics seems indicated, carefully 
consider individual pharmacologic effects, 
particularly in use of potentiating drugs 
such as IVIAO inhibitors and phenothia- 
zines. Observe usual precautions in pres- 
ence of impaired renal or hepatic function. 
Paradoxical reactions (e.g., excitement, 
stimulation and acute rage) have been 
reported in psychiatric patients and hy- 
peractive aggressive children. Employ 
usual precautions in treatment of anxiety 
states with evidence of impending depres- 
sion; suicidal tendencies may be present 
and protective measures necessary. Vari- 
able effects on blood coagulation have 
been reported very rarely in patients re- 
ceiving the drug and oral anticoagulants; 
causal relationship has not been estab- 
lished clinically. 



Adverse Reactions: Drowsiness, ataxia 
and confusion may occur, especially in the 
elderly and debilitated. These are revers- 
ible in most instances by proper dosage 
adjustment, but are also occasionally ob- 
served at the lower dosage ranges. In a 
few instances syncope has been reported. 
Also encountered are isolated instances of 
skin eruptions, edema, minor menstrual 
irregularities, nausea and constipation, 
extrapyramidal symptoms, increased and 
decreased libido— all infrequent and gen- 
erally controlled with dosage reduction; 
changes in EEG patterns (low-voltage fast 
activity) may appear during and after treat- 
ment; blood dyscrasias (including agranu- 
locytosis), jaundice and hepatic dysfunction 
have been reported occasionally, making 
periodic blood counts and liver function 
tests advisable during protracted therapy. 
Usual Daily Dosage: Individualize for 
maximum beneficial effects. Oral— Adults: 
Mild and moderate anxiety and tension, 
5 or 10 mg t.i.d. or qJ.d.; severe states, 20 
or 25 mg t.i.d. or q.i.d. Geriatric patients: 
5 mg b.i.d. to q.i.d. {See Precautions.) 
Supplied: Librium? (chlordiazepoxideHCI) 
Capsules. 5 mg, 10 mg and 25 mg — bottles 
of 100 and 500; Tel-E-Dose's packages of 
100, available in trays of 4 reverse-num- 
bered boxes of 25, and in boxes contain- 
ing 10 strips of 10; Prescription Paks 
of 50. available singly and in trays of 10, 
Libritabs- (chlordiazepoxide) Tablets, 
5mg, 10 mg and 25 mg — bottles of 100 and 
500 With respect to clinical activity, cap- 
sules and tablets are indistinguishable. 



_ .^ Roche Laboratories 
ROCHE y Division of Hoffmann-La Roche Inc. 
Nutley. New Jersey 07110 



Please see following page. 



LIBRIUM 

chlordiazepoxide HCI/Roche 
5mg,10mg, 25mg capsules 



LIBRIUM 

(chlordiazepoxide HCI) 

FOR ALLTHE RIGHT 
REASONS. 

Yesterday's decision to use Librium for a clinically anxious 
patient was based on several good reasons. Safety. Effectiveness. 
Versatility. And the reasons you chose it yesterday are as valid today. 

Librium has accumulated an unsurpassed clinical record A 
record validated in several thousand papers published both here 
and abroad. 

Librium, when used in proper dosage, rarely interferes with a 
patient's mental acuity or ability to perform. However, as with all CNS- 
acting agents, good medical practice suggests that patients be cautioned 
against hazardous activities requiring complete mental alertness. 

Librium has an established safety record and a documented 
benefit'to-risk ratio. And Librium is used concomitantly with such drugs 
as cardiac glycosides, diuretics, anticholinergics and antacids. 

So when you consider antianxiety therapy, consider Librium. 

It's a good choice. For today. And tomorrow. 




ROCHE 




PROVEN ADJUNCT FOR CLINIC AL ANXIETY 

LIBRIUM ' 

epoxide HCI/Roche 



Please see preceding page for summary of product informatioa 




NORTH CAROLINA 



Medical Journal 



IN THIS ISSUE: Infant Mortality in Cleveland County: A Recent Secular Increase, Olivia Black, B.S., Jane Gordon, M.S., 
Wayne Lednar, Ph.D., Cecil Slome, M.D., D.P.H., Helen Balkcom, M.P.H., Laura Carillo, M.P.H., Mary Slawter, B.S.N., 
Sally Ann Williamson, M.P.H., Carol Cox, M.P.H., Earl Siegel, M.D., M.P.H., Don Kaiser, B.A., and Rick Steeves, M.P.A.; 
Local Public Health Departments and Their Directors in North Carolina and the United States, Edward F. Brooks, M.B.A., 
Gordon H. DeFriese, Ph.D., Sagar C. Jain, Ph.D., Florence Kavaler, M.D., and C. Arden Miller, M.D.; Cardiopulmonary 
Resuscitation (CPR) as Treatment of Cardiac Arrest (Second of Three Articles), James T. McRae, M.D. 



New from Lilly/Dista Research 

NALFON^ 

fenoppofen calcium 

300-mg.* Pulvules' 




»® 



Dista Products Company 

Division of Eli Lilly and Company 
Indianapolis, Indiana 46206 



Additional information available to the profession 
on request. 

•Present as 345.9 mg. of tfie calcium salt of fenoprofen dihydrate 
equivalent to 300 mg. fenoprofen. 



1976 Committee Conclave 1977 ANNUAL SESSIONS 

Sept. 22-26— Southern Pines May 5-8— Pinehurst 



Both often 




Predominant 
• psychoneurotic 



anxiety 



Associated 

• depressive 

symptoms 



Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Indications: Tension and anxiety states; 
somatic complaints wliich are concomi- 
tants of emotional factors; psychoneurotic 
states manifested by tension, anxiety, ap- 
prehension, fatigue, depressive symptoms 
or agitation; symptomatic relief of acute 
agitation, tremor, delirium tremens and 
hallucinosis due to acute alcohol with- 
drawal; adiunctively in skeletal muscle 
spasm due to reflex spasm to local pathol- 
ogy, spasticity caused by upper motor 



neuron disorders, athetosis, stiff-man syn- 
drome, convulsive disorders (not for sole 

therapy). 

Contraindicated: Known hypersensitivity 
to the drug. Children under 6 months of 
age. Acute narrow angle glaucoma; may 
be used in patients with open angle glau- 
coma who are receiving appropriate 
therapy. 

Warnings: Not of value in psychotic pa- 
tients. Caution against hazardous occupa- 
tions requiring complete mental alertness. 
When used adjunctively in convulsive dis- 



orders, possibility of increase in frequency 
and/ or severity of grand mal seizures may 
require increased dosage of standard anti- 
convulsant medication; abrupt withdrawal 
may be associated with temporary in- 
crease in frequency and/ or severity of 
seizures. Advise against simultaneous in- 
gestion of alcohol and other CNS depres- 
sants. Withdrawal symptoms (similar to 
those with barbiturates and alcohol) have 
occurred following abrupt discontinuance 
(convulsions, tremor, abdominal and mus- 
cle cramps, vomiting and sweating). Keep 
addiction-prone individuals under careful 



respond to one 



According to her major 
symptoms, she is a psychoneu- 
rotic patient with severe 
anxiety. But according to the 
description she gives of her 
feelings, part of the problem 
may sound like depression. 
This is because her problem, 
although primarily one of ex- 
cessive anxiety, is often accom- 
panied by depressive symptom- 
atology. Valium (diazepam) 
can provide relief for both— as 
the excessive anxiety is re- 
lieved, the depressive symp- 
toms associated with it are also 
often relieved. 

There are other advan- 
tages in using Valium for the 
management of psychoneu- 
rotic anxiety with secondary 
depressive symptoms: the 
psychotherapeutic effect of 
Valium is pronounced and 
rapid. This means that im- 
provement is usually apparent 



in the patient within a few 
days rather than in a week or 
two. although it may take 
longer in some patients. In ad- 
dition, Valium (diazepam) is 
generally well tolerated; as 
with most CNS-acting agents, 
caution patients against haz- 
ardous occupations requiring 
complete mental alertness. 

Also, because the psycho- 
neurotic patient's symptoms 
are often intensified at bed- 
time, Valium can offer an addi- 
tional benefit. An h.s. dose 
added to the b.i.d. or t.i.d. 
treatment regimen can relieve 
the excessive anxiety and asso- 
ciated depressive symptoms 
and thus encourage a more 
restful night's sleep. 




Wium; ^ 

(diazepam) ^ 

2-nig, 5-mg, lO-mg scored lableis 



in psychoneurotic 

anxiety states 

with associated 

depressive symptoms 



surveillance because of their predisposi- 
tion to habituation and dependence. In 
pregnancy, lactation or women of child- 
bearing age, weigh potential benefit 
against possible hazard. 
Precautions: If combined with other psy- 
chotropics or anticonvulsants, consider 
carefully pharmacology of agents em- 
ployed; drugs such as phenothiazines, 
narcotics, barbiturates, MAO inhibitors 
and other antidepressants may potentiate 
its action. Usual precautions indicated in 
patients severely depressed, or with latent 
depression, or with suicidal tendencies. 



Observe usual precautions in impaired 
renal or hepatic function. Limit dosage to 
smallest effective amount in elderly and 
debilitated to preclude ataxia or over- 
sedation. 

Side Effects: Drowsiness, confusion, diplo- 
pia, hypotension, changes in libido, nausea, 
fatigue, depression, dysarthria, jaundice, 
sl<in rash, ataxia, constipation, headache, 
incontinence, changes in salivation, 
slurred speech, tremor, vertigo, urinary 
retention, blurred vision. Paradoxical re- 
actions such as acute hyperexcited states, 
anxiety, hallucinations, increased muscle 



spasticity, insomnia, rage, sleep disturb- 
ances, stimulation have been reported; 
should these occur, discontinue drug. Iso- 
lated reports of neutropenia, jaundice; 
periodic blood counts and liver function 
tests advisable during long-term therapy. 



X '^oc^s Laboratories 
nOCHE y Division of Hoffmann-La Rocfie Inc. 
Nutley, New Jersey 07110 



TREATMENT AND LEARNING CENTER For 

ALCOHOL RELATED PROBLEMS 




FELLOWSHIP HALL 

THE ONLY HOSPITAL OF ITS KIND IN THE SOUTHEAST 

• Safe Comfortable Withdrawal • No Alcohol Employed • Private Non-Profit 
Tax-Exempt • A Controlled and Pleasant Psychological Atmosphere 

• Psychiatric Hospital 

FOUR WEEK MULTI-DISCIPLINE THERAPY PROGRAM 



Member of: 

• The American Hospital Association 
• The N. C. Hospital Association 

• Accredited by the Joint Commission 

on the Accreditation of Hospitals 



Individual Counseling • Group Therapy 

Nature Trail • Indoor/Outdoor Recreation 

Relaxation and Sleep Therapy 

Audio-Video Therapy 



FOR ADMITTANCE CALL 

JAMIE CARRAWAY 

EXECUTIVE DIRECTOR 

919-621-3381 



FELLOWSHIP HALL 

p. 0. BOX 6929 • GREENSBORO, N. C. 27405 

Located off U.S. Hwy. No. 29 at Hicone Road Exit, 

6V2 miles north of downtown Greensboro, N. C. 

Convenient to 1-85, 1-40, U.S. 421, U.S. 220, 

and the Greensboro Regional Airport. 



INC. 



FOR MEDICAL INFORMATION CALL 

J. W. WELBORN, JR., M.D. 

MEDICAL DIRECTOR 

919-275-6328 




Facility, program and en- 


Films, tapes, lectures, 


Medical examination 


upon 


Modern, motel-like accom- 


A therapeutic nature trail 


vironment allows the indi- 


grc'p discussions and in- 


admission. 




modations with private bath 


to encourage physical ex- 


vidual to maintain or re- 


div dual counseling are 






and individual temperature 


ercise, and arouse objec- 


gain respect and recover 


used with emphasis on 






control. 


tive interest in the miracle 


with dignity. 


reality therapy. 








of nature. 



FELLOWSHIP HALL WILL ARRANGE CONNECTION WITH COMMERCIAL TRANSPORTATION. 










pS«'' 



>^« 



0V°' 



.O^^' 









,<:<;,..' 



.-<'■>-" 

::»-" 



>!?<- 









,^**>^'' 












Ae 
























»o»^ ,tv\* „o»^ »Q^ , ^^^' o< "" 












^O A 



^€^^$$^' 









,,=,e»^'^ ^^Me' ,e<<^^ ,vO<5 









^ss^^^ 






nVP' 



,eV' 



.\»^ 



ox^' 



,e< 



>•-"!::•'"■ 






' Q,'^ vx><« 






>P^_,«v»^ -,^^»■ ..\<*^* _ ,e^V° .r.»^^ ^>i(<> ° 





















^^ ,eO° ,x.e 










V' 



-'::# y^^ 

^ 



>> 






John H. Felts, M.D. 
Winston-Salem 

EDITOR 

John S. Rhodes, M.D. 
Raleigh 

ASSOCIATE EDITOR 

Mr. William N. Hilliard 
Raleigh 



NORTH CAROLINA 
MEDICAL JOURNAL 

Published Monthly as the Official Organ of 

The North Carolina 

Medical Society 



June 1976, Vol. 37, No. 6 



BUSINESS MANAGER ^ 

Original Articles 

EDITORIAL BOARD Infant Mortality in Cleveland County: A Recent Secular 

Increase 287 

Charles w. Styron, M.D. Olivia Black, B.S., Jane Gordon, M.S., Wayne Lednar, 

Raleigh Ph.D., Cecil Slome, M.D., D.P.H., Helen Balkcom, 

CHAIRMAN M.P.H., Laura Carillo, M.P.H., Mary Slawter, B.S.N. , 

Sally Ann Williamson, M.P.H., Carol Cox, M.P.H., Earl 
George Johnson^Jr.,MJD^ gj , ^^ ^^^ ^^^ ^^. 

Chapel HiU Sleeves, M.P.A. 

Robert w. Prichard, M.D. Local Public Health Departments and Their Directors in 

Wmston Salem ^orth Carolina and the United States 293 

Rose Pully, M D Edward F. Brooks, M.B.A., Gordon H. DeFriese, Ph.D., 

Kjnston Sagar C. Jain, Ph.D., Florence Kavaler, M.D., and 

C. Arden Miller, M.D. 

j^jjlgj . Cardiopulmonary Resuscitation (CPR) as Treatment of 

Cardiac Arrest (Second of Three Articles) 299 

Louis Shaffner, M.D. James T. McRae, M.D. 

Winston-Salem 

Editorials 

Robert E. Whalen. M.D. Positive Implications in a Negative Phenomenon 302 

Durham Professional Common Ground 307 

Diverticulosis — A Social Disease 307 

Committees & Organizations 

Executive Council of the North Carolina Medical Society 308 

Bulletin Board 

New Members of the State Society 309 

What? When? Where? 309 

NORTH CAROLINA MEDICAL JOURNAL, 300 S. v, xT . c .u tt • » r XT _>l. /^ 1- 

Hawthorne Rd, Winston-Salem, N.c. 27103, is owned Ncws Notcs from the Univcrsity of North Carolina 

and published by The North Carolina Medical Society nivicinn nf Hpalfh AffQirc 110 

under the direction of its Editorial Board. Copyright " i-'IVISIUIl Ui nCdllU /\liairs JIU 

manusc'ri'pts a^d 'c"ommm'ications"rega!di'ng ^dto'ril' Ncws Notcs from thc Dukc Univcrsity Mcdical Center . . 312 

matter to this Winston-Salem address. Questions reial- »t vt i* it^ ^^ r^ t t t- ^ a i- • 

ing to subscription rates, advertising, etc , should be Ncws Notcs trom thc Bowman Gray School of Medicinc 

addressed to the Business Manager, Box 27167, r. ,^, ii^.tt--* tt j 

Raleigh, N.C. 27611. Alladvenisementsareaccepted OI Wake TOrCSt UniVCrSlty 314 

subject to the approval of a screening committee of the f., , •!• *-,t^/^ r* j i t^ o i j i 

state Medical Journal Advertising Bureau, 711 South Syphilis — CUC Kecommendcd I rcatmcnt Schedules, 

Blvd. , Oak Park, Illinois 60302 and/or by a Committee < Q'7^ •! K 

ofthe Editorial Board of the North Carolina Medical IV/D JiD 

Journal in respect to strictly local advertising. Instruc- 
tions to authors appear in the January and July issues. »* 11/ -» 1 o 

AnnualSubscriplion.SlO.OO. Single copies, $1.00. Pub- MONTH IN WASHINGTON Ho 

licalion office: Edwards & Broughton Co.. P.O. Box 
27286, Raleigh, N.C. TldW . Second-class postage paid 
at Raleigh. North Carolina 27611. BOOK REVIEWS 324 

In Memoriam 324 

Classified Ads 325 

Index to Advertisers 326 

Contents listed in Current Contents/Clinical Practice 



T 



Famous Fighters 




NEOSPORIN' Ointment 

( polymyxin B-bacitracin-neomycin) 

is a famous fighter, too. 



Each gram contains; Aerosponn- brand Polymyxin B Sulfate 5,000 units^ zinc 
bacitracin 400 units, neomycin sulfate 5 mg (equivalent to 3 5 mg neomycin base) 
special white petrolatum qs in tubes ot 1 oz and 1/2 oz and 1/32 oz (approx ) 
(oil packets ^ ^ , hi 

INDICATIONS-. Therapeutically (as an adiunct to systemic therapy when indicated) 
for topical intections. primar7 or secondary, due to susceptible organisms, as in 
. infected burns, skin grafts, surgical incisions, otitis externa • primary 
pyodermas (impetigo, ecthyma, sycosis vulgaris, paronychia) • secondarily 
Infected dermatoses (eczema, herpes, and seborrheic dermatitis) • traumatic 
lesions inflamed or suppurating as a result of bacterial infection 
Prophylactically the ointment may be used to prevent bacterial contamination in 
F urns skin gra fts, incisions, and other clean lesions For abrasions minor cuts 
and wounds accidentally incurred, its use may prevent the development of infec- 
tion and permit wound healing CONTRAINDICATIONS: Not for use in the eyes or 
external ear canal if the eardrum is perlorafed This product is contraindicated in 
those individuals who have shown hypersensitivity to any ot the components 
WARNING' Because of the potential hazard of nephrotoxicity and ototoxicity due to 



^iS^ 



>(I0<P(1I11>' 
OIMWM 



» 



neomycin, care should be exercised when using this product in treating ex ensive 
burns trophic ulceration and other extensive conditions wf^e/e ^bsorpho o 

omycin is possible In burns where more than 20 percent of the body surtace 
affected especially H the patient has impaired renal function or is receiving other 
aminoglycoside antibiotics concurrently, not more than one application a day is 
recommended PRECAUTIONS: As with other antibacterial preparations^prolonged 
use may result in overgrowth of nonsusceptible "^5^;=„'"^^' '"f '"^J^^ ""'' 
Appropriate measures should be taken if this occurs ADVERSE REACT DNS. 
Neomycin is a not uncommon cutaneous sensitizer Articles in the currem litera- 
ture indicate an increase in the prevalence of persons allergic to neomycin Oto- 
toxicity and nephrotoxicity have been reported (see Warning section) 
Complete literature available on request from Professional Services Dept PML, 



^^ / Burroughs Wellcome Co. 

Ta / Researcti Triangle Park 
Wellcome/ North Carolina 27709 



'.'^i' 









"■* J->> 



Testing in Humans: 
Who,Whei« & When. 



me weight of ethical opinion: 

Few would disagree that the efFective- 
less and safet\- of any therapeutic agent 
Dr device must be determined through 
|:linical research. 

But now the practice of cUnical re- 
feearch is under appraisal by Congress, the 
jress and the general public. Who shall 
administer it.' On whom are the products 
fO be tested.' Under what circumstances? 
^nd how shall results be evaluated and 
Jtilized.' 

The Pharmaceutical Manufacturers 
Association represents firms that are sig- 
nificantly engaged in the discovery and 
development of new medicines, medical 
devices and diagnostic products. Clinical 
research is essential to their efforts. Con- 
Isequcntly, PMA formulated positions 
Iwhich it submitted on July 1 1, 1973, to 
|the Subcommittee on Health of the Sen- 
ate Labor and Public Welfare Committee, 
las its official policy recommendations. 
iHere are the essentials ot PMA's current 
Ithinking in this vital area. 

I. PMA supports the mandate and 
Imission of the National Commission for 
Ithe Protection of Human Subjects of 
JBiomedical and Behavioral Research and 
loffers to establish a special committee 
{composed of experts of appropriate 
Idisciplines familiar with the industry's 
Iresearch methodology to volunteer its 
Jservice to the Commission. 

2« PiSIA supports the formation of an 
I independent, expert, broadly based and 
[representative panel to assess the current 
[state of drug innovation and the impact 
upon it of existing laws, regulations and 
I procedures. 

3« When FDA proposes regulations, 
it should prepare and publish in the Fed- 
eral Register a detailed statement assess- 
ing the impact of those regulations on 
drug and device innovation. 

4«PjMA proposes that an appropri- 
ately qualified medical organization be 
encouraged to undertake a comprehen- 
sive study of the optimum roles and 
responsibilities of the sponsor and physi- 
cian when company-sponsored clinical 
research is performed by independent 
clinical investigators. 



5«PMA recognizes that the physician- 
investigator has, and should have, the 
ultimate responsibility lor deciding the 
substance and form ot the intormed con- 
sent to be obtained. However, PMA 
recommends that the sponsor ot the ex- 
periment aid the investigator in dis- 
charging this important responsibility by 
providing (1) a document detailing the 
inx'estigator's responsibilities under FDA 
regulations with regard to patient consent, 
and ( 2 ) a written description of the 
relevant facts about the investigational 
item to be studied, in comprehensible 
la\' language. 

O.In the case ot children, the sponsor 
must require that informed consent be 
obtained from a legally appropriate rep- 
resentative of the participant. Voluntary 
consent of an older child, who may be 
capable ot understanding, in addition to 
that of a parent, guardian or other legally 
responsible person, is advisable. Safety of 
the drug or device shall have been assessed 
in adult populations prior to use in 
children. 

7«PMA endorses the general prin- 
ciple that, in the case of the mentally 
infirm, consent should be sought from 
both an understanding subject and trom 
a parent or guardian, or in their absence, 
another legally responsible person. 

8« Pharmaceutical manuftcturers 
sponsoring investigations in prisons must 
take all reasonable care to assure that the 
tacilities and personnel used in the con- 
duct of the investigations are suitable for 
the protection ot participants, and for the 
a\oidance of coercion, with a respect for 
basic humanitarian principles. 

9» Sponsors intending to conduct non- 
therapeutic clinical trials through the 
participation of employee volunteers 
should expand the membership and scope 
of Its existing Medical Research Commit- 
tee, or establisii such an internal Medical 
Research Committee, with responsibility 
to approve the consent torms of all 
volunteers, designs, protocols and the 
scope of the trial. The Committee should 
also bear responsibility to ensure tuU 
compliance with all procedures intended 
to protect employee volunteers' rights. 

XO. Where the sponsor obtains medi- 
cal information or data on individuals, it 
shall be accorded the same confidential 



status as provided in codes of ethics gov- 
erning health care professionals. 

U.PMA and its member firms accept 
responsibility to aid and encourage ap- 
propriate follow-up ot human subjects 
who have received investigational prod- 
ucts that cause latent toxicity in animals 
or, during their use in clinical investiga- 
tion, are found to cause unexpected and 
serious adverse effects. 

U.PMA supports the exploration 
and development by its member compa- 
nies of more systematic surveillance pro- 
cedures for newly marketed products. 

13.When a pharmaceutical manu- 
facturer concludes, on the basis of early 
clinical trials of a basic new agent, that a 
new drug application is likely to be sub- 
mitted, a proposed development plan 
accompanied by a summary of existing 
data, would be submitted to the FDA. 
Following a review of this submission, 
the FDA, and its Advisory Committee 
where appropriate, would meet with the 
sponsor to discuss the development plan. 
No funiidl FDA approval should be re- 
quired at this stage. Rather, the emphasis 
should be on identification of potential 
problems and questions for the sponsor's 
ttirther study and resolution as the pro- 



gram develops. 



The PMA believes that health profes- 
sionals as well as the public at large 
should be made aware of these 13 points 
in its Policy on Clinical Research. For 
these recommendations envisage con- 
structive, cooperative action by industry, 
research institutions, the health profes- 
sions and government to encourage crea- 
tive and workable responses to issues 
involved in the clinical investigation of 
new products. 



P-M-A 



Pharmaceutical Manuficturers 

Association 
jl 1155 Fifteenth Street, N.W 
™ Washington, D. C. 20005 



Officers 
1976-1977 



NORTH CAROLINA MEDICAL 
SOCIETY 



President Jesse Caldwell, Jr., M.D., 

114 W. 3rd Ave., Gastonia 28052 

President-Elect E. Harvey Estes, Jr., M.D. 

Duke Univ. Med. Ctr., Box 2914, Durham 27710 (1979) 

First Vice-President J. Benjamin Warren, M.D. 

Box 1465, New Bern 28560 

Second Vice-President John C. Grier, M.D. 

Box 791, Pinehurst 28374 

Secretary Jack Hughes, M.D. 

923 Broad St., Durham 27705 

Speaker Marvin N. Lymberis, M.D. 

1600 E. 3rd St., Charlotte 28204 

Vice-Speaker Henry J. Carr, Jr., M.D. 

603 Beamon St., CImton 28328 

Past-President James E. Davis, M.D. 

1200 Broad St., Durham 27705 

Executive Director William N. Hilliard 

222 N. Person St., Raleigh 27611 

Councilors and Vice-Councilors — 1976-1977 

First District Edward G. Bond, M.D. 

Chowan Med. Ctr., Edenton 27932 (1977) 

Vice-Councilor Joseph A. Gill, M.D. 

1202 Carolina Ave., Elizabeth City 27909 (1977) 

Second District Charles P. Nicholson, Jr.. M.D. 

3108 Arendell St., Morehead City 28557 (1979) 

Vice-Councilor J. Elliott Dixon. M.D. 

215 E. 2nd St.. Ayden 28513 (1979) 

Third District E. Thomas Marshburn, Jr., M.D. 

1515 Doctors Circle, Wilmington 28401 (1979) 

Vice-Councilor Charles M. Hicks, M.D. 

1914 Glen Meade Rd., Wilmington 28401 (1979) 

Fourth District Harry Weathers, M.D. 

P.O. Box 1 146, Roanoke Rapids 27870 (1977) 

Vice-Councilor Robert H. Shackelford, M D. 

P.O. Box 649, Mt. Ohve 28365 (1977) 

Fifth District .August Oelrich, M.D. 

Box 1169. Sanford 27330 (1978) 

Vice-Councilor Bruce B. Blackmon, M.D. 

P.O. Box 8. Buies Creek 27506 (1978) 

Sixth District J. Kempton Jones, M.D. 

1001 S. Hamilton Rd.. Chapel Hill 27514 (1977) 

Vice-Councilor W. Beverly Tucker, M.D. 

Ruin Creek Rd., Henderson 27536 (1977) 

Seventh District William T. Raby, M.D. 

1900 Randolph Rd.. Charlotte 28207 (1978) 

Vice-Councilor J. Dewey Dorsett, Jr.. M.D. 

1851 E. Third St., Charlotte 28204 (1978) 

Eighth District Ernest B. Spangler, M.D. 

Drawer X3, Greensboro 27402 (1979) 

Vice-Councilor Shahane R. Taylor. Jr., M.D. 

348 N. Elm St., Greensboro 27408 (1979) 

Ninth District Jack C. Evans, M.D. 

244 Fairview Dr.. Lexington 27292 (1979) 

Vice-Councilor Benjamin W. Goodman, M.D. 

24 2nd Ave., NE, Hickory 28601 (1979) 

Tenth District Kenneth E. Cosgrove. M.D. 

510 7th Ave., W., Hendersonville 28739 (1978) 

280 



Vice-Councilor Otis B. Michael, M.D 

Suite 208. Doctors Bldg., Asheville 28801 (1978) 

Section Chairmen — 1976-1977 

Anesthesiology 

Dermatology 

Emergency Medicine Frederick W. Glass, M.D.' 

Bowman Gray, Winston-Salem 27103 

Family Physicians 

Internal Medicine William W. Fore, M.D. 

1705 W. 6th St., Greenville 27834 

.\eurologY Si Ps\chiatr\- Martin A. Hatcher, M.D. 

' 1305 W. Wendover Ave., Greensboro 27408 
Neurological Surgery 

Obstetrics & Gynecology R. Pinkney Rankin, Jr., M.D. 

1851 E.'3rd St.. Charlotte 28204 

Ophthalmologx Harold N. Jacklin, M.D, 

1014 N. Elm St., Greensboro 27401 

Orthopaedics 

Otolaryngology 

Pathology 

Pediatrics Archie T. Johnson, Jr., M.D. 

701 Vick Ave., Raleigh 27609 

Public Health & Education 

Radiology 

Surger\- WiLLlAM W. Shingleton, M.D, 

Duke Univ. Med. Ctr., Box 3814, Durham 27710 

Uroloi>\ Charles A. Hoffman, M.D. 

348 Valley Rd.. Fayetteville 28305 
Students. Medical 



Delegates to the American Medical Association 

James E. Davis, M.D 1200 Broad St., Durham 27705 

(December 31. 1978) 

John Glasson, M.D 306 S. Gregson St., Durham 27701 

(December 31, 1978) 
Frank R. Reynolds, M.D. 

1613 Dock Street, Wilmington 28401 
(December 31, 1978) 
David G. Welton, M.D. 

3535 Randolph Road. Charlotte 28211 
(December 31, 1977) 
FLdgar T. Beddingeield, Jr., M.D. 

Wilson Clinic, Wilson 27893 
(December 31, 1977) 

Alternates to the American Medical Association 

George G. Gilbert. M.D 1 Doctor's Park, Asheville 28801 

(December 31, 1978) 
Lxiuis deS. Shafener. M.D. 

Bowman Gray, Winston-Salem 27103 

(December 31, 1978) 
Jesse Caldwell. Jr.. M.D. ..114 W. 3rd Ave., Gastonia 28052 

(December 31, 1978) 
Charles W. Styron. M.D. . . .615 St. Marys St.. Raleigh 27605 

(December 31, 1977) 
D. E. Ward. Jr.. M.D 2604 N. Elm St., Lumberton 28358 

(December 31. 1977) 

Vol. 37, No. 6 






NORTH CAROLINA 
MEDICAL SOCIETY'S OFFICIAL 
DISABILITY INSURANCE PLAN 



Now Pays Up To 

$500 4^ 

WEEKLY INCOME 



^^lditlO 



„alM%_B««»^'"'"; 



50. ">• 



i?jr"5w.«e,".. 



\obet 8, 



($2J66.00 per mo.) 

plus Bonus 

For eligible members under age 50. 

To meet today's needs in our inflated economy, we require 
adequate income when disabled from practice. 



GUARANTEED RENEWABLE 



DIRECT PERSONAL SERVICE 



You are guaranteed the privi- 
lege of renewing $300-week to 
age 70. The other $200 per week 
renewable to age 60. This is an 
exclusive and most important 
feature. 



Since 1939, it has been our 
privilege to administer your pro- 
gram from Durham, N. C. includ- 
ing payment of all claims! 



^ 



J. L. & J. SLADE CRUMPTON, INC. 

GENE GREER 
Office Manager 

. 0. Drawer ] 767— Durliam, N. C. 27702, Telephone: 919 682-5497 
Underwritten by The Continental Insuronce Cos. of New York 

JACK FEATHERSTON, Field Representative 

P. 0. Box 17824. Charlotte. N. C. 28211, Telephone: 704 366-9359 

North Carolina Professional Group Administrators for: 

NORTH CAROLINA MEDICAL SOCIETY • NORTH CAROLINA DENTAL SOCIETY • NORTH CAROLINA SOCIETY OF ENGI- 
NEERS . NORTH CAROLINA CHAPTER OF ARCHITECTS • NORTH CAROLINA ASSOCIATION OF C.P.A.'S AND BAR GROUPS 




Even Chicago Stadium 
couldn't hold all 
the physicians the AMA 
helped put through school. 







Every year, thousands of young men and women struggle 
to scrape up the funds to pay for their medical educa- 
tion and training. Many, though highly qualified, simply 
can't swing it alone. 

Where can they turn for financial assistance? One 
important source is the American Medical Association 
Education and Research Foundation (ERF). It was set 
up in 1962 to help just such qualified individuals 
complete their training. 

Through its Loan Guarantee Program, AMA-ERF 
has arranged for over $57 million in loans to more 
than 26,000 medical students, interns and residents 
in the last 1 1 years. 

Physicians often ask what the AMA really does. 
Helping to increase the number of doctors is just one 
of many things. Find out more about the AMA, how 
it serves the profession, how it serves the public. 
Just send us the completed coupon. 



Join us. 

We can do much more together. 

Dept. DW 

American Medical Association 
535 N. Dearborn St. 
Chicago, III. 60610 

Please send me more information on 
the AMA and AMA membership. 

Name 




Address - 



City/State/Zip_ 



North Carolina Medical Society 
Major Hospital and Nurse Expense Insurance 



$25,000 Major Hospital and Nurses Expense Policy- 
75 percent — 25 percent Co-Insurance 



I 



PLAN A 

$100 DEDUCTIBLE 


Member's Age 


Member 


Member and Spouse 


Member, Spouse & 
All Children 


Under 40 
40-49 
50-59 
60-64* 


$ 82.50 
125.00 
182.50 
286.50 


$206.00 
302.50 
417.00 
640.00 


$288.00 
384.50 
499.00 
722.00 


PLAN B 

$300 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 


$ 50.00 

76.00 

118.50 

180.00 


$114.00 
176.00 
254.00 
402.00 


$150.00 
212.00 
290.00 
438.00 


PLAN C 

$500 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 31.50 

51.50 

82.50 

138.50 

58.00 


$ 69.00 
118.50 
182.50 
308.00 
170.00 


$ 91.50 
141.00 
205.00 
330.50 
192.50 


PLAN D 

$1,000 DEDUCTIBLE 


Under 40 
40-49 
50-59 
60-64* 
65-69** 


$ 23.50 

38.50 

62.00 

104.00 

43.00 


$ 51.50 

89.00 

137.00 

231.00 

127.00 


$ 68.50 
106.00 
154.00 
248.00 
144.00 



* Shown for renewal only. Enrollment limited to members under age GO. 

"Integrates with Medicare at age 65. 

Premiums apply at current age on entry and attained age on renewal. Semi-annual premiums are one-half the annual plus 50 cents. 



Term Life Insurance Program 



Member's 












Spouse's 




Age 


$10,000 


$20,000 


$30,000 


$40,000 


$50,000 


Age 


$5,000 


Under 30 


$ 27 


$ 54 


$ 81 


$ 108 


$ 135 


Under 30 


$ 11 


30-34 


29 


58 


87 


116 


145 


30-34 


12 


35-39 


38 


76 


114 


152 


190 


35-39 


15 


40-44 


56 


112 


168 


224 


280 


40-44 


22 


45-49 


84 


168 


252 


336 


420 


45-49 


34 


50-54 


131 


262 


393 


524 


655 


50-54 


52 


55-59 


203 


406 


609 


812 


1,015 


55-59 


81 


60-64 


306 


512 


918 


1,224 


1,530 


60-64 


122 


65-69 


242 


484 


726 


968 


1,210 


65-69 


97 



All Children— $12 annually. $2,500 after age 6 months 

The above plans quality for use in the Professional Association. 



For Full Information — Write or Call 



Golden-Brabham Insurance Agency, Inc. 

Ralph J. Golden Van Brabham III 

108 E. Northwood St., Phone: BRoadway 5-3400, Box 6395, Greensboro, N. C. 27405 





fTlandolo Center 



A fully accredited private multi-disciplin- 
ary psychiatric hospital, partial care and 
out-patient clinic for the acutely ill to the 
mildly distressed. Children, young people, 
adults, couples or entire families may enter 
the treatment programs. 

A modified form of the therapeutic com- 
munity, a full spectrum of treatment mo- 



dalities are used. The services consist of 
individual, couple, group and family psycho- 
therapies; sexual and marriage counseling; 
pastoral counseling; vocational guidance and 
rehabilitation; alcohol and drug counseling; 
psychological testing, chemotherapy, elec- 
trotherapy and other somatic therapy ser- 
vices. 




Blue Cross participating hospital 

JCAH Accredited 

Richard B. Boren, M.D. Glenn N. Burgess, M.D. 

Psychiatrist-in-Chief Psychiatry 

For Information Call Collect (919) 724-9236 or Write: 
741 Highland Avenue • Winston-Salem, N. C. 27101 



Towards Wholeness 



Medicine/Osteopathy 

PRACTKE 
■SPERfEQ 
IN THE 
AIRfOfiCE^ 

A minimum of administrative details. New and modern facilities in 
research or clinical practice. Patient treatment without regard for ability to 
pay. Time for your family. A planned career to take the fullest advantage of 
your skills, knowledge, and ambition in many different areas of specialty. 
Individual opportunity is stressed and the Air Force training programs in 
both military and civilian hospitals are unexcelled. You'll be supported by 
a highly qualified staff, including nurses, dieticians, therapists, adminis- 
trators, and many others. Get the complete details - write today for more 
information. 

Look up. Be looked up to. Air Force 

310 New Bern Ave . Rm 303. Raleigh. N C 27611, Call 919/755-4134 

Name Social Security No 




Address 
City 



Slate 

Specialty . 



Date of Birth 



-Zip. 



Phone, 



AIR FORCE. Health Care At Its Best 





Just what is North Carolina 
Drug Utilization Review all about? 



Drug Utilization Review is part of the Medicaid drug program in your state. The goal is to assist in the delivery of rational 
drug therapy tor Medicaid patients and reduce the over all cost of the Medicaid drug program. 



How c